Transcript Insurance Use in Early Intervention

Billing & Insurance Use in
Early Intervention
May 2005
Training Objectives
Participants will be made aware of the following:
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ICD-9 Code Usage;
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The Difference between Treatment and Eligibility Diagnosis
Coding;
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Services that must be billed to insurance;
Training Objectives (Cont.)
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Length of time you have to bill CBO after services have been
provided;
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Type of billing forms that are acceptable to bill CBO; and
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Private Insurance Use.
Agenda
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Diagnosis Coding
Billing Requirements
Responsibilities
Insurance Use
Benefit Verification
Waivers & Exemptions
Provider Safety Net
Technical Assistance
Resources
Billing & Insurance Use
I. Diagnosis Coding
Diagnosis Coding
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Diagnosis coding discussed in this session does not refer to assigning a
medical diagnosis but rather a billing diagnosis. A billing diagnosis tells us
“why” you saw the child.
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Diagnosis codes submitted on claim forms (and on other medical
documentation) are generally used to determine insurance coverage.
Insurance payment is dependent upon meeting insurance company
requirements.
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Knowledge of billing and coding requirements are professional
development issues in which each provider must invest time and resources
to ensure they can comply with insurance company guidelines.
Diagnosis Coding (Cont.)
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Specific questions regarding insurance denials relating to diagnosis
coding should be addressed with the insurance company.
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Accurate diagnosis and procedure coding directly impacts correct and
maximum benefit payment.
Diagnosis Coding (Cont.)
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Proper coding involves using the ICD-9-CM volumes to identify
the appropriate codes for items or services provided (as recorded
in the patient record), and using those codes correctly on the
medical claim forms.
Diagnosis Coding (Cont.)
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Use the ICD-9-CM codes that describe the diagnosis, symptom,
complaint, condition, or problem.
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Use the ICD-9-CM code that is chiefly responsible for the item or
service provided.
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Assign codes to the highest level of specificity. Use the fourth and fifth
digits when indicated as necessary in your ICD-9-CM volumes.
Diagnosis Coding (Cont.)
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Code a chronic condition as often as applicable to the patient's
treatment.
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Code all documented conditions which coexist at the time of the
visit that require or affect care or treatment. (Do not code
conditions which no longer exist.)
Eligibility vs. Treatment Diagnosis
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Diagnosis coding is translating the medical terminology used for each
service/item given by a provider into a code for billing purposes.
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The diagnosis determined for EI eligibility will not necessarily be the
same diagnosis used for billing purposes.
Billing & Insurance Use
II. Billing Requirements
Billing Requirements
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Bill using only CMS 1500 or UB92. Transportation providers may
continue to use the DHS Transportation Billing Form.
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CMS 1500 forms can be obtained at most office stores or online.
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DHS Transportation Billing Forms are available through the Early
Intervention website.
*Copies are acceptable.
Billing Requirements (Cont.)
Required on CMS 1500 Claim Form:
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Child’s name (last and first) (field 2);
Child’s complete address (field 5);
6 digit EI number (field 1a);
Date of birth (field 3);
Payee name and address (field 33);
Tax ID (field 25);
Name of enrolled provider who performed the service (field 31)
and, if applicable;
Name of associate provider - listed under name of EI enrolled
supervisor (field 19).
Billing Requirements (Cont.)
Required on CMS 1500 Claim Form (cont.):
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Date of service (field 24A, lines 1-6);
CPT or HCPCS codes (field 24D, lines 1-6);
Treatment diagnosis code (field 21 1-4);
Place of service code (field 24B, lines 1-6);
Length of session (field 24G, lines 1-6);
Amount billed (field 24F, lines 1-6);
Patient account number – if applicable (field 26), and;
Total charge (field 28).
Billing Requirements (Cont.)
Things to remember:
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Utilization of private insurance benefits is mandatory.
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You must accept insurance and/or CBO payment as payment in full for services
and agree not to bill the family for further payment.
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Always notify the CFC immediately of any change of insurance for the family
you are serving.
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Providers should not bill the family directly for any EI service unless the
insurance payment was paid to the family versus the provider.
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CBO pays patient co-pays and deductible charges, up to the maximum allowed
per service. An EOB from the insurance company must be attached to your
claim.
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EI provider agreements specify you must send a claim to the CBO with the
insurance EOB attached even if insurance has paid the claim in full.
Billing Time Period
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Beginning July 1, 2005, claims must be received by the
CBO within 90 days of the date of service.
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When insurance billing is required, the CBO must receive
the claim, with the insurance carrier’s EOB attached, within
90 days of the date of the most recent correspondence
from the insurance company.
Acceptable Billing Forms
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Beginning July 1, 2005 all providers of service, with the exception
of transportation providers, must submit all claims on either a
CMS 1500 or UB92.
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Claims received at the CBO on any other type of form other than
listed above beginning October 1, 2005, will be denied.
Billing & Insurance Use
III. Responsibilities
Responsibilities
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Child & Family Connections
Service Provider
Family
CBO
Child and Family Connections
Responsibilities
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Assist family in completing Insurance, Affidavit, Assignment
and Release Form.
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Provide copies of the family’s insurance card to the provider
and CBO.
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Request approval of pre-billing waivers and exemptions from
the CBO.
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Update CBO and provider of changes in insurance
policy/benefits.
Provider Responsibilities
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Verify insurance benefits with all insurance companies covering
the family.
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Verify that insurance coverage has not changed before each
service is performed. The provider must be aware of who their
payer will be and their requirements for each service provided.
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Bill the insurance company and CBO appropriately.
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Update CFC and CBO of changes in insurance policy/benefits.
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Follow up with insurance company per CBO instructions.
Family Responsibilities
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Assist the CFC and provider in determining insurance
benefits and obtaining required documentation, if necessary.
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Provide timely notification of changes in insurance
policy/benefits to CFC, CBO, and/or provider.
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Turn over recouped payments to the provider as appropriate.
CBO Responsibilities
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Benefit verification.
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Forward insurance data to CFC.
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Approval/denial of pre-billing waiver and exemption requests.
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Provide technical assistance to providers to help maximize
insurance benefits.
Billing & Insurance Use
IV. Insurance Use
Insurance Use
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All credentialed providers must bill insurance,
whenever insurance exists, before submitting a
claim to the CBO.
*Unless a pre-billing waiver or exemption has been issued.
Insurance Use (Cont.)
Providers performing the following services must bill private insurance
before submitting their claims to the CBO:
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Assistive Technology (DME)
Aural Rehabilitation Services
Developmental Therapy
Services (includes: DT
Hearing and DT Vision)
Health Services
Nursing Services
Nutrition Services
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Occupational Therapy
Services
Physical Therapy Services
Psychological and Other
Counseling Services
Social Work and Other
Counseling Services
Speech Therapy Services
Vision Services (including:
optometric exam and
dispensing fees)
Insurance Use (Cont.)
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Providers performing the following services are excluded from billing
insurance:
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Assessment Services
Audiology (examination by an Audiologist or a hearing aid assessment)
Evaluation Services
Family Training and Support
IFSP Development Services
Interpretation
Medical Services for diagnostic/evaluation
Parent Liaison
Transportation
Billing & Insurance Use
V. Benefit Verification
Insurance Benefit Verification
CFC
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Distribute copy of insurance card (front and back) to the CBO
and provider.
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Distribute copy of Insurance, Affidavit, Assignment and Release
Form to the CBO and provider.
Insurance Benefit Verification (Cont.)
Provider
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Verify benefits as they relate to specific services.
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Note: In consultation with insurance companies, EI services
rendered in the natural environment most closely fall under the
“outpatient” category of service. Confer with the insurance
company to determine their preference on the appropriate service
delivery billing classification.
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Determine and follow all pre-service requirements of the
insurance policy.
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Bill the insurance company as soon as possible after the service has
been provided.
Insurance Benefit Verification (Cont.)
Provider
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Follow up with the Illinois Department of Financial and
Professional Regulations if no response is received.
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Forward claim and copy of the insurance carrier’s EOB to the
CBO once a response from insurance is received.
Failure to follow insurance company policy
guidelines will result in loss of payment from
the insurance company and the CBO.
Insurance Benefit Verification (Cont.)
Steps to Verify Benefits:
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Phone the benefits verification department of the insurance carrier usually found on the back of the family’s insurance card.
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Identify yourself as a provider and that you want to verify benefit
coverage.
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Give the representative any required information and define the type
of benefits you are calling on.
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The representative will give you a “quote only” response. Final
determination regarding payment will be made when your claim has
been submitted.
Insurance Benefit Verification (Cont.)
Steps to Verify Benefits:
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Ask about any policy limitations or provider restrictions. Below are a
few examples of questions you may want to ask:
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Is a pre-certification or pre-authorization required?
Is a referral from the primary care physician required?
Are there a limited number of visits allowed per year? If so, what
is the benefit year?
Is there a maximum amount payable per year? Per lifetime?
Are there out of network benefits available?
Remember, it is the provider’s responsibility to know
the policy guidelines to ensure payment for services.
Billing & Insurance Use
VI. Waivers & Exemptions
Pre-Billing Insurance Waivers
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Pre-billing waivers will only be issued for the following
situations:
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An insurance required provider is not available to receive the
referral and begin services.
No insurance required providers are credentialed in Early
Intervention
Travel to the insurance required Center based provider would
be a hardship for the family.
Pre-billing waiver requests will be submitted to the CBO by the
CFC where they will be approved or denied.
Pre-Billing Insurance Waivers (Cont.)
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Approval/denial will be forwarded in writing to the CFC,
provider, and family.
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Pre-billing waiver becomes void if the family’s insurance
coverage changes or if provider receives payment from the
insurance company.
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Pre-billing waivers are effective for the IFSP period in which
the authorization was issued.
Post-Billing Insurance Waivers
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Will be issued by the CBO based on the denial reason listed on
the EOB.
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Expire at the end of the insurance plan’s benefit year and the
provider will be required to bill the insurance company according
to program requirements.
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If the family’s insurance coverage changes, all waivers become
void and the provider must bill the new insurance company.
Insurance Exemptions
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Exemptions may be issued by the CBO for the following reasons
when the appropriate documentation has been forwarded by the
CFC:
• Privately Purchased/Non-Group Plan
• Lifetime Cap (overall policy or service specific)
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Approval/denial will be forwarded to the family, CFC, and
provider, if appropriate.
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Exemption becomes void if the family’s insurance coverage
changes.
EI Insurance Use
Insurance Billing Required
CBO Verifies
Insurance
Benefits
CFC Receives
Referral
CFC Refers to Insurance
Approved Provider
Provider Verifies Benefits
and Provider
Restrictions with
Insurance
Provider Bills CBO
with Insurance EOB
Attached
Provider Renders
Service and Bills
Insurance
EI Insurance Use
Pre-Billing Waiver/Exemption
CFC Receives
Referral
CFC Assists Family in
Completing Pre-Billing
Waiver or Exemption
Request and
Forwards to CBO
CBO Verifies
Insurance
Benefits
CBO Approves and
Forwards Determination to
CFC and Family
CFC Determines
Pre-Billing Waiver or
Exemption is Needed
or
CBO Denies and
Forwards
Determination to
CFC and Family
CFC Refers to EI Credentialed
Provider to Begin Services
CFC Refers to Insurance
Approved Provider
Provider Performs Service
And Bills CBO for
Remainder of IFSP Period
Provider Bills Insurance
and Then Bills CBO
Claim with EOB Attached
Billing & Insurance Use
VII. Provider Safety Net
Provider Safety Net
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Provider bills insurance and if no response is received within 30
days, they should follow up with the insurance company and
document the method of contact.
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Provider complies with requests for any additional information
and documents that submission.
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After 60 days, if the insurance company has not responded, the
provider submits a complaint form to the Illinois Department of
Financial & Professional Regulations – IDFPR (formerly IL
Department of Insurance).
Provider Safety Net (Cont.)
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Once the IDFPR has received a response from the insurance
company, they will notify the provider in writing of the outcome.
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If the insurance company agrees to pay, the provider submits the
claim along with the insurance company EOB to the CBO.
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If the insurance company denies the claim, the provider submits
the claim and denial within 90 days to the CBO. CBO will review
based upon normal program requirements.
Billing & Insurance Use
VIII. Technical Assistance
Technical Assistance
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Technical assistance to help providers with insurance issues will be
available from the CBO.
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This insurance training will be available on the internet.
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DHS and CBO websites will contain the latest updates to insurance
billing requirements and/or procedures.
Billing & Insurance Use
IX. Resources
Early Intervention Resources
Bureau of Early Intervention
• 217.782.1981
• www.dhs.state.il.us/ei
Early Intervention Central Billing Office
• 1.800.634.8540
• www.eicbo.info
Provider Connections
• 1.800.701.0995
• www.wiu.edu/providerconnections
UCP – Greater Chicago
• 1.866.509.3687
• www.illinoiseitraining.org
Illinois Office of the Comptroller
• 217.782.6000
• www.ioc.state.il.us
Illinois Dept. of Financial & Professional
Regulation
• 1.877.527.9431
• http://www.ins.state.il.us
Free ICD-9 Coding Website: www.icd9coding1.com/flashcode/home.jsp