May 21, 2012

MO HealthNet reimburses coinsurance and/or deductible amounts for therapy provided in the nursing home under the following circumstances:

• Resident has traditional Medicare Part B; or
• Resident has Medicare Part C with QMB (Qualified Medicare Beneficiary).

The majority of Medicare/Medicaid claims for residents with traditional Medicare Part B will automatically cross from Medicare to MO HealthNet. Medicare Part C claims are not electronically forwarded to MO HealthNet. The following is clarification for submission of therapy services on the Medicare UB-04 Part B and/or Part C Professional claim formats on the MO HealthNet billing Web portal.

• Service line detail information should be entered online as it was submitted to Medicare.
• Procedure codes, as well as modifiers, are to be entered by line item, by date of service (DOS).
• Like therapy disciplines cannot be bundled together as a single line item or date spanned.
• Revenue codes are not required for Part B claims.

Medicare Part B claims crossed from Medicare to MO HealthNet in excess of 28 line items will “split” and process as multiple claims however the claims processing system can only process 25 edits or less on one claim. Providers are encouraged to reference MO HealthNet Bulletin Crossover Claim Editing, dated August 21, 2006, Volume 29, Number 8 . If services are bundled or the same therapy was provided on the same DOS but with different modifiers, services would deny as duplicates if resubmitted. As an example, the resident received four units of 97530 GO during the month of April and ten units of 97530 GP; it is incorrect to bill 15 units of 97530 with a date span of April 1st -30th. Should it be determined a unit of 97530 GP was overlooked during the month of April and submitted after the initial 15 units paid, the single unit of 97530 would deny as a suspect duplicate as the DOS fell sometime between April 1st and April 30th.

Webinars for Nursing Home Medicare Institutional and Professional Crossover Claim Filing are available from the MO HealthNet Provider Education Unit. See schedule and registration information. .