You have javascript disabled. We recommend that you turn it on for the best experience on our site.

July 2010 Hospital Newsflash

Inside This Issue: CASE RATE – CLAIM PROCECSSING CLARIFCATION
IDENTIFYING HOSPITAL CARE TRANSITIONS
THE AMERICAN RECOVERY AND REINVESTMENT ACT
EPSDT CODE CHANGES
CLAIM SUBMISSION GUIDELINES FOR MEDICARE ASSURED® HMO SNP MEMBERS ENROLLED IN HOSPICE
SG MODIFIER CLAIM PROCESSING CHANGE
NEW CLAIMS MAILING ADDRESSES – REMINDER

IMPORTANT INFORMATION

CASE RATE CLAIM PROCESSING CLARIFCATION

When an outpatient surgical facility claim is billed with ALL of the following elements, the claim is processed at a "case rate". These elements are:

Operating Room/Ambulatory Surgery Room (Rev Codes 360, 361, 362, 367, 368, 490 and 499)

Recovery Room (Rev Codes 710, 719)

Anesthesia (Rev Codes 370, 379)

The surgical code with the highest allowable benefit will be paid and all of the other services will be denied D18-Denied - Other Services Included with Payment of Primary Services.

IDENTIFYING HOSPITAL CARE TRANSITIONS

Gateway HealthSM Medicare Assured® HMO SNP is a Medicare Special Needs Plan that insures dual eligible patients with Medicare and Medicaid/Medical Assistance. Since older and/or disabled patients moving between different health care settings are particularly vulnerable to receiving fragmented and unsafe care during poorly coordinated care transitions, the Centers for Medicare and Medicaid Services (CMS) requires special efforts from special needs plans to manage the care transition process. Care transitions occur when patients’ healthcare needs change from one setting to any other setting, such as when a patient is admitted to a hospital, or is discharged from the hospital to a skilled nursing facility or home.

Some of the ways that Medicare Assured® HMO SNP facilitates safe care transitions are: identifying unplanned and planned care transitions between settings; establishing a single point of contact internally that is responsible for support throughout the care transition process; and increasing communication about the care transition process with the member, member's responsible party, care providers and the patient’s PCP. In order to be successful in identifying and facilitating safe care transitions for members, Medicare Assured® must collaborate with its participating practitioners and providers who deliver patient care.

The prior authorization review and discharge planning processes are key components for the identification of unplanned and planned care transitions. Therefore, timely provider notification of planned and unplanned transitions, such as an emergency hospital admission or transfer to a skilled nursing facility, is critically important. Although transitions should be identified as proactively as possible (with at least two business days advance notice recommended for elective admissions,) CMS requires Medicare Assured® HMO SNP to identify transitions to inpatient care within one business day of the transition.

As a reminder, the Utilization Management Department (UM) at Gateway HealthSM Medicare Assured® HMO SNP is committed to assuring prompt, efficient delivery of healthcare services and to monitor quality of care provided to its members. Utilization Management can be contacted between the hours of 8:30am and 4:30pm, Monday through Friday, at 1-800-685-5207. When calling before or after operating hours or on holidays, providers are asked to leave a voicemail message, and a UM Representative will return the call the next business day. Urgent requests or questions are directed to call 1-800-685-5209.

Gateway HealthSM Medicare Assured® HMO SNP looks forward to collaborating with its provider network to identify and coordinate safe care transitions for our vulnerable patient population. Suggestions for improving the care transition process as well as any questions regarding the processes outlined above, can be forwarded to your Gateway Provider Relations Representative or the Gateway HealthSM Provider Services Department at 1-800-685-5205.

AMERICAN RECOVERY and REINVESTMENT ACT
ARRA: More to Know

The American Recovery and Reinvestment Act (ARRA) is the $787 billion economic stimulus package signed into law last year. ARRA includes a number of provisions intended to strengthen and improve enforcement of privacy and security under the HIPAA regulations. The penalties are tough. We wanted to share information with you should you want to be tougher on identifying potential security breaches before they occur.

In case you didn't know, the new ARRA legislation:

  • Increases penalties for HIPAA violations
  • Expands the breach definition to include verbal, paper, or electronic information
  • Requires notification to affected persons within 60 days AND to Health and Human Services (HHS) when a breach occurs
  • Requires notification to media in certain circumstances
  • Permits criminal penalties to be assessed to individuals for wrongful disclosures
  • Grants state attorneys general authority to bring civil actions on behalf of state residents

Here are a few tips to remain compliant under ARRA:

  • Understand what a breach is. A breach is any unauthorized acquisition, access, use or disclosure of protected health information that compromises the security or privacy of such information. A breach can be verbal, paper or electronic.
  • Be proactive. Identify risk areas and take steps to minimize or eliminate the risks.
  • Determine the likelihood of harm. The regulation permits organizations to asses likelihood of harm to determine if notification is required. It is important to retain information regarding how that decision was reached.
  • Notify members and HHS within timelines. Members must be notified within 60 days of when a breach is discovered. The timing to notify HHS is dependent upon the number of people impacted.
  • Review information on the HHS website. You can find lots of helpful information and review the HHS form to report breaches at the following website: www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule

EPSDT CODE CHANGES

Per MA Bulletin 99-10-06, effective June 13, 2010, CPT codes 99431 and 99435 for newborn inpatient screenings are being end dated. These codes have been replaced with 99460 and 99463, effective June 14, 2010.

CLAIM SUBMISSION GUIDELINES FOR MEDICARE ASSURED® HMO SNP MEMBERS ENROLLED IN HOSPICE

Per Medicare billing guidelines, claims for members enrolled in hospice must first be submitted to traditional Medicare to determine if the services are hospice related. If traditional Medicare determines that the services are not hospice related, then the claim can be submitted to Gateway Medicare Assured® HMO SNP for consideration.

Non-hospice related services billed on a CMS 1500 must be submitted with one of the two following modifiers:

GW – Services not related to hospice

or

GV – Attending physician not hospice

Non-hospice related services billed on a UB-04 must be submitted with a condition code – 07 – Treatment of non-terminal condition for hospice.

If a claim is received for a Gateway Medicare Assured® HMO SNP member, which is enrolled in hospice and does not contain either the appropriate modifiers or condition code, as outlined above, it will be denied with a D105 adjustment code. Upon receipt of a D105 denial, the claim will need to be submitted to traditional Medicare who will determine if the charges are hospice related. If a denial is received from traditional Medicare indicating that they have deemed the services unrelated to hospice, then the claim should be submitted back to Gateway Medicare Assured® HMO SNP with the appropriate modifiers or condition code to be reconsidered for payment.

Claims will not be adjusted based on a telephone call from a provider or facility to Provider Services. Gateway must receive a corrected claim within the established timely filing guidelines in order to be reconsidered for reprocessing.

SG MODIFIER CLAIMS PROCESSING CHANGE

Effective July 1, 2010, Gateway HealthSM has begun processing claims submitted with the SG (ASC Facility Service) modifier based on the rates established by the DPW MA Fee Schedule. Prior to July 1, 2010, codes billed by a hospital, either with or without the SG modifier, were paid at the higher SG modifier rate. This has been changed and the higher SG modifier rate will only be paid if the SG modifier is present on the claim. Please be sure to bill all codes with the appropriate modifiers to ensure correct reimbursement of your claims.

NEW CLAIMS MAILING ADDRESSES - REMINDER

Gateway's claims office is moving from Albany, NY to Harrisburg, PA, and as a result beginning September 5, 2010 all claims MUST be submitted to the new mailing addresses provided below for processing.

PA Medicaid
Mailing Address for Medical Claims and Referral Forms:
Gateway HealthSM
P.O. Box 69360
Harrisburg, PA 17106-9360

PA Medicare Assured® HMO SNP
Mailing Address for Medical and Behavioral Health Claim Forms:
Gateway HealthSM
P.O. Box 69359
Harrisburg, PA 17106-9359

Please be sure to educate your billing staff regarding this important change. The new P.O. Boxes will not be in service until September 5, 2010, so please do not begin sending claims to the new addresses until then. Claims and Referral Forms sent to the old Albany P.O. Boxes after September 5, 2010 will be forwarded to the new Harrisburg P.O. Boxes only through March 2011. Please be advised that submitting claims to the incorrect mailing address may result in a delay in claims processing or possibly Gateway not receiving the claim at all.

In addition to the above changes Gateway will be issuing new Member ID Cards to all existing members, which will include this new address information, beginning in August, 2010. BOTH the Gateway PA Medicaid and Medicare Assured® HMO SNP cards will be white with the red heart and bridge in the background. The Gateway PA Medicaid cards will no longer be green or yellow like they are today.

If you have any questions regarding any of these changes please contact Gateway's Provider Services Department at 1-800-392-1147 Monday through Friday between 8:30am and 4:30pm or your Provider Relations Representative.