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Florida and U.S. Virgin Islands Part A POE-AG minutes -- July 11, 2023
Last Modified: 3/21/2024
Location: FL, USVI
Business: Part A
External participants
Gloria Beazley, DaVita Kidney Care
Melissa Burns, Memorial Healthcare Systems
Dale Gibson
Margaret Gil, Baptist Health South Florida
Shirley Knoll, TLC Rehab
Sharon Miles, Baptist Health South Florida
Internal participants
Bradley Bohner, Provider Education Specialist (PES), Provider Outreach and Education (POE)
Gloria Franceschini, PES, POE
Cesar Hernandez, Sr. PES, POE
Charles Johnson, PES, POE
Kimberly Karnes, MAC JN Project Manager, POE
Robert Lewis, PES, POE
Ursula Weaver, PES, POE
1. Welcome and introductions
• Review of minutes/action items from prior meeting
3. Reason code 34963 FAQ re: MLN 12889
4. Dental services
5. Review of Customer Service escalation process
6. SPOT updates
7. What’s new with the prior authorization program
8. New campaigns on the horizon
• Appeals
• LCD process
9. Upcoming events
10. Open discussion
11. Verify all action items and process out: Next meeting – October 31, 2023
Kim Karnes welcomed everyone to the meeting and First Coast staff introduced themselves. Kim verified there were no action items from the previous meeting.
Ursula provided an update on the use of JW and JZ modifier. We published an article, Drugs and biologicals Part B – Using the JW and JZ modifiers, to help explain the use of the modifiers and provide claim examples to demonstrate when to use them. Please review the article for additional assistance.
Effective with claims received on or after April 1, a new consistency edit was implemented in FISS that validates the attending provider’s NPI. Institutional providers are required to indicate the attending provider name and identifiers for the patient’s medical care and treatment reported on institutional claims for any services other than nonscheduled transportation claims. Additionally, institutional providers are required on outpatient claims to send the referring provider NPI and name when the referring provider for the services is different from the attending provider.
We identified an increase in inquiries to our Provider Contact Center as a result of the claim returns and reiterated educational resources available on this topic. Reason code 34963 is validating the physician to the NPI and if there is a mismatch on the last name, it hits this edit. The issue is the NPI/physician name does not match PECOS. Information has been added to MM12889 explain how the attending physician information on a claim is verified.
If you don’t have PECOS access, you can use the order and referring data set at data.cms.gov to verify the physician’s name and spelling as seen in PECOS. It is recommended to search by the provider’s NPI to correctly display the information.
We also identified through inquiries that Part A providers billing outpatient therapy services did not understand the billing requirement. For the purposes of processing institutional claims for outpatient therapy services, the attending provider field must contain the NPI of the certifying physician or NPP for a therapy plan of care. We published a separate article to address these services. Review the following articles for more information:
Medicare generally precludes payment under Medicare Parts A or B for any expenses incurred for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. Prior to 2023, there were a limited number of circumstances listed as examples in regulations for when Medicare payment could be made for dental services.
The 2023 Physician Fee Schedule (PFS) Final Rule issued guidance to clarify Medicare should make payment in circumstances where the dental services are so integral to other medically necessary services that they are inextricably linked to the clinical success of that medical service(s). As such, Medicare will provide payment for more types of dental services associated with a broader set of medical services than before 2023.
Additionally, effective for CY 2023, payment can be made under Medicare Parts A and B, under the applicable payment system, for such dental services that occur within the inpatient hospital and outpatient setting, as clinically appropriate. Review our new
dental services webpage to read about the coverage guidelines and billing requirements.
Kim reminded our providers that we have an escalation process in the Customer Service department. Anytime you call our general inquiries line and are not satisfied with that level of service received or the issue is not resolved, you can ask to speak with a supervisor and that supervisor will return your call. You should be given a reference number for the call in case you need to call back. Please pass this information to any of your peers and colleagues that may need to escalate their issue.
The CMS identify management system, or IDM, changed passwords rules effective last June 27. How is this impacting you? The IDM manages your SPOT ID and password, and with this change you will no longer be required to change your password. The password will no longer expired if you keep your account active. Accounts in an inactive status for 60 days will have their password expired.
Remember to log into SPOT at least once a month to avoid having your account inactivated for lack of use.
Robert provided an update for the prior authorization program. Effective July 1, a new service category, facet joint interventions, was added to the list of services provided in the hospital outpatient department that require prior authorization before those services are provided. A prior authorization request or PAR form is available via our website, along with instructions on how to complete it, which should be submitted to receive affirmation of coverage. This request (along with supporting documentation) can be submitted in different ways, with the best option being the SPOT since photos don’t come through clearly via fax.
We have a prior authorization webpage devoted to guidelines and resources, and this now includes resources relating to facet joint interventions. We offered a webinar on May 17 to introduce this new service, and the webinar included detailed review of the LCD and local coverage article relating to these services (L33930). The recording is available on our On-Demand Learning webpage.
The other services that require prior authorization are listed on our prior auth webpage also, with links to corresponding articles, LCDs and other resources addressing each separate category of service.
The repetitive scheduled non-emergent ambulance transport (RSNAT) prior authorization program is also in effect and a RSNAT webinar is scheduled for July 25. We have a RSNAT webpage with links and resources to assist such as a comprehensive FAQ list and links to a prior authorization coversheet and instructions on its completion.
Appeals campaign: We will provide more focused education for appeals and the appeals process.
LCD process: We will provide more focused education on the LCD process and how providers can participate in the decision-making process. This is a good opportunity to reinforce changes made to the LCD process with the intent to make it more transparent. We’ll be providing more education over the next year, partnered with our Medical Affairs department, with a team approach.
Bradley highlighted several webinars from the events calendar. We are constantly adding new webinars to the calendar so be sure to bookmark this page and sign up for eNews which highlights our events as we post them.
Nothing added.
• Verify with claims if the middle initial is a part of the editing for reason code 34963.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
