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Tuning Up Hospital Billing Skills. Agenda. Test of knowledge Questions from Policy and Procedure Review answers and where to locate them in Policy and Procedure. Three Day Rule. Where is the Three Day Rule found? Policy and Procedures Part II, Hospital Services, Section 904

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  • Test of knowledge
  • Questions from Policy and Procedure
  • Review answers and where to locate them in Policy and Procedure
three day rule
Three Day Rule
  • Where is the Three Day Rule found?

Policy and Procedures Part II, Hospital Services, Section 904

  • What is the Three Day Rule?

Service discharge and re-admit with like or same diagnosis that happen within 72 hours of each other.

  • What are the conditions to the Three Day Rule combining of claims?

Less than 72 hours from discharge to re-admit, like or same diagnosis

pre certification
  • What section of Policy and Procedures Part II, Hospital Services Manual will you find requirements of pre-certification?

Section 801

  • Who reviews request for pre-certifications? Do they have a website? Is training offered on this site?

Georgia Medical Care Foundation, www.gmcf.org, yes, on the left Medicaid , Provider Educational and Training Materials , select title

  • What services are exempt from pre-certification?

Only deliveries, newborn births less than 30 days and services for members who are Medicare Part A eligible

pre certification continued
Pre-certification Continued
  • When does an authorization require re-certification?

An authorization must be recertified every 90 days.

  • What does pre-certification pertain to?

Medical necessity and appropriateness of setting.

  • Is authorization for newborns staying in house greater than 30 days required?


pre certification continued7
Pre-certification Continued
  • Can appeals for denied authorizations be made? If so how would the appeal be initiated?

Yes, log on to www.ghp.georgia.gov Provider information, Claims, Prior Authorization / Pre-Certification, Request a Prior Authorization…

directions for authorization appeal
Directions for Authorization Appeal
  • Click on Change an Existing Prior Authorization
pre certification continues
Pre-certification Continues
  • What is the time frame allowed for obtaining a retro authorization for those members that were approved for Medicaid retro-actively?

Six months from retro date.

  • If there is a primary payer is an authorization still needed? Are there any extenuating circumstances?

Yes and yes; the extenuating circumstances are deliveries and for inpatient services if the member is Medicare Part A eligible. If the claim is an outpatient service and the member is Medicare Part B eligible a Medicaid authorization is not needed.

pre certification testing continued
Pre-certification Testing continued…
  • If an authorization was obtained for an outpatient procedure or a different procedure was necessary what is the time frame allowed updating the authorization?

30 days from the authorization approval date

  • If a physician is not a Medicaid provider can a pre-certification be obtained for hospital services?

Yes, the responsibility will fall on the facility to request and obtain the authorization.

transferring of member for services
Transferring of Member for Services
  • What is a Contractual Shared Agreement?

When a facility must seek services for Medicaid Members from another facility. The arrangement must be pre-arranged verbally and in a written manner. The receiving facility will forward their charges to the original facility who will add them to their claim and bill Medicaid. The original facility is responsible for reimbursing the receiving facility for their services rendered. Section 903.2, Policy and Procedures Part II, Hospital Services

testing continued
Testing continued…
  • Is there a difference between shared contractual agreement and transfer cases?

Yes, shared agreement - the member is transported to another facility for services and returns to the original facility. Transfer cases – the member is transferred from one facility to another not to return. If BOTH facilities fall into the same DRG they will be reimbursed the lesser of the DRG or CCR (cost to charge ratio) rate. If the DRG is different for the facilities each hospital will be reimbursed the amount that a non-transfer claim would be paid. *Authorization will be required for the receiving facility. Appendix C, number 8, Policy and Procedure Part II, Hospital Services

tcn numbers
TCN Numbers
  • What is a Julian date and what is it used for?

Julian date is the number day of the year; for example today is the 9th day of 365 and there are 356 days left in the year.

The Julian date is used in the TCN number of the claim and identifies the date the claim was received and entered the claims processing protocol. Providers may use this date to prove timeliness.

http://www.fs.fed.us/raws/book/julian.shtml - for a Julian Calendar

tcn number testing
TCN Number Testing
  • Can the claim submission be identified by the TCN number?

Yes, 2 = electronic crossover, 3 = electronic (straight or vender) submissions, 4 = mass adjustments (requested and approved by DCH), 6 = web portal form, 8 = paper submissions

  • What is an observation stay?

Services furnished by a hospital, use of a bed, periodic monitoring by nursing or other staff, which is necessary to evaluate the member/patient’s condition to determine if an inpatient admission is required.

  • How many hours of observation does Medicaid pay for?

48 hours or less

  • A provider may bill for how many observation hours without medical records?

Up to 24

  • Observation documentation must contain?

The setting for observation is determined using qualifying criteria such as those published by InterQual, severity of illness and intensity of service, medical necessity and the physician’s orders for the observation, inpatient admit or discharge.

  • What section of Policy and Procedures Part II, Hospital Services can the requirements of observation be found? When was the last update to this section?

Section 903.6, January 1, 2008

  • What revenue code is used to bill for observation time?

Revenue code 762

  • When a member/patient is admitted as an inpatient how is the claim billed?

The inpatient admit date becomes the ‘admit date” and the from date with the observation hours reported on the claim with revenue code 762.

  • What rehabilitation services are covered in the hospital setting?

Short-term rehabilitation services such as, physical, occupational and speech therapy. These services must be rendered immediately following and in treatment of an acute illness, injury or impairment. Section 903.5, Policy and Procedures Part II, Hospital Services

  • What requirements must be met for rehabilitation services in the in the hospital setting?

There must be a written plan of treatment established by the physician, which must identify rehabilitation potential, realistic goals and measure progress. The plan must contain the type of modalities, procedure, frequency of visits, estimated duration, diagnosis, functional goals and recovery potential.

The physician must initially certify and re-certify every 30 days that continued therapy is needed. This must include the diagnosis, date of onset of the acute illness, injury or impairment and an estimate of how much longer the service will be needed.

  • What requirements must be met for rehabilitation services in the in the hospital setting? (continued)

Services must be performed under the supervision of a qualified therapist.

There must be an expectation that the member’s/patient’s condition will improve significantly in a reasonable and predictable amount of time.

attachments dma311
Attachments DMA311
  • Under what circumstances is the DMA311 used?

The DMA311 is the “Certificate if Necessity for Abortion”; this document should be used only in the situations of life endangerment to the mother’s life if the fetus were carried to term, a victim of rape or incest. This document may be completed and signed by the physician before or after the procedure has been performed. Section 911.1, Policy and Procedure Part II, Hospital Services

attachments dma31124
Attachments DMA311
  • Are there codes that ALWAYS require the DMA311 attachment?

Yes, they are:

69.01 Dilation and curettage for termination of pregnancy.

69.51 Aspiration curettage if uterus for termination of pregnancy.

74.91 Hysterectomy to terminate pregnancy

75.0 Intra-amniotic injection for abortion

attachments medical records
Attachments Medical Records
  • Are there codes that resemble that of an abortion that will deny for the DMA311, “Certificate of Necessity of Abortion” but do not meet the requirements of the documents?

Yes and these claims should be submitted paper with the following medical records:

History and Physical

Operative Report

Pathology Report

The Department reserves the right to request additional documentation in order to complete the review of these claims.

attachments medical records26
Attachments Medical Records
  • Where can the codes be located that should be submitted with medical records?

Section 911.1, Policy and Procedure Part II, Hospital Services

attachments dma69
Attachments DMA69
  • How old does the member have to be in order to sign the DMA69, Sterilization Consent?

The member must be 21 years of age at the time the document is signed.

Medicaid can not reimburse for sterilizations for those members who are not mentally competent, institutionalized in a correctional facility, mental or other rehabilitation facility.

attachments dma6928
Attachments DMA69
  • When must the person obtaining the member’s consent sign the document?

The document must be signed by the member at least 30 days prior to the procedure being performed and the person obtaining the consent must sign at the time the member signs document.

  • A physician has certified that either emergency abdominal surgery or premature delivery and the document is within the 30 days of the member signature but less than _______, the conditions will be review for possible payment of the procedure.

72 hours

attachment dma69
Attachment DMA69
  • How long is the document with the member’s and person obtaining consent signatures good for?

The sterilization procedure must be completed within 180 days of signatures.

  • When will the physician signed the DMA69 form?

The physician must sign the DMA69 after the procedure has been performed.

attachments dma6930
Attachments DMA69
  • Are there codes that always require the DMA69?

Yes, they can be located in Policy and Procedure Part II, Hospital Services, sections 911.2

  • Are there codes that resemble sterilizations that can be submitted with medical records for claim resolution?

Yes, if the procedure was performed for medical necessity rather than sterilization purposes; these codes are found in the above referenced policy.

general billing questions
General Billing Questions
  • Are charges for mother and baby claims billed together or separately? Is one or two numbers used?

These claims are billed separately with their own numbers.

  • When does a hospital claim require a GBHC number?

Never, GBHC is used for primary care physician referral to a specialty.

billing questions
Billing Questions
  • A provider be reimbursed for multiple MRIs per day; true or false.

True, with supporting medical records that show the necessity of the additional test.

  • When a psychiatric diagnosis is on a claim how many inpatient days are allowed?

30 days without medical records, stays with a psychiatric diagnosis and more than 30 days should be submitted paper with medical records supporting that the service was not for treatment of psychiatric services.

billing questions33
Billing Questions
  • Are all discharge codes valid for Medicaid?

No, valid codes may be located on the web portal, www.ghp.georgia.gov , log in with your user ID and password, Claims tab , Enter Claim , scroll down to Discharge status click on drop down box; the codes found in the drop down are the covered codes by Georgia Medicaid

billing questions34
Billing Questions
  • Is all lab work ok to work in a hospital setting?

No, there are certain laboratory services that must be billed to the state laboratory. These services are identified in Appendix E, Policy and Procedure Part II, Hospital Services.

  • How are inpatient claims reimbursed?

Inpatient claims are reimbursed based on a DRG prospective payment system; based on the Tricare Grouper version 24.0. Chapter 1001 and Appendix C, Policy and Procedure Part II, Hospital Services,

billing questions35
Billing Questions
  • How is a DRG payment calculated?

Base rate multiplied by the DRG weight =

Answer + facility specific add on = reimbursement.

  • If there is a primary payment will Medicaid still make the full DRG reimbursement?

No, Medicaid will pay up to the DRG less the primary payment.

billing questions36
Billing Questions
  • Is the DRG paid when the member is Medicare/Medicaid?

No, Medicaid will pay up to the Medicare deductible.

  • How are outpatient claims paid?

Outpatient services are reimbursed by either 90% or 85.6% of cost; the methodology for outpatient reimbursement is found in section 1001 for Policy and Procedure Part II, Hospital Services. *All clinical diagnostic services performed for outpatients and non-patients are reimbursed at the lesser of the submitted charges or at the Department’s fee schedule rates used for the laboratory services program. Section 1001.3, paragraph D, Policy and Procedure Part II, Hospital Services.

billing questions37
Billing Questions
  • What document must be completed and signed by a Medicaid eligible mother after giving birth to her newborn?

DMA550, Newborn Certification should be completed and signed. However, the baby’s temporary number can be obtained through the GHP web portal, www.ghp.goergia.gov

register for provider training
Register for provider training
  • Phone 877-660-2080
  • Web https://events.regrover.com/event/ghp
contacting ghp
Contacting GHP
  • General inquiries/claims questions
  • Phone 404-298-1228 (metro Atlanta)

800-766-4456 (toll free)

  • Web www.ghp.georgia.gov

Contact Us

contacting ghp41
Contacting GHP
  • Claims submissions
  • Web www.ghp.georgia.gov

Claims tab

  • Mail P. O. Box 5000

McRae, Georgia 31055-5000

contacting ghp42
Contacting GHP
  • Claim Attachments
  • Phone 866-483-1044 (fax)
  • Mail P. O. Box 5000

McRae, Georgia 31055-5000

Don’t forget your Attachment Form

contacting ghp43
Contacting GHP
  • Prior Authorizations
  • Phone 404-298-1228 (metro Atlanta)

800-766-4456 (toll free)

  • Web www.ghp.georgia.gov

Contact Us (inquiries)

or Claims tab (request)

  • Mail P. O. Box 7000

McRae, Georgia 31055-7000

contacting ghp44
Contacting GHP
  • Provider Enrollment
  • Phone 404-298-1228 (metro Atlanta)

800-766-4456 (toll free)

866-309-0935 (fax)

  • Web www.ghp.georgia.gov

Contact Us

  • Mail P. O. Box 4000

McRae, Georgia 31055-4000

sources of communication
Sources of communication
  • www.ghp.georgia.gov

Provider Information

  • Provider Manuals - Update quarterly
  • Banner Messages – post daily/weekly
  • Provider Focus – post quarterly