Claims Corner — Policy

POLICY

Policies and procedures for the coordinated care of our members

New HIP Outpatient Imaging Self-Referral Payment Policy	1/25/13
Look Back Periods to Reconcile Overpayments	11/22/12
Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans	10/28/10
Coverage Denied for Never Events	8/19/10
Reminder GHI HMO DME Policy
Claims Review Software	4/28/10

New HIP Outpatient Imaging Self-Referral Payment Policy

Effective July 2013, EmblemHealth will implement a new Outpatient Imaging Self-Referral Payment Policy (SRPP) to replace the Radiology and Cardiology Imaging Privileging programs for plans underwritten by HIP. Prior approval rules will continue to apply where applicable.

This policy promotes appropriate use of diagnostic imaging by our network clinicians in an office setting (POS 11). SRPP designates the minimum accreditation and certification requirements for specific imaging procedures performed by designated provider specialties. Only clinicians who meet the requirements may be reimbursed for those services (subject to member benefits).

Accreditation Requirements and Submissions
To determine whether requirements have been met, network practitioners will be reviewed for active accreditation in national databases from the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) for echocardiography services, and the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL) or the American College of Radiology (ACR) for nuclear medicine/nuclear cardiology services.  

Note: As of October 1, 2012, EmblemHealth no longer manages the credentialing process for radiology and cardiology imaging accreditation and privileging. For questions about your current accreditation status for performing radiology procedures in your office or about updates to your accreditation certificate, please contact CareCore National by one of the following methods:

•  e-mail CareCore at: provideraccreditations@carecorenational.com
•  call CareCore at: 1-800-918-8924, ext. 27901
•  fax the Fax Cover Sheet for Accreditation Update - HIP to CareCore at: 1-866-699-8160

To obtain information on accreditation requirements and instructions on how to submit an application for accreditation, please refer to the accrediting organizations below.
 
American Board of Internal Medicine (ABIM)
American Board of Nuclear Medicine (ABNM)
American College of Radiology (ACR)
American Osteopathic Board of Internal Medicine (AOBIM)
Certification Board for Nuclear Cardiology (CBNC)
Intersocietal Accreditation Commission (IAC)
National Board of Echocardiography (NBE)

Claims Inquiries
EmblemHealth now sends provider claims that contain diagnostic imaging codes to CareCore. On receipt of these claims, CareCore applies our current privileging rules as published in the EmblemHealth Provider Manual. If you have any questions about claims for dates of service on or after October 1, 2012, please contact CareCore at 1-800-918-8924.

SRPP Exclusions
This policy does not apply to HIP members assigned to a Montefiore (CMO) or Health Care Partners (HCP) primary care physician or members assigned to one of our four physician group practices: Queens-Long Island Medical Group, Staten Island Physician Practice, Manhattan’s Physician Group and Preferred Health Partners. These members can be identified by their member ID card or by accessing member eligibility information on our Web site. Requirements for GHI, GHI HMO and Vytra members are not changing at this time.

Look Back Periods to Reconcile Overpayments

(Applies to: All Plans)

To ensure fair and accurate claims payment, EmblemHealth conducts audits of previously adjudicated claims. The time period for these audits is referred to as the “Look Back Period.” Claims may be audited based on the settlement or paid/check date, not the date(s) of service. The date range for each audit is primarily determined by regulatory requirements and varies with the member’s plan type. The Look Back Periods are summarized in the table below (and may be modified as needed to reflect statutory, regulatory changes and exceptions).

Plans	Look Back Period
Commercial Plans	2 years
FEHB Plans and Medicaid Reclamation Claims	3 years
Medicare Advantage Plans	Pre-American Taxpayer Relief Act of 2012 Within one year for any reason and 3 years after the year in which payment was made for good cause (new and material evidence has come to light) Post-American Taxpayer Relief Act of 2012 Within one year for any reason and 5 years after the year in which payment was made for good cause (new and material evidence has come to light)
Medicaid, Child Health Plus, Family Health Plus and Veterans Administration (VA) Facilities’ Claims*	6 years

If an overpayment is identified, notices and requests for repayment will be sent to the provider. The notices will provide a detailed explanation of the erroneous payment, as well as instructions for repayment options and how to dispute the repayment request. The provider may challenge an overpayment recovery by following the Provider Grievance process set out in the applicable Dispute Resolution section of the Provider Manual: Commercial/Child Health Plus, Medicaid/Family Health Plus or Medicare.

If the overpayment is not returned within the requested time frame or the dispute of overpayment is not submitted in a timely manner, EmblemHealth will withhold funds from future payment(s) to the provider up to the amount of the identified overpayment.

Note: These time frame limitations do not apply to:

• Claims that fall under the False Claims Act
• Duplicate claims
• Fraudulent or abusive billing claims
• Claims of self-funded members
• Claims of members enrolled in coverage provided by the state or a municipality to its employees
• Claims subject to specifically negotiated contract terms between an EmblemHealth company and a provider; contractual time frames will apply

Also important to note:

Commercial Plans

• Section 3224-b of the Insurance Law limits recovery of overpayments to 24 months.
• Notice must be sent to provider specifying the patient name, service date, payment amount, proposed adjustment and a reasonably specific explanation of the proposed adjustment.
• The 24-month limitation does not apply to: (i) claims that are fraudulent or abusive billing; (ii) claims of self-funded plan members; (iii) claims of members enrolled in a state or federal government program; or (iv) claims of members enrolled in coverage provided by the state or a municipality to its employees.

FEHB Plans

• 30/60/90-day interval notices must be sent to provider; offset may occur if debt remains unpaid and undisputed for 120 days after first provider notice.
• The 3-year look back limitation does not apply to False Claims Act claims.
• Provider Notice must provide: (a) an explanation of when and how the erroneous payment occurred; (b) the appropriate contractual benefit provision (if applicable); (c) the exact identifying information (i.e., dollar amount paid erroneously, date paid, check number, etc.); (d) a request for payment of the debt in full; (e) an explanation of what may occur should the debt not be paid, including possible offset to future benefits; (f) offer installment options; and (g) provide the provider with an opportunity to dispute the existence and amount of the debt.

Medicaid Reclamation Claims

• NYS has the right to recoup payments from EmblemHealth that Medicaid fee-for-service paid on behalf of a patient who has commercial insurance.

Medicaid, Child Health Plus and Family Health Plus

• Required by Model Contract with SDOH.

Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans

(Applies to CompreHealth, HIP and Vytra benefit plans.)

The In-Office Testing List, as published in the EmblemHealth Provider Manual, has been updated to allow certain in-office tests to be performed by additional types of specialists. It also includes an additional test that all practitioners may perform.

These changes are effective November 1, 2010, and are noted in bold in the list excerpt below:

Excerpt from: In-Office Testing List - CompreHealth/HIP/Vytra Effective November 1, 2010
Code	Description	Specialty*
80100	Drug screen; multiple	Pain Medicine, Addiction Medicine
80101	Drug screen; single	Pain Medicine, Addiction Medicine
86485	Skin test; candida	Infectious Disease, Allergy/Immunology
86702-QW	OraQuick rapid HIV-2 antibody test
86735	Antibody; mumps	Infectious Disease, Allergy/Immunology

*Please note: Most of the codes on the In-Office Testing List may be performed by all practitioners. However, some codes may only be performed by practitioners in the specialty type(s) listed within the “Specialty” column of the table.

Effective November 1, 2010 the following CPT-4 code will be added to the In-Office Testing List and may be performed by all specialty types:

86702-QW: OraQuick rapid HIV-2 Antibody Test

Coverage Denied for Never Events — Updated Information

(Applies to all ASOs, EmblemHealth, GHI and HIP lines of business.)

Since January 1, 2010, EmblemHealth and its companies GHI and HIP has denied all claims submitted for never events. The Centers for Medicare and Medicaid Services (CMS) no longer covers surgical or other invasive procedures for the treatment of medical conditions when such procedures are performed in error by a practitioner or group of practitioners. These errors are known collectively as never events. The CMS ruling became effective on January 15, 2009. As a result of the CMS decision, EmblemHealth has determined that we no longer pay for never events in any line of business as of January 1, 2010.

Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are cut into or an instrument is introduced through a natural body opening. Procedures range from the minimally invasive to major surgeries. This applies to all procedures found in the surgery section of the Current Procedural Terminology (CPT) coding. It does not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.

Never event errors include:

• Performing a different procedure altogether
  A surgical or invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for the patient.
• Performing the correct procedure on the wrong body part
  A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for the patient. This includes surgery on the appropriate body part, but in the wrong place, for example, operating on the left arm versus the right or on the left kidney not the right, or at the wrong level (spine).
• Performing the correct procedure on the wrong patient
  A surgical or other invasive procedure is considered to have been performed on the wrong patient if that procedure is not consistent with the correctly documented informed consent for that patient.

Related Services
All related services provided during the same hospitalization in which the error occurred are not covered for either CMS or EmblemHealth companies. We also do not cover other services related to these noncovered procedures as defined in the Medicare Benefit Policy Manual (BPM):

• All services provided in the operating room when such an error occurs are considered related.
• All providers who could bill individually for their services and who are in the operating room when the error takes place are not eligible for payment.
• Related services do not include performance of the correct procedure after the never event has occurred.

NOTE: Emergent situations that change the plan in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under the CMS ruling. This also includes the discovery of new pathologies near the surgery site, if the risk of a second surgery outweighs the benefit of patient consultation, or the discovery of an unusual physical configuration (e.g., adhesions, extra vertebrae, etc.).

Medicaid and Family Health Plus Never Events
For surgeries performed on patients enrolled in Medicaid or Family Health Plus (FHP), the New York State Department of Health has identified 13 avoidable hospital conditions as non-reimbursable:

1. Surgery performed on the wrong body part
2. Surgery performed on the wrong patient
3. Wrong surgical procedure performed on a patient
4. Patient disability associated with a medication error
5. Patient disability associated with use of contaminated drugs, devices, biologics provided by a health care facility
6. Patient disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
7. Patient disability associated with an electric shock while being cared for in a health care facility
8. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by a toxic substance
9. Patient disability associated with a burn incurred from any source while being cared for in a health care facility
10. Patient disability associated with the use of restraints or bed rails while being cared for in a health care facility
11. Retention of a foreign object in a patient after surgery or other procedure
12. Patient disability associated with a reaction to administration of ABO-incompatible blood or blood products
13. Patient disability associated with intravascular air embolism that occurs while being cared for in a health care facility

The Department of Health will continually review this list of non-reimbursable adverse (never) events. The list will be modified and expanded over time.

Medicaid and FHP Hospital Partial Payment Procedure
For those Medicaid and Family Health Plus cases where a serious never event occurs and the hospital anticipates at least partial payment for the admission, the hospital will follow a two-step process for billing the admission:

1. The hospital will first submit their claim for the entire stay in the usual manner, using the appropriate rate code (i.e., rate code 2946 for DRG claims or the appropriate exempt unit per diem rate code such as 2852 for psychiatric care, etc.). That claim will be processed in the normal manner and the provider will receive full payment for the case.
2. Once remittance for the initial claim is received, it will be necessary for the hospital to then submit an adjustment transaction to the original paid claim using one of the following two new rate codes associated with identification of claims with serious adverse (never) events:

• 2591 (DRG with serious adverse events), or
• 2592 (Per Diem with serious adverse events)

All claims identified as never events will be reviewed on a case by case basis.

A fuller explanation of never events and the new ruling may be found on the CMS Web site. Information about never events may also be found in the EmblemHealth Provider Manual, under Claims. If you have additional questions, you may also e-mail them to mdq&adownstate@emblemhealth.com if you practice in New York City, Long Island or Westchester County. For upstate counties, please send your e-mails to mdq&aupstate@emblemhealth.com.

Reminder GHI HMO DME Policy

As a reminder, we only reimburse vendors of durable medical equipment (DME) that participate in our GHI HMO network. These DME vendors supply products or services previously furnished in an office setting. DME, such as orthotic or prosthetic devices, braces, special shoes, etc., must be ordered from a supplier that is specifically contracted with GHI HMO to provide durable medical equipment. This ensures that the member has the smallest out-of-pocket expense possible.

Procedure for ordering DME
A prescription for the DME may be required. Once your patient has obtained the DME order from one of our network DME vendors, it is the responsibility of the DME vendor to confirm member eligibility and request all necessary prior approvals.

You may direct your office staff and patients to the Find a Doctor provider search feature at emblemhealth.com to locate an appropriate DME provider in your area. (Select “Other Facilities and Services” as “Type of Provider.”)

What about previous claims?
If you have prescribed and furnished DME in your office and have submitted a claim for the product or service, please log on to emblemhealth.com with your GHI user ID and password to confirm the status of the claim(s). We are examining such claims on a case by case basis to determine reimbursement. If you do not have a user ID and password, you may register to obtain them.

If you have any general questions about this or other claims policy, contact us via the Message Center by logging on to emblemhealth.com with your EmblemHealth, GHI or HIP user ID and password. The Message Center is located on the left hand side of the Web page. Follow the prompts to write your message. If you do not have a user ID and password, you may register for EmblemHealth, GHI and HIP.

Claims Review Software

We use multiple types of commercially available claims review software in order to provide the most proper and efficient claims reimbursement for each line of business in our companies. Read the EmblemHealth Provider Manual for more information on individual software packages.