Andrea Zito, RN, Medicare BCBSRI
Cynthia Cote, RN, Medicare BCBSRI
Lori Langevin, Professional Relations, Medicare BCBSRI
Rocco Bruno, Manager, Audit & Reimbursement, Medicare BCBSRI
Merle Francis, Manager, Professional Services, Arkansas BC
Bobbie Yotter, Manager, Medical Review & Data Analysis,ArkansasBC
George DeLuna, CMS, Dallas Office
Heidi Louro, Lifespan
Christine Rawnsley, Lifespan
Cheryl Adessi, A/R Specialist, Roger Williams Hospital
Katherine Viveiros, A/R Coordinator, Roger Williams Hospital
Nilda Mendoza, Roger Williams Hospital
Mickey Lourenco, Patient Accounts, Kent County Hospital
Lynn Gauvin, Patient Accounts, Kent County Hospital
Pat Moran, HARI
Judith Longo, Rehab Hospital of RI
Debra Dzialo, Rehab Hospital of RI
Kelly Facteau, Rehab Hospital of RI
Maria Figueroa, Butler Hospital
Jacalyn Pappas, Rehab Hospital of RI
Donna Demers, BCBSRI, Professional Relations

1. Old Business:
   • Review of 8/21/03 meeting minutes
     There are still claims that need adjustments. However, until CWF makes the necessary corrections, the claims can not be adjusted.
      
2. New Business
   CMS, Dallas Regional Office, George DeLuna 214-767-6437
   George introduced himself as the representative from the Dallas regional office. He explained how Rhode Island will be working with two regional offices, Boston and Dallas.
    
   1. Workload Transition to Arkansas, Merle Francis, PR Manager
      Merle Francis, Manager of Professional Services at Arkansas BCBS, gave the group a background of Arkansas Blue Cross Blue Shield which currently processes Part B claims for 5 states and Part A claims for the state of Arkansas. Merle informed the group that they will continue to have an office in RI, and Arkansas has offered jobs to many of the existing RI Medicare staff.

      It was noted that some functions such as provider enrollment would be handled in Arkansas. Merle informed the group that Arkansas BCBS, RI BCBS, and CMS are actively involved in the transition process.

      Merle informed the group that electronic funds transfer would be available to RI providers sometime in March. Merle discussed the upcoming EDI and Transition Workload Workshops, scheduled in December and January, for Part A & B providers, that will address any changes that will take place as of 2/1/04. She also informed the group about the Arkansas Medicare web-site, http://www.arkmedicare.com, and web-based training that is available via their web site.

      Providers should be receiving monthly newsletters with updates from Arkansas BC.

      Christine Rawnsley asked about T-lines and concerns with the MSS reporting. She was given David Bailey’s e-mail address.
       

   2. Arkansas Post-pay Medical Review and Data Analysis, Bobbie Yotter, Manager
      Bobbie discussed her role as manager for Arkansas post-pay medical review and data analysis. She elaborated that the results of data analysis aid in the determination of the areas that require provider education. The data analysis team in Arkansas includes statisticians and nurses that do the actual data analysis. Arkansas BCBS will be taking over the RI Data Analysis functions. The results of the data analysis will be communicated to the RI Medical Review Unit and Professional Relations Representatives. Post- Pay Medical Review will also be performed in Arkansas. If the results of data analysis is performed in Arkansas for RI warrants, a post-pay medical review, this task will be performed in Arkansas. If education is needed, RI will be responsible for educating the provider community.

      Bobbie also stated that current RI LMRPs will remain in effect in their present format for at least 6 months. Any new LMRPs will go through the normal procedures and be presented to the CAC (Carrier Advisory Committee).
       

   3. FISS DDE training
      1. Any new issues
         None mentioned
      2. Sign-on to FISS DDE
         Advised the group to make sure that they can sign-on to FISS DDE and to contact me, if there are any sign-on issues. Also advised to practice on FISS DDE as much as possible to prepare for the APASS to FISS conversion on 2/1/04.
      3. Open discussion - Any issues or questions pertaining to FISS DDE should be emailed or addressed to Lori Langevin
          
   4. Current Crossover Issues for part A claims
      1. Insurer Codes for claims processing
         "E" is to be utilized for FEP
         "I" is to be utilized for CCERT and all other Blue Cross Plans
         "G" was needed for Plan 65 but now no code is needed, since Plan 65 is an eligibility file, however if the beneficiary is not on the Plan 65 eligibility file or was added to the eligibility file after the date of service in questions than crossover will not take place.
      2. The current trading partners having an existing eligibility file are:
         • HEALTH DATA MANAGEMENT CORP
         • MUTUAL OF OMAHA
         • PL65
         • AMERICAN POSTAL WORKERS'
         • SIERRA MILITARY HLTH SVS

         (These plans do not need an insurer code filed on the paper or electronic claim)

      3. Filing instructions for Medigap plans (FEP, CCERT and BCBSRI)
         1. Paper UB-92 form and Remote Entry
            Field 50B – Enter the type of payer code and the Medigap/Crossover
            Payer’s name.

         Example, if a patient had Medicare and FEP as secondary payer, Field 50B would have the following information on the claim:
          E FEP
          

         2. Electronic UB-92 format
            • Record type "30" using sequence number "02"
            • Field # 4 – Source of payment code – the alpha code will designate the
            • Type of payer.
            • Field # 8 - Payer Name
            • Example, if a patient had Medicare and Classic Blue Cross as secondary payer,
            • Field # 4 = I
            • Field # 8 = BCBSRI

            (These plans are NOT on an eligibility file and crossover will NOT take place if the correct codes are not used on the proper claim fields. )
             

   5. RI Medical Review Nurses – Cindy Cote and Andrea Zito
       
      1. CERT
         The purpose of CERT is to review the ability of the contractor to correctly process claims. This has forced RI Medicare to become more stringent in the way in which it does business in order to meet CMS guidelines. The process for sending requested claims to CERT was explained to the audience. It was emphasized that the request for records by CERT can not be ignored. If records are not received by CERT in the proper format and on time they will deny the claim and take back monies. If CERT makes a claim denial, the provider may use the normal appeals process and send the appeal to RI Medicare for review.
          
      2. Rehab Advisory
          

         Cindy presented the Out-Patient Rehabilitation Advisory that she had written and had put on the RI Medicare web-site. She stated that recent medical review of out-patient rehabilitation medical records have resulted in claim denials due to incomplete documentation, unclear documentation in the medical records, improper use of CPT codes, or medical necessity issues. She elaborated on this by stating that the documentation must support the type of therapy (CPT code) and the number of units billed. Documentation is considered incomplete, in many instances, because the treatment time is not recorded. Treatment time for time based therapy codes must be recorded in minutes by the therapist.
         
         The Advisory also includes CMS guidelines related to obtaining certifications and recertifications for out-patient rehabilitation services. The physician must certify at least every 30 days, that they have reviewed the plan and that there is a continuing need for rehabilitation services. Another issue included in the Advisory is instances of improper coding with 97110.
          

      3. HBO – Hyperbaric Oxygen
         As a follow-up to the last Hospital PCOM meeting, Cindy presented to the members the memo from the RI Medicare website dated 10/02/03 which gave clarification regarding coverage of HBO therapy. Under Conditions of Coverage, applicable ICD-9-CM diagnosis shall include 707.15. Also, some of the diagnosis codes listed in the original AB-02-183 need more digits to be considered a valid ICD-9-CM. For example, 250.7, 250.8 and 707.1 need a fifth digit. Also, 707 was mistakenly listed in CR 2388. Refer to CR 2769, Transmittal AB-03-102.
          
   6. Audit & Reimbursement – Rocco Bruno
      Credit Balance Reports
      • May only be signed by the administrator or CFO ( No fax copies accepted; need original signature)
      • Be careful to differentiate between open and closed cost reports. (FY2001 all closed/Some FY2002 still open)
      • As you are receiving reminders of due dates by letter, please do not expect telephone call reminders from Rocco. He can no longer do this.
         
   7. Open Discussion
      Concerns were raised by the provide in regards to non-payment of out-patient therapy services because they were considered overlapping services within the Home Health Agency Consolidated Billing. The example given described a situation in which therapy was provided by the hospital to a patient in observation. The patient was a home health agency patient prior to admission to observation. There are no written exceptions to consolidated billing for this situation. The solution that was suggested by Andrea Zito, was to have pre-authorization agreements with the home health agencies that service the hospital catchment area. This would allow the hospital to bill the home health agency for the services that they provide
       
   8. Next meeting & agenda items
      Beginning of February for next meeting
      Advised to please send agenda items to Lori Langevin
      Suggested agenda item was education on consolidated billing between Hospitals, SNF’s and Homehealth agencies.
       
3. Action Items
   • Lori Langevin to send filing instructions for Medicare crossover process
     Incorporated in these minutes
   • Lori Langevin to update hospital mailing list for Lifespan and Kent County Hospital so Arkansas newsletters go to the attention of their Patient Accounts Depts.