Mental Health ServicesClaiming & Productivity Training

Agenda

Contract Budgets Invoice/Billing Process Medi-Cal Billing Cost Report Productivity Reports Procedures Resources

Handout: PowerPoint Presentation Tab

Contract Budgets

Service Budgets› Mental Health Services

Outpatient Mental Health Services Group Home TBS

› Triple P› Budget Transfers

Advance Request in writing No Transfers from Triple P to Mental Health Services

Invoice/Billing Process

Provider submits DCFs to County

County verifies Authorization for services

Provider submits Invoice to County

County verifies services

against DCFs

County submits invoice to

Auditor/Controller for payment

County enters services &

submits billing to DMH

DMH adjudicates claim and

submits to DHCS

DHCS submits to CMS (Fed)

CMS pays DHCS

DMH pays CountyDHCS pays

DMH

Medi-Cal BillingOther Health Coverage (OHC)

Short Doyle Medi-Cal Phase II requires billing primary insurance prior to billing Medi-Cal

Bill Medi-Cal following denial› Provide EOB with acceptable denial code

Bill Medi-Cal if no response from primary insurance in 90 days› Provide copy of HCFA to confirm OHC was billed timely

Services billed direct to Medi-Cal (without billing to OHC)

› T1017 – Case Management› H2019 – TBS (not H0031TG – TBS functional behavior

analysis) Medi-Cal Code V

› County can request removal› If code changes to A, OHC must be billed

Medi-Cal BillingOther Health Coverage - Denials

Review EOB for denial reason Requested additional information must

be provided to insurance Acceptable denial code

› Not a covered service› Paid a portion

Bill remaining amount to Medi-Cal› Not a contracted provider

Medi-Cal BillingOther Health Coverage - Denials

Medi-Cal BillingOther Health Coverage - Denials

Medi-Cal BillingOther Health Coverage - Denials

Cost Report

Annual fiscal report reconciling total costs and total units› Establishes actual rate

Actual rate is used as interim rate› Medi-Cal Units are settled to actual rate

with providers Up to Statewide Maximum Allowance (SMA) Up to total Contract Amount

Service Categories still apply

› All Triple P units are settled to actual rate

Cost ReportGeneral Concepts/Strategies

Costs by Service Category should never exceed Contract Max › Consistent costs

Keeping costs within the contract budget ensures providers will be kept whole as long as: Settled rate is less than SMA All units are paid by Medi-Cal

Increased/Decreased total units affect rate but do not affect settled reimbursement.

Cost ReportGeneral Concepts/Strategies

Example 1 – Consistent Costs & Units› Provider Contract - $120,000 max› Provider actual expenditures - $10,000/month ($120,000 total)› Provider units of service – 10,000/month› Interim Rate - $1.00› Settled Rate - $1.00› Provider receives total reimbursement by June› Total paid - $120,000

Example 2 – Consistent Costs & Increased Units› Provider Contract - $120,000 max› Provider actual expenditures - $10,000/month ($120,000 total)› Provider units of service – 15,000/month› Interim Rate - $1.00› Settled Rate - $.67› Provider receives total reimbursement by March› Total paid - $120,000

Cost ReportGeneral Concepts/Strategies

Example 3 – Increased Cost & Units› Provider Contract - $120,000 max› Provider actual expenditures -

$11,000/month ($132,000 total)› Provider units of service – 11,000/month› Interim Rate - $1.00› Settled Rate - $1.00› Provider reimbursement does not cover

actual expenditures› Total paid - $120,000

ProductivityDefinition & Purpose

Definition› The amount of time spent providing direct

service as a percentage of total hours paid

Purpose› Ensures we provide as many quality

services as we can within the resources we have available

ProductivityCalculation

Total Productive Hours/Total Paid Hours› Productive Hours

Direct Client Service Hours (billed time)› Total Paid Hours

All paid hours Regular Hours Worked Paid Time Off Overtime

ReportsProgram Caseload Report - Monthly

ReportsSummary TAR Report - Quarterly

ReportsService Code Report- Quarterly

Procedures

Triple P – Billing private insurance Transitioning youth at 21 Notification of major incident Referrals

› Medi-Cal› Triple P

Medi-Cal Walk In HHSA

Procedures

Annual TAR Process› Start Date September 1

TARS submitted prior to September 1 TARS that had an initial authorization period

prior to September 1 Coordinating Assessments with TARS

Do another assessment with TAR regardless of when the new assessment is due

TAR authorization period to match assessment due date

Resources

Updated Contact Information Updated Org Provider Manual

› In process Updated version will be provided by the QM

meeting in October Billing Codes

Questions????