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Policy Areas

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The Centers for Medicare and Medicaid Services (CMS) has scheduled the next hospital/quality initiative open door forum (ODF) for Tuesday, April 19, 2016 at 2:00 pm. Two of the agenda topics that will be addressed include the upcoming Improving Medicare Post-Acute Transformation (IMPACT) Act stakeholder engagement activities and the self-identified overpayment final rule.

To participate in the ODF, call 1-800-837-1935 and reference conference ID: 39978935. An encore recording of the call will be available beginning two hours after the call has ended and will expire after two business days. To listen to the encore recording, call 1-855-859-2056 and reference conference ID: 39978935.

SAMHSA and the Centers for Medicare & Medicaid Services (CMS) invite you to join a presentation of the final rule on mental health and substance use disorder parity for Medicaid and CHIP, to be held on Thursday, April 14, 1:00 – 2:00 pm.

This rule implements the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) for 23 million beneficiaries enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and the Children’s Health Insurance Program (CHIP), ensuring that benefits for mental health and substance use disorder treatments and services are offered on equal footing with medical and surgical benefits. This presentation will include a discussion of the application of parity to Medicaid and CHIP programs, key changes from the Notice of Proposed Rulemaking, and answers to frequently asked questions.

A Question and Response Addendum has been added to the PA e-Marketplace website, for the request for proposals (RFP) for managed care organizations that will be submitting their proposals and responses for the Community HealthChoices program. The addendum is located under “Flyers/Addendums” on the web page. The 81-page addendum includes the RFP section, questions, and answers to each question posed.

RCPA has become aware that there have been higher than normal claims denials by both Medicare and Medicaid related to certain diagnoses. Those diagnoses are Schizophrenia and Post Traumatic Stress Disorder (PTSD) as defined by the DSM-V and ICD-10.

The DSM-V only identifies Schizophrenia Not Otherwise Specified (NOS) and PTSD NOS, versus the ICD-10 which offers eight schizophrenia diagnoses and three PTSD diagnoses. As a result, our practitioners are likely choosing Schizophrenia or PTSD NOS, since they are mostly using the DSM-V. Billing staff have options of eight or three diagnoses respectively, but will use what the practitioner has selected, the only DSM-V diagnosis available. It is highly probable that the individual being evaluated meets something other than NOS. There are very specific criteria for the NOS diagnosis which can certainly be used as the criteria is met, but when the criteria is not met, the claims are accurately denied. RCPA wants to hear from you about how this is affecting your business.

The second billing issue is related to electronic health records (EHR) that have not yet loaded the ICD-10 codes for billing. It is our understanding that there are at least two vendors doing business in Pennsylvania who have not loaded the ICD-10 billing codes into the EHR. RCPA wants to hear from members about how they are billing in the absence of the EHR, not having the ICD codes, and other universal billing concerns.

Please find more information about claims rejections here. Send comments to Sarah Eyster by Friday, April 15.