Prosthetic And Orthotoc Devices Billing Guide

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Washington Apple Health (Medicaid)Prosthetic andOrthotic (P&O)DevicesBilling GuideJanuary 1, 2018Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between thisdocument and an agency rule arises, the agency rules apply.

Prosthetic and Orthotic (P&O) DevicesAbout this guide This publication takes effect January 1, 2018, and supersedes earlier billing guides to thisprogram.HCA is committed to providing equal access to our services. If you need an accommodation orrequire documents in another format, please call 1-800-562-3022. People who have hearing orspeech disabilities, please call 711 for relay services.Services, equipment, or both, related to any of the programs listed below, must be billed usingtheir program-specific billing guides: Wheelchairs & Durable Medical Equipment and Supplies Billing GuideMedical Nutrition Billing GuideHome Infusion Therapy Billing GuideWashington Apple Health means the public health insurance programs for eligibleWashington residents. Washington Apple Health is the name used in WashingtonState for Medicaid, the children's health insurance program (CHIP), and stateonly funded health care programs. Washington Apple Health is administered bythe Washington State Health Care Authority. This publication is a billing instruction.2

Prosthetic and Orthotic (P&O) DevicesWhat has changed?SubjectClient EligibilityChangeThis section is reformatted andconsolidated for clarity and hyperlinkshave been updated.Reason for ChangeHousekeeping andnotification of newregion moving to FIMCEffective January 1, 2018, the agencyis implementing another FIMC region,known as the North Central region,which includes Douglas, Chelan, andGrant Counties.What does the agencyrequire whensubmitting photos andX-rays for medical andP&O requests?Cleaned up text to be current with Vyne HousekeepingMedical.How can I get agency provider documents?To access provider alerts, go to the agency’s provider alerts web page.To access provider documents, go to the agency’s provider billing guides and fee schedules webpage.Where can I download agency forms?To download an agency provider form, go to HCA’s Billers and providers web page, selectForms & publications. Type the HCA form number into the Search box as shown below(Example: 13-835).3

Prosthetic and Orthotic (P&O) DevicesTable of ContentsAbout this guide . 2What has changed? . 3How can I get agency provider documents? . 3Where can I download agency forms? . 3Available Resources . 6Definitions . 7About the Program . 8What is the purpose of the Prosthetic and Orthotic Devices (P&O) program? . 8Client Eligibility . 9How do I verify a client’s eligibility? . 9Are clients enrolled in an agency-contracted managed care organization (MCO)eligible? . 10Managed care enrollment . 11Behavioral Health Organization (BHO) . 11Fully Integrated Managed Care (FIMC) . 12Apple Health Foster Care (AHFC) . 13What if the client has third-party liability (TPL) coverage? . 13Coverage . 14What is covered? . 14What are the general conditions of coverage? . 14What are habilitative services under this program? . 15Billing for habilitative services . 15Billing for occupational therapist evaluation . 15What if a service is covered but considered experimental or has restrictions orlimitations?. 16What is not covered? . 16Coverage Table. 18Provider Requirements . 73Who does the agency reimburse for providing prosthetic and orthotic (P&O) devices,related supplies and services to agency clients? . 73Which providers are eligible and what are the requirements? . 74How can interested parties request that equipment/supplies be added to the “covered”list in this billing guide? . 75Authorization. 76What is prior authorization (PA)? . 76Alert! This Table of Contents is automated. Click on a page number to go directly to the page.4

Prosthetic and Orthotic (P&O) DevicesIs PA required? . 76How do I request PA? . 76What are the general policies for PA? . 77What does the agency require when submitting photos and X-rays for medical andP&O requests? . 79What is expedited prior authorization (EPA)? . 80EPA criteria coding table . 81Reimbursement . 87What is the general reimbursement for prosthetic and orthotic (P&O) devices andrelated supplies and services? . 87What is the specific reimbursement for P&O devices? . 88Who owns the purchased P&O devices and related supplies? . 89Billing . 91What are the general billing requirements? . 91How do I bill claims electronically? . 91How are Medicare crossovers submitted? . 91What does the agency require from the provider-generated EOMB to process acrossover claim?. 92Alert! This Table of Contents is automated. Click on a page number to go directly to the page.5

Prosthetic and Orthotic (P&O) DevicesAvailable ResourcesTopicBecoming a provider orsubmitting a change of addressor ownershipFinding out about payments,denials, claims processing, oragency-contracted managed careorganizationsElectronic billing.Finding agency documents (e.g.,billing guides, fee schedules)Private insurance or third-partyliability, other than agencycontracted managed careRequesting thatequipment/supplies be added tothe covered list in this guideRequesting prior authorization ora limitation extensionQuestions about the paymentrate listed in the fee scheduleContact InformationSee the agency’s Billers and Providers web page(800) 562-3022 (toll free)(866) 668-1214 (fax)(toll free)Cost Reimbursement AnalystProfessional ReimbursementPO Box 45510Olympia, WA 98504-5510(360) 753-9152 (fax)6

Prosthetic and Orthotic (P&O) DevicesDefinitionsThis section defines terms and abbreviations, including acronyms, used in this billing guide.Refer to Chapter 182-500 WAC for a complete list of definitions for Washington Apple Health.Artificial limb – See prosthetic device.(WAC 182- 543-1000)Prosthetic device or prosthetic – Areplacement, corrective, or supportivedevice prescribed by a physician or otherlicensed practitioner of the healing arts,within the scope of his or her practice asdefined by state law, to:Code of Federal Regulations (CFR) Rules adopted by the federal government.Date of Delivery – The date the clientactually took physical possession of an itemor equipment. (WAC 182- 543-1000) Health Care Financing AdministrationCommon Procedure Coding System(HCPCS) – A coding system established bythe Health Care Financing Administration todefine services and procedures.(WAC 182- 543-1000) Resource Based Relative Value Scale(RBRVS) – A scale that measures therelative value of a medical service orintervention, based on amount of physicianresources involved. (WAC 182- 543-1000)Orthotic Device or Orthotic – A correctiveor supportive device that: Artificially replace a missing portion ofthe body.Prevent or correct physical deformity ormalfunction.Support a weak or deformed portion ofthe body. (WAC 182- 543-1000)Prevents or corrects physical deformityor malfunction.Supports a weak or deformed portion ofthe body. (WAC 182- 543-1000)Plan of Care (POC) – (Also known as planof treatment (POT). A written plan of carethat is established and periodically reviewedand signed by both a physician and a homehealth agency provider, that describes thehome health care to be provided at theclient’s residence.(WAC 182- 551-2010)7

Prosthetic and Orthotic (P&O) DevicesAbout the Program(WAC 182- 543-1100)What is the purpose of the Prosthetic andOrthotic Devices (P&O) program?For eligible clients, the Prosthetic and Orthotic Devices (P&O) program covers the purchase ofmedically necessary P&O and related supplies when they are not included in otherreimbursement methods (e.g., inpatient hospital diagnosis related group (DRG), nursing facilitydaily rate, health maintenance organization (HMO), or managed care organizations (MCOs)).The federal government considers P&O and related supplies as optional services under theMedicaid program, except when: Prescribed as an integral part of an approved plan of treatment under the Home Healthprogram. Required under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT)program.The agency may reduce or eliminate coverage for optional services, consistent with legislativeappropriations.8

Prosthetic and Orthotic (P&O) DevicesClient EligibilityMost Apple Health clients are enrolled in an agency-contracted managed care organization(MCO). This means that Apple Health pays a monthly premium to an MCO for providingpreventative, primary, specialty, and other health services to Apple Health clients. Clients inmanaged care must see only providers who are in their MCO’s provider network, unless priorauthorized or to treat urgent or emergent care. See the agency’s Apple Health managed care pagefor further details.It is important to always check a client’s eligibility prior toproviding any services because it affects who will pay for the services.How do I verify a client’s eligibility?Check the client’s Services Card or follow the two-step process below to verify that a client hasApple Health coverage for the date of service and that the client’s benefit package covers theapplicable service. This helps prevent delivering a service the agency will not pay for.Is the client enrolled in an agency-contracted managed care organization (MCO), in a behavioralhealth organization (BHO), or is the client receiving services through fee-for-service (FFS)Apple Health?Verifying eligibility is a two-step process:Step 1. Verify the patient’s eligibility for Apple Health. For detailed instructions onverifying a patient’s eligibility for Apple Health, see the Client Eligibility, BenefitPackages, and Coverage Limits section in the agency’s ProviderOne Billing andResource Guide.If the patient is eligible for Apple Health, proceed to Step 2. If the patient is noteligible, see the note box below.Step 2. Verify service coverage under the Apple Health client’s benefit package. Todetermine if the requested service is a covered benefit under the Apple Health client’sbenefit package, see the agency’s Program Benefit Packages and Scope of Services webpage.9

Prosthetic and Orthotic (P&O) DevicesNote: Patients who are not Apple Health clients may submit an application forhealth care coverage in one of the following ways:1.By visiting the Washington Healthplanfinder’s website at:www.wahealthplanfinder.org2.By calling the Customer Support Center toll-free at: 855-WAFINDER(855-923-4633) or 855-627-9604 (TTY)3.By mailing the application to:Washington HealthplanfinderPO Box 946Olympia, WA 98507In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visitwww.wahealthplanfinder.org or call the Customer Support Center.Are clients enrolled in an agency-contractedmanaged care organization (MCO) eligible?(WAC 182-538-060 and 182-538-095)Yes. Most Medicaid-eligible clients are enrolled in one of the agency’s contracted managed careorganizations (MCO). For these clients, managed care enrollment will be displayed on the clientbenefit inquiry screen in ProviderOne. All services must be requested through the client’sprimary care provider (PCP). Clients can contact their MCO by calling the telephone numberprovided to them.All medical services covered under an agency-contracted MCO must be obtained by the clientthrough designated facilities or providers. The MCO is responsible for both of the following: Payment of covered servicesPayment of services referred by a provider participating with the MCO to an outsideproviderThe agency does not pay for medical equipment and/or services provided to a client who isenrolled in an agency-contracted MCO, but did not use one of the plan’s participating providers.(See WAC 182-543-1100)10

Prosthetic and Orthotic (P&O) DevicesNote: To prevent billing denials, check the client’s eligibility prior to schedulingservices and at the time of the service, and make sure proper authorization orreferral is obtained from the agency-contracted MCO, if appropriate. See theagency’s ProviderOne Billing and Resource Guide for instructions on how to verifya client’s eligibility.Managed care enrollmentApple Health (Medicaid) places clients into an agency-contracted MCO the same month they aredetermined eligible for managed care as a new or renewing client. This eliminates a person beingplaced temporarily in FFS while they are waiting to be enrolled in an MCO or reconnected witha prior MCO. This enrollment policy also applies to clients in FFS who have a change in theprogram they are eligible for.New clients are those initially applying for benefits or those with changes in their existingeligibility program that consequently make them eligible for Apple Health managed care.Renewing clients are those who have been enrolled with an MCO but have had a break inenrollment and have subsequently renewed their eligibility.Checking eligibility Providers must check eligibility and know when a client is enrolled and with whichMCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s GetHelp Enrolling page. MCOs have retroactive authorization and notification policies in place. The provider mustknow the MCO’s requirements and be compliant with the MCO’s policies.Behavioral Health Organization (BHO)The Department of Social and Health Services (DSHS) manages the contracts for behavioralhealth services (mental health and substance use disorder) for eight of the Regional ServiceAreas (RSAs) in the state. The remaining regions have fully integrated managed care (FIMC).See the agency’s Mental Health Services Billing Guide for details.11

Prosthetic and Orthotic (P&O) DevicesFully Integrated Managed Care (FIMC)For clients who live in an FIMC region, all physical health services, mental health services, anddrug and alcohol treatment are covered and coordinated by the client’s agency-contracted MCO.The BHO will not provide behavioral health services in these counties.Clients living in an FIMC region will enroll with an MCO of their choice that is available in thatregion. If the client does not choose an MCO, the client will be automatically enrolled into oneof the available MCOs, unless the client is American Indian/Alaska Native (AI/AN). Clientscurrently enrolled in one of the available MCOs in their region may keep their enrollment whenthe behavioral health services are added.Effective July 1, 2017, American Indian/Alaska Native (AI/AN) clients livingin an FIMC region of Washington may choose to enroll in one of the agencycontracted MCOs available in that region or they may choose to receive all theseservices through Apple Health FFS. If they do not choose an MCO, they will beautomatically enrolled into Apple Health FFS for all their health care services,including comprehensive behavioral health services. See the agency’s AmericanIndian/Alaska Native webpage.For more information about the services available under the FFS program, see theagency’s Mental Health Services Billing Guide and the Substance Use DisorderBilling Guide.For full details on FIMC, see the agency’s Changes to Apple Health managed care webpage.FIMC RegionsClients who reside in either of the following two FIMC regions and who are eligible for managedcare enrollment must choose an available MCO in their region. Specific details, includinginformation about mental health crisis services, can be found on the agency’s Apple Healthmanaged care webpage.North Central Region – Douglas, Chelan and Grant CountiesEffective January 1, 2018, the agency will implement the second FIMC region knownas the North Central Region, which includes Douglas, Chelan, and Grant Counties.Southwest Washington Region – Clark and Skamania CountiesE

Jan 01, 2018 · State for Medicaid, the children's health insurance program (CHIP), and state- . This Table of Contents is automated. Click on a page number to go directly to the page. 5 . What does the agency require when subm

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