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Billing Newsletter | August 2022

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A U G U S T 2 0 2 2

BILLING

NEWSLETTER

C O N T E N T

What to do if clinic receives insurance

check

Patient Balance/Refund

Code New/Established visits

Patients Information

"Clinic to Review"

Employee Fee Schedule

Insurance information

Insurances Updates

How to verify patients for Meritian Health

& Cigna

Insurance Verification

Considerations

PCP Information

Verify Benefits for Cigna Plus

Payor Specific

Authorization for Eye Exams

COVID-19 Vaccines Guidelines


W H A T T O D O I F C L I N I C R E C E I V E S I N S U R A N C E C H E C K

1. Complete deposit for all insurance checks that has pay to Topcare Medical PA and/or Topcare Medical Group Inc.

2. Scan/email deposit (include deposit slip with date, check, and EOB) – should be emailed to deposits@mdmedicalgorup.us

3. Carbon copy Tory Stinson – Payments Team Supervisor – tstinson@clinicasmidoctor.com

Acquisition clinics 042-054 receive live checks made payable to CHPG please send them to:

CHPG

PO Box 848468

Dallas, TX 752848468

If you are unsure at any time, please reach out to:

Anika – Ext. 8107 Email: awoodard@mdmedicalgroup.us

Tory – Ext. 8102 Email: tstinson@mdmedicalgroup.us

David – Ext. 8131 Email: dlang@mdmedicalgroup.us

P A T I E N T B A L A N C E / R E F U N D

Patients with

balance

Please allow to pay at the clinic. We

should never turn patients that want

to make a payment away.

Questions about balance – Billing dept. 972-957-3000 option 2.

Payment by phone – Patient Payment Collectors: Nuvia Lucio Ext. 8124

Email: nlucio@mdmedicalgroup.us

Patient Collections phone number – 1 800 711 6521

Medical Record Requests need to be sent to – Email: mdmedical@dmrs.net / Fax

(213) 225-5070 / Phone (800) 359-8520

Patient refunds

need an allowance period of 30 days to complete processing.

How to code new/established visits on the same day.

(when the patient is truly a new patient to our facilities)

PAYOR GROUP PATIENT AGE RULE CPTS YOU MAY USE

COMMERCIAL

ALL AGES

Well visits are going to be

billed as a new patient

Sick visits billed as if

patient was established

99381 - 99387

99211 - 99215

0 - 20 YEARS

Well visits are going to be

billed as a new patient

99381 -

99385

99201 -

99205

MEDICAID

21 YEARS AND

MORE

Well visits are going to be

billed as a new patient

Sick visits billed as if

patient was established

99385 - 99387

99211 - 99215

If visit is done by a Locum, two separate notes will need to be attached to the patients file

LOCUMS

Make sure progress note is signed and scanned, the correct template is used

(acute / preventive), if correct template is needed, please ask RDO. Locum

providers should never see Medicare patients.

*Updates found in green font.


P A T I E N T S ' I N F O R M A T I O N

Please remember to update patient's information such as address and

telephone number. Please update Medicare patient accounts with their new

identification cards.

Make sure that for children the demographics contains

GUARANTOR/RESPONSIBLE PARTY. We are seeing numerous account where

this is missing.

If patient with insurance signs the "Self-Pay Form" please remove insurance

from claim at the time of creation.

" C L I N I C T O R E V I E W "

Clinics are removing the insurance from claims and billing patients – no one at

the clinic should be removing insurance nor clearing the balances to the

patients. Please respond to the Biller/Insurance Collector in the browser notes

along with updating claim status to “Clinic to Review Complete”.

Once modifications to the claims have been addressed, make sure you specify

the changes in the billing notes before moving the claim to "Clinic to Review

Complete".

E M P L O Y E E F E E S C H E D U L E

If employee is coming for Office Visit, choose the correct "Employee Fee

Schedule" and adjust ONLY Employee adjustment to $0.01. Do not adjust any

other service. Employee has to be charged the full amount under Employee Fee

Schedule.

Charges should be collected when service is performed.

*Updates found in green font.


*Updates found in green font.

INSURANCE

information

C H I P C O - P A Y M E N T S

Medical office visit co-payments are waived for

all CHIP members for services provided from

March 13, 2020 through August 31, 2022. Copayments

are not required for covered services

delivered via Telemedicine or Telehealth to

CHIP members.

P A R T I C I P A T I O N R E M I N D E R S

We are NOT in contract with out of state Medicare plans.

We currently DO NOT participate with:

Aetna Memorial Herman

Palmetto (Railroad Medicare)

Bright Healthcare Super Plan

C R E D E N T I A L I N G

U t i l i z e t h e M C O g r i d t o k n o w w h i c h p a y e r

w e a r e P A R w i t h .

I f y o u d o n o t s e e a p a y e r l i s t e d p l e a s e c a l l

a n d v e r i f y b e n e f i t s f o r t h e s e r v i c i n g

p r o v i d e r t o d e t e r m i n e i f t h e p a t i e n t h a s

i n / o u t o f n e t w o r k b e n e f i t s .

C R E D E N T I A L I N G F O R T H E N E W L Y O N B O A R D E D

N E W W O R K F L O W T O E N T E R

L O T N U M B E R W H E N

R E C E I V I N G I M M U N I Z A T I O N

I N V E N T O R Y

As of 05/09/22, the workflow for

adding a new immunization lot

number into eCW has changed. It is

now clinic responsibility.

The clinic staff is in charge of

maintaining the system up to date

with the lot numbers and NDCs in

stock at their corresponding clinic.

This process needs to be performed

every time the clinic receives new

immunization stock.

The manual on how to enter a new lot

number into eCW is attached in the

newsletter email and was also sent to

CQI team. Please refer to CQI team for

training about this matter.

Newly onboarded MDs cannot see patients until they are confirmed to be credentialed.

Otherwise Medicaid & Marketplace claims will deny and Commercial/Medicare MCOs will

process claims as OON.

New onboarded Midlevels cannot see the following plans until they are confirmed to be

credentialed

- Cook Children - Amerigroup - CHC

We are only PAR with the Medicaid product for Cigna Healthsprings.

So please make sure you verify benefits! We will notify you when our providers are PAR with

the Medicare product.

Before using BCBS HMO plan we need to check the member benefits with the individual providers

NPI that Will be seeing the member, since we must be their PCP.

None of our DFW locations should see patients who have TCHP, only Houston Providers are PAR

with this plan.


I N S U R A N C E S U P D A T E S

B C B S I N S U R A N C E R E C O R D

It is very important to add correct BCBS

insurance record on patient account when

adding to any patient account. We are

encountering claim denials due to claim being

billed to BCBS of New Mexico, but should have

been billed to BCBS PPO or BCBS POS and/or

BCBS HMO

U H C C O M M U N I T Y

Some of the Dallas providers are now showing

in-network with this product and have been

added to the grid. Please still call and verify

benefits as there are 8 different plans listed

under this product.

B C B S

We have been terminated from the Medicare

Advantage HMO, Dual Special Needs and

WellMed MA HMO Plans under Blue Cross Blue

Shield.

Contract has been sent to contracting once we

are back in-network you will be notified

B R I G H T H E A L T H P L A N F O R

H O U S T O N A N D D F W

Per contracting we are on a direct contract and

providers will not be added to the super plan.

With that said, eventually the providers who are

showing in-network with the super plan will be

updated to the standard plan only. Please

continue to verify benefits prior to seeing

these patients

M E R I T I A N H E A L T H

H O W T O V E R I F Y P A T I E N T S F O R :

1. Call the number on the card to verify if we are PAR with the network the patient is part of.

2. When calling, please look at your latest MCO grid to see the providers that are PAR with Aetna.

3. As mid-levels are not credentialed with Aetna, only MD’s, please give them the name of the midlevels

supervising physician so they are able to locate them on the list. Also, let them know the

location in where the supervising physician works, because most of the rep’s search by location first.

C I G N A

1. As mid-levels are not credentialed with Cigna, only MD’s, please give them the name of the midlevels

supervising physician so they are able to locate them on the list. Also, let them know the

location in where the supervising physician works, because most of the rep’s search by location first.

Please contact LeKeysha Sewell if you have any question 972-957-3000 ext. 8182

Notice: It is important to call every time a patient comes in with this card, since there are many different networks under Meritain Health.

All patient encounters should have insurance verification attached for each encounter which includes front/back

copy of identification card

H E A L T H C A R E 2 U P A T I E N T S S H O U L D N E V E R B E B I L L E D F O R L A B S

We should be charging patient for labs not covered based upon their current plan after we have

verified benefits. If labs are billed to LabCorp it is the clinic responsibility to update requisition form “Bill

to Client”, so that the patient does not receive a statement from LabCorp.

*Updates found in green font.


I N S U R A N C E

v e r i f i c a t i o n

C O N S I D E R A T I O N S

ALL CLINICS PLEASE CONSIDER AND MAKE SURE WE ARE VERIFYING:

When adding a new insurance Add effective date of plan.

When an insurance becomes inactive Add termination date of plan.

Always scan Front & Back from copy of ID Card at the time of service, for EACH

encounter.

Benefits on all patients as well as collecting co-pays, deductibles and/or coinsurances

at the time of the service. (please use Master Fee Schedule for

collecting deductibles / co-insurances)

Patient's benefits through TMHP and payor's portal every time a patient returns

to clinic.

That the provider is linked to Topcare Medical Group Inc.

Benefits to know if Sports Physical is a covered benefit, for Superior Ambetter.

P C P I N F O R M A T I O N

For all HMO’s, staff should update the PCP to our provider treating the patient

at the time of service.

Amerigroup has finished loading Amerivantage to our providers. You can call

Amerigroup and they should be able to change PCP.

V E R I F Y B E N E F I T S F O R C I G N A P L U S

Imperative all clinics Verify benefits for Cigna Local Plus for provider that will be

rendering services to the patient.

P A Y O R S P E C I F I C

All Medicaid Insurance needs to be verified on the 1st of every month.

If patient has a Dual Plan please make sure you use the presentation provided

"Dual Policies" to verify insurance and load correct Medicaid and Medicare

plans.

If the patient has BCBS HMO then they should not add BCBS PPO to the

patients account but add BCBS HMO insurance record.

A U T H O R I Z A T I O N F O R E Y E E X A M S

Ambetter requires PRIOR authorization for Eye Exams.

If patient has CHC we must obtain authorization for CPT 17340 prior to performing.

*Updates found in green font.


COVID-19

VACCINES GUIDELINES

COVID 19 VACCINE AGES TYPE OF CODE CPT ECW CPT NAME

EFFECTIVE

VACCINE 91303 COVID 19 (JANSSEN) >18YRS

J&J (JANSSEN)

18 & OLDER 1ST DOSE ADMIN

0031A

COVID-19 IM ADMIN (J&J) BOOSTER COMPONENT

2/27/2021

BOOSTER VACCINE

0034A

COVID-19 IM ADMIN (JANSSEN) BOOSTER

VACCINE

91301 COVID 19 (MODERNA) >18YRS

MODERNA

18 & OLDER

1ST DOSE ADMIN

2ND DOSE ADMIN

3RD DOSE ADMIN

0011A

0012A

0013A

COVID-19 IM ADMIN (MODERNA) 1ST COMPONENT

COVID-19 IM ADMIN (MODERNA) 2ND COMPONENT

COVID-19 IM ADMIN (MODERNA) 3RD COMPONENT

12/18/2020

BOOSTER VACCINE

BOOSTER ADMIN

91306

0064A

BOOSTER-COVID 19 (MODERNA-0.25ML) >18YRS

COVID-19 IM ADMIN (0.25 ML MODERNA) BOOSTER

COMPONENT

10/20/2021

VACCINE 91305 COVID 19 (PFIZER- GRAY) >12YRS

1ST DOSE ADMIN

0051A

COVID-19 IM ADMIN (PFIZER-GRAY) 1ST DOSE

GRAY

12 & OLDER

2ND DOSE ADMIN 0052A COVID-19 IM ADMIN (PFIZER-GRAY) 2ND DOSE

1/3/2022

PFIZER

3RD DOSE ADMIN

0053A

COVID-19 IM ADMIN (PFIZER-GRAY) 3RD DOSE-

IMMUNO

BOOSTER ADMIN 0054A COVID-19 IM ADMIN (PFIZER-GRAY) BOOSTER

VACCINE 91308 COVID-19 (PFIZER) >12YRS

MAROON 6 MONTHS -

4 YEARS

1ST DOSE ADMIN 0081A COVID-19 IM ADMIN (PFIZER) 1ST COMPONENT

2ND DOSE ADMIN 0082A COVID-19 IM ADMIN (PFIZER) 2ND COMPONENT

3RD DOSE ADMIN 0033A COVID-19 IM ADMIN (PFIZER) 3RD COMPONENT

8/12/2021

10/20/2021

VACCINE

91307

COVID 19 (PFIZER) PEDIATRIC 5-11YRS

PFIZER

PEDIATRICS ORANGE

CHILDREN

5-11

1ST DOSE ADMIN

2ND DOSE ADMIN

3RD DOSE ADMIN

0071A

0072A

0073A

COVID-19 IM ADMIN CHILD - (PFIZER) 1ST

COMPONENT

COVID-19 IM ADMIN CHILD - (PFIZER) 2ND

COMPONENT

COVID-19 IM ADMIN CHILD - (PFIZER) 3RD

COMPONENT

10/29/2021

BOOSTER ADMIN

0074A

COVID-19 IM ADMIN CHILD - (PFIZER) BOOSTER

COMPONENT

*COVID-19 Vaccines Guidelines has

been updated

*Updates found in green font.


C O V I D V A C C I N E F O R S E L F P A Y P A T I E N T S

Self-Pay/Underinsured Patients: Vaccine administration will be FREE

for Self-Pay and Underinsured Patients.

P R O C E S S F O R C O V I D V A C C I N E

D O C U M E N T A T I O N O N E C W

Documentation on eCW is required (progress note and claim) for all

patients.

Document in ECW (as any other service) by creating a progress note.

Lock the note for the claim to be created automatically.

Adjust the claim using TERMCVD adjustment code.

P R O C E S S F O R C O V I D T E S T I N G ( R A P I D A N T I G E N

A N D P C R ) :

Covid Rapid Antigen and PCR Testing will no longer be “free” or billed to the Care’s

Act for self-pay patients. Please follow these prices for COVID testing:

Covid Rapid Antigen Test CPT - 87426: Self-Pay $15.00 (does not include office visit).

PCR Test CPT - 87913: Self-Pay Price $150.00 (does not include office visit).

Commercial patients: Verify benefits to see if Covid test will be applied to any

deductible and/or co-insurances.

P R O C E S S F O R E M P L O Y E E C O V I D T E S T I N G

Covid Rapid Antigen Test CPT - 87426: Self-Pay $10.00 (Office visit is Free, please

refer to employee fee schedule)

If employee has Insurance the self pay price does not apply.

Employee can test at their home clinic so long as the test is ordered and

documented by a provider

C O V I D - 1 9 V A C C I N E S : C H A N G E S

F O R M E D I C A R E A D V A N T A G E P L A N

Effective with DOS 1/1/2022, for patients with a Medicare

Advantage plan, the COVID vaccine administration will be

filed to the Advantage plan, not traditional Medicare.

Claims with DOS prior to 1/1/22, will follow 2021 protocol,

billing COVID vaccine administration to traditional Medicare

(using the patient’s Traditional Medicare number).

*Updates found in green font.

"Make EACH DAY your

MASTERPIECE".

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