KIDNEY HEALTH CARE PROVIDER MANUAL
Table of Contents
KIDNEY HEALTH CARE PROVIDER MANUAL 1
Table of Contents 2
Introduction 4
Chapter 1: Overview of the Kidney Health Care Program (KHC) 5
History of Kidney Health Care 5
KHC Benefits 5
Client Eligibility Criteria 6
Chapter 2: Provider Enrollment 7
Interim Enrollment and Claims Filing 7
Enrollment of Pharmacies 8
Enrollment of Texas Medicare Prescription Drug Plans 8
Change of Ownership (CHOW) 8
Reasons for Suspension or Termination of Enrollment 8
Chapter 3: Provider Responsibilities 10
Contract Requirements 10
KHC Training Opportunities 12
Chapter 4: Provider Rights 13
Administrative Review and Fair Hearing 13
Administrative Review Process 13
Fair Hearing Process 14
Chapter 5: Submission of Client Applications, Updates and Travel Claims 16
Submission of Client Applications 16
Submission of Client Updates and Travel Claims 17
Travel Claim Filing Deadlines 18
Limitations to KHC Travel Benefits 18
Chapter 6: Premium Payment Assistance 19
Medicare Parts A and B Premium Payment 19
Medicare Part D Premium Payment 19
Low-Income Subsidy (LIS) and How It Affects KHC’s Payments 20
Prescription Drug Plan (PDP) Reference Sheet 20
Chapter 7: Medical Benefits and Claims Filing 21
Medical Services Covered Under the Medical Benefit 21
Dialysis Treatments 21
Payment for dialysis treatments that exceed monthly maximum 21
Rates 22
Access Surgery Services 22
Retroactivity of access surgery benefits 22
Claim Filing and Deadlines 23
Access Surgery 23
Inpatient and Outpatient Dialysis Treatment 23
Resubmitting Claims 23
How to Complete Medical Claim Forms 24
UB-04 CMS-1450 Required Fields 26
Medical Benefit Limitations 31
Medical Benefit Start and End Dates 31
Special Notes About Medicare and Medicaid: 32
Chapter 8: Drug Benefits 33
KHC Drug Benefit Categories 33
KHC Standard Drug Benefit 34
KHC Drug Benefit in Coordination with Medicare Part D 34
KHC Drug Benefit in Coordination with Medicare Parts B and D (for kidney transplant clients only) 35
KHC Drug Benefit Limitations 36
Special Note about Open Enrollment for KHC clients with Medicare Part D 36
The KHC Formulary (also called the Reimbursable Drug List) 36
Pharmacy Information 37
Appendix A: KHC Documents and Forms 38
Table of Figures 39
Introduction
Welcome to Kidney Health Care! This provider manual is designed to answer the questions you may have about what to do as a provider with our program. It is separated into chapters that identify your rights and responsibilities as a provider, the different benefits we offer our clients, and how to file your claims so that we can process them efficiently.
We recognize that there may be times when you cannot find the answer you need, so please feel free to call our help desk at 1-800-222-3986, Monday through Friday from 8 a.m. to 5 p.m. Central Time. We are here to serve you.
Thank you for enrolling in Kidney Health Care and for the care you extend to our clients!
Kidney Health Care
Texas Department of State Health Services
MC-1938
PO Box 149347
Austin, TX 78714-9347
1-800-222-3986 Toll-free
(512) 776-7150 in Austin
(512) 776-7162 FAX
Chapter 1: Overview of the
Kidney Health Care Program (KHC)
The Kidney Health Care program (KHC) of the Texas Department of State Health Services (DSHS) improves access to health care by providing a source of limited benefits for eligible Texas residents with end-stage renal disease (ESRD). This goal aligns with the DSHS mission "to improve health and well-being in Texas," and shares the DSHS vision of "A Healthy Texas."
History of Kidney Health Care
In April of 1973, the Kidney Health Care Act established the Kidney Health Care Program (KHC). In passing the act, the state recognized that patients with chronic kidney disease might die for lack of personal resources required to pay for the expensive equipment and care necessary for their survival, and recognized its responsibility to allow its citizens to remain healthy without being pauperized by that care. Patients who are either uninsured or have not yet qualified for Medicare based on ESRD or other reasons are responsible for the costs for their care. Even those who qualify for Medicare based on their diagnosis of ESRD have to wait for three months before their Medicare benefits begin and will incur the costs of their care during that time. KHC exists to help people in these situations.
KHC operates under the Texas Administrative Code, Title 25, Part 1, Chapter 61, Subchapter A at the Texas Department of State Health Services (formerly the Texas Department of Health). The rights and responsibilities of KHC providers are described in the later chapters of this manual.
KHC Benefits
All KHC benefits are contingent upon funding from the state legislature. They also depend on the type of treatment provided and the client’s eligibility for benefits from private insurance or other programs, including Medicare, at the time of treatment.
There are different types of KHC benefits. KHC clients may get some or all of these benefits.
· Medical
The KHC Medical Benefit helps clients with their medical costs for access surgery and dialysis treatments until their Medicare starts.
· Drugs
The KHC Drug Benefit helps clients with their out-of-pocket costs for ESRD-related drugs, including the immunosuppressive drugs for kidney transplant clients.
· Premium Payment Assistance
KHC can help clients pay their Medicare premiums for Parts A, B and D.
· Travel
The KHC Travel Benefit helps clients pay for the costs associated with travel to and from their dialysis treatments or ESRD-related medical visits. KHC enrolled dialysis providers submit most of the travel claims on behalf of KHC clients.
Client Eligibility Criteria
KHC clients must meet all of the following criteria:
· Have a diagnosis of ESRD certified by a physician.
· Be receiving regular dialysis treatments or have received a kidney transplant.
· Be a Texas resident.
· Have a gross annual income of less than $60,000.
· Must apply for Medicare based on ESRD
KHC clients cannot:
· Have full Medicaid (drugs, transportation, and medical benefits).
· Be a ward of the state or be incarcerated in a city, county, state or federal jail or prison.
Only approved dialysis facilities or hospitals can submit applications for KHC benefits, by using the web-based Automated System for Kidney Information Tracking (ASKITWeb), or by mailing the original paper application to the KHC office in Austin. For a facility to be approved to submit client applications, it must be enrolled as a KHC provider and certified by the Centers for Medicare and Medicaid Services.
Chapter 2: Provider Enrollment
The outpatient dialysis facility is the most common KHC provider, but KHC also enrolls physicians, physician groups, Certified Registered Nurse Anesthetists (CRNAs), hospitals, Ambulatory Surgical Centers (ASCs), pharmacies, and stand-alone Medicare Prescription Drug Plans in Texas.
KHC providers must be located within Texas. However, providers who are within 50 miles of the Texas state border but within the United States are considered to be in-state providers if they are a Texas Medicaid provider. Military hospitals also can enroll as providers with KHC but are not eligible for KHC payments.
To enroll in KHC, a provider must complete the enrollment application and:
· Be in good standing with KHC, the State of Texas, and the Texas Medicaid Program;
· Be a current Texas Medicaid provider;
· Have Medicare approval when required;
Out-of-state outpatient dialysis facilities, hospitals, ASCs, physicians and CRNAs that enroll in KHC must meet the same requirements. However, their licenses or certifications must be from the state in which they are providing services and they must be in good standing in their respective state.
Interim Enrollment and Claims Filing
Providers who want to enroll in KHC have six months to complete their enrollment packet and submit it along with all the supporting documentation. During this interim enrollment period, the provider can:
· submit client applications, travel reports and client updates (hospitals and dialysis facilities only), and
· file medical claims for services rendered to KHC clients. (These claims will be denied but can be resubmitted after the provider’s enrollment is complete. All filing deadlines and client eligibility will be applied. See “Claim Filing” Section for details.)
If the provider receives full approval and becomes enrolled during the interim period, KHC will be able to pay those medical claims that are a benefit of the program if the following two conditions are met:
- the provider submitted the original claim within regular filing deadlines, and
- the provider resubmits those claims after receiving full approval within 60 days from the date on the agreement approval letter, but not later than 180 days from the date of service. (See “Claim Filing” section for deadlines.)
If the provider fails to complete the enrollment process or meet the provider eligibility requirements (e.g. become Medicare certified or enrolled in Medicaid) during that six-month period, any claims filed during that period will no longer be eligible for payment. Additionally, those providers will have to start the entire enrollment process again and commence a new interim enrollment period.
Enrollment of Pharmacies
Pharmacies, including mail order pharmacies, become KHC providers by entering into an agreement to participate in KHC through the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP) or its designated contractor. More information is located on the HHSC website.
Enrollment of Texas Medicare Prescription Drug Plans
KHC enrolls stand-alone Texas Medicare Prescription Drug Plans (PDP) to coordinate premium payment benefits for KHC clients. Texas PDPs that enroll in KHC receive a separate provider manual. Contact KHC at 1-800-222-3986 for more information.
Change of Ownership (CHOW)
Any KHC-enrolled provider that changes ownership must notify KHC immediately and submit a new enrollment packet, including provider agreement, for that new ownership. KHC will also need to know if the new owner will assume liability for outstanding balances in effect or incurred by the previous owner. KHC will assign a new provider number upon completion of enrollment.
Once the Medicare ESRD certification letter for the new dialysis facility or hospital owner is received and the old provider’s account has been cleared, KHC will terminate the old provider account, initiate a new provider account, and transfer clients to the new provider’s account. This will enable the dialysis facility to submit client updates and new client applications as well as submit travel claims on behalf of their KHC clients. Social workers will not have ASKIT Web access until the provider completes the packet and is enrolled.
KHC will notify the old owner by letter if there is a problem with clearing the provider’s account. The old owner’s account must be cleared before the new owner can progress with the enrollment process.
Contact KHC at 1-800-222-3986 or to start or learn more about the process if your organization is planning or has undergone a change of ownership.
Reasons for Suspension or Termination of Enrollment
KHC can terminate or suspend a provider’s enrollment for any of the following reasons:
· loss of approval or exclusion from participation in the Medicare program;
· exclusion from participation in the Medicaid program;
· providing false or misleading information;
· a material breach of any contract or agreement with KHC;
· filing false or fraudulent information or claims;
· failure to submit a payable claim to KHC during a minimum period of 12 consecutive months; or
· failure to maintain participation criteria as outlined in the contract.
A provider may appeal a termination or suspension through the administrative review and fair hearing process described later.
Chapter 3: Provider Responsibilities
KHC providers must follow the KHC Program Rules and the responsibilities detailed in the KHC provider agreement. KHC includes two provider agreements with the enrollment packet it sends to providers. Providers who elect to enroll in KHC must sign and return both copies as part of the enrollment process. Providers will receive one of the agreements back once KHC enrollment is completed. Note: The provider agreement is a binding, legal document.
Contract Requirements
Providers must:
· Be aware that any false claims, statements, documents, or concealment of material fact, may be prosecuted under applicable state laws.
· Be aware that KHC will withhold payment of claims and apply any reimbursed amount to recoup any overpayments to the provider for medical claims.
· Not discriminate against an individual on the basis that the person is a KHC client.
· Identify KHC clients who demonstrate Limited English Proficiency (LEP) to ensure they are provided with the necessary language assistance and have equal access to KHC services.
· Promptly report to KHC temporary closures of their facility.
· Promptly report to KHC changes in any of the following:
· ownership
· name
· address
· acting agents (e.g., social workers)
· status of Medicare, Medicaid, DSHS licensing, or other required license and certifications
· Providers must file all claims within filing deadlines.
· See "Medical Benefits and Claims Filing" chapter for details on filing medical claims.
· See "Submission of Client Applications and Travel Claims" chapter for details on filing travel claims.
Many times, the enrolled dialysis and hospital providers use social workers to act as agents on its behalf in complying with their KHC responsibilities and in conducting some of the business with KHC clients. Those providers must inform and ensure that these agents understand and follow KHC rules and the terms of the KHC Provider Agreement. The list that follows includes some of the more common roles that social workers fill.
· Screen patients for KHC eligibility and submit completed KHC application forms for client benefits through the mail or ASKITWeb, if approved for use.
· Provide an explanation of KHC benefits and limitations to applicants, using the KHC flier for new applicants: You just applied to KHC! E-KHC-010 in English and ¡Acaba de solicitar KHC! E-KHC-010A in Spanish. The flier can be downloaded using the links or ordered from the DSHS Publication Warehouse online at http://webds.dshs.state.tx.us/mamd/litcat.
· Screen and assist KHC applicants when applying for Medicare, the Low-Income Subsidy through Medicare, Medicaid, or any other funding to help pay for their health care.