Fidelis SecureCare of North Carolina Provider Manual

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Frequently Asked Questions 1. How does Fidelis reimburse for Part A skilled nursing services? Fidelis will reimburse facilities for Part A skilled services using Medicare PPS (Prospective Payment System) rates. The facility may submit either charges or contracted rates to Fidelis, but claims will be adjusted based on the contract between Fidelis and the facility. SNFs should also file a claim to the SNFs intermediary using Condition Code 04 (Information Only) to update the Common Working File 2. Can the nursing facility or other providers bill Fidelis for DME? Fidelis follows Medicare guidelines for determining if DME benefits will be covered. Currently, DME is covered to the extent that it is provided in the patient’s home. Nursing facilities are generally excluded from Medicare’s definition of home. In addition, DME provided during the same Part A “spell of illness” as skilled services is included in the PPS rate and cannot be billed separately to Fidelis. Prosthetics and orthotics may be reimbursable when billed by the original provider (i.e. not the nursing facility). 3. Do I need to place my Authorization Number on the claim form? Yes, authorization numbers should be included on each claim form. They should be added to Box 63 on the UB04 and Box 23 on the CMS 1500 or the electronic equivalents. 4. How do I bill for Part B Therapy Services (Physical Therapy, Speech- Language Pathology Services and Occupational Therapy)? Outpatient therapy services are paid as Part B if the member has exhausted or is ineligible for benefit days under Part A. Such services may be furnished directly by the SNF or under arrangements with another provider; however, they must be billed by the nursing facility. Charges must be billed on UB04 Form, or its electronic equivalent. The correct bill type for a SNF Part B therapy claim is 22X. Use Revenue codes 0420 (PT) 0430 (OT) and 0440 (SLP). FAQs
Fidelis will reimburse the facility for authorized services at Medicare rates subject to therapy limits and member co-pays and deductibles. Providers may bill for authorized therapy in excess of benefit limits using appropriate modifiers KX (requirements specified in the medical policy have been met) and GP (services delivered under outpatient therapy plan of care). 5. How to bill Non- Emergent Transportation Services? Non-emergency, routine wheelchair transportation services should be billed using HCPCS code A0130 for each round trip. When wait times are included in contracts, they should be billed using HCPCS code A0170 for each 30-minute (1 Unit) increment. HCPCS codes should be placed in Field 24d on the CMS 1500 form and Field 44 on the CMS 1450/UB04 or its electronic equivalent. Use the standard Medicare ambulance transportation modifiers attached to the A0130 to indicate the “To/From” information. 6. Does Fidelis do cross-over billing? Yes, Fidelis will begin to cross over claims to Medicaid to the extent that correct information is provided on an electronic claim. 7. Does Fidelis enroll hospice patients? Yes, Fidelis SecureCare will enroll Hospice patients. However, the hospice benefit is managed and paid for by original Medicare. It should be clear to the resident or responsible party that most of Fidelis clinical benefits such as extra physician visits could be contrary to the hospice plan of care. 8. Once a member elects hospice, how should professional services be billed? Physicians should add a modifier GV (attending physician not employed or paid under arrangement by the patient’s hospice provider) to CPT codes on the CMS 1500 form. FAQs
Page 1 and 2: Provider Manual North Carolina
Page 3 and 4: Utilization Management Affirmative
Page 5 and 6: Fraud, Waste and Abuse Provider and
Page 7 and 8: Regulations and Responsibilities Co
Page 9 and 10: • Contracted providers agree to r
Page 11 and 12: Physician Responsibilities Primary
Page 13 and 14: Access to Care Fidelis has adopted
Page 15 and 16: The Care Management team is compris
Page 17 and 18: • Psychotropic Medication Managem
Page 19 and 20: Credentialing Credentialing Program
Page 21 and 22: SecureCare members only as a result
Page 23 and 24: • Have no significant utilization
Page 25 and 26: Medical/treatment record keeping re
Page 27 and 28: Eligibility You may verify the elig
Page 29 and 30: You can receive your username and p
Page 31 and 32: Quality Program Purpose The purpose
Page 33 and 34: Referral and Prior Authorization Pr
Page 35 and 36: Referrals to Non-Participating Prov
Page 37 and 38: Criteria for Authorizing Part A Ski
Page 39 and 40: Fidelis SecureCare Criteria for Aut
Page 41 and 42: OUTPATIENT CARE COORDINATION PHONE:
Page 43 and 44: Remittance Advice (RA) Payments rec
Page 45 and 46: Claims Look-Up Once logged in, you
Page 47: Claim Disputes and Appeals Appealin

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