Update A Newsletter for MassHealth Providers DECEMBER 2005 / VOLUME 5 / ISSUE 5 Inside This Issue Revised Regulations for Family Planning Agency and Acute Inpatient Hospitals 2 Moving “Dual Eligibles” to Comprehensive Drug Coverage with Medicare 2 New on mass.gov/masshealth 2 Automated Solutions: PCSS 3 Checking into the Provider Library 3 Mass.gov/masshealth for All Your MassHealth Transactions 3 Submitting Acute Inpatient Hospitals Claims for Clinical Review 3 MassHealth Reminders 4 New Informative E-mail About Casemix Errors for Nursing Facility Providers Effective November 1, 2005, nursing facility providers began receiving e-mails detailing casemix error information. This e-mail is in addition to the e-mail from MassHealth to notify facilities when a casemix submission has been received. To comply with the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements, the casemix error e-mails are sent via our secure e-mail application. The first time the e-mail is received, the user is directed to a link and prompted to complete a one-time registration. Access to the secure e-mails is granted once a valid user name and password are created. On the first business day after the successful technical processing of a casemix submission, nursing facilities receive a second e-mail if any of the data was unable to be posted to MassHealth’s claims processing system. Facilities receive an e-mail indicating the reason data was not posted. Some typical reasons include the following: There was no long-term-care segment found for the MassHealth member for whom casemix information was submitted. The member for whom casemix information was submitted was not found on the file, indicating that an incorrect MassHealth member identification number was included on the Management Minutes Questionnaire (MMQ). A casemix segment was not found, which occurs if a Significant Change MMQ is submitted when there is no casemix information on file to be changed. After nursing facilities receive this detailed error information, they are able to begin to take corrective action immediately. They no longer need to wait for a remittance advice (RA) and claim denials before taking the appropriate corrective action. The information in the e-mail will also reduce the number of calls that facilities need to make to MassHealth Customer Service or the Casemix Unit. The detailed error e-mail contains the submitted MassHealth member ID (RID), the member name (when the RID is valid), and the error that prevented the update from being successful. If there are multiple errors, the errors are all reported in a single e-mail. MassHealth is excited to bring this new business process solution to providers. As mentioned before, this new service was introduced in November. For more information, please view the October 2005 message text located in the Provider Library at www.mass.gov/masshealth. Improvements in the MassHealth Dental Program Continue Effective for dates of service beginning November 14, 2005, MassHealth has eliminated the prior-authorization (PA) requirement for certain services and reduced the limitations for certain other services. Elimination of PA requirements for: Oral/facial photographic images (D0350) Removal of impacted tooth – soft tissue (D7220) Removal of impacted tooth – partially bony (D7230) Fabrication of athletic mouthguard (D9941) Reduced limitations for preventive services for: Periodic oral examination (D0120) twice per 12-month period, instead of once per 12-month period Oral prophylaxis (D1110 and D1120) twice per 12-month period without PA, instead of once every six months without PA Topical application of fluoride (D1203) without limitations or PA for members under age 21 Sealants (D1351) for primary or permanent first and second non-carious molars, first and second non-carious bicuspids (premolars) with deep pits and fissures, and non-carious third molars with deep pits and fissures for members under age 21, instead of limiting this service to members aged 5 through 20 for permanent first molars and second molars only Additional program changes for: Other nonemergency medically necessary treatment will be covered during the same visit as an emergency-care visit. That is, other nonemergency service codes may be billed in conjunction with the code for emergency visit—D9110 (palliative treatment). Continued on page 4 page 1 Revised Regulations for Family Planning Agencies and Acute Inpatient Hospitals MassHealth has revised specific regulations related to family planning agencies (FPA) and acute inpatient hospitals (AIH). This information was sent to affected providers in October 2005, in transmittal letters FPA-39 and AIH-40. Transmittal Letter FPA-39 Overview Effective for dates of service on or after November 1, 2005, FPA regulations have been updated to: reflect current standards; provide coverage for HIV pre- and post-test counseling in family-planning agencies; use American College of Gynecology Standards to determine frequency of covered Pap smears; increase the provider recordkeeping requirement from four to six years; and eliminate specific language about Norplant. Implantable contraceptives remain covered services. Also, service code revisions have been added to Subchapter 6. Please refer to Transmittal Letter FPA-39 in the online Provider Library on the MassHealth Web site for additional information. Transmittal Letter AIH-40 Overview Effective for dates of service on or after October 1, 2005, MassHealth has revised regulations for acute inpatient hospitals to restore coverage of all adult acute inpatient hospital services provided after 20 days. For more information about these changes, please refer to Transmittal Letter AIH-40 in the online Provider Library. Moving “Dual Eligibles” to Comprehensive Drug Coverage with Medicare As originally mentioned in the October 2005 Update, effective January 1, 2006, Medicare will become the primary payer of prescriptions for those members covered by both MassHealth and Medicare. These dual-eligible MassHealth members are able to change their drug plan at any time. The Centers for Medicare & Medicaid Services (CMS) are taking action to ensure that members eligible for both Medicare and Medicaid are aware of the upcoming changes in their prescription-drug coverage plans. One such initiative by CMS is that of direct mailings. In October, affected members received a letter informing them of the drug plan they will be enrolled in if they take no action before January 1, 2006. Members were also mailed a Medicare & You booklet to further describe the drug plans. In addition to these resources, the individual prescription drug plans will be mailing enrollment materials (such as a list of covered drugs and the in-network pharmacies) to the eligible members or beneficiaries in their plan. Beneficiaries can learn more information on the various coverage options by calling 1-800-MEDICARE, or visiting the Medicare Web site at www.medicare.gov. Medicare has a trained nationwide network of outreach and enrollment partners qualified to assist beneficiaries and address their questions and concerns. Other considerations for beneficiaries when evaluating different coverage options include whether or not a premium is applicable for the plan. If a beneficiary chooses a plan with a premium, the plan is required to inform them that they are responsible for some of the premium and that zero-premium options are available. Medicare does not expect many beneficiaries to enroll in a drug plan with a premium since all zero-premium plans provide comprehensive coverage with convenient access to all medically necessary treatments. Providers should note that special rules apply for MassHealth members who are also enrolled in one of the following plans: Medicare Advantage Plans, Program for All-Inclusive Care for the Elderly, Senior Care Organization, or a drug plan offered by a past or current employer or union. MassHealth suggests that those affected members contact their assigned plan for details. If you have additional questions, or would like to find out more information about the new Medicare prescription-drug plans, please visit the Medicare Web site at www.medicare.gov, or call 1-800-MEDICARE. You may also call SHINE (Serving the Health Information Needs of Elders) at 1-800-AGE-INFO (1-800-243-4636), or the MassMedLine at 1-866-633-1617. New on mass.gov/masshealth: Special Handling Instructions for Patient Paid Amounts Certain MassHealth members receiving long-term care contribute toward the cost of their health care through a monthly dollar amount called a patient paid amount (PPA). A PPA can be applied only to claims paid by MassHealth during the month in which the member’s income is received. The PPA is displayed on the claim and usually deducted during claims processing. Generally, once the PPA is deducted from the claim, no further action is required. However, there are some circumstances in which special handling procedures must be followed in order to resolve paid claims where the PPA is not deducted. Scenario A provider receives a payment on a Medicare/MassHealth crossover claim and the PPA has not been deducted; or the member is in a nursing facility, receiving hospice services. The hospice receives a payment on the claim and the PPA is not automatically deducted. Resolution Return of the entire PPA to MassHealth: In cases where the PPA is less than, or equal to, the amount paid by MassHealth, the provider must submit a check for the entire PPA, along with a brief note of explanation and a copy of the corresponding page of the MassHealth Remittance Advice (RA) to the following address: MassHealth Benefit Coordination and Recovery P.O. Box 85 Essex Station Boston, MA 02112 Return of a partial PPA to MassHealth: In cases where the PPA is greater than that amount paid by MassHealth, the provider should return only the amount of the overpayment by MassHealth. Continued on page 4 page 2 Automated Solutions: Provider Claim Submission Software (PCSS) Using no-cost MassHealth software, providers can bill electronically AND reduce the possibility of data-entry errors. You will have more control over your claim submissions and you will be able to submit your claims at your convenience. To support the submission of electronic claims, MassHealth offers a free software program called Provider Claim Sub-mission Software (PCSS). We are offering training on how to use this software. There are several options for trainings, including in-person and Web-cast sessions. Here is what you need to do: Sign Up Sign up for training by going to www.mass.gov/masshealth, and click on the “Information for MassHealth Providers” link and then select “MassHealth Provider Training.” New sessions for providers are being scheduled for the upcoming months, so be sure to check back often to see the latest posting. Download PCSS Download PCSS software from www.mass.gov/masshealth/pcss. If you prefer the software on CD, call MassHealth Customer Service at 1-800-841-2900 to arrange for a copy to be sent to your mailing address. If the scheduled trainings are not convenient or available, MassHealth can accommodate your needs. Please contact MassHealth by e-mail at providersupport@mahealth.net or fax to 617-988-8974. MassHealth will contact you once the request has been received and reviewed. Our Customer Service team looks for-ward to working with you in your transition to electronic billing. We are here to support you through training, testing, and claim submission. If you have any questions, please contact MassHealth Customer Service at 1-800-841-2900 or e-mail providersupport@mahealth.net. Checking into the Provider Library The Provider Library is a tool available on the Web that contains many informative documents for providers. In the Provider Library, you can find previous Update newsletters, transmittal letters, provider bulletins, remittance advice message texts, provider forms, Clinical Practice Guidelines for MassHealth providers, and MassHealth Guidelines for Medical Necessity Determination. Also, in upcoming weeks, provider manuals will be available for viewing and downloading from the library. To access the Provider Library, click on the “MassHealth Regulations and Other Publications” link on the www.mass.gov/masshealth home page, then select “Provider Library.” Sign up to receive e-mail notifications any time new bulletins, transmittal letters, regulations, and this newsletter get posted on www.mass.gov/masshealth. Stay up-to-date with MassHealth by going to our Provider Library to sign up today! Mass.gov/masshealth for All Your MassHealth Transactions Many of our providers are already familiar with the great benefits of electronic claim submission through the mass.gov/masshealth Web site. When you electronically submit your claims, MassHealth receives your claim faster, and you avoid the hassle of mail delivery. In addition, only through electronic submission will you receive confirmation in the 997 acknowledgement that your file was received by MassHealth. Save more time and reduce paperwork by also taking advantage of our other online transactions, such as viewing and downloading your 835 remittance advice (RA) and Supplemental RAs, and your submission history for up to six months. You can go online 24 hours a day, seven days a week, to access any of these transactions when you take advantage of the automated solutions offered through www.mass.gov/masshealth. Submitting Acute Inpatient Hospital Claims for Clinical Review MassHealth would like to remind acute inpatient hospital providers to follow the instructions outlined in Acute Inpatient Hospital Bulletin 116 (August 2000) and send claims for clinical review when: the medical record supports that the member was admitted for a non-behavioral medical treatment; the principal diagnosis upon discharge is behavioral; and the claim is for a MassHealth member enrolled on the service date(s) with the Massachusetts Behavioral Health Partnership (MBHP). For claims that meet the above criteria, and may have also denied for error 539 (“Managed Care Service Should Be Paid By RMC”), acute inpatient hospitals should now send the claim, other documentation, and the medical record to the following address: Executive Office of Health and Human Services Office of Medicaid Attn: Utilization Management-Clinical Review 600 Washington St, CTC RM 310 Boston, MA 02111. If you have any more questions about this information, please review the October 25, 2005, message text, or Acute Inpatient Hospital Bulletin 116, located in the “Provider Library” under the “Information for MassHealth Providers” link. page 3 Improvements in the MassHealth Dental Program Continue Continued from page 1 The minimum number of radiographs required for a full-mouth series (D0210), has been reduced from 12 periapical and two posterior bitewing radiographs to 10 periapical and two posterior bitewing radiographs. Regulations at 130 CMR 420.425(B) will be updated to indicate that four or more surface composite restorations are allowed on a single anterior or posterior tooth, as reflected in the service codes currently in effect (D2335 and D2394). Accordingly, as reflected in Subchapter 6, MassHealth providers are not limited to the maximum allowable amount for two-surface restorations for anterior teeth (D2335) or to the maximum allowable amount for three-surface restorations for posterior teeth (D2394). Elimination of the restriction on the number of teeth on which root canal therapy (D3310, D3320, and D3330) may be performed during a period of treatment. Prior-authorization requirements still apply to root canal therapy. For more information, view the November transmittal letter (TL-DEN 71) on the Web, call MassHealth Customer Service at 1-800-841-2900, or e-mail your inquiry to providersupport@mahealth.net. New on mass.gov/masshealth: Special Handling Instructions for Patient Paid Amounts Continued from page 2 The balance of the PPA should be returned to the patient. Scenario A member is in two facilities during the same month. Resolution Providers are reminded to coordinate with the other facility about the submission of claims and the PPA. The first facility must notify the second facility of the disposition of the patient-paid amount, and must issue a check to the second facility for the prorated amount. Do not return money to MassHealth. Scenario A long-term-care provider receives payment on a non-crossover claim with no PPA deducted because the member’s file shows $0 PPA. After the claim is processed, the PPA was assigned and added to the member’s file. Resolution Do not return a check. Submit an adjusted claim to the following address: MassHealth Attn: Adjustments P.O. Box 9118 Hingham, MA 02043 Include the transaction control number (TCN) from the original payment. For electronic claims, use the “void and replace” transaction. Scenario A member has primary insurance including Medicare and MassHealth. A provider receives full payment for a claim from the primary insurance. Resolution Do not bill MassHealth and do not send the PPA to MassHealth. The provider must return the PPA directly to the member. A flyer is available for viewing and downloading in the “Billing Tips” section of the mass.gov/masshealth Web site. The “Billing Tips” section is located in the “Provider Library” section found in “MassHealth Regulations and Other Publications.” Additional MassHealth billing instructions are found in Subchapter 5 of your provider manual. MassHealth Reminders All previously run message texts are available in the online Provider Library. 90-Day Waivers As posted in the message for the September 27, 2005, remittance advices, all 90-day waiver requests should be mailed to the following address: MassHealth Attn: 90-Day Waivers P.O. Box 9118 Hingham, MA 02043 Any requests mailed to 600 Washington will be forwarded to the Hingham address. An updated transmittal letter conveying this information will be posted in the Provider Library on the mass.gov/masshealth Web site in the upcoming weeks. Vision Care Providers On the September 20, 2005, remittance advice, vision-care providers were reminded that modifier YX was discontinued on February 1, 2003. Any claims billed with this modifier will be denied. For all dates of service on or after this date, please use modifier 52 for eye exams performed without cycloplegic or mydriatic drops, or for additional patients seen in a nursing facility. Reminder to Send Claims to the Correct Address MassHealth reminds providers that the correct address for sending paper claims and correspondence is: MassHealth P.O. Box 9118 Hingham, MA 02043 Do not send mail to the previous Somerville, MA address (P.O. Box 9101), or 55 Summer St, Boston, MA. MassHealth contact information is available in the revised Quick Reference Directory on the Web at www.mass.gov/masshealth under “Information for MassHealth Providers” and then “MassHealth Customer Service for Providers.” E-mail: providersupport@mahealth.net Web: www.mass.gov/masshealth MassHealth Customer Service P.O. Box 9118 Hingham, MA 02043 Phone: 1-800-841-2900 Fax: 617-988-8974 page 4