Provider manual amerigroup

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For example, if a standard hospital bed was ordered and a semi-electric bed was provided as a provider-initiated upgrade, MHCP will pay for repairs to a broken caster, but would not reasonably require repair to a motor.

If the repair would not be reasonably required by the medically necessary item, the provider must repair the upgraded item but cannot bill MHCP or the member for the repairs. Supplier Documentation The medical supplier must have the following information on file additional details about each requirement can be found under this bulleted list :. Treating practitioners can include: physicians, physician assistants, or advanced practice nurses.

Ordering practitioners must be working within their scope of practice. Specific policies may have different treating practitioners allowed to prescribe, see each policy for specific details. MHCP accepts the following order types according to Medicare guidelines. New Order A new order is needed in the following circumstances:. General Provisions. Face-to-Face Documentation Providers must maintain written or electronic documentation of face-to-face encounters on file and available to DHS upon request.

Documentation must include:. Documentation of face-to-face encounters may be included in clinical and progress notes and discharge summaries.

Ongoing Services Ongoing services are not subject to the face-to-face rule. A face-to-face encounter is only required for new medical equipment, supplies or appliances. Financial Implications Payment for services can be subject to payment recovery if a timely face-to-face encounter was not documented.

S ee the Code of Federal Regulations, title 42, part for more information. Medical records must contain the following information:. DHS may request this information in select cases. The supplier is liable for the dollar amount involved if the information is not received, or does not substantiate medical necessity.

Provide proof of delivery in any of the following methods:. Method 1: Supplier delivers items directly to the member or authorized representative. Method 3: Supplier uses a delivery or shipping service to deliver items. Method 4: Items delivered to an LTC facility on behalf of the member. Suppliers must work with the LTC facility staff to implement inventory control to ensure that:.

All services that do not have appropriate proof of delivery from the supplier will be denied and all payments must be returned to DHS. This includes drugs, supplies used with the DME or prosthetic devices, surgical dressings, urological supplies, or ostomy supplies applied in the hospital including items worn home by the member.

Follow these guidelines when dispensing equipment and supplies:. The provider must obtain authorization when required. Refer to General Authorization Criteria and Documentation Requirements to see all general criteria that are required for authorization requests. Authorization can be requested for any piece of medical equipment, supply, prosthetic, or orthotic that is typically considered a non-covered item.

The item must be medically necessary. Enter this request under the HCPC code specified for the item and submit documentation that demonstrates the item meets all the following criteria:.

Also, follow these billing guidelines specific to equipment and supplies when applicable. M innesota S tatutes B. Report this page. Find in Table of Contents:. Covered Services MHCP covers medical supplies and equipment, subject to limitations, authorization and other requirements. Equipment that is intended to rent until converted to purchase must be new equipment. Used equipment may be used for short-term rental, but if eventually converted to purchase, must be replaced with new equipment.

Members cannot automatically obtain a new piece of equipment after five years if the first piece is still in working order. Likewise if repairs are requested for a piece of equipment that is over five years old, the integrity of the equipment and ability to last another five years will be assessed and the least costly alternative recommended replacement versus repair.

Per Diem Coverage Skilled Nursing Facility Nearly all durable medical equipment and supplies are covered in the per diem for long-term care, with the exclusion of customized wheelchairs for members who cannot use a standard wheelchair. The first date in the date span should be the date the supplies are dispensed.

The number of supplies distributed in the date span should not exceed the daily limit for any day within that date span unless an NCCI exception is allowed and the correct modifiers are used.

Authorization is required for quantities exceeding our policy limits. Miscellaneous Products Sharps Disposal Containers Members who self-administer medications using syringes may receive sharps disposal containers. Weighted Blankets or Vests Code: E NU Weighted blankets or vests are covered for members who have developmental disabilities, including autism spectrum disorders.

State law does not allow medical equipment and supply providers or home health care agencies to provide items that meet the definition of a drug. Billing and Documentation Follow the general billing information in the Billing Policy section of the manual.

Add-ons and Upgrades An add-on is a noncovered item that can be added to a piece of covered equipment. Provider-Initiated Upgrades Medical equipment that has features that go beyond what is medically necessary are considered upgrades. See Telemedicine for more information. Non-physician practitioners are authorized to complete the documentation requirements.

They may include hospital, nursing home or home health agency records, or records from medical professionals such as nurses, physical or occupational therapists, prosthetists and other. Providers are encouraged to talk to their insurers to discuss liability for replacing items if a member reports the product damaged or missing.

Authorization Requirements The provider must obtain authorization when required. When requesting authorization for bilateral prosthetics or orthotics where more units are required than are allowed by the MUEs, the units must be requested on different lines, with modifiers NU RT and NU LT or other approved modifiers as appropriate. A unique description of each item must be entered into the model number field for each line.

The unique description may be a model number or narrative description up to 20 characters. If approved, the approved rate will include all requested and approved parts or accessories. We will accept a price list or a quote from the manufacturer dated within three months of the authorization request. We will accept an invoice from the manufacturer if manufacturer pricing is not available. Clearly indicate each item being requested.

Do not modify, alter or change the pricing documentation but you may star or circle the item. Each K modifier must be on a separate line on the authorization request. Authorization requests for typically noncovered items Authorization can be requested for any piece of medical equipment, supply, prosthetic, or orthotic that is typically considered a non-covered item. Authorization can be retroactively requested. Use the Claim Notes field on the Claim Information tab.

If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization. If MSRP is not available we will accept an invoice from the manufacturer. Additional modifiers may be appropriate depending on the item or service. A new capped rental period is allowed if over 60 days have lapsed from the previous payment or if a new provider takes over the rental.

Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs. Example: Submit one claim no authorization required for the number of units up to the quantity limit.

Submit another claim with the prior authorization for the additional quantity dispensed over the quantity limit. Legal References M innesota S tatutes B.

Procedure Code. Prior Authorization Requirements. Incontinence supply; miscellaneous. Use for supplies relating to urinary or fecal incontinence.

Iowa Total Care will process most standard prior authorization requests within five days. If we need additional clinical information or the request needs to be reviewed by a Medical Director, additional days may be needed to make a determination. Detailed information on prior authorization determination timelines is included in the Provider Manual.

CST excluding holidays. After normal business hours, we have an after hours service available to answer questions and intake requests for prior authorization. Failure to obtain the required prior authorization for a service may result in denied claims. All services are subject to benefit coverage, limitations, and exclusions, as described in applicable plan coverage guidelines.

All out-of-network services require prior authorization except for family planning, emergency room, post-stabilization services and table top x-rays. Iowa Total Care providers are contractually prohibited from holding any member financially liable for any service administratively denied by Iowa Total Care for the failure of the provider to obtain timely prior authorization.

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The AMA is a third party beneficiary to this Agreement. Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept". All rights reserved. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories.

You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials. No fee schedules, basic unit, relative values or related listings are included in CDT.

The ADA does no t directly or indirectly practice medicine or dispense dental services. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. The ADA is a third party beneficiary to this Agreement. The scope of this license is determined by the ADA, the copyright holder. End Users do not act for or on behalf of the CMS. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. For instructions on how to navigate the portal and file a claim, or check the status of a claim, use the IntegraNet Provider Portal User Guide.

Use your existing clearing house or enroll and use the IntegraNet clearing house - Visibiledi. Please continue to use your current method of checking for eligibility. You may also refer directly to Amerigroup to check eligibility for Amerigroup members Visibiledi is in the process of loading eligibility. Out of network providers filing a claim electronically or by paper will also need to complete Wavier of Liability.

Amerigroup Members Scan Health Members. Box For additional information, please reference the IntegraNet Provider Manual.