Transcript Blue Cross of Northeastern Pennsylvania Act 62 Autism

Blue Cross of Northeastern Pennsylvania
Act 62 Autism Mandate Orientation
Effective 7/1/2009
Updated 5/5/2014
Pennsylvania's Autism Insurance Act
(Act 62- 2008)
• Act 62 requires private health insurance companies to cover the
cost of diagnostic assessment and treatment of autism spectrum
disorders (ASD).
– Act 62 coverage information:
• Applies to children under the age of 21
• Insured employer groups having 51 or more employees upon group
renewals
– Customer service can assist in determining if the group has 51+ employees
• CHIP Program renews on February 1, 2010
• Maximum benefit of $40,000 per year of our contracted rates
– Coverage is subject to copayment, deductible and coinsurance as they would
be for other covered medical services and any other general exclusions or
limitations
– Once the member reaches the $40,000 they may be eligible for additional
Medical Assistance (MA) program benefits.
– The maximum benefit was increased from $36,000 to $40,000 on January 1,
2013. The increase applied on or after each affected group’s plan year renewal
beginning January 1, 2013
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Pennsylvania's Autism Insurance Act
(Act 62) continued
– Pharmacy
• Prior authorization is required for employer groups that do not have a
pharmacy benefit
– Prior authorization can be obtained by contacting Express Scripts at
1.877.603.8399
• If the group does have a pharmacy benefit, no prior authorization is
required.
• Pharmacy charges will not accumulate towards the $40,000 benefit cap
Contact Customer Service Representatives at the following phone #’s
to verify member benefits, eligibility and information on accumulated
ASD services.
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FPLIC PPO – 1-866-262-5635
FPLIC Custom PPO/EPO – 1-888-345-2353
FPLIC Traditional/Major Medical – 1-888-827-7117
EPO – 1-888-345-2353
FPH – 1-800-822-8752
FEP (Federal Plan) – Check back of card for phone number
BlueCard – Check back of card for phone number
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BCNEPA Medical Policy and other resources
• Medical Policy
– The BlueCross of Northeastern Pennsylvania Autism
Spectrum Disorder Medical Policy is available on BCNEPA’s
Provider Center at www.bcnepa.com or via the link on Navinet
on 7/1/2009.
– Check your Provider Bulletins for updates
– Another resource is the DPW’s site
• http://www.dpw.state.pa.us/forchildren/autism/index.htm
• http://www.dpw.state.pa.us/foradults/autismservices/index.htm
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Covered Diagnosis codes for Medical
Management of ASD
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Pennsylvania's Autism Insurance Act
(Act 62) continued
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Treatment Plan requirements
•
Treatment of ASD must be identified in a treatment plan and should include
any medically necessary pharmacy care, psychiatric care, psychological
care, rehabilitative care including applied behavioral analysis, and
therapeutic care that is:
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Prescribed, ordered or provided by a licensed physician, licensed physician
assistant, licensed psychologist, licensed clinical social worker or certified
registered nurse practitioner.
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Provided by an autism provider.
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Provided by a person, entity or group that works under the direction of an autism
service provider.
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Treatment Plan and Continuity of care
•
The provider is responsible for maintaining a copy of the autism assessment and
treatment plan, to be made available upon request.
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Prior Authorizations will not currently be required for ASD services. Although we
are not requiring prior authorization while the member is utilizing their private
insurance coverage, we encourage providers to continue to request authorizations
from Community Care Behavioral Health Organization/Medical Assistance
(CCBHO/MA) to avoid possible claim rejections upon transition of care.
*Please be advised, some Highmark HMO Products may required prior
authorizations
•
In an effort to administer a smooth transition between plan coverages, a notice will
be mailed to members advising them that they have accumulated $25,000 worth of
ASD services.
We encourage providers to work closely with the families to keep informed of the
dollar amount accumulated. Providers can also contact customer service to obtain
information regarding the member’s accumulated amount.
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Provider Reimbursement
• BCNEPA/FPH/FPLIC will follow the current standard fee
schedules and contract rates. These fee schedules will
include:
– Therapeutic Behavioral Services (H2019)
– Community Based Wrap Around Services (H2021)
– Mental Health Service Plan Development (H0032)
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Billing Guidelines
• Professional Claims must be submitted on the
NUCC-1500 Form
– When billing First Priority Health claims, please be sure to list the Autism
Spectrum Disorder diagnosis codes as the primary diagnosis codes on claim.
– When billing for First Priority Life Insurance, line item procedure codes must
ONLY reference an Autism Spectrum Disorder diagnosis code.
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Multiple diagnosis codes referenced via the diagnosis pointer (on 1500
form) will not process accurately.
– Please bill ASD claims according to CPT Code Standard Guidelines
– Providers billing for Behavioral Health Rehabilitation Services (BHRS) must
list the supervising psychologist or psychiatrist in the rendering provider field.
– Attached is the BCNEPA Billing Guidelines
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Billing Guidelines continued
• Facility claims are to be submitted on the NUBC UB-04 form.
Remember to include the NPI and Taxonomy Code.
Claims Addresses:
BlueCross/Major Medical/FPLIC
Claims
P.O. Box 890179
Camp Hill, PA 17089-0179
First Priority Health- HMO
First Priority Health
P.O. Box 69699
Harrisburg, PA 17106-9699
Federal Employee Program (FEP)
Highmark Blue Shield
P.O. Box 898854
Camp Hill, PA 17089-8854
BlueCard Claims
Highmark Blue Shield
P.O. Box 890062
Camp Hill, PA 17089-0062
– Electronic billing-
See attached billing guidelines
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Rejection Codes/Messages once maximum
$40,000 benefit cap has been met/exceeded
•
Once a member has met or exceeded their ASD benefit limit of $40,000, the
provider remittance advices will show the following rejection codes and description
per product line:
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For First Priority Health (FPH) -BL0 = Meets/exceeds the ASD benefit limit for
service rendered and a ANSI (American National Standards Institute) adjustment
reason code of PR 119 (patient responsibility). PSO = Not covered charge(s) and
ANSI adjustment reason code of PR 96 with a remark code of N174.
For First Priority Life Insurance Company (FPLIC) and out of area claims- X8851=
the maximum benefit available under the patient’s coverage for ASD services has
been paid. Therefore, no payment can be made. Along with this an ANSI
adjustment reason code of PR 119.
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• Descriptions of adjustment reason codes can be found on the
Washington Publishing Company at www.wpc-edi.com
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Sample NUCC 1500 Form
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Attachments
• Listing of the alpha prefixes utilized by Blue Cross of
Northeastern Pennsylvania (BCNEPA), First Priority
Health (FPH) and First Priority Life Insurance Company
(FPLIC). Prefixes that do not appear in this listing
should be considered out-of-area.
• Product Reference Guide
• BCNEPA Billing Guidelines
• ASD Medical Policy
• ASD Fee Schedules
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Contact Information
• If you have any questions please contact your Provider
Relations Consultant.
• If you do not know who your consultant is you can call
our Provider Relations Department at 570-200-4700
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