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Frequently Asked Questions

Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.

FAQ Library

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Upon analysis by states, what if an edit is found to be in conflict with a state law or regulation, but is currently included within a National Correct Coding Initiative (NCCI) methodology?

CMS allows states to consider edits on an individual, state-by-state basis. If a state determines that an edit in the Medicaid NCCI methodologies conflicts with one or more state laws, regulations, administrative rules, or payment policies, the state can request permission from CMS to deactivate the conflicting edit. States are not afforded the flexibility to deactivate edits after March 31, 2011, due to a lack of operational readiness.

If a state determines and documents that there is no other feasible way to comply with Medicaid NCCI edits, the state can send a request to deactivate that edit or those individual edits using the NCCI mailbox at NCCIPTPMUE@cms.hhs.gov. The request must include sufficient primary source documentation of the conflicting state law, regulation, administrative rule, or payment policy. States are no longer required to send NCCI deactivation requests to CMS Regional Offices.

FAQ ID:95166

Care managers often do not document data elements in the assessment and care plan measures unless the member has "a problem." For example, they may not document that they assessed the member's vision or need for an assistive device if no problem was identified. How can states or plans address this issue?

Managed Long Term Services and Supports (MLTSS) plan managers should provide training on proper documentation practices to care managers and other delegated staff. States and MLTSS plans could consider including data field entry options to remind care managers to record all results of the assessment, even if findings are negative, that is, the member does not have a problem or need assistance or services. For example, states and plans could include a question in the member’s record that requires the care manager to document both whether an assessment was performed and whether a problem was identified, along with another required field to include the details of the problem if there was a problem identified.

FAQ ID:89046

Must a Managed Long Term Services and Supports (MLTSS) member have a documented care plan to be eligible for the LTSS Shared Care Plan with Primary Care Practitioner (PCP) measure?

Yes, the denominator for this measure includes all MLTSS members with a care plan meeting the criteria outlined in the LTSS Comprehensive Care Plan and Update measure core rate.

FAQ ID:89201

Who is considered a primary care practitioner (PCP) for the purpose of calculating the LTSS Shared Care Plan with Primary Care Practitioner (PCP) measure?

A PCP is a physician, non-physician (for example, nurse practitioner, physician assistant), or group of providers who offers primary care medical services. However, a care plan can be shared with a medical care practitioner other than the PCP if the practitioner is identified by the member as the primary point of contact for their medical care. Therefore, any medical care practitioner identified by the member as the primary point of contact for their medical care is considered their PCP for the purpose of calculating the measure.

FAQ ID:89206

Why is the care plan shared just with the primary care practitioner (PCP) or other documented medical care practitioner identified by the Managed Long Term Services and Supports (MLTSS) member?

The care plan is shared with the PCP to promote coordination of medical and LTSS services.

FAQ ID:89211

What are some acceptable ways to share the care plan with the primary care practitioner (PCP)? What if the Managed Long Term Services and Supports (MLTSS) participant refuses to share it?

The measure specifications allow sharing the care plan by mail, fax, secure email, or mutual access to an electronic portal or Electronic Health Record. Members who refuse to share their care plan are excluded from the measure denominator, but there must be documentation in the record that the member refused to share the care plan (noting verbal refusal suffices). The rate of exclusion due to a member refusing to share their care plan with the PCP should also be reported along with the measure performance rate.

FAQ ID:89216

Does the full Managed Long Term Services and Supports (MLTSS) care plan need to be shared with the primary care practitioner (PCP) to meet the numerator criteria for the LTSS Shared Care Plan with Primary Care Practitioner (PCP) measure?

No. MLTSS plans are not required to share the full care plan with the PCP or other documented medical care practitioner. MLTSS plans may choose which parts of the care plan are most relevant to the practitioner.

FAQ ID:89221

Is the provider's signature on the shared Managed Long Term Services and Supports (MLTSS) care plan required?

No, the LTSS Shared Care Plan with Primary Care Practitioner (PCP) measure only looks to see that a care plan was sent to a primary care practitioner (PCP) by the MLTSS plan. No signature from the PCP is necessary to count towards the numerator of this measure.

FAQ ID:89226

Do plans need to get a release of information from the Managed Long Term Services and Supports (MLTSS) member to share the care plan with the primary care practitioner (PCP)?

There is no need for a release of information. If a member gives the plan the contact information for their PCP, the plan can share information with that PCP. Plans or other providers of LTSS should try to coordinate LTSS services with medical services, even if they are not the primary payer for medical services for the member. Plans that do not know the member’s PCP can/should ask the member to identify their PCP and request their contact information. The measure is intended to determine whether plans tried to connect with the medical care provider. There is an exclusion in this measure for members who refuse to have their care plan shared with the PCP, so if the member refuses, this should be documented, and such members are excluded from the measure rate.

FAQ ID:89231

What are National Correct Coding Initiative (NCCI) methodologies and are these methodologies compatible with the Medicaid program?

The NCCI methodologies are made up of the following four components:

  1. Sets of edits
  2. Definitions of types of claims subject to the edits
  3. Sets of claim-adjudication rules for applying the edits
  4. Sets of rules for addressing provider/supplier appeals of denied payments for services based on the edits

The NCCI methodologies include both NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs).

CMS issued SMDL #11-003 (PDF, 159.55 KB) on April 22, 2011, to state CMS policy on the requirement for appeals of claims for which payment was denied due to an NCCI edit. The nature of the appeals process in each state is left to the discretion of the state's Medicaid agency.

CMS currently has six methodologies for Medicare Part B. These methodologes are the following:

  1. NCCI PTP edits for practitioner and ambulatory surgical center (ASC) services
  2. NCCI PTP edits for outpatient services (including emergency department, observation, and hospital laboratory services) in hospitals reimbursed through the hospital outpatient prospective payment system (OPPS). Edits are applied to all facility therapy services billed to the Medicare Fiscal Intermediary (Part A Hospital / Part B Practitioner Medicare Administrative Contractors processing claims with the Fiscal Intermediary Shared System).
  3. MUE units-of-service edits for practitioner and ASC services
  4. MUE units-of-service edits for outpatient services in hospitals
  5. MUE units-of-service edits for supplier claims for durable medical equipment
  6. Add-on code edits for practitioner and ASC services (added in April 2013).

After review, CMS determined that the first five NCCI methodologies listed above were compatible methodologies for claims filed in Medicaid. A sixth methodology for Medicaid was added in 2012: NCCI PTP edits for Durable Medical Equipment (DME).

FAQ ID:95121

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