Reimbursement Methodology & Policy. Gulf States

Welcome to the Advocate Development Program Assessment! This is an individual open book/resource assessment, however please do not collaborate with your counterparts. There will be 25 randomized questions so please allow enough time to complete this assessment (approx 60 mins) and minimize distractions. As you move through the assessment feel free to reference:

Quick Reference Guide: UnitedHealthcare’s Top 12 Frequently Referenced Reimbursement Policies for Commercial Health Plans
Advocate Development Program - Reimbursement Methodology Study Guide
The Policy in KL
NDB

Question 1: What is your first and last name?

A hospital is contracted with DRG methodology for inpatient with a base rate of $12,000. We receive a claim for dates of service 11/1/2016-11/3/2016 that maps to DRG 462. What will the allowable be for this claim? Outline all steps taken to determine your answer.

What is the Per Unit rate for Anesthesia for MPIN 188254 for 2017 dates of service?

Name two ways you can confirm the professional/technical split for a specific CPT code.

Where can you find a list of Assistant Surgeon codes eligible for reimbursement?

What is the % amount allowed for Assistant Surgeons who are physicians (Modifiers 80 ,81 and 82)?

What does "CCI" in the CCI Editing Policy stand for?

What modifiers may be used to indicate a repeat procedure performed on the same day by the same group physician or other health care professional?

An E&I claim is received from a surgery group containing cpt codes 41100 and 41108. The place of service is 11. The group's contract rate is $624.00 for cpt 41100 and $610.00 for cpt 41108. What will the allowable be for each code? Explain how you arrived at your answer.

A physician has a primary specialty in NDB of Cardiology. Another physician under the same TIN has primary specialty of Internal Medicine and secondary specialty of Cardiology. If a claim was received from each of these physicians for the same member on the same date of service, would they be subject to the same day/same service policy? Explain your answer.

MPIN 1819313 is on fee schedule 09223, Market # 0032540. If this practice filed a claim with DOS 11/23/17 billed codes 47539 and 47540, what is the allowable for each code and which code would be reimbursed at 100% according to the Multiple Procedure policy?

Where can you find the list of codes that will receive a reduction when billed in combinaiton with each other by the Same Group Physicians and/or other Health Care Professional for the same member on the same date of service?

Regarding the Rebundling policy, what is the difference between a "definitive" source and an "interpretive" source?

Do all facility contracts include an implantable pass through?

On an electronic claim, How should the Present on Admission (POA) field be populated for diagnoses that are exempt from POA?

If a member calls and activates their Passport benefit the provider is paid as contracted or non contracted rate?

Medicare Outpatient Procedure Groupers can be found in the Medicare Payer Appendix. Where can you find information concerning Commercial Outpatient Surgery Groupers?

What is a Medically Unlikely Edit?

High cost drugs are defined by which Revenue Codes?

When multiple sugeries are performed in the same episode, how should be anesthesia be reported?

What are the range of CPT codes that must be billed when billing anesthesia services?

Which policy addresses the following modifiers: 80, 81, 82 or AS.

Which modifiers can appended to timed procedures/modalities to receive separate payment by different specialists (physical, occupational and speech therapy) within a multispecialty group that are reported under a single Tax ID Number (TIN)?

POA indicators are required for inpatient submissions under which line of business?

Where can you find the Maximum Frequency Per Day (MFD) on a code?

UnitedHealthcare will allow only the units up to the Maximum Frequency Per Day (MFD value). In some situations a physician or other health care professional may report units accurately and still exceed the established MFD value. What modifiers can be appended to a code that will allow the additional units to be considered. Is documentation required when these modifers are appended to a code?

What revenue codes are used for implantables in an implantable passthrough provision?

Member is seen for physical therapy 5 times in one week. Contracted rate is $59 Per visit. Member has a $10.00 copay for each visit. What will be the calculated payment for the claim?

Is separate reimbursement on E/M codes considered for high risk pregnancies?

Define at a granular level the meaning of Per Case and Per Visit

Medicare Outpatient Procedure Groupers can be found in the Medicare Payer Appendix. Where can you find information concerning Commercial Outpatient Surgery Groupers?

Does a member’s Passport coverage end?

How many times will UHC reimburse timed procedure/modalities to distinguish timed procedures provided by different specialists (physical, occupational and speech therapy) within a multispecialty group that are reported under a single Tax ID Number (TIN)?

What screen in Cosmos can you access to confirm if a member has Passport activated?

Most plans have this member accessibility which is set up by state and was created to still cover someone traveling to see relatives in a different state.

Within the Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy, How is the primary, secondary and subesequent procedures reimbursed?

What type of payment methodology is used for Outpatient Procedure Grouper (OPG) - Per Case, Per Visit or Per Unit?

What is the Technical Component?

What is the standard Anesthesia policy formula for all anesthesia modifiers except AD?

What is the cap of minutes allowed on code 01967?

What is one possible reason why a procedure code would not be reimbursable when billed with a modifier 50?

What 3 components does UHC include in the Global OB Reimbursement?

Is a member’s Passport coverage indefinite?

What are two scenarios that could trigger an outlier provision?

Name one possible payment methodology for an outlier provision.

Are Present on Admission (POA) indicators required on inpatient Medicare claims, outpatient Medicare claims, or both?

Can a care provider or their staff activate a member’s Passport benefit?

Who do members need to call in order activate their PASSPORT for the highest coverage?

Are NCDs applied nationally or locally?

NCDs: Which federal/government entity publishes NCDs to clarify what Medicare covers?

A surgical group's contracted rate for cpt 35636 is $820.00. An E&I claim is received for the assistant surgeon in this group with modifier -AS. What will the allowable be for this procedure?

Where can you locate the Per Unit rate for an anesthesia group in NDB?

Name one possible reimbursement methodology that may be used in an implantable passthrough.

Where can you find the CCI table?

Per the Laboratory Services policy, which modifier indicator indicates a modifier cannot be used to bypass the edit to allow both submitted services or procedures?

Codes on the Multiple Procedure Payment Reduction [MPPR] field on the CMS National Physician Fee Schedule) are reduced if they have an indicator of ____ when performed on a single date of service.

Demonstrate how a provider has a per diem rate of $1214.00 when the member is inpatient for 4 days; what is the allowable per contract?

In the same day/same service policy, how is "same physician" defined?

Member is scheduled to have an outpatient procedure. They are enrolled in a PPO product. Contract allows 85% of billed charges for PPO members. What is the allowable if the provider bills $2500.00?

What does "MSPS" stand for?

What are codes that are priced out at a flat negoiated rate in a physician fee schedule called? .

During a single admission the Inpatient stop loss threshold was $75,000.00. The hospital will be paid a Payment Rate of 45% of Customary Charges. Total Charges were $95,000.00. What is the total charge?

Name one possible reimbursement methodology that may be used in a high cost drug passthrough.

Per Diem is reimbursed per ___?

A contract has a case rate for Vaginal delivery of $6579.00 for two days, with per diem payment of $1,122 for any additional days. If a member stays 3 days, what is the allowable?

A contract has a case rate for Cesarean Section of $8605.00 for three days, with a Per Diem rate of $1122.00 for any additional days. If a member stays 5 days, what is the allowable?

What is an OCE?

Medicare claim is denied for OCE 92 as indicated by remark code 5592. Where can you view the description of the OCE error?

Do all facility contracts include an implantable pass through?

What is the rate for a physician on fee schedule 9624, market 32540, for CPT code 99213 for date of service 2/1/2017?

Is CPT code 35636 eligible for reimbursement for the assistant surgeon?

According to the Anesthesia Policy, UHC allows for separate reimbursement of Moderate Sedation services when reported by the same physician reporting diagnostic or therapeutic procedures with which codes? .

How should Bilateral Procedures be billed on a claim?

Will Individual laboratory codes which together make up a laboratory panel code be combined and reimbursed as the more comprehensive panel code?

Per the Maximum Frequency Per Day policy, may a provider use a modifier to support additional units for codes where the CMS MAI value is "2"?

What are the 4 global OB codes per the Obstertical Policy?

List the codes UHC will not reimbuse when billed by a speech therapist.

The professional component is represented by which modifier? The technical component is represented by which modifier?

What is the Professional Component?

What should be reported to indicate a separately identifiable service was provided on the same day when reported by providers with the same specialty and TIN.

A provider on fee schedule 71907/Market # 0032540, bills an anesthesia claim with 120 minutes of anesthesia. How many Time Units will be used in this claim's reimbursement calculation?

MPIN 1219028, Market # 0032540 is on fees schedule # 78689 bills codes 66984 with a 50 modifier and 1 unit, Date of service 8/30/17. What is the providers allowable? Note, this CPT code is subject to the Multiple Procedure policy.

Member received services by a private duty nurse. The contract says for each 15 minute increment = 1 unit at $13.50. The nurse spent 45 minutes with the member. How many unit does the provider bill for and what is their reimbursement?

Do E&I physician reimbursement schedules typically reflect the same % of CMS RBRVS for all service types?

What is the inpatient reimbursement methodology for the Mississippi Can product?

For MS Medicaid, what is the DRG cost outlier payment equal to?

For MS Medicaid, How is observation reimbursed?

For MS Medicaid, How many days are ER visits limited to?

For MS Medicaid, what is Multiple Procedure Discounting?

For MS Medicaid, will outpatinet services within three days prior to the adimission date considered to be part of the inpatient paid seperately?

For MS Medicaid, Are inteerim claims required if the stay exceeds 30 days.

For C&S, A provider bills an emergency room code and the claim is processed and deemed as not meeting emergent criteria. The provider is in disagreement with this. What next step could you advise the provider to take?

Will UHC C&S reimburse a provider with a Family Practice specialty for a new patient code if the same member has been seen by a Cardiologist within the provider's group [same tin] but not been seen before by a Family practice provider there?

If a Community Plan member is seen by their OB provider for a condition unrelated to pregnancy (such as Strep) will UHC C&S consider payment for this service outside of the OB global period payment?

An OB provider contacts you because they recently received a clinical policy edit denial on an ultrasound[ procedure code 76811] billed with dx 099321 for a Community Plan member. Can you verify if this is correct or an UHC error?

Will UnitedHealthcare C&S require medical records for all reported E/M services?

A multispecialty group receives non covered denials on E/M code 99201 when billed under their physical therapist. What C&S reimbursement policy(ies) can you use to further explain the reason behind this denial?

A provider states they are considering purchasing a new Welch-Allyn hearing machine to provide screening tests mainly to be used for well child visits and the manufacturor has suggested they use the cpt codes 92558, 92587, and 92588 for billing. Will UHC C&S cover these codes?

Per the Vacines for Children policy, how should a provider bill for the admin and serum code and will Community Plan pay for both codes?

List the approved dx codes for which UHC Community Plan will reimburse code 84153.

Explain how Unitedhealthcare Community Plan will reimburse a co-surgeon when billing for the same procedure as the primary surgeon.

If a cardiologist performs a procedure having a Global Days Value of 010, and then another cardiologist in the same group with the same tax identification number provides a follow-up visit for the patient during this 10-day period, would UnitedHealthcare Community Plan reimburse the second cardiologist for a separate E/M service?

Verify if Provider XYZ's contracted EMTALA rate in the claim system matches what is stated in the Community Plan Emergency Room [professional]Reimbursement policy.

Where should you direct a provider who is looking for a specific C&S reimbursment or medical policy?

Where should you direct an internal customer and/or peer who is looking for a specific C&S reimbursement policy?

Where can Provider Relations Advocates (and other internal parties) go to find out updates redently made to C&S reimbursement and/or medical policies?

Where can a provider go to access the network bulletin and/or sign up to receive the network bulletin?

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