Riverbend

ListServ Messages 04/04/2008

March 31, 2008

Information from The CMS. 

As a result of the delayed issuance of the following Change Requests, contractors have been instructed by The CMS to hold all Outpatient Prospective Payment System (OPPS) claims with discharge dates on and after April 1, 2008, until these Change Requests have been installed into production. Contractors will code all held claims as clean to meet the criteria to pay interest.

CR 5977, Type of Service (TOS) Corrections, 
CR 5980 April Update to the 2008 Medicare Physician Fee Schedule Database, 
CR 5982 April 2008 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and

Revisions to Prior Quarterly Pricing Files,
CR 5994 April 2008 Update to the ASC Payment System; Summary of Payment Policy Changes, 
CR 5999 April 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS); and
CR 5956 Instructions for FISS and MCS Healthcare Integrated General Ledger Accounting System (HIGLAS) Changes.

Please call our office at 1-877-296-6189 if you have questions.

Information from The CMS.

New:
MM5969  April 2008 Integrated Outpatient Code Editor (I/OCE) Specifications Version 9.1
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5969.pdf

MM5982  April 2008 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5982.pdf


NPI Reminder!  
The NPI is here.  The NPI is now.  Are you using it?

Important Information for Medicare FFS Providers

The NPI will be Required for all HIPAA Standard Transactions on May 23^rd
As of May 23, 2008, the NPI will be required for all HIPAA standard transactions.  This means:

For all primary and secondary provider fields, only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, DDE, 276/277, 270/271 and 835), paper claims (UB-04 and CMS-1500) and SPR remittance advice.   

The reporting of Medicare legacy identifiers in any primary or secondary provider fields will result in the rejection of the transaction.  

REMINDER: May 23^rd is Only Two Months Away, Be Prepared! 
TEST NPI only NOW

Now that the NPI is required on all Medicare claims in the primary provider fields, if your claims are being successfully processed with NPI/legacy pairs (and most are) now is the time to begin testing claims using the NPI alone.  If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should do this test now!  If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI.  If the claims reject, go into your NPPES record and validate that the information you are sending on the claim is consistent with the information in NPPES.  If it is different, make the updates in NPPES and resend a small batch of claims 3-4 days later.  If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem.  Call the Customer Service Representative at your Medicare carrier, FI, or A/B MAC enrollment staff or your DME MAC to discuss your situation and, if necessary, have it investigated. Have a copy of your NPPES record or your NPI Registry record available.  The contractor telephone numbers are likely to be quite busy, so don't wait.

Doing this testing now will allow time for any needed corrections prior to May 23, 2008, the date when only the NPI will be accepted in all provider fields.

Need More Information?
Still not sure what an NPI is and how you can get it, share it and use it?  As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.  Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.  Having trouble viewing any of the URLs in this message?  If so, try to cut and paste any URL in this message into your web browser to view the intended information. 

Note: All current and past CMS NPI communications are available by clicking "CMS Communications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand CMS webpage.

Visit the Medicare Learning Network  ~ it’s free!

April 1, 2008

Reminder: Important information from Riverbend GBA.
For Medicare Providers that are currently completing an 855A, please see the information below regarding the Most Common Errors noted on the 855A.  By following this guideline, our goal is to help you complete the 855A in a manner that will enable the approval process to be initiated on your first submission.  This information is also listed on our Website at www.rgbagov.com 
The link to the information below is:  http://www.rgbagov.com/Providers/Enrollment/Common-Errors/855A.shtml

Most Common Errors on the CMS 855A

Section 1A
Marking the wrong reason for submitting the application

Missing the NPI and Medicare number on Change of Ownership and Change of Information applications.

On CHOW applications, the NPI reported for new owner is the NPI of the old owner. New owner needs a NPI for the facility that matches the legal business name and tax id number for the new owner.

Section 1B
Failure to complete all sections required for the type of application being submitted

Section 2A
Marking the incorrect type of provider

Section 2B1
Legal Business Name does not match IRS documentation.

• Missing IRS Documentation.
  
• Missing the Medicare Year-End cost report date.
  
• Missing the Incorporation Date and State where incorporated
  
• Missing incorporation documentation
  
• For sole proprietor, the tax identification number (TIN) is the individual’s SSN not the Employer Identification Number (EIN) for the provider.
  
• For sole proprietor, the name on the 1st line of the IRS CP575 is the legal business name. The name on the 2nd line is the Doing Business Name (DBA) name.
  
  Section 2B2
• Failure to check not applicable box if not completing this section for licensure
  
• Failure to check not applicable box if not completing this section for certification
  

• The legal business name does not match the one reported in Section 2B1 of the old owners CHOW 855A.

Section 3
This section does not have yes or no marked.

• The zip code is missing the additional 4 digits
  
• Missing telephone and fax numbers
  
• NPI number missing and/or no NPI documentation attached.
  
• NPI documentation does not match name or address on 855A.
  
• The NPI reported is for a physician and not the facility
  
• For a CHOW, the NPI reported in 4A does not match the NPI reported in 1A.
  
• CLIA number is missing. Enter N/A if it does not apply or Pending if you have applied but not received the number.
  
• Medicare number reported is not a Part A or OSCAR number.
  
• For sole proprietor, the NPI reported on the 855 should be associated with the individuals SSN in NPPES.

Section 4B

• EFT (CMS Form 588) agreement and/or documentation is missing
  
• Did not answer special payments address, or did not include the plus 4 in the zip code.

• This section should have the box marked for Not applicable or be completed.
  
• Zip code is missing the additional 4 digits.
  
• Failure to complete this section for the home office in Section 7.
  
• Missing IRS documentation for tax id numbers for all entities reported.

• If 5A is completed then this section should be answered yes or no.
  
• If 5A is not completed then this section should be left blank.

• Entire section is left blank. This section should be completed for each officer, owners, partners and/or managing employees of the facility.
  
• Failure to report at least one person as a managing employee.
  
• Failure to complete this section for the authorized and/or delegated official.
  
• Failure to complete this section for the Administrator or CEO of the home office in Section 7.
  
• Missing or incorrect Social Security numbers or dates of birth
  
• Reporting NPI and Medicare number that do not belong to the individual in this section.

• Failure to mark fields all that apply.
  
• Failure to report at least one person as a managing employee.

• If 6A is completed then this section should be answered yes or no.
  
• If 6A is not completed then this section should be left blank.

• Failure to complete this section or mark that it is not applicable
  
• If section is completed, ensure the Home Office fee-for-service contractor and Home Office Chain number is listed.
  
• If section is completed, need to include additional 4 digits in the zip code.

• Failure to complete this section or mark that it is not applicable
  
• If completed, ensure a copy of the billing agreement is attached and enter an effective date.
  
• If completed, need to include additional 4 digits in the zip code

• Failure to mark the box that indicates that this section does not apply if the section is not completed.

• Signature and dates in this section are not an original signature. Do not submit copies or stamped signature. Use blue ink to authenticate signature.
  
• This section should be signed and dated by an officer, owner or partner of the facility, not a managing employee.
  
• A section 6 must be completed on the individual signing this section of the application.
  
• The person signing is not officer, partner, or owner of the applicant/facility but is an officer or partner of an owning or parent company.

• Application does not have an original signature and date
  
• Person signing this section must also have a section 6
  
• Person signing this section must be an officer, partner, or owner of the applicant but not of an owning or parent company.
  
• The person has indicated in Section 6 that they are a contracted managing employee. Delegated officials must be W-2 employees.

• IRS verification of the TIN reported in Sections 2B1, 5 or 7.
  
• NPI notification from NPPES for the NPI reported in 4A.
  
• EFT Agreement.
  
• Copy of adverse legal action documentation if applicable.
  
• Attestation from government entities that they are liable for any debts owed to CMS when applicable.
  
• Copy of the final bill of sale or sales agreement with all exhibits referenced in the agreement for a change of ownership
  
• The names/entities on the bill of sales or sales agreement do not match the names on the old and new owner CHOW 855As.
  
  Let’s Go Paperless…
  
  We are encouraging all providers to submit their cost report supporting documentation on electronic media instead of in hardcopy.  We can accept flash drives, compact discs (CD), or 3 ¼ floppy disks.  Logs for bad debts, disproportionate share, injections, etc. that are submitted electronically (Excel versions please!) are much easier for our staff to review. We can accept Excel files, Word documents, .tif and .pdf files.  Please ensure your electronic files are properly labeled so our staff can determine what the files represent.
  
  Submitting electronic files in lieu of paper will also reduce your postage cost for mailing the cost report since it won’t weigh nearly as much.  CMS does still require that you submit the certification page of the cost report and the CMS Form 339 Questionnaire with original signatures so we still require hardcopies of these documents.If you are unable to provide all of your supporting documentation electronically, please do not use staples, spiral binders or notebooks to separate or hold your data.  Effective, May 1, 2008, Riverbend will image all incoming mail (including cost reports).  Paper clips, binder clips, rubber bands, or folders are acceptable.  If you are submitting more than one cost report in a package, please ensure proper separation of the various reports.
  
  If you have questions, contact Riverbend’s Provider Audit & Reimbursement department at (423) 535-5906.

This listserv message is being resubmitted as a reminder of the payment floor explanation.  

The Medicare Claims Processing Manual; 100-04, Chapter 1, General Billing Requirements located at: http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf  provides payment floor explanations for both clean and non-clean claims received by an FI/Carrier.  The information listed below is excerpts from the manual, and will aide providers in accurately determining within which time-frame Medicare payment will be made for your claims.

Section 80.2.1.2  of the Medicare Claims Processing Manual; 100-04 Chapter 1 - General Billing Requirements, defines the Payment Floor Standards as:

The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date� is the earliest day after receipt of the clean claim that payment may be made. The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

Based on the waiting periods, the payment floor dates are as follows:

Claim Receipt Date                           Payment Floor Date
07-01-04 and later                           14th day for HIPAA-compliant EMC
                                                      27^th day for paper and non-HIPAA EMC

01/01/2006 and later                        29^th day for paper

Section 80.3 of the Medicare Claims Processing Manual; 100-04 Chapter 1 - General Billing Requirements, defines Other Claims (other than clean) as:

Claims that do not meet the definition of clean claims are other claims. Other claims require investigation or development external to the carrier or FI’s Medicare operation on a prepayment basis. Other claims are those that are not approved by CWF for payment that the FI identifies as requiring outside development.

Examples are claims on which the provider’s FI/carrier:

Requests additional information from the provider or another external source. This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;

Requests information or assistance from another contractor. This includes requests for charge data from the carrier, or any other request for information from the carrier;

Develops Medicare Secondary Payer (MSP) information; 

Requests information necessary for a coverage determination;

Performs sequential processing when an earlier claim is in development; and

Performs outside development as a result of a CWF edit.

Section 80.2.2 the Medicare Claims Processing Manual; 100-04 Chapter 1 - General Billing Requirements, clarifies interest payments- Interest Payment on Clean Non-PIP Claims Not Paid Timely as:

Interest must be paid on clean claims if payment is not made within the applicable number of calendar days (i.e., 30 days) after the date of receipt as described above. The applicable number of days is also known as the payment ceiling. For example, a clean claim received on October 1, 1993, must have been paid before the end of business on October 31, 1993. Interest is not paid on:

Claims requiring external investigation or development by the provider’s FI or carrier;

Claims on which no payment is due;

Full denials;

Claims for which the provider is receiving PIP; or

HH PPS RAPs

Interest is paid at the rate used for §3902(a) of title 3l, U.S. Code (relating to interest penalties for failure to make prompt payments). The interest rate is determined by the applicable rate on the day of payment.

Providers are encouraged to review these manual sections for clarification regarding clean and non-clean claims and payment floor application.

April 2, 2008

The following is an important message regarding Quarterly updates to the Prospective Payment (PPS) Pricer.    

Riverbend GBA receives mandated software updates quarterly from The CMS regarding the Prospective Payment (PPS) Pricers that are necessary to properly adjudicate Medicare claims.  This update process requires an installation and testing phase of the software by the Riverbend systems.  
|
Claims that are received by Riverbend into FISS prior to the installation and testing phase completion will be placed in a temporary hold location with an assignment of “SMHKXXâ€�, (the XX being representative of any set of letters or numbers and are specific to pricer software we may still be testing).  The Current Hold locations and temporary suspend reason codes are:

Hold Location          Reason Code Assigned
SMHOOK                    WW200 – This Reason Code will hold any claims (that come in with service dates in the new quarter until the releases are installed, effective the first Monday of the new quarter to insure the claims process correctly.) 

SMHKIP                      37150
SMHKSN                     37148
SMHKOP                    OPPS1
SMHKLT                     37167
SMHKHC                    HCP07
SMHKIR                      37147 (Inpatient Rehab Facility)
SMHKPS                     37181 (Inpatient Psychiatric Facility)

The claims will be held in this location until the software testing is completed, but no longer than 14 days from the date the changes were installed. At that time the claims will be released into FISS for processing.  If The CMS anticipates the hold will surpass the normal 14 day payment process, specific instructions will be sent from The CMS and the affected providers will be notified via the Riverbend GBA Listserv.  

The Riverbend Website at www.rgbagov.com has an available listing of claims currently placed in certain hold locations.  The list includes; location ID, number of claims in each location, and the reason for the hold. Also listed is release information that is known to Riverbend. 


April 3, 2008

Now Available!  The Medicare Learning Network (MLN) Matters Special Edition Article # SE0805 entitled ~ “Overview of New Medicare Competitive Bidding Program for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) – The first in a series of articles on the implementation of this program.â€� ~ is now posted on the CMS Website at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0805.pdf.

This is the first in a series of educational articles that will assist you in understanding this new DMEPOS program and help you interact with your patients.  The new program begins July 1, 2008 and additional educational materials will be made available to you as we approach this date.

This article will be of particular interest to any provider that that may order, refer, or supply durable medical equipment to a Medicare beneficiary affected by the new Medicare DMEPOS Competitive Bidding Program. 

 
The Centers for Medicare & Medicaid Services (CMS) has developed a fact sheet that explains the program for Medicare beneficiaries. This fact sheet, entitled, “What You Should Know if You Need Medicare-covered Equipment or Supplies� is available at, http://www.medicare.gov/Publications/Pubs/pdf/11307.pdf. You may want to provide this fact sheet to your Medicare patients.

Flu Shot Reminder
It’s Not Too Late to Give and Get the Flu Shot!

In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination.  Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated!

Remember - Influenza and pneumococcal vaccinations and their administration are covered Part B benefits.  Note that influenza and pneumococcal vaccines are NOT Part D covered drugs.  You and your staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748  http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS website.

Information from The CMS.
New:
SE0810 – Announcing the Release of the Revised CMS-855 Medicare Enrollment Applications
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0810.pdf