Attachment 3 - Miscellaneous Documents.pdf

Attachment 3 – Miscellaneous Documentation for RFP OPEO-SOL-NDMS-2012

The following Documents are included in this attachment:

Attachment J.100 – Definitions – Page 1 Attachment J.101 - MEMORANDUM OF AGREEMENT FOR DEFINITIVE MEDICAL CARE – Page 4 Attachment J.102 - Definitive Medical Care Reimbursement Program – Specified Disasters or Public Health

Emergencies Coverage Guidelines – Page 8 Attachment J.103 - NDMS Reimbursement Program – Specified Disasters or Public Health Emergencies – Page 9 Attachment J.104 - NDMS Reimbursement Program – Specified Disasters or Public Health Emergencies - NDMS

Coordination of Benefits Guidelines – Page 11 Attachment J.105 - NDMS Denial Guidelines – Page 14

Attachment J.100

NDMS DEFINITIONS

ASPR The Office of the Assistant Secretary for Preparedness and Response (formerly the Office of Public Health Emergency Preparedness) was created under the Pandemic and All Hazards Preparedness Act in the wake of Katrina to lead the nation in preventing, preparing for, and responding to the adverse health effects of public health emergencies and disasters. ASPR focuses on preparedness planning and response;

building federal emergency medical operational capabilities;

countermeasures research, advance development, and procurement; and grants to strengthen the capabilities of hospitals and health care systems in public health emergencies and medical disasters. The office provides federal support, including medical professionals through ASPR’s National Disaster Medical System, to augment state and local capabilities during an emergency or disaster.

CMS The Centers for Medicare & Medicaid Services, the operating division of HHS that is responsible for administration of the Medicare and Medicaid programs.

Definitive Medical Care To the extent authorized by NDMS in a particular public health emergency, medical treatment or services beyond emergency medical care, initiated upon inpatient admission to an NDMS hospital and provided for injuries or illnesses resulting directly from a specified public health emergency, or for injuries, illnesses and conditions requiring non-deferrable medical treatment or services to maintain health when such medical treatment or services are temporarily not available as a result of a public health emergency. (Source: NDMS Partners MOA dated October 24, 2005)

DHS The federal Department of Homeland Security, which is one of the NDMS Federal Partners.

DRG Diagnosis-Related Group – Groupings established under the Medicare Hospital IPPS based on patient diagnostic status at admission and medical service/procedure codes. Each DRG is assigned a unique “weighting factor” (that measures the resources typically consumed for a patient in that DRG relative to patients classified in other DRGs) that is used to compute the amount of payment due an inpatient hospital under the Medicare Hospital IPPS.

Facility An organization reimbursable under Medicare Part A or Part B including but not limited to:

Part A:

1) Hospitals (inpatient)

2) Long Term Care Facilities (LTCs) (i.e., Skilled Nursing

Facilities (SNFs))

3) Hospice (Inpatient and Residential)

4) Home Health Agencies (HHAs)

Part B:

5) Hospitals (outpatient)

6) Comprehensive Outpatient Rehabilitation Facilities (CORFs)

7) Clinics, Rehabilitation Agencies, and Public Health

Agencies as Providers for Outpatient Therapy and Speech –Language Pathology Services

8) Rural Health Clinics (RHCs); Federally Qualified Health Centers (FQHCs)

9) Community Mental Health Centers (CMHCs)

10) End Stage Renal Disease Facilities (ESRD)

11) Ambulatory Surgical Centers (ASCs)

12) Practitioners

“Facilities” shall also include those institutions that do not participate in or are not reimbursable under Medicare Part A and Part B but do participate in and are reimbursable under their State’s Medicaid program for services rendered. Such facilities could include:

1) Nursing Facilities (NFs)

2) Inpatient Psychiatric Residential Treatment Facilities for

Individuals under Age 21 (PRTFs)

3) Intermediate Care Facilities for the Mentally Retarded

(ICFs/MR)

4) Outpatient Pharmacies.

Facilities and Practitioners are collectively referred to as Providers.

FCCs Federal Coordinating Centers - FCCs recruit Facilities and maintain local non-Federal Facility participation in the NDMS; coordinate exercise development and emergency plans with participating Facilities and other local authorities in order to develop patient reception, transportation, and communication plans; and, during system activation, coordinate the reception and distribution of patients being evacuated to the area. Care is normally not reimbursable by NDMS unless coordination of the patient’s activation was managed by an FCC.

FEMA The Federal Emergency Management Agency, which is responsible for coordinating the federal response to disasters and emergencies; FEMA is an agency within DHS.

HHS The federal Department of Health and Human Services.

Medicaid The health insurance program for poor families and individuals, established by Title XIX of the Social Security Act; Medicaid is financed jointly by the federal and state governments, but most operational activities are managed at the state level.

Medicare The federal health insurance program for the elderly, disabled, and individuals with End Stage Renal Disease established by Title XVIII of the Social Security Act.

Medicare Hospital Inpatient Prospective Payment System

(IPPS)

The policy framework for reimbursing most acute care hospital inpatient services under the Medicare program, as established under section 1886 of the Social Security Act and implementing regulations and Federal Register notices. Also referred to herein as Medicare Part A.

Medicare Physicians’ Fee Schedule

The policy framework for reimbursing most services furnished by physicians and other licensed practitioners under the Medicare program, as established under section 1848 of the Social Security Act and implementing regulations and Federal Register notices. Also referred to herein as Medicare Part B.

NDMS The National Disaster Medical System, as established in law (42 U.S.C.

300hh-11) and as further defined in the NDMS MOA. The NDMS program office exists within the HHS/ASPR/OPEO.

NDMS Coverage NDMS coverage begins when an FCC authorizes placement of a patient, who has been evacuated from a disaster area, into a Facility for Definitive Medical Care. NDMS payment will end when one of the following occurs, whichever comes first: completion of medically indicated treatment as defined by the Centers for Medicare & Medicaid Services diagnostic related group, based on ICD-9 (and ICD-10 when available) codes (maximum of 30 days); voluntary refusal of care; return to originating facility or other location for follow on care.

NDMS Federal Partners The federal Departments of Homeland Security (DHS), Health and Human Services (HHS), Defense (DOD), and Veterans Affairs (VA).

NDMS Hospital An acute care hospital that has executed an agreement with the NDMS system to provide Definitive Medical Care services.

NDMS MOA for Definitive Medical Care

The NDMS MOA for Definitive Medical Care was approved by the NDMS Federal Partners dated April 11, 2011. This MOA supersedes prior NDMS Provider MOAs.

NDMS Patient Any patient transported via Federal assets, who is processed through an FCC and referred for Definitive Medical Care.

NDMS Reimbursement Program

To the extent authorized by NDMS in a particular public health emergency, the mechanism established by HHS to reimburse Facilities that participate in the NDMS and authorized non-participating Facilities for Definitive Medical Care provided to NDMS patients during specified public health emergencies. This program also reimburses the separately-billable professional services of physicians and other medical Practitioners who treated NDMS-patients within the first thirty (30) days of the patient’s initial admission to a NDMS Facility.

Practitioner Any type of licensed professional or organization reimbursable under Medicare Part B. “Practitioners” shall also include those licensed professionals or organizations that do not participate in or are not reimbursable under Medicare Part B but do participate in and are reimbursable under their State’s Medicaid program for professional services rendered. An illustrative example would be patient transport companies providing non-emergency patient transportation requested by NDMS for NDMS patients. While this type of transportation is not typically reimbursable under Medicare unless medical necessity is established, if a transportation company participates in Medicaid, NDMS will reimburse the transportation company for the non-emergency transportation using Medicaid rates if covered in their State.

Facilities and Practitioners are collectively referred to as Providers.

PRICER A CMS-maintained software module which analyzes patient DRG information on a hospital claim, along with hospital wage index and various data from the hospital-specific file to determine that actual payment amount under the Medicare Hospital IPPS.

Provider Facilities and Practitioners that actively participate in the Medicare and Medicaid program.

Qualified Non-Participating Hospital

An acute care hospital that (1) is not an NDMS hospital but which (2) accepted patients from an FCC during the evacuations required for specified disasters and public health emergencies.

TRICARE The health insurance program for active duty and retired uniformed military personnel and their dependents (see 32 C.F.R. Part 199).

Attachment J.101

Attachment 1. Standard National Disaster Medical System (NDMS) Provider Memorandum of Agreement (MOA) for Definitive Medical Care

MEMORANDUM OF AGREEMENT

FOR DEFINITIVE MEDICAL CARE

1. PARTIES

The Parties to this Memorandum of Agreement are ______________________________ (the Provider) and the National Disaster Medical System (NDMS), which consists of a coordinated partnership among the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), the Department of Veterans Affairs (VA), and the Department of Defense (DoD), collectively the NDMS Federal Partners.

2. AUTHORITY

This Agreement is authorized under Section 2812 of the Public Health Service Act, 42 U.S.C. 300hh-11, as amended.

3. PURPOSE

A. The NDMS statute provides that the NDMS shall be a coordinated effort by the NDMS Federal Partners, working in collaboration with the States and other appropriate public or private entities, to (i) provide health services, health-related social services, other appropriate human services, and appropriate auxiliary services to respond to the needs of victims of a public health emergency and (ii) be present at locations, and for limited periods of time, when such locations are at risk of a public health emergency during the time specified.

B. This Agreement is to help ensure that the United States is prepared to respond medically to mass casualty emergency situations in this country or to a military health emergency by facilitating a coordinated response of both Federal and civilian health care facilities.

C. The NDMS Federal Partners acknowledge the willingness of the various medical communities within the United States to respond to a catastrophic public health emergency, and the need for unusually rapid and complex response, transportation and treatment. A rapid response requires the development of a comprehensive emergency medical plan so that those patients needing definitive medical care would receive it in federal or private sector facilities in the United States.

4. RESPONSIBILITIES

A. The NDMS Federal Partners and the Provider agree to plan jointly for the transportation, admission, treatment, discharge, and return of all patients transferred to the Provider's facility under the NDMS.

B. The Provider agrees to participate in joint Federal Coordinating Center exercises, designed to also meet external disaster standards established by applicable accrediting bodies.

C. The Provider agrees to report the number of beds available (e.g., in HAvBED) when requested to support NDMS exercises or operations and then make those beds available to the NDMS for patients in real-life events. The FCC will assess the real-time status of the reported beds prior to distributing inbound patients.

D. The Provider agrees to return patient movement items (i.e., medical equipment) to the originating organization identified on the equipment or from maintenance tags.

E. The NDMS will provide transportation to return patients to their originating facility or other location as appropriate. HHS has established a contract to provide return transportation of patients and attendants, who were evacuated through NDMS, to appropriate locations within their home state or other final destination.

The Service Access Teams (SATs) coordinate all patient movement activities and communicates with the patient movement contractor to arrange for transportation. If a federally evacuated NDMS patient passes away during the response operation, the SAT will coordinate with the local and State medical examiner’s office and the patient’s family for disposition of remains.

F. HHS will provide SATs as facilitators to ensure discharge planning is accomplished and human services support is provided to discharged patients and attendants evacuated through the NDMS. The SATs will coordinate all aspects of patient return to ensure a smooth transition from the host state to the home state or other appropriate location. The SATs will operate and provide services in accordance with the “Emergency Support Function (ESF) #8 Return Movement of Domestic Medical Evacuees’ Concept of Operations”.

Once a patient is discharged, HHS SATs will ensure human services support is provided to the discharged patient (and non-medical attendants) until the patient is returned to their home state or other appropriate location.

G. If transportation to a final destination is not possible when the patient is ready for discharge, HHS will establish locations to receive the discharged NDMS patients. These locations may include hotels, skilled nursing facilities, nursing homes, Federal Medical Stations, or general population shelters as appropriate.

5. REIMBURSEMENTS

A. Reimbursements, subject to the availability of appropriations, will be limited to care provided for:

injuries or illnesses resulting directly from a specified public health emergency; injuries, illnesses and conditions requiring essential medical services necessary to maintain a reasonable level of health temporarily not available as a result of the public health emergency; or injuries or illnesses affecting authorized emergency response and disaster relief personnel responding to the public health emergency.

HHS, as payer, will define what constitutes an “NDMS patient.”

B. The following table identifies the various sources of funding for reimbursement and the order of payment. The Provider agrees to seek reimbursement in accordance with this table. The NDMS will reimburse the Provider for medical treatment or services rendered by the Provider as indicated in the following table.

Patient’s Insurance Status

Provider will first bill Provider will bill secondly

NDMS status for payments

Uninsured NDMS Covered at 110% Medicare rate Medicaid NDMS Covered at 110% Medicare rate Other insurance or health program coverage (other than Medicaid, Medicare, or

TRICARE)

Other insurance NDMS for balance, not to exceed 110% Medicare rate

* Covered at 110% of Medicare rate when combined with private insurance

Medicare Medicare Not eligible TRICARE Per TRICARE Not eligible

* not including the deductible amount and other cost sharing under the health insurance or health program coverage.

C. For patients eligible for military health coverage (i.e., TRICARE), payment will be made under TRICARE according to the applicable payment rates and procedures, as set forth in 32 C.F.R. Part 199.

D. NDMS payment will end when one of the following occurs, whichever comes first: completion of medically indicated treatment as defined by the Centers for Medicare & Medicaid Services diagnostic related group, based on ICD-9 (and ICD-10 when available) codes (maximum of 30 days); voluntary refusal of care; return to originating facility or other location for follow on care.

E. NDMS will provide reimbursements, subject to the availability of appropriations, for the same type of services covered under the Medicare benefit packages provided to authorized NDMS patients by qualified Medicare health care providers. It is anticipated that medical facilities may use consultants/health care providers that bill separately for their services. These providers will rarely have executed an MOA with NDMS. However, when that care is provided as part of the inpatient stay, NDMS will reimburse, subject to the availability of appropriations.

F. HHS will work directly with a financial intermediary to process submitted claims.

6. POINTS OF CONTACT

A. For the NDMS Federal Partners

B. For the Provider

7. OTHER PROVISIONS

A. Notwithstanding anything in this Agreement, each of the NDMS Federal Partners shall have the exclusive authority to direct its employees and to implement its own statutory responsibilities.

B. Nothing in this Agreement is intended to conflict with current federal or state law, or the regulations, agreements, or directives of the NDMS Federal Partners or the Provider. If a term of this Agreement is inconsistent with such authority, then that term shall be invalid, but the remaining terms and conditions of this Agreement shall remain in full force and effect.

1. EFFECTIVE DATE

This Agreement shall become effective upon signature of one of the NDMS Federal Partners and the Provider.

2. INFORMATION LAWS

All parties understand and will adhere to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Privacy Act, to the extent these laws are applicable.

3. TERMINATION

The agreement may be canceled at any time by mutual written consent of the Provider and any of the NDMS Federal Partners. The agreement also may be terminated by either the Provider or any of the NDMS Federal Partners upon giving 90 days written notice to the other party. Unless otherwise noted, this Agreement shall remain in effect for a period not to exceed five years upon date of the last signature.

For the NDMS Federal Partners

Printed Name Signature

Title Date

For the NDMS Provider Facility Name

Printed Name Signature

Title Date

Attachment J.102

Definitive Medical Care Reimbursement Program – Specified Disasters or Public Health Emergencies

Coverage Guidelines

1) As described in the NDMS Partners MOA dated October 24, 2005, The Definitive Medical Care Reimbursement Program covers Definitive Medical Care services. Definitive Medical Care is defined as: “To the extent authorized by NDMS in a particular public health emergency, medical treatment or services beyond emergency medical care, initiated upon inpatient admission to an NDMS hospital and provided for injuries or illnesses resulting directly from a specified public health emergency, or for injuries, illnesses and conditions requiring non-deferrable medical treatment or services to maintain health when such medical treatment or services are temporarily not available as a result of a public health emergency.”

Definitive Medical Care can be provided for:

a. illnesses and injuries resulting directly from a specified public health emergencies or

b. injuries, illnesses, and conditions requiring essential medical services necessary to maintain a reasonable level of health temporarily not available as a result of the public health emergency or

c. injuries or illnesses affecting authorized emergency response and disaster relief personnel responding to the public health emergency.

2) Beyond inpatient hospitalization, the Definitive Medical Care Program is expanded to reimburse for the medical care services provided by various Facilities and Practitioners currently reimbursed under Part A, Part B, and Medicaid for:

a. illnesses and injuries resulting directly from a specified public health emergencies or

b. injuries, illnesses, and conditions requiring essential medical services necessary to maintain a reasonable level of health temporarily not available as a result of the public health emergency or

c. injuries or illnesses affecting authorized emergency response and disaster relief personnel responding to the public health emergency.

3) A condition of NDMS coverage is that the patient is transported via Federal assets, processed through an FCC, and referred for Definitive Medical Care. Attendants, defined as family member(s) or other person(s) who are transported via Federal assets to accompany a patient, are covered as well.

4) The Definitive Medical Care Reimbursement Program will reimburse Providers for the services it provides in accordance with the Reimbursement Guidelines. The Program will also reimburse the separately-billable professional services of physicians, and other medical Practitioners who treated Definitive Medical Care patients during the course of their medical care, in accordance with the Reimbursement Guidelines.

5) For definitive medical care associated with inpatient hospitalization, as described in the NDMS Provider MOA for Definitive Care (Attachment J.101) that the NDMS utilizes with hospitals, Definitive Medical Care coverage ends when one of the following occurs, whichever comes first: completion of medically indicated treatment as defined by the Centers for Medicare & Medicaid Services diagnostic related group, based on ICD-9 (and ICD- 10 when available) codes (maximum of 30 days); voluntary refusal of care; return to originating facility or other location for follow on care.

6) Beyond inpatient hospitalization, Definitive Medical Care coverage ends when one of the following occurs, whichever comes first: completion of medically indicated treatment as defined by the Centers for Medicare & Medicaid Services based on ICD-9 (and ICD-10 when available) codes (maximum of 30 days); voluntary refusal of care; return to originating facility or other location for follow on care.

Attachment J.103

NDMS Reimbursement Program – Specified Disasters or Public Health Emergencies

Reimbursement Guidelines for Facilities:

1) The NDMS Reimbursement Program will reimburse NDMS-participating hospitals Facilities for inpatient care services provided to NDMS patients (individuals who qualify for program coverage) in accordance with the following approach.

2) The NDMS Reimbursement Program will reimburse only for medically-necessary medical services (Definitive

Medical Care) furnished during the course of the initial, NDMS-covered medical stay and additional medical care after discharge from the initial NDMS placement if received within the first 30 days of the initial placement and is related to the care a patient received from their initial provision of medical care.

3) The Facility must provide certified data on the NDMS patient, his/her diagnostic profile, procedures/services furnished, admission and discharge dates, insurance status, etc., in accordance with Medicare program billing requirements.

4) To qualify for reimbursement from NDMS, the Facility must currently participate in either the Medicare or the

Medicaid program.

5) For Facilities actively participating in the Medicare program, subject to the Coordination of Benefits

Guidelines, the Program will reimburse the NDMS Facility (or Qualified Non-Participating Hospital) at the lesser of (1) billed charges for covered services or (2) 110% of the amount that the Facility would be paid under Medicare Part A or Medicare Part B if the Facility has executed a MOA (Attachment J.102) with NDMS or (3) 100% of the amount that the Facility would be paid under Medicare Part A or Medicare Part B if the Facility chooses not to execute a MOA (Attachment J.102) with NDMS.

To this extent –

a) The Facility will receive credit for the IPPS operating payment amount based on the DRG applicable to the patient’s diagnostic profile & procedures/services furnished and the Facility’s wage index value.

b) Beyond inpatient hospitalization, the Facility will receive credit for the outpatient prospective payment system (OPPS) operating payment amount based on the ICD-9 or ICD-10 applicable to the patient’s diagnostic profile & procedures/services furnished and the Facility’s wage index value

c) The Facility will receive credit for the IPPS capital payment amount based on the DRG applicable to the patient’s diagnostic profile, etc., and the Facility’s geographic adjustment factor.

d) The Facility will receive credit for the outpatient prospective payment system (OPPS) capital payment amount based on the ICD-9 or ICD-10 applicable to the patient’s diagnostic profile, etc., and the Facility’s geographic adjustment factor.

e) If the Facility receives disproportionate share and/or indirect graduate medical education adjustments to its IPPS payments from Medicare, the Facility will receive credit for these amounts in the same manner as it would under the Medicare program (based on the national PRICER).

f) The NDMS Reimbursement Program recognizes cost outlier adjustments (NDMS coverage ends no later than 30 days after admission), but it will not recognize pass-through payment components under the Medicare program (e.g., direct medical education, etc.).

g) The sum of creditable amounts (IPPS operating and capital payments, plus disproportionate share and indirect medical education adjustments) will be increased by 10% to achieve the final payment amount.

h) If the Facility is a hospital and the hospital does not participate in the Medicare program (e.g., is a federal Provider, such as within the U.S. Department of Veterans Affairs (VA)) or normally receives Medicare payment on a cost basis, the NDMS Reimbursement Program will make payment based on the patient’s DRG (or ICD-9 or ICD-10 codes, if available) and the wage index/geographic adjustment factors applicable to the geographic area of the hospital, as if the hospital were under the Medicare IPPS. Payment will be at 110% of the Medicare Part A rate and 110% of the Medicare Part B rate, but no credit will be given for disproportionate share and graduate medical education factors in these cases.

i) Payment will be based on the Medicare IPPS or OPPS rates in effect at the time of discharge.

6) For Facilities that are not hospitals and do not actively participate in the Medicare program but do participate in the Medicaid program, subject to the Coordination of Benefits Guidelines, the Program will reimburse such NDMS Facility at the lesser of (1) billed charges for covered services or (2) 100% of the amount that the Facility would be paid under Medicaid.

Reimbursement Guidelines for Practitioners:

1) The NDMS Reimbursement Program will reimburse Practitioners for their professional medical services furnished to NDMS patients (individuals who qualify for program coverage) in accordance with the following approach.

2) The Program will reimburse only for medically-necessary professional services furnished to patients during the course of their NDMS-covered medical care.

3) In certain cases, the ASPR OPEO program office may authorize coverage or reimbursement for services not specified in this Attachment J.103 or Attachment J.102 and direct the contractor on how to process reimbursement.

4) The Practitioner must be currently licensed to furnish the care provided and must not be excluded from participation in federal programs or federal/state health care programs.

5) The Practitioner must provide certified data on the NDMS patient, his/her diagnostic profile, procedures/services furnished, care setting, insurance status, etc., in accordance with Medicare or Medicaid program billing requirements for Practitioners. The medical charts of the hospital must support the billing of the Practitioner.

6) Subject to the Coordination of Benefits Guidelines, the Program will reimburse the Practitioner for care that conforms to the above criteria at the lesser of (1) billed charges for covered services or (2) 100% of the amount that the practitioner would be paid under the Medicare physicians’ fee schedule under section 1848 of the Social Security Act (and implementing regulations).

7) If a Practitioner does not currently participate in the Medicare program but does participate in Medicaid, subject to the Coordination of Benefits Guidelines, the Program will reimburse such Practitioner at the lesser of (1) billed charges for covered services or (2) 100% of the amount that the Practitioner would be paid under Medicaid.

NDMS SOW

Attachment J.104

NDMS Reimbursement Program – Specified Disasters or Public Health Emergencies - NDMS Coordination of Benefits Guidelines

1) The NDMS Reimbursement Program reimburses Providers for patient care services rendered to NDMS-covered patients for up to thirty (30) days from the date of the NDMS patient’s initial admission to a NDMS Facility, in accordance with the NDMS Coverage Guidelines and the NDMS Reimbursement Guidelines, subject to the following requirements.

2) If the NDMS patient has coverage under the federal TRICARE or Medicare programs, or qualifies for free care through the US Department of Veterans Affairs, Providers, if applicable, should bill the patient’s applicable covering program, and payment from those programs will constitute full reimbursement. The NDMS Reimbursement Program will not make additional payment for patients with these forms of federal coverage (i.e., NDMS does not displace these federal provisions).

3) If the NDMS patient has no federal coverage under (2) above, but has private health insurance coverage, whether employment-based or from some other source, or non-federal public coverage other than coverage under the Medicaid program, Providers, if applicable) should bill for primary payment to the patient’s private (or non-federal public) coverage(s).

a) After collecting the deductible and any coinsurance from the patient (or from additional coverage available to the patient) and payment from the patient’s primary health insurance coverage(s), and only to the extent permitted by any contract between the Facility and such primary health insurance coverage(s), a Facility may bill the NDMS Reimbursement Program for the difference between all amounts allowed by other payers and the amount due the Facility under the NDMS Reimbursement Guidelines for Facilities described in Attachment J.103.

b) After collecting the deductible and any coinsurance from the patient (or from additional coverage available to the patient) and payment from the patient’s primary health insurance coverage(s), and only to the extent permitted by any contract between the Practitioner and such primary health insurance coverage(s), a Practitioner may bill the NDMS Reimbursement Program for the difference between all amounts allowed by other payers and the amount due the Practitioner under the NDMS Reimbursement Guidelines for Practitioners described in Attachment J.103.

4) If the NDMS patient has no health insurance coverage (individuals whose only source of coverage would otherwise be the program established by Section 1011 of Public Law 108-173 are deemed to fall into this category, as are individuals whose only source of coverage would otherwise be state-administered uncompensated care pools under approved section 1115 waivers), or if the NDMS patient only has coverage under the Medicaid program (Title XIX of the Social Security Act), then the Providers, should bill for primary payment to the NDMS Reimbursement Program. The NDMS Reimbursement Program will make full payment in accordance with the NDMS Coverage Guidelines and the NDMS Reimbursement Guidelines (with no deductible or coinsurance charged) in these cases.

5) The following table identifies the various sources of funding for reimbursement of hospitals and other Medicare participating providers and the order of payment. The contractor agrees to process reimbursements in accordance with this table. The NDMS will reimburse the Provider for medical treatment or services rendered by the Provider as indicated in the following table.

Receiving Provider:

Part A

Status

Provider will first bill

Provider will bill secondly

NDMS status for payments

Hospitals Uninsured NDMS 110% of Medicare rate (if Hospital has executed MOA with NDMS); 100% of Medicare rate (if Hospital elects not to execute MOA with

NDMS).

Medicaid NDMS 110% of Medicare rate (if Hospital has executed MOA with NDMS); 100% of Medicare rate (if Hospital elects not to execute MOA with

NDMS).

Medicare Medicare Not eligible Dual eligible Medicare NDMS NDMS will reimburse Medicare deductible and coinsurance id at 100% of the receiving State’s Medicaid rate.

Other insurance or health program coverage (other than Medicaid, Medicare, or Tricare)

Other insurance NDMS for balance, not to exceed 110% of Medicare

* Covered at 110% of Medicare rate when combined with private insurance (if Hospital has executed MOA with NDMS);

100% of Medicare rate (if Hospital elects not to execute MOA with NDMS).

Tricare Tricare Not eligible Receiving Provider:

Part A

Status

Provider will first bill

Provider will bill secondly

NDMS status for payments

Including but not Limited to, Skilled Nursing Facilities (SNFs) Home Health Agencies (HHAs);

Hospice

Uninsured NDMS 100% of Medicare rate. (110% of Medicare rate if facility is owned or operated by a Hospital which has executed the MOA with NDMS).

Medicaid NDMS 100% of Medicare rate. (110% of

Medicare rate if facility is owned or operated by a Hospital which has executed the MOA with NDMS).

Medicare Medicare Not eligible Dual eligible Medicare NDMS NDMS will reimburse Medicare deductible and coinsurance at 100% of the receiving State’s Medicaid rate.

Other insurance or health program coverage (other than Medicaid, Medicare, or Tricare)

Other insurance NDMS for balance, not to exceed 100% of Medicare

* Covered at 100% of Medicare rate when combined with private insurance

Tricare Tricare Not eligible Receiving Provider:

Part B

Patient’s Insurance Status

Provider will first bill

Provider will bill secondly

NDMS status for payments

Hospitals Uninsured NDMS 110% of Medicare rate (if Hospital has executed MOA with NDMS); 100% of Medicare rate (if Hospital elects not to execute MOA with

NDMS).

Medicaid NDMS 110% of Medicare rate (if Hospital has executed MOA with NDMS); 100% of Medicare rate (if Hospital elects not to execute MOA with

NDMS).

Medicare Medicare Not eligible Dual eligible Medicare NDMS NDMS will reimburse Medicare deductible and coinsurance id at 100% of the receiving State’s Medicaid rate.

Other insurance or health program coverage (other than Medicaid, Medicare, or Tricare)

Other insurance NDMS for balance, not to exceed 110% of Medicare

* Covered at 110% of Medicare rate when combined with private insurance (if Hospital has executed MOA with NDMS);

100% of Medicare rate (if Hospital elects not to execute MOA with NDMS).

Tricare Tricare Not eligible Including but not Limited to, Various Other Part B Providers

Uninsured NDMS 100% of Medicare rate

Medicaid NDMS 100% of Medicare rate

Medicare Medicare Not eligible Dual eligible Medicare NDMS NDMS will reimburse Medicare deductible and coinsurance at 100% of the receiving State’s Medicaid rate.

Other insurance or health program coverage (other than Medicaid, Medicare, or Tricare)

Other insurance NDMS for balance, not to exceed 100% of Medicare

* Covered at 100% of Medicare rate when combined with private insurance

Tricare Tricare Not eligible Receiving Provider:

Service or Provider Covered by Medicaid but not Medicare

Patient’s Insurance Status

Provider will first bill

Provider will bill secondly

NDMS status for payments

Including but not limited to, Nursing Facilities (NFs);

Inpatient Psychiatric Residential Treatment Facilities for Individuals Under Age 21 PRTFs);

Intermediate Care Facilities for the Mentally Retarded (ICFs/MR);

Outpatient Pharmacies

Uninsured NDMS 100% of receiving State’s Medicaid rate

Medicaid NDMS 100% of receiving

Medicare NDMS 100% of receiving

Dual eligible NDMS 100% of receiving

State’s Medicaid rate Other insurance or health program coverage (other than Medicaid, Medicare, or Tricare)

Other insurance * Covered at 100% of receiving State’s Medicaid rate when combined with private insurance

Tricare Tricare Not eligible Transport Services

Medicaid NDMS 100% of receiving

* Not including the deductible amount and other cost sharing under the health insurances or health insurance program.

C. Part B providers include, but are not limited to, Hospitals, Comprehensive Outpatient

Rehabilitation Facilities (CORFs); Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers for Outpatient Therapy and Speech-Language Pathology Services; Rural Health Clinics (RHCs); Federally Qualified Health Centers (FQHCs); End Stage Renal Disease Facilities (ESRD); Ambulatory Surgical Centers (ASCs); and Practitioners.

D. For patients eligible for military health coverage (i.e., TRICARE), payment will be made under

TRICARE according to the applicable payment rates and procedures, as set forth in 32 C.F.R. Part 199.

NDMS Reimbursement Program SOW

Attachment J.105

NDMS Denial Guidelines

Facility Claims

In the event that claims or billed charges need to be denied, the contractor will prepare a remittance advice or explanation of benefits (EOB) document for the COR to review which identifies any denial(s) and the reasons for the denial(s). All potential denials will be reviewed by the COR. No denial action should be taken until instructed by the COR. Once approved by the COR, the contractor may send the remittance advice or EOB document to the Facility.

Deny Facility claims seeking NDMS reimbursement that exhibit any of the following characteristics without further development –

• It has been definitively established that the patient was not an NDMS patient (i.e., the patient is not on the FCC roster and the FCC has not added the name based on Facility inquiry.

• The initial date of service is prior to the date of NDMS evacuation windows relating to the specified disasters or public health emergencies, as applicable.

• The initial date of service is more than two days after the date of evacuation windows, as recorded in FCC records.

• If the Facility actively participates in Medicare, any service that is not reimbursable under Medicare Part A, as defined by Medicare program coverage rules and is not covered under Medicaid in the State where medical care was provided.

• NDMS has already paid for an admission relating to the patient except as defined in J.104.2.

• The claim is an exact duplicate of another claim already received.

• The Facility identifies the patient as having coverage under the TRICARE or Medicare programs, with the exception of dual eligibles.

• The claim submitted by a Facility indicates coverage under another payer, and the Facility has not submitted a copy of the other payer’s remittance advice indicating no payment or partial payment made by the other payer.

• The Facility has received a primary payment from another payer, and the payer’s remittance advice indicates that the hospital is obligated (by law or contract) to accept the payer’s payment as payment in full.

NOTE: Contact the Provider if the name billed closely resembles the name of an individual that FCC records indicate was referred to the Provider. Return the claim to the Provider when the claim indicates that the patient has private coverage available, but the claim nonetheless has been presented to NDMS for primary payment. Contact the Provider with respect to all claims involving individuals who are not identified as having insurance, but who are aged 65 or older or who have end-stage renal disease (based on diagnosis), and obtain written confirmation that there is no Medicare coverage prior to approving the claim. For all submissions, it should be assumed that there is no other insurance or Medicare coverage unless otherwise indicated on the claim.

Practitioner Claims

In the event that claims or billed charges need to be denied, the contractor will prepare a remittance advice or explanation of benefits (EOB) document for the COR to review which identifies any denial(s) and the reasons for the denial(s). All potential denials will be reviewed by the COR. No denial action should be taken until instructed by COR. Once approved by the COR, the contractor may send the remittance advice or EOB document to the Practitioner.

Deny Practitioner claims seeking NDMS reimbursement that exhibit any of the following characteristics without further development –

• It has been definitively established that the patient was not an NDMS patient (i.e., the patient is not on the FCC roster and the FCC has not added the name based on Facility inquiry.

• The date of service is prior to the date of the NDMS evacuation windows relating to the specified disasters or public health emergencies, as applicable.

• The date of service is more than thirty (30) days after the date of the NDMS evacuation windows relating to the specified disasters or public health emergencies, as applicable.

• If the Practitioner actively participates in Medicare, any service that is not reimbursable under Medicare Part B, as defined by Medicare program coverage rules and is not covered under Medicaid in the State where care was provided.

• The claim is an exact duplicate of another claim already received.

• The Practitioner identifies the patient as having coverage under the TRICARE or Medicare programs.

• The claim submitted by a Practitioner indicates coverage under another payer, and the Practitioner has not submitted a copy of the other payer’s remittance advice indicating no payment or partial payment made by the other payer.

• The Practitioner has received a primary payment from another payer, and the payer’s remittance advice indicates that the hospital is obligated (by law or contract) to accept the payer’s payment as payment in full.

NOTE: Contact the Provider if the name billed closely resembles the name of an individual that FCC records indicate was referred to the Provider. Return the claim to the Provider when the claim indicates that the patient has private coverage available, but the claim nonetheless has been presented to NDMS for primary payment. Contact the Provider with respect to all claims involving individuals who are not identified as having insurance, but who are aged 65 or older or who have end-stage renal disease (based on diagnosis), and obtain written confirmation that there is no Medicare coverage prior to approving the claim. For all submissions, it should be assumed that there is no other insurance or Medicare coverage unless otherwise indicated on the claim.