Q & As FQHC Billing Changes

Q & As FQHC Billing Changes

Q & As – FQHC Billing Changes

General

  1. Why did you make this change?

There were several reasons. First, for quality purposes, we wanted to be able to obtain the CPT or HCPC procedure codes to identify the services that are actually provided. Second, we wanted consistency in billing. For example, since FQHCs provide dental services as well as medical, we wanted all providers to claim for dental services ADA claim form, rather than dental to be incorporated into the clinic code using the 1500 claim form. Third we wanted to simplify provider enrollment so that FQHCs will not have to keep track of multiple provider numbers to serve SoonerCare (SC) Choice and SC Traditional members, as you prepare for National Provider Identification (NPI) implementation.

  1. This change will have a significant impact on my cash flow. What can be done so that I can remain viable?

We can make monthly wrap around/Prospective Payment System (PPS) settlements for both SC Choice and SC Traditional (Fee-for Service). We will use the Tax ID# to determine the total payments made and the number of encounters from our system.

  1. Will the Prospective Payment system (PPS) cost settlement be a separate payment than what I receive for the Medicaid wrap around payment? Will the wraparound report be discontinued?

There appears to be some confusion regarding the wrap around payment and the cost settlement. They are both the same thing and can be used interchangeably. Yes, the wraparound “report” you previously submitted will no longer be required in order to receive the quarterly SoonerCare Choice wraparound payments. We will now settle up with you quarterly (or monthly) on both the SoonerCare Traditional and SoonerCare Choice for the difference in the PPS rate and Medicaid payments, but you will no longer be required to file a report. Instead, we will pull the encounter claims from our system to determine the amount of additional payment (if any). The detail used to determine the payment will be provided to you.

  1. Will you ever go back to the previous method of paying the encounter rate for SoonerCare Traditional?

We are reviewing alternative payment methods and/or system changes so that FQHCs will be able to receive more of their PPS rate upfront.

Enrollment

  1. Is it true that we will need to begin using one group ID# to file all Medicaid claims?

Yes. In general beginning 8/1/06, you will need to use one group ID# to file all Medicaid claims for each physical location. If you have a separate number for pharmacy claims, you will continue to use it for pharmacy claims. In most instances the group ID# that you were paid capitation under is the number that will continue to be active.

  1. FQHCs provide “core” services and non-core services, such as inpatient hospital visits. Do I need a separate provider number for covered non-core services?

Prior to this change, you were required to have separate provider numbers to identify “subparts” (to use NPI terminology) of your organization. For example, you were required to have SC group numbers, or individual numbers, and FQHC numbers to bill for SC traditional members. In addition, some services that are considered non-core sore services, (e.g. pharmacy and durable medical equipment) required separate provider numbers if the FQHC offered these services. In setting the PPS rates, Oklahoma chose to do an “all-inclusive” rate for core and other ambulatory services. (see state plan language http://www.cms.hhs.gov/medicaid/stateplans/State_Data/OK/spa/OK01_003.pdf. Currently, the following rules apply:

  1. Services included in PPS rate; use same number per physical location for the following:
  • Core Services
  • Non-Core Services
  • Dental (dental claim form)
  • Lab, and radiology
  • Inpatient Hospital Visits
  1. Non-Core services included in PPS rate; separate provider number required:
  • Pharmacy (pharmacy claim form)
  • Durable Medical Equipment
  1. Non-Core services not included in PPS rate, separate provider number required:
  • Home Health
  • Personal Care
  • Psychosocial Rehabilitation Mental Health Visits
  • Skilled Nursing
  1. If only one number is used, how will SoonerCare Choice members be identified?

SC Choice will no longer have a separate remit. Depending on the services billed, they could be identified on the remit by the way we pay them. Capitated services will continue to zero pay.

Billing

  1. The T1015 procedure code is set to zero pay but the 837 Professional Claim will not accept a zero in the charge field. How do I bill for services?

The OHCA has corrected this problem. You should now be able to file the T1015 with a zero in the charge field. If you continue to have problems with this, it could be a problem with your billing software rather than the OHCA system.

  1. How will SoonerCare members be identified if the T1015 is listed on the claim?

Our system can identify them based on the client ID and will process the claim according to the benefit plan they are enrolled in.

  1. I see a lot of patients that are enrolled with another PCP. Will I need a referral? If so, what is the procedure?

Yes. Please refer to the SoonerCare billing manual.

  1. Do I bill a global for OB services or can I continue to bill one visit at a time?

You will not be able to bill a global for OB services for dates of service on or after August 1st 2006; you will need to bill one visit at a time. This applies to both SoonerCare Traditional and SoonerCare Choice members. If prenatal care began prior to August 1st you will continue to bill as you were until care is completed. We will revise the rules to incorporate this change. You must enter the T1015 on the first line of the claim and one of the following E/M Codes on subsequent lines, along with the appropriate pregnancy diagnosis code on the claim:

99201-99317

99319-99338

99372 or

99381-99440

  1. I am filing 59514 for a “caesarean delivery only” and the postpartum claim is denying. How do I bill for these visits?

For both non-global delivery codes – the 59409 and the 59514 – our system considers the postpartum visit as included in the post-op days and denies the claim. Continue to file the claim (but please just file it once) and we will pick up the denied claim and include it in the monthly wrap around/PPS settlements. A listing of the denied claims included in the settlement will be provided to you.

  1. Why is my claim for a second ultrasound denying?

OHCA policy (317:30-5-22) states: Additional ultrasounds, including detailed ultrasounds and re-evaluations of previously identified or suspected fetal or maternal anomalies, must be performed by an active candidate or Board Certified diplomat in Maternal-Fetal Medicine.

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