Hospital OPPS Payment System Changes for 2018-Revisions to the Laboratory Date of Service Policy

  • Nov 27, 2017

CMS is increasing the OPPS payment rates by 1.35 percent for 2018. CMS estimates an overall impact of 1.4 percent payment increase for providers paid under the OPPS in CY 2018. CMS has made revisions to the Laboratory Date of Service Policy. For a clinical diagnostic laboratory test, the date of service (DOS) is typically the date the specimen was collected, unless certain conditions are met. CMS...

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Correct Excessive Copay on Multi-Month Claims, TR 50671

  • Nov 27, 2017

The issue where the system was not correctly calculating copay totals for each month that is limited by the Deficit Reduction Act Maximum (DRA Max) out-of-pocket expenses when the dates of service on the claims spanned multiple months has been corrected. Affected claims will be reprocessed. No provider action is needed. 

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Federal law prohibits all Medicare providers from billing Qualified Medicare Beneficiaries, also known as QMBs, for Medicare deductibles, coinsurance or copayments

  • Nov 27, 2017

All Medicare and Medicaid payments a provider receives for furnishing services to a qualified Medicare beneficiary are considered payment in full. These billing rules apply to BCN Advantage dual‑eligible members (those who have BCN Advantage as their primary coverage and a Medicaid product as their secondary coverage.) The Centers for Medicare & Medicaid Services language in BCN provider...

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Update to EWC Diagnostic and Screening Mammography Benefits

  • Nov 27, 2017

Effective for dates of service on or after October 1, 2017, the following CPT codes are no longer reimbursable by the Every Woman Counts (EWC) program: 77055-77057. Effective for dates of service on or after October 1, 2017, the following CPT codes are reimbursable by the EWC program: 77065-77067. The Medi-Cal claims processing system is being updated to process claims with CPT codes 77065 –...

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Accepting Payment From Patients with a Medicare Set-Aside Arrangement

  • Nov 27, 2017

This article is based on information received from Medicare beneficiaries, their legal counsel, and other entities that assist these individuals, indicating that physicians, providers, and other suppliers are often reluctant to accept payment directly from Medicare beneficiaries who state they have a MSA and must pay for their services themselves. This article explains what a MSA is and explains...

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Anticipated Adoption of 2018 CPT and HCPCS Updates

  • Nov 27, 2017

The 2018 updates to the CPT  and HCPCS Level II codes are anticipated to adopt in the first quarter of 2018. This update will be effective for Medi-Cal and all specialty programs under the fee-for-service program. More information about the forthcoming updates will be provided in future notices. To help providers easily locate the latest 2018 CPT and HCPCS updates, a 2018 CPT and HCPCS...

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CY 2018 CLFS - Final Payment Rates and Crosswalking/Gapfilling Determinations

  • Nov 27, 2017

CMS has published the final payment rates and supporting documentation for the new private payor rate-based CLFS payment system. CMS also published final CY 2018 Clinical Lab Fee Schedule (CLFS) determinations on gapfilling and/or crosswalking methodologies for new laboratory tests and laboratory tests with no reported private payor rate information. The new private payor rate-based...

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National Correct Coding Initiative (NCCI) – Medically Unlikely Edits Review Process

  • Nov 27, 2017

The Department of Social Services (DSS) is implementing a process for reviewing claims denied solely due to exceeding the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) limit for dates of service July 1, 2016 and forward. A Medicaid NCCI MUE edit is a unit of service claim edit that defines the number of units of service beyond which the reported number of units of...

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