Claims Clues: a publication of the AHCCCS Claims Department

              Claims Clues
$ 3XEOLFDWLRQ RI WKH $+&&&6 &ODLPV 'HSDUWPHQW )HEUXDU\      
Dialysis Claims to Face Medical Review
ee-for-service dialysis
claims submitted to the
AHCCCS Administration
are subject to medical review.
Dialysis facilities are reimbursed
a composite rate, and services
included in the composite rate may
not be billed separately unless they
are provided more frequently than
specified by policy. AHCCCS
follows Medicare requirements for
billing and reimbursement of
dialysis services.
Services that are billed separately
because they were provided more
frequently than specified by policy
must be justified by supporting
documentation. The AHCCCS
Medical Review Unit will review
dialysis claims to determine if
separate charges for services
included in the composite rate are
supported by the documentation.
If no documentation is submitted
with the claim or if the document-ation
does not support the charges,
those charges will be disallowed.
AHCCCS also is reviewing
claims for dialysis services that
have been paid since Aug. 1, 1995.
Providers who billed separately
for services normally included in
the composite rate will receive a
letter requesting documentation to
substantiate the separate billing.
If the documentation is not
received within 30 days or if it does
not support the charges, payment
for those services will be recouped.
Drugs included in the composite
rate and which may not be billed
separately include:
· Heparin and heparin antidotes
· Mannitol
· Glucose
· Antiarrythmics
· Saline
· Antihypertensives
· Protamine
· Pressor drugs
· Antihistamines
· Local anesthetics
· Dextrose
· Antibiotics (if used to treat
peritonitis associated with
peritoneal dialysis)
· Albumin (if used as a volume
expander)
Laboratory services that
areincluded in the composite rate
and which may not be billed
separately include:
· All routine clinical chemistry
tests.
· Hematocrit or hemoglobin and
clotting time tests incident to
dialysis treatments if performed
per treatment or less frequently.
· Prothrombin time for patients on
anticoagulant therapy, Serum
creatinine, and BUN if performed
weekly or less frequently.
The following laboratory services
may not be billed separately if
performed monthly or less
frequently:
· Serum calcium
· Serum chloride
· Total protein
· CBC
· Serum bicarbonate
· Serum phosphorous
· Total potassium
· Serum albumin
· Alkaline phosphates
· SGOT
· LDH
If any of these services are
performed more frequently than
specified, they may be billed
separately. The services may be
covered only if medically justified
by supporting documentation. r
AHCCCS to Require Tax ID on Claim Form
HCCCS has begun to
capture providers’ federal
tax identification numbers,
and providers soon will be required
to enter their tax ID numbers on
claim forms.
AHCCCS began capturing tax IDs
on February 1. Effective May 1, all
claims must include the providers tax
ID number. Claims without a tax ID
will be denied.
On a UB-92 claim form, the
provider’s tax ID is entered in Field 5
near the top of the form.
On the HCFA 1500 claim form, the
tax ID is entered in Field 25 near the
lower left corner.
On the Universal form used for
pharmacy claims, the tax ID should
be entered in the signature box in the
middle of the form. r
F
A
Page 2 Claims Clues February, 1998
Fee-for-Service Not Totally Eliminated by PPC
es, Virginia, there really is
a fee-for-service recipient.
Lots of them, in fact.
The recently implemented prior
period coverage (PPC) extends from
the beginning date of an AHCCCS
recipient’s eligibility to the date prior
to the recipient’s date of enrollment
with a health plan or program
contractor.
Effective October 1, 1997, the
plans and program contractors are
responsible for reimbursing
providers for covered services
rendered during this PPC time frame.
These services formerly were
reimbursed by AHCCCS on a fee-for-
service basis.
However, implementation of PPC
did not eliminate the fee-for-service
population entirely. The fee-for-service
population now essentially
consists of four major groups:
· Recipients in the federal or state
Emergency Services Program
(ESP)
· Recipients enrolled in Indian
Health Services (IHS)
· On-reservation Native Americans
eligible for long term care services
· The prior quarter period for
recipients with prior quarter
eligibility
When verifying eligibility,
providers will be informed of a
recipient’s eligibility and enrollment
status. If a recipient was fee-for-service
on the date(s) of service,
claims for this services must be
submitted to the AHCCCS
Administration.
Implementation of PPC makes
verification of eligibility and
enrollment extremely important, as
plans and program contractors may
establish policy requirements (e.g.,
prior authorization requirements)
which differ from the AHCCCS
Administration’s requirements for
fee-for-service claims.
Providers may use any one of
three verification processes.
The Interactive Voice Response
system (IVR) allows an unlimited
number of verifications by entering
information on a touch-tone
telephone. Call IVR at:
· Phoenix: 417-7200
· All others: 1-800-331-5090
The on-line Eligibility
Verification System (EVS) allows
providers to use a PC or terminal to
access eligibility and enrollment
information. For information on
EVS, contact the Potomac Group:
· 1-800-444-4336
The AHCCCS Verification Unit is
staffed 24 hours a day, 7 days a
week. To contact the AHCCCS
Verification Unit, call:
· Phoenix: 417-7000
· All others: 1-800-962-6690 r
Provider Should Not Return Check to Correct Overpayment
ee-for-service providers who
receive an overpayment from
the AHCCCS Administration
should not return the overpayment to
AHCCCS unless specifically
requested to do so.
Providers should submit either an
adjustment or a void, whichever is
appropriate, of the paid claim.
Documentation substantiating the
overpayment, such as an EOB if the
overpayment from AHCCCS
resulted from payment from another
third party payer, should be attached.
If a provider returns an over-payment,
AHCCCS will proceed
with the adjustment process and
recoup the overpayment. It will then
be necessary to issue a new check to
the provider, resulting in a delay in
the appropriate reimbursement. r
Cover Sheet Needed When Faxing PA Information
roviders who fax
documentation to the
AHCCCS Prior
Authorization Unit should ensure
that a cover sheet accompanies the
documentation.
The cover sheet should list the
provider’s name and AHCCCS
provider ID number, the name of a
contact person, a telephone number
and a fax number.
This will enable an AHCCCS PA
nurse to contact the provider in case
additional information or
clarification is needed before services
can be authorized.
Without such information,
authorization may not be estab-lished,
and claims may be denied.
The PA Unit’s fax number is
256-6591. r
Y
F
P