DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012 Presented by: Debbie Leblanc and Yesenia Osorio

1. DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012 Presented by: Debbie Leblanc and Yesenia Osorio HP Enterprise Services

2. INTRODUCTIONS • HP Enterprise Services • Division of Medical Assistance (DMA)

3. AGENDA • Program Integrity • EPSDT • N. C. Health Choice • Community Care of North Carolina/Carolina Access • Policy Updates • Prior Approval • Billing Tips • Q & A

4. PROGRAM INTEGRITY Dma

5. Federally mandated Prevent, identify, and combat fraud, waste, and abuse within the Medicaid Program Ensure Medicaid recipients receive quality care and do not abuse their benefits Take administrative actions when aberrancies are identified Program (PI) Integrity Unit

6. Program (PI) Integrity Unit It is the mission of Program Integrity to ensure compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupments, and identifying avenues for cost avoidance.

7. Federal Code of Federal Regulations (Title 42 Public Health) Social Security Act Amendments Affordable Care Act State General Statues State Plan State Clinical Policies and Bulletin Articles Program (PI) Integrity Authority

8. Provider Medical Review Home Care Review Section Behavioral Health Review Section Third-Party Recovery Section Special Projects Section Quality Assurance Section Program Integrity Sections

9. IBM Fraud and Abuse Management System (FAMS) • Data mining software using behavior models to detect common fraud and abuse schemes • Models configured to North Carolina Medicaid using input from DMA staff • Algorithms and models used across Healthcare Industry (both public and private payers) as well as cell phone companies, property and casualty insurers, and more

10. DME Model • Model: Measurement of provider behavior • Used to analyze provider as a whole • DMA Program Integrity, DMA Clinical Policy, and IBM worked together to develop criteria • Example: Number of diapers per patient per month • PI Data analytics team performed analysis to identify suspicious behavior for further review

11. Examples of Initial Findings • Billing for up to 480 nutritional kits per patient, per month • Various sizes of diapers for same patient, same date of service • Two year old receiving enough thickener for 2 gallons of fluid per day

12. EPSDT

13. EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) MEDICAID FOR CHILDREN Contacts: Director c/o Assistant Director for Clinical Policy and Programs Division of Medical Assistance 2501 Mail Service Center Raleigh, NC 27699-2501 Fax: 919-715-7659

14. EPSDT Websites • Basic Medicaid & N.C. Health Choice Billing Guide http://www.ncdhhs.gov/dma/basicmed/index.htm • Health Check Billing Guide http://www.ncdhhs.gov/dma/healthcheck/index.htm#guide • EPSDT Provider Page http://www.ncdhhs.gov/dma/provider/epsdthealthcheck.htm

15. N. C. HEALTH CHOICE

16. N. C. Health Choice (NCHC) Claims • Run-out period with BCBSNC was February 29, 2012 for dates of service through September 30, 2011 • Dates of service prior to October 1, 2011 contact DMA Claims Analysis unit at 919-855-4045 Basic Medicaid Billing Guide – Section 3

17. Health Choice Eligibility Criteria • Children ages 6-18 (last day of month they turn 19) • No EPSDT • Does not qualify for Medicaid, Medicare, or other federal government sponsored health insurance • NC resident • Has paid enrollment fee (if applicable) • Within 101% - 200% of the Federal Poverty Level • Co pays do not apply for DME or O&P Basic Medicaid Billing Guide – Section 3

18. Health Choice Identification Card Basic Medicaid Billing Guide – Section 3

19. Health Choice Secondary Insurance Pursuant to N.C. GEN. STAT. §108A – 70.18(8): Health Choice does not allow secondary insurance. It is the recipient’s duty to notify the Department of Social Services (DSS) prior to approval, and/or within 10 days of receipt of the other health insurance. The DSS, upon receipt of notice, shall disenroll the child from the Program. Basic Medicaid Billing Guide – Section 3

20. Health Choice Resources • Clinical Coverage Policies http://www.ncdhhs.gov/dma/hcmp/index.htm • What’s New in DMA http://www.ncdhhs.gov/dma/provider/index.htm • NC Healthy Start Foundation www.NCHealthyStart.org • Fee Schedules http://www.ncdhhs.gov/dma/fee/index.htm • Children with Special Health Care Needs Help Line 1-800-737-3028

21. Medicaid ID Card ISSUE DATE MARCH 1, 2012 DHHS Customer Service Center at 1-800-662-7030.

22. Federal Regulations • Medicaid is the “payer of last resort” • If the Medicaid-allowed amount is more than third-party payment, Medicaid will pay the difference up to the Medicaid-allowed amount • If insurance payment is more than Medicaid-allowed amount Medicaid will not pay any additional amount • Does not apply to NCHC

23. Noncompliance Denials • Medicaid does not pay for services denied by private health plans due to noncompliance with the private health plan’s requirements • Compliance with the plan’s requirements is the responsibility of the provider and the patient • It is the recipient’s responsibility to inform the County DSS of any third-party insurance as well as any changes in insurance coverage.

24. CCNC/CA

25. CCNC Structure • Statewide program of 14 regional networks • Non-profits that operate in partnership with hospitals, health depts., DSS, PCPs and others • Include more than 3000 physicians • Physician led by clinical director http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm Basic Medicaid Billing Guide – Section 6

26. Process for Giving a CCNC/CA Referral • For Carolina ACCESS enrollees, the PCP’s NPI number must be provided to the specialist or other health service provider as the authorization number • Please use the NPI that the PCP reported to DMA for the Medicaid Provider Number (MPN) used to link Carolina ACCESS recipients to their practice Basic Medicaid Billing Guide – Section 6

27. CCNC/CA Override Requests • Only for extenuating circumstances • Only considered within 6 months • Carolina Access Override Request Form http://www.ncdhhs.gov/dma/provider/forms.htm • DME Override Requests are forwarded to DMA for evaluation Basic Medicaid Billing Guide – Section 6

28. POLICY

29. Policy Guidelines • Refer to Clinical Coverage Policy: • 5A, Durable Medical Equipment refer to website http://www.ncdhhs.gov/dma/mp/dmepdf.pdf • 5B, Orthotics and Prosthetics refer to website http://www.ncdhhs.gov/dma/mp/5B.pdf

30. General DME Policy Updates • Changes retroactive to October 1, 2011 • HCPCS Code list, item description and lifetime expectancy or quantity limitations – Attachment A of policy • Effective May 11, 2012, please note the additions to the following sections of the Medical Coverage Policy #5, Durable Medical Equipment have been posted for 15 day public comment; section 5.3.6 Rental Wheelchairs, section 5.6 Delivery of Service and section 7.2 Record Keeping.

31. Roche ACCU-CHEK Diabetic Supplies Under the DME and Pharmacy Programs • Effective November 15, 2011, Roche Diagnostics Corporation Diabetes Care is N.C. Medicaid's designated preferred manufacturer for blood glucose monitors, diabetic test strips, control solutions, lancets, and lancing devices. These products are covered under the Durable Medical Equipment and Outpatient Pharmacy Programs and will be reimbursed under the pharmacy point-of-sale system with a prescription.    • Prior authorization will be allowed for insulin-pump dependent recipients who cannot use Roche products.  Pharmacy and DME providers need to ensure that invoices are easily retrievable in case documentation is needed to support the billing of these products.  This could be requested to support the quantities being invoiced to Roche for the rebates due back to N.C. Medicaid and N.C. Health Choice. • Effective November 15, 2011, there are no designated preferred manufacturers of insulin syringes. • For additional information, providers may call ACCU-CHEK Customer Care, 1-877-906-8969 or DMA Clinical Policies and Programs at 919-855-4310 (DME) or 919-855-4300 (Pharmacy).

32. Diabetic Supplies • Roche ACCU-CHEK Diabetic Supplies Program Extension. • Prodigy diabetic supplies coverage extended until July 31, 2012. • Roche and Prodigy diabetic supplies will be covered until July 31, 2012. • Overrides will not be required. This applies to the durable medical equipment (DME) and pharmacy point-of-sale claims processing systems. • Effective August 1, 2012 only ACCU- CHEK diabetic supplies will be covered.

33. Prior Authorization Instructions for Insulin Pump Users With an effective date based on date of service of January 15, 2012 prior authorization will be required for insulin-pump dependent recipients who cannot use Roche products due to a dedicated glucometer communicating with their insulin pump.  In these instances the provider must be a durable medical equipment (DME) provider or a pharmacy/DME provider.  Claims with a prior authorization on file will need to be submitted with a NU and U9 modifier.  Claims for test strips not supplied by Roche that do not have a Prior authorization on file for A4253 NU, U9 will be denied for lack of authorization.  The U9 modifier will indicate that test strips not supplied by Roche have been authorized for payment.  Prior authorization requests should be submitted to HPES at the following addresses:  N.C. Medicaid P.O. Box 31188  Raleigh, NC 27622 N.C. Health Choice P.O. Box 322490 Raleigh, NC 27622

34. Prior Authorization Instructions for Insulin Pump Users Billing Instructions for Submitting Diabetic Supplies under Pharmacy Point-of-Sale System Claims for diabetic test strips, control solution, lancets and lancing devices submitted at point-of-sale must be billed using the NDC.  Test strips must be billed in multiples of 50 and lancets must be billed in multiples of 100 except for the ACCU-CHEK Compact Test Strips, 51 count package size and the ACCU-CHEK Multiclix Lancets, 102 count package size.  In order to accommodate the unbreakable package sizes under the pharmacy point-of-sale system, the ACCU-CHEK Compact Test Strips (NDC 50924-0988-50) can be billed up to 204 test strips per month for recipients 21 years of age and older and up to 306 test strips per month for recipients under 21 years of age will be allowed.  At this time, test strip quantities over 204 per month must be requested through the DME program; however, point-of-sale system changes are underway to accommodate the higher quantity limits for pediatric recipients.  Additional information will be provided when this system change has been completed.  The same rules apply for the ACCU-CHEK Multiclix Lancets (NDC 50924-0450-01).  For Medicaid billing, 1 lancing device = 1 unit.  Rates apply to these diabetic supplies; therefore, no copayments and no dispensing fees apply.

35. Pediatric Specialty Beds • New addition to hospital beds • Examples are SleepSafe or Pedicraft bed • Special safety features • Designed for children with physical/cognitive disabilities • Prior Approval (PA) required Clinical Coverage Policy 5A - Section 5.3.1

36. Wheelchairs • PA is required for all wheelchairs • Basic criteria must be met • In addition, more justification for other wheelchairs • Standard criteria change • Home evaluation required • Adequate access between rooms • Maneuvering space and services • All Wheelchairs are to be used in the home Clinical Coverage Policy 5A - Section 5.3.6

37. Ultra Light Weight Wheelchair • Recipient in wheelchair minimum of 6 hours • MUST have clinical wheelchair evaluation from a Physical or Occupational Therapist (PT/OT) • Description of recipient’s medical condition, mobility limitations, and other physical /functional limitations • PT/OT shall have no financial relationship with supplier • Manufacturer Suggested Retail Price (MSRP) quote for PA required for wheelchair and accessories Clinical Coverage Policy 5A - Section 5.3.6

38. High-Strength Lightweight Wheelchair • Basic manual wheelchair coverage criteria • Recipient in wheelchair minimum of 6 hours a day Clinical Coverage Policy 5A - Section 5.3.6

39. Adult Manual Wheelchair • Basic Manual Wheelchair coverage criteria • Coverage criteria for tilt in space option • Letter of medical necessity from PT/OT • MSRP quote • Clinical wheelchair evaluation Clinical Coverage Policy 5A - Section 5.3.6

40. Transport Chairs/Rollabout Chairs • Adult/Pediatric covered if recipient needs to be mobilized by caregiver • Covered when medically necessary • PA IS required for transport chairs • PA is NOT required for rollabout chair • For specific codes covered refer to: Attachment A, C: Procedure Code(s) Lifetime Expectancies and Quantity Limitations for DME and Supplies, Transport Chairs Clinical Coverage Policy 5A - Section 5.3.6

41. Power Wheelchairs • Standard power wheelchair criteria plus additional information has to be met • Height, weight, and body measurements must be included in evaluation for Heavy Duty Power chairs • Manufacturer’s specified weight capacity is needed • Power Seat Elevation ONLY covered for 0-20 years of age Clinical Coverage Policy 5A - Section 5.3.6

42. Power Wheelchairs • Face-to-face examination consisting of in-person visit to treating physician required to request chair and comprehensive medical exam • Examination must be documented in detail in physician chart • Must indicate major reason for visit was mobility exam • Must document recipient strength, mobility and functional deficits to support need Clinical Coverage Policy 5A - Section 5.3.6

43. Power Wheelchairs • Face-to-face evaluation prior to physician’s order • Information of condition and progression of disease • Ambulatory status • Medical justification for accessories billed • Additional clinical health care records can be submitted to supplement Clinical Coverage Policy 5A - Section 5.3.6

44. Power Wheelchairs • Onsite written assessment of recipient’s home required • Verifies, documents and supports use • Performed by supplier • Must include measurements of home layout, doorway widths and thresholds and surfaces traveled Clinical Coverage Policy 5A - Section 5.3.6

45. Power Wheelchairs • MSRP quote from the manufacturer required • Wheelchair supplier generated form MUST NOT be used for documentation of physician’s exam • Backup chairs are not covered • Power wheelchair is not medically necessary when condition is reversible and length of need less than 3 months Clinical Coverage Policy 5A - Section 5.3.6

46. Activity/Positioning Chairs • PA required and now reviewed at HPES • Recipients ages 0 - 20 years of age • Physical disabilities and positioning support to sit and perform activities • Meet medically necessary criteria Clinical Coverage Policy 5A - Section 5.3.7

47. Osteogenesis Stimulator • Surgery removed as requirement • Requires 2 sets of radiographs prior to treatment • Radiographs require multiple views of facture site • Written interpretation by MD, PA or NP of no evidence healing Clinical Coverage Policy 5A - Section 5.3.13

48. Continuous Glucose Monitoring System and Supplies • Ages 0 - 20 years • PA required • Medicaid covered criteria: • Insulin-dependent diabetes • Documentation of recurrent severe hypoglycemic episodes or fasting hyperglycemia, nocturnal hypoglycemic episodes, hypoglycemic unawareness • Recipient has external insulin pump which communicates with a CGMS Clinical Coverage Policy 5A - Section 5.3.15

49. High-Frequency Chest WallOscillation Device • Diagnoses added to criteria • Neuromuscular diagnosis • Neuromuscular conditions • High level spinal cord injuries • Covered diagnoses – Attachment A & B in Policy Clinical Coverage Policy 5A - Section 5.3.18

50. Cough-Stimulating Device • Diagnoses added to criteria • Neuromuscular diagnosis • Neuromuscular conditions • High level spinal cord injuries • Covered diagnoses – Attachment A & B in Policy Clinical Coverage Policy 5A - Section 5.3.19