Michigan Breast and Cervical Cancer Control Program Billing Manual Fiscal Year 2010 Table of Contents 12/14/2009 Intentionally left blank Table of Contents History and Overview ………………………………………………………………1 Residency Requirement……………………………………………………..1 Age Requirement............................................................................................2 Income Level Requirement………………………………………………….2 Insurance Requirement-uninsured………………………………………..…2 Insurance Requirement-underinsured……………………………………….2 Women enrolled in the following are not eligible for the program…………3 Services available-Screening………………………………………………..3 Services available-Diagnostic……………………………………………….3 Cancer Treatment……………………………………………………………3 Medicaid Eligibility……………………………………………………...….3 Illegal Aliens………………………………………………………………...4 MI BCCCP Goal…………………………………………………………….4 Provider information………………………………………………………………...5 Contracting with Local Coordinating Agency………………………………5 Client Enrollment……………………………………………………………6 Client Services………………………………………………………………7 Claim Submission…………………………………………………………...8 Adjudication Process………………………………………………………..9 Non-reimbursable Procedures………………………………………………10 Providing Screening and/or Diagnostic Services…………………………...10 Billing BCCCP……………………………………………………………...10 Clients with Insurance………………………………………………………11 Clients with No Insurance…………………………………………………..11 Claims will be paid if……………………………………………………….12 Why are claims Pended……………………………………………………..13 Why would my claims be rejected………………………………………….13 Who should I contact if I have a question about my claim…………………13 What information is required to check the status of a claim………………..13 Health Insurance Portability and Accountability Act (HIPAA)…………….14 Electronic Billing (EDI)…………………………………………………….14 BCCCP Web Site…………………………………………………………...17 Billing/Clinical Algorithms…………………………………………………18 Pap Billing Date……………………………………………………………..27 Claim Forms…………………………………………………………………………28 “BCCCP” must be placed on all claim forms……………………………….28 Provider Payment Report……………………………………………………31 Check………………………………………………………………………..32 Billing Information………………………………………………………………….33 Claims will be reject if……………………………………………………...34 Hold codes…………………………………………………………………..35 BCCCP and County Health Plan (CHP)…………………………………….41 Facility Charges and Fees…………………………………………………...41 Common Billing Issues……………………………………………………...41 Claim Return Letters......................................................................................44 Fiscal Year End Information………………………………………………………..51 Frequently Asked Questions………………………………………………………...52 Paper and EDI claim submission Information………………………………52 What is needed for a claim to be PAID……………………………………..52 What happens if a client does not have a SSN……………………………...52 Who can a provider contact regarding CLAIM issues……………………...52 Where can a provider go online for BCCCP information…………………..52 Why do claims pend (for up to 30 days)…………………………………….53 Contact Information…………………………………………………………………54 Figures Figure 1 - MI BCCCP Goal…………………………………………...…….4 Figure 2 - Client Enrollment………………………………………………...6 Figure 3 – Client Services…………………………………………………...7 Figure 4 – Claim Submission………………………………………………..8 Figure 5 – Adjudication Process………………………………………….....9 Figure 6 – Explanation of Benefits Payment Example……………………..11 Figure 7 – Data entry and Billing Authorization of File……………………12 Figure 8 – Data Entry and Billing No Authorization on file………………..13 Figure 9 – UB-04……………………………………………………………29 Figure 10 – HCFA 1500…………………………………………………….30 Figure 11 – Health Advantage Provider Payment Report…………………..31 Figure 12 – BCCCP Check………………………………………………….32 Figure 13 – Example of Unit billing………………………………………...33 Figure 14 – How claims are authorized……………………………………..37 Figure 14 – Example of Unit Billing………………………………………..38 Figure 15 – Provider Payment Report………………………………………40 Figure 16 – BCCCP Logo…………………………………………………...40 Figure 17 – HCFA-1500 example…………………………………………...41 Figure 18 – UB-04 example…………………………………………………42 Figure 19 – Example of a missing ICD-9 code……………………………...43 Figure 20 –Example of a claim being sent to Nationwide…………………..43 Figure 21 –Claim does not indicate number of units………………………..44 Figure 22 – Not billed with “BCCCP” min the correct location…………….45 Figure 23 – Claim not on file………………………………………………...46 Figure 24 – Invalid CPT Code……………………………………………….47 Figure 25 – Claim billed to Nationwide Health plan………………………...48 Figure 26 – Social Security Number does not match member file…………..49 Figure 27 – Invalid Anesthesia CPT code(s) and/or Modifier(s)……………50 Appendixes Appendix A-BCCCP Documents BCCCP Unit Cost Reimbursement Rate Schedule Family Planning Unit Cost Reimbursement Rate Schedule BCCCP Approved ICD-9 Codes BCCCP Approved Revenue Code List BCCCP Approve Place of Service Codes Hold Codes BCCCP Procedure Code Reference Chart Appendix B-WISEWOMAN Documents WISEWOMAN Unit Cost Reimbursement Rate Schedule WISEWOMAN Approved ICD-9 Codes WISEWOMAN Approved Revenue Code List WISEWOMAN Approve Place of Service Codes Hold Codes WISEWOMAN Procedure Code Reference Chart Appendix C-CRC Documents CRC Unit Cost Reimbursement Rate Schedule CRC Approved ICD-9 Codes CRC Approved Revenue Code List CRC Approve Place of Service Codes Hold Codes CRC Procedure Code Reference Chart 2010 Billing Manual History and Overview Congress passed the Breast and Cervical Cancer Mortality Prevention Act in 1990. Centers for Disease Control and Preventation (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides access to breast and cervical cancer screening services to underserved women in all 50 states, the District of Columbia, five U.S. territories, and 12 tribes. Since 1991, the Michigan Department of Community Health (MDCH) has implemented a comprehensive Breast and Cervical Cancer Control Program (BCCCP) through a multi- year grant from the CDC. With these funds, low income women can receive access to life-saving cancer screening services and follow-up care, including cancer treatment if that should be needed. BCCCP services are coordinated through 21 Local Coordinating Agencies (LCA). These agencies partner with physicians, hospitals, and other health care organizations in their communities to provide all necessary follow-up services. LCAs are required to provide or arrange for basic screening services. This includes clinical breast exams (CBE), screening mammograms, pelvic exams, Pap smears, and patient education. To be enrolled in the BCCC Program, women must meet the following criteria: • Residency Requirement • Age Requirement • Income Level Requirement • Insurance Requirement – Uninsured, or – Underinsured Residency Requirement: 1. Michigan resident with a verifiable current address (e.g. driver’s license, voter ID, etc.) 2. EXCEPTIONS: • Migrant workers - is a worker moving from one region of the country to another to find employment. Migrant workers are used extensively for crop harvesting. This requires that they follow the harvest seasons. • Women living near the border of a neighboring state (Indiana, Ohio, and Wisconsin) who plan to receive all screening and diagnostic services in Michigan. 1 2010 Billing Manual Age Requirement: 1. Age 40 – 64 are eligible to receive: • Breast and/or cervical cancer screening, and/or • Diagnostic services; or 2. Age 18-39: • Must be referred to BCCCP from a Family Planning (FP) program provider. • ONLY eligible to receive cervical diagnostic services for follow-up of a cervical abnormality. Income Level Requirement: 1. Determining Income Level: The woman’s income level must be < 250% of the current year’s federal poverty level (FPL). 2. Poverty level is determined based on a woman’s verbal responses to the following two questions. (No written verification or review of tax documents is required.) • What is your yearly household family income? • How many people live in your family? (Family consists of married persons or a single individual with or without dependent children) 3. The following link is to Poverty Guidelines, Research, and Measurement http://aspe.hhs.gov/poverty/. Insurance Requirement - uninsured: At the discretion of the LCA, women with insurance are eligible for the program if: 1. Her insurance plans will not reimburse nurse practitioner services because a physician may not be “on site” when the service(s) were performed, these women are considered “uninsured” and are eligible to enroll in BCCCP. Information regarding non-coverage of nurse practitioner services MUST be documented in the client’s chart. Insurance Requirement – underinsured: 1. BCCCP funds must pay for partial or all of a breast or cervical cancer screening and/or diagnostic service for the woman to meet the eligibility requirements for the program. 2. A large deductible (determine by the LCA) must be paid prior to the woman receiving program covered services. Inability to pay the deductible would be considered a financial hardship for the woman and would prevent her from receiving breast/cervical cancer screening and/or diagnostic services. 3. The woman’s insurance plan does not reimburse OR only partially reimburses for breast and/or cervical cancer screening and/or diagnostic services. 4. Prior authorization to determine eligibility of underinsured women is NOT required by MDCH staff. 5. The woman must be notified at the time of enrollment (informed consent) that IF it is discovered she either has insurance or inaccurately reported her deductible she will be responsible for the costs incurred in providing BCCCP screening and/or diagnostic services.