GATEWAY HEALTH PLAN^®

HOSPITAL NEWSFLASH

US Steel Tower, Floor 41, 600 Grant Street, Pittsburgh, PA 15219

Inside This Issue

1.             IMPORTANT INFORMATION ABOUT (POA) PRESENT ON ADMISSION

2.             MATERNITY OUTCOME AUTHORIZATION FORM CHANGE

3.             THIRD PARTY LIABILITY REMINDERS

IMPORTANT INFORMATION ABOUT

(POA) Present On Admission Indicator Reporting

Please Read This Information Carefully

The following information was taken from the CMS website:   http://www.cms.hhs.gov/HospitalAcqCond/Downloads/poa_fact_sheet.pdf

Gateway is encouraging all providers to become familiar with these CMS requirements and to notify providers that your encounter data may be denied if the Present on Admission indicators are not completed correctly on your claims.

The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Diagnosis Related Group (DRG) payment for certain hospital-acquired conditions.  CMS has titled the program “Hospital-Acquired Conditions and Present on Admission Indicator Reporting” (HAC & POA).  Inpatient Prospective Payment System (IPPS) hospitals are required by law to submit POA information on diagnoses for inpatient discharges on or after October 1, 2007.

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission.  In the context of the official coding guidelines the term “provider” means a physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.

NOTE:  Providers, their billing offices, third party billing agents, and anyone else involved in the transmission of this data must ensure that any resequencing of diagnosis codes prior to their transmission also includes a resequencing of the POA indicators.

Effective with discharge dates after June 30, 2008 the Department of Public Welfare will require POA indicators for Inpatient and Inpatient Crossover encounters.  Editing will be done to determine if the POA indicator is being submitted for each diagnosis code and that the POA indicator is valid.

CHANGE IN MATERNITY OUTCOME

AUTHORIZATION FORM

Our Utilization Management Department recently updated the Maternity Outcome Authorization Forms.  There is an updated form attached to this Newsflash for each Gateway line of business including: Gateway Health Plan^® (PA Medicaid), Gateway Health Plan PA Medicare Assured^SM , and Gateway Health Plan Ohio Medicare Assured^SM. In the near future, these updated forms will also be available on our Website. 

Reminder

The Maternity Outcome Authorization Form is a notification that a Gateway mom has delivered a newborn.  The form should be faxed to the specific Utilization Management Team.  The completed form helps Gateway ensure payment for the delivery charges. Gateway’s Utilization Management Department responds by faxing the form back to the hospital with an authorization number to cover delivery.  Our Utilization Management Department also notifies enrollment.  Keep in mind that a newborn will not receive a Gateway ID until we receive confirmation from DPW or CMS that the newborn has been enrolled. 

THIRD PARTY LIABILITY

Reminders

• When submitting a claim with an EOB attached, our Claims Office will process the claim based on EOB information.
• If an EVS tape, Navinet print screen or letter with policy holder and eligibility information is attached to the claim, but Gateway is showing TPL exists, the claim will be denied D11 and forwarded to Gateway's TPL Department for additional investigation.
• Please keep in mind that a letter from the provider does NOT initiate a TPL investigation and is NOT accepted as a format for confirming Third Party Liability.  

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