TR595Molina Healthcare, Inc', UB92 Billing Presentation

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UB 92
October 2005
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Agenda

• Outpatient Services
• Prior Authorization
• 72 Hour Rule
• Emergency Room
• Ambulatory Surgical Services
• Treatment Rooms
• Standalone Services
• Inpatient Reimbursement
• Prior Authorization
• DRG Methodology
• Outliers, Medical Education Costs and Capital
  Costs
• Level of Care
• Psychiatric Services
• Home Health Services

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Preface
UB-92 Procedures It
is the intent of Molina Healthcare of Indiana to
mirror as closely as possible the claim
completion requirements and reimbursement
policies of traditional Medicaid. Detailed
information and instructions are contained in the
IHCP Provider Manual, pages 8-17 through 8-100
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Preface
UB-92 Procedures Molina
Healthcare of Indiana has an open provider
network non-contracted facilities and providers
are welcome to provide services to Molina
members. Services rendered by non-par providers
will be reimbursed at 100 of the Indiana Health
Coverage Programs Fee Schedule.

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Outpatient Services
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Outpatient Services - PA

• Prior Authorization
• PA is required for most surgical procedures
• PA is not required for Cesarean sections
• PA is not required for Family Planning services
• Tubal Ligations, Vasectomies
• Routine Requests 2 business days
• Urgent Requests - 24 hours (immediate as
  appropriate)
• Retro-authorization is available on a case by
  case basis, based upon medical necessity
• No tracking is required for claim processing

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Outpatient Services - Definitions

• 3 Day Rule
• Outpatient services that occur within 3 days (72
  hours) of an inpatient stay to the same facility
  for the same or a related diagnosis will be
  considered part of the inpatient admission
• The terms same and related diagnosis refers
  to the primary diagnosis and is based on the
  first three digits if the ICD-9-CM code
• If an outpatient claim is paid prior to the
  processing of the inpatient claim, the inpatient
  claim will deny

To insure correct processing, the time of
discharge must be noted on each claim
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Outpatient Services - Definitions

• 3 Day Rule (contd)
• Outpatient services rendered within 3 days (72
  hours) of a stay lasting less than 24 hours
  should continue to be billed as outpatient
  services.
• This rule does not include services rendered by
  two separate providers as defined by two
  different provider numbers.

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Outpatient Services - ER

• Emergency Room Services
• Non-emergent ER claims will pay as foll0ws
• If the treatment was authorized by the PMP, the
  fee schedule rates will be paid.
• If the member was instructed to go to the ER by
  the Molina Nurse Line staff, the fee schedule
  rates will be paid.
• If treatment was provided for a non-emergent
  condition without authorization, a triage fee of
  35.00 will be paid to the hospital.

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Nurse-Line

• Nurse-Line is available 24/7 - 365 days a year
• RNs are available to review the need for
  Emergency Room visits

• Bilingual Staff (English/Spanish)
• Interpreters are available for other languages

1-888-275-8750
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Outpatient Services - Surgery

• Outpatient Surgery
• Surgeries provided in a hospital or an ambulatory
  surgical center (ASC) are reimbursed an
  all-inclusive flat fee that includes all related
  procedures.
• Reimbursement is also available in other settings
  such as treatment rooms, emergency departments
  and clinics.
• Reimbursement is based on the assignment of the
  CPT code to one of fourteen (14) ASC groups.

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Outpatient Services - Surgery

• Outpatient Surgery (contd)
• Molina will follow the IHCP policy reimbursing a
  maximum of two (2) units regardless of the number
  of incisions.
• The procedure with the highest ASC rate is
  reimbursed at 100.
• The procedure with the second highest rate is
  reimbursed at 50.
• Bilateral procedures are reimbursed at 150.
• To denote multiple surgeries, the appropriate
  revenue and CPT codes must be listed as separate
  detail line items.
• All outpatient services provided on the day of
  surgery must be included on a single claim.
  Add-on or standalone services are not separately
  reimbursable.

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Outpatient Services - Surgery

• Outpatient Surgery (contd)
• When billing multiple surgeries, the procedure
  with the highest rate of reimbursement must be
  listed on the first detail line

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Outpatient Services - Surgery

• Outpatient Surgery (contd)
• The cost of certain implantable durable medical
  equipment is separately reimbursable
  reimbursement for these items requires PA.
• Only the following items are separately
  reimbursed
• Cardiac Pacemakers Single Chamber
• Cardiac Pacemaker Dual Chamber
• Implantable Loop Recorders
• Phrenic Nerve Stimulators
• New Technology Intraocular Lens
• Vagal Nerve Stimulators
• Claims for the equipment are submitted on a
  CMS-1500 or via an 837P transaction

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Outpatient Services - Surgery

• Outpatient Surgery (contd)
• Surgical Revenue codes are defined as 360/361 and
  490/499.
• The revenue codes for treatment rooms including
  450, 510, 520, 700, 720 and 760 are defined as
  surgical revenue codes when accompanied by a
  surgical HCPCS code. These codes are then
  reimbursed at the appropriate ASC rate.
• Multiple Surgeries are reimbursed as follows
• Primary Procedure 100
• Secondary Procedure 50
• Bilateral procedures 150
• A maximum of two procedure codes will be
  reimbursed

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Outpatient Services Treatment Rooms

• Treatment Rooms
• Treatment Rooms are reimbursed at a flat rate
  that includes most drugs and supplies.
• Treatment Room codes are as follows
• 450 - Emergency dept.
• 510 - Clinic
• 520 - Free-standing clinic
• 700 - Cast room
• 720 - Labor/Delivery room
• 760 - Treatment/Observation room

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Outpatient Services Treatment Rooms

• Treatment Rooms (contd)
• Add-on services as listed below are allowed if
  billed in conjunction with a treatment room

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Outpatient Services Standalone Svcs

• Several types of services may be billed as
  standalones
• Laboratory Services (Technical Component)
• Hospitals must bill utilizing the most
  appropriate Revenue Code-HCPCS combination.
  Revenue codes billed without a HCPCS will be
  denied.
• Only one claim should be submitted when multiple
  laboratory services are performed.
• The professional component is to be billed on a
  CMS 1500 or 837P transaction.
• Radiology
• Hospitals must bill only the technical component
  for services provided in an outpatient setting on
  the UB-92.
• Radiology revenue codes must be billed with the
  appropriate HCPCS code.
• For free-standing radiology facilities, both the
  professional and technical components are to be
  billed on the CMS 1500 or 837 P transaction.

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Outpatient Services Standalone Svcs

• Standalones (contd)
• Chemotherapy and Radiation Treatment
• All outpatient hospital chemo and radiation
  treatment services are to be billed on the UB-92
  claim form or the 837I transaction.
• Chemotherapy services consists of four separate
  components which are separately reimbursable as
  follows
• Administration of chemotherapy agent Rev codes
  331, 332 or 335 with CPT chemotherapy codes
  96400-96549
• Chemotherapy agent Rev coded 636 with the
  appropriate HCPCS code
• IV solution and equipment Rev code 258 for the
  solution and 261 for IV equipment
• Treatment Room services Rev codes 45x, 51, 52x
  or 76x

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Outpatient Services Standalone Svcs

• Standalones (contd)
• Radiation Treatment
• Radiology treatment services consist of two
  components and may be reimbursed using the
  following code combinations
• Administration of radiation treatment Rev codes
  330, 333 or 339 with CPT radiation codes 77261
  77799
• Treatment Room services - Rev codes 450, 510, 520
  and 760
• Renal Dialysis
• Free standing renal dialysis facilities should
  use Type of Bill code 721
• Outpatient hospital facilities should use Type of
  Bill code 131
• Inpatient services should be billed with Type of
  Bill code 111

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Outpatient Services Standalone Svcs

• Standalones (contd)
• Renal Dialysis (contd)
• The diagnosis codes for dialysis services are
• 585 Chronic Renal Failure
• 586 Renal Failure Unspecified
• Revenue Codes utilized for dialysis services are
  as follows only one unit per each date of
  service is allowed
• 821 hemodialysis/composite or other rate
• 831 peritoneal dialysis/composite or other rate
• 841 CAPD/composite or other rate

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Outpatient Services Standalone Svcs

• Standalones (contd)
• Renal Dialysis (contd)
• Administration of Epoetin The following revenue
  codes are to be utilized with the appropriate
  HCPCS (Q) codes
• Rev code 634 Epoetin less than 10,000 units
• Rev code 635 Epoetin, 10,000 or more units
• Drugs Requiring Detailed Coding Revenue code
  636 is used with the appropriate HCPCS code to
  report charges for drugs or biological products
  requiring specific identification.
• Rev code 636 Field 42
• HCPCS (including J codes) Field 44
• of units administered Field 46

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Outpatient Services Standalone Svcs

• Standalones (contd)
• Renal Dialysis (contd)
• Lab Services Routine charges are included in
  the composite rate and cannot be billed
  separately. Non-routine services may be
  reimbursed separately when medically justified.
• Supplies are not reimbursed if billed in
  conjunction with a treatment room code
• Supplies The composite rate includes all
  durable and disposable and medical supplies
  necessary for dialysis. Revenue Code 270 may be
  used for those supplies outside of the list of
  those included in the rate. Supplies will only
  paid in conjunction with Diagnosis Codes 584,
  584.5, 584.6, 584.7, 584.8, 584.9, 585 and 586.

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Outpatient Services Standalone Svcs

• Standalones (contd)
• Mental Health
• Mental health, substance abuse, and chemical
  dependency services (Behavioral Health Services)
  rendered by providers enrolled in the IHCP with a
  mental health specialty are carved out of RBMC.
  These specialties include
• Psychiatric Hospitals
• Outpatient Mental Health Clinics
• Community Mental Health Centers

Note Claims for these services are to be
submitted to EDS
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Inpatient Services
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Inpatient Services - PA

• Prior Authorization
• PA is required for scheduled inpatient admissions
  and most surgical procedures
• Routine Requests 2 business days
• Urgent Requests - 24 hours (immediate as
  appropriate)
• Notification to Molina is required for emergency
  or after-hours admissions (next business day)
• Retro-authorization is available on a case by
  case basis, based upon medical necessity
• No tracking is required for claim processing

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Inpatient Services - DRG

• Diagnosis Related Groups (DRGs)
• Molina utilizes the same inpatient reimbursement
  methodology as the IHCP the methodology
  currently in use is the All-Patient (AP) DRG
  Grouper, version 18
• Outliers/Medical Education Costs
• The threshold for determining an outlier payment
  remains 34, 425.00
• Eligibility for medical education costs remains
  the same

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Inpatient Services - DRG

• Premature Newborns
• Claims for premature newborns require the listing
  of the birth weight to insure appropriate DRG
  assignment. The fifth digit of diagnosis codes
  764 and 765 denotes birth weight the following
  fifth-digit sub classification codes should be
  used

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Inpatient Services Mental Health

• Mental Health
• Inpatient mental health services, including
  substance abuse treatment, provided to Molina
  members in acute care facilities, are the
  responsibility of Molina Healthcare.
• Inpatient mental health services, including
  substance abuse treatment, provided to Molina
  members in freestanding psychiatric hospitals are
  carved out. Claims for these services are
  submitted to EDS.

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Home Health Care Services
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Home Health Care

• Home Health Care
• Services are available to those Molina members
  medically confined to home, when
• services are ordered in writing by a physician
  and,
• are performed in accordance with the written
  plan of care.
• Medically confined includes those individuals
  who, due to injury or illness are unable to leave
  home
• without the assistance of another person or
• an assistive device (such as a wheelchair or
  walker) or
• for whom leaving home is contrary to medical
  advice.

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Home Health Care - PA

• Home Health Care
• Prior Authorization is required for home care
  services except in the following instance
• The service does not exceed 30 units in 30
  calendar days following a hospital discharge
  (nursing and HHA),
• the therapy service does not exceed 120 units in
  30 calendar days,
• services must be ordered in writing by the
  physician prior to the members discharge from
  the hospital and
• the member must be homebound.

Note - Occurrence Code 50 is utilized with the
discharge date in Fields 32- 35
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Home Health Care

• Home Health Care
• Units of Service
• Each date of service is a separate line item
• Each service provided on the same date is billed
  as a separate line item
• If a service was refused, or the member is not at
  home, the provider may not bill any units of
  service
• Overheads
• For each encounter, a staffing reimbursement
  component and an administrative component
  (overhead) are paid.
• An encounter is defined as an RN, LPN, HHA or
  therapist entering the home, providing services
  and then leaving.

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Home Health Care

• Home Health Care
• Overheads (contd)
• For consecutive dates of service, Fields 32-36 on
  the UB-92 are used
• For non-consecutive dates, Fields 32-35 a-b,
  corresponding to each date of service are used
• Overhead rates are identified by the following
  codes
• Code 61 one encounter per date of service
• Code 62 two encounters
• Code 63 three encounters
• Code 64 four encounter
• Code 65 five encounters
• Code 66 six encounters

Occurrence codes 64 66 are used only in
exceptional circumstances
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Hospice Services

• Members enrolled in Risk Based Managed Care
  (RBMC) are not eligible for hospice care and must
  be disenrolled before the member elects the
  hospice benefit

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Long Term Care Services
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Long Term Care

• Nursing Facility Placement
• Short-Term (30 day maximum) is a covered benefit
  for Molina Healthcare members stays requiring
  longer than 30 days will require disenrollment
  from RBMC
• Prior Authorization is required for all NF
  admissions
• The case mix rate paid to facilities includes all
  medical and non-medical supplies, personal care
  items and reimbursement for therapy services no
  separate billing is allowed

Note NF services are not a covered benefit for
Package C members
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The Molina Mission

• Molina Healthcare is an innovative health care
  leader providing quality care and
• accessible services in an
  efficient and caring manner
• Core Values
• We strive to be an exemplary organization
• We provide quality service
• We are healthcare innovators and respond
  quickly to change
• We respect each other and value ethical
  business practices
• We are careful in the management of our
  financial resources
• We care about the people we serve.
• This is the
  Molina Way

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www.molinahealthcare.com 1-800-642-4509
450 E. 96th St., Suite 5006 Indianapolis, IN.
46240 8001 Broadway, Suite 400, Merrillville,
IN. 46410