The 8 Keys to Getting Paid
As the contracted entity for our health plan partners Integra follows all CMS guidelines. This includes submitting the appropriate documentation at the time your claims are submitted. By submitting these 8 key pieces of information with your claim, you will be on your way to fewer denials, and a quicker turnaround time!
- Copy of patient’s insurance card- must include any secondary or co-insurance information as well
- Signed and dated physician order and/or prescription
- Signed and dated delivery ticket
- Signed and dated letter of medical necessity
- Signed and dated patient consent form
- Signed and dated patient assignment form
- Patient medical history form
- Provider patient contact history
Local Coverage Determination
Do you have the latest LCD for Ankle-Foot/Knee-Ankle-Foot Orthosis? If not, be sure to e-mail Nicole Robinson on our Network Development Team at email@example.com for the latest on; bill type codes, revenue codes, modifiers, prescription requirements, and much more!
Prescription Footwear Benefit Coverage
Prescription footwear is orthopedic shoes, shoe modifications or shoe additions. Benefit coverage is limited to:
- Children under 21 years of age who require orthopedic footwear to correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot; to support a weak or deformed structure of the ankle or foot.
- When a shoe is attached to a lower limb orthotic brace. Prior Approval is required for beneficiaries who are age 21 and older, using only codes L3224 and L3225 and any addition and/or modifications to those shoe codes.
- As a component of a comprehensive diabetic treatment plan to treat amputation, or pre-Presfulcerative calluses, or peripheral neuropathy with evidence of callus formation of either foot, or a foot deformity or poor circulation. For DVS authorization and billing, see below for codes limited to shoes, inserts and/or modifications for diabetics only.
A5500 # For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe.
A5501 # For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient’s foot (custom-molded shoe), per shoe.
A5503 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe.
A5504 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe
A5505 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe.
A5506 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe.
A5507 # For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth inlay shoe or custom-molded shoe, per shoe.
A5512 # For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each
A5513 # For diabetics only, multiple density insert, custom molded from model of patient’s foot, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer, (or higher), includes arch filler and other shaping material, custom fabricated, etc.
Questions may be directed to the Division of Provider Relations and Utilization Management, 1-800-342-3005 option 1.
KX Modifier Billing Reminder
Below is a list of LCDs which include a KX modifier requirement for some or all items within that specific LCD. Use of the KX modifier with any other DMEPOS is inappropriate language.
Please note that repeatedly billing incorrect or missing modifiers will result in a mandatory training session with the Integra Partners billing department. If you have questions or concerns regarding the appropriateness of modifiers please e-mail Nora Strong, Supervisor of Billing & Senior Claims Resolution Specialist at firstname.lastname@example.org.
- Ankle-Foot/Knee-Ankle-Foot Orthosis
- Automatic External Defibrillators
- Cervical Traction Devices
- External Infusion Pumps
- Glucose Monitors
- High Frequency Chest Wall Oscillation Devices
- Hospital Beds
- Immunosuppressive Drugs
- Knee Orthosis
- Manual Wheelchair Bases
- Negative Pressure Wound Therapy Devices
- Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
- Oral Appliances for Obstructive Sleep Apnea
- Orthopedic Footwear
- Patient Lifts
- Positive Airway Pressure Devices
- Power Mobility Devices
- Pressure Reducing Support Surfaces
- Refractive Lenses
- Respiratory Assist Devices
- Speech Generating Devices
- Therapeutic Shoes for Persons with Diabetes
- Transcutaneous Electrical Nerve Stimulators (TENS)
- Urological Supplies
- Wheelchair Options and Accessories
- Wheelchair Seating
Questions may be directed to the Division of Provider Relations and Utilization Management, 1 800 342-3005, option 1.
Completing an Accurate Letter of Medical Necessity
National and local Medicare policy specifies that upon complete of a face-to-face examination, the treating practitioner or physician must complete a written order containing seven specified elements. As the supplier of these services you may choose to provide physicians with a form that outlines the necessary fields to ensure the necessary requirements are met.
If you submit an LMN without proper documentation the claim will not be processed and you will NOT be paid on the claim. In order to ensure efficiency’s before submitting a claim, be sure to check that the LMN contains the following;
1. Beneficiary Name
2. Item Ordered
3. Date of Face-to-Face Examination
4. Diagnosis/Condition Relating to Need for Item
5. Length of Need
6. Physician Signature
7. Signature Date
It is not permissible for a supplier to “lead” the referring physicians as to the type of equipment rendered. No forms should be pre-inscribed with items ordered or any other pertinent information. An example of what not to do includes but is not limited to;
• A form with “Power Mobility Device” already entered in the “Item Ordered” field.
• A form that contains check boxes for certain items.
New Requirement of a Face-to-Face Encounter Prior to Ordering DME
Effective July 1, 2013, in accordance to rules governed by Medicare and Medicaid, orders for durable medical equipment (DME) must include physician documentation that a face-to-face encounter with the patient occurred during the previous six months.
What does this mean for DME Suppliers?
Beginning July 1, 2013, DME Suppliers must obtain a written order and supporting documentation from the treating physician indicating that a healthcare practitioner had a face-to-face encounter with the beneficiary within a period no greater than the previous six months.
The Aftermath of Hurricane Sandy
These past few months have brought difficult times to our area as we are still picking up the pieces in the aftermath of Hurricane Sandy. Many of our providers, health plans, and employees were affected by the storm. An Integra Employee Relief Fund was established to help our employees combat these unexpected expenses and our thoughts and prayers remain with all those affected in our area.
Please note that many of our health plan partners in the Tri-State area were without power for 6-9 days (MetroPlus, GHI & HIP are still experiencing some issues). This resulted in a stalemate on payments being received, processed and released for claims pending in their system during this time frame. We ask that you remain patient as they are working diligently to get back on track.
Additionally, as a result of the storm, the previously scheduled NJ AAOP conference was canceled for 2012. We would like to thank all of you who had planned on attending the event and visiting us both at our booth as well as at our private reception. Although we did not get the chance to meet this year, we look forward to seeing all of you at the event next year!
Direct Deposit- Speeding up the Flow of Your Money
With our NEW Direct Deposit feature, Integra Partner providers are being paid quicker than ever before! With 75 providers already enrolled, they no longer need to wait for paper checks to come in the mail, walk down to their local bank, and then continue to wait as the check goes through the clearing process. With ACH deposit, the money is automatically deposited directly into their bank accounts! Not to mention, for those 70+ providers who were already enrolled in ACH when Hurricane Sandy hit, they were able to receive their deposits without any delays!
Fast Facts for Existing ACH Enrollees
- Our bank requires us to schedule ACH payments at least one business day before the payment date.
- Generally, the ACH instructions are uploaded to the bank on Sunday evenings.
- Since Sunday is not a business day, the payment cannot be scheduled until Tuesday.
- Some receiving banks will post to your account the same day, other banks do over-night posting.
- If your bank does overnight posting, you may not see the deposit in your account until Wednesday.
If you have any questions or concerns please feel free to e-mail Frank Bianco at email@example.com or call him directly at (718) 819-3914.
Integra Partners Cultural Elements
- Create a WOW Company
- Value Each Other
- Push the Boundaries
- Make it FUN!
Provider Spotlight- Mt. Carmel Pharmacy “A Thanksgiving Story”
Thanksgiving – The Past and The Present
The tradition of Thanksgiving has been a long standing American tradition which dates back to the Pilgrims in 1621. After a plentiful harvest season, Governor William Bradford proclaimed a day of giving thanks, inviting Indian Chief Massasoit and many of his people to this three-day feast. These rich principles of community, selflessness, and valuing one another are still on display today as every year we gather with friends, family, neighbors, strangers, and everything in between to share in what has become more than just a meal.
Dating back to 1993, Bronx, NY based Mt. Carmel Pharmacy and Surgicals has exemplified this behavior and has become a pioneer in their local community. From serving 75 people at their first annual Thanksgiving Day feast, they now proudly serve between 1000 and 1200 people every year for the past 15 years. From the homeless, to elderly couples, to lonely, to young and old, all are welcome as their doors remain open for any and everyone.
In 1993, Iris Garcia was working as a receptionist in a doctor’s office that was run by the Paganelli brothers – Armand, Michael, and Roger who are third generation Bronx-based pharmacy owners. One day, she was approached by a friend of hers asking if she would put together a Thanksgiving feast for the poor in the Church Gym. At the time, Iris had lived across the street from the Church where she also was/is a parishioner. Having had some Thanksgivings where she had nothing for her own family, Iris felt as though this was her chance to help others and to give back.
She decided to speak with the Paganelli brothers who were already involved in other community outreach programs. They loved the idea and the passion Iris brought to the table and an arrangement was quickly made. Mt. Carmel Pharmacy would become a sponsor and help provide the financial support to make it happen and Iris, along with help from her family, friends, and neighbors would make it happen.
That first year, Mt. Carmel purchased 7 turkeys and Iris and her dedicated team provided all of the fixins’. They served 75 people that day in 1993, a number which surprised many of the organizers. They had no idea that there were so many people in the community that needed a place to share Thanksgiving. Little did they know that as the years went on, that number would increase to over a thousand attendees each year! They now prepare 50-60 turkeys every year and the volume prepared by Iris and her crew is quite remarkable. That doesn’t even count desert, where they go through 150 pies and more than 50 lbs of cookies!
Whether you come to fill a carry out container to bring home or choose to dine in the beautifully decorated gymnasium filled with balloons, centerpieces, and candles, Governor Bradford would be proud of the tradition Mt. Carmel Pharmacy and Iris Garcia continue to make special.
For the efforts put forth by Mt. Carmel Pharmacy, Iris, and all of those involved in this heartwarming story we recognize your efforts and commend you on a job well done.
Affordable Care Act- Reimbursable Products
Did you know that under the ACA breastfeeding support and supplies will be covered by the insurance companies? Breastfeeding is one of the most effective preventative measures mothers can take to protect their health and that of their children. One of the biggest barriers over the years has been the cost of purchasing or renting breast pumps and nursing related supplies. Pregnant and postpartum women will now have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment.
The service of this equipment will primarily come from Durable Medical Equipment suppliers. If you are already selling these items, please e-mail Scott Brennan at firstname.lastname@example.org so that you can become eligible for referrals!
Are Your Requests for Consumable Supply Refills Being Denied?
The Durable Medical Equipment Medicare Administrative Contactors have been conducting reviews on claims for consumable supplies and they have found that there are a large number of denials on requests for refills due to incomplete documentation. The most prevalent error is the way in which the suppliers are documenting the quantity of an item the beneficiary has remaining.
A few examples of items which are categorized as consumable products are; ostomy, urological supplies, surgical dressings, glucose supplies, etc. When filling out documentation for reimbursement for items such as these it is essential that the supplier assess the quantity of each item that the beneficiary still has on hand. This will aid in determining that the amount left is nearly exhausted.
Below are a few examples of situations where insufficient documentation to justify reimbursement occurs (not all inclusive);
- “Yes” or “No” questions only regarding whether the beneficiary wants or needs more supplies.
- Documentation which only provides information regarding the amount of supplies the beneficiary is requesting.
- Documentation which only states that the beneficiary has less than the required threshold number of supplies left.
To minimize denials on consumable goods it is essential that the supplier presents a customized and detailed record specific to each beneficiary’s requested refills. A physical count is recommended but not necessary. However, it is vital that the documentation proves that there was an individualized assessment completed.