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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|
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:
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)
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.
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.
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
Post-American Taxpayer Relief Act of 2012
|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:
Also important to note:
Medicaid Reclamation Claims
Medicaid, Child Health Plus and Family Health Plus
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|
|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
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:
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):
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:
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:
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 email@example.com if you practice in New York City, Long Island or Westchester County. For upstate counties, please send your e-mails to firstname.lastname@example.org.
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.
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.
|GHI and HIP are EmblemHealth companies. ©2013 EmblemHealth. All Rights Reserved. Last Updated 3-15-2013. Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information.|