Newsletter Vol. 16, No. 06

REQUIREMENTS: 1. IMMEDIATE (Transportation PA Elimination): - Billing team must stop submitting prior authorization requests for beneficiary transportation when origin or destination is an Assisted Living Facility (ALF) or Residential Health Care Facility (RHCF). These are now treated as nursing homes. - Update billing software to remove PA requirement flags for transportation claims to/from ALF and RHCF. - When billing hard copy claims: use place of service "#5" for ALF/RHCF. When billing electronically: use place of service "N". - Brief all providers and front desk staff that PA is no longer required for these facility types. - Consequence: Claims may be denied if PA is incorrectly submitted for ALF/RHCF transportation. 2. By July 1, 2006 (Dental Procedure Code Changes): - Billing team must update all dental claim submission processes to implement new procedure code modifiers for paper claims effective July 1, 2006. - Consult pages 16-18 of this newsletter for specific modifier details (details not fully provided in excerpt). - Update encounter forms and billing templates to reflect new modifier requirements. - Notify dental providers of upcoming changes and retraining requirements. - Consequence: Dental claims submitted after July 1 without correct modifiers will be denied or delayed. 3. Effective January 1, 2006 (Epogen Code Change - RETROACTIVE): - Billing team must immediately update all Epogen billing to use new HCPCS code J0886 instead of former code Q4055. - Update billing system fee schedules: change maximum allowance from $12.26 to $13.31 per 1000 Units. - Audit any Epogen claims submitted since January 1, 2006 using old code Q4055 and resubmit with J0886 if necessary. - Notify all prescribers and infusion centers of the code change. - Consequence: Claims using obsolete code Q4055 may be rejected or underpaid. 4. Ongoing: - Billing team to review and implement pharmacy MAC changes (page 9) and pharmacy NJ FamilyCare/Medicaid labeler code changes Release No. 140 (page 11). - Review pharmacy PDUR standard changes (page 12). - Update laboratory billing for genotype and phenotype testing per new rates (page 15). - Ensure all providers document age-appropriate lead screening per federal and state requirements (page 20). - Update HIPAA claims submission processes per updated Pharmacy NCPDP-HIPAA Companion Guide available on Unisys website. 5. Medical Exception Process (MEP): - Prescribers and pharmacists must use updated Unisys MEP contact: 1-877-888-2939 (effective January 1, 2006). - Train providers on new Error Codes related to Medicare Part D prescription drug program.