Definition - primary care physician, QIO, specialist physician, subscriber

“Primary Care Physician (PCP)” means a Participating Physician who supervises, coordinates
and provides primary care services to Enrollees, including the initiation of their referral for specialist
services and other non-PCP services, and who meets all the other requirements for PCP contained in
CAREPLUS’ rules and regulations and in the Primary Care Physician Agreement. Also referred to
as “PCP”.

“Primary Care Services” means Covered Services customarily provided by a PCP in his or her
office as well as services customarily provided by an attending PCP to institutionalized patients.
This includes, by way of example and not limitation, the primary care services as set forth in
Attachment “A” of the PCP Agreement.

“QIO (Quality Improvement Organization)” means an Organization comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and
improve the care given to Medicare enrollees. QIOs review complaints raised by enrollees about the
quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital
emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans, and
ambulatory surgical centers. The QIOs also review continued stay denials for enrollees receiving
acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs and CORFs.

“Special Needs Plan” or “SNP” were created by Congress in the Medicare Modernization Act
(MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups
of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or
disabling chronic conditions. SNPs offer the opportunity to improve care for Medicare beneficiaries
with special needs by through improved coordination and continuity of care and by combining
benefits available through Medicare and Medicaid.

“Specialist Physician” means a Participating Physician who is Board Certified or has met the
academic requirements to sit for the Board in a certain medical specialty; who provides services to
Enrollees within the range of such specialty; who elects to be designated as a Specialist Physician by
CAREPLUS; and who meets all other requirements for Specialist Physicians contained in
CAREPLUS’ rules and regulations and in the Agreement between CAREPLUS and the Specialist
Physician.


“Specialist Services” means those services of a Specialist Physician, within the scope of his/her
Board Certified or Board Eligible specialty, that are:
(1) provided upon the referral of a PCP pursuant to CAREPLUS’ rules and regulations;
and
(2) Covered Services, but not PCP Services.

“Subscriber” means any individual who has entered into a Subscriber Agreement with CAREPLUS
directly or through his or her employer for the provision of Covered Services. Dependents that are
eligible to receive Covered Services under CAREPLUS’ applicable Subscriber Agreement shall be
considered as Enrollees.

“Urgent Care” means care provided for those problems which, though not life-threatening, could
result in serious injury or disability unless medical attention is received (e.g., high fever, animal
bites, fractures, severe pain) or do substantially restrict a Member’s activity (e.g., infectious
illnesses, flu, respiratory ailments, etc.)

What is Interdisciplinary Care Team, Medical Group, participating physician

“Interdisciplinary Care Team” or “ICT” refers to interdisciplinary services provided by a
treatment team in which all of its members participate in a coordinated effort to benefit the patient
and the patient’s significant others and caregivers. Interdisciplinary services, by definition, cannot
be provided by only one discipline. Though individual members of the interdisciplinary team work
within their own scopes of practice, each professional is also expected to coordinate his or her
efforts with team members of other specialties, as well as with the patient and the patient’s
significant others and caregivers. The purpose of the interdisciplinary team is to foster frequent,
structured, and documented communication among disciplines to establish, prioritize, and achieve
treatment goals

“MA Organization” means a public or private entity organized and licensed by a State as a riskbearing entity (with the exception of provider-sponsored organization receiving waivers) that is
certified by CMS as meeting the MA contract.


“Medicaid” is a joint Federal and State program that provides health coverage for selected
categories of people with low incomes. Its purpose is to improve the health of people who might
otherwise go without medical care for themselves. Medicaid is different in every state. In Florida,
the AHCA develops and carries out policies related to the Medicaid program.

“Medicaid Fiscal Agent” refers to the State Medicaid Program’s vendor contracted to serve as the
state’s fiscal agent. Some of the fiscal agent functions include: enroll non-institutional providers,
process Medicaid claims, serve as the enrollment broker for Medicaid recipients, and distribute
Medicaid forms and publications.

“Medical Director” means a physician contracted by the organization to provide consultation
regarding member policies and services.

“Medical Group” means a group of PCP and/or Specialist Physicians who:
(1) are formally organized as a partnership or professional corporation;
(2) provide for the diagnosis or direct care and treatment of a medical condition; and
(3) divide their income based on a specified, fixed formula.

“Medically Necessary” shall be determined by CarePlus’ Medical Director and shall include
consideration of whether services:
(1) are appropriate and necessary for the symptoms, diagnosis or treatment of a medical
condition;
(2) provide for the diagnosis or direct care and treatment of a medical condition; and
(3) are not primarily for the convenience of the Enrollee, the Enrollee’s attending or
consulting physician, or another healthcare provider.

“Participating Physician” means any physician licensed to practice in the State of Florida who
satisfies the participation criteria established by CAREPLUS and who has entered into a contractual
arrangement with, or is otherwise engaged by, CAREPLUS to provide physician services to
Enrollees.

Medical billing basic terms, definitions - capitation fee, covered services, dependent, emergency Medical condition

“Capitation Fee” means the monthly payment made by CarePlus to the Provider for each Enrollee
assigned to Provider. The amount of the Capitation Fee is set forth in the PCP Agreement.

“Clean Claim” is a claim that has no defect or impropriety, including lack of required
substantiating documentation for non-contracted providers and suppliers, or particular circumstances
requiring special treatment that prevents timely payment from being made on the claim. A claim is
“clean” even if CarePlus refers it to a medical specialist for examination. If additional
documentation in the medical record involves a source outside CarePlus, the claim will not be
considered “clean”.

“Copayment” means the amount required to be paid by Member to Provider as additional payments
for Covered Services as are Medically Necessary and shall include fixed payments to be paid as well
as percentage amounts based on the cost of a service (i.e. “co-insurance”). Copayments will vary in
amount for Members, depending on benefit structure

“Covered Services” means those medical and hospital services that are expressly covered under
any Subscriber Certificate and are medically necessary as determined by CarePlus’ Medical
Director

“Covering Provider” means a physician who will continue to render Covered Services to Members
during those times when Provider cannot provide these services as set forth in this Agreement, but is
doing so under the same terms of this Agreement


“Dependent” means a family member of a Subscriber who are eligible for coverage under the
Subscriber Certificate and who have been enrolled in CarePlus

“Emergency Medical Condition” means a medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain) such that a prudent layperson, with an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in:
(1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman,
the health of the woman or her unborn child;
(2) Serious impairment to bodily functions; or
(3) Serious dysfunction of any bodily organ or part.

“Emergency Services” means covered inpatient and outpatient services that are:
(1) Furnished by a provider qualified to furnish emergency services; and
(2) Needed to evaluate or stabilize an emergency medical condition.
  

“Enrollee” means a Subscriber or Dependent who is enrolled in CarePlus. An enrollee is also
referred to as a “Member”. “Medicare Enrollee” means an Enrollee who is entitled to medical and
hospital benefits under Title XVIII of the Social Security Act, as amended

Where do I submit claims to MediPass?

Where do I submit claims to MediPass? What is the claim address and can it be submitted electronically? 
 I have contacted different Medicaid provider phone numbers, but I have not received any response back.

Claims for recipients in MediPass are billed just like any other Medicaid claim. Please consult the appropriate billing handbook Florida Medicaid Provider Reimbursement Handbook, CMS-1500, Florida Medicaid Provider Reimbursement Handbook, UB-04; etc. Or contact Provider Support with the Medicaid Fiscal Agent.

You will find the contact information for the fiscal agent, HP Enterprise Services, at: https://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/Training/032409%20Complete%20General%20Information.pdf . The claims addresses are in the center of the page. The Medicaid Area Office for your county can also assist.

Is the NPI# the authorization number for MediPass kids? I have some pediatricians who write their NPI# as authorization and others who put their Medicaid #.
No. The National Provider Identifier (NPI) number cannot be used to replace the MediPass authorization number. Providers who are not sure what to use as the MediPass authorization number should contact their Medicaid Area Office. NPI numbers are 10 digits while the MediPass authorization numbers will be 9 digits.

Do MediPass patients have dental benefits?
Dental services do not require prior approval or referral by the MediPass primary care provider, except in an area with the Prepaid Dental Plan. Some Medicaid HMOs cover dental services. If the HMO does not cover dental services, they may be covered by a Prepaid Dental Plan. Such plans currently operate in Miami-Dade, and they will expand statewide starting in 2012. If the person is not in a prepaid dental plan, the person would be covered under the fee-for-service Dental Services for Children or Dental Services for Adults. Note that the services for adults are very limited. Currently the following health plans cover optional (State Plan) dental services in all of their non-Reform counties of operation: JMH, Healthy Palm Beaches, Integral, Sunshine, and Molina. Beginning on January 1, 2012, only the following health plans will cover optional (State Plan) dental services: Healthy Palm Beaches, Integral, and Molina. Please be careful to request service authorization and to bill accordingly. Information on the implementation of the Statewide Prepaid Dental Health Plan program is available at the following website: www.AHCA.MyFlorida.com/MedicaidPDHP

Do we need to save verification eligibility screen as a proof

How do I document verification of recipient eligibility?

You can obtain a call reference number through the AVRS. If you use the Web Portal you may choose to save a copy of the screen print or print out a hardcopy. If you use a MEVS vendor you will receive hard copy when you verify eligibility that you can save.

To show proof that we verified eligibility, we use a spreadsheet with recipient name, Medicaid number, date checked and comment box. Is this enough to show or document verification of eligibility? We verify eligibility using the web portal.

Many providers print out or save a screen shot of the page when they look up the eligibility and put it with the recipient’s file. If there is ever a discrepancy at a later time with the recipient’s eligibility it will show what the provider saw at the time the provider checked the eligibility


It is the provider’s responsibility to verify a patient’s Medicaid eligibility prior to providing any Medicaid reimbursable services.” If a recipient is not eligible for the month of September until the 15th of the month (and then eligibility is retroactive for the entire month), but services were provided earlier in September… will those services be billable once the recipient becomes eligible for the month?

Yes, once the recipient has eligibility for the date of service. Keep in mind that if you provide services for a person who is not eligible, you should not expect Medicaid payment. The recipient must be informed and agree to receive services that may not be covered by Medicaid. See Page “1-7” in Chapter 1 of the Florida Medicaid Provider General Handbook. All Medicaid handbooks, fee schedules, forms, provider notices, and other important Medicaid information are available on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/


Will the system’s speed ever be improved? We have 60+ individuals to verify eligibility on. This process currently takes hours and hours to complete because the system response is so slow.

You may want to look into submitting batch transmissions. These can be done on the web portal or with most of the eligibility vendors. You can contact the fiscal agent for assistance with the web portal at www.mymedicaid-florida.com.

Basic billing question on Medicaid Managed care

MANAGED CARE

How do we find out which network provider to call?

If you check eligibility through the web portal, look for this information in the Managed Care section of the recipient’s eligibility screen. You will find the name, type and phone number of the HMO, PSN or other managed care plan.

Is the network provider the one who is going to give us the authorization for the services?
No, you would get the authorization from the Health Plan. The only time you will get authorization from a provider is for a person managed under MediPass.


Referring to Slide 50: If recipients don’t have managed care, will it be blank or will it state FL Medicaid? If the recipient does not have managed care, the Web Portal screen will show ***No rows found***.

A patient will come in with a Medicare managed plan yet also show us a Medicaid card. The Medicaid eligibility will show full Medicaid benefits but does not show the Medicare Advantage plan yet we do call and verify eligibility with the Medicare HMO. Does Medicaid pay as a secondary in this case?

Medicaid is not currently paying crossover claims for beneficiaries in Medicare HMOs (Part C plans), but there are changes in the works that may take place as soon as the end of the year. Please watch for any upcoming provider alerts on this subject. You may also contact your Local Medicaid Area Office for questions on this topic. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/


If I have a situation where our claims are being underpaid with our HMO contract and we have sent several requests, spreadsheets and calls to get this rectified; what other recourse do we have as a provider?

The Medicaid contract requires that the provider address any claims/billing disputes through the provider complaint system of the individual Health Plan. Language from the contract is provided below. If the provider is unable to resolve this with the Health Plan, they are able to access an outside claims arbitrator, Maximus, which deals with claims disputes between Health Plans and providers. Application forms and instructions on how to file claims are available from Maximus.


How can I check for eligibility for a specific service by a managed care plan?
You may ask the recipient’s managed care plan when you contact them for authorization.
If you do not have a specific recipient, you may contact the managed care plan for general information. Your Area Medicaid office may be able to provide the contact telephone numbers for the managed care plans in your county.

Medicaid THIRD PARTY LIABILITY (TPL) - During eligibility

When checking eligibility, sometimes, there is COMMERCIAL INSURANCE listed on the Medicaid website as primary payer. After checking the primary payer websites, I find that the commercial insurance has terminated - sometimes up to 8 months prior. What can I tell parents to do to get the commercial insurance removed, so that we can utilize their Medicaid coverage? Who do they need to contact? Who can they call? If you can please help us with this, it would be very much appreciated.


If a recipient has other insurance coverage through a third party source, such as Medicare, TRICARE, insurance plans, AARP plans, or automobile coverage, we refer to that as Third Party Liability (TPL). As you know, these other sources must be billed prior to billing Medicaid. Florida Medicaid currently contracts with Affiliated Computer Systems (ACS) to manage TPL operations. Providers who have questions or problems concerning third party insurance can contact the Medicaid third party contractor:

*  By telephone at 877-357-3268 (FL-RECOV),
*  By fax at 866- 443- 5559,
*  Through the website at http://www.FLMedicaidTPLRecovery.com,
*  By e-mail at FLMedicaidTPLRecovery@acs-inc.com,
*  Or in writing to:

ACS; Florida TPL Recovery Unit; 230; Killearn Center Blvd., Bldg A1; Tallahassee, Florida 32309
The TPL contractor can make the necessary corrections to the information on the recipients’ files.


How do we handle patients with FULL MEDICAID who also have an individual plan (ex. BCBS) and they refuse to acknowledge the individual coverage. BCBS makes it a patient responsibility/deduct and then Medicaid paid for the service. What do I do?
Medicaid is always the payer of last resort. Other insurance, including Medicare, must be billed prior to requesting Medicaid payment. Florida Medicaid currently contracts with Affiliated Computer Systems (ACS) to manage Third Party Liability (TPL) operations. Providers who have problems concerning third party insurance information can contact ACS, and they will make the necessary corrections to the information on the recipients’ files. If the TPL approves the service, but does not make a payment because it is applied to the patient’s deductible the provider can bill to Medicaid with the TPL EOB and is entitled to received payment for the service up to the Medicaid fee.

What is Medicaid Share of Cost - explain with example

Can you please let me know how to check eligibility on share of cost patients?

A Medically Needy recipient is an individual who would qualify for Medicaid, except that the individual’s income or resources exceed Medicaid's income or resource limits. A Medically Needy recipient becomes eligible on the day that the recipient incurs allowable medical expenses that equal or exceed the amount by which his income exceeds the Medicaid income standard (share of cost).

Recipients with a Share of Cost should be treated as private pay patients until they meet the Share of Cost amount. They should be informed that they will be responsible for the charges if they do not incur enough medical expenses to meet the Share of Cost. Information on the Share of Cost amount can be provided by the recipient or the Department of Children and Families (DCF).


Is DCF the only agency that determines share of cost?

Yes. Enrollment in the Medically Needy program only happens with DCF determinations. There is no similar program for SSI determinations through the Social Security Administration. Their applicants are either eligible for full coverage or not at all.

What is “Share of Cost” Medicaid?

When eligibility for Medicaid is determined, some people will meet all the technical requirements except that their income or the value of their assets (resources) is too high. These people can be enrolled in the Medically Needy program. The difference between the person’s income and the qualifying limit for full Medicaid is their “Share of Cost” (SOC).

For example, if the income limit for a person to get full Medicaid is $350/month and the person makes $500/month, this person’s SOC would be $150. Any month that this person’s medical expenses are more than $150, the person will get Medicaid coverage. Coverage will begin on the day the SOC is met and continues to the end of the month. Persons enrolled in Medically Needy will not be listed when you try to verify eligibility unless medical bills or other proof of medical expenses have been sent to the appropriate DCF office. DCF uses the bills to establish the date when the person is Medicaid eligible. Please contact your Area Medicaid Office for information on sending bills to DCF for tracking. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at:
http://mymedicaid-florida.com/.

Do we bill for share cost monthly or wait until monthly bills are submitted?
You can bill at any time after the person’s eligibility is established for the month

How do we check how much a recipient has already met or needs to meet before being considered eligible for full Medicaid?
If the recipient cannot give you the information on his/her Share of Cost, you will need to get the information from DCF. You can use the DCF Provider View link from the secure area of http://mymedicaid-florida.com . You can also contact the DCF call center at: 1-866-762-2237 or send a written request at this web site: https://www.dcf.state.fl.us/contact/contact_email.shtml?recv=ACCESS.

Can we billed Medicaid patient for Medicare coins ?

Can you clarify if Medicaid only covers Medicare part B premium? Is the patient responsible for the 20% coinsurance?

If you are referring to persons who only have coverage as Special Low Income Medicare Beneficiaries (SLMB) or as Qualifying Individuals I (QI1), this would be correct, but note that it is possible for a person to be eligible for both SLMB and a full Medicaid coverage program at the same time. Crossover claims policy would apply for those persons. More information can be found in the Florida Medicaid Provider General Handbook


Patients that are enrolled in a Medicare Advantage Plan still think that they have Medicaid second. What can we do to help us and them?


Florida Medicaid covers the Medicare Part C deductible and coinsurance up to the Medicaid fee, less any amounts paid by Medicare. If this amount is negative, no Medicaid payment is made. If this amount is positive, Medicaid pays the coinsurance and deductible up to the billed or allowed amount, whichever is less. The Florida Medicaid system is in the process of being programmed to comply with the state’s policy governing Medicare Advantage plan copayments. The system changes will be retroactive to January 1, 2010

Slide 38 of the presentation states that full Medicaid over-rules lower programs. Then, on slide 61 it states that as the recipient is QMB along with full Medicaid, the provider can bill for level of care (Medicare coinsurance). Could you please clarify this issue?

The QMB coverage means that the person has Medicare (another payer) in addition to the Medicaid coverage. The “level of care” refers to Nursing Facilities. Even though this person does not have the Long Term Care Medicaid, they have Medicare that could pay for Nursing Facility days (up to a limit). In this case the facility can bill Medicaid for part A coinsurance only – level of care =X. Of course, during the process of verifying eligibility, you would have already seen the Medicare coverage information.

SLMB: What is the definition of a Medicare Premium?
The Medicare premium is the amount that a person with Medicare Part A and/or Medicare Part B pays to Medicare to receive coverage.

Can you go over reimbursement for Share of Cost Medicaid patients? Is Medicaid now paying the full 20% after Medicare pays 80% of their allowed amount?
Information on Medicaid reimbursement for persons with both Medicare and Medicaid (dual eligibles) can be found in Chapter 4 of the Florida Medicaid Provider General Handbook. Claims with Medicare as the primary payer are called crossover claims. In the section labeled “Medicaid Program Limits,” you will find the information on how Medicaid reimburses crossover claims. If the Medicare payment is greater than the Medicaid payment for the same procedure, you must accept the Medicare payment as “payment in full.” You cannot “Balance Bill” or require any additional payment from the recipient.

Medical billing basic - What is CPT

What is CPT? 

CPT was developed by the American Medical Association (AMA) in 1966. The AMA revises and publishes CPT each year to keep pace with changes in medical practice. They delete obsolete procedures, modify existing procedures, and add newly developed procedures.
Your physicians’ office should make it a policy to order the current book from the AMA each year. Begin using the new CPT codes on January 1.

•  listing of descriptive terms and five-digit, numeric codes for reporting medical services and procedures performed by physicians.

• provides a uniform language to accurately designate medical, surgical and diagnostic services.

•     serves as an effective means of reliable nationwide communication between physicians, patients and third-party payers.


Each time you submit a claim, identify the service provided by using one of these five-digit CPT codes, plus a two-digit modifier when appropriate.

HCPCS Levels of Codes

HCPCS is the acronym for the Healthcare Common Procedure Coding System. This system is a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies.

There are three levels of codes within the HCPCS system:

Level I. Level I is the largest component, made up of five-digit numeric CPT codes and two-digit modifiers. Both CPT codes and modifiers have descriptive terms for reporting services performed by health care providers. The first edition of CPT was published by the American Medical Association (AMA) in 1966 and it continues to release updates each year.

Example: 10060 * Incision and drainage of abscess

Level II. These national codes, created by The Centers for Medicare and Medicaid Services (CMS), were developed to cover services not specifically reported in CPT. Level II HCPCS codes consist of one alpha character (A through V), followed by four numbers. Level II HCPCS modifiers are two-digit codes which can be used with any level of codes. Level II codes are grouped by the type of service or supply they represent and are updated annually by CMS with input from private insurance companies.
Example: A4580 Cast supplies

Level III. Level III codes are used to report services and supplies that may be covered but not listed in the other two levels of HCPCS. These codes begin with a letter (W - Z) followed by four numeric digits. Wellmark has eliminated all Level III codes in accordance with HIPPA (Health Insurance Portability and Accountability Act of 1996) requirements.


Remember:

•     CPT* provides a uniform language to accurately designate medical, surgical and diagnos-tic services.

•     CPT and HCPCS are updated annually to reflect medical practice changes.

•     The AMA is responsible for revising CPT and CMS updates HCPCS Level II codes.

•    CPT is used to report the medical services and procedures performed by physicians to insurance carriers.

•    To assure that correct CPT codes are used for all procedures, a new CPT book should be purchased annually.

•    Choose a procedure code that accurately identifies the service performed. Do not choose an approximate code (use an unlisted code if none exists to accurately describe it).