Name of Manual

Transcription

Name of Manual

Employer Provider Network, Inc
(EPNI)
Provider Policy &
Procedure Manual
CPT codes copyright 2014 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA.
Summary of Changes (2014)
Chapter 1 – At Your Service
Date
4/22/14
Page(s)
1-5 to 1-8
Summary of Change
Care Management Contact Information table was updated with current
phone and fax numbers.
Chapter 2 – Provider Agreements
Date
Page(s)
Summary of Change
Chapter 3 – Health Care Improvement
Date
Page(s)
Summary of Change
Chapter 4 – Care Management
Date
4/22/14
5/12/14
Page(s)
4-33
Summary of Change
Plan-of-Care Review Procedure topic:
 Removed reference to MCS and made it more generic.
all
Updated manual to reflect changes made in Blue Cross Manual.
Updated UM information.
4-14, 19,
20, 22, 25,
26, 27, 30,
31, 32, 45
References to the Pre-Authorization Request Form updated and
CCStpa hyperlinks added throughout chapter.
Chapter 5 – TRICARE
Date
Page(s)
Summary of Change
Chapter 6 – Claims Filing
Date
Page(s)
EPNI Manual (12/01/14)
Summary of Change
1
Summary of Changes (2014)
Chapter 7 – Reimbursement Reconciliation
Date
12/01/14
Page(s)
7-1, 7-6
Summary of Change
Definitions and settlement language updated
Chapter 8 –Appeals
Date
Page(s)
Summary of Change
Chapter 9 – Coding Policies and Guidelines
Date
Page(s)
Summary of Change
Chapter 10 – Template Policies and Procedures
Date
2
Page(s)
Summary of Change
EPNI Manual (12/01/14)
Chapter 1
At Your Service
Table of Contents
Introduction................................................................................................................................ 1-2
Provider Policy and Procedure Manual ................................................................................. 1-2
EPNI Overview...................................................................................................................... 1-2
CPT Copyright..................................................................................................................... 1-2
How to Contact Us ..................................................................................................................... 1-3
Provider Services ................................................................................................................... 1-3
Provider Inquiry / Appeal Form............................................................................................. 1-4
General Address..................................................................................................................... 1-4
Claims Address ...................................................................................................................... 1-5
Care Management Numbers and Addresses .......................................................................... 1-5
Other Numbers and Addresses............................................................................................... 1-8
ID Cards...................................................................................................................................... 1-9
Introduction............................................................................................................................ 1-9
ID Cards ................................................................................................................................. 1-9
Helpful Tips ......................................................................................................................... 1-10
Electronic Commerce .............................................................................................................. 1-11
Overview.............................................................................................................................. 1-11
Electronic Transactions........................................................................................................ 1-11
Electronic Data Interchange (EDI) Guidelines .................................................................... 1-11
Provider Communications ...................................................................................................... 1-12
EPNI Provider Policy and Procedure Manual (04/22/14)
1-1
At Your Service
Introduction
Provider Policy and
Procedure Manual
Employer Provider Network, Inc. (EPNI) developed the Provider
Policy and Procedure Manual for participating health care
providers and your business office staff. The manual provides
information about our claims filing procedures, payment, provider
agreements, managed care requirements, communications, and
other topics that affect patient accounts and patient relations. As
our policies and procedures change, we will keep you updated
through Provider Bulletins, Quick Points, and the Provider Press,
found on our website at www.ccstpa.com. Information in this
manual is a general outline but is part of your provider contract.
Provider and member contracts determine benefits.
EPNI Overview
EPNI is a general business corporation which contracts with health
care providers to establish open access and managed care networks
for third party administrators, such as Comprehensive Care
Services, Inc. (CCStpa).
CPT Copyright
CPT codes copyright 2010 American Medical Association. All
Rights Reserved. CPT is a trademark of the AMA. No fee
schedules, basic units, relative values or related listings are
included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to
government use.
1-2
At Your Service
How to Contact Us
Provider Services
A conversation with one of our service representatives often can
solve a problem immediately or give you an answer to a claims
question. The representatives answering the provider services
numbers are available to assist you:

Monday – Thursday ..........8:00 a.m. – 5:00 p.m. CT
 Friday ................................9:00 a.m. – 5:00 p.m. CT
In an industry that is constantly changing, ongoing education of
our provider services representatives is necessary. To meet this
challenge, we conduct staff training every Friday morning from
8:00 - 9:00 a.m.
Please have your provider number and if applicable, the member’s
identification number, account number, and claim number ready
when you call. The provider services telephone numbers listed are
for the provider’s use only. Please refer members to the customer
service telephone number on the back of their member ID card.
The general provider services phone numbers are:
(651) 662-5940 (Twin Cities area) and 1-800-365-2735
(toll-free). Listen for the current phone options when you call.
The general provider services fax number is (651) 662-1533.
1-3
At Your Service
Provider Inquiry /
Appeal Form
The Provider Inquiry and the AUC Appeal forms are designed for
providers to fax or mail inquiries and appeals to EPNI.
Fax the form to the number listed on the form or mail it to the
general EPNI address.
All the fields are required to be completed, if applicable. Make
sure to clearly state the contact name, phone number, and fax
number on all correspondence.

Inquiries
The inquiries can be an adjustment request or claim status
request.
The form will not be returned to you unless we need
clarification on your request. All adjustments that are
completed will be found on a future Remittance Advice.

Appeals
You will receive written notification if your request is denied.
All adjustments that are completed will be found on a future
Remittance Advice.
A sample of the Provider Inquiry form can be found at:
ccstpa.com.
The AUC Appeal form can be found at:
www.health.state.mn.us/auc/index.html
General Address
The general address is:
Employer Provider Network, Inc.
P.O. Box 64560
St. Paul, MN 55164-0560
Inquiries and appeals should be mailed to this address.
1-4
At Your Service
Claims Address
Submit claims electronically whenever possible. All participating
providers are required to electronically submit all claims. Paper
claims submitted by the provider will be rejected and will need to
be resubmitted electronically. EPNI will not consider such paper
claims to have been received until resubmitted electronically. If
mailing a scannable claim form, please use the address listed
below:
Employer Provider Network, Inc. Claims
P.O. Box 64338
St. Paul, MN 55164-0338
Care Management
Numbers and
Addresses
The phone numbers, fax numbers and addresses for care
management programs and services are listed below.
The most current pre-authorization/pre-certification list and current
medical policies are located ccstpa.com under “For Providers”.
Additional review guidelines are also found in chapter four of this
manual, Care Management. Providers can also contact Provider
Services at (651) 662-5940 (Twin Cities area) or 1-800-365-2735
(toll-free). for assistance.
Area
Phone/Fax Numbers
and Addresses
Case Management
1-866-489-6947
Disease Management
1-866-489-6947
Prenatal Support
1-866-938-9743
Preadmission Notification
(PAN)
PANs should be submitted on
Provider self-service
Provider self-service:
www.availity.com
General inquiries:
Phone: 1-866-938-9741
Fax: 1-866-938-9754
Behavioral Health Review
(Outpatient)
Fax: (651) 662-0854
Mail:
Integrated Health
Management
Behavioral Health, R472
P.O. Box 64265
St. Paul, MN 55164-0265
Behavioral Health Review
(Inpatient)
Phone: 1-866-938-9741
Fax:
1-866-938-9754
1-5
At Your Service
Area
Phone/Fax Numbers
and Addresses
Chiropractic Review
Fax: (651) 662-7816
Mail to:
Integrated Health Management
Allied Team, R472
P.O. Box 64265
St. Paul, MN 55164-0265
Medical Dental Review
Fax: (651) 662-2810
Pre-service requests can be
mailed or faxed
Mail:
Utilization Management, R472
P.O. Box 64265
St. Paul, MN 55164-0265
Durable Medical Equipment
Review
Fax: (651) 662-2810
mailed or faxed
Home Care Review
 Home Health Services
 Home Infusion Services
 Hospice Care
mailed or faxed
Inpatient Admission
Pre-Certification Review
Mail:
P.O. Box 64265
St. Paul, MN 55164-0265
Fax: (651) 662-1004
Mail:
Allied Team, R472
P.O. Box 64265
St. Paul, MN 55164-0265
Phone: 1-866-938-9741
Fax: 1-866-938-9754
For medical and behavioral
health related inpatient
admissions
Pre-certification requests can be
submitted via fax or phone
1-6
At Your Service
Phone/Fax Numbers
and Addresses
Area
Care Management
Numbers and
Addresses (continued)
Outpatient Therapy Review
(PT, OT, SLP)

Pre-service requests can
be mailed or faxed
Fax: (651) 662-7816
Mail:
Allied Team, R472
P.O. Box 64265
St. Paul, MN 55164-0265
Skilled Nursing Facility
Admission Review
Fax: (651) 662-1004
Transplant Review
Fax: (651) 662-1624
mailed or faxed
Mail:
Transplant Team, R472
P.O. Box 64265
St. Paul, MN 55164-0265
All Other Medical
Procedure Review
Fax: (651) 662-2810
mailed or faxed
Mail:
P.O. Box 64265
St. Paul, MN 55164-0265
1-7
At Your Service
Other Numbers and
Addresses
These phone numbers, fax numbers and addresses may be helpful
to you.
Company
Phone Number
Address
Delta Dental of Minnesota
(651) 406-5900 or
1-800-328-1188
Fax: (651) 406-5934
Delta Dental
3560 Delta Dental Drive
Eagan, MN 55122
USAble Life
(651) 662-5065
1-800-859-2144
USAble Life
3535 Blue Cross Road
P.O. Box 64193
St. Paul, MN 55164-9828
Prime Therapeutics, LLC.
(651) 286-4000 or
1-800-858-0723
Prime Therapeutics
1020 Discovery Rd.
Eagan, MN 55121
Customer Service
Refer the member to their
customer service number printed
on the back of their ID card. They
may also call (651) 662-5425 or
1-866-356-2425 (toll-free).
Fraud Hot Line
(651) 662-8363 or
1-800-382-2000 ext. 28363
1-8
At Your Service
ID Cards
Introduction
ID Cards
Your patient’s ID card contains information that is essential for
claims processing. We recommend that you look at the patient’s
ID card at every visit and have a current copy of the front and back
of the card on file. Some of the following information is found on
the ID card:

Name of the plan

Member’s ID number including alpha prefix

Member’s name and group number

Primary care clinic (PCC) name - for managed care plans only

EPNI plan code

Prescription coverage

Copay for prescription drugs

Copay for office visits

Dependent-coverage indicator

Claims submission information
Note: Workers’ Compensation - The Minnesota Department of
Labor and Industry requires the use of Social Security numbers for
anyone who has ever filed a work comp claim.
1-9
At Your Service
Helpful Tips
1-10
EPNI plans have the option of creating identifiers with any
combination of up to 14 letters or digits following the three digit
alpha prefix.

Verify the identity of EPNI cardholders by asking for
additional picture identification. If you suspect fraudulent use
of an ID card, please call our fraud hot line at (651) 662-8363.
You may remain anonymous.

Ask members for their current ID card and regularly obtain
new photocopies (front and back). Having the current card will
enable you to submit claims with the appropriate member
information and avoid unnecessary claims payment delays.

Check eligibility and benefits by calling (651) 662-5940 or
1-800-365-2735.

If the member presents a debit card be sure to verify the
copayment amount before processing payments.

Do not use the card to process full payment up front. If you
have questions about the debit card processing instructions or
payment issues, please contact the toll-free debit card
administrator’s number on the back of the card.
At Your Service
Electronic Commerce
Overview
An important part of EPNI’s cost containment strategy is
automating the electronic exchange of information.
Electronic Transactions
Electronic transactions option includes the submission of the
following HIPAA compliant transactions:

Healthcare Electronic claim submission (837 P and I)

Healthcare Electronic remittance advice (835)

Healthcare Benefit request and response (270/271)

Healthcare Claims status request and response (276/277)

Healthcare Service review- Request for review and response
(278)
EPNI uses Availity for exchanging HIPAA mandated EDI
transactions. You can get information on how to register and
conduct electronic transactions through Availity by going to
availity.com.
Electronic Data
Interchange (EDI)
Guidelines

Minnesota Statute 62J.536 requires all Minnesota providers to
submit claims electronically to Minnesota group purchasers. In
addition, participating out-of-state providers are required by
contract to submit all claims electronically.

All nonparticipating, out-of-state providers who do not have
electronic claim submission capabilities must submit claims on
an optical character recognition scannable claim form.

EPNI reserve the right to modify these guidelines with advance
written notice.

Providers are encouraged to obtain or develop EDI transaction
software from the many sources available.
1-11
At Your Service
Provider Communications
Provider
Communications
1-12
EPNI publishes the following communications for providers.
Title
Description
Provider Bulletins
EPNI communicates immediate policy and
procedure changes through Provider
Bulletins. The Provider Bulletins are
contractually binding. Portions of this
manual will also be updated periodically to
reflect policy and procedure changes.
Provider
Information
Quick Points
This is a communication tool that we are
using to get helpful information to you.
Medical Policy
Update
This update is included as part of the
Provider Press on a quarterly basis. The
update contains a summary of medical
technologies that have been reviewed,
revised, or are new to EPNI’s investigative
list. Prior Authorization Request
requirements are also indicated in this
publication.
Chapter 2
Provider Service Agreements
Table of Contents
Participation and Responsibilities ............................................................................................ 2-2
Advantages of Participation................................................................................................... 2-2
Responsibilities of Participating Providers............................................................................ 2-2
Requirements of Minnesota Law ........................................................................................... 2-5
EPNI’s Responsibilities ......................................................................................................... 2-5
Written Notification and Provider Liability........................................................................... 2-6
Credentialing .............................................................................................................................. 2-7
Overview................................................................................................................................ 2-7
Provider Numbers .................................................................................................................. 2-7
National Provider Identifier (NPI) ......................................................................................... 2-7
Overview................................................................................................................................ 2-8
Credentialing Requirements and Processes ........................................................................... 2-8
Provider Questions and Answers ......................................................................................... 2-10
Accounting for Disclosure Request ........................................................................................ 2-25
Guidelines for the Accounting Disclosure Request ............................................................. 2-25
When to Use the Form ......................................................................................................... 2-25
Disclosures Related to Provider’s Status as a Business Associate ...................................... 2-26
Carrier Replacement Law....................................................................................................... 2-27
Carrier Replacement ............................................................................................................ 2-27
How Carrier Replacement Works........................................................................................ 2-27
Continuous Stay ................................................................................................................... 2-27
Self-Funded Groups ............................................................................................................. 2-27
Governmental and Compliance Required Provisions .......................................................... 2-28
Overview.............................................................................................................................. 2-28
Governmental Required Definitions .................................................................................... 2-28
Compliance with Laws ........................................................................................................ 2-29
HIPAA Requirements .......................................................................................................... 2-31
Non-Interference .................................................................................................................. 2-35
Network Access Agreements............................................................................................... 2-36
Termination of Provider Service Agreements....................................................................... 2-37
Required Notification........................................................................................................... 2-37
2-1
Participation and Responsibilities
Advantages of
Participation
Responsibilities of
Participating Providers
2-2
Advantages of being an Employer Provider Network, Inc. (EPNI)
participating provider include:
•
Direct payment from EPNI reduces administrative expense and
improves cash flow
•
EPNI Subscribers have financial incentives to use participating
providers
•
Participating providers’ names are included in directories that
EPNI publishes for its Subscribers
•
EPNI Provider Service Agreements do not contain exclusivity
clauses that prohibit providers from participating with other
health plans
•
Participating providers receive a Statement of Provider Claims
Paid or electronic 835 remittance explaining how claims are
processed
•
Opportunity to attend provider seminars offered free of charge
by EPNI
•
Dedicated service staff available to assist participating
providers
•
Electronic options such as provider web self-service to obtain
information
Responsibilities of being a participating provider include:
•
Participating providers are required to electronically submit all
claims. Paper claims will be rejected and will need to be
submitted electronically. EPNI will not consider such paper
claims to have been received until resubmitted electronically.
•
Participating in the EPNI credentialing process.
•
Participating in EPNI managed care programs.
Responsibilities of
(continued)
•
Submitting preadmission notifications (PANs) or prior
authorizations or Pre-certifications when required. PANs may
be submitted through provider web self-service or faxed to 1866-938-9754.
•
Referring Subscribers to other participating EPNI providers
and facilities.
•
Accepting payment provisions outlined in the Provider Service
Agreement. If EPNI determines that Health Services are
experimental, investigative, or not Medically Necessary,
providers may not bill the Subscriber unless the provider gives
the Subscriber written notification of non-coverage
immediately before the Health Services are performed.
•
Notifying EPNI of new programs prior to implementation (i.e.,
technology, new procedures being performed).
•
Maintaining confidentiality of EPNI's contractual and financial
arrangements.
Health Services rendered by all providers must be within the scope
of the provider’s registration, license, and training and consistent
with community standards for quality and utilization.
•
Agreeing not to bill EPNI for any professional services
provided by Health Care Professionals to themselves, their
immediate family members or those living in the same
household. Immediate family members include the Health Care
Professional's spouse, children, parents or siblings.
•
Agreeing not to bill Subscribers for missed scheduled
appointments except for missing a scheduled behavioral health
appointment, provided the provider has notified the Subscriber
in writing in advance that this is the provider's policy.
2-3
Responsibilities of
(continued)
2-4
•
Promptly furnishing at the provider’s own expense any
additional information that EPNI or the Plan Sponsor shall
reasonably request as necessary to respond to claims,
utilization review, coordination of benefits, quality
improvement and care management review, and medical
abstract reports. The provider shall be responsible for obtaining
any authorization required to release such information to EPNI
or the Plan Sponsor.
•
Collecting appropriate copayment amounts and not waive these
amounts, in accordance with applicable law.
•
Billing the Subscribers for services listed as exclusions in the
Subscriber Contract.
•
Participating providers may not collect any difference between
the amount billed and EPNI’s allowance for covered Health
Services, except for Subscriber liabilities such as deductibles
and copayment amounts.
•
Charging the general public the same amounts as EPNI
Subscribers (individual hardship cases are an exception).
•
Billing only for Health Services personally performed by
Provider's medical staff or other Health Care Professionals
employed by Provider or a facility that meet the eligibility
criteria defined by EPNI.
Requirements of
Minnesota Law
EPNI’s Responsibilities
Minnesota law requires participating providers to look to EPNI for
payment of Health Services covered by the Subscriber Contract.
Following are requirements:
•
Except for copayments, deductibles and coinsurance amounts,
providers may not bill Subscribers for Health Services covered
by their EPNI health plan until EPNI has completed processing
of the claim or adjustment.
•
Providers may not refer a Subscriber's account to collection for
nonpayment of Health Services covered by the EPNI health
plan. Copayments, coinsurance and deductibles can be
coordinated through Provider's normal billing, and if
applicable, its collections process.
•
Interest on Health Services covered by EPNI may not be
applied to a Subscriber's account.
•
Effective August 1, 2010, Minnesota Statute [62Q.751] allows:
•
Providers may collect deductibles and coinsurance from
Subscribers at or prior to the time of service.
•
Providers may not withhold a service to a Subscriber based
on a Subscriber's failure to pay a deductible or coinsurance
at or prior to the time of service.
•
Overpayments by Subscribers to providers must be
returned to the Subscriber by the provider by check or
electronic payment within 30 days of the date in which the
claim adjudication is received by the provider.
EPNI’s responsibilities include the following:
•
Make payment directly to participating providers for covered
Health Services, respond to inquiries and resolve claims in a
timely manner
•
Maintaining confidentiality of a provider’s charge data in
accordance with the terms of the Provider Service Agreement
•
Establishing a peer-review process to make decisions about
Medical Necessity
•
Keeping Subscribers informed of participating providers
through publication of directories
•
Keeping providers informed of changes which are
contractually binding through Provider Bulletins or other
communications (e.g. Provider Policy & Procedure Manual)
2-5
Written Notification
and Provider Liability
2-6
If it is necessary to recommend that a Subscriber see a
nonparticipating provider, the participating provider must give the
Subscriber advance, written notification that the recommendation
is to a nonparticipating provider. Once notice is given, the
Subscriber is responsible for any increased liability if he or she
decides to schedule the service. If a Subscriber is not properly
informed, the provider making the recommendation to a
nonparticipating provider will be liable for increased costs that a
Subscriber incurs. Please refer to Waivers in Chapter 4.
Credentialing
Overview
EPNI works with many different types of providers through its
Provider Service Agreements to establish networks of participating
providers.
Provider Numbers
Contracting provider numbers are assigned to providers for
contracting purposes. Atypical providers must use this number for
billing as well. Other providers will use their NPI for billing. In
addition, individual provider numbers are assigned to atypical
practitioners to identify which individual performed specific
services. All other providers will use their NPI for billing. Each
practitioner’s service must be within the scope of their registration,
license, training and consistent with community standards for
quality and utilization.
National Provider
Identifier (NPI)
The Health Insurance Portability and Accounting ActAdministrative Simplification (HIPAA-AS) is the result of
legislation passed by the U.S. Congress. The legislation mandates
standards for business to business electronic data interchange and
code sets, establishes uniform heath care identifiers and seeks
protection for the privacy and security of patient data.
As it pertains to uniform health care identifiers, the Department of
Health and Human Services (DHHS) published the final ruling for
the implementation of the National Provider Identifier (NPI) on
January 23, 2004.
The NPI is a unique all numeric 10 digit number that is assigned
by the Centers for Medicare & Medicaid Services (CMS). The NPI
replaces all payer assigned providers identifiers, individual and
facility, and will be the single provider identifier with which you
do business.
The purpose of implementing the NPI is to improve the efficiency
and effectiveness of the health care system by reducing the number
of identifiers associated with any specific provider or provider
facility. Implementation will simplify provider identification and
billing processes across multiple third party payers (including
government programs) and prevent fraud and abuse.
Providers who are covered entities (as defined by HIPAA) began
applying for NPIs on May 23, 2005, the effective date of the final
rule. NPIs must be used solely by providers, clearinghouses and
payers as a means to identify provider covered entities.
To register on-line or to find the NPI paper application form,
access the CMS website at http://nppes.cms.hhs.gov.
It is a provider's responsibility to report its NPI to payers.
2-7
Overview
EPNI uses a credentialing process to provide Subscribers with a
selection of Providers and Health Care Professionals which have
demonstrated backgrounds consistent with the delivery of high
quality, cost-effective health care. The credentialing criteria that
EPNI has established serve as the foundation for determining
eligibility in all EPNI networks. Providers and Health Care
Professionals are expected to remain in compliance with
credentialing criteria at all times.
Credentialing
Requirements and
Processes
To learn more about credentialing requirements and processes,
please reference the Credentialing and Recredentialing Policy
Manual, available at CCStpa.com. Credentialing requirements
include, but are not limited to the following:
2-8
•
EPNI may require credentialing no less than every three years.
Recredentialing may occur as often as EPNI determines
necessary. Providers may appeal adverse credentialing or
recredentialing decisions through EPNI's established appeal
process as specified in the Credentialing and Recredentialing
Policy Manual.
•
In the event one or more of Provider’s Health Care
Professionals are excluded from participation with EPNI,
because he or she has not met the credentialing standards of
EPNI or because EPNI has terminated or suspended the Health
Care Professional as provided for in the Provider Service
Agreement, that Health Care Professional will be treated as a
nonparticipating provider by EPNI. Provider agrees to provide
prior written notice to any Subscriber receiving treatment from
such Health Care Professional that he or she is
nonparticipating. If such notice is not provided, neither
Provider nor Provider’s nonparticipating Health Care
Professional may collect from the Subscriber more than the
amount allowed by EPNI. Provider further agrees to be
responsible for any applicable nonparticipating penalty
payments required in Subscriber Contracts and to hold
Subscriber harmless for these payments in such circumstances.
Either the affected Health Care Professional or the Provider, on
behalf of the affected Health Care Professional, may appeal a
suspension or for cause termination as specified in the
Credentialing and Recredentialing Policy Manual. This
provision shall survive termination of this Agreement.
Credentialing
Requirements and
Processes
(continued)
•
Some participating Health Care Professionals are exempt from
EPNI's credentialing and recredentialing process unless a
potential quality of care issue arises, at which time EPNI will
undertake a standard credentialing or recredentialing process.
In all cases, Provider is responsible for verification that Health
Care Professionals hold and maintain (a) a current and
unrestricted license, registration, or certification appropriate to
their practice; and (b) minimum malpractice coverage
appropriate to their scope of practice (not less than $1 million
per incident) except to the extent the health care professional is
covered by a state or federal Tort Claim Liability statute. The
Credentialing and Recredentialing Policy Manual contains a
listing of health care professional specialties for which
credentialing is required.
Sanctions, Reprimands or Investigations
EPNI reserves the right to terminate the Provider Service
Agreement upon 30 days' prior written notice to Provider with
respect to any Provider or Health Care Professional of a Provider
which fails to complete the credentialing or recredentialing process
or is sanctioned or reprimanded by any review organization,
including but not limited to, any other health insurer or health plan,
peer review organization, hospital medical staff or any state
licensing board. Providers must immediately notify EPNI in
writing of any such sanction or reprimand or any investigation of
any Provider or Health Care Professional of which Provider is
aware. If the sanction or reprimand is limited to a single Health
Care Professional, then the termination shall be effective only to
that Health Care Professional.
2-9
Provider Questions and
Answers
1. Why is EPNI recredentialing providers?
EPNI believes that the credentialing and recredentialing of
Health Care Practitioners is an essential step in ensuring that
highly qualified Health Care Practitioners treat its Subscribers.
This is an important risk management process for EPNI. EPNI
feels that the regular monitoring of Health Care Practitioners
through the initial and periodic recredentialing process will
allow it to ensure that practitioners in its networks are qualified
to provide safe and effective care.
2. What do I need to do to be recredentialed?
EPNI will send forms that need to be completed about four
months in advance of the month that the process must be
completed. If Provider has additional questions, call provider
services at (651) 662-5200 or toll free at
1-800-262-0820.
3. What forms must I complete?
EPNI will send the Health Care Professional a pre-populated
credentialing application form that the Health Care
Professional will be able to update and fill in missing
information. If EPNI is unable to provide the Health Care
Professional with a pre-populated credentialing application, the
Health Care Professional will be instructed to download the
Minnesota Uniform Credentialing Application form that is
available by calling provider services. Completed forms may
be mailed or faxed.
Fax: (651) 662-2905
Mail:
EPNI
Credentialing Department, R3-11
P.O. Box 64560
St. Paul, MN 55164-0560
2-10
Answers
(continued)
4. How long does the credentialing process take and how will
I be notified?
It currently takes an average of 45 days to complete the
credentialing process. If an application is either incomplete or
requires additional research it will take longer. It is critical that
all required information is provided on the application, as this
will aid in processing time.
If the Health Care Professional does not provide all required
information, the application will be returned to the Health Care
Professional with the missing information highlighted. The
application will not be processed until a completed application
is returned to EPNI. If EPNI is unable to obtain all required
information to complete the credentialing process, it may result
in the loss of the Health Care Professional's network
participation status.
EPNI only notifies Health Care Practitioners when
recredentialing is complete if there is an adverse outcome from
the recredentialing process. In this situation, the Health Care
Professional will be notified in writing within 60 days of the
Credentialing Committee’s decision.
2-11
Answers
(continued)
5. What can I do to ensure that my credentialing application
is processed in a timely manner?
When completing the Minnesota Uniform Credentialing
Application form, the following information is often
overlooked:
•
Minnesota Medicaid ID Number
•
Explanation of all time gaps in Employment / Practice
History greater than three months
•
Full Employment/Practice History since completion of post
graduate training
•
Complete all fields pertaining to Medical/Graduate/
Professional Education
•
Complete all fields pertaining to Primary and Other
Hospital Affiliations
•
Date and sign the Authorization and Release
•
Include a copy of current malpractice liability insurance
documentation
•
Answer all Disclosure Questions, sign, and explain any
affirmative responses
•
Include a legible copy of the Health Care Professional's
current DEA registration
•
Return the completed application promptly. The
information is time sensitive
6. What happens if I do not meet your credentialing
requirements?
As noted, the Health Care Professional will be notified in
writing if there is an adverse outcome to the recredentialing
process. Included with this notification is an explanation of the
Health Care Professional's right to reconsideration of the
Credentialing Committee’s decision. If a Credentialing
Committee decision is unchanged as a result of the
reconsideration process, Health Care Professionals are then
notified of their appeal rights, if applicable. Appeal hearing
decisions are final.
2-12
Answers
(continued)
7. Who does EPNI credential?
EPNI credentials certain Health Care Professionals and
provider types:
•
•
Medical Providers:
•
Hospitals
•
Home Health Care
•
Skilled Nursing Facilities
•
Ambulatory Surgical Centers (free standing)
Behavior Providers:
•
•
•
•
Behavioral Health Institutions (Inpatient, residential or
ambulatory settings)
Doctors:
•
Physician (M.D., D.O.)
•
Podiatrist (D.P.M.)
•
Dentists (D.D.S., D.M.D.)
•
Chiropractors (D.C.)
Social Workers:
•
Licensed Certified Social Worker (L.C.S.W.)
•
Licensed Clinical Social Worker (L.C.S.W.)
•
Licensed Independent Clinical Social Worker
(L.I.C.S.W.)
•
Licensed Independent Social Worker (L.I.S.W.)
Counselors:
•
Licensed Mental Health Counselor (L.M.H.C.)
•
Licensed Professional Clinical Counselor (L.P.C.C.)
•
Licensed Professional Counselor (L.P.C.)
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Answers
(continued)
•
Therapists:
•
•
•
Licensed Marriage and Family Therapist (L.M.F.T.)
Advanced Practice Registered Nurses:
•
Certified Nurse Midwife (C.N.M.)
•
Registered Nurse Clinical Specialist (R.N.C.S., C.N.S.)
•
Registered Nurse Practitioner (N.P.)
Other Practitioner Types:
•
Physician Assistants (P.A.)
•
Optometrists
•
Psychologists (M.A., Ph.D., Psy.D.)
• Licensed Acupuncturist (LAc)
Note: Health Care Professional titles and abbreviations vary from
state to state. Check with appropriate state licensing
agencies for specific titles.
8. How often are practitioners routinely recredentialed?
Health Care Professionals are recredentialed every three years.
They may be recredentialed more frequently as a condition of
participation.
9. Are there other situations that result in recredentialing?
Yes, credentialing or recredentialing may occur whenever
EPNI deems appropriate (e.g., when there are quality of care
concerns or when reasonable information has been identified
by EPNI that a Subscriber may be endangered by potentially
unsafe or unethical care or treatment).
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Answers
(continued)
10. Are there circumstances when practitioners are not
credentialed or recredentialed?
Yes, the following are examples of situations when
credentialing is not required:
•
A Health Care Practitioner is currently in approved
residency training
•
A Health Care Practitioner making a first request to take a
locum tenens position for 3 months or less
•
A Health Care Practitioner who provides services that are
not covered by EPNI
•
A Health Care Practitioner not eligible for an EPNI
Provider Service Agreement is consequently not
credentialed
Health Care Professionals EPNI does not typically credential:
•
Audiologist
•
Certified registered nurse anesthetist (C.R.N.A.)
•
Licensed Assoc. Counselor (L.A.C.)
•
Licensed Assoc. Marriage & Family Therapist
(L.A.M.F.T.)
•
Licensed Psychological Practitioner (L.P.P.)
•
Occupational Therapist (O.T.)
•
Physical Therapist (P.T.)
•
Registered Nurse (R.N.)
•
Registered Nurse First Assistant (R.N.F.A.)
•
Resident
•
Social Worker (Levels: L.G.S.W., L.S.W., L.M.S.W.,
C.S.W., C.I.S.W., C.A.S.W.)
•
Speech and Language Therapist
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Answers
(continued)
11. Does EPNI credential hospital-based practitioners?
No, hospital-based Health Care Practitioners include
pathologists, radiologists, anesthesiologists, (unless practicing
pain management) and emergency room physicians. They do
not have an independent relationship with EPNI. They work
exclusively in the patient setting and provide care only as a
result of Subscribers being directed to the inpatient setting for
Health Services by the health plan.
Exception: All hospital-based behavioral Health Care
Professionals listed under the Q&A, “Who do we
credential?” are credentialed.
12. Who makes credentialing decisions?
Credentialing decisions are made by the Credentialing
Committee, which consists of six physicians (including at least
one D.O. whenever possible) who also participate in at least
one EPNI network. At least one Health Care Practitioner is
board-certified in family practice. Two Health Care
Practitioner are board-certified in psychiatry, with
subspecialties in one of the following areas: child or adolescent
psychiatry, or addiction psychiatry. One Health Care
Practitioner is board-certified in a surgical specialty. One
Health Care Practitioner is board certified in obstetrics and
gynecology.
Additional voting members of the committee are two nonphysician Health Care Practitioner who are participating in at
least one EPNI network and who are licensed or registered to
practice a healing art, dentistry or podiatry under Minnesota
statutes. Two additional voting members of the committee are
EPNI staff.
2-16
Answers
(continued)
13. What are the conditioned actions taken related to adverse
practitioner, provider, or delegated credentialing
decisions?
Actions may reflect an increasing level of severity. Note:
These are examples only.
•
Increased frequency of recredentialing, site visits, or
delegation of a file review
•
Requirement of a work plan to describe steps to comply
with credentialing standards, or if applicable, the terms of a
delegation agreement
•
Continuing education requirements or education by EPNI
Staff
•
Increased frequency of medical record or coding audits by
EPNI
•
Counseling by a peer practitioner, approved by a EPNI
medical director or designated provider services director
•
Formal supervision by a peer
•
Evaluation by an external peer organization i.e. Health
Professionals Services Program (HPSP) or Colorado
Personalized Education for Physicians (CPEP)
•
Participation condition or limitation i.e. practice site, type
(group vs. solo), scope of practice
•
Non-participation
•
Termination of Provider Contract or delegation agreement
14. When does the Credentialing Committee meet?
Meetings occur monthly. Health Care Professional
Practitioners' application materials are distributed to committee
members one week in advance of the meeting. The medical
director reviews complete credentialing applications that do
not require additional information on a weekly basis.
15. What are the decision options available to the
Credentialing Committee?
•
Approve participation (initial credentialing)
•
Approve continuing participation
•
Participation with a condition or limitation
•
Non-participation
•
Terminate the contract
2-17
Answers
(continued)
16. How is a practitioner or provider notified about the
Credentialing Committee decision?
All new practitioners and providers are notified in writing of
initial participation decisions.
Providers and individual Health Care Practitioners are
routinely notified in writing of conditional participation status
decisions, including a description of the conditions and
reconsideration appeal rights.
All Health Care Practitioners /Providers are notified in writing
by credentialing staff of any denied credentialing participation
decision and appeal rights. Clinic administrators are also
notified and are required to facilitate Subscriber transition and
proper billing procedures for non-participation status. EPNI
staff shall make reasonable efforts to notify the Health Care
Practitioner before notifying clinic administrative staff.
2-18
Answers
(continued)
17. What if I do not agree with the Credentialing Committee
decision?
Health Care Professionals and Providers have the right to
request a Reconsideration Appeal according to established
policy. To request a Reconsideration Appeal, Health Care
Practitioners and Providers must provide EPNI written notice
postmarked within 30 days from the date of the conditional,
non-participation or termination decision notification letter.
The request typically outlines why the appealing Health Care
Practitioner or Provider disagrees with the decision and
includes new additional information or highlights specific
points for reconsideration. Upon receipt of the Health Care
Practitioner’s request notice, a Credentialing Committee
reconsideration is initiated. The Health Care Practitioner may
submit new or additional written information at an upcoming
Credentialing Committee meeting. Health Care Professionals
are not required to appear in person.
Health Care Professionals or Providers may choose to waive
individual rights to a Reconsideration Appeal, in which case
the appellant may immediately request a hearing before a panel
of independent Health Care Practitioners or Providers by
requesting such hearing within 30 days of the date of the
decision notice letter. If the Health Care Practitioner or
Provider chooses to request a Reconsideration Appeal and the
Committee upholds its original determination, the Health Care
Practitioner also has the right to a hearing before a panel of
independent Health Care Practitioners or Providers. The Health
Care Practitioner or Provider will be sent a notice regarding the
time, date and place of the hearing. At the hearing the Health
Care Practitioner or Provider have the following rights:
•
A right to representation by an attorney or other person of
the Health Care Practitioner's or Provider's choice
•
To have a record made of the proceedings
•
To call, examine and cross-examine witnesses
•
To present relevant evidence determined to be relevant by
the appeal panel, regardless of its admissibility in a court of
law
•
To submit a written statement at the close of the hearing
2-19
Answers
(continued)
17. The Health Care Practitioner or Provider's participation status
in the EPNI network may continue pending the outcome of the
appeal and hearing process. This is determined on a case-bycase basis by the Credentialing Committee at the time of the
decision.
If the Health Care Practitioner or Provider chooses not to
request a formal appeal of this decision, participating status
will end on the date specified in the original notice or if
applicable, the conditions will remain. After that date, the
Health Care Practitioner will be regarded as non-participating.
Details regarding non-participation are conveyed directly to the
Health Care Practitioner and clinic administrator.
18. Who are the Appeal Hearing members?
Membership consists of two voting external participating
Health Care Practitioners or Providers, including one Health
Care Practitioner or Provider representing the same or similar
specialty area of the appellant, and one EPNI medical director.
Each voting member has one vote. The Appeal Hearing’s
decision is reached by majority vote.
19. What are the clinic site visit requirements?
Prior to contracting with a new EPNI primary care practitioner,
OB/GYN, or a potential high-volume behavioral health
practitioner, staff conducts a site visit. The site visit includes
evaluation of medical record-keeping practices, physical
environment, quality improvement structure, access and
availability and written clinic policies. Staff evaluates the
finding against established criteria and thresholds for
compliance and makes a recommendation that is presented to
the Credentialing Committee or medical director for review
and decision.
2-20
Answers (continued)
20. What are the site visit requirements for potential highvolume behavioral health practitioners?
The criteria for determining a potential high-volume behavioral
health practitioner is:
•
A psychiatrist or behavioral health professional at the
masters level or above who is licensed to practice
independently, e.g., a psychologist, social worker or a
practitioner who intends to work full-time at a primary
practice location with at least two other such practitioners,
in any combination.
When this criterion is met, the primary practice location
must pass the initial site visit. The site visit includes an
assessment of access and availability, quality improvement,
policies, physical environment and treatment recordkeeping practices.
21. Who do I call if I have questions about credentialing or
recredentialing?
Call provider services at (651) 662-5200 or 1-800-262-0820.
22. Why did EPNI enact a policy requiring Board
Certification?
Requiring physicians to be board-certified is consistent with
the EPNI purpose to seek partnerships with qualified Health
Care Practitioners and Providers committed to delivering
quality health care and services to its Subscribers. EPNI
Subscribers' expectation is to have consistently trained and
educated providers across Minnesota.
2-21
Answers
(continued)
23. What is the Board Certification policy and when did it go
into effect?
A Health Care Practitioner's education and training is
appropriate, relevant to and consistent with their current scope
of practice as demonstrated by completing a residency,
fellowship, obtaining board certification or obtaining a
Certificate of Added Qualification (CAQ) from a EPNI approved board.
a. Physicians requesting network participation after
March 15, 2005, must be board-certified or have boards in
process.
b. Physicians participating in an EPNI network (without any
restrictions or conditions on their participation) on
March 15, 2005, are deemed to be compliant with this
requirement.
c. An EPNI -approved board refers to the American Board of
Medical Specialties (ABMS) http://www.abms.org/, the
American Osteopathic Association
http://www.osteopathic.org/index.cfm or the Royal
College of Physicians and Surgeons.
d. Physicians with specialties that require recertification must
comply with the board’s recertification requirements.
e. Physicians who have the status of boards in progress must
become board certified within six (6) years from the
completion date (month/year) of an approved residency
program.
f. The Credentialing Committee makes the final decision on a
case-by-case basis.
24. How will EPNI keep track of board certifications and
recertifications?
EPNI is fortunate to have sophisticated software capable of
tracking credentialing activity. It has the capacity to monitor
certification beginning and end dates. In addition, EPNI can
review recertification and track the progress toward board
certification.
2-22
Answers
(continued)
25. Will M.D.s and D.O.s who are actively pursuing board
certification be allowed to continue to participate with
EPNI if the certification process takes longer than six (6)
years?
Yes, practitioners who are actively pursuing their board
certification will be considered on a case-by-case basis by the
Credentialing Committee for continued participation if the
board certification process takes longer than six years.
26. In some cases foreign-trained physicians may not be
eligible for board-certification; will EPNI make exceptions
to this policy in these cases?
Yes. There may be physicians, trained in foreign countries,
who are not eligible for board certification programs through
the ABMS or AOA, who will seek participation with EPNI.
EPNI does not wish to discourage qualified physicians from
joining; therefore, foreign trained physicians who are not
eligible for the ABMS or AOA board certification programs
will be considered by the Credentialing Committee on a caseby-case basis. The final decision will rest with the EPNI
Credentialing Committee.
27. Are there criteria that EPNI considers equivalent to board
certification?
Yes. In some cases, international graduate physicians who
meet the following state licensing eligibility requirements
would be exempt from the board certification requirement:
Other criteria that EPNI considers equivalent to board
certification are the following.
•
International graduate physicians licensed in the state of
Minnesota and admitted as a permanent immigrant to the
United States as a person of exceptional ability in sciences
pursuant to the rules of the U.S. Department of Labor.
•
International graduate physicians licensed in the state of
Minnesota and issued a permanent immigrant visa as a
person of extraordinary ability pursuant to the rules of the
U.S. Department of Labor.
•
An outstanding professor or researcher and who has a valid
license in another country.
2-23
Answers
(continued)
28. Board certification is time limited. Will EPNI also require
proof of periodic recertification?
Yes, proof of recertification will be required. Since board
certifications do expire, physicians who participate with EPNI
will be expected to obtain periodic recertification. EPNI will
confirm the certification status of all physicians during the
initial and recredentialing process.
29. What happens when the board certification lapses for a
physician who is currently board certified at the time this
new policy takes effect (3/15/2005) or meets the board
certification requirement subsequent to the policy effective
date?
In some situations, it may be acceptable for a physician’s board
certification to lapse. For example, if a physician is boardcertified in family practice, he/she may obtain certification in a
family practice subspecialty such as geriatric medicine. In
cases where EPNI confirms that a physician obtains
certification in an approved subspecialty the primary specialty
certification may be allowed to lapse.
If a physician’s specialty or subspecialty board certification
lapses and the physician is not actively pursuing recertification
or fails to recertify, EPNI retains the right to terminate the
physician’s participation in networks.
30. Do I need an Individual Provider Number for a locum
tenens?
A practitioner making a first request to be a locum tenens for
three months or less does not need to be credentialed. The
clinic needs to submit a practitioner add form to get a provider
number for the locum tenens to bill with, and we set the
number up to be valid for 90 days.
31. When is credentialing required for a locum tenens?
2-24
•
If a locum tenens will be staying longer than 90 days they
will need to be credentialed. The credentialing process
should be started as soon as this is known. Providers do not
have to wait until the 90 days is over to begin the
credentialing process.
•
If the practitioner has ever been a locum tenens in our
network at any time, they do not qualify for locum tenens
status and would need to be credentialed.
•
The provider number for the locum tenens will become
invalid after 90 days.
Accounting for Disclosure Request
Guidelines for the
Accounting Disclosure
Request
EPNI Subscribers have the right to an accounting of certain
disclosures that are made of their protected health information
(PHI) within six years prior to their request. EPNI will fulfill these
requests with a Subscriber disclosure summary. Providers are
requested to follow the guidelines listed below and forward
required disclosures to:
EPNI
Attention: Compliance and Regulatory Affairs
P.O. Box 64560
St. Paul, MN 55164-0560
When to Use the Form
If a disclosure is subject to an accounting, Providers must use the
enclosed form to record the disclosure information. This form can
be found at CCStpa.com. Disclosures which require an accounting
include disclosures which are made:
1. pursuant to applicable law;
2. for cadaveric organ donation purposes;
3. to avert a serious threat to health or safety;
4. for certain marketing or fundraising exceptions; and
5. to the Secretary of Health and Human Services.
The attached form provides a more detailed list of those
disclosures that must be accounted for. Not all disclosures of an
individual’s PHI are subject to an accounting.
Providers are not required to account for disclosures they make:
•
before the privacy rules compliance date (April 14, 2003)
•
to the individual
•
to or for notification of persons involved in an individual’s care
•
for treatment, payment, or health care operations
•
for national security or intelligence purposes
•
to correctional institutions or law enforcement officials
regarding inmates
•
for research if it involves at least 50 records and we provide
individuals with a list of all the research protocols and the
researcher’s name and contact information
•
using de-identified health information
2-25
Disclosures Related to
Provider’s Status as a
Business Associate
The Provider Service Agreement requires Provider to account for
only those disclosures of records that it holds in its capacity as a
business associate. Provider is EPNI's business associate because
the Provider Service Agreement requires you Provider to perform
certain activities on EPNI's behalf. These business associate
activities are:
•
Compliance with and implementation of quality
improvement/managed care requirements such as providing
specific patient records for a quality study; and
• Receiving and resolving Subscriber complaints.
Thus, for example, if Provider reports a complaint to EPNI as
required by the Provider Service Agreement, Provider is gathering
that information and forwarding it to EPNI as its business
associate. Provider does not have to report the disclosure to EPNI
because it is part of health care operations. If, however, a regulator
were to audit EPNI's compliance with handling Subscriber
complaints and Provider must release correspondence or records to
the regulator, it is a disclosure Provider must account for.
Another example would be records that Provider provided to EPNI
for Child and Teen Checkups. If the Department of Health were to
decide to monitor managed care plans for child and teen checkups,
they may ask for all the information Provider provided to EPNI as
part of the on-site audits. The disclosure is permitted to the
Department of Health without authorization as a public health
activity, but it must be accounted for.
Provider does not have to account for disclosure of records that it
has in its capacity as a provider. For example, as discussed above,
Provider might have medical records from providing a teen with a
checkup. Subsequently, the teen is involved in a crime and the
medical records are necessary for identification purposes. Provider
may disclose the medical record to law enforcement authorities
and must account to the teen for that disclosure. Provider does not,
however, have to account to EPNI for that disclosure.
2-26
Carrier Replacement Law
Carrier Replacement
The Law
The Minnesota Carrier Replacement Law applies when a
Subscriber group terminates its fully insured coverage with one
carrier and replaces it with another fully insured group contract.
EPNI may apply this law to self-insured groups to determine
liability for charges incurred by a Subscriber whose inpatient
treatment occurred during this change in coverage.
How Carrier
Replacement Works
Continuous Stay
•
The carrier whose coverage is in effect when a Subscriber is
admitted to a facility is liable for all institutional charges
incurred by the Subscriber whose inpatient treatment spans the
change in coverage.
•
The carrier in effect at the time of admission is liable for all
professional charges incurred up to the termination date of the
coverage.
•
The new carrier is liable for all professional charges incurred
beginning on the effective date of the new coverage.
•
The definition of “discharge” is the date the Subscriber is
formally released from the inpatient facility with discharge
papers completed.
Continuous stay occurs when the patient is sent to another facility
for services unavailable at the current facility and no discharge or
admission papers are processed upon transfer.
•
In the case of a patient who is discharged and transferred to
another facility, both the transportation and charges incurred at
the new facility will become the liability of the new carrier.
If…
then…
a new Subscriber was
hospitalized prior to the
effective date of EPNI coverage
EPNI pays the hospital claim on
a pro rata basis beginning on the
date coverage becomes
effective.
a new Subscriber remains
hospitalized on and after the
first date of coverage
the new Subscriber's other
carrier stops paying for the
hospitalization or there is no
other carrier
Self-Funded Groups
Carrier Replacement law does not apply to self-insured business
unless otherwise documented in the group agreement.
2-27
Governmental and Compliance Required Provisions
Overview
Federal and state governmental agencies require health plans,
such as EPNI, to inform providers of certain information.
Additional requirements are also necessary for accreditation and
other quality compliance.
Governmental Required
Definitions
•
"Managing Employee" means an individual (including a
general manager, business manager, administrator or director)
who exercises operational or managerial control over the
entity or any part thereof, or who directly or indirectly
conducts the day-to-day operations of the entity or any part
thereof, as defined in 42 C.F.R. Section 455.101.
•
"Medicare Advantage" means Medicare Advantage programs
as defined by Centers for Medicare and Medicaid (CMS),
where EPNI is the payor for health services provided to
Medicare Subscribers.
•
"Medicare Advantage Special Needs Plan" means a Medicare
Advantage program as defined by CMS under which EPNI is
the payor for health services provided to Medicare
Subscribers with special needs. An example of such a plan is
Minnesota Senior Health Options (MSHO).
•
"Minnesota Senior Health Options" (MSHO) means the
Minnesota prepaid managed care program, pursuant to
Minnesota Statutes, Section 256B.69, subd. 23, that provides
integrated Medicare and Medicaid services for Medicaid
eligible seniors, age sixty-five (65) and over. MSHO includes
Elderly Waiver services for enrollees who qualify, and one
hundred eighty (180) days of nursing facility care.
•
"Person with an Ownership or Control Interest" means a
person or corporation that (1) has an ownership interest,
directly or indirectly, totaling five percent or more in EPNI or
a disclosing entity; (2) has a combination of direct and
indirect ownership interests equal to five percent or more in
EPNI or a disclosing entity; (3) owns an interest of five
percent or more in any mortgage, deed of trust, note or other
obligation secured by EPNI or a disclosing entity, if that
interest equals at least five percent of the value of the property
or assets of EPNI or a disclosing entity; or (4) is an officer or
director of EPNI or a disclosing entity (if it is organized as a
corporation) or is a partner in EPNI or a disclosing entity (if it
is organized as a partnership).
2-28
Compliance with Laws
In order to have a Provider Service Agreement with EPNI,
Providers and EPNI are required to abide by all applicable state
and federal laws, rules, regulations, orders and requirements that
are related to providing health care and billing for health care.
•
Cooperation with EPNI. In addition to complying with all
state and federal laws, rules, regulations, orders and
requirements, Provider further agrees to cooperate with EPNI
in its efforts to comply with any and all obligations imposed
by state and federal laws, rules, regulations, orders and
requirements. This includes 1) promptly notifying EPNI in the
event the Provider transfers "substantial financial risk" (as
defined in 42 C.F.R. Section 422.208) to any of the health
care professionals in its employment; and 2) notifying EPNI
within 20 days of entering into any private contract with a
Medicare beneficiary pursuant to Section 1802 of the Social
Security Act (such notice to include a copy of the private
contract and any other information reasonably requested by
EPNI).
2-29
Compliance with Laws
(continued)
•
•
2-30
Minnesota Department of Human Services Disclosure
Requirements.
•
Disclosure of Agreements. Provider must ensure that no
agreements exist between itself and an excluded entity or
individual for the provision of items or health services
under a Provider Service Agreement. Provider shall search
the Medicare Exclusion Database (MED) or the Office of
Inspector General (OIG) List of Excluded
Individuals/Entities (LEIE) databases on a monthly basis
to insure that no providers, agents, Persons with an
Ownership or Control Interest and Managing Employees
are (a) excluded from participation in Medicaid under
Sections 1128 or 1128A of the Social Security Act, or (b)
have been convicted of a criminal offense related to
involvement in any program established under Medicare,
Medicaid or the Title XX services program. Provider shall
notify EPNI within five days of identifying any
subcontracting individuals or entities listed in (a) or (b) of
this paragraph.
•
Disclosure of Ownership Information. To assure
compliance with 42 C.F.R. Section 438.610, Provider
shall report the following information to EPNI prior to the
effective date of the Agreement: (a) the name and address
of each Person with an Ownership or Control Interest in a
disclosing entity or in any subcontractor in which a
disclosing entity has direct or indirect ownership of five
percent or more; and (b) a statement as to whether any
Person with Ownership or Control Interest is related to
any other Person with an Ownership or Control Interest
•
as spouse, parent, child or sibling; and (c) the name of any
other organization in which a Person with an Ownership
or Control Interest in a disclosing entity also has
Ownership or Control Interest.
Advance Directives. Provider must make information
available to Subscribers to aid them in completing advance
directives, including but not limited to helping them to
understand medical terminology, medical care options and
referring them to appropriate resources such as the Minnesota
Department of Health Website. Upon a Subscriber's request,
Provider must maintain a copy of a Subscriber's advance
directive in the medical record maintained by Provider.
HIPAA Requirements
HIPAA Compliance. Pursuant to the federal Health Insurance
Portability and Accountability Act (HIPAA), and the
requirements of the Health Information Technology for Economic
and Clinical Health Act, as incorporated in the American
Recovery and Reinvestment Act of 2009 (the "HITECH Act")
that are applicable to business associates, Provider agrees that it
shall:
•
Not use or further disclose Protected Health Information
(PHI) other than as permitted or required by the Provider
Service Agreement between EPNI and Provider, and further
agrees that it shall not use or further disclose PHI in a manner
that would violate requirements of HIPAA and its
implementing regulations (45 C.F.R. parts 160-64) ("HIPAA
Regulations") or the HITECH Act;
•
Report to EPNI any use or disclosure of PHI not provided for
by the Provider Service Agreement of which it becomes
aware, within five (5) days after such discovery, and ensure
that any agents, including any subcontractors, to whom it
provides to or receives from PHI, agree to the same
restrictions and conditions that apply to Provider with respect
to such information;
•
Upon any termination of the Provider Service Agreement,
extend the protections of this Section to any PHI in the
possession of Provider, and limit any further use and
disclosure of such PHI to those purposes set forth in the
Provider Service Agreement;
•
Develop, implement, maintain and use appropriate
administrative, technical and physical safeguards, in
compliance with Social Security Act Sec. 1173(d) (42 U.S.C.
Sec. 1320d-2(d)), 45 C.F.R. Sec. 164.530(c)) and any other
implementing regulations issued by the U.S. Department of
Health and Human Services;
•
Upon receipt of notice from EPNI, promptly amend or permit
EPNI access to amend any portion of the PHI which the
provider created or received from EPNI so that EPNI may
meet its amendment obligations under 45 C.F.R. Sec.
164.526;
2-31
HIPAA Requirements
(continued)
•
•
2-32
With the exception of disclosures of PHI made for the
purposes specified in 45 C.F.R 164.528(a)(1)(i)-(ix),
document and report each disclosure, if any, the provider
makes of any PHI Provider has created for EPNI or received
from EPNI within five (5) days of the discovery of the
disclosure. The provider shall cooperate with EPNI in
investigating the disclosure and in meeting EPNI'S
obligations under the HIPAA regulations and HITECH Act.
In the event of any such disclosure, the provider shall:
•
Identify the nature of the non-permitted access, use or
disclosure, including the date of the breach and the date of
discovery of the breach;
•
Identify the PHI accessed, used or disclosed as part of the
breach (e.g. full name, social security number, date of
birth etc.);
•
Identify who made the non-permitted access, use or
disclosure and who received the non-permitted disclosure;
•
Identify what corrective action the provider took or will
take to prevent further non-permitted access, uses or
disclosures;
•
Identify what the provider did or will do to mitigate any
deleterious effect of the non-permitted access, use or
disclosure; and
•
Provide such other information, including a written report,
as EPNI may reasonably request.
Provider acknowledges and agrees that in the event the
Provider breaches this HIPAA requirements, EPNI may
terminate the Provider Service Agreement upon written notice
to the Provider and/or report such breach by the Provider to
the United States Department of Health and Human Services.
HIPAA Requirements
(continued)
HIPAA Security. The Provider agrees to the following:
•
The Provider shall implement administrative, physical and
technical safeguards that reasonably and appropriately protect
the confidentiality, integrity and availability of the electronic
Protected Health Information ("e-PHI") that it creates,
receives, maintains or transmits on behalf of EPNI, as
required by 45 C.F.R. Part 164 (the "Security Rules").
•
To ensure that any agent, including a subcontractor to whom
it provides e-PHI agrees to implement reasonable and
appropriate safeguards to protect it, and
•
To report to EPNI any security incident involving e-PHI of
which it becomes aware. The Security Rules define a
"Security Incident" as an attempted or successful
unauthorized access, use, disclosure, modification or
destruction of information or interference with system
operations in an information system, involving e-PHI that is
created, received, maintained or transmitted by or on behalf of
Provider or EPNI. Since the Security Rules include attempted
unauthorized access, use, disclosure, modification or
destruction of information, EPNI needs to have notification of
attempts to bypass electronic security mechanisms. Provider
and EPNI recognize and agree that the significant number of
meaningless attempts to, without authorization, access use,
disclose, modify or destroy e-PHI will make a real-time
reporting requirement formidable for Provider. Therefore,
Provider and EPNI agree to the following reporting
procedures: Security Incidents that result in unauthorized
access, use, disclosure, modifications or destruction of
information or interference with system operations
("Successful Security Incidents") and for Security Incidents
that do not so result ("Unsuccessful Security Incidents").
2-33
HIPAA Requirements
(continued)
•
•
2-34
For Unsuccessful Security Incidents, Provider and EPNI agree
that this paragraph constitutes notice of such Unsuccessful
Security Incidents. By way of example, Provider and EPNI
consider the following to be illustrative of Unsuccessful
Security Incidents when they do not result in actual
unauthorized access, use disclosure, modification or
destruction of e-PHI or interference with an information
system:
•
Pings on the Provider's firewall.
•
Port scans.
•
Attempts to log onto a system or enter a database with an
invalid password or username.
•
Denial-of-service attacks that do not result in a server
being taken off-line.
•
Malware (worms, viruses, etc.).
For Successful Security Incidents, the Provider shall give
notice to EPNI not more than five (5) business days after
learning of the Successful Security Incident.
Non-Interference
Provider agrees not to interfere in the business relationships of
EPNI with its group purchasers, Subscribers, Plan Sponsors or
other providers by discouraging or attempting to discourage
group purchasers, Subscribers, Plan Sponsors, or other providers
from initiating or maintaining their business relationship with
EPNI. This provision does not prohibit normal business activities
such as participation in other health plans. This provision
prohibits Provider activity such as disclosing proprietary
information such as specific financial or other terms of the
Provider Service Agreement (as well as specific financial
information relating to any other agreement between a provider
and EPNI) unless otherwise expressly authorized by EPNI in
writing signed by an officer of EPNI or required by law. This
provision also prohibits the Provider from defaming EPNI for
financial or participation purposes, including but not limited to
suggesting other providers, group purchasers, Subscribers or Plan
Sponsors terminate their relationships with EPNI. This provision
is not intended to interfere with the provider-patient relationship
and this provision is not intended to prohibit the Provider from
communicating with Subscribers as provided by Minnesota
Statutes Section 62J.71. EPNI encourages and permits open
communication between the Provider and the patient regarding
treatment options available to them regardless of benefit coverage
limitations. Benefit coverage is always governed by the terms of
the Subscriber Contract. EPNI similarly agrees not to interfere in
the business relationships of the Provider with its group
purchasers, or other providers by discouraging or attempting to
discourage group purchasers or other providers from initiating or
maintaining their business relationship with Provider.
2-35
Network Access
Agreements
In addition to providing Health Services to Subscribers enrolled
in health benefit plans underwritten or administered by EPNI, the
Provider Service Agreement applies to health services provided in
the following instances:
•
2-36
Health Services provided to Subscribers for whom EPNI or its
Affiliates provides access to an EPNI participating provider
network, where no administrative or claims payment services
are provided and neither EPNI nor its affiliates assume any
financial risk or obligation with respect to claims. In all such
network access arrangements, EPNI shall ensure that (a)
Subscribers are directed to receive Health Services from a
provider through benefit differentials outlined in the
Subscriber Contract, (b) Subscribers are required to produce a
membership card that identifies him/her as a Subscriber who
is entitled to use the participating provider network, (c) the
application of the EPNI fee schedule is clearly listed on the
explanation of benefits furnished to the Subscriber, and (d)
that the entity which has contracted with EPNI for access to
the participating provider network agrees to comply with the
prompt payment/prompt response provisions of the Provider
Service Agreement. EPNI shall notify Provider of such
network access arrangements and furnish information
regarding any special requirements for the applicable
Subscriber's contract.
Termination of Provider Service Agreements
Required Notification
A Provider Service Agreement may be terminated according to
any one or more of the following provisions:
•
Without cause by either Party upon prior written notice to the
other Party with termination to become effective 130 days after
receipt of written notice.
•
By a Party upon prior written notice to the other Party in the
event of a material breach of the Provider Service Agreement
by such other Party and which breach remains uncured 30 days
after written notice reasonably specifying the nature of the
breach is given to the breaching Party, with termination to
become effective on the 30th day after receipt of such written
notice.
•
Immediately upon written notice by EPNI to Provider in the
event that EPNI acquires evidence of the potential for
significant patient harm or of fraudulent or illegal conduct on
the part of Provider or any of Provider's Health Care
Professionals with regard to the practice of medicine, claim
submission, health care professional eligibility, the delivery of
care under the Provider Service Agreement, or in the event of
any sanction by CMS under the Medicare program.
•
By EPNI upon 30 days' prior written notice to Provider with
respect to any Provider or Health Care Professional of Provider
which fails to complete the credentialing or recredentialing
process or is sanctioned or reprimanded by any review
organization, including but not limited to, any other health
insurer or health plan, peer review organization, hospital
medical staff or any state licensing board. The Provider agrees
to immediately notify EPNI in writing of any such sanction or
reprimand or any investigation of any Provider or Health Care
Professional of which Provider is aware. If the sanction or
reprimand is limited to a single Health Care Professional, then
the termination shall be effective as to that Health Care
Professional only.
2-37
Required Notification
(continued)
2-38
•
By EPNI of Provider's participation in benefit plans (including
but not limited to the Minnesota Comprehensive Health
Association, the Minnesota Advantage Health Plan, political
subdivisions, and Workers' Compensation) if Provider is
determined by DHS to be out of compliance with Minnesota
Statutes, Section 256B.0644 (requiring providers to accept
medical assistance patients) or any other applicable laws.
Provider shall notify EPNI immediately in event of such noncompliance. The termination shall be effective as of the first
date of such non-compliance.
•
By EPNI upon 130 days' prior written notice to Provider if
Provider's practice moves outside the contracting service area
served by this Agreement. Provider shall immediately notify
EPNI of any change to its address.
Chapter 3
Health Care Improvement
Table of Contents
Introduction to Health Care Improvement ............................................................................. 3-2
General Overview .................................................................................................................. 3-2
Basic Elements of an HCI Program ....................................................................................... 3-2
Leadership.............................................................................................................................. 3-3
Formalized Mechanism for Customer Feedback ................................................................... 3-3
Health Care Improvement Projects....................................................................................... 3-4
Cooperation with EPNI HCI Program ................................................................................... 3-5
Telephone Care: During Office Hours................................................................................... 3-5
Telephone Care: In-coming calls ........................................................................................... 3-5
Telephone Care: After Hours................................................................................................. 3-6
Complaint Review System..................................................................................................... 3-7
Access & Availability ........................................................................................................... 3-7
Written Policies...................................................................................................................... 3-8
Continuity and Coordination of Care................................................................................... 3-12
Medical Record Keeping Practices...................................................................................... 3-13
Medical Record Documentation .......................................................................................... 3-14
Health Care Improvement for Behavioral Health Providers .............................................. 3-16
General Overview ................................................................................................................ 3-16
Cooperation with EPNI HCI Program ................................................................................. 3-16
Additional Requirements for Select Network Providers ..................................................... 3-16
Cooperation with EPNI HCI Program ................................................................................. 3-17
Complaint Review System................................................................................................... 3-17
Additional requirements for Select Network Providers....................................................... 3-17
Access and Availability ....................................................................................................... 3-18
Physical Facility................................................................................................................... 3-19
Written Policies.................................................................................................................... 3-19
Treatment Record Documentation....................................................................................... 3-20
Provider Specific Health Care Data....................................................................................... 3-25
Release of Provider Data by EPNI....................................................................................... 3-25
3-1
Introduction to Health Care Improvement
General Overview
This chapter contains detailed information about the EPNI Health
Care Improvement (HCI) program, formerly Quality Improvement.
The material explains what is expected from participating
providers regarding their quality programs and defines provider
requirements including medical record keeping practices. The
information provided in this chapter is intended for all Open
Access providers, however; some requirements may not apply in
every facility. Additionally, some requirements for behavioral
health providers are different than those described below.
Requirements that are different or more stringent for behavioral
health providers are detailed.
Basic Elements of an
HCI Program
Rationale:
EPNI subscribes to the philosophy of Health Care Improvement
(HCI) and the multifaceted benefits it offers. All providers
associated with EPNI networks must include health care
improvement activities in their facilities. Striving to meet or
exceed customer expectations should be a driver for a successful
program. A well-established program enables Provider to discover
root causes, use data to increase production, and maximize
available resources. A successful program has three basic
elements: it must be customer-focused, data-driven, and processoriented.
EPNI supports the six aims for improvement identified in the
Institute of Medicine’s Crossing the Quality Chasm. These six
aims are that care should be safe, effective, patient-centered,
timely, efficient, and equitable. All EPNI providers are expected to
incorporate these aims into their health care improvement
programs. Some models are available to guide and direct HCI
project efforts.
Requirements:
•
3-2
Provide annual HCI program report upon request to EPNI.
Leadership
Rationale:
Leadership within an organization must support and embrace the
philosophy of health care improvement for it to succeed. Advising,
supporting, and actively participating in the development and
implementation of process improvement is a vital function of
leadership.
Improving processes within an organization promotes better care
and services to customers, creating a marketplace advantage.
Requirement:
•
Formalized Mechanism
for Customer Feedback
Designated HCI Medical Director, who is a practicing
physician and is either a MD or DO
Rationale:
Patient feedback is an excellent resource that provides innovative
and practical ideas for improving care or service. Analyzing
feedback for the purpose of improving processes provides
opportunities essential to maintaining customer loyalty.
Patient feedback is collected in a variety of ways. Surveys provide
needed information about particular areas; comment cards capture
a patient’s thoughts at the time of a visit; focus groups facilitate
discussion; and external surveys provide comparative statistics.
Requirements:
Collection and analysis of customer feedback.
•
Action on collected feedback through the use of a multidisciplinary team where appropriate to initiate system change.
3-3
Health Care
Improvement
Projects
Rationale:
Good business practices consist of effective and efficient work
processes. Addressing problems or opportunities within Provider's
facility using the HCI process offers distinct advantages. Health
Care Improvement projects employ systematic analysis of current
practices to reveal refined approaches to everyday operations.
Using a defined model means that changes can be tested and
adopted effectively.
Requirements and changes regarding HCI reporting are distributed
annually in the first quarter to all main site primary care providers.
EPNI does not routinely collect project information from
providers. Requirements listed below should be followed if
Provider's facility chooses to implement improvement activities.
Suggested project categories may include clinical guideline
implementation or improvement, administrative or processoriented improvements, or improvements based on customer
feedback. Often providers choose to do one project that is clinical
and one that is service-related. EPNI encourages Provider to
conduct a survey or focus group of customers as it develops
system changes.
Requirements:
3-4
•
Provide HCI program description, contact information, or
project reports upon request.
•
Clinical projects must be based on approved and established
guidelines [i.e., Institute for Clinical Systems Improvement
(ICSI)].
•
Projects have completed a full PDCA Cycle or Seven-Step
process. Refer to the PDCA or Seven-Step Process
information.
Cooperation with EPNI
HCI Program
Rationale:
Collaborative efforts need to mutually service EPNI's Subscribers
with excellent care and services.
Requirements:
Telephone Care:
During Office Hours
•
Consultation and cooperation to resolve individual patient
complaints.
•
Provide medical records for HCI purposes upon request.
•
Collaborate on corrective action plan when EPNI quality
thresholds are not met. The EPNI Quality Council determines
thresholds.
Rationale:
Patients need telephone access to medical care with a response
time based on the urgency of their symptoms.
Requirements:
During office hours, Subscribers calling a provider will be
assessed according to patient care needs by a physician or
designee:
Telephone Care:
In-coming calls
•
Immediately for emergencies, 100% of the time
•
Within 30 minutes for urgent issues, 85% of the time
•
Within 4 hours for all other call types, 85% of the time
Rationale:
A timely response to incoming phone calls promotes patient
satisfaction.
Requirements:
•
Calls answered in six rings
•
On hold two minutes or less
3-5
Telephone Care:
After Hours
Rationale:
When Subscribers call Provider's facility, it is important to provide
them with information they need, regardless of the time. The best
method is having a person answer the phone when the facility is
closed, such as an answering service or triage line. To achieve this,
providers must have a telephone number that is answered 24 hours
a day by either a live person, or an answering system that will
provide patients information as outlined below.
•
The provider’s name
•
What to do if the patient feels this is an emergency (i.e. hang
up and call 911)
•
What to do if it is not an emergency, but the patient still needs
medical advice
•
Give the name of the person or location the patient should call,
and phone number(s), including the area code
•
Speak slowly and clearly. State numbers one at a time, such as
“six zero five zero” instead of “sixty fifty”
Additional tips:
•
Make sure it is quiet in the background when recording the
message
•
If the patient is being asked to call another location, make sure
that location has a message or someone answering the phone
who can help the patient
•
EPNI recommends Provider audit its message outside of
normal business hours according to these guidelines to make
certain it is in compliance with the requirements.
Requirements:
•
3-6
Provide 24 hours/day, 7 days/week telephone answer with a
triage process to determine call back appropriate for the
situation
Complaint Review
System
Rationale:
Patient complaints and concerns reflect their perceptions and
expectations. Feedback, whether solicited or unsolicited, presents
an opportunity to identify issues and implement systematic
processes to improve care or service. Providers and EPNI share a
joint commitment to Subscriber satisfaction and to the
improvement of care and Health Services delivered to EPNI
Subscribers.
Requirements:
All providers will have a policy and procedure in place detailing
the following:
Access &
Availability
•
Process to receive written and verbal complaints for EPNI
Subscribers
•
Designate an individual to be the primary contact for complaint
management, including the tracking of such complaints
•
Document the substance of the complaint, the investigation,
and any actions taken
•
Notify Subscribers of the right to complain and appeal to their
health plan
•
Track complaints by categories and report at least annually to
an in-house committee
Rationale:
Subscribers' concept of the quality of care they receive often
begins when they make an appointment. EPNI also wants to insure
that Subscribers are able to schedule appointments within a timely
manner, relative to the services they seek.
Requirements:
Satisfaction – Primary Care Providers Only
•
Routine Care: 85% of Subscribers will usually or always be
satisfied with when they get a routine care appointment
(routine care is that which the Subscriber does not need to see a
practitioner right away.)*
•
Urgent Care: 85% of Subscribers will usually or always be
satisfied with when they get an urgent care appointment
(urgent care is that which is needed right away for an illness,
injury or condition.)*
* EPNI conducts semi-annual Subscriber satisfaction surveys.
3-7
Access &
Availability
(continued)
Written Policies
Wait Times
•
Preventive Care – within 30 days 85% of the time for well
child exam, annual physical exam, etc.
•
Routine Primary Care – within 7 days 85% of the time for nonurgent symptomatic conditions
•
Urgent Care – Same day 85% of the time for Medically
Necessary care which does not meet the definition of
emergency care
•
Emergency Care – Immediate 100% of the time for
immediately life threatening illnesses, injuries and conditions
Rationale:
To protect the safety and privacy of all Subscribers, and for the
protection of Provider, EPNI requires all providers to develop and
implement written policies and procedures applicable to the Health
Services they provide. Providers are encouraged to have policies
that are facility specific, signed, dated and reviewed annually.
Requirement:
Each provider will have policies and procedures in place for the
following topics that apply to the services provided in the facility.
Policy Required
Recommended Risk Management Elements
Advance
Directives
•
Information made available
•
Discussion is documented in medical record
•
Copies retained
•
Hospitals notified upon admission
•
Eligibility defined (birth through age 20,
children)
•
Forms for documentation addressed
•
Age-appropriate services defined
•
Documentation in medical record
•
Correct coding
Child and Teen
Check-ups
3-8
Written Policies
(continued)
Policy Required
Communicable
Disease
Reporting
•
Requirement to report communicable
diseases by State Health Department
•
Reporting timeframe (within one day)
•
Responsibility of reporting defined
•
Forms, completion and submittal addressed
Complaint
Management
•
See Complaint Review System Section
Confidentiality
•
Training, including how soon initial training
occurs, when or how often refresher training
occurs, verified by signatures of trainer and
individual being trained, and on file for six
years
•
Accountability, including how control is
maintained (i.e., who has keys, who is
allowed into the facility and when)
•
Personal health information (PHI) disposal
•
Security of both paper and electronic PHI,
follow HIPAA guidelines
•
Reviewed annually
Confidentiality
and Security of
Medical
Records
•
Refer to the Medical Records section
Foreign
Language
Translation and
Hearing
Impaired
Services
•
Assistance provided for both situations
•
Interpreter available for phone calls and
face-to-face interactions
•
Patients/family are notified that interpreter
is provided
•
Resources are identified
3-9
Written Policies
(continued)
Policy Required
Hazardous
Materials and
Waste
Management
•
Written plan in place and maintained
•
Hazardous material and waste defined
•
Mechanism in place for responding to a spill
•
MSDS (material safety data sheets)
available
•
Hazardous materials and waste are
identified and inventoried
•
Mechanism defined for responding to a
spill/breach of containment
•
Chemical and regulated medical waste
addressed
•
Hazardous gas and vapors addressed
•
Orientation and education of staff outlined
•
Basic overview of infection control and how
it relates to controlling disease
•
Hand washing outlined, when and how
•
Universal precautions addressed, including
glove use
•
Personal protection equipment addressed
•
Screening employees for TB
•
Vaccinating employees for Hepatitis B
•
Steps taken when employee is exposed to
breach of infection control or exposure, how
to report to OSHA
•
Mechanism in place for responding
•
Medical emergency code is identified
•
Identify who directs activities
•
Identify who determines if 911 is called
Infection
Control
Medical
Emergency
3-10
Written Policies
(continued)
Policy Required
Medication
Management
•
Mechanism in place for procuring, storing,
controlling and distributing medications
•
Narcotics addressed, even if to say they are
not kept at the facility
•
Recalls addressed
•
Emergency and sample drugs addressed
•
Sign-out log covered
•
Prescription pad accessibility addressed
Non-Medical
Emergency
Policy
•
Mechanism in place for responding
•
Include power outages, weather
emergencies, bomb threats, and both fire
and fire drills
Treating
Unaccompanied
Minors Policy
•
Minor defined, exceptions covered
•
Scheduling appointments addressed
•
Mechanism in place to respond when an
unaccompanied minor calls/arrives asking to
be seen
•
Sample of authorization to consent to
treatment of a minor is provided
3-11
Continuity and
Coordination of Care
Rationale:
Patient continuity and coordination of care (COC) across settings
such as inpatient and ambulatory care and transition from specialty
to primary care, is critical in ensuring the best care for EPNI's
Subscribers and Provider's patients. All providers share a joint
responsibility to ensure continuity and coordination of care.
Guidelines:
Health Records:
•
Establish a consistent location(s) for external communications
from facilities and/or consultants including but not limited to
discharge summaries or notes, consult letters, progress notes,
and test or lab results.
Referrals:
•
Communicate with specialists/consultants to share the rational
for the referral and establish expectations for follow-up and
future communications.
Specialty Care and Consultants:
•
Provider written communication to the patients’ primary care
provider including, but not limited to progress notes,
consultation letters and test or lab results.
Inpatient:
•
3-12
Request that all discharge summaries and discharge notes be
copied to the primary care provider in the dictation process.
Medical Record
Keeping Practices
Rationale:
EPNI requires Provider to have a policy and procedure for
confidentiality of health information and medical records that
meets state and federal requirements.
EPNI expects strict adherence to state and federal laws with
regards to maintaining Subscribers' medical information and
records in a confidential manner. EPNI requires medical records to
be maintained in a manner that is current, detailed and organized.
Providers must have a tracking process in place for ease of
retrieval.
Requirements:
Each element required 100% of the time.
•
A written policy and procedure of medical record keeping
practices, which includes the confidentiality and security of
medical records, and release of information, is available.
•
Medical records are kept in a secure location.
•
Review of the confidentiality policy and procedure is
performed at least annually with staff.
•
A tracking system for medical records is in place.
•
The medical record forms are available for release.
3-13
Medical Record
Documentation
Rationale:
The patient medical record is a vehicle for documenting services
provided and evaluating continuity and coordination of care. It also
serves as legal protection for the patient and practitioner. EPNI,
per contractual agreement with both the subscriber and Provider,
has access to the Subscriber's medical record for examination and
evaluation. EPNI’s corporate confidentiality policy requires that
the personal and health information of its Subscribers be
maintained as confidential information. All employees are required
to attest to their knowledge of this policy and their intent to
comply with it.
Medical record review is an essential component of a
comprehensive health care improvement program. The EPNI
Quality Council, which includes practicing physicians, establishes
minimum patient medical record documentation standards.
Requirements:
Each element required 100% of the time.
Format
3-14
•
The content and format of the medical record is organized and
includes patient’s address and home and work phone numbers.
•
Each page in the medical record contains the patient’s name or
identification number.
•
All entries in the medical records contain the author’s
identification. Author identification may be a handwritten
signature, a unique electronic identifier, or a stamped signature
verified with initials.
•
Medical records are legible to someone unfamiliar with the
author’s handwriting.
•
All encounters/entries are dated.
•
Immunization status information for all ages is recorded on a
single page location.
•
A summary of preventive services screening is documented in
a consistent place.
Medical Record
Documentation
(continued)
Content
•
Medication allergies and adverse reactions are prominently
noted in the record. If the patient has no known allergies or
history of adverse reactions, this is appropriately noted in the
record.
•
Significant illnesses and medical conditions are indicated on a
problem list.
•
Past medical history (for patients seen three or more times) is
easily identified and includes, as appropriate, significant family
history, serious accidents, operations and illnesses. For
children and adolescents (18 years and younger), past medical
history relates to prenatal care, birth, operations and childhood
illnesses.
•
For patients 10 years and older, there is an appropriate notation
concerning the use of tobacco, alcohol and substances.
•
The history and physical exam identifies appropriate subjective
and objective information pertinent to the patient’s presenting
complaints and includes medications.
Assessment and Plan
•
Laboratory and other studies are ordered, as appropriate
•
Assessment of each encounter reflects patient’s chief
complaint
•
Treatment plans are consistent with diagnoses
Follow-up
•
Encounter forms or notes have a notation, when indicated,
regarding follow-up care calls or visits. The specific time of
return is noted in weeks, months or as needed.
•
Unresolved problems from previous office visits are addressed
in subsequent visits.
•
If a consultation is requested, there is a note concerning this
visit in the record.
•
Consultation, lab and imaging reports filed in the chart are
reviewed by the primary care physician.
•
Clinically significant abnormal consultation results, lab or
imaging study results have an explicit notation in the follow-up
plans.
3-15
Health Care Improvement for Behavioral Health
Providers
General Overview
This section contains detailed information about the EPNI Health
Care Improvement (HCI) program that is specific to behavioral
health providers. The information in this section is in addition to or
more specific than the requirements in the greater chapter. The
material explains what is expected from participating providers
regarding their quality programs and defines Provider
requirements.
HCI Program
Rationale:
Additional
Requirements for
Select Network
Providers
Requirements:
Collaborative efforts need to mutually serve EPNI Subscribers and
Provider's patients with excellent care and services.
Actively participate in the following EPNI HCI activities.
Follow-up after hospitalization for mental illness
•
Offer appointments to new and returning patients within seven
days of mental health hospitalization discharge. Appointments
should be provided within the timeframe commensurate with
patient clinical need. EPNI recommends that behavioral health
providers develop an appointment scheduling strategy to
accommodate newly discharged patients, if they have not
already done so.
Standardized substance abuse screening in assessment
3-16
•
Routinely utilize standardized substance abuse screening
questionnaires, e.g. CAGEAID, in mental health assessments
for new patients age 12 and older. (Routine substance use
assessment of 10 and 11 year-old children is also
recommended.)
•
Recommend or complete a comprehensive substance abuse
assessment based on the standardized screening results and
corroborating clinical information when results indicate the
likelihood of substance abuse.
HCI Program
Exchange of information with primary care physicians
•
Routinely ask all new patients to authorize exchange of
information with primary care/treating physicians.
•
Establish a distinct section in the treatment record, if one does
not exist, dedicated to case management activities. The section
should contain:
•
Documentation of patient authorization or refusal to
exchange information with the physician
•
When authorized, documentation of communication the
physician, e.g. report, letter, telephone or email
communication
•
When authorized, the treating psychiatrist should provide the
current diagnosis(es), initial medication management
information, and general treatment plan to the physician
•
When recommending the patient seek psychopharmacologic
treatment from their physician or if the physician
recommended mental health assessment and/or treatment,
provide the physician with the current behavioral health
diagnosis(es), and general treatment plan if applicable
Complaint Review
System
Rationale:
Additional
requirements for
Select Network
Providers
Requirements:
The practice of managing patient complaints in behavioral health
clinics is consistent with practices in primary care clinics. Please
review page 3-7 for additional information on maintaining a
complaint review system.
All providers will have a policy and procedure in place detailing
the following:
•
Process to receive written and verbal complaints for EPNI
Subscribers
•
Designate an individual to be the primary contact for complaint
management, including the tracking of such complaints
•
Document the substance of the complaint, the investigation,
and any actions taken
•
Notify Subscribers of the right to complain and appeal to their
health plan
•
Track complaints by categories and report at least annually to
an in-house committee
3-17
Access and Availability
Rationale:
Subscribers' concept of the quality of care they receive often
begins when they make an appointment. EPNI wants to ensure that
Subscribers are able to schedule appointments in a timely manner;
commensurate with the level of care they need.
Requirements:
Routine initial appointments: 90% of requests within 10 business
days. Routine care is defined as a circumstance in which the
individual does not present either emergent or urgent conditions
and requests clinical services.
Follow-up appointment: 90% of requests within 10 business days
of the initial appointment.
Urgent appointment: 100% of requests within 24 hours. Urgent
care is defined as a circumstance in which the individual presents
no emergency or immediate danger to self or others; however, the
individual, clinician, or concerned party believes that the
individual’s level of distress and/or functioning warrants
assessment as soon as possible. An urgent condition is a situation
that has the potential to become an emergency in the absence of
prompt treatment.
Non-life-threatening emergency appointment: 100% of requests
within 6 hours. A non-life-threatening emergency is defined as a
circumstance in which the individual is experiencing a severe
disturbance in mood, behavior, thought, or judgment. There may
be evidence of uncontrolled behavior and/or deterioration in ability
to function independently that could potentially require intense
observation, restraint, or isolation.
Emergency care: 100% of Subscriber requests immediately. An
emergency is defined as a circumstance in which there is imminent
risk of danger to the physical integrity of the individual; the
individual cannot be maintained safely in his or her typical daily
environment.
3-18
Physical Facility
Rationale:
EPNI requires behavioral health clinics to provide a safe
environment, which protects patient privacy and ensures handicap
accessibility for disabled patients. EPNI will monitor and review
physical environment to evaluate conformity with regulatory, plan,
and accreditation standards.
Requirements:
Written Policies
•
Provider open reasonable working hours
•
Provide 24 hour/7 day on-call coverage
•
Accessibility to handicapped Subscribers as defined by the
Americans with Disabilities Act, 1990
•
Controlled substances are secure in a locked cabinet or space
and dispensation is logged
•
A system is in place to ensure that all medications are within
the expiration date
Rationale:
To protect the safety and privacy of all patients, and for the
protection of the clinic, EPNI requires all behavioral health clinics
to develop and implement written policies and procedures.
Providers are encouraged to have policies that are specific to the
clinic and are signed, dated and reviewed annually.
Requirement:
Each clinic will have policies and procedures in place for the
following topic in addition to the policies listed previously in this
chapter.
•
Behavioral Health Accessibility Standards
Policy Required
Behavioral Health
Accessibility
Standards
Recommended Risk Management
Elements
•
Access to behavioral health
appointments commensurate with
clinical need
•
Access to follow-up appointments
commensurate with clinical need
•
Crisis access to clinician 24 hours a
day/7 days a week
3-19
Treatment Record
Documentation
Rationale:
The patient behavioral health treatment record is a vehicle for
documenting services and evaluating continuity and coordination
of care. It also serves as legal protection for the patient and
practitioner. EPNI, per contractual agreement with both the
Subscriber and Provider, has access to the Subscriber's record for
examination and evaluation. EPNI corporate confidentiality policy
requires that the personal and health information of its Subscribers
be maintained as confidential information. All employees are
required to attest to their knowledge of this policy and their intent
to comply with it.
Treatment record review is an essential component of a
comprehensive Health Care Improvement program. The EPNI
Quality Council establishes minimum record documentation
standards.
Annually, EPNI audits a random sample of patient records from
the EPNI population. The records are reviewed in accordance with
the required documentation elements. If potential deficiencies are
identified at a given site, a more intensive review may occur.
Aggregate audit results are disseminated to the Select Network and
clinic-specific results are disseminated to each audited clinic.
Requirements for Treatment Record Format and Content
Record Organization
3-20
•
The format of the treatment record must be logical and
organized.
•
All forms used in the treatment process must be standardized
and consistent for all records.
•
The treatment record must contain the patient’s current
address, employer or school, home and work phone numbers,
marital or legal status, appropriate consent forms, and
guardianship status information.
•
Special status situations, such as imminent risk of harm,
suicidal or homicidal ideation, or elopement potential, must
be prominently documented and updated.
Treatment Record
Documentation
(continued)
•
There must be a signed patient authorization for all external
persons with whom treatment information is exchanged. No
treatment information can be exchanged without patient
authorization or court order.
•
Each page in the record must contain the patient’s name or
identifying number.
•
All entries must be dated and contain the author’s name,
professional degree/designation, and relevant identification
number if applicable. If a non-degreed professional completes
the entry, the title of the author must accompany the signature,
e.g. Family Skills Worker. Author identification may be a
handwritten signature or unique electronic identifier. Initials
alone are not an acceptable form of identification. Initials may
be used in conjunction with a typed signature block that clearly
identifies the author.
•
Errors in documentation must be corrected with a single line
drawn through the error with the author’s initials.
Initial Assessment
•
Presenting problem(s), as well as relevant psychological or
social conditions affecting the patient's medical or psychiatric
status, must be documented.
•
Presenting symptoms that are consistent with DSM-IV-TR
criteria must be clearly identified and documented, including
the onset, duration, and intensity of symptoms.
•
A psychiatric history must be documented. The psychiatric
history should include, if applicable, previous treatment dates,
identification of former treating practitioner(s), therapeutic
interventions and responses, relevant family psychiatric
history, lab test results, and consultation reports.
•
A medical history must be documented which includes current
and/or past major or chronic medical conditions and a current
list of medications. Medication allergies and adverse reactions
must be prominently noted. If the patient has no known
allergies or history of adverse reactions, this must be noted.
•
For children and adolescents through age 17, a comprehensive
developmental history must be documented that includes
prenatal and perinatal events, achievement of developmental
milestones, and psychological, social, intellectual, and
academic history.
3-21
Treatment Record
Documentation
(continued)
•
For individuals ten years and older, a substance use history
must be documented. The history must include past and present
use of tobacco, alcohol, illicit drugs and any misuse of
prescription or over-the-counter drugs. Additionally, negative
consequences of use and history of assessment and/or
treatment should be documented.
•
Standardized substance abuse screening questionnaire results
should be incorporated into the assessment of all new patients
twelve years and older.
•
A social history must be documented that includes family
history, current family status, history of physical, sexual or
mental abuse or trauma, current social network, and academic
or vocational status.
•
A mental status examination must be documented which
includes, at minimum, information about appearance, speech,
affect, mood, thought content, judgment, insight, attention,
concentration, memory, and impulse control.
•
A risk assessment that identifies level of risk for harm,
including suicidal, homicidal or elopement risk, must be
predominantly documented.
•
Patient strengths and weaknesses that enable or inhibit the
individual’s ability to achieve treatment goals must be
documented.
•
An initial treatment plan must be documented.
•
All behavioral health care practitioners must attempt
consultation and coordination of treatment with the patient’s
primary care or treating physician. Patient authorization must
be obtained prior to the release of any information. If the
patient does not wish to have treatment information exchanged,
patient refusal must be documented.
Diagnosis
3-22
•
A DSM-IV-TR diagnosis must be documented. The diagnosis
must be consistent with presenting problems, symptoms,
clinical history, mental status exam, and other clinical data.
•
All fives axes must be documented according to the DSM-IVTR multi-axial diagnostic system. The fifth digit of Axes I and
II diagnoses must be listed when applicable.
•
ICD-9-CM codes must be used when submitting claims for
payment.
Treatment Record
Documentation
(continued)
Treatment Plan
•
The treatment plan must be comprehensive, current, and
consistent with the diagnosis. The formal treatment plan must
be completed within the first three visits.
•
The treatment plan must contain clear, objective, and
measurable goals as well as the estimated timeframes for goal
attainment or problem resolution. Interventions must be
appropriate for the diagnosis and/or presenting problem(s).
•
The patient must participate in the development of the
treatment plan and should sign the initial plan and sign or
initial all updates or revisions.
Progress Notes
•
All entries must contain the date, actual face-to-face contact
time, and current diagnosis.
•
All entries must document the persons present during the visit
without using the names of persons other than the identified
patient.
•
The interventions must be consistent with the diagnosis and
correspond with current treatment goals.
•
Recommendations or referrals for preventive or other external
services, e.g., stress management, relapse prevention, or
community services, must be documented.
•
The documentation of each entry must clearly state the chief
complaint and current status of symptoms as well as patient
strengths and limitations in reaching treatment goals.
•
There must be a notation in each entry about need for followup care, plans for a return visit, or termination of treatment.
The specific date or timeframe of a return visit must be noted.
•
There must be documentation of patient cancellation or failure
to show for a visit.
•
Evidence of coordination of care with other relevant behavioral
health providers and/or medical professionals must be
documented.
•
Unresolved problems from previous visits must be addressed
and the outcomes documented.
•
If safety or risk characteristics are identified, they must be
prominently documented and addressed during each visit.
•
Phone conversations with persons relevant to treatment, e.g.
referral sources, physicians, or parents, must be documented.
3-23
Treatment Record
Documentation
(continued)
3-24
Medication Management
•
Significant illnesses, clinical risks, and medical conditions are
to be clearly noted and revised periodically.
•
Current medications prescribed by all prescribing physicians
must be listed. Dosages and dates of initial prescription and/or
refills must be documented.
•
Evidence of informed patient consent for the receipt of
medication must be documented.
•
Laboratory orders and results must be documented as well as
review of the results by the ordering physician. If abnormalities
are found, follow-up plans must be documented.
Chapter 4
Table of Contents
Integrated Health Management................................................................................................ 4-4
Introduction............................................................................................................................ 4-4
Objectives .............................................................................................................................. 4-4
Provider Contractual Obligations – Important Program Points............................................. 4-5
Integrated Health Management Decision Making ................................................................. 4-6
Utilization Management ............................................................................................................ 4-7
Overview................................................................................................................................ 4-7
Goals ...................................................................................................................................... 4-7
Integrated Health Management Medical and Behavioral Health Clinical Staff .................... 4-8
Medical Policy ............................................................................................................................ 4-9
Medical and Behavioral Health Policy Development............................................................ 4-9
Medical Policy and Behavioral Health Policy Manual........................................................ 4-10
Pre-Certification & Pre-Authorization Request Forms........................................................ 4-11
Pre-Certification/Authorization ............................................................................................. 4-12
Overview.............................................................................................................................. 4-12
Learn Scope and Purpose..................................................................................................... 4-13
Decision Making and Notification Time Frames................................................................. 4-13
Definition of Urgent Request............................................................................................... 4-14
Utilization Management Services Requiring Pre-Certification/Authorization.................. 4-15
Overview.............................................................................................................................. 4-15
Pre-Certification Requirements ........................................................................................... 4-15
High Technology Diagnostic Imaging Decision Support...................................................... 4-16
Overview.............................................................................................................................. 4-16
Prior Authorization-Chiropractic .......................................................................................... 4-17
Overview.............................................................................................................................. 4-17
Compliance Audits............................................................................................................... 4-17
Prior Authorization Form Tips............................................................................................. 4-17
Prior Authorization-Durable Medical Equipment (DME) .................................................. 4-19
Overview.............................................................................................................................. 4-19
Requirements ....................................................................................................................... 4-19
Eligible or Non-Covered DME (unless specified in Subscriber Contract).......................... 4-20
Prescriptions or Doctor’s Order ........................................................................................... 4-20
DME and Supplies Reviewed .............................................................................................. 4-20
DME & Medical Supply Pre-Authorization Request Form................................................. 4-20
4-1
Prior Authorization-Medical/Dental...................................................................................... 4-21
Medical-Surgical Procedures ............................................................................................... 4-21
Temporomandibular Joint (TMJ) Disorder.......................................................................... 4-22
Address ................................................................................................................................ 4-22
Prior Authorization-Outpatient Mental Health.................................................................... 4-23
Overview.............................................................................................................................. 4-23
Medication Management ..................................................................................................... 4-23
Medical Necessity and Level of Care Guidelines................................................................ 4-24
Prior Authorization-Outpatient Chemical Dependency ...................................................... 4-25
Overview.............................................................................................................................. 4-25
Medical Necessity and Level of Care Guidelines................................................................ 4-25
Prior Authorization-PT/OT/ST .............................................................................................. 4-26
Overview.............................................................................................................................. 4-26
Prior Authorization Recommendation ................................................................................. 4-26
Outpatient Therapy Prior Authorization Form .................................................................... 4-26
Prior Authorization-Organ Transplants ............................................................................... 4-27
Overview.............................................................................................................................. 4-27
Contact ................................................................................................................................. 4-27
Case & Disease Management.................................................................................................. 4-28
Overview.............................................................................................................................. 4-28
Program Goals ..................................................................................................................... 4-28
Referrals to Case Management ............................................................................................ 4-28
Disease Management ........................................................................................................... 4-29
Home Health Care Request Form ........................................................................................ 4-30
Home Infusion Services Prior Authorization....................................................................... 4-31
Inpatient Admission Notification & Pre-Certification Request Form. ................................ 4-32
Hospice Care Prior Authorization........................................................................................ 4-33
Minnesota Pregnancy Assessment....................................................................................... 4-34
Preadmission Notification, Plan-of-Care Review, Continued-Stay Notification ............... 4-35
Overview.............................................................................................................................. 4-35
Information Needed for Preadmission Notification............................................................ 4-36
Preadmission Notification Procedure .................................................................................. 4-36
Admissions Requiring Plan-of-Care Review....................................................................... 4-37
Plan-of-Care Review Procedure .......................................................................................... 4-37
Continued-Stay Notification ................................................................................................ 4-39
Discharge Call Back Process ............................................................................................... 4-39
Inpatient Mental Health and Chemical Dependency Notification....................................... 4-40
Suggestion Outpatient Procedures ....................................................................................... 4-41
PAN Fax Forms ................................................................................................................... 4-45
4-2
Focused Utilization Review ..................................................................................................... 4-46
Overview.............................................................................................................................. 4-46
Messages Provider May Receive ......................................................................................... 4-47
Special Investigations .......................................................................................................... 4-48
Documentation in the Medical Record .................................................................................. 4-49
Documentation Requirements.............................................................................................. 4-49
Overview.............................................................................................................................. 4-50
GA Modifier......................................................................................................................... 4-50
Directing Subscribers To Nonparticipating Providers......................................................... 4-51
Upgraded/Deluxe Durable Medical Equipment (DME) ...................................................... 4-51
DME Waiver Requirement .................................................................................................. 4-51
DME Claims Submissions ................................................................................................... 4-51
Sample DME Waiver........................................................................................................... 4-51
4-3
Introduction
Per the Employer Provider Network, Inc. (EPNI) Provider Service
Agreement, Provider has agreed to comply with care management
programs administered by EPNI. These care management
programs are designed to ensure that the treatment Subscribers
receive is reimbursable according to the Medical Necessity
guidelines in their Subscriber Contracts. In addition, EPNI reviews
investigative and new procedures/Health Services for coverage
determinations. Care management programs also ensure the most
cost-effective and appropriate use of the health care delivery
system.
These programs include:

Pre-certification/authorization of selected procedures, services,
supplies, and drugs

Preadmission notification (PAN), pre-certification and
concurrent review for inpatient admissions

Retrospective review of claims and medical records

Case and Disease Management
To make utilization decisions, EPNI uses established utilization
review decision criteria based on sound clinical evidence. The
criterion used to evaluate an individual case is available, free of
charge, upon request for Provider's review.
Objectives
4-4
Integrated Health Management programs are designed to:

Maximize the coordination of care and health outcomes

Ensure appropriate and efficient utilization of health care
resources

Promote efficient use of health care resources

Define and agree upon appropriate standards of care

Manage service for Subscribers with complex care
coordination needs

Identify gaps in Subscribers' care and navigation of resources

Identification of Subscribers with conditions that will benefit
from self-care efforts, care intervention and communication
Provider Contractual
Obligations –
Important Program
Points
The following points pertain to all of the care management
programs. Any Medical Necessity denial determination may be
discussed with a physician reviewer by telephone.

Any Health Services denied using EPNI’s medical necessity
guidelines cannot be billed to the Subscriber unless Provider
has specifically notified the Subscriber prior to the Health
Service being rendered that it is medically unnecessary and
will not be covered, and the Subscriber has agreed in writing to
pay for the service. This applies to investigative services as
well as some non-covered services for mental health.

The care management process is a review for Medical
Necessity only. Payment for Health Services is still subject to
all other terms of the Subscriber Contract. Therefore, denials
may occur for preexisting conditions, benefit maximums, or
riders in the Subscriber's Contract, which supersede Medical
Necessity.

EPNI recommend that Provider contact provider services to
verify coverage, benefits, contract eligibility and limitations for
all Subscribers. Service representatives will also verify which
care management procedures apply to a Subscriber's Contract.

Providers will continue to be held financially liable for services
that are determined to be not Medically Necessary during a
review or an audit process even if preauthorization/certification and/or concurrent review is not
recommended.
4-5
Integrated Health
Management Decision
Making
Integrated Health Management including utilization management
(UM) decision-making is based only on appropriateness of care,
service and existence of coverage. EPNI does not compensate
Providers, Health Care Practitioners or other individuals
conducting utilization review decision-making activities for
denials of coverage or service. EPNI does not offer incentives to
decision-makers to encourage denials of coverage or service that
would result in less than appropriate care or underutilization of
appropriate care and services.
EPNI UM decision-making processes ensure that Subscribers are
not discriminated against in the delivery of Health Services
consistent with the benefits covered in their Subscriber Contract
based on race, ethnicity, national origin, religion, sex, age, mental
or physical disability, sexual orientation, genetic information or
source of payment through the use of specific clinical criteria and
consideration of the individual needs of each case.
This statement exists to inform and remind Providers, their
employees, their supervisors, upper management, medical
directors, UM directors or managers, licensed UM staff, and other
personnel and UM staff employed by Providers who make
utilization management decisions of this philosophy and practice.
This includes delegates conducting utilization management
services on behalf of EPNI.
4-6
Utilization Management
Overview
The purpose of the Utilization Management (UM) Program is to
promote effective, appropriate and efficient use of medical and
behavioral health care resources for our members.
According to Minnesota statute, “‘Utilization review’ means the
evaluation of the necessity, appropriateness, and efficacy of the
use of health care services, procedures, and facilities, by a person
or entity other than the attending health care professional, for the
purpose of determining the medical necessity of the service or
admission.”
The UM program is a set of continuously improving processes,
designed to both meet Subscribers' needs, as well as regulatory and
accreditation requirements. The UM program includes processes
for:

Identifying over and under utilization

Identifying members with complex health issues that may
benefit from case management

The collection and distribution of UM data
IHM uses the UM program processes, procedures and criteria to
review and coordinate Subscribers' benefits to enhance the
efficiency, affordability and quality of care.
Goals
The UM program purpose of promoting effective, appropriate, and
efficient use of health care resources is accomplished by adhering
to the UM processes described in this program. The program goals
are to:

Ensure objective and consistent utilization management
decision-making

Ensure that Subscribers have access to appropriate and timely
medical and behavioral health care across the provider network

Improve service and claims processes to provide optimal
handling of pre-service authorization and post-service payment
 Ensure timely resolution of identified problems
Continually build and maintain collaborative relationships with
medical and behavioral health care providers
4-7
Integrated Health
Management Medical
and Behavioral Health
Clinical Staff
IHM medical and behavioral health clinical staff is responsible for
the coordination of utilization management functions for eligible
Subscribers. Clinical staff is required to maintain an active
unrestricted health license in Minnesota. The IHM medical and
behavioral health clinical staff is permitted to approve requested
authorizations based on plan documents, policies, procedures, and
established medical and behavioral health clinical criteria.
Physicians or appropriately licensed peer reviewers make
necessary medical necessity denials.
Contractual benefits, Medical Necessity, appropriateness, and
individual needs are evaluated during the review process to
determine coverage of Health Services. All requests for services
that do not meet Medical Necessity criteria are reviewed through
the physician peer review process.
UM decision-making is based only on appropriateness of care and
service, and existence of coverage. No financial incentive is
awarded to clinical staff for denying requests for service or based
on coverage decisions.
4-8
Medical Policy
Medical and Behavioral
Health Policy
Development
Medical and behavioral health policies are developed by the EPNI
Medical and Behavioral Health Policy Committee, which is
comprised of practicing physicians and providers representing a
variety of specialties in the local community and one health plan
representative.
EPNI makes its determination of experimental, investigative or
unproven based upon a preponderance of evidence after the
examination of the following reliable evidence, none of which
shall be determinative in and of itself:
1. Whether there is final approval from the appropriate
government regulatory agency, if approval is required;
2. Whether there are consensus opinions and recommendations
reported in relevant scientific and medical literature, peerreviewed journals, or the reports of clinical trial committees
and other assessment bodies; and
3. Whether there are consensus opinions of national and local
health care providers in the applicable specialty or subspecialty
that typically manages the condition as determined by a survey
or poll of a representative sampling of these providers.
The committee considers a number of additional factors when
evaluating each of the criteria. These factors include, but are not
limited to: quality of the available peer-reviewed medical
literature; safety, effectiveness, appropriateness of technology; and
the relevant impact and consequences of coverage for the
technology (for example, patient, health plan, ethical, societal,
legal).
A drug, device, medical treatment, diagnostic procedure,
technology or procedure for which reliable evidence does not
permit conclusions concerning its safety, effectiveness, or effect on
health outcomes. EPNI bases its decision upon an examination of
the following reliable evidence, none of which is determinative in
and of itself.
Drugs and devices cannot be lawfully marketed without the
approval of the U.S. Food and Drug Administration and approval
for marketing has not been given at the time the drug or device is
furnished.
4-9
Medical and Behavioral
Health Policy
Development
(continued)
The drug, device, diagnostic procedure, technology, or medical
treatment or procedure is the subject of ongoing Phase I, II, or III
clinical trials:

Phase I clinical trials determine the safe dosages of medication
for Phase II trials and define acute effects on normal tissue.

Phase II clinical trials determine clinical response in a defined
patient setting. If significant activity is observed in any disease
during Phase II, further clinical trials usually study a
comparison of the experimental treatment with the standard
treatment in Phase III trials. Phase III trials are typically quite
large and require many patients to determine if a treatment
improves outcomes in a large population of patients); or
Medically reasonable conclusions establishing its safety,
effectiveness or effect on health outcomes have not been
established. For purposes of this subparagraph, a drug, device,
diagnostic procedure, technology, or medical treatment or
procedure shall not be considered investigative if reliable evidence
shows that it is safe and effective for the treatment of a particular
patient.
Medical Policy and
Behavioral Health
Policy Manual
The EPNI Medical and Behavioral Health Policy Manual ("Policy
Manual") contains an overview of the criteria used to determine a
policy position based on evaluation by EPNI's Medical and
Behavioral Health Medical Policy Committee ("Policy
Committee") of a new technology (i.e., drug, device, diagnostic
procedure, behavioral health procedure, and medical treatment or
procedure).The Policy Manual explains how to locate medical
policies on www.ccstpa.com. These policies assist EPNI in making
a determination if a Health Service is Medically Necessary and/or
investigative and include general coding information and prior
authorization instructions. The Provider Policy & Procedure
Manual is available at www.ccstpa.com, and is incorporated by
reference herein. To view the policies, select "For Providers," then
select “Learn More”. Select “Medical Policies”, then select “View
Policies”. Read and accept the medical policy statement, and then
select “View All Active Policies.” The following are several
selections to assist with inquires:

4-10
The “Upcoming Policies” section lists new or revised policies
approved by the Policy Committee; these policies become
effective 45 days from the date they were posted to the
“Upcoming Policies” section of the Policy Manual.
Medical Policy and
Behavioral Health
Policy Manual
(continued)
Pre-Certification &
Pre-Authorization
Request Forms

The “What’s New” section identifies the latest new or revised
policies approved by the Policy Committee at least 90 days
earlier. These policies are currently in effect and providers
should begin following these policies immediately. These
policies also appear in the “Active Policy” section of the Policy
Manual.

The “Active Policy” section contains the entire list of policies
in effect at the time of Provider's inquiry.

The “Prior Authorization Recommended” sections identify
procedures, Health Services, devices and drugs for which prior
authorization is recommended or required, as stated in the
policy. For Provider's convenience, a link to “Prior
Authorization Forms” has also been provided.
Request forms are available at ccstpa.com in the For Providers
section under Additional Information – Access Forms.
4-11
Pre-Certification/Authorization
Overview
The purpose of Pre-certification/authorization is to review Health
Services prior to being rendered to determine if the Health
Services are contractually eligible and Medically Necessary.
Medical policy criteria and Subscriber Contract language is used to
assist in determining if benefits are available for the requested
Health Service. Certification/Authorization for a Health
Service, device or drug does not in itself guarantee coverage,
but notifies Provider that as described, the Health Service, device
or drug meets the criteria for medical necessity and
appropriateness. Services are only covered only if:
• The member is enrolled in the health plan on the date of
service
• The services or items are covered benefits
• The provider is eligible for payment
• The provider bills for the services that are approved
Payment for services and/or supplies EPNI approves in advance
are also subject to the terms of the Subscriber’s coverage including
any applicable copays and/or deductibles, preexisting condition
limitations, contract exclusions and health plan allowed amounts.
The “Pre-certification/authorization” section identifies various
Health Services, procedures, prescription drugs, and medical
devices that require Pre-certification/pre-authorization.
The EPNI clinical reviewer uses local and national medical policy,
Medicare guidelines, behavioral health criteria and Subscriber
Contract language to assist in determining if benefits are available
for the request. Criteria are determined by the type of plan in
which the Subscriber is enrolled. Authorization for a Health
Service, device, or drug does not in itself guarantee coverage but
notifies Provider if the request meets the criteria for Medical
Necessity and appropriateness. The provider should always check
with customer service to make sure the Subscriber or patient has
contract benefits and that the coverage is up to date.
EPNI will evaluate Provider's request for Pre-certification and will
make a determination once all the necessary medical information
is received. Review decisions will be made and communicated
within required time frames as defined by state and federal law.
4-12
Learn Scope and
Purpose
These policies are applicable to all commercial and government
program products; medical, surgical, and behavioral health
services are included.
Benefit plans vary in coverage and some plans may not provide
coverage for certain services discussed in the medical policies.
Coverage decisions are subject to all terms and conditions of the
applicable benefit plan, including specific exclusions and
limitations, and to applicable state and/or federal law.
Decision Making and
Notification Time
Frames
To ensure timely processing and assist us in meeting compliance
with state and federal guidelines, please submit precertification/authorization requests at least 15 business days prior
to any elective services being rendered.
Decision-Making Timeframe for
Initial Notification (by Telephone or fax to Practitioner only)
Follow-up Notification (Electronic or written notification to Members and Providers)
Non-Urgent Pre-certification Requests
File Type
Initial and Concurrent
Within 10 business days* of receiving request, not to exceed 15
Review:
calendar days**.
Urgent Pre-certification Requests
Initial Review:
Within 72 hours of receiving request or as
expeditiously as the member's health condition warrants
Concurrent Review:
Within 24 hours of receiving request.
Post-service Request
Retrospective Review
Within 30 calendar days** of receiving the request
*Business day: Day in which EPNI is open for business, does not include weekends or holidays.
**Calendar day: Days in sequence on calendar, including weekends and holidays.
4-13
Definition of Urgent
Request
The federal regulations define an urgent request as:

Requires immediate action to prevent a serious deterioration of
a Subscriber’s health that results from an unforeseen illness or
an injury, or

Could jeopardize the ability of the individual to regain
maximum function based upon a prudent layperson’s
judgment, or

In the opinion of the treating physician, would subject the
individual to severe pain that cannot be adequately managed
without the treatment being requested. An urgent condition is a
situation that has the potential to become an emergency in the
absence of treatment.
Care that has already been provided is not considered urgent.
Requests not meeting the conditions for an urgent request will be
considered nonurgent. Both urgent and nonurgent requests will be
reviewed and completed within current state and federal timelines.
For expedited requests, EPNI adheres to federal and state
requirements for decision-making time frames. EPNI uses the
following definitions to determine if a request is expedited:
Requires immediate action to prevent a serious deterioration of a
Subscriber’s health that results from an unforeseen illness or an
injury, or
Could jeopardize the ability of the individual to regain maximum
function based upon a prudent layperson’s judgment, or
In the opinion of the treating physician, would subject the
individual to severe pain that cannot be adequately managed
without the treatment being requested. An urgent condition is a
situation that has the potential to become an emergency in the
absence of treatment.
Requests not meeting the criteria for the urgent definition for an
urgent request will be considered non-urgent. Providers submitting
the request will be notified by EPNI that the request does not meet
urgent criteria and will be managed according to non-urgent
criteria. Both urgent and non-urgent requests will be reviewed.
4-14
Utilization Management Services Requiring PreCertification/Authorization
Overview
Medical and behavioral health policies and the list of services that
require pre-authorization are available for Provider's use and
review at ccstpa.com.
Pre-Certification
Requirements
1. At the bottom of the For Providers column, select “Learn
More”. At the bottom of the Medical Policy column, select
“View Policies”.
2. Read and accept the EPNI Medical Policy Statement
3. Select “View All Active Policies” at the top of the page
4. The “Pre-Certification/Authorization” links on the left-hand
side will direct you to the Pre-authorization requirement list.
This list identifies the services, procedures, prescription drugs,
and medical devices that require pre-certification/authorization.
4-15
High Technology Diagnostic Imaging Decision
Support
Overview
EPNI recommends seeking authorization of the following high
technology diagnostic imaging procedures:

CT including CTA

MRI including MRA, MRS, MRM

Nuclear Cardiology

PET

fMRI
American Imaging Management (AIM) conducts decision support
for these procedures on behalf of EPNI. The decision support
process used by AIM uses evidence-based appropriateness criteria
to evaluate the requested imaging procedure.
Prior to performing these procedures, it is recommended that the
ordering or the imaging provider by contacting AIM electronically
or by telephone.
AIM website
www.americanimaging.net
www.providerportal.net
(available 24/7)
AIM Call Center:
1-866-455-8417
Select Option 2
Monday through Friday
Central Time
8:00 a.m. – 5:00 p.m.
4-16
Prior Authorization-Chiropractic
Overview
Providers are encouraged call provider services to obtain
Subscriber benefits prior to beginning service. Self-insured groups
may require prior authorization and impose visit limits.
The Chiropractic Treatment Request Form may be faxed or mailed
to EPNI. The form is available at www.ccstpa.com
Compliance Audits
The Provider Service Agreement includes certain quality assurance
requirements. Pursuant to the Agreement, EPNI may conduct
audits to evaluate Provider’s compliance with Medical Necessity
guidelines and standards of practice in the community. Such an
audit could include post-service claims review, which may result
in Provider liability if the care is determined to be not Medically
Necessary or medically inappropriate.
Prior Authorization
Form Tips
Below are some tips that Provider may find helpful as it completes
the Chiropractic Prior Authorization Form. All information on the
form must be completed or authorization may be delayed.

Pain Severity Scale
The Pain Severity Scale should be the patient’s rating of his or
her pain. Many forms come in with a 10 rating. Be sure
patients understand that a pain rating of 10 indicates severe
pain that is incapacitating or intractable.

Exact Views Taken
For the Exact Views Taken field, list the specific number of
views being requested.

Treatment Goals
These treatment goals should be specific and patient oriented.
For example:

Return to recreational activities

Be able to care for children

Restore cervical range of motion for safe driving

Increase time sitting, reading, lifting or performing

Household tasks
4-17
Prior Authorization
Form Tips (continued)
4-18

Active Care
Active Care is instruction to the patient about how to care for
himself or herself. Examples are exercise, weight loss, stress
reduction, lifestyle modification or changes in the work
environment.

Smoker and BP>140/90
Make sure the “Y” or “N” are circled in the area at the top of
the form.
Prior Authorization-Durable Medical Equipment
(DME)
Overview
EPNI does not accept prior authorizations for durable medical
equipment (DME) from the Subscriber or physician. All requests
must be made by the DME Provider. The DME Provider can
provide all details required, such as specific features, costs,
alternatives, and documentation of Medical Necessity as provided
by the physician.
Requirements
DME Providers should use the Pre-Authorization Request Form,
whenever submitting a prior authorization. This form is available
at www.ccstpa.com. All prior authorizations must include medical
documentation.
The prior authorization request should include the following
information:

The medical diagnosis related to the need for the equipment

The patient’s functional abilities and deficits related to the
need for the equipment

Whether the equipment is to be rented or purchased

A breakdown of the charges, if available

The anticipated length of time the equipment will be needed

All applicable HCPCS codes and narratives
Note: HCPCS code E1399 and other unlisted codes should be
used only when there is no other HCPCS code to describe
the equipment, such as custom-made equipment.
Incomplete information or incorrect use of HCPCS codes
may result in delayed review of the prior authorization
request or incorrect claim payment. EPNI reserves the right
to return to the Provider any prior authorization request or
to reject a claim that is submitted with an E1399 and other
unlisted HCPCS codes without complete description of the
equipment. EPNI will accept all valid HCPCS codes and
will reimburse as appropriate.
4-19
Eligible or NonCovered DME
(unless specified in
Subscriber Contract)
Equipment that is primarily and customarily used for a nonmedical purpose, may not be considered “medical” equipment for
which payment can be made. Equipment primarily for
independence, self-sufficiency and prevention or reoccurrence of
medical conditions, are not generally considered as treatment of
existing disease.
Examples of ineligible DME include:

environmental aides

exercise equipment

safety equipment

home modifications

sensory aides

vehicle modifications

transportation aides
Note: In certain circumstances, some equipment, even though not
necessarily medical equipment, may be eligible when it is
serving a similar function of typically eligible DME. Cases
must be considered individually since eligibility depends
upon the specific situation.
Prescriptions or
Doctor’s Order
Please submit a copy of the prescription or doctor’s order for
DME. The prescription or doctor’s order for DME provides
necessary information to assure appropriate notification of
decisions to the attending Health Care Provider.
DME and Supplies
Reviewed
Provider can write or fax its Prior Authorization Request Form to
Medical Review. Refer to Chapter 1 – At Your Service for the
address or fax number. The following is a general list of DME or
Supplies that Medical Review evaluates.
DME & Medical Supply
Pre-Authorization
Request Form
4-20

Communications devices

DME over $1,000 without an assigned HCPCS code

Electrical bone growth stimulator

Implantable infusion pumps

Specialty beds/overlays

Vest percussor for cystic fibrosis

Wheelchair (purchase only) Commercial, only
A sample of the DME and Medical Supply Pre-Authorization
Request Form is available at www.ccstpa.com.
Prior Authorization-Medical/Dental
Medical-Surgical
Procedures
Self-insured groups may have different requirements and Provider
is encouraged to use provider services to obtain Subscriber
benefits prior to beginning service.
Many Subscriber Contracts cover specific medical-surgical
procedures that dentists perform. The procedures which fall into
this category are:

Treatment of accidental injury to natural teeth, which is not
regular dental repair or maintenance. Initial treatment must
begin within a time frame specified by the Subscriber's
Contract and is only to repair or replace teeth. Biting or
chewing does not constitute an accident. Treatment involving
dental implants and dentures is specifically excluded.

Surgical and nonsurgical treatment of temporomandibular joint
(TMJ) syndrome and craniomandibular disorder.

Treatment of cleft lip and palate for Subscribers who have
initiated or scheduled services prior to age 19.

Reconstructive surgery to correct a functional physical defect
for dependent children (dependent child is defined by the age
limit for a dependent child or student dependent, whichever is
later, if applicable, as specified in the Subscriber's Plan.)—this
would include orthognathic surgery & surgical treatment of
cleft lip and palate. Treatment involving dental implants is
specifically excluded.

Anesthesia and inpatient and outpatient hospital charges for
dental care provided to a covered person who is a child under
age five (5); is severely disabled; or has a medical condition
that requires hospitalization or general anesthesia for dental
treatment. The actual dental service should be billed to the
Subscriber's dental carrier.
Prior Authorization is recommended for Health Services related to
surgical TMJ, orthodontia for TMJ and reconstructive surgery. A
prior authorization is strongly suggested for accidental injury
treatment beyond the emergency visit. A prior authorization is
recommended for Subscribers over the age of four for facility and
anesthesia charges related to a dental procedure.
Please direct these requests to Medical/Dental Review.
4-21
Temporomandibular
Joint (TMJ) Disorder
Some Subscriber Contracts offer coverage for TMJ disorders. A
prior authorization is recommended for surgical treatment and
orthodontia.
The following information is recommended to be submitted with
all PA requests to justify the diagnosis and to provide evidence
that all probable etiologies for the TMJ disorder have been
considered and that the proposed treatment is appropriate for the
identified condition. Documentation must include a complete
treatment plan. A diagnosis of TMJ alone is not sufficient.
Sufficient evidence must be provided to show medical necessity.
The treatment must be appropriate and based on the most costeffective alternative.
Address
Please direct all correspondence to:
P.O. Box 64265
St. Paul, MN 55164-0265
Fax: (651) 662-2810
4-22
Prior Authorization-Outpatient Mental Health
Overview
Outpatient mental health services are no longer subject to prior
authorization and Medical Necessity determination, unless
required by the Subscriber's Contract. Providers are encouraged to
call provider services to obtain Subscriber benefits prior to
beginning services.
Note: Please contact provider services for group exceptions to
these general prior authorization rules.
To obtain prior authorization for Health Services when
required by the Subscriber's Contract, Providers should
complete the Minnesota Universal Outpatient Mental
Health/Chemical Health Authorization Form. The form is
available at www.ccstpa.com. The form may be requested
by calling provider services.
Medication
Management
Prior Authorization for medication management (code 90862 or
M0064) is no longer required for sessions exceeding 12 per
calendar year, unless required by the Subscriber's Contract.
4-23
Medical Necessity and
Level of Care
Guidelines
EPNI Medical Necessity Criteria and Level of Care Guidelines
were developed with a national advisory panel. The criteria are
based on current scientific evidence and community standards, and
are reviewed annually by a multidisciplinary behavioral health
advisory panel made up of providers from around the state. Copies
of the criteria, as related to a specific request for services are
available upon request.
Mental health and chemical dependency Medically Necessary
services are defined as those which are:

Intended to identify or treat a diagnosable disorder (using the
DSM- IV) that causes pain or suffering, threatens life, results
in illness as manifested by impairment in social, occupational,
scholastic or role functioning.

Consistent with nationally accepted standards of medical
practice.

Individualized, specific and consistent with the individual’s
signs, symptoms, history and diagnosis.

Reasonably expected to help restore or maintain the
individual’s diagnosable disorder.

Not primarily for the convenience of the individual, provider or
another party.

Provided in the least restrictive setting that balances safety,
effectiveness and efficiency.
Licensed behavioral health review staff use Medical Necessity and
therapeutic appropriateness criteria to determine severity of need
and appropriate level of care when determining treatment
authorizations for mental health and chemical dependency services
provided in inpatient, partial hospitalization, residential, day
treatment and outpatient level of care settings. Criteria are
reviewed annually for effectiveness, appropriateness and
consistent application based on clinical practice advances in the
field of behavioral health, review of current scientific literature and
input from currently practicing behavioral health care practitioners.
Compliance Audits
4-24
audits to evaluate a Provider’s compliance with Medical Necessity
Prior Authorization-Outpatient Chemical
Dependency
Overview
Outpatient chemical dependency services are no longer subject to
Prior Authorization and Medical Necessity determination, unless
required by the Subscriber's Contract when provided by a
participating provider. It is recommended that Provider call
provider services to verify Subscriber benefits prior to beginning
treatment. Please contact provider services for group exceptions to
these general prior authorization rules.
To obtain Prior Authorization for Health Services when required
by the Subscriber's Contract, beyond the first two-hour assessment,
Provider should complete the Minnesota Universal Outpatient
Mental Health/Chemical Health Authorization Form. The form is
available at www.ccstpa.com.
EPNI behavioral health staff will determine if the Health Services
meet the criteria for Medical Necessity and if services are eligible
based on documentation supplied and coverage provided by the
Subscriber's Contract.
Compliance Audits
Medical Necessity and
Level of Care
Guidelines
Please reference the Medical Necessity and Level of Care
Guidelines information in the Prior Authorization-Outpatient
Mental Health section earlier in this chapter.
4-25
Prior Authorization-PT/OT/ST
Overview
Prior authorization for outpatient physical, occupational and
speech therapy services is recommended in situations listed below
for fully insured groups. Self-insured groups may have different
requirements and Providers is encouraged call provider services to
verify benefits. Provider may write or fax Chiropractic and Allied
Health. Refer to Chapter 1 – At Your Service, for the fax number
and address.
Prior Authorization
Recommendation
1. Non-participating providers:
All outpatient therapy services performed by a provider that
does not have a Provider Service Agreement.
2. All Maintenance and Specialized Therapy:
A prior authorization is required for all lines of business and all
diagnoses.
Compliance Audits
Outpatient Therapy
Prior Authorization
Form
A sample of the Outpatient Physical, Occupational & Speech
Therapy Request Form is available at www.ccstpa.com.
4-26
Prior Authorization-Organ Transplants
Overview
Prior Authorization for major organ (excluding kidney or cornea
transplants), bone marrow and stem cell transplants must be
coordinated through EPNI's transplant unit. Prior Authorization for
transplants are submitted by the transplant provider.
Kidney and Cornea Transplants:
Contact

Covered on the same basis as any other illness

Not included in the EPNI transplant network

Prior authorization is not recommended
Pre-Service requests can be mailed or faxed using the Transplant
Request form. The form is available at www.ccstpa.com.
Contact information:
P.O. Box 64265
St. Paul, MN 55164-0265
Fax: (651) 662-2810
4-27
Case & Disease Management
Overview
Mission Statement
Integrated Health Management (IHM) combines historically
fragmented Disease and Case Management services to provide a
whole person approach to improving Subscriber health, working
with Subscribers who are facing chronic, complex, catastrophic
injuries, illness or diseases.
IHM clinicians work collaboratively with Subscribers, Providers,
and the community to promote optimal health, and coordinate
access to services across the continuum of care that is holistic,
seamless and easily accessible.
Clinicians
Licensed Nurses/Clinicians, using a collaborative process,
advocate, assess, plan, implement, coordinate, monitor and
evaluate options and services to meet an individual’s specific
health care needs through education and communication of
available resources to promote high quality, cost effective
outcomes for Subscribers with medical and behavioral conditions
that require ongoing or intermittent care. Clinicians are required to
maintain an active unrestricted health license in Minnesota.
Program Goals
Referrals to Case
Management
4-28

Maximize optimal health and functional outcomes.

Identify gaps in care

Reach out to the Subscribers with the greatest need and educate
them about their condition

Support and encourage individual accountability for health and
wellness (self-care management)

Help Subscribers coordinate their needs and navigate services
in the health care system

Tailor interventions and outreach to promote the appropriate
use of health care services

Improve Subscribers satisfaction with the health plan and
health care system
A referral can be made by contacting the Nurse Guide Team at 1866-489-6947.
Disease Management
Disease management is a multidisciplinary, continuum-based
approach to health care delivery that proactively identifies
populations who have or are at risk for, chronic medical and
behavioral health conditions. Disease management supports the
practitioner-patient relationship and plan of care, emphasizes the
prevention of exacerbation and complications using cost-effective,
evidence-based practice guidelines and patient empowerment
strategies such as education and self-management. The process of
disease management evaluates clinical, social/humanistic and
economic outcomes with the goal of improving overall health of
the whole person.
Subscribers who receive disease management services receive
support from a dedicated clinician, who assists in facilitating the
health of the whole person, not just their individual condition.
*Services are offered to Subscribers, participation is optional.
* Subscriber eligibility for disease management is determined by
the Subscriber Contract.
Disease States

Asthma

Coronary Artery Diseases (CAD)

Chronic Kidney Disease (CKD)

Chronic Obstructive Pulmonary Disease (COPD)

Depression

Diabetes

Heart Failure

Low Back Pain

Oncology
In addition to the above conditions, EPNI also offers a prenatal
support program to eligible Subscribers. Please contact customer
service to determine if a Subscriber is eligible.
A nurse or clinician may contact Provider's office for assistance
with a Subscriber's needs or to verify a Subscriber’s contact
information. They may also send a Provider a letter including
Subscriber goals and/or gaps in care to inform Provider on what
EPNI is working with the Subscriber to advance their health care
needs. EPNI looks forward to working with its Subscribers' Health
Care Practitioners to improve the health of its Subscribers.
4-29
Home Health Care
Request Form
During the prior authorization process, EPNI's purpose is to assure
that home health care services are reasonable and necessary for the
treatment of the Subscriber's illness or injury. Health Services
must be ordered in writing from a physician and performed by a
Medicare certified/Joint Commission approved home health
agency. Home health care must be skilled rather than non-skilled
or custodial and of such a level of complexity and intensity that the
services can only be performed by a Medicare certified or Joint
Commission approved home health agency. Our review is
performed referencing Medicare Criteria. The Home Health Care
Request Form is available at www.ccstpa.com.
Information requested from Provider over the phone or by fax:
4-30

Caller’s name and phone number

Subscriber's name, CCStpa ID #, and group #

Home health agency name, phone number, and EPNI
contracting provider #

Diagnosis

Physician’s name recommending the home health care

Treatment request

Homebound status

Subscriber's support system (available caregivers)

Medical history (onset of conditions, test results, surgeries,
complications, previous treatment and response)

Problems and functional limitations (measurements, baseline)

Goals (objective, measurable, functional, time-specific)

Plan of care

Home program (physical, occupational, and speech therapies)

Re-evaluation (response and alterations in plan)
Home Infusion
Services Prior
Authorization
During the prior authorization process EPNI's purpose is to assure
that home infusion services meet EPNI’s Medical Policy
guidelines. Prior Authorization is only required for the following
situations: Factor Products and IVIG therapy.
Services must be ordered in writing from a physician and
performed by a Medicare certified/Joint Commission approved
home infusion provider/agency.



Home infusion provider name, phone number and EPNI

Ordering physician’s name, phone number, and EPNI

Diagnosis

Medical history (onset of conditions, test results, surgeries,
complications, previous treatment and response)

Problems and functional limitations (measurements, baseline)

Goals (objective, measurable, functional, time-specific)

Plan of care (infusion request, parenteral, enteral;
caregiver/self potential ability to administer infusion; duration)
and frequency of infusion
4-31
Inpatient Admission
Notification & PreCertification Request
Form.
During the prior authorization process EPNI's purpose is to review
extended care (i.e., skilled nursing facility, nursing home, extended
care unit, swing bed or transitional care unit) for both the
appropriateness of the admission and continued length of stay.
EPNI's review is performed referencing Medicare criteria.
Extended care must be ordered in writing from a physician and
performed by a Medicare certified facility. In order to be eligible
for coverage, services must be skilled and provided on a daily
basis. Custodial care is not a covered service. The Inpatient
Admission Notification & Pre-Certification Request Form is
available at www.ccstpa.com.
Information requested from the provider over the phone or by fax:
4-32



Skilled nursing facility name, phone number, and EPNI

Diagnosis

Physician’s name that is recommending skilled nursing care

Medical history (onset of condition; complications, problems
and functional limitations; previous treatment response; recent
hospitalizations or surgeries; support system)

Plan of care

Anticipated length of stay (Is the goal to return home or is this
a permanent placement?)

Therapies being provided, if applicable (Will the claim be
submitted using the extended care or the rehabilitation
agency’s provider number?)

Name and number of contact person for concurrent review
updates
Hospice Care Prior
Authorization
During the prior authorization process EPNI's purpose is to
provide a holistic approach to the recipient’s end of life care needs.
EPNI assures that the frequency and type of hospice services are
tailored to meet the needs of the recipients and verify that a
hospice benefit is available. The hospice provider must be
Medicare and/or Joint Commission certified.


Subscriber's name, EPNI ID #, and group #

Hospice agency name, phone number, and EPNI contracting
provider #

Diagnosis

Ordering physician’s name

Has the physician signed a six-month life expectancy form?

Has the family/Subscriber accepted the “hospice philosophy”?

Subscriber's support system (available caregivers)

Medical history (onset of condition and current status)

Services needed (volunteers, nursing, equipment)

Person to whom we should send the hospice letter

Contact person for updates
4-33
Minnesota Pregnancy
Assessment
The Minnesota Council of Health Plans initiated a collaborative
effort to design a uniform pregnancy assessment tool. The tool,
Minnesota Pregnancy Assessment Form, was designed to enable
health plans and the Minnesota Department of Human Services
(DHS) to accept the same form for all pregnant women in
Minnesota.
The Minnesota Pregnancy Assessment Form Training Manual was
developed to provide providers with the background concerning
the form’s development and to assist providers with using the form
as part of providing high quality prenatal care. A copy of this
manual may be requested from EPNI Case Management.
To obtain forms: The Minnesota Pregnancy Assessment Form,
#DHS-3294, can be downloaded off the DHS website:
http://www.dhs.state.mn.us/provider/forms/
http://edocs.dhs.state.mn.us/lfserver/legacy/DHS-3294-ENG
To assure quality care, EPNI requires Provider to do a risk
assessment for all its pregnant EPNI Subscribers. EPNI
recommends that the Minnesota Pregnancy Assessment Form be
used for all patients.
For other health plans insured or administered by EPNI:
Complete and mail or fax the assessment and the form at the initial
visit and again at 24-28 weeks. Send the form to the EPNI Case
Management Department at the address or fax number below. Use
Provider's EPNI contracting provider number for these
Subscribers.
EPNI Case Management
Perinatal Unit R4-72
P.O. Box 64560
St. Paul, MN 55164-0560
Fax: (651) 622-1004
Phone: (651) 662-1818 or 1-888-878-0139, x1818
Refer to Chapter 11 – Coding Policies and Guidelines, for coding
and reimbursement information related to the assessment and
form.
4-34
Preadmission Notification, Plan-of-Care Review,
Continued-Stay Notification
Overview
Per the Provider Service Agreement, preadmission notification
(PAN), plan-of-care review, or continued-stay notification is
recommended for inpatient admissions. PAN is the notification to
EPNI of an inpatient facility stay. This does not represent an
approval or a denial of the admission; it is only a notification of
the admission. Listed below are descriptions detailing when each is
recommended for EPNI (fee-for-service) plans and EPNI
(managed care) plans.
EPNI (fee-for-service plan) admissions:

PAN – all admissions-notification only

Plan-of-care review - admissions listed in Admissions
requiring plan-of-care review

EPNI (managed care plan) admissions:

PAN - all admissions-notification only

Plan-of-care review - admissions listed in Admissions
requiring plan-of-care review
4-35
Information Needed
for Preadmission
Notification
The following information is necessary for PAN on inpatient
admissions:

Subscriber identification and group numbers

Subscriber name and address

Patient name, birth date, and sex

Admitting physician’s name and EPNI’s individual provider
number

Admitting diagnosis code

ICD-9-CM surgical procedure code and narrative, if applicable

Date of surgery, if applicable
 Date of admission
Clinical information supporting the need for inpatient admission
(plan-of-care) is only necessary for those admissions requiring a
plan-of-care review.
Maternity/delivery admissions are exempt from PAN.
Most Inpatient Admissions for Mental Health or Chemical
Dependency do not require plan-of-care review. Admissions for
the Subscribers with the following coverage require a plan-of-care
review: VA and CCStpa. Refer to Admission Requiring Plan of
Care.
Preadmission
Notification Procedure
The PAN procedure applies to admissions not requiring plan-ofcare review or continued-stay notification. The provider should
contact EPNI as soon as the admission is scheduled, but no later
than two working days after the admission occurs.
How to contact EPNI:

Phone – Call provider services and please have the
information under Information Needed for Preadmission
Notification in the previous section available.

Fax – The fax form may only be used for the following
exceptions:

4-36
non-rehab acute inpatient admissions
Admissions Requiring
Plan-of-Care Review
As a general guide, the plan-of-care review pertains only to the
following EPNI acute inpatient admissions:

Direct admissions to acute rehabilitation units or facilities

Admissions for inpatient pain management programs

Residential admissions (inpatient gambling treatment
programs, inpatient smoking cessation programs)

Cases where the Medical/Behavioral Health policy
recommends a plan of care review

All admissions to nonparticipating providers

Skilled nursing facilities (EPNI Case Management reviews
these admissions).
There may be hospital-specific requirements. EPNI recommends
that Provider contact provider services to verify coverage, benefits,
contract eligibility, and limitations for all Subscribers. Provider
services representatives will determine if plan of care is required
for that Subscriber's Contract.
Plan-of-Care Review
Procedure
Outlined below are the steps to obtain a plan-of-care review for
required admissions. Provider should call provider services as soon
as the admission is scheduled but no later than two working days
after the admission occurs. This information is critical to ensure
seamless payment of claims, as well as triggering review for
inclusion of the patient in the discharge follow-up process. EPNI
will complete this process in one working day whenever possible.
Provider should assume the admission is approved unless unless
EPNI initiates further contact.
1. The admitting physician’s office or hospital representative
calls EPNI provider services with the necessary information
(refer to Information Required for Preadmission Notification)
as well as the clinical information supporting the need for
inpatient admission (plan-of-care). The provider services
representative documents the information, quotes benefits, and
then transfers the caller to a clincian.
If Provider does not require benefits to be quoted and know
that the admission requires a plan-of-care review, Provider
may contact the clinician directly. (Refer to Chapter 1 for
phone numbers).
4-37
Plan-of-Care Review
Procedure (continued)
2. A clincian uses established criteria to screen the medical
necessity of the admission.
If the clinician…
Then, the clinician…
can approve the
admission
will document the information in their
tracking tool and inform the caller of the
approval and case number. Provider does
not need to go beyond this step.
cannot approve
coverage for the
admission
contacts a physician reviewer who reviews
the case.
Continue to Step 3.
3. A physician reviewer will review a case that the clincian
cannot approve for medical necessity.
If the physician
reviewer…
Then, the clinician will contact the
provider…
is able to approve
the admission
who initiated the review and inform the
caller of the approval and the case number.
Provider does not need to go beyond this
step.
is unable to approve
coverage for the
admission
by phone and written communication is
sent to the Subscriber, physician, and
hospital. The admitting physician,
hospital, or Subscriber may appeal the
denial within 30 days.
Continue to Step 4.
4. After additional information is provided to us, the physician
reviewer will review the case.
4-38
If the physician
reviewer…
Then, the clinician will contact the
provider…
approves the
admission
who initiated the review and inform of the
approval and provide the case number.
is unable to approve
the admission and no
more information is
obtained
by phone and written communication is
sent to the Subscriber, physician, and
hospital. The admitting physician,
hospital, or Subscriber may appeal the
denial within 30 days.
Continued-Stay
Notification
The information required is the same as for PAN. It is usually a
notification process only.
Length-of-stay or continued-stay medical necessity review will be
performed on cases outlined in the “Admissions Requiring Planof-Care Review” section.
Hospital staff is encouraged to contact Case Management if they
have identified a Subscriber who may benefit from case
management services (refer to the Case Management section).
Discharge Call Back
Process
Subscribers with short hospitalizations may not meet the triggers
for case management support. To better address their needs, EPNI
initiated a discharge follow-up program in the summer of 2005 to
help make sure Subscribers have the resources they need to safely
manage their care at home. The purpose of discharge follow-up is
to achieve the following:

Support the physician’s discharge and ongoing treatment plans

Assess the Subscriber's /family member’s understanding of his
or her diagnosis, discharge plan, medication and treatment
plans, and physician follow-up

Coach Subscribers /family members to a better understanding
of their conditions, treatment plans and wellness strategies

Identify Subscribers at risk and refer them to appropriate
resources

Identify opportunities for integration or referral to other EPNI
programs such as care support, clinician phone line, tobacco
cessation, or EAP services.
4-39
Discharge Call Back
Process (continued)
How does this all work?
Currently, if a Subscriber is hospitalized with a condition related to
cardiac, respiratory, or obesity surgery, EPNI care managers will
call them within a few days following their discharge from the
hospital (assuming EPNI has been made aware of the admission).
EPNI also follows up with a letter to the Subscriber which informs
them that they can call EPNI if EPNI is unsuccessful in reaching
them at home.
EPNI conducts this call back process for Subscribers who have
experienced a behavioral health admission also. The focus is on
the following admissions:
Inpatient Mental
Health and Chemical
Dependency
Notification
4-40

Child/adolescent residential

Mental health inpatient admissions for patients younger than
age 16

Mental health inpatient admissions for patients older than 65

Mental health inpatient admissions for patients between 17 and
64 if diagnosed with anxiety or mood disorders
The facility is required to contact EPNI for mental health and/or
chemical dependency admissions. This is a notification process
only for participating Providers for the following Health Services:
Acute Care, Partial Hospital and Residential Treatment. Plan-ofcare notification may be required per Subscriber Contract.
Suggestion Outpatient
Procedures
These procedures are usually done on an outpatient basis. If any of
these procedures are done on an inpatient basis, preadmission
notification is recommended. Below are suggested outpatient
procedures. Please refer to the Prior Authorization section of this
chapter for additional surgical review requirements.
Procedure Name(s)
ICD-9-CM Codes
Adenoidectomy with or without tonsillectomy
28.2, 28.3, 28.6
Anal Fistulectomy
49.12
Antral Puncture, Sinus Puncture, other than Antrum Intranasal 22.01, 22.02, 22.2, 22.50
Antrostomy, Antrostomy, Sinusotomy
Arteriography
88.40-88.58
Arthrodesis (Metatarsophalangeal) Joint and Interphalangeal
Joint
81.16, 81.28
Arthroscopy, Arthrotomy, Capsulotomy, with Exploration
Drainage or Removal of Foreign body, (Includes Elbow,
Knee & others)
80.20-80.29
Biopsy of Perineum, Vulva, Uterus, with or without
Fulguration
49.22, 68.13, 71.11, 70.24
Biopsy of Skin, Soft Tissue, Facial Bone, Muscle
76.11, 83.21, 86.11
Blepharectomy, Blepharoplasty, Reconstruction of Eyelid
08.09, 08.61-08.64, 08.6908.74
Breast Biopsy, Incision and Excision, Biopsy of Breast,
Needle Biopsy
85.11, 85.12
Bronchoscopy-Rigid, Flexible Biopsy/No Biopsy/Brush,
Biopsy & Washings
33.21-33.25, 98.15
Bunionectomy
77.51-77.59
Bursectomy
82.31, 83.5
Canthotomy, Canthoplasty
08.51, 08.59
Capsulotomy-Cutting or Division of Joint Capsule,
Capsulectomy
80.40-80.49, 80.94
Cardiac Catheterization (left, right)
37.21-37.23
Carpal Tunnel Release
04.43
Cataract Extraction
13.19
Chalazion Excision, Incision and Drainage Abscess
08.21
Circumcision, Non-Pediatric and Pediatric
64.0
4-41
Procedure Name(s)
ICD-9-CM Codes
Colostomy Revision, Simple
46.40-46.41, 46.43
Culdoscopy, Culdocentesis
70.0, 70.22, 70.23
Cystometrogram
89.22
D&C with or without Cone, Sturmdorf Repair Cryocautomy,
Injection, Endometrial Biopsy
67.2, 67.33, 68.13, 69.02,
69.09, 69.59, 69.95
Dental Procedures (Root Canal, Extraction)
23.01-23.49, 23.70-23.71
Dilatation of Bladder
96.25
Discission Lens, Needling Lens, Secondary Membrane
Aspiration of Lens Material for Cataract
13.2, 13.3, 13.64
Ectropion, Entropion Repair
08.41-08.49
Endoscopies with or without Biopsy or Removal of Foreign
Body
44.11, 44.13-44.15, 45.1145.15, 45.21-45.27, 50.11,
51.11
Esophogoscopy with or without Biopsy, with Foreign Body
Removal
42.22, 42.23, 42.24, 98.02
Examination under Anesthesia
89.39
Excision of Ganglion, Ganglionectomy (usually Wrist)
Excision/Incision of Pilonidal Cyst
82.21, 83.39, 86.03, 86.21
Excision of Morton’s Neuroma, Neuroma of Somatic Nerve,
Neurectomy
04.07
Excision and Simple Closure-Lesion, Cyst Lipoma, Polyps,
Nevus, Ingrown Toenails, Fibroma, including Malignant
Lesions, Sebaceous Cyst, Planter’s Wart, Basal Cell
Melanoma
82.29, 83.39, 83.45, 86.04,
86.23, 86.3, 86.4, 86.51, 86.59
Excision of Turbinate, Inferior Turbinate Fracture
21.61-21.69
Exostosis Excision
77.60
Eye Muscle Surgery; Resection; Recession, Advancement,
etc. Any number of muscles, one or both Eyes a) Initial b)
Subsequent
08.33, 08.38, 15.11-15.13,
15.19, 15.21, 15.22, 15.29,
15.3-15.7, 15.9
Ganglionectomy, Excision of Ganglion (usually wrist)
82.21, 83.39
Gastrotomy Tube Removal
97.51
Hallux Valgus, Simple Correction by Exostosectomy and
Radical Exostosectomy, Exostosis
77.53, 77.54, 77.59, 77.60
Hammer Toe Operation
81.17, 77.56
4-42
Procedure Name(s)
ICD-9-CM Codes
Hemodialysis
39.95
Hemorrhoidectomy, Excision of Hemorrhoid Tags by Simple
Ligature (Rubber Band) or by Cryotherapy, Other
Hemorrhoid Procedures
49.44, 49.45, 49.46, 49.47,
49.49, 49.03
Hernia Repair (Inguinal and Umbilical, Simple Ventral)
53.00-53.02, 53.10-53.13,
53.49, 53.59
Hydrocele Excision, Hydroelectomy
61.2, 63.1
Hysterosalpingogram
87.82, 87.83
Insertion of Catheter or Injection Agent into Spinal Canal
03.90-03.92
Incision and Drainage of Bartholin’s Abscess, Excision or
other Destruction of Bartholin’s Gland
71.22-71.24
Incision and Drainage, Biopsy, or Excision of Nodes
40.0, 40.11, 40.21-40.24, 40.29
Iridectomy, any type
12.13-12.14
Lacrimal Duct Probing or Reconstruction, Splitting of
Lacrimal Papilla, Drainage of Lacrimal Duct
09.0, 09.43, 09.51, 09.44
Laparoscopy
54.21
Laryngoscopy, with insertion of Radioactive Substance,
Indirect with Removal of Foreign Body
31.42, 92.27, 98.14
Ligation and Excision of Small Varicosity of Long and Short
Saphenous, Occlusion of Leg Veins
38.50, 38.59, 38.80, 38.89
Temporal Artery Ligation
38.82
Lithotripsy (ESWL)
59.95, 98.59
Liver Biopsy, Percutaneous
50.11
Lumbar Puncture
03.31
Myelogram
87.21
Myringoplasty, Type II-V
19.4, 19.52-19.55
Myringotomy, with or without Tube Insertion Unilateral or
Bilateral, Tympanoplasty, Tympanotomy, Stapedectomy
19.11-19.19, 20.01, 20.09
Nail, Removal of any number, Fingernail or Toenail Removal
86.23
Nasal Polypectomy
21.31, 21.32
Neurolysis, including Carpal Tunnel Decompression, Tarsal
Tunnel Release
04.43, 04.44, 04.49
4-43
Procedure Name(s)
ICD-9-CM Codes
Orchiopexy
62.5
Otoplasty, Unilateral, Bilateral
18.79
Palmar Fasciectomy
82.35
Pelvic Examination under Anesthesia
89.26
Perineal Biopsy
86.11, 71.11
Perineoplasty, Perineorrhaphy, Repair of Vulva Fistula
71.71, 71.72, 71.79
Pilonidal Sinus Excision/Incision
86.03, 86.21
Phalangectomy, Finger and Toe Amputation, Metatarsal Head 77.68, 77.88, 77.89, 77.99
Excision
Prostate Biopsy
60.11, 60.12
Proctoscopy
48.23
Pterygium (Excision or Transposition)
11.31-11.39
Reduction of Nasal Fracture
21.71, 21.72
Removal of Foreign Body in Muscles and Skin
82.02, 83.02, 86.05, 98.20
Removal of Screws and/or Wires, Foreign Bodies Simple,
Superficial
78.60-78.69, 82.02, 83.02,
97.83
Repair of Inguinal Hernia, Non-Pediatric or Pediatric
53.00-53.02, 53.10-53.13,
53.49
Repair of Umbilical Hernia (Pediatric)
53.49
Revision Vessel to Vessel Cannula
39.27, 39.42, 39.93
Rhinoplasty
21.84, 21.85, 21.87
Sclerotomy
12.89
Septoplasty
21.88
Skin Graft
85.83, 86.60, 86.61, 86.63,
86.69
Temporal Artery Ligation
38.82
Temporal Artery, Ligation or Biopsy
38.21, 38.82
Tendon Repair without/with Graft, Implant or Transfer
82.45, 83.64
Tenotomy Hands, Fingers, Feet or Major Tendon
82.11, 83.11, 83.13
Tenovaginomotomy for DeQuervain’s Disease, Release of
82.01
4-44
Procedure Name(s)
ICD-9-CM Codes
Tendon, Sheath for DeQuervain’s Tendonitis
Tenosynovectomy, Finger, Toe, Wrist, Flexor or Extensor
Tendon Sheath, Synovectomy
80.71-80.74, 80.78, 82.33,
83.41, 83.42
Tissurectomy
49.39
Tongue Biopsy
25.01, 25.02
Tonsillectomy with or without Adenoidectomy
28.2, 28.3, 28.6
Tooth Extraction, Surgical Forceps, Root Canal
23.01-23.49, 23.70-23.71
Trabeculectomy
12.64
Trigger Finger Repair, Release of Trigger Finger, Lysis of
Hand Lesions
82.01, 82.91
Tubal Ligation
66.39
Turbinate Excision
21.61-21.62
Ureteroscopy
56.31
Urethral Dilation
58.6
Ureteral Stent Placement
59.8
Vagus Nerve Stimulation (VNS)
02.93, 86.94, 86.95, 86.96,
86.97, 86.89
Vasectomy
63.73
Venous Catheterization (Placement, Removal)
38.93
Wedge Resection of Lip, Excision Lesion of Lip, for
Malignant Lesion
27.42, 27.43
PAN Fax Forms
A sample of the PAN fax forms titled Admission Notification and
Continued-Stay Notification Fax Form is available at
www.ccstpa.com.
4-45
Focused Utilization Review
Overview
Focused utilization review programs contribute to EPNI's goals of
containing health care costs by assuring that Health Services are
Subscriber Contract benefits and appropriate. EPNI systematically
monitors Health Services of Providers for patterns of overuse,
underuse, misuse and abuse in addition for obsolete or
questionable practices.
EPNI has data warehousing and software programs that look for
patterns outside established norms. The analysts review medical
records and work with providers to resolve questions on coding,
benefits and medical necessity. On-site audits, using a sample of
up to the last three years of claims history may be performed.
Prompt response to medical records requests will speed up
processing of claims under review. Claims are denied as provider
liability if the necessary information is not received within 14
calendar days.
4-46
Messages Provider May
Receive
The following message appears on the Statement of Provider
Claims Paid to tell Provider that EPNI did not receive the
information needed to review the claim:

We cannot continue processing of this claim because the
medical information we requested has not been received. We
will reprocess your claim upon receipt of the requested
information.
During utilization review, claims are screened for Medical
Necessity. Peer review agents or consultants deny claims only after
careful evaluation. Slightly longer processing time is required for
claims that must go through the utilization review process. The
following messages appear on the Statement of Provider Claims
Paid for utilization review denials:

This contract does not cover charges for treatment, services, or
supplies which do not meet our criteria for medical necessity or
are not normally provided for the treatment of this condition as
determined by our medical staff and/or an independent health
care professional reviewer.

These charges are not covered because this contract does not
allow services from a provider performing this type of health
care.

This service and related charges are considered investigative
and are not covered according to this contract. Our Medical
Policy Committee continually reviews medical procedures in
order to determine the investigative status of this and other
services.

These charges are not allowed because there was no
documentation in the medical records to support this level of
care.
Participating providers agree not to bill the Subscriber for any
services EPNI determines to be not Medically Necessary or
investigative. Medical Necessity denials can be appealed within 30
days from the date Provider is notified. EPNI requests that
Provider submit written appeals outlining the issues and ATTACH
supporting documentation such as medical records, operative
reports, and any medical information documenting unusual
circumstances at the time of the request.
4-47
Special Investigations
EPNI actively investigates possible fraudulent claims submissions
from both Subscribers and providers. Fraud and abuse
investigations conducted by EPNI's Special Investigations
Department are among the most thorough in the industry.
Inconsistent charges, forged or altered charges, or services billed
but never rendered are just a few examples of inappropriate
practices that EPNI may verify when conducting its investigation.
EPNI's investigation process may include, but is not limited to,
record requests, audits, and survey letters.
EPNI often conducts its investigations and criminal proceedings in
collaboration with outside agencies such as the State Attorney
General’s Office, the FBI, postal inspectors, or local authorities.
EPNI's goal is to protect EPNI Subscribers and Providers from
losses due to fraudulent acts.
Information about any person’s inappropriate use of an EPNI
policy, ID card, or questionable billing practices should be
reported by calling EPNI's fraud hot line. The phone number is
listed in Chapter 1 – At Your Service. Callers may remain
anonymous if they wish.
4-48
Documentation in the Medical Record
Documentation
Requirements
To avoid denials for medical necessity, the patient’s medical
record must contain certain pertinent information that may be
subject to review by EPNI. The Centers for Medicare and
Medicaid Services (CMS) in conjunction with the American
Medical Association (AMA) has developed guidelines for the
medical documentation necessary to support a given level of
evaluation and management service. EPNI adopted these
guidelines to ensure that its Subscribers receive quality care and
that Health Services are consistent with the insurance coverage
provided.
The general guidelines are listed below:

The medical record should be complete and legible.

The documentation of each patient encounter should include:

reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results;

plan of care; and

date and legible identity of the observer.

If not documented, the rationale for ordering diagnostic and
other ancillary services should be easily inferred.

Past and present diagnoses should be accessible to the treating
and/or consulting physician.

Appropriate health risk factors should be identified.

The patient’s progress, response and changes in treatment, and
revision of diagnosis should be documented.

The CPT/HCPCS and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be supported
by the documentation in the medical record.
Charge slips, super bills, travel cards, or office ledgers are not
considered supporting documentation for services provided to a
patient.
Use of the term IBID (same as above) and/or the use of quotation
marks to replace or repeat previously documented information is
not acceptable. All information must be in date-sequence order.
Health Services not documented as indicated above are not
covered by EPNI. Subscribers are not financially liable for Health
Services that are denied for inadequate documentation.
4-49
Overview
Per the Provider Service Agreement, Provider may not bill:

Any Subscriber for medically unnecessary or investigative
services.
Provider may bill the Subscriber only if the following conditions
are met:

The Subscriber is notified prior to the Health Service being
rendered that it is not a covered benefit.

The Subscriber agrees, by signing a waiver, to pay for the
service.
In addition, Provider should not direct fee-for-service Subscribers
to nonparticipating providers (Refer to Referrals to
Nonparticipating Providers).
EPNI does not consider blanket (nonspecific) waivers sufficient
notice to meet the Subscriber notification requirements in the
Provider Service Agreement. The waiver must be dated and
must specifically identify the procedure or service. The waiver
must also advise the Subscriber that he or she would not be
liable for these charges unless the waiver is signed.
GA Modifier
Use the -GA modifier in field 24D of the CMS-1500 form to
indicate:

Provider has notified a Subscriber that a specific service has
been determined by EPNI to be investigative or not Medically
Necessary.

Those Health Services will not be covered under the
Subscriber's Contract.
After this notice, and prior to receiving the Health Services, the
Subscriber must have agreed in writing that charges incurred will
be the Subscriber's liability.
The use of this modifier will result in allowed amounts related to
these Health Services being reported in the patient responsibility
column of your Statement of Provider Claims Paid with the
following message:

This contract does not cover services or supplies that are not
medically necessary or are investigative in nature. Since the
patient was notified in advance and agreed in writing to pay for
these services, the charges are the patient’s responsibility.
Note: The -GA modifier should not be used routinely on all of
Provider's claims submittals. Inappropriate use of the -GA
modifier may result in an audit of Provider's files and
possible payment adjustments.
4-50
Directing Subscribers
To Nonparticipating
Providers
EPNI Providers are required to direct EPNI Subscribers to other
EPNI participating providers. Directories of participating providers
are available upon request by contacting provider services. The
Subscriber will have reduced benefits and incur higher Subscriber
liability when using nonparticipating providers.
Upgraded/Deluxe
Durable Medical
Equipment (DME)
Participating durable medical equipment (DME) suppliers may bill
Subscribers for an equipment upgrade or deluxe charge if a waiver
is on file and the DME charges are billed correctly. EPNI will
continue to reimburse for Medically Necessary standard DME.
DME Waiver
Requirement
Participating DME suppliers must obtain a signed, written waiver
from the Subscriber that includes the cost for the deluxe features or
upgrade. The waiver must also state the following:

the standard piece of equipment or least costly alternative
offered to the Subscriber,

the Subscriber is aware and agrees that EPNI will only pay the
standard allowance, and

the Subscriber will be responsible for the deluxe or upgrade
charge in addition to his or her contractual obligation.
This waiver must be kept on file at Provider's office. Do not send
it to EPNI. EPNI does, however, reserve the right to see it.
DME Claims
Submissions
Two lines of service must be billed. The first line will include the
DME HCPCS code and the standard charge for the equipment. The
second line must include the same DME HCPCS code with the GA modifier (waiver of liability statement on file) and the upgrade
or deluxe charge. For example:

E0202 - $550.00 (standard charge that will be subject to
standard allowance and reductions)

E0202 GA - $150.00 (deluxe/upgrade charge that will be
denied as Subscriber liability)
The -GA modifier must be submitted as the first modifier on the
second service line. Other applicable modifiers, such as -NU
(Purchase), should be submitted on the first service line.
Sample DME Waiver
A sample waiver for use in Provider's office is available upon
request by calling provider services. The waiver includes the
information required in order to hold the Subscriber financially
liable for deluxe features or upgrades to a durable medical
equipment purchase. The waiver should be incorporated into
Provider's usual business forms and customized to include
Provider's business letterhead.
4-51
Chapter 5
TRICARE
Table of Contents
Introduction to TRICARE ........................................................................................................ 5-2
Overview................................................................................................................................ 5-2
What is TriWest Healthcare Alliance? .................................................................................. 5-2
What is TRICARE? ............................................................................................................... 5-2
What’s the Difference Between a Contracted and Certified Provider? ................................. 5-2
Who Do I Contact Regarding TRICARE for Life? ............................................................... 5-2
What’s the Difference Between TRICARE’s Standard, Extra, and Prime? .......................... 5-3
Who Processes TRICARE Claims? ....................................................................................... 5-3
How Can I Start Receiving Electronic Remittance Advice (ERA) ....................................... 5-3
How Do I Identify TriWest/TRICARE Beneficiaries?.......................................................... 5-3
Where Can I Obtain Additional Information? ....................................................................... 5-4
What Are Some Common Acronyms? .................................................................................. 5-4
5-1
Introduction to TRICARE
Overview
A separate Employer Provider Network, Inc. (EPNI) contract is being
used for the contracting efforts for the TRICARE product due to this
being a nonbranded product.
What is TriWest
Healthcare
Alliance?
TriWest Healthcare Alliance is a Phoenix-based U.S. Department of
Defense contractor that manages the military’s health care entitlement
program, TRICARE, in 21 states. TriWest is not an insurance company.
Under TRICARE, TriWest serves members and retirees of the U.S.
Armed Forces with civilian health care providers. EPNI works with
TriWest to enhance that network of civilian physicians, specialists,
hospitals and clinics in Minnesota.
What is TRICARE?
TRICARE is the managed care program of the U.S. Department of
Defense. It was previously called CHAMPUS. TRICARE receives its
funding as part of the annual defense budget, which is approved by
Congress and signed by the President. TRICARE provides for
mechanisms to ensure health care benefits and services to active duty
and retired members of the uniformed services, their families, and
survivors worldwide.
What’s the
Difference
Between a
Contracted and
Certified
Provider?
A contracted provider, also referred to as a network provider, has a
TRICARE contract through EPNI. Their issues are resolved by calling
TriWest at 1-888-TriWest or the Network Management Consultants
(NMC) or the TRICARE Team at (651) 662-3484.
Who Do I Contact
Regarding
TRICARE for Life?
Wisconsin Physician Services (WPS) is responsible for all TRICARE
for Life questions and claims processing. Their website is
www.tricare4u.com and their telephone number is 1-866-773-0404.
5-2
A certified provider, also referred to as a non-network/non-contracted
provider, has been certified by TriWest and can provide services to
TRICARE beneficiaries. Their issues are resolved by TriWest at
1-888-TriWest. If the non-network provider is participating (meaning
they are certified, but not contracted) then they accept assignment and
are paid for services at 100 percent of the TRICARE allowable amount
(CMAC). If a non-network provider is nonparticipating then they do not
accept assignment. The nonparticipating provider may charge up to
115 percent of CMAC allowable, but any payments are sent to the
beneficiary. The provider must collect their payment from the
beneficiary.
What’s the
Difference
Between
TRICARE’s
Standard, Extra,
and Prime?
All eligible beneficiaries are given TRICARE Standard as an
entitlement. When a TRICARE Standard beneficiary receives services
from a non-contracted provider, out-of-pocket costs are generally 20
percent plus a deductible. When the TRICARE Standard beneficiary
receives services from a contracted provider they are then eligible for
TRICARE Extra, in this case the beneficiary’s out-of-pocket cost
decreases to about 15 percent plus a deductible. TRICARE Prime is
available only to those beneficiaries who reside within the Prime
Service Area (PSA). The beneficiary must sign up for TRICARE Prime
and choose a Primary Care Manager (PCM). When a Prime beneficiary
receives their care from a contracted provider, there is generally no outof-pocket cost. Prime beneficiaries may also seek care from noncontracted providers and then their copay can be up to 50 percent of the
allowable CMAC charges plus a deductible. The exception to the above
is for active duty service members (ADSM): ADSM members have the
Prime benefit and must always have a referral for services at a provider
other than their Primary Care Manager (PCM).
Who Processes
TRICARE Claims?
Wisconsin Physician Services has been contracted by TriWest for this
function.
How Can I Start
Receiving
Electronic
Remittance
Advice (ERA)
To enroll, please download and complete the Electronic Remittance
Advice (PDF) document or the fill and print version located at
www.triwest.com, Find a Form tab and return it to:
WPS Electronic Data Services
PO Box 8128
Madison, WI 53708-8128
When you choose to receive ERAs, your files will be sent to you in the
ANSI (American National Standards Institute) X12 835 format, version
4010A1, and can be downloaded from the WPS Bulletin Board System
(BBS) or through the secure website at triwest.com/provider.
For further information about ERA, refer to the 835 Electronic
Remittance Advice Transaction guide located in the EDI/Secure Web
area of www.triwest.com/provider.
How Do I Identify
TriWest/TRICARE
Beneficiaries?
Providers can verify eligibility by contacting TriWest at
1-888-TRIWEST or by checking on the secure provider portal at
www.triwest.com.
Samples of the Military identification (ID) cards are on pages 5-4 and
5-5.
5-3
Where Can I
Obtain Additional
Information?
Most issues can be resolved by contacting TriWest at 1-888TRIWEST, or utilizing their website at www.triwest.com. You will
have access to the TRICARE Provider Handbook, which goes into
much more detail about TriWest and the TRICARE program. If you
register on the TriWest website, you will also be able to obtain
additional information regarding patient eligibility, claims submission
and status, benefit information and referrals and authorizations relative
to your group. Contracted TRICARE providers can work with the
TRICARE program coordinator. Certified TRICARE providers can
contact Triwest at 1-888-874-9378.
What Are Some
Common
Acronyms?
Common Acronyms are:
•
ADSM - Active Duty Service Military
•
CMAC-CHAMPUS Maximum Allowable Charge (comparable to
Medicare pricing in most cases)
•
CSP – Corporate Service Provider
•
DoD – Department of Defense
•
MTF – Military Treatment Facility
•
OHI – Other Health Insurance
•
PSA – Prime Service Area
•
PCM – Primary Care Manager (this is at the physician level, not
clinic level)
•
TFL – TRICARE For Life
•
TMA – TRICARE Management Activity
•
TMOP – TRICARE Mail Order Pharmacy
Sample Military Identification, Enrollment Cards
There are several identification (ID) and enrollment cards providers should be familiar with in
order to verify a patient’s eligibility for TRICARE. Providers should ensure patients have a
valid uniformed services (military) ID card, Common Access Card (CAC), or authorization
letter of eligibility. It is both allowable and advisable for providers to copy the beneficiary’s ID
card for proof of eligibility and for the purpose of rendering needed services. Beneficiaries
under the age of 10 are not routinely issued ID cards, so the parent’s ID card may serve as proof
of eligibility.
5-4
Uniformed Services (Military) ID Card
The uniformed services ID card is credit-card sized and
incorporates a digital photograph of the bearer, bar
codes containing pertinent machine-readable data, and
printed identification and entitlement information. The
beneficiary category determines the ID card’s color:
•
Active duty service members–CAC or DD Form
2ACT (green)
•
Active duty family members–DD Form 1173 (tan)
•
Members of the National Guard/Reserve—CAC or
DD Form 2RES (green)
•
Family members of National Guard/Reserve
members—DD Form 1173-1 (red)
•
Retirees–DD Form 2RET (blue)
•
Retiree family members–DD Form 1173 (tan)
•
TAMP-eligible members–DD Form 2765 (tan)
Uniformed Services Identification Card Active Duty
Uniformed Services Identification Card Active Duty Family Member
The card has the following information:
•
Rank and Pay Grade: Indicates sponsor’s rank and
pay grade on the front.
•
Sponsor Status: Indicates the sponsor’s status (e.g.,
active duty or retired, “INDEF” for retirees) on the
front.
•
Eligibility: Indicates eligibility for TRICARE on the
back. The center section should say, “YES” under
the box entitled “CIVILIAN.” If a beneficiary using
TRICARE For Life (TFL) has an ID card that says
“NO” in this block, they are still eligible to use TFL
if they are enrolled in Medicare Part B.
•
Expiration Date: Indicates the expiration date on the
back in the box entitled “EXP DATE.” If expired,
the beneficiary will need to update their information
in the Defense Enrollment Eligibility Reporting
System (DEERS) and get a new card.
Common Access Card
HO440002PRAL0206
Common Access Card
Most active duty service members and drilling National
Guard/Reserve members now carry the CAC. The CAC
is replacing the uniformed services ID card. Please
honor valid CACs – they are valid uniformed services
ID cards.
5-5
TRICARE Prime/Prime Remote Enrollment Card
Beneficiaries enrolled in TRICARE Prime, TRICARE Prime Remote (TPR), and TRICARE
Prime Remote for Active Duty Family Members (TPRADFM) receive TRICARE Prime
enrollment cards. Network providers may require beneficiaries to show the card at the time of
service. These cards are not required to obtain care but do contain important information for the
beneficiary. Only the uniformed services ID card or new CAC card may be used to verify
eligibility for care.
TRICARE Prime Card
TRICARE Prime Remote (TPR) Card
TRICARE Reserve Select Card
Beneficiaries enrolled in TRICARE Reserve Select (TRS) receive TRS enrollment cards.
TRICARE Reserve Select Card front
TRICARE Reserve Select Card back
HO440002PRAL0206
5-6
Chapter 6
Claims Filing
Table of Contents
Administrative Simplification................................................................................................... 6-4
Introduction............................................................................................................................ 6-4
Web-based Claim Submission, Eligibility, and Remittance Tool ......................................... 6-4
Pharmacy and Dental Claims................................................................................................. 6-4
Pre-system Edits..................................................................................................................... 6-4
Claims with Attachments....................................................................................................... 6-5
Claims with Attachments: Questions and Answers ............................................................... 6-5
Claims with Coordination of Benefits ................................................................................... 6-7
Medicare/Uniform Companion Guide Coding Alignment .................................................. 6-10
Questions.............................................................................................................................. 6-11
1500 HICF Form ...................................................................................................................... 6-12
Professional Claim Submission ........................................................................................... 6-12
Completing the 1500 HICF Form ........................................................................................ 6-12
Common Submission Errors ................................................................................................ 6-13
Zero Billed Charges ............................................................................................................. 6-14
Optical Scanning.................................................................................................................. 6-14
Year 2000 Date Format........................................................................................................ 6-15
Linking and Sequencing ...................................................................................................... 6-15
Linking and Sequencing Example ....................................................................................... 6-16
Place of Service Codes......................................................................................................... 6-16
Site of Service ...................................................................................................................... 6-22
Freestanding Ambulatory Surgery Center Billing ............................................................... 6-23
K3 Segment Usage Instructions for Condition Codes ......................................................... 6-24
Revised 1500 Health Insurance Claim Form ....................................................................... 6-24
NUCC Transition ................................................................................................................. 6-24
Form Availability................................................................................................................. 6-25
About the NUCC.................................................................................................................. 6-25
UB-04 (CMS 1450) Form......................................................................................................... 6-26
Institutional Claim Submission............................................................................................ 6-26
Completing the UB-04 Form ............................................................................................... 6-26
Common Submission Errors ................................................................................................ 6-27
Situations Requiring Electronic Submission ....................................................................... 6-28
Sample UB-04...................................................................................................................... 6-28
UB-04 Implementation ........................................................................................................ 6-28
About the NUBC.................................................................................................................. 6-28
Reminder.............................................................................................................................. 6-28
Claims Filing
Ordering Forms and Manuals ................................................................................................ 6-29
HCPCS, CPT and ICD-9-CM Manuals ............................................................................... 6-29
HIPAA Implementation Guides........................................................................................... 6-29
Minnesota Uniform Companion Guides.............................................................................. 6-29
1500 HICF (CMS-1500) UB-04 (CMS-1450) Forms ........................................................ 6-29
UB-04 Manual ..................................................................................................................... 6-29
1500 HICF Manual .............................................................................................................. 6-29
Institution/Facility Billing ....................................................................................................... 6-30
Claim Format Regulations ................................................................................................... 6-30
Procedure Code Regulations................................................................................................ 6-31
Revenue Codes (FL 42) ....................................................................................................... 6-31
HCPCS/ Accommodation Rates/HIPPS Rate Codes (FL 44).............................................. 6-31
Duplicate Billing.................................................................................................................. 6-31
Treatment Room .................................................................................................................. 6-32
Observation Room ............................................................................................................... 6-32
Clinic Charges...................................................................................................................... 6-32
Transfer Case ....................................................................................................................... 6-32
Zero Billed Charges ............................................................................................................. 6-33
Lactation Education ............................................................................................................. 6-33
0636 Drugs Requiring Prior Auth........................................................................................ 6-33
Present on Admission .......................................................................................................... 6-34
Form Completion Instructions ............................................................................................. 6-34
K3 Segment Usage Instructions for POA ............................................................................ 6-35
Claims Filing............................................................................................................................. 6-36
Timely Filing ....................................................................................................................... 6-36
Claims Crossover for Medicare and Medicare Supplement ................................................ 6-36
Medicare Crossover ............................................................................................................. 6-37
UB-04 (CMS-1450) Crossover Information........................................................................ 6-37
1500 HICF (CMS-1500) Crossover Information................................................................. 6-37
Duplicate Claims.................................................................................................................. 6-38
Submission of Claims .......................................................................................................... 6-39
Cancel/Void and Replacement Claims ................................................................................ 6-40
Section A – General Information......................................................................................... 6-41
Section B – COB Related Scenarios Q & A ........................................................................ 6-44
Release of Medical Records................................................................................................. 6-44
Provider Assistance Requested ............................................................................................ 6-45
Medical Records Management Process Improvement......................................................... 6-45
Verify Subscriber Identity.................................................................................................... 6-45
Verify Subscriber Eligibility................................................................................................ 6-46
Basic Character Set Values in the Electronic Transaction................................................... 6-47
Claim Service Dates Restricted to Same Calendar Month .................................................. 6-48
Reporting MNCare and Sales Tax ....................................................................................... 6-49
6-2
Claims Filing
Rural Health Clinics and Federally Qualified Health Centers............................................ 6-50
Billing for Medicare Primary............................................................................................... 6-50
Billing Other Than Medicare Primary ................................................................................. 6-50
Coordination of Benefits (COB) ............................................................................................. 6-51
Overview.............................................................................................................................. 6-51
Primacy Determination ........................................................................................................ 6-51
Workers’ Compensation ...................................................................................................... 6-53
No-fault Auto ....................................................................................................................... 6-53
Subrogation .......................................................................................................................... 6-53
TEFRA................................................................................................................................. 6-54
DEFRA ................................................................................................................................ 6-54
COBRA................................................................................................................................ 6-54
OBRA .................................................................................................................................. 6-54
Non-Physician Health Care Providers ................................................................................... 6-55
Introduction.......................................................................................................................... 6-55
Eligibility Criteria ................................................................................................................ 6-55
Definitions............................................................................................................................ 6-55
Employment......................................................................................................................... 6-56
Incident to ............................................................................................................................ 6-56
Direct Supervision ............................................................................................................... 6-57
General Supervision............................................................................................................. 6-57
Collaboration/ Independent Practice.................................................................................... 6-57
Chiropractic Doctors and Multidisciplinary Clinics ............................................................ 6-57
Surgical Technicians............................................................................................................ 6-58
Mid-level Practitioners......................................................................................................... 6-58
Mid-Level Reduction Exemption ........................................................................................ 6-58
6-3
Claims Filing
Administrative Simplification
Introduction
Minnesota Statute 62J.536, requires health care providers and
group purchasers (payers, health plans) to exchange claims
electronically using a standard format beginning July 15, 2009.
The intent of the law is to reduce costs, simplify and speed up
health care transactions and to give providers and health plans one
set of rules to follow for electronic transactions. This statute
applies to all health care providers that submit claims regardless of
participating status.
Web-based Claim
Submission, Eligibility,
and Remittance Tool
EPNI offers a no-cost, web- based tool through Availity to comply
with the Minnesota Statute 62J.536. Availity also provides no-cost
solutions for providers to obtain eligibility and benefits as well as
viewing remittance information. Availity is a one stop shop that
optimizes information exchange between multiple heath care
stakeholders through a single secure network. Providers may also
take advantage of a range of optional, value-added services for a
nominal cost. For more information contact Availity at
availity.com to register for their no-cost web based tools.
Pharmacy and Dental
Claims
The requirement to submit all claims electronically includes dental
and pharmacy formatted claim types. EPNI is completing system
changes to accept and properly adjudicate these electronic claim
types. Due to the complexity of the changes and need for extensive
testing, EPNI can not accept dental formatted or pharmacy
formatted electronic claims at this time. Pharmacy and dental
providers should continue to submit these claim types on paper
until notified by EPNI.
Pre-system Edits
EPNI has upgraded its pre-system edits to align with the rules
published in the Uniform Claims Companion Guides found on the
Administrative Uniformity Committee website at
www.health.state.mn.us/auc.
6-4
Claims Filing
Claims with
Attachments
EPNI accepts claims with attachments electronically. The claim
must adhere to the electronic rules found in the Uniform
Companion Guides and include the appropriate populated data as
indicated in section 4.2.3.4 of the Guides. The related attachment
should be faxed to EPNI at 1-800-793-6928 or mailed to:
EPNI
P.O. Box 64338
St. Paul, MN 55164-0338.
The attachment cover sheet found on the AUC website must be
used on each claim attachment. Instructions for completing the
attachment cover sheet are also available on the AUC website.
EPNI has compiled a list of questions and answers in response to
provider inquiries regarding sending attachments on electronic
claim transactions.
Claims with
Attachments:
Questions and Answers
1. My clinic has a policy of covering all documentation with
an internal cover sheet to protect PHI. Should I be covering
the attachments I am sending with this cover sheet?
No. Per the AUC Guidelines the only acceptable cover sheet
for attachments is the AUC Uniform Cover Sheet for Health
Care Claim Attachments. This form can be modified to put a
PHI message on the bottom of the page if you desire, but it is
the ONLY acceptable cover sheet when sending attachments.
2. Can I send appeals, adjustment requests, status checks and
general correspondence using the AUC Uniform Cover
Sheet for Health Care Claim Attachments?
No. The AUC Uniform cover sheet for Health Care Claim
Attachments is ONLY for use when submitting attachments for
claims that have been sent electronically. It is not to be used
for appeals, adjustment requests, status checks or general
correspondence.
There are separate forms for these types of correspondence.
Please use the appropriate cover sheet for each type of
correspondence. Below is a list of the forms and fax numbers
for each type of correspondence:

AUC Uniform Cover Sheet for Health Care Claim
Attachments: 1-800-793-6928 (use for attachment to
original claims only)

AUC Appeal Request Form: (651) 662-2745 (use to submit
claim appeals)
EPNI Provider Status Check: (651) 662-2745 (use to submit to
request a status check. The form is located at ccstpa.com.
6-5
Claims Filing
Claims with
Attachments:
Q&A
(continued)
For further reference on the submission of attachments, please visit
the AUC website: www.health.state.mn.us/auc
3. Can I change or remove the AUC logo on the AUC
Uniform Cover Sheet for Health Care Claim Attachments?
No. EPNI's automated intake process looks for the AUC logo
when preparing to scan the attachment. If the logo is missing or
has been changed, the automated process cannot take place.
This causes delays in the imaging of documents and ultimately
can lead to delays in the processing and payment of claims.
This is another reason why Provider must not use an internal
cover sheet. Provider must also fax attachments face-up or top
of the page first as the recognition software scans the top third
of the page for the logo.
4. If I have the other insurance carrier payment information
in the 837 electronic claim transaction, do I also have to
send the EOB in an attachment or notify EPNI that it is in
my office?
No. Per the AUC guidelines, why Provider should submit the
other insurance carrier payment information within the 837.
HIPAA regulations prohibit populating the claim record with
other insurance carrier information and sending the same
information in an attachment. They further prohibit sending
data in an attachment that can be codified within the claim
record.
5. Can I send the attachment before I send the 837 claim
transaction?
Yes, provided Provider completes the PWK segment on the
837 with the appropriate information from the AUC Uniform
Cover sheet for Health Care Claim Attachments. The PWK
segment must include the Report Type code, Report
Transmission Code and the Transaction Control Number (the
Attachment Control Number on the AUC Uniform Cover sheet
for Health Care Claim Attachments). Failure to include this
information on the 837 will cause delays in processing and
payment and may result in a denial of a claim.
6-6
Claims Filing
Claims with
Coordination of
Benefits
EPNI accepts electronic claims with previous payer payment
information populated per the requirements in the Minnesota
Uniform Companion Guides. The claims must contain all previous
payer group codes, ANSI Claim Adjustment Reason Codes and
Remittance Advice Remark Codes as they were received from the
previous payer for proper adjudication. These claims will not
require an attachment when populated within the claim record.
Refer to the Minnesota Uniform Companion Guides, section
4.2.3.5 for more information.
Provider agrees to make a good faith effort to secure information
on the sources of third party coverage available to each Subscriber
and forward such information to EPNI or the Pan Sponsor.
Provider agrees to coordinate benefits with other payers in
accordance with EPNI’s or the Plan Sponsor’s procedures, and to
submit copies of all applicable claims including the applicable
payment information received on previous payers remittances to
EPNI or the Plan Sponsor. EPNI or the Plan Sponsor shall use its
best efforts to coordinate Health Services due a Subscriber in
accordance with the provisions of the Subscriber Contract, and to
exercise any subrogation in regard to Health Services provided to
Subscriber. Provider shall provide any reasonably requested
assistance to this effort. EPNI or the Plan Sponsor will administer
coordination of benefits consistent with applicable law. When
EPNI or the Plan Sponsor is the secondary payer, EPNI shall make
payment according to the terms of the Subscriber Contract, except
that payment by EPNI shall not exceed the amount that EPNI
would make if it had Primary Coverage Responsibility. If
Medicare is primary, EPNI shall coordinate benefits according to
the coordination of benefits provisions of the Subscriber Contract.
EPNI has compiled a list of questions and answers in response to
provider inquiries regarding the electronic submission of
Coordination of Benefits (COB) information.
6-7
Claims Filing
Claims with
Attachments:
Coordination of
Benefits Q & A
(continued)
1. I understand that there is information on the HIPAA 835
transaction that I have to include on the electronic 837
COB transaction. Can you tell me what I have to include so
I can make sure I get paid accurately?
It is important to use the Minnesota Uniform Companion
Guides along with the HIPAA Implementation Guides to
ensure the correct segments and elements are completed. The
2320, 2330A, 2330B, and the 2430 loops carry a good portion
of the COB information a payer needs to process a secondary
claim.
The HIPAA 835 transaction provides most of the necessary
information to complete the appropriate segments and
elements.
The HIPAA 835 transaction from the prior payer(s) should
provide the CAS segments (loops 2100 and/or 2110), CLP
segment (loop 2100), and the SVC segment (loop 2110) that
are used to complete the 837 COB transaction.
2. I understand the CAS segment is important for the correct
processing of my COB 837 transaction. Where do I get the
CAS segment information?
Again, the CAS segment information on the 837 COB
transactions should come directly from the prior payer’s
HIPAA 835 or Remittance Advice/Explanation of Benefits.
This information must never be altered or combined in any
manner.
3. Do I need to do any combining of claim adjustment Reason
Codes or change them to specific codes a supplemental
insurer might want?
No, when completing the COB information on the 837 use the
information as it was provided on the prior payer(s) HIPAA
835 or Remittance Advice/Explanation of Benefits. Never
change or alter any of the prior payer(s) payment information
including the Claim Adjustment Reason Codes (CARC), Claim
Adjustment Group Codes, and Remittance Advice Remark
Codes. Changing codes is a violation of HIPAA and could
result in payment errors or processing delays. Per the HIPAA
Implementation Guide, “Codes and associated amounts should
come from 835s (Remittance Advice) received on the claim.”
Payers utilize the codes to adjudicate based on the information
sent.
6-8
Claims Filing
Claims with
Attachments:
Coordination of
Benefits Q & A
(continued)
4. I know there are Medicare primary claims that should have
crossed over and Medicare has had some problems lately
with not being able to cross claims over to supplemental
payers. Should I send all my Medicare primary COB
claims just in case?
No, “automatic” rebilling often results in duplicate claims,
increases administrative costs, and delays processing. Please
go to Medicare primary COB claim later in this chapter.
If the claim is not showing as crossed over on provider web
self-service after 30 days from the date the provider received
its Medicare payment, then the provider may submit the claim
electronically populating the claim record with the COB
information exactly as it was received on the Medicare ERA.
5. I have situations where my Medicare primary claims have
been adjusted and Medicare is now paying on claims they
have denied. How do I send these COB claims to my
supplemental insurer?
These claims are COB adjustments to the original claim and
should crossover to EPNI directly from Medicare. Again,
please go to Medicare primary COB claim later in this chapter.
If the adjustment did not crossover as it should have within 30
days after Provider received the updated Medicare ERA,
submit an adjustment/replacement claim.
6. I have a claim where Medicare paid first. They have now
decided to pay one of the services on my three line claim.
Should I just send in the COB claim for that one line for
EPNI to pay the coinsurance and deductible?
No, never send a partial claim. This would be a violation of the
rules in the Minnesota Uniform Companion Guides. Again,
this could result in duplicate claims, increased administrative
costs and processing delays. If the prior payer has made a
change to the original or prior claim processing outcome, the
original or prior claim must be adjusted to ensure the
secondary payment is correct. A “partial” claim should never
be sent regardless of whether it is an original or adjustment. As
noted in response to question #3, if the prior payer has
adjudicated a claim with three services lines, all three service
lines should be sent to the secondary payer. Never alter the
charges and critical claim information when sending it to a
secondary / tertiary payer for payment consideration.
6-9
Claims Filing
Claims with
Attachments:
(continued)
7. I have talked with other providers and they tell me that a
COB claim must balance. What must balance?
The claim paid amounts must be equal to or greater than the
line level paid amounts. The CAS segments must always
reflect exactly what the prior payer has indicated on HIPAA
835 transaction or Remittance Advice/Explanation of Benefits.
Do not add or combine the CAS information. Typically, the
professional claim allowed and paid amounts should not be
greater than the billed amounts. More information regarding
balancing is available in the HIPAA Implementation Guides
available for purchase from Washington Publishing
(wpc-edi.com).
8. When the prior payer is Medicare how do I list them as the
primary payer? Do I list them by the Medicare office,
CMS, Federal Medicare, the name of the Medicare
contractor, etc?
When Medicare is the prior payer, EPNI suggests listing the
prior payer as “Medicare.”
9. I am sending COB in the 837 transaction and also sending
the EOB as an attachment with the report type code EB
and report transmission code AA. This is to make sure that
you get the COB information.
This specific issue was addressed in the August 6, 2009,
Provider Quick Points (QP18E-09). Specifically, in these
situations, the Report of Transmission (PWK02) is AA
indicating the EOB is available upon request at the provider’s
office. The HIPAA 837 Implementation Guides, Report of
Transmission (PWK Segment), states: “The PWK segment is
required if there is paper documentation supporting this claim.
The PWK segment should not be used if the information
related to the claim is being sent within the 837 ST-SE
envelope.” Therefore sending the information within the
transaction and also sending the PWK would be non-compliant
and result in a rejection.
Medicare/Uniform
Companion Guide
Coding Alignment
6-10
EPNI has made several system modifications to accept claims
coded using the rules indicated by either Medicare or the
Minnesota Uniform Companion Guides, Appendix A. Some billed
charges still may not be covered due to Subscriber benefits or
EPNI payment policy. Code claims to meet the specifications set
forth in the Minnesota Uniform Companion Guides.
Claims Filing
Questions
Questions regarding the content of the PA02 electronic reports or
Availity payer reports should be directed to provider services at
(651) 662-5200 or 1-800-262-0820. Questions regarding the
payer’s electronic reports not being received should be directed to
Provider's clearinghouse. If Provider's clearinghouse is Availity,
please refer to availity.com.
For questions regarding the attachment requirements, attachment
cover sheet and related instructions, COB or coding requirements,
refer to the AUC website at health.state.mn.us/auc.
6-11
Claims Filing
1500 HICF Form
Professional Claim
Submission
The 1500 Health Insurance Claim Form (HICF) (also referred to as
the CMS-1500) and the electronic transaction 837P are the only
accepted claim submission formats for professional claims.
Note: Effective July 15, 2009, only out of state, nonparticipating
providers are allowed to submit paper claim forms per
Minnesota Statute 62J.536 and the Provider Service
Agreement.
Completing the 1500
HICF Form
All required fields on the 1500 HICF claim form must be
completed with correct information. Required fields include the
following:
1a .........Insured ID number
2...........Patient’s name
3...........Patient date of birth and sex
4...........Insured name
5……...Patient’s address
6...........Patient relationship to insured
11a……Insured’s date of birth, Sex
21.........Diagnosis or nature of illness or injury
24A......Date(s) of service
24B ......Place of service
24D......Procedures, services, or supplies (includes modifiers)
24E ......Diagnosis code
24F ......$ Charge
24G......Days or units
24I……ID Qualifier
24J……Rendering Provider ID (NPI)
25…….Federal tax ID number
33.........Billing provider info and phone number
6-12
Claims Filing
Common Submission
Errors
Items commonly missed or incorrectly completed on claim forms
include:

Incorrect insured’s ID. Include all numeric and alpha
characters with no spaces. Do not include the Subscriber
number, group number, plan code, or anything other than
insured’s ID

Patient’s Date of Birth (3) requires eight digits
(MMDDCCYY)

Insured’s Date of Birth (11a) requires eight digits
(MMDDCCYY)

EMG (24C) - enter “Y” if emergency, leave blank for “No”

ID qualifier (24I –shaded) – enter two character qualifier (1B
for EPNI legacy ID, 1G for UPIN)

Rendering Provider ID (24J – shaded) – enter the individual
provider’s legacy ID, if applicable

Rendering Provider ID (24J – unshaded) – enter the individual
provider’s ten digit NPI, if applicable

Procedure codes billed with incorrect units of service (UOS)

Incorrect linking of box 24E to box 21

Service Facility Location Information (32) – enter name and
actual address of facility where services were rendered if other
than box 33 or patient’s home. Enter in the following format:



Line 1: name of physician or clinic

Line 2: street address

Line 3: city, state, ZIP code. Do not enter other information
like from and to locations.
Billing provider info and phone number (33) – enter in the
following format:

Line 1: name of physician or clinic

Line 2: address

Line 3: city, state, ZIP code
Name and address is required. Phone number is not required. If
providing a phone number it must be entered in the area to the
right of the box title. The area code is entered in parenthesis;
do not use a hyphen or space as a separator.
6-13
Claims Filing
Common Submission
Errors
(continued)

NPI (33a – unshaded) – enter ten-digit clinic NPI

Other ID (33b – shaded)– enter two-character qualifier (1B for
EPNI) and legacy ID failure to submit all surgical procedures
for the same date of service on one claim

Patient’s name; submit exactly the way it is on their
identification card

Uppercase alpha characters are required
Zero Billed Charges
EPNI will allow zero-billing or no charge submission lines or
claims.
Optical Scanning
EPNI uses an optical scanner for the entry of claims into its
processing system. Use of the scanner improves accuracy and
timeliness of claims processing. The following instructions for
completing the 1500 HICF form must be followed:
1. Use only the official Drop-Red-Ink 1500 HICF forms. EPNI
cannot accept black-and-white or photocopied forms.
2. Providers who preprint their name and address in box 33
should use a 10 or 12 character pitch.
3. Print requirements:

Ink should be dark, which may require frequent ribbon
changes.

Ink should be dense. Some older dot matrix printers may
produce a print that is too “spacey”.

Use UPPERCASE characters only.

Use 10 or 12 font size.

Use a standard font such as Courier.

Do not hand write anything on the claim form.

Do not use slashes, dashes, decimal points, dollar signs or
parentheses.
4. Enter all information on the same horizontal line.
5. Left justify all fields and enter all information within the
designated field.
6. Do not fold claims.
7. A maximum of six line items is allowed in box 24. Line items
must be double-spaced. If an unlisted procedure code is used, a
narrative description is required. Enter supplemental
information in the shaded section of 24A through 24G above
the corresponding service line.
6-14
Claims Filing
Year 2000 Date Format
Linking and
Sequencing
EPNI follows the 2006 guidelines set forth by the Administrative
Uniformity Committee in the Minnesota Standards for the Use of
the CMS-1500 Claim Form document. Specifically, EPNI
recommends that submitters use:

eight-digit dates for the birth date fields (3, 9b, and 11a)

six-digit dates for field 24a

six-digit or eight-digit for fields 12, 14, 15, 16, 18, 31
There are two diagnosis boxes, one is box 21 and the other is box
24E. Box 21 has space for four ICD-9-CM diagnosis codes and
these codes relate to all the services indicated on the claim detail
lines (24). Box 24E specifies what diagnosis or diagnoses relate to
that particular line only. It is essential to communicate the primary
diagnosis for the service performed, especially if more than one
diagnosis is related to a line item. Adjudication is based on the first
linked diagnosis. Note: do not key the actual diagnosis.
Linking/sequencing rules:

Sequence numbers relate to the ICD-9-CM diagnosis codes in
box 21 and are 1, 2, 3, and 4.

The primary diagnosis is listed first in the sequence if more
than one diagnosis is related.

If multiple pages are submitted, the diagnoses must be in the
same order on each page in field 21.
6-15
Claims Filing
Linking and
Sequencing Example
21.
DIAGNOSIS OR NATURE OF ILLNESS
1.
V72.5
3.
2.
845.01
4.
24.
A
DATE(S) OF
SERVICE
1. 02 05 10
2. 02 05 10
B
POS
C
EMG
11
11
V76.2
D
PROCEDURES,
SERVIES OR
SUPPLIES
99212
88150
E
DX
POINTE
R
21
3
Box 21
There are three diagnosis codes indicated.
Box 24
Detail line item 1 indicated the service in box 24D as
99212, E/M office service. The linked diagnoses are 2
and 1, or 845.01 and V72.5. The diagnoses are
sequenced as 2 then 1. This indicates the primary
diagnosis is 845.01 and V72.5 is secondary. V72.5 is
considered a routine diagnosis, but this is not a primarily
routine service.
Detail line item 2 indicates the service in box 24D as
88150, pap smear. There is only one diagnosis linked to
the service. The linked diagnosis is 3, or V76.2.
Place of Service Codes
Only nationally assigned place of service codes are accepted.
These codes are also available at
http://www.cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pd
f
Following are the current place of service codes as of November
2009. These codes should be used on professional claims to
specify the entity where service(s) were rendered.
Place
of
Service
Codes
Place of Service Name
Place of Service Description
01
Pharmacy
A facility or location where drugs and other medically
related items and services are sold, dispensed or otherwise
provided directly to patients.
02
Unassigned
N/A
03
School
A facility whose primary purpose is education.
04
Homeless Shelter
A facility or location whose primary purpose is to provide
temporary housing to homeless individuals (e.g.,
emergency shelters, individual or family shelters).
6-16
Claims Filing
Place
of
Service
Codes
05
Indian Health Service
Free-standing Facility
A facility or location, owned and operated by the Indian
Health Service, which provides diagnostic, therapeutic
(surgical and non-surgical), and rehabilitation services to
American Indians and Alaska natives who do not require
hospitalization.
06
Indian Health Service
Provider-based Facility
A facility or location, owned and operated by the Indian
Health Service, which provides diagnostic, therapeutic
(surgical and non-surgical), and rehabilitation services
rendered by, or under the supervision of, physicians to
American Indians and Alaska Natives admitted as
inpatients and outpatients.
07
Tribal 638 Free-standing A facility or location owned and operated by a federally
Facility
recognized American Indian or Alaska native tribe or
tribal organization under a 638 agreement, which provides
diagnostic, therapeutic (surgical and non-surgical), and
rehabilitation services to tribal members who do not
require hospitalization.
08
Tribal 638 Providerbased Facility
A facility or location owned and operated by a federally
recognized American Indian or Alaska native tribe or
tribal organization under a 638 agreement, which provides
diagnostic, therapeutic (surgical and non-surgical), and
rehabilitation services to tribal members admitted as
inpatients or outpatients.
09
Prison-Correctional
Facility
A prison, jail, reformatory, work farm, detention center or
any other similar facility maintained by either federal,
state or local authorities for the purpose of confinement or
rehabilitation of adult or juvenile criminal offenders.
10
Unassigned
N/A
11
Office
Location other than a hospital, skilled nursing facility
(SNF), military treatment facility, community health
center, state or local public health clinic or intermediate
care facility (ICF), where the health professional routinely
provides health examinations, diagnosis and treatment of
illness or injury on an ambulatory basis.
12
Home
Location other than a hospital or other facility, where the
patient receives care in a private residence.
6-17
Claims Filing
Place
of
Service
Codes
13
Assisted Living Facility
Congregate residential facility with self-contained living
units providing assessment of each resident’s needs and
on-site support 24 hours a day, seven days a week, with
the capacity to deliver or arrange for services including
some health care and other services.
14
Group Home
A residence with shared living areas, where clients receive
supervision and other services such as social and/or
behavioral services, custodial service, and minimal
services (e.g., medication administration).
15
Mobile Unit
A facility/unit that moves from place-to-place equipped to
provide preventive, screening, diagnostic and/or treatment
services.
16
Temporary Lodging
A short-term accommodation such as a hotel, camp
ground, hostel, cruise ship or resort where the patient
receives care, and that is not identified by any other POS
code. (Effective 04/01/08.)
17
Walk-in Retail Health
Clinic
A walk-in health clinic, other than an office, urgent care
facility, pharmacy or independent clinic and not described
by any other Place of Service code, that is located within a
retail operation and provides, on an ambulatory basis,
preventive and primary care services. (This code is
available for use immediately with a final effective date of
May 1, 2010.)
18-19
Unassigned
N/A
20
Urgent Care Facility
Location distinct from a hospital emergency room, an
office, or a clinic, where the purpose is to diagnose and
treat illness or injury for unscheduled, ambulatory patients
seeking immediate medical attention.
21
Inpatient Hospital
A facility, other than psychiatric, which primarily
provides diagnostic, therapeutic (both surgical and
nonsurgical) and rehabilitation services by, or under, the
supervision of physicians to patients admitted for a variety
of medical conditions.
22
Outpatient Hospital
A portion of a hospital which provides diagnostic,
therapeutic (both surgical and nonsurgical) and
rehabilitation services to sick or injured persons who do
not require hospitalization or institutionalization.
6-18
Claims Filing
Place
of
Service
Codes
23
Emergency RoomHospital
A portion of a hospital where emergency diagnosis and
treatment of illness or injury is provided.
24
Ambulatory Surgical
Center
A freestanding facility, other than a physician’s office,
where surgical and diagnostic services are provided on an
ambulatory basis.
25
Birthing Center
A facility, other than a hospital’s maternity facilities or a
physician’s office, which provides a setting for labor,
delivery and immediate postpartum care as well as
immediate care of newborn infants.
26
Military Treatment
Facility
A medical facility operated by one or more of the
Uniformed Services. Military Treatment Facility (MTF)
also refers to certain former U.S. Public Health Service
(USPHS) facilities now designated as Uniformed Service
Treatment Facilities (USTF).
27-30
Unassigned
N/A
31
Skilled Nursing Facility
A facility which primarily provides inpatient skilled
nursing care and related services to patients who require
medical, nursing or rehabilitative services, but does not
provide the level of care or treatment available in a
hospital.
32
Nursing Facility
A facility which primarily provides residents with skilled
nursing care and related services for the rehabilitation of
injured, disabled or sick persons, or on a regular basis,
health-related care services above the level of custodial
care to other than mentally retarded individuals.
33
Custodial Care Facility
A facility which provides room, board and other personal
assistance services, generally on a long-term basis, and
which does not include a medical component.
34
Hospice
A facility, other than a patient’s home, in which palliative
and supportive care for terminally ill patients and their
families are provided.
35-40
Unassigned
N/A
41
Ambulance-Land
A land vehicle specifically designed, equipped and staffed
for lifesaving and transporting the sick or injured.
42
Ambulance-Air or
Water
An air or water vehicle specifically designed, equipped
and staffed for lifesaving and transporting the sick or
injured.
6-19
Claims Filing
Place
of
Service
Codes
43-48
Unassigned
N/A
49
Independent Clinic
A location, not part of a hospital and not described by any
other Place of Service code, that is organized and operated
to provide preventive, diagnostic, therapeutic,
rehabilitative or palliative services to outpatients only.
50
Federally Qualified
Health Center
A facility located in a medically undeserved area that
provides Medicare beneficiaries preventive primary
medical care under the general direction of a physician.
51
Inpatient Psychiatric
Facility
A facility that provides inpatient psychiatric services for
the diagnosis and treatment of mental illness on a 24-hour
basis, by or under the supervision of a physician.
52
Psychiatric FacilityPartial Hospitalization
A facility for the diagnosis and treatment of mental illness
that provides a planned therapeutic program for patients
who do not require full time hospitalization, but who need
broader programs than are possible from outpatient visits
to a hospital-based or hospital-affiliated facility.
53
Community Mental
Health Center
A facility that provides the following services: outpatient
services, including specialized outpatient services for
children, the elderly, individuals who are chronically ill,
and residents of the CMHC’s mental health services area
who have been discharged from inpatient treatment at a
mental health facility; 24-hour a day emergency care
services; day treatment, other partial hospitalization
services, or psychosocial rehabilitation services; screening
for patients being considered for admission to state mental
health facilities to determine the appropriateness of such
admission; and consultation and education services.
54
Intermediate Care
Facility/Mentally
Retarded
A facility which primarily provides health-related care and
services above the level of custodial care to mentally
retarded individuals but does not provide the level of care
or treatment available in a hospital or SNF.
55
Residential Substance
Abuse Treatment
Facility
A facility which provides treatment for substance (alcohol
and drug) abuse to live-in residents who do not require
acute medical care. Services include individual and group
therapy and counseling, family counseling, laboratory
tests, drugs and supplies, psychological testing and room
and board.
6-20
Claims Filing
Place
of
Service
Codes
56
Psychiatric Residential
Treatment Center
A facility or distinct part of a facility for psychiatric care
which provides a total 24-hour therapeutically planned
and professionally staffed group living and learning
environment.
57
Non-residential
Substance Abuse
Treatment Facility
A location which provides treatment for substance
(alcohol and drug) abuse on an ambulatory basis. Services
include: individual and group therapy and counseling,
family counseling, laboratory tests, drugs and supplies,
and psychological testing.
58-59
Unassigned
N/A
60
Mass Immunization
Center
A location where providers administer pneumococcal
pneumonia and influenza virus vaccinations and submit
these services as electronic media claims, paper claims or
using the roster billing method. This generally takes place
in a mass immunization setting, such as a public health
center, pharmacy or mall but may include a physician
office setting.
61
Comprehensive
Inpatient Rehabilitation
Facility
A facility that provides comprehensive rehabilitation
services under the supervision of a physician to inpatients
with physical disabilities. Services include: physical
therapy, occupational therapy, speech pathology, social or
psychological, orthotics and prosthetics.
62
Comprehensive
Outpatient
Rehabilitation Facility
A facility that provides comprehensive rehabilitation
services under the supervision of a physician to
outpatients with physical disabilities. Services include
physical therapy, occupational therapy and speech
pathology services.
63-64
Unassigned
N/A
65
End-Stage Renal
Disease Treatment
Facility
A facility other than a hospital that provides dialysis
treatment, maintenance, and/or training to patients or
caregivers on an ambulatory or homecare basis.
66-70
Unassigned
N/A
71
Public Health Clinic
A facility maintained by either state or local health
departments that provides ambulatory primary medical
care under the general direction of a physician.
72
Rural Health Clinic
A certified facility which is located in a rural medically
underserved area that provides ambulatory primary
medical care under the general direction of a physician.
6-21
Claims Filing
Place
of
Service
Codes
73-80
Unassigned
N/A
81
Independent Laboratory
A laboratory certified to perform diagnostic and/or clinical
tests independent of an institution or a physician’s office.
82-98
Unassigned
N/A
99
Other Place of Service
Other place of service not identified above.
Site of Service
EPNI is specifying, for clarity, the difference between a facility
and a non-facility with respect to the place of service where a
service was rendered. For billing purposes, professional (1500)
billers should use an appropriate place of service code to indicate
where services were rendered. Examples of facilities include
hospitals and ambulatory surgery centers. Examples of nonfacilities include a provider's office and all places not listed below.
The following is a current comprehensive list of facilities, as
defined by EPNI:
6-22
Place of service code
Place of service name
21
Inpatient hospital
22
Outpatient hospital
23
Emergency room - hospital
24
Ambulatory surgical center
26
Military treatment facility
31
Skilled nursing facility
34
Hospice
41
Ambulance - land
42
Ambulance - air & water
51
Inpatient psychiatric facility
52
Psychiatric facility - partial
53
Community mental health center
56
Psychiatric residential treatment center
Claims Filing
Freestanding
Ambulatory Surgery
Center Billing
In order to streamline its administrative processes and comply with
regulatory requirements, EPNI transitioned all freestanding
ambulatory surgery center providers to new Provider Service
Agreements, which are based on the following guidelines and
provisions:

Use of Professional Claims Submission Formats
Freestanding Ambulatory Surgery Center providers submit
claims utilizing a CMS 1500 claim form or the HIPAA 837P
claims transaction, in compliance with Minnesota Statute
62J.52. Use the national place of service code 24.

Fee Schedule Based Payment Methodology
APC weights were used to create fee schedule allowances
(Allowance=APC weight x conversion factor) for each
procedure code, as appropriate.

Recognition of Multiple Surgeries and Bilateral Procedures
For multiple surgeries, the procedure with the highest billed
charge is reimbursed at 100% of the allowed amount.
Subsequent services are reimbursed at 50% of the allowed
amount. Bilateral surgeries are billed on one line with a 50
modifier and reimbursed at 150% of the allowed amount.

Adjudication of Services at the Claim Line Level
Payment is calculated at the lesser of the percent of Provider’s
Regular Billed Charges as detailed in the Provider Service
Agreement or the EPNI fee schedule allowance, implemented
at a claim line/service level.
6-23
Claims Filing
Freestanding
Ambulatory Surgery
Center Billing
(continued)
Payment of individual procedures--APC methodology
determines which Health Services are included/excluded from
separate reimbursement, including implants/devices and tissue.
Services excluded from separate reimbursement are listed on the
provider fee schedule with a zero allowance. Professional services,
including anesthesia, should not be billed under this Provider
Service Agreement. Individual provider NPI numbers are not
required.
Corneal tissue – Claims that contain corneal tissue charges must
be submitted with the invoice for that corneal tissue.
K3 Segment Usage
Instructions for
Condition Codes
Condition Code
The NUBC has added condition codes to their code set to identify
situations where Workers' Compensation requires duplicate or
appeal submissions. The 837P format does not include a
standardized way of reporting condition codes. To report
applicable condition codes on a professional claim, the K3
segment should be used.
BG is the qualifier to indicate this value and should be followed by
the appropriate condition code (refer to the NUBC Guide and Code
Set available from the National Uniform Billing Committee at
http://www.nubc.org).
Report at 2300 loop only.
K3*BGW2~
Revised 1500 Health
Insurance Claim Form
A sample of the new 1500 claim form can be found at ccstpa.com.
NUCC Transition
The National Uniform Claim Committee (NUCC) revised the
CMS-1500 claim form in part, to complement the transition from
the UB-92 to the UB-04 and ensure its function prior to the May
23, 2007, deadline for reporting the NPI.
The revised form, the 1500 Health Insurance claim form (version
08/05) was effective April 1, 2007. Only the revised (08/05) form
is to be used. All rebilling of claims should use the revised (08/05)
form from this date forward, even though earlier submissions may
have been on the current (12/90) 1500 claim form.
6-24
Claims Filing
Form Availability
Documents related to the release of the new version of the form,
including the revised form, a new reference instruction manual, a
log of changes to the current form and the recommended transition
timeline, are available at nucc.org.
In addition to revising the 1500 claim form, the NUCC has drafted
a reference instruction manual detailing how to complete the form.
The purpose of this manual is to help standardize nationally the
manner in which the form is being completed. A copy of the
instruction manual is available on the NUCC website.
About the NUCC
The National Uniform Claim Committee is a voluntary
organization whose members include representatives from major
providers, payers, health researchers and other organizations
representing billing professionals and electronic standard
developers. The NUCC maintains the uniform data set known as
the National Uniform Claim Committee Data Set designed for the
non-institutional claims. The NUCC is also a signatory to a
Memorandum of Understanding with five other organizations
designated by the U.S. Department of Health and Human Services
to collectively serve as the Designated Standard Maintenance
Organizations (DSMO) to the HIPAA Transaction Standard
Implementation Guides.
6-25
Claims Filing
UB-04 (CMS 1450) Form
Institutional Claim
Submission
The UB-04 (also referred to as the CMS-1450) and the electronic
transaction 837I are the only accepted claim submission formats
for institutional claims.
Note: Effective July 15, 2009, only out of state, nonparticipating
providers are allowed to submit paper claim forms per
Minnesota Statute 62J.536 and the Provider Service
Agreement.
Completing the UB-04
Form
Providers must complete all required field locators on the UB-04
claim form. EPNI requires the fields listed below. For a more
detailed explanation of each field locator, reference the NUBC
UB-04 manual.
1
Provider name
47
Total charges
3a
Patient control number
50a-c
Payer name
4
Type of bill
51a-c
5
Federal tax number
Health plan
identification number
6
Statement covers period
52a-c
8b
Patient name/identifier
Release of
information
certification indicator
53a-c
Assignment of
benefits certification
indicator
9a-e Patient address
6-26
10
Patient birth date
11
Patient sex
58a-c
Insured’s name
14
Priority (Type) of visit
59a-c
15
Source of referral for
admission or visit
Patient’s relationship
to insured
60a-c
Insured’s unique
identifier
66
Diagnosis and
procedure code
qualifier (ICD version
indicator)
67
Principal diagnosis
code and present on
admission indicator
17
Patient discharge status
42
Revenue codes
43
Revenue description
46
Units of service
Claims Filing
Common Submission
Errors
Items commonly missed or incorrectly completed on the UB-04
claim form include:

Claims must be typed and spaced within guide lines

Uppercase alpha characters are required

FL 1 BILLING PROVIDER ADDRESS – first line must be
the name of the facility. Second line must be the street address.
Third line must be the city, state, and ZIP code. Fourth line
must be the telephone number

FL 3A PAT. CNTL - # must not be blank

FL 4 TYPE OF BILL - must be 4 digits, first digit is a leading
zero (for paper claims)

FL 6 STATEMENT COVERS PERIOD – Enter the from and
through dates in MMDDYY format

FL 8B PATIENT NAME - needs the name of the patient, must
not be blank

FL 10 DATE OF BIRTH - must be in MMDDCCYY format

FL 13 ADMISSION HOUR – required for inpatient claims.
Enter the code that corresponds with the time the patient was
admitted. Code 99 is invalid and will no longer be accepted

FL 14 ADMISSION TYPE and 15 ADMISSION SOURCE
OF REFERRAL - must not be blank

FL 42 Line 23 of the itemization REV CODE 0001 must be
listed along with a "CREATION DATE" and a total charge

FL 42 REV CODE - all revenue codes must be 4 digits

FL 45 SERVICE DATE - must be in MMDDYY format

FL 50 PAYER NAME – enter the payer’s name only, do not
include the payer’s address

FL 51 HEALTH PLAN ID – until it becomes mandated, enter
the (legacy/proprietary) number as assigned by the
corresponding payer in FL 50 A, B, C

FL 54 PRIOR PAYMENTS – Enter amount paid by the payer
toward payment of bill. If claim was processed and nothing
paid, list 0.00. If claim has not been processed, leave blank

FL 56 NATIONAL PROVIDER IDENTIFIER

FL 57 OTHER PROVIDER ID – provider’s legacy number if
provider is a Minnesota provider

FL 66 DIAGNOSIS AND PROCEDUREE CODE
QUALIFIER - small box below, must be a 9 (ninth revision) at
this time
6-27
Claims Filing
Situations Requiring
Electronic Submission
EPNI will not accept CMS-1450 HICF paper claims if one of the
following fields have been exceeded:

Line dollar amount is greater than $9,999,999.99

Total dollar charge is greater than $9,999,999.99
Any claims submitted over these limits will be rejected.
Adjustments will not be allowed on these claims. A new claim
must be submitted using the proper format.
Sample UB-04
A sample of the UB-04 (CMS-1450) claim form is at ccstpa.com.
UB-04 Implementation
The UB-04 was approved by the National Uniform Billing
Committee (NUBC) as a replacement for the UB-92. The UB-04
contains a number of improvements and enhancements that
resulted from nearly four years of research, including better
alignment with the electronic HIPAA ASC X12N 837-Institutional
transaction standard.
On May 23, 2007, the UB-92 was discontinued; only the UB-04
form and data set specifications should be used. All rebilling of
claims must use the UB-04 from this date forward, even though
earlier submissions may have been on the UB-92.
About the NUBC
Established in 1975, the NUBC is the official data content body
responsible for maintaining the data set for institutional health care
providers. Representation includes provider, payer, electronic
standards development organizations, public health data standards
organizations, and others. The NUBC is also one of six Designated
Standard Maintenance Organizations (DSMO) responsible for the
maintenance and development of HIPAA administrative
simplification transaction standards. (Note: Also see
http://www.nubc.org/INFORMATION_ON_UB-04.pdf)
Reminder
Providers are encouraged to submit claims electronically whenever
possible. If submitting paper claims, the timeline for submission of
the correct paper claim form must be followed. A sample of the
revised claim form can be found on ccstpa.com.
6-28
Claims Filing
Ordering Forms and Manuals
HCPCS, CPT and
ICD-9-CM Manuals
HCPCS, CPT and ICD-9-CM manuals can be purchased from
major bookstores or publishers, such as the American Medical
Association.
HIPAA Implementation
Guides
To order national Electronic Data Interchange Transaction Set
Implementation guides on paper or electronic versions, contact
Washington Publishing Company:
1-800-972-4334
Or visit their website at http://www.wpc-edi.com.
Minnesota Uniform
Companion Guides
Minnesota Uniform Companion Guides containing instructions for
electronic transactions are available free of charge on the
Administrative Uniformity website under “Guides” at
www.health.state.mn.us/auc/.
1500 HICF (CMS-1500)
UB-04 (CMS-1450)
Forms
To order 1500 HICF and UB-04 forms contact:
U.S. Government Printing Office
(202) 512-0455 or visit the website at
http://www.cms.hhs.gov/CMSForms/
Form vendors or publishers, such as the American Medical
Association or the American Hospital Association.
UB-04 Manual
To order the UB-04 Manual contact:
National Uniform Billing Committee (NUBC) at
http://www.nubc.org/become.html for more information and an
order form, or call the American Hospital Association at (312)
422-3390 for questions.
1500 HICF Manual
To order a paper copy of the Minnesota standards for the use of the
1500 HICF Claim Form contact:
Minnesota’s Bookstore
660 Olive Street
St. Paul, MN 55155
or call: (651) 297-3000 or 1-800-657-3757
This manual may also be downloaded from the AUC website at
http://www.health.state.mn.us/auc/index.html.
The National Uniform Claim Committee 1500 Health Insurance
Claim Form Reference Instruction Manual is also available at
http://www.nucc.org/.
6-29
Claims Filing
Institution/Facility Billing
Claim Format
Regulations
HIPAA Administrative Simplification code and transaction
regulations dictate the standard claim format and codes for
electronically submitted claims. Institutional claims are billed on
the 837I electronic format. The paper equivalent is the UB-04
claim form.
EPNI considers the following providers as ‘institutional’ and as
such, should bill on the institutional claim format (837I or UB-04).
6-30
Category
Definition
Home Health
Agency
HHA is a public agency or private organization
that is primarily engaged in providing skilled
nursing services and other therapeutic services,
such as physical therapy, occupational therapy,
medical social services and home health aide
services. Can be freestanding or hospital attached.
Care is rendered in the home and is in lieu of a
hospital confinement.
Hospice
Hospice programs provide health care for
terminally ill patients. Care may be done in the
patient’s home, at special hospice units, or a
separate hospice care facility.
Hospital
An institution that provides medical, diagnostic
and surgical care. Services can be rendered on an
inpatient or outpatient basis.
Nonresidential
treatment
center
This type of institution is the same as a residential
primary treatment center with the exception that
services are rendered on an outpatient basis only.
Nursing home
A Skilled Nursing Facility (SNF) provides skilled
nursing care and related services for patients who
require medical or nursing care; or rehabilitation
services for injured, disabled, or sick person.
Claims Filing
Claim Format
Regulations
(continued)
Category
Definition
Psychiatric
hospital
A psychiatric hospital provides care to
emotionally ill patients. These facilities must be
licensed by the state in which they are located.
Residential
primary
treatment
center
Residential treatment programs for chemical
dependency are planned and purposeful sets of
conditions and events for the care of inebriated
and drug dependent persons which provides care
and treatment for five or more inebriate or drug
dependent persons on a 24 hour basis. Excluded
for this definition are receiving (detoxification)
centers.
(IP chem dep)
Procedure Code
Regulations
The medical procedure code set for inpatient services is ICD-9CM procedure codes. Procedure information will be reported on
outpatient claims using HCPCS codes.
Revenue Codes (FL 42)
A revenue code identifies a specific accommodation and/or
ancillary service or billing calculation. The revenue code is four
characters. The first digit is usually a 0 (zero); however, there are
codes that begin with other than 0 (100X, 210X, 310X). It is
important to report all four digits.
HCPCS/
Accommodation
Rates/HIPPS Rate
Codes (FL 44)
For inpatient bills, the accommodation rate relating to the room
and board revenue code is entered in form locator 44.
Duplicate Billing
EPNI will only reimburse the professional of clinic services when
a Subscriber is seen in a clinic setting (POS 11). Facilities that
have clinics physically located onsite or next to a hospital
frequently bill an additional claim either electronically or on a
UB04 with a place of service 22 for the same services that the
physician is billing. In some cases, facilities submit revenue code
0361. EPNI considers this practice duplicate billing. Facility
overhead is included in the professional reimbursement weighting
and conversion factor; therefore, complete and final
reimbursement will be made on the professional claim only.
For outpatient bills, report the HCPCS code, if applicable, to
indicate the specific outpatient service in form locator 44. Some
HCPCS codes or billing situations may require submission of
modifiers. Modifiers are reported following the HCPCS code.
EPNI accepts modifiers; however, we currently do not adjudicate
the claim/service based on modifiers.
6-31
Claims Filing
Treatment Room
EPNI considers a treatment room as an overhead expense
reimbursed as part of the physician’s professional fee. Therefore,
billing facility fees through the 0760, 0761 or 0769 codes
duplicates the physician’s professional claim (1500 HICF) and will
deny as provider liability.
If Medicare is primary, and EPNI is secondary, EPNI will accept
the 0760, 0761 or 0769 revenue codes, and process according to
Medicare’s guidelines.
Observation Room
Observation Care, billed under revenue code 0762, is allowed for
admits of less than 24 hours. Claims for observation services over
24 hours will be processed as an inpatient claim.
Clinic Charges
Clinic charges, billed under revenue code 051X, are considered an
overhead expense reimbursed as part of the physician’s
professional fee. Therefore, billing facility fees through the 05100519 revenue codes duplicates the physician’s professional claim
(1500 HICF) and will deny as provider liability.
Transfer Case
Effective January 1, 2007, a transfer case will be defined as when a
patient is discharged from one facility to another.
Patient status codes are a required field (Form Locator 17) on the
institutional claim (837I or UB-04). This code indicates the
patient’s status as of the “Through” date of the billing period. It is
important to note that the patient status code indicates a destination
and not a level or type of care received.
When a patient is transferred/discharged to another facility, patient
status may affect reimbursement. All patient status codes are
accepted but not all will result in a transfer case classification. The
following patient status codes are used by EPNI to classify a
transfer case.
6-32
Code
Definition
02
Discharged/transferred to a short-term general hospital for
inpatient care
05
Discharged/transferred to another type of healthcare
institution not defined elsewhere in this code list
43
Discharged/transferred to a federal health care facility
65
Discharged/transferred to a psychiatric hospital or
psychiatric distinct part unit of a hospital
70
Discharged/transferred to another type of healthcare
institution not defined elsewhere in this code list
Claims Filing
Zero Billed Charges
EPNI will allow zero-billing or no charge submission lines or
claims.
Lactation Education
For billing purposes, lactation services are considered to be part of
the mother’s charges and should not be billed on the newborn’s
claim.
Submit all claims for lactation education on the 837I or UB-04
claim for m using revenue code 0942. These charges must be
submitted on the mother’s original maternity/delivery claim and
require a narrative description.
Claims for lactation services submitted under infant’s name or
number will be rejected.
If lactation education is necessary after discharge, it can be billed
as part of the post-partum visit under the mother’s identification
number.
0636 Drugs Requiring
Prior Auth
The revenue code 0636, by definition, is for drugs requiring
detailed coding. A HCPCS code must always be submitted with
0636. However, some drugs that may be submitted under this
revenue code also require prior authorization. The following
require prior authorization:

IVIG

Aminolevulinic Acid

Factor products
6-33
Claims Filing
Present on Admission
The present on admission (POA) indicator is required on all claims
for inpatient admissions to general acute care hospitals for
Medicare beneficiaries with discharge dates on or after October 1,
2007.
General Reporting Requirements
Form Completion
Instructions

The POA indicator is required for all claims involving
Medicare and commercial inpatient admissions to general
acute care hospitals.

The POA indicator is assigned to principal and secondary
diagnoses.

Present on admission is defined as present at the time the order
for inpatient admission occurs. Conditions that develop during
an outpatient encounter while in the emergency room, under
observation or during outpatient surgery are also considered as
present on admission.

If the condition would not be coded and reported based on
Uniform Hospital Discharge Data Set definitions and current
coding guidelines, then the POA would not be reported.

The POA indicator is not required for the external cause of
injury code unless it is being reported as an “other diagnosis”.

Critical access hospitals, Maryland waiver hospitals, long-term
care hospitals (LTCH), cancer hospitals and children’s
inpatient facilities are exempt from this requirement.
For electronic claims using the 837I, refer to the Minnesota
Uniform Companion Guide for the Institutional Electronic Health
Care Claim Transaction (ANSI ASC X12 837I). Information on
submission of the POA indicator is found in Appendix D of the
guide. The guide can be accessed at
http://www.health.state.mn.us/auc/mn837i.pdf. POA indicators
should only be submitted along with correlating diagnosis codes.
On UB-04 (CMS-1450) paper claims, the POA indicator is the
eighth digit of Form Locator (FL) 67, Principal Diagnosis and the
eighth digit of each of the Other Diagnosis fields FL 67 A-Q. One
POA indicator is submitted per diagnosis. POA indicators should
only be submitted along with correlating diagnosis codes.
Use the POA indicators as Provider would normally submit to
Medicare. For more information, refer to
http://www.cms.hhs.gov/HospitalAcqCond.
6-34
Claims Filing
K3 Segment Usage
Instructions for POA
To send present on admission (POA) indicator(s), send the letters
“POA”, followed by a single POA indicator for every diagnosis
reported on the claim, except for admitting diagnosis and patient
reason for visit diagnosis. The POA indicator for the principal
diagnosis should be the first indicator after “POA”. POA indicators
for secondary diagnoses would follow next, if applicable. The “Z”
is used to indicate the end of POA information for most claims and
the “X” indicates the end of POA information for claims that have
an exception to processing. The “X” value was added to provide a
way to indicate an exception to processing if necessary in the
future. For “E” diagnosis codes, put the POA after the “Z” or “X.”
Note: The X value indicates there is an exception to how the
values are to be used in the processing of the indicators.
Report at 2300 loop only.
POA indicator values:

Y=Yes, present at the time of inpatient admission.

N=No, not present at the time of inpatient admission.

U=Unknown, the documentation is insufficient to determine if
the condition was present at the time of inpatient admission.

W=Clinically Undetermined; the provider is unable to
clinically determine whether the condition was present at the
time of inpatient admission or not.

1=Represents a space or blank and means the dx code is
exempt from reporting of POA.

Z=Indicates the end of reporting of POA indicators for the
other dx codes.

X=Indicates the end of reporting of POA indicators for the
other dx for Inpatient Exempt Providers (CR6086).
6-35
Claims Filing
Claims Filing
Timely Filing
Most Subscriber Contracts contain a time limit for claims
submittal. The limit is usually six months after the date of service,
with a few exceptions. The provider is liable for claims not
submitted within the timely filing limit. Providers are required to
submit claims in accordance with the timely filing provision of the
Provider Service Agreement. Provider is liable for claims not
submitted within the timely filing limit.
For medical care that involves follow-up, such as surgery and
routine postoperative care, it is better to bill EPNI after all services
have been completed, as long as it is within the time limit.
Replacement Claims
Effective May 22, 2010, EPNI requirements for timely filing of
replacement claims will be as follows:

The timely filing limit on replacement claims will be six
calendar months from the process date of the predecessor
claim.

There is no timely filing limit on cancel claims (claim
frequency code of 8).
Provider Submitted Appeals
Claims Crossover for
Medicare and Medicare
Supplement

Effective May 22, 2010, EPNI requirements for timely filing of
provider appeals will change as follows:

The timely filing limit on appeals will be 90 days from the
remit date of the claim on all provider submitted appeals.

In no event may Provider send a replacement claim with no
data changes to the payer in order to extend the 90 days
allowed from remittance date of the claim to appeal.
The claims crossover system reduces Provider's paperwork by
using the Medicare claim form to process both Medicare and
Medicare Supplement benefits. Through the crossover, Medicare
generates a second claim automatically for Subscribers who have
secondary or supplemental benefits with EPNI. Providers have
only one claim form to submit—the 1500 HICF (CMS-1500) for
Medicare Part B or the UB-04 (CMS-1450) for Medicare Part A.
While EPNI can only accept changes from the Subscriber, it
encourages providers who are aware of Heath Insurance Claim
Number (HICN) changes to assist their patients in communicating
this information to EPNI.
6-36
Claims Filing
Medicare Crossover
EPNI provides COBC a weekly eligibility file of all EPNI
Subscribers enrolled for coverage under the Medicare program.
When Medicare processes a claim, the Medicare Subscriber's
HICN will be compared to the HICNs on the eligibility file sent by
EPNI. If found, the date of service on the Medicare claim will be
compared to the EPNI coverage effective and cancel dates. If the
claim’s date of service falls within those dates, the claim will be
crossed over to EPNI electronically.
UB-04 (CMS-1450)
Crossover Information
The current message indicating the claim was sent to EPNI will
continue to be displayed on the Subscriber's Medicare Summary
Notice (MSN) or on the Explanation of Medicare Benefits
(EOMB). Medicare will indicate on the Provider’s Remittance
Advice (RA) if the claim was sent to the supplemental insurer. On
the Intermediary RA, claim status codes of 19, 20, or 21 indicate
that the claim was crossed over. If the HICN is not found on the
EPNI eligibility file, or if the date of service on the claim is outside
the given EPNI coverage effective and cancel dates, the claim will
not be forwarded to EPNI electronically.
1500 HICF (CMS-1500)
Crossover Information
A note associated with the ANSI remark code indicates which
payer will receive the claim information. Providers will continue to
see MA18 and the name of the payer on the Medicare RA when
the payment information is forwarded to a single payer. However,
code N89 will be used when the payment information is forwarded
to multiple payers; only one of those payers will be named on the
RA even though the payment information is forwarded to multiple
payers.
Paper claims submitted to EPNI with the Medicare RA attached
and the N89 remark code stating the payment information was
forwarded to EPNI will be returned to the provider. Adjusted
Medicare B claims will not be crossed over to EPNI.
If the claim is not forwarded, then:

The statement or code indicating the claim was forwarded to
EPNI will not appear on the MSN, EOMB or RA.

The patient or provider must submit the paper claim to EPNI
along with the MSN, EOMB or RA.
6-37
Claims Filing
Duplicate Claims
6-38
Duplicate billing adds millions of dollars each year to health care
administrative costs. Many providers operate under the erroneous
assumption that frequent rebilling leads to faster payment.
Unnecessary rebilling increases overhead costs of providers and
EPNI. Below are several ways Provider can help reduce duplicate
claims costs:

When filing the claim, be sure to tell patients not to bill on
their own.

Eliminate “automatic” rebillings. Wait 30 calendar days for
EPNI to process claims.

Before rebilling, use provider web self-service or call provider
services for claims status information.

Don’t submit previously billed claims with new claims “just to
be safe.” This only delays payment of all new claims.

Upon receipt of a Medicare RA showing that the claim has
electronically been ‘‘crossed over’’ to EPNI, do not submit the
paper RA as a claim.

If a claim has been denied, electronically resubmitting the RA
will only result in a second denial. Check with provider
services before pursuing the matter.
Claims Filing
Submission of Claims
EPNI's goal is to pay claims as quickly as possible. By following
the above suggestions, Provider can help hold down everyone’s
administrative costs.
To ensure the proper administration of benefits by EPNI, providers
shall submit claims to EPNI even when their claims have been
paid in full by other third parties such as Medicare. When
submitting claims in these cases, the provider shall submit a copy
of the explanation of medical benefits with the claim.
Providers shall submit claims to EPNI for all services provided,
even in cases when the provider suspects a service will not be
covered. This will ensure the proper administration of benefits and
take advantage of changes in coverage that providers may not be
aware.
Provider must submit claims to EPNI electronically in most cases.
Upon reasonable advance written notice to Provider, EPNI may
refuse to process paper claims, or charge Provider for processing
paper claims. Both Provider and EPNI are subject to Minnesota
Statute, Section 62J.356 and other applicable laws, regulations or
guidance that governs electronic claims submission.
EPNI reserves the right to verify the clinical accuracy of claims
through its claims systems. All health plan administration
including application of benefits and patient eligibility is applied
after clinical correctness has been established. Provider must
comply with coding and billing requirements based on coding
rules of CPT, ICD-9-CM, HCPCS and/or Minnesota Department
of Health Uniform Companion Guides, including any updates or
changes to such coding rules and/or guides as applicable and as
interpreted by EPNI and as set forth in the coding policies and
guidelines of the Provider Policy & Procedure Manual. Provider
further agrees to submit claims for Health Services to EPNI in the
most cost effective manner when more than one billing option
exists. Provider is responsible for obtaining any authorization
required to release such information to EPNI and/or the Plan
Sponsor.
6-39
Claims Filing
Cancel/Void and
Replacement Claims
Minnesota statute 62J.536, requires Provider to submit all claims
electronically. This requirement includes all cancel and
replacement claims as well as original submissions. Cancel claims
are claims that should not have been billed or where key claim
information such as the billing provider or patient name were
submitted incorrectly. Replacement claims are sent when data
submitted on the original claim was incorrect or incomplete.
Effective on and after May 1, 2010, EPNI will no longer accept
adjustment requests via paper or through provider web self-service
at providerhub.com. Providers will be required to adhere to the
State of Minnesota Uniform Companion Guide requirements and
the Administrative Uniformity Committee (AUC) Best Practices
for replacement claims. Additionally, as of May 1, 2010, provider
services will no longer accept requests to change data elements
within a claim as these should be sent electronically as
replacement claims. Provider services will still accept requests to
adjust claims in situations where the claim processed incorrectly
even though correct information was provided on the original
submission.
Exceptions
Exceptions to this electronic replacement claims enforcement are
as follows:
6-40

Dental formatted adjustment requests will still be accepted if
received on paper.

Pharmacy formatted adjustment requests will still be accepted
if received on paper.

Nonparticipating providers that are located in counties that
border Minnesota are exempt from the statute; therefore, paper
claims will still be accepted from these providers.

Adjustment requests received from the Veterans
Administration (VA) and Indian Health Services.
Claims Filing
Cancel/Void and
Replacement Claims
(continued)
Additional Information
If Provider is unable to send electronic replacement and/or cancel
claims, EPNI has secured the services of Availity to provide a free
web-based service for provider data entry of claims. To learn more
about submitting claims using Availity’s no-cost web-based tool,
go to availity.com.
EPNI has completed system changes to accept and properly
adjudicate electronic cancel and replacement claims.
Following are some of the common questions related to proper
submission requirements. Section A contains general information,
and section B is for specific handling of coordination of benefits
(COB) related scenarios.
Section A – General
Information
1. What is an example of a replacement claim? I have read
the Administrative Uniformity Committee (AUC)
description and would like some clarity on these claims.
A replacement claim, to paraphrase the Minnesota Uniform
Companion Guides for claims, is used to completely replace a
previously submitted claim when data within the claim record
is added, changed or deleted. An example would be a
professional claim sent with all diagnosis pointers set to “1.”
On review by the provider after original payment, it is
determined the second procedure was done in reference to the
third diagnosis on the claim. A replacement claim is sent to
correct the diagnosis pointer on line 2.
See section 4.2.3.2 of the Minnesota Uniform Companion
Guides, version 4.0, dated March 2009, and the related AUC
Replacement/Void Claims Best Practice available on the AUC
website at health.state.mn.us/auc.
2. Can I send a replacement claim if I have the wrong
subscriber ID on the previous submission?
No. According to the AUC Replacement/Void Claims Best
Practice, “When identifying elements change, a void
submission is required to eliminate the previously submitted
claim.” Changes to identifying information related to the
billing provider, patient, payer, subscriber or statement covers
period dates, require that a cancel claim transaction be
submitted for the original claim and that a new claim with the
corrected information be submitted to the payer. These
requirements are similar to the Centers for Medicare and
Medicaid Services (CMS) requirements.
6-41
Claims Filing
Section A- General
Information
(continued)
3. Can I send an attachment on a replacement claim?
Yes, if it is relevant to the changes being made on the
replacement claim or needed to support a particular coding
change. For example, the addition of a 59 modifier to indicate
that the service being billed is a distinct procedure or service
will require supporting medical documentation to be submitted
with the replacement claim.
4. If EPNI denied my claim because the date of injury was
required but not submitted in the claim, can I send an AUC
Appeal Request Form to have the claim reconsidered and
list the requested date of injury in the Reason for Appeal
section?
No. Provider must submit a replacement claim with the
corrected data (injury date) in the 837 transaction.
5. What is an appeal?
The Minnesota Uniform Companion Guides, version 4.0, dated
March 2009, section 4.2.3.2, describe an appeal as “Provider is
requesting a reconsideration of a previously adjudicated claim
but there is no additional or corrected data to be submitted.”
For example, Provider receives a claim denial because EPNI
considered the procedure investigative. Provider's request to
reconsider must be submitted on the AUC Appeal Request
Form along with supporting documentation following the
instructions in the AUC Submission of Appeals Best Practice.
Fax the AUC Appeal Request Form and supporting
documentation to EPNI at (651) 662-2745.
6. What are some examples of reasons for appeals?
The following is a list of reasons to send an appeal, according
to the Minnesota Uniform Companion Guide(s) for Claims:
6-42

timely filing denial

payer allowance

incorrect benefit applied

eligibility issues

benefit accumulation errors

medical policy/Medical Necessity
Claims Filing
Section A- General
Information
(continued)
7. All of the claim information was submitted correctly;
however, it appears not all claim data I sent was recognized
by the system. Is it acceptable for me to call EPNI to simply
have my claim adjusted using what was previously
submitted or do I need to appeal?
It is acceptable for Provider to request the claim be adjusted to
recognize the data within the submission through a phone call
to provider services. It would also be acceptable for Provider to
submit its request using the AUC Appeal Request Form.
8. I am sending documentation in response to a request for
additional documentation from EPNI. Do I need to send a
replacement claim with the attached medical records?
If Provider is responding to an information request letter sent
by EPNI, regardless of whether Provider has also received a
denial on its remittance, Provider should submit the requested
information, along with a copy of the information request
letter. Do not send an AUC Appeal Request Form. These same
instructions are included on the letter that Provider receives.
9. I am sending documentation in response to a denial on my
remittance advice from EPNI. Do I need to send a
replacement claim with the supporting information
needed?
If Provider is sending the additional documentation as a result
of a denial on a remittance advice only, and not in response to
an information request letter from EPNI, and the claim requires
changes to claim data elements (such as date of injury,
procedure code changes, diagnosis code changes, etc.), then a
replacement claim must be sent which includes any necessary
attachments.
If Provider is sending the additional documentation as a result
of a denial on a remittance advice only and the claim does not
require changes to claim data elements Provider also may send
a replacement claim.
If Provider is are sending additional documentation because
Provider believes it did not receive correct payment and this
documentation supports its position, Provider must send the
AUC Appeal Request Form along with the documentation to
support its request.
6-43
Claims Filing
Section B – COB
Related Scenarios
Q&A
How do I send COB information when it was not included with
the previous submission?

Scenario 1
If Provider has received a HIPAA compliant remittance
advice (835) and its system has the capability to populate
the information within a secondary claim, or the
submission date is after December 15, 2009, Provider must
submit a replacement claim with the data appropriately
entered within the claim record.

Scenario 2
If Provider has received a HIPAA compliant remittance
advice (835) from a prior payer and its system is not
capable of populating the information within the HIPAA
secondary claim transaction (837) before December 15,
2009, Provider may send a replacement claim with the
addition of the PWK segment and send the paper
remittance advice from the previous payer as an
attachment.

Scenario 3
If Provider has not received a HIPAA compliant remittance
advice (835) from the previous payer, Provider may send a
replacement claim transaction with the addition of the
PWK segment and send the paper remittance advice from
the previous payer as an attachment.
Note: After December 15, 2009, all Minnesota group
purchasers must provide a HIPAA and State of
Minnesota compliant remittance advice. Providers are
required by the Minnesota Uniform Companion Guides
(section 4.2.3.5) to submit the previous payment
information electronically using the proper fields within
the claim transactions.
Additional Information
For additional information on these types of claims, please
refer to the Minnesota Uniform Companion Guides and related
Best Practice documentation on the Administrative Uniformity
website at www.health.state.mn.us/auc/guides.htm.
Release of Medical
Records
6-44
The Minnesota Statute that states “consent for the release of
medical records are valid for only one year,” also provides that
consents to release medical records to insurers for purposes of
claims payment do not expire after one year. Since there are
circumstances where such consents are only valid for one year,
providers may wish to update their records on an annual basis.
Claims Filing
Provider Assistance
Requested
Medical Records
Management Process
Improvement
Verify Subscriber
Identity
Providers are reminded that:

Provider Service Agreements state “The provider shall
promptly furnish any additional information EPNI or the Plan
Sponsor shall reasonably request as necessary to respond to
claims.”

HIPAA considers release of such records as required for
“business operations.”

ARIs are required under Minnesota law.

Providers gather information from patients on an annual basis
to facilitate timely processing of claims.
EPNI is improving its medical records management process to
better serve providers.

Reduced requests- Changes to the EPNI internal medical
records procedures will eliminate unnecessary medical record
requests.

Clearer instructions- A form will accompany all medical record
requests to facilitate claims processing.
EPNI has received a number of calls from its Subscribers who
have stated that they did not receive certain Health Services that
were billed under their Subscriber identification number.
Upon comparing consent for treatment forms with signatures on
file it appears that such Health Services were provided to an
imposter.
In order to prevent this occurrence, providers are requested to take
appropriate steps to verify Subscribers' identity, such as viewing a
government issued identification card and an EPNI member ID
card at each encounter.
If Provider suspects fraudulent use of a member ID card, please
call EPNI's fraud hotline at (651) 662-8363. Callers may remain
anonymous.
6-45
Claims Filing
Verify Subscriber
Eligibility
Effective January 15, 2009, Minnesota Statute 62J.536 required
health care providers and group purchasers (payers, plans) to
exchange eligibility electronically using a standard format. The
intent of the law is to reduce costs, simplify and speed up health
care transactions, and give providers and health plans one set of
rules to follow for electronic transactions. This statute applies to
all health care providers that request benefit or eligibility
information regardless of participating status.
Rules for Checking Eligibility and Benefits
According to the Minnesota Department of Health, the compliant
modes for initial eligibility inquiries and responses are either via
provider hub or submission of the Eligibility Inquiry and Response
Electronic Transaction (ANSI ASC X12 270/271). If, after an
initial compliant exchange (via web or EDI), additional
information or review is needed, Provider may place a phone call
to a service representative.
The Minnesota Administrative Uniformity Committee (AUC) has
published a best practice related to checking eligibility and
benefits for Subscribers. The best practice covers four major areas:

When and how to verify

Preferred methods of eligibility inquiry

Sharing eligibility information

Data elements that should be used to update information
systems
The recommendation of the AUC is that eligibility be checked
for each patient once per calendar month since most eligibility
changes occur at the beginning of a month. Please refer to the
best practice at the following link for other helpful tips.
www.health.state.mn.us/auc/bstprac01.pdf.
Questions?
If Provider wants to register to receive the electronic eligibility
(270/271) transaction, contact Availity at availity.com.
Provider can also use the provider web self-service site to check
eligibility and benefits. To apply, go to the Welcome page on
providerhub.com. Click on the link “Want access to this online
service for your office?”
6-46
Claims Filing
Basic Character Set
The AUC has published a best practice regarding utilization of the
Values in the Electronic basic character set values within the transaction data.
Transaction
The basic character set includes some punctuation characters and
spaces. These values when used unnecessarily can cause issues
with matching to the payers’ enrollment for the provider or the
Subscriber; or may cause the data to be incorrectly
extracted/interpreted within the payers’ applications.
If any of the punctuation characters within the basic character set
are used as delimiters then they cannot be used in the transmitted
data within a data element.
Punctuation and spaces should only be utilized within the elements
when they add value to the data. They should not be used when
their usage is not essential to the interpretation of the data content.
Basic character set: uppercase letters (A-Z), numeric digits (0-9),
space ( ), exclamation point (!), double quote (“), single quote (‘),
ampersand (&), right parenthesis, left parenthesis, asterisk (*),
period (.), plus sign (+), comma (,), hyphen (-), forward slash (/),
colon (:), semi-colon (;), question mark (?), and equals sign (=).
Even though the “@” character is in the extended character set it is
allowed for email addresses within the PER segment. This
character must not be used as a delimiter.
Examples to illustrate best practice:
Description
Incorrect Examples
Correct Example
Name Titles (no
period should be
used)
JR.
JR
MR.
MR
PhD.
PHD
M.D.
MD
Address – no
periods should be
used as part of the
address
P.O.
PO
AVE.
AVE
Commas and
periods should be
used at the end of a
sentence in a text
field to separate
from another
sentence within the
text field.
A PERIOD
WITHIN A
SENTENCE MAY
HAVE VALUE
DESCRIPTION OF
SERVICE IS ABC
A PERIOD
WITHIN A
SENTENCE MAY
HAVE VALUE.
DESCRIPTION OF
SERVICE IS ABC.
6-47
Claims Filing
Description
Basic Character Set
Values in the Electronic
Transaction
(continued)
Hyphens and
apostrophes should
not be used within a
last name field
Leading and trailing
spaces within fields
should not be used
Claim Service Dates
Restricted to Same
Calendar Month
Incorrect Examples
Correct Example
SMITH-JONES
SMITHJONES
O’BRIEN
OBRIEN
Rendering
practitioner last
name = “_JONES”
or “JONES_”
Rendering
practitioner last
name = “JONES”
The AUC has published a best practice regarding claim service
dates in the same calendar month. The purpose of this best practice
is to avoid split claims and rejections. Most eligibility changes
occur at the beginning or end of a calendar month. Some payer
systems require claims contain only services that are associated
with a particular eligibility period. Current practice is to split these
claims at the payer site to push through systems or to reject the
claim.
On a professional claim, service date spans should only be within
the same calendar month. Multiple claims may be submitted for
different dates within the same calendar month based on the
provider’s billing practices.
On an institutional outpatient claim, statement and service date
spans should only be within the same calendar month.
Observation, extended recovery and emergency department
services beginning before and completing after midnight are
exceptions to this best practice if performed during the same visit.
Procedures beginning on one day and ending on another should be
billed together.
This best practice does not apply to an institutional inpatient claim.
Pharmaceuticals should be billed with the administration/dispensed
date rather than a span of dates.
Monthly equipment rental should be billed with the start date of
the rental period only rather than the span of days.
Equipment rented on other than monthly basis needs both from and
through dates. Units of service should be reported as one (1) per
rental period. These service date spans should only be within the
same calendar month. Example would be daily rental of
equipment.
6-48
Claims Filing
Claim service dates
Restricted to Same
Calendar Month
(continued)
Supplies should be billed with the purchase date rather than the
span of days.
Refer to Appendix A of the MN Uniform Companion Guides for
additional guidance on service date coding.
Examples to illustrate best practice:
Example 1 (equipment rental single month):
Equipment is rented for January 17 through February 16. Service
date should be reported as January 17 with no end date.
DTP*472*D8*20080117~
Example 2 (equipment rental multiple months):
Equipment is rented for March 3 through May 15. Should be
submitted as three separate claims, claim one would be reported as
March 3 with no end date; claim two would be reported as April 3
with no end date; claim three would be reported as May 3 with no
end date.
DTP*472*D8*20080303~
DTP*472*D8*20080403~
DTP*472*D8*20080503~
Reporting MNCare and
Sales Tax
Instructions for MNCare tax billing only apply if the provider bills
the group purchaser for MNCare tax. Some providers do not bill
the group purchaser for MNCare tax. This document DOES NOT
require them to do so but if they do identify the tax it must be done
as follows. Some group purchasers may not reimburse MNCare tax
unless it is identified in the AMT. Sales tax instructions for
professional claims are as follows:

MNCare tax must be reported as part of the line item charge
and reported in the corresponding AMT tax segment on the
lines.
Sales tax must be reported using HCPCS code S9999 for the tax
and must be billed on the same claim as the related taxable service.
6-49
Claims Filing
Rural Health Clinics and Federally Qualified Health
Centers
Billing for Medicare
Primary
Rural Health Clinics (RHC) and Federally Qualified Health
Centers (FQHC) are Medicare provider designations. Medicare
requires RHCs and FQHCs to bill services on a UB-04 claim form.
Since billing as a RHC or FQHC would be secondary to Medicare,
we will only accept these clinic claims on the UB-04 (or 837I).
The claim should be submitted following Medicare billing
requirements (e.g., TOB 071X and revenue code 0521 for a clinic
visit to a RHC).
Billing Other Than
Medicare Primary
6-50
If Medicare is not primary, services must be billed as a clinic, not
as a RHC/FQHC, under Provider's EPNI clinic provider number or
NPI and submitted as a professional claim 837P (1500 HICF,
CMS-1500).
Claims Filing
Coordination of Benefits (COB)
Overview
Third-party payers rely on Coordination of Benefits (COB) to
eliminate duplicate payments when a Subscriber has more than one
coverage for Health Services. Please complete the information
under ‘‘other coverage’’ on claims for EPNI Subscribers. List the
names of any other carriers and the Subscriber's ID number, if
possible. EPNI determines which carrier is primary payer and
ensures that duplicate payments are not made for the same
services.
Primacy Determination
EPNI follows the National Association of Insurance
Commissioners (NAIC) rules to identify the primary insurance
carrier.
6-51
Claims Filing
Coordination of Benefits Types. There are seven types of coordinating benefits that are outlined
below. The only way to determine what type of COB a Subscriber has is to contact provider
services.
All seven types follow these first 3 steps:
1. The primary carrier pays appropriate benefits under its contract.
2. The claim is submitted to the secondary plan's carrier.
3. The secondary plan will never pay more than it would pay in the absence of coordination.
COB Type 1 and 2
(Standard Coordination)
COB Type 3 (Benefits less
Other Insurance Benefits)
COB Type 4 (only with
Medicare)
4. The secondary plan pays
the difference between the
higher allowed amount and
what the primary plan paid.
4. The secondary plan
processes up to the secondary
plan's allowed amount. The
secondary plan subtracts the
amount the primary plan paid
from the amount it would
have paid without
coordination.
4. The secondary plan's
allowed amount is determined
by subtracting Medicare's paid
from Medicare's allowed.
5. The combined payment of
the primary and secondary
plans will not exceed the total
incurred expenses.
5. If the primary plan paid less 5. That amount is reduced by
than what the secondary plan
the any applicable deductibles
would have paid without
and coinsurance.
coordination, the secondary
plan pays the difference.
6. If the primary plan paid
more than what the secondary
plan would have paid without
coordination, the secondary
plan pays nothing.
(Integration)
incurred expenses.
incurred expenses.
6-52
Claims Filing
COB Type 1 and 2
(Standard Coordination)
COB Type 3 (Benefits less
Other Insurance Benefits)
COB Type 4 (only with
Medicare)
The result:
The result:
The result:
The Subscriber would not be
responsible for payment of a
portion of his or her eligible
medical expenses.
The Subscriber is responsible
for any applicable deductible
or coinsurance amounts for
eligible medical expenses
under both plans.
The Subscriber may be
responsible for a portion of
his or her eligible medical
expenses.
Note: When coordinating benefits with Medicare all COB Types coordinate up to Medicare's
allowed amount when the provider accepts assignment and the provider is located within
the state of Minnesota. The federal Medicare Secondary Payer (MSP) law dictates when
Medicare pays secondary.
When coordinating benefits with another commercial carrier all COB types coordinate
up to the higher allowed amount between the two plans except when integration is
involved. Integration will coordinate up to EPNI’s allowed amount.
It is important that all charges submitted to the primary payer be submitted to the
secondary payer, even though charges were paid in full.
Workers’
Compensation
In cases where an illness or injury is employment-related,
Workers’ Compensation is primary. If notification is received that
the Workers’ Compensation carrier has denied the claim, Provider
should submit the claim to EPNI regardless of whether the case is
being disputed. It is also helpful to send the other carrier’s denial
statement with the claim.
No-fault Auto
The No-fault Automobile Insurance Act calls for automobile
insurance coverage to be primary without regard to cause or fault
for the accident. The health insurance carrier would be the
secondary payer. If notification is received that the no-fault auto
carrier has denied the claim, Provider should submit the claim to
EPNI regardless of whether the case is being disputed. It is also
helpful to send the other carrier’s denial statement with the claim.
Subrogation
Subrogation literally means the substitution of one person for
another. It is the right to recover payments for a Subscriber whose
personal injuries are caused by the negligence or wrongdoing of
another. Minnesota does not have specific statutes or laws that
apply to subrogation. Some group health care coverage plans do
have subrogation in their certificates or contracts.
6-53
Claims Filing
TEFRA
The 1982 Tax Equity and Fiscal Responsibility Act (TEFRA)
applies to employers with 20 or more employees. Under TEFRA,
group health coverage becomes the primary payer and Medicare
the secondary payer for active employees between ages 65 and 70.
TEFRA applies to active employees from the first day of the
month of their 65th birthday to the first day of the month following
their 70th birthday.
DEFRA
Effective January 1, 1985, the Deficit Reduction Act (DEFRA)
expands the TEFRA aged workers’ guidelines to include
dependent spouses (ages 65 to 70) of actively employed workers
under 70.
COBRA
On April 7, 1986, the Consolidated Omnibus Budget
Reconciliation Act (COBRA) amended the Working Aged
Provision to eliminate the age 69 limit. Medicare will no longer
become primary payer when an employed person turns age 70 or
the spouse of an employed person turns 70. The group remains
primary payer until the employee retires.
OBRA
The Omnibus Budget Reconciliation Act (OBRA) of 1986
introduces the term ‘‘active individual’’ and defines it as the
employee, the employer, or individual associated with the
employer in a business or family relationship. Medicare will now
be the secondary payer for disabled Medicare beneficiaries who
elect to be covered by an employer-based group health plan, either
as current employees or family of such employees. The minimum
number of employees under this provision is set at 100. The
employer’s insurance pays primary.
6-54
Claims Filing
Non-Physician Health Care Providers
Introduction
EPNI and its affiliates will pay for reasonable and necessary
Health Services performed by certain non-physician Health Care
Providers. Eligible Health Services are determined by the Health
Care Provider’s scope of practice and the Subscriber's Contract.
Eligibility Criteria
Below is the eligibility criteria for non-physician Health Care
Providers:
Definitions

Non-physician Health Care Practitioners must meet applicable
state or federal laws or licensing standards.

When collaboration is required, non-physician Health Care
Providers in independent practice must work in collaboration
with a physician licensed in the state where the Health Services
take place.

A non-physician Health Care Provider not eligible as an
independent contractor must be an employee of a physician or
limited-license practitioner (such as chiropractor or
optometrist) licensed in the state where the Health Services
took place. The employing provider must be legally and
medically responsible for the supervised employee’s services.

Eligible non-physician Health Care Providers must apply for
and meet EPNI credentialing criteria.

Credentialed practitioners must use the EPNI individual
provider number or NPI when submitting Health Services.

Services rendered by supervised employees who are not issued
individual provider numbers must be submitted under the
supervising physician’s provider number or NPI. The -U7
modifier should be appended to the HCPCS code to indicate a
non-physician Health Care Providers rendered the Health
Service.

Health Services rendered must be eligible under the Provider
Service Agreement and Subscriber Contract and the Health
Care Provider’s scope of practice.

A countersignature of notes and orders by the employing or
supervising physician is required if the non-physician Health
Care Provider’s licensure and/or scope of practice requires a
signature.
Centers for Medicare and Medicaid Services (CMS) guidelines are
the basis for the following definitions. For added clarification,
EPNI has further defined supervision as either direct or general.
6-55
Claims Filing
Employment
As defined by CMS, the non-physician performing an “incidentto” service may be a part-time, full-time or leased employee of the
supervising physician group practice or the legal entity that
employs the supervising physician. A leased employee is a nonphysician working under a written employee leasing agreement,
which provides that:

The non-physician, although employed by the leasing
company, provides services as the leased employee of the
physician or other entity; and

The physician or other entity has control over all actions taken
by the leased employee with regard to medical services
rendered to the same extent that the physician or other entity
would have such control if the leased employee were directly
employed by the physician or other entity.
To satisfy the employment requirement, the non-physician must be
considered an employee of the supervising physician or other
entity under the common law test of an employer/employee
relationship.
Services provided by auxiliary personnel not employed by the
physician, physician group practice, or other legal entity are not
covered as incident to a physician’s service.
Incident to
“Incident to” physician’s professional services means that the
Health Services or supplies are furnished as an integral, although
incidental, part of the physician’s personal professional services in
the course of diagnosis or treatment or an injury or illness.

The Health Care Provider’s service must be furnished as an
integral part of the physician’s personal professional service in
the course of diagnosis or treatment of an illness or injury.

An employee of the physician must render service under the
physician’s direct supervision.

The physician must perform the initial and subsequent service
with a frequency that reflects his/her active participation in
managing the course of treatment.
Health Care Providers who are issued individual provider numbers
are considered incident to the physician when performing services
within the same encounter on the same day as the physician.
Incident to services are applicable in the office place of service
only.
6-56
Claims Filing
Direct Supervision
The physician must be present in the office suite and immediately
available to assist and direct throughout the performance of the
Health Service. Direct personal supervision does not mean that the
physician must be present in the same room with the non-physician
practitioner. A physician cannot provide direct or personal
supervision via telemedicine. Direct Supervision is only applicable
in the office place of service.
General Supervision
General supervision refers to Health Services furnished under the
physician’s overall direction and supervision. The physician does
not have to be physically present in the same office suite. He or
she may provide general supervision by periodic review of the
non-physician’s practice and availability either in person or
through electronic communications (telemedicine, telephone, etc.).
Collaboration/
Independent Practice
Certain Health Care Providers are qualified to set up their own
practice. Although these practitioners work independently and do
not require physician supervision, they must work with or
collaborate with a physician. For example, a physical therapist
may perform therapy independently; however, the patient’s
physician makes the initial determination that the patient requires
or will benefit from physical therapy. The physical therapist works
in collaboration with the physician.
Chiropractic Doctors
and Multidisciplinary
Clinics
Chiropractic doctors must maintain a separate Provider Service
Agreement and provider number when practicing in a
multidisciplinary clinic setting with medical doctors. EPNI does
not allow chiropractors to bill services as “incident to” a
physician’s services. Services performed by a chiropractor must
bill under the chiropractor’s own provider number.
The assignment of a chiropractic provider number is fundamental
to the appropriate processing of EPNI Subscriber Contracts and
Provider Service Agreements. It allows EPNI to identify the
specialty of the individual providing the services. This is especially
important to enable EPNI to correctly administer those Subscriber
Contracts that have visit limitations, exclusions and other benefit
variances.
A multidisciplinary clinic with medical and chiropractic doctors
must adhere to this requirement that independently licensed
chiropractors must maintain a separate Provider Service
Agreement with EPNI and bill appropriately. There are no
exceptions to this policy. Any deviation from this billing
requirement is a violation of the Provider Service Agreement.
6-57
Claims Filing
Surgical Technicians
Surgical technicians are considered to be hospital-based
practitioners and as such cannot have an independent relationship
with EPNI nor can their services be billed under a supervising
physician’s individual provider number. Surgical technicians are
members of the operating team that prepare the patient and the
operating room for surgery, transport patients, observe vital signs
and check charts during surgery.
Mid-level Practitioners
EPNI is clarifying the definition of mid-level practitioners based
on practitioner specialties. The practitioner's specialty is
established based on their current state license and is appropriately
determined during the credentialing process.
The following is a comprehensive current list of mid-level
practitioners:
Mid-Level Reduction
Exemption
6-58

Adult nurse practitioner

Certified nurse midwife

Clinical nurse specialist

Family nurse practitioner

Gerontological nurse practitioner

Licensed practical nurse

Neonatal nurse

OB/GYN nurse practitioner

Optician

Pediatric nurse practitioner

Physician assistant

Public health agency/nurse

Registered nurse first assistant

School nurse practitioner
Retail Health providers and online care providers are exempt from
the mid-level reduction as defined in the provider contract.
Chapter 7
Reimbursement / Reconciliation
Table of Contents
Reimbursement .......................................................................................................................... 7-2
Payment Methodology ........................................................................................................... 7-2
Direct Payment....................................................................................................................... 7-7
Electronic Funds Transfer ...................................................................................................... 7-7
CPIU Payment Increase ......................................................................................................... 7-8
Inpatient Claims Paid at DRG Rates ...................................................................................... 7-8
Complication and Co-Morbidity Defined .............................................................................. 7-9
Serious Preventable Medical Errors....................................................................................... 7-9
Replacement of Medical Devices ........................................................................................ 7-10
Overpayments ...................................................................................................................... 7-10
Settlement for Hospitals ....................................................................................................... 7-11
Remittance Advice ................................................................................................................... 7-13
Introduction .......................................................................................................................... 7-13
Sample Statement of Provider Claims Paid ......................................................................... 7-13
2006 Remittance Advice Change......................................................................................... 7-13
ANSI Codes ......................................................................................................................... 7-13
Questions and Answers ........................................................................................................ 7-14
Remit Balancing Tips .......................................................................................................... 7-18
Provider Remittance Reconciliation Report ......................................................................... 7-19
Introduction .......................................................................................................................... 7-19
Provider Remittance Reconciliation Report ........................................................................ 7-20
Field Description .................................................................................................................. 7-21
7-1
Reimbursement
Payment Methodology
Additional information regarding payment methodology is
available in the Provider Service Agreement.
Definitions:
"All Patient Refined DRGs" (APR-DRG)" means the 3M™
classification system that forms a clinically coherent set of severity
of illness and risk of mortality adjusted patient groups, designed to
describe the complete cross-section of patients seen in acute care
hospitals. See Attachment A – APR-DRG Rate Table, if
applicable, of the Provider Service Agreement for the then-current
APR-DRG version number.
“Allied Case” (for child caring institutions, group homes, and
residential primary treatment centers) means a single Subscriber
inpatient admission to the Provider, including any readmissions on
the day of, or day subsequent to, discharge.
"APR-DRG Base Rate" means the negotiated dollar rate per
Relative Weight of One (1.0) indicated in the Provider Service
Agreement used to calculate the APR-DRG Case Rate for a given
APR-DRG category.
"APR-DRG Case Rate" means the total amount paid for an
Inpatient Case which is reimbursed using an APR-DRG and is
either calculated by multiplying the APR-DRG Base Rate by the
APR-DRG Relative Weight, or where an allowed amount has been
specified for an APR-DRG, as specified in the Attachment A-Rate
Table of the Provider Service Agreement. The APR-DRG Case
Rate includes EPNI’s payment and amounts due from all other
parties and will not exceed Provider's allowed regular billed
charges.
"APR-DRG Outlier Threshold" means the network wide Outlier
cost threshold established for each APR-DRG.
When the Case Cost for the APR-DRG exceeds the APR-DRG
Outlier Threshold, additional reimbursement may be realized in
addition to the calculated case payment. An example of
calculating an additional payment for an Outlier Case is as follows:
Case Cost: facility charge ($124,968) x facility applicable RCC
(0.29) = Case Cost ($36,241).
Outlier Payment: Case Cost ($36,241) – Outlier Cost Threshold
($21,256) = Outlier Payment ($14,985).
7-2
Payment Methodology
(continued)
APR-DRG Case Rate: Case Weight (3.0654) x Facility Base Rate
($13,905) = APR-DRG Case Rate ($42,624).
Final Outlier Case Payment: APR-DRG Case Rate ($42,624) +
Outlier Payment ($14,985) = Total Outlier Case Payment
($57,609).
"APR-DRG Relative Weight" means the weight assigned to a
specific APR-DRG which is intended to reflect the relative
resource consumption related to the procedures and/or diagnoses
associated with that APR-DRG. The relative weight assigned to
each APR-DRG is calculated by EPNI, and assigned a version
number. See Attachment A-Rate Table of the Provider Service
Agreement, if applicable, for the then-current EPNI version
number.
"Enhanced Ambulatory Patient Groups" (EAPG) means the 3M™
visit-based patient classification and payment system for
ambulatory care and Health Services used to organize and pay
Outpatient Health Services with similar resource consumption
across multiple settings. See Attachment A-EAPG Rate Table of
the Provider Service Agreement if applicable for the then-current
patient classification version number.
“EAPG Ancillary Packaging” means lower level ancillary services
are packaged and not considered for additional reimbursement.
"EAPG Base Rate" means the negotiated dollar rate per Relative
Weight of One (1.0) indicated in the Provider Service Agreement,
if applicable.
"EAPG Multiple Services Discounting” means a reduction in
payment rate for multiple significant procedures, tests or therapies
performed on the same day, repeat ancillary EAPGs, bilateral
procedures and terminated procedures.
"EAPG Relative Weight" means weight assigned to a specific
EAPG which is intended to reflect the relative resource
consumption related to the procedures and/or diagnoses associated
with that EAPG. The Relative Weight assigned to each EAPG is
calculated by EPNI, and assigned a version number. See
Attachment A-Rate Table of the Provider Service Agreement, if
applicable, for the then-current EPNI version.
“Interim Billing” Claims submitted with a patient discharge status
code of 30 (still a patient or expected to return for outpatient
Health Services) will be reimbursed according to the facility's
interim billing payment percentage as indicated in Attachment ARate Table of the Provider Service Agreement.
7-3
Payment Methodology
(continued)
“MS-DRG” means the then current version (as set forth on
Attachment A Rate Table of the Provider Service Agreement) of a
Diagnostic Related Group as defined and published by the Centers
for Medicare and Medicaid Services (CMS).
“MS-DRG Base Rate” means the negotiated dollar rate per
Relative Weight of One (1.0) indicated the Provider Service
Agreement used to calculate the DRG Case Rate for a given DRG
category.
“MS-DRG Relative Weight” means the weight assigned to a
specific DRG which is intended to reflect the relative resource
consumption related to the procedures and/or diagnoses associated
with that DRG. The Relative Weight, diagnoses and procedures
assigned to each DRG are calculated by CMS, and assigned a
version number. See Attachment A Rate Table of the Provider
Service Agreement, if applicable, for the then current CMS version
number being applied.
“Major Diagnostic Category” or “MDC” means a clinically
coherent grouping of ICD9-CM diagnoses by major organ system
or etiology that is used in the first step in assignment of DRGs.
"Medical Outpatient Visit" (ambulatory surgery centers, hospital
emergency departments and outpatient clinics) means all
outpatient Health Services rendered within a single encounter or
visit. If multiple outpatient Health Services are performed and
submitted on a single claim with the same service date, it will be
considered as one Medical Outpatient Visit. Claims with multiple
dates of service will split into multiple Medical Outpatient Visits
with the exception of emergency department, recovery and direct
admit for observation claims. All claims must be submitted in
accordance with Claims Submission Guidelines.
“Negotiated Outpatient Payment Categories” means all those
specific categories of Health Services described in Attachment BDefinition of Outpatient Health Service Categories, if applicable,
and identified on Attachment A-Rate Table.
“Negotiated Payment Per Day” means the dollar amount agreed
upon by EPNI and the Provider as payment in full for each covered
day per inpatient category, if applicable, of Health Services
indicated on the Attachment A-Rate Table. The Negotiated
payment per day rate includes EPNI’s payment and amounts due
from all other parties and will not exceed Provider’s allowed
regular billed charges.
7-4
Payment Methodology
(continued)
"Negotiated Payment Per EAPG Visit" means the dollar amounts
used to determine EPNI's total liability for all Outpatient Health
Services as indicated in Attachment A-Rate Table, if applicable.
These payments include EPNI payment and all amounts due from
all other parties and will not exceed Provider's allowed Regular
Billed Charges.
“Negotiated Percent of Charge” means the percent of charge
amount indicated in the Provider Service Agreement.
“Non-APR-DRG or Non- EAPG Pricing” means for services and
procedures not reimbursed using APR-DRG or EAPG
methodology, reimbursement will be the then current standard
EPNI Open Access Preferred network reimbursement with no
further decrease applied.
“Ratio of Cost to Charge” (RCC) means the ratio of Provider’s
cost (total expenses exclusive of bad debt) to its charges (gross
patient and other operating revenue) as determined by the
Provider's Medicare Cost Report.
“Ungroupable DRG” means a DRG to which has assigned a
Relative Weight of Zero (0).
“Case” Definitions:
1. “EAPG Case Rate” means the total amount paid for an
Outpatient Case which is reimbursed using an EAPG and is
either calculated by multiplying the EAPG Base Rate by the
EAPG Relative Weight, or where an allowed amount has been
specified for an EAPG, as specified in the Attachment A –
Rate Table of the Provider Service Agreement. The EAPG
Case Rate includes EPNI’s payment and amounts due from all
other parties and will not exceed Provider’s regular billed
charge.
2. “MS-DRG Case Rate” means the total amount paid for an
Inpatient Case which is reimbursed using a DRG and is either
calculated by multiplying the DRG Base Rate by the DRG
Relative Weight, or where an allowed amount has been
specified for a DRG, as specified in the Attachment A Rate
Table to the Provider Service Agreement. The DRG Case Rate
includes EPNI’s payment and amounts due from all other
parties and will not exceed Provider’s allowed regular billed
charges.
7-5
Payment Methodology
(continued)
3. “MS-DRG Outpatient Case” (for outpatient acute care
hospital) means all outpatient Health Services rendered within
a single encounter or visit. If multiple outpatient Health
Services are performed and submitted on a single claim, it will
be considered as an Outpatient Case, and will be assigned to a
single category or service, and counted as one encounter for
payment purposes as defined in Attachment B: Definition of
Outpatient Health Service Categories of the Provider Service
Agreement.
4. “MS-DRG Outlier Case” or “MS-DRG Outlier” (for inpatient
hospital outlier services) means a Medically Necessary
Inpatient Case that meets all of the criteria as specified in the
Attachment A Rate Table of the Provider Service Agreement,
if applicable.
5. “MS-DRG Inpatient Case” (for inpatient acute care hospital)
means a single inpatient admission to the Provider, as
described in the applicable Schedule of Payment Plan, attached
to the Provider Service Agreement
6. “Negotiated Per Case Rate” or “Per Case” means the dollar
amounts used to determine EPNI’s total liability for all Health
Services in an outpatient category, if applicable, of Health
Services indicated in Attachment A-Rate Table. These
payments include EPNI payment and all amounts due from all
other parties.
Fee Schedules
A list of applicable fee schedule allowances is available to
Provider upon request of Provider, up to twice annually. Employer
Provider Network, Inc. (EPNI) will not accept retroactive charge
increases from Provider. Payment amounts may be affected by
Provider certification or EPNI credentialing criteria, as detailed in
the Provider Policy & Procedure Manual. If Provider begins billing
for a new Health Service (e.g. newly accepted medical practice,
new technology, new services for practice), Provider agrees to give
EPNI ninety (90) days' advance written notice prior to submitting
claims or billing for any such new Health Service.
Changes to Minnesota Health Care Programs Payment
In the event that CMS or DHS has published rate or methodology
changes, EPNI shall implement such changes within 90 days of the
date that such change is effective or by the first day of the
following calendar quarter after the changes are released,
whichever is later, unless otherwise specified by the state or
federal regulatory agency. Provider shall not request adjustments,
and EPNI shall not adjust any claims paid prior to the effective
date EPNI implements any such changes.
7-6
Direct Payment
EPNI sends claims payments directly to participating providers.
Payments are sent weekly.
Effective December 15, 2009, Minnesota Statute 62J.536 requires
all providers to accept from group purchasers the health care
payment and remittance advice transaction (835). The statute
further allows the use of web-based technology for complying with
the requirements as long as the data content and rules of the
Minnesota Uniform Companion Guides are followed.
Beginning second quarter 2011, EPNI will no longer print and
mail any paper remittances. Providers will also not be able to
obtain a printed copy of the remittance through provider services
except for remittances produced before February 2010. Providers
must register through Availity to receive the electronic 835 or
register for access to the provider portal, provider web self-service
(PWSS) to view its remittance information. Providers can register
for both options. The full on-line view through the portal via
PWSS was available as of September 22, 2010
A nonparticipating provider generally receives neither direct
reimbursement from EPNI nor a copy of the statement for any
Subscriber that has EPNI coverage. Subscribers cannot assign
benefits to providers. EPNI pays the Subscriber directly for
nonparticipating providers.
Electronic Funds
Transfer
EPNI offers Electronic Funds Transfer (EFT). Instead of weekly
checks with remits, Provider can now receive electronic payments
directly into its facility’s checking or savings account. The funds
are securely transferred via the Automated Clearinghouse (ACH)
process.
Electronic payment will streamline Provider's reconciliation
process, eliminate deposit delays due to check handling, and
improve cash flow.
If Provider currently receives an 835 electronic remittance advice
and registers for EFT, paper remittances will be shut-off 60
business days from the 835 go-live date.
The Provider Automatic Payment application is available at
ccstpa.com; click on the Provider tab and then Forms.
7-7
CPIU Payment
Increase
Consumer Price Index" or "CPIU" means the Minneapolis/Saint
Paul Average All Items Consumer Price Index for Urban
Consumers as published by the U.S. Department of Labor, Bureau
of Labor Statistics.) EPNI reserves the right to conduct an audit to
assure that increases to payment have not exceeded the Maximum
Increase. In the event that an increase in Provider's Regular Billed
Charges exceeds the Maximum Increase, payment to Provider
shall be reduced proportionately. Any payments made in excess of
the Maximum Increase shall be subject to the over payment
provisions herein. The method used in determining if the payment
increase from one contract year to the next exceeded the Maximum
Increase will be calculated in aggregate, rather than on a claim-byclaim basis, and will include a case mix adjustment as determined
by EPNI. That calculation will 1) omit any Health Services
provided less than five (5) times during the contract year being
reviewed; and 2) include only Health Services that have been
performed in both the current contract year and prior contract year.
Inpatient Claims Paid
at DRG Rates
EPNI pays inpatient claims at DRG (Diagnosis-related group) rates
for most hospitals. Some rural hospitals may continue to be paid at
a percentage of charge.
About DRGs
The DRG reimbursement methodology has over 500 inpatient
categories of care, which are updated annually by the Centers for
Medicare and Medicaid Services (CMS). DRGs are a way of
categorizing inpatient hospital services by diagnosis groups that
have similar patterns of hospital resource use and similar lengths
of stay. DRG assignment is based on the patient’s principal and
secondary diagnoses, principal and secondary procedure codes,
age, sex and discharge status. Payments are based on the assigned
DRG case weight, multiplied by a base rate (conversion factor)
that EPNI negotiates with hospitals.
Coding Compliance
Coding compliance relates to the accuracy and completeness of the
ICD-9-CM diagnosis and procedure codes that are used to assign
DRGs and determine payment. EPNI requests that hospitals
establish adequate internal procedures to ensure the accuracy of
claims submissions. EPNI reserves the right to conduct random
chart audits on a sample of records to ensure that diagnoses
submitted justify the DRG and adhere to ICD-9-CM coding rules.
Coding errors that are determined to represent a fraudulent claim
may be subject to penalties.
7-8
Complication and
Co-Morbidity Defined
According to St. Anthony Publishing, a “complication” is a
condition that arises during a hospital stay and prolongs the length
of stay by at least one day in approximately 75 percent of the
cases. The same source defines “co-morbidity” as a pre-existing
condition that, because of its presence with a specific diagnosis,
will cause an increase in length of stay by at least one day in
approximately 75 percent of cases. The condition must affect the
patient’s hospital care by requiring one or more of the following:

Clinical evaluation

Therapeutic treatment

Diagnostic studies or procedures

Increased length of stay
 Increased nursing care and/or monitoring
Although there is a standard list of diagnoses that are considered
complications or co-morbidities, if the diagnosis does not require
one or more of the above services, it should not be listed as a
diagnosis. The physician must verify and document the conditions,
based on clinical findings and treatment in the record.
Serious Preventable
Medical Errors
When the negligence, omission, or error on the part of Provider
results in the Subscriber incurring additional medical expenses no
payment will be made by EPNI for, nor shall Provider bill either
EPNI or the Subscriber for said additional medical expenses. The
National Quality Forum has defined certain events as serious
preventable medical errors, and these are the situations for which
no payment shall be made by EPNI or the subscriber.
A listing of these events can be found at www.qualityforum.org.
This listing will be updated periodically by the National Quality
Forum.
Examples of serious preventable errors include:

Unintended retention of a foreign object in a patient after
surgery.

Patient death or serious disability associated with a medication
error (e.g., errors involving the wrong drug, wrong dose, wrong
patient, wrong time, wrong rate, wrong preparation or wrong
route of administration).

Surgery performed on the wrong body part.

Surgery performed on the wrong patient.

Wrong surgical procedure performed on a patient.

Infant discharged to the wrong person.
7-9
Replacement of
Medical Devices
No payment will be made by EPNI and neither EPNI nor the
Subscriber shall be billed for the cost of a replacement device in
excess of the actual cost paid by Provider for the replacement
device. Provider is obligated to submit to EPNI proof of the actual
payment amount made by Provider to the manufacturer or reseller
of the replacement device for such replacement device and is
likewise obligated to advise EPNI of any rebate, retroactive
payment, warranty program payment and/or waiver of payment
received from the device manufacturer or reseller. This applies to,
but is not limited to, devices subject to warranty replacement
programs and/or recalls, whether or not such warranty replacement
programs and/or recalls are due to device failures design defects
and/or defective materials. If a third party such as a medical device
manufacturer or reseller recalls or replaces a device and Provider is
either reimbursed for the cost of the device or is not charged for
the replacement device, no charge for the device will be billed to
EPNI or the Subscriber. Provider shall bill only for the
professional services associated with the replacement procedure;
provided however, that no payment will be made by EPNI, and
Provider shall not bill EPNI or Subscriber for any Health Service
in the event that the Subscriber is held harmless by the
manufacturer and/or other third party for such Health Services
rendered in the removal of a defective device and/or insertion of a
replacement device.
Overpayments
In the event EPNI makes a corrective adjustment EPNI may deduct
any overpayments from future payments owed to Provider together
with an explanation of the credit action taken. EPNI shall be
entitled to use a statistically valid sample when determining
overpayment amounts. EPNI shall have the right to offset against
any amounts due and owing or which become due and owing to
Provider under the Provider Service Agreement, any amount (a)
due and owing or which become due and owing to EPNI and/or
any Affiliate under the Provider Service Agreement and/or (b) that
may have been paid by EPNI and/or its Affiliates to Provider in
error, including without limitation, payments made to Provider for
non-covered Health Services. To the extent EPNI exercises the
foregoing right to offset against claims for Health Services
otherwise properly payable, such claims to which the offset is
applied shall be deemed to be paid by EPNI, and Provider shall not
have the right to balance bill Subscriber for such claim amounts.
7-10
Settlement for
Hospitals
A. Applicable Cases/Settlement Time Frame. Settlements will be
calculated and paid only on cases where EPNI has Primary Coverage
Responsibility. In addition, settlements shall exclude all claims
under network access only arrangements. Unless otherwise specified,
a final settlement will be calculated by EPNI within 180 days after
the applicable term ends, and will include a three-month run-out of
claims data.
B. Payment of Settlement. EPNI shall be under no obligation to
complete any settlements if the Agreement has not been signed by
Provider. Any amounts due to the Provider from EPNI will first be
netted against any outstanding balances due to EPNI from the
Provider. If no outstanding balance is due, EPNI will then pay the
settlement amount to the Provider. If an outstanding balance is due
EPNI, all such payments shall be made within ninety (90) days of
when the settlement is sent by EPNI to Provider, or upon a mutually
agreed upon payment plan. If payment is not received within the
ninety (90) day period or an arrangement for payment has not been
agreed upon, any unpaid amounts due EPNI will be collected in four
(4) weekly amounts by reducing EPNI's future claim payments to the
Provider.
C. Non-Adjudicated Claims. In the event a claim or claim adjustment is
not adjudicated prior to the three-month settlement run-out period, it
will not be included in the settlement unless otherwise agreed to at
EPNI's discretion.
D. Settlement Amounts. Any settlement amounts (either due to or due
from Provider) totaling less than one hundred dollars ($100) in
aggregate (across all EPNI lines of business) may be waived at
EPNI's discretion. Provider agrees not to bill Subscriber for any such
amounts which would otherwise be due from EPNI.
E. Settlement Appeals.
1. The Provider is entitled to one appeal and, if need be, one
secondary appeal. After that, any unresolved issues will be
resolved via a meeting and, if necessary, via the dispute
resolution process described in the Arbitration provision of the
Agreement. Secondary appeals must be submitted with
additional information over and above what was submitted with
the initial appeal.
2. Provider agrees to forward final settlement appeals, if any, to
EPNI within ninety (90) calendar days of Provider's receipt of
the final settlement. In the event of an appeal, the Provider still
must make payment for the full balance due EPNI in
accordance the payment of settlement provision. If such
payment is not timely received by EPNI, any unpaid amounts
due EPNI will be collected in four (4) weekly amounts by
reducing future claim payments to Provider.
7-11
Settlement for
Hospitals
(continued)
7-12
3. EPNI reserves the right to review, and, if necessary, correct the
settlement in its entirety, upon Provider's appeal. EPNI is not
limited to reviewing only appealed items.
4.
Secondary appeals. Provider shall have sixty (60)
calendar days from the date of receipt of EPNI's response
to the original appeal, to submit a secondary appeal for the
same original appeal.
5.
Failure of Provider to appeal or submit a secondary
appeal within the timeframe(s) specified herein; constitute
a waiver of EPNI's obligation to review the appeal or
secondary appeal.
6.
If Provider disputes EPNI's response to a secondary
appeal, the Parties shall meet within 60 days to attempt to
reach agreement on the completion of the final settlement.
Provider shall provide EPNI with the reasons for its
dispute and any needed background documentation prior
to the meeting. Both Parties shall ensure that the
appropriate staff members attend the meeting. The Parties
shall be subject to the dispute resolution process described
in the Arbitration provision of the Agreement if
disagreement remains after the first meeting.
Remittance Advice
Introduction
The remittance advice is mailed or transmitted via an 835
electronic transaction every week. The weekly remittance will
include claims that are processed or adjusted before the end of the
day Friday. Provider will receive a separate remittance for each
NPI and each type of claim (i.e. institutional, professional).
Remember to always keep remittances to meet HIPAA
requirements in a central location for easy retrieval, as they are an
essential resource for business.
Sample Statement of
Provider Claims Paid
A sample of the PDF version of the provider remittance with field
descriptions is available on CCStpa's web site.
2006 Remittance
Advice Change
The Health Care Administrative Simplification Act of 1996
allowed Minnesota health care providers and payers the chance to
implement administrative standards and simplified procedures
throughout the industry. Minnesota Statute 62J.536 further
required payers and providers in Minnesota to develop and
implement a uniform paper Explanation of Benefits (EOB) and
Remittance Advice report (remit). The Minnesota rules prescribe
specific data fields that must appear on the EOB and remit.
ANSI Codes
EPNI will adopt all the conventions addressed in the “Minnesota
Paper Explanation of Benefits and Uniform Paper Remittance
Advice Report” manual developed by the Administrative
Uniformity Committee (AUC) in the PDF version of the
remittance.
A copy of the manual is available on their website at:

http://www.health.state.mn.us/auc/index.html; or
 Minnesota’s Bookstore at (651) 297-3000 or 1-800-657-3706.
The guide sets forth the standard approach to be adopted by payers
and providers.
7-13
1. Where will adjusted claims appear?
They will appear on the Statement of Provider Claims Paid or
835 remittance as noted in the guide.
2. How can I identify adjustments in the statement?
The claim number will be the same as in the original statement,
except the last two digits. For example: If the original claim
ended in 00 the adjusted claim will end in 01. If it needs to be
adjusted again, it will end in 02, etc. On a paper Statement of
Provider Claims Paid, if EPNI then makes additional or
adjusted payment for that claim, the newly processed claim
will be printed above the original claim.
3. How do I use the Accounts Receivable Recoupment Report?
This report is sent out under separate cover from the weekly
remittance and lists the claims that will be recouped that week.
The amount listed on this report will be reflected on the weekly
statement. Remember to keep this report in a central location
for easy retrieval.
4. Do I have to credit the subscriber’s account based on the
Accounts Receivable Recoupment Report?
If Provider has already credited the Subscriber’s account based
on the remittance that reflected the adjustment, then do not
adjust the Subscriber’s account again. This is an internal
workflow for Provider's office. Adjusting the Subscriber’s
account using both the weekly remittance and the Accounts
Receivable Recoupment Report may result in duplication.
7-14
(continued)
5. What if there is a claim on my statement for a Subscriber
that is not ours?
Request an adjustment by contacting provider services. Please
do not return EPNI's payment check or send EPNI a refund
check unless EPNI requests it.
6. What can I bill the Subscriber and how can I identify it on
the statement?
The Patient Responsibility field reflects the total Subscriber
liability. This is the amount that the Subscriber is responsible
to pay. However, Provider may have already billed the
Subscriber for copayments or Subscriber liability amounts up
front.
7. What do I have to write-off and how can I identify so on
the statement?
The group code 'CO' signifies a provider contractual
obligation. Any amounts associated to the use of this code
should be written off.
8. Do Subscribers receive their Explanation of Health Care
Benefits (EOB) at the same time as Providers?
No, the Subscriber’s EOB is mailed daily and Provider’s
remittances are sent or posted weekly. However, EPNI mails
Subscribers’ EOBs monthly if there is zero Subscriber liability
and payment was made to the Provider. If a Subscriber
references a claim that Provider hasn't received notice on yet, it
should be on Provider's next remittance.
7-15
(continued)
9. What does the claim number represent?
The claim number is a sequence of numbers that identifies each
claim. Knowing what the claim number consists of may assist
Provider in better understanding the claim. The information
below describes a claim number.
Example: Claim number 0109361034020
0109= Julian date the claim was entered into EPNI's claims
processing system (i.e., 109th day of 2010).
361034= the sequence number for claims entered on that date
02= The second position reflects if the claim has been adjusted
(i.e., 0= original claim, 1= claim adjusted the first time, 2=
claim adjusted the second time, etc.)
This also may reflect a claim has been split. If a claim is split,
EPNI is unable to process as one claim so EPNI processes it as
two. Two main reasons to split a claim are when benefits have
changed in the middle of the claim or there are too many lines
for EPNI to process it as one claim.
10. How do I request an adjustment or inquiry?
An adjustment should be requested when Provider notices the
adjudication error. Please remember if data on the claim needs
to be changed, Provider must send a complete replacement
claim rather than request an adjustment.
Provider can request an adjustment by:

Submitting a request through provider web self-service.

Fax in the Provider Inquiry fax form to:
(651) 662-2745.

Mail in a request to:
EPNI
P.O. Box 64560
St. Paul, MN 55164-0560
For inquiries:
7-16

Provider Web self-service is found at:
www.providerhub.com

Call provider service at (651) 662-5940 or 1-800-365-2735.
Please wait 30 days before checking the status of a claim or
adjustment.
(continued)
11. What do I do with interest payments?
Interest payments that Provider receives should be posted to a
miscellaneous account. This is money that is Provider's and
should not be posted to the account of the Subscriber it pertains
to. By posting this money to a Subscriber’s account they may
end up with a credit.
12. Are there any limits for making adjustments?
EPNI may make, and Provider may request, corrective claim
adjustments (recoupments or additional payments) to
previously processed claims for Health Services within six
months of the date a claim is paid or denied unless the
adjustment is made for the following circumstances (and thus
are not limited to this six month period):

One or more insurer is involved, whether primary or
secondary (i.e., Medicare secondary payer, no-fault
automobile coverage, subrogation, coordination of benefits,
workers’ compensation, TEFRA, etc.)

The adjustment is required due to provider error (i.e., the
provider should not have billed for services, a claim was a
duplicate of a claim previously paid, fraud, incorrect
billing, etc.)

The adjustment is required pursuant to applicable law,
regulation, rule, order or contractual requirement or

The adjustment is required as part of a contractual
settlement obligation with the provider.
Note: Provider errors or data changes require a replacement
claim or cancel claim be submitted within six months of the
last adjudication date.

Corrective adjustment requests must be received within six
months from the date the claim was last paid or denied by
EPNI.
7-17
Remit Balancing Tips
Amounts reported in the remittance, if present, must balance at
three levels: service line, claim and total remittance.
Service Line Balancing
Although the service payment information is situational, it is
required for all professional claims or anytime payment
adjustments are related to specific lines from the original
submitted claim. When used, the submitted service lines minus the
sum of all monetary adjustments must equal the amount paid for
the service line.

Charge – Adjustment Amount = Payment Amount
Claim Balancing
Balancing must occur at the claim level so that the submitted
charges minus the sum of all monetary adjustments equals the
claim paid amount.

Charge – Adjustment Amount = Claim Payment Amount
Remit Balancing
Within the transaction, the sum of all payments minus the sum of
all adjustments equals the Payment Amount.

7-18
Sum of all Payments totaled – the Sum of all
Adjustments = Total payment amount of this remittance
Provider Remittance Reconciliation Report
Introduction
The Provider Remittance Reconciliation Report lists the amount
credited, amount recovered, and any balance due on claims for
Subscribers. It will only be sent if there are funds to be recovered
that week. All the recouped claims for the week will be listed on
the Provider Remittance Reconciliation Report.
The amount being recovered can also be found at the end of the
Statement of Provider Claims Paid:

The Provider Adjustment Amount field on the Statement of
Provider Claims Paid reflects the amount of money being
recouped that week.

Provider Adjustment Code field on the Statement of Provider
Claims Paid reflects the Adjustment Reason Code WU or FB.
Note: The Adjustment Reason Codes are located in the PLD
segment of the 835 transaction.
The Report is sent out under separate cover from the Statement of
Provider Claims Paid or 835 transaction. Remember to always
keep these reports in a central location for easy retrieval.
7-19
Provider Remittance
Reconciliation Report
7-20
The following is a copy of the Provider Remittance Reconciliation
Report. Field descriptions follow the report.
Field Description
A brief explanation of the fields on the Provider Remittance
Reconciliation Report follows:

Name — Name and address of the billing provider.

Page — Page number of the report.

Remit Date — This date coincides with the Statement of
Provider Claims Paid or 835 transaction. The information
found on this report reflects the activity which occurred on the
Statement of Provider Claims Paid with this same date.

Check/EFT – The check or Electronic Funds Transfer number
associated with the credit, recovery or balance due amount.

Payee ID – The National Provider Identifier or EPNI
contracting provider number assigned by us.

Payee Tax ID - The provider Tax Identification Number.

Tot Paid - The amount that would have been paid for claims
processed on the remittance.

Check Amt – The actual check amount (total paid +/- any
adjustment to the payment.

Mbr ID— Subscriber identification number under which the
overpayment occurred. Patient Name — Name of the patient.

Pat Acct - The patient account number on which the
overpayment occurred.

Claim ID— Number of the claim which was overpaid or paid
in error.

Adj Amt— The amount either adjusted or recouped on the
remittance.

Code – The reason for the recovery (see CODE LEGEND on
the bottom of the report).
7-21
Chapter 8
Appeals
Table of Contents
Provider Appeals........................................................................................................................ 8-2
Introduction............................................................................................................................ 8-2
Prior Authorization and Pre-Admission Notification Appeal Process .................................. 8-2
Appeals of Medical Necessity Determination ....................................................................... 8-3
Appeals of Processed Claims................................................................................................. 8-3
Initial Appeal ......................................................................................................................... 8-3
Voluntary Second Appeal ...................................................................................................... 8-4
Coding Appeals...................................................................................................................... 8-5
Supporting Documentation .................................................................................................... 8-6
Urgent / Expedited Appeals ................................................................................................... 8-7
Standard Appeals (Medical record) ....................................................................................... 8-7
Arbitration.................................................................................................................................. 8-8
Timeline to Commence Arbitration ....................................................................................... 8-8
Venue/Applicable Law .......................................................................................................... 8-8
Process to Invoke Arbitration ................................................................................................ 8-9
Arbitration Expenses/Award.................................................................................................. 8-9
8-1
Appeals
Provider Appeals
Introduction
An appeal is a written request for review.
Appeals require the provider to include with the request
documentation of items such as chart notes, medical records,
operative reports and letters of medical necessity. Appeals present
detailed information in an attempt to change a previous decision
made by EPNI.
To ensure a thorough review, appeals submitted without
appropriate supporting documentation will be returned to Provider.
For information about settlement appeals, refer to the Provider
Service Agreement.
Prior Authorization and
Pre-Admission
Notification Appeal
Process
Provider may appeal a prior authorization request denied as
medically unnecessary within 30 days of notification. Provider’s
request must be in writing and should be addressed to the analyst
who signed the denial letter. An appeal reviewer will review the
case and make a final decision. Please contact the appeal reviewer
who signed the denial letter for any questions about a specific
approval or denial.
When coverage is denied for prior authorization or preadmission
notification based on Medical Necessity, the appeal reviewer
notifies Provider by telephone and/or sends letters to the
Subscriber, hospital, and physician. The physician, Subscriber or
facility may appeal the denial within 30 days of the date of the
denial letter. The appeal may be initiated either by telephone or by
letter.
EPNI’s review is only a Medical Necessity review and is subject to
all other limitations in the Subscriber’s Contract. Services may be
denied because of exclusions, limitations on preexisting
conditions, and Medical Necessity requirements contained in the
Subscriber’s Contract. These contract provisions will prevail over
a Medical Necessity decision. The decision to continue an
inpatient stay or Health Services ultimately rests with the patient
and the physician.
All available information is provided to a physician reviewer who
is board certified in the same or similar general specialty as
typically manages the medical condition or treatment and was not
involved in the original determination.
8-2
Appeals
Appeals of Medical
Necessity
Determination
When a Medical Necessity denial is made, the Provider or
Subscriber has the right to appeal the case. The exact appeals
process will be communicated to Provider in the event of a denial.
Provider may call EPNI to discuss the denial decision with the
physician reviewer. Provider or the Subscriber may also request a
free copy of the guideline that EPNI used to determine Medical
Necessity/appropriateness for a specific denial decision.
Appeals of Processed
Claims
The EPNI provider appeals process has two levels: Initial appeal
and voluntary second appeal.
Situations brought to appeal include the following categories:
•
benefit administration
•
claims processing
•
determinations of allowed amount
•
provider profiles
•
services denied due to lack of preadmission notification or
prior authorization occurring after claim submission
• timely filing denials
This appeal process does not apply to settlement appeals, Medical
Necessity, prior authorization and preadmission denials occurring
prior to claim submission. Adjustment requests and information
return requests are not appeals. As such, they should be sent to
the general EPNI address listed in Chapter 1, At Your Service.
Initial Appeal
Initial Appeals must be requested within 90 days of the date claim
notification is issued. There is no limit on the dollar amount. This
appeal review may be conducted by EPNI appeals staff, medical
review staff, and/or utilization review staff.
Mail initial appeal requests to:
EPNI
Attn: Appeals Department Route S150
P.O. Box 64668
St. Paul, MN 55164-0668
8-3
Appeals
Voluntary Second
Appeal
Voluntary second appeals must be filed within 60 days of the
initial appeal decision. The amount at issue must be $500 or more.
Calculate the amount at issue by subtracting the deductible,
coinsurance and paid amount from the billed charge. For example:
Billed amount
$ 2,000
- (deductible)
500
- (coinsurance)
200
- (paid amount)
500
Amount at issue
$
800
If the amount at issue is $500.00 or more then this appeal review
may be conducted by EPNI appeal staff, medical review staff,
utilization review staff, peer review, or a committee comprised of
medical and non-medical staff.
Claims for the same patient or multiple patients relating to the
same category can be aggregated at this level (Provider may
combine two or more claims to meet the $500.00 amount-incontroversy requirement).
Provider must be able to provide additional information at the
voluntary second appeal level than that which was available at the
Initial Appeal level. Examples of additional information include
RVU studies, and published reports supporting Provider’s position.
Mail voluntary second appeal requests to:
EPNI
Attn: Appeals Department Route W350
P.O. Box 64668
St. Paul, MN 55164-0668
8-4
Appeals
Coding Appeals
EPNI’s coding edits are updated at minimum annually to
incorporate new codes, code definition changes and edit rule
changes. All claims submitted after the implementation date of this
update, regardless of service date, will be processed according to
the updated version.
Where Medicare’s CCI (Correct Coding Initiative) edits are
identical, EPNI will consider the appeal with additional
documentation; however, the issue may be upheld. Adjustments,
and/or request refunds will not be made when processing changes
are a result of new code editing rules due to a software version
update. Notice of this update will be published in a Provider
Bulletin.
EPNI has adopted a standard process to review edit appeals and
providers have the right to appeal with additional information.
Appeals received without additional information will not be
reviewed. The denial will be upheld.
If Provider has a question or appeal about EPNI’s policy regarding
a particular coding combination, provide a written statement of the
concern, along with the following and/or documentation normally
required for a medical review.
•
Written explanation supporting the procedures submitted, i.e.,
specific references, specialty specific criteria.
•
Documentation from a recognized authoritative source that
supports Provider’s position on the procedure codes submitted.
Once received, the inquiry or appeal will be reviewed. The review
may result in approval or denial of the claim, based on review of
the information submitted.
Note: Requests to add modifier -24, -25, or -59 to a denied service
must be submitted as an electronic replacement claim with
supporting documentation.
Appeal requests may be faxed or mailed. Send appeal requests to
the following address:
EPNI
Attn: Appeals Department Route W350
P.O. Box 64668
St. Paul, MN 55164-0668
Fax appeal requests to:
(651) 662-2745
8-5
Appeals
Supporting
Documentation
The two key elements for submitting documentation with appeal
requests are the patient’s name and the date of service. Both should
be included on each page of the documentation submitted.
Additionally, the documentation should correspond with the dates
of service at issue.
When the provider submits the appealed claim, the responsibility
for gathering and submitting documentation that supports the
service rests with the provider. EPNI will offer guidance and
assistance as necessary, but the responsibility for identifying what
is needed and where it is located is the provider’s.
The list below includes common types of claim denials/reductions
which may be submitted for appeal and the sources of
documentation suggested for each type. This information is
presented as a guide, and is not a complete listing.
Supporting
Documentation
(continued)
Type of denial or
reduction
Documentation
Surgical
Complications
Operative report, chart notes, letter
stating rationale for complication
Medical Necessity
Medical records and rationale for service
performed
Investigative
Medical records and rationale for service
performed
Claim Denied for no
PA
Medical records and rationale for services
Cosmetic
Medical records and rationale for services
DRG/Category Code
Rationale for questioning of payment
Private Room
Notes, doctor’s order and letter of
Medical Necessity
Allowed Amount for
unlisted code
Chart notes or invoice, NDC number and
a letter to review allowance for an
unlisted code. This is independent from
Medical Necessity review process.
Note: An invoice is required for DME or
supply allowance appeals.
Allowed Amount – for Chart notes, letter and operative report
modified CPT/HCPCS when applicable to review allowance.
codes.
Allowed Amount –
excluding unlisted
codes.
8-6
Copy of fee schedule or Provider Service
Agreement.
Appeals
Supporting
Documentation
(continued)
Urgent / Expedited
Appeals
Type of denial or
reduction
Documentation
Incompatible
Diagnosis
Letter requesting review of codes that are
denying as incompatible and related notes
Timely Filing
Documentation supporting submission of
a claim after timely filing, such as
secondary coverage, patient expired
during timely filing period, or DME
rental charges that span the timely filing
period.
Coding Edit
All supporting documentation for
corresponding date of service.
An urgent appeal is done when an initial or continued treatment is
dependent on a quick determination. Urgent is defined as medical
care or treatment with respect to which the application of the time
periods for making non-urgent care determinations:
1. Could seriously jeopardize the life or health of the claimant or
the ability of the claimant to regain maximum function,
although it may not rise to the level of being a life threatening
circumstance, or
2. In the opinion of a physician with knowledge of the claimant’s
medical condition, would subject the claimant to severe pain
that cannot be adequately managed without the care or
treatment that is the subject of the claim.
Urgent appeals are completed within 72 hours of receipt of the
appeal request, or sooner, based on the medical exigencies of the
case. Providers should contact the EPNI clinician who signed the
denial letter to initiate an Urgent Appeal.
Standard Appeals
(Medical record)
A standard or medical record appeal is completed within 60 days
of receipt of medical information. The appeal decision is final
unless new information is provided.
8-7
Appeals
Arbitration
Timeline to Commence
Arbitration
The Parties agree that any disputes or controversies relating to
payment for Health Services shall be commenced no later than two
years from the date of the provision of said Health Services by
Provider (provided that such time limit shall not apply to those
circumstances where claims adjustments are not limited to 12
months, as set forth in the Provider Policy & Procedure Manual).
If the source of a dispute or controversy does not in any respect
involve a payment for a Health Service, then such action must be
commenced within two years of the date on which Provider’s
claim arose. Any action not brought within the time limits set forth
above shall be barred, without regard to any other limitations
period set forth by law or statute.
Venue/Applicable Law
All arbitrations between the Parties shall be venued in
Minneapolis, Minnesota and shall be conducted in accordance with
Minnesota law and, except to the extent inconsistent with
Minnesota law, the Commercial Arbitration Rules of the American
Arbitration Association. If any of the Parties are defendants to a
claim which is not subject to mandatory arbitration, including,
without limitation, claims involving medical malpractice, then that
Party may assert indemnity or contribution claims against any
other Party within the nonarbitrable action.
8-8
Appeals
Process to Invoke
Arbitration
A Party may invoke arbitration by serving written notice on the
other Party. The notice will include a list of arbitrator candidates.
If the Parties agree on one of the arbitrator candidates in the notice,
then the arbitrator will serve as the sole arbitrator of the dispute. If
the Parties do not agree on an arbitrator within fifteen (15)
calendar days after receipt of the notice, the recipient of the notice
will select one arbitrator and the Party providing notice will select
one arbitrator within ten (10) calendar days thereafter and the two
arbitrators so selected will select a third arbitrator within ten (10)
calendar days thereafter. The third arbitrator so selected will be the
sole arbitrator and will conduct the arbitration.
All disputes between the Parties will be separately arbitrated and
will not be joined or combined with the arbitration or other
resolution of disputes between EPNI and any other person(s) or
class of persons, unless expressly agreed to by the Parties in
writing. Not withstanding the above, and except for medical
necessity reviews as detailed in Minnesota statute 62M, the Parties
further agree that any appeals decision involving Medical
Necessity or provider credentialing for which arbitration is pursued
will be overturned or modified only if the arbitrator determines
that the decision of the appeals panel or reviewer was arbitrary and
capricious. Nothing in this mandatory arbitration provision shall
provide a right of arbitration where such rights have been waived
or another review process has been agreed to.
Arbitration
Expenses/Award
Each Party will be responsible for payment of its own attorneys or
other advisors and for its appointed arbitrator. The expenses and
fees of the sole arbitrator and of the arbitration proceeding will be
shared equally by each of the Parties. The Parties will abide by and
perform any award rendered by the arbitrators and a judgment of
the court having jurisdiction in accordance with this Agreement
may be entered on the award.
8-9
Chapter 9
Coding Policies and Guidelines
Table of Contents
Coding ......................................................................................................................................... 9-9
Overview................................................................................................................................ 9-9
HCPCS Codes........................................................................................................................ 9-9
CPT® /Level I ....................................................................................................................... 9-10
Level II HCPCS ................................................................................................................... 9-12
ICD-9-CM............................................................................................................................ 9-14
Revenue Codes..................................................................................................................... 9-15
Compatibility ....................................................................................................................... 9-16
General Guides..................................................................................................................... 9-16
Zero-billing .......................................................................................................................... 9-16
Coding Edits ............................................................................................................................. 9-17
Overview.............................................................................................................................. 9-17
Edit Descriptions.................................................................................................................. 9-18
Mutually Exclusive Procedures ........................................................................................... 9-19
Incidental Procedures........................................................................................................... 9-20
Medical Visits on the Same Day as Surgery........................................................................ 9-21
Global Surgical Package - Pre and Post Operative Services ............................................... 9-22
General Claims Processing Information .............................................................................. 9-23
Medical and Surgical Supplies............................................................................................. 9-23
Multiple Surgery Guidelines................................................................................................ 9-23
Patient Billing Impact .......................................................................................................... 9-23
Coding Appeals.................................................................................................................... 9-24
Helpful Coding Tips ............................................................................................................ 9-24
Coding Immunizations and Injections ................................................................................. 9-25
Copays....................................................................................................................................... 9-26
Office Call Copays............................................................................................................... 9-26
Modifiers................................................................................................................................... 9-27
Modifiers.............................................................................................................................. 9-27
Modifier Guidelines ............................................................................................................. 9-28
Anatomical Modifiers .......................................................................................................... 9-36
Modifiers defined by DHS................................................................................................... 9-37
Anesthesia ................................................................................................................................. 9-41
Overview.............................................................................................................................. 9-41
Full-time Anesthesia Services.............................................................................................. 9-41
Part-time (Medically Directed) Anesthesia Services........................................................... 9-42
9-1
Qualifying Circumstances.................................................................................................... 9-42
Physical Status ..................................................................................................................... 9-42
Qualifying Circumstances and Physical Status Submission................................................ 9-43
Electroconvulsive Treatments.............................................................................................. 9-43
Local Anesthesia.................................................................................................................. 9-43
Medical Services and Invasive Procedures.......................................................................... 9-43
Epidural Anesthesia for a Surgical Procedure ..................................................................... 9-43
Epidural Anesthesia for Pain Management.......................................................................... 9-44
Anesthesia for Nerve Blocks ............................................................................................... 9-44
Daily Management of Epidural Drug Administration ......................................................... 9-44
Epidural Anesthesia for Labor and Delivery ....................................................................... 9-45
Moderate (conscious) Sedation............................................................................................ 9-46
Monitored Anesthesia Care.................................................................................................. 9-46
Patient Controlled Analgesia ............................................................................................... 9-46
Standby ................................................................................................................................ 9-46
Documentation..................................................................................................................... 9-46
Time Designation/Submission ............................................................................................. 9-47
Diagnosis Coding................................................................................................................. 9-47
Multiple Surgery .................................................................................................................. 9-47
Add-on Anesthesia Procedures ............................................................................................ 9-47
Behavioral Health Services for CMS-1500 ............................................................................ 9-48
Overview.............................................................................................................................. 9-48
Practitioners who Should be Using this Section .................................................................. 9-48
Units..................................................................................................................................... 9-48
Coding Restrictions.............................................................................................................. 9-49
Psychiatry and Chemical Dependency Assessments ........................................................... 9-49
Family Therapy.................................................................................................................... 9-50
Medication Management ..................................................................................................... 9-50
Behavioral Health Evaluation & Management (E&M) Office Calls................................... 9-51
Nutritional Counseling......................................................................................................... 9-51
Eligibility of Dieticians / Nutritionists................................................................................. 9-51
Psychological Testing .......................................................................................................... 9-52
Practitioner Key ................................................................................................................... 9-55
Policies................................................................................................................................. 9-56
Marital Counseling............................................................................................................... 9-56
Opiod Maintenance Drug Therapy ...................................................................................... 9-56
Tobacco Cessation ............................................................................................................... 9-57
Rule 29 Setting..................................................................................................................... 9-57
Day Treatment ..................................................................................................................... 9-57
Compatibility ....................................................................................................................... 9-58
Health and Behavior Assessment Codes.............................................................................. 9-58
Missed Appointments .......................................................................................................... 9-59
Court Ordered Treatment..................................................................................................... 9-60
Guidelines for Court Ordered Evaluations .......................................................................... 9-61
Parity .................................................................................................................................... 9-64
Behavioral Health Quality Improvement Objectives........................................................... 9-64
Prior Authorization .............................................................................................................. 9-66
Preadmission Notification.................................................................................................... 9-66
9-2
Groups that Carve Out Behavioral Health Benefits............................................................. 9-66
Where to Bill Claims ........................................................................................................... 9-66
Professional Behavioral Health Coding Grid ...................................................................... 9-67
Behavioral Health Services for UB-92 ................................................................................... 9-92
Overview.............................................................................................................................. 9-92
Practitioners Who Should be Using this Section ................................................................. 9-92
Behavioral Health Evaluation or Testing Coding Guidelines.............................................. 9-92
Units..................................................................................................................................... 9-92
Individual Behavioral Health Therapy................................................................................. 9-92
Family and Group Therapy.................................................................................................. 9-93
Chemical Dependency and Alcohol Rehabilitation............................................................. 9-94
Restricted Codes .................................................................................................................. 9-94
Billing a Behavioral Health Assessment.............................................................................. 9-94
Testing.................................................................................................................................. 9-94
Family Therapy.................................................................................................................... 9-95
Revenue Code 0916 with 90847 .......................................................................................... 9-95
Nutritional Counseling / Dieticians ..................................................................................... 9-95
Detox.................................................................................................................................... 9-95
Health and Behavioral Assessment Codes........................................................................... 9-96
Non-Residential Treatment Centers..................................................................................... 9-96
Compatibility ....................................................................................................................... 9-96
Partial Psych Admissions..................................................................................................... 9-96
Rule 5 – Emotionally Handicapped Facilities ..................................................................... 9-97
Recreational Therapy ........................................................................................................... 9-97
Court Ordered Treatment..................................................................................................... 9-97
Prior Authorizations............................................................................................................. 9-97
Parity .................................................................................................................................... 9-98
Groups that Carve Out Behavioral Health Benefits............................................................. 9-98
Where to File Claims ........................................................................................................... 9-98
Institutional Behavioral Health Coding Grid....................................................................... 9-99
Chiropractic Services............................................................................................................. 9-101
Overview............................................................................................................................ 9-101
Examination Codes ............................................................................................................ 9-101
Chiropractic Manipulation Treatment................................................................................ 9-102
Chiropractic Manipulation with Visit ................................................................................ 9-102
Manual Therapy ................................................................................................................. 9-103
Massage Therapy ............................................................................................................... 9-103
Conjunctive Therapy, Modality: Office, Home or Nursing Home.................................... 9-103
Maintenance or Palliative Care.......................................................................................... 9-103
Source of Condition ........................................................................................................... 9-104
Diagnostic Services............................................................................................................ 9-104
Practicing in Multi-Disciplinary Clinics............................................................................ 9-104
Documentation Guides....................................................................................................... 9-105
Prior Authorization ............................................................................................................ 9-106
Form Required ................................................................................................................... 9-106
Compliance Audits............................................................................................................. 9-106
Dental Services ....................................................................................................................... 9-107
9-3
Medical-Surgical Procedures ............................................................................................. 9-107
Claim Form ........................................................................................................................ 9-108
Coordination Between Dental and Medical Carriers ......................................................... 9-109
TMJ Claims Submission .................................................................................................... 9-109
Diagnostic Studies ............................................................................................................. 9-110
Emergency Room............................................................................................................... 9-110
Dental Procedures and Pre-op / Medical Exams................................................................ 9-110
Durable Medical Equipment and Supplies.......................................................................... 9-111
Durable Medical Equipment (DME) Definition ................................................................ 9-111
Prior Authorization Requirements ..................................................................................... 9-111
Ineligible Items .................................................................................................................. 9-113
DME Rental Guidelines..................................................................................................... 9-114
Waivers and Upgraded/ Deluxe DME ............................................................................... 9-114
Waiver Claim Submission ................................................................................................. 9-115
Sample Waiver Form ......................................................................................................... 9-115
DME Coding...................................................................................................................... 9-116
Sales Tax............................................................................................................................ 9-116
Handling / Conveyance...................................................................................................... 9-116
Claims Filing Requirements .............................................................................................. 9-116
Hearing Aids ...................................................................................................................... 9-116
Oxygen and Oxygen Aiding Equipment (Includes Ventilators)........................................ 9-117
Coding Modifiers ............................................................................................................... 9-117
DME Repairs and Maintenance (Excludes Oxygen Equipment) ...................................... 9-118
Replacement of Purchased Equipment .............................................................................. 9-118
Billing for Supplies ............................................................................................................ 9-119
Rental Unit Submission ..................................................................................................... 9-120
Hospital DME Providers.................................................................................................... 9-120
DME/Supply Internet Purchases........................................................................................ 9-120
Home Health, Home Infusion, and Hospice ........................................................................ 9-121
Definitions.......................................................................................................................... 9-121
Home Health ...................................................................................................................... 9-122
Home Infusion ................................................................................................................... 9-123
Hospice .............................................................................................................................. 9-125
Hospital Care.......................................................................................................................... 9-126
Initial Hospital Care........................................................................................................... 9-126
Subsequent Hospital Visits ................................................................................................ 9-126
Critical Care ....................................................................................................................... 9-126
Hospital Observation Services........................................................................................... 9-127
Observation Care Discharge Day Management................................................................. 9-127
Hospital Discharge............................................................................................................. 9-127
Continuing Intensive Care Services................................................................................... 9-127
Swing Beds ........................................................................................................................ 9-127
Skilled-Nursing Facility Care ............................................................................................ 9-127
9-4
Institutional Care ................................................................................................................... 9-128
Facility Clinic..................................................................................................................... 9-129
UB-92 Manual ................................................................................................................... 9-129
UB-04................................................................................................................................. 9-129
Procedure Code Regulations.............................................................................................. 9-129
Revenue Codes (Form Locator 42).................................................................................... 9-129
HCPCS / Rates (Form Locator 44) .................................................................................... 9-130
Revenue Codes Requiring HCPCS / CPT ......................................................................... 9-130
Outpatient Facility Fee Billing........................................................................................... 9-134
Returned Paper Claims ...................................................................................................... 9-134
Education / Training 0942 and Other Therapeutic Services 0949..................................... 9-134
Lactation Education ........................................................................................................... 9-135
Zero Line and Negative Dollar Charges ............................................................................ 9-135
Diabetic Education............................................................................................................. 9-135
Revenue Code 0636 ........................................................................................................... 9-135
Revenue Codes 0500 and 0509.......................................................................................... 9-135
Behavioral Health Revenue Codes .................................................................................... 9-136
Transfer of Care / Transfer Case........................................................................................ 9-136
Laboratory Services............................................................................................................... 9-137
Overview............................................................................................................................ 9-137
Organ or Disease-Oriented Panels ..................................................................................... 9-137
Lyme Disease Titer ............................................................................................................ 9-137
Office Visits ....................................................................................................................... 9-137
Standing Orders ................................................................................................................. 9-138
Venipunctures and Lab Handling ...................................................................................... 9-138
Papanicolaou Smears ......................................................................................................... 9-139
Pregnancy Tests ................................................................................................................. 9-140
Purchased Services/Outside Lab........................................................................................ 9-140
Stat Lab Charges ................................................................................................................ 9-140
Maternity/Obstetrical Services ............................................................................................. 9-142
Global Obstetrical Care...................................................................................................... 9-142
Antepartum Care................................................................................................................ 9-142
Delivery.............................................................................................................................. 9-142
Subsequent VBACs ........................................................................................................... 9-142
Postpartum Care................................................................................................................. 9-142
Intitial Visit and Itemized Services.................................................................................... 9-142
Submission Options and Coding Alternatives ................................................................... 9-143
Pre-term Birth Prevention Services ................................................................................... 9-144
Two Physicians Involved in Care / Same Tax ID.............................................................. 9-145
New Born Care .................................................................................................................. 9-145
Complications or Unusual Circumstances ......................................................................... 9-145
Exceptions.......................................................................................................................... 9-145
Lactation Education ........................................................................................................... 9-145
Collection of umbilical cord blood .................................................................................... 9-146
Obstetrical Care Coding Alternatives ................................................................................ 9-146
9-5
Medical Emergency ............................................................................................................... 9-147
Introduction........................................................................................................................ 9-147
Criteria for Medical Emergencies...................................................................................... 9-147
Emergency Department Services....................................................................................... 9-148
Medical Services..................................................................................................................... 9-149
Allergy Testing .................................................................................................................. 9-149
Allergy Immunotherapy..................................................................................................... 9-149
Anticoagulation Clinic – S9401......................................................................................... 9-149
Blood, Occult, Feces Screening ......................................................................................... 9-150
Cardiovascular Stress Test................................................................................................. 9-150
Chemotherapy Administration........................................................................................... 9-151
Chemical Dependency Assessment ................................................................................... 9-151
Office or Other Outpatient and initial Inpatient Consultations.......................................... 9-152
Day Treatment ................................................................................................................... 9-152
Diabetic Education............................................................................................................. 9-152
E-Care Visits...................................................................................................................... 9-153
G0101................................................................................................................................. 9-155
Hospital Discharge............................................................................................................. 9-155
Immunizations.................................................................................................................... 9-156
Injections............................................................................................................................ 9-157
Infusion Therapy................................................................................................................ 9-158
Interpreter Services ............................................................................................................ 9-158
Transfusion – Blood and Blood Products .......................................................................... 9-158
Locum Tenens.................................................................................................................... 9-158
Natural Family Planning .................................................................................................... 9-158
Nicotine Dependence ......................................................................................................... 9-159
Revenue Codes Used by Facilities 0944 or 0945 .............................................................. 9-160
Eligibility to Bill for Specific Procedures.......................................................................... 9-160
Coverage for Tobacco Treatment Medications.................................................................. 9-160
New and Established Patients ............................................................................................ 9-160
Oral Medication ................................................................................................................. 9-161
Non-Physician Healthcare Practitioners ............................................................................ 9-161
Practitioners Credentialed by EPNI with an Individual Provider Number........................ 9-162
Practitioners Not Credentialed by EPNI with an Individual Provider Number................. 9-163
Preventive Medicine .......................................................................................................... 9-164
Couseling and/or Risk Factor Reduction ........................................................................... 9-164
Room or Machine Set-up Charges..................................................................................... 9-164
Supplies in the Office......................................................................................................... 9-164
Adjunct CPT Codes ........................................................................................................... 9-164
Care Plan Oversight Services............................................................................................. 9-165
Prolonged Physician Services ............................................................................................ 9-165
Telephone Calls ................................................................................................................. 9-165
Team Conferences ............................................................................................................. 9-166
Televideo Consultations..................................................................................................... 9-166
Exceptions.......................................................................................................................... 9-167
Urgent Care........................................................................................................................ 9-167
Weight Management Care ................................................................................................. 9-167
9-6
Optometric/Optical Services ................................................................................................. 9-172
Opthalmological Services .................................................................................................. 9-172
Charges for Lenses and Contact Lens Fitting .................................................................... 9-172
Eyewear Billing and Reimbursement ................................................................................ 9-172
Vision Therapy Services .................................................................................................... 9-173
Claims Filing Requirement ................................................................................................ 9-173
Pharmacy Services ................................................................................................................. 9-174
Claims Filing Requirements .............................................................................................. 9-174
Drug Claims Submission ................................................................................................... 9-174
Injectable Drugs ................................................................................................................. 9-174
Copays / Coinsurance ........................................................................................................ 9-174
Vacation Prescription Requests ......................................................................................... 9-174
Drug Formulary ................................................................................................................. 9-175
Non-Formulary .................................................................................................................. 9-175
Compounded Prescriptions ................................................................................................ 9-176
Prescription Cost Less Than Copay................................................................................... 9-177
Over-the-Counter Drugs .................................................................................................... 9-177
NDC Numbers ................................................................................................................... 9-177
Discounting or Waiving Copays........................................................................................ 9-177
Dispense as Written (DAW) .............................................................................................. 9-177
Prescribing Physician’s DEA............................................................................................. 9-177
Pharmacy Audits................................................................................................................ 9-177
Investigative Drug Use ...................................................................................................... 9-177
Radiology Services ................................................................................................................. 9-178
General Guidelines............................................................................................................. 9-178
Diagnosis............................................................................................................................ 9-178
Modifiers............................................................................................................................ 9-178
Radiation Treatment Management..................................................................................... 9-178
Maternity Ultrasound Compatibility.................................................................................. 9-179
Purchased Services / Outside Lab...................................................................................... 9-179
Diagnostic and Screening Mammogram............................................................................ 9-179
Code 76140 ........................................................................................................................ 9-179
Comparison Xray ............................................................................................................... 9-179
Rehabilitative Services........................................................................................................... 9-181
Physical Therapy Modalities.............................................................................................. 9-181
Physical Therapy Procedures............................................................................................. 9-181
Physical Therapy Evaluation Codes .................................................................................. 9-181
Occupational Therapy........................................................................................................ 9-182
Occupational Therapy Evaluation Codes........................................................................... 9-183
Speech Therapy and Evaluation......................................................................................... 9-183
9-7
Surgical Services .................................................................................................................... 9-184
General Guidelines............................................................................................................. 9-184
Bilateral Services ............................................................................................................... 9-184
Unlisted Procedures ........................................................................................................... 9-184
Facility Fees for Office Surgery ........................................................................................ 9-184
Global Surgical Package .................................................................................................... 9-185
Fractures............................................................................................................................. 9-185
Incidental Surgery.............................................................................................................. 9-185
Lesions ............................................................................................................................... 9-186
Surgical Trays and Supplies............................................................................................... 9-186
Standby Services................................................................................................................ 9-186
Treatment of Warts ............................................................................................................ 9-186
Assistant Surgeons ............................................................................................................. 9-187
Co-Surgeons....................................................................................................................... 9-188
Multiple Surgeries.............................................................................................................. 9-188
9-8
Coding
Overview
EPNI requires submission of valid codes to report medical services and
supplies on both professional and institutional claims. This includes
Healthcare Common Procedural Coding System (HCPCS) codes,
International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM) diagnosis and procedure codes, and Revenue
codes.
The Health Insurance Portability and Accountability Act (HIPAA)
Transaction and Code Set regulation stipulates submission and
acceptance of approved medical code sets. HCPCS and ICD-9-CM codes
are among the approved HIPAA medical code sets and must be valid for
the actual date of the service. If a HCPCS or ICD-9-CM code is not valid
for the date of service, the claim will be returned or denied.
Revenue codes are a data element of the institutional claim (837I or UB92) and must be valid for the date of submission. If a Revenue code is not
valid on the date submitted, the claim will be returned or denied.
HCPCS Codes
The HCPCS coding system was developed by CMS (Centers for
Medicare and Medicaid Services) to standardize coding systems used to
process claims for all payers, including Medicare and Medicaid. HCPCS
is a two level coding system-Level I, a.k.a., CPT®, and Level II.
All nationally developed codes are accepted; however, coverage is not
guaranteed and other restrictions may apply. Services may deny for
various reasons including a member contract exclusion or service
limitation, EPNI corporate or medical policy, or subject to standardized
coding edits.
HCPCS codes are updated several times throughout the year. The
primary update is January of each year. CMS provides updates to Level
II codes on a quarterly basis. In addition to January, code updates are
done in April, July, and October. CPT codes are generally updated only
in January; however, the AMA can release codes early and make codes
slated for the next year’s publication available in the prior July.
9-9
CPT® /Level I
Level I or CPT® (Current Procedural Terminology) codes are developed
and maintained by the American Medical Association. Each procedure is
identified with a five digit numeric or numeric-alpha code. CPT is a set
of codes, descriptions, and guidelines intended to describe procedures
and services performed by physicians and other health care providers.
Inclusion or exclusion of a procedure does not imply any health
insurance coverage or reimbursement policy.
There are eight main sections to the CPT manual, including subsections
with anatomic, procedural, conditions, or descriptor subheadings. All
listings are in numeric order except for Evaluation and Management
(E/M) codes. E/M codes are the most frequently used and are listed first
in the CPT manual.
Section Numbers and Sequences:
Anesthesiology
00100 to 01999
99100 to 99140
9-10
Category II Codes
0001F to 4018F
Category III Codes
0003T to 0161T
Evaluation and Management (E/M)
99201 to 99499
Medicine (except Anesthesiology)
90281 to 99602
Pathology and Laboratory
80048 to 89356
Radiology
70010 to 79999
Surgery
10021 to 69990
CPT® /Level I
(continued)
Modifiers
A modifier is used to indicate that the service or procedure that has been
performed has been altered by some specific circumstance but has not
changed the definition or code. A complete listing of modifiers is found
in Appendix A of CPT. Level I codes are not limited to CPT modifiers.
HCPCS Level II modifiers may also be used with Level I codes and/or in
combination with CPT modifiers.
Genetic Testing Code Modifiers are found in Appendix I of CPT.
CPT Format
CPT codes are five characters in length (either all numeric or numericalpha) and designed as stand-alone descriptions of medical procedures.
Some procedures in CPT are not printed in their entirety but refer back to
a common portion of the procedure listed in the preceding entry. These
are sometimes referred to as indented procedures.
For example:
97010: Application of a modality to one or more areas; hot or cold packs
97012: traction, mechanical
The common part of the code 97010 is before the semicolon and is also
considered part of the code 97012. The full narrative for 97012 is
“Application of a modality to one or more areas; traction, mechanical”.
Guidelines
Guidelines are presented at the beginning of each of the main eight
sections. Some section subheadings may contain instructions or
information specific to those codes.
Code Symbols
Certain symbols may precede a code to indicate additional information.
New CPT codes will be preceded by a bullet (z) symbol. Revised CPT
codes will be preceded by a triangle (▲) symbol. Add-on CPT code will
be preceded by a plus (:) symbol. Codes that include conscious sedation
will be preceded by a target (~) symbol.
9-11
Level II HCPCS
Level II HCPCS are developed and maintained by CMS. Level II
consists of codes for supplies, materials, injections, and services. Each
Level II code is identified with a five digit (alphanumeric) code.
Level II codes are generally referred to simply as HCPCS codes to
differentiate them from the Level I (CPT) codes. HCPCS codes are
generally used because CPT has a limited code selection for these areas.
All listings are in alpha category order except for modifiers.
Format
HCPCS codes are five characters in length, consisting of one alpha and
four numeric characters. Level II codes start with alpha characters A
through V and relate to these nationally defined categories:
9-12
Code
Description
A0000 - A0999
Transportation Services Including Ambulance
A4000 - A8999
Medical and Surgical Supplies
A9000 - A9999
Administrative, Miscellaneous, and
Investigational
B4000 - B9999
Enteral and Parenteral Therapy
C1000 - C9999
Outpatient PPS
D0000 - D9999
Dental Procedures
E0100 - E9999
G0000 - G9999
Procedures/Professional Services (Temporary)
(including Injections, Laboratory, Medical
Services, Supplies)
H0001 - H2037
Alcohol and Drug Abuse Services (includes
prenatal care codes)
J0000 - J9999
Drugs Administered Other than Oral Method
(J0000-J8999-Injection; J9000-J9999Chemotherapy Drugs)
K0000 - K9999
Temporary Codes (for DMERCS including
Durable Medical Equipment, Orthotics &
Prosthetics, Supplies)
L0000 - L4999
Orthotics Procedures
L5000 - L9999
Prosthetic Procedures
Level II HCPCS
(continued)
Code
Description
M0000 - M0301
Medical Services
P0000 - P9999
Pathology and Laboratory (including Blood
Products)
Q0000 - Q9999
Q Codes (Temporary) (including Injections,
Laboratory, Occupational Therapy, Physical
Therapy)
R0000 - R5999
Diagnostic Radiology Services (including
Portable X-ray)
S0000 - S9999
Temporary National Codes (Non-Medicare)
T1000 - T9999
National T Codes Established for State Medicaid
Agencies
V0000 - V2999
Vision Services
V5000 - V5999
Hearing Services
Modifiers
A modifier is used to indicate that the service or supply has been altered
by some specific circumstance but has not changed the definition or
code. A complete listing of modifiers is found as an appendix to the
HCPCS manual. Level II codes are not limited to HCPCS modifiers.
CPT modifiers may also be used with Level II codes and/or in
combination with HCPCS modifiers.
Code Changes
New HCPCS codes will be preceded by bullet (z) symbol.
Revised HCPCS codes will be preceded by a triangle (σ ) symbol.
Reinstated HCPCS codes will be preceded by a circle ({ ) symbol.
Reinstated codes were previously deleted codes that have been
reactivated.
9-13
ICD-9-CM
ICD-9-CM is a statistical classification system that arranges diseases,
injuries, and procedures into groups. Most ICD-9-CM are numeric and
consist of three, four, or five digit numbers and a description. The
coding structure is revised approximately every 10 years by the World
Health Organization. Annual updates, effective October 1, are published
by NCVHS and CMS.
Code Changes (not all publishers will include this information)
New ICD-9-CM codes will be preceded by a bullet (z) symbol.
Revised ICD-9-CM codes will be preceded by a triangle (σ ) symbol.
Format
ICD-9-CM consists of three volumes:
• Volume I - The Tabular List
Volume I is a numeric listing of diagnosis codes and descriptions
consisting of seventeen chapters that classify diseases and injuries. In
addition, two sections of supplementary codes (V and E codes) are
included.
Most diagnosis codes are four or five digit codes. The base ICD-9-CM
diagnosis code consists of three digits which may be further defined or
classified by a fourth or fifth digit following a dot (this divides and
identifies the base diagnosis). For example: 738.1 is the diagnosis
“Other acquired deformity of head.” “Zygomatic hyperplasia” is coded
as “738.11”. The addition of “1” specifically defines the acquired
deformity.
• Volume 2 - The Alphabetical Index
Consists of an alphabetic list of terms and codes.
• Volume 3 - Procedures: Tabular List and Alphabetic Index
Volume 3 is a numeric listing of procedure codes and descriptions
consisting of 17 chapters containing codes and descriptions for surgical
procedures and miscellaneous diagnostic and therapeutic procedures.
Codes from Volume 3 are intended only for use by hospitals.
ICD-9-CM procedure codes are two, three or four digit codes. The base
ICD-9-CM procedure code consists of two digits that may be further
defined or classified by a third or fourth digit following a dot (this
divides and identifies the base procedure). For example: 50 is the
procedure “Operations on liver”. “Closure of laceration of liver” is
coded as “50.61”. The addition of “.61” specifically defines the liver
operation. Only valid diagnoses, submitted to their full specificity, are
accepted. If a fourth or fifth digit applies to a specific diagnosis code, it
must be submitted.
9-14
ICD-9-CM
(continued)
Linking or Sequencing
Revenue Codes
Revenue codes are developed by the National Uniform Billing
Committee and are used to identify specific accommodation charges,
ancillary service charges, or a type of billing calculation. They are only
to be submitted on the uniform bill, or UB-92 (CMS-1450 claim form)
or the institutional electronic claim format (837I).
On the CMS-1500 claim form there are two diagnosis boxes, one is box
21 and the other is box 24E. Box 21 has space for four ICD-9-CM
diagnosis codes and these codes relate to all the services indicated on
the claim detail lines (24). Box 24E specifies what diagnosis or
diagnoses relate to that particular line only. The primary diagnosis for
the service performed must be appropriately linked to that service,
especially if more than one diagnosis relates to a line item. Up to four
diagnoses can be linked to a detail service line; however, adjudication is
based on the first linked diagnosis.
Format
Revenue codes are four digits in length. The first three digits define the
category and the fourth digit defines the subcategory. It is important for
the subcategory to be properly defined for appropriate payment. For
example: 012X is the category for “Room & board-Semi-Private Two
Bed (Medical or General)”. While 012X indicates the type of
accommodations it does not identify the department or area in the
hospital where the patient is staying. However, the code 0122
(OB/2BED) would properly indicate a semi-private room in the OB.
The list of revenue code is extensive and can be found in the UB-92
manual under FORM LOCATOR SPECIFICATIONS, form locator 42.
HIPAA transaction standards require submission of HCPCS/CPT codes
on outpatient facility claims. Guidelines for submission of HCPCS/CPT
codes including modifiers can be found in the UB-92 manual under
FORM LOCATOR SPECIFICATIONS, form locator 44
9-15
Compatibility
HCPCS and ICD-9-CM Codes
EPNI requires that diagnosis codes and procedures performed be
compatible. These conditions are identified separately not only to assure
correct coding, but also appropriately apply benefits.
A chart of the patient condition and the compatible diagnosis codes is
found in the EPNI Provider Policy and Procedure Manual, Chapter 6
and can be used as a general guide for determining compatibility.
Revenue Codes
Revenue codes must also be compatible with the claim type of bill*.
Some revenue codes are very specific to the place where the service was
rendered.
*The type of bill (TOB) is three digits and indicates the type of facility
(1st digit), bill classification (2nd digit), and frequency (3rd digit) of the
services indicated on the claim. For example, the TOB 111 indicates
hospital inpatient admit through discharge claim.
General Guides
Submit the code that most accurately identifies the service(s)
performed. Documentation in the patient’s medical record must
support the codes submitted.
Do not use multiple codes when services can be represented by a single
code, unless otherwise instructed. Fragmented services (reporting
several codes when one adequately defines the service) will be subject
to our coding software edits and may be denied.
Unlisted codes should only be used if no code exists to describe the
service or supply. HCPCS codes for unlisted services require a complete
narrative description.
Submit all services for the same date of service on the same claim.
Codes C1000-C9999 are for items classified in new-technology
ambulatory payment classifications (APCs) under the outpatient
prospective payment systems. These codes are exclusively for use in
billing for institutional transitional pass-through payments. “C” HCPCS
codes may be submitted on institutional (UB-92) claims only. “C” codes
submitted on a professional claim (CMS-1500) will deny as provider
liability.
If you do not agree with how a claim was processed and wish to appeal,
refer to Chapter 8. Chapter 8 defines the appeal process and gives
guidelines for filing an appeal.
Zero-billing
9-16
Beginning September 1, 2006, any claim type filed to EPNI with a
$0.00 billed charge will be accepted for processing. Providers will no
longer need to add a nominal charge, such as $.01 or $1.00 to a service
line item for which they intended to bill or indicate as (zero) $0.00.
Coding Edits
Overview
EPNI uses an automated procedure editing tool. This tool has been
adopted and modified by EPNI to assist in a consistent and fair claim
review process. The procedure code edits may also reflect EPNI’s
Medical Coverage Guidelines, benefit plans, and other EPNI policies.
Unbundling, fragmentation, mutually exclusive procedures, duplicate,
obsolete, or invalid codes are all identified through the use of this
coding edit application. The procedure code edits are based on CPT
guidelines, a review of the Center for Medicare and Medicaid Services
(CMS) Correct Coding Initiative policies and guidelines, specialty
society guidelines, agreed upon industry practices and analysis by an
extensive clinical consultant network. This automated review process is
designed to apply the same industry criteria consistently across all
professional claims.
9-17
Edit Descriptions
Procedure Code Unbundling/Replacement
Procedure code unbundling is the submission of multiple procedure
codes for a group of specific procedures that are components of a single
comprehensive code. Procedure unbundling may occur in one of two
ways:
A professional claim could be submitted that has procedure codes for
both the individual components, and the procedure code for the
comprehensive procedure. EPNI would rebundle the individual
component codes into the comprehensive procedure code for payment.
Procedure unbundling could also occur when a professional claim is
submitted with only the individual components of the comprehensive
code. In this situation, the software will recognize the relationship
between the comprehensive code and its individual components. Then,
it will automatically add the comprehensive code to the claim and
rebundle the individual components into that comprehensive code for
payment.
An example would be billing the following procedure codes together:
33207- Insertion of heart pacemaker, ventricular
33208- Insertion of heart pacemaker, atrial and ventriucular
Procedure 33208 is identified as the primary procedure code. CPT
33207 would be rebundled because it is an integral part of procedure
33208. Rather than a line item denial, the procedure and related charge
will be summed together and a new allowance for the surviving code
will be established based on your contracted fee schedule.
Another example would be billing the following procedure codes
together:
•
82374- Carbon dioxide
•
82435- Chloride
•
84132- Potassium
• 84295- Sodium
In combination, the four codes above would be rebundled and replaced
with the more appropriate procedure 80051-electrolyte panel. Related
charges will be summed together and the allowance based on the
comprehensive code 80051.
When this edit is applicable, the following message will appear on your
current remittance advice:
This service is a component of a procedure that has already been
processed on this or another claim.
9-18
Mutually
Exclusive
Procedures
Mutually exclusive procedures exist when a claim is submitted for two
or more procedures that are not usually performed on the same patient,
on the same date of service. In mutually exclusive relationships, the
most clinically intense code is recognized for payment. Clinical
intensity is generally based on the total RVU for the procedures
submitted.
•
58260- Vaginal Hysterectomy
• 58150- Total Abdominal Hysterectomy
Since a hysterectomy would not be performed using two different
approaches, the vaginal hysterectomy would be denied as mutually
exclusive to the abdominal hysterectomy. This edit would result in the
line item denial of procedure 58260 and would be the participating
network provider’s liability.
Another example would be billing the following procedures together:
•
27550- Closed treatment of a knee dislocation
• 27556- Open treatment of a knee dislocation
The knee would not be reduced by doing both procedures. The open
procedure would survive as the one that was more clinically intense.
This would result in the line item denial of procedure 27550 and would
be the participating network provider’s liability.
When this edit is applicable, the following message(s) will appear on
your current remittance advice:
Payment is included in the allowance of the other procedure. Service is
not payable with other service rendered on the same date.
These charges are not covered. Less complex procedures with the same
outcome and date of service as another procedure are not eligible.
9-19
Incidental
Procedures
Incidental is defined as a procedure carried out at the same time as a
primary procedure, but is clinically integral to the performance of the
primary procedure, and therefore, should not be reimbursed separately.
•
59300- Episiotomy
• 59409- Vaginal delivery
An episiotomy performed as part of the overall management of a
delivery does not warrant a separate identification. This would result in
the line item denial of procedure 59300 and would be the participating
network provider’s responsibility.
Another example would be billing the following procedure codes
together:
44005- Enterolysis (lysis of adhesions, separate procedure)
44140- Partial colectomy with anastomosis
Services that are identified by CPT with the term “separate procedure”
are commonly carried out as an integral component of a total service.
Separate procedures are not reported in addition to the total procedure
or service of which it is considered an integral component. This would
result in the line item denial of procedure 44005 and would be the
participating network provider’s liability.
When this edit is applicable, the following message(s) will appear on
your current remittance advice:
9-20
•
This procedure is incidental to another procedure processed on this
or another claim.
•
This procedure is incidental to the primary procedure.
Reimbursement is included in the allowance for that primary
procedure.
Medical Visits on
the Same Day as
Surgery
In keeping with the CPT surgical “package”, related Evaluation and
Management (E/M) services are not reimbursed separately when
submitted with a procedure performed on the same day. Modifiers may
be used with E/M services that are not considered part of the same day
surgical package. Please refer to the current year’s CPT manual for
evaluation and management services and surgery guidelines.
Some of the related CPT modifiers would include:
-24 unrelated E/M service by the same physician during a postoperative
period
-25 significant, separately identifiable E/M service by the same
physician on the day of a procedure
The provider should add these modifiers when a patient’s condition
requires a significant, separately identifiable service above and beyond
the usual care associated with the procedure.
Documentation in your files must support the use of modifier –25 with
E/M codes as defined in CPT. Use modifier –25 with new-patient and
established-patient E/M codes to prevent denial of significant,
separately identifiable E/M services performed on the same day as a
procedure or other service. Some of these other services are allergy
injections, joint injections, chemotherapy administration, brachytherapy
services, and dialysis. Modifier –25 is not required by EPNI with
consultation and emergency room codes.
One of the following messages will appear on your current remittance
advice:
•
Payment is included in the allowance for another service/procedure
•
Based on the other services submitted for this service date,
reimbursement is not considered for this medical visit.
9-21
Global Surgical
Package - Pre
and Post
Operative
Services
As defined by CPT, the surgical “package” includes the surgical
operation, local infiltration, metacarpal/digital block or topical
anesthesia when used, and the normal, uncomplicated follow-up care
visits. These services, when billed in addition to surgery, are denied as
included in the surgical allowance. The surgical package includes all
normal and uncomplicated care including pre-and post-operative visits
as part of the reimbursement for the surgical procedure. Pre-operative
visits are defined as visits by the surgeon or another practitioner in the
same practice on the day of a surgery for minor procedures and the day
before or day of major surgical procedures.
We do not consider new patient codes exceptions to the package. The
fact that the patient is new is not reason alone to exclude the visits from
the global package. EPNI follows the same post-operative timeframes
associated with surgical procedures as Medicare of 10, or 90 days.
These can be found in the Federal Register. Routine post-operative
medical visits rendered with this timeframe and related to the surgery
will not be recognized for separate reimbursement as an unbundled
component of the total surgical package.
One of the following messages will appear on your current remittance
advice:
•
This procedure is within the postoperative range for a surgery found
on this or another claim.
•
This procedure is within the preoperative range for a surgery found
on this or another claim.
•
Pre and post-operative care is a covered benefit and these services
are included in the allowance
Modifiers -55 and -56
For EPNI, modifiers –55 and –56 for pre- and post-operative care are
used with E/M codes, not with surgery codes.
Modifier –57
Modifier –57 is used to indicate that the E/M service resulted in the
initial decision to perform surgery either the day before a major surgery
(90 day global) or the day of a major procedure.
9-22
General Claims
Processing
Information
Scope Procedures
Our coding software makes the following assumptions when
determining payment for multiple scope procedures billed on the same
date of service:
•
A diagnostic scope is always incidental to a surgical scope.
•
A diagnostic scope with biopsy is always incidental to a surgical
scope.
•
A diagnostic scope with or without biopsy is always incidental to an
open surgical procedure in the same area.
•
A diagnostic scope rebundles to a diagnostic scope with biopsy
unless the code description makes the distinction with biopsy vs.
without biopsy.
•
CPT descriptions such as: complete vs. partial, with vs. without,
complex vs. simple, etc. means there are two mutually exclusive
codes for the procedures.
Medical and
Surgical Supplies
Medical and surgical supplies during an outpatient or physician office
visit are included as incidental to the evaluation and management
service or procedure performed, and will not be separately reimbursed.
Multiple Surgery
Guidelines
Multiple surgical procedures performed during the same operative
session are processed in accordance with EPNI multiple surgical
guidelines. These guidelines state the primary procedure is reimbursed
at 100% of the fee schedule or billed amount, whichever is less.
Secondary, tertiary procedures, etc., are reimbursed at 50% of the fee
schedule or billed amount, whichever is less, regardless of separate site
or incision.
In addition, procedures noted in CPT as “modifier –51 exempt” are not
subject to multiple surgery reductions. Overall, the most clinically
intense service coincides with the higher relative value unit (RVU)
assigned, although occasionally, this may not be the case. All
questionable claims decisions are eligible for inquiry and/or appeal. In
these cases, the appeals process should be followed.
Patient Billing
Impact
The patient is not responsible and must not be balance billed for any
procedures for which payment has been denied or reduced by EPNI as
the result of a coding edit. Edit denials are designed to ensure
appropriate coding and to assist in processing claims accurately and
consistently.
9-23
Coding Appeals
EPNI’s coding edits are updated at minimum annually, to incorporate
new codes, code definition changes and edit rule changes. All claims
submitted after the implementation date of this update, regardless of
service date, will be processed according to the updated version. Where
Medicare’s CCI (Correct Coding Initiative) edits are identical, we will
consider the appeal with additional documentation, but the issue may be
upheld. No retrospective payment changes, adjustments, and/or request
refunds will be made when processing changes are a result of new code
editing rules due to a software version update. Notice of this update will
be published in a Provider Bulletin, with a ‘Summary of Change’
summarizing new edits.
EPNI has adopted a standard process to review edit appeals and
providers have the right to appeal with additional information. If you
have a question or appeal about our policy regarding a particular coding
combination, provide a written statement of the concern, along with the
following information and/or documentation normally required for a
medical review.
Written explanation supporting the procedures submitted, i.e., specific
references, specialty specific criteria
Documentation from a recognized authoritative source that supports
your position on the procedure codes submitted
Once received, the inquiry or appeal will be reviewed and if necessary,
forwarded to the medical review department for determination. The
review may result in approval or denial of the claim, based on review of
the information submitted.
Send your request for review to the following address:
EPNI
Attn: Provider Coding Appeals
P.O. Box 64560
St. Paul, MN 55164-0560
Helpful Coding
Tips
We recognize the challenges you have in staying up-to-date with coding
changes. Below are some helpful tips to assist with accurate and
effective coding to support correct claim processing and reimbursement.
Code using current coding books. Order new CPT and HCPCS manuals
every year, as codes are added, deleted, and revised annually.
Submitting invalid or deleted codes will result in claim denials. Web
links to review for possible updates:
http://www.ama-assn.org/ama/pub/category/3884.html
http://www.cms.hhs.gov/medicare/hcpcs/default.asp
http://www.cms.hhs.gov/medlearn/icd9code.asp
9-24
Coding
Immunizations
and Injections
It is appropriate when administering an immunization or injection to bill
administration codes (90465-74, 90772- 90774, G0008-10).
Reimbursement for vaccines/toxoids and immunization administration
is currently allowed in addition to preventive medicine services
(99381-99384, 99391-99394, 99401-99404) and newborn care services
(99431, 99432, 99435).
Immunizations
If only an immunization is administered, bill the CPT code for the
vaccine/toxoid administered and the applicable CPT administration
code (90465-90474).
Example: A 65-year old patient comes to your office just for a flu
vaccine. Bill the vaccine code 90658 and vaccine administration code
90471.
Immunizations and E/M Visits
Evaluation and management codes 99201-05 and 99212-15 are eligible
for separate reimbursement when billed on the same date of service as
vaccine/toxoid codes 90476-90749 and the immunization administration
codes 90465-90474.
Example: A one-year-old established patient has a preventive visit and a
polio vaccine. Bill the appropriate preventive visit CPT code (i.e.,
99392), the polio vaccine (i.e., 90712) and in this case, the oral
administration code (90473).
9-25
Copays
Office Call
Copays
Following is a listing of procedure codes to which the office call copay
may apply when included in the contract benefits. This is not an allinclusive list.
Code
Description
90804 - 90815
Psychotherapy
90847, 90853
Family therapy/ Group therapy
92002 - 92014
Ophthalmological services (new or established
patient)
9-26
92597
Evaluation for use/fitting of voice prosthetic
device
92605, 92607
Evaluation for prescription of speech/ non-speech
generating device
97001 - 97004
Physical and occupational evaluations and
reevaluations
98925 - 98929
Office or outpatient visit with osteopathic
manipulative therapy
98940 - 98943
Chiropractic visit with manipulation/adjustment
99201 - 99215
Office or other outpatient services, new and
established patient
99218 - 99220
Initial observation care
99241 - 99245
Consultations (office, outpatient) new or
established patient- Based on place of service
99354 - 99357
Prolonged physician services
99381 - 99387
Preventive medicine, new patient
99391 - 99397
Preventive medicine, established patient
99401 - 99404
Preventive medicine individual counseling
99411 - 99412
Preventive medicine group counseling
99420, 99429
Other preventive medicine services
G0245 - G0246
E/M of a diabetic patient
H1000, H1001,
H1003
Prenatal risk assessment, high risk antepartum
care, nutrition education
Modifiers
Modifiers
General Guidelines
Modifiers are two digit codes that are appended to a service as a means to
indicate that the service/procedure is affected or altered by a specific
circumstance and to add specificity, but not changed in its definition.
Modifiers are found both in both CPT and HCPCS manuals. CPT
modifiers can be found in Appendix A. Genetic Testing Code Modifiers
are found in Appendix I of CPT. A complete list of HCPCS modifiers is
found as an appendix to the HCPCS manual.
CPT codes are not limited to CPT modifiers. HCPCS codes are not
limited to HCPCS modifiers. HCPCS modifiers may also be used with
CPT codes and/or in combination with CPT modifiers. CPT modifiers
may also be used with HCPCS codes and/or in combination with HCPCS
modifiers. For example, -TC and –76 can be appended to a radiology
procedure to indicate the technical component of the services was
repeated.
Modifiers may be used to indicate that:
•
A service or procedure has both a professional and technical
component.
•
A service or procedure was performed by more than one physician
and/or in more than one location.
•
A service or procedure has been increased or reduced.
•
Only part of a service was performed.
•
A bilateral procedure was performed.
•
A service or procedure was provided more than once.
•
Unusual events occurred.
• A purchased or rented DME item.
You may submit more than one modifier per detail line; however, the
EPNI claims system cannot always adjudicate the claim based on all
modifiers submitted. Submit the modifier affecting payment in the first
position.
Note: If your claim is denied due to lack of documentation to support the
use of a specific modifier, you may submit a claim payment
appeal. Your appeal must be in writing and accompanied by the
necessary documentation.
9-27
Modifier
(continued)
The information outlined below is a general guideline regarding the use of
modifiers. The list is not all-inclusive. Refer to you CPT and HCPCS for a
complete list of modifiers. When a specific service/circumstance requires
the use of a modifier, the submission criteria is outlined in the applicable
specialty section of the Coding Chapter of the EPNI Provider Policy and
Procedure Manual.
Modifier
Guidelines
The impact to payment statements below are a general guide and not a
guarantee of payment
Mod
Description
Submission Guidelines
Impact To Payment
-22
Unusual
Procedural
Service
Requires submission of an operative
report, narrative and/or other relevant
documentation that adequately describes
what care/service was greater than
usually required.
The availability of
additional payment will
be determined based on
review of supporting
documentation.
Do not use modifier –22 when there is an
existing code to describe the service.
-24
Unrelated
Evaluation and
Management
(E/M) Service
by the Same
Physician
During a
Postoperative
Period.
Note: EPNI
defines the
“same
physician” as
the same
physician, or
physicians of
the same or
similar specialty
within the same
clinical
practice.
9-28
By appending the –24 modifier to an
unrelated E/M service you are indicating
that the patient’s condition requires a
significant, separately identifiable E/M
service above and beyond the other
service provided, or beyond the usual
preoperative and postoperative care
associated with the procedure that was
performed. Services appended with a –24
modifier must be sufficiently
documented in the patient’s medical
record that the visit was unrelated to the
post operative care of the procedure. An
ICD-9-CM that clearly indicates that the
reason for the encounter was different
and unrelated to the postoperative care
may provide sufficient documentation.
Separate payment of
the E/M may be
allowed.
Mod
Description
Impact To Payment
-25
Significantly
Separately
Identifiable
Evaluation and
Management
(E/M) Service
by the Same
Physician on
the Same Day
of the
Procedure of
Other Service
Use the –25 modifier when an E/M
service is rendered on the same day as a
minor surgical procedure (0 or 10 day
global period).
Separate payment of
the E/M may be
allowed.
Professional
Component
Certain procedures are a combination of
a physician component and a technical
component. When the physician
component is reported separately, the
service may be identified by adding the
modifier ‘26’ to the usual procedure
number.
-26
The use of –25 is appropriate only when
the E/M service provided is above and
beyond the usual pre and post op service
associated with a procedure.
No documentation needs to be submitted
with the initial claim. However, E/M
services submitted with a –25 modifier
are subject to review. Furthermore,
medical documentation, when requested ,
needs to support the significant,
separately identifiable E/M service.
Payment is made based
on the professional
portion of the RVU
associated with the
service.
The professional component applies to
the physician who interprets the
procedure and provides a written report.
-50
Bilateral
Procedure
Surgical procedures performed on
bilateral pieces of anatomy should be
billed on two lines. The –50 modifier
should be appended to one of the
submitted lines of service.
Payment is made at
50% of the allowed
amount for the
secondary procedure.
EPNI adheres to CMS’ published list of
bilateral procedures
9-29
Mod
Description
Impact To Payment
-51
Multiple
Procedure
When more than one service is
performed during the same operative
session, the –51 modifier should be
appended to all secondary surgical
procedures.
Multiple surgical
payment is based on
the allowed amount.
The lowest valued
procedure(s) will have
the multiple surgical
reduction applied.
When covered,
payment is made at
50% of the allowed
amount for all
allowable secondary
procedures.
It is not necessary to append the –51
modifier to “add on” or –51 modifier to
exempt codes.
Applicable code edits will be applied to
services submitted.
-52
Reduced
Services
Append the –52 modifier to indicate that
a service or procedure is partially
reduced or eliminated at the physician’s
discretion. This provides a means of
reporting reduced services without
disturbing the identification of the basic
service.
The normal full charge
billed or a reduced
charge for the
procedure may be
submitted. EPNI will
pay the lesser of either
90% of the physician
fee schedule allowance
for the procedure or the
charge submitted.
-53
Discontinued
Procedure
Append –53 when the physician elects to
terminate the procedure
The normal full charge
or reduced charge
should be submitted.
-54
Surgical Care
Only
Append –54 when one physician
performs intraoperative portion of a
surgical procedure while another
practitioner(s) from a different practice
provides preoperative and/or
postoperative management.
Payment is made at
90% of the allowed
amount.
Surgery should be billed globally (no
modifier) if the pre-, intra-, and –post
operative services are rendered by the
same provider or other practitioners who
are employed by the same clinic (same
tax ID number).
9-30
Mod
Description
Impact To Payment
-55
Postoperative
Management
Only
Append –55 to each post-op visit (E&M)
only when post-op is provided by a
different clinic than performed the
surgery.
Separate payment of
the E/M may be
allowed.
Do not append –55 to the surgical
procedure code
-56
Preoperative
Management
Only
Append –56 to the pre-op visit (E&M)
only when pre-op is provided by a
different clinic than performed the
surgery
Do not append –56 to the surgical
procedure code.
-57
Decision for
Surgery
The –57 modifier is appended to indicate
that the E/M service resulted in the initial
decision to perform surgery either the
day before or the day of a major surgical
procedure (90 day global period).
Services will be denied
if the surgical
procedure code is
submitted with the –55
modifier or billed by a
practitioner who is
employed by the same
clinic (same tax
ID number) as the
surgeon.
Separate payment of
the E/M may be
allowed.
Services will be denied
if the surgical
procedure code is
submitted with the –56
modifier or billed by a
practitioner who is
employed by the same
clinic (same tax ID
number) as the
surgeon.
Separate payment of
the E/M may be
allowed.
Do not append this modifier when a
minor surgical procedure (0, 10 day
global period) is performed.
The –57 should not be used to report an
E/M service that was pre-planned or prescheduled the day before or the day of
surgery, as they would be included as
part of the global surgical package.
9-31
Mod
Description
Impact To Payment
-59
Distinct
Procedural
Service
Modifier –59 may be appended to
identify procedures/services that are not
normally reported together, but are
appropriate under the circumstances.
However, when another already
established modifier is appropriate it
should be used rather than modifier –59.
Only if no more descriptive modifier is
available, and the use of modifier –59
best explains the circumstances, should
be modifier –59 be used. Modifier –59 is
always appended to the component
procedure code. Documentation
supporting the separate and distinct status
must be present in the patient’s medical
record.
Modifer-59 may not
affect edits or payment.
However, if applicable,
the modifier should be
appended to the
service. Generally, the
–59 modifier is only
applicable to those
code combinations
noted in the Correct
Coding Initiative (CCI)
code list with a
modifier indicator of
“1” which specifies the
services are distinct and
separate and thus
allowed. Service denied
may be considered on
subsequent appeal.
-62
Two Surgeons
The use of this modifier is appropriate to
identify the use of two primary surgeons
when required during a surgical
procedure. Documentation should be
submitted to support the use of the –62
modifier.
Payment will be
determined based on
the Medicare Physician
Fee Schedule Database
(MPFSDB) indicators 1
or 2 and based on
Medical Review of
supporting
documentation.
-66
Surgical Team
The use of this modifier is appropriate to
identify the services of a physician
involved as part of a surgical team.
Under some circumstances, highly
complex procedures (requiring the
concomitant services of several
physicians, often of different specialties)
are carried out under the “surgical team”
concept.
Payment will be
determined based on a
case-by-case basis and
review of supporting
documentation.
9-32
Mod
Description
Impact To Payment
-76
Repeat
Procedure,
Same Physician
The practitioner may need to indicate that Separate payment of
a procedure or service was repeated
the service may be
subsequent to the original procedure or
made.
service on the same day. This
circumstance may be reported by adding
modifier –76 to the repeated
procedure/service (i.e., 82947 glucose,
82947-76 repeat glucose).
Note: In situations warranting the use of
both the –26 and –76 modifier (e.g.,
reading multiple chest x-rays of a patient
performed on the same day), submit the –
26 modifier in the first position with the
initial procedure and the –76 in the first
position for the repeat procedure.
-77
Repeat
Procedure,
Another
Physician
The practitioner may need to indicate that Separate payment of
a procedure or service was repeated
the service may be
subsequent to the original procedure or
made.
service on the same day. This
circumstance may be reported by adding
modifier –77 to the repeated
procedure/service (i.e., 82947 glucose,
82947-77 repeat glucose).
Note: In situations warranting the use of
both the –26 and –77 modifier (e.g.,
reading multiple chest x-rays of a patient
performed on the same day), submit the –
26 modifier in the first position with the
initial procedure and the –77 in the first
position for the repeat procedure.
-79
Unrelated
Procedure/Servi
ce, same
physician
during post-op
period
Append this modifier to
Separate payment of
procedures/services performed during the the service may be
post operative period of another
made.
procedure, if the procedure/service is
unrelated to the original procedure.
-80
Assistant
Surgeon
Append this modifier to surgical assists
performed by a physician, nurse
practitioner, or RNFA.
Payment is made at
16% of the allowed
amount.
EPNI adheres to CMS’ published list of
services eligible for surgical assist.
Multiple surgery
pricing logic also
applies to assistant at
surgery services.
9-33
Mod
Description
Impact To Payment
-90
Reference
(outside) Lab
The use of the –90 modifier is
appropriate when a lab provider, not the
treating physician, performs a laboratory
procedure. The –90 modifier should be
appended to the procedure code/test that
was sent to the lab.
The modifier does not
impact payment for the
lab test; however, it
may be used in
determining whether
payment will be made
for more than one type
of specimen collection.
-91
Repeat Clinical
Diagnostic Lab
Test
Append the modifier to a lab procedure
that was repeated during the day.
Separate payment of
the service may be
made.
-AA
Anesthesia
services
performed
personally by
the
anesthesiologist
Append the modifier when the
anesthesiologist is physically present in
the operating room, personally performs
the induction and emergence, and
directly monitors the patient throughout
the entire operative procedure.
Payment is made at the
full-time anesthesia
conversion rate.
-AD
Medical
supervision by a
physician; more
than four
concurrent
anesthesia
procedures
anesthesiologist supervises more than
four concurrent anesthesia procedures.
The anesthesiologist may perform the
induction and emergence but may not be
present during the entire operative
session.
part-time anesthesia
conversion rate.
-AS
Assistant at
Surgery
Append this modifier to surgical assists
performed by a physician assistant.
Payment is made at
16% of the allowed
amount.
Multiple surgery
pricing logic also
applies to assistant as
surgery services.
-QK
9-34
Medical
direction (by
physician) of
two, three or
four concurrent
procedures by
qualified
personnel
anesthesiologist supervises more than
four concurrent anesthesia procedures.
session.
conversion rate.
Mod
Description
Impact To Payment
-QS
Monitored
anesthesia
service
anesthesiologist provides specific
anesthesia services to a particular patient
undergoing a planned procedure
including performing a preanesthetic
examination, be physically present in the
operating suite, monitors the patient’s
condition, and is prepared to furnish
anesthesia services as necessary.
conversion rate. Only
one –QS service per
day will be allowed.
-QX
CRNA service
with medical
direction by a
physician
Append the modifier on the CRNA
charges when the anesthesiologist
supervises the CRNA who performed the
anesthesia procedure. The
anesthesiologist may perform the
session.
conversion rate.
-QY
Medical
direction of one
Certified
Registered
Nurse
Anesthetist by
an
anesthesiologist
Append the modifier on the
anesthesiologist charges when the
anesthesiologist supervises the CRNA
who performed the anesthesia procedure.
session.
conversion rate.
-QZ
CRNA service
without medical
direction by a
physician
Append the modifier when the CRNA is
physically present in the operating room,
personally performs the induction and
emergence, and directly monitors the
patient throughout the entire operative
procedure.
full-time anesthesia
conversion rate.
-TC
Technical
component
Under certain circumstances, a charge
may be made for the technical
component alone. Under those
circumstances the technical component
charge is identified by adding modifier
‘TC’ to the usual procedure number.
Payment is made based
on the technical portion
of the RVU associated
with the service.
The technical component applies to the
actual physical performance of the
service, which includes the equipment,
supplies and personnel.
9-35
Anatomical
Modifiers
The following modifiers indicate a specific anatomic site. They should
be submitted in the first modifier position, if applicable. Appropriate
use of these modifiers may assure correct claims adjudication.
Code
Definition
E1
Upper left eyelid
E2
Lower left eyelid
E3
Upper right eyelid
E4
Lower right eyelid
F1
Left hand second digit
F2
Left hand third digit
F3
Left hand fourth digit
F4
Left hand fifth digit
F5
Right hand thumb
F6
Right hand second digit
F7
Right hand third digit
F8
Right hand fourth digit
F9
Right hand fifth digit
FA
Left hand thumb
LC
Left circumflex coronary artery
LD
Left anterior descending coronary artery
LT
Left side (used to identify procedures performed on the left side of the body)
RC
Right coronary artery
RT
Right side (used to identify procedures performed on the right side of the body)
T1
Left foot second digit
T2
Left foot third digit
T3
Left foot fourth digit
T4
Left foot fifth digit
T5
Right foot great toe
T6
Right foot second digit
9-36
Code
Definition
T7
Right foot third digit
T8
Right foot fourth digit
T9
Right foot fifth digit
TA
Left foot great toe
Modifiers defined
by DHS
The national HCPCS Panel developed several modifiers that could be
defined by the various state Medicaid agencies. The Minnesota
Department of Human Services has defined these as follows.
Each modifier has more than one definition dependent on what service it is
appended to or the program affected. The modifiers are generally
informational only.
Code
Definition
Instruction
U1
Definition 1= Vulnerable Adult Case Management
Append the modifier if
directed to in guidelines that
may be found elsewhere in
this manual.
Definition 2= IEP Physical Therapy (T1018)
Definition 3= Added absorbency (A4521-A4554)
Definition 4= CDCS- Personal Assistance (T2028)
Definition 5= Transitional Services- furniture
(T2038)
U2
Definition 1= Home Care Case Management
Definition 2= IEP Occupational Therapy (T1018)
Definition 3= Maximum absorbency (A4521-A4554)
this manual.
Definition 4= CDCS – Treatment & Training
(T2028)
Definition 5= Transitional Services- supplies
(T2038)
U3
Definition 1= CWTCM
Definition 2= IEP Speech Therapy (T1018)
Definition 3= NET Broker admin fee (A0080,
A0090, A0100, A0110, A0120)
this manual.
Definition 4= CDCS- Environmental Modifications
& Provisions (T2028)
9-37
Code
Definition
Instruction
U4
Definition 1= Case Management via Telephone
this manual.
Definition 2= IEP Mental Health Services (T1018)
Definition 3= NET Taxi or equal, door to door
(A0100)
Definition 4= CDCS- Self-direction Support
Activities (T2028)
U5
Definition 1= Partial Day (DT&H)
Definition 2= IEP Nursing Services (T1018)
Definition 3= NET Taxi or equal, wheelchair, curb
to curb (A0100)
this manual.
Definition 4= End tidal CO2 monitor, monthly
rental (E1399)
U6
Definition 1= Temporary Service Increase
Definition 2= IEP PCA/Paraprofessional Services
(T1018)
this manual.
Definition 3= NET Taxi or equal, wheelchair, door
to door (A0100)
Definition 4= End tidal CO2 spot check, weekly
rental (E1399)
U7
Definition 1= Physician Extender (medical services)
Definition 2= IEP Assistive Technology Devices
(T1018)
Definition 3= NET Bus/train, monthly pass (A0110)
Definition 4= Oximeter spot check, weekly rental
(E0445)
Append this modifier to
services by non-credentialed
or non-enrolled practitioners
when performing incident-to
services under the direct
supervision. The services
would be reported under the
directing physician’s provider
number. The modifier does
not impact payment.
this manual.
9-38
Code
Definition
Instruction
U8
Definition 1= Home Based Mental Health Service
this manual.
Definition 2= IEP Special Transportation (T1018)
Definition 3= NET Level of need assessment (LON)
(T1023)
Definition 4= CDCS-Flexible case management
(T2028)- separately recognized component of selfdirection support devices
U9
Definition 1= Therapeutic Support Foster Care
Definition 2= Behavioral Programming by Aide
(S5135)
directed in guidelines that
this manual.
Definition 3= NET level of need assessment (LON)
II (T1023)
Definition 4= Corporate settings (S5140, 55141,
T2030TG, T2032, T2017, T2016)
UA
Definition 1= Children’s Therapeutic Services and
Supports
Definition 2= Night Supervision (S5135)
this manual.
Definition 3= NET Broker review (T1023)
Definition 4= Supervision (T1019 and T1003)
UB
Definition 1= Non-reservation American Indian
Chemical Health only
Definition 2= 24-Hour Emergency Service (S5135,
S5136)
this manual.
Definition 3= NET Taxi or equal, wheelchair,
assisted
station to station (A0100)
Definition 4= DT&H Pilot Rate C (T2021)
Definition 5= Out-of-town Respite (S5150)
UC
Definition 1= Specialized Maintenance Therapy
Definition 2= Extended Home Care Services
Definition 4= Waiver Case Management (T1016)
this manual.
9-39
Code
Definition
Instruction
UD
Definition 1= Professional service for fitting and
evaluation of customized DME/PO (use with K0108)
this manual.
Definition 2= Transitioning to community living
services (90882, H2017)
Definition 3= ER Triage (99201, 99211)
Definition 4= AC Discretionary Service (T2025)
9-40
Anesthesia
Overview
EPNI accepts the CPT American Society of Anesthesiologists codes
(ASA), 00100-01999, for anesthesia services billed on a CMS-1500
claim form. We do not accept surgical codes submitted with anesthesia
modifiers. All services for the same operative session should be
submitted on the same claim.
Full-time
Anesthesia
Services
We define full-time anesthesia as follows:
Full-time anesthesia services are provided personally by the
anesthesiologist to an individual patient. The anesthesiologist is
physically present in the specific operating room, personally performs
the induction and emergence, and directly monitors the patient
throughout the entire operative procedure. The anesthesiologist may
leave the specific operating suite to perform necessary administrative
duties. However, the anesthesiologist does not perform other revenuegenerating procedures when billing full-time anesthesia services. This
definition includes one-on-one supervision of a certified registered
nurse anesthetist (CRNA) present in the same operating suite.
Use modifier AA for full-time physician services.
EPNI also considers anesthesia services provided by independent
CRNA and physician-employed CRNA to be full-time if the above
criteria are met and medical direction is not provided by a physician.
Modifier QZ would be used for full-time CRNA services.
The HCPCS level II modifiers (AA and QZ) should be listed in the first
modifier position.
The anesthesia modifiers should only be reported with the CPT
anesthesia codes 00100-01999. Other services (such as nerve blocks),
may be performed by an anesthesiologist or CRNA, but should not be
submitted with an anesthesia modifier.
9-41
Part-time
(Medically
Directed)
Anesthesia
Services
Medically directed anesthesia services are provided by the
anesthesiologist when he or she is supervising two or more CRNAs.
The anesthesiologist may perform the induction and emergence but is
not necessarily present during the entire operative session and may be
supervising two or more procedures at the same time.
Use modifier -AD or -QK for the medical direction provided by a
physician (part-time services).
Use modifier -QY for part-time medical direction of one CRNA by an
anesthesiologist.
Use modifier -QX for medically directed CRNA services (part-time).
Use modifier -QS for part-time monitored anesthesia care.
The HCPCS level II modifiers (AD, QK, QS, QX and QY) should be
listed in the first modifier position.
Qualifying
Circumstances
Physical Status
9-42
In accordance with CPT, the following circumstances are recognized for
submission of risk. The corresponding eligible base units that may be
allowed are also listed.
Code
Base Units
Description
99100
1
Anesthesia for patient of extreme age; under
one year and over 70. (List separately in
addition to the code for the primary anesthesia
procedure.)
99116
5
Anesthesia complicated by utilization of total
body hypothermia. (List separately in addition
to the code for the primary anesthesia
procedure.)
99135
5
Anesthesia complicated by utilization of
controlled hypotension. (List separately in
addition to the code for the primary anesthesia
procedure.)
99140
2
Anesthesia complicated by emergency
conditions (specify). (An emergency is defined
as existing when delay in treatment of the
patient would lead to a significant increase in
the threat of life or body part.) (List separately
in addition to the code for the primary
anesthesia procedure.)
Six levels are currently recognized for patient physical status that may
be used to distinguish various levels of complexity of the anesthesia
service provided. Submit these physical status modifiers in the second
modifier position, on the same line as the anesthesia service code. The
corresponding eligible base units that may be allowed are also listed.
Qualifying
Circumstances
and Physical
Status
Submission
Modifier
Base
Units
Description
P1
0
Normal, healthy patient
P2
0
Patient with mild systemic disease
P3
1
Patient with severe systemic disease
P4
2
Patient with severe systemic disease that is a
constant threat to life
P5
3
A moribund patient who is not expected to
survive without the operation
P6
0
Declared brain-dead patient whose organs are
being removed for donor purposes
The example below illustrates a claim that is submitted appropriately. It
is for a situation where both qualifying circumstances and physical
status may apply.
Procedure
Code
Modifier
Description
00862
AA
Anesthesia for extra- peritoneal procedures in
lower abdomen, including urinary tract; renal
procedures, including upper 1/3 of ureter, or
donor nephrectomy; performed by a full-time
M.D.; patient with severe systemic disease.
P3
99140
AA
Emergency procedure performed by a full-time
MD.
Electroconvulsive
Treatments
To bill for anesthesia for electroshock treatments (00104), submit the
appropriate anesthesia modifier. Time units and risk are recognized for
this service.
Local Anesthesia
Local anesthesia, such as a nerve block, is included in the surgical
procedure code. Do not submit a separate charge for this service.
Medical Services
and Invasive
Procedures
Anesthesia HCPCS modifiers should be submitted with ASA codes
only. Do not submit anesthesia modifiers with medical services such as
hospital visits, consultations, ventilation management, CPR, daily
epidural management, or with invasive procedures such as vascular
injections or nerve blocks.
Epidural
Anesthesia for a
Surgical
Procedure
The insertion and administration of an epidural by an anesthesia
provider for anesthesia during a surgical procedure should be reported
with the appropriate anesthesia code. Codes 62311 or 62319 should not
be used.
9-43
Epidural
Anesthesia for
Pain
Management
The insertion of an epidural catheter for pain management services by a
qualified provider should be reported with either code 62311 or 62319,
as appropriate. Time units are not appropriate for codes 62311 and
62319, and anesthesia modifiers are not required.
Anesthesia for
Nerve Blocks
Anesthesia services for diagnostic or therapeutic nerve blocks and
injections are submitted under codes 01991 or 01992 only when a
different provider performs the block or injection.
Daily
Management of
Epidural Drug
Administration
Daily management of an epidural catheter performed on the same date
as the insertion of the catheter is considered to be included in the
insertion and should not be reported separately.
Subsequent daily management of epidural drug administration in the
inpatient setting, including daily visits and removal of the epidural
catheter, may be reported using CPT code 01996 (daily management of
epidural or subarachnoid drug administration).
Do not submit anesthesia modifiers or time for epidural daily
management.
Removal of the epidural catheter alone does not constitute daily
management. If the only service performed is removal of the catheter,
code 01996 should not be reported. Subsequent daily management of an
epidural catheter performed in a setting other than inpatient hospital
should be reported using the appropriate Evaluation and Management
code.
9-44
Epidural
Anesthesia for
Labor and
Delivery
Insertion Only
When a provider performs the insertion of an epidural catheter for
continuous analgesia, but does not participate in the ongoing
management and monitoring of the epidural analgesia for labor and
delivery, the claim should be for the insertion service only (code
62319). Time units are not appropriate for code 62319, and anesthesia
modifiers are not required.
Insertion and Management
When a provider inserts the epidural catheter and participates in
ongoing management and monitoring of the patient's epidural analgesia,
the anesthesia code 01967 (neuraxial labor analgesia/ anesthesia for
planned vaginal delivery) or 01968 (anesthesia for cesarean delivery
following neuraxial labor analgesia/anesthesia) should be reported for
the complete service using the appropriate anesthesia modifier, with
anesthesia time units for actual face-to-face time. It would not be
appropriate to report 62319 for the insertion of the catheter in addition
to the epidural management.
99140
It is also not appropriate to bill the emergency qualifying circumstance
code (99140) with normal deliveries. Emergency code 99140 applies
only to cases where a “delay in treatment would result in an increased
risk to life or body part,” according to the ASA Relative Value Guide.
Do not confuse inconvenient case with emergencies, such as a surgery
that takes place on the weekend or after normal business hours.
Management Only
In many cases, a physician will insert the epidural catheter, but a CRNA
is responsible for the ongoing management and monitoring of the
patient’s epidural analgesia. When this is the case, the CRNA should
submit the anesthesia code 01967 or 01968 using the appropriate
anesthesia modifier, with anesthesia time units for actual face-to-face
time.
9-45
Moderate
(conscious)
Sedation
The physician who performs a procedure may bill moderate sedation,
codes 99143 - 99145, in addition to billing the procedure. The use of
these codes requires and includes an independent trained observer. The
observer is not eligible to bill for anesthesia. Do not submit an
anesthesia modifier with these codes.
When a second physician, other than the healthcare professional
performing the procedure, provides moderate sedation in the facility
setting (e.g., hospital, outpatient hospital/ambulatory surgery center) the
second physician reports 99148 - 99150. Codes 99148 - 99150 may not
be reported in a non-facility setting (e.g., office).
Do not submit 99143 - 99150 with procedures that include conscious
sedation as an inherent part of providing the procedure. These
procedures are listed in Appendix G of the 2005 CPT manual. The
target symbol (~) will precede applicable codes in the main body of the
CPT manual.
Monitored
Anesthesia Care
Monitored anesthesia care (MAC) refers to instances in which an
anesthesiologist has been called on to provide specific anesthesia
services to a particular patient undergoing a planned procedure. In this
case, the physician performs a preanesthetic examination, is physically
present in the operating suite, monitors the patient’s condition, makes
medical judgments regarding the patient’s anesthesia needs, and is
prepared to furnish anesthesia service as necessary.
For those circumstances under which such care is medically necessary
and requested by the performing surgeon, EPNI will allow submission
for MAC the same as for any other anesthesia service.
Use modifier -QS for monitored anesthesia services.
Patient
Controlled
Analgesia
EPNI recognizes that patient-controlled analgesia (PCA) has
demonstrated clear value to the patient. However, we do not recognize a
separate charge for this service because postoperative pain control has
already been included in the reimbursement of the surgical fee, which
was paid to the performing surgeon. Patient controlled analgesia is also
given to patients who have not had surgery (such as cancer patients) for
pain control. It will be covered in such cases.
Standby
Anesthesia standby occurs when an anesthesiologist or CRNA is present
in case his or her services are required for anesthesia, but otherwise
performs no medical intervention. EPNI does not cover anesthesia
standby. Standby services are considered ineligible and should not be
billed to EPNI or the patient.
Documentation
The anesthesia record (either at the facility or the provider’s office)
must clearly identify the professional or professionals providing the
anesthesia service. For legal reasons, and in order to justify charges,
EPNI requests that both the CRNA and anesthesiologist signatures be
present for medically directed care.
9-46
Time
Designation/Sub
mission
Anesthesia time should be indicated on the CMS-1500 claim form in the
unit field (24G). Anesthesia time begins when the anesthesiologist or
CRNA begins to prepare the patient for the induction of anesthesia in
the operating room, or an equivalent area, and ends when they are no
longer in personal attendance.
Code the anesthesia time as minutes in the units of service field. See the
sample CMS-1500 form, fields 24D-24G.
Diagnosis Coding
Use ICD-9-CM diagnosis codes. Select the diagnosis code that best
describes the reason for the surgery based on the patient’s medical
record. Use code V50.1, plastic surgery for unacceptable cosmetic
surgery appearance, when the patient has requested elective surgery and
that is the only surgery performed during an operative session.
Multiple Surgery
Code anesthesia services associated with multiple or bilateral surgical
procedures performed during the same operative session with the single
anesthesia code that has the highest base unit value.
Add-on
Anesthesia
Procedures
Only one anesthesia code will be accepted and processed. Do not
submit “add-on” anesthesia procedures.
9-47
Behavioral Health Services for CMS-1500
Overview
This section of the manual is intended for all mental health (behavioral
health) practitioners who bill on the CMS-1500 claim form. This section
is not intended for practitioners whose services are billed on the UB-92.
Practitioners
who Should be
Using this
Section
Psychiatrists, PhD level psychologists, masters level psychologist,
Licensed Independent Clinical Social Worker, Certified Nurse
Specialist in Psychiatry and Licensed Marriage and Family Therapist,
and Psychiatric Mental Health Nurse Practitioner.
For Rule 29 clinics all other behavioral health practitioners should bill
with these codes under the supervising practitioner's individual provider
number and with the "U7" modifier.
Units
9-48
One unit should be submitted based on the HCPCS code narrative. If
there is no time designation the service is considered ‘per session’ and
only one unit should be submitted regardless of actual time spent.
Coding
Restrictions
Psychiatry and
Chemical
Dependency
Assessments
Code
Restriction
90816 90829
Inpatient Therapy codes are not covered based on APA
coding guidelines.
90845
Psychoanalysis is generally a member contract exclusion. If
covered, must be provided by a MD.
90846
Family Therapy without the patient present is generally not
covered if the patient is over the age of 18.
90882
Environmental intervention for medical management
purposes is not covered because it is included in the
practitioner's basic service.
90885
Psychiatric evaluation of hospital records - not covered
because it is included in the practitioner's basic service.
90887
Interpretation or explanation of exam results - not covered
because reimbursement is included in the testing code.
90889
Preparation of report- not covered as a contract exclusion.
90899
Unlisted code-narrative and documentation of time must be
submitted. Must be provided by a MD.
90801 and 90802
This is a per session code. Bill one unit of service per session regardless
of time.
Either 90801 or 90802 can be billed with either a chemical dependency
diagnosis, or a psychiatric condition diagnosis.
If the assessment does not reveal a behavioral health condition, bill with
the sign or symptom precipitating the assessment.
Rule 25 – Chemical dependency assessors should submit their
assessments with a 90801 on a CMS-1500 form.
9-49
Family Therapy
90846
90846 is billed for family therapy when the patient is not present. It is
usually only covered until the patient is 18, but there may be specific
contract exclusions on some self-insured groups.
90846 should be billed under the specific patient, not the member.
Bill one unit per session regardless of total time.
90847
90847 is billed for family therapy when the patient is present. It is
usually only covered until the patient is 18, but there may be a specific
contract exclusion on some self-insured groups.
90847 should be billed under the specific patient, not the member.
Bill one unit per session regardless of total time.
Medication
Management
M0064 and 90862
It is not appropriate to bill a medication management code on the same
day as an evaluation and management. If both are billed on the same
day the medication management service will deny as incidental to the
evaluation and management code.
Medication management can be billed by a nurse practitioner, physician
assistant, M.D. and clinical nurse specialist in psychiatry, and
psychiatric mental health nurse practitioner.
Medication management is eligible with a psychiatric diagnosis but is
not with a chemical dependency diagnosis.
This service is eligible when billed in the office or skilled nursing
facility. It is not an eligible service when billed with an inpatient place
of service. A medication management visit billed on the same day as an
inpatient visit will deny as incidental to the inpatient visit.
Medication management rendered in the outpatient clinic setting should
be billed on a professional claim only (837P or CMS-1500). If billed on
a facility claim it will be denied.
M0064 includes a component for a brief office visit.
9-50
Behavioral
Health
Evaluation &
Management
(E&M) Office
Calls
99201 – 99215
Patients who receive an E/M service billed with a behavioral health
diagnosis within their designated primary care clinic by a nonbehavioral health practitioner will have services reimbursed according
to their behavioral health contract benefit.
This E/M service will not be accumulated towards any dollar or visit
maximums.
A member who receives a behavioral health E/M service by a nonbehavioral health practitioner outside their PCC, but not within the
Select Behavioral Health Network will require a referral for their
highest level of benefits.
Fee for service members who have open access to the EPNI network
and receive a behavioral health E/M service by a non-behavioral health
practitioner will have services reimbursed according to their behavioral
health contract benefit.
This E/M service will not be accumulated towards any dollar or visit
maximums.
Behavioral health E/M services provided outside the EPNI network will
be subject to the member’s nonparticipating provider benefit limitations.
Nutritional
Counseling
97802 - 97804, S9470
Eligibility of
Dieticians /
Nutritionists
Eating disorder diagnosis:
For eating disorder diagnosis 307.1, 307.50 & 307.51, licensed
nutritionists and licensed dieticians can bill independently for procedure
codes S9470, 97802, 97803, and 97804. No referral is required for the
highest benefit level.
Nutritional counseling is eligible if billed with either a behavioral health
diagnosis or a medical diagnosis.
Registered dietician services must be submitted to EPNI by an eligible
medical clinic or hospital. The individual provider number of the
registered dietician must be submitted on the claim. Registered
dieticians can only bill for procedure codes S9470, 97802, 97803, and
97804 with behavioral health diagnoses.
All other diagnoses:
Licensed nutritionists and licensed/certified dietitians can bill
independently for procedure codes S9470, 97802, 97803, and 97804 for
any diagnosis.
Claims for registered dieticians billing services outside of behavioral
health diagnoses will deny unless the services are submitted under the
individual provider number of a supervising physician. The modifier U7 should also be submitted.
9-51
Psychological
Testing
96101 - 96103, 96118 - 96120
There are no limits on the number of hours required to complete the
testing. Total time will accumulate towards the patient’s benefit
maximums.
Each test should be associated with medical necessity-not a battery of
test for screening purposes.
90887 (explanation of findings) should not be billed, reimbursement for
these services is included in the testing reimbursement.
The CPT® codes for psychological and neuropsychological testing were
effective January 1, 2006. These new codes reflect who does the testing:
a psychologist, a technician or a computer. EPNI is providing coverage
and billing policies for these codes on the following pages.
9-52
Code
Narrative
Units
Practitioner
General Policies
96101
Psychological
testing (includes
psychodiagnostic
assessment of
emotionality,
intellectual abilities,
personality and
psychopathology,
e.g., MMPI,
Rorschach, WAIS),
per hour of the
psychologist’s or
physician’s time,
both face-to-face
time with the patient
and time interpreting
test results and
preparing the report.
Report 1unit per
hour of face-toface testing,
interpretation and
preparation of
report
MD, LP-PhD,
LP-MA
The psychologist
or psychiatrist
administers and
interprets the
test(s) and prepares
the report.
Psychological
testing (includes
psychodiagnostic
assessment of
emotionality,
personality and
psychopathology,
e.g., MMPI and
WAIS), with
qualified health care
professional
interpretation and
report, administered
by technician, per
hour of technician
time, face-to-face.
Report 1 unit per
hour of face-toface testing
96102
Billed under the
MD, LP-PhD, LPMA individual
provider number.
MD, LP-Ph.D.,
LP-MA,
LICSW, CNSPsych, LMFT
A technician under
direct supervision,
administers the
test(s).
The supervising
qualified licensed
practitioner
interprets the
the report.
Billed under the
supervising
licensed
practitioner
provider number.
9-53
Code
Narrative
Units
Practitioner
General Policies
96103
Psychological
testing (includes
psychodiagnostic
assessment of
emotionality,
personality and
psychopathology,
e.g., (MMPI),
administered by a
computer, with
professional
interpretation and
report.
Report 1 unit per
testing session
regardless of the
number of tests
taken
MD, LP-Ph.D.,
LP-MA,
LICSW, CNSPsych,
PMHNP,
LMFT, NP, PA
Patient is alone and
taking a computerbased test.
Neuropsychological
testing (e.g.,
Halstead-Reitan
neuropsychological
battery, Wechsler
memory scales and
Wisconsin card
sorting test), per
hour of the
psychologist’s or
physician’s time,
both face-to-face
time with the patient
and time interpreting
test results and
preparing the report.
Report 1 unit per
hour of face-toface testing,
interpretation and
preparation of
report
96118
9-54
A qualified
licensed
practitioner
interprets the
the report.
Billed under the
licensed
practitioner
provider number.
MD, LP-PhD,
LP-MA
The psychologist
or psychiatrist
administers and
interprets the
the report.
Billed under the
MD, LP-PhD, LPMA individual
provider number.
Code
Narrative
Units
Practitioner
General Policies
96119
Neuropsychological
testing (e.g.,
Halstead-Reitan
nuropsychological
battery, Wechsler
memory scales and
Wisconsin card
sorting test), with
professional
interpretation and
report administered
by technician, per
hour of technician
time, face-to-face.
Report 1 unit per
hour of
MD, LP-PhD,
LP-MA
A technician,
under direct
supervision,
administers the
test(s).
Neuropsychological
testing (e.g.,
Wisconsin card
sorting test),
administered by a
computer, with
professional
interpretation and
report.
Report 1 unit per
testing session
regardless of the
number of tests
taken
96120
The supervising
qualified licensed
practitioner
interprets the
the report
Billed under the
supervising
licensed
practitioner
provider number.
MD, LP-PhD,
LP-MA
taking a computerbased test.
A qualified
licensed
practitioner
interprets the
the report.
Billed under the
licensed
practitioner
provider number
Practitioner Key
CNS-Psych = Clinic Nurse Specialist, Psychiatric specialty;
LP-Ph.D. = Licensed Psychologist, Doctorate; LP-MA = Licensed
Psychologist, Masters; LICSW = Licensed Clinical Social Worker;
MD = Psychiatrist; PMHNP = Psychiatric Mental Health Nurse
Practitioner; LMFT = Licensed Marriage and Family Therapist;
PA = Physician’s Assistant; NP= Nurse Practitioner
9-55
Policies
Policies applicable to the codes on the previous pages:
•
Test result interpretation and report preparation are an inherent part
of the testing service and not separately billable. Only one testing
code may be billed.
•
Only a licensed psychologist or other licensed health care
professional may bill for the psychological and neuropsychological
tests.
•
The date of service submitted should be the date the test(s) is
completed, regardless of when the test and/or report is completed.
•
Testing, scoring and interpretation done solely by a computer is not
a billable service.
•
There is no specific definition of technician: a technician may be a
psychometrist, student or trainee. However, the testing may be
reported if the service is rendered under direct supervision of a
qualified practitioner. The testing will be billed under the
supervising practitioner’s individual provider number.
•
Direct supervision definition: The physician/qualified practitioner
must be present in the office and immediately available to assist and
direct throughout the performance of the service.
•
Direct personal supervision does not mean that the
physician/qualified practitioner must be present in the same room
with the non-physician/qualified practitioner. A physician/qualified
practitioner cannot provide direct or personal supervision via
telemedicine. Direct supervision is only applicable in the office
place of service.
Marital
Counseling
Diagnosis Code V61.10
Opiod
Maintenance
Drug Therapy
H0020
Generally, marital counseling is a member contract exclusion and will
deny as member responsibility when this diagnosis code is used as the
primary diagnosis.
Participating freestanding opioid treatment clinic services should be
billed on a CMS-1500 using HCPCS code H0020 and the appropriate
chemical dependency iagnosis code. H0020 would be used for either
Methadone or Buprenorphine administration.11
Members will have services paid at the highest level of benefits within
the Select Network. No referral will be required.
Services can be billed on one line, 1 unit = 1 day.
No individual provider number is required.
9-56
Tobacco
Cessation
Diagnosis Codes 305.1 or V15.82
If the intent is counseling and/or visit to obtain a prescription for
smoking cessation medication/patches submit diagnosis 305.1 or
V15.82.
If linked to an E/M service a preventative or general illness benefit will
be applied depending on the member’s benefits.
Do not use as a primary diagnosis if the member has a primary
behavioral health diagnosis that is being treated such a depression but
member also uses tobacco. If so, 305.1 or V15.82 should be listed as a
secondary diagnosis.
Rule 29 Setting
State licensed Rule 29 clinics will have three provider numbers:
•
One for services in the clinic
•
One for M.D/Psychiatrists to bill for inpatient services
• One for PhD level psychologists to bill for inpatient services
Services should be billed under the appropriate provider number. Any
inpatient services billed under the Rule 29 clinic provider number will
be denied.
Rule 29 clinics can only provide outpatient mental health services under
this licensure. Some Rule 29 clinics will also be licensed as
nonresidential chemical dependency providers. It is important to keep
these two entities separate.
Chemical dependency assessments (code as 90801) with a chemical
dependency diagnosis can be provided under the Rule 29 provider
number but no other chemical dependency services.
If a patient is being treated for depression secondary to a chemical
dependency, the depression diagnosis should be billed as the primary
diagnosis under the Rule 29 clinic provider number.
Non-licensed practitioners may treat patients, however their services
MUST be billed under the supervising practitioner’s individual provider
number with the ‘U7’ modifier.
Day Treatment
H2012
Day treatment services are provided at a licensed Rule 29 facility. Day
treatment is defined by the patient attending a minimum of three hours
per day.
Bill one line for each day and one unit for each hour the patient attends
the program.
Services are reimbursed under the patient’s behavioral health benefit.
9-57
Compatibility
This is a very common and frequent cause for claim denials.
The diagnosis code and CPT code must be compatible with the
practitioner’s licensure.
Mental health diagnosis codes are generally only compatible with the
psychiatric CPT codes with the exception of 90801 and 90802 which
are also compatible with a chemical dependency diagnosis.
Health and
Behavior
Assessment
Codes
96150 - 96155
Codes 96150 - 96155 are eligible to be billed by all behavioral
practitioners. However, per CPT, 96150 - 96155 describe services
offered to patients who present with established illnesses or symptoms,
are not diagnosed with mental illness, and may benefit from evaluations
that focus on biopsychological factors related to the patients’ physical
health status. The primary diagnosis for the claim line containing the
assessment, and intervention codes should be a non-behavioral
diagnosis code.
An example would be a newly diagnosed cancer patient or a patient
struggling with infertility.
9-58
Missed
Appointments
EPNI does not pay for missed scheduled appointments. EPNI
recommends that your clinic establish a uniform cancellation policy
requiring 24-hour advance notification. Your clinic may bill a patient
who misses a scheduled behavioral health appointment, provided you
have notified the member in writing in advance that this is your policy.
A copy of this signed notification should be maintained in your patient’s
medical record. Your patient should be billed no more than your
contracted rate. Government programs like Medicare prohibit billing for
missed appointments.
Policy applies to:
This policy applies to providers whose scope of practice is Behavioral
Health, including Psychiatrists, Licensed Psychologists (LP), Licensed
Independent Clinical Social Workers (LICSW), Licensed Marriage and
Family Therapists (LMFT), Registered Nurse Clinical Specialist (CNS)
and Out-patient Chemical Dependency (OPCD) facilities. This policy
change is not intended to apply to medication management provided
within the member’s primary care clinic or internist’s office.
Guidelines to be followed:
EPNI would expect Behavioral Health providers to abide by the
following guidelines:
Medicare members cannot be charged for missed appointments
Establish a reasonable business policy that allows for patients not to be
charged for failed appointments due to circumstances outside of their
control
Abide by guidelines established by the American Medical Association
(AMA) and the American Psychological Association (APA), which
state it is ethical for providers to charge for missed appointments or for
appointments not canceled at least 24 hours in advance, if patients are
fully advised of the possibility of such charges
9-59
Court Ordered
Treatment
When a court order for treatment is based on evaluation and
recommendation by a physician, licensed psychologist, licensed alcohol
and drug dependency counselor or a certified chemical dependency
assessor (rule 25) we will consider the order medically necessary.
EPNI will provide coverage for these court ordered services according
to the patient’s contract benefits. For example if the member does not
have inpatient chemical dependency benefits and the patient is court
ordered into inpatient chemical dependency treatment, there will be no
coverage for the services.
The evaluation and court order MUST be faxed in to Care Management
at (651) 662-0851 as soon as possible so the necessary approval can be
entered into the claim system and ensure the claim is paid accurately.
If the court order is to a specific non-network provider but the member
does not have any benefits for non-network providers, EPNI will cover
the services as they would for any other network provider. However,
fee-for-service members will be responsible for the difference between
the billed amount and EPNI’s allowed amount.
9-60
Guidelines for
Court Ordered
Evaluations
An appropriately licensed physician or psychologist must perform the
mental health assessment. A physician, licensed alcohol and drug
dependency counselor, or certified chemical dependency assessor must
perform the chemical dependency assessment.
The following services are eligible for EPNI coverage (subject to the
terms of the member's contract):
•
Mental Health evaluations/diagnostic assessments and related
testing
•
Chemical Health evaluations
•
72 hour holds under the Mental Health Act, Minn. Stat. § 253B.05
•
24 hour mental health observation beds
•
Mental Health evaluations to determine the need for civil
commitment for treatment
The following are EPNI guidelines regarding Mental Health Evaluation
components: (From EPNI Behavioral Health Guidelines for Treatment
Record Documentation previously sent to providers by EPNI Quality
Improvement.)
•
The assessment or mental status exam is to identify appropriate
subjective and objective information pertinent to the patient's
presenting complaint. The presenting symptoms are to be clearly
identified with the onset, duration and intensity documented.
•
The assessment contains the patient's presenting problem(s) as well
as relevant psychological or social conditions affecting the patient's
medical or psychiatric status. For children and adolescents (18 and
under), past medical history and psychiatric history includes
prenatal and perinatal events and a complete developmental history
(physical, psychological, social, intellectual, and academic).
•
The mental status exam is to document the patient's affect, speech,
mood, thought content, judgment, insight, attention or
concentration, memory, impulse control, suicidal ideation and
homicidal ideation.
•
For patients 10 years and older, there is to be an appropriate notation
in the assessment concerning past and present use of tobacco,
alcohol, as well as illicit, prescribed and over-the-counter
substances.
•
Past medical/behavioral history is easily identifiable in the record
and includes, if applicable; previous treatment dates, former
provider information, therapeutic interventions and responses,
source of clinical data, relevant family information, results of lab
test and consultation reports.
9-61
Guidelines for
Court Ordered
Evaluations
(continued)
•
To determine if a comprehensive substance abuse evaluation is
needed, a substance abuse screening is to be incorporated into the
assessment of all new patients. This can be accomplished by the use
of brief questionnaires such as the CAGAID or the AUDIT.
•
The provider is to have procedures in place for the re-assessment of
patients who return for treatment after having been out of treatment
for an extended period of time.
•
The MH evaluation components of the following assessments are
eligible for EPNI coverage (subject to the terms of the member's
contract):
•
Civil Competency evaluations (Evaluation to guide courts in
determining whether a person is mentally competent to manage their
own affairs)
•
Competency and Diminished Capacity Evaluations (Evaluation to
guide courts in determining whether to award guardianship of an
adult)
Domestic violence assessments
Pre-placement assessments (For evaluation prior to county placement in
various settings, which may include foster care, shelter care, residential
treatment, corrections, etc.)
Sex offender evaluations (does not cover the criminal history review nor
risk assessment portions as identified in MN Rule 2955.0100, Subp.7.
A, B, C, D, G, and J)
Forensic Evaluations:
EPNI does not cover forensic evaluations conducted to answer specific
legal questions.
In contrast to a Mental Health Evaluation, a forensic evaluation is
conducted primarily to assist the legal system in making decisions
regarding family, civil or criminal matters. In these instances, the
summary and conclusions relate directly to the legal issues, and the
relationship between psychological factors and the legal issues are
described. (For more information go to
www.psychologyinfo.com/forensic/index.html, a link provided through
the American Psychological Association Web site.)
It is our expectation that a MH professional conducting one of the
following assessments will use their clinical judgment. In the event the
MH professional determines that the member requires a MH evaluation
as a component of one of these evaluations for the purpose of
identifying and determining treatment needs, EPNI will consider the
component eligible for coverage, subject to the terms of the member's
contract.
9-62
Guidelines for
Court Ordered
Evaluations
(continued)
The following are examples of forensic evaluations that are not covered
by EPNI:
•
Adoption home studies (Evaluation to guide courts in decision
whether to allow adoption of children by an individual or couple)
•
Adoption Readiness Evaluations (Evaluation to guide courts in
decisions regarding adoption placement planning)
•
Adult Pre-sentencing Evaluations (Evaluation to guide courts in
determining sentencing of adults in criminal matters)
•
Assessment of Emotional Factors in Sexual Harassment and
Discrimination (Evaluation to guide courts decision regarding
sexual harassment and/or discrimination)
•
Child Abuse Evaluations, including sexual abuse evaluations
(Investigative evaluation to determine presence and/or extent of
child physical and/or sexual abuse)
•
Child Custody Evaluations (Evaluations to guide the courts decision
in determining who should have custody of minor children)
•
Criminal Competency Evaluations (Evaluation to determine whether
a person is competent to stand trial)
•
Development of Family Reunification Plans (Service to guide courts
decisions regarding child placement/return to family setting)
•
Education classes for DUI offenses (Education classes/program
regarding driving under the influence. A CD diagnosis is not
required for attendance.)
•
Evaluating the Credibility of Child Witnesses (Evaluation to guide
courts in determining credibility of a child witness)
•
Evaluations of Juveniles accused of Criminal Acts (Evaluation to
guide courts in determining whether a minor should be tried as an
adult)
•
Evaluations to Assess Termination of Parental Rights (Evaluation to
guide courts decision regarding termination of parental rights)
•
Juvenile Pre-sentencing Evaluations (Evaluation to guide courts
decision related to sentencing in criminal matters)
•
Juvenile Probation Evaluations (Evaluation to guide courts decision
related to probation terms in criminal matters)
•
Mediation of Parental Conflicts about Children (Service to provide
assistance to parents engaged in a legal dispute over child custody
and/or visitation)
9-63
Guidelines for
Court Ordered
Evaluations
(continued)
•
Parenting Assessments/Parental Competency Evaluation
(Evaluation to guide the courts decisions about parental rights,
custody and placements)
•
Personal Injury Evaluations (Evaluation to guide courts decision in
awarding damages related to personal injury)
•
Visitation Risk Assessments (Evaluations to guide the courts
decision in determining child visitation rights. May include
grandparent visitation.)
•
Worker's Compensation Evaluations (Evaluation to determine extent
of damage related to a worker's compensation claim)
Parity
There are federal laws and state mandates that dictate mental health
parity laws which are applicable to all fully insured groups. Self-insured
groups are not subject to parity laws and legislation, unless they choose
to add this benefit. Parity means that a member’s behavioral health
benefits are exactly the same as their medical benefits. For example, if
the member has coverage from a non-network provider for illness E&M
service then they will have coverage for a non-network provider for a
behavioral health service.
Behavioral
Health Quality
Improvement
Objectives
Based upon results of the 2004 quality improvement activities and
National Committee for Quality Assurance (NCQA) standards, EPNI
requires participation from behavioral health providers in the following
activities.
Follow-up After Hospitalization for Mental Illness:
Offer appointments to new and returning patients within seven days of
mental health hospitalization discharge. Appointments should be
provided within the timeframe commensurate with patient clinical need.
EPNI recommends that behavioral health providers develop an
appointment scheduling strategy to accommodate newly discharged
patients, if they have not already done so.
Standardized Substance Abuse Screenings in Mental Health
Assessments:
Routinely utilize standardized substance abuse screening questionnaires
(e.g., CAGEAID) in mental health assessments for new patient’s age 12
and older. (Routine substance use assessment of 10- and 11-year-old
children is also recommended.)
Recommend or refer patients for comprehensive substance abuse
assessment based on the screening results and corroborating clinical
information from the substance use assessment.
9-64
Behavioral
Health Quality
Improvement
Objectives
(continued)
Exchange of Information with Primary Care Physicians
Routinely ask all new patients to authorize exchange of information
with primary care/specialty physicians.
Establish a distinct section in the treatment record, if one does not exist,
dedicated to case management activities. This section should contain:
Documentation of patient authorization/refusal to exchange information
with the physician.
When authorized, documentation of communication with the physician
(e.g., report, letter, telephone or e-mail communication).
When recommending the patient seek psychopharmacologic treatment
from their physician or if the physician recommended mental health
assessment and/or treatment, provide the physician with the current
behavioral health diagnosis(es), diagnostic criteria (i.e., symptoms with
onset, duration and severity) and treatment plan, if applicable.
When authorized, the treating psychiatrist or clinical nurse specialist
should provide the current diagnosis(es) and initial medication
management information to the primary care/specialty physician. This
requirement is important for patient safety.
Appointment Accessibility
Provide routine initial appointments within 10 business days of the
request.
Provide routine follow-up appointments within 10 business days of the
initial appointment.
Provide urgent appointments within 24 hours of the request.
Provide non-life-threatening-emergency appointments within 6 hours of
the request.
Provide or facilitate life-threatening-emergency care immediately.
Questions
Questions, comments, or material requests should be directed to:
Attn: Mary Rains R4-18
EPNI
P.O. Box 64179
St. Paul, MN 55164-0179
Phone: (651) 662-0826 or 1-800-382-2000 ext. 20826
Fax: (651) 662-3625
9-65
Prior
Authorization
EPNI does not require prior authorization for outpatient mental health
or chemical dependency services.
Will be required if the patient is seen out of network and the patient
does not have any benefits out of the network.
Exception:
Some groups still require a prior authorization. Contact Provider
Service for the specific group’s requirements.
Preadmission
Notification
Call (651) 662-2474 or 1-800-469-1110 or fax form 15715 to (651)
662-0856 to notify EPNI of admissions into day treatment, partial psych
or inpatient programs.
Groups that
Carve Out
Behavioral
Health Benefits
There are some self-insured groups that contract with another carrier to
handle their behavioral health coverage. This means that any type of
behavioral health treatment billed to EPNI will be denied. The claims
should be filed to the designated Third Party behavioral health carrier
for processing. This information should be obtained from the patient or
their family. EPNI may not have access to the carrier’s information.
Exception:
Behavioral health E/M and medication management services are
eligible as stated above, if provided in either the patient’s primary clinic
or a fee-for-service eligible non-behavioral health practitioner’s office.
If a behavioral health E/M service is denied, EPNI should be contacted
for the claim to be reprocessed.
Where to Bill
Claims
9-66
All behavioral health claims should be filed to EPNI.
Professional Behavioral Health Coding Grid
Code
Description
Units
Who May Submit
90801
Psychiatric diagnostic interview exam
1 per session
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT
90802
Interactive diagnostic interview exam
1 per session
90804
Individual psychotherapy, insight oriented, 1 per session
office/outpatient, 20-30 min.
90805
office/outpatient, 20-30 min., w/E/M
MD, CNS-Psych, PMHNP
90806
90807
90808
90809
90810
Individual psychotherapy, interactive,
1 per session
90811
1 per session
90812
1 per session
Misc
9-67
Code
Description
Units
Who May Submit
Misc
90813
1 per session
90814
1 per session
90815
1 per session
90816
inpatient, 20-30 min.
Not applicable
Not covered – part
of inpatient
payment based on
APA guides
90817
inpatient, 20-30 min., w/E/M
Not applicable
of inpatient
payment based on
APA guides
90818
Not applicable
of inpatient
payment based on
APA guides
90819
Not applicable
of inpatient
payment based on
APA guides
90821
Not applicable
of inpatient
payment based on
APA guides
9-68
Code
Description
Units
Who May Submit
Misc
90822
Not applicable
of inpatient
payment based on
APA guides
90823
1 per session
Not applicable
of inpatient
payment based on
APA guides
90824
1 per session
Not applicable
of inpatient
payment based on
APA guides
90826
1 per session
Not applicable
of inpatient
payment based on
APA guides
90827
1 per session
Not applicable
of inpatient
payment based on
APA guides
90828
1 per session
Not applicable
of inpatient
payment based on
APA guides
90829
1 per session
Not applicable
of inpatient
payment based on
APA guides
9-69
Code
Description
Units
Who May Submit
Misc
90845
Psychoanalysis
1 per session
MD only
Not covered – may
be a contract
exclusion
90846
Family psychotherapy (without patient
present)
1 per session
May be a contract
exclusion
90847
Family psychotherapy (with patient
present)
1 per session
90849
Multiple family group psychotherapy
1 per session
90853
Group psychotherapy (other than family)
1 per session
90857
Interactive group psychotherapy
1 per session
90862
Pharmacologic management w/minimal
psychotherapy
1 per session
MD, CNS-Psych, PMHNP, PA, NP
90865
Narcosyntheses
1 per session
90870
Electroconvulsive therapy; single seizure
1 per day
MD only
90871
Electroconvulsive therapy; multiple
seizures, per day
1 per day
MD only
90875
Individual psychophysiological therapy
incorporating biofeedback, 20-30 min.
1 per session
90876
Individual psychophysiological therapy
incorporating biofeedback, 45-50 min.
1 per session
9-70
Code
Description
Units
Who May Submit
Misc
90880
Hypnotherapy
1 per session
90882
Environmental intervention for medical
management purposes
1 per session
MD only
Not covered - incl.
in basic service
90885
Psychiatric evaluation of hospital records
1 per day
MD only
Not covered - incl.
in basic service
90887
Interpretation or explanation of exam
results
1 per day
Not covered - incl.
in basic service
90889
Preparation of report of patient’s
psychiatric status
1 per service
MD only
Not covered contract exclusion
90899
Unlisted psychiatric service or procedure
1 - submit time
Submit narrative
90901
Biofeedback training by any modality
1 per session
MD only
Not covered in
home POScontract exclusion
90911
Biofeedback training, perineal muscles,
anorectoal or urethral sphincter, including
EMG and/or manometry
1 per session
MD only
Not covered in
home POScontract exclusion
9-71
Code
Description
Units
Who May Submit
Misc
96101
Psychological testing, (includes
psychodiagnostic assessment of
emotionality, intellectual abilities,
personality and psychopathology, e.g.,
MMPI, Rorschach, WAIS), per hour of the
psychologist’s or physician’s time, both
face-to-face time with the patient and time
interpreting test results and preparing the
report
1 unit per hour
of face-to-face
testing,
interpretation
and
preparation of
report
MD, LP-Ph.D., LP-MA
The psychologist or
psychiatrist
administers and
interprets the test(s)
and prepares the
report. Billed under
the MD, LP-PhD,
LP-MA individual
provider number.
96102
Psychological testing (includes
MMPI and WAIS), with qualified health
care professional interpretation and report,
administered by technician, per hour of
technician time, face-to-face
Report 1 unit
per hour of
face-to-face
testing
MD, LP-PhD, LP-MA, LICSW, CNSPsych, LMFT
A technician under
direct supervision,
administers the
test(s). The
supervising
qualified licensed
practitioner
and prepares the
the supervising
licensed
practitioner
provider number.
96103
Psychological testing (includes
MMPI), administered by a computer, with
qualified health care professional
interpretation and report
Report 1 unit
MD, LP-PhD, LP-MA, LICSW, CNSper testing
Psych, PMHNP, LMFT, NP, PA
session
regardless of
number of tests
9-72
Code
Description
Units
Who May Submit
96116
Neurobehavioral status exam (clinical
assessment of thinking, reasoning and
judgment, e.g., acquired knowledge,
attention, language, memory, planning and
problem solving, and visual spatial
abilities), per hour of the psychologist’s or
physician’s time, both face-to-face time
with the patient and time interpreting test
results and preparing the report
1 per hour
MD, LP-PhD., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA
96118
Neuropsychological testing (e.g.,
Halstead-Reitan neuropsychological
battery, Wechsler memory scales and
Wisconsin card sorting test), per hour of
the psychologist’s or physician’s time,
both face-to-face time with the patient and
time interpreting test results and preparing
the report
Report 1 unit
per hour of
face-to-face
testing,
interpretation
and
preparation of
report
MD, LP-Ph.D., LP-MA
Misc
The psychologist or
psychiatrist
administers and
and prepares the
the MD, LP-PhD,
LP-MA individual
provider number.
9-73
Code
Description
Units
Who May Submit
Misc
96119
Halstead-Reitan neuropsychological
battery, Wechsler memory scales and
Wisconsin card sorting test), with
qualified health care professional
interpretation and report, administered by
technician, per hour of technician time,
face-to-face
Report 1 unit
per hour of
face-to-face
testing
MD, LP-PhD, LP-MA
A technician under
direct supervision,
administers the
test(s). The
supervising
qualified licensed
practitioner
and prepares the
the supervising
licensed
practitioner
provider number.
96120
Wisconsin card sorting test), administered
by a computer, with qualified health care
professional interpretation and report
Report 1 unit
MD, LP-PhD, LP-MA
per testing
session
regardless of
number of tests
taking a computerbased test. A
qualified licensed
practitioner
and prepares the
the licensed
practitioner
provider number.
9-74
Code
Description
Units
Who May Submit
Misc
96150
Health and behavior assessment (eg,
health-focused clinical interview,
behavioral observations,
psychophysiological monitoring, healthoriented questionnaires), each 15 minutes
face-to-face with the patient; initial
assessment
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA
MH/CD diagnosis
is NOT primary
diagnosis
96151
Health and behavior assessment (eg,
health-focused clinical interview,
behavioral observations,
psychophysiological monitoring, healthoriented questionnaires), each 15 minutes
face-to-face with the patient; reassessment
1 per 15
minutes
MH/CD diagnosis
is NOT primary
diagnosis
96152
Health and behavior intervention, each 15
minutes, face-to-face; individual
1 per 15
minutes
MH/CD diagnosis
is NOT primary
diagnosis
96153
minutes, face-to-face; group (2 or more
patients)
1 per 15
minutes
MH/CD diagnosis
is NOT primary
diagnosis
96154
minutes, face-to-face; family (with the
patient present)
1 per 15
minutes
MH/CD diagnosis
is NOT primary
diagnosis
96155
minutes, face-to-face; family (without the
patient present)
1 per 15
minutes
MH/CD diagnosis
is NOT primary
diagnosis
9-75
Code
Description
Units
Who May Submit
Misc
98960
Education and training for patient selfmanagement by a qualified, nonphysician
health care professional using a standard
curriculum, face-to-face with the patient
(could include caregiver/family) each 30
minutes; individual patient
1 per 30
minutes
98961
health care professional using a
standardized curriculum, face-to-face with
the patient (could include
caregiver/family) each 30 minutes; 2-4
patients
1 per 30
minutes
98962
health care professional using a
standardized curriculum, face-to-face with
the patient (could include
caregiver/family) each 30 minutes; 5-8
patients
1 per 30
minutes
9920199205
Office or other outpatient E/M – new
patient
1 per visit
MD only
9921199215
Office or other outpatient E/M –
established patient
1 per visit
MD only
9922199223
Hospital inpatient E/M – initial
1 per visit
MD only
9923199233
Hospital inpatient E/M – subsequent
1 per visit
MD only
9-76
Code
Description
Units
Who May Submit
Misc
99234
–
99236
Observation or inpatient hospital care
1 per day
MD only
99238
Hospital discharge, 30 minutes or less
1 per day
MD only
99239
Hospital discharge, more than 30
1 per day
MD only
9924199245
Office or other outpatient consultation
1 per session
MD only
9925199255
Inpatient consultation, initial
1 per session
MD only
9926199263
Inpatient consultation, follow-up
1 per session
MD only
9928199285
Emergency department E/M
1 per session
MD only
G0175
Scheduled interdisciplinary team
conference (minimum of three exclusive
of patient care nursing staff) with patient
present
1 per session
N/A
Denied. If IP or
partial hospital part of hospital
rates. If OP – no
medically necessary
care is provided.
G0176
Activity therapy, such as music, dance, art
or play therapies not for recreation, related
to the care and treatment of patient’s
disabling mental health problems, per
session (45 minutes or more)
1 per session
N/A
Denied. If IP or
rates. If OP – no
medically necessary
care is provided.
9-77
Code
Description
Units
Who May Submit
Misc
Denied. If IP or
rates. If OP – no
medically necessary
care is provided.
G0177
Training and educational services related
to the care and treatment of patient’s
disabling mental health problems per
session (45 minutes or more)
1 per session
N/A
H0001
Alcohol and/or drug assessment
1 per session
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, Rule 25
H0002
Behavioral health screening to determine
eligibility for admission to treatment
program
1 per session
H0003
Alcohol and/or drug screening; laboratory
analysis of specimens for presence of
alcohol and/or drugs
1 per session
H0004
Behavioral health counseling and therapy,
per 15 minutes
1 per 15
minutes
H0005
Alcohol and/or drug services; group
counseling by a clinician
1 per session
H0006
Alcohol and/or drug services; case
management
1 per session
H0007
Alcohol and/or drug services; crisis
intervention (outpatient)
1 per session
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, mobile crisis
provider specialty, Rule 29.
H0008
Alcohol and/or drug services; sub-acute
detoxification (hospital inpatient)
1 per session
MD
9-78
Code
Description
Units
Who May Submit
H0009
Alcohol and/or drug services; acute
detoxification (hospital inpatient)
1 per session
MD
H0010
detoxification (residential addiction
program inpatient)
1 per session
MD
H0011
program inpatient)
1 per session
MD
H0012
program outpatient)
1 per session
MD
H0013
program outpatient)
1 per session
MD
H0014
Alcohol and/or drug services; ambulatory
detoxification
1 per session
H0015
Alcohol and/or drug services; intensive
outpatient (treatment program that
operates at least 3 hours/day and at least 3
days/week and is based on an
individualized treatment plan), including
assessment, counseling; crisis
intervention, and activity therapies or
education
1 per session
N/A
H0016
Alcohol and/or drug services;
medical/somatic (medical intervention in
ambulatory setting)
1 per session
MD, PA, NP, CNS-Medical
Misc
Denied – CD
treatment part of
facility charges.
9-79
Code
Description
Units
Who May Submit
Misc
H0017
Behavioral health; residential (hospital
residential treatment program), without
room and board, per diem
1 per diem
N/A
Denied – CD
treatment part of
facility charges.
H0018
Behavioral health; short-term residential
(non-hospital residential treatment
program), without room and board, per
diem
1 per diem
N/A
Denied – CD
treatment part of
facility charges.
H0019
Behavioral health; long-term residential
(non-medical, non-acute care in residential
treatment program where stay is typically
longer than 30 days), without room and
board, per diem
1 per diem
N/A
Denied – CD
treatment part of
facility charges.
H0020
Alcohol and/or drug services; methadone
administration and/or service (provision of
the drug by a licensed program)
1 per session
Methedone clinic
Covered when
provided within a
methadone clinic.
H0021
Alcohol and/or drug training service (for
staff and personnel not employed by
providers)
1 per session
N/A
Not covered
H0022
Alcohol and/or drug intervention service
(planned facilitation)
1 per session
N/A
Not covered
9-80
Code
Description
Units
Who May Submit
Misc
H0023
Behavioral health outreach service
(planned approach to reach a target
population)
1 per session
N/A
Not covered
H0024
Behavioral health prevention information
dissemination service (one-way direct or
non-direct contact with service audiences
to affect knowledge or attitude)
1 per session
N/A
Not covered
H0025
Behavioral health prevention education
service (delivery of services with target
population to affect knowledge, attitude
and/or behavior)
1 per session
N/A
Not covered
H0026
Alcohol and/or drug prevention process
service, community-based (delivery of
services to develop skills of impactors)
1 per session
N/A
Not covered
H0027
Alcohol and/or drug prevention
environmental service (broad range of
external activities geared toward
modifying systems in order to mainstream
prevention through policy and law)
1 per session
N/A
Not covered
H0028
Alcohol and/or drug prevention problem
identification and referral service(e.g.
student assistance and employee
assistance programs), does not include
assessment
1 per session
N/A
Not covered
H0029
Alcohol and/or drug prevention
alternatives service (services for
populations that exclude alcohol and other
drug use e.g. alcohol free social events)
1 per session
N/A
Not covered
9-81
Code
Description
Units
Who May Submit
Misc
Not covered
H0030
Behavioral health hotline service
1 per session
N/A
H0031
Mental health assessment, by nonphysician
1 per session
LP-Ph.D., LP-MA, LICSW, CNS-Psych,
PMHNP, LMFT, NP, PA
H0032
Mental health service plan development
by non-physician
1 per session
N/A
H0034
Medication training and support, per 15
minutes
1 per 15
minutes
N/A
H0035
Mental health partial hospitalization,
treatment, less than 24 hours
1 per day
Rule 29
H0036
Community psychiatric supportive
treatment, face-to-face, per 15 minutes
1 per 15
minutes
N/A
Not covered
H0037
Community psychiatric supportive
treatment program, per diem
1 per day
N/A
Not covered
H0038
Self-help/peer services, per 15 minutes
1 per 15
minutes
N/A
Not covered
H0039
Assertive community treatment, face-toface, per 15 minutes
1 per 15
minutes
N/A
Not covered
H0040
Assertive community treatment program,
per diem
1 per day
H0046
Mental health services, not otherwise
specified
1 per 1 minute
9-82
Not covered
Not covered
Code
Description
Units
Who May Submit
Misc
H0047
Alcohol and/or other drug abuse services,
not otherwise specified
1 – submit
time
N/A
Denied – CD
treatment part of
facility charges.
H0048
Alcohol and/or other drug testing:
collection and handling only, specimens
other than blood
1 per service
N/A
Denied – CD
treatment part of
facility charges.
H2001
Rehabilitation program, per ½ day
1 per day
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP
Pends for review.
H2010
Comprehensive medication services, per
15 minutes
1 per 15
minutes
H2011
Crisis intervention service, per 15 minutes
1 per 15
minutes
Not covered
H2012
Behavioral health day treatment, per hour
1 per hour
Not covered with a
chemical
dependency
diagnosis.
H2013
Psychiatric health facility service, per
diem
1 per day
N/A
Not covered
H2014
Skills training and development, per 15
minutes
1 per 15
minutes
Eligible for all
programs with
autism diagnosis.
Not covered for all
other diagnoses.
9-83
Code
Description
Units
Who May Submit
Misc
H2015
Comprehensive community support
services, per 15 minutes
1 per 15
minutes
Not covered.
Submit UA
modifier for crisis
intervention.
H2016
Comprehensive community support
services, per diem
1 per day
N/A
Not covered
H2017
Psychosocial rehabilitation services, per
15 minutes
1 per 15
minutes
N/A
Not covered
H2018
Psychosocial rehabilitation services, per
diem
1 per day
N/A
Not covered
H2019
Therapeutic behavioral services, per 15
minutes
1 per 15
minutes
Not covered
H2020
Therapeutic behavioral services, per diem
1 per day
PMAP/MNCare
only
H2021
Community based wrap-around services,
per 15 minutes
1 per 15
minutes
N/A
Not covered
H2022
Community based wrap-around services,
per diem
1 per day
N/A
Not covered
H2023
Supported employment, per 15 minutes
1 per 15
minutes
N/A
Not covered
H2024
Supported employment, per diem
1 per day
N/A
Not covered
H2025
Ongoing support to maintain employment,
per 15 minutes
1 per 15
minutes
N/A
Not covered
9-84
Code
Description
Units
Who May Submit
Misc
H2026
Ongoing support to maintain employment,
per diem
1 per day
N/A
Not covered
H2027
Psychoeducational service, per 15 minutes
1 per 15
minutes
N/A
Not covered
H2028
Sexual offender treatment, per 15 minutes
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP,
Certified Residential Sex Offender
Treatment Facility
H2029
Sexual offender treatment, per diem
1 per day
MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP,
Certified Residential Sex Offender
Treatment Facility
H2030
Mental health clubhouse services, per 15
minutes
1 per 15
minutes
Not covered
H2031
Mental health clubhouse services, per
diem
1 per day
Not covered
H2032
Activity therapy, per 15 minutes
1 per 15
minutes
Not covered – used
for Therapeutic
Camp
H2033
Multisytemic therapy for juveniles
1 per session
N/A
Not covered
H2034
Alcohol and/or drug abuse halfway house
services, per diem
1 per day
N/A
Not covered
H2035
Alcohol and/or other drug treatment
program, per hour
1 per hour
N/A
Not covered
9-85
Code
Description
Units
Who May Submit
Misc
1 per day
N/A
Not covered
Not covered
H2036
Alcohol and/or other drug treatment
program, per diem
H2037
Developmental delay prevention activities, 1 per 15
dependent child of client, per 15 minutes
minutes
N/A
M0064
Brief office visit for monitoring or
changing drug prescriptions
1 per session
MD, CNS-Psych, PMHNP, PA, NP
S3005
Performance measurement, evaluation of
patient self assessment, depression
1 per session
N/A
S9475
Ambulatory setting substance abuse
treatment or detoxification services, per
diem
1 per day
S9480
Intensive outpatient psychiatric services,
per diem
1 per day
S9482
Family stabilization services, per 15
minutes
1 per 15
minutes
N/A
Not covered
S9484
Crisis intervention mental health services,
per hour
1 per hour
Rule 29, Mobile Crisis
Submit –UA
modifier for MH
professional
Child/Adolescent
practitioner.
Submit –HN
modifier for BA
level practitioner.
9-86
Not covered
Code
Units
Who May Submit
Crisis intervention mental health services,
per diem
1 per diem
Rule 29, Mobile Crisis
T1006
Alcohol and/or substance abuse services,
family/couple counseling
1 per session
T1007
treatment plan development and/or
modification
1 per session
N/A
T1008
Day treatment for individual alcohol
and/or substance abuse services
1 per day
T1009
Child sitting services for children of the
individual receiving alcohol and/or
substance abuse services
1 per session
N/A
Not covered
T1010
Meals for individual receiving alcohol
and/or substance abuse services (when
meals not included in the program)
1 per day
N/A
Not covered
T1011
not otherwise classified
1 – submit
time
T1012
skills development
1 per session
N/A
Not covered
T1023
Screening to determine the
appropriateness of consideration of an
individual for participation in a specified
program, project or treatment protocol, per
encounter
1 per session
N/A
Not covered
S9485
Description
Misc
UA modifier for MH professional
Child/Adolescent practitioner. HN
modifier for BA level practitioner.
Not covered
9-87
Code
Description
Units
Who May Submit
Misc
T1024
Evaluation and treatment by an integrated,
specialty team contracted to provide
coordinated care to multiple or severely
handicapped children, per encounter
1 per session
N/A
Not covered
T1025
Intensive, extended multidisciplinary
services provided in a clinic setting to
children with complex medical, physical,
mental and psychosocial impairments, per
diem
1 per day
N/A
Not covered
T1026
Intensive, extended multidisciplinary
services provided in a clinic setting to
children with complex medical, physical,
medical and psychosocial impairments per
hour
1 per hour
N/A
Not covered
T1027
Family training and counseling for child
development, per 15 minutes
1 per 15
minutes
N/A
Not covered
T1028
Assessment of home, physical and family
environment, to determine suitability to
meet patient's medical needs
1 per session
N/A
Not covered
T1029
Comprehensive environmental lead
investigation, not including laboratory
analysis, per dwelling
1 per session
N/A
Not covered
T2010
Preadmission screening and resident
review (PASRR) level I identification
screening, per screen
1 per screen
N/A
Not covered
9-88
Code
Description
Units
Who May Submit
Misc
T2011
Preadmission screening and resident
review (PASRR) level II evaluation, per
evaluation
1 per
evaluation
N/A
Not covered
T2012
Habilitation, educational; waiver, per diem
1 per hour
N/A
Not covered
T2013
Habilitation, educational, waiver; per diem
1 per hour
N/A
Not covered
T2014
Habilitation, prevocational, waiver; per
diem
1 per day
N/A
Not covered
T2015
Habilitation, prevocational, waiver; per
hour
1 per hour
N/A
Not covered
T2016
Habilitation, residential, waiver; per diem
1 per day
N/A
Not covered
T2017
Habilitation, residential, waiver; 15
minutes
1 per 15
minutes
N/A
Not covered
T2018
Habilitation, supported employment,
waiver; per diem
1 per day
N/A
Not covered
T2019
Habilitation, supported employment,
waiver; per 15 minutes
1 per 15
minutes
N/A
Not covered
T2020
Day habilitation, waiver; per diem
1 per day
N/A
Not covered
T2021
Day habilitation, waiver; per 15 minutes
1 per 15
minutes
N/A
Not covered
T2022
Case management, per month
1 per calendar
month
N/A
Not covered
T2023
Targeted case management; per month
1 per calendar
month
N/A
Not covered
9-89
Code
Description
Units
Who May Submit
Misc
T2024
Service assessment/ plan of care
development, waiver
1 per session
N/A
Not covered
T2025
Waiver services; not otherwise specified
(NOS)
1 per session
N/A
Not covered
T2026
Specialized childcare, waiver; per diem
1 per day
N/A
Not covered
T2027
Specialized childcare, waiver; per 15
minutes
1 per 15
minutes
N/A
Not covered
T2028
Specialized supply, not otherwise
specified, waiver
1 per session
N/A
Not covered
T2029
Specialized medical equipment, not
otherwise specified, waiver
1 per session
N/A
Not covered
T2030
Assisted living; waiver, per month
1 per calendar
month
N/A
Not covered
T2031
Assisted living; waiver, per diem
1 per day
N/A
Not covered
T2032
Residential care, not otherwise specified
(NOS), waiver; per month
1 per calendar
month
N/A
Not covered
T2033
Residential care, not otherwise specified
(NOS), waive; per diem
1 per day
N/A
Not covered
T2034
Crisis intervention, waiver; per diem
1 per day
N/A
Not covered
T2035
Utility services to support medical
equipment and assistive technology/
devices, waiver
1 per session
N/A
Not covered
9-90
Code
Description
Units
Who May Submit
Misc
T2036
Therapeutic camping, overnight, waiver;
each session
1 per session
N/A
Not covered
T2037
Therapeutic camping day, waiver; each
session
1 per session
N/A
Not covered
T2038
Community transition, waiver; per service
1 per session
N/A
Not covered
T2039
Vehicle modifications, waiver; per service
1 per session
N/A
Not covered
Continued next page
T2040
Financial management, self-directed,
waiver; per 15 minutes
1 per 15
minutes
N/A
Not covered
T2041
Supports brokerage, self-directed, waiver;
per 15 minutes
1 per 15
minutes
N/A
Not covered
T2048
Behavioral health; long-term care
residential (non-acute care in a residential
treatment program where stay is typically
longer than 30 days), with room and
board, per diem
1 per day
N/A
Not covered
9-91
Behavioral Health Services for UB-92
Overview
This section of the manual is intended for all behavioral health
practitioners who bill on the CMS-1450 (UB-92) claim form. This
section is not intended for practitioners whose services are billed on the
CMS-1500.
Practitioners
Who Should be
Using this
Section
Residential treatment centers, non-residential treatment centers, Rule 5
facilities, Rule 8 facilities, hospitals, state hospitals and treatment
centers, freestanding detox centers.
Behavioral
Health
Evaluation or
Testing Coding
Guidelines
Use the following codes for submitting behavioral health evaluation or
testing services on the UB92.
Units
Revenue
Code
HCPCS
Code
Narrative
Time
Units
0914
90801
Psychiatric diagnostic
review
Per
session
1 unit
0914
90802
Interactive psychiatric
diagnostic interview
Per
session
1 unit
0918
96101 –
96102
Psychological testing
per hour
60
minutes
1 per
hour
0918
96118 –
96119
Neuropsychological
testing battery with
interpretation or report
60
minutes
1 per
hour
One unit should be submitted based on the HCPCS code narrative. If
there is no time designation, the service is considered ‘per session’ and
only one unit should be submitted regardless of the actual time spent.
Unit guidelines are also noted in the appropriate following sections.
Individual
Behavioral
Health Therapy
9-92
Use the following codes for billing individual behavioral health
services.
Revenue
Code
HCPCS
Code
0911
Family and
Group Therapy
Narrative
Time
Units
Psychiatric/Psychologic
al service/rehabilitation.
Do not use for CD
services
Based on
CPT code
used
1 unit
on CPT
code
used
0912
H2012
Psychiatric/Psychologic
al service/partial
hospitalization - less
intensive
One line
for each
day the
patient
attends the
program
1 unit
for each
hour the
patient
attends
the
program
0914
See
CPT
codes
for
individu
al
therapy
Psychiatric/psychologic
al service/individual
therapy
Based on
CPT code
Depend
s CPT
code
used
Use these codes when billing behavioral health family and group
therapy services on an UB-92.
Revenue
Code
HCPCS
Code
Narrative
Time
Units
0915
See
HCPCS
codes
for
group
therapy
Psychiatric/Psychological
service/group therapy
Based
on CPT
code
Based
on CPT
code
0916
90846
or
90847
Psychiatric/Psychological
service/family therapy
Per
session
1 unit
per
session
0917
90875
or
90876
Psychiatric/psychological
service/biofeedback
Per
session
1 unit
per
session
0918
96101 96102,
96118 96119
Psychiatric/psychological
service/testing
60
minute
1 unit
per 60
minutes
9-93
Chemical
Dependency and
Alcohol
Rehabilitation
Restricted Codes
Billing a
Behavioral
Health
Assessment
Use these codes when billing alcohol or chemical dependency
rehabilitation services on a UB-92.
Revenue
Code
HCPCS
Code
0944
Submit
code
describing
service
0945
Narrative
Time
Units
Submit
Drug Rehabilitation code
individual or group
describin
g service
Based on
CPT code
Based
on CPT
code
Submit
Alcohol Rehabilitation
code
- individual or group
describin
g service
Based on
CPT code
Based
on CPT
code
These revenue codes have restrictions on use and/or coverage
Revenue
Code
Restriction
0911
Can only bill with a mental health diagnosis
0913
EPNI does not recognize
0917
Can only bill with a mental health diagnosis
0919
Contract exclusion and is not covered
0944
Can only bill with a drug dependency diagnosis code
0945
Can only bill with an alcohol dependency diagnosis code
Bill 0912 and 90801/90802 with a mental health, chemical dependency
or alcohol diagnosis code
Bill 0944 and 90801/90802 with a chemical dependency diagnosis code
Bill 0945 and 90801/90802 with an alcohol dependency diagnosis
Testing
0918 with 09101 – 96103, 96118 - 96120
Testing is compatible with all behavioral health diagnosis codes.
9-94
Family Therapy
0916 with 90846
Revenue code 0916 and CPT 90846 is billed for family therapy when
the patient is not present. It is usually only covered until the patient is
18. But there may be a specific contract exclusion on some self-insured
groups.
0916 and 90846, should be billed under the specific patient, not the
member.
Bill one unit per session, regardless of total time.
Revenue Code
0916 with 90847
Revenue 0916 and CPT 90847 is billed for family therapy when the
patient is present. This service may be a contract exclusion on all ages
or over age 18 on some self-insured groups.
0916 and 90847 should be billed under the specific patient, not the
member.
Bill one unit per session, regardless of total time.
Nutritional
Counseling /
Dieticians
0942 with 97802 – 97804
Nutritional counseling is eligible if billed with either a behavioral health
diagnosis or a medical diagnosis.
Eating disorder diagnosis:
For eating disorder diagnosis codes 307.1, 307.50, & 307.51, licensed
nutritionists and licensed dietitians can bill independently for procedure
codes S9470, 97802, 97803, and 97804. No referral is required for the
highest benefit level.
Registered dietitians services must be submitted to EPNI by an eligible
registered dietitian must be submitted on the claim. Registered
dieticians can only bill for procedure codes S9470, 97802, 97803, and
97804 with behavioral health diagnoses.
Detox
0126
Bill one unit of service per night spent in a detox bed.
A chemical dependency or an alcohol dependency diagnosis must be
submitted.
Detox services are eligible when they are provided in a state licensed
freestanding detoxification center, a hospital or residential treatment
center.
9-95
Health and
Behavioral
Assessment
Codes
96150 - 96155
Non-Residential
Treatment
Centers
State licensed non-residential treatment centers can only bill outpatient
chemical services. No mental health services will be covered in this
setting.
CPT 96150 - 96155 describe services offered to patients who present
with established illnesses or symptoms and not diagnosed with mental
illness. The primary diagnosis should be a non-behavioral diagnosis
code. On facility claims 96150-96155 should not be reported with
revenue codes 0900-0919. Codes 96150-96155 may be submitted under
revenue code 0940.
Some non-residential treatment centers are dually licensed as both a
Rule 29 clinic and a residential treatment center. It is important to bill
appropriate services under each separate entity. Mixing services and
provider specialty will cause a claim to deny.
Compatibility
This is a frequent and common cause of claim denials.
Revenue code 0944 should only be billed with a chemical dependency
diagnosis code.
Revenue Code 0945 should only be billed with an alcohol dependency
diagnosis code.
Partial Psych
Admissions
0120
Partial psych is billed under a facility provider with a K in the fifth
position. Example would be 1234KAB.
Patients must attend a minimum of six hours per day.
Reimbursement is made according to the patient's inpatient mental
health benefits.
All partial psych program services are combined into one charge and
billed under revenue code 0120 using 1 unit of service for each day the
patient is in the program. This includes group and individual therapy
services.
All other services such as lab work or radiology services should be split
out and billed on a separate UB92 under the hospital provider number
using the appropriate revenue codes.
All partial psych program days should be billed on one claim. No
interim billing can be accepted.
Partial psych services are not eligible with a primary alcohol or
chemical dependency diagnosis.
9-96
Rule 5 –
Emotionally
Handicapped
Facilities
Rule 5 facilities must have state licensure to provide services.
Preadmission notification is required.
Services are processed under the patient's inpatient medical benefit and
are subject to any day or dollar limitations. Some self-insured contracts
may deny as a contract exclusion.
Benefits will end the day the patient turns 18.
Recreational
Therapy
0941
Court Ordered
Treatment
When a court order for treatment is based on an evaluation and
recommendation by a physician, licensed psychologist, licensed alcohol
and drug dependency counselor or a certified chemical dependency
assessor (rule 25) we will consider the order for treatment medically
necessary.
Recreational therapy may be part of an approved CD outpatient
program. It is included under the CD program charges and should not be
billed separately under revenue ode 0941.
EPNI will provide coverage for these court ordered services according
to the patient's contract benefits. For example, if the member does not
have inpatient chemical dependency benefits and the patient is court
ordered into inpatient chemical dependency treatment, there will be no
coverage for the services.
The evaluation and court order MUST be faxed in to Care Management
at (651) 662-0851 as soon as possible so the necessary approval can be
entered into the claim system and ensure the claim is paid accurately.
If the court order is to a specific non-network provider but the member
does not have any benefits for non-network providers, EPNI will cover
the services as they would any other in-network provider. However, feefor-service members will be responsible for the difference between the
billed amount and EPNI’s allowed amount.
Prior
Authorizations
EPNI does not require prior authorization for outpatient mental health
or chemical dependency services provided within the EPNI network.
Will be required if the patient is seen out of network and the patient
does not have any benefits out of the network.
Exception:
Some groups still require a prior authorization. Contact Provider
Services for the specific group's requirements.
9-97
Parity
There are federal and state mandates that dictate mental health parity
laws that are applicable to all fully insured groups. Self-insured groups
are not subject to parity laws and legislation.
Parity means that a member's behavioral health benefits are exactly the
same as their medical benefits. For example, if the member has
coverage from a non-network provider for an illness E/M service then
they will have coverage for a non-network provider for a behavioral
health service.
Groups that
Carve Out
Behavioral
Health Benefits
There are some self-insured groups that contract with another carrier to
handle their behavioral health coverage. This means that any type of
behavioral health treatment billed to EPNI will be denied. The claims
should be filed to the designated Third Party behavioral health carrier
for processing. This information should be obtained from the patient or
their family. EPNI may not have access to the carrier's information.
Exception:
Behavioral health E/M and medication management services are
eligible as stated above, if provided in either the patient's primary care
clinic or a fee-for-service eligible non-behavioral health practitioner's
office. If a behavioral health E/M service is denied, EPNI should be
contacted for the claim to be reprocessed.
Where to File
Claims
9-98
All behavioral health claims should be filed to EPNI.
Institutional Behavioral Health Coding Grid
Code
Description
Units
0900
Behavioral Health Treatments/Services,
General Classification
1 unit based on
CPT/HCPCS
0901
Electroshock Treatment
1 unit based on
CPT/HCPCS
0902
Milieu Therapy
1 unit based on
CPT/HCPCS
0903
Play Therapy
1 unit based on
CPT/HCPCS
0904
Activity Therapy
1 unit based on
CPT/HCPCS
0905
Intensive Outpatient Services – Psychiatric
1 unit based on
CPT/HCPCS
0906
Intensive Outpatient Services - Chemical
Dependency
1 unit based on
CPT/HCPCS
0907
Community Behavioral Health Program
(Day Treatment)
1 unit based on
CPT/HCPCS
0910
Reserved for National Use
1 unit based on
CPT/HCPCS
0911
Rehabilitation
1 unit based on
CPT/HCPCS
0912
Partial Hospitalization - Less Intensive
1 unit based on
CPT/HCPCS
0913
Partial Hospitalization - Intensive
1 unit based on
CPT/HCPCS
0914
Individual Therapy
1 unit based on
CPT/HCPCS
0915
Group Therapy
1 unit based on
CPT/HCPCS
0916
Family Therapy
1 unit based on
CPT/HCPCS
Misc
Not valid
9-99
Code
Description
Units
0917
Bio Feedback
1 unit based on
CPT/HCPCS
0918
Testing
1 unit based on
CPT/HCPCS
0919
Other Behavioral Health
Treatments/Services
1 unit based on
CPT/HCPCS
0944
Drug Rehabilitation
1 unit based on
CPT/HCPCS
0945
Alcohol Rehabilitation
1 unit based on
CPT/HCPCS
1000
Behavioral Health Accommodations,
1 per day
Room and Board
1001
Residential Treatment - Psychiatric
1 per day
Room and Board
1002
Residential Treatment - Chemical
Dependency
1 per day
Room and Board
1003
Supervised Living
1 per day
Room and Board
1004
Halfway House
1 per day
Room and Board
1005
Group Home
1 per day
Room and Board
9-100
Misc
Chiropractic Services
Overview
Chiropractors should use CPT codes when billing for services.
Providers should submit the code that most accurately identifies the
service(s) performed, paying close attention to attended versus
unattended procedures (for example, 90732 versus 97014). The fact that
a code exists does not guarantee the service is covered for all EPNI
members. The member's health coverage contract defines the services
that are eligible for payment.
Examination
Codes
An examination includes inspection of the patient and review of
diagnostic tests to diagnose disease or evaluate progress. Use of the
E/M codes must be supported within your medical record.
Per CPT, "Chiropractic manipulative treatment codes include a premanipulation patient assessment. Additional E/M services may be
reported separately using the modifier -25, if the patient's condition
requires a significant, separately identifiable E/M service, above and
beyond the usual pre-service and post-service work associated with the
procedure".
It would be inappropriate to bill 99214, 99215, 99204 or 99205 along
with manipulative treatment codes. These will be rejected as Provider
liability.
Documentation in the patient’s record, must support the additional E/M
service.
As noted by the Minnesota Chiropractic Association, an E/M would be
appropriate for the following situations:
New Patient
A new patient is one that has not received any professional services
from the chiropractor or another chiropractor in the same group practice
within the past three years.
Established Patient –New Injury or Exacerbation
The E/M is needed to obtain history and fully evaluate the patient's
condition for an initial treatment plan or, in the event of an
exacerbation, modify a previous treatment plan.
Established Patient –Re-examination
Periodic examinations are typically performed in order to formally
assess the patient's response to treatment, progress, and make necessary
changes to the treatment plan.
For any of the above circumstances, a -25 modifier must be submitted
on the E/M service if there was a significant separately identifiable E/M
service.
9-101
Chiropractic
Manipulation
Treatment
The chiropractic manipulation treatment codes (CMT) include a premanipulation patient assessment, the adjustment, and evaluation of the
effect of treatment. The CMT codes 98940 - 98942 are used to indicate
the number of spinal areas manipulated. CMT code 98943 is used to
report chiropractic manipulation of one or more of the extra-spinal
regions (head region; lower extremities; upper extremities; rib cage;
abdomen).
PRE Service
PRE Service work may include a review of:
•
the patient’s records
•
their diagnostic tests
•
communication with other providers
• the actual preparations for care
INTRA Service
INTRA Service work would include:
•
discussion about the service with the patient
•
a pertinent evaluation and assessment of the patient
•
the procedure
POST Service
POST Service work includes:
Chiropractic
Manipulation
with Visit
9-102
•
an evaluation and discussion with the patient about the effect of
treatment
•
arrangement of additional services or referral to another provider
•
discussion of the case with other providers
•
review of literature about the patient’s condition
•
documenting the service
If an evaluation and management service is done with the manipulation,
the E/M will deny unless it is submitted with a -25 modifier, signifying
significant, separately identifiable illness or injury.
Manual Therapy
Code 97140, manual therapy techniques (e.g., mobilization/
manipulation, manual lymphatic drainage, manual traction), one or
more regions, each 15 minutes.
The primary difference between 97140 and the CMT codes
(98940-98943) is that the CMT codes specify the number of
spinal/extra-spinal regions manipulated, and the 97140 specifies one or
more regions, per 15 minutes of service.
When CMT services (98940-98943) and 97140 are provided to the
same body region, it would not be appropriate to separately report both
services. The services within 97140 would include a manipulation.
When CMT services and 97140 are provided to separate body regions
by different techniques, it would be appropriate to bill both. Code 97140
should be submitted with a modifier –59. Documentation must indicate
and support the submission of the –59 modifier.
Massage Therapy
An independent massage therapist is an ineligible provider. When a
massage therapist is employed and supervised by the chiropractor, the
massage therapy must be performed as an adjunct to or in preparation
for the chiropractic manipulation. The chiropractor should submit
procedure code 97124 with a -U7 modifier. “Relaxation massages” are
non-covered services.
Conjunctive
Therapy,
Modality: Office,
Home or Nursing
Home
Therapies must be used in conjunction with adjustment or manipulation
on the same day for most contracts. If more than one therapy is done per
treatment, submit documentation with the claim to support the necessity
for the additional therapy.
Maintenance or
Palliative Care
Rehabilitation services that would not result in measurable progress
relative to established goals are non-covered services. The “AT”
modifier distinguishes active/corrective treatment from maintenance
therapy. The AT modifier should be appended to all manipulative and
therapeutic procedures (such as chiropractic manipulations and physical
therapy modalities) performed for active/corrective treatments. The
absence of the AT modifier would indicate maintenance or palliative
care.
9-103
Source of
Condition
Incorrect coding of "source of condition" is the major reason for delay
in processing chiropractic claims. Follow the procedures outlined below
to eliminate claim delays.
Illness
Typically an illness diagnosis is found in the 700 range of ICD-9-CM
codes. If services are not related to a specific injury, choose a diagnosis
code outside of the ranges given below.
Injury
Injury is defined as bodily harm caused by an accident. The term
includes all related conditions and recurrent symptoms. If services are
related to a specific injury, choose a diagnosis code in the 800 - 977 and
980 - 994 ranges.
Submit the date of injury in field 14 on the CMS-1500 whenever the
services are related to a specific injury. An exacerbation is not
necessarily the result of an injury, therefore the appropriate illness
diagnosis should be submitted.
Diagnostic
Services
Use CPT codes to submit laboratory and X-ray services. The number of
services on your claim must be the number of procedures performed,
not the number of views taken.
For example:
Code Units
71020 (Chest x-ray, 2 views) 1
Practicing in
MultiDisciplinary
Clinics
9-104
Chiropractors practicing in multidisciplinary clinics shall maintain a
separate contract and billing number.
Documentation
Guides
To avoid denials for medical necessity, the patient’s medical record
must contain certain pertinent information that may be subject to our
review. The Centers for Medicare and Medicaid Services (CMS) in
conjunction with the American Medical Association (AMA) has
developed guidelines for the medical documentation necessary to
support a given level of evaluation and management service. EPNI
adopted these guidelines to ensure that our members receive quality
care and that the services are consistent with the insurance coverage
provided. The general guidelines are listed below:
The medical record should be complete and legible.
The documentation of each patient encounter should include:
•
reason for the encounter and relevant history, physical examination
findings and prior diagnostic test results;
•
plan of care;
•
If not documented, the rationale for ordering diagnostic and other
ancillary services should be easily inferred.
•
Past and present diagnoses should be accessible to the treating
and/or consulting physician.
•
Appropriate health risk factors should be identified.
•
The patient’s progress, response and changes in treatment, and
revision of diagnosis should be documented.
The CPT/HCPCS and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be supported by the
documentation in the medical record. Charge slips, super bills, travel
cards, or office ledgers are not considered supporting documentation for
services provided to a patient.
Use of the term IBID and/or the use of quotation marks to replace or
repeat previously documented information is not acceptable. All
information must be in date-sequence order.
Services not documented as indicated are not covered by EPNI. Patients
are not financially liable for services that are denied for inadequate
documentation. In addition, chart documentation should clearly list the
name of the practitioner rendering services to the member, including the
names and credentials of employees providing care under the
supervision of a chiropractor.
9-105
Prior
Authorization
Beginning January 1, 2006 chiropractic services rendered by EPNI
Chiropractic Providers are no longer subject to prior authorization for
members of EPNI fully insured groups. For EPNI self-insured groups, it
is recommended that prior authorization for chiropractic services be
done after 20 visits. Benefits are allowable only for services that are
medically necessary. Providers are encouraged to use provider web selfservice or contact Provider Services to obtain member benefits prior to
beginning services.
Form Required
To obtain prior authorization, providers should complete the EPNI
Chiropractic Prior Authorization Request Form, form number X15718.
Compliance
Audits
Your provider service agreement includes certain quality assurance
requirements. Pursuant to this agreement, EPNI may conduct audits to
evaluate a provider’s compliance with medical necessity guidelines and
standards of practice in the community. Such an audit could include
post-service claims review using provider utilization thresholds
established by EPNI, which may result in provider liability if care is
determined to be not medically necessary or medically inappropriate.
Medical necessary services are directed toward a diagnosis or condition
that is supported by documented subjective and objective findings.
Medically necessary care means health care services are appropriate, in
terms of type, frequency level, setting and duration, to the member’s
diagnosis or condition, and diagnostic testing and preventive services.
The intensity of treatment must be consistent with the severity or acuity
of the patient’s current level of impairment and/or symptomatology.
Additionally, there must be documentation of reasonable progress
consistent with the intensity of treatment and the severity/acuity of the
patient’s condition.
9-106
Dental Services
Medical-Surgical
Procedures
Many of our member contracts cover several medical-surgical
procedures that dentists perform. The procedures are:
•
Treatment (repair or replacement only) of accidental injury to
natural teeth, which is not regular dental repair or maintenance.
•
Surgical and nonsurgical treatment of TMJ and craniomandibular
disorder.
•
Treatment of cleft lip and palate for a dependent child up to age 19,
if medically necessary.
•
Reconstructive surgery to correct a functional physical defect for
dependent children — this would include orthognathic surgery.
Treatment involving dental implants is specifically excluded.
•
Removal of cysts/lesion(s)/tumor(s) and the accompanying
pathology reports, scans, anesthesia and allowable supplies.
Certain dental services may be reported using either a CPT or dental
HCPCS code. CPT codes are generally five numeric digits. Dental
HCPCS codes, which are developed by the American Dental
Association (ADA), start with the letter D and are followed by four
numeric digits.
It is important to note that pricing will vary between a comparable CPT
and dental HCPCS code and that claims will be reimbursed based on the
pricing associated with the code submitted. Pricing for CPT codes is
based on Resource Based Relative Value System (RBRVS). Pricing for
dental HCPCS codes is based on Delta Dental pricing.
9-107
Prior
Authorization
If a service requires prior authorization, make sure the CPT or dental
HCPCS procedure code on the claim is the same as on the prior
authorization. For example, if a dental HCPCS code is approved on a
prior authorization, use the same code on the claim.
Prior authorization requests
Begin mailing or faxing prior authorization (PA) requests to:
Utilization Management Dept. R4-72
EPNI
P.O. Box 64265
St. Paul, MN 55164-0265
Fax: (651) 662-7816
Prior authorization recommendations have changed
PAs are recommended for the following services:
Claim Form
•
Surgical TMJ services
•
Orthognathic/osteotomies
•
Orthodontics for TMJ and cleft lip/palate
•
Bone grafts
•
Bridges for accidental injuries
Use a CMS-1500 claim form when submitting dental-related claims (the
ADA claim form is accepted; however, EPNI prefers the CMS-1500). If
you are using the ADA form, be sure to include the diagnosis if the
treatment is accident related, for cleft lip/palate or TMJ diagnosis or
include the narrative.
Treatment of accidental injury to natural teeth
Initial treatment must begin within 12 months of the accidental injury
and completed at 24 months from date of initial treatment.
“Injury” does not include bruxism or biting and chewing.
Complete the “date of injury” field on the claim. Submit the appropriate
accidental injury diagnosis code on the initial and subsequent claims
throughout treatment.
Include documentation in support of the accidental injury diagnosis or
narrative description of the accident with the claim.
Note: Prior authorization for anesthesia for children is not required.
Benefits are paid in accordance with the contract.
9-108
Coordination
Between Dental
and Medical
Carriers
If you perform the types of service listed above for your patients, bill
EPNI as usual. If the patient has a dental plan in addition to a medicalsurgical policy, the dental plan is the primary payer.
TMJ Claims
Submission
The following guidelines should be used when preparing TMJ-related
disorder claims for submission:
Note: If you receive payments from both the dental and medical plans
for the same services, refund the medical carrier. We will
coordinate up to our U&C allowances or billed charges,
whichever is less.
Codes
Guideline
ICM-9-CM
The primary diagnosis code should be 524.60temporomandibular joint disorders. All other
primary diagnosis codes submitted for TMJ and
craniomandibular disorders will be rejected.
HCPCS codes
The HCPCS code for orthotic therapy should be
D7880. All other orthotic codes submitted for TMJ
and craniomandibular disorders will be rejected.
Study casts and/or mounted or unmounted study
models are considered an integral part of the splint
therapy and should not be billed separately.
CPT codes
nonsurgical
Orthotic adjustments and office call visits are
considered an integral part of the orthotic therapy
and should not be billed separately. Only the initial
visit may be billed separately.
CPT codes
surgical
The following procedure codes are considered
eligible for reimbursement for surgical services of
the temporomandibular joint: 21050, 21060, 21070,
21240, 21242, 21243, 29804 (TMJ arthroscopy—
surgical only). Please Note: All postoperative office
visits are considered an integral part of the surgical
fee and should not be billed separately unless there
are documented complications.
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Diagnostic
Studies
The following radiographs are considered eligible for TMJ disorders
when medically necessary:
•
70328
•
70330
•
70332
•
70336
•
70355
•
70486
•
70487
• 70488
Benefits are not provided for cephalometric radiographs for TMJ
disorders.
Electromyography (EMG), Computerized Mandibular Scanner,
Computerized Jaw Tracking/Motion Analysis, Doppler Auscultation,
and Sonography/ultrasound are considered investigative and therefore
ineligible when used in the diagnosis and treatment of
temporomandibular and craniomandibular disorders.
Emergency Room
Emergency room services submitted with dental diagnosis will be
processed as a medical service.
Dental
Procedures and
Pre-op / Medical
Exams
When a member comes to your clinic for a pre-op exam for a dental
related procedure, code the exam as a medical pre-op. The charges will
fall under their medical benefits. Providers should only code as a pre-op
exam if they know the procedure will be covered.
9-110
Durable Medical Equipment and Supplies
Durable Medical
Equipment
(DME) Definition
Prior
Authorization
Requirements
EPNI defines DME as equipment and related health care supplies and
services that are:
•
able to withstand repeated use; and
•
used primarily for a medical purpose; and
•
generally not useful in the absence of illness or injury;
•
determined to be reasonable and necessary; and
•
prescribed by a physician; and
•
represents the most cost-effective alternative
Fax all prior authorization requests using the Prior Authorization
Request for DME form (X15717) to (651) 662-2810. EPNI will approve
or deny prior authorization requests based on a member's contract
benefits and the criteria defined in applicable medical policies. Prior
authorizations should be submitted by the durable medical equipment
supplier who will be providing the equipment and should include the
appropriate HCPCS code(s).
For questions about prior authorizations, call (651) 662-5270 or 1-800528-0934 (choose option 2, then option 4). Providers can also fax prior
authorization questions to (651) 662-2810. Members should call the
number on the back of their ID card for customer service if they have
questions.
The items listed in the table on the next page have written medical
policies associated with them. To determine eligibility for these items
see the applicable medical policy and specific contract benefits.
Item
Medical Policy Number
Prior Authorization
Required?
Ambulatory blood pressure monitoring
VII-13
Yes
Apnea appliances
IV-7,VII-26
Yes
Beds, specialty, overlays
VII-9
Yes
Coagucheck/Home Prothrombin Time
Monitoring
VI-1
Yes
Cochlear implants and accessories
IV-2
Yes
Communication devices
VII-52
Yes
Dorsal column stimulation devices
IV-74
Yes
Electrical bone growth stimulators
VII-17
Yes
9-111
Item
Medical Policy Number
Prior Authorization
Required?
Enteral feedings
II-41
Yes
Gravity lumbar reduction device (e.g.
SD, LTX 3000)
VII-43
Yes
Infusion pumps, implantable
IV-34
Yes
Neuromuscular stimulator
VII-25
See Medical Policy
Oral elemental diets
II-48
Yes
Phototherapy lights for SAD
VII-41
Yes
PUVA light therapy
II-15
Yes
Spinal cord stimulators
IV-74
Yes
Pelvic TENS or Pelvic Floor Electrical
Stimulation
VII-49
No
Uterine contraction monitors
VII-22
Yes
Vest percussors (e.g. Thairapy vests)
VII-35
Yes
Wheelchairs
VII-4
Yes, purchase only
Wound healing devices
II-45
Yes
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Ineligible Items
The following list of items is considered ineligible DME. There is no
need to submit prior authorization requests for ineligible items.
Note: This is not an all-inclusive list.
•
Abdominal support belts for
pregnant women
•
Grab bars
•
•
Heading pads
Adaptive eating equipment
•
•
Home monitors
Air conditioners
•
•
Air filters
•
Back huggers
Incontinence supplies (e.g.
diapers, underpants,
underpads, Attends)
•
Balls for therapy
•
Lifeline medical alert
•
Bedpans and urinals
•
Maternity belts
•
Biofeedback device, purchase
•
Overbed tables
•
Blood pressure cuffs and
accessories
•
Positioning aids (e.g. bolsters,
wedges)
•
Car seats
•
Reachers
•
Computer software & hardware
•
Roman chairs
•
Copes scoliosis brace total
recovery program
•
Scales
•
StimMaster E4000
•
Telephone communication
device (TTDY)
•
Thera cane
•
Tub stool or bench
•
Croup tent
•
Cryocuff (icing device)
•
Drionic devices (sweating
devices)
•
Elevators/stairlifts
•
•
Exercise equipment (e.g.
bicycles, tricycles, treadmills
and ski machines)
Vehicle modifications (hand
controls, lifts and car seats)
•
Vitrectomy, seated support
system (special chair for eye
surgery patients)
•
Wheelchair vehicle lift/ramps
•
Whirlpools/Jacuzzi/hot tubs
•
Feeding chairs
•
Floor sitters
•
Formula, infant
9-113
DME Rental
Guidelines
Most DME can only be rented for 10 months. DME is considered
purchased after 10 months of rental payments. Ten months rental for a
particular item equals EPNI allowed amount for the purchase price of
that item. No additional claims for rental or purchase of the same device
should be submitted after the EPNI allowed amount for the purchase
price of that item has been met.
The following items are rental only:
Waivers and
Upgraded/
Deluxe DME
•
ventilators
•
negative pressure ventilators
•
CPM machines
•
oximeters
•
large volume air compressors
•
airway pressure monitors oxygen concentrators
•
electric breast pumps
The following is EPNI’s policy for provision of upgraded or deluxe
equipment.
Providers may bill members for an equipment upgrade or deluxe charge
if a waiver is on file and the DME charges are billed correctly to EPNI.
EPNI will continue to reimburse only for medically necessary standard
DME. Providers must ask for a signed, written waiver that includes the
cost for the deluxe features or upgrade. (A sample waiver form can be
found on the next page.)
The waiver must state ALL of the following:
9-114
•
The standard piece of equipment or least costly alternative was
offered to the member; and
•
The member is aware and agrees that EPNI will only pay the
standard allowance; and
•
The member will be responsible for the deluxe or upgrade charge in
addition to his or her contractual obligation
•
Providers must keep all signed waivers on file. Do not send waiver
forms to EPNI. EPNI reserves the right to request waiver forms
from a provider's office when necessary.
Waiver Claim
Submission
Two lines of services must be billed. The first line will include the
HCPCS code and the charge for the standard (non-deluxe) equipment.
This dollar amount will be subject to contract benefits and usual and
customary reductions.
The second line must include the same HCPCS code with the -GA
modifier (waiver of liability statement on file) and the amount charged
for the upgrade or deluxe feature.
Example:
•
E0202 NU $550.00 (standard, charge that will be subject to standard
allowance and member contract benefits)
•
E0202 GA $150.00 (deluxe/upgrade charge that will be denied as
member liability)
The -GA modifier must be submitted as the first modifier on the second
service line. Other applicable modifiers should be submitted on the first
service line only.
Sample Waiver
Form
As a participating provider with Employer Provider Network (EPNI),
we are obligated to notify you of services that are medically
unnecessary. This notification will allow us to hold you financially
responsible for the upgrade to the durable medical equipment that you
are purchasing.
We have offered you the standard _______________________
(list type of equipment)
at the customary price of $________________ .
We have informed you of the least costly alternative, which is
the charge for the upgrade or deluxe features is $___________ .
By signing and dating this waiver, you are acknowledging that:
You are aware of and agree that EPNI will allow only standard
equipment.
Only the allowed amount for the standard equipment will apply to
deductible and coinsurance amounts.
You will be financially responsible for the deluxe or upgrade charge.
The upgrade charge is in addition to any contractual obligations you
have such as deductible and coinsurance amounts.
Signature ____________________________ Date: _________
9-115
DME Coding
DME suppliers and others who bill supply items should use HCPCS
level II codes. Our research shows that codes E1399 and K0108 are
used excessively and incorrectly. These should be used ONLY when
there is no code listed in the HCPCS manual for the equipment. Do not
use this code for supplies or equipment that can be coded with a specific
code or combination of codes.
Unlisted codes (such as K0108 or E1399) require submission of a
narrative describing the equipment along with the Manufacturers
Suggested Retail Price (MSRP).
Sales Tax
Include any tax in your charge for the item. Do not code tax separately.
If submitted, S9999 will be denied as provider liability.
Handling /
Conveyance
Handling, conveyance, and/or any other service in connection with the
implementation of an order involving devices (code 99002) is not
separately reimbursable. These charges should be included in charge for
the item.
Claims Filing
Requirements
Use the CMS-1500 claim form to report your services to EPNI. To
obtain forms, please refer to Chapter 6 – Claims Filing in this manual.
Submit ICD-9-CM codes to report an appropriate diagnosis for your
patient.
Use HCPCS level II codes to report your services.
The place of service must be a valid CMS two-digit place of service
code.
Submit units based on narrative description.
DME providers and Skilled Nursing Facilities, billing for place of
service 31, 32, or 33, are required to submit an Explanation of Medicare
Benefits (EOMB) for their services unless the provider has opted out of
Medicare. If the provider has opted out then the provider will need to
include the Opt Out letter with claims submitted. Any other place of
service does require an EOMB. This applies only to Medicare
recipients.
Hearing Aids
Hearing aids are generally not covered for any contracts.
Binaural Hearing Aid Units
Binaural hearing aid codes should be submitted with 1 unit only. The set
allowance reflects two hearing aids.
When submitting a charge for hearing aid repair, use HCPCS code
V5014. Coverage of hearing aids, services and supplies is contractually
based.
9-116
Oxygen and
Oxygen Aiding
Equipment
(Includes
Ventilators)
Coding Modifiers
Oxygen and Oxygen aiding equipment are defined as the following
items:
•
Oxygen
•
Ventilators
•
Negative Pressure Ventilators
•
Oximeters
•
Large Volume Air Compressors
•
Airway Pressure Monitors (excluding CPAP)
•
Oxygen Concentrators
•
Oxygen Conservers
•
Oxygen equipment is reimbursed on a rental basis only, as long as
the equipment is medically necessary.
•
Oxygen contents will only be reimbursed separately when the
member owns an oxygen system, or rents or owns only a portable
oxygen system.
EPNI requires all DME Providers to submit procedure code modifiers to
differentiate rental, purchase and repair or replacement of DME.
Modifiers include the following:
Rental Modifiers:
•
BR: The beneficiary has been informed of the purchase and rental
options and has elected to rent the item.
•
LL: Lease/rental (Use the LL modifier when DME rental is to be
applied against the purchase price.)
•
RR: Rental (Use the RR modifier when the DME is to be rented.)
•
Purchase modifiers:
•
BP: The beneficiary has been informed of the purchase and rental
options and has elected to purchase the item.
•
NR: New when rented. (Use the NR modifier when DME which
was new at the time of rental is subsequently purchased.)
•
NU: New Equipment
•
RP: Replacement and repair. RP may be used to indicate
replacement of DME, orthotic and prosthetic devices which have
been in use for some time. The claim shows the code for the part,
followed by the RP modifier and the charge for the part.
Note: Do not use the following modifiers as they will not be recognized
in processing: BU and UE.
9-117
DME Repairs and
Maintenance
(Excludes
Oxygen
Equipment)
Repair of rental DME is not covered.
Repair may be allowed for purchased DME. To submit repair, report the
HCPCS code for the DME being repaired with the –RP modifier.
Submit E1340 (repair or non-routine service for DME requiring the skill
of a technician, labor component, per 15 minutes) on a separate line.
Include the appropriate number of units (one per 15 minutes). The cost
of the repair (including parts and loaner fee) should not exceed our
allowable for the purchase of the equipment.
Charges for maintenance of DME are not covered. Maintenance would
be indicated with the –MS modifier.
Replacement of
Purchased
Equipment
EPNI’s policy is to pay for replacement of DME, due to normal use and
wear, every five (5) years, unless unusual circumstances necessitate
replacement of an item sooner than 5 years.
Replacement of obsolete or inoperable DME equipment which has been
purchased is subject to the same Prior Authorization guidelines as the
purchase of the original equipment.
9-118
Billing for
Supplies
Supply items should be submitted with the HCPCS Level II code that
most appropriately describes the item. Unlisted supply codes should be
used if there is no other code that describes the item. A narrative must
be submitted with every unlisted code.
Supplies are generally allowed separately only in conjunction with
approved home health care. Reimbursement for supplies used in the
office is included in the overhead component of the professional service
(such as an E&M). Office supplies, such as Betadine or alcohol wipes,
will be denied.
Payment for supplies is based per narrative description (e.g., each, per
pair, per 100, etc.). It is necessary to identify the total number of each
supply in the “units” block or the 24F block of the 1500 claim form.
Disposable gloves can be reported per 100 (a single box) or per pair.
Code A4927 reflects billing per 100. HCPCS code A4930 reflects
billing per pair. The unit descriptions for each code differ significantly.
It is important to submit the units correctly to ensure appropriate
reimbursement. Following is the narrative for each glove code along
with a coding example:
Code: A4927 Narrative: Glove, non-sterile, per 100
Example: One 100 count box of non-sterile gloves, submit 1unit in box
24G (days or units) on CMS-1500 claim form.
Code: A4930 Narrative: Gloves, sterile, per pair
Example: One 100 count box of sterile gloves, submit 50 units in box
24G on CMS-1500 claim form.
Gloves are restricted to home use only (for approved home health, home
infusion, or home dialysis services). Eligibility for reimbursement is
subject to member benefits.
The following quantities of ostomy and urology-related supplies are
considered to be reasonable for a monthly (30-day) period. When
quantities in excess of these amounts are supplied to the same patient
for use during the same month, the claim(s) must contain an explanation
of the medical necessity for such quantities. If the documentation is not
on the claim, there may be a delay in processing the claim or the claim
may be denied.
9-119
Billing for
Supplies
(continued)
•
Indwelling catheters—two per month
•
Catheter insertion trays—two per month
•
Sterile irrigation tray/kit—four per month
•
Irrigation syringe, bulb or piston—four per month
•
Bottles of irrigation solution—four per month
•
Bedside drainage bags—four per month
•
Leg drainage bags—four per month
•
Bedside drainage bottle, rigid or expendable—one per month
•
Leg strap, foam or fabric—one per month
•
Urinary catheters (straight catheter)—31 per month
•
Ostomy Pouches—70 per month
•
If a member signs a waiver accepting responsibility for supplies
billed in excess of recommended guides. Bill two lines of service.
The first line will include the HCPCS supply code and the second
line should be submitted with the same HCPCS code with a –GA
modifier. See “Waivers and Upgraded/Deluxe DME” for additional
waiver sample and submission information.
Rental Unit
Submission
Service counts must be submitted on a monthly basis only and generally
submitted as one (1) service per month, instead of 30 units or services.
Do not submit claims for more than a thirty day supply of any related
supplies. Rental is on a monthly basis only.
Hospital DME
Providers
Hospital DME providers are required to bill DME on a UB-92 claim
form.
DME/Supply
Internet
Purchases
DME or supplies purchased from Internet auction sites (such as e-Bay)
or private parties are generally not covered. If a DME supply company
is the actual supplier, that provider’s number will be assigned and the
claim will be processed per the member’s benefits. If the provider is not
a DME/supply company (e.g., private party, estate sale), the claim will
be denied.
E0935 Rental
Guides
Continuous passive motion devices are usually only used for a short
period of time during a patient’s recovery period. Therefore, the
HCPCS code E0935 (passive motion exercise device) is assigned a
daily rental allowance and it limited to 21 days of rental. Submit one
unit for each day of rental. For example, if the device is rented for 14
days, indicate 14 in the unit field.
9-120
Home Health, Home Infusion, and Hospice
Definitions
Prior
Authorization
Service
Definition
Home Health
Home health care is care provided in a patient's
home by qualified personnel.
Home Infusion
Home infusion is the administration of medications
or nutrition intravenously or through a feeding tube.
Hospice
Hospice care is a concept of care which provides
palliative care (rather than curative care) to a
terminally ill patient and family.
All home health and hospice services require prior authorization. Prior
authorization is required for the following home infusion services:
Blood Factor Products
•
IVIG
•
Aldurozyme®
•
Fabrazyme®
•
Home health, Blood factor and IVIG prior authorization is
performed by:
Case Management
Route code: R4-72
(651) 662-5520
888-878-0139 ext. 25520
Fax: (651) 662-1004
Address:
P.O. Box 64265
St. Paul, MN 55164-0265
Aldurozyme and Fabrazyme prior authorization is performed by:
Medical Review
R4-72
P.O. Box 64265
St. Paul, MN 55164-0265
Fax: (651) 662-2810
EPNI must be notified of any changes in treatment plans.
9-121
Home Health
Examples of home care services requiring review include: skilled home
nursing visits, home health aid services, home social worker visits, and
personal care attendants.
Note: Personal care attendants are not eligible for coverage under most
health plans, with the exception of Public Programs.
Coverage of services is subject to contract benefits and limitations.
Services must be skilled versus non-skilled or custodial.
Services must be intermittent and of medical nature.
Home health care must be ordered in writing by a physician and
performed by a Medicare certified/JCAHO approved home health
agency.
Services must be submitted on a UB-92 claim form. The appropriate
revenue code(s) should be submitted for the services supplied. Home
Health revenue code categories are:
•
055X: Skilled nursing
•
056X: Medical Social Services
•
057X: Home Health-Health Aide
•
058X: Other visits (Home Health)
•
059X: Home Health - Units of Service
• 060X: Home Health - Oxygen
Prior authorization is recommended except for members who we have
been notified are eligible for the elderly waiver program. The
authorization number provided by EPNI must be entered in form locator
63 on the UB-92 claim form.
9-122
Home Infusion
Home infusion services must be ordered in writing by a physician and
performed by a Medicare certified/JCAHO approved home infusion
agency.
Claim Submission Changes
Submit claims using either the electronic ASC ANCI X 12N 837
format, or on a paper CMS-1500 form using CPT and HCPCS codes.
Use the Place of Service code 12 (Home) for services provided in the
patient’s home, or in an infusion suite located at the home infusion
provider’s office.
Professional Id numbers are issued with contracts for all participating
home infusion providers. Individual provider numbers are not required.
As always, reimbursement is subject to the member’s contract benefits.
Per Diem Payment
The HCPCS “S” codes for home infusion services are based on a “per
diem” reimbursement methodology. The per diem includes all supplies,
care coordination and professional pharmacy services. The per diem is
billed for each day that a patient is on service from date of admission
through date of discharge. Nursing services, drug products and enternal
formulas are billed separately from the per diem.
Drugs
Code all drugs with a HCPCS or CPT code. If a specific code is not
available you may use J3490, J7799, or J9999. Provide the narrative,
NDC number, and dosage/units supplied, in field 24D on the CMS 1500
claim form. These claims will require manual review.
Use drug units as described in the HCPCS or CPT description of the
code.
Nursing
Code home nursing visits lasting up to two hours using CPT code
99601. Report each additional hour beyond the initial two with 99602
with the appropriate number of units.
When provided in the infusion suite of a home infusion agency, code
each nursing visit lasting up to two hours using CPT code 99199, with a
narrative description. Report each additional hour beyond the initial two
with 99199-52 with the appropriate number of units, in accordance with
the NHIA (National Home Infusion Association) recommendations for
billing.
9-123
Home Infusion
(continued)
Catheter Care
Bill catheter care per diems (S5498, S5501, S5502) when provided as a
stand-alone therapy. Insertion by a nurse of a PICC line (S5522) or
midline (S5523) is coded separately from the other nursing visit code
and per diem. Supplies required from non-routine catheter procedures
such as declotting supplies (S5517), repair kits (S5518), PICC insertion
supplies (S5520) and midline insertion supplies (S5521) are coded
separately.
Prior Authorization
Prior authorization is recommended when supplying IVIG, Factor
products, Aldurazyme, and Fabrazyme, or other drugs not yet identified.
A PA can be completed using the standard PA form X15709.
Multiple Therapies
For multiple therapies in the same category done on the same date of
service as primary therapy, append the following modifiers to the “S”
code per diem:
•
SH- second concurrently administered infusion therapy
• SJ- third or more concurrently administered therapy
Notification Recommended
Notification is recommended to our Case Management department for
obstetrical patients receiving hydration therapy, tocolytic therapy (i.e.,
Terbutaline) or anti-emetic infusion (i.e., Reglan or Zofran). This serves
as notification to EPNI that the patient may need additional support
from our staff. This can be done by calling (651) 662-5520.
9-124
Home Infusion
(continued)
Medicare Primary with EPNI Secondary
Medicare Supplement policies will only coordinate with the services
that Medicare allows:
Submit the nursing claims to Medicare Part A. The claim may crossover
to EPNI and process with your Home Health provider number.
Agencies who are not certified by Medicare A should subcontract the
nursing portion of the service to Medicare A certified home care
agency.
Submit the drugs and supply charges to Medicare Part B. The claim
may crossover to EPNI and should process using your DME provider
number.
Verification of the crossover may be done through our secure provider
web self-service. If the claim is not found, attach the Medicare EOMB
and cover letter to a paper claim and submit to EPNI.
For services that would be denied by Medicare, but may be allowed by
EPNI:
A Medicare denial is not required. Submit the claim to EPNI and
append the -GY modifier to each line of service.
Hospice
Hospice care must be ordered in writing by a physician and performed
by a Medicare certified/JCAHO approved hospice agency.
Services must be submitted on a UB-92 claim form using a hospice
contracting provider ID number. The appropriate revenue code(s)
should be submitted for the services supplied. Hospice revenue codes
are 0650-0659.
Prior authorization is recommended.
Claims Submission
Hospice claims should be submitted on paper for manual processing to
the Case Manager listed on the prior authorization letter to:
EPNI
Case Management R4-72
P.O. Box 64265
St. Paul, MN 55164
All hospice members are case managed.
9-125
Hospital Care
Initial Hospital
Care
EPNI patients have coverage for a physician’s daily inpatient care.
Submit a separate charge for medical care on the admission day, using
codes 99221 - 99223. Always submit this charge as one unit of service.
Subsequent
Hospital Visits
Bill all other inpatient visits as subsequent care, using codes
99231 - 99233. If the patient is still hospitalized when you bill, use the
last visit as the discharge date on the claim.
Subsequent visits may be combined on one line if all services,
diagnoses, and charges are identical, provided by the same individual
provider and the dates of service are sequential. Each visit counts as one
unit of service. The place-of-service code is inpatient hospital.
Critical Care
Coding of Critical Care is based first on the age of the patient.
Neonates- birth through the 28th postnatal day would utilize 99295 and
99296. These are inpatient per day codes.
Pediatrics- 29 days old through 24 months would utilize 99293 and
99294. These are inpatient per day codes.
Over 24 months of age- anyone older than 24 months would utilize
99291 and 99292. These are time- based codes.
Use code 99291 for up to 74 minutes of critical care. Submit one unit of
service for this code. Time duration beyond 74 minutes should be coded
as 99292 with the appropriate number of units. The narrative for 99292
states “each additional 30 minutes.” Code 99292 must always be
submitted with 99291.
Example: Critical care for a 26 year old of 2 hours duration
Code Units of Service
9-126
99291
1
99292
2
Hospital
Observation
Services
EPNI considers hospital stays for 24 hours or more as inpatient. The
hospital observation codes 99218 - 99220 should not be submitted if the
hospital stay is more than 24 hours.
Evaluation and management services on the same date provided in sites
that are related to initiating “observation status” should NOT be
reported separately.
Subsequent visits provided to patients who have been admitted to the
hospital for 24 hours or more should be submitted with codes
99231 - 99233.
Observation or inpatient care services provided to patients admitted and
discharged on the same date of service are reported using codes
99234 - 99236. The place of service can be either inpatient or
outpatient.
Observation Care
Discharge Day
Management
The discharge management code 99217 may be submitted for the day
following initial observation care when a physician performs a final
exam, discusses the observation period, provides instructions for
continued care, and prepares the discharge record.
Hospital
Discharge
Hospital discharge day management services, 99238 or 99239, are only
billable by the provider who actually discharged the patient on the
actual date of discharge. Face to face contact is required on the day of
discharge.
Discharge summaries prepared before the patient is discharged are not
billable.
Continuing
Intensive Care
Services
The codes 99298 - 99300 are used to report services subsequent to the
day of admission provided by a physician directing the continuing
intensive care of the low birth weight (LBW), very low birth weight
(VLBW) infant, or normal weight newborn who no longer meets the
definition of critically ill but continue to require intensive observation,
frequent interventions, and other intensive services. These codes are
global 24-hour codes and not reported as hourly services.
Swing Beds
If the hospital census reports the patient as inpatient, use inpatient E&M
codes with an inpatient place of service. If the patient has been
discharged from inpatient status, use the skilled nursing place of service
and the corresponding E/M codes 99304-99310.
Skilled-Nursing
Facility Care
Follow the same guidelines for skilled-nursing facility care as for inhospital medical care above. Use codes 99304-99306 for medical care
on the day of admission to a skilled-nursing facility. For follow-up care,
use codes 99307-99310. The place-of-service code is 31. Claims for
skilled-nursing care require admit and discharge dates.
Discharge day management codes 99315 or 99316 are used to report the
total duration of time spent by a physician for the final nursing facility
discharge of a patient.
9-127
Institutional Care
Definitions
Category
Definition
Ambulatory
Surgical or
Surgicenter
An ambulatory surgical or medical center is a
facility that provides ambulatory (walk-in) surgical
or medical treatment. These centers provide care
usually done in an acute care hospital on an
outpatient basis.
Claim Format
Regulations
HIPAA Administrative Simplification code and
transaction regulations dictate the standard claim
format and codes for electronically submitted
claims. Institutional claims are billed on the 837I
electronic format. The paper equivalent is the UB-92
or CMS-1450 claim form.
EPNI considers the following providers as
‘institutional’ and as such, should bill on the
institutional claim format (837I or UB-92).
9-128
Home Health
Agency
HHA is a public agency or private organization that
is primarily engaged in providing skilled nursing
services and other therapeutic services, such as
physical therapy, occupational therapy, medical
social services and home health aide services. Can
be freestanding or hospital attached. Care is
rendered in the home and is in lieu of a hospital
confinement.
Hospice
Hospice programs provide health care for terminally
ill patients. Care may be done in the patient’s home,
at special hospital units, or a separate hospice care
facility.
Hospital
An institution that provides medical, diagnostic and
surgical care. Services can be rendered on an
inpatient or outpatient basis.
Non-residential
Treatment
Center
This type of institution is the same as a residential
primary treatment center with the exception that
services are rendered on an outpatient basis only.
Nursing Home
A Skilled Nursing Facility (SNF) provides skilled
nursing care and related services for patients who
require medical or nursing care; or rehabilitation
services for injured, disabled, or sick person.
Definitions
Category
Definition
Psychiatric
Hospital
A psychiatric hospital provides care to emotionally
ill patients. These facilities must be licensed by the
state in which they are located.
Residential
Primary
Treatment
Center (IP
Chemical Dep)
Residential treatment programs for chemical
dependency are planned and purposeful sets of
conditions and events for the care of inebriated and
drug dependent persons which provides care and
treatment for five or more inebriate or drug
dependent persons on a 24 hour basis. Excluded for
this definition are receiving (detoxification) centers.
Facility Clinic
If a hospital operates a clinic in their facility, clinic charges must be
billed as if the clinic were free-standing. Submit clinic charges under
the assigned EPNI professional provider number on a professional claim
form (CMS-1500 or 837P). The clinic place of service code 11 should
be submitted.
UB-92 Manual
The Uniform Billing Manual (UB-92) was developed and maintained by
the National Uniform Billing Committee. The data element
specifications for all institutional claims are found in the UB-92 manual.
This data is for use in EDI billing and payment transactions and related
business applications as well as paper claim submission.
Providers billing institutional claims should have a UB-92 manual
readily available. The manual is available from several sources
including directly from the NUBC, commercial publishers, or the state
specific manual from the Minnesota Hospital Association. Data
elements are updated several times throughout the year.
UB-04
The UB-04 is scheduled to replace the UB-92 beginning with bills
created on March 1, 2007. Refer to Chapter 6 for additional
information.
Procedure Code
Regulations
The medical procedure code set for inpatient services is ICD-9
procedure codes. Procedure information will be reported on outpatient
claims using HCPCS codes.
Revenue Codes
(Form Locator
42)
A revenue code identifies a specific accommodation and/or ancillary
service or billing calculation. The revenue code is four characters. The
first digit is usually a 0 (zero); however, there are codes that begin with
other than 0 (100X, 210X, 310X). It is important to report all four
digits.
9-129
HCPCS / Rates
(Form Locator
44)
For inpatient bills, the accommodation rate relating to the room and
board revenue code is entered in form locator 44.
Revenue Codes
Requiring HCPCS
/ CPT
To align more closely with the Centers for Medicare & Medicaid
Services (CMS) on revenue codes that require HCPCS/CPT codes on
Outpatient Institutional claim submissions, EPNI are adding revenue
codes to what is currently required within your provider contract.
For outpatient bills, report the HCPCS code, if applicable, to indicate
the specific outpatient service in form locator 44. Some HCPCS codes
or billing situations may require submission of modifiers. Modifiers are
reported following the HCPCS code. EPNI accepts modifiers; however,
we currently do not adjudicate the claim/service based on modifiers.
The list of revenue codes requiring submission of a HCPCS/CPT code
is below. In addition to the codes listed below, there may be revenue
codes that may be subject to additional coding requirements. These
codes will be listed elsewhere (such as 0942).
Revenue
Codes
Descriptions
Revenue
Codes
Descriptions
0274
Medical/Surgical Supplies and
Devices – Prosthetic / Orthotic
Devices
0291
(Other than Renal) – Rental
0292
(Other than Renal) – Purchase
of New DME
0293
(Other than Renal) – Purchase
of Used DME
0300
Laboratory – General
Classification
0301
Laboratory – Chemistry
0302
Laboratory – Immunology
0303
Laboratory – Renal Patient
(Home)
0304
Laboratory – Non-Routine
Dialysis
0305
Laboratory – Hematology
0306
Laboratory – Bacteriology &
Microbiology
0307
Laboratory – Urology
0309
Laboratory – Other Laboratory
0310
Laboratory Pathological –
0311
Cytology
0312
Histology
0314
Biopsy
0319
Other/Mantoux
9-130
Revenue
Codes
Descriptions
Revenue
Codes
Descriptions
0320
Radiology-Diagnostic –
0321
Angiocardiography
0322
Arthrography
0323
Arteriography
0324
Radiology-Diagnostic – Chest
X-Ray
0329
Radiology-Diagnostic – Other
Radiology-Diagnostic
0333
Radiology-Therapeutic and/or
Chemotherapy Administration
– Radiation Therapy
0340
Nuclear Medicine – General
Classification
0341
Nuclear Medicine – Diagnostic
Procedures
0342
Nuclear Medicine –
Therapeutic Procedures
0343
Nuclear Medicine – Diagnostic
Radiopharmaceuticals
0344
Nuclear Medicine –
Therapeutic
Radiopharmaceuticals
0349
Nuclear Medicine – Other
0350
CT Scan – General
Classification
0351
CT Scan – Head Scan
0352
CT Scan – Body Scan
0359
CT Scan – Other CT Scan
0360
Operating Room Service –
0361
Minor Surgery
0362
Organ Transplant (other than
kidney)
0367
Kidney Transplant
0369
Other Operating Room Services
0400
Other Imaging Services –
0401
Diagnostic Mammography
0402
Ultrasound
0403
Screening Mammography
0404
Positron Emission
Tomography/PET Scan
0409
Other Imaging Services – Other
Imaging Services
0413
Respiratory Services –
Hyperbaric Oxygen Therapy
0450
Emergency Room – General
Classification
0451
Emergency Room – EMTALA
Emergency Medical Screening
Service
0452
Emergency Room – ER Beyond
EMTALA Screening
9-131
Revenue
Codes
Descriptions
Revenue
Codes
Descriptions
0456
Emergency Room – Urgent
Care
0459
Emergency Room – Other
Emergency Room
0460
Pulmonary Function – General
Classification
0469
Pulmonary Function – Other
Pulmonary Function
0471
Audiology – Diagnostic
0480
Cardiology – General
Classification
0481
Cardiology – Cardiac Cath Lab
0482
Cardiology – Stress Test
0483
Cardiology – Echocardiography
0510
Clinic – General Classification
0511
Clinic – Chronic Pain Center
0512
Clinic – Dental Clinic
0513
Clinic – Psychiatric Clinic
0514
Clinic – OB-GYN Clinic
0515
Clinic – Pediatric Clinic
0516
Clinic – Urgent Care Clinic
0517
Clinic – Family Practice Clinic
0519
Clinic – Other Clinic
0530
Osteopathic Services – General
Classification
0610
Magnetic Resonance
Technology (MRT) – General
Classification
0611
Magnetic Resonance
Technology (MRT) – MRI –
Brain (Including Brainstem)
0612
Magnetic Resonance
Spinal Cord (Including Spine)
0614
Magnetic Resonance
Other
0615
Magnetic Resonance
Technology (MRT) – MRA –
Head and Neck
0616
Magnetic Resonance
Technology (MRT) – MRA
Lower Extremities
0618
Magnetic Resonance
Technology (MRT) – MRA –
Other
0619
Magnetic Resonance
Technology (MRT) – Other
MRT
0636
Pharmacy – Extension of 025X
– Drugs Requiring Detailed
Coding
0730
EKG/ECG (Electrocardiogram)
– General Classification
0731
– Holter Monitor
0732
– Telemetry
0739
– Other EKG/ECG
0740
EEG (Electroencephalogram) –
0749
EEG (Electroencephalogram) –
Other EEG
0750
Gastro-Intestinal Services –
0759
Gastro-Intestinal Services –
Other Gastro-Intestinal
9-132
Revenue
Codes
Descriptions
Revenue
Codes
Descriptions
0771
Preventive Care Services –
Vaccine Administration
Miscellaneous Dialysis –
Ultrafiltration
Miscellaneous Dialysis - Other
0880
Miscellaneous Dialysis – Home
Dialysis Aid Visit
Behavioral Health Treatment/
Services – General
Classification
0901
Services – Electroshock
Treatment
0903
Services – Play Therapy
0914
Services – Individual Therapy
0915
Services – Group Therapy
0916
Services – Family Therapy
0917
Services – Biofeedback
0918
Services – Testing
0920
Other Diagnostic Services –
0921
Peripheral Vascular Lab
0922
Electromyelogram
0923
Pap Smear
0924
Allergy Test
0925
Pregnancy Test
0929
Other Diagnostic Service
0940
Other Therapeutic Services –
0943
Other Therapeutic Services –
Cardiac Rehabilitation
0881
0889
0882
0900
9-133
Outpatient
Facility Fee
Billing
Questions are often directed at EPNI regarding reimbursement for
specific revenue codes. Codes for treatment and observation rooms
(0760, 0761 and 0769) are frequently questioned, as are clinic charge
revenue codes (0510-0519). These billing codes are explained below.
Treatment Room
Facilities should not bill EPNI for a treatment room using UB-92
revenue codes 0760, 0761 and 0769. EPNI considers a treatment room
as an overhead expense reimbursed as part of the physician’s
professional fee. Therefore, billing facility fees through the 0760, 0761
and 0769 codes duplicates the physician’s professional claim (CMS1500) and will deny as provider liability if submitted on the UB-92
claim.
There is one exception to this policy. If Medicare is primary, and EPNI
is secondary, we will accept the 0760, 0761 and 0769 revenue codes,
and process according to Medicare’s guidelines.
Observation Room
Observation Care, billed under revenue code 0762, is allowed for
admits of less than 24 hours. Claims for observation services for 24
hours or more will be processed as an inpatient claim.
Clinic Changes
Clinic charges, are considered an overhead expense and are reimbursed
as part of the physician’s professional fee. Therefore, billing clinic
charges through the 0510-0519, and 0520, 0523, 0526, and 0529
revenue codes duplicate the physician’s professional claim (CMS-1500)
and will deny as provider liability if submitted on the UB-92 claim.
Returned Paper
Claims
When you submit a paper claim that is missing required information, or
the claim does not meet EPNI’s edits, a letter is sent back to you along
with a copy of the entire claim. EPNI will send back a copy of only the
first page of the claim, along with the letter. Corrections should be
made, the claim reprinted on a UB-92 red drop claim form, and returned
by mail. If attachments are necessary, they should be submitted with the
corrected claim.
Education /
Training 0942
and Other
Therapeutic
Services 0949
Education or training services may be limited by policy or contract, thus
we require submission of a HCPCS/CPT or narrative to determine
coverage.
9-134
Lactation
Education
For billing purposes, lactation services are considered to be part of the
mother’s charges and should not be billed on the newborn’s claim.
Submit all claims for lactation education on the 837I or UB-92 claim
form using revenue code 0942. These charges must be submitted on the
mother’s original maternity/delivery claim and require a narrative
description.
Claims for lactation services submitted under infant’s name or number
will be rejected.
If lactation education is necessary after discharge, it can be billed as part
of the post-partum visit under the mother’s identification number.
Zero Line and
Negative Dollar
Charges
Paper claims submitted to EPNI require that all necessary fields be
completed with valid data. This includes charges for each line, and the
total charge. Claims that contain a $0.00 line charge, a negative (-) total
charge will be returned, with the following exceptions:
HIPPS revenue codes (Health Insurance Prospective Payment System)
0022, 0023, 0024
Revenue code 018X (Leave of Absence)
Diabetic
Education
Diabetic education services should be billed under revenue code 0942.
The appropriate HCPCS code must be submitted in FL44. The codes
G0108 or G0109 may be submitted only if the program is certified by
the National Diabetes Association. Medical Nutrition Therapy may be
billed using codes 97802-97804.
Revenue Code
0636
The revenue code 0636, by definition, is for drugs that require detailed
coding. Revenue 0636 must always be submitted with a HCPCS code.
However, some drugs that would be submitted under this revenue code
also require prior authorization. The following drugs require prior
authorization.
IVIG HCPCS codes J1563, J1564, Q9941, Q9942, Q9943, Q994
Aminolevulinic Acid HCI code J7308
Factor products HCPCS codes J7190, J7191, J7192, J7193, J194, J7195,
J7198, J7199, Q0187, Q2022
If a specific HCPCS code is not available, an unlisted code, such as
J3490, J7199 or J9999 may be submitted. When using an unlisted code
a narrative, NDC and dosage/units supplied are also required in form
locator 84.
Revenue Codes
0500 and 0509
The revenue codes 0500 and 0509 are for outpatient services,
specifically for charges for services rendered to an outpatient who is
admitted as an inpatient before midnight the day following the date of
service. It should not be used as a clinic or a room charge.
9-135
Behavioral
Health Revenue
Codes
Refer to the Behavioral Health for UB-Billers section of this chapter for
guidelines relating to behavioral health services, including mental health
and chemical dependency services.
Transfer of Care
/ Transfer Case
Transfer of care is when a patient is discharged from one physician to
another or from one facility to another. Moving a patient in the hospital
from one unit to another does not constitute a transfer.
Patient status codes are a required field (Form Locator 22) on the
institutional claim (837I or UB-92). This code indicates the patient’s
status as of the “Through” date of the billing period. It is important to
note that the patient status code indicates a destination and not a level or
type of care received.
When a patient is transferred/discharged to another facility, patient
status may affect reimbursement. All patient status codes are accepted
but not all will result in a transfer case classification. The following
patient status codes are used by EPNI to classify a transfer case.
9-136
Patient
Status
Definition
02
Discharged/Transferred to Another Short-Term
General Hospital for Inpatient Care in anticipation of
covered skilled care
05
Discharged/Transferred to Another Type of Institution
not defined elsewhere in this code list
43
Discharged/Transferred to a Federal Hospital
65
Discharged/Transferred to a Psychiatric Hospital or
Psychiatric Distinct Part Unit of a Hospital
Laboratory Services
Overview
EPNI does not allow providers to bill the health plan for laboratory
services or imaging studies that are not ordered by a physician or other
qualified practitioner. It is the belief of EPNI that in addition to
receiving lab or radiology results, the patient also needs interpretation of
the tests, recommend for future care, and a course of action that only a
physician or other qualified practitioner can deliver. In addition, tests
must be medically necessary in order to be eligible for coverage, as
determined by a medical professional. As a result, we will only issue
payment for services that are coordinated by a physician or other
qualified practitioner. A qualified practitioner is a practitioner
recognized as an eligible provider by EPNI and practices within the
scope of his or her licensure. Specific licensing questions should be
directed to your specialty’s licensing board.
Laboratory and pathology procedures should be submitted using the
HCPCS level I or II code that best describes the service. CPT codes
80048 - 89356 encompass level I codes for the majority of laboratory
and pathology procedures.
The services listed in the pathology and laboratory section of the CPT
manual may be provided by the pathologist or alternatively by
technologists who are under the supervision of the pathologist or
practitioner.
The guidelines outlined below should be adhered to when submitting
laboratory services to EPNI.
Organ or
Disease-Oriented
Panels
The tests listed under each panel (80048 - 80076) identify the defined
components of that panel and all tests listed must be performed in order
to bill for that panel. Tests performed in addition to those specifically
indicated for a particular panel can be billed separately in addition to the
panel code.
Lyme Disease
Titer
Laboratory testing for Lyme disease titer should be submitted using
code 86618.
Office Visits
A level-of-service office visit may be submitted in addition to
laboratory tests only when additional separately identifiable services are
provided. Obtaining a specimen for a streptococcus test, for example,
and relaying the results to the patient are included in the reimbursement
for the test itself and may not be billed separately. A minimal level of
service may be submitted if a brief history and examination is
performed in addition to the laboratory test.
9-137
Standing Orders
Generally, we do not cover laboratory tests performed because of
standing orders on file for certain patients. One example of this is a
standing order for routine screening tests when the patient has no
clinical symptoms or is not taking medications. Laboratory services
based on standing orders are covered only if you can show the medical
necessity of the services through your medical records or if the patient
has routine screening benefits and the tests are coded with an ICD-9CM as routine services.
Venipunctures
and Lab Handling
The following codes apply to venipunctures and lab handling:
Code
Description
36415
Collection of venous blood by venipuncture
36416
Collection of capillary blood speciman (eg., finger,
heel, ear stick)
99000
Handling and/or conveyance of specimen for
transfer from the physician’s office to a laboratory
Code 36415 is submitted when the provider performs a venipuncture
service to collect a blood specimen(s).
As opposed to a venipuncture, a finger/heel/ear stick (36416) is
performed in order to obtain a small amount of blood for a laboratory
test.
These codes should be billed only once regardless of the number of tests
performed from that specimen.
Code 99000 is an adjunct code submitted to indicate handling and/or
conveyance of a specimen for transfer from the physician’s office to a
laboratory. This code is never used for lab services performed
completely within the physician’s office.
If the lab is picking up the specimen, there is no handling cost incurred
and the clinic should not bill 99000.
The test that is being done from the specimen must be indicated on the
claim. This can be indicated by submission of the lab test code with the
-90 modifier (if you are billing for the test) or narrative indicating the
test code and/or name (done if lab will bill for test instead of clinic). If
this information is not present on the claim, the charge will be denied if
billed in addition to a venipuncture code 36415.
For lab tests requiring routine venipuncture and subsequently sent to an
outside lab, the physician office may bill either the venipuncture service
or the handling charge, but not both (i.e., 36415 or 99000).
9-138
Papanicolaou
Smears
The procedure codes, diagnosis codes, specimen collection codes, and
handling fee, which apply to papanicolaou smears are detailed below:
Procedure Codes
Codes 88142 - 88154, 88164 - 88167, 88174 - 88175, P3000, P3001,
G0123 - G0124, and G0141 - G0148 are for cytopathology screening
of cervical or vaginal smears. Submit the appropriate code to reflect the
service provided.
Procedure code 88141 and 88155 are used to report physician
interpretation of a cervical or vaginal specimen and should be listed in
addition to the screening code chosen when the additional services are
provided.
Diagnosis Codes
Routine cervical papanicolaou smears should be reported with
appropriate ICD-9-CM diagnosis codes:
Use this code…
In this situation…
V72.32
As part of a general gynecological examination
V76.2
Without a general gynecological examination
Pap smears performed due to illness, specific related symptoms, or
relevant personal or family history should be reported with the most
specific ICD-9-CM code available.
Specimen Collection Codes
The specimen collection codes for a pap smear (Q0091) may be billed
in addition to the pap smear code. If an E/M is done at the same time,
the specimen collection is included in the level of service reported for
the examination and evaluation and should not be billed separately. The
collection code will be denied as incidental to the E/M if billed.
Handling Fee
Code 99000 may be submitted for the cost incurred by the clinic for the
handling and/or conveyance of the pap smear for transfer from the
physician’s office to an outside laboratory. This code is never submitted
for cytopathology screening performed within the physician’s office.
Modifier -90 (reference outside laboratory) must also be submitted
when the screening is performed by a party other than the treating or
reporting physician. This modifier would be submitted with the pap
smear code (e.g., 88150-90). Narrative indicating the test being done
may be submitted in lieu of the procedure code and modifier if the lab
will be billing EPNI for the test instead of the clinic.
9-139
Pregnancy Tests
Pregnancy tests should be coded as follows:
Code
Description
84702
Quantitative, serum
84703
Qualitative, serum
81025
Urine
Laboratory records must document the method (quantitative or
qualitative) of testing done and the type of specimen used (serum or
urine).
Purchased
Services/Outside
Lab
The entity that performs a test should be the one to bill for that test.
However, a provider may, under arrangement with another provider, bill
a service that is purchased from that other provider. For example, a
clinic may bill for a pap smear that is sent to an independent lab for
analysis, or for an X-ray that is done at a hospital because the clinic did
not have the appropriate equipment. It is important to remember that
only one provider may bill for the service.
Claims for purchased services should be submitted on the CMS-1500
as follows:
•
Item 24B (place of service)–enter the place of service code where
the service was done by the performing provider.
•
Item 24D (procedure/modifier)–enter the procedure code of the test
and the modifier 90.
•
Item 24K (provider number)–enter the EPNI individual provider
number of the ordering physician.
•
Item 32 (where rendered)–enter the name and address of the
performing provider.
Please see the example that follows on the next page.
Stat Lab Charges
9-140
Charges for stat laboratory requests (S3600 and S3601) are not allowed.
If submitted, they will deny as provider liability.
Example
24.
TO
MM
MM
A
DATES OF SERVICE
FROM
DD
DD
YY
B
C
Place
of
Svc
Type
of
Svc
YY
D
PROCEDURES,
SERVICES, OR
SUPPLIES
(Explain
Unusual
Circumstances)
CPT/HCPCS
MODIFIER
05
02
00
06
1
1
99212
05
02
00
06
1
1
88150
05
02
00
06
1
1
05
02
00
06
05
02
00
06
25. FEDERAL TAX I.D.
NUMBER
E
DIAG
NOSI
S
G
DAYS
OR
UNITS
H
EPSDT
Family
Plan
I
EMG
K
J
COB
RESERVED FOR
LOCAL USE
$CHA
RGES
CODE
12
30.00
1
12345AB
2
10.00
1
12345AB
99000
2
10.00
1
12345AB
1
1
80050
1
50.00
1
12345AB
1
1
36415
1
5.00
1
12345AB
SSN
EIN
90
26. PATIENT’S
ACCOUNT NO.
27. ACCEPT
ASSIGNMENT?
(For govt
claims, see back)
Yes
31. SIGNATURE OF PHYSICIAN
OR SUPPLIER
INCLUDING DEGREES OR
CREDENTIALS
(I certify that the statements
on the reverse
apply to this bill and are made
a part thereof.)
SIGNED
F
No
32. NAME AND ADDRESS OF
FACILITY WHERE SERVICES
WERE
RENDERED (If other than home
or Office)
28.
TOTAL
CHARGE
29.
AMOUNT
PAID
30.
BALANCE
DUE
$ 105.00 $
$
33. PHYSICIAN’S, SUPPLIER’S
BILLING NAME, ADDRESS, ZIP
CODE & PHONE
XYZ Lab
123 Main St.
St. Paul, MN
DATE
PIN#
GRP#
54321BA
9-141
Maternity/Obstetrical Services
Global
Obstetrical Care
EPNI accepts the global obstetric care codes 59400, 59510, 59610 and
59618, which include antepartum care, delivery, and postpartum care.
Antepartum Care
Antepartum care includes the subsequent history and physical
examinations, recording of weight, height, blood pressures, fetal heart
tones, chemical urinalysis, maternity counseling, and monthly visits up
to 28 weeks gestation, biweekly visits to 36 weeks gestation, and
weekly visits until delivery. Any other visits or services within this time
period should be coded separately.
The provider may choose to bill globally, visit-by-visit, or to use codes
59425 or 59426 for antepartum care. The date of service submitted for
antepartum care should be the date of delivery.
If antepartum care is not performed for the entire period, code each E/M
service separately.
Delivery
Delivery includes admission history and physical, management of
uncomplicated labor, and delivery (with or without episiotomy or
forceps). Vaginal delivery only should be submitted with procedure
code 59409 or 59612 (VBAC).
Cesarean delivery only should be submitted with code 59514 or 59620
(VBAC).
Multiple births are coded as any other single birth delivery.
Subsequent
VBACs
Vaginal births after a Cesarean should be coded using CPT codes
59618, 59620, 59622 regardless if the vaginal birth is the first or
subsequent following the Cesarean.
Postpartum Care
Postpartum care includes hospital visits and one to two office visits for
usual, uncomplicated postpartum follow-up, urinalysis, and
hemoglobins. The global codes (59400, 59510, 59610, or 59618) and
delivery codes (59410, 59515, 59614, or 59622) include postpartum
care.
Submit the postpartum care package (separate procedure) code 59430
only when another provider does the delivery. Submit this code one
time with one unit of service. The date of service should be the delivery
date.
Intitial Visit and
Itemized
Services
9-142
The initial visit may be billed separately with an appropriate E/M code.
An obstetrical profile (80055) and any laboratory procedure codes
(other than urinalysis) should also be submitted separately.
Submission
Options and
Coding
Alternatives
The following submission options are available:
•
The global codes 59400, 59510, 59610, and 59618 may be
submitted with one charge. For contracts subject to Minnesota
legislative mandated benefits and others that waive deductibles,
copays, or coinsurance on antepartum care, EPNI will process these
services separately from the delivery and postpartum care. The
global maternity charge will be split based on RBRVS (Resource
Based Relative Value System) work values. The provider Statement
of Provider Claims Paid will report procedure code 59426 with a
payment at 100 percent of the allowance and a delivery code 59410,
59515, 59614, or 59622 with a payment determined according to the
contract’s benefits.
For contracts that are not subject to Minnesota legislative mandated
benefits and/or where antepartum care is subject to regular contract
benefits, the global codes 59400, 59510, 59610 and 59618 will
process with the charge and code as submitted.
•
Providers may submit the appropriate E&M codes for each
antepartum visit individually with the delivery code 59410, 59515,
59614, or 59622 as an alternative to submitting the global maternity
codes 59400, 59510, 59610, or 59618.
9-143
Pre-term Birth
Prevention
Services
EPNI will reimburse for certain pre-term birth prevention services when
the patient’s contract covers these services.
Code
Narrative
Billing
H1000
Prenatal Care, at-risk
assessment
Done twice for all
patients; once at initial
OB visit, and once at
24-28 weeks.
[use the Pregnancy
Assessment Form, DHS
3294 (1/97) to complete
assessment or the
American College of
Obstetrics and
Gynecology (ACOG)
pregnancy assessment
form]
H1001
Prenatal care, at-risk
enhanced service;
antepartum management
If the patient is
identified via the
assessment as high risk.
This code may be billed
once.
H1003
Prenatal care, at-risk
enhanced services;
education
If the patient is
identified via the
assessment as high risk.
This code may be billed
once.
The services represented by the prenatal care at-risk codes H0002,
H0004 and H0005 are already included in the provider’s normal
prenatal care and not separately reimbursed.
9-144
Two Physicians
Involved in Care
/ Same Tax ID
New Born Care
There are situations where the primary physician provides prenatal and
postnatal care but does not deliver the baby. The most common
situation noted is when a surgeon from the same medical group as the
primary physician delivers the baby via C-section. Many times the
primary physician is also acting as an assistant-at-surgery. In the case
where both physicians are in the same practice (same tax ID), EPNI is
recommending the following submission guides:
•
Same tax-ID – clinic provider number reported for the claim
•
Surgeon – bills the global C-section (59510); individual provider
number of the surgeon reported on the service line
•
Primary physician – bills the C-section assist (59514-80); individual
provider number of the physician reported on the service line
•
Provider production and disbursement of reimbursement is an
internal process. It is the clinic’s responsibility to assure the
providers participating in the patient’s care are appropriately paid.
Submit procedure code 99431 or 99433 and diagnosis code V20.1 to
bill for routine services in the hospital for well newborns. If the
newborn is ill, submit codes 99221 - 99233 for hospital visits. For
discharge day management, submit 99238. Pediatric standby should be
submitted with code 99436. Standby services are requested by another
physician. The physician may not be providing care or services to other
patients during this period. Standby, 99436, includes the initial
stabilization of the newborn, thus services may be denied as incidental
to 99436. When billing a newborn circumcision (54150 or 54160) on
the day of discharge, add modifier –25 to code 99238. A diagnosis
indicating the circumcision (V50.2) must be linked as the primary
diagnosis to the circumcision procedure (54150 or 54160).
For neonatal critical care or intensive (non-critical) low birth-weight
services see codes 99295-99300.
Complications or
Unusual
Circumstances
Submit modifier –22 with specific documentation to justify additional
reimbursement along with the delivery or operative report for
complications during delivery. Unusual circumstances resulting in
extensive antepartum or postpartum care should be coded separately. A
narrative/operative report should be sent with the claim.
Exceptions
There may be some contracts that do not follow the
maternity/obstetrical guidelines. For contracts that require a copayment
per visit, EPNI will request the number of antepartum visits if the global
maternity codes 59400, 59510, 59610, or 59618 or the antepartum codes
59425 or 59426 are submitted.
Lactation
Education
If done as part of the delivery, serivce should be billed on the UB-92, on
the mother’s claim. If this is done after discharge, it should be
incorporated into the E/M for postpartum care.
9-145
Collection of
umbilical cord
blood
Collection of umbilical cord blood may be done at the time of a delivery
either for donation to organizations such as the Red Cross or per the
patient’s request to bank the blood for possible future need. Regardless
of intent, cord blood collection is not a reimbursable service. If billing
for the collection per the request of the patient, the patient must be
notified that this charge will be their liability. The charge should be
submitted using an unlisted procedure code, such as 59899, with a
narrative description and will be denied as member liability.
Obstetrical Care
Coding
Alternatives
Different options are available for billing Obstetrical care. Listed below
are some of the variations. Generally, global billing is preferred.
Global Billing
Global Billing includes the antepartum care, delivery, and post-partum
care.
•
59400 -Vaginal delivery
•
59510 - C-Section
•
59610 - VBAC
• 59618 - C-Section after VBAC
Antepartum Care Only
•
59425 - 4 to 6 Visits
•
59426 - 7 Visits
• E/M - Evaluation and Management codes billed for each visit.
Delivery Only
•
59409 - Vaginal delivery
•
59514 - C-Section
•
59612 - VBAC
Delivery and Post-partum Only
•
59410 - Vaginal delivery
•
59514 - C-Section
•
59612 - VBAC
Post-partum Care Only
9-146
•
59430
•
E/M - Evaluation and Management codes billed for each visit
Medical Emergency
Introduction
Some members have full coverage for an outpatient medical emergency,
which we generally define as the sudden and unexpected onset of a
condition requiring immediate medical attention. To receive full
benefits, the member must seek care within specified time limits,
usually within 24 to 72 hours of the onset of acute symptoms.
Accidental injury is not included in the medical emergency benefits.
Many coverage plans have separate first-aid or accident benefits.
Criteria for
Medical
Emergencies
Use the guidelines below to determine if you should submit a claim as a
medical emergency. Medical emergency charges should be submitted
with the date and time the emergency occurred. If the emergency is
related to pregnancy, also indicate that the charges were for emergency
services.
•
Were the symptoms sudden, severe, and life threatening?
•
Did the condition require immediate medical (not surgical)
attention?
•
Did the patient see a doctor no later than 72 hours after the problem
began?
•
Did the time or date of the visit indicate it was an emergency?
•
The following situations generally would not indicate a medical
emergency:
•
scheduled surgeries or diagnostic procedures such as colon or
IVP X rays
•
follow-up visits for further injections, such as antibiotics
•
suture removal
•
urgent but non-life threatening situations seen during regular
office hours
9-147
Emergency
Department
Services
Emergency department services (codes 99281 - 99285) are submitted by
the physician assigned to the emergency room.
Assignment is defined as a formal relationship between the physician
and the hospital whereby the physician is solely responsible for seeing
patients in the emergency room during a specified time period.
Physicians who specialize in emergency medicine and use the
emergency department as their place of business are generally
considered assigned to the emergency room.
Other physicians who have arrangements with the hospital to be ‘‘on
call’’ to see patients in the emergency department during specific hours
may also be considered assigned to the emergency department while
seeing patients there. In this case, the physician’s primary responsibility
is to the emergency department and the arrangement is between the
physician and the hospital, as opposed to an agreement between
physicians to cover one another’s patients over the weekend, etc.
Any physician seeing a patient in the emergency department to which
he/she is not assigned must submit level-of-service office calls
according to CPT guidelines.
9-148
Medical Services
Allergy Testing
Allergy testing (95004 - 95078) refers to the evaluation of selective
cutaneous and mucous membrane tests to assist in the determination of
appropriate immunotherapy.
Submit the number of services in accordance with the CPT description.
Allergy tests and their interpretation are a single entity; do not submit
separately. An office visit with the modifier –25 may be submitted in
addition to allergy testing only when additional identifiable services are
provided.
Allergy
Immunotherapy
Code 95115 should be submitted with one unit of service when one
injection is given.
Code 95117 should be submitted with one unit of service when multiple
injections are given (regardless of the number of injections).
Codes 95120 - 95180 should be submitted with the number of services
in accordance with the CPT description.
Codes 95115 and 95117 include professional services necessary for
allergen immunotherapy.
A level-of-service office visit with modifier –25 may be submitted in
addition to an allergy injection only when additional identifiable
services are provided.
Anticoagulation
Clinic – S9401
EPNI will accept code S9401 for scheduled visits to an anticoagulation
clinic (S9401- anticoagulation clinic, inclusive of all services except
laboratory tests, per session). This service will be treated and
reimbursed the same as the evaluation and management (E/M) code
99211. Code S9401 will be subject to an office call copay.
Code S9401 will not be allowed in addition to an E/M, unless the E/M
represents a significant separately identifiable service. If so, the E/M
should be appended with the –25 modifier and the appropriate diagnosis
linked. Additionally, some contracts may not allow the service and/or
code. For example, ‘S’ codes are not accepted for our Medicare
products.
9-149
Blood, Occult,
Feces Screening
Codes 82270 (blood, occult; feces, consecutive collected specimens
with single determination) or G0107 (colorectal cancer screening; fecaloccult test, 1-3 simultaneous determinations) are to be submitted with
one unit of service.
These screenings typically test three specimens, but units of service
should reflect the series, not number of specimens.
The date of service submitted should be the date the test card is returned
to the clinic.
Codes 82271 and 82272 are also limited to one unit of service.
Cardiovascular
Stress Test
Code 93015 is the global code for a cardiovascular stress test, which
includes both the professional component (interpretation, report, and
physician monitoring) and the technical component (tracing). Submit
code 93016 for physician supervision only, without interpretation and
report. Submit code 93017 for the technical component only. Submit
code 93018 for the professional component only, which includes
interpretation report and physician monitoring. Submit prolonged
services (codes 99354 - 99357) only if acute intervention is required
beyond routine physician monitoring during the test.
The monitoring of a patient by a physician during a cardiovascular
stress test is considered an integral part of the professional component
of the test and not reimbursable as a separate service.
9-150
Chemotherapy
Administration
Chemotherapy administration codes are used for services of a physician
or qualified assistant employed by and under the supervision of a
physician. The preparation of the chemotherapy agent(s) and related
supplies are included in the code for administration of the agent(s). Use
the CPT codes below:
•
Codes 96401 - 96542 and 96549 cover chemotherapy
administration. Specific Level II HCPCS codes should be used to
identify the chemotherapy drug(s) utilized.
•
Codes J8999 or J9999 should be submitted only if no HCPCS code
exists. Specify the drug, dosage and NDC code.
When billing a dosage higher than that listed in the HCPCS Manual, use
the units field to indicate a higher dosage.
Example:
If the common dosage is 200 mg. but 490 mg. was administered, submit
three units of service (round up the dosage).
Chemotherapy codes may be independent of the patient’s office visit.
An office visit with modifier –25 may be submitted in addition to or
subsequent to chemotherapy administration only when additional
identifiable services are provided.
Professional charges and codes for chemotherapy administration should
not be submitted when services are administered by hospital or home
health agency personnel.
Services of an Oncologist during a postoperative period are rarely
“routine postoperative care.” To avoid unnecessary denials, we suggest
diagnosis code V58.0 for services related to radiotherapy, and code
V58.11 for services related to chemotherapy.
Chemical
Dependency
Assessment
Often providers perform chemical dependency assessments when a
court of law orders an evaluation or a family member requests one.
Under circumstances like these, providers may submit the following
diagnosis code:
V79.1, screening for alcoholism use when an alcohol or chemical
dependency assessment or evaluation reveals no illness, abuse, or
dependency.
Services billed with a V79.1 code will apply to the member’s chemical
dependency benefit limit.
9-151
Office or Other
Outpatient and
initial Inpatient
Consultations
Consultation codes 99241 - 99255 include a physician’s services
requested by another physician or other appropriate source, for further
evaluation or management of the patient. They are designated according
to place of service and apply to new or established patients.
The consultant must document the consult request and the reason for the
consult in the patient record and must also appear in the requesting
practitioner’s plan of care.
The consult request is typically in writing but it may be verbal so long
as both the requestor and the consultant document the conversation in
the patient medical record. The consultant must provide a written report
to the requesting practitioner.
A consultation may include the diagnostic tests needed to provide an
opinion or advice. If the physician consultant introduces further
therapeutic services, documentation must show that the consultant
recommended a course of action at the request of the attending
physician. Any subsequent services and continuing care rendered by the
consultant cease to be a consultation and become established patient
care services. Initial or subsequent services rendered by a consultant
may make an initial consultation invalid if records show that patient
care was immediately assumed as in a referral.
A referral is the transfer of total or specific care of a patient from one
physician to another and does not constitute a consultation. Initial
evaluation and subsequent service for a referral are designated as levelof-service office visits.
Second or confirmatory consults are coded as the appropriate E/M for
the setting and type of service.
Day Treatment
Submit one unit of service per day for day treatment programs for
behavioral health diagnoses (H2012). Include the actual time of therapy
on the claim also.
Diabetic
Education
G0108 or G0109 may be submitted for diabetic education only if the
program is certified by the National Diabetes Association.
9-152
E-Care Visits
Effective July 1, 2006 coverage will be extended to E-Care visits.
Description:
E-Care is a term used to describe limited healthcare services provided
over the Internet. E-Care may also be referred to as online medical
evaluations, online visits, E-visits, E-consultations, or virtual visit.
E-Care is a member initiated online evaluation and management (E/M)
visit provided remotely to patients via the Internet. This visit is used to
address non-urgent medical symptoms including medication and
prescription refills or renewals and review of lab and test results. E-Care
visits are not normally ‘real-time’. The provider responds to the
patient’s issue within a prescribed time limit.
Coverage Criteria:
Services obtained from the rendering practitioner by means of online
email communication via the Internet may be eligible for coverage for
non-urgent care when ALL of the following criteria are met:
•
The individual initiating the E-Care visit is an established patient of
the provider and has previously received face-to-face treatment
•
In the judgment of the practitioner, the E-Care visit is medically
necessary and involved sufficient resource use, time and complexity
to warrant separate recognition as a unique event
•
Written documentation related to the service must be included in the
patient’s medical record and should include the following:
•
Medical information exchange, assessment, and plan of
treatment/care (e.g., symptoms, counseling)
•
Services must be billed under the rendering practitioner’s provider
number
Qualifying Criteria:
•
Qualifying criteria for reimbursement of online services are as
follows:
•
Practitioner responds within on business day AND one or more of
the following:
•
Patient describes new symptoms and is requesting intervention
and/or advice from practitioner to treat new symptoms
•
Patient describes ongoing symptoms from a recent acute problem or
chronic health problem and is requesting intervention and/or advice
from practitioner to treat ongoing acute problem or chronic health
problem
9-153
E-Care Visits
(continued)
•
Evidence that practitioner is giving substantive medical advice,
revising treatment plan, prescribing/revising medication,
recommending additional testing, and/or providing self care/ patient
education information for new and/or chronic health problem
•
Evidence that practitioner is making a new diagnosis and is
prescribing new treatment
•
Patient requesting interpretation of lab and/or test results with
evidence that practitioner is providing substantive explanation and
recommendations to modify treatment plan, revising medications,
etc.
•
Evidence that practitioner is providing extended personal patient
counseling that is changing the course of treatment and impacting
the potential health outcome
Billing/Coding Information:
CODING: 0074T- Online evaluation & management service, per
encounter, provided by a physician, using the Internet or similar
electronic communications network, in response to a patient’s request;
established patient
CLAIM FORMAT: Billed on the professional claim format- 837P or
CMS-1500.
UNITS: One (1). Reimbursement for online medical evaluations is
limited to one per day.
PROVIDER NUMBER: An individual provider number is required.
This service is limited to MD, PA, NP, and CNS-Medical practitioners.
EDITS: An E-Care visit, 0074T, will not be allowed on the same day as
another E/M visit. Code 0074T will deny as mutually exclusive to these
other services. An E-Care visit will not be allowed as a routine followup to surgical care. Code 0074T will deny as part of the post-op period
in this case.
Not Covered:
E-Care services are not covered when provided for the following:
NOTE: The following is not an all-inclusive list. E-Care visits may be
denied for reasons other than noted below.
9-154
•
Provider initiated email
•
Appointment scheduling
•
Refilling or renewing existing prescriptions without substantial
change in clinical situation
•
Scheduling diagnostic tests
E-Care Visits
(continued)
•
Reporting normal test results
•
Updating patient information
•
Providing educational materials
•
Brief follow-up of a medical procedure to confirm stability of the
patient’s condition without indication of complication or new
condition including, but not limited to, routine global surgical
follow-up
•
Brief discussion to confirm stability of the patient’s chronic
condition without change in current treatment
•
When information is exchanged and the patient is subsequently
asked to come in for an office visit
•
A service that would similarly not be charged for in a regular office
visit
•
Reminders of scheduled office visits
•
Requests for a referral
•
Consultative message exchanges with an individual who is seen in
the provider’s office immediately afterward
•
Clarification of simple instructions
Program Exceptions:
Benefits are determined by the individual member contract language in
effect at the time services were rendered. Check for patient benefits
before services are rendered. The following groups do not provide for
coverage of E-Care visits:
•
Medicare Supplements
•
Some self-insured groups
G0101
G0101 (cervical or vaginal cancer screening; pelvic and clinical breast
examination) is an accepted code. However, G0101 will deny if billed
in conjunction with an evaluation and management service.
Hospital
Discharge
Hospital discharge services, 99238 or 99239, can only be billed when
services are performed on the actual date the patient left the hospital. A
discharge is not billable for a patient’s death.
9-155
Immunizations
Immunizations are injections separately identified in CPT (codes 90476
- 90749). Submit the code which describes the immunization
administered. It is inappropriate to code each component of a
combination vaccine separately. The administration code(s) 90465 90474 must be reported in addition to the vaccine and toxoid code(s)
90476 - 90749.
Serum from Department of Human Services
If receiving serum from the Department of Human Services (DHS) for
child immunizations, the provider should bill EPNI for the
administration charge only. Providers should submit the immunization
code with an –SL modifier to indicate the serum was received from
DHS. The administration codes 90465 - 90474 must be reported in
addition to the vaccine.
9-156
Injections
Therapeutic or diagnostic injections may be subcutaneous,
intramuscular, intra-arterial, or intravenous. These codes do not include
injections for allergen immunotherapy or immunizations.
Injectable Drugs
Submit the HCPCS Level II code that best describes the injection given
in terms of the drug and dosage. Codes for injections include the charge
for the drug only. When the dosage given is greater than that listed, use
the units field to specify the appropriate number of units according to
the HCPCS manual.
Example:
The patient received 7 mg. of haloperiodol. The common dosage for
haloperiodol (J1630) is “up to 5 mg;” 2 UOS should be submitted. The
dosage is rounded up to the next unit.
The administration charge should be submitted separately.
Codes 90779 and J3490 are for unlisted therapeutic injections. The drug
name and dosage must be included on each claim, as well as the
National Drug Code (NDC) number.
Report the drug name, dosage and NDC starting in box 24D of the
CMS-1500 or narrative file for electronic claims.
Administration
Choose the appropriate administration code for the route of
administration 90765 - 90779.
It is inappropriate to bill an intravenous injection in addition to an
intravenous infusion on the same date of service when an injection is
administered through the same line as the infusion. The provider may
submit the infusion or the injection, but not both.
Units of service reflect the number of injections given.
If an office visit is submitted on the same day of the subcutaneous or
intramuscular injection (90772 - 90775), the administration would be
included in the E/M and will deny if submitted separately.
Surgical Injections
Performed as stand-alone procedures, the injections should be submitted
with the appropriate CPT code for the administration of the injection. In
addition, submit the HCPCS Level II code for the drug. If no specific
HCPCS code exists for the drug, submit J3490 with a narrative
indicating the drug name, dosage and NDC.
When surgical injections are performed as part of a surgical procedure,
submit the HCPCS Level II code for the drug. The administration of the
injection is considered part of the surgical procedure itself and should
not be submitted separately.
9-157
Infusion Therapy
Infusion therapy as described below excludes chemotherapy. For
prolonged intravenous infusions performed in the office or clinic,
submit CPT codes 90765 - 90768 for the administration and the
appropriate HCPCS Level II code for the drug. The CPT code includes
the administration and supplies. Submit code J3490 with a narrative
indicating the drug name, dosage and NDC if a specific HCPCS code
for the drug does not exist. When billing a higher dosage than listed in
the HCPCS Manual, use the units field to indicate the higher dosage.
Codes 90765 - 90768 typically require direct physician supervision for
any or all purposes of patient assessment, provision of consent, safety
oversight, and intra-service supervision of staff. Professional charges
for infusion therapy should not be submitted when the service is
administered by hospital or home health agency personnel. Do not use
these codes to indicate intradermal, subcutaneous, intramuscular,
routine IV injections, or chemotherapy.
Interpreter
Services
Interpreter services are not separately billable or reimbursed for most
members. Use provider web self-service or call Provider Services for
benefit information.
Transfusion –
Blood and Blood
Products
Transfusion of blood and/or blood products is submitted with code
36430 when administered by a physician or qualified assistant
employed by and under the supervision of a physician. Preparation of
blood and blood products is included in the service for administration of
the agent.
Professional charges/codes for the transfusion of blood or blood
products should not be submitted when administered by hospital or
home health agency personnel. Bill the blood separately with the
appropriate HCPCS code.
Locum Tenens
A substitute physician who takes over another physician’s practice
when that regular physician is absent for specific reasons is generally
referred to as a “locum tenens” physician. The regular physician may
submit the services rendered by the locum tenens physician under the
regular physicians’ provider number. The modifier Q6 should be
appended to these services.
Natural Family
Planning
The natural family planning (NFP) code H1010 is restricted only to
those participating non-clinic providers contracted as a NFP provider.
Clinics/medical practitioners providing NFP would bill their services
using the appropriate evaluation and management code.
9-158
Nicotine
Dependence
EPNI covers services for the treatment of tobacco dependence.
However, coverage for these services depends on the type of provider
submitting the claim, the procedure and diagnosis codes submitted, and
the patient’s contract with EPNI. Due to these many variables, exact
payment can not be determined until we receive the claims for
processing.
Diagnosis Codes
If the primary reason for the outpatient visit to the clinician is tobacco
use, claims should be submitted with one of the following diagnosis
codes:
•
305.1 tobacco use disorder
• V15.82 history of tobacco use
Procedure Codes
Clinicians should submit the HCPCS code that reflects the service
furnished. Claims may process differently depending on the code
submitted. The difference reflects the application of the member’s
contract benefits.
Evaluation and Management (E/M) codes 99201 - 99215: Claims
submitted using these problem-related visit codes will process
according to the illness portion of the patient’s contract.
E/M codes 99241 - 99245: Claims submitted using these preventive
consultation codes will also process according to the illness portion of
the patient’s contract when submitted with a tobacco diagnosis.
E/M codes 99401 - 99404: Claims submitted using these counseling
visit codes will process according to the illness portion of the patient’s
contract.
Codes G0375 and G0376: Claims submitted using these preventive
counseling visit codes will process according to the illness portion of
the patient’s contract.
Code S9453 for stop-smoking classes is generally not an eligible service
under the patient’s contract.
E/M codes 99384 - 99387 and 99394 - 99397: These comprehensive
preventive medicine services include counseling/anticipatory
guidance/risk factor reduction interventions. Tobacco cessation
counseling is part of a comprehensive preventative medicine evaluation.
Therefore it is not separately reportable under these codes.
Psychiatric codes 90804 - 90862: Claims submitted using these codes
will process according to the substance abuse portion of the patient’s
contract.
9-159
Nicotine
Dependence
(continued)
Group counseling codes 99411 - 99412 will process according to the
illness portion of the patient’s contract when submitted with a tobacco
diagnosis.
For questions regarding “incident to” services please refer to Chapter 6
of this manual.
Revenue Codes
Used by Facilities
0944 or 0945
Facilities such as hospitals, skilled nursing facilities, and residential
treatment centers, must bill for tobacco use under revenue codes 0944
(drug rehabilitation) or 0945 (alcohol rehabilitation). Claims submitted
using these codes will process according to the substance abuse portion
of the patient’s contract.
Eligibility to Bill
for Specific
Procedures
Standard guidelines regarding provider eligibility apply to procedures
submitted with a tobacco diagnosis. Provider eligibility depends on the
provider’s scope of practice and the type of procedure being billed. For
example, consultation codes are generally only allowed when performed
by a MD; however, evaluation and management codes may be eligible
if billed by a qualified practitioner such as a Nurse Practitioner, or
Physician Assistant. Some procedure codes specific to mental health
and chemical dependency may have to be performed by a qualified
mental health provider.
Coverage for
Tobacco
Treatment
Medications
All fully insured EPNI plans with drug coverage cover stop-smoking
medications. The same copayments and deductibles apply. With a
physician’s prescription these patients are eligible for Zyban® and/or
any FDA-approved nicotine replacement therapy drug (patch, gum,
lozenge, inhaler, and nasal spray).
Note: In order to trigger this benefit, the patient does need a physician’s
prescription even if the medication is available over the counter.
Each self-insured group account chooses whether or not if will cover
prescription and/or over-the-counter stop-smoking aids. Thus coverage
varies greatly among self-insured groups. Your patients who have EPNI
coverage through a self-insured group should call the customer service
number on the back of their ID card to determine if they have coverage
for tobacco treatment medications and what restrictions might apply. If
you have questions you may contact EPNI Provider Services.
New and
Established
Patients
A new patient is one who has not received any professional services
from the provider or another provider of the same specialty who belongs
to the same group practice within the past three years.
An established patient is one who has received services from the
provider or another provider of the same specialty who belongs to the
same group practice, within the past three years.
9-160
Oral Medication
When submitting oral drugs for your EPNI patients, use the procedure
codes in your HCPCS manual. HCPCS includes many codes for oral
medications and injections which are commonly dispensed in
physicians’ offices.
Use J8499 (prescription drug, oral, nonchemotherapeutic, NOS) only in
limited situations such as after-hours emergency visits, house calls, or in
rural areas where access to a community pharmacy is limited. Drug
name, dosage, and NDC must be included on each claim.
Benefits cannot be extended for drug samples provided by
pharmaceutical companies.
Non-Physician
Healthcare
Practitioners
If the service is rendered by a non-physician healthcare practitioner that
we credential, and/or verify licensure and are issued individual
provider numbers, we expect that practitioner to submit the services
under the individual provider number that EPNI issued to him or her.
Some practitioners who are not credentialed or issued individual
provider number (such as LPN, RN, dietician), work under the
supervision of a physician. The services must be submitted under the
supervising physician’s provider number. The -U7 modifier must be
submitted with the procedure to indicate these services. This includes
those clinics with a pharmacist on staff. Services would be billed under
the supervising MD with the -U7 modifier.
9-161
Practitioners
Credentialed by
EPNI with an
Individual
Provider Number
9-162
Listed below are practitioners that are credentialed by EPNI and issued
an individual provider number:
•
Certified Ind. Clinical Social Worker (CICSW)
•
Certified Marriage and Family Therapist (CMFT)
•
Certified Nurse Midwife (CNM)
•
Certified Professional Counselor (CPC)
•
Chiropractor (DC)
•
Dentist (DDS, DMD)
•
Licensed Certified Social Worker (LCSW)
•
Licensed Ind. Clinical Social Worker (LICSW)
•
Licensed Ind. Social Worker (LISW)
•
Licensed Marriage & Family Therapist (LMFT)
•
Licensed Prof. Clinical Counselor (LPCC)
•
Optometrist (OD)
•
Physician Assistant (PA)
•
Physician (MD, DO)
•
Podiatrist (DPM)
•
Psychiatric Mental Health Nurse Practitioner (PMHNP)
•
Psychologist (PhD., MA, PsyD., MS, EDD)
•
Registered Nurse Clinical Specialist (CNS)
•
Registered Nurse Practitioner (NP)
Practitioners Not
Credentialed by
EPNI with an
Individual
Provider Number
Listed below are practitioners that are NOT credentialed by EPNI but
are issued an individual provider number:
Note: Although the following practitioner types do not go through the
credentialing process, they do require an individual provider
number for claims submission.
•
Audiologist
•
Certified Registered Nurse Anesthetist (CRNA)
•
Licensed Assoc. Counselor (LAC)
•
Licensed Assoc. Marriage & Family Therapist (LAMFT)
•
Licensed Psychological Practitioner (LPP)
•
Occupational Therapist (OT)
•
Physician Therapist (PT)
•
Registered Nurse First Assist (RNFA)
•
Resident
•
Social Worker (Levels: LISW, LGSW, LSW, LMSW, CSW, LSW,
LMSW, CISW, CASW)
•
Speech and Language Therapist
9-163
Preventive
Medicine
Routine examinations for adults and children should be submitted with
CPT codes 99381 - 99397, according to the age of the patient. The
routine nature of the examination should also be indicated by the ICD9-CM code submitted (usually a V-code). Illness and injury-related
visits, should be submitted with the office or outpatient evaluation and
management codes 99201 - 99215 with the appropriate ICD-9-CM code
indicating the illness, injury, symptom, or complaint.
The ICD-9-CM code indicates the purpose of performing the
examination. Examinations performed in the absence of complaints
should be billed as preventive medicine to be compatible with the ICD9-CM code submitted.
Providers can bill both an E&M code and a preventive medicine code
when a patient goes in for a routine exam and an illness is found that is
significant enough to require additional work. Providers should bill
99381 - 99397 with a routine diagnosis code and an illness E&M code
99211 - 99213 with a -25 modifier and an illness diagnosis code. The 25 modifier indicates a significant, separately identifiable evaluation
and management service by the same physician on the day of a
procedure. The appropriate level of E&M should be submitted.
Generally, a level 4 or 5 illness E/M (99204, 99205, 99214, 99215) is
not allowed in conjunction with a preventive E/M. Because a level 4 or
5 would require significant additional work, it would seldom be
appropriate to bill both. Denials can be appealed, but would require
documentation to support both E/M services.
Couseling and/or
Risk Factor
Reduction
Individual preventive medicine counseling (codes 99401 - 99404) are
reimbursed per contract benefits. Group preventive medicine counseling
(codes 99411 - 99412) is not reimbursed by EPNI and will deny if
submitted.
Room or Machine
Set-up Charges
Room or machine set up charges are considered to be an integral part of
the procedure being done. Do not submit separately for these services.
Supplies in the
Office
Supplies in the clinic setting are generally included or part of the
procedure or service. Codes 99070, A4649 and A4550 will be denied.
Other supplies, such as Betadine or alcohol wipes, will be denied.
Generally, supplies are only allowed separately in conjunction with
approved home health care.
Adjunct CPT
Codes
Adjunct CPT codes 99050 - 99060 are designed for the provider to
report special circumstances under which a basic procedure is
performed.
EPNI does not consider these or provider inconvenience fees as
reimbursable services, and as such are denied as a provider liability.
9-164
Care Plan
Oversight
Services
Care plan oversight services codes 99374 - 99380 are not reimbursed by
EPNI as a separate service from the evaluation and management codes
and will deny as provider liability.
Prolonged
Physician
Services
EPNI reimburses face-to-face prolonged physician services codes
99354 - 99357. Codes 99358 - 99359 are not reimbursed (prolonged
services without face-to-face patient contact) and will deny as provider
liability.
Telephone Calls
Telephone calls, codes 99371 - 99373, are non-covered services. Calls
are considered an integral part of other services the patient receives
(usually an evaluation and management service) and not separately
reimbursable.
9-165
Team
Conferences
Medical conferences without face-to-face patient contact, codes
99361 - 99362, are not reimbursed, and will deny as provider liability.
Televideo
Consultations
EPNI provides reimbursement for certain televideo consultations. These
consultations are also sometimes referred to as telemedicine or
telehealth services. Televideo consultations are interactive audio and
video communications, permitting real-time communication between a
distant site physician or practitioner and the member, who is present and
participating in the televideo visit at a remote facility.
Coverage of televideo consultations includes consultations, office visits,
psychotherapy, substance use disorders, as well as the codes allowed
per Medicare policy. Facilities may be reimbursed for the origination
fee. Both the consulting physician and the remote clinic or remote site
will submit a claim for their services. The consulting physician will bill
the appropriate CPT® evaluation and management, psychotherapy code
or ESRD code. The remote provider will bill for the originating site
facility fee only. This service is billable on either the professional or
institutional claim format.
Coding
Remote Clinic or
Remote Site
Consulting Physician/Practitioner
Q301: Telehealth
originating site
facility fee
99241 – 99255: Consultations
0780:Telemedicine,
General
Classification
90801: Psychiatric diagnostic
interview
0789: Telemedicine,
Other Telemedicine
90804 - 90809: Individual
psychotherapy
99201 – 99215: Office or other
outpatient visits
90862: Pharmacologic
management
G0308 - G0309, G0311 - G0312,
G0314 - G0315, G0317 - G0318:
ESRD related services
WITH…
-GT- Via interactive audio and
video telecommunication systems
Note: All of the above services
must be appended with the
–GT modifier.
Co-pay
9-166
None
Co-pays would apply
Televideo
Consultations
(continued)
Global
Period
Remote Clinic or
Remote Site
Consulting Physician/Practitioner
Not included in the
global surgical period
Global surgical package edits apply
Exceptions
Televideo consultations are subject to the terms of the member’s
contract and may not be covered under the member’s health plan.
Televideo consultations do not include telephone calls or Internet
consultations. Telephone and Internet consultations are contract
exclusions and will be denied.
Urgent Care
Clinic-based urgent care services may be billed under the place of
service (POS) 20. The POS code 20 will apply office benefits to the
services if submitted. DO NOT bill a corresponding facility claim with
the revenue code 0456 if already billing for urgent care on the
professional claim (CMS-1500). This would be considered duplicate
billing.
Hospital based emergency room urgent care should be billed on the UB92 only with the revenue code 0456.
Codes S9083 (global fee urgent care centers) and S9088 (services
provided in an urgent care center) represent where the service was
rendered, not the service itself. Thus, they are not separately covered
and will be denied as part of the primary service (such as E/M).
Weight
Management
Care
In general, EPNI covers services for the treatment of obesity, weight
management, nutrition, and physical activity counseling. However,
coverage for these services depends on the type of provider submitting
the claim, the procedure and diagnosis codes submitted, and the
patient’s contract with EPNI. We encourage you to request that your
patients check on their coverage before extensive services are provided.
Due to the many variable, exact payment can not be determined until we
receive the claim for processing.
The outline reviews the following seven categories as they relate to
coverage for services related to obesity, weight management, nutrition,
and physical activity counseling.
1. Diagnosis Codes
2. Procedure Codes
3. Eligible Providers
4. Weight Loss Programs
5. Weight Loss Drugs
6. Physical Activity
7. Surgery
9-167
Weight
Management
Care
(continued)
Diagnosis Codes
The physician determines if the patient meets the criteria to be classified
as obese. If the patient meets those criteria, two specific obesity
diagnosis codes may be used:
•
278.00 Obesity, Unspecified
• 278.01 Morbid Obesity
In addition to the two specific obesity codes, the provider may also bill
for obesity or weight management counseling with routine diagnosis
codes such as:
•
V65.3 Dietary Surveillance and Counseling
•
V70.0 Routine General Medical Examination at a Health Care
Facility.
The obesity diagnosis codes of 278.00. 278.01 and code V65.3 will
cause claims to pay according to the illness portion of the patient’s
contract. All EPNI contracts have benefits for illness-related services. If
the claim is submitted with a routine medical exam code of V70.0, it
will pay based on the routine benefits, if any, that are provided by the
patient’s contract. Some contracts exclude routine benefits.
Claims may be submitted for obesity, weight management, nutrition
counseling etc. with the diagnosis of the underlying symptom that
brought the patient to the provider. For example, the claim may be
submitted with a diagnosis of elevated blood cholesterol, shortness of
breath, or diabetes. These claims will process according to the medical
illness benefit.
Procedure Codes
No specific procedure codes exist for the counseling of obesity and
weight management. Services for obesity/weight management
counseling may be billed under evaluation/management (E/M) codes
(99201-99215) provided that those services meet the components of an
E/M service. These E/M codes are compatible with all causes, illness or
routine related, and will pay according to the diagnosis submitted.
Claims may also be submitted as preventive counseling (99401-99404).
These codes, however, are only compatible with routine diagnosis codes
(e.g. V70.0). Claims submitted with these procedure codes and a routine
diagnosis code will process according to the patient’s preventive
benefit, provided the patient has coverage for preventive services. If
CPT codes 99401-99404 were submitted with a diagnosis of obesity
(e.g. 278.00) the claim would reject because the service was
incompatible with the diagnosis.
9-168
Weight
Management
Care
(continued)
Medical nutritional therapy codes (97802, 97803, S9470) may be billed
when counseling patients on obesity or weight management. These
codes are compatible with any diagnosis but are most appropriate or
intended for illness or disease-related diagnoses such as obesity or
diabetes. Note that code 97804 is nutritional therapy in a group setting.
Group therapy services are generally only covered when submitted with
diagnosis codes for anorexia, bulimia, diabetes, congestive heart failure,
and some maternity diagnosis codes.
Nutritionist, Dieticians and Other Providers
For many lines of business, EPNI pays Minnesota Licensed
Nutritionists, Licensed Dieticians, and Registered Dieticians directly for
services submitted with an eating disorder code 307.1, 307.50 and
307.51. The provider may submit using procedure codes S9470, 97802,
97803, or 97804 based on the service provided. No referral is necessary
for the highest benefit level. Some self-insured plans, however, may
exclude coverage by a dietician, so benefits should be verified.
Licensed dieticians and licensed nutritionists can bill for procedure
codes S9470, 97802, and 97803 for diagnosis codes other than eating
disorders. Services provided by licensed dieticians and nutritionists
must be submitted to EPNI using the provider number of an eligible
licensed dietician or licensed nutritionist must also be submitted on the
claim.
Registered dieticians billing for services outside of behavioral health
diagnosis codes will have those claims denied unless the services are
submitted under the individual provider number of a supervising
physician. The –U7 modifier should also be submitted.
Health Educators and Exercise Physiologists are not recognized as
eligible providers and their services will be rejected if received by
EPNI.
9-169
Weight
Management
Care
(continued)
Weight Loss Programs
EPNI does not cover commercial weight loss programs (e.g., Nutrasystems, Jenny Craig, LA Weight Loss, Weight Watchers etc.).
While we have a medical policy for very low calorie diets, VII-08, most
weight loss programs do not qualify under this medical policy and the
benefits covered are limited. The program must be based in a clinic or
hospital, physician directed, and the provider must obtain a separate
provider number for reimbursement. The patient must also meet criteria
in order to be eligible to participate, and we highly recommend that the
services be prior authorized. Some self-insured groups may exclude
coverage for very low calorie diets or may have specific reimbursement
provisions.
Weight Loss Drugs
Xenical and Meridia are on our formulary as approved weight loss
drugs. All fully insured groups cover weight loss drugs. However, each
self-insured account chooses whether or not to cover weight loss drugs.
Note that patients covered by certain State Health Plan products have
specific authorization requirements for weight loss drugs.
Physical Activity
There are no procedure codes specifically for physical activity
counseling. Providers typically bill counseling services for physical
activity as an E/M service (99201-99215) provided that the counseling
meets the components of an E/M service. There is no specific diagnosis
code for physical activity counseling.
The provider may also submit codes for preventive counseling (9940199404). These codes however, are only compatible with routine
diagnosis codes (e.g., V70.0). Claims submitted with these procedure
codes and a routine diagnosis code will process according to the
patient’s preventative benefit, provided the patient has coverage for
preventative services.
Services billed by a personal trainer or an exercise physiologist are not
covered. Claims for their services will be denied as an ineligible
provider, regardless of the procedure code and diagnosis code
submitted.
Surgery
EPNI has a detailed medical policy, IV-19, regarding provider and
patient eligibility criteria for obesity surgery.
Some groups exclude coverage for obesity surgery in their contracts;
however, fully insured groups cover obesity surgery. Prior authorization
is highly recommended.
9-170
Weight
Management
Care
(continued)
Disclaimer: The fine print
This information is designed for reference purposes only and does not
guarantee coverage. EPNI will consider each individual member’s
condition and unique circumstances in making coverage determinations
and will make each determination on a case-by-case basis and according
to the terms and conditions of the member’s contract, certificate of
coverage, or summary plan description, as applicable, including
provisions relating to exclusions and limitations. If there is a conflict
between the information above and the contract or plan documents, the
contract or plan documents govern.
This information is current as of second quarter 2005. As you know,
EPNI reviews its policies and coverage periodically and may make
changes in the future.
Any providers who have questions about this information are invited to
contact EPNI Provider Service.
Physician Certification and Supervision
Physician certification and supervision codes G0179-G0182 are not
reimbursed as a separate service from the E/M service and will be
denied as provider liability. These services may be allowed for
Medicare members.
9-171
Optometric/Optical Services
Opthalmological
Services
EPNI coding policy follows the CPT system of descriptive terms and
identifying codes for reporting medical services and procedures
performed by physicians and optometrists.
Both E/M codes and ophthalmology codes 92002, 92004, 92012,
92014, and 92015, may be appropriate to use by optometrists or
ophthalmologists. The level of E/M service or the selection of
ophthalmology codes must appropriately reflect the medical condition,
the medical necessity, the tests performed, and be documented in the
patient record. Selection of either an E/M code or an ophthalmology
code may be appropriate for both routine or medical diagnoses, and
should be based on the CPT definitions of services provided. Details of
the patient encounter, as recorded on the patient record, must meet or
exceed the stated CPT requirements to qualify for the code selected.
EPNI requires that all medical services be performed by professionals
eligible and credentialed to perform the service. The diagnosis and CPT
coding must appropriately reflect the medical condition and that the
medical record reflect the medical necessity and severity of the
condition.
Charges for
Lenses and
Contact Lens
Fitting
Submit charges for any type of lenses using Level II HCPCS codes.
Any fee for fitting and prescription of contact lenses may be reported by
submitting a CPT code from the contact lens services section in addition
to the contact lens supply code. The fee for fitting and prescription of
contact lenses may also be included in the contact lens charge.
Eyewear Billing
and
Reimbursement
Eyewear claims will be paid to the member, not the provider.
If you bill eyewear for a member, you should bill the eyewear on a
separate claim form from the one used for the eye exam. Use your
optician’s contracting provider number when billing for the eyewear.
Your optometrist’s contracting provider number should be submitted
when billing for the eye exam. EPNI requires that eye exams and
eyewear claims not be billed on the same claim form.
Participating providers are allowed to collect only the copayment at the
time of service. The exception to this rule is for eyewear services.
Providers are now allowed to collect a payment from the member for
eyewear at the time of purchase because EPNI will reimburse the
member.
9-172
Vision Therapy
Services
EPNI will reimburse the initial visit under 92060. Visual therapy
instruction by any method that is provided during the first visit is
included in this description. Separate billing for CPT code 92065 will
not be allowed for the initial visit. Vision therapy services involve nonsurgical orthoptics, medical, or sensory-motor re-education for patients
who suffer from conditions such as strabismus, amblyopia, exotropia,
and/or esotropia.
All subsequent visits for patient evaluation and monitoring of treatment
will be billed to EPNI under CPT code 92065. Office calls (9920199215, 92002-92014) and sensorimotor exams (92060) are not eligible
for separate billing from the providers of the visual therapy during the
course of treatment unless a medical examination is clinically indicated
for other reasons.
Claims Filing
Requirement
Use CPT codes or HCPCS level II code to bill your services.
ICD-9-CM codes should be used to submit an appropriate diagnosis for
your patient. Please note the correct code for routine vision care is
V72.0 or 367.0-367.9 completed to the appropriate fourth and fifth
digits.
9-173
Pharmacy Services
Claims Filing
Requirements
The majority of our member contracts contain basic drug coverage.
Drug claims are either processed by EPNI or RGS/Propar. To determine
if a drug claim should be submitted to EPNI or RGS for processing,
check the member’s ID card. If the member has drug processing
through RGS/Propar, the medical identification (ID) card will indicate
RGS/Propar under processor with the carrier code “PGIGN”. Gold Net
will be indicated under coverage to acknowledge that a Gold Net
provider must be used. You must include the two digit numeric
dependent code, which is indicated before the name on the ID card.
Drug Claims
Submission
RGS claims from Gold Net providers must be processed electronically.
If the member has RGS coverage, but the RGS information is not
printed on the ID card, the member should pay the prescription in full
and submit the claim to RGS for direct reimbursement.
Submit RGS member drug claims to:
EPNI
P.O. Box 64338
St. Paul, MN 55164-0338
Prior
Authorization
The prescribing physician must obtain prior authorization through
EPNI’s Medical Review area for certain drugs. Some examples of
medications requiring Prior Authorization include injectable infertility
drugs and growth hormones.
Injectable Drugs
Most prescription benefit plans allow injectable processing online. Be
sure to use the appropriate NDC and submit your claim electronically to
the processor.
Copays /
Coinsurance
The drug copay/coinsurance amount varies for each subscriber. Please
rely on “claim response” to correctly identify the amount to collect from
the member. If a member’s contract contains the formulary amendment,
a dual copay may be in effect. Again, rely on “claim response” to
determine the correct amount to collect from the member.
Vacation
Prescription
Requests
Requests for additional drug quantities (beyond the 34-day supply or
100 unit dosage) may be made by the member, physician, or
pharmacist. The member would contact the Customer Service number
listed on the back of their ID card. The physician or pharmacist would
contact Provider Service. Please keep in mind that some medications are
controlled substances and may require a new prescription.
9-174
Drug Formulary
EPNI promotes the use of the drug formulary. It was developed to
provide a listing of drugs that are safe, effective, high-quality, and
economical. A new drug formulary is mailed yearly to each
participating pharmacy.
Any participating health care provider may request the addition of a
drug to the formulary by completing a formal request form and
submitting it to EPNI. The form is included at the end of this section
and may be obtained by contacting EPNI Provider Service. A new
FDA-approved drug is not considered to be on the drug formulary until
it has been approved by the Formulary Committee.
Non-Formulary
Physicians may request non-formulary medication by completing the
Physician Request for Non-Formulary Exception, form X15786. A
sample follows.
9-175
Compounded
Prescriptions
9-176
Compounded prescriptions are considered formulary drugs provided
they contain at least one listed formulary drug in the final product. Use
of the compound indicator for compounded prescriptions is reserved for
prescriptions requiring the pharmacist to combine two or more
ingredients.
Prescription Cost
Less Than Copay
If the cost of the prescription is less than a member’s copay, the
member should pay the lesser of the allowed amount as shown on the
claims response.
Over-theCounter Drugs
Most plans do not cover over-the-counter drugs; however, insulin and
diabetic supplies are covered by most benefit plans. Some contracts will
cover Nicotine Replacement products.
NDC Numbers
The NDC numbers submitted on the pharmacy claim must be taken
from the container from which the drug was dispensed. The NDC
number must match the manufacturer and package size.
Discounting or
Waiving Copays
In order to maintain the level of subscriber responsibility specified in
EPNI contracts, it is essential that members pay the agreed-upon copay
for their formulary and non-formulary drugs. Both member and
provider agreements specifically state that the copay must be collected
in full. Noncompliance of this provision, through discount or waiver,
could result in termination of the provider agreement.
Dispense as
Written (DAW)
EPNI provides for the payment of claims coded ‘‘dispense as written’’
(DAW). Consistent with state law, DAW must be in the physician’s
own handwriting or when an oral prescription is given, specifically
stated. Physicians may use DAW to prevent generic substitution or to
override the non-formulary status of a drug when it is medically
necessary. However, most contracts only allow for one DAW override.
Only a physician may indicate DAW on a prescription. Neither member
nor pharmacist may change this status for any reason. A DAW may not
always result in a lower copay. This will be dependent on the patient’s
benefit plan.
Prescribing
Physician’s DEA
The physician’s DEA (Drug Enforcement Agency) number must be
entered on all electronic or paper claims submitted for payment. This
information is used for drug utilization review aimed at improving the
quality of health care delivered to our members. Leaving this data
element out or use of a dummy DEA number constitutes an incomplete
pharmacy claim. The prescribing number issued for eligible
optometrists must be included when appropriate.
Pharmacy Audits
EPNI performs comprehensive pharmacy program integrity audits to
ensure compliance with its programs.
Investigative
Drug Use
Drugs used investigatively are not eligible for reimbursement.
9-177
Radiology Services
General
Guidelines
Codes 70010-79999 are used for reporting radiology procedures. The
number of services on your claim must be the number of procedures
performed, not the number of views taken.
For example:
Code
No. of services
71020 (chest X-ray, two views)
1
Diagnosis
A diagnosis code is required for radiology services and should match
the services provided. For example, 76805 should have a maternity
diagnosis. For a preoperative chest X-ray, use ICD-9 code V72.82.
Modifiers
Use modifier -26 to indicate a physician’s professional component when
only the professional component is reported. Likewise, if only the
technical component is being reported, modifier -TC should be added to
the CPT code. We expect the global procedure to be reported if both
components are performed by personnel in the same clinic.
Radiation
Treatment
Management
The weekly management code is 77427. Radiation treatment
management is reported in units of five fractions or treatment sessions,
regardless of the actual time period in which the services are furnished.
The services need not be furnished on consecutive days. Multiple
fractions representing two or more treatment sessions furnished on the
same day may be counted separately as long as there has been a distinct
break in therapy sessions, and the fractions are of the character usually
furnished on different days. Code 77427 is also reported if there are
three of four fractions beyond a multiple of five at the end of a course of
treatment; one or two fractions beyond a multiple of five at the end of a
course of treatment are not reported separately. The professional
services furnished during treatment management typically consists of:
•
Review of port films;
•
Review of dosimetry, dose delivery, and treatment parameters;
• Review of patient treatment set-up;
Examination of patient for medical evaluation and management (e.g.,
assessment of the patient’s response to treatment, coordination of care
and treatment, review of imaging and/or lab test results.)
The code 77431 is meant to be utilized for radiation therapy
management that includes the complete course of therapy, consisting of
one or two fractions only. This code is not meant to fill in the gaps for
the one or two fractions that may be left over at the end of a long course
of therapy.
9-178
Maternity
Ultrasound
Compatibility
The pregnant uterus ultrasound CPT codes 76801 - 76817 are not
compatible with routine or non-specific diagnoses. This includes the
diagnosis code V72.5 (Radiological examination, not elsewhere
classified). If a definitive diagnosis is not available, a sign or symptom
necessitating the ultrasound should be submitted.
Purchased
Services /
Outside Lab
The entity that performs a test should be the one to bill for that test.
However, a provider may, under arrangement with another provider, bill
a service that is purchased from that other provider. For example, a
clinical provider may bill for an x-ray that is done at a hospital because
the clinic did not have the appropriate equipment. It is important to
remember that only one provider may bill for the service.
Claims for purchased services should be submitted on the CMS-1500 as
follows:
Field
Enter
item 24B
(place of service)
enter the place where the service was done
by the performing provider
item 24D
(procedure/ modifier)
enter the procedure code of the test and the
modifier –90
item 24K
(provider number)
enter the provider number of the ordering
physician
item 32
(where rendered)
enter the name and address of the performing
provider
Diagnostic and
Screening
Mammogram
Generally, screening and diagnostic services done on the same day are
considered mutually exclusive and the screening service will be denied.
However, if a diagnostic mammogram is followed by a screening
mammogram on the same day, both may be allowed. The modifier –GG
must be appended to the diagnostic mammogram code 76090.
Code 76140
Code 76140 (consultation on x-ray examination made elsewhere,
written report) is considered an over-read is not allowed. (Over-reads
are additional interpretations of film and as such, are not billable to the
plan or the patient as a separate charge.)
Comparison Xray
Xrays taken for comparison purposes are generally not covered. Rexrays are allowed if performed at different times of day or before and
after surgery, such as orthopedic procedures including casting. Add a –
76 modifier to the second or subsequent xrays.
9-179
An example is illustrated below.
24.
A
D
B
C
DATES OF
SERVICE
FROM
TO
MM
DD
YY
MM
DD
YY
Place
of
Svc
Type
of
Svc
09
01
00
06
1
1
99214
09
01
00
06
2
2
71010
25. FEDERAL TAX
I.D. NUMBER
SSN
EIN
E
PROCEDURES,
SERVICES, OR
SUPPLIES
(Explain
Unusual
Circumstances)
CPT/HCPCS
MODIFIER
DIAG
NOSI
S
27. ACCEPT
ASSIGNMENT?
(For govt
claims, see back)
Yes
31. SIGNATURE OF
PHYSICIAN OR SUPPLIER
INCLUDING DEGREES
OR CREDENTIALS
(I certify that the statements
on the reverse
apply to this bill and are
made a part thereof.)
SIGNED
No
32. NAME AND ADDRESS OF
FACILITY WHERE SERVICES
WERE
RENDERED (If other than home
or Office)
DAYS
OR
UNITS
EPSDT
Family
Plan
I
J
EMG
COB
RESERVED FOR
LOCAL USE
$CHA
RGES
40.00
1
12345AB
30.00
1
12345AB
28.
TOTAL
CHARGE
29.
AMOUN
T PAID
30.
BALANCE
DUE
$
$
$
33. PHYSICIAN’S, SUPPLIER’S
BILLING NAME, ADDRESS, ZIP
CODE & PHONE
ABC Radiologists
XYZ Hospital
123 Main St.
Little, MN
DATE
PIN#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE
(12/90)
9-180
G
K
CODE
90
26. PATIENT’S
ACCOUNT NO.
F
H
GRP#
1A111ZA
FORM CMS-1500
Rehabilitative Services
Physical Therapy
Modalities
Physical Therapy
Procedures
The following physical medicine codes require a physician or therapist
to be in constant attendance. Submit the following CPT codes for
physical therapy services:
Code
Units of Service
97010 - 97028,
97039
1 unit for each modality
97032 - 97036
1 unit for each 15 minutes
The following codes should be used for physical therapy procedures:
Code
Units of Service
97110 - 97124
1 unit for each modality
Example:
Coding for massage, 50 minutes:
Code Time Units of service
97124 50 min.
4
Additional physical therapy codes are 97140-97542 and 97597-97606
should be used as outlined in CPT.
Physical Therapy
Evaluation Codes
Physical therapists evaluation and re-evaluation services should be
submitted using CPT codes 97001 and 97002.
Code
Category
Units of Service
97001, 97002
Evaluation and re-evaluation
1 unit
If these codes are billed with other services performed on the same day,
they will be denied. These codes may be reported separately only if the
patient’s condition requires significant separately identifiable services,
above and beyond the usual pre-service and post-service work
associated with the procedure performed. In these instances, add
modifier –25 to the evaluation or re-evaluation.
9-181
Occupational
Therapy
9-182
Listed below are the CPT-4 physical medicine and rehabilitation codes
and additional codes that occupational therapists may submit.
Code
Category
Units of Service
97010 - 97028
Modalities, supervised
1 unit for each
modality
97032 - 97036
Modalities, constant attendance
1 unit for each 15
minutes
97039
Modality, constant attendance,
unlisted
1 unit for each
modality
97110 - 97140
Therapeutic procedures
1 unit for each 15
minutes
97150
Therapeutic procedure(s), group
1 unit
97530 - 97542
1 unit for each 15
minutes
97545
1 unit for 2 hours
97546
1 unit for each
additional 60
minutes
97597 - 97606
Active wound management
Unit per session
97750 - 97755
Test and measurements
1 unit for each 15
minutes
97799
Other procedures
1 unit (designate
time)
97760 - 97762
Orthotic and Prosthetic
management
1 unit for each 15
minutes
29105 - 29131
and 29505 29515
Splints
1 unit
29240 - 29280
Strapping
1 unit
92526, 92610 92617
Special otorhinolaryngologic
services
1 unit
95831 - 95852
and 95999
Neurology and neuromuscular
procedures
1 unit
96105 - 96111
Central nervous system
assessments/tests
1 unit per hour
Occupational
Therapy
Evaluation
Codes
Occupational therapists should submit evaluation and re-evaluation
services using the CPT codes 97003 and 97004.
Code
Category
Units of Service
97003 - 97004
Evaluation and re-evaluation
1 unit
If these codes are billed with other services performed on the same day,
they will be denied. These codes may be reported in addition to the
therapeutic procedures (97010-97546) if a –25 modifier is appended to
the evaluation or re-evaluation (97003-97004) codes.
Speech Therapy
and Evaluation
Speech therapists, physicians, or M.D. clinics should use CPT code
92507 for their speech therapy services and 92506 for speech evaluation.
Submit one unit of service per encounter.
9-183
Surgical Services
General
Guidelines
Generally, EPNI covers only surgical procedures performed by a
physician for the treatment of illness or injury.
Follow these procedures to bill surgical charges:
Bilateral
Services
•
Submit each surgical procedure on a separate line. (Do not submit
multiple procedures on one line even if identical procedures were
performed.)
•
Submit all surgeries performed on the same date on one claim. List
the appropriate procedure code for each one.
•
Use modifier -51 for secondary procedures
The bilateral modifier –50 is used to indicate cases in which a procedure
normally performed on only one side of the body is performed on both
sides. The CPT descriptors for some procedures specify that the
procedure is bilateral. In such cases, the bilateral modifier should not be
used. Some payers such as Medicare require a one-line entry; however,
third-party payers may have different requirements. EPNI requires
submission of two lines for bilateral procedures. The –50 modifier should
be appended to the second line of service.
Example:
Line 1= 69421
Line 2= 69421-50
Unlisted
Procedures
If a code cannot be found for a surgical procedure, submit the unlisted
code from the related section of CPT and attach an operative report to the
claim.
Facility Fees for
Office Surgery
EPNI does not allow a separate reimbursement for approved office
surgery suites. No additional reimbursement will be made for fees
associated with procedures performed in office surgical suites regardless
if the service(s) is modified with the –SU or –SG modifier. This includes
additional units of service for the preoperative preparation, anesthesia
and surgical trays.
9-184
Global Surgical
Package
Surgical procedures include the operation itself, local infiltration,
metacarpal/digital block or topical anesthesia, when used, and normal,
uncomplicated follow-up care. This concept is referred to as a
‘‘package’’ for surgical procedures, and typically begins the day before
surgery. Do not submit separate, itemized services for uncomplicated
surgical follow-up.
Surgical Care Only
The post-operative period includes all visits by the primary surgeon
unless the visit is for a problem unrelated to the diagnosis for which the
surgery was performed or is for an added course of treatment other than
the follow-up care that is usually associated with the surgical procedure.
When billing for the surgery only, submit the surgical procedure code
with a -54 modifier and an appropriately reduced charge to reflect that
post-operative care was not provided. Reimbursement for allowable
intraoperative services will reflect 90% of the physician fee schedule
allowance for the procedure.
Pre- or Post-Op Management
EPNI is unable to accept the -55 and -56 modifiers with the surgical
procedure codes. Submit the appropriate evaluation and management
code for each visit with the -55 or -56 modifier when pre-operative
and/or post-operative care is provided by a different clinic than
performed the surgery.
Fractures
Codes for fracture treatment include the application and removal of the
first cast. Do not submit separate charges for these services. Submit cast
removal codes only if a different physician does the removal.
Submit codes 29000-29590 for the application of casts and strapping
only when performed as a replacement during the period of follow-up
care. Additional visits are reportable only if additional significantly
identifiable services are provided at the time of the cast application or
strapping. Removal of a second or third cast by the physician who
applied it is included in the casting and strapping codes and not billable
separately.
If cast application or strapping is provided as an initial procedure in
which no surgery is performed (e.g., casting of a sprained ankle or knee),
use the appropriate level-of-office visit in addition to the appropriate
HCPCS code for the supplies. The removal of an initial cast (in which no
surgery was performed) should be submitted as an office visit.
Incidental
Surgery
EPNI does not cover procedures that are incidental to other major surgery
and unrelated to illness, injury, or sterilization.
Incidental surgical procedures do not usually warrant separate
identification.
9-185
Lesions
Certain CPT codes for the integumentary system indicate a second or
third lesion. Use these codes only with the primary code for the first
lesion. Use an office call code for treatment of wounds, punctures,
abrasions, and lacerations that do not require sutures or debridement.
Codes 11400-11446, for removal of benign lesions such as keratosis,
cover a variety of techniques. The excision of benign lesions with a laser
is considered a variation of a surgical excision. The dimension and
location of the lesion should be recorded in the operative report. Submit
the appropriate code from the range listed above.
Surgical Trays
and Supplies
No additional reimbursement will be made for surgical trays, surgical or
other miscellaneous supply codes A4550, A4649, and 99070. The
allowance for these codes is considered bundled into payment for the
other services rendered.
Supplies/devices implanted as part of the surgical procedure, are
considered integral to the procedure and are generally not separately
reimbursable.
Standby
Services
All standby services except anesthesia standby should be submitted with
code 99360 with one unit per 30 minutes. The type of standby (operative,
PTCA) and the total number of minutes the service was provided must be
indicated in the medical record. The physician may not be providing care
or services to other patients during this time. Do not bill for anesthesia
standby as it is considered ineligible and will deny as provider liability.
Treatment of
Warts
The treatment of warts (verrucae, papillomas) via surgical or laser
excision is considered a variation of destruction of a benign lesion. Use
the CPT procedure codes 17000-17004.
A cluster of warts is considered a single destruction of warts and should
be submitted using one unit of service.
Paring or curettement or shaving of warts with or without chemical
cauterization should be coded using CPT procedure codes 11055-11057.
Electrocauterization or ‘‘burning off’’ of warts should be coded using
CPT procedure code 17110. This procedure code includes up to 14
lesions. Fifteen or more lesions are coded as 17111. A cluster of warts is
considered a single operative procedure and should be coded as such.
EPNI does not recognize the use of CPT procedure codes 11420-11446
for the treatment of warts. This range of codes is considered for other
types of skin lesions, such as a keratosis, etc.
9-186
Assistant
Surgeons
Almost all EPNI members have coverage for assistant surgeon’s services
when the following criteria are met:
•
The surgical assistant is a licensed physician, nurse practitioner (NP),
registered nurse first assistant (RNFA), or physician assistant (PA).
•
The surgical assistant’s services are medically necessary. (This is
determined by the complexity of the surgery.)
•
To bill services of an assistant surgeon (MD, NP, or RNFA acting as
an assistant at surgery), use the surgical procedure code with modifier
-80. To bill the services of a physician assistant acting as an assistant
at surgery, use modifier -AS or -80.
•
If more than one surgical procedure was done during the same
session, give the total hours and minutes for all procedures done. List
each procedure separately.
•
Generally, reimbursement for eligible assistant surgeon services are
reimbursed at 16% of the surgery allowance. When an assistant
surgeon is involved in multiple surgical procedures, the same method
used for determining reimbursement for the primary surgeon shall be
used in determining reimbursement for the assistant surgeon.
•
We do not publish a list of surgeries for which an assistant surgeon is
allowed. Generally, we follow the list that CMS has furnished to
Medicare carriers, for approved codes.
9-187
Co-Surgeons
Co-surgery services are identified by use of the CPT modifier -62. Cosurgery involves a surgical procedure report with a single procedure code
that requires two surgeons of different specialties or a surgical procedure
that involves two surgeons performing parts of the procedure
simultaneously. The additional surgeon is not acting as an assistant at
surgery (modifier –80 or –AS) or as part of a surgical team (modifier –
66).
Documentation must support the use of the –62 modifier. An operative
report(s) is required and will be requested if not submitted.
Claims must be coordinated by the surgeons prior to filing their claims.
One operative report may be used, as long as both surgeons’
responsibilities are identified. The following criteria must be met:
Co-surgery services should be submitted using the appropriate CPT
surgical procedure code and the modifier -62. If more than one modifier
is being reported, list -62 first.
Both providers billing the -62 modifier should normally be surgeons of
different specialties. Examples would include Gynecology/Urology,
General Surgery/ENT, etc.
It must be medically necessary and an accepted standard of care to have
two surgeons of different specialties perform the surgery.
Each surgeon must perform a distinct portion of the surgery.
EPNI follows Medicare’s guidelines regarding which procedures will be
reimbursed for co-surgery services. The MPFSDB indicators are:
•
0 = Co-surgeons are not permitted for this procedure.
•
1 = Co-surgeons may be paid if supporting documentation is supplied
to establish medical necessity.
• 2 = Co-surgeons permitted.
Allowable co-surgery services will be determined on a case-by-case basis
and upon review of supporting documentation. Reimbursement will be
62.5 percent of the global surgery fee schedule amount for allowable cosurgery services. Additionally, global surgery rules will be applied to
each of the physicians participating in a co-surgery.
Multiple
Surgeries
9-188
All multiple surgeries will be reimbursed the same regardless of whether
the subsequent surgical procedure was performed through the same or
different incisions. The major surgery is reimbursed at 100% of the
allowed amount, and any/all additional procedures are reimbursed at 50%
of the allowed amount.
Chapter 10
Template Policies and Procedures
Table of Contents
Instructions for Use.................................................................................................................... 10-2
Advance Directives.................................................................................................................... 10-4
Child and Teen Checkups .......................................................................................................... 10-5
Communicable Disease Reporting............................................................................................. 10-6
Complaint Management............................................................................................................. 10-7
Patient Complaint Intake Template ........................................................................................... 10-9
Confidentiality ......................................................................................................................... 10-10
Confidentiality Statement ........................................................................................................ 10-14
Confidentiality and Security of Medical Records.................................................................... 10-15
Authorization for Release of Information................................................................................ 10-19
Foreign Language Translation and Hearing-Impaired Services .............................................. 10-20
Interpreter Resources ............................................................................................................... 10-22
Interpreter Services Billing Information.................................................................................. 10-23
Hazardous Materials Management .......................................................................................... 10-24
Infection Control...................................................................................................................... 10-28
Medical Emergency ................................................................................................................. 10-32
Medication Management ......................................................................................................... 10-33
Non-Medical Emergency Preparedness................................................................................... 10-37
Treating Unaccompanied Minors ............................................................................................ 10-39
Authorization to Consent to Treatment of a Minor ................................................................. 10-41
Consent to Allergy Treatment for Unaccompanied Minor ...................................................... 10-42
Behavioral Health Accessibility Standards.............................................................................. 10-43
EPNI Provider Policy and Procedures Manual (11/01/07)
10-1
Instructions for Use
Introduction
EPNI provides these templates of policies and procedures to assist your
facility in creating and personalizing your own policy and procedure.
Written policies and procedures describing key functions and activities
of your facility serve as risk management tools and provide training
materials for employees. Policies provide:
•
Direction in decision making and promote consistency of
interpretation and applications across organizational lines;
•
Guidance for future policy development
•
A frame work for revisions; and
•
A clear understanding of facility operation, thus minimizing the
possibility of illegal and/or authorized action.
•
Policies are established when persons capable of reasonable
judgment could logically arrive at a different decision.
Chapter 1 Requirements
EPNI requires the following around policies and procedures:
•
Policies are personalized with provider information if templates are
used. Replace {ALL TEXT IN BRACKETS} with information that
is specific to your facility/health system.
•
Policies are dated and signed by either provider administration or
the medical director each time they are reviewed
•
On an annual basis, review appropriate policies and procedures with
all employees and update if necessary
Disclaimer
EPNI provides these policies and procedures as samples only. EPNI
makes no representations or warranties regarding the completeness or
accuracy of such policies and procedures; nor, does it represent or
warrant that these policies and procedures meet all applicable
requirements of any federal or state law, regulation, rule, or order. These
policies should not be construed as legal advice, and the provider should
consult its own legal counsel and/or liability carrier prior to
implementing any new policy or procedure.
10-2
EPNI Provider Policies and Procedures Manual (11/01/07)
Suggestions
Suggestions for Customizing and Adopting a Policy and Procedure
We recommend the following steps in customizing and adopting a
policy and procedure within your facility system/medical group.
Preparation
Implementation
Maintenance
1. Review the template
policy and procedure
and customize the
template to include
information relevant to
your facility setting.
Consider additional
pertinent information.
5.
Educate all appropriate
personnel and practitioners
about the approved policy
and procedure.
10. Establish an annual
review process for
reviewing and
updating policies and
procedures.
2. Review with key
facility administration
for their input (e.g.,
administrator, medical
director).
6.
Maintain a single location
for storage of original
policies.
11. Consult with your
legal counsel and/or
liability carrier for
advice on record
maintenance for
retired policies and
procedures.
3. Have your legal
counsel and/or liability
carrier review your
policy and procedure.
7.
Provide copies of policies
in appropriate patient care
areas for reference.
4. Bring the draft policy
and procedure to an
internal clinic
committee for review
and approval.
8.
Include review of policies
and procedures as part of
new employee orientation.
9.
On an annual basis, review
appropriate policies and
procedures with all
employees.
10-3
{Health Care Entity Name}
Subject:
Advance Directives
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} makes information regarding advance directives, including how
to execute advance directives, available to its competent adult patients and their families.
Purpose
The purpose is to encourage communication between patients and health care practitioners on
the issue of advance directives.
Procedure
1.
Practitioners will assess and discuss each patient’s desire for Advance Directives.
2.
Upon request, information on advance directives is provided to patients and their families.
3.
The patient’s practitioner discusses advance directives issues with the patient and his/her
family.
4.
Discussions about advance directives are documented in the medical record.
5.
Copies of executed advance directives are maintained in the medical record.
6.
Patients and their families desiring additional information or counseling on advance
directives are referred to appropriate community resources.
7.
The facility notifies the hospital of advance directives on file at the facility when the
patient is admitted to the hospital.
8.
Patients and their families are informed of this practice.
Disclaimer
EPNI provides these policies and procedures as samples only. EPNI makes no representations
or warranties regarding the completeness or accuracy of such policies and procedures; nor, does
it represent or warrant that these policies and procedures meet all applicable requirements of
any federal or state law, regulation, rule, or order. These policies should not be construed as
legal advice, and the provider should consult its own legal counsel and/or liability carrier prior
to implementing any new policy or procedure.
10-4
Subject:
Child and Teen Checkups
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITIY} provides comprehensive health services that facilitate early
discovery and treatment of health problems to children from birth through age 20 years.
Purpose
The purpose is to appropriately perform, record, and bill C&TC services as required for
children.
Procedure
1. Identify patients from birth through age 20 years.
2. Schedule a sufficient amount of time for the C&TC exam.
3. Attach the appropriate forms to the patient’s medical record when preparing it for the
appointment.
4. Perform the appropriate services for the age of the child or teen.
5. Document all completed components and results on the facility or C&TC form in the
medical record:
6. Route the C&TC service information to the appropriate person for correct coding and
billing for reimbursement.
Use the following two-character alpha referral codes:
AV – Patient refused referral
ST – Referral to another provider for diagnostic or corrective treatment or scheduled for another
appointment with screening provider for diagnostic or corrective treatment for at least
one health problem identified during an initial or periodic screening service (does not
include dental referrals)
S2 – Patient is currently under treatment for referred diagnostic or corrective health
problem(s)
NU – No referral(s) made
Document each component abnormality and the plan for follow-up.
If unable to provide all appropriate services, document the reason the service(s) was/were not
performed.
Disclaimer
EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or
accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements
of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its
own legal counsel and/or liability carrier prior to implementing any new policy or procedure.
10-5
Subject:
Communicable Disease Reporting
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
The reporting of communicable diseases to the Department of Health is critical to controlling
the spread of disease. These diseases are of such major public health importance that
surveillance of their occurrence is in the public interest. The Department of Health has a list of
communicable diseases that must be reported from the physician/provider. Cases, suspect cases,
carriers, and deaths due to the reportable diseases and infectious agents should be reported
within one working day
Purpose
It is the responsibility of the laboratory, nursing and practitioner staff to be knowledgeable of
the reportable communicable tests and conditions and the reporting process. Communicable
disease reporting helps to reduce the spread of disease and control outbreaks, and to plan public
health interventions. Health care providers are an essential part of the disease surveillance
process. While laws mandate reporting, the voluntary cooperation of all concerned is needed for
the system to function.
Procedure
1.
If a communicable disease identified as reportable by the Department of Health is reported out
from the laboratory or any of the reference laboratories used by {HEALTH CARE ENTITY},
it will be the responsibility of the laboratory and/or nurse to bring the result to the attention of
the doctor or nurse. Vaccine-preventable diseases should be reported at the time they are
suspected. Waiting for laboratory confirmation can delay vital public health action that might
control the spread.
2.
When a positive reports comes through the laboratory, the lab tech will attach the appropriate
form depending on the test done. The nurse should also be familiar with the communicable
disease list in case the attachment of forms is missed.
3.
The nurse/doctor will be responsible to complete the forms and send them to the Department of
Health within one working day after the reportable communicable disease is discovered.
4.
The reference laboratories do notify the Department of Health of positive reports on
communicable diseases, but the {HEALTH CARE ENTITY} must send the appropriate forms
with the complete patient history and information within one working day after the reportable
communicable disease is discovered/known.
5.
The Department of Health may communicate with the practitioner/nurse if more information is
necessary.
Disclaimer
10-6
Subject:
Complaint Management
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} will receive and respond within 30 calendar days to both oral and
written complaints. All complaints should be resolved at the level the issue occurred.
Purpose
Complaints or concerns received by facility staff reflect patient perceptions and expectations.
Feedback, solicited or unsolicited, presents an opportunity to identify issues and implement
systematic processes to improve care and/or service.
Procedure
Both oral and written complaints will be taken and trended.
Designated complaint staff will be responsible for receiving complaints. Complaints related to a
specific department will be forwarded to the department supervisor. Complaints related to
physicians will be forwarded to either Administration or the Medical Director.
1.
Any staff person may receive either verbal or written patient complaints.
2.
The person receiving the complaint will initiate the complaint intake form.
3.
If the complaint can be resolved at this level, staff member receiving the complaint will:
•
Resolve complaint.
•
Notify patient of outcome.
•
Complete complaint intake form including signature and date.
•
Completed form will be forwarded to the (designated complaint person) for logging.
4.
If the complaint cannot be immediately resolved, the complaint will be forwarded to
(designated complaint staff).
5.
Patient is notified of their right to appeal to the health plan.
6.
(DESIGNATED COMPLAINT STAFF) will review and research the complaint.
7.
(DESIGNATED COMPLAINT STAFF) will notify the patient of the outcome.
8.
The complaint form will be completed, signed, and dated.
9.
The complaint will be logged and filed.
10-7
Patient Complaint Records/Trends:
Complaints will be trended and reported at least quarterly by issue/type to the appropriate
internal committee, e.g., the HCI Committee or Risk Management Committee. It may be
appropriate to trend and report more frequently as appropriate for your system.
Improvement activities will be identified.
Action plans will be developed for improvement opportunities to include the person
accountable and the projected date for completion.
The appropriate internal committee will monitor the action plans.
An annual report will be presented to the HCI Committee including improvement made as a
result of patient complaint/concerns.
The facility’s Board of Directors will review patient complaints at least annually
Disclaimer
10-8
Patient Complaint Intake Template
EPNI
Medica
Health Partners
Ucare
Other
Patient ID:
Patient Name:
Home Address:
Telephone Number:
Date of Birth:
Primary MD:
Date Received:
Occurrence Date:
Issue:
Received By:
Access
Communication/Behavior
Coordination of Care
Technical Competence & Appropriateness of Service
Facility/Environment Concerns
Benefit Coverage, Finance, & Contractual Issues/Concerns
Description of Issue:
Summary of Investigation and Resolution:
Date Resolved:
Date Patient Notified
of Outcome:
Resolved By:
Patient Accepting of Resolution?
Yes / No* /NA
*Patient referred to health plan?
Yes / No
Signature:
Date:
Disclaimer
10-9
Subject:
Confidentiality
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{Health Care Entity} assures confidentiality and security of patient information. All sources of
patient information containing clinical, social, financial, and other personal or protected
information are treated in a confidential manner. All patient information including but not
limited to the following, is considered confidential:
•
Name
•
Date of birth and age
•
Race
•
Sex
•
Address
•
Phone number
•
E-mail address
•
Place of employment
•
Marital status
•
Sexual preference
•
Medical history
•
Current medical conditions
•
Financial history
•
Insurance information
•
Lab tests and radiology results
Purpose
1.
To provide principles and guidelines for the confidentiality and privacy of patient
information.
2.
A sound confidentiality program promotes the overall quality of care and service rendered
to a patient.
3.
To meet or exceed requirements set forth by HIPAA (Health Insurance Portability and
Accountability Act).
10-10
Scope
1.
This policy applies to every individual who comprises the workforce at this facility, either
in a permanent or temporary capacity, and whether for employment, as a student or as a
volunteer. This includes people performing work on a contractual basis.
2.
It is incumbent upon each person to whom this policy applies directly to ensure that
persons performing occasional services at this facility, such as salespeople, maintenance,
and housekeeping abide by this policy and sign it, or are not allowed access to information.
This policy does not apply to:
1.
Disclosure to or requests by healthcare providers for treatment purposes, if the other
provider is within a related health care entity and the disclosure is for current treatment of
the patient,
2.
Disclosures to the individual who is the subject of the information,
3.
Uses or disclosures made pursuant to an authorization requested by the individual,
4.
Uses or disclosures required by compliance with the standardized HIPAA transactions,
5.
Disclosures to the Department of Health and Human Services when disclosure of
information is required under the rule for enforcement purposes, and
6.
Uses or disclosures required by law.
References
Journal of the American Health Information Management Association, “A Reasonable
Approach to Physical Security,” Chicago, IL, April 2002.
Journal of the American Health Information Management Association, ‘HIPAA Privacy and
Security Training,” Chicago, IL, April 2002.
Journal of the American Health Information Management Association, “Understanding the
Minimum Necessary Standard,” Chicago, IL, January 2002.
Procedures
1.
Training
A. Every individual described under Scope in paragraph 1 will receive training regarding
this facility’s confidentiality policy within {length of time} of his/her start date
(1) Training will be documented and verified by signature of the individual and
trainer, and maintained on file for six years.
(2) Training will include:
a. The vulnerabilities of health information in one’s possession, and
b. Procedures which must be followed to ensure protection of the information.
B. Refresher training will occur every {frequency of time}, and record of the training will
be maintained on file for six years.
10-11
2.
Physical Security
A. Media Controls {List here how you will control confidential information that is in
records, faxes, computers, diagnostic films, etc.}
(1) Fax transmissions
a. Stand alone machines. Medical and personal information will be received only
on a designated machine where confidentiality may be protected. People who
do not have access to confidential information within the facility will not be
permitted access to the designated machine.
b. Computer fax capabilities. Only people in the facility who are permitted to
handle confidential information will be permitted to receive fax transmissions
that contain medical and personal information.
(2) File rooms
a. Only people whose job duties require them to have access to records will be
permitted into file rooms where medical and personal information is
maintained, to include paper and film records.
b. Files will be physically secured when necessary to insure that unauthorized
access does not occur. The individual file cabinets will be locked, or the
room(s) in which the records are stored will be locked.
(3) Back-up files and copies of data
a. All back-up files, to include, but not limited to tapes, disks, and microfilm will
be stored in a secured area, separate from the original source of information.
Only people whose job duties require them to have access to confidential
information will be permitted to enter the secure area.
b. If back up files and copies are stored off site, such as in a warehouse, obtain a
copy of that facility’s policies regarding confidentiality.
B. Accountability (List here how you plan to be able to trace peoples’ routes and actions
and remind people of their responsibilities).
(1) All areas that are restricted in access will be labeled as such, with permanent signs.
Where possible, keep doors locked or visually monitored.
(2) Where possible, use sign-in and sign-out sheets, especially for people performing
work that would not usually have access to confidential information, such as
vendors and contractors.
(3) Change combinations and/or locks on doors when employees leave, even when
under “good” circumstances. Keep logs of when locks are changed. Keep lists of
who has keys. Keep spare keys locked up. Use swipe cards that will track
individual movement through entrances and exits.
(4) A provider employee will escort each visitor during his/her entire stay.
(5) When possible, make arrangements for housekeeping and maintenance to occur
during hours of normal business. Otherwise, they should have to sign a
confidentiality agreement.
10-12
C. Disposal of Confidential Information (Discuss how you will discard of items that
contain medical and personal information).
(1) All excess paper documents containing identifiable medical or personal
information will be shredded when it is no longer needed. (This will consist of the
majority of information within a facility, so it might be advisable that all excess
paper documents will be shredded.)
(2) Think about how you will destroy medical supplies that contain personal medical
information, such as IV bags and plastic medicine vials
D. Computer Security
(1) All computer screens will be arranged in such a way that only those employees
permitted to view medical and personal information will be able to see them.
(2) Automatic log off will employ (number) of minutes after the last use. (Idea: When
automatic log off occurs, use a screen saver with which you can create messages,
make messages regarding security reminders, and change the messages
occasionally.)
(3) All computers will require individual log-on identification and passwords.
(4) When switching users on a computer, the first user will log out before the second
user logs on.
3.
Personal Confidentiality
A. Ensure discussions with patients or about specific patients occur in areas where others
will not overhear the discussion. This includes, but is not limited to:
(1)
(2)
(3)
(4)
(5)
(6)
Appointments
Reception desk
Exam rooms
Consultation rooms
Waiting areas
Dictation areas
B. Sign-in Rosters
(1) Whenever possible, avoid using a patient sign-in roster.
(2) If it is necessary to use one, keep all information covered, so that the current
patient does not have unintended access to the roster.
C. Do not leave documents with personal or medical information in places where people
other than the authorized user will be able to read them.
D. X-ray view boxes
(1) Do not use x-ray view boxes in areas traversed by patients or other people not
authorized access to personal and medical information.
(2) Do not leave diagnostic films on view boxes while they are not in use
Disclaimer
10-13
Confidentiality Statement
I confirm that I have reviewed the confidentiality policy of {Health Care Entity}, received
necessary training in its implementation, and agree to operate within its limitations and
requirements. I understand that information I may have access to is protected by {state} and
federal law, and that I may not discuss patients or disclose a patient’s personal or medical
information to non-provider personnel, without the patient’s expressed consent, or otherwise
permitted by law or statute.
I understand that unauthorized release of confidential health care information may be grounds
for immediate termination of employment and may subject me to penalties under {state} and/or
federal law.
Employer’s Name Printed
Employer’s Signature:
Date
{Health Care Entity Name}Manager
or Information Security Manager
Date:
Disclaimer
10-14
Subject:
Confidentiality and Security of Medical
Records
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} assures confidentiality and security of patient information. Any
patient record containing clinical, social, financial or other data is treated in a confidential
manner. Records are reasonably protected from loss, tampering, alteration, destruction and
unauthorized or inadvertent disclosure of information.
Medical records are the property of {HEALTH CARE ENTITY} and shall not be removed
from the facility’s record keeping system, except when required by law.
When applicable, the above principles shall hold for any patient information that is stored in an
electronic form outside of the permanent paper record.
Unauthorized handling of medical records and/or discussion or patient information in nonpatient areas is cause for disciplinary action.
{HEALTH CARE ENTITY} upholds patient rights to confidentiality and privacy of patient
information. Confidential information is information that is accessible to the patient, but is not
public. Medical data, including reports based on examination, treatment, observation, or
conversation with the patient are considered confidential. Patients have the right to disclose
their confidential and privileged information and only they can exercise that right. Employees
sharing in the care of a patient may review records only as necessary in the performance of
his/her duties. Other persons who wish to review or obtain copies of patient information
(Medical record) must have written permission from the patient.
Only information about care rendered by {HEALTH CARE ENTITY} is released. Requests for
other outside records are referred to the agency where the patient received the service.
Purpose
The purpose is to provide principles and guidelines for the confidentiality and security of the
medical record and to set standards and guidelines for the release of patient information.
10-15
Procedure
1. Confidentiality
A. Upon hire and annually thereafter, employees are educated in and agree to abide by
patient confidentiality policies. Attestation of this instruction will be documented
annually with the signature of the employee. The signed documents will be maintained
in the employee’s file.
B. The medical record is to be read only by {HEALTH CARE ENTITY} staff for medical,
education, business or other institutional purposes.
C. Discussions of patient information are conducted only in patient areas and only in the
presence of persons authorized to receive the information.
2. Security
A. Active medical records are stored in a {SECURE CENTRAL AREA/MEDICAL
RECORDS DEPARTMENT} Inactive records (charts three years older than the current
year) are stored {LOCATION}.
B. Access to records within the {SECURE CENTRAL AREA/MEDICAL RECORDS
DEPARTMENT} is restricted to authorized Medical Record personnel.
C. Medical records are retrieved in advance of patient appointments. They are placed in a
secured area in the registration area each morning prior to the first scheduled
appointment.
D. Additional medical records are retrieved throughout the day. For these records, a request
slip must be completed with the following information:
Date of request
Patient name
Patient date of birth
Chart number (if available)
Requestor name
E. Upon receipt of a medical record request, medical record staff will locate and pull the
chart. They place the request slip in an out guide and place the out guide in the space
where the chart was located.
F. When a chart is moved to a new location in the facility, an updated request slip is
completed and forwarded to the Medical Record Department.
G. Medical Records are returned to {SECURE CENTRAL AREA/MEDICAL RECORDS
DEPARTMENT} at the end of each business day.
H. The {SECURE CENTRAL AREA/MEDICAL RECORDS DEPARTMENT} is locked
at the end of each day by the Medical Record staff.
I. In the event that a medical record is not returned to {SECURE CENTRAL
AREA/MEDICAL RECORDS DEPARTMENT} at the end of the day, it must be stored
in a locked drawer or file. Medical Records personnel must be notified of the location of
the chart.
10-16
3. Release of Information
A. Authorization
A valid authorization for release of information may by an original, a photocopy, or a
facsimile copy. The authorization contains the following elements:
•
It is in writing.
•
It designates the facility to which the request is directed.
•
It identifies the patient with full name.
•
It designates the names of each person or organization to which information
is to be released.
•
It includes an authorizing signature of the patient:
(1) If the patient is a minor, the parent or guardian must sign the authorization. In
situations where the minor has given his/her consent for care (pregnancy, sexually
transmitted diseases, contraception, alcohol or drug abuse), the minor may authorize
release of medical and mental health care information.
(2) If the patient has a legally appointed guardian, the authorization is to be signed by the
guardian.
(3) If the patient is unable to sign his/her name but uses some other means to indicate
authorization, such marks must be witnessed and notarized.
(4) If the patient is deceased, the personal representative of the estate must authorize
release of information. If the patient does not have a personal representative, the spouse
or a child may authorize release of information.
(5) If the validity of the signature is questioned, a notarized signature may be requested.
It is dated. NOTE: The authorization is valid for one year from the date of signature.
It designates the specific medical condition and dates of treatment and states the
authorization includes information pertaining to drug or alcohol related problem if
that type of information is to be released.
It states that the patient may revoke the authorization in writing at any time.
B. Release of Information Process
(1)
(2)
(3)
(4)
(5)
(6)
Requests for release of information are forwarded to and processed by the {MEDICAL
RECORDS DEPARTMENT}.
The medical record is pulled and the parts of the record designated in the authorization are
photocopied. EXCEPTION: Under very limited circumstances where the information
requested is detrimental to the physical or mental health of the patient, the health care
practitioner may withhold the information from the patient and provide it instead to an
appropriate third party. The third party, however, may then release the information to the
patient.
Medical records are faxed to other health care agencies, e.g. hospitals, if needed in urgent
and emergency situations. Faxing is otherwise discouraged.
In case of an emergency, information may be released by telephone to a physician or to a
hospital. The requestor is called back to verify their identity prior to releasing the
information. Documentation of the release of information, including what information was
released and the name of the requestor, is placed in the medical record.
Requests to view medical records must be accompanied by a valid, written authorization
from the patient. Before the chart is viewed, the sections that contain correspondence and
medical reports from other institutions are removed.
The records must be viewed on-site in the presence of a medical record staff member.
10-17
C. Subpoenas, Court Orders, and Search Warrants
All subpoenas, court orders and search warrants are forwarded to the {MEDICAL
RECORDS DEPARTMENT} for processing. {MEDICAL RECORDS
DEPARTMENT} immediately notifies the {ADMINISTRATOR} receipt of a
subpoena, court order or search warrant.
Subpoenas are processed as follows:
(1)
(2)
(3)
(4)
Document the date, time and method of delivery of the document.
An original subpoena is preferred but a copy of the subpoena is acceptable.
Review the document for validity. A valid subpoena contains the following:
Name of party being subpoenaed
a. Name of the court and title of the action
b. Names of the plaintiff and the defendant
c. Date, time, place and manner of the requested appearance
d. Specific documents being subpoenaed
e. Name and telephone number of the attorney issuing the subpoena
f. Signature or stamp and seal of the official empowered to issue the subpoena
g. Appropriate fee, unless a method for charging has been established
(5) The subpoena must be accompanied by a valid patient authorization or court order
to release the records referred to in the subpoena. If an authorization or court order
is not present, it must be received prior to release of the information identified in
the subpoena.
(6) Assure that the record is complete (up to date). Identify the pages requested in the
subpoena, number them and photocopy.
(7) A certified photocopy of the record is allowed to be entered into evidence at a trial.
A certification statement is prepared to accompany the medical record copies. This
statement includes:
a. Statement that the copy is a true copy of all records described in the subpoena
b. Statement that the records were prepared by personnel of the health care
provider or designee
c. Number of pages being certified
d. Notarized signature of the custodian of the records or designee
(8) The subpoena and any associated documentation are placed in the patient’s
medical record.
a. Court orders and search warrants are processed in the same manner as a
subpoena. A separate authorization to release medical records is not required.
Disclaimer
10-18
Authorization for Release of Information
I,
Last Name
First Name
Date of Birth
Middle Name
Maiden Name
Social Security Number
hereby authorize
To furnish information from medical records to
The information to be released is:
All/any medical information present in any medical record (including
treatment for mental health, chemical dependency and HIV status).
Selected medical information about
The information is needed for the purpose of:
Transfer of medical care
Insurance
Legal
Other (please specify)
****************************************************************************
I understand that I may revoke this consent at any time except to the extent it has been acted
upon and that upon fulfillment of the above stated purpose or one year from this date
(whichever occurs first), this consent will automatically expire without my express revocation.
I do not authorize re-release of chemical dependency-related information by the party receiving
it.
I also understand that I am responsible for any charges associated with transfer of this
information.
Signature
Date
Patient (or Parent or Guardian)
Relationship to Patient
Witness
Disclaimer
10-19
Subject:
Foreign Language Translation and
Hearing-Impaired Services
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} provides communication assistance for those patients and families
who require foreign language interpretation and for those who are hearing impaired. These
services are provided at no cost to the patient.
Purpose
The purpose is to ensure that patients and families with language and/or hearing barriers are
provided with necessary and appropriate communication assistance to assure accurate and
thorough communication of all aspects of patient care, including, but not limited to:
•
taking patient history
•
obtaining informed consent or permission for treatment
•
explanation of medical procedures and medications
•
explanation of legal rights and financial matters
•
health education
Procedure
1.
The patient and/or family may request sign language or oral foreign language interpreter
services. Practitioners and/or nursing staff may make the determination of need for
interpreter services.
2.
The use of family members for interpreter services is discouraged. Utilize family members
only as a last resort. If family members are used, be sensitive to cultural issues (e.g. family
roles, health conditions that do not translate, etc.)
3.
When a need for interpreter services is identified, contact the appropriate interpreter
service based on patient and family need and insurance coverage. Interpreter services
resources, including the AT&T Language Line and TDD/TTY Device, are listed on the
Attachment.
Have the following information available when contacting the interpreter service:
•
name and address of provider
•
phone number and contact person at provider
•
where, when and to whom interpreter is to report the
10-20
• name of the patient
4. Arrange for appropriate interpreter to be available for patient’s appointment. If patient has
previously used an interpreter for a provider appointment, attempt to schedule the same
interpreter for future appointments.
5.
Notify patient/family that an interpreter has been scheduled for the patient’s visit. Request
that patient notify provider of appointment cancellation at least 24 hours prior to the
appointment so that the interpreter service may be cancelled also.
6.
Notify the receptionist/front desk of the interpreter services that have been scheduled.
Disclaimer
10-21
Interpreter Resources
I.
(Foreign Language and Hearing Impaired Services)
Foreign Language Interpreters
A. Spanish
1. Interpreter Agency Name
Address
Telephone Number
2. AT&T Language Line
B. Hmong
Address
Telephone Number
C. Add languages as needed for your patient population
II.
Hearing Impaired Services
A. Sign Language
Address
Telephone Number
B. TDD/TTY Device
Disclaimer
10-22
Interpreter Services Billing Information
Date of Service
Provider of Service
Patient Name
Account Number
Date of Birth
Address
Insurer
Disclaimer
10-23
Subject:
Hazardous Materials Management
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENITY} maintains a hazardous materials and waste management plan to control
hazardous materials and waste. A hazardous material is any material in use that is considered to
represent a threat to human life or health. A hazardous waste is a material no longer in use that
represents such a threat. Once a material is used, contaminated or determined to be in excess of the
amount required, it is considered waste.
{HEALTH CARE ENITY} has a mechanism in place in the event of a hazardous material or waste
spill. The {SAFETY OFFICER} maintains an inventory of hazardous materials. A “Spill Kit”
containing the following items is readily available:
Absorbents
Isolation gowns
Vinyl gloves
Wet-Vac
Plastic bags and containers
Goggles
Surgical masks
Impervious shoe covers
In the event of a spill, the MSDS for that material is reviewed and the proper procedures are
followed.
Purpose
The purpose of the hazardous materials and waste management plan is:
To identify, evaluate and inventory hazardous materials and waste generated or used consistent with
applicable regulations and laws
To provide adequate space and equipment for the safe handling and storage of hazardous materials
and waste
To establish emergency procedures to use during hazardous materials and waste spills or exposures
To provide education to personnel on the elements of the Hazardous Materials and Waste
Management Plan
To address hazardous materials spills in a safe, appropriate and timely manner
10-24
Procedure
A. Identifying, evaluating and taking inventory of hazardous materials and waste
1. {DESIGNATED STAFF} are responsible for identifying and labeling hazardous
materials and waste. Upon ordering of these materials, the {DESIGNATED STAFF}
notifies the {SAFETY OFFICER} that hazardous materials are being ordered.
2. The {SAFETY OFFICER} maintains an inventory of hazardous materials within the
organization.
3. A Material Safety Data Sheet (MSDS) is kept on site for every chemical used in the
facility and identified as hazardous.
B. Management of chemical waste and regulated medical waste (i.e., sharps)
1. Chemical waste is handled using the following procedures:
a. The components of each type of chemical waste are clearly labeled. The label
indicates that the material is hazardous waste and lists the components, the
strength of the waste and type of hazard it represents.
b. Chemical containers are picked up in carts and transported in tote boxes.
c. Tote boxes are not over filled and the materials in a tote box are chemically
compatible.
d. Blood and blood product waste is disposed of in red plastic bags labeled as
hazardous waste.
e. Sharps, including hypodermic needles and syringes, suture needles, knife blades,
trocars from drains and opened glass ampules of medication are disposed of in
puncture-proof sharps containers.
C. Hazardous Gas and Vapors
1. Regular visual inspection of compressed gas cylinders is performed to ensure cylinders
are in safe condition.
2. Pressure relief safety devices meet the Compressed Gas Association (CGA)
requirements.
3. Oxygen cylinders are stored a minimum of 20 feet from combustible materials.
Cylinders are stored in a secure area to prevent access by unauthorized individuals.
10-25
D. Storage and Handling
1.
Hazardous materials are stored in a designated area and are properly labeled.
2.
Materials that ignite easily (flammable) are stored in a cool, dry, well-ventilated area,
away from areas of fire hazard. The flammable storage area has “Flammable Material”
signs posted and is equipped with a fire extinguisher.
3.
Materials that are toxic or that can decompose into toxic components from contact
with heat, moisture, acids or acid fumes are stored in a cool, well-ventilated area out
of direct rays of the sun.
4.
Corrosive materials are stored in a cool, well-ventilated area, isolated from other
materials.
5.
Personal protective clothing and equipment is used when handling these materials.
E. Hazardous materials or waste spills, exposures, and other incidents
1.
An incident report is completed on hazardous materials, waste spills and exposures.
2.
Major spill
a. A spill is considered major under these conditions:
•
A life threatening condition exists; the condition requires the assistance of
emergency personnel
•
The condition requires the immediate evacuation of the building
•
The spill contains quantities greater than 2 liters
•
The contents of the spilled material are unknown
•
The spilled material is highly toxic, biohazardous, or flammable
•
Physical symptoms are present
b. Procedures for a major spill are:
10-26
•
Determine what was spilled
•
Avoid inhaling
•
Evacuate the area; close doors
•
Notify the supervisor and the {SAFETY OFFICER}. Report the name of the
spilled chemical, amount spilled and the location.
•
Direct clean up
•
For disposal of hazardous materials, refer to Hazardous Materials and Waste
Management Plan
3.
Minor spills
a. A spill is considered minor under these conditions:
•
A relatively small area is affected and only a small number of people need to
leave the area until the spill is cleaned up
• The spill can be cleaned up without the assistance of emergency personnel
b. Procedures for minor spills are:
•
Put absorbent from the Spill Kit on the material if the material spilled is in
liquid form (and if this can be done safely)
•
Notify the supervisor and the {SAFETY OFFICER}
•
Take appropriate action to remove the hazard
•
Clean up the area
For disposal of hazardous materials refer to Hazardous Materials and Waste
Management Plan
Emergency procedures
•
4.
a. Identify the chemical before attempting to clean up hazardous chemical spill or
splash
b. Follow established procedures for cleaning up the specific chemical spill or leak
c. Notify persons in the immediate area, the supervisor and the {SAFETY
OFFICER}
d. Evacuate patients and staff from the area; close doors
e. Ensure adequate ventilation
F. Orientation and education
1. Orientation and job training are provided for persons who manage or handle hazardous
materials and waste.
2. Orientation includes information on the following:
a. Precautions for selecting, handling, storing, using and disposing of hazardous
materials
b. Hazard communication procedures
c. Location of policies and procedures, MSDS
d. Emergency procedures in the event of an exposure or a spill
e. Reporting procedures
3. Retraining is done annually and whenever a new hazard is introduced.
Disclaimer
10-27
Subject:
Infection Control
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} is committed to the prevention of disease transmission. Infection
control is an ongoing, integrated process that facilitates effective methods of prevention and
control of infection in patients, employees and visitors.
The basis for prevention and control of infection is frequent thorough hand washing in
conjunction with Universal Precautions. The risk of infection among employees can be lowered
through compliance with immunization policies and post-exposure management.
{HEALTH CARE ENTITY}’s staff, volunteers, contractors and residents/students use proper
hand-washing techniques as part of the infection control program. Handwashing facilities are
located throughout the facility near places of exposure and activity. In areas where sinks are
unavailable, antimicrobial products that do not require water for use are available.
{HEALTH CARE ENTITY} consistently uses blood and body precautions for all patients. All
blood and certain body fluids are treated as if known to be infectious for HIV, HBV, HCV or
other bloodborne pathogens.
{HEALTH CARE ENTITY} provides personal protective equipment for employees who may
have actual or potential exposure to blood or other potentially infectious materials within their
job duties. Employees are trained in the use of personal protective equipment.
Fluids that have been recognized by the Center for Disease Control as directly linked to the
transmission of HBV and/or HIV are blood, blood products, semen, vaginal secretions,
cerebrospinal fluid, amniotic fluid, concentrated HBV and HIV viruses in saliva in the dental
setting, peritoneal and pericardial fluid.
These precautions do not apply to feces, urine, sweat, tears, sputum, vomitus or breast milk
unless they contain visible blood. However, proper hand washing technique is observed
whenever contact is made with body secretions.
{HEALTH CARE ENTITY} screens its employees for tuberculosis (Mantoux) upon hire and
annually thereafter, using a “two-step” process{HEALTH CARE ENTITY} does not treat
active tuberculosis; individuals with active disease are referred to the {STATE} Department of
Health Tuberculosis Prevention and Control Program.
{HEALTH CARE ENTITY} offers the Hepatitis B vaccination series to employees who
reasonably anticipate occupation exposure. {HEALTH CARE ENTITY} provides a systematic
response to blood or body fluid exposure. The vaccination series, post-exposure evaluation and
follow-up are provided at no cost to the employee.
Updates and ongoing education about infection control is communicated through in-services,
annual training, newsletters, etc. and provides personal protective equipment
10-28
Purpose
The purpose is to ensure the safety and health of patients and employees by preventing the
spread of infectious agents.
Procedure
Handwashing
1. Hands are washed
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
2.
Before starting work
When visibly contaminated
Before and after patient contact
After removal of gloves and other protective equipment
Before leaving clinical areas
Before and after eating, drinking, smoking, applying make-up, changing contact lenses,
using the lavatory, blowing or wiping the nose, or similar activities
Before and after all activities that entail hand contact with mucous membranes
or
a break in the skin
After handling specimen containers or other surfaces that may be contaminated
Before performing invasive procedures
Before handling medications
Handwashing Steps
a. Wet hands thoroughly and apply a small amount of soap
b. Keep fingers pointed down to avoid contaminating the arm
c. Vigorously rub hands together for at least 15 seconds
d. Wash carefully between fingers and at least tow inches above the wrist
e. Rinse thoroughly with water in a downward motion
Universal Precautions
1. Employees, volunteers, and residents/students are trained in the use of universal
precautions prior to beginning a job assignment.
2.
Health care workers wash hands before and after patient contact in accord with the Hand
Washing Policy.
3.
Health care workers use barrier precautions to prevent skin and mucous membrane
exposure when in contact with blood or body fluids of patients.
4.
Gloves are worn when:
a. Touching blood or body fluids, mucous membranes or non-intact skin
b. Handling items or surfaces soiled with body fluids
c. Performing venipuncture or other invasive procedure
d. Health care worker has cuts, scratches or other breaks in the skin
e. Cleaning up spills that may contain body fluids
f. Handling specimens
g. There is potential for direct contact with blood or body fluids
10-29
5.
Mask, protective eye wear (goggles or face shield), gown or apron are worn during
procedures that are likely to generate splashes of blood or body fluids.
6.
Hand and skin surfaces are thoroughly washed with a germicidal agent immediately if
contaminated with blood or body fluids.
7.
Blood and body fluid specimens are placed in well-constructed containers with secure lids
to prevent leakage.
8.
Work surfaces are cleaned daily and as needed with an EPA registered tuberculocidal
disinfectant agent.
9.
To prevent needle stick injuries, needles are never recapped, bent, broken or removed from
disposable syringes. After use, needles and other sharp items are placed in a puncture proof
container. Sharps containers are never manually opened or reused.
10. Containers for infectious waste are clearly marked with the biohazard symbol. These
containers are lined with red leak-proof bags and have tight-fitting lids, with a footoperated mechanism
Personal Protective Equipment
1.
2.
Gloves are worn when there is exposure to blood, body fluids or hazardous substances.
The appropriate hand protection is selected depending on the task:
a. Utility gloves for maintenance and scrubbing work. These are reusable.
b. Sterile gloves for procedures involving contact with sterile areas. These are not reused.
c. Examination gloves for patient diagnostic procedures not requiring sterile gloves.
These are not reused.
Masks are worn in conjunction with eye protection in the event of potential contamination
through splashing or splattering of blood, body fluids or hazardous materials. Prescription
glasses may be worn in lieu of goggles if they furnish adequate protection.
3.
Gowns and head coverings are worn when splashes of blood, body fluids, or hazardous
materials are likely to occur. These are changed when they become soiled or wet.
4.
Shoes that cover the entire foot are required in areas where blood or body fluids are
processed and in areas where hazardous materials may be spilled.
5.
Wash hands immediately after removal of personal protective equipment. Place used
equipment in designated areas or containers.
Tuberculosis
1.
2.
10-30
Employees are screened for tuberculosis:
a. Upon hire
b. Annually
c. When displaying symptoms of tuberculosis
d. When there is a skin test conversion
e. When exposed to a tuberculosis patient where appropriate precautions were not
observed
f. At termination of employment
Employees who refuse tuberculosis screening sign a refusal statement
3.
4.
When triaging a patient with suspected tuberculosis, mask the patient and all employees
who come in contact with the patient. Place the patient in an examination room apart from
other patients. Use tuberculocidal disinfectants to clean the room after the patient has left.
Conduct a screening test (Mantoux) for the patient. If the test is positive, refer the patient
to the {STATE} Department of Health Tuberculosis Program. Alternatively, the provider
may decide to immediately refer the patient to the state program.
Hepatitis B (Vaccination and Post Exposure Evaluation)
1. The HBV series is made available to employees who may reasonably anticipate
occupational exposure after they have been trained and within ten working days of initial
job assignment unless:
a. The employee has received the HBV series
b. Antibody testing reveals immunity
c. Vaccine is contraindicated for medical reasons
d. The employee refuses the HBV series
2. Employees who refuse to complete the HBV series sign a refusal statement.
3. If an employee receives a needle stick or other exposure to patient body fluids, she washes
the area with germicidal immediately. In the case of eye contact, flush the eyes for five
minutes.
4. Isolate the source of the exposure.
5. Report the incident to the {SAFETY OFFICER} immediately. Complete an incident report
form.
6. Provide for a confidential medical evaluation for the employee, including baseline HBV,
HCV and HIV testing.
7. Obtain consent and test source individual’s blood sample to determine a baseline for the
source patient for HBV, HCV and HIV serological status.
8. Provide follow-up for the employee in accordance with current recommendations of the
United States Health Service.
9. Provide counseling to the employee regarding precautions to be taken during the period
after the exposure incident. The employee is also given information about potential
illnesses to be alert for and is asked to report any related experiences.
10. For OSHA 200 record keeping purposes, an occupational bloodborne pathogen exposure
incident is classified as an injury. It is recorded if it meets one of the following criteria:
a. It is a work-related injury that involves loss of consciousness, transfer to another job, or
restrictions of work or motion
b. The incident results in the administration of medical treatment beyond first aid
c. The incident results in a diagnosis of seroconversion. The serological status of the
employee is not recorded on the OSHA 200.
Disclaimer
10-31
Subject:
Medical Emergency
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} has a mechanism is place to respond to medical emergencies. Full
codes are not conducted at this facility. At least one currently certified CPR person is in the
office whenever patients are present. The goal of the medical emergency response team is to
stabilize the patient and to contact 911 emergency services if needed.
Purpose
The purpose is to safeguard the health and well being of patients.
Procedure
1.
Upon discovery of a medical emergency, page {MEDICAL EMERGENCY} (use code
word for your facility) and the location.
2.
Practitioners, nurses and other staff who are assigned to the medical emergency team
respond. The practitioner directs assessment procedures. {STAFF PERSON} records the
time and actions of the response.
3.
The {designated person} makes the determination if 911 is to be called.
4.
Staff not directly involved in responding to the medical emergency should maintain
“business as usual” along with reassuring family members and other patients.
5.
Within 24 hours, evaluate the effectiveness of the response to the medical emergency
Disclaimer
10-32
Subject:
Medication Management
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} has a mechanism in place to manage the procuring, storing,
controlling and distributing of sample and stock medications. A licensed health care
professional with prescription capabilities is present during facility hours.
{HEALTH CARE ENTITY} has a mechanism in place to manage narcotics and other
controlled substances. Narcotics stored in a manner that precludes unauthorized access; all such
items are stored in a double locked cabinet. The Head Nurse or designee carries the keys to the
cabinet during facility hours. After hours, they are locked in the security box.
Controlled substances are signed out for use only by practitioners or by Registered Nurses.
A count of items in the cabinet is completed and signed by two individuals at the beginning and
at the end of each shift.
Purpose
The purpose is to provide guidelines for appropriate storage, use, and management of
medications (including controlled substances) to ensure that legal requirements are met and to
ensure safe distribution to patients.
Procedures
Procuring
1.
Stock medications are purchased.
a. An assigned nursing staff person coordinates the purchasing process.
b. The nursing staff person places the medications in the stock medication storage area.
2.
Drug company representatives provide sample drugs.
a. An assigned nursing staff person coordinates the drug representatives’ time. Upon
arrival at the facility, drug representatives check in with the front desk. They are given
an identification tag if needed. They are escorted to other areas of the facility by the
assigned nursing staff.
b. Drug representatives, accompanied by the nursing staff person, place the sample drugs
in the storage area and log in the sample drugs that they are providing to the provider.
10-33
Storing
1.
Sample drugs and stock medications are stored in a secure area not accessible to patients.
2.
Access to the area is restricted to practitioners and assigned nursing personnel.
3.
Drugs are organized alphabetically within classes.
4.
Medications requiring refrigeration are stored in the medication refrigerator or freezer as
appropriate. This refrigerator is used only for the storage of medications; i.e. no food or
other items are stored in the medication refrigerator/freezer. Refrigerator and freezer
temperatures are monitored daily.
Controlling
1.
The assigned {STAFF PERSON} maintains a stock medication inventory. Log information
includes the lot number of the medication. Expiration dates are monitored. Medications are
discarded prior to their expiration date.
2.
The assigned {STAFF PERSON} maintains an inventory of sample drugs. The drug
representative who provides the sample logs the medication in. Log information includes
the lot number of the drug. The drug representatives, in collaboration with the nursing staff
person, are responsible for monitoring expiration dates and removing drugs prior to the
expiration date.
3.
The Medical Director approves new medications prior to their addition to the inventory.
4.
Prescription pads are kept in a locked area when not with the provider. Needles and
syringes are kept in a secure area.
Distributing
1.
Practitioners prescribe and dispense medications. As necessary, they communicate
medication orders either verbally or in writing to nursing staff.
2.
The practitioner or the nursing staff person procures the medication, logs the transaction,
and gives the medication to the patient.
3.
The practitioner is responsible for verification that the correct medication is given to the
patient.
4.
Medications are labeled with the patient’s name, the name of the medication, the strength,
dose and frequency, and lot number.
5.
Education about the medication, its effects, its administration and applicable monitoring
procedures and follow-up is given to the patient at the time they receive the medication.
The practitioner or the nursing staff document the education in the medical record.
Recalls
1.
Upon notification of a drug recall, the assigned {STAFF PERSON} removes the drug from
the inventory and returns it to the drug representative or disposes of it according to the
manufacturer’s instructions. This action is documented on the log.
2.
The log is checked to identify all patients that have received the drug. These patients are
notified and requested to return any unused drugs to the provider and/or are advised of
actions recommended by the manufacturer.
10-34
Emergency Drugs
1.
The assigned {STAFF PERSON} maintains a stock emergency drug inventory. All
emergency drugs are logged and include the lot number of the medication and the
expiration date.
2.
Emergency drugs are kept secure at all times in an emergency drug cabinet with the use of
a security lock.
3.
On a daily basis, the {STAFF PERSON} checks the integrity of security lock. This check
also includes monitoring for expiration dates of emergency drugs. Documentation of this
monitoring is noted on the daily check sheet. This information includes initials of person,
date and time.
4.
If the security lock is broken, the assigned {STAFF PERSON} completes an inventory of
entire emergency drug cabinet and inspects the emergency drugs against the inventory list.
Any emergency drugs used, missing, or expired are immediately replaced.
Controlled Substances
Count Procedures
1.
The Head Nurse or designee obtains the keys to the controlled substance cabinet from the
security box upon arrival at the facility each morning.
2.
The Head Nurse or designee, in conjunction with another nursing staff person, counts the
controlled substances and documents the count. The count information is recorded in the
log. This information includes:
•
Date and time
•
Drug counts
•
Signatures of both individuals doing the count
3.
Prior to the start of evening shift, the controlled substances are counted by the Head Nurse
or designee and the evening Lead Nurse.
4.
A final count is conducted at the end of business hours each day. Two individuals conduct
this count.
5.
The keys to the controlled substance cabinet are placed in the security lock box at the end
of patient care hours each day.
6.
If a discrepancy in the count occurs, the nurses conducting the count are responsible for
investigating and correcting discrepancies in the count.
7.
If a discrepancy is unable to be corrected, the outgoing nurse notifies the Manager
immediately.
8.
An incident report is completed for all discrepancies in the count.
10-35
Sign-out Procedures
1.
A practitioner’s order is required for the administration of controlled substances. The order
may be oral or written. The order must specify the medication, dosage and route of
administration.
2.
A Registered Nurse verifies the order prior to removal of the controlled substance from the
locked cabinet.
3.
After verification of the order, the Registered Nurse obtains the appropriate medication
from the locked cabinet and completes all fields on the sign-out log including:
4.
•
Patient name
•
Date
•
Name of drug
•
Dosage of drug
•
Signature, including credentials, of person accessing the box
If the dose is not a unit dose, wasting of the excess medication must be witnessed by two
nurses or by a nurse and a practitioner. The amount wasted is documented and both
witnesses sign the documentation.
Disclaimer
10-36
Subject:
Non-Medical Emergency Preparedness
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} has mechanisms in place to respond to emergencies such as
power outages, severe weather, and bomb threats.
Purpose
The purpose is to ensure the safety of patients and employees.
Procedure
1.
Power Outage
In the case of power outages, flashlights are available in {SPECIFIC LOCATION}. The
{SAFETY OFFICER} assesses the extent and duration of the outage and then makes a
determination whether or not to close the facility.
When it is necessary to close the facility, patients in the facility will be notified and
escorted to the door. A notice will be placed on the exterior door. Patients who have
appointments scheduled for later in the day are contacted about the closure of the facility.
Their appointments are rescheduled.
2.
Weather Emergency
In the event of a tornado warning, an announcement is made to advise patients, employees
and visitors of the situation. Close doors. Employees, under the direction of the {SAFETY
OFFICER}, guide patients and visitors to the lower level of the building. In buildings
without a lower level, everyone moves to the center most location in the building. Patients
and visitors are assisted in lying flat or crouching if possible, and in keeping their heads
down.
At the expiration of the tornado warning, the {SAFETY OFFICER} assesses the facility
for damage or safety hazards. If the patient care area is safe, an “All Clear” announcement
is made and employees, patients and visitors return to their previous activities. If the
facility is damaged, an evacuation may be ordered.
10-37
3.
Bomb Threat
In the event of a bomb threat telephone call, keep the caller on the line as long as possible.
Write down as much information as possible. Be alert to any distinguishing voice
characteristics and to any background noises. Ask for the location of the bomb.
If possible, notify a co-worker while you are on the telephone. The co-worker notifies the
{SAFETY OFFICER} immediately. S/he calls 911. If the caller states that the bomb is
going off immediately, call 911 before alerting the {SAFETY OFFICER}.
The {SAFETY OFFICER} pages {FIRE ALERT} (use facility’s code for fire). Evacuate
the building.
4.
Fire
Ongoing Compliance
•
Review local fire code regulations for compliance annually.
•
Post fire evacuation routes in all patient areas including exam rooms.
•
Fire drills are conducted annually. The {SAFETY COMMITTEE} evaluates
the fire drill
•
In an emergency:
•
Upon discovery of a fire, rescue any patients in immediate danger.
•
Page {FIRE ALERT} (use facility’s code for fire) and the location of the
fire.
•
{DESIGNATED EMPLOYEE/POSITION} calls 911.
•
Confine the fire. Do not endanger yourself or others in this process.
5.
Evacuate all persons from the building. The {DESIGNATED EMPLOYEE/POSITION} is
responsible for ensuring that all persons have been evacuated.
6.
Resume usual operations when “All Clear” has been declared.
Disclaimer
10-38
Subject:
Treating Unaccompanied Minors
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
{HEALTH CARE ENTITY} has a mechanism in place to treat unaccompanied Minors.
Minors, particularly teens and pre-teens, frequently arrive for appointments without the
accompaniment of a parent or guardian. A signed authorization consent for regular (i.e., noninvasive, non-complex) treatment is preferable to no consent or the minor going without
medical care. The following guidelines apply to such situations unless one of the exceptions
below is present.
Purpose
The purpose is to provide a clear guideline for all staff in the occurrence of an unaccompanied
minor seeking treatment.
Procedure
General Rule
Minor patients (under age 18) lack the legal capacity of consent to medical or dental treatment
and the consent of a parent or legal guardian should be obtained. Step parents (unless legally
adoptive), foster parents, other relatives, etc. have no recognized legal standing to consent on
behalf of a minor. All parents and/or legal guardians should be encouraged to accompany their
minor children to all medical or dental examinations and/or treatment.
Exceptions
Minors have the status of adults with respect to health care decisions if they fit in one of three
categories:
1.
Emancipated minors – living apart from parents and managing own financial affairs (not
necessarily financially independent)
2.
Married minors – minor has been or is married
3.
Minor mother – minor who has borne a child may consent on her own and on her child’s
behalf
10-39
Minors also may consent on their own behalf for diagnosis and treatment involving one of the
following five medical conditions:
1.
Pregnancy and associated conditions (interpreted to include contraception).
Exception: Abortions require notification of both parents.
2.
Venereal disease
3.
Alcohol or drug abuse
4.
Hepatitis B vaccination
5.
Emergency treatment
Finally, exceptions may exist based on the mature minor doctrine, i.e., a minor may legally consent
to treatment if he/she is capable of understanding the nature and consequences, and can weigh
alternatives, of the treatment. However, the legal status of this doctrine is unclear and it should be
used only when absolutely necessary.
Guidelines
1.
When an appointment is scheduled for a minor, the caller should be informed that, as a rule,
minors cannot be evaluated or treated without the consent of a parent or legal guardian. The
caller should be encouraged to have a parent or guardian accompany the patient to the
appointment unless one of the exceptions mentioned above is applicable. The caller may also
be informed of the availability of parental consent forms.
2.
If a minor shows up for an appointment without a parent or guardian, the following factors
should be considered in making a determination whether or not to treat the patient:
a. Nature of visit: i.e., a provider may choose to treat very minor self-limiting conditions or
provide routine follow-up checks.
b. Severity of illness/injury: e.g. emergency treatment may be provided without consent. For a
less life threatening yet significant illness/injury, parental consent should be obtained if at
all possible, or if there is any question that a patient might choose to remain untreated.
c. Invasive procedures, unless in a true emergency, require parental consent.
3.
For routine health maintenance visits, an examination may be conducted, but the parent should
be contacted to consent to routine treatment such as updating immunizations (except Hepatitis
B), etc.
4.
For continuing treatment, where the parent has given consent at the outset of the proposed
treatment/therapy program, treatment may be provided as long as it is within the scope of the
original treatment plan. Any unforeseen complications, which require a change in the treatment
plan, should be discussed with the parent.
5.
With the exception of treatment for pregnancy (including contraception), venereal disease,
alcohol or drug abuse, a provider is encouraged to err on the side of obtaining parental consent
for treatment of a minor. This may be done via phone contact when feasible. In some
circumstances, evaluations or treatment may have to be delayed until consent can be obtained.
Disclaimer
10-40
Attachment A
Authorization to Consent to Treatment of a Minor
To:
Re:
Date of Birth:
Medical Record Number:
, a minor
I hereby authorize _________________________________ (related to the above-named minor
as his/her __________________________________________) to consent to such regular
health care, including immunization procedures and allergy treatments, on the minor’s behalf as
is necessary for the minor’s health and best interests.
I also authorize the above-named person to act on my behalf in case the minor experiences a
reaction to the authorized treatments or is a victim of injury or illness when immediate medical
or surgical care is needed, provided diligent effort is made to notify me of the situation and
obtain my preferences. If such efforts to contact me are unsuccessful, I authorize the abovenamed person to take such action and give such consent on the minor’s behalf as that person’s
reasonable judgement dictates.
I understand that this consent will last for one year unless I change my mind and withdraw by
consent sooner in writing. If I withdraw consent, it will not affect actions already taken by
Date
Signature of person who is granting authority to consent
Relationship to minor
Disclaimer
10-41
Attachment B
Consent to Allergy Treatment for Unaccompanied
Minor
To:
Re:
Date of Birth:
Medical Record Number:
, a minor
I hereby authorize the doctors of ____________________________________ and such
assistants as the doctors may designate to administer allergy treatments to the above-named
minor at such intervals as are necessary for the minor’s health and best interests. The treatments
may be administered whether or not such minor is alone or accompanied by another adult or
me.
In case the minor experiences a reaction to the authorized allergy treatments, I understand that
you will make every effort reasonable under the circumstances to notify me of the situation and
obtain my preferences. If such efforts to contact me are unsuccessful or if the situation requires
action without delay, I authorize the above named _________________________ personnel to
take such action as is medically necessary on the minor’s behalf.
I understand that this consent will last for one year unless I change my mind and withdraw by
consent sooner in writing. If I withdraw consent, it will not affect actions already taken by
Date
Signature of person who is granting authority to consent
Relationship to minor
Disclaimer
10-42
Subject:
Behavioral Health Accessibility
Standards
Effective Date:
Approved By:
Review/Revision
Date
Signature
Policy
[HEALTH CARE ENTITY] will ensure timely access to mental health and chemical
dependency appointments.
[HEALTH CARE ENTITY] will monitor performance and take actions to improve
performance when performance is below its standards.
Purpose
Ensure that the clinical need (emergent, urgent, and routine) of the patient is addressed with the
appropriate level of care when accessing behavioral health care services.
Definitions
Life-threatening emergency
care
A circumstance in which there is imminent risk of danger
to the physical integrity of the individual; the individual
cannot be maintained safely in his or her typical daily
environment.
Standard: 100% of the time seen immediately.
Non-life-threatening
emergency care
A circumstance in which the individual is experiencing a
severe disturbance in mood, behavior, thought, or
judgment. There may be evidence of uncontrolled behavior
and/or deterioration in ability to function independently
that could potentially require intense observation, restraint,
or isolation.
Standard: 100% of the time seen within 6 hours.
10-43
Urgent care
A circumstance in which the individual presents no
emergency or immediate danger to self or others; however,
the individual, clinician, or concerned party believes that
the individual’s level of distress and/or functioning
warrants assessment as soon as possible. An urgent
condition is a situation that has the potential to become an
emergency in the absence of prompt treatment.
Standard: 100% of the time seen within 24 hours.
Routine care
A circumstance in which the individual does not present
either emergent or urgent conditions and requests clinical
services.
Standard: 90% of the time seen within 10 business
days.
Follow-up care
A circumstance in which the individual has undergone an
assessment and commenced treatment for a non-emergent
or non-urgent mental disorder.
Standard: 90% of the time seen within 10 business days
24 hours/7 days
A practice site will provide crisis access to a clinician
twenty-four hours per day, seven days per week.
per week accessibility
Standard: 100% of time practice site accessible 24
hrs/7 days
10-44
Procedure
1.
Intake phase
[HEALTH CARE ENTITY] administrative staff member receives a telephone call from
new/returning patient and documents the following.
Name, date and time of call, person calling and telephone number(s).
Request for service type and reason for request.
If the caller does not identify an emergent/urgent clinical need, an appointment will be
scheduled within ten business days of the call.
• If the caller identifies an emergent/urgent service need, the administrative staff person
will transfer the call to a clinician for triage.
2. Triage phase
•
•
•
A clinician will complete a triage assessment for emergent/urgent service requests based
upon clinic protocols and make a recommendation for level of care.
3.
Scheduling phase
If the caller identifies a life-threatening emergency, the caller is advised to seek care at
the Emergency Room of the nearest appropriate hospital. Access to ER care is
facilitated by obtaining the agreement of the caller to seek ER treatment and
ascertaining his/her ability to be safely transported. The clinician will direct the caller to
the identified ER and notify the ER of the recommendation.
• If the caller does not agree to the ER recommendation or is not able to be safely
transported, emergency assistance will be obtained via 911. The clinician may flag
another staff member to call emergency service, while maintaining contact with the
caller until emergency service arrives at the caller’s location.
• For an assessment that results in a non-life-threatening emergent appointment
recommendation, an appointment is scheduled within six hours of the call.
• For an assessment that results in an urgent appointment recommendation, an
appointment is scheduled within 24 hours of the call.
• For an assessment that results in a routine appointment recommendation, an
appointment is made within ten business days of the call.
• The clinician may request the assistance of administrative staff to schedule the
outpatient appointment.
• Appointment date and time are confirmed; practitioner’s name and caller instructions
are given.
• If an appointment is not available within the timeframe standard for non-life-threatening
emergency or urgent need, the clinician/ administrative staff member will locate a
provider that is able to provide an appointment within the standard or actively facilitate
the caller obtaining assistance from the appropriate health plan.
4. Appointment verification
•
The clinical/administrative staff member will confirm life-threatening emergency care at
the identified ER within an hour of the call.
5.
Appointment accessibility monitoring
Activity
Frequency
Process
10-45
Accessibility
Performance Report
Semiannual
Number calls/month
Number/percent of appointment
types met
Disclaimer
10-46

Name of Manual

Transcription

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