Thursday, 20 October 2016

What is Consumer Direct Health care

Consumer-Directed Health Care

Consumer-directed health care (CDHC) is a movement in the healthcare industry designed to empower members, reduce employer costs and change consumer healthcare purchasing behavior. CDHC provides the member with additional information to make informed and appropriate healthcare decisions through the use of member support tools, provider and network information, and financial incentives. CDHC includes many different benefit plans and services including consumer-directed health plans (CDHP), high deductible health plans and the option to use debit cards for payment. In conjunction with these plans, members may have a health reimbursement account (HRA), health savings account (HSA) or flexible spending-account (FSA).
When the consumer is paying more of the bill, you may need to devote resources to conducting preservice work with patients. Consumers on a high deductible health plan may require more specialized service work due to the questions on cost and options.

• Seeks education about choices
• Selects health plan
• Selects network/ providers
• Seeks information
• Estimates costs to compare providers and treatment options
• Seeks quality information about providers
• Knows what they owe
• Can apply payment from a variety of sources, including access to credit
• Seeks help with next steps of treatment plan
- Health information/ coaching
- Efficient sources
• Promotion to consumers
• Performance information for consumers
• Determines member eligibility and benefits
• May estimate member responsibility for upcoming service
• May inform member of estimate in advance
• Determines eligibility, benefits and specific member responsibility
• Collects correct amount from the source selected by the member
• Provides feedback on performance
• Seeks improvements
- Administrative
- Clinical

Consumer Directed Health Plans

High-deductible health plans (HDHPs) partnered with member personal savings accounts (PSAs), such as an HSA, an HRA, or a FSA, form a CDHP. The type of account used in these arrangements has strong implications to the administration of the CDHP, as the IRS regulations governing these tax-favored PSAs vary significantly.

Once members have met their deductible, covered expenses are paid based on the member’s benefit plan. As a participating provider, you should treat these members just as you would any other Blue Cross member:

• You should accept the Blue Cross reimbursement amount/allowable charge (up to the member’s deductible amount) and any co-insurance amount, if applicable, as payment in full.

• If you collect billed charges up front, you must refund the member the difference between your charge and the Blue Cross reimbursement amount/allowable charge within 30 days.

BlueCard members whose plan includes a debit card can pay for out-of-pocket expenses by swiping the card through any debit card swipe terminal. These cards are used just like any other debit card. The funds will be deducted automatically from the member’s appropriate HRA, HSA or FSA account. If your office currently accepts credit card payments, there is no additional cost or equipment necessary. The cost to you is the same as the current cost you pay to accept any other signature debit card.

Combining a health insurance ID card with a source of payment is an added convenience to members and providers. Members can use their debit cards to pay outstanding balances on billing statements.
They can also use their cards via phone in order to process payments. In addition, members are more likely to carry their current ID cards, because of the payment capabilities.



A. Multiple Practice Locations
Hospices are not precluded from having multiple practice locations if permitted by the regional office (RO). If the RO disapproves an additional practice location, the location must seek Medicare approval as a separate hospice with its own enrollment and provider agreement. (See Pub. 100-07, State Operations Manual (SOM), chapter 2, section 2081, for the policies regarding multiple hospice locations.)

B. Site Visits
• Initial application – If a hospice submits an initial application, the contractor shall order a site visit through the Provider Enrollment, Chain and Ownership System (PECOS) after the contractor receives the tie-in notice (or approval letter) from the RO but before the contractor conveys Medicare billing privileges to the hospice. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section of this chapter. The National Site Visit Contractor (NSVC) will perform the site visit. The contractor shall not convey Medicare billing privileges to the provider prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
• Revalidation – If a hospice submits a revalidation application, the contractor shall order a site visit through PECOS. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section of this chapter.

The NSVC will perform the site visit. The contractor shall not make a final decision regarding the revalidation application prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
• New/changed location - If a hospice is (1) adding a new location or (2) changing the physical location of an existing location, the contractor shall order a site visit of the new/changed location through PECOS after the contractor receives notice of approval from the RO but before the contractor switches the provider’s enrollment record to “Approved.” This is to ensure that the new/changed location is in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section of this chapter. The NSVC will perform the site visit. The contractor shall not switch the provider’s enrollment record to “Approved” prior to the completion of the NSVC’s site visit and the contractor’s review of the results.

For more information on hospices, refer to:
• Sections 1861(u) and 1861(dd) of the Social Security Act
• 42 CFR Part 418
• Pub. 100-07, chapter 2, sections 2080 – 2087 (SOM)
• Pub. 100-04, chapter 11 (Claims Processing Manual)
• Pub. 100-02, chapter 9 (Benefit Policy Manual)
See sections through of this chapter for additional hospice site visit information.

Tuesday, 18 October 2016

Home Health Agencies (HHAs)

Home Health Agencies (HHAs)

A. General Background Information
An HHA is an entity that provides skilled nursing services and at least one of the following therapeutic services: speech therapy, physical therapy, occupational therapy, home health aide services, and medical social services. The services must be furnished in a place of residence used as the patient’s home.

Like most certified providers, HHAs receive a State survey (or a survey from an approved accrediting organization to determine compliance with Federal, State, and local laws), and must sign a provider agreement. All HHA services, moreover, must be part of a plan of care established by a physician, accompanied by a certification from the physician that the patient needs home health services. HHA services can be covered even if the patient lives with someone who might ordinarily be able to perform such services himself/herself.

B. Capitalization and Site Visit Requirements
See section 15.26.2 of this chapter for more information on HHA capitalization requirements. See sections 15.19.2 through for more information on HHA site visit requirements.

C. HHA Components
There are three potential “components” of an HHA organization:
Parent – The parent HHA is the entity that maintains overall administrative control of its location(s).
Sub-unit – A sub-unit is associated with the parent HHA but services a different geographic area. It is thus considered a semi-autonomous HHA, since it is too far away from the parent HHA to share administration/supervision on a day-to-day basis. This means that HHA sub-units must separately enroll in Medicare, obtain a separate State survey, and sign a separate provider agreement. As with parent HHAs, sub-units receive their own 6-digit CMS Certification Number (CCN).

Branch – A branch is a location or site that services patients in the same geographic area as the parent and shares administration with the parent on a daily basis. Consequently, unlike sub-units, branches need not enroll separately. They can be listed as practice locations on the main provider’s (or sub-unit’s) Form CMS-855A. Though the branch receives a 10-digit CCN identifier, it bills under the parent HHA’s or sub-unit’s CCN number.

The question of whether a particular location qualifies as a branch or a sub-unit – which will determine whether a separate Form CMS-855A enrollment is needed – is resolved by the RO.
Consider the following scenario:

owns owns owns

Here, the parent HHA has two branches (A and C) and one sub-unit (B). B also has a branch (D).

They will be enrolled as follows:• The parent HHA must complete a Form CMS-855A, undergo a State survey, and sign a provider agreement.
• Branches A and C must be listed as practice locations on the parent’s Form CMS-855A because a branch is sufficiently “attached” to the parent to be considered part of it.
• Sub-unit B must: (1) enroll separately from the parent, (2) complete its own Form CMS-855A, (3) undergo its own survey, and (4) sign its own provider agreement. For enrollment purposes, it is considered a separate and distinct entity from the parent, hence requiring a separate enrollment. (This also means that Sub-unit B would not have to be listed on the parent’s Form CMS-855A as a practice location.)
• Because sub-units, like parents, can have branches, Branch D would be listed as a practice location on Sub-unit B’s application.
See Pub. 100-07, chapter 2, section 2182, for more information on branches.

D. Out-of-State HHA Branches 
In general, an HHA can only have a branch in another State (and treat it as a branch, rather than a separate HHA) if there is a reciprocity agreement between the two States. If none exists, the out-of-state location must enroll as a new provider by submitting a new Form CMS-855A and signing a separate provider agreement. It cannot be treated as a branch/practice location of the main HHA. (See Pub. 100-07, chapter 2, section 2184 for specific provisions regarding HHAs that cross State lines.)

E. Additional Data
For more information on HHAs, refer to:
• Sections 1861(o) and 1891 of the Social Security Act
• 42 CFR Part 484
• 42 CFR § 489.28 (capitalization)
• Pub. 100-07, chapter 2, sections 2180 – 2198C (State Operations Manual)
• Pub. 100-04, chapter 10 (Claims Processing Manual)
• Pub. 100-02, chapter 7 (Benefit Policy Manual)

Monday, 17 October 2016

Histocompatibility Laboratories / Receipt/Review of Internet-Based PECOS Applications

Histocompatibility Laboratories

A histocompatibility laboratory does “matching” tests in preparation for procedures such as kidney transplants, bone marrow transplants, and blood platelet transfusions. It is the only type of laboratory that must submit a Form CMS-855A application. Each histocompatibility lab must meet all applicable requirements in 42 CFR Part 493 (see 42 CFR §493.1278 in particular) and undergo a State survey.

For information on the appropriate contractor jurisdiction for incoming histocompatibility lab applications, see CMS Pub. 100-04, chapter 1, section 20.

 Receipt/Review of Internet-Based PECOS Applications

A. Submission of Paper Certification Statement
1. Background and Timeframe
If the provider chooses to submit its certification statement via paper rather than through e-signature, it may do so by mail, fax, or scanned e-mail. Unless stated otherwise in this chapter or in another CMS directive:

• The provider must submit the certification statement within 45 calendar days of the date on which it submitted its Internet-based PECOS application. (This applies to all Form CMS-855 Internet-based PECOS submissions, regardless of the type of transaction involved.)

• If the contractor does not receive the certification statement in its mailroom (or via fax/email) within the 45-day period, the contractor may either return the application (unless another CMS directive states otherwise) or contact the provider via any means to request the certification statement. If the contractor chooses the latter option, it shall inform the provider (1) of the deadline by which the statement must be received and (2) that the provider may still sign the application via e-signature. (The specific deadline in (1) lies within the contractor’s discretion.)

• If the provider submits an invalid certification statement (e.g., undated; incorrect individual signed it; not all authorized officials signed it), the contractor shall treat this as missing information and shall develop for a correct certification statement using – unless another CMS directive states otherwise - the procedures outlined in this chapter.

• If the provider wishes to submit a paper CMS-855 certification statement (downloaded from, it should write the tracking ID on the top of the certification statement.

2. Switch to “In Review” and Application Returns
After – and only after – the contractor receives the provider’s certification statement and application fee (if applicable), the contractor shall: (1) enter the date of signature in the “Certification Date” box in the logging & tracking (L & T) record, and (2) change the L & T status to “In Review.” The contractor shall not begin processing the application prior to its receipt of the certification statement and its completion of tasks (1) and (2) in the previous sentence.
If the provider submitted an invalid certification statement, the contractor shall still complete tasks (1) and (2) above. (If the certification statement was undated, the contractor shall use the date that the 45-day clock expired as the date of signature.) An appropriate certification statement can be solicited as part of the development process.

If the contractor can determine (without having yet begun processing the application) that an application can be returned under section 15.8.1 of this chapter (e.g., Form CMS-855I was submitted more than 60 days prior to the effective date), the contractor may return the application without waiting for the arrival of the certification statement.

B. Processing of Application
After tasks (1) and (2) above have been completed, the contractor shall begin processing the application. Subject to the processing alternatives in sections through, processing includes (but is not limited to):

• Ensuring that all required data elements on the application have been completed and that all required supporting documentation has been submitted (either via paper or the Digital Data Repository (DDR))
• Validating all data on and submitted with the application

Sunday, 16 October 2016

Federally Qualified Health Centers (FQHCs)

Federally Qualified Health Centers (FQHCs)
FQHCs furnish services such as those performed by physicians, nurse practitioners, physician assistants, clinical psychologists, and clinical social workers. This also includes certain preventive services like prenatal services, immunizations, blood pressure checks, hearing screenings and cholesterol screenings. (See CMS Publication 100-02, chapter 13, for more information). Even though they complete the Form CMS-855A application, FQHCs are considered Part B certified suppliers.

FQHCs are not required to obtain a State survey; there is no State agency involvement with FQHCs. As such, the contractor will either deny the application or make a recommendation for approval and forward it directly to the RO. The RO will then make the final decision as to whether the entity qualifies as a FQHC. Generally, in order to so qualify, the facility must be receiving, or be eligible to receive, certain types of Federal grants (sometimes referred to as “grant status”), or must be an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act or by an Urban Indian organization. The Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services (DHHS) may assist the RO in determining whether a particular supplier meets FQHC standards, since HRSA maintains a list of suppliers that met certain grant requirements. (See CMS Pub. 100-07, chapter 2, sections 2825-2826D for more information.)

NOTE: Additional information about FQHCs:
• As stated above, there is no State agency involvement with FQHCs. However, FQHCs still must meet all applicable State and local requirements and submit all applicable licenses. Typically, HRSA will verify such State/local compliance by asking the FQHC to attest that it meets all State/local laws.
• FQHCs can be based in a rural or urban area that is designated as either a shortage area or an area that has a medically underserved population.
• To qualify as an FQHC, the facility must, among other things, either (1) furnish services to a medically underserved population or (2) be located in a medically underserved area.
• The FQHC must submit a signed and dated Attestation Statement for Federally Qualified Health Centers (Exhibit 177). This attestation serves as the Medicare FQHC benefit (or provider/supplier) agreement. (See Pub. 100-07, chapter 2, section 2826B.) The FQHC must also submit, as indicated above, a HRSA “Notice of Grant Award” or Look-Alike Status. A completed FQHC crucial data extract sheet (Exhibit 178), however, is no longer required.
• The contractor shall ensure that the attestation statement (Exhibit 177) contains the same legal business name and address as that which the FQHC provided in section 2 and section 4, respectively, of the Form CMS-855A. If the attestation contains a different name, the contractor shall develop for the correct name.
• An FQHC cannot have multiple sites or practice locations. Each location must be separately enrolled and will receive its own CMS Certification Number.
• If an FQHC submits a change of information request to change its location, the contractor may wish to contact the RO to see whether the change (1) is such that an initial enrollment is required (i.e., the change constitutes the establishment of a new FQHC) or (2) makes the clinic no longer eligible for enrollment as an FQHC (i.e., the change is to a location that is neither a shortage area nor an area with a medically underserved population).

When sending a recommendation for approval letter to the RO for an initial FQHC application, the contractor shall indicate in the letter the date on which the FQHC’s application was complete. To illustrate, assume that the FQHC submitted an initial application on March 1. Two data elements were missing; the contractor thus requested additional information. The two elements were submitted on March 30. The contractor shall therefore indicate the March 30 date in its letter as the date the application was complete.

See CMS Publication 100-07, chapter 2, section 2826F for information regarding the effective date of an FQHC’s agreement with CMS.

For additional general information on FQHCs, refer to:
• Section 1861(aa)(3-4) of the Social Security Act
• 42 CFR Part 491 and 42 CFR Part 405.2400
• Pub. 100-07, chapter 2, sections 2825 – 2826H
• Pub. 100-07, Exhibit 179
• Pub. 100-04, chapter 9 (Claims Processing Manual)
• Pub. 100-02, chapter 13 (Benefit Policy Manual)

For information on the appropriate contractor jurisdictions for incoming FQHC enrollment applications, see:
• Pub. 100-04, chapter 1, section 20
• Pub. 100-04, chapter 9, section 10.3

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