URGENT REMINDER: Dual-Use Periods Are Ending for ADA and CMS-1500 Claim Forms; New Forms Must Be Used [Web Announcement 729]
Ordering, Prescribing and Referring Provider Enrollment Requirement to be Implemented August 18, 2014 [Web Announcement 774]
Attention Pharmacies: Update Regarding Implementation of Claims Adjudication Process to Validate Ordering, Prescribing and Referring (OPR) Practitioners [Web Announcement 799]
July, August and September 2014 Provider Training [Web Announcement 761]
Nevada Medicaid and Nevada Check Up News (Second Quarter 2014 Provider Newsletter) [Read]
Provider Web Portal Quick Reference Guide (Updated April 16, 2012)
Web Announcement 799
Attention Pharmacies: Update Regarding Implementation of Claims Adjudication Process to Validate Ordering, Prescribing and Referring (OPR) Practitioners
In order for Medicaid to reimburse for services or medical supplies that require a provider’s order, prescription or referral, the Affordable Care Act (42 CFR Parts 405, 447, 455, 457 and 498) requires that the ordering, prescribing or referring provider be enrolled in Medicaid. Compliance with this requirement necessitates future changes to Nevada Medicaid claims and provider enrollment processes. The Division of Health Care Financing and Policy (DHCFP) will implement this new requirement on October 29, 2014
How will this affect you?
The practitioner writing a prescription for a Medicaid Fee-for-Service recipient needs to be enrolled as a full Medicaid service provider or an OPR-only provider by October 29, 2014.
To comply with these provisions, Nevada Medicaid, with the implementation of the OPR claims adjudication process, will verify both the presence of a valid practitioner National Provider Identifier (NPI) and the practitioner’s enrollment in Nevada Medicaid as either a full Medicaid service provider or an OPR-only provider. Pharmacy claims will post a soft edit 45 days prior to October 29, 2014, informing the billing provider if the NPI for the prescriber is not present or if the prescriber is not enrolled in Nevada Medicaid. Effective on and after October 29, 2014, if the prescriber does not have prescriptive authority or if the prescriber is not enrolled as a full Nevada Medicaid service provider or an OPR-only provider, then the edit will result in a claim denial. There will be a 30-day override period starting October 29, when the pharmacist may choose to override a denied claim for OPR. If a claim hits the soft edit, pharmacies should notify the recipient to contact their prescriber because after implementation their claims will deny.
Regarding the use of NPIs: Every prescriber must include their personal NPI on each prescription. Every pharmacy must accurately submit this prescriber NPI with each prescription claim. If a provider intentionally submits a claim with a prescriber NPI which they know to be inaccurate, they are committing a fraudulent act, and may be subject to administrative, civil and/or criminal actions.
For more information about the changes to billing and the new OPR provider enrollment category, call the Catamaran Technical Call Center at (866) 244-8554.
Web Announcement 798
Speech Pathologists May Bill CPT Code 92520 Effective September 1, 2014
Effective with claims submitted on or after September 1, 2014, provider type 34 (Therapy) specialty 29 (Speech Pathologist) may bill CPT code 92520 (Laryngeal function studies, i.e., aerodynamic testing and acoustic testing). Prior authorization is required. Modifier GN is required for prior authorization and billing.
Web Announcement 797
Urgent Announcement Regarding CMS-1500 (02-12) Paper Claims Submitted with Incorrect Diagnosis Pointers
CMS-1500 (02-12) paper claims submitted with incorrect diagnosis pointers that were processed October 28, 2013, through June 10, 2014, have been reprocessed. Providers saw both a debit (DR) and a credit (CR) for each of the affected reprocessed claims on remittance advices dated August 15, 2014.
Reminder: Valid ICD-9 diagnosis codes and/or principal diagnosis codes are required on all paper and electronic CMS-1500 (02-12) claims. On paper claims, diagnosis pointers are required in Field 24E when diagnosis codes are entered in Field 21.
Web Announcement 796
Attention Provider Types 20 and 43: Pathology Claims Denied with Edit Code 0825
Claims with dates of service September 16, 2013, through November 10, 2013, for pathology procedure codes 88304, 88305, 88307, 88311, 88312, 88321 and 88160 submitted by provider types 20 (Physician, M.D., Osteopath) and 43 (Laboratory, Pathology Clinical) that denied with edit code 0825 (once in a lifetime service) in error will be automatically reprocessed. The adjudication of any affected reprocessed claims will be reflected on remittance advices dated August 29, 2014.
Web Announcement 795
Medicaid Services Manual and Nevada Check Up Manual Updated
Changes to the Medicaid Services Manual (MSM) Chapter 400 (Mental Health and Alcohol/Substance Abuse Services) and the Nevada Check Up (NCU) Manual, Chapter 1000, were approved at a Division of Health Care Financing and Policy (DHCFP) Public Hearing held on August 14, 2014, and are effective September 1, 2014.
Please review the updated MSM Chapter 400 and the NCU Manual on the DHCFP website. The schedule and agendas for future hearings are on the DHCFP’s Public Notices webpage.
Web Announcement 794
Attention Provider Type 39: Adult Day Health Care Billing Per Diem vs. Unit
Providers are responsible for requesting the appropriate number of days or units the recipient requires for attendance. This may be at the daily rate or the unit rate, but not both in the same day.
If a recipient is expected to be in attendance full-time, which is six (6) or more hours per day, the daily rate will be utilized. If the recipient is expected to be in attendance less than six (6) hours a day, the unit rate should be utilized.
Should the absences of the recipient become more frequent or the needs of the recipient change, the ADHC provider may request a new prior authorization for the unit rate. A change to the unit rate is required if the recipient attendance has been less than six (6) hours a day for ten (10) days within a two-week period. When the unit rate is authorized, the provider must bill for the exact number of units the recipient is in attendance. The maximum number of billable units per day is 24 units.
Web Announcement 793
Nursing Facility Tracking Form
Nursing facilities are instructed to submit a Nursing Facility Tracking Form (available at: https://dhcfp.nv.gov/pdf%20forms/NFTF%20Confirmation%20Page.pdf) for any Fee-For-Service Medicaid recipient, including those on a waiver, at the date of admission. For recipients who are currently enrolled in a Managed Care Organization, the Nursing Tracking Form is required no later than day 46 of the stay. The Medicaid Services Manual will be updated accordingly. Tracking Form instructions are available on the DHCFP Forms webpage at: https://dhcfp.nv.gov/nursing.htm
Web Announcement 792
PayerPath Claim Submission Training for September 2014
The HP Enterprise Services’ Electronic Data Interchange (EDI) department has scheduled virtual room training sessions for providers who have recently signed up to use PayerPath for their Nevada Medicaid claim submissions. This training will cover claim set up, submission, reviewing your claims, reporting and remittance advice review.
In order to participate in the training, you will need to select a date from the calendar below for the claim form you use and send in your request with your name, National Provider Identifier (NPI) and contact information to the following email address: firstname.lastname@example.org. Please send in your request at least 5 days prior to the training you have selected as space is limited. If you have any questions, please call the EDI department: (877) 638-3472, option 2, option 0 and option 3.
A confirmation email will be sent to you with the conference line for the training as well as the link you will use to access the virtual room for the training session.
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*All times indicated are Pacific Time (PT).
Web Announcement 791
CPT Code 90644 (MenHibrix®) is FDA-Approved and is a Vaccines for Children (VFC) Vaccine
CPT code 90644 (MenHibrix® vaccine) was recently approved by the Food and Drug Administration (FDA). Effective with dates of service on or after June 1, 2014, the vaccine is provided free of charge to Vaccines for Children (VFC) providers for eligible recipients age 2 to 15 months.
CPT code 90644 is not reimbursed through Nevada Medicaid/Nevada Check Up. Providers who administer the vaccine must bill the administration code (CPT code 90460, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component) at the usual and customary charge and bill the vaccine (CPT code 90644) at a zero dollar amount.
Web Announcement 790
Attention Provider Types 20, 24 and 77: Pediatric Enhancement-Surgical Services Claims Reprocessed
Update to Web Announcements 751 and Web Announcement 769: Rates for Pediatric Enhancement-Surgical Services codes for provider type (PT) 20 Physicians, PT 24 Certified Nurse Practitioner and PT 77 Physician Assistant have been updated in the Medicaid Management Information System (MMIS) effective July 1, 2013. Claims with dates of service on or after July 1, 2013, and processed before March 16, 2014, with the previous rates have been reprocessed. The adjudication of the reprocessed claims appears on remittance advices dated August 15, 2014.