Transcript Covered Services Service Authorization Medical Assistance
Behavioral Health Compliance Solutions, LLC
Covered Services Service Authorization Medical Assistance Billing & Payment Post-Payment Activities (Appeals, Audits)
Behavioral Health Medicaid Training 7 AAC 135
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) • • • Refer to Alaska Medical Assistance Program Policies and Claim Billing Procedures Manuals http://www.medicaidalaska.com
Section I Services, Policies and Procedures Professional Claims Management General Program Information ( Includes revision history)
•Section I, Part B – Service Detail Sheets – –Service Definition/Description – from regulations –Service Code/Code Set Description – from national code sets •Current Procedural Terminology – CPT •Health Care Procedure Coding System – HCPCS •Section I, Appendix I-D – Claims Billing & Payment Information –List of Procedure Codes & Modifiers, Adult/Child Coverage, Brief Descriptions, Unit Values, Payment Rates, Service Limits, Program Approval Categories 2
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Coverage EXCLUSIONS & LIMITATIONS •EXCLUSIONS –Persons in the custody of Federal, State, or Local Law Enforcement (including juveniles in detention) Authority: 42 CFR 435.1009, 42 CFR 436.1005, 7 AAC 105.110 –Persons between age 22 and 65 who are residents of an Institution for Mental Diseases (IMD) Authority: 42 CFR 436.1005 •IMD is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care to patients with mental diseases –Persons of any age who are residents of a Skilled Nursing or Intermediate Care Facility (SNF/ICF) Authority: 7 AAC 140.505, 7 AAC 140.580 3
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Coverage EXCLUSIONS & LIMITATIONS •LIMITATIONS Persons who are inpatients of an acute care hospital or a residential psychiatric treatment center are limited to coverage of assessment and case management services for treatment planning or preparation for transition to lower level of care within 30 days of discharge from the acute care hospital 4
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Service Authorization Annual Service Limits changed from CALENDAR year to STATE FISCAL year (July 1 through June 30) NEW Service Authorization request forms are available in provider manuals and via DBH and fiscal agent websites Requests are to be made in correlation with Client Status Review requirements Requests limited to a maximum of 90 to 135 days of planned services (to be submitted approximately 3 to 4 times annually) Requires signature of directing clinician ALL Requests to be submitted to the fiscal agent for capture/control and entry into Medicaid Management Information System (MMIS). 5
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Claims Billing - General • • ALL CLAIMS MUST BE FILED WITHIN 12 MONTHS OF THE DATE SERVICE The 12-month timely filing limit applies to all claims, including those that must first be filed with a third party carrier. Submit on paper form or electronically; complete required fields –Use Paper CMS-1500 Claim Form for Professional Services - Set B for billing behavioral health services –Use Electronic Claim Transaction (837-Professional) –Include Service Authorization number as required if services billed exceed annual service limits Ensure services are: –Performed as active treatment, documented in treatment plan, stated as a need in assessments, etc. –Performed by staff qualified 6
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) • • • • • • • • Claims Adjudication, Editing & Response All claims submitted are processed according to program rules which will result in one of the following outcomes: adjudicated claim (paid or denied) reduction in payment denial of service in-process claims (further internal review or information needed) pending status requiring internal staff review additional information requested from the provider (via RTD) Remittance Advice (RA) statement includes the claims processing details that include three-digit claims edit codes each with a unique explanation of how the claim was processed. These edit codes are listed on the Explanation of Benefit (EOB) description page of the RA and lists all EOB codes and a brief description of each code used within that specific Remittance Advice statement.
Contact the fiscal agent’s Provider Inquiry for clarification as needed 7
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Medical Assistance Appeals for Providers (7 AAC 105.270) REASONS for Providers to Request an Appeal –Denied or reduced claims (180 days) –Denied or reduced service authorization (180 days) –Disputed recovery of overpayment (60 days) Three Levels of Appeals –First level appeals –Second level appeals –Commissioner level appeals 8
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Medical Assistance Appeals for Providers (7 AAC 105.270) First Level Appeals- Fiscal Agent Must be submitted in writing within 180 days of remittance advice for claim or other notification (service authorization decision, request for recovery of funds) Appeal form is available in provider manual, include: •A copy of the Claim or Disputed Authorization Decision •A copy of the Remittance Advice Statement •Supporting Documentation •Completed Adjustment Request, if applicable •Mail to: Xerox Provider Services Unit P. O. Box 240808, Anchorage, AK 99524-0808 9
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Medical Assistance Appeals for Providers (7 AAC 105.270) Second Level Appeals – DBH, Must be submitted in writing to Division of Behavioral Health within 60 days of First Level Appeal Decision. Include: –Reason for Appeal including a description of the issue or decision being appealed –Copy of decision from First Level Appeal –Copy of denial or payment notice (Remittance Advice) –Copy of Original Claim –All other information and materials for consideration 10
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Medical Assistance Appeals for Providers (7 AAC 105.270) Commissioner Level Appeals •ONLY used to challenge/appeal adverse timely filing denials/reductions •Must be submitted in writing to the DHSS Commissioner within 60 days of Second Level Appeal decision •Include clear description of the reason for appeal (the issue or decision being appealed) 11
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
)
Recommended Keys to Achieve Success in Billing/Payment:
•Read and maintain your billing manual •Verify recipient eligibility •Verify eligibility code •Verify dates of eligibility •Verify Third Party Liability 12
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
)
Recommended Keys to Achieve Success in Billing/Payment:
•Verify the services you are eligible to provide •Verify procedure codes •File your license renewals and/or certification/ permits timely (keep your enrollment current) • Ensure completion of claim forms 13
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
)
Recommended Keys to Achieve Success in Billing/Payment:
• Document Third Party Liability payment on claim, if applicable • Include attachments as required • FILE TIMELY • RECONCILE PAYMENTS (Remittance Advice (RA) Statements) 14
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
)
Recommended Keys to Achieve Success in Billing/Payment:
• Read and distribute RA messages • Address problems/issues promptly • Call Provider Inquiry with questions 15
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Alaska Medical Assistance Regulations Request for Records 7 AAC 105.240 – Request for records At the request of a DHSS representative or authorized federal, or other representative, including an employee of the Department of Law, a provider shall provide records, including financial, clinical, and other records, that relate to the provision of goods or services on behalf of a recipient: – To the person making the request at the address specified in the request – No later than the deadline specified in the request – Without charge and in the format stated in the request 16
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) Audits • • Federal Audits – – – – Department of Health and Human Services (DHHS) Office of Inspector General Department of Justice U. S. Government Accountability Office (GAO) State Audits – Department of Health and Social Services (DHSS) – Department of Law – Legislative Audits – Fiscal Audits 17
Covered Services, Service Authorization, Medical Assistance Billing & Payment, Post-Payment Activities (Appeals, Audits
) • • Previous Audit Findings No client signature on treatment plan No treatment plan reviews to cover dates of service • • • • • • • • • No documentation to match billed services Progress notes do not match service billed Duplicates of notes for the same service on a different day Units billed and documented do not match notes Duration of service is not supported by content of note No treatment plan Insufficient documentation to support units of service billed Wrong service code submitted Agency forms that contained check boxes that were unchecked and the missing information was not supported by a narrative explanation elsewhere in the note 18
Resources Alaska Medical Assistance Provider Billing
• • •
Manuals
Section I: Community Behavioral Health Clinic Services, Policies and Procedures: https://medicaidalaska.com/dnld/PBM_CBHC.pdf
Section II: Professional Claims Management: https://medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf
Section III: General Program Information: https://medicaidalaska.com/dnld/PBM_Gen_Program_Info.pdf
19
Medicaid Enrollment Billing Procedures Service Authorization
20
Medicaid Enrollment
21
When a client requests services the agency must verify the client’s insurance information. If a client may be eligible for Medicaid and is not enrolled, the agency must provide the client with the Medicaid Enrollment Documentation and follow through to make sure that the enrollment process is completed.
Before rendering services verify that the patient is eligible for Alaska Medical Assistance by using one of the following options: Request to see and photocopy the recipient's Medical Assistance coupon or card that shows the current month of eligibility Phone Eligibility Verification System (EVS) (see more about EVS below)
800.884.3223 (Toll-free)
Complete Xerox Recipient Eligibility Fax form call 907.644.8126) (Use Hyperlink to download or Phone Provider Inquiry
907.644.6800 or 800.770.5650 (Toll-free)
22
Eligibility Verification System (EVS)
All providers are assigned an EVS Personal Identification Number (PIN) upon enrollment for obtaining information from EVS The EVS helps providers verify: Medical Assistance eligibility of their patients Providers must supply either the Medical Assistance recipient ID number or the recipient’s social security number and date of birth Third Party Liability (TPL) resource and carrier codes The most recent Remittance Advice (RA) payment amount Service Authorization (SA) information (only when the provider using EVS matches the provider specified in the SA record) Service limit information Providers may use EVS 24 hours a day, 7 days a week Eligibility for up to 30 individuals or dates of service can be verified per telephone call EVS contains the most recent 12 months of eligibility history 23
Billing Process
24
Each agency should have a formal tracking process that provides reconciliation of services billed with revenue received: 1. The billing submission documents should be reconciled with the remittance advice then 2. The progress notes should be reconciled with the billing sheet 25
Service Authorization Process
26
Each agency should be aware of the service authorization process:
1. When the treatment plan is developed use the frequency and duration of services as well as the length of time before the plan will be reviewed to determine how whether a service authorization is needed.
2. Each time the Client Status Review is completed (every 90-135 days) review the services frequency and duration and length of time before next CSR process to determine if more service needs to be authorized.
27
Goal 1,2,3 Service Modality
Individual Therapy Comprehensive Community Support Services Group
Interventions(s)
Counselor will explore with client the impact that substance abuse has had on her life Provide and review assignments designed to assist client in developing a program of recovery, prevent relapse, and gaining skills needed to increase positive expression, management of feelings and correct thinking errors in group setting
Frequency Duration
1x wkly Up to 6x per wk 1 hour 6 hours
Projected Date for Goal Attainment
90 days from plan beginning date or review date
Date Goal Completed
Clinician SA Counselor Clinical Associate
Service Provider Clinician Counselor 1,2,3
Comprehensive Community Support Services- Individual Counselor will facilitate client’s program participation, interactions with peer community and adherence to program format.
1x wk 1 hour
1,2,3 Case Management Comprehensive Community Support Services Family Counseling will arrange for client to attend 12 step support groups and will facilitate access to needed services from DJJ and other providers as needed Facilitate parental involvement
Up to 3x week 1x weekly 1 hour 1 hour 90 days from plan beginning date or review date 90 days from plan beginning date or review date
Counselor Case Manager Counselor
28
Each agency should be aware of the service authorization process:
3.
For information on how to Authorize Services use the Service Authorization Power Point Presentation at the State of Alaska Division of Behavioral Health (DBH) web site
http://dhss.alaska.gov/dbh/Documents/PDF/ServiceAuthTraining2012.pdf
If you have further question you may contact Anne Gibson at DBH (907)269-8867
Or
Lisa Brown at DBH (907)269-2051
29
Behavioral Health Medicaid Training 7 AAC 135
Behavioral Health Compliance Solutions, LLC Contact information
•
Connie Greco
E-mail: [email protected]
• Phone: 907-522-8170
Pam Miller
E-mail: [email protected]
Phone: 907-717-9180 Blog site address: www.bhcompliance.com
Facebook page: https://www.facebook.com/pages/Behavioral-Health Compliance-Solutions-LLC/185142004863501 30