Transcription
Immunization Billing ProjectFunded by the Centers for Disease Control and Prevention Grant Number 1H23IP000573-01RESOURCE MANUALFor the Public Health Departments of NevadaA Guide to Successful Billing
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AcknowledgementsThe Nevada Public Health Immunization Project would like to thank the following individuals for theirparticipation and assistance:Angela Barosso, Public Health Preparedness Manager, Carson City Health and Human ServicesVeronica Galas, Clinical Services Manager, Carson City and Douglas County Community HealthNicolette Fisher, Carson City Consolidated MunicipalityMarti Cote, RN, Nevada Division of Healthcare Financing and PolicyAmanda Harris, Manager, Nevada WebIZ, Nevada Division of Public and Behavioral Health,(formerly the Nevada State Health Division)Erin Seward, Health Program Manager, Nevada Division of Public and Behavioral HealthHeidi Parker, Executive Director, Immunize NevadaJeff Finch, Regional Manager – Provider Contracting, Anthem Blue Cross Blue ShieldSteve Neufeld, Senior Executive Sales Representative, GlaxoSmithKline (GSK)Andrea Seratte, Executive Vice President, POC Network TechnologiesJennifer Tinney, Program Director, The Arizona Partnership for Immunizations (TAPI)Patricia Iorizzo, UPP TechnologyNar Ramkissoon, UPP TechnologyHeather Press, Billing SpecialistPam Beal, Consultant (formerly Executive Director, Southern Nevada Immunization Coalition)Kathleen Haynie, LPNProject CoordinatorNevada Immunization Billing Project
DisclaimerThis document represents a collective effort to provide a guide on billing healthinsurance for Public Health services. Billing processes and websites change frequently.Information provided in this document was current at the time it was collected.
Table of ContentsSection I. Introduction1.1 Background . 11.2 Grant Overview . 51.3 Snapshot of Nevada . 91.4 Getting Started . 131.4.1 Legal Review . 141.4.2 Stakeholders . 201.4.3 Local Health Departments Analysis . 251.5 Pilot Projects1.5.1 Carson City . 331.5.2 Southern Nevada Health District . 391.5.3 State of Nevada Community Health Nursing Review of Billing Processes. 41Section II. Billing 1012.1 Planning and Preparation/Doing the Homework2.1.1 Cost Analysis . 482.1.2 Fee Schedules . 482.1.3 Practice Management Software/Electronic Medical Records . 492.2 Billing Defined2.2.1 Billing Numerical Identifiers . 512.2.2 Codes. 52A. Taxonomy Codes . 52B. Provider Types . 52C. Place of Service (POS) Codes . 52D. Type of Service (TOS) Codes . 52E. Evaluation and Management (E/M) Codes . 53F. Current Procedural Terminology (CPT) Codes and Billing . 541. Healthcare Common Procedure Coding System (HCPCS) . 542. International Classification of Diseases ICD-9 Codes . 553. International Classification of Diseases ICD-10 Codes. 55G. Modifiers . 56H. Clinical Laboratory Improvement Amendments (CLIA) Numbers . 572.2.3 Claims Submission. 57A. Clearing Houses . 58B. Pros and Cons for Having a Billing Clearing House. 59
2.2.4 Credentialing . 65A. Steps to Credential . 66B. Checklist for Credentialing . 66C. Credentialing Documents . 66D. Shared Experiences . 672.2.5 Contracting. 68A. What Are the Steps Involved?. 68B. State Your Case . 71C. In-Network vs. Out-of-Network Provider . 71D. Looking at the Figures . 72E. Negotiations . 722.2.6 What Happens Now? . 73A. Claims Denials . 73B. Explanation of Benefits and Remittance Advice . 74C. Payments – Receiving and Posting . 762.3 Medicaid2.3.1 Overview . 772.3.2 Medicaid in Nevada . 782.3.3 Becoming a Medicare Provider . 78A. Provider Types. 79B. Taxonomy Codes . 792.3.4 Medicaid Managed Care . 79A. Health Plan of Nevada. 80B. Amerigroup . 802.3.5 Immunizations and Medicaid. 812.3.6 Client Eligibility Verification . 81A. Nevada Medicaid Portal . 81B. Magnetic Card Reader . 822.3.7 Claims And Billing . 82A. Paper Claims . 82B. Direct Data Entry . 82C. Electronic Filing . 82D. Training . 83E. Lessons Learned . 83
2.4 Medicare2.4.1 How to Become a Medicare Provider . 852.4.2 Mandatory Assignment. 862.4.3 Medicare and Vaccines . 87A. Medicare Specific Billing Requirements . 871. G Codes . 872. Q Codes . 87B. Advanced Beneficiary Notice . 88C. Part D Plans . 882.4.4 Billing Method Options . 88A. Roster Billing (Influenza/Pneumococcal Only . 89B. CMS-1500 Instructions . 92C. Electronic Billing . 92D. Electronic Media Claim Submission Alternatives. 931. TransactRX . 932. Paper Claims . 932.4.5 Medicare Advantage Plans . 942.5 Private Health Insurance . 952.5.1 Provider Services Representative . 962.5.2 Becoming an In-Network Provider. 962.5.3 Provider/Clinic Responsibilities . 982.6 Outsourcing vs. Hiring an Internal Biller . 1012.6.1 Outsourcing of Credentialing . 1012.6.2 Outsourcing of Billing . 1022.7 Processes . 1072.7.1 Front Desk Reception . 107A. Front Office Process Detail . 109B. Eligibility Verification. 1092.7.2 Back Office Process . 110A. Back Office Process . 110B. Billing Process Detail . 112C. Claim Denials . 112D. Claim Follow-up . 113E. Reports . 113F. Management and Administration . 114G. Quality Assurance and Improvement . 114
Section III. Appendices3.1 Glossary . 1193.2 Acronyms. 131Forms and Templates4.1 Letter of Intent to Contract Template. 1374.2 Superbill/Encounter Form . 1394.3 CMS-1500 Form . 1414.4 Medicare Roster Bill . 1434.5 Patient Statement . 145Resources5.1 Vaccines CPT and ICD-9 List . 1495.2 ICD-9 Crosswalk to ICD-10 . 1515.3 Contracting Checklist . 1555.4 Credentialing Checklist. 156Policies and Procedures6.1 Front OfficeSliding Fee Assessment . 161Title X Clients and Contributions . 1636.2 Billing DepartmentA. Scrubbing and Sending Claims . 164B. Overpayments and Refunds . 165C. Insufficient Check Funds . 166D. Soft Collection Calls . 167E. Hardship Policy. 169Job Descriptions7.1 Billing Specialist . 1737.1 Receptionist . 175
Page 1Section I. Introduction1.1. BackgroundIn Nevada the program responsible for overseeing all immunization practices is the Nevada StateImmunization Program (NSIP). The NSIP is federally funded by the Centers for Disease Control andPrevention (CDC), and operates under the direction of the Nevada Division of Public and BehavioralHealth (DPBH) within the Department of Health and Human Services.The NSIP oversees all aspects of vaccines in Nevada, including but not limited to: Vaccines for Children (VFC) Program Special Projects Perinatal Hepatitis B Prevention Nevada Web IZ, which is a statewide immunization registryOn December 13, 2011, the NSIP was awarded a grant from the Centers for Disease Control andPrevention to create a strategic plan for billing for immunizations at public health departmentsacross the state. The NSIP contracted Carson City Health and Human Services to execute this grant.The grant was fully funded through grant # IP11-1107PPHF11.In order to understand the significance of this grant to the state of Nevada, a little historicalperspective is necessary. Historically Nevada has had some of the lowest immunization rates in theUnited States. There are many factors contributing to this outcome, including a lack of access tohealthcare providers offering vaccines due to the significant financial burden associated withpurchasing, storing and maintaining vaccines. Public health was not immune to this burden;however, most avoided it by not carrying private vaccine, continuing to depend on state suppliedvaccines through the Vaccines for Children and Section 317 programs.317 ProgramThe 317 program has historically provided funding to support State immunization infrastructure andoperation costs, as well as many of the vaccines provided by public health departments. This fundalso covers individuals that are not eligible for the Vaccines for Children (VFC) Program, and includesindividuals that are uninsured or whose primary insurance doesn’t cover the costs of the vaccine.Due to the decrease in federal funding for 317 vaccines, a statement came out by the CDC advisingparents that as of October 1, 2012, insured children receive their immunizations from their primaryhealthcare provider. If their insurance does not cover immunizations, or their primary care providerdoes not provide vaccines, or the child is VFC-eligible, they can continue to receive their
Page 2immunizations at their local health departments.3 There are additional exceptions where 317vaccines may continue to be used to vaccinate adults and children: Hepatitis B birth dose – vaccine costs can be divided between VFC and 317 fundsPandemic exercises, such as Points of Dispensing (POD) eventsOutbreak situations (regardless of insurance status)Disaster relief effortsPost-exposure prophylaxisThe Nevada State Immunization Program will continue to use section 317 vaccines for: Adult Tdap for cocooning in birthing hospitals and OB/GYN clinicsAdult influenza for cocooning in OB/GYN clinicsTwinrix for high-risk adultsAdult vaccines for uninsured and underinsured adultsVaccines for Children ProgramThe Vaccines for Children (VFC) Program, created in 1994 by the federal government through theOmnibus Budget Reconciliation Act (OBRA), is a federal entitlement program aimed at improvingvaccine availability. The VFC Program provides free vaccination to children whose parents orguardians cannot financially afford to vaccinate their children, and is allocated for children frombirth through 18 years who meet at least one of the following criteria: Currently enrolled in or are eligible for Medicaid Enrolled in Nevada Check Up Program Have no health insurance coverage Are underinsured* Are American Indian, Native American, or Native AlaskanIf a child is eligible for the VFC Program, they are entitled to receive the full immunization seriesrecommended by the CDC’s Advisory Committee on Immunization Practices (ACIP)*Underinsured – the child’s current health insurance doesn’t cover vaccines or doesn’t guaranteecoverage for required vaccines, or covers vaccines but there is a deductible that must be met firstbefore there is coverage for the vaccine. Children that are underinsured will have to go to adeputized provider for any VFC vaccines as of January 1, 2013.
Page 3Parents or guardians can obtain their child’s vaccinations in three primary ways:1. If the child if VFC eligible, they can receive their vaccines from a VFC provider at no charge,but they will be charged for administrative fees**2. Visit a community clinic that offers vaccinations, which may be at a reduced price and alsoadministration fees may be waived or less than those at a Private provider3. Visit a Private provider that offers privately stocked vaccines**In the State of Nevada the administrative fees associated with a VFC vaccine is capped at 22.57per vaccination.With the extent of Federal funding decreases over the past several years, local public health officialsrealized that there was a greater need than ever to adapt to the times and address the need for abilling infrastructure. The goal was to develop a method to bill those with insurance, thus increasingavailability of federally funded vaccines to those with the greatest need.
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Page 51.2 Grant OverviewCarson City Health and Human Services, in collaboration with the State Immunization Program,developed an operational scope of work to fulfill the goals of the grant. The mission of the projectwas to transition to billing insurance as seamlessly as possible while continuing to deliver thehighest level of care to clients.The following is a copy of the scope of work used as a guide to assist with meeting the overarchinggoals of the billing planning grant. It is important to note that it was a guide only and the timelineswere scalable where needed.The following are the objectives set forth in the Scope of Work: Objective 1: By November 2012, collect data on the current status of immunization billing inNevada Objective 2: By October 2012, perform capacity integration and cost analyses of majorsystems for billing third party payers for immunization services Objective 3: By August 2013, determine the best system(s) to bill private and public insurersfor vaccine and the administration fee, as appropriate, and develop an action plan for statehealth division clinics and local health departments to efficiently and cost-effectivelyimplement billing third party payers for immunization services.
Page 6Objective 1) By November 2012, collect data on the current status of immunization billing in NevadaActivitiesOutcomes, Documents,EvaluationTimelineReports1. Conduct a literature search of Nevada A synopsis of the laws andThe information will be evaluatedFebruarylaws and regulations relative toregulations governing thefor its completeness and relevance 2012immunizations and billing processes and insurance industry, theas it is reviewed by NSIP inauthority. Publish a summary of findings. authority for immunizationsestablishing the current landscape.and billing processes.2. Create and administer a survey forA report on patient insuranceThe survey tool will be evaluated to May 2012health department clinics to determinestatus in Nevada, includingensure it will capture the necessarypatient insurance status. The survey willpercentage of patients withinformation; the report will beneed to capture age, zip code, insuranceinsurance, and the breakout of assessed as to its effectivenessstatus and, if privately insured, thethe insurance carriers,when performing the analysis of theinsurance company, group number,including Medicare, Medicaid data and using it to estimate thecontact information, and co-paymentand Nevada Check Up.potential revenue that can beinformation.generated by billing third partypayers that are not currently beingbilled.3. Research the payer policies andA matrix detailing the thirdNSIP management will evaluate the Nov.2012regulations of the third party payersparty payer policies coveringdocument for comprehensiveness ofidentified from the patient insurancebilling practices, software orinformation and the relevance ofstatus survey, including billingelectronic filing processes,data to accomplish a financialcompanies, clearinghouse and/or software credentialing requirements and analysis/comparison of third partythat they work with, credentialingreimbursement rates.payers.requirements and reimbursement rates.Objective 2) By October 2012, perform capacity integration and cost analyses of major system(s) for billing thirdparty payers for immunization services.ActivitiesOutcomes, Documents,EvaluationT TimeReports1. Evaluate the electronic medicalEnvision, the contractor forNSIP and health departmentJuly 2012records systems currently in use forNevada WebIZ, will generate a management will analyze the reportfeasibility of enhancing interoperabilityreport that identifies specificto determine feasibility andwith the state immunization registry,EMRs and their capability offinancial cost for possibleNevada WebIZ, using Health Level 7interfacing with Nevadaintegration of systems with Nevada(HL7) standard messages.WebIZ, including costs forWebIZ.integration.2. Analyze the advantages /There will be at least threeNSIP will incorporate the findings Augustdisadvantages of using roster billing with proposals for the workgroup to from this evaluation into the report 2012the insurance carriers.compare using a standardizedgenerated by proposals from thirdevaluating tool that will beparty billers to providedeveloped under the directionimmunization billing services.of NSIP management.3. Request proposals from third partyThere will be at least threeNSIP will write a reportSeptemberbillers to provide immunization billingproposals for the workgroup to summarizing the results of the2012services.compare using a standardizedevaluation of the proposals andevaluation tool that will bepresent the information to thedeveloped under the directionhealth departments.of NSIP management.4. Provide the community, providers,Ideally, the goal will be to have NSIP management will reviewOctoberhealth department and third party payers’ a face-to-face meetingfeedback obtained from2012and other stakeholders a status reportsupported by videoconference. stakeholders.summarizing the findings resulting fromHowever, if this is not possible,capacity integration and cost analyses ofthe report will be mailed tomajor system(s) for billing third partystakeholderspayers for immunization services.
Page 7Objective 3) By August 2013, determine the best system(s) to bill private and public insurers for vaccine and theadministration fee, as appropriate, and develop an action plan for state health division clinics and local healthdepartments to efficiently and cost-effectively implement billing third party payers for immunization services.ActivitiesOutcomes, Documents, ReportsEvaluationTimeline1. Develop draft strategic plan for billing thirdNSIP will publish the draft strategic NSIP management and Januaryparty payers for immunization services based onbilling plan.leadership from2013results of patient insurance status surveys,Nevada’s healthevaluation of health department billing processesdepartments willand capabilities, review of third party payerreview and providesystem proposals, and analysis of the costinput on the draftedeffectiveness and return on investment of thebilling plan.billing systems under consideration.2. Identify and create pilot group of third partypayers to evaluate strategic billing plan forimmunization services.3. Develop billing policies and proceduresincorporating the health departments’ delivery ofimmunization services practices. Createdocumentation and train appropriate staffregarding the billing processes.There will be a minimum of 5 thirdparty payers identified in the pilotgroup.AppropriateFebruarycredentialing will be 2013completed andcontracts will be inplace to ensure abilityto bill forimmunization servicesprovided by healthdepartment clinics.Billing specialists in the pilot willProject Manager will March 2013have been trained and received forreview training /reference a “cheat sheet” outliningeducation plans tothe process for billing third partyensure alignment withpayers. The pilot group of third party processes developedpayers will each have assigned ain strategic plan andrepresentative as the point person for procedures of thirdthe project who has been briefed and party payers.is an available resource once thepilot begins.4. Begin submitting immunization claims to pilot Successfully receive reimbursementgroup of third party payers to evaluate
Adult Tdap for cocooning in birthing hospitals and OB/GYN clinics Adult influenza for cocooning in OB/GYN clinics Twinrix for high-risk adults Adult vaccines for uninsured and underinsured adults Vaccines for Children Program The Vaccines for Children (VFC) Program, created in 1994 by the federal government through the
