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Vermont Medicaid Provider Manual

Provider Manual #/home 2/1/2019 Green Mountain Care Provider Manual 2 Summary of Updates The Detailed Summary of Provider Manual Changes contains all detailed changes made to this Provider Manual is maintained and available for review at #/manuals Date Section Information Section Number 02/01/2019 Timely Filing 02/01/2019 Timely Filing Reconsideration Requests 12/19/2018 Choices for Care Short-Term Respite Stays 12/4/2018 Telemedicine Services 11/6/2018 Vermont Medicaid Billing 10/29/2018 Promoting Interoperability Program (Formerly Electronic Health Record Incentive Program) 18 10/29/2018 Promoting Interoperability Program/Electronic Health Record Incentive Program Reconsideration Process 10/29/2018 Appeal of Promoting Interoperability Program/EHR Incentive Program Reconsideration 10/17/2018 Radiology 8/21/2018 Telemedicine Services 7/11/2018 Determination Time 7/10/2018 Scope-of-Service Related Encounter Rate Adjustments 05/29/2018 Audiological Services/Hearing Aids 05/29/2018 BICROS/CROS (Contralateral Routing of Sound) 05/23/2018 Rental/Loaned 05/23/2018 Rental Reimbursement Policies 05/23/2018 Durable Medical Equipment (DME), Prosthetics, Orthotics & Medical Supplies 11 05/03/2018 Payment DVHA Primary/Ma

Fee Schedule 9.6 01/19/2016 Supervised Billing for Behavioral Health Services 8.4 12/18/2015 Payment DVHA Primary 10.1 Incident-To Billing For Licensed Physicians 8.3 Supervised Billing For Behavioral Health Services 8.4 12/01/2015 Provider Enrollment, Licensing & Certification 5

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Transcription of Vermont Medicaid Provider Manual

1 Provider Manual #/home 2/1/2019 Green Mountain Care Provider Manual 2 Summary of Updates The Detailed Summary of Provider Manual Changes contains all detailed changes made to this Provider Manual is maintained and available for review at #/manuals Date Section Information Section Number 02/01/2019 Timely Filing 02/01/2019 Timely Filing Reconsideration Requests 12/19/2018 Choices for Care Short-Term Respite Stays 12/4/2018 Telemedicine Services 11/6/2018 Vermont Medicaid Billing 10/29/2018 Promoting Interoperability Program (Formerly Electronic Health Record Incentive Program) 18 10/29/2018 Promoting Interoperability Program/Electronic Health Record Incentive Program Reconsideration Process 10/29/2018 Appeal of Promoting Interoperability Program/EHR Incentive Program Reconsideration 10/17/2018 Radiology 8/21/2018 Telemedicine Services 7/11/2018 Determination Time 7/10/2018 Scope-of-Service Related Encounter Rate Adjustments 05/29/2018 Audiological Services/Hearing Aids 05/29/2018 BICROS/CROS (Contralateral Routing of Sound) 05/23/2018 Rental/Loaned 05/23/2018 Rental Reimbursement Policies 05/23/2018 Durable Medical Equipment (DME), Prosthetics, Orthotics & Medical Supplies 11 05/03/2018 Payment DVHA Primary/ Manual Pricing 05/03/2018 Procedure Codes & Pricing 04/16/2018 Obstetrical Care (Section # change only) 04/16/2018 Midwife Services (Section # change only)

2 04/16/2018 Timely Filing Reconsideration Requests 04/16/2018 DME Face-to-Face Requirements 04/16/2018 Home Health Face-to-Face Requirements 03/21/2018 Payment DVHA Primary 01/23/2018 Durable Medical Equipment (DME), Prosthetics, Orthotics & Medical Supplies 11 12/29/2017 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals 12/29/2017 Claim Copy Requests 12/08/2017 Refunds 12/08/2017 Audiological Services/Hearing Aids 11/09/2017 Subacute Care 10/26/2017 09/29/2017 Telemedicine Services Telemedicine Services 08/23/2017 Payment DVHA Primary Payment Dual Eligible / Medicare Primary 06/22/2017 Anesthesia 06/12//2017 Psychiatry/Psychology TENS/NMES 2/1/2019 Green Mountain Care Provider Manual 3 Provider Reconsideration Requests Timely Filing (Section # change only) Timely Filing Reconsideration Requests Adjustments (Section # change only) Prior Authorization of Medical Services 7 Immunizations Health Examination of Defined Subpopulation National Correct Coding Initiative (NCCI) Guidelines Bilateral Billing Procedures 02/10/2017 Telemedicine Outside a Facility Supervised Billing Concurrent Review for Admissions at Vermont and In-Network Border Hospitals 12/23/2016 Reimbursable Services - Home Health Hospice Home Health Agency & Hospice Services Billing Instructions/Field Locators Hospital Clinical Laboratory Tests Place of Service (POS)

3 Codes 12/01/2016 Assistant Surgeon 10/13/2016 Rehabilitative Therapy Wheelchairs & Seating Systems 08/17/2016 Claims System & Provider Services Prior Authorization Requirements 07/01/2016 Provider Based Billing 06/02/2016 Choices for Care: ERC/Nursing Facilities/HBW, Moderate Needs 15 Hospital Outpatient Billing Instructions/Field Locators 04/18/2016 Long Acting Reversible Contraceptives Provided in an Inpatient Hospital Post-Partum Setting 04/01/2016 Supervised Billing for Behavioral Health Services Psychiatry/Psychology 03/01/2016 Provider Based Billing Place of Service (POS) Codes Provider Claim Modification Process Provider Administrative Review Process Continuous Passive Motion (CPM) Devices Electronic Health Record Program Reconsideration Process Appeal of EHR Incentive Program Reconsideration 02/10/2016 Inpatient Newborn Services Correct Coding Practices New, Revised and Deleted Codes fee schedule 01/19/2016 Supervised Billing for Behavioral Health Services 12/18/2015 Payment DVHA Primary Incident-To Billing For Licensed Physicians Supervised Billing For Behavioral Health Services 12/01/2015 Provider Enrollment, Licensing & Certification 5 National Correct Coding Initiative (NCCI) Guidelines 11/01/2015 Inpatient Newborn Services (Physician)

4 Organ Transplant Organ Transplant Donor Complication 2/1/2019 Green Mountain Care Provider Manual 4 Important Telephone Numbers, Addresses and Websites In-State & Out of State Psychiatric & Detoxification Inpatient Services 10/15/2015 Obstetrical Care 10/01/2015 ICD-9/ICD-10 References (Throughout Entire Manual ) All Abortions Midwife Services CMS 1500 Paper Claim Billing Instructions/Field Locators 09/01/2015 Psychiatry/Psychology ICD-9/ICD-10 References (Throughout Entire Manual ) All 08/01/2015 Organ Transplant Donor Complication Electronic Health Record Incentive Program (EHRIP) 18 EHR Incentive Program Reconsideration Process EHR Incentive Program Appeal Process Medical Necessity Obstetrical Care Midwife Services Concurrent Review for Admissions at Vermont & In-Network Hospitals Timely Filing Psychiatry/Psychology 07/13/2015 Provider Administrative Review Process Program Integrity Reconsideration & Appeal Process 07/01/2015 Claims System & Provider Services Third Party Liability (TPL)/Other Insurance (OI)

5 CMS 1500 Paper Claim Billing 06/01/2015 Telemonitoring 04/15/2015 Member Information Medicaid and Medicare Crossover Billing Rehabilitative Therapy Bilateral Procedures Physician/Professional Billing Enteral Nutrition Inpatient/Outpatient Overlap Hospital Inpatient Billing Instructions Hospital Outpatient Billing Instructions 02/01/2015 Individual Consideration/ Manual Pricing Rehabilitative Therapy Chiropractic Services Midwife Services Bilateral Billing Procedures 01/01/2015 Prior Authorization Reviewers Telemedicine Hospital Inpatient Billing Instructions/Field Locators Hospital Outpatient Billing Instructions/Field Locators Home Health Agency & Hospice Services Billing Instructions/Field Locators Short Term Stays Home Based Waiver (HBW) Billing Instructions/Field Locators 12/01/2014 Midwife Services 2/1/2019 Green Mountain Care Provider Manual 5 CMS 1500 Paper Claim Billing Instructions/Field Locators Home Health Agency & Hospice Services Billing Instructions Home Based Waiver (HBW) Billing Instructions/Field Locators 11/03/2014 Contractual Allowance Rehabilitative Therapy Ambulance Services EPSDT Program Well Child Health Care CMS 1500 paper Claim Billing Instructions/Field Locators Inpatient Claims.

6 Medicare Part A Exhausts or Begins During the Inpatient Stay Provider Based Billing 10/01/2014 Claim Submission & Correspondence Mailing Addresses Member Bill of Rights Contractual Allowance Out-of-Network Elective Outpatient Referrals Psychiatric/Psychology Short Stays Same/Next Day Readmission Policy Transfer Cases Dialysis 08/23/2014 Cardiac Rehabilitation 2/1/2019 Green Mountain Care Provider Manual 6 Table of Contents SUMMARY OF UPDATES .. 2 SECTION 1 GENERAL INFORMATION AND ADMINISTRATION .. 14 Important Telephone Numbers, Addresses and Websites .. 14 Administration & Responsibilities .. 14 Member Eligibility Determination .. 14 Administration of Insurance Programs .. 15 Claims System & Provider Services .. 15 Claim Submission & Correspondence Mailing Addresses .. 16 Claim Copy Requests .. 16 Provider Claim Modification Process.

7 17 Provider Reconsideration Process .. 17 SECTION 2 GREEN MOUNTAIN CARE .. 18 Medicaid for Adults .. 18 Dr. Dynasaur (Children) .. 18 Prescription Assistance Pharmacy-Only Programs .. 18 Medicare Savings Programs (MSP) .. 18 Primary Care Plus (PC PLUS) .. 18 Allowed Practitioner Types .. 19 Application .. 20 Enrollment Minimum/Maximum .. 20 Monthly Enrollment List .. 20 Provider Enrollment Status Change .. 20 Notice of Termination of Participation in PCP 20 Hospital Admitting Privileges .. 20 Referrals .. 20 Case Management Responsibilities .. 22 Case Management Fee and Treatment Plan .. 22 SECTION 3 POLICIES & OTHER INFORMATIONAL RESOURCES .. 23 Advisory .. 23 Vermont Medicaid Banner .. 23 Claim Edit Standards .. 23 Correct Coding Practices .. 23 New, Revised and Deleted Codes .. 24 Correct Form Versions .. 24 Manuals for Providers .. 24 Medicaid Rule & State Plan Resources.

8 24 National Correct Coding Initiative (NCCI) Guidelines .. 25 Remittance Advice .. 26 2/1/2019 Green Mountain Care Provider Manual 7 The 835 Transaction (Electronic Remittance Advice) .. 27 SECTION 4 MEMBER INFORMATION .. 27 Eligibility .. 27 Partial Eligibility .. 27 Eligibility Verification .. 27 Identification .. 29 Member Bill of Rights .. 29 Member Cost Sharing/Co-pays and Premiums .. 30 Qualified Medicaid Member (QMB) .. 31 Notice of Decision .. 31 Court Ordered Services .. 31 Retroactive Eligibility .. 31 Member Grievance Process .. 31 Member Appeal Process .. 31 Fair Hearing .. 32 Advanced Directives .. 32 SECTION 5 Provider ENROLLMENT, LICENSING & CERTIFICATION .. 32 Enrollment & Certification .. 32 Enrollment Agreement Signatures .. 33 Payment Conditions .. 34 Conditions of Participation .. 34 Documentation of Services .. 34 Rights & Responsibilities.

9 34 Termination .. 35 SECTION 6 COORDINATION OF BENEFITS/ Medicaid PAYMENT LIABILITY/THIRD PARTY LIABILITY .. 35 Contractual Allowance .. 35 Reimbursement of Overpayments .. 35 Who is Responsible for Payment? .. 36 Supplementation .. 36 Who Is Primary .. 36 Notice That Medicaid Will Not Be Accepted .. 37 Medicaid & Medicare Crossover Billing .. 37 Third Party Liability (TPL)/Other Insurance (OI) .. 38 Third Party Liability Coverage Codes .. 41 Workers Compensation/Accident Liability Billing .. 42 SECTION 7 PRIOR AUTHORIZATION FOR MEDICAL SERVICES .. 43 Clinical Practice Guidelines .. 43 Prior Authorization Requirements .. 43 2/1/2019 Green Mountain Care Provider Manual 8 Required Documentation .. 43 Immediate Need Exception .. 44 Determination 44 PA Decision Reconsiderations .. 45 Medical Necessity .. 46 Medical Necessity Form (MNF) .. 46 Utilization 46 Prior Authorization Notice Of Decision.

10 47 Services Requiring Prior Authorization .. 47 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals .. 47 Out of-State Elective Inpatient Hospital 47 Out-of-Network Elective Outpatient 48 In-State & Out of State Psychiatric & Detoxification Inpatient Services .. 48 Out-of-State Urgent/Emergent Inpatient Hospital Admissions .. 48 Rehabilitative Therapy .. 48 SECTION 8 REIMBURSEMENT, BILLING PROCEDURES AND CLAIM PROCESSING .. 50 Adjustments Requests .. 50 Timely Filing .. 51 Timely Filing Reconsideration Requests .. 52 Usual & Customary Rate (UCR) .. 53 Incident-To Billing For Licensed Physicians .. 53 Supervised Billing for Behavioral Health Services .. 54 Locum Tenens .. 57 Time-based Procedure Codes Billing Guidelines .. 57 Electronic Claim Submission .. 58 Electronic Funds Transfer (EFT) .. 58 Claim Disposition Information Introduction.


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