Ga. Medicaid Part II Policies & Procedures for Hospital Services § 911

911.1. Medicare Part B Only Services: Many Medicaid members also are eligible for

Medicare. Hospital claims submitted to the Division for members with Medicare “Part

B only” will be reimbursed at the Per Case Rate. Inpatient hospital admissions for “Part

B Only” members must be pre-certified. See Chapter 800 for precertification

requirements

911.2. Providers should bill Medicare for all Part B reimbursable ancillary services (i.e.…lab,

radiology, pharmacy, supplies, etc.). Medicare Part B services will cross over to

Medicaid and adjudicate as a crossover claim. Providers may then bill Medicaid for the

Part A inpatient hospital services. Do not use bill classification 121 for these claims;

bill classification 111 should be used. Enter “Medicare Part B” as the Primary payer

online A of Field Locator 50 and the total amount paid by Medicare under Part B for

the Part B ancillary charges entered as a prior payment in Field Locator 54A with a

Claim Filing indicator of MB (Medicare Part B). Enter the Claim Filing indicator of

MC (Medicaid) in Field Locator 54B and the total amount paid by Medicaid under Part

B for the Part B ancillary charges entered as a prior payment. Attach a copy of the

EOMB from Medicare and the Remittance Advice from Medicaid showing the amount

paid for the Part B ancillary charges to the claim: All claims are to be submitted

electronically through EDI or on the web portal at www.mmis.georgia.gov.

911.3. For more detailed billing instructions, please review the Medicaid Secondary Claims

User Guide.

911.4. Exhaustion of Medicare Lifetime Reserve Days

911.4.1. When the total Medicare Lifetime Reserve Days are exhausted, the

Division may be billed for charges incurred by Medicaid members.

911.4.2. The claims for these charges must be filed on the UB-04 claim form with

the Report of Eligibility or Explanation of Medicare Benefits attached.

The attachment must state that the patient’s total Lifetime Reserve Days

are exhausted and include the last date of Medicare entitlement. When

filing the UB-04, Medicaid liability begins with charges incurred after

Medicare benefits were exhausted.

911.4.3. Please refer to Part I, Chapter 300 for more details regarding

Medicare/Medicaid policies and procedures.

911.5. Partial Medicare Eligibility:

911.5.1. When a Medicaid member’s Medicare eligibility begins during the

course of an inpatient hospitalization, but after the admission date, the

Division may be billed for the dates the patient was Medicaid only and as

a secondary payer for the dates the member became Medicare Primary.

911.5.2. Limits to Abortion, Sterilization and Hysterectomy Coverage

911.5.2.1. Medicaid funds are unavailable for sterilization,

hysterectomies, or abortions performed without the

documentation required by federal regulations (See 42

CFR 441.206 and 441.256). As such, claims for payment

submitted without the required documentation or with

incomplete or inaccurate documentation will be denied.

The Division does not accept documentation meant to

satisfy informed consent requirements which has been

completed or altered after the service was performed.

911.6. Abortion

911.6.1. The Department of Labor, Health and Human Services, and Education

and Related Agencies Appropriations Act, 1998, Public Law Number

105-78 (1997), Congress passed a revision of the Hyde Amendment

pertaining to Federal funding of abortions under the Medicaid program.

Enacted as 509 of the Department of Labor Appropriations Act, 1994,

107 Stat. 1082. Section 510 directs that “none of the funds appropriated

under this Act shall be expended for any abortion except when it is made

known to the Federal entity or official to which funds are appropriated

under this Act that such procedure is necessary to save the life of the

mother of that the pregnancy is the result of an act of rape or incest.

911.6.2. A “Certificate of Necessity for Abortion” form, DMA-311, certifying the

above situation must be properly executed and attached to the claim at

the time of submission to the Division. This form may be filled out and

signed by the physician before or after the abortion is performed. See

Appendix I for a copy of this form.

911.6.3. To ensure that abortions are not being billed through the use of other

Rev. 10/11procedure codes, the Division requires the following

procedures to require an abortion certification along with submission of

the History& Physical, Operative Report, and the Pathology Report with

all claims that have the following procedures;

911.6.3.1. Other cesarean section of unspecified type

911.6.3.2. Other genitourinary installations

911.6.3.3. Dilation and curettage for termination of pregnancy

911.6.3.4. Aspiration curettage of uterus for termination of

pregnancy

911.6.3.5. Hysterectomy to terminate pregnancy

911.6.3.6. Intra-amniotic injection for abortion

911.7. Sterilizations

911.7.1. NOTE: Medicaid funds are unavailable for sterilization, hysterectomies,

or abortions performed without the documentation required by federal

regulations (See 42 CFR 441.206 and 441.256). As such, claims for

payment submitted without the required documentation or with

incomplete or inaccurate documentation will be denied. The Division

does not accept documentation meant to satisfy informed consent

requirements which has been completed or altered after the service was

performed.

911.7.2. The Division is prohibited from making payment for sterilizations

performed on any person who: is under twenty-one (21) years of age at

the time he/she signs the consent; or is not mentally competent; or is

institutionalized in a correctional facility, mental hospital, or other

rehabilitation facility. See Appendix J for a copy of the required consent

form.

911.7.3. For sterilization procedures performed on and after March 8, 1979, the

mandatory waiting period between signed consent and sterilization is

thirty (30) days.

911.7.4. The signed consent form expires one hundred and eighty (180) days from

the date of the member’s signature.

911.7.5. In the case of premature delivery or emergency abdominal surgery

performed within thirty (30) days of signed consent, the physician must

certify that the sterilization was performed less than thirty (30) days but

not less than seventy- two (72) hours after informed consent was

obtained. Although these exceptions are provided, the conditions of the

waiver will be subject to review.

911.7.6. In the case of premature delivery or emergency abdominal surgery, the

sterilization consent form must have been signed by the member thirty

30 Days prior to the originally planned date of sterilization. A

sterilization consent form, DMA- 69, must be properly filled out and

signed for all sterilization procedures and attached to the claim at the

time of submission to the Division. The member must sign the consent

form at least thirty (30) days, but not more than one hundred and eighty

(180) days, prior to the sterilization. The physician must sign the consent

form after the sterilization has been performed.

911.7.7. For information on ordering forms, please refer to the Hospital Billing

Section published by Georgia Healthcare Partnership.

911.7.8. The following is a list of procedures associated with sterilization. All

claims with these procedures will be reviewed prior to payment to ensure

proper coding and to ensure that the sterilization consent form is attached

to those claims requiring a form.

NOTE: Two (2) of the procedures always require a sterilization consent

form. The remaining codes require the consent form if the procedure was

done for sterilization purposes.

911.7.9. Sterilizations that always requires the Sterilization Consent Form.

911.7.9.1. Male sterilization procedure, not otherwise specified

911.7.9.2. Other bilateral destruction or occlusion of fallopian

tubes

911.7.10. If done for sterilization purposes, requires Sterilization Consent Form

911.7.10.1. Vasectomy and ligation of vas deferens

911.7.10.2. Vasectomy

911.7.10.3. Bilateral Salpingo-oophorectomy

911.7.10.4. Removal of both ovaries and tubes at same operative

episode

911.7.10.5. Removal of remaining ovary and tube

911.7.10.6. Operations on fallopian tubes

911.7.10.7. Salpingostomy

911.7.10.8. Bilateral endoscopic destruction or occlusion of

fallopian tubes

911.7.10.9. Bilateral endoscopic ligation and crushing of fallopian

tubes

911.7.10.10. Bilateral endoscopic ligation and division of fallopian

tubes

911.7.10.11. Other bilateral endoscopic destruction or occlusion of

fallopian tubes

911.7.10.12. Other bilateral destruction or occlusion of fallopian

tubes

911.7.10.13. Other bilateral ligation and crushing of fallopian tubes

911.7.10.14. Other bilateral ligation and division of fallopian tubes

911.7.10.15. Total unilateral salpingectomy

911.7.10.16. Removal of both fallopian tubes at same operative

episode

911.7.10.17. Removal of remaining fallopian tube

911.7.10.18. Other salpingectomy

911.7.10.19. Bilateral partial salpingectomy, not otherwise specified

911.7.10.20. Other partial salpingectomy

911.8. Hysterectomy

NOTE: Medicaid funds are unavailable for sterilization, hysterectomies, or abortions performed without the

documentation required by federal regulations (See 42 CFR 441.206 and 441.256). As such, claims for payment

submitted without the required documentation or with incomplete or inaccurate documentation will be denied.

The Division does not accept documentation meant to satisfy informed consent requirements which has been

completed or altered after the service was performed.

911.8.1. Hysterectomy procedures are reimbursable only when the following

requirements are met:

911.8.1.1. The hysterectomy was performed for medical necessity

and not for the purpose of family planning, sterilization,

hygiene or mental incompetence.

911.8.1.2. The member was informed prior to the hysterectomy that

she would be permanently incapable of reproducing (this

does not apply if the individual was sterile prior to the

hysterectomy or in the case of an emergency

hysterectomy);

911.8.1.3. The member and the attending physician sign the

“Patient’s Acknowledgement of Prior Receipt of

Hysterectomy Information,” form DMA-276, either

before or after the surgery is performed. The individual

is not required to sign in the cases of prior sterility or

emergency hysterectomy; and the properly executed

“Patient’s Acknowledgement of Prior Receipt of

Hysterectomy Information” form is attached to the claim

submitted to the Division. See Appendix H for a copy of

this form.

911.8.1.4. The following is a list of procedures associated with

hysterectomies. All claims with these procedure codes

will be reviewed prior to payment to ensure proper

coding and to ensure that the hysterectomy

acknowledgement form is attached. All hysterectomy

procedures listed require a hysterectomy

acknowledgement form

911.8.1.5. Hysterectomies that require Hysterectomy

Acknowledgement form:

911.8.1.5.1. Subtotal abdominal hysterectomy

911.8.1.5.2. Total abdominal hysterectomy

911.8.1.5.3. Vaginal hysterectomy

911.8.1.5.4. Radical abdominal hysterectomy

911.8.1.5.5. Radical vaginal hysterectomy

911.8.1.5.6. Pelvic evisceration

911.8.1.5.7. Other unspecified hysterectomy

911.9. General Claims Submission Policy for Ordering, Prescribing, or Referring

(OPR)Providers

911.9.1. The Affordable Care Act (ACA) requires physicians and other eligible

practitioners who order, prescribe and refer items or services for

Medicaid beneficiaries to be enrolled in the Georgia Medicaid Program.

As a result, CMS expanded the claim editing requirements in Section

1833(q) of the Social Security Act and the providers’ definitions in

sections 1861-r and 1842(b) (18) C. Therefore, claims for services that

are ordered, prescribed, or referred must indicate who the ordering,

prescribing, or referring (OPR) practitioner is. The department will

utilize an enrolled OPR provider identification number for this purpose.

Any OPR physicians or other eligible practitioners who are NOT already

enrolled in Medicaid as participating (i.e., billing) providers must enroll

separately as OPR Providers. The National Provider Identifier (NPI) of

the OPR Provider must be included on the claim submitted by the

participating, i.e., rendering, provider. If the NPI of the OPR Provider

noted on the Georgia Medicaid claim is associated with a provider who is

not enrolled in the Georgia Medicaid program, the claim cannot be

paid.

911.9.2. Effective 4/1/2014, DCH will begin editing claims submitted through the

web, EDI and on CMS-1500 forms for the presence of an ordering,

referring or prescribing provider as required by program policy. The edit

will be informational until 6/1/2014. Effective 6/1/2014, the ordering,

prescribing and referring information will become a mandatory field and

claims that do not contain the information as required by policy will

begin to deny.

911.10. For the NEW CMS-1500 claim form:

Enter qualifiers to indicate if the claim has an ordering, referring, or prescribing

provider to the left of the dotted line in box 17 (Ordering = DK; Referring = DN or

Supervising = DQ).

911.11. For claims entered via the web:

Claims headers were updated to accept ordering or referring Provider ID and name for

Dental and Institutional claims and the referring provider’s name for Professional

claims. The claim detail was updated to accept an ordering or referring provider ID and

name.

Utilize the “ordering” provider field for claims that require a prescribing physician.

911.12. For claims transmitted via EDI:

The 837 D, I, and P companion guides were updated to specifically point out the

provider loops that capture the rendering, ordering, prescribing, referring and service

facility provider information that is now used to transmit OPR information.

The following resources are available for more information:

Access the department’s DCH-I newsletter and FAQs at

http://dch.georgia.gov/publications

Search to see if a provider is enrolled at

https://www.mmis.georgia.gov/portal/default.aspx

Click on Provider Enrollment/Provider Contract Status. Enter Provider ID or NPI and

Provider’s last name.

Access a provider listing at

https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%2

0 Notices/tabId/53/Default.aspx

Click on Georgia Medicaid FFS Provider Listing or OPR Only Provider Listing