Chapter A-200, Handbook for Practitioners Rendering Medical ...

Handbook for Practitioner ServicesChapter A-200 – Policy and Proceduresdepartment will accept the medical school’s or sponsoring hospital’s residencyprogram supervision protocol and other medical record documentation in thedetermination of whether the teaching physician has provided appropriatesupervision and assumed appropriate responsibility for the services provided by theresident. If the protocol and residency records are not readily available in the eventof a department audit, the medical school or sponsoring hospital will be held to therequirements specified in the first paragraph of this topic.=A-202.15 Allowable Charges for Services Provided at a Hospital-Owned Off-SiteFacilityEffective Date: June 15, 2011Facilities Located within 35 Miles of the HospitalHospital BillingCharges may be submitted for services provided at an off-site hospital-owned clinic,express care or urgent/priority care facility. The hospital may bill facility charges forprocedures from the Ambulatory Procedures Listing (APL) as described in theHandbook for Hospital Services, Topic H-270. Services that fall within the limits ofTopic A-202.13 of this handbook and do not contain a billable APL service may bebilled fee-for-service.Practitioner BillingProfessional services provided in conjunction with a procedure from the APL mustbe billed following the policy located in Topic A-202.12. Other professional servicessuch as office visits must be billed by the practitioner who rendered the service. Ifbilling electronically, indicate the rendering practitioner in the Rendering ProviderLoop.Facilities Located more than 35 Miles from the HospitalA salaried practitioner may submit charges for the services provided at an off-sitehospital-owned clinic, express care or urgent/priority care facility. The salariedpractitioner may submit charges for office visits and for only the technical componentof any laboratory or radiology services performed. The interpreting practitioner mustsubmit charges for the professional component of the laboratory and radiologyservices. Charges submitted for any office visits, laboratory or radiology servicesperformed must be submitted with place of service “office”. The salaried practitionermay request that the hospital’s CLIA be posted to the practitioner’s enrollment file.Refer to Appendix A-15, for billing examples.HFS A-202 (4)

Handbook for Practitioner ServicesChapter A-200 – Policy and ProceduresA-202.2 Electronic Claim SubmittalAny services that do not require attachments or accompanying documentation maybe billed electronically. Further information concerning electronic claims submittalcan be found in Chapter 100, Topic 112.3 or Chapter 300, Topic 302.Providers billing electronically should take special note of the requirement that FormHFS 194-M-C, Billing Certification Form, must be signed and retained by theprovider for a period of three (3) years from the date of the voucher. Failure to do somay result in revocation of the provider’s right to bill electronically, recovery ofmonies or other adverse actions. Form HFS 194-M-C can be found on the last pageof each Remittance Advice that reports the disposition of any electronic claims.Refer to Chapter 100, Topic 130.5 for further details.Please note that the specifications for electronic claims billing are not the same asthose for paper claims. Please follow the instructions for the medium being used. If aproblem occurs with electronic billing, providers should contact the department in thesame manner as would be applicable to a paper claim. It may be necessary forproviders to contact their software vendor if the department determines that theservice rejections are being caused by the submission of incorrect or invalid data.A-202.3 Claim Preparation and SubmittalRefer to Chapter 100, Topic 112, for general policy and procedures regarding claimsubmittal. For general information on billing for Medicare covered services andsubmittal of claims for participants eligible for Medicare Part B, refer to Chapter 100,Topics 112.5 and 120.1. For specific instructions on preparing claims for Medicarecovered services, refer to Appendix A-2.The department uses a claim imaging system for scanning paper claims. Theimaging system allows more efficient processing of paper claims and also allowsattachments to be scanned. Refer to Appendices A-1 through A-5 for technicalguidelines to assist in preparing paper claims for processing. The department offersa claim scanability/imaging evaluation. Please send sample claims with a request forevaluation to the following address.A-202.4 PaymentHealthcare and Family Services201 South Grand Avenue EastSecond Floor - Data Preparation UnitSpringfield, Illinois 62763-0001Attention: Provider/Image System LiaisonPayment made by the department for allowable services will be made at the lower ofthe provider's usual and customary charge or the maximum rate as established bythe department.HFS A-202 (5)

Handbook for Practitioner ServicesChapter A-200 – Policy and ProceduresRefer to Chapter 100, Topics 130 and 132, for payment procedures utilized by thedepartment and General Appendix 8 for explanations of Remittance Advice detailprovided to providers.For participants eligible for Medicare Part B benefits, payment will be considered onthe deductible and coinsurance amounts and/or for department’s Medical Programscovered services not covered by Medicare. (See Chapter 100, Topic 120).A-202.5 Fee ScheduleThe fee schedule of allowable Procedure Codes and special billing information isavailable on the department’s Web site. The Web site listings and the downloadablerate file are updated quarterly.HFS A-202 (6)

Handbook for Practitioner ServicesChapter A-200 – Policy and ProceduresHFS A-226 (2)

Handbook for Practitioner ServicesChapter A-200 – AppendicesHFS Appendix A-8 (2)

Handbook for Practitioner ServicesChapter A-200 – AppendicesAppendix A-15Billing Instructions for Hospital Owned Off-Site Clinics Facilities Located more than 35 Miles from the HospitalEffective Date: June 15, 2011PaperClaimsProfessionalComponentsTechnicalComponentsOffice Visit Laboratory Services Patient Not Seen By APhysician at theClinic/ReferredSalaried PhysicianPOS = OfficeBilling Provider =Physician’s NPIHospital – PayeeNonePathologistModifier 26POS = OfficeBilling Provider =Pathologist’s NPI(Salaried or Non-Salaried)Hospital or Pathologist –PayeeSalaried PhysicianModifier TCPOS = OfficeBilling Provider =Physician’s NPIHospital – PayeeCLIA assigned toPhysicianPathologistModifier 26POS = OfficeBilling Provider =Pathologist’s NPI(Salaried or Non-Salaried)Hospital or Pathologist –PayeePathologistModifier TCPOS = OfficeBilling Provider =Pathologist’s NPIHospital or Pathologist –PayeeCLIA assigned toPathologistRadiology ServicesRadiologistModifier 26POS = OfficeBilling Provider =Radiologist’s NPI(Salaried or Non-Salaried)Hospital or Radiologist– PayeeSalaried PhysicianModifier TCPOS = OfficeBilling Provider =Physician’s NPIHospital – PayeePatient Not Seen By APhysician at theClinic/ReferredRadiologistModifier 26POS = OfficeBilling Provider =Radiologist’s NPI(Salaried or Non-Salaried)Hospital or Radiologist –PayeeRadiologistModifier TCPOS = OfficeBilling Provider =Radiologist’s NPIHospital or Radiologist –PayeeHFS Appendix A-15 (1)

Handbook for Practitioner ServicesChapter A-200 – Appendices837PCLAIMSProfessionalComponentsTechnicalComponentsOffice Visit Laboratory Services Patient Not Seen By APhysician at theClinic/ReferredSalaried PhysicianPOS = OfficeBilling Provider =Hospital’s NPIRenderingProvider =Physician’s NPINonePathologistModifier 26POS = OfficeBilling Provider =Hospital’s NPI, if thePathologist is salariedby the hospital.Rendering Provider =Pathologist’s NPIBilling Provider =If the Pathologist is notsalaried by thehospital, the BillingProvider =Pathologist’s NPINo RenderingProviderSalaried PhysicianModifier TCPOS = OfficeBilling Provider =Physician’s NPIPay-To Provider =Hospital Payee NPINo RenderingProviderCLIA assigned toPhysicianPathologistModifier 26POS = OfficeBilling Provider =Hospital’s NPI, if thePathologist is salaried bythe hospital.Rendering Provider =Pathologist’s NPIBilling Provider =If the Pathologist is notsalaried by the hospital,the Billing Provider =Pathologist’s NPINo Rendering ProviderPathologistModifier TCPOS = OfficeBilling Provider =Pathologist’s NPIPay-To Provider =Hospital or Pathologist’sNPINo Rendering ProviderCLIA assigned toPathologistRadiology ServicesRadiologistModifier 26POS = OfficeBilling Provider =Hospital’s NPI, if theRadiologist is salaried bythe hospital.Rendering Provider =Radiologist’s NPIBilling Provider =If the Radiologist is notsalaried by the hospital,the Billing Provider =Radiologist’s NPINo Rendering ProviderSalaried PhysicianModifier TCPOS = OfficeBilling Provider =Physician’s NPIPay-To Provider =Hospital Payee NPINo Rendering ProviderPatient Not Seen By APhysician at theClinic/ReferredRadiologistModifier 26POS = OfficeBilling Provider =Hospital’s NPI, if theRadiologist is salariedby the hospital.Rendering Provider =Radiologist’s NPIBilling Provider =If the Radiologist is notsalaried by the hospital,the Billing Provider =Radiologist’s NPINo RenderingProviderRadiologistModifier TCPOS = OfficeBilling Provider =Radiologist’s NPIPay-To Provider =Hospital orRadiologist’s NPINo RenderingProviderHFS Appendix A-15 (2)