Medical Assistance Letters
V. Is the group practice required to share the NPI numbers assigned to the group practice or assigned to the individual physicians in the group with other entities?
Yes, physicians and physician group practices must disclose their NPI, when requested, to any entity that needs the NPI to identify that physician/physician group practice in a standard transaction. This includes disclosing your NPI to Medicaid, Medicare, other health plans, and any other provider that needs to identify the physician on transactions.
Pharmacies will need the appropriate individual NPI to submit as the prescribing provider on pharmacy claims; hospitals and long term care facilities (LTCF) will need your NPI to submit as the attending provider, the operating provider or other provider on hospital and LTCF claims; durable medical
equipment (DME) suppliers will need your NPI to submit as the ordering provider on DME claims. You are required to share the appropriate NPI with them.
ODJFS appreciates the attention of the providers in this matter, and as a result of their cooperation anticipates a successful transition to NPI enumeration.
Questions pertaining to this MAL should be addressed to:
P.O. Box 1461
Columbus, Ohio 43216-1461
Toll free telephone number 1-800-686-1516
You can also obtain information about NPI as it pertains to the Ohio Medicaid program at http://jfs.ohio.gov/OHP/providers/npi.stm
NPI………GET IT...SHARE IT...USE IT
MAL 516 (November 9, 2006 - Employee Education about False Claims Recovery)
Medical Assistance Letter No. 516. is maintained in the General Information e-book.
Medical Assistance Letter No. 495. is maintained in the Pharmacy Services e-book.
MAL 491 (September 28, 2005 - Pharmacy Program Preferred Drug List)
Medical Assistance Letter No. 491. is maintained in the Pharmacy Services e-book.
August 11, 2005
TO: Providers of Physician Services, Atten: Specialty Providers of Otolaryngology Directors, County Departments of Job and Family Services
Medical Assistance Coordinators FROM: Barbara E. Riley, Director
SUBJECT: Reminder for billing with the bilateral modifier
This is an important reminder about bilateral surgical procedure billing, which is outlined in rule 5101:3-4-22 (issued via MHTL 3336-05-02, dated 7/14/05).
Bilateral procedures must be billed on one line using the code modifier 50. This code modifier indicates that the procedure was done bilaterally on the same date of service. For example, if you billed 6943650 with modifier 50, that would indicate a tympanostomy was performed on both ears. If the code were given without the modifier 50, that would indicate the procedure was performed on one ear only.
A bilateral procedure should never be billed on two lines or on separate bills. The department is in the process of implementing systems logic that will begin denying bilateral services that are billed twice.
This MAL is posted on the department's web site at: http://emanuals.odjfs.state.oh.us/emanuals/
in the Physician Services Handbook under the links "Ohio Health Plans - Provider" (left column), "Physician Services" (right column), "Medical Assistance Letters" (left column).
Questions pertaining to this MAL should be addressed to:
Bureau of Plan Operations
The Provider Network Management Section P.O. Box 1461
Columbus, Ohio 43216
In-state toll free telephone number 1-800-686-1516
MAL 473 (September 2, 2004 - Pharmacy Program Initiatives: Clinical Utilization Edits and Preferred Drug List Implementation)
Medical Assistance Letter No. 473. is maintained in the Pharmacy Services e-book.
Medical Assistance Letter No. 460. is maintained in the Pharmacy Services e-book.
MAL 456 (September 15, 2003 - PDL Information)
Medical Assistance Letter No. 456. is maintained in the Pharmacy Services e-book.
July 28, 2003 To: Providers billing for pre-natal services
From: Thomas J. Hayes, Director
Re: Prenatal care reimbursement- Important Billing Change
This is a follow-up notice relating to Medical Assistance Letter (MAL) # 450 dated June 26, 2003 regarding reimbursement for pre-natal services. Effective for dates of service on and after July 1, 2003, the local level code 59420 is no longer reimbursable since it is not HIPAA-compliant. Providers should bill the appropriate office visit code which best describes the type of obstetrical visit provided and modify the code with the TH modifier to document that pre-natal services were provided. Billing instructions for obstetrical services were provided in MHTL 3336-02-05 dated December 6, 2002.
If the office visit code is modified by the TH modifier, providers will receive the reimbursement amounts shown below for prenatal services billed with the TH modifier:
99201-9 9 2 0 3
$48.40
99204 $70.32
99205 $87.97
99211 $19.73
99212-9 9 2 1 3
$48.40
99214 $52.57
99215 $81.04
Should you have any questions, please call Provider Network Management at 1-800-686-6108 in state or 614-728-3288 for out-of-state providers.
MAL 450 (Prenatal Care Reimbursemen)
Medical Assistance Letter (MAL) No. 450
June 26, 2003 TO: Physicians, Clinics, Advanced practice nurses
Directors, County Department of Job and Family Services FROM: Thomas Hayes, Director
SUBJECT: Prenatal care reimbursement
BILLING CHANGES EFFECTIVE JULY 1, 2003
It has been brought to our attention that the billing instructions for prenatal care visits (formerly billed as code 59420) provided in MHTL 3336-02-05 dated December 6, 2002 for physicians and MHTL 3355-02-05 for advanced practice nurses could, in some instances, result in reduced reimbursement to providers billing for prenatal visits.
It is not the intent of the Department to pay providers less in the aggregate than what providers are currently receiving if the non-HIPAA compliant code 59420 is billed. The Department will be implementing system changes to implement the following rates for a prenatal obstetrical visit when the TH modifier is billed effective for dates of service on and after 7/1/03:
The Department plans to implement system fixes by July 1, 2003.
It will be critical for providers to bill the TH modifier when the service is for a prenatal visit to receive the correct reimbursement for prenatal visits.
* Note: An RN visit will be paid less but complex physician visits (99214, 99215) will be reimbursed at a higher level
Questions pertaining to this MAL should be addressed to:
The Bureau of Plan Operations
Columbus, OH 43216-1461
In state toll free telephone number 1-800-686-6108 Out-of-state telephone number 614-728-3288
MAL 447 (PDL Information)
Medical Assistance Letter No. 447 Attachments
Ohio PDL Quick-Preferred Only Listing PDL Combo II Listing
March 6, 2003 To: Prescribers of Pharmacy Services
From: Tom Hayes, Director
Subject: Preferred Drug List (PDL) Information
Effective April 7, 2003 Ohio Medicaid will move to the next phase of pharmacy management - a Preferred Drug List (PDL). The classes listed below were reviewed to determine those products that the Department considers "preferred" for Ohio Medicaid recipients. A "preferred" status in these classes indicates that the product does not require prior authorization (PA) in most situations. Those products in these classes that are
"non-preferred" are subject to prior authorization.
What does this mean for you?
Click here to view the explanation chart.
All drugs in classes not listed below remain available as per current coverage. Those classes listed below will require PA for "non-preferred" products beginning with all new prescriptions or refills filled on or after the dates indicated below:
April 7 - PPIs, H-2 Receptor Antagonists April 14 - Narcotics, NSAIDs
April 21 - Nasal Steroids, Inhaled Steroids, Inhaled Beta-Agonists, 2nd Generation Antihistamines April 28 - ACE Inhibitors, Angiotensin Receptor Antagonists, Beta-Blockers, Calcium Channel Blockers May 5 - COX-IIs for patients under age 60 only
You can be proactive and request prior authorization prior to the effective rollout date for a given category.
The enclosed documents have been included for your benefit. We encourage you to keep them available for quick reference.
• The list printed on color paper gives a listing of "preferred" drugs in each category. It has been arranged so you can make it a tri-fold to keep in your pocket.
• A more comprehensive list includes both "preferred" and "non-preferred" products in each class. This can be duplicated and hung on a wall or placed in a binder for reference.
Effective immediately, a new fax number has been implemented for requesting PA. The new fax number is 1-800-396-4111. The phone numbers have remained the same:
Technical Calls 1-877-518-1545 PA Requests 1-877-518-1546 These PDL documents can also be found on our website:
http://www.state.oh.us/odjfs/ohp/bhpp/meddrug.stm
If you have additional questions or would like to schedule an educational visit, please call our vendor, First Health Services, at 614-481-3519.
We appreciate your continued support of our efforts to maintain a quality, cost-effective pharmacy program.
Medical Assistance Letter (MAL) No. 437
October 25, 2002 TO: All Providers of Anesthesia Services
Directors, County Departments of Job and Family Services Directors, District Offices
FROM: Thomas Hayes, Director
SUBJECT: Billing Anesthesia for Missed or Spontaneous Abortions and Miscarriages BILLING CHANGE EFFECTIVE IMMEDIATELY
The purpose of this Medical Assistance Letter (MAL) is to clarify which code should be billed to the Department for services related to anesthesia for missed or spontaneous abortions and miscarriages.
The Current Procedure Terminology (CPT) book for 2002 produced a new anesthesia code specific to abortion procedures (01964, abortion procedures). If this code is billed for anesthesia services related to missed or spontaneous abortions or miscarriages, the claim will deny since an abortion consent form must be submitted. Until the American Medical Association (AMA) develops codes that recognize the difference
between a legal abortion and a missed/spontaneous abortion or miscarriage, the following billing procedures apply:
• To bill for anesthesia services related to missed or spontaneous abortions and miscarriages, use code 00940, anesthesia for vaginal procedures.
• To bill for anesthesia services related to a legal abortion, use code 01964, abortion procedure. Legal abortions must meet all requirements of the Ohio Administrative Code (OAC) rule 5101:3-17-01. An Abortion Consent Form, ODJFS Form 3197, must be submitted certifying that the abortion meets the criteria for a legal abortion.
Any claims that have been submitted to the Department in 2002 using code 01964 that have not paid should be resubmitted observing the billing procedures outlined in this MAL.
Questions pertaining to this MAL should be addressed to:
Bureau of Plan Operations
The Provider Network Management Section P.O. Box 1461
Columbus, OH 43216-1461
In-state toll free telephone number 1-800-686-6108 Out-of-state telephone number 1-614-728-3288
MAL 382 (Physician Services Fee Update)
MEDICAL ASSISTANCE LETTER (MAL) No. 382
January 4, 2000 TO: All Providers of Physician Services
Directors, County Departments of Human Services Directors, District Offices
FROM: Jacqueline Romer-Sensky, Director SUBJECT: PHYSICIAN SERVICES FEE UPDATE
HANDBOOK UPDATE FOR 2000 HCPCS CHANGES PHYSICIAN SERVICES