Effective July 5, 2012, a Service Authorization will be required for all virtual colonoscopy services (Computed Tomography Colonography) for PrimeWest Health members. PrimeWest Health will be following DHS criteria to determine medical necessity for the following three codes:

• 74261
• 74262
• 74263

The coverage criteria are posted on the DHS website. Service Authorization requests should be faxed to PrimeWest Health’s Utilization Management Department at 1-866-431-0804 (toll free). Questions about Service Authorization requirements should be addressed to the Provider Contact Center at 1-866-431-0802 (toll free).

PW_2012_224

In December 2011, an update was posted regarding legislative changes to reimbursements for Medicare crossover claims on outpatient therapy. PrimeWest Health has received several calls from providers asking for clarification about these changes.

PrimeWest Health will pay the Medicare allowed amount (including contractual adjustments) up to the unit that exceeds the annual therapy cap. If the service meets Medicare criteria, once the therapy cap is reached for a member payment will change to paying the greater of Medicare paid or Medicaid allowed amounts, including any legislative and contractual adjustments.

If the service does not meet criteria for continuing Medicare coverage, covered services will be paid at the Medicaid allowed amount, including any legislative and contractual adjustments.

If you have questions about these changes, please call the Provider Contact Center 1-866-431-0802 (toll free).

PW_2012_215

Effective July 1, 2012, denosumab (Xgeva^®; J0897) will require a Service Authorization prior to initiation of therapy. PrimeWest Health is following Minnesota Department of Human Services (DHS) criteria, which are available on the DHS website.

Members who have been receiving this medication prior to July 1, 2012, will be grandfathered in for continued treatment even if they do not meet the current criteria. For ease of claims payment, an authorization will be required. Please include appropriate information about past and current medication use when requesting the authorization.

Denosumab (Prolia^®; J0897) will also require authorization. Diagnoses that are appropriate for use of Prolia^® are as follows:

• Senile osteoporosis
• Drug-induced osteoporosis
• Prostate cancer
• Breast cancer

Please call the Provider Contact Center at 1-866-431-0802 (toll free) if you have questions about authorization requirements.

PW_2012_219

PrimeWest Health received a notice from the Minnesota Department of Human Services (DHS) regarding May MinnesotaCare enrollment.

After reviewing enrollment numbers for May 2012, DHS managed care staff noticed a decrease in MinnesotaCare enrollment. Payments made online April 30, 2012, were not posted and members’ coverage did not reinstate.

As a result, members received a disenrollment notice and providers accessing the DHS Enrollment Verification System (EVS) see these members listed as having fee-for-service coverage for May. DHS decided to not retroactively enroll affected members back into managed care for May 1, 2012, but to re-enroll these individuals for June 1, 2012.

The DHS recipient help desk and the Ombudsman have been made aware of the issue and will be assisting members with service delivery and coverage issues. 

PW_2012_212

Effective May 1, 2012, Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), hospices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs) were required to start issuing the new combined Notice of Medicare Non-Coverage, CMS Form 10123, to alert members that their Medicare-covered items and/or services are ending. This notice also informs members of their right to Appeal the decision to end Medicare coverage of the service/item and tells them how to file a request for an immediate Appeal to a quality improvement organization (QIO).

You can download the new notices from the Centers for Medicare & Medicaid Services (CMS).

PW_2012_203

In compliance with 5010/837 claims processing standards, effective June 15, 2012, PrimeWest Health will require the rendering, attending, or referring provider’s National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) to be included on claims if such providers are present in the claim transaction at either the Claim Level or Service Line. If this information is not included, the claim will be rejected back to the provider.

PW_2012_191

Hearing aid checks provided by an audiologist or hearing instrument dispenser are limited to four per calendar year. Hearing aid checks provided by an audiologist have previously been subject to this requirement, which is being extended to hearing instrument dispensers effective June 15, 2012. The limits are as follows:

PW_2012_195

Notification forms are now available on the provider portal under Resource Center.

Providers are now able to submit admission notifications, discharge notifications, and Skilled Nursing Facility (SNF) notifications to PrimeWest Health via the provider portal.

To submit a notification:

1. Under the Resource Center menu, select Forms and Notifications
2. Select the form you want to complete
3. Complete the required information and submit the notification to PrimeWest Health

Please note the "Canceled" status on any message indicates the notification has been acknowledged by PrimeWest Health.

Please call the Provider Contact Center at 1-866-431-0802 (toll free) with any questions.

PW_2012_187

Due to new reporting requirements, effective June 1, 2012, PrimeWest Health will require claims to include the reason for unscheduled outpatient visits. Please note the following:

• An unscheduled outpatient visit is defined as type of bill (TOB) 013X or 085X with type of admission 1, 2, or 5 and revenue codes 045X, 0516, 0526, or 0762
• Outpatient claims must include the ICD-9-CM code describing the patient’s stated reason or condition (such as follow-up or pregnancy in labor)
• The reason for visit is not required for all scheduled outpatient encounters. It may be reported for scheduled visits, such as encounters for ancillary tests, when the data provides additional information to support medical necessity. The information may be any documented reason for the service provided, including the patient’s stated reason for seeking care or the reason provided by the provider as part of the order for the service. PrimeWest Health will not reject outpatient claims that contain the patient’s reason for a scheduled outpatient visit if this information is not needed for the adjudication of the claim.

Please call the Provider Contact Center at 1-866-431-0802 (toll free) if you would like additional information.

PW_2012_185

NIIW is an annual observance that highlights the importance and benefits of immunizations and aims to improve the health of children ages two and under.

You can find more information, including parent/provider resources, on the Minnesota Department of Health website. You can also learn more by calling the Minnesota Immunization Program at 1-800-657-3970 (toll free) or the Centers for Disease Control and Prevention (CDC) Immunization Hotline at 1-800-232-4636 (toll free).

PW_2012_183

PrimeWest Health may deny authorizations for short inpatient hospital stays if utilization review (UR) determines the inpatient admission was not medically necessary because the treatment or services rendered during the inpatient stay could have been conducted through observation services (OBS) on an outpatient basis.

The purpose of OBS is to provide services to determine whether the patient should be admitted as an inpatient or released from the hospital. OBS are billed the same as all other outpatient services. The provider responsible for the patient’s care can change a patient’s status from outpatient to inpatient at any time. If the provider admits the patient as inpatient but wishes to change the status to outpatient, the patient must be notified prior to discharge. Condition Code 44, inpatient admission changed to outpatient, should be used in these situations.

The use of Condition Code 44
In some instances, a provider may order a member admitted to an inpatient bed, but upon subsequent review, it is determined that an inpatient level of care does not meet the hospital’s admission criteria. The National Uniform Billing Committee (NUBC) issued Condition Code 44, effective April 1, 2004, to identify cases when this occurs. The definition of Condition Code 44 is as follows:

• Condition Code 44: inpatient admission changed to outpatient
• For use on outpatient claims only, when the provider ordered inpatient services, but upon internal UR performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria

Hospitals should report Condition Code 44 in Form Locator (FL) 24-30 (or its electronic equivalent) on outpatient claims (type of bill 13X, 85X) to signal a change in patient status from inpatient to outpatient.

For more information, please see Medicare Learning Network (MLN) Matters #SE6022.

PW_2012_181

Effective October 1, 2011, Minnesota legislation required PrimeWest Health to pay certain relative caregiver personal care assistant (PCA) services at 80 percent of the non-relative PCA provider rate. On October 26, 2011, the Second Judicial District Court issued a temporary restraining order preventing PrimeWest Health from implementing this legislation. Until ordered to do otherwise, PrimeWest Health continues to pay PCA relative caregiver services at the same rate as the non-relative caregiver rate.

Some PCA agencies have considered or already opened an escrow account for the 20 percent difference between the non-relative caregiver rate (100 percent) and the 2011 legislative-required relative caregiver rate (80 percent).

If the Court upholds the PCA relative rate legislation, PrimeWest Health intends to recover the 20 percent difference between the two rates unless the Court or subsequent legislation prohibits PrimeWest Health from doing so.

If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

PW_2012_177

PrimeWest Health’s Durable Medical Equipment (DME) Lunch & Learn was a great success! If you were unable to attend or would like to review any of the information, we have posted the PowerPoint presentation on our website. If you have any questions, please call our Provider Contact Center at 1-866-431-0802 (toll free).

PW_2012_176

The National Health Service Corps (NHSC) provides loan repayment for primary care providers who have a desire to practice in underserved areas. The NHSC Loan Repayment Program (LRP) offers two levels of funding: in exchange for a two-year full-time service commitment, the LRP will provide up to $60,000 to primary care providers practicing at an NHSC-approved site with a Health Professional Shortage Area (HPSA) score of 14 or above, and up to $40,000 to those practicing at an NHSC-approved site with a HPSA score of 13 and below. All NHSC LRP participants must practice at an NHSC-approved site.

In August 2011, a new pilot program was announced that would allow primary care clinicians in CAHs to qualify for loan repayment for a period of three years with an optional extension if NHSC clinicians are serving in the site after the three-year pilot. The pilot allows CAHs to recruit physicians (MD or DO) specializing in family medicine, obstetrics/gynecology, general internal medicine, geriatrics, general pediatrics, and psychiatry; physician assistants (PAs) or nurse practitioners (NP) specializing in adult medicine, family medicine, pediatrics, psychiatry, mental and behavioral health, geriatrics, and women’s health; and certified nurse-midwives.

Becoming an NHSC-approved site
In order to offer current and prospective providers loan repayment through the NHSC, you must first apply to become an NHSC service site. You can find detailed instructions on how to apply and start the application process on the NHSC website. To qualify, a CAH must be in an HPSA.

In addition to the website, the NHSC Site Reference Guide contains further information on site eligibility requirements.

If you are interested in applying and need additional information, please call the NHSC Customer Care Center at 1-800-221-9393 (toll free).

PW_2012_173

CMS Webinar: Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

The Center for Medicare & Medicaid Services’ (CMS) Medicare-Medicaid Coordination Office and Innovation Center will be holding a webinar on April 3, 2012, to discuss its “Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents.” The webinar will provide an overview of the new initiative and describe the application process for prospective participants. 

Date: Tuesday, April 3, 2012 
Time: 1 – 2 p.m., Central Time
Call-in: 1-800-837-1935 (toll free)
Conference ID: 66913606

To submit questions in advance, please email NFInitiative2012@cms.hhs.gov.

Additional information on this initiative, including the solicitation and how to complete the Notice of Intent to Apply, can be found on the CMS Innovation website. The slides that will be used in the webinar will be posted on this website by April 2, and a recording of the webinar will be made available here as well.

PW_2012_165

For Medicaid-only members, hospitals are required to follow Minnesota Health Care Programs (MHCP) guidelines and submit claims to PrimeWest Health in the same manner they would submit them to the Minnesota Department of Human Services (DHS). For members on a PrimeWest Health Medicare program or members who have Medicare as their primary insurance, claims should be submitted to PrimeWest Health following Centers for Medicare & Medicaid Services (CMS) guidelines and should be billed exactly as they are to Medicare.

The billing requirements outlined below are effective for all inpatient claims submitted on or after August 1, 2010.

Billing for members enrolled in PrimeWest Health Medicare-based programs or members who have Medicare as their primary insurance

• Bill separately (multiple claims) for hospital, specialty unit, and mental health unit.
• Use the hospital NPI for acute hospital claim(s) and the specialty unit NPI or mental health unit NPI for specific unit claim(s). This will ensure the correct Medicare/Online Survey, Certification, and Reporting (OSCAR) number is used.
  

Billing for Medicaid-only PrimeWest Health members

• Bill one claim, regardless if transfers are involved between units (e.g., combine hospital claim[s] and mental health unit claim[s]) or if inpatient stay is within a specialty unit for the entire length of stay.
• Use the mental health NPI only. Do not separate claims out by unit NPI. Do not use any specialty unit NPIs that your facility may have.
  

Please continue to notify PrimeWest Health Utilization Management of all inpatient hospital admissions.

• Phone: 1-866-431-0803 (toll free)
• Fax: 1-866-431-0804 (toll free)

If you have questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

Effective June 1, 2012, PrimeWest Health will follow the Minnesota Department of Human Services (DHS) authorization requirements and quantity limits for continuous oximeters and associated probes, as follows:

• Continuous oximeters (E0455) require authorization after three months of rental
• All purchases of continuous oximeters require authorization
• Disposable oximeter probes (A4606) will be limited to five per month. Authorization is required if more than five disposable probes per month are requested.
• Durable probes are expected to last six months. Authorization is required to exceed this limitation.

PW_2012_157

Effective June 1, 2012, the following Healthcare Common Procedure Coding System (HCPCS) codes will require an authorization if the billed amount exceeds $400:

• E1399 (DME miscellaneous)
• A9999 (supply or accessory, miscellaneous, not otherwise specified)
• A4649 (surgical supply, miscellaneous)

Miscellaneous codes should not be used if there is a more specific code that is appropriate; always use the most specific HCPCS code for the item being dispensed.

The 5010 versions of the institutional and professional claim implementation guides
mandate that when claims use non-specific procedure codes, a corresponding description of the service is required. This means when billing any of these miscellaneous DME codes on a claim, you must include a description of the item.

You can find additional information in Medicare Learning Network (MLN) Matters #SE1138.

PW_2012_155

When used for ophthalmic purposes, Avastin^® (bevacizumab) should be billed as J3590 (unclassified biologics). Code J9035 (injection, bevacizumab, 10 mg) is specific to chemotherapy and should be used for chemotherapy purposes only. If a claim is being billed on a UB04 form for an outpatient hospital setting, use code C9257 (injection, bevacizumab, 0.25mg).

As a reminder, all claims using J3590 must also include the National Drug Code (NDC) of the drug being billed.

PW_2012_151

PrimeWest Health will be hosting a Lunch & Learn for durable medical equipment (DME) providers on Tuesday, April 3, 2012, from 11 a.m. – 1 p.m. Please see our flyer for more information, including discussion topics and how to RSVP.

PW_2012_129

Children’s Therapeutic Service and Supports (CTSS) Children’s Day Treatment Service Code Changes

Effective January 1, 2012, PrimeWest Health follows Minnesota Department of Human Services (DHS) changes to the Children’s Therapeutic Service and Supports (CTSS) children’s day treatment coding. This change is being made to do the following:

• Create consistency between children and adult day treatment coding
• Reduce the number of different service codes being billed as day treatment
• Simplify CTSS day treatment billing

While PrimeWest Health is following DHS on the code changes, a frequency limitation of CTSS children’s day treatment services is not currently in place. Claims are reviewed on a retrospective basis.

Effective for dates of service on and after January 1, 2012, use code H2012 for CTSS children’s day treatment.

• Modifiers UA and HK should be used when billing for children’s day treatment.
• When billing for interactive day treatment, add modifier U6 to the claim in addition to the UA and HK modifiers.

If you have questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

PW_2012_140

The Minnesota Department of Health (MDH) will host a telephone conference call on March 30, 2012, to update providers on the Critical Access Hospital (CAH) surveys conducted by MDH during 2011. The call will also include information on other CAH regulatory guidelines and updates.

All CAH providers are invited to participate at no cost. You may submit questions you would like addressed during the conference call to maria.king@state.mn.us with the subject line "CAH." Please have your CAH regulations available during the call.

Date: Friday, March 30, 2012
Time: 1:30 – 2:30 p.m.
Call-in number: 1-888-742-5095 (toll free)
Conference code number: 1218281770

PW_2012_138

Meningococcal and polio vaccines
Effective January 1, 2012, the meningococcal (CPT 90734) and polio (CPT 90713) vaccines for adults (19 and over) are no longer available through the Minnesota Health Care Programs (MHCP) Adult Program at the Minnesota Department of Health (MDH). Providers will need to purchase doses of the meningococcal and polio vaccines for adults and will need to bill fee-for-service for the vaccine and PrimeWest Health for the vaccine administration.

Meningococcal and polio vaccines administered to children younger than 19 years of age will continue to be provided through the Minnesota Vaccines for Children (MNVFC) Program, and providers should continue to bill PrimeWest Health for the vaccine administration.

Tdap
Effective January 1, 2012, the Adacel^® brand of Tdap (CPT 90715) is no longer available through the MHCP Adult Program through MDF for adults ages 19 and over. However, the Boostrix^® brand of Tdap will continue to be available through the Adult Program. Providers must continue to obtain the Boostrix^® Tdap vaccine through the MHCP Adult Program at MDH and bill PrimeWest Health for the vaccine administration.

Hepatitis A and pneumococcal polysaccharide vaccines
Beginning January 1, 2012, hepatitis A and pneumococcal polysaccharide vaccines are available through the MHCP Adult Program at MDH for members 19 years and over. Providers will need to obtain these vaccines from the MHCP Adult Program at MDH and bill PrimeWest Health for the vaccine administration. There are no changes to the coverage of hepatitis A and pneumococcal polysaccharide vaccines administered to children younger than 19.

Please see DHS Provider Update # PHY-12-01 for additional details on these changes.

PW_2012_132

Clinical Dental Education Innovation Grants are given to support innovative clinical training for dental professionals and programs that increase access to dental care for underserved populations. Applications for these grants are being accepted now through April 23, 2012.

Eligible applicants include sponsoring institutions, training sites, or consortia that provide clinical education to dental professionals: dentists, dental therapists, dental hygienists, and/or dental assistants. Applicants must be affiliated with a training program that is accredited by an organization that meets Medical Education and Research Costs (MERC) accreditation requirements as described in MN Stat. sec. 62J.692.

The Clinical Dental Education Innovations Fund operates on an annual funding cycle, with a Request for Proposal (RFP) posted in late spring and proposals selected roughly two months later. A review committee, consisting of experts on the dental workforce and on broader health policy issues along with representatives of the dental professions, reviews all qualifying proposals and makes recommendations to the Commissioner of Health for grant awards. 

PW_2012_134

When submitting electronic claims to PrimeWest Health for reimbursement, the claim should include only one identifying billing provider number. The number submitted should be either the National Provider Identifier (NPI) or the Unique Minnesota Provider Identifier (UMPI).

According to the Minnesota Administrative Uniformity Committee (AUC) Companion Guides, the NPI of the billing provider should be included in Loop 2010AA. The UMPI should be submitted only if there is not an NPI available for the billing provider.

Effective April 15, 2012, if claims include both an NPI and UMPI in the billing provider section, PrimeWest Health will only validate the NPI. If the NPI is present, PrimeWest Health will not check for an UMPI submission.

If you have questions, please contact the Provider Contact Center at 1-866-431-0802 (toll free).

PW_2012_136

Effective March 1, 2012, PrimeWest Health is revising its requirement for authorization of certain outpatient services.

The following services will no longer require Service Authorization:

• Standard wheelchairs for members age 65 and over (authorization will still be required for all other members)
• Chiropractic manipulation by contracted providers only*
• Eyeglasses for children (up to age 21)
• Cervical and lumbar radiofrequency ablation (thoracic radiofrequency ablation does require authorization)
• Certain specialty services (due to provider network limitations)**:
• Plastic surgery
• Neurosurgery
• Infectious disease
• Rheumatology
• Oncology
• Gastroenterology
• Dermatology

*Utilization will be monitored. Non-contracted chiropractors must have authorization for all services provided to PrimeWest Health members.

**Any procedure that requires authorization will still require separate authorization. For example, a visit to a non-contracted plastic surgeon would not require authorization, but authorization is required for any plastic surgery procedure that requires authorization, such as panniculectomy or breast reduction. Likewise, an outpatient office visit (OOP) neurosurgeon visit would not require authorization, but spinal fusion would; an OOP gastroenterologist visit would not require authorization, but gastric neurostimulator would require authorization.

Please call the Provider Contact Center at 1-866-431-0802 (toll free) if you have questions about the Service Authorization process and procedures that require authorization.

PW_2012_086