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Reference Tools and Alerts



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Provider Alert
Date: 10/7/2008
Description: Claims Denied Incorrectly for DME Services Submitted with RR Modifier
Alert: Medica has identified a claims processing error involving HCPCS “A”, “E”, “K”, “L” and “S” codes submitted by durable medical equipment (DME) vendors. Affected claims were inappropriately denied with reason code FE, for using an incorrect modifier. Only claims processed on Medica's new administrative platform were affected. Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days.
Action: Providers do not need to submit adjustment requests. Medica will have all affected claims reprocessed.

Date: 9/2/2008
Description: Claims Denied Incorrectly Due to System Error on 8/29/08
Alert: Medica has identified a claims processing error for hospital and physician claims processed on August 29, 2008. A portion of Medica commercial and Minnesota Health Care Programs claims processed on this date were inappropriately denied with denial reason code 22 ("Not an eligible charge; do not bill patient"). Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days.
Action: No action is needed at this time as Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests.

Date: 8/25/2008
Description: Claims Denied Incorrectly for Hospital and Physician Services
Alert: Medica has identified a claims processing error for hospital and physician claims processed on August 13, 2008. All Medica Choice Product claims processed on this date were inappropriately denied with denial reason code 68 (“Your plan does not cover this expense”). Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days.
Action: No action is needed at this time as Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests.

Date: 8/25/2008
Description: 'Insights by Medica' Claims Paid Incorrectly for Hospital and Physician Services
Alert: Medica has identified a claims processing error for hospital and physician claims with dates of service from January 1, 2008, through July 29, 2008, for services provided to Patient Choice InsightsSM by Medica members. A portion of claims were not reimbursed correctly based on the appropriate fee schedule. The following places of service (POS) were affected by this issue: 21-24 (IP Hosp, Out-PT Hosp, ER and Ambulatory Surgery Ctr.), 26 (Military Treatment Facility), 31 (SNF), 34 (Hospice), 41-42 (Ambulance land & air), 51-53 (IP Psychiatric Facility, Psychiatric Facility – Partial Hospitalization and Community MH Care), 56 (Psychiatric Residential Treatment Center) and 61 (Comprehensive IP Rehabilitation Facility).

This issue did not apply to claims that were billed using the following modifiers: AA, AD, QK, QS, QX, QY and QZ. Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days.
Action: No action is needed at this time as Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests.
Product Impact: Only Patient Choice Insights by Medica claims are affected by this issue.
Date: 8/22/2008
Description: Medica to Update Policy on Avastin to Cover Treatment of Ovarian Cancer
Alert: Medica will update its coverage policy on bevacizumab (Avastin®) to also cover bevacizumab treatment when used for metastatic ovarian cancer, effective with September 1, 2008, dates of service. The change is due to this condition no longer being considered investigative. As of September 1, the updated coverage policy will be available online at www.medica.com in the "Providers" section, under "Clinical & Quality Resources," then "Medical Policies," under "Coverage Policies."
Action: No action is necessary. To bill Medica for this service on or after September 1, providers may use current applicable HCPCS code J9035 (Injection, bevacizumab, 10 mg).

Date: 8/21/2008
Description: Claims Denied Incorrectly for Pediatric Behavioral Health Screening
Alert: Medica has identified a claims processing error involving CPT code 96110 UC, used for pediatric behavioral health screening. The claims were denying for an inappropriate diagnosis, with denial reason code 478 or OM, when submitted with a preventive diagnosis. The error was identified and the system has been corrected as of August 18, 2008. Medica will be identifying all inappropriately denied claims for reprocessing. Providers should notice adjustments to such claims within 90 days.
Action: Providers do not need to submit adjustment requests. Medica will have all affected claims reprocessed.

Date: 8/21/2008
Description: Claims Denied Incorrectly for Initial Hospital Care of Neonate
Alert: Medica has identified a claims processing error involving CPT code 99477, used for initial hospital care of a neonate. The claims were denying for requiring a modifier, with denial reason code 093 or MQ. The error was identified and the system has been corrected as of July 30, 2008. Medica will be identifying all inappropriately denied claims for reprocessing. Providers should notice adjustments to such claims within 90 days.
Action: Providers do not need to submit adjustment requests. Medica will have all affected claims reprocessed.

Date: 8/15/2008
Description: Medica Covers 3 Newly FDA-Approved Vaccines
Alert: Medica covers the following vaccines, as specified. These immunization drugs were recently approved by the U.S. Food and Drug Administration (FDA).
  • Kinrix – On 6/24/08, the FDA approved Kinrix, a combination vaccine that offers protection against diphtheria, tetanus, pertussis, and polio in a single shot. As of the FDA approval date, related CPT code 90696 is eligible for reimbursement for all Medica members.
  • Pentacel – On 6/20/08, the FDA approved Pentacel, a combination vaccine that combines diphtheria, tetanus, pertussis, polio and Haemophilus influenza type b (Hib) vaccines into a single shot. As of the FDA approval date, related CPT code 90698 is eligible for reimbursement for all Medica members.
  • Rotarix – On 4/3/08, the FDA approved Rotarix, a live, oral, vaccine for use in preventing rotavirus gastroenteritis in infants. Rotarix is a liquid vaccine given by mouth in two doses. As of the FDA approval date, related CPT code 90681 is eligible for reimbursement for Medica members through 12 months of age. Claims received outside this age restriction will be denied as provider liability.
Action: Providers can bill for these 3 vaccines, as necessary. If you have questions, you can call the Medica Provider Service Center toll-free at 1-800-458-5512.

Date: 8/15/2008
Description: Medica's claim processing system is tentatively scheduled to be updated to include the 2009 MS-DRG changes on October 1, 2008
Alert: The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2009 Medicare Severity (MS) Diagnosis-Related Group (DRG) changes scheduled for publication in the August 19, 2008, Federal Register. The final rule to the FY 2009 inpatient prospective payment system can be accessed through the following link:

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf

The IPPS inpatient rule includes 999 MS-DRGs for 2009. For 2009 the MS-DRG weights are based on 100 percent to the cost determined MS-DRG values.

Medica’s claim processing system is tentatively scheduled to be updated in mid-November. Although implementation of the 2009 MS-DRG update will occur in November, consistent with CMS, the effective date of implementation will be October 1, 2008. Additional detail regarding the timeline will be provided in the next thirty days.
    Action: Should this change require an alteration to your reimbursement, your Contract Manager will contact you.
    Date: 8/15/2008
    Description: Medica plans to implement ‘Present on Admission’ requirement for inpatient acute care PPS hospitals for Medicare product claims on October 1, 2008
    Alert: The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2009 Inpatient Prospective rule on July 31, 2008. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Medicare has been requiring the POA indicator since October 1, 2007. The final rule to the FY 2009 inpatient prospective payment system can be accessed through the following link:

    http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf

    Medica is not requiring the Present on Admission indicator at this time for non Medicare claims.
    Action: Report the Present on Admission indicator on Medica’s Medicare product claims where Medica is primary starting on October 1, 2008.
    Date: 8/15/2008
    Description: PRA Balancing Issues
    Alert: Medica has identified a system error involving some types of claim adjustments causing balancing issues on provider remittance advices (PRAs) for claims processed on the Cosmos platform. Some fields, including the “Adjusted amount” and “Provider Totals,” may not balance; however, the check payment amounts are correct. A system fix is scheduled for August 24, 2008.
    Action: No action is needed at this time. Providers do not need to submit adjustment requests.

    Date: 8/8/2008
    Description: Medica to Implement EPRA Enhancements Related to New Administrative Platform
    Alert: Medica will soon implement several enhancements to its electronic provider remittance advice (EPRA) for claims processed on the new administrative platform only. These changes in the HIPAA 835 transaction should improve both convenience and security of EPRAs for providers. The date for these changes is tentatively August 19, 2008. The five scheduled updates are:
    • Group/policy numbers will be split into a separate field from the 9-digit member ID number as part of the HIPAA 835 transaction (numbers are currently all combined).

    • New remark codes will be used regarding individual claims:
      A1 = Claim/Service Denied
      16 = Claim/service lacks information which is needed for adjudication
      17 = Payment adjusted because requested information was no provided or was insufficient/incomplete
      96 = Non covered charge(s)
      125 = Payment adjusted due to a submission/billing error(s)

    • On the EPRA for institutional claims, the national provider identifier (NPI) for the billing provider will show up under "Servicing Provider NPI."

    • For adjusted claims, the HIPAA 835 transaction will reflect the NPI number submitted on the original claim.

    • Bulk recovery claims reported in HIPAA 835 transactions will contain the entire patient account number (not truncated) as submitted on the original claim.
    Action: Providers may need to update programming for acceptance of these EPRA format changes. You can get further details about these enhancements online in a related EPRA Enhancements reference document. If you have questions, you can call the Medica Provider Service Center toll-free at 1-800-458-5512.

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