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Summary of ProviderManual Updatesdvha.vermont.gov/vtmedicaid.com/#/home
Summary of UpdatesDetailed Summary of Updates .16Updates for 8/1/2020 .16General Billing and Forms Manual.166.4.7 High Dollar Inpatient Stays .166.4.8 Interim Inpatient Claims .16Updates for 7/1/2020 .17ABA Supplement .172.3Fee-For-Service Requirements – Members who have other insurance .17Durable Medical Equipment (DME) Supplement .173.3 Payment DVHA Primary/Manual Pricing .17General Billing and Forms Manual.183.3.1 Timely Filing Limits .18Updates for 5/1/2020 .18Durable Medical Equipment (DME) Supplement .184.12 Medical Supplies .18Updates for 4/1/2020 .18General Billing and Forms Manual.185.3.52 Telemedicine Services .18Updates for 3/1/2020 .19General Provider Manual .191.2.11 Provider Reconsideration Process .19DME Supplement .193.6.1 Use of a Detailed Standard Written Order (DSWO) for Durable Medical Equipment(DME) and Supplies .194.13 Oxygen .19Updates for 2/1/2020 .20PT/OT/ST Supplement .20Section 2 Re/habilitative Therapy .202.1 Adult Coverage .212.2 Members Under Age 21.21Section 3 Outpatient Therapy Modifiers .224.4 Obtaining SAME DAY coverage .228/3/2020Green Mountain Care - Summary of Provider Manual Updates1
4.5 Prior Authorization .234.5.1 Errors in Documentation .244.5.2 Electronic signatures .245.3 Outpatient Therapy Modifiers.245.3 Revenue and Procedure Codes for Hospitals, Outpatient clinics, and Home HealthAgencies (previously Section 7).245.4 Correct Coding .258.1 Documentation .268.1.1 Errors in Documentation .268.1.2 Electronic signatures .268.1.3 Determining the date of initial therapy for the condition.27DME Supplement .273.6.1 Use of a Detailed Written Order (DWO) for Durable Medical Equipment (DME) andSupplies .27Updates for 1/1/2020 .27Dental Supplement .272.1 Adult Program (AP) .272.19 Member Cost Sharing/Co-Pays .272.19.1 Exceptions to Co-Payments .272.24 Prior Authorization .284.13.3 Other Surgical Procedures/Splints .285.4.1 Space Maintainers .285.4.3 Custom Crowns .285.9.1 Fixed Partial Denture Pontics .285.9.2 Fixed Partial Denture Retainers – Crowns .285.11.5 Other Orthodontic Services .28PT/OT/ST Supplement .292.2 Members Under Age 21.295.7.1 Under 21.29DME Supplement .292.1 Capped Rentals (CR) .293.3 Payment DVHA Primary/Manual Pricing .303.4 Enhanced Pricing Criteria .323.5 Medical Necessity Form .32Update for 12/16/2019 .338/3/2020Green Mountain Care - Summary of Provider Manual Updates2
General Billing and Forms Manual.335.3.9 Children with Special Health Needs Infant Toddler Programs .33Update for 12/11/2019 .33General Billing and Forms Manual.333.3 Timely Filing .333.3.1 Timely Filing Limits .343.3.2 Timely Filing Reconsideration Requests .35Update for 11/25/2019 .37General Billing and Forms Manual.375.2 Non-Reimbursable Services .375.2.1 EPSDT Services for Medicaid Beneficiaries Under Age 21 .37Update for 9/30/2019 .38Dental Supplement .38Section 7 Fee Schedule .38Updates for 9/16/2019 .38General Billing and Forms Manual.381.6 Vermont Medicaid & Medicare Crossover Billing .38Updates for 8/26/2019 .38General Billing and Forms Manual.386.4.4 Inpatient Claims: No Medicare Part A; Has Medicare B Coverage .38General Billing and Forms Manual.386.4.5 Inpatient Claims: Medicare Part A Exhausts or Begins During the Inpatient Stay .38Vermont Medicaid Applied Behavior Analysis and Mental Health Services Supplement .39Section 7 Applied Behavior Analysis Benefit Provider Guidance .39Section 8 Policy References .43Updates for 7/30/2019 .43General Billing and Forms Manual.433.6 Supervised Billing for Behavioral Health Services.43Updates for 5/21/2019 .43General Billing and Forms Manual.433.8.1 Critical care procedure codes that are time-based .43Dental Supplement .445.8.6 Interim Prosthesis .44Updates for 4/5/2019 .44General Billing and Forms Manual.448/3/2020Green Mountain Care - Summary of Provider Manual Updates3
3.6.1.2 Procedures for Billing .44Updates for 2/4/2019 .448.2.1 Timely Filing Reconsideration Requests .44Updates for 2/1/2019 .458.2 Timely Filing .458.2.1 Timely Filing Reconsideration Requests .46Updates for 12/20/2018 .4815.2.10 Choices for Care Short-Term Respite Stays .48Updates for 12/4/2018 .4810.3.54 Telemedicine Services .48Updates for 11/6/2018 .489.8.3 Vermont Medicaid Billing .48Updates for 10/29/2018 .49Section 18 Electronic Health Record Incentive Program .49Section 18 Promoting Interoperability Program (Formerly Electronic Health Record IncentiveProgram) .4918.1 Electronic Health Record Program Reconsideration Process .5018.1 PROMOTING INTEROPERABILITY PROGRAM/ELECTRONIC HEALTH RECORDINCENTIVE PROGRAM RECONSIDERATION PROCESS .5018.2 Appeal of EHR Incentive Program Reconsideration .5118.2 APPEAL OF PROMOTING INTEROPERABILITY PROGRAM/EHR INCENTIVEPROGRAM RECONSIDERATION .51Updates for 10/25/2018 .5210.3.49 Radiology .52Updates for 8/21/2018 .5210.3.54 Telemedicine Services .52Updates for 7/11/2018 .527.3 Determination Time .52Updates for 7/10/2018 .5310.3.24 Scope-of-Service Related Encounter Rate Adjustments.53Updates for 5/30/2018 .5510.3.6 Audiological Services/Hearing Aids .5511.15.3 BICROS/CROS (Contralateral Routing of Sound) .56Updates for 5/23/2018 .5611.3 Rental/loaned .568/3/2020Green Mountain Care - Summary of Provider Manual Updates4
11.1 Rental Reimbursement Policies .5711 Durable Medical Equipment (DME), Prosthetics, Orthotics & Medical Supplies .57Updates for 5/3/2018 .5711.5 PAYMENT DVHA PRIMARY/MANUAL PRICING .5711.9 PROCEDURE CODES & PRICING.58Updates for 4/16/2018 .588.2.1 Timely Filing Reconsideration Requests .588.2.1 Timely Filing Reconsideration Requests .5911.3 Face-to-face Requirements .5913.2 Face-to-face requirements .60UPDATES FOR 3/22/2018 .616.7 INDIVIDUAL CONSIDERATION/MANUAL PRICING.6111.2 PAYMENT DVHA PRIMARY .6111.2 PAYMENT DVHA PRIMARY .62UPDATES FOR 12/29/2017 .631.2.5 Claim Copy Requests .637.7.1 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals .63Updates for 12/08/2017 .648.12 Refunds .6410.3.6 Audiological Services/Hearing Aids .64updates for 11/09/2017.6412.4.11 Subacute Care .64Updates for 10/26/17 .6510.3.53 Telemedicine .65UPDATES FOR 09/28/17 .6510.3.53 Telemedicine Outside a Facility Services .65UPDATES FOR 08/24/17 .6610.1 Payment DVHA Primary .6611.3 Payment Dual Eligible/ Medicare Primary .66Updates for 06/22/2017 .6710.3.3 Anesthesia .67Updates for 06/12/2017 .6810.3.467 Psychiatry/Psychology .6811.11.19 TENS/MNES NMES .7010.3.27 Immunizations .708/3/2020Green Mountain Care - Summary of Provider Manual Updates5
1.2.7 Provider Administrative Review Reconsideration Process.718.2.1 Timely Filing Reconsideration Requests .72Section 7 Prior Authorization of Medical Services .739.7 Health Examination of Defined Subpopulation .933.7 National Correct Coding Initiative (NCCI) Guidelines .9312.4.1 Bilateral Billing Procedures .93Updates for 02/10/2017 .9310.3.52 Telemedicine Outside a Facility .938.4 Supervised Billing .947.8.1 Concurrent Review for Admissions at Vermont and In-Network Border Hospitals .94Updates for 12/23/2016 .9512.1 Reimbursable Services - Home Health Hospice .9513.3 Home Health Agency & Hospice Services Billing Instructions/Field Locators .9612.5.4 Hospital Clinical Laboratory Tests .979.11 Place of Service (POS) Codes .98Updates for 12/01/2016 .9810.3.5 Assistant Surgeon .98Updates for 10/13/2016 .997.8.6 Rehabilitative Therapy .9911.11.22 Wheelchairs & Seating Systems.100Updates for 08/17/2016 .1001.2.3 Claims System & Provider Services .1007.2.3 Prior Authorization Requirements.100Updates For 07/01/2016 .10112.5.7 Provider Based Billing .101Updates for 06/02/2016 .101Section 15 Choices for Care: Enhanced Residential Care (ERC)/Nursing Facilities HomeBased Waiver (HBW), Moderate Needs .10112.5.9 Hospital Outpatient Billing Instructions/Field Locators .102Updates for 04/18/2016 .1029.14 Long Acting Reversible Contraceptives Provided in an Inpatient Hospital Post-PartumSetting .102Updates for 04/01/2016 .1028.4 Supervised Billing for Behavioral Health Services .10210.3.46 Psychiatry/Psychology .1038/3/2020Green Mountain Care - Summary of Provider Manual Updates6
Updates for 03/01/2016 .10412.5.7 Provider Based Billing .1049.11 Place of Service (POS) Codes .1041.2.6 Provider Claim Modification Process .1051.2.7 Provider Administrative Review Process .10511.11.6 Continuous Passive Motion (CPM) Devices .10518.1 Electronic Health Record Program Reconsideration Process .10618.2 Appeal of EHR Incentive Program Reconsideration .106Updates for 02/10/2016 .106Section 9.9 Inpatient Newborn Services.106Section 3.3.1 Correct Coding Practices.106Section 3.3.2 New, Revised and Deleted Codes .107Section 9.6 Fee Schedule .107Updates for 01/19/2016 .107Section 8.4 Supervised Billing for Behavioral Health Services .107Updates for 12/18/2015 .113Section 10.1 .113Section 8.3 Incident to Billing for Licensed Physicians .113Section 8.4 Supervised Billing for Behavioral Health Services .114Updates for 12/01/2015 .117Section 5 Provider Enrollment, Licensing & Certification .117Enrollment Agreement Signatures .118Section 5.1 Enrollment & Certification .1183.7 National Correction Coding Initiative (NCCI) .1203.7 National Correction Coding Initiative NCCI Guidelines .120Updates for 11/01/2015 .121Inpatient Newborn Services (Physician) .1219.3 Organ Transplant .1219.3.1 Organ Transplant Donor Complication .1211.1 Important Telephone Numbers, Addresses and Websites .1217.8.4 In-State & Out of State Psychiatric & Detoxification Inpatient Services.121Updates For 10/15/2015 .12210.3.39 Obstetrical Care New Instructions for OB Code Billing Instructions for ICD-10 .122Updates for 10/01/2015 .1239.1 Abortions.1238/3/2020Green Mountain Care - Summary of Provider Manual Updates7
11.12 CMS 1500 Paper Claim Billing Instructions/Field Locators .123ICD-9 and ICD-10 References Throughout Entire Manual .123Updates for
18.1 promoting interoperability program/electronic health record incentive program reconsideration process .50 18.2 appeal of ehr incentive program reconsideration.51 18.2 appeal of promoting interoperability program/ehr incentive
