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Personal Care Option Services

FEBRUARY/MARCH 2006. Announcements and RemindersPCO Assessment ProcessHow to Bill UnitsCommon Denials for PCOList of Common PCO Codes. FEBRUARY/MARCH 2006. Billing Manual on the Web . Please see the new regulations and billing instructions under the Personal Care Option" heading at the followi

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Personal Care Option Services

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    1. Personal Care Option Services

    2. FEBRUARY/MARCH 2006 Announcements and Reminders PCO Assessment Process How to Bill Units Common Denials for PCO List of Common PCO Codes

    3. FEBRUARY/MARCH 2006 Billing Manual on the Web Please see the new regulations and billing instructions under the “Personal Care Option” heading at the following web page: http://www.state.nm.us/hsd/mad/Regs.htm

    4. FEBRUARY/MARCH 2006 PCO Billing “Policies” Providers of personal care services may not: Bill for services prior to delivery of services Bill for the entire year at one time Bill for personal care services during the time the consumer is institutionalized

    5. FEBRUARY/MARCH 2006 Announcements and Reminders PCO Assessment Process How to Bill Units Common Denials for PCO List of Common PCO Codes

    6. FEBRUARY/MARCH 2006 PCO Assessment Process Existing clients will receive notification 90 days prior to the expiration of their Personal Care Service Plan that their annual assessment is due and that they must take the MAD 075 to their doctor, have it filled out, and fax or mail it to Lovelace for review.

    7. FEBRUARY/MARCH 2006 PCO Third-Party Assessment Process All clients enrolled in PCO will be assigned to Lovelace Health Plan for their determination of PCO services. Consumers who were previously assigned to Molina or Presbyterian will be re-assigned to Lovelace 90-days prior to their plan expiration date.

    8. FEBRUARY/MARCH 2006 PCO Assessment Process PCO providers should direct their clients to call the PCO assessment request line: The client is requesting personal care services for the first time.

    9. FEBRUARY/MARCH 2006 PCO Assessment Process If a client is currently receiving PCO services and experiences a change in health status which requires a revision to their current service plan, the PCO agency should contact Lovelace Health Plan. Requests for revisions need to include a cover letter and documentation from a health care provider documenting the consumer’s change in health status.

    10. FEBRUARY/MARCH 2006 PCO Assessment Process PCO Assessment Request Line: 1-866-364-3310 (toll free) or 841-8407

    11. FEBRUARY/MARCH 2006 Announcements and Reminders PCO Assessment Process How to Bill Units Common Denials for PCO List of Common PCO Codes

    12. FEBRUARY/MARCH 2006 Billing Units Correctly If you are billing incorrect unit values, your claims will be overpaid, underpaid, or denied. If you have been paid for claims where units have been billed incorrectly, you will need to submit an adjustment and corrected claim for those claims.

    13. FEBRUARY/MARCH 2006 Billing Units Correctly Example: 99509, 1 unit = 1 hour T1019, 1 unit = 15 minutes (for DOS beginning 1/1/2004) Billing 4 units for 99509 is the same as billing for 4 hours Billing 4 units for T1019 is the same as billing for 1 hour.

    14. FEBRUARY/MARCH 2006 T1019 Personal Care Consumer Delegated Ongoing Care - Procedure code T1019 with modifier U1 is used for the first 100 hours of services for the month Personal Care Consumer Delegated Ongoing Care - Procedure code T1019 without modifier is used for 101 plus hours for the month

    15. FEBRUARY/MARCH 2006 T1019 Consumer delegated services If the 100th and 101st hours occur on the same day, the “to” DOS on the claim for the 100th hour equals the “from” DOS on the claim for the 101+ hours. This is the only overlap of dates allowed

    16. FEBRUARY/MARCH 2006 T1019 Example: For 100 hours used up on the 25th Bill 01/01/06 – 01/25/06 T1019 with U1 Bill 01/25/06 – 01/31/06 T1019 w/o modifier for additional hours used starting the 25th

    17. FEBRUARY/MARCH 2006 6078 – Personal Care Limit 100 Hours This denial will post when T1019 + U1 modifier has been billed for more than 100 hours for the month.

    18. FEBRUARY/MARCH 2006 6078 – Personal Care Limit 100 Hours “How can units at the U1 rate be paid in the 3rd week of a month and denied on the first week?”

    19. FEBRUARY/MARCH 2006 How to track Units Here is an example of how you can track your units used so that you do not bill for more than 100 hours at the U1 rate:

    21. FEBRUARY/MARCH 2006

    22. FEBRUARY/MARCH 2006 How to Calculate Monthly Hours from Total Annual Units The PA approved plan is approved as Annual Units – 5,000 The annual units are divided by 12, by the provider, and the sum equals the monthly units – 5,000/12 = 416.66 The monthly units are then divided by 4, by the provider, and the new sum then equals the monthly hours – 416.66/4 = 104.17

    23. FEBRUARY/MARCH 2006 Announcements and Reminders PCO Assessment Process How to Bill Units Common Denials for PCO List of Common PCO Codes

    24. FEBRUARY/MARCH 2006 1361 – Exact Duplicate This denial is the result of the exact same claim being processed after the original has already been approved for payment.

    25. FEBRUARY/MARCH 2006 1361 – Exact Duplicate If there has been an incorrect payment and you are submitting to have the payment corrected, you must file an adjustment. Resubmitting the claim again will only result in a duplicate denial.  

    26. FEBRUARY/MARCH 2006 1361 – Exact Duplicate PCO claims will deny as duplicates if the line items have the exact date span using one line item with a modifier and the other line item without a modifier.

    27. FEBRUARY/MARCH 2006 0436 - Auth Required/ PA is missing/invalid A PA is required for this service. The PA number was either missing from the claim, or it was an incorrect number

    28. FEBRUARY/MARCH 2006 0430 – Procedure not on File The line item procedure code on the claim does not exist in the MMIS (Omnicaid).

    29. FEBRUARY/MARCH 2006 0430 – Procedure not on File Verify that you keyed the procedure code correctly. If incorrect, correct and resubmit the claim. If the procedure code is the same on the claim as on the RA, check your crosswalk to be sure you are using the correct procedure code.

    30. FEBRUARY/MARCH 2006 Announcements and Reminders PCO Assessment Process How to Bill Units Common Denials for PCO List of Common PCO Codes

    31. FEBRUARY/MARCH 2006 Consumer Delegated Model Codes

    32. FEBRUARY/MARCH 2006 Consumer Delegated Model Codes

    33. FEBRUARY/MARCH 2006 Consumer Directed Model Codes

    34. FEBRUARY/MARCH 2006 Consumer Directed Model Codes

    35. FEBRUARY/MARCH 2006 Worker’s Comp Reminder Reimbursement for worker’s compensation has been added to the overall reimbursement that will be made for code 99509. It cannot be billed separately.

    36. FEBRUARY/MARCH 2006

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