Transcript Provider Relations - Illinois Mental Health Collaborative

Illinois Department of Human Services /
Division of Mental Health
and
Illinois Mental Health Collaborative
Present
ICG Claims Submission Training
March 2009
ICG Claims

ICG Residential and Community Service
claims may be submitted to the Collaborative
for dates of service 4/1/09 and after.

Program Codes:
Residential - ICG
Community - ICGC
2
ICG Residential Per Diem and
Community Services Workflow

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3
Provider submits claim to Collaborative
Collaborative processes claim resulting in a
Provider Voucher or 835
Collaborative sends claim information to
DHS/DMH
DHS/DMH issues payment to provider
ICG Residential Services
Claim Submission

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4
Authorization is required
Submit on 837P or Direct Claim Submission
Quarterly Report is required timely. If not
received, claims for dates of service after it is
due will be denied
Per Diem and Encounter Claims are
submitted separately
ICG Residential Services
Claim Submission
5

Per Diem Codes – submit actual charges

Always bill residential services with place of service
code 11

Bill Per Diem Room & Board type codes with 1
unit/day
ICG Residential Services
Encounter Services
Claim Submission

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
6
Encounter services are the professional
services provided during residential stay
Use Program Code ICG for encounter
services during a residential stay
Use Place of Service code 11
See Website
http://www.illinoismentalhealthcollaborative.c
om
ICG Residential
Encounter Services
Claim Submission, continued
7

Message code on Provider Voucher states that
services were included in per diem

835 message code is 97 - The benefit for this
service is included in the payment/allowance for
another service/procedure that has already been
adjudicated.
ICG Claims - Quarterly Report
Residential and Community Service
Claims will reject if quarterly report is not
submitted.
Once submitted, provider is responsible to
resubmit rejected claims.
8
ICG Residential
Per Diem (room & board) Service Codes
CPT
New Modifier Order
H
C
P
C
S
9
W Code
Service Name
1
2
Bill Unit (hrs)
3
S9986
W017B
ICG services, group home, bedhold
Day
S9986
W017M
ICG services, group home, consumer present
Day
S9986
W019B
ICG services, residential, bedhold
Day
S9986
W019M
ICG services, residential, consumer present
Day
S9986
W020B
ICG services, special unit 1, residential, bedhold
Day
S9986
W020M
ICG services, special unit 1, residential, consumer
present
Day
S9986
W021B
ICG services, special unit 2, residential, bedhold
Day
W021M
ICG services, special unit 2, residential, consumer
present
Day
S9986
ICG Residential
Encounter Service Codes
New Modifier Order
CPT HCPCS
10
W Code
1
2
Service Name
3
Bill Unit
(hr
s)
H0031
AH
Mental health assessment (LCP)
0.25
H0031
HN
Mental health assessment (MHP)
0.25
H0031
HO
Mental health assessment (QMHP, AM/MA)
0.25
H0032
HN
Treatment plan development, review, modification (MHP)
0.25
H0032
HO
Treatment plan development, review, modification (QMHP)
0.25
90862
52
Psychotropic medication monitoring
0.25
90862
SA
Psychotropic medication monitoring (APN)
0.25
90862
UA
Psychotropic medication monitoring (MD/DO/DC)
0.25
H0002
HE
Case management - LOCUS
H0004
HN
Therapy/counseling--individual (MHP)
0.25
H0004
HO
Therapy/counseling--individual (QMHP)
0.25
H0004
HQ
HN
Therapy/counseling--group (MHP)
0.25
H0004
HQ
HO
Therapy/counseling--group (QMHP)
0.25
H0004
HR
HN
Therapy/counseling--family (MHP)
0.25
H0004
HR
HO
Therapy/counseling--family (QMHP)
0.25
Event
ICG Residential
Encounter Service Codes
New Modifier Order
CPT HCPCS
W Code
1
2
Bill Unit
(hr
s)
Psychotropic medication training--Individual
0.25
Psychotropic medication training--group (APN)
0.25
3
H0034
HN
H0034
HQ
H0034
HQ
Psychotropic medication training--group
0.25
H0034
SA
Psychotropic medication training--Individual (APN)
0.25
Crisis intervention
0.25
Crisis intervention--multiple staff
0.25
SA
H2011
11
Service Name
H2011
HT
H2015
HE
HM
Community support, residential, individual (RSA)
0.25
H2015
HE
HN
Community support, residential, individual (MHP)
0.25
H2015
HE
HO
Community support, residential, individual (QMHP)
0.25
H2015
HQ
HM
HE
Community support, residential, group (RSA)
0.25
H2015
HQ
HN
HE
Community support, residential, group (MHP)
0.25
H2015
HQ
HO
HE
Community support, residential, group (QMHP)
0.25
H2017
HM
Psychosocial rehabilitation, individual (RSA)
0.25
H2017
HN
Psychosocial rehabilitation, individual (MHP)
0.25
H2017
HO
Psychosocial rehabilitation, individual (QMHP)
0.25
ICG Residential
Encounter Service Codes
CPT HCPCS
12
W Code
New Modifier Order
1
2
3
Service Name
Bill Unit
(hrs)
S9986
W00V1
Vocational assessment
0.25
S9986
W00V2
Vocational engagement, group
0.25
S9986
W00V3
Vocational engagement, individual
0.25
S9986
W00V4
Job finding supports, group
0.25
S9986
W00V5
Job finding supports, individual
0.25
S9986
W00V6
Job retention supports, group
0.25
S9986
W00V7
Job retention supports, individual
0.25
S9986
W00V8
Job leaving/termination supports, group
0.25
S9986
W00V0
Job leaving/termination supports, individual
0.25
ICG Community Services
Claims Submission

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13
Use Program Code ICGC
Follow Service Matrix for covered Community
Service codes
Follow same rules as submitting ABC
services (rolling services, units, etc.)
ICG Community Services
Two services require an authorization after
maximum is met:
W072M - ICG Child Support Services
Authorization is required after $1570 in approved claims per
consumer in the fiscal year

W097M - ICG Behavior Management
Authorization is required after $3500 in approved claims per
consumer in the fiscal year

14
ICG Community
New Service Codes
15
S9986
W051M
ICG application assistance
S9986
W072M
ICG child support services
S9986
W097M
ICG behavior management
Questions?
16
Claims Submission
Claims and Service Reporting Training
Agenda
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18
Billing and Service Reporting Guidelines
Direct Claim Submission on ProviderConnect
HIPAA 837P Technical Information
EDI Claims Set-up
Claim Helpful Hints
Billing with Psuedo-RINs
eClaims link on ProviderConnect
Service Reporting
Under the Collaborative IT system, all services are
submitted as claims.
Mental Health claims must be submitted
electronically and meet all HIPAA
compliance standards
 HIPAA standards govern both the file format and the
codes used within the file
 Some claims require data elements for which there
are no standard fields. The notes fields will be used
to submit these values
19
HIPAA 837P Software
The Illinois Collaborative will accept all HIPAA
compliant 837P formatted files
Files must include all required DHS/DMH
data elements
The Illinois Collaborative provides free
electronic claims submission software
 eClaims Link, or
 Direct Claims Submission (web-based)
20
Billing Guidelines
Required Claims Data
Registration Requirement
Before claim is submitted, consumer must be
registered by the agency performing the
service
22
Consumer Information


23
Standardized claims transactions require
certain consumer information to verify the
individual’s identity
The Collaborative has minimized the
consumer information necessary for a claim
to be submitted, while assuring that each
service claim is correctly associated to the
appropriate consumer
Claim Level Information
Consumer Information Required
•
RIN
Consumer Name
Date of Birth
•
Gender
•
All must match exactly to the registration information
on file
Consumer address is optional
•
•
•
24
Claim Level Information
(cont.)
Pseudo RIN
•
•
Appropriate only for specific services when a
specific consumer isn’t identified
A list of these pseudo RIN numbers, name, and
date of birth is provided on-line at
http://www.illinoismentalhealthcollaborative.com/
For example, ICG Application Assistance can be billed with a pseudo RIN
if consumer information is not available.
25
Claim Level Information
(cont.)
Provider Information required on each
claim
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26
10 digit NPI number that matches the NPI on
file with the Collaborative
Tax ID Number (FEIN)
Service Location
Taxonomy Codes are optional
Service code and modifier combinations will
identify staff level
Claim Level Information
(cont.)
Subcontractors
The Subcontractor’s Federal Employer ID
Number (FEIN) must be provided when
subcontracting services to a different agency
27
Claim Level Information (cont.)
Program Codes
Submit the Program Code for the service
provided:
 Program Codes:

Residential - ICG
Community - ICGC
28
Claim Line Level Information
Service Codes
29

Service codes must be valid HCPCS or CPT
codes as shown on Service Matrix found at
http://www.illinoismentalhealthcollaborative.com/

Service code S9986 is used when a “W” code
specifies the service. The W code is entered in
claim line notes (LOOP 2400)
Claim Line Level Information (cont.)
Modifiers

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30
Staff Level Modifiers drive the allowable
amount applied to a service
– If no staff level modifier is submitted, the
lowest allowable amount for the service
code is assumed
Modifier Position is very important
– Staff Level Modifier should always be in the
last modifier position when multiple
modifiers are submitted
Claim Line Level Information (cont.)
Staff Level Modifiers
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31
AH – LCP - Licensed Clinical Psychologist
HN – MHP - Mental Health Professional
HO – QMHP - Qualified Mental Health
Professional
SA – APN -Advanced Practice Nurse
HM – RSA - Rehabilitative Services Associate
UA – MD, DO, DC
Claim Line Level Information (cont.)
Diagnosis Codes
32

Must be ICD-9 and include 4th and 5th digit
according to ICD-9 guidelines

Only Mental Health diagnoses that are
DMH/DHS defined will be accepted.
Claim Line Level Information (cont.)
Line Notes
For all services, the following are required:
 Delivery method
 Service start time
 Service duration
 Staff ID
Situational Requirements:
 Activity code is required for S9986 services
 For group based services show the group id, # clients in group, and #
of staff in the group
33
DMH considers these data elements to be important and necessary
components of billing and service reporting
Review Services Matrix
The Service Matrix provides the following information:
Specific activities/services that are to be reported for S9986
Information regarding the use of specific pseudo-RINS for consumers
who are not identifiable (previously referred to as unregistered
consumers).
This information will be posted on the Collaborative Website in an
Excel Spreadsheet that you may download.
http://www.illinoismentalhealthcollaborative.com/
34
Questions?
35
Direct Claim Submission
For all providers
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ProviderConnect
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EDI Claims Link/Batch submissions
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
The Collaborative can receive your 837 Batch
transaction directly
Access the Collaborative web site at
www.valueoptions.com
Access “For Providers” on the left hand side of the
screen
Access Handbooks – Administration- Online
Services.
Required Forms referenced in Online Services are
available by accessing the forms menu on the left
side of the screen
EDI help is available from eSupport Services at
EDI Claims Link
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Technical Information
Third Party Software
837P submissions
Illinois Health Care Claim
Companion Guide 837 Professional
HIPAA 4010 Version
The Companion Guide only applies to
DHS/DMH specific services

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51
The same requirements apply for third party
software as well as the Collaborative’s free
software
The loops in this guide are in numerical order
only to facilitate discussion
Standard Implementation Guide
For complete technical information, please
refer to the Standard Implementation Guide
which contains the entire set of instructions for
the EDI HIPAA 4010 version of the 837P
The Implementation Guide must be purchased.

52
The sequencing of the loops should follow that
specified within the Implementation Guide
Consumer Information

Loop 2000B- Consumer Information
–

Loop 2010BA- Consumer Name
–
–
53
DMS/DMH Program Code
Name should be shown as it is in the enrollment
system
RIN or Pseudo- RIN
Billing/Pay to Provider Information

Loop 2010AA- Billing Provider Name
–
–

Loop 2010AB- Pay- to- Provider Name
–
54
Agency NPI (National Provider Identifier)
FEIN
Required if Pay-to is different than Billing Provider
Purchased Service Provider/Service
Facility Location

Loop 2310C- Purchased Service Provider
–

Loop 2310D- Service Facility Location
–
–
55
FEIN is required when Subcontractor is used
If not using a subcontractor, and the service
location is different than Billing Provider location
this must be completed
If Subcontractor is used, this field should be blank
Claim Level Information

Loop 2300- Claim Information
–
–
–
–
–
56
Individual ClientID | ClaimID
POS (Place of Service)
Assignment of Benefits
Diagnosis Codes
Claim Notes
 Qualification Levels for staff
– 01 = LPHA
– 02 = QMHP
– 03 = MHP
– 04 = RSA
Service Line

Loop 2400- Service Line
–
Procedure code

For Section E (capacity grant services) services use S9986
–
–
Modifiers

–
–
–
Maximum of four modifiers, last modifier must be staff level
modifier
Units
Date of Service
Line Control Number

57
Add appropriate W-code in note segment
up to 30 bytes
Service Line (cont.)

Line Notes
– This field is used for various data needs. Please be
sure to include the pipe (|) between the identifiers. If
pipe does not work in your software you can use a
semi colon (;).
 W- code (non-standard codes for capacity grant
services/Section E)
–
58
Delivery Method
 Face to face
 Telephone
 Video
Service Line (cont.)
 Time
–
–
Service begin date (military time)
Duration in minutes (000)
 Group
based services
– Group ID
– # clients in group
– # staff in group
 Staff ID
59
Coordination of benefit information

Loop 2320- Other Consumer Information
–
Other insurance information

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Loop 2330B- Claims adjudication date
–
60
Insurance Code
Carrier allowed amount
Carrier paid amount
Date of other insurance payment
Submitting Corrected/Replacement
Claims LOOP 2300 – CLAIM INFORMATION

When an original claim was denied or incorrectly
billed, send a corrected or replacement claim by
indicating the Claim Frequency Type Code
–
6=Corrected
– 7=Replacement

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Enter the Collaborative’s original Claim Number
prefixed with “RC” in the Reference Identification
EDI Claim Submission
For all providers
EDI Claims Set-up
Submit via http://www.illinoismentalhealthcollaborative.com
The same guidelines apply for all submitters regardless of the
software used to submit a file


All submitters must submit a completed Account Request Form
Billing agents must also submit an Intermediary Form
–
–
–
–
–
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Fax forms to 866-698-6032
Allow 3 days for your submitter account to be set up
You will receive an email with your ID and Password
You will be set up in test mode
After submitting a successful file, call to be taken out of test mode
EDI Claims Set-up cont.
Submit file
 1st email from eSupport confirms receipt of
file
 2nd email from eSupport confirms pass/failure
of file
–
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If file fails email will give you the reason for failure
EDI Helpdesk
 888-247-9311
 M-F 8-6 EST
Collaborative’s Website for Claims
Activities
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Access the Collaborative web site at
www.illinoismentalhealthcollaborative.com
Select “For Providers” on the left hand side of the
screen
Access Handbooks – Administration- Online
Services.
Required Forms referenced in Online Services are
available by accessing the forms menu on the left
side of the screen
EDI help is available from eSupport Services at
1.888.247.9311 (Mon-Fri. 8am – 6pm Eastern)
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Questions?
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Claims Helpful Hints
Helpful Hints to Faster Claim
Processing

Submit the Consumer’s RIN in the Patient ID
field
–
77
if the RIN doesn’t match the DHS assigned number,
the claim will be uploaded to our claims processing
system identifying the Consumer as “UNKNOWN”
please submit the correct RIN
Helpful Hints to Faster Claim
Processing (cont.)

To be in compliance with HIPAA Regulations, the
National Provider Identifier (NPI) must be submitted on
all claims. The Agency NPI should be entered into the
NPI field
– If the NPI is not on the claim, the file will be rejected
–
78
If the NPI submitted does not match the NPI we have
on file for your agency, the claim will be delayed for
resolution of the NPI discrepancy
Helpful Hints to Faster Claim
Processing (cont.)
Examples
Agency has multiple sub-NPIs for various service locations
in addition to the Agency NPI:
–
–
79
Submit the Agency NPI in Billing Pay-to loop, enter the
Service Location NPI in Service location loop
All NPIs used on the 837P must be on file with the
Collaboration
Agency has multiple sub-NPIs by Program.
– Enter Agency NPI in Billing Pay-to loop, Program NPI
in Service location loop
Helpful Hints to Faster Claim
Processing (cont.)
When billing for specific services that allow or
require a “pseudo- RIN” enter the pseudo RIN
exactly as provided to you.
Also enter the pseudo-name and date of birth
associated to the pseudo- RIN exactly as
shown.
80
Helpful Hints to Faster Claim
Processing (cont.)

Multiple units of service rendered by the same
practitioner staff level, on the same day, for the
same client, must be submitted on one claim.
–
–
81
All units for one service code must be submitted on
one line.
If claims are submitted separately, claims will be
denied as a duplicate service.
Helpful Hints to Faster Claim
Processing (cont.)

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Example:
H2015 HN
Community support, individual
(MHP) For Consumer RIN 123456789
– 10 AM 4 units, noon 2 units, 6PM 3 units
– Submit H2015 HN on one line, with 9 units. Start
time is 10 AM, duration: 135 minutes
Helpful Hints to Faster Claim
Processing (cont.)
A separate claim must be submitted for every
different staff level rendering services (except
for multiple disciplinary groups)
83
Most Common Reasons for Claim
Denial
Consumer Information:
–
–
–
–
84
RIN doesn’t match the RIN assigned by DHS or
registration
Service code on the claim is not on the list of
covered service
Service code billed is not one the provider is
contracted to render (the service is not on the
provider’s fee schedule).
Consumer is not eligible on the date of service.
Most Common Reasons for Claim
Denial (cont.)
Codes/Modifiers
–
–
–
–
–
–
85
Service code is not a covered code
Place of service code on the claim is not a valid place
of service code for the service rendered
Modifier code billed on the claim is not valid with the
CPT or HCPCS code
Staff level modifier is not billed on the claim
Diagnosis code is not current ICD-9 standard
Diagnosis code does not contain a required 4th or 5th
digit
Most Common Reasons for Claim
Denial (cont.)
Authorization
–
–
86
There is not an authorization in the system for the
date of service billed or for the provider
There is an authorization on the system but the
dates of service on the claim are either before the
effective date or after the expiration date of the
authorization
Timely Filing of Claims
87

Claims for all services must be received by the
Collaborative within 365 days of the date of service

Claims Involving Third Party Liability (TPL) must be
received by the Collaborative within 365 days of the
date of the other carrier’s Explanation of Benefits
(EOB), or notification of payment / denial.

Timely filing limit applies to replacement claims as
well as original claims; claims must be received by the
Collaborative within 365 days from date of service.
Billing with Pseudo-RIN
Reason for Pseudo-RINS
The database has entries for pseudo
consumers to be used for reporting services
to consumers known in the current system as
un-registered consumers. This helps to
identify what populations
(children/adolescents, adults, homeless
persons) are served under capacity grants
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Pseudo-RIN
Example: if a provider is billing for Urban
systems of Care (Program Code 140):
–
–
–
90
for a child or adolescent use Pseudo-RIN 140001
for an adult use Pseudo-RIN 140002
for a group of consumers, or not consumer
related use Pseudo-RIN 140000
Pseudo-RIN cont.
Certain client information is required for all claims
to help identify the claim for reporting purposes:
Each Pseudo-RIN has a specific Pseudo-consumer
name, date of birth (DOB), and gender:
–
–
–
–
91
DOB used for Any/All Groups Pseudo – 01-01-1980
DOB used for Child/adolescent- 01-01-2000
DOB used for Adult – 01-01-1970
Gender is always U
Pseudo-RIN (cont.)


The provider should always use the most definitive
Pseudo-RIN available for the program. For example,
there is a different Pseudo-RIN for a child or adult who is
homeless or not, under the PATH Grant program.
The following funds will always be associated to a
Pseudo-RIN. There will never be a consumer attached to
these funds.
–
–
–
92
–
Urban Systems of Care
Geropsychiatric Services
Co-Location Project
Crisis Staffing Service
140
540
576
580
Pseudo-RIN (cont.)
The following funds will never be associated to a PseudoRIN. Provider can only bill with true RINs for services in
these programs:
93
CHIPS
ICG
Medicaid/
non Medicaid FFS
CILA
Supported Res
Permanent Supported
Housing
Supervised Res
Crisis Residential
550
ICG
ABC
620
820
821
830
860
Questions and Answers
94
Thank you!
Illinois Mental Health Collaborative for
Access and Choice
Comparison of Submission Methods
Action/Fields
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Direct Claim
Submission
(DCS)
ECLW - Batch
Claim
Submission
Provider access to
claim
submission
method
Via website ProviderConnect
Downloaded to provider's
computer desktop
Claims Corrections
As each claim is submitted
through
ProviderConnect it is
immediately
adjudicated in the
Collaborative's
system. Once
submitted, no
changes can be made
to it. If an error was
made, a corrected
claim is required.
Batches can be submitted at
the provider's
discretion, which offers
the opportunity to
correct claims entered
before batch is
submitted.
Enter Consumer's RIN and
date of birth on each
claim
One time set-up of Consumer
demographics in
member screen.
Consumer is selected
from drop-down box
during claim entry
Consumer
Identification
Pros and Cons
DCS- ProviderConnect access allows for
immediate availability of software
updates
ECLW- updates must be downloaded
after receiving update message
DCS - because submitted claims are
adjudicate immediately, any
corrections require a corrected claim
ECLW - if an error is identified before
batch submission the claim can be
corrected without sending a new claim
DCS - immediate consumer eligibility
feedback.
ECLW - eligibility feedback not
received until claim is finalized and
835/ Provider Voucher is received