Sunday, August 28, 2016

What form used for change of ownership

 Change of Ownership

When an organization having a provider agreement undergoes a change of ownership in accordance with the principles articulated in 42 CFR Part 489 and §3210 of the State Operations Manual, the agreement with the existing provider is automatically assigned to the new owner so that there is no interruption in service. However, a new agreement with updated information must subsequently be signed and a Form CMS-855A must be submitted by both the old and new owners. Only if the provider, under the change of ownership, meets the applicable requirements for approval can the agreement be executed. For FQHCs, these requirements include PHS approval.

An organization that plans to change ownership must give advance notice of its intention so that a new agreement can be negotiated or so that the public may be given sufficient notice in the event that the new owners do not wish to participate in the Medicare program. A provider that plans to enter into a lease arrangement (in whole or in part) should also give advance notice of its intention.

A change of ownership occurs, for example, when:

• A sole proprietor transfers title and property to another party;

• In the case of a partnership, there is an addition, removal, or substitution of a partner unless the partners expressly agree otherwise;

• An incorporated organization merges with an incorporated entity that is approved by the program and the latter entity is the surviving corporation. It also occurs when two or more corporate providers consolidate and the consolidation results in the creation of a new corporate entity;

• An unincorporated organization (a sole proprietorship or partnership) becomes incorporated; or

• The lease of all or part of an entity constitutes a change of ownership of the leased portion.

When an organization’s agreement is terminated, whether by the entity or by CMS, no payment is available to the provider for services it furnishes to Medicare beneficiaries on or after the effective date of the termination.

Wednesday, August 24, 2016

ISA (Interchange Control Header Segment)

The ISA is a fixed record length segment and all positions within each of the data elements are required. The first element separator defines the element separator used through the entire interchange. The segment terminator used after the ISA defines the segment terminator to be used throughout the entire interchange.

The Input Data column below contains text in [bracketed italics], which indicates special input data dependent on sender, time, date, etc.

Elements Size Name Input Data Remarks   

ISA01 2 Authorization Information Qualifier 00 No Authorization Information Present.  

ISA02 10 Authorization Information [Submitter-specific ID number, or ten-space placeholder] If no Authorization Information number is present, simply enter10 spaces in this field.  

ISA03 2 Security Information Qualifier 00 No Security Information Present.  

ISA04 10 Security Information/Password [Submitter-specific ID number, or ten-space placeholder] If no Authorization
Information number is present, simply enter10 spaces in this field.  

ISA05 2 Interchange ID Qualifier/Trading Partner Qualifier ZZ Mutually Agreed.  

ISA06 15 Interchange Sender ID/ Trading Partner ID [Tufts Health Plan Submitter ID] Sender ID (Provided by Tufts
Health Plan).  

ISA07 2 Interchange ID Qualifier/Tufts Health Plan Qualifier 01 DUNS (Dun & Bradstreet).  

ISA08 15 Interchange Receiver ID/Tufts Health Plan ID 170558746 Tufts Health Plan DUNS.  

ISA09 6 Interchange Date [Enter the date using the format YYMMDD; for example, January 1, 2012 would be entered as
120101] Date of the interchange.

ISA10 4 Interchange Time [Enter the time using the format HHMM; for example, 1:30 PM would be entered as 1330] Time of the interchange.  

ISA11 1 Repetition Separator The repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator.  

ISA12 5 Interchange Control Version Number Version Number.  

ISA13 9 Interchange Control Number/Last Control Number [Sender-specific control number] Assigned and maintained by the interchange sender, must be identical to the associated Interchange Trailer, IEA02.

Must increment by one number at the end of the value with each file submitted within the same business day (12:00 am to 11:59 pm).  

ISA14 1 Acknowledgement Request [Enter either 0 or 1] The 999 will be sent regardless of Input Data.  

ISA15 1 Interchange Usage Indicator/ Acknowledgment Test Indicator [Enter either T or P] T - Test Data,   P - Production Data.

ISA16 1 Component Element Separator (Sub-Element) [Enter any separator character, for example : or >] Used to separate component data elements within a composite data structure; must be unique.

ASCII Value - Component element separator.

Saturday, August 20, 2016

Can we billing Medicare patients for missed appointments ?

 Charges for Missed Appointments

CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.

The amount that the physician or supplier charges for the missed appointment must apply equally to all patients (Medicare and non-Medicare), in other words, the amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients (whatever amount that may be).

With respect to Part A providers, in most instances a hospital outpatient department can charge a beneficiary a missed appointment charge without violating its provider agreement and 42 CFR 489.22. Because 42 CFR 489.22 applies only to inpatient services, it does not restrict a hospital outpatient department from imposing charges for missed appointments by outpatients. In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee.

Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers. Charges to beneficiaries for missed appointments should not be billed to Medicare.

If contractors receive any claims for missed appointment charges, the following reason code and MSN messages should be used to deny the claims—

Reason Code 204: This service/equipment/drug is not covered under the patient’s current benefit plan.

MSN messages:

16.59 - Medicare doesn’t pay for missed appointments.

16.59 – Medicare no paga por citas médicas a las que no se presentó.

Friday, August 19, 2016

IEA (Interchange Control Trailer Segment)

This segment defines the end of an interchange of zero or more functional groups and interchange-related control segments.

The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc.

Elements Size Name Input Data Remarks   

IEA01 1/5 Number of Included Functional Groups [Submitter-specific ID number] A count of the number of functional groups included in an interchange.  

IEA02 9 Interchange Control Number [Submitter-specific ID number] A control number assigned by the interchange sender.

(Functional Group Header Segment) 

This segment indicates the beginning of a functional group and to provide control information.

The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc.

Elements Size Name Input Data Remarks   

GS01 2 Functional Identifier Code HC Health Care Claim.  

GS02 2/15 Application Sender’s Code [Tufts Health Plan Submitter ID] Code identifying party sending transmission.  
GS03 2/15 Application Receiver’s Code 170558746 Code identifying party receiving transmission.  

GS04 8 Date [Enter the date using the format YYYYMMDD; for example, January 1, 2012 would be entered as 20120101] Functional Group creation date.

GS05 4/8 Time [Enter the time using the format HHMM; for example, 1:30 PM would be entered as 1330] Functional Group creation time. Time expressed in 24-hour clock.  

GS06 1/9 Group Control Number/Last Control Number [Submitter-specific number] Assigned and maintained by the sender, must be identical to the associated functional group trailer, GE-02.  

GS07 1/2 Responsible Agency Code X Accredited Standards Committee X12.  

GS08 1/12 Version/Release/Industry Identification Code 005010X223A2 Health Care Claim for Institutional or   005010X222A1  Health Care Claim for Professional.

 GE (Functional Group Trailer Segment) 

The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc.

Elements Size Name Input Data Remarks   

GE01 1/6 Number of Transaction Sets Included [Submitter-specific number] Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element.  

GE02 1/9 Group Control Number [Submitter-specific number] Assigned number originated and maintained by the sender

Tuesday, August 16, 2016

What is Limiting charge and rules of limiting charges with example

 Carrier Rules for Limiting Charge

Effective January 1, 1991, the maximum allowable actual charge (MAAC) for non-participating physicians is replaced by the limiting charge. The limiting charge is the maximum that the non-participating provider may charge the beneficiary. It also effectively replaces the special charge limits for overpriced procedure, anesthesia associated with cataract and iridectomy surgery, A-mode ophthalmic ultrasound and intraocular lenses (IOLs, and designated specialty, because the limiting charge is always less than or equal to the special charge limits.

The limiting charge applies to all of the following services/supplies, regardless of who provides or bills for them, if the services/supplies are covered by the Medicare program and are provided:

• Physicians’ services;

• Services and supplies furnished incident to a physician’s services that are commonly furnished in a physician’s office;

• Outpatient physical therapy services furnished by an independently practicing physical therapist;

• Outpatient occupational therapy services furnished by an independently practicing occupational therapist;

• Diagnostic tests; and

• Radiation therapy services (including x-ray, radium, and radioactive isotope therapy, and materials and services of technicians).

NOTE: This means that, effective for services/supplies provided on or after January 1, 1994, the limiting charge applies to drugs and biologicals provided incident to physicians’ services, to physical therapy services provided by independently practicing physical therapists, and to occupational therapy services provided by independently practicing occupational therapists. These changes are made because of provisions in OBRA 1993. OBRA 1993 expanded the limiting charge to apply to services/supplies which the law permits Medicare to pay for under the physician fee schedule methodology but which Medicare has chosen to pay for under some other method. “Incident to” drugs and biologicals, previously excluded from the limiting charge because of their exclusion from physician fee schedule payment, are, effective January 1, 1994, still excluded from physician fee schedule payment but subject to the limiting charge. Also, OBRA 1993 applies the limiting charge to all of the above listed services/supplies, regardless of who provides or bills for the services/supplies. No longer are services of suppliers and other nonphysicians, such as physician assistants, nurse midwives, and independently practicing physical and occupational therapists, excluded from the limiting charge.

Physicians, non-physician practitioners, and suppliers must take assignment on claims for drugs and biologicals furnished on or after February 1, 2001, under §114 of the Benefits Improvement and Protection Act (BIPA).

Effective January 1, 1993, the limiting charge is 115 percent of the fee schedule amount for nonparticipating physicians.


participating fee schedule amount                $2000

Nonparticipating fee schedule amount           $1900 (95% of $200

Limiting charge                    $2185 ($1900 times 1.15)

Charges to either a payer for whom Medicare is secondary or to a payer under the indirect payment procedure are not subject to the limiting charge if the physician accepts the payment received as full payment (i.e., if there is no payment by the beneficiary).

The provider may round the limiting charge to the nearest dollar if they do so consistently for all services.

Friday, August 12, 2016

General instruction on EDI 873 FORMAT

General Instructions

** All NPIs on claims submitted to Tufts Health Plan must be registered with the Provider Information Department prior to transmission. Please call (888) 880-8699 x3153 to verify or register the NPIs of your organization with Tufts Health Plan.

** Tufts Health Plan will require a valid NPI when NM109 is used in any provider loops and will not accept Provider Secondary Identification after the mandated NPI Implementation date.

** New submitters must go through the appropriate set-up/authorization process in order to transmit electronic claims with Tufts Health Plan.
Please refer to the Communications/Connectivity Component of this document for details.

** Tufts Health Plan will accept 837 Institutional and 837 Professional Claim Transactions for all business products, however the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file.

** As stated in the technical reports, a maximum of 5000 CLM segments will be accepted by Tufts Health Plan.

** Tufts Health Plan is adhering to structural specifications for required and situational fields as stated in the technical reports. If the incoming 837I or 837P has a single ST/SE and the structure does not comply, the entire file will fail in the validation process. If the incoming 837I or 837P has multiple ST/SEs, only the failed ST/SEs in the file will fail in the validation process. The submitter receives a 999 acknowledgement for notification for the ST/SEs that failed.

** Tufts Health Plan will capture payee information from the Billing Provider Name loop (Loop 2010AA).

** The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that Tufts Health Plan will continue making payments to the addresses in our backend system database instead of the addresses submitted in loop 2010AB.

** Tufts Health Plan cannot currently support billing for atypical provider type submissions.

** For Frequency Types 5, 7, and 8, (Element CLM05-3), Tufts Health Plan’s original claim number (Original Reference Number – Element REF02) must be submitted as stated in the technical report. We also strongly recommend sending the Original Reference Number with Frequency Types 2, 3, and 4.

** When contacting Tufts Health Plan with questions for claims with Frequency Types 2, 3, 4, 5, 7, and 8, (Element CLM05-3), please use the original claim number even though a new claim number for that submission will be assigned.

** The Tufts Health Plan implementation of Coordination of Benefits (COB) Information utilizes claim header information in the COB Header Other Subscriber Information (Loop 2320), Other Subscriber Name (Loop 2330A), and Other Payer Name (Loop 2330B) as well as line level information in the Line Adjudication Information Details (Loop 2430) within the 837 transactions. We strongly recommend closely reviewing these loops in the technical reports before submitting COB information. Many data segments have been changed or deleted.

** Although the HIPAA Transaction Set technical report allows the repeating of Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20% by using only one repeat of Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together.

** ICD-10 Codes will not be accepted until the regulatory compliance effective date of October 1, 2014.

** For compliance purposes, Tufts Health Plan will only accept qualifier MJ for minutes when billing anesthesia procedure codes. UN is a valid qualifier for procedures other than anesthesia.

** Tufts Health Plan is unable to accept claims submitted electronically with charges total one million dollars (or more) due to system limitations.

Tuesday, August 9, 2016


Assessment H0031 $93.00 Per service 

Description - Mental health assessment, by non-physician
Place of Service where its performed - 03, 12, 13, 31, 32, 53, 99
Service Limits -  Daily 1 service, Yearly 4 service

Eligible service providers  - Aide, Assistant, Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS), Counselor Trainee (CT), Doctor of Osteopathic Medicine (DO), Independent Marriage & family Therapist (IMFT), Independent Social Workers (ISW/ISW-S)

Eligible service supervisors - Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS),  Doctor of Osteopathic Medicine (DO), Independent Marriage & family Therapist (IMFT), Independent Social Workers (ISW/ISW-S)

As you submit new and renewing treatment plans for your Anthem members, beginning with dates of service January 1, 2014, please request ABA services using H0031, H0032, H2012, H2019 & H2014. For dates of service prior to January 1, 2014, Anthem will continue to process claims with the previously approved CPT codes until December 31, 2013. If you have authorized treatment plans dating after January 1, 2014, we will contact you to change the authorized CPT codes for those plans to the new H codes.  A schedule of the new codes and their maximum allowable amounts, effective for dates of service on and after January 1, 2014, will be available online, at our secure provider portal, on or after December 1, 2013.

 Effective January 1, 2014, the only codes payable to ABA will be H0031, H0032, H2012, H2019 & H2014. All other codes will be denied.

Any services provided under a current authorization should be billed to match that authorization, except for authorized dates of service on or after January 1, 2014, which we will change to H codes with your assistance. Requests for concurrent reviews and/or new authorizations will reflect the coding changes and should be billed to match what is authorized. Coding other than what is reflected in an authorization for ABA services should not be billed and is not covered.

H0031 Service Definition 

Mental Health Assessment by non-physician (Behavioral Health Assessment and Initial Treatment Plan)

Assessment is an integrated series of procedures conducted with an individual to provide the basis for the development of an effective, comprehensive and individualized treatment plan. It is an intensive clinical and psychosocial evaluation of an individual’s mental health and/or co-occurring (mental health/substance abuse) conditions which results in an issuance of an integrated written document. This service may be conducted by an individual or by a multidisciplinary team and includes face-to-face interview contacts with the individual; and may include the individual’s family and/or significant others, collateral contacts and other agencies to determine the individual’s problems and strengths, to identify the disability(ies), and to identify natural supports.

An initial treatment plan, including discharge criteria and/or treatment recommendations is included as part of the assessment.

Billing and coding Guide

Authorized practitioners:

ƒ Bachelor’s degree in human servicesrelated field and a combination of relevant education, training, and experience totaling four years; or ƒ LADAC; or ƒ Masters Degree in human servicesrelated field.

NOTE: Completed assessment must be signed and dated by staff completing the assessment and, as appropriate, a masters level supervisor.

Special Instructions:
 DOH will use for all individuals. ƒ For DOH school-based, use modifier TR.
ƒ CYFD will use for mental health assessment to determine eligibility for services. Use modifier HA.
ƒ HSD/Medicaid will use this code for PSR only. Use modifier U8.
ƒ For multi-disciplinary team, use modifier HT. ƒ For substance abuse assessment, use modifier HF. ƒ For substance abuse/mental health assessment, use modifier HH

H0031/2 - Initial Assessment and Plan Development Performed by masters/doctorallevel provider

Magellan provides authorizations for the Initial FBA and plan development using H0031 code (1-hour increments) or H0032 code (15-minute increments).

For continued services, Magellan provides the authorization in units of 15-minute increments:

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