Produced by - Mead Johnson Nutrition

Once the number is obtained, the provider reimbursement personnel contact the company to determine the likelihood andamount of reimbursement. Unfortunately, this isn’t a guarantee of reimbursement, but an important step in the reimbursementprocess. Specific areas that need to be addressed are:Coverage InformationPolicy RestrictionsProvide: ➝ Pre-existing conditionsPatient name, sex, insured’s name, relation ➝ Homecare restrictionsto patient, insured’s identification number, ➝ Contracted providers and restrictionsgroup number and patient date of birth ➝ Time of service limitations➝ Timely filing requirementsDetermine: ➝ Precertification/preauthorization requirements➝ Whether or not the patient/insured are covered➝ Effective coverage dates➝ Enteral nutrition coverage➝ Certification/credentialling requirements➝ DeductiblesBilling Documentation and ProcessPricing➝ Claim forms (HCFA-1500, other) ➝ Acceptable methodologies➝ Codes (HCPCS) ➝ Negotiated rates➝ Medicare documentation ➝ Payment terms➝ Documentation process➝ Billing process (case management)CODES AND FORMSPrivate and managed care payers generally acceptthe HCFA-1500 for billing enteral products in the home.When the HCFA-1500 is required by the payer, theneither the HCPCS codes with a narrative will be requiredfor enteral billing or the payer may accept internallydeveloped codes by the provider. The ICD-9-CM codesare also typically required by payers to identify thepatient’s diagnosis. Where per diem billing has beennegotiated, the HCFA-1500 can still be used to denote theper diem rates. Some payers require itemizations with perdiem billing.When capitation payment methodologies are in place,billing and coding may not be required by the payer,depending upon how the capitation contract is written.Because the payer reimburses the provider a per memberper month (PMPM) rate prior to each month, the payer mayonly require utilization summaries of services for theirparticular member population. Where a payer requirescodes and forms on each patient, there is essentially anundue administrative burden placed on the provider.TIMELY FILINGManaged care organizations (MCOs) have differentpolicies on timely filings of claims. Some MCOs attemptto shorten the timely filing requirements to 30 to 60 daysand this may be unreasonable for your organization. Aminimal timely filing of 90 days should be requested anda period of one year is ideal. The reimbursementdepartment should work closely with the managed carecontracting department to ensure contracts are written in areasonable manner. Whatever the timely filing limits maybe, it is advisable to bill as soon as possible after servicesare rendered.74MEDICAL DOCUMENTATIONEven when insurance verification takes place,insurance companies will only approve services “subjectto medical necessity.” Private insurance companies do notrequire, nor do they prefer Medicare CMNs, so these arenot recommended.Medical documentation needed is a single page ofpatient information that is signed by the prescribingphysician. Sometimes these are called letters of medicalnecessity (LOMN). These can be completed in a letter orform and they typically need to include:❏ The patient’s name❏ The insured’s name❏ Patient diagnosis❏❏❏❏Type(s) of enteral products and servicesrenderedMethod of administrationEstimated durationThe provider name, address, telephone numberand federal tax identification number❏ The prescribing physician’s name, address,telephone number, signature and dateManaged care payers often require a precertification(precert) or prior authorization before services aredelivered and/or to continue services. Sometimes these areverbal and other times there is a paper certificationgenerated that needs to be submitted with the claim form.Other times there is a certification number that needs to beput on the claim form.May, 2002