March 2017
Submit Medical Records When Billing For Summer Camp
Non-Government Plans Only
To ensure claims for summer camp services are billed and paid correctly, please submit medical records with the initial claim submission when billing diagnosis code Z02.89 – Encounter for other administrative examinations. Summer camp is the only service under this Z02.89 diagnosis code that is considered for coverage and it is often billed incorrectly.
If you submit a claim submitted under this Z02.89 diagnosis code without supporting medical records, the claim will be automatically denied. You will receive the following message: “Member responsibility PR 96,” indicating that the service was a non-covered charge. If this occurs, please resubmit the claim along with the required medical records.
Please note: This guideline applies to non-government plans only. Government plans allow diagnosis code Z02.89 to be used for billing child and teen checkups.
Billing for Major Depressive Disorder
Among older adulst, 80 percent have at least one chronic health condition and 50 percent have two or more chronic conditions. Depression is more common among people who also have other illnesses, such as heart disease or cancer, or whose function has become limited due to illness.
The Centers for Medicare & Medicaid Services (CMS) recognizes the value of screening and treating depression in older adults, and provides reimbursement for annual depression screenings under HCPCS code G0444.
Billing Tips:
Document major depressive disorder episodes, including: episode (single or recurrent), severity (mild, moderate, severe, with or without psychotic features), and clinical status (in partial or full remission).
If the patient’s depression is stable and the patient does not currently meet “major depressive” criteria, document and code the patient as “in remission.”
- Partial remission is defined as symptoms coming from a previous depressive episode that do not meet the full criteria or with a hiatus of less than two months without significant symptoms.
- Full remission is defined as no significant signs or symptoms of the disorder during the past two months.
Billing Codes:
| F32.0 | Major Depressive disorder, single episode, mild |
| F32.1 | Major Depressive disorder, single episode, moderate |
| F32.2 | Major Depressive disorder, single episode, severe without psychotic features |
| F32.3 | Major Depressive disorder, single episode, severe with psychotic features |
| F32.89 | Other specified depressive episodes |
| F32.9 | Major Depressive disorder, single episode, unspecified |
| F33.0 | Major depressive episode, recurrent, mild |
| F33.1 | Major depressive episode, recurrent, moderate |
| F33.2 | Major depressive episode, recurrent, severe without psychotic features |
| F33.8 | Other recurrent depressive disorders |
| F33.9 | Major depressive disorder, recurrent, unspecified |
| F32.4 | Major Depressive disorder, single episode, in partial remission |
| F32.5 | Major Depressive disorder, single episode, in full remission |
| F33.40 | Major Depressive disorder, recurrent, in remission, unspecified |
| F33.41 | Major Depressive disorder, recurrent, in partial remission |
| F33.42 | Major Depressive disorder, recurrent, in full remission |
Don't Forget to Return Your Provider Validation Form
In the next few days, Mayo Clinic Health Solutions will be sending a Provider Validation form to all contracted providers.
The purpose of this mailing is to ensure all contracted providers have up-do-date information on file with Mayo Clinic Health Solutions, such as tax ID number and facility names. We use this information to populate the provider search tools that members use to find in-network providers which, in turn, drives business to your practice.
Please complete and submit your form as soon as possible. If you have any questions about completing the Provider Validation form, please contact us at RSTHealthSolutionsCredentialing@mayo.edu.
Immunizations for Adults and Children
Health plans administered by Mayo Clinic Health Solutions usually follow the 2017 Advisory Committee on Immunization Practices (ACIP/CDC) Recommended Immunization Schedules for adults (over age 18) and children (birth to age 18).
Some health plans, however, may include some exclusions or deviations from this schedule. These exclusions or deviations are listed in the plan document. Please contact Customer Service at the number shown on the member’s ID card if there are any questions regarding covered immunizations.
UCare News
Read on to learn more about how to avoid claims processign delays, recent changes to the provider appeal process, implementation of Medicare pricing software, and a new provider assurance statement required for telemedicine.
Avoid Claims Processing Delays: Send Provider and Facility Updates to Mayo Clinic Health Solutions
To ensure you have your most current provider and facility information on file, all provider and facility updates should be sent directly to Mayo Clinic Health Solutions, rather than to UCare. This process is outlined in the Mayo Clinic Health Solutions Provider Manual. If you send your updates to UCare, rather than to Mayo Clinic Health Solutions, the information may not be updated in our system which can cause claims processing delays.
New Provider Appeal Process and Form
UCare will implement a new formal provider appeal process effective April 1, 2017. When a provider is requesting an adjustment, recoupment or appeal on a claim, the new Universal Claim Reconsideration Request Form must be thoroughly completed and submitted to UCare along with additional documentation to support the appeal request.
- Providers must begin using the new form for appeals, adjustment and recoupment requests effective April 1, 2017. The previous Adjustment/Recoupment Request Form will no longer be accepted after April 1, 2017.
- If the previous form is submitted to UCare after April 1, 2017, it will be returned immediately to the provider via the method it was received. No action will be taken on the request until the new Claim Reconsideration Request Form is submitted.
UCare will review claim appeal requests upon receipt and a determination will be made within 60 calendar days. After review, providers will receive a written notice of appeal determination. For more detailed information regarding the provider appeal process, please refer to the UCare Provider Manual, Claim Adjustments section, page 10-5.
Notice of UCare Implementation of Medicare Pricing Software
On March 1, 2017, UCare began implementing third-party software to calculate pricing on most Medicare professional services. Through the use of this software, UCare will improve payment accuracy and consistency by aligning more closely with Centers for Medicare & Medicaid Services (CMS) professional reimbursement methodologies.
Implementation schedule:
- UCare for Seniors and EssentiaCare: Claims received by UCare on or after March 1, 2017, with dates of services on or after January 1, 2017.
- Minnesota Senior Health Options (MSHO) and UCare Connect + Medicare: Claims received by UCare on or after April 1, 2017, with dates of services on or after January 1, 2017.
UCare is implementing this pricing software to increase the auto-adjudication rate of claims. In addition, use of this pricing software will improve UCare’s ability to more rapidly align with CMS code and legislative changes to ensure compliance with CMS and UCare payment policies. Upon implementation of this new pricing tool, providers may experience processing or pricing changes on claims submitted for the products indicated above.
The following services may price more closely with Medicare reimbursement methodology than they have in the past:
- Multiple Procedure Payment Reductions (MPPR): UCare will apply MPPR rules for diagnostic imaging, cardiology, ophthalmology, selected therapy services and endoscopies. These reductions apply when more than one of same or similar service is performed by the same provider or more than one provider within the same group practice for the same patient on the same date of service. UCare has not consistently taken these reductions according to Medicare payment methodology, so providers may see a reduction in payment on the services below once the pricing tool is implemented.
- Diagnostic Imaging: MPPR are applied to the professional and technical components of diagnostic imaging services. Effective upon pricing tool implementation, the highest valued service for both professional component and technical component for diagnostic imaging services will be allowed at the full allowed amount on the UCare Medicare fee schedule. The allowed amount for subsequent professional services is reduced by 5 percent, and subsequent technical components are reduced by 50 percent.
Please note: Through December 31, 2016, Medicare applied a 25 percent (vs. 5 percent) reduction to subsequent professional service reduction. UCare’s partial implementation of MPPR for diagnostic imaging will continue until all system enhancements are implemented. At that time, UCare will identify and adjust any claims received between January 1 and February 28, 2017, with dates of service on or after January 1, 2017, where a 25 percent reduction rather than a 5 percent reduction was applied.
Provider Assurance Statement for Telemedicine Required to Deliver Telemedicine Services to Certain UCare Members
UCare providers are required to complete and submit a Provider Assurance Statement for Telemedicine to UCare before supplying telemedicine services to members enrolled in Minnesota Health Care Programs (MHCP) and Commercial products.
To be eligible for reimbursement for telemedicine services provided to MHCP and commercial members, providers must attest that they meet all the requirements outlined in the telemedicine policy in the Claims section of the UCare Provider Manual.
By submitting this Provider Assurance form, providers are indicating assurance for telemedicine services provided to members enrolled in the following UCare products:
- Prepaid Medical Assistance Program (PMAP)
- MinnesotaCare
- Minnesota Senior Health Options (MSHO)
- Minnesota Senior Care Plus, UCare Connect (SNBC)
- UCare Connect + Medicare
- Fairview UCare Choices
- UCare Choices
This Provider Assurance form is not needed for providing telemedicine services to members enrolled in UCare for Seniors or EssentiaCare.
Take Advantage of Tools on the UCare Provider Portal
The UCare Provider Portal is a secure website that allows registered users of UCare’s provider network to access electronic transactions such as:
- View explanation of payments
- Claim status inquiry
- Eligibility inquiry
- Primary Care Clinic enrollment roster
- Authorization status checks
To receive access to the UCare Provider Portal, please contact the UCare Provider Portal administrator at your organization. The administrator has access rights to add, update and remove users within your organization.
If there is no designated administrator account established for your organization, you can register online. Requesters will receive a response within three to five business days. If the request is approved, the administrator must activate the administrator account prior to adding other users within your organization. If the request is denied, UCare's response will explain the reasons.
If you have any questions or need assistance with the UCare Provider Portal, please call the Provider Assistance Center at 612-676-3300 or 1-888-531-1493 toll-free, Monday through Friday, 8 a.m. to 5 p.m., CT.
South Country Health Alliance News
Review the latest updates from South Country Health Alliance (SCHA), including billing rules for dual-eligible beneficiaries, 2017 formulary changes, and information on the mammogram incentive program.
Billing Rules for Dual-Eligible Beneficiaries
“Dual-eligible” is defined as beneficiaries who are eligible for both Medicare and Medicaid. South Country Health Alliance has two dual-eligible programs, SeniorCare Complete (MSHO) and AbilityCare (SNBC).
Federal law prohibits Medicare providers from collecting Medicare Part A and Part B deductibles, coinsurance, or copayments from those enrolled in SeniorCare Complete or AbilityCare, which exempts individuals from Medicare cost-sharing liability. Balance billing prohibitions may also apply to other dual-eligible beneficiaries in Medical Assistance plans if the State Medicaid Program holds these individuals harmless for Part A and Part B cost sharing. Prohibition on collecting Medicare cost-sharing is limited to services covered under Parts A and B. Low Income Subsidy (LIS) copayments still apply for Part D benefits.
For more information, please refer to 42 CFR 422.504 (g)(1)(iii) Contract Provisions, regarding beneficiary financial protections that are part of the contract between MA organizations and CMS.
2017 Formulary Changes
South Country Health Alliance’s Medicare Part D formulary and Medicaid formulary were updated effective January 1, 2017. These changes to the formulary were routine, due to new medications arriving on the market, new generics added as alternatives, and changes to the categories of medications.
Members impacted received written communication of medications that changed and were encouraged to talk with their physician or provider to determine if an alternative was available on the formulary.
SCHA provides an online drug search tool. The tool is user-friendly and offers important information about medication coverage. To use this tool:
- Select which program the member is enrolled in (this information is available on the member’s ID card or in MN-ITS)
- Search for the name of the drug, either by typing it in the search bar or finding it in an alphabetical list.
- Each listing includes information regarding the drug status and if there are any notes or restrictions on the drug.
- Alternative drugs are also available by clicking on the Therapeutic Class link.
If you have any questions about these formulary changes, please call the Pharmacy Help Desk at PerformRx – Medicaid 1-866-935-8874 or Medicare 1-866-935-6681.
Mammogram Incentive Program Boosts Screening Rates
Improvement initiatives have been developed and implemented through a collaborative effort between several departments within South Country Health Alliance, including consultation with county staff and medical providers.
One of these is an incentive reward program to encourage women ages 50 to 74 years old to complete an annual mammogram screening. Reminder letters, along with a voucher for a $50 gift card reward, are mailed to women as they became due for their annual mammogram as a means of encouragement for completing this preventive care service.
Participation in the mammogram reward program has increased significantly over the past few years as result of promotional changes and targeted reminder mailings directed at engaging members to seek preventive care. An analysis of members participating in the mammogram rewards program during 2015 indicated that approximately 76% of the members participating were first-time recipients, and a limited percentage of members participated in the program during 2013 and 2014.
The HEDIS performance measure for breast cancer screening looks at the percentage of SeniorCare Complete members who have one or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year. Results for HEDIS 2016 were promising as they improved 5 percentage points from HEDIS 2015.