Using the Medicaid Services Manual (MSM) - Nevada Medicaid and ...

Using the Medicaid Services Manual (MSM) Presented by: DHCFP and HPES September 2012 ©2012 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice

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Objective • • • • •

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What is it and whyy it is important p How chapters apply to providers Where to find information Using the search function Learning check

HP Confidential - Using the Medicaid Services Manual

Introduction HHS

CMS

NV HHS

NV DHCFP 3


Disclaimer • Policies are updated on a regular and ongoing basis. To assure you are in compliance with the Division of Health Care Financing and Policy’s Policy s (DHCFP’s) policies, always use current versions of all policies. • The slides in this handout are not designed to replace current policies and may not be used as a policy reference. reference

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Medicaid Manuals

Nevada Medicaid Medicaid Operations Manual

Nevada Check Up Manual REFERENCES

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Nevada Medicaid Medicaid Services Manual

Public Notices

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Agenda example

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Medicaid Manuals

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Requirements Chapter 100 – Medicaid Program Program Overview Program Overview

Chapter 3100 ‐ Hearings Recipient Hearings Recipient Hearings

Provider Hearings Provider Hearings

Chapter 3300 – Program Integrity Fraud and Abuse 9


Improper Payments p p y

Chapter 100 – Program Overview • Eligibility • Provider enrollment • Rules R les and req requirements irements • Billing time frames • Provider P id ttypes

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Section 101a Division of Welfare and Supportive Services (DWSS) 

Accepts applications for Medicaid assistance (not N Nevada d Check Ch k U Up))

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Determines eligibility

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Creates and updates recipient case files

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Division of Health Care Financing and Policy (DHCFP) 

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Establishes policies for administration of the N Nevada d Medicaid M di id programs Determines eligibility for Nevada Check Up and advises recipients in all aspects of Nevada Check Up coverage


HP Enterprise Services (HPES) 

Fiscal agent

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Receive and process provider enrollments and claims

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Customer Service Center

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P id ttraining Provide i i

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Prior authorization (PA)

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Follow policy and guidelines in the MSM

Section 102 Medicaid may reimburse only enrolled providers. The following are conditions of enrollment: • Provides their NPI/API number on the application and requests for payment; • M Meets allll off the h professional f l credentialing d l requirements or other conditions of participation for the provider type; yp ; • Completes the Nevada Medicaid Provider Application and Contract; and • Received notice from Nevada Medicaid that the credentials have been met and the provider agreement h been has b accepted. t d 12 HP Confidential - Using the Medicaid Services Manual

Section 103d Rules and requirements: All M Medicaid di id providers id who h acceptt M Medicaid di id reimbursement for treatment accept responsibility for understanding g and comprehending p g their p provider contract and all chapters of the MSM that pertain to their individual provider type and services they provide. This applies to all institutions and medical groups as well. well

13 HP Confidential - Using the Medicaid Services Manual

Section 105.2b Billing Time Frames (Stale Dates):  180-day deadline (from date of service or date of decision whichever is later) for claims without Third Party Liability (TPL) from in in-state state providers  365-day deadline for claims with TPL and from out-of-state providers from date of service or date of decision,, p whichever is later


Section 110

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Chapter 3100 – Hearings • Recipient fair hearings • Service provider fair hearings • Hearing decision


Section 3103.1 The DHCFP will provide an opportunity for a Fair Hearing to any person whose h claim l i for f assistance it iis d denied, i d reduced, d d suspended, terminated or not acted upon promptly.

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Section 3105.1 A Nevada Medicaid/Nevada Check Up provider may request a Fair Hearing when they disagree with an adverse determination taken against them by the agency, the Quality Improvement Organization (QIO) vendor/fiscal agent or the Health Plan.

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Sections 3104.11 and 3105.9 • The Hearing Officer’s decision must be in writing and comply with M di id/N Medicaid/Nevada d Ch Checkk U Up program policy • At the conclusion of the Fair Hearing, g the Hearings Officer will close the record and render a final decision within 30 days • A copy of the Hearing Officer Officer’ss Decision is provided to both parties • An unfavorable decision may be petitioned f JJudicial for di i l R Review i wb by either ith party t • Reference Nevada Revised Statute (NRS) 422.306 19


Chapter 3300 – Program Integrity • Compliance audits • Surveillance and Utilization Review (SUR) • Abuse and fraud • Improper payment • Civil and Criminal Penalties

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Financial and policy compliance audits • DHCFP will conduct regular financial and policy compliance audits of programs and services provided under the Medicaid and Nevada Check Up programs. • These audits consist of a thorough review of program policy, claims processing and/or medical or service record documentation.


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Surveillance and Utilization Review (SUR) • Statewide program to safeguard against unnecessary or inappropriate use of services • Prevent excess payments in the Nevada Medicaid and Nevada Check Up programs • Develop D l statistical i i l provider id profiles fil • Analyze claims data to identify potential fraud, waste, overutilization and abuse • Collect provider overpayments and refer appropriate cases to the g and Medicaid Fraud Control Unit ((MFCU)) for criminal investigation prosecution • A Fair Hearing process is available to dispute some actions by SUR 22 HP Confidential - Using the Medicaid Services Manual

Section 3302.1 Abuse: Provider practices that are inconsistent with sound fiscal, fiscal business or medical practices, and result in an unnecessary cost to the Medicaid or Nevada Check Up programs. Includes reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care care. It also includes recipient practices that result in unnecessary cost to the Medicaid or Nevada Check Up programs. (42 CFR 455.2)

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Section 3302.3 Fraud: I t ti Intentional l deception d ti or misrepresentation i t ti made d b by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. p It includes any act that constitutes fraud under applicable federal or state law. (42 CFR 455.2)


Section 3302.4 • An improper payment is any payment that is billed to or paid by the DHCFP that is not in accordance with: – The Medicaid or Nevada Check Up policy governing the service provided – Fiscal agent billing manuals – Contractual requirements – Standard record keeping requirements of the provider discipline – Federal law or state statutes • An improper payment can be an overpayment or an underpayment d 25 HP Confidential - Using the Medicaid Services Manual

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Examples of improper payments • Payments for ineligible recipients • Payments y for ineligible, g , non-covered or unauthorized services • Duplicate payments • Payments for services that were not provided or received • Payments for unbundled services when an all-inclusive bundled code should have been billed • Payments not in accordance with applicable pricing or rates • Data entry errors resulting in incorrect payments • Payments where the incorrect procedure code was billed ( (up-coding) d ) 26 HP Confidential - Using the Medicaid Services Manual

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Examples of improper payments, continued • Payments over Medicaid allowable amounts • Payments P t for f non-medically di ll necessary services i • Payments where an incorrect number of units were billed • Submittal b l off claims l ffor unauthorized h d visits • Payments that cannot be substantiated by appropriate or sufficient medical or service record documentation IImproper payments t can also l b be classified l ifi d as ffraud d and/or abuse


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Section 3303.3A Administrative Actions: • Issuance of warning letters • Issuance of recoupment/recovery letters • Recovery of improper payments • Special claims reviews or on-site audits • Suspension and termination of provider status • Civil Monetaryy and Criminal Penalties • Referral to the Medicaid Fraud Control Unit

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Provider specific chapters • Provider standards • References by provider type • Using the search feature

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Provider standards • Provide medically necessary services • Adhere to the regulations prescribed in the chapter and all applicable Division chapters • Provide only those services within the scope of their practice and expertise p with higher g • Ensure care coordination to recipients intensity of needs • Comply with recipient confidentiality laws and Health Insurance Portability and Accountability Act (HIPAA)

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Provider standards, continued • Maintain required records and documentation • Comply C l with ith requests t ffrom th the QIO QIO-like lik vendor d • Ensure client’s rights • Cooperate C with h DHCFP’ DHCFP’s review process

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Reference by Provider Type (PT) PT 14 PT 14

PT 13

Chapter

PT 26

400 PT 63


PT 82

Search-this-page feature To locate a specific term or phrase in the Medicaid Services Manual: 1. Go to: www.dhcfp.nv.gov 2. Open the .pdf of the document in your web browser or select the specific chapter to narrow the search field 3. On your keyboard – press CTRL+F 4 In 4. I the h search h box b type your phrase h

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Search example

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Search example, continued

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Reminders • Required chapters – 100 Program P overview i – 3100 Hearings – 3300 Program integrity • Reference provider specific chapters • Use the search-this-page feature • DHCFP Provider Support – (775) 684-3701 or [email protected]

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Chapters

Provider Types

Medley

Learning Check 37 HP Confidential - Using the Medicaid Services Manual

Improper Payments

Chapters

Provider Types yp

Medley

Improper Payments y

100

100

100

100

200

200

200

200

300

300

300

300

400

400

400

400

500

500

500

500


Chapters

What is the MSM chapter What is the MSM chapter number for Nursing F ili i ? Facilities?

Return to Main Board 39 HP Confidential - Using the Medicaid Services Manual

Answer 39

Chapters

Chapter 500


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Chapters

What is the MSM chapter number for Dental Services? number for Dental Services?


Answer 41

Chapters

Chapter 1000


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Chapters

What is the MSM chapter What is the MSM chapter number for Behavioral H l hS i ? Health Services?


Answer 43

Chapters

Chapter 400


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Chapters

MTL What does this acronym stand for? df ?


Answer 45

Chapters

Manual Transmittal Letter


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Chapters

A _______ is posted on the DHCFP website when changes to the MSM are changes to the MSM are being reviewed. Return to Main Board 47 HP Confidential - Using the Medicaid Services Manual

Answer 47

Chapters

Public Notice


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Provider Types

What is the Provider Type number for Durable Medical Equipment (DME), Equipment (DME), Disposable, Prosthetics? Return to Main Board 49 HP Confidential - Using the Medicaid Services Manual

Answer 49

Provider Types

33


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Provider Types

A Provider Type 22 is a ?


Answer 51

Provider Types

Dentist


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Provider Types

A Provider Type 29 is a Home Health Agency and the relevant MSM chapter the relevant MSM chapter numbers are? Return to Main Board 53 HP Confidential - Using the Medicaid Services Manual

Answer 53

Provider Types

900 and 1400


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Provider Types

Behavioral Health Outpatient is which Provider Type? Provider Type? and B h i lH l h Behavioral Health Rehabilitative is which Provider Type? Return to Main Board 55 HP Confidential - Using the Medicaid Services Manual

Answer 55

Provider Types

14 14 and 82


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Provider Types

All providers should be All providers should be familiar with these three (3) MSM h MSM chapters.


Answer 57

Provider Types

100 3100 3300


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Medley

SUR What does this acronym What does this acronym stand for? Return to Main Board 59 HP Confidential - Using the Medicaid Services Manual

Answer 59

Medley

Surveillance and Utilization Review


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Medley

Use this keyboard feature to search this page search‐this‐page


Answer 61

Medley

CTRL + F


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Medley

www.dhcfp.nv.gov includes a link to the includes a link to the Medicaid Services Manual True or False Return to Main Board 63 HP Confidential - Using the Medicaid Services Manual

Answer 63

Medley

True


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Medley

Public Hearings are held Public Hearings are held and/or teleconferenced in both Las Vegas and Carson City locations. City locations. TTrue or False F l Return to Main Board 65 HP Confidential - Using the Medicaid Services Manual

Answer 65

Medley

True


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Medley

DHCFP will not DHCFP will not provide an provide an opportunity for a fair hearing to a person whose request for assistance is request for assistance is denied. TTrue or False F l Return to Main Board 67 HP Confidential - Using the Medicaid Services Manual

Answer 67

Medley

False


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Improper Payments

A type of improper payment: Payment over Medicaid Payment over Medicaid _______ amounts. Return to Main Board 69 HP Confidential - Using the Medicaid Services Manual

Answer 69

Improper Payments

Allowable


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Improper Payments

A type of improper A type of improper payment: Payments where an y incorrect number of ____ were were billed. billed Return to Main Board 71 HP Confidential - Using the Medicaid Services Manual

Answer 71

Improper Payments

Units


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Improper Payments

A type of improper payment: Data entry errors resulting D t t lti in ____ payments. Return to Main Board 73 HP Confidential - Using the Medicaid Services Manual

Answer 73

Improper Payments

Over


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Improper Payments

A type of improper payment: Payments for non‐covered, P t f d ineligible or __________ services. Return to Main Board 75 HP Confidential - Using the Medicaid Services Manual

Answer 75

Improper Payments

Unauthorized


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Improper Payments

Improper payments can Improper payments can also be classified as _____ and/or _____. d/


Answer

Improper Payments

Fraud and/or Abuse


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Questions?


Contact information Customer Service Center Claim inquiries and general information Phone: ((877)) 638-3472 Automated Response System (ARS) Phone: (800) 942-6511 Requests R t for f P Provider id T Training i i Email: [email protected]

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Thank you for your attention Please complete the course evaluation before leaving class Enjoy the remainder of your day

81 HP Confidential – Using the Medicaid Services Manual