Fax Telephone 855-454-5584 502-719-8600 9900 Corporate Campus Dr. Ste. 1000 Louisville, Ky. 40223 FAX To: Providers Fax: Location fax From: CoventryCares of Kentucky Date: September 5, 2014 Re: Important Reminders & Updates: Pages: 3 pages including cover 1.Provider Information on Claims Reprocessed for Co-pay changes 2. Prior Authorization List 3. Diabetes Mellitus 4. NDC Billing Requirements 5. Notice of Claims Edit Implementation 6. Updated “Who’s My Provider Relations Representative” Listing Urgent For Review Please Comment Please Reply Please Recycle Notes: We appreciate your participation in the CoventryCares of Kentucky provider network and hope you find the enclosed information helpful. IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message. To: From: Date: RE: CoventryCares of Kentucky Providers CoventryCares of Kentucky September 5, 2014 1. Provider Information on Claims Reprocessed for Co-pay changes 2. Prior Authorization List 3. Diabetes Mellitus 4. NDC Billing Requirements 5. Notice of Claims Edit Implementation 6. Updated “Who’s My Provider Relations Representative” Listing 1. Provider Information on Claims Reprocessed for Co-pay changes CoventryCares of Kentucky has received updated enrollment files from the Department for Medicaid Services to correct the co-pay eligibility for members who were tied to a co-pay plan in error. We are reprocessing claims for which provider payment was reduced due to this error. Future remittance advices will reflect the adjustment. If a provider has collected a co-pay from a member related to one of these claims, it is the responsibility of the provider to refund the co-pay back to the member. If you have any questions, please contact your provider representative. 2. Prior Authorization List Effective on 9/17/14, CoventryCares of Kentucky will no longer be utilizing DirectProvider as a reference for procedures or codes that require prior authorization. Please refer to our CoventryCares of Kentucky website, www.CoventryCaresky.com, for the list or procedures that require prior authorization. 3. Diabetes Mellitus Category 250 Coding Tips CoventryCares of Kentucky is committed to ensuring our members receive the best care possible. As our provider partners, we ask that you code claims correctly to help us identify resources for members with chronic or serious medical conditions. This is the second in a series of helpful coding hints to assist providers. Please see the following page for additional information. DIABETES MELLITUS CATEGORY 250 CODING TIPS Three digit category code 250 4th Digit Category Description Diabetes Mellitus 4th digit represents the manifestation (See ICD 9 Coding book for additional manifestation codes) 250.0X 250.1X 250.2X 250.3X 250.4X 250.5X 250.6X 250.7X 250.8X 250.9X DM W/O mention of complication (or manifestation classifiable to 250.1-250.9) DM W/ ketoacidosis (W/O mention of coma) DM W/ hyperosmolarity (hyperosmolar nonketotic coma) DM W/ other coma DM W/ renal manifestations (required additional code to identify manifestation*) DM W/ ophthalmic manifestations (required additional code to identify manifestation*) DM W/ neurologic manifestations (required additional code to identify manifestation*) DM W/ peripheral circulatory disorder (required additional code to identify manifestation*) DM W/ other specified manifestations (required additional code to identify manifestation*) DM W/ unspecified complication First….choose the correct code to the 4th digit to most accurately describe the condition *Sequence the DM code first 5th digit represents Type 1 or Type 2 5th digit** 250.X0 250.X1 250.X2 250.X3 **Always code to the 5th digit to correctly identify the patient’s condition Type 2 or unspecified***, not stated as uncontrolled Type 1, not stated as uncontrolled Type 2 or unspecified***, uncontrolled Type 1, uncontrolled *** If a certified coder cannot locate the appropriate documentation in the chart for them to assign Type 1 or Type 2, the Type 2 code will be used by default per ICD 9 guidelines. This shouldn’t be a problem in primary care when the provider is doing the coding or is available to document clarification prior to claims submission. Next…..choose the correct code to the 5th digit to describe type 1 or type 2 NOTE: Also code V58.67 (Long term use of insulin) to patients with Type 2 taking insulin for management. (Does not apply to temporary use or for Type 1). Correct ICD 9 codes: Accurately records a patient’s medical history and treatment Improves patient safety and outcomes Supports services provided (CPT codes) Saves time and reduces costs associated with resubmitting claims Affect timely appropriate reimbursements 4. NDC Billing Requirements CoventryCares of Kentucky follows the NDC billing requirements that are mandated by the Kentucky Department for Medicaid Services The NDC requirement applies to professional and facility outpatient claims. Inpatient places of service do not require NDC. POS with NDC requirement: 1-5, 9-20, 22-50, 52-60, 62-99 The NDC number, unit of measure and quantity will be required for the following codes: Facility revenue codes 250-253, 256-259, 634-636. Physician codes requiring NDC can be found at this link. http://chfs.ky.gov/dms/fee/ Select the Physician Injectable Drug List pdf. The HCPCS/NDC code combination and dates of service must match the Commonwealth’s Physician Injectable Drug List (PIDL) of rebateable drugs to be eligible for reimbursement. Claim lines not meeting the NDC billing requirements will deny with disposition code 2208/NDCDS/ REJ-NDC DATA SET INVALID FOR SERVICES BILLED. 5. Provider Information on Claims Edit Implementation The Kentucky Medicaid program requires a provider have a Kentucky Medicaid identification number to receive payment for services provided to a Kentucky Medicaid enrollee. Additionally, the Kentucky Department for Medicaid Services (DMS) requires a provider’s1 NPI and taxonomy for encounters2. DMS uses encounter data for a number of purposes including determination of enhanced primary care payments under the Affordable Care Act, and incentive payments for Electronic Health Record providers. To ensure provider encounter data is accepted by DMS, CoventryCares of Kentucky will be implementing further provider validation measures. Beginning September 17, 2014, CoventryCares of Kentucky will validate the billing and rendering provider information as submitted on the claim against the DMS provider file. Provider information on claims billed to CoventryCares of Kentucky that is not on file with the DMS and effective on the date of service will be rejected. Please ensure that your provider information with which you bill CoventryCares of Kentucky is also on file with DMS. Should a provider not file timely an Annual Disclosure of Ownership or other information with DMS, DMS may terminate the Medicaid ID. Providers may update or validate their NPI, taxonomy(ies) and Medicaid IDs on file with DMS by contacting the Provider Enrollment Division: Telephone: Email: Provider Maintenance Forms: (877) 838-5085 Monday-Friday 8 a.m.-4:30 p.m. ET [email protected] http://www.chfs.ky.gov/dms/provEnr/Forms.htm It is also important for providers to keep their provider information current with CoventryCares of Kentucky. If you have questions about, or updates to, the provider information on file with CoventryCares of Kentucky, please contact Customer Service at 1-855-300-5528 Monday-Friday 7 a.m.–7 p.m. ET. 1 Atypical providers (providers whose service type cannot obtain an NPI) are excluded. However, an atypical provider must have a Kentucky Medicaid ID. 2 An Encounter is the provider’s claim information and the adjudication status and details. Who Is My Provider Relations Representative? Region 1 Ballard Region 2 Christian Region 3 Grayson Region 4 Breckinridge Adair Region 5 Anderson Region 6 Boyle Region 7 Boone Region 8 Bath Bell Clay Floyd Johnson Caldwell Daviess Jefferson Bullitt Allen Bourbon Estill Campbell Boyd Breathitt Calloway Hancock Nelson Carroll Barren Clark Fayette Gallatin Bracken Harlan Carlisle Henderson Hardin Butler Franklin Garrard Grant Carter Knox Knott Laurel Letcher Crittenden Hopkins Henry Casey Harrison Jackson Kenton Elliot Fulton McLean Larue Clinton Montgomery Jessamine Pendleton Fleming Leslie Magoffin Graves Muhlenberg Marion Cumberland Nicholas Lincoln Greenup Owsley Martin Lawrence Whitley Perry Wolfe Pike Hickman Ohio Meade Edmonson Livingston Todd Oldham Lyon Trigg Shelby Spencer Logan Trimble McCreary Morgan Washington Metcalfe Robertson Monroe Rowan Marshall McCracken Union Webster Owen Madison Green Scott Mercer Lewis Hart Woodford Powell Mason Rockcastle Menifee Lee Pulaski Russell Simpson Taylor Warren Wayne Illinois Indiana All Other States Michigan, California, Florida, and Texas Regina Gullo Kimberly Berry Lesley Lewis Phillip Kemper Abbi Wilson Gina Gullo Sherry Farris Jennie Cahill JoAnn Rose Lori Kelley Jacqulyne Pack (502) 612-9958 (812) 660-1394 (502) 719-8743 (502) 719-8604 (270) 498-1443 (502) 612-9958 (513) 218-7725 (859) 412-0052 (859) 669-6217 859-302-6334 (606) 331-1075 [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Tennessee Missouri North Carolina Ohio West Virginia [email protected] Virginia [email protected] [email protected] **FOR INITIAL OR GENERAL INQUIRIES CALL CUSTOMER SERVICE AT 1-855-300-5528** Rev 9.05.14 tlk
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