October 2007 Issue of Update Submission Procedure for Third-Party-Liability and Medicare Claims 2 Changes to Tamper-Resistant Prescription Requirement 3 MassHealth Reminders 3 and 4 Provider Association Day The Provider Association Day held in late July was a great opportunity to learn more about what’s going on at MassHealth, along with other Massachusetts health-care programs. Speakers from MassHealth Operations, the Commonwealth Care program, the New Medicaid Management Information System (NewMMIS), the new MassHealth Wellness Program, and the MassHealth Provider Outreach Team all contributed to the informative session. MassHealth would like to thank the associations that attended this event. Communication with provider associations is a critical component of disseminating the changes in MassHealth billing and policy that impact providers’ billing procedures. We ask associations to share with their constituency the valuable information presented at this event. If you were unable to attend this meeting, read on to learn about the topics and features, such as NewMMIS, the wellness program, and MassHealth initiatives most relevant to MassHealth providers. The project update on NewMMIS brought providers up to speed on what they can expect once NewMMIS is implemented in the summer of 2008. After highlighting the main benefits and objectives of the new system, along with introducing some of the system’s features, such as real-time claims adjudication and the creation of the provider online service center, attendees had the opportunity to ask questions of the NewMMIS project team. In September and October, MassHealth also offered statewide educational forums with the main objective of providing MassHealth providers with the information and resources they will need to ready themselves for the implementation of NewMMIS. As the implementation date approaches, MassHealth will continue to offer education and training forums. Our professional associations continue to play a significant role in disseminating information regarding these education opportunities, so please stay tuned to www.mass.gov/masshealth for the latest information and details on future opportunities. New Wellness Program MassHealthy, the new Wellness Program, was introduced as an initiative to promote the alignment of education and incentives supporting healthy lifestyle choices for MassHealth members. The mission of the program is to encourage and empower members to maintain healthy lifestyle practices. The program focuses on the following health issues: tobacco cessation; diabetes screening for early detection; teen-pregnancy prevention; and cancer screening for early detection. For more information on this program, review the program page online at www.mass.gov/masshealth/wellness. Provider Outreach Summary The MassHealth Provider Outreach team discussed provider initiatives such as the recredentialing project, national provider identifier (NPI) implementation, and changes to paper billing procedures. MassHealth would like to extend a sincere thank you to the associations for their assistance in aiding in the success of phase one of the recredentialing initiative. As the second phase of the initiative begins, we will continue to need the support and assistance of our associations in getting the message out to providers and informing us of any feedback or questions they receive from the MassHealth provider community. NPI is moving along, with more and more providers receiving and sharing their NPI with MassHealth. MassHealth has issued several publications on NPI and its affects on provider billing, and we ask associations to remind their members that www.mass.gov/masshealth/npi is a great resource to address their NPI questions. We thank all the associations that were able to attend the forum meeting in July, and encourage associations’ attendance and participation in future sessions. These meetings are for you to ask the questions and cover the topics that are most important to your association members. Don’t miss these opportunities to be heard--make sure you attend the next Provider Association Day. Dealing With Rejected Claims A transaction control number (TCN) is your best bet to save time when dealing with claim rejections. Every claim you submit to MassHealth on paper is automatically issued a TCN, as indicated at either the top or bottom of the rejection letter. Rejected claims usually are returned to the provider with a rejection letter for one of three main reasons listed below. It is incorrect or incomplete. For example: the national provider identifier (NPI) is invalid or missing; the claim is for an amount exceeding $999,999.99; or the claim form is missing. It has unacceptable forms or attachments. For example: negative charges are listed on the claim form; the claim form used is not an acceptable form for billing MassHealth; and the attachment submitted is not the standard 8½” x 11” size. It is illegible. For example: the ink used on a handwritten claim is not black; or standard-size font and black ink was not used for printing on the claim. Required forms are missing or incomplete. This reason usually applies only to Medicare/Medicaid crossover claims that are submitted without a complete or correct Explanation of Medicare Benefits (EOMB), CMS-1500, or other another required attachment. Sometimes claims are rejected for another reason, which is specified in the “Other” category. If a claim is rejected for this reason, it will be explained in the letter. Standard rejected reasons for Medicare/Medicaid crossover claims that are returned for the provider with a rejection letter are usually for one of the reasons listed below: required forms are missing; or the CMS-1500, EOMB, or other attachment was incorrectly completed. Find Your TCN If your claim was rejected, MassHealth sent you a rejection letter listing the TCN of the rejected claim. This number is the 12-digits listed in grey at the very top or bottom of the letter. Submitting a Corrected Claim Once you have corrected your claims as requested in the rejection letter, and it is within 90-days from the original date of service listed on the claim, you may resubmit the claim following standard procedures without requesting a 90-day waiver. Please refer to the standard correction procedures outlined in Subchapter 5, Part 7 of your MassHealth provider manual. Submitting Your Corrected Claims After 90 Days If submitting the corrected claim more than 90 days after the original date of service listed on the claim, you will need to submit the claim to the 90-Day Waiver Unit for a 90-day waiver request. This request requires you to prove timely filing of the original claim, which can be supported by attaching a copy of the rejection letter with the TCN listed at the top. Providers should keep a copy of any rejection letters received from MassHealth. Failure to include a copy of this letter, or to correctly reference the TCN of the rejected claim, will cause time delays and a possible denial in the processing of the resubmitted claim. When submitting the corrected claim to the 90-Day Waiver Unit, you will need to include a cover letter, a copy of the corrected claim, and a copy of the rejection letter. For more information on these procedures, refer to the billing-tip flyer, Submitting a 90-Day Waiver Request. You can access billing-tip flyers from the Billing Information link under the Customer Service for MassHealth Provider section in the Information for MassHealth Providers link on www.mass.gov/masshealth. Submission Procedure for Third-Party Liability Claims MassHealth has been receiving Explanations of Benefits (EOBs) and Explanations of Medicare Benefits (EOMBs) for third-party-liability (TPL) claims that do not contain all of the information clearly and legibly printed. As a result, we have had to return these claims unprocessed. We would like to remind providers of the standards of submission as they relate to TPL and Medicare crossover claims, and how to correct and resubmit denied claims. How to Submit a TPL Claim to MassHealth on Paper Attach to the claim form a photocopy of the other insurance carrier’s notice of final disposition. The dates of service, provider name, and patient’s name on the notice of disposition must correspond to the information on the MassHealth claim form. If the carrier’s notice of final disposition, EOB, notice of rejection, or some other explanation on the carrier’s letterhead does not itemize payment for each service provided or reduces payment by a nonitemized deductible amount, estimate the portion of the total benefit amount that was paid for each service on that notice. Enter in the Other Paid Amount field of the MassHealth claim form the amount that was paid by the other insurance carrier for each service. The other paid amount must include the contractual adjustment from the commercial carrier. The total for all the lines in the Other Paid Amount fields must equal the total benefit amount on the notice of final disposition, including the contractual amount. If submitting a photocopy of the EOB or EOMB, be sure that all information entered on the form (including the header, member details, and dates of service) is shown in its entirety, without any details or values missing or cut off. For additional directives on how to submit an original TPL claim within 90 days from the date of service, either on paper or electronically, refer to Subchapter 5, Part 8 of your MassHealth provider manual posted in the online Provider Library at www.mass.gov/masshealthpubs. Correcting Denied Claims If you submitted a TPL claim to MassHealth and it was denied, and if a TCN is required, you will need to resubmit the claim on paper. If a TCN is not required, you can resubmit a claim using the 837 transaction (see the December 2006 Feature of the Month for more information). A TCN must be included when the original claim was submitted within 90 days, and one or more of the following items are changing: service date; revenue code; and/or service code. Prepare a new claim form with the correct information and attach the EOB from the other insurer. Also include the reasons for the original claim denial, if applicable. Be sure the EOB submitted has all the information in its entirety; copies of EOBs and EOMBs with values missing or cut off will be returned to the provider. Submit the completed claim, attach the EOB, and send them to: MassHealth Attn: Resubmittals P.O. Box 9118 Hingham, MA 02043. For Medicare Crossover Denied Claims When submitting a Medicare crossover claim that was previously denied, please follow the above procedures, include the reason(s) for the original claim denial, and attach a copy of the EOMB. If submitting a photocopy of the EOMB, be sure that all information entered on the form (including the header, member details, and dates of service) is shown in its entirety. Also include the intermediary name in the header, with any other applicable details. For additional information, refer to the provider billing tips flyer, Corrective Action for Denied Paper Claims, or All Provider Bulletin 123. You can access the billing tips flyer from the Billing Information link under the Customer Service for MassHealth Provider section in the Information for MassHealth Providers link at www.mass.gov/masshealth. You can access All Provider Bulletin 123 from the Provider Library at www.mass.gov/masshealthpubs. MassHealth Reminders Using the New MassHealth Claim Forms Providers are reminded that MassHealth no longer accepts paper claims submitted on the old paper claim forms. All paper claims submitted to MassHealth after September 1, 2007, must be submitted on the claim forms revised in 2007. The updated forms include entries for National Provider Identifier (NPI) and taxonomy codes. Any claims submitted on the outdated forms after this deadline will be returned to you unprocessed. You may order the revised paper claim forms from the Order Provider Publications link on www.mass.gov/masshealthpubs. Changes to Tamper-Resistant Prescription Requirements Six-Month Delay for Tamper-Resistant Prescription Requirements Congress passed the health-care extender bill H.R. 3668, which, among other things, delays by six months the implementation of the tamper-resistant prescription law, scheduled to go into effect on October 1, 2007. The new effective date is now April 1, 2008. Due to this new legislation, MassHealth will not require tamper-resistant prescriptions until the federal requirements become effective on April 1, 2008. MassHealth issued All Provider Bulletin 167: Requirement for Tamper-Resistant Written Prescriptions (September 2007), stating that these requirements would start on Oct, 1, 2007. Another bulletin will be issued shortly to formally announce the new effective date. The intent of the requirement to use tamper-resistant prescriptions is to reduce forged and altered prescriptions and to deter drug abuse. MassHealth stresses the importance of ensuring that MassHealth members receive appropriate care, and urges prescribers to use alternatives to paper prescriptions where possible. The new requirement applies to both prescription drugs and over-the-counter drugs prescribed for MassHealth members. The requirement is applicable when MassHealth is the primary or secondary payer of the prescription being filled. It includes drugs prescribed for MassHealth members in nursing facilities. Drug Enforcement Administration regulations, Board of Registration in Pharmacy regulations, DPH regulations, MassHealth regulations, and Massachusetts Controlled Substances laws at M.G.L. c. 94C still apply. However, if a MassHealth member presents a written prescription to the pharmacist that is not on a tamper-resistant prescription blank, the pharmacist may telephone the prescriber to obtain a verbal order to satisfy the requirement that the prescription be tamper resistant. MassHealth does not endorse specific suppliers of tamper-resistant prescription blanks. Requirements for Tamper-Resistant Prescription Blanks Effective for dates of service on and after April 1, 2008, a prescription blank must contain at least one of the characteristics listed below: prevents unauthorized copying of a completed or blank prescription form; prevents erasure or modification of information written on the prescription by the prescriber; or prevents the use of counterfeit prescription forms. Exceptions to the Requirement for Tamper-Resistant Prescription Blanks The federal law exempts from the tamper-resistant prescription requirement MassHealth prescriptions that are: e-prescribed or faxed to the pharmacy from the provider’s office; telephoned to the pharmacy by the provider; paid by MassHealth managed-care organizations (MCOs); provided in institutional and clinical settings where the drug is not separately reimbursed, but is reimbursed as part of a bundled payment rate; or refilled when the original prescription was executed before the effective date. Emergency Fills Emergency fills for prescriptions written on non-tamper-resistant blanks are permitted as long as the prescriber provides a verbal, faxed, electronic, or compliant written prescription within 72 hours after the date on which the prescription was filled. This allows a pharmacy, in an emergency situation, to telephone a prescriber to obtain a verbal order for a prescription written on a noncompliant prescription blank. Additional Resources For more information, please see the Centers for Medicare & Medicaid Services (CMS) Letter to State Medicaid Directors (SMDL #07-012, 8/17/2007). The full letter is available at www.cms.hhs.gov/SMDL/downloads/SMD081707.pdf. You can also view the CMS Frequently Asked Questions Concerning the Tamper-Resistant Prescription Pad Law online by going to the CMS link at www.cms.hhs.gov/DeficitReductionAct/Downloads/MIPTRPFAQs9122007.pdf. Please Note: These materials were created before the announcement of the postponed implementation date of April 1, 2008. MassHealth Reminders Transmittal Letter DEN-79 MassHealth issued Transmittal Letter DEN-79 (August 2007) to announce the addition of new service codes in Subchapter 6 of the Dental Manual. You can download this publication from the online Provider Library at www.mass.gov/masshealthpubs. Home Health Services When using Service Codes T1002 and T1003 to bill for services provided on a holiday, the units billed as “holiday units” must be entered on a separate claim line from the other dates of service, if applicable. Please Note: When billing for holidays, the “from” date of service and “to” date of service should be the same date. For a list of the holidays, see 114.3 CMR 50.00 (Home Health Services) from the DHCFP Regulations link on the Division of Health Care Finance and Policy Web site at www.mass.gov/dhcfp. Using CMS-1500 for Claims Submitted On or After September 1, 2007 With the implementation of the National Provider Identifier (NPI) on May 23, 2007, MassHealth began accepting both the CMS-1500 (rev. 8/05) and the HCFA-1500 for Medicare Part B crossover claims submitted on paper. Beginning on September 1, 2007, regardless of the date of service, MassHealth now accepts only the new CMS-1500 (rev. 08/05) for all Medicare Part B crossovers. Any claims submitted with the HCFA-1500 will be returned to the provider unprocessed. Using National Provider Identifier (NPI) on Claims Submitted to MassHealth The September 30, 2007, deadline for submitting the NPI on MassHealth claims has been extended. MassHealth will follow the Centers for Medicare and Medicaid Services (CMS) guidance to require NPI only by May 23, 2008. MassHealth recommends that providers continue to work toward NPI compliance at the earliest possible date before May 23, 2008. We thank providers currently using NPI on MassHealth claims, and ask providers who have not submitted NPI information to MassHealth to do so as soon as possible. Please refer to the MassHealth NPI Web page at www.mass.gov/masshealth/npi for the latest NPI updates.