Billing for Habilitation Services

Magellan Health Services

June 11, 2013

Billing for Services

Magellan providers billing for Iowa Medicaid Habilitation (HAB) services must bill with HIPAA compliant codes for services rendered beginning July 1, 2013. Claims submitted with non-HIPAA compliant codes (e.g. old W codes) will be denied.

Provider Billing Tips

• • • • • • • • Coding changes are effective July 1, 2013.

Billing the new HIPAA codes is mandatory; non-compliance is a HIPAA violation.

The switch to the new HIPAA codes is based on the date of service, not the date the claim was submitted.

Be sure to include required modifier.

Use covered diagnosis codes.

Use valid place of service codes.

Submit claims timely. Timely filing limit is 1 year from date of service.

These services require pre-authorization. To authorize services, please call 1-800-638-8820 to schedule an appointment.

Provider Billing Codes

IA Medicaid HAB Service Name

Day Habilitation Day Habilitation Home-based habilitation Home-based habilitation Pre-Vocational Services Pre-Vocational Services Supported Employment: Maintain employment/job coaching Supported Employment: Maintain employment/enclave Supported Employment: Job Development Supported Employment: Employer Development Supported Employment: Enhanced Job Search

Time Unit/Basis

Per 15 Min Per Day Per 15 Min Per Day Per Hour Per Day Per 15 Min Per 15 Min Per Unit Per Unit Per 15 Min

Old W Code

W1206 W1204 W1207 W1208 W4425 W1425 W1431 W1433 W5019 W5020 W5021

New HIPAA Code

T2021 T2020 H2015 H2016 T2015 T2014 H2025 H2023 T2018 H2024 H2019

HIPAA Modifier*

UC UC UC UC UC UC *For all Iowa Medicaid Habilitation services, the UC modifier must be included on claims. Claims for this service submitted without this modifier will be denied.

UC UC UC UC UC

Magellan Covered Diagnosis

299 300 301 302 306 307 308 309 311 312 313 314

Code

290 291 292 293 294 295 296 297 298

Description

Senile and presenile organic psychotic conditions Alcoholic psychoses Drug psychoses Transient organic psychotic conditions Other organic psychotic conditions (chronic) Schizophrenic disorders Affective psychosis Paranoid states Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology) Psychoses with origin specific to childhood Anxiety states Personality disorders Sexual deviations and disorders Physiology malfunction arising from mental factors Special symptoms or syndromes, not elsewhere classified Acute reaction to stress Adjustment reaction Depressive disorder, not elsewhere classified Disturbance of conduct, not elsewhere classified Disturbance of emotions specific to childhood and adolescence Attention deficit disorder

Note: 310.00-310.99 – Mental Retardation is NOT covered.

Place of Service (POS) Codes

03 04 11 12 13 14 22 23 31

Code Definition

School Homeless Shelter Office Home Assisted Living Facility Group Home Outpatient Hospital Emergency Room Skilled Nursing Facility 32 33 49 50 53 54 57 71 72

Code Definition

Nursing Facility Custodial Care Facility Independent Clinic Federally Qualified Health Center Community Mental Health Center Intermediate Care Facility Non-residential SA Treatment Facility State or Local Health Clinic Rural Health Clinic

Rounding Rules – 15 Min. Unit

• • • • • • Add together the minutes spent on all billable activities during a calendar day for a daily total. For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day. Round the remainder using these guidelines: round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit. Add the number of full and rounded units to determine the total number of units to bill for that day. Providers will not determine daily units by the number of encounters they have with the member during a day, but by the total amount of time spent with the member. Units will not be determined by adding the number of minutes of service for the month and then dividing; units are to be determined on a daily basis.

Rounding Rules – Hourly Units

• Add all the minutes provided for a day.

• When the total minutes for the day is less than 60, round up to one (1) whole unit.

• When the total minutes for the day is more than 60, divide the total by 60 to get the number of hours for the day. This should be rounded to the nearest whole unit, by rounding down for 1-30 minutes, and rounding up for 31-59 minutes.

Daily Units

• Daily Home-Based HAB is defined as 8 or more hours per day, based on the average hours of service provided during a 24-hour period as an average over a calendar month.

• Day HAB and Prevocational Services, the daily unit is defined as 4.25 to 8 hours per day. There is no averaging for these services.

Authorizations

• • • • Existing service plans for HAB services active as of July 1, 2013, will be honored by Magellan.

Magellan staff will be reviewing service plans for members whose plan has an end date of August 2013.

Magellan staff will be contacting HAB providers on any existing ETP needing renewal.

For new HAB clients July 1, 2013 or after – the case manager or Integrated Health Home (IHH) staff should contact Magellan at 1-800-638-8820 to make an appointment to review a new HAB request.

Getting Paid

• Claim Submission – – Electronic Claim Submission Paper Claim Submission • Submit a “Clean” Claim • Submit Within Timely Filing Guidelines – Claims must be completely adjudicated within one year of date of service.

Top Claim Denial Reasons

• • • • • • • • No authorization Client not eligible for services Duplicate claim submission Invalid diagnosis codes Invalid CPT/HCPCS codes Invalid or missing modifier or place of service code Missing name and degree of provider – CMS 1500 only Site not contracted/credentialed – Sites ON contract means you should bill that rendering site.

– Sites NOT on contract means you should bill the main site as the rendering site.

Electronic Claim Submission – Preferred Method What’s in it for you?

• • • Improved Efficiency – – No paper claims, envelopes or stamps. Prompt confirmation of receipt or incomplete claim. Faster Reimbursement – cuts out the mailman, “clean” claims processed within 36 hours. Improved Quality – Up-front electronic review ensures higher – percentage of clean claims. Secure process with encryption keys, passwords, etc.

Electronic Claim Submission Options

• Claims Courier – Magellan’s Web Option – Small volume submitters • Direct Submission to Magellan – Medium to high volume submitters • Clearinghouse – Large volume submitters

Website Resources

•

www.MagellanProvider.

com

•

www.MagellanofIowa.

com

On-Line Resources

On-Line Resources, cont.

Electronic Claim Submission – On-Line Training Available

• • • Go to www.MagellanProvider.com .

Choose “Education”, and then “Online Training”. The section on “Electronic Transactions” includes the following demos: – – – – – 835 Transactions Clearinghouse Submit EDI Claims EDI Testing Center Electronic Funds Transfer

Claims/Website Contact Information

General Billing Questions

Customer Service at 1-800-638-8820.

EDI Technical Assistance

Getting Started – visit our EDI Testing Center at www.edi.MagellanProvider.com

EDI Hotline at 877-326-7525, ext. 75841 or

email [email protected].

General Website Technical Assistance

For all other website technical assistance, call Provider Services at 800-788-4005.

Magellan Customer Service Contact Information

Customer Service – 800-638-8820; Fax 888-656-5302

Christine Bryant, Customer Svc. Supervisor, 515-273-5009 Email – [email protected] Dennis Petersen, Director, Operations, 515-273-5044 Email – [email protected]

Claims address: PO Box 1869 Maryland Heights, MO 63043 Customer Service address: PO Box 71129 Des Moines, IA 50325

Questions?