Web Announcement 902
Update Regarding 2015 New CPT, HCPCS and ADA Codes
Update to Web Announcement 882: Effective March 9, 2015, rates and prior authorization (PA) requirements for the new 2015 CPT, HCPCS and ADA codes have been updated in the Nevada Medicaid Management Information System (MMIS). Providers are reminded to use the appropriate 2015 codes, when applicable, on claims with dates of service on or after January 1, 2015. Claims with the 2015 codes that denied with edit codes 0210 (No fees found on file) and/or 0309 (Services not covered) and/or 0148 (Rendering provider is not certified to perform procedure) because the rates and PA requirements were not updated for the new covered codes in MMIS will be automatically reprocessed with no further action required by providers. The results of the reprocessed claims will appear on remittance advices dated April 3, 2015.
Web Announcement 901
Attention Inpatient Provider Types 11 and 75: Cesarean Section and Vaginal Delivery Procedures Cannot Be Billed on the Same Claim
Effective with claims with dates of service on or after February 16, 2015, hospital claims for Cesarean section procedure codes and vaginal delivery procedure codes on the same claim that were being cutback inappropriately will now deny with edit code 0643 (Cannot combine vaginal with C-section procedures). Cesarean section and vaginal delivery procedures cannot be billed on the same claim.
Web Announcement 900
Pharmacy Claims Payments to be Delayed One Week
Point of Sale (POS) pharmacy claims submitted the week of March 16, 2015, did not process due to a system issue. Payments for the week of March 16 that would normally pay on remittance advices dated March 27 and payments for the week of March 23 will be processed together and will be reflected on remittance advices dated April 3, 2015.
Web Announcement 899
Attention Provider Type 12: Reimbursement for ESRD Services Changing to a Bundled Prospective Payment Rate under New Provider Type 81
Effective April 6, 2015, in-state and catchment area Nevada Medicaid providers currently enrolled as provider type 12 (Hospital, Outpatient) will be automatically enrolled as a provider type 81 (Hospital Based ESRD), with no action required by providers, in order to bill outpatient ESRD services. All other out-of-state hospital providers that offer outpatient ESRD services will be required to enroll as a provider type 81.
Effective with claims with dates of service on or after April 6, 2015, hospital providers must bill outpatient ESRD services under the new provider type 81. Any hospital based ESRD services not billed with provider type 81 will be denied. Provider type 12 will no longer be reimbursed for hospital based outpatient ESRD services.
Provider type 81 must bill ESRD services using the following codes:
- CPT code 90945 (Dialysis procedure other than hemodialysis, with single evaluation by a physician or other qualified health care professional)
- CPT code 90999 (Unlisted dialysis procedure)
In addition, provider type 81 may bill CPT code 90688 (Influenza virus vaccine).
Pursuant to the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), Medicaid changed the process for its reimbursement of dialysis services to facilities to a bundled prospective payment system (PPS). Codes 90945 and 90999 are reimbursed per the bundled PPS and will include all treatment associated with ESRD services, with the exception of specific drugs identified by National Drug Codes (NDCs). Any drugs administered that are not included in the bundled PPS must be billed by NDC. For a list of drugs included in the PPS, refer to the CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 2134. For more information regarding the new reimbursement system, please refer to Section 153(b) of the MIPPA and the Code of Federal Regulations Title 42 Part 413.171.
The rates for PT 81 for CPT codes 90945, 90999 and 90688 will be available on the DHCFP Rates Unit webpage by April 6, 2015.
For any questions, please contact the HP Enterprise Services Customer Service Center at (877) 638-3472.
Web Announcement 898
Primary Care Physician (PCP) Rate Increase Program Extended through June 30, 2015
Update to Web Announcement 865: The Division of Health Care Financing and Policy (DHCFP) recently submitted a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) requesting to extend the Primary Care Physician (PCP) rate increase program through June 30, 2015.
DHCFP has received notification that CMS has approved the SPA.
It is anticipated that the first quarter payments for Calendar Year (CY) 2015 will be processed in April 2015.
Web Announcement 897
Prior Authorizations and Billing for Day Treatment Services (H2012) Effective April 1, 2015
Please be advised that providers who did not submit a Day Treatment Model or whose model was not approved and has been denied for not meeting policy criteria per Medicaid Services Manual (MSM) Chapter 400, Attachment A, Policy #4-01 through #4-03, will no longer be reimbursed for Day Treatment services, HCPCS code H2012, effective April 1, 2015. In order to be eligible to bill Day Treatment services past April 1, providers will be required to enroll as a Provider Type 14, Specialty 308 and have an approved Day Treatment Model. Effective April 1, 2015, provider types 26 and 82 can no longer bill Day Treatment services.
Prior authorizations for day treatment services will be end dated effective March 31, 2015, for any provider that does not have an approved day treatment model. Other authorized services will be unchanged.
The Billing Guides for Provider Types 14 and 82 and the Enrollment Checklists will be updated to reflect this change for Day Treatment. All prior authorizations for Day Treatment services must be submitted via the Provider Web Portal effective April 1, 2015. If you do not have access to the Web Portal, please contact HP Enterprise Services at (877) 638-3472, option 2, then 0 and 3.
The Day Treatment policy has been in effect since September of 2013. The Division of Health Care Financing and Policy (DHCFP) held various workshops prior to the implementation of the new enrollment procedures. DHCFP has worked diligently with providers in preparation for the change in enrollment process by providing Public Workshops, web announcements and technical assistance webinars.
If there are questions concerning the new process, please submit questions to email@example.com
Web Announcement 896
Payerpath Claim Submission Training for April 2015
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.
To participate in the training, please 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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||4 to 5 p.m.
*All times indicated are Pacific Time (PT).
Web Announcement 895
Update for Inpatient Hospital Provider Types 11 and 13: Temporary Concurrent Review Prior Authorization Process Discontinued Effective April 1, 2015
Update to Web Announcement 652: Effective April 1, 2015, hospital provider types 11 and 13 will no longer have the policy exception of an additional seven (7) calendar days from the last requested date of service to submit inpatient Medical Surgical and Behavioral Health requests for concurrent review. The process is reverting back to time frames per State of Nevada Policy; therefore, requests for concurrent review prior authorizations are to be submitted on/by or before the end date of the last requested date of service regardless of the status of the current/existing authorization. Providers are advised not to wait to request concurrent authorization based on a pending appeal. Please refer to Medicaid Services Manual Chapter 200, Section 203.1A.2.h.1.
Enhancements have been made to the Provider Web Portal to make the temporary measure unnecessary. Please review Web Announcement 868 and Web Announcement 760 regarding Provider Web Portal enhancements for prior authorizations.
Web Announcement 894
A Reason Code/Message will Appear on Remittance Advices when Claims are Cutback
Effective with claims processed on or after December 22, 2014, when claims are cutback for any reason, a corresponding reason code and message will also appear on remittance advices to assist providers in reconciling their claims. For example, recent claims that cutback for edit code 0640 (Maternity/Newborn stay allowed limit for vaginal or C-section) also received reason code 198 (Precertification/authorization exceeded).
Web Announcement 893
New Prior Authorization Form to be Required for Oxygen Equipment and Supplies
Effective April 1, 2015, the Nevada Division of Health Care Financing and Policy (DHCFP) will require a new specialized prior authorization form for all oxygen requests (equipment and supplies).
The new form will identify DHCFP’s policy requirements such as:
- Arterial blood gases or an oximetry reporting:
- PO2 Level of 60 mmHg or less on room air; or
- 80 mmHg or less on O2; or
- O2 saturation (sat) level of 89 percent or less; and
- Medical Necessity;
- Conditions of study (rest, sleeping, exercising, room air, on oxygen) (required).
- Children: 92 percent or less room air saturation, at rest.
- O2 sats must be performed within 60 days of requested dates of service.
For the complete list of oxygen requirements, please reference Medicaid Services Manual (MSM) Chapter 1300 (DME, Disposable Supplies and Supplements) at https://dhcfp.nv.gov/Index.htm. There will be NO changes to policy located within MSM Chapter 1300, Appendix B, Forms and Documentation Requirements.
The new prior authorization request form for Oxygen Equipment and Supplies (FA-1C) will be located on the Provider Forms webpage (https://www.medicaid.nv.gov/providers/forms/forms.aspx under Prior Authorization Forms) by the April 1, 2015, effective date.
Web Announcement 892
EPSDT Screenings for All Children Include Autism Spectrum Disorder
The Centers for Medicare & Medicaid Services (CMS) released guidance on July 7, 2014, indicating all children must receive Early Periodic Screening, Diagnostic and Treatment (EPSDT) screenings designed to identify health and developmental issues, which include Autism Spectrum Disorder (ASD). Currently, Nevada Medicaid and Nevada Check Up cover developmental screens (CPT code 96110) which are provided by Special Clinics (provider type (PT) 17), Physicians (PT 20), Advanced Practice Registered Nurses (PT 24) and Physician’s Assistants (PT 77).
Web Announcement 891
Changes for Pharmacies and Prescribers of Psychotropic Medications for Children and Adolescents (Updated March 24, 2015)
Psychotropics for Children and Adolescents:
- The Nevada Division of Health Care Financing and Policy (DHCFP) discourages polypharmacy. Polypharmacy is defined as the prescribing of more than one medication from the same class or prescribing three or more psychotropic medications from different drug classes. (Medicaid Services Manual Chapter 1200*)
- DHCFP does not pay for medications which are prescribed outside the Federal Drug Administration (FDA) guidelines unless that usage is supported by peer-reviewed literature.
UPCOMING CHANGES EFFECTIVE APRIL 1, 2015:
- A Letter of Medical Necessity (LMN) will be required for prior authorization (PA) requests outside FDA guidelines for medications prescribed to children ages 0-5. A template for the LMN can be found on the Provider Forms webpage (https://www.medicaid.nv.gov/providers/forms/forms.aspx under Pharmacy Forms) and on the Pharmacy Forms webpage.
- Prescribers will also be required to submit peer-reviewed citations justifying all requests outside FDA guidelines. This will be accompanied by the LMN and the PA form. To search for FDA approved ages and indications for use, please access the link below:
- The Psychotropic Agents for Children and Adolescents prior authorization form (FA-70) has been updated to include Target Symptom/Side Effect, all psychotropics the recipient is taking, and Multi-Agent Criteria. Use the updated form on and after April 1, 2015.
- Please be sure to review and complete the new prior authorization form carefully.
For any questions regarding this announcement please contact Catamaran at 855-455-3311.
*There are NO changes to policy located within MSM Chapter 1200.
Please see the full Web Announcement 891 for lists of medications considered to be psychotropic medications for purposes of the PA and LMN requirement.