GATEWAY HEALTH PLAN®
US Steel Tower, Floor 41, 600 Grant Street, Pittsburgh, PA 15219
HOSPITAL NEWSFLASH
Inside This Issue:
IMPORTANT INFORMATION
Present on Admission Diagnosis and POA Indicators – Correction to Billing Requirements
In MA Bulletin No. 1-07-11(“Preventable Serious Adverse Events”), DPW announced its payment policy for preventable serious events (PSAEs) to acute care general hospitals participating in the MA program. Case identification of PSAEs is undertaken in part through claims reviews; therefore, DPW also announced in the MA Bulletin the requirement for hospitals to include the applicable Present on Admission (POA) indicator for all diagnosis codes on inpatient claims, regardless of the manner in which claims are submitted (i.e., paper or electronic).
DPW has given similar direction to the HealthChoices managed care organizations (MCOs), by mandating that the MCOs include POA indicators on inpatient encounters that the MCOs are required to submit to DPW. DPW is requiring the MCOs to implement the POA requirements according to their specifications. Gateway Health Plan® is therefore implementing the requirements outlined below with respect to POA indicators on inpatient acute care hospital claims. POA indicators for all diagnosis codes must be included on inpatient hospital claims to MCOs. DPW will validate the submission of POA indicators through inpatient managed care encounter submissions, which will then serve as a basis for enforcement by DPW.
Instructions for Reporting Present on Admission (POA) Indicators on UB-04 Claim Form and via Electronic Format
Reporting POA on the UB-04 Claim Form
****CORRECTION****: You are not required to submit a POA for any diagnosis code submitted in field 72 A-C
Field 67 A-Q Valid primary and secondary diagnosis codes (up to 5 digits), are to be placed in the unshaded portion of 67 A-Q followed by the applicable POA indicator (1 character) in the shaded portion of 67 A-Q.
Valid POA Indicators
Reporting POA in Electronic Format
The 837I Institutional Electronic Claims process requires the POA be entered in Loop 2300, segment K3, data element K301. K301 = “POA”, followed by a single POA indicator for the primary and all secondary diagnoses reported in the claim. “POA” must be placed in position 1-3 of the K3 segment and immediately followed by the applicable POA indicators. The POA indicator for the primary diagnosis code would be the first indicator after “POA”, and when applicable, the POA indicators for each secondary diagnosis code would follow. The last (primary/secondary) POA indicator must be followed by the letter “Z” or “X” to indicate the end of the data element.
There must be one POA indicator reported for EACH primary and secondary diagnosis code in the claim. Spaces between the letter “POA” and the POA indicators are not acceptable and will cause your claim to deny.
PROVIDER SERVICES DEPARTMENT – NEW HOURS OF OPERATION
Effective Monday, August 17, 2009 Gateway’s Provider Services phone lines will be closed between 12 pm and 1 pm, Monday through Friday. This change in operations coincides with our least busy time of the day and allows for complete staffing of the phones when you need us the most.
Provider Services is available to answer your claim inquiries, verify eligibility and handle supply requests. Just call 1-800-392-1145 for Gateway Health Plan® Medicaid or 1-800-685-5205 for Gateway Health Plan Medicare Assured®
Gateway offices will be closed to observe the following holidays: New Years Day, Martin Luther King Day, Good Friday, Memorial Day, Independence Day, Labor Day, Thanksgiving (and the day immediately following), Christmas Eve and Christmas. Operations will resume the following business day.
CORRECTED CLAIMS - CANCELLED CLAIMS - OVERPAYMENTS
Gateway Health Plan® has defined processing policies which allow providers to submit requests for corrected claims, cancelled claims, late charges, and refunds on claims which were incorrectly submitted and/or overpaid by the health plan, to be processed in a timely and efficient manner.
Provider Services can not accept verbal requests for any corrected claims or retractions for any overpaid claims.
Corrected Claims - Bill Type 137
Bill Type 137, corrected claims, can be accepted via paper or electronic submission. If submitted on paper it must be stamped “Corrected Claim’. It may also include the original claim document number; however, it is not required.
Claims billed with a 137 bill type should never deny as D25 – Duplicate Claim.
Cancelled Claims - Bill Type 138 and Refunds
Bill Type 138 claims should NOT be submitted to Gateway either via paper or electronic submission. No adjustments, reversals or retractions will be made when this bill type is submitted.
Claims with 138 bill type will always deny with a D25 – Duplicate Claim.
Providers should send a refund request and check directly to the attention of the Finance Department at Gateway Health Plan®
Refund requests can be sent via the Gateway Health Plan® Overpayment/Refund Form (Attached) or a letter stating the reason for the refund. If sending a letter, it must also contain the following information:
Group/Provider Name
Group/Provider ID#
Member Name
Member ID#
Line of Business
Claim #
DOS
Amount of refund
Late Charges – Additional Charges after Submission of Original Claim
If a claim was previously billed to Gateway and then it is determined that additional charges need to be added to the bill, it must be submitted as a “Corrected Bill” (type 137) which includes all of the original charges and all new additional charges.
Late charges should never be billed alone on a separate bill.
CARE TRANSITIONS - Gateway Health Plan Medicare Assured®
Managing Care Transitions
Gateway Health Plan Medicare Assured® is a Medicare Special Needs Plan that insures dual eligible patients with Medicare and Medicaid/Medical Assistance. Since older and/or disabled patients moving between different health care settings are particularly vulnerable to receiving fragmented and unsafe care during poorly coordinated care transitions, the Centers for Medicare and Medicaid Services (CMS) requires special efforts from special needs plans to manage the care transition process. Care transitions occur when patients’ healthcare needs change from one setting to any other setting, such as when a patient is admitted to the hospital, or is discharged from the hospital to a skilled nursing facility or home.
Some of the ways that Medicare Assured® is required to facilitate safe care transitions are: coordinating planned care transitions between settings, identifying unplanned care transitions, establishing a single point of contact internally that is responsible for support throughout the care transition process and increasing communication about the care transition process with the member, member’s responsible party, the providers of care and the patient’s usual practitioner. Medicare Assured® recognizes that in order to be successful in meeting CMS standards for facilitating safe care transitions for members, it must partner with the participating practitioners and providers in the Gateway Health Plan® network who actually deliver this care. You may begin to notice a new communication when care transitions are identified by Medicare Assured® staff via the current prior authorization and discharge planning processes.
For example, when an approved inpatient authorization is given for a Medicare Assured® member at a hospital, skilled nursing facility or rehabilitation hospital beginning in “late August,” the facility will receive a faxed approval notice and brochure on behalf of the patient that will explain about care transitions. The faxed letter and brochure, which is titled, “Planning for Your Discharge: A Checklist for Patients and Caregivers Preparing to Leave a Hospital, Nursing Home or Other Healthcare Setting,” will give the patient contact information and resources if the patient should need help in preparing for future care transitions. Medicare Assured® is asking all of its facilities to deliver these faxes to Medicare Assured® members. The patients’ Primary Care Physicians (PCPs) will also be receiving copies of the inpatient approval letters via US mail.
If a concurrent inpatient authorization is denied because it does not meet Medicare Assured® or Medicare standards, a Notice of Denial of Medical Coverage is mailed to the patient with copies forwarded to the inpatient provider and individual PCP. This process continues to meet CMS standards. However, Medicare Assured® will fax the care transition brochure listed above to the facility on behalf of the patient in order to support the patient through the care transition process. Please note that Medicare Assured® is asking all of its facilities to deliver the care transition faxes to Medicare Assured® members.
Gateway Health Plan Medicare Assured® looks forward to collaborating with its provider network to coordinate safe care transitions for our vulnerable patient population. If you have suggestions for improving the care transition process or questions regarding the processes outlined above, please contact your Gateway Provider Relations Representative or the Gateway Health Plan® Provider Services Department at 1-800-685-5205.