NYM, FHP, CHP 1 V14.2-03/31/14
Medicaid, Family Health Plus, Child Health Plus Authorization Grid
FIDELIS CARE AUTHORIZATION REQUIREMENTS
SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION
I. Inpatient Admissions-All inpatient admissions require an authorization.
Fidelis Care does not require authorization of emergency room services or any emergent
service required to provide stabilization of an emergent condition. Fidelis Care does
require authorization of post stabilization services and inpatient admissions after
emergency room services are completed. All facility admissions are reviewed for
A. All acute inpatient facility services Inpatient Detoxification and Mental Health
services are limited for FHP to 30 days per calendar year of combined inpatient mental
health/substance abuse admissions. CHP and Medicaid benefits are unlimited when
B. Inpatient Rehabilitation Services: (acute, sub acute and skilled nursing
rehabilitation) require prior authorization.
1. Medical rehabilitation can be completed at an acute or sub acute level of care.
2. Inpatient substance abuse rehabilitation requires prior authorization.
C. Out of Network: Any Medicaid, FHP and CHP service provided by a nonparticipating
provider/facility/physician requires authorization.
All solid organ and bone marrow / tissue transplants require authorization at the time of
the transplant evaluation.
Includes but not limited to: 32850-32856, 33930-33945, 38204-38215, 38230-38242,
44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757.
E. Breast Cancer Surgery Centers:
Fidelis Care Medicaid members must receive mastectomy and lumpectomy procedure
associated with a breast cancer diagnosis, at high volume facilities. This link provides
information regarding New York State policies.
F. Elective Surgical Procedures:
Many surgical and medical procedures which are completed within 24 hours will not be
approved at an in-patient level of care. These same services when billed as an out-patient
level of care do not require authorization if performed within the Fidelis Care network.
Such procedures include, but are not limited to, cardiac catheterization and stenting,
laparoscopic procedures, and thyroid surgery if completed within 24 hours from the onset
The link provides a list of inpatient only procedures for Medicaid, FHP and CHP.
II. Outpatient surgery: The following services require prior authorization:
A. Obstetrical procedure: 58340
B. Bariatric surgery: 43770-43774, S2083
C. Blepharoplasty: 15820-15823
D. Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396
NYM, FHP, CHP 2 V14.2-03/31/14
E. Skin surgery and other dermatological procedures:
The auth requirement for many skin surgery treatments and repairs has been removed if
performed in the office or outpatient facility (POS 11 and 22). The following codes will
continue to require authorization if completed as ambulatory surgery (POS 24): 10040,
11300-11313, 11400 – 11471, 11721
Only the following codes continue to require authorization for any place of service:
11200-11201, 11719, 15775-15829, 17340-17999
F. Services for the following codes performed in free standing ambulatory surgery
centers billing with bill type 0831 require an authorization (10060, 11100, 11900 and
17000, 20600, 20605, and 20610).
G. Ear repair and ear piercing: 69300 and 69090
H. Eyelid & ocular surgery: 65760-65771, 65772-65775, 67900-67911
I. Abdominoplasty, lipectomy, panniculectomy: 15830-15839, 15847, 15876-15879
J. Reduction mammaplasty: 19300, 19318
K. Facial cosmetic, septoplasty, rhinoplasty: 21120-21296, 30400-30450, 30465-30520,
L. Vascular procedures i.e. vein stripping, ligation, ablation and sclerotherapy: 36468-
36479, 37718-37785, 36011, and 37204.
III. Behavioral Health – Outpatient services
The authorization requirement has been removed from all outpatient behavioral health
services except the following, which will continue to require authorization:
A. Psychological/Neuropsychological Testing:
96101, 96102, 96103, 96116, 96118, 96119, 96120, 96125. All requests should
be submitted on the Neuropsychological testing form.
B. Developmental Pediatric Testing:
96105, 96111 Note: 96110 is a non-covered service
C. Outpatient ECT: 90870
D. Partial Hospitalization (Mental Health and/or Substance Abuse)
Bill type 131, Revenue code 913,944, and 945
E. Intensive Outpatient Treatment
Bill type 131, Revenue code 912, CPT code 90899
F. Autism Spectrum Disorder (ASD):
The State has expanded benefits for CHP members with ASD to include increased
case management services, certain DME items to assist speech performance, and
Applied Behavioral Analysis, a form of enhanced behavioral modification.
1. Authorization is required for DME speech generation equipment.
2. Authorization is required from Behavioral Health for Applied Behavioral
3. Attestation of the diagnosis of ASD must be provided, at the time of request, by a
licensed physician or psychologist.
IV. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
1. Sleep Studies
2. Breast Cancer testing (BRCA) and other Genetic Testing
3. Wireless Capsule Endoscopy
B. Durable Medical Equipment:
DME coverage information is available in the Medicaid DME Program Manual at:
NYM, FHP, CHP 3 V14.2-03/31/14
1. For Medicaid, supplies and disposable items are covered by Fidelis Care.
Disposable items and supplies are not covered by Fidelis Care for FHP and CHP
lines of business. Sections 4.1 to 4.3 in the DME Manual describe the specific
codes for Supplies that are covered and do not require authorization.
2. These DME codes that do not require an authorization:
E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424,
E0431, E0434, E0439, E0570, E0575, E0580, E0621, E0655, E0660, E0776,
E0890, E0900, E0942, E2361, E2363, L0130, L0140, L0150, L0160, L0170,
L0172, L0174, L0180, L0190, L0200, L1652, L2106, L2108, L2112, L2114,
L2116, L2126, L2128, L2132, L2134, L2136, L3100, L3762, L7360, L7362,
L7364, L7366, S8421, S8424, V5266
3. These orthotic codes do not require an authorization:
A4565 A8000, A8001, L0220, L0861, L0970, L0972, L0974, L0976, L0978,
L0980, L0982, L0984, L1010, L1020, L1030, L1040, L1050, L1060, L1070,
L1080, L1085, L1090, L1100, L1120, L1240, L1250, L1260, L1270, L1280,
L1290, L1600, L1610, L1620, L1630, L1650, L1660, L1810, L1820, L1902,
L2180, L2182, L2184, L2190, L3650, L3710, L3913, L3919, L3921, L3923,
L3925, L3929, L3931, L3933, L3935, L3995, L8010, L8035, L8300, L8310,
L8320, L8330, L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440,
L8460, L8465, L8470, L8480, L8485, L8505, V2624
4. Other DME and orthotic codes require an authorization.
5. Compression and Surgical Stockings: For Medicaid, FHP and MLTC, the
following codes do require authorization: A6540, A6541, A6549. The following
codes do not require authorization: A4495, A4500, A4510, A6530-A6539,
A6544. Benefit limits as defined in the DME Manual apply.
6. The footwear benefit for Medicaid and FHP is described in Section 4.6 of the
Medicaid DME Manual for Medicaid, FHP, and CHP. Prescription footwear
means orthopedic shoes, shoe modifications and shoe additions. The following
codes do require authorization: A5501, L3000 – L3003, L3010, L3020, L3160,
L3230, L3250, L3330. The following codes do not require authorization: A5500,
A5503-A5505, A5507, A5512, A5513, L3030-L3100, L3140, L3150, L3170,
3201-L3209,L3211-L3217, L3219, L3221, L3222, L3224, L3225, L3252-L3255,
L3257, L3260, L3265, L3300-L3320, L3332, L3334, L3340,-L3485, L3540,
L3570, L3580, L3600-L3640, L3649. Benefit limits as defined in the DME
C. Home Health Care: Home care approvals are based on the medical need for
skilled services. The FHP benefit maximum is 40 skilled visits per calendar year.
1. Personal Care Services for Medicaid and Managed Long Term Care (MLTC-
Fidelis Care at Home and MAP).
All services require authorization and use of the following codes:
T1001-for a nursing assessment (not for nurse supervision)
T1019-Personal Care Level I- 15 minute intervals, maximum of 8 hours a
T1020-Personal Care Level II-hourly intervals, up to 24 hours a day
G0162 – Nursing Supervision of Personal Care Providers is applicable to
bill for services outside of New York City.
2. Personal Emergency Response System (PERS) is a Medicaid and MLTC benefit
and requires an authorization.
NYM, FHP, CHP 4 V14.2-03/31/14
3. Consumer Directed Personal Assistance services (CDPAS) is a benefit for
Medicaid and Medicare and requires authorization.
D. Effective October 1, 2013, Hospice requests for Medicaid members should be
submitted to Fidelis Care.. FHP and CHP requests also should continue to be
submitted to Fidelis Care. For Medicaid members enrolled in Hospice prior to
October 1, 2013, the services will be covered by Medicaid FFS until member is
no longer enrolled in Hospice.
E. Imaging Studies: The following services below require authorization:
1. The first 3 OB ultrasounds can be performed without an authorization. Four or
more ultrasounds require authorization
2. The authorization requirement for PET scans (CPT codes 78608 and 78811-
78816) with a cancer diagnosis (ICD 9 codes 140.x-239.x) has been removed. All
other diagnosis codes continue to require authorization.
F. Outpatient Therapy: Physical, Occupational, Speech Therapy:
The initial evaluation does not require prior authorization. Additional visits require
authorization. The Medicaid, FHP and MLTC benefit is limited to 20 visits per member
for each service per calendar year. There is no visit limit for CHP. Services received at
home are not included in this restriction.
G. Podiatry Services:
Authorization is no longer required for podiatric services rendered to members with a
confirmed diagnosis of Diabetes Mellitus. The Diabetes diagnosis must be included on
the claim when services are billed. Podiatric services to members without a diagnosis of
diabetes will continue to require authorization. Podiatrists will continue to require
authorization for all DME and orthotic codes that are supplied in the office, regardless of
H. Therapeutic Services:
1. Phototherapy (96900, 96910, 96912, 96913)
2. Hyperbaric Oxygen Therapy
3. Pain Management Codes (i.e. injections, TENS, therapeutic services):
20526, 20550-20553, 21073, 62263-62264, 62273, 62280-62282, 62310-62311,
62318-62319, 63650-63688, 64400-64530, 64550-64595, 64600-64640 (for nonorthopedists
4. The following services are not covered for members with a diagnosis of Low
b. Therapeutic facet joint steroid injections in the lumbar and sacral regions
with or without CT fluoroscopic image guidance;
c. Therapeutic injections of steroids into intervertebral discs; and
d. Continuous or intermittent traction.
5. Topical oxygen requires prior authorization.
I. Long Term Home Health Care Services
Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered
with an authorization for Medicaid Managed Care enrollees who have transitioned
from the Medicaid Fee-for-Services Long Term Home Health Care Program
(LTHHCP) and were in receipt of these services at the time of transition into
Medicaid Managed Care.
NYM, FHP, CHP 5 V14.2-03/31/14
J. Adult Day Health Care/AIDS Adult Day Health Care (ADHC/AADHC)
Authorization is required for any new ADHC/AADHC patient. Prior
authorization is also required for the initial assessment, up to two visits. Members
already enrolled in an ADHC/AADHC program as of 8/1/13 may remain in their
current care plan for up to 90 days. Requests for continuation of services beyond
that time period will be reviewed for medical necessity.
V. Counseling Services
A. Diabetes Self-Management Training (DSMT)
Members are allowed 10 hours/20 units in a continuous 12 month period. These services
must be provided by certified providers and no longer require authorization. Services are
covered when billed with codes G0108 and G0109
B. Asthma Self-Management Training (ASMT):
Asthma self-management training services may be provided in individual sessions, or in
group sessions of no more than eight patients. Authorization is required for codes S9441,
S9445, S9446, 98960-98962.
Members, including pregnant women, with newly diagnosed asthma or with asthma and a
medically complex condition (such as an exacerbation of asthma, poor asthma control,
diagnosis of a complication, etc.) will be allowed up to ten (10) hours of ASMT during a
continuous six-month period. Members with asthma who are medically stable may
receive up to one (1) hour of ASMT during a continuous six-month period.
C. Smoking Cessation Counseling (SCC):
Billing for FHP and Medicaid members must meet the following criteria. No
authorization is required.
1. Smoking cessation counseling will be reimbursed for up to 6 visits per calendar
year using the sum of codes 99406 or 99407 and billed ONLY with DX code
VI. New Technology/Experimental Treatment: Prior authorization is required and
based on medical necessity.
VII. Services provided by outside vendors
A. Dental and fluoride varnish treatment- Medicaid and CHP members up to and
including age 6 can receive fluoride varnish treatments.
Prior authorizations are completed by DentaQuest 1-800-516-9615.
Fluoride varnish treatment (D1206) is authorized by DentaQuest. Pediatricians,
Family and Nurse Practitioners can also obtain authorization through DentaQuest
to provide these treatments.
Orthodontic services are available for Medicaid members under age 21. Services
require prior authorization by DentaQuest 1-800-516-9615.
B. Vision: Prior authorizations by Davis Vision 1-800-601-3383
C. Transportation Link:
VIII. Pharmacy: As per formulary for Medicaid, FHP and CHP.
A. Enteral Therapy-HCPCS codes B4034-B4162 describe the available enteral
formulas or disposable items that require authorization.
NYM, FHP, CHP 6 V14.2-03/31/14
Benefit applies to:
1)Tube-fed individuals who can only obtain nutrition through a tube, 2) Individuals with
inborn metabolic disorders requiring specific nutritional formulas not available through
any other means, 3) Children under age 21 who require medical formulas due to
mitigating growth and development factors. 4) Adults with a diagnosis of HIV infection,
AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who
require supplemental nutrition, demonstrate documented compliance with an
appropriate medical and nutritional plan of care, and have a body mass index
(BMI) under 18.5 as defined by the Centers for Disease Control, up to 1,000
calories per day; or
(b) require supplemental nutrition, demonstrate documented compliance with an
appropriate medical and nutritional plan of care, and have a body mass index
under 22 as defined by the Centers for Disease Control and a documented,
unintentional weight loss of 5 percent or more within the previous 6 month
period, up to 1,000 calories per day; or
(c) require total nutritional support, have a permanent structural limitation that
prevents the chewing of food, and the placement of a feeding tube is medically
Pharmacy supplies do not require an authorization (supplies not covered for FHP and
CHP, please refer to benefit plan).
B. These injectable codes require authorization.
J0129, J0135, J0150, J0180, J0205, J0215, J0220, J0221, J0256, J0257, J0270,
J0476, J0480, J0490, J0585, J0586, J0587, J0588, J0592, J0597, J0598, J0638,
J0706, J0718, J0725, J0775, J0897, J1290, J1300, J1325, J1438, J1459, J1460,
J1557, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1595, J1599, J1740, J1742,
J1743, J1745, J1786, J1826, J1830, J1835, J1930, J1931, J2020, J2170, J2323, J2357,
J2358, J2426, J2440, J2503, J2507, J2562, J2778, J2793, J2794, J2796, J3262, J3285,
J3355, J3357, J3385, J3396, J3490, J3590, J7180, J7183, J7185, J7187, J7189,J7190,
J7192, J7193, J7194, J7195, J7198, J7199, J7302, J7307, J7308, J7309, J7312, J7321,
J7323, J7324, J7325, J7326, J7335, J7511, J7515, J7516, J7517, J7518, J7520, J7525,
J7527, J7599, J7607, J7609, J7610, J7622, J7624, J7626, J7629, J7633, J7634, J7635,
J7636, J7637, J7638, J7639, J7641, J7642, J7643, J7680, J7681, J7683, J7684, J7685,
J7686, J8510, J8515, J8520, J8521, J8560, J8562, J8597, J8600, J8650, J8700, J8999,
J9228, J9302, J9310
NYM, FHP, CHP 1 V14.2-03/31/14
|LCD and Policy Article Revisions Summary for March 27, 2014
Outlined below are the principal changes to DME MAC Local Coverage Determinations (LCDs) and a Policy Articles (PA) that have been revised and posted. Please review the entire LCD and each related PA for complete information.
Oral Anticancer Drugs
Pneumatic Compression Devices
Spinal Orthoses: TLSO and LSO
Note: The information contained in this article is only a summary of revisions to LCDs and Policy Articles. For complete information on any topic, you must review the LCD and/or Policy Article.
Billing Reminder: Modifier Usage for Urological Supplies –
The Urological Supplies Local Coverage Determination (LCD) provides for the use of modifiers with each submitted HCPCS code to indicate whether the applicable payment criteria are met (KX modifier) and to provide other information related to coverage and/or liability (GA, GZ and GY modifiers) when the policy criteria are not met. This article reviews the appropriate use of each modifier to ensure correct use. Instructions for the GA and GZ modifiers were recently included in this LCD for proper consideration of usage (December 2013).
Proper selection of the correct G modifier requires an assessment of the possible cause for a denial. Some criteria are based upon statutory requirements. A failure to meet a statutory requirement justifies the use of the GY modifier. When Reasonable and Necessary (R&N) criteria are not met, either the GA or GZ modifier is appropriate based upon Advance Beneficiary Notice of Noncoverage (ABN) status.
Urological supplies are payable under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)). Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in the affected beneficiary within 3 months. These requirements are statutory benefit requirements. When a beneficiary does not meet these requirements, the GY modifier must be used.
Aside from the above statutory coverage criteria, the remaining payment requirements are classified as R&N requirements. Examples (not all-inclusive) include utilization limits, medical necessity criteria for sterile kits, correct coding, etc. For those situations where R&N criteria are not met, either the GA or GZ modifier would be the appropriate choice depending upon ABN status.
Use of these modifiers is mandatory. Claims lines billed without a KX, GA, GY or GZ modifier will be rejected as missing information.
KX – Requirements specified in the medical policy have been met
The KX modifier must be appended to a catheter code, an external urinary collection device or a supply item when all of the statutory and R&N requirements have been met. Suppliers are not required to secure all of the required documentation prior to claim submission, however, appending the KX modifier to each of the urological codes billed serves as an attestation by the supplier that the requirements for its use have been met.
GA – Waiver of liability (expected to be denied as not reasonable and necessary, ABN on file)
When a Medicare claim denial is expected because an item or service does not meet the R&N criteria, the supplier must issue an ABN to the beneficiary before furnishing the item or service. When the beneficiary accepts financial responsibility and signs a valid ABN, the supplier submits the claim to Medicare appending modifier GA to each corresponding Healthcare Common Procedural Coding System (HCPCS) code. Modifier GA indicates that the supplier has a waiver of liability statement on file. Modifier GA must not be submitted if a valid ABN is not issued. Claims submitted with the GA modifier will receive a medical necessity denial holding the beneficiary liable.
GZ – Item or service not reasonable and necessary (expected to be denied as not reasonable and necessary, no ABN on file)
When a Medicare claim denial is expected because an item or service does not meet the R&N criteria, the supplier is expected to issue an ABN to the beneficiary. If the beneficiary refuses to sign the ABN accepting financial responsibility, or the supplier fails to issue the ABN for items and services furnished when ABN issuance is required, the supplier must append the GZ modifier to the claim line. Claims submitted with the GZ modifier will receive a medical necessity denial holding the supplier liable.
GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit
The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. For urological supplies, the prosthetic benefit requires that the beneficiary must have a permanent impairment of urination.
In cases where the statutory criteria are not met, suppliers are required to code their claims for urological supplies with the GY modifier. Claims submitted with the GY modifier will be denied as statutorily noncovered holding the beneficiary liable for the excluded services.
Refer to the Urological Supplies LCD and related Policy Article for additional information about the payment rules, coding and documentation requirements.
- Bill Medicare and obtain an official decision;
- File a claim with the beneficiary’s secondary insurer once the Medicare decision is received
- Collect a payment or partial payment from the beneficiary for the item if Medicare and/or the secondary insurer do not pay.
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.
- An updated Fee Schedule was sent out this past week, current as of 9/1/2012. If you have not already received a copy please e-mail email@example.com . Be aware that sometimes these e-mails end up in the ‘Junk’ or ‘Spam’ folder.
- A special training session to review the WellCare of NY procedures has been scheduled for October 3 at 10am and 2pm. Please contact Rita in Customer Service if you would like to join the session.
- Please revert to the Insurance List for all Integra contracted Healthplans. As always call us if you have questions regarding the Healthplans.
DME MAC Jurisdiction A Fall Webinar Schedule – Open Sessions
The DME MAC Jurisdiction A Outreach & Education Team still has the following FREE educational Webinar sessions open for registration.
All times Eastern Standard
October 02, 2012 from 9:30am – 11:30am Advance Beneficiary Notice of Noncoverage
October 02, 2012 from 1:30pm – 3:30pm Durable Medical Equipment (DME) Modifiers
October 04, 2012 from 9:30am – 11:30am Orthotics & Prosthetics Billing Essentials
October 04, 2012 from 1:30pm – 3:30pm Lower Limb Prosthesis Billing
October 09, 2012 from 9:30am – 11:30am DME MAC Essentials I
October 09, 2012 from 1:30pm – 3:30pm DME MAC Essentials II
October 23, 2012 from 9:30am – 11:30am Orthotics & Prosthetics Billing Essentials
October 23, 2012 from 1:30pm – 3:30pm Advance Beneficiary Notice of Noncoverage
October 25, 2012 from 9:30am – 11:30am DME MAC Essentials I
October 25, 2012 from 1:30pm – 3:30pm DME MAC Essentials II
October 31, 2012 from 9:30am – 11:30am Lower Limb Prosthesis Billing
October 31, 2012 from 1:30pm – 3:30pm Durable Medical Equipment (DME) Modifiers
For further details please visit the “Events & Seminars” section of the DME MAC A Web site or click here.
DME Coding Changes – Is your Head Spinning?
We all know how vital DME coding is to our business and how important it is to stay current with their policies. As you may already know CMS is making significant changes to the coding system and it is changing right before our eyes. In a joint effort, the NHIC DME Mac Jurisdiction A Provider Outreach & Education Team has partnered with the Pricing, Data Analysis and Coding (PDAC) Contractor to conduct two webinars focusing on the use of Durable Medical Equipment Coding System (DMECS).
The following topics will be discussed in these DMECS webinars:
- What is DMECS?
- Search by HCPCS Information
- HCPCS Details, Features, and Functions
- DMEPOS Product Classification Listing
- Sorting Results
Registration for these seminars is FREE however they are filling up fast so reserve your spot today! You can register by going to the website given below and following the links to courses titled “Durable Medical Equipment Coding System (DMECS) Training” held at the following times;
September 18th 2012 from 2:30pm-3:30pm
September 20th 2012 from 2:30pm-3:30pm
Get Started By Clicking Here –> http://www.medicarenhic.com/dme/dmerc_seminars.shtml
10 Tips to Remember When Billing
1. The Date of Service (DOS) must be within the effective dates of the authorization. (For Example: If the authorization date range given is from 06/08/2012 to 07/09/2012, you must bill within these dates. Claims that fall before or after the authorization will be denied)
2. Place of Service (POS) must be “HOME” (12) for MetroPlus, WellCare, and HIP
3. Be sure to check the number of units, under the authorization to see how many units were approved.
4. Be sure to enter the member’s ID.
5. If you bill a rental under HealthFirst be sure to use an RR modifier. Do not use BR modifier.
6. When billing for rental items, please be sure to verify patient coverage for the DOS.
7. When performing maintenance as a service, you must be bill every 6 months after the item was originally purchased.
8. Please do not change override charges when entering claims. The system is setup according to our contract rates.
9. Be sure to verify member’s maximum benefits for DME or Orthotics per calendar year
10. Cost invoice is required for all miscellaneous and unspecified procedures. (For Example: Manufacturer’s cost invoice is needed when billing code L2999, K0108, L3999, E1399, etc.)
What is NEW?
Integra Providers NOW have Access to Wellcare of NY
We are excited to report the positive progress with the addition of WellCare of NY; our newest health plan member covering both the Durable Medical Equipment and Orthotic and Prosthetics. Here are some fast facts about WellCare of NY:
- NY membership approximately 100,000 members
- Primary plans: [Medicare HMO, Medicaid HMO, Medicare Advantage]
- A for-profit public company with a stock market value of $3 billion
Other Health Plan updates:
- *NEW* as of 7/1/12: Village Care
- *NEW* as of 4/1/12: Access Medicare
- Changed as of 6/1/12: GHI – O&P only
- Ended as of 7/31/12: Humana
We at Integra, continually strive to improve our offering of health plans and services for you, our provider community. We have additional initiatives underway with more health plans and services, while we look to improve our communication with you.
**** NEW Referral Cards**** to help you grow your referral base
Are you looking to increase your referral base??? Give us a call and we will mail you Referral cards; a marketing piece outlining current Health plans with a space for your business card. Network Development team can be reached at 718-298-256 or firstname.lastname@example.org
**** NEW Electronic Direct Deposit ****
Integra Partners is pleased to announce it will soon be offering its provider community a new and faster way to receive reimbursements.
In the near future, providers will have the ability to have their weekly reimbursement checks deposited directly into their bank accounts as an ACH deposit. This will eliminate the time it takes to mail, receive and deposit funds and speed up cycle time by a week on average.
The Customer Service Team – same familiar voices, just different numbers
We strive to be the best in the industry and have implemented a new phone system that will help us reach our goals. Rita and her team are available every day to answer your questions.
The NEW Direct contact number for Customer Service is: 718-369-0012.
NEW Fax number: 718-287-1229 or service email is Administration@AccessIntegra.com
A friendly reminder from the Customer Service team: please enter all the patients’ demographic information in Doctor.com. The more information we have; the better we can service the patients!
Introducing – the Network Development team!
Integra Partners is growing and we recently added several team members to our Network Development department.
Craig Gambardella – Account Manager email@example.com or 718-541-4344
Scott Brennan – junior Account Manager firstname.lastname@example.org or 718-715-1724
Nicole Robinson – junior Account Manager email@example.com or 718-819-3922
Bianca Flikweert – VP of Network Development firstname.lastname@example.org or 718-298-2156
Contact the Network Development team to order Referral cards!!
Update from the Accounts Receivable Team- a Clarification for Non Medicare codes
Please note that both Neighborhood and Healthfirst are contracted under Medicare guidelines. Procedures that are not listed under Medicare but are listed under Medicaid will be paid 100% of Medicaid rates.
Other important facts form this team:
Incorrect information will cause a delay in the processing of claims, so when entering a member’s insurance information:
- Carefully select the correct plan type, as some plans have separate selections for Medicare and Medicaid.
- Always verify your patient’s demographic information and review the entry of this information into the billing system. Correctly captured member name, ID number, and date of birth, gender and policy effective dates are needed for uninterrupted claim processing.
Health Plus Medicaid -T Codes (T4521 – T4543) for incontinence products should not have a modifier when billing.
- American Orthotic & Prosthetic Association National Assembly Meeting – Hynes Convention Center Boston, MA – September 6-9, 2012
- New Jersey Academy of Orthotists & Prosthetist Annual Meeting – Bally’s Hotel & Casino, Atlantic City, NJ – November 7-9, 2012
We look forward to assisting you and helping to grow your business through accessing a greater network with Integra Partners. As always, we welcome any feedback on how we can further strengthen our relationship, improve our services or increase the value we are providing you.
Dear Integra Providers,
Happy Holidays and best wishes for a great New Year! With 2012 having just begun, we want to remind you that the 2012 Fee Schedule for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is now effective. You can find all your information on the code changes on our website. As a reminder, CMS announced an overall 2.4% rate increase for DMEPOS in 2012!
New Email Contacts
In order to help improve our response time to any provider questions, required assistance and claims needs, we have created new direct email addresses. Your use of these email addresses will help us to quickly, orderly and efficiently respond to any needs you might have:
email@example.com – for bill entry corrections, copies of Integra documents, copies of pre auths/denials, doc-tor.com entries and software issues or questions
firstname.lastname@example.org – for any claim status, cost invoices and detailed LMN/clinicals
email@example.com – patient consents from providers to Integra
firstname.lastname@example.org – general questions or information requests
Billing Software Training Manual
We have recently introduced a customized, easy-to-use, Integra training manual that provides a step-by-step tutorial on how to use all the features of the doc-tor.com billing software along with a short Q&A guide. If you should have any questions about using the billing software, features and capabilities or just need to train a new employee, please email us at email@example.com and we will email a copy of the manual and answer any questions you might have.
Claim Reminders and Tips
In order to help reduce some common mistakes in submitting claims and avoid inaccurate reimbursements or denials from payors, please find some helpful reminders and tips.
Patient and Benefit Verification
The member’s policy/insurance must be verified on the initial visit and again for each date of service along with the benefits. This verification will identify those patients who might have lost coverage after the initial visit or who are not covered for certain DME or O&P benefits.
After authorization is given for service, it is important that all services are provided within the effective date span. Failure to submit within the given date span will result in a claim denial by the payor.
GHI – claims with an ID that begin with “NA” must be sent by paper to American Plan Administrators (APA)
Multiplan – all claims must be sent to the claims submission address on each participant’s individual card
All DME procedures for all insurances require an NU or RR modifier.
All orthotics must include an RT or LT modifier for payors: BCBS, Fidelis, GHI, Health Plus, HIP and MetroPlus.
Prosthetic claims require a K functional modifier for payors: BCBS, Fidelis, GHI, HIP and Montifiore CMO.
As always, we appreciate the trust you have placed in us and we will continue to work on improving our partnership with you. Over the coming year, we will roll out new features, capabilities and services to assist you and improve how we interact. We also want to hear from you and welcome any feedback on how we can further strengthen our relationship, improve our services or increase the value we are providing you. Please email us at firstname.lastname@example.org.