2012 PREVENTIVE CARE GUIDELINES AND IMMUNIZATION SCHEDULES NOW AVAILABLE
The Massachusetts Health Quality Partners (MHQP) has released the 2012 Pediatric and Adult Preventive Care Guidelines and Immunization Schedules. They can be accessed via the MHQP web site.
For Pediatric Preventive Care Recommendations, go to: www.mhqp.org/guidelines/pedPreventive/pedPreventive.asp?nav=041100
For Adult Preventive Care Guidelines, go to: www.mhqp.org/guidelines/adultPreventive/adultPreventive.asp?nav=040900
IMPORTANT MESSAGE FOR GROUP PRACTICE PROVIDERS SUBMITTING MEDICARE CROSSOVER PART B CLAIMS
MassHealth has implemented a processing change for Part B crossover claims billed by group practice providers.
As of 12/16/12, all Part B crossover claims submitted by group practice providers will be priced based on the rendering provider ID submitted in the claim detail. Previously, MassHealth priced these claims based on the billing provider ID. The rendering provider ID must be on file with MassHealth and is required on the claim submission. The following informational edits will appear on your remittance advice if the rendering provider ID is not on file or is not eligible to bill the service: Edit 1007 -DETAIL RENDERING PROVIDER I.D. NOT ON FILE or Edit 1002 -DTL PERFORMING PROV NOT ELIG AT SERV LOC FOR PROG.
Group practice providers are responsible for ensuring that all individuals who practice as rendering providers in the group are enrolled and active providers with MassHealth before claims may be submitted for payment. Failure to do so may result in claims denials
NEW NCCI MODIFIERS
Effective January 01, 2013, four (4) modifiers have been added to the list of modifiers that providers can use, when medically appropriate and in accordance with CMS regulations, to bypass National Correct Coding Initiative (NCCI) procedure code to procedure code (PTP) edits.
The following two new HCPCS modifiers will be added to the list of allowable PTP associated modifiers for Medicaid fee-for-service claims subject to the Practitioner (PRA) NCCI edits and Outpatient Hospital (OPH) NCCI edits:
LM – LEFT MAIN CORONARY ARTERY
RI – RAMUS INTERMEDIUS CORONARY ARTERY
The following two existing CPT modifiers will be added to the list of designated PTP-associated modifiers for use for Medicaid fee-for-service claims subject to PRA NCCI edits, but not for claims subject to OPH NCCI edits:
24 – UNRELATED MANAGEMENT AND EVALUATION SERVICE BY THE SAME PHYSICIAN DURING POST-OPERATIVE PERIOD
57 – DECISION FOR SURGERY
Note that these two modifiers have previously been allowable by MassHealth for purposes of bypassing global surgery edits. For questions, please contact MassHealth Customer Service at firstname.lastname@example.org or call 1-800-841-2900. For general information on modifier use, please see Provider Bulletin 227.
IMPORTANT MESSAGE ABOUT THIRD PARTY LIABILITY CLAIMS FOR QUALIFIED MEDICAL BENEFICIARIES (QMB) MEMBERS WITH MEDICARE ADVANTAGE PLANS
On 12/02/2012, MassHealth implemented a system change to allow third party liability claim payment for MassHealth non-covered services provided to MassHealth QMB members with Medicare Advantage Plan coverage. Claims processed on or after 12/02/2012 for MassHealth non-covered services provided to members with Medicare Advantage will be paid if there is a remaining MassHealth liability on the claim.
As a result of this change, providers may see the following new EOB codes on remittance advices:
- 1806 - PAID PATIENT RESPONSIBILITY AMOUNT (header)
- 1807 - PAID PATIENT RESPONSIBILITY AMOUNT (detail)
MassHealth plans to reprocess previously denied claims and will provide an update in a future message. For questions, please contact MassHealth Customer Service at email@example.com or call 1-800-841-2900.
TPL EDITS SETTING ON NURSING HOME CLAIMS
Nursing Facility providers are reminded that they must follow the billing guidelines in Bulletin 133, dated May 2012, as well as the guidelines published in Transmittal Letter NF 58, dated December 2011, when billing claims for members with Medicare, Medicare Advantage and/or other insurance coverage.
Claims denying for Edit 2528 - POTENTIAL MEDICARE A IN FIRST 100 DAYS, Edit 2556 – POTENTIAL MEDICARE C IN FIRST 100 DAYS or Edit 2557 – POTENTIAL PRIVATE INSURANCE IN FIRST 100 DAYS can be resolved by following the instructions in the above-mentioned publications. Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/ and click on the links for Bulletins and Transmittal Letters. For questions, please contact MassHealth Customer Service at firstname.lastname@example.org or call 1-800-841-2900.
MULTIPLE PAYER NON-COVERED AMOUNTS
MassHealth has resolved an issue with some TPL exception claims that were incorrectly denying for other insurance with Edit Code 2502 - MEMBER COVERED BY OTHER INSURANCE or Edit 2505 – MEMBER COVERED BY MEDICARE when there are multiple payers reported on the claim and one of the payers has a total non-covered amount. The issue was resolved on 12/02/12 and the affected claims will be reprocessed on future remittances. Providers may also re-submit the affected claims to MassHealth. For any questions, please contact MassHealth Customer Service at email@example.com or 1-800-841-2900.
NEW EDIT SETTING ON MEDICARE PART B DENIED SERVICES
MassHealth implemented a new edit, 410 – MEDICARE DENIAL ON CROSSOVER CLAIM, on 12/02/12 for certain Part B crossover claim lines when Medicare has denied the service. Claims denied for Edit 410 may be resubmitted to MassHealth, including the COB adjudication details and any other required documentation, if Medicare has denied the claim for reasons other than a correctable error. For any questions, please contact MassHealth Customer Service at firstname.lastname@example.org or 1-800-841-2900.
COORDINATION OF BENEFITS (COB) - DIRECT DATA ENTRY (DDE) ENHANCEMENTS ON THE POSC
Providers are advised that MassHealth has made enhancements on the POSC for all COB claim submissions. Certain COB fields in the Coordination of Benefits and Procedure tabs will now auto-populate for you:
Coordination of Benefits Tab: In the “Coordination of Benefits (COB) Detail” panel, if the “Relationship to Subscriber,” is “18-Self”, there is now an option to click “Populate Subscriber” which will auto-populate the following data fields that have already been entered on the “Billing and Service” tab:
- Subscriber Last Name
- Subscriber First Name
- Subscriber Address
- Subscriber City
- Subscriber State
- Subscriber Zip Code
Procedure tab: In the COB Line Details panel, the following data fields will auto-populate from the information that has been entered on the “Coordination of Benefits” tab and “Institutional/Professional Service Detail” panel:
- Carrier Code (if multiple carrier codes have been entered from the “Coordination of Benefits” tab, there will be a drop down to select the appropriate carrier code)
- Paid Units of Service
- Revenue Code (applies to Institutional claims)
- Procedure Code
For questions, please contact MassHealth Customer Service at email@example.com or call 1-800-841-2900.
VISION CARE CPT CODE 92340- MUE EDIT
Effective 10/01/2012, service code 92340 (Fitting of spectacles, except for aphakia; monofocal) was included on the NCCI Medically Unlikely Edit list, limiting this service code to one unit per date of service.
To receive payment for fitting two pairs of eyeglasses instead of bifocals for members, providers must now bill service code 92340 with a single unit on two claim lines. The first claim line must be reported with no modifier and the second claim line with modifier 59 (Distinct procedural service). For claims which have already denied under edit code 5930 (MUE Units Exceeded), please re-bill these claims as described above rather than submitting an appeal.
PROCEDURE CODE CHANGES FOR MENTAL HEALTH CENTERS
The 2013 Current Procedural Terminology (CPT) manual, published by the American Medical Association (AMA), has made some major changes to psychiatric procedure codes.
The following codes, previously allowed for Mental Health Centers, will no longer be valid for dates of service after January 01, 2013: 90801, 90862, 90804, 90806, 90816 and 90818. Medication Management services previously billed under 90862 should now be billed as an evaluation and management office visit (99213).
New psychiatric codes covered for Mental Health Centers include:
- 90791 - Psychiatric Diagnostic Evaluation
- 90832 - Psychotherapy, 30 minutes with patient and/or family member
- 90833 - Psychotherapy, 30 minutes with patient and/or family member when performed with E&M service
- 90834 - Psychotherapy, 45 minutes with patient and/or family member
- 90836 – Psychotherapy, 45 minutes with patient and/or family member when performed with E&M service
- 99213 - Office or other outpatient visit for evaluation and management
Please refer to the 2013 CPT manual for details regarding these codes.
EARLY INTERVENTION SERVICE CODE T1015 DENIALS FOR EDIT 5930
MassHealth understands that due to the recent CMS NCCI quarterly update, MMIS has been denying Early Intervention provider claims for service code T1015 –TL (clinic visit/encounter, all-inclusive) when more than one unit is billed, with denial edit 5930 (MUE units exceeded).
MassHealth has reviewed this matter and has implemented a change to address this issue to ensure that future Early Intervention claims for T1015 TL will process according to MassHealth regulations and as stated in subchapter 6 of the Early Intervention provider manual. We will systematically reprocess previously adjudicated claims for T1015 denied due to edit 5930 on future remittance advices. No action is required on the part of the provider.
We apologize for any inconvenience this may have caused. For questions, please contact MassHealth Customer Service at firstname.lastname@example.org or call 1-800-841-2900.
PRIOR AUTHORIZATION REQUESTS
Effective Monday, December 3, 2012, providers who submit Prior Authorization (PA) requests via the MMIS Provider Online Service Center (POSC) will no longer be able to add a line item to a previously adjudicated PA.
To modify an existing PA on the POSC, providers must submit a NEW PA request for the procedure code and the number of units being requested for review. When submitting a new PA request for an adjustment or modification, providers must enter ADJUSTMENT/MODIFICATION in the PROVIDER COMMENTS section and, if applicable, include the active PA number to be adjusted/modified along with units already used/billed. With the exception of adjustment requests to change the size of absorbent products, the provider must include all required documentation to justify the medical necessity of the request, including a letter signed by the member’s prescribing provider that states the reason for the adjustment/modification and prescription, if required.
Upon receipt of the adjustment/modification request, the Prior Authorization Unit (PAU) will review for medical necessity and adjudicate the request as appropriate.
If you have any questions regarding this information, please contact the PAU at 1-800-862-8341 or PriorAuthorization@umassmed.edu.
NEW MASSHEALTH PUBLICATIONS POSTED ON THE WEB
MassHealth has posted the following publications on the MassHealth website:
Provider Bulletins from November 2012
- All Provider Bulletin 229: Physician Designees and the Ambulance Medical Necessity Form
- Nursing Facility Bulletin 134: Nursing Facility Pay for Performance (NF P4P) Program for Fiscal Year (FY) 2013
You can download a copy of a transmittal letter or bulletin from the online Provider Library (www.mass.gov/masshealthpubs).
To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.