Volume 2, March 2024

Welcome to Managed Care Consultants of America’s Home Health newsletter. Below you will find updates and information for your team to utilize as related to managed care.  

Did you know CareCentrix has a home health newsletter?

Connecting the Dots: Q1 2024 - CareCentrix Provider Newsletter (pardot.com)

TriWest recently sent out a reminder to providers contracted under the VACCN network that skilled bundled home health services are reimbursed via the Medicare Patient-Driven Groupings Model (PDGM).

“These types of claims should be billed on a CMS UB-04 claim form using Type of Bill (TOB) 32X. The claim submission must include the VA referral number associated to a skilled bundled home health Standardized Episode of Care (SEOC).

Additionally, skilled unbundled (or non-bundled) services are reimbursed on a fee-for-services basis and can be billed on a CMS-1500 claim form using Place of Service 12, or a CMS UB04 claim form, using TOB 34X. The claim submission must include the VA referral number associated with a skilled unbundled SEOC.

Effective for dates of service Sept. 1, 2023 and after, skilled bundled home health services are rejected if the claim is not submitted with TOB 32X and if it is not submitted with a VA referral associated with a skilled bundled home health SEOC and includes TOB 32X.

Also, effective for dates of service Sept.1, 2023 and after, skilled unbundled home health services are rejected if not submitted with TOB 34X (CMS UB-04) or Place of Service 12 (CMS 1500) and if not submitted with a VA referral associated with a skilled unbundled home health SEOC.”

VACCN provider billing resources can be located at the following links Skilled Home Health Care Reference Guide v6 .pdf (vacommunitycare.com) and ccn-home-health-quick-reference-guide (triwest.com)  

Healthplans are required by CMS to ensure that FDR (First Tier, Downstream or Related Entity) training is completed and attested to by providers for Fraud, Waste, and Abuse and General Compliance training. This is an annual requirement for all CMS tied health plans. One training a year will comply with the requirement, but each plan must capture the attestation that the training has been completed.  Please see the attached document that provides links to the required training and the attestation form from Integrated/ IHCS. If your organization is contracted with IHCS, please return the document to them or Managed Care Consultants of America. 

Remember that once your organization completes the annual requirements, then all that is needed is attesting to the completion for all health plans as requested.

Failure to comply may result in your organization’s contract becoming inactive.

FDR Attestation

Integrated Home Care Services (IHCS) Manual / Claims update

IHCS has made updates to their claims process requirements per their manual for acceptance of claims submitted through Netsmart and IHCS. Please review their entire manual for complete details.

Claims missing required information or containing incorrect required information will be rejected or denied. Paper claims without correct or required information may be returned. The Provider will be informed of the information that is missing or incorrect. The clearinghouse with corresponding reasons for the rejection may reject electronic claims submitted without correct or required information. Incomplete claims must be resubmitted by the Provider to IHCS to ensure a complete (clean) claim is received by IHCS within the original timely filing timeframe as specified below subject to applicable law.

More Information

Excerpt (found in pages 21-22) from the Claims Section of the Provider Manual

Exciting news for ARPNs and PAs!  The Florida House unanimously passed Senate Bill 1798 (2024) - The Florida Senate (flsenate.gov) and has refferred it to the Senate for approval before it will be then sent to Governor DeSantis for final signature. This bill will enable advanced practice registered nurses (ARPNs) and physician assistants (PAs) to write orders for Medicaid home health services and the associated agency to also receive reimbursement. “HB935 grants APRNs and PAs the Authority to order Medicaid Funded home health care services. This enhances the efficiency and accessibility for home health care services for Medicaid recipients needing home health care but also introduces an innovative solution to address the healthcare workforce shortages particularly in underserved areas facing physician shortages which I consider healthcare deserts….The value proposition is rooted in reducing overhead costs, personalized care plans and heightened patient satisfaction….” Per sponsor Representative Gallop Franklin (D-Tallahassee).  

Exclusive Provider Organization Plans (EPO Plans) can be a confusing managed care product. At first glance, you might see PPO but they have no relations to PPOs that offer out of network benefits. So, what is an EPO and how do they impact your admissions or intake of a member? EPO plans have exclusive networks which means that you may be contracted with the managed care organization’s PPO network but NOT necessarily the EPO network EPO networks do not allow for any out of network benefits with out prior arrangements; EPOs operate a very tight network. While individual plan rules may vary, EPOs do not always require authorizations either so your intake team may accept without fully understanding the non-contracted status. This is why the proper validations of benefits for all members is key to financial success. 

The Details!

  • Verify benefits monthly as a best practice
  • New employees, please let our liaisons know so we can setup training
  • Have you registered for our new portal? Register here!

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