Newsletter Vol. 20, No. 12

By June 30, 2010: Billing team must complete all pending audit responses to Horizon Blue Cross/Blue Shield for claims with service dates prior to January 1, 2010. Effective July 1, 2010: Direct all new audit requests and inquiries to HMS (1-800-310-0865) instead of Horizon. Billing team and medical supply managers must implement compliance measures: (1) Establish and maintain unique patient profiles for each Medicaid/NJ FamilyCare beneficiary including original NJ Prescription Blank prescriptions with prescriber NPI, beneficiary DOB/gender, CMS certificates of medical necessity, purchase invoices supporting pricing, proof of other insurance coverage/payments/denials, and proof of delivery or customer certification; (2) Ensure all prescriptions include prescriber's full name, address, telephone, license number, NPI, full patient demographics, detailed equipment description (not generic terms like 'wheelchair'), quantity, frequency, duration, refill authorization, diagnosis supporting medical necessity, and original handwritten signature; (3) Maintain all documentation for minimum 5 years from service date in HIPAA-compliant format; (4) Dispense only the least expensive equipment/supply meeting medical necessity; (5) Ensure prescriptions are valid only 6 months from date written and new original prescriptions are required for services needed beyond 6 months; (6) Accept only original, faxed, or electronically-transmitted prescriptions (no telephone-rendered prescriptions); (7) Verify NPI accuracy on all claims. Failure to comply with HMS audit requests and provide required documentation will result in audit findings and potential claim denials.