CCLA – Medicare Policy

Paul O’Donnell

Jurisdiction E Project Manager (Medicare)

Welcome / Corporate Experience

Noridian is a wholly owned subsidiary of Noridian Mutual Insurance Company (dba, Blue Cross Blue Shield of North Dakota) headquartered in Fargo, ND

Began Medicare work as “MAC” in CA in Sept 2013

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Functions of a MAC

Primary Functions Include:• Claims - Initial Processing, Reopening of Claims,

Redeterminations (Appeals)• Provider Enrollment• Provider Customer Service Program - Provider

Outreach and Education; Telephone, Written, Complex, and Congressional Inquiries

• Medicare Secondary Payer• Medical Review• Local Coverage Determinations

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What Does Noridian Administer?

• Part A & B Medicare – 13 States (14.7%)• DME – 17 States/territories (20.2%)• Medicaid – Iowa• PDAC – All US/Territories• Medicare Audit Programs:

– Essential Hospitals – All US/Territories– Children’s Hospitals – Select States

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Noridian: States We Serve

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California Site Functions

• Part A Audit• Provider Education• Provider Contact Center

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*Camarillo*Westminster

MolDX Responsibilities

Palmetto GBA• Determinations regarding coverage• Pricing• Coordination with McKesson to establish a

unique identification numbers• Coordination and communication with

Noridian on all claims processing guidelines

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MolDX Responsibilities

Noridian• Implement MolDX guidelines provided by

Palmetto GBA• Process claims with Palmetto GBA

guidelines• Appeals/Reopenings for claims processing

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MolDX LCDs

• Palmetto drafts new LCDs• Noridian concurrently opens that draft LCD

for notice/comments in JE• After review of comments, Noridian

implements LCDs across entire Jurisdiction• The JE LCDs would include references and

links to the MolDX website, i.e., MolDX LCD and JE LCD policy will be same

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MolDX Claim Administration

• Noridian will administer/apply the MolDX claim edits consistent with MolDX coverage and coding guidelines

• Approach is collaborative between Noridian and Palmetto

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Medically Unlikely Edit (MUE)

• Providers should not interpret MUE values as utilization guidelines. MUE values do not represent units of service providers may report and avoid further medical review.

• Providers should continue to report only services that are medically reasonable and necessary.

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MUE Editing

• MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment.

• NOTE – MUEs do not just address clerical billing errors

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MUE Editing

Additional claim edits are being added January 1, 2015 to aggregate all services billed on the same day for MUE purposes.

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MUE Appeals

• For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process if medical necessity can be determined by review of the clinical records.

• Since claim lines are denied at the MAC, MUE based claim denials may be appealed to Noridian.

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MUE Changes

• Requests for modification of an MUE value should be sent to the following:

National Correct Coding Initiative Correct Coding Solutions, LLC P.O. Box 907 Carmel, IN 46082-0907 FAX: 317-571-1745

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MUE Resources

• CMS Website (www.cms.gov)– Home > Medicare >

National Correct Coding Initiative Edits > Medically Unlikely Edits

• Noridian Website (www.noridianmedicare.com)– Search MUE

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Who reviews Medicare claims?

• Multiple post pay contractors/agencies are able to review Medicare claims– Comprehensive Error Rate Testing (CERT)– Noridian Medical Review (MR)– Recovery Auditor (RA)– Office of the Inspector General (OIG)– Zone Program Integrity Contractor (ZPIC)

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