Habilitation Services – Billing and Claims Process
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Habilitation Services – Billing and Claims Process Presented by Dennis Petersen, COO – February 18, 2014
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Habilitation Services – Billing and Claims Process. Presented by Dennis Petersen, COO – February 18, 2014. Magellan Transition. Only services rendered 7/1/13 or AFTER, should be billed to Magellan. - PowerPoint PPT Presentation
Transcript of Habilitation Services – Billing and Claims Process
Habilitation Services – Billing and Claims ProcessPresented by Dennis Petersen, COO – February 18, 2014
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Magellan Transition
• Only services rendered 7/1/13 or AFTER, should be billed to Magellan.
• For all services rendered PRIOR to 7/1/13, claims should be submitted directly to Iowa Medicaid Enterprise (IME).
• Existing service plans for HAB services active as of July 1, 2013, were transferred to Magellan.
• Why the change in billing procedures? Magellan has processes in place to ensure HIPAA and CMS compliance. The codes/processes previously used were not in compliance in order for us to process a claim.
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Provider Billing Codes
IA Medicaid HAB Service Name Time Unit/Basis Old W Code New
HIPAA Code HIPAA Modifier* Date Span
Day Habilitation Per 15 Min W1206 T2021 UC Daily
Day Habilitation Per Day W1204 T2020 UCDaily, could bill date span as long as span matches
the # of units billed.
Home-Based Habilitation Per 15 Min W1207 H2015 UC Daily
Home-Based Habilitation Per Day W1208 H2016 UCDaily, could bill date span as long as span matches
the # of units billed.
Pre-Vocational Services Per Hour W4425 T2015 UC Daily
Pre-Vocational Services Per Day W1425 T2014 UCDaily, could bill date span as long as span matches
the # of units billed.
*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.
*For those members with an ETP/Ad Hoc rate, you must bill with a KX modifier in the first position, and the UC modifier in the second position in order for the claim to process at the correct rate. (i.e. T2021 KX UC)
Note: This is a list of all HAB services. Please check your contract for the services your site can provide.
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Provider Billing Codes, cont.
*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.
*For those members with an ETP/Ad Hoc rate, you must bill with a KX modifier in the first position, and the UC modifier in the second position in order for the claim to process at the correct rate. (i.e. T2021 KX UC)
IA Medicaid HAB Service Name Time Unit/Basis
Old W Code
New HIPAA Code HIPAA Modifier* Date Span
Supported Employment: Maintain Employment/Job Coaching Per 15 Min W1431 H2025 UC Daily
Supported Employment: Maintain Employment/Enclave Per 15 Min W1433 H2023 UC Daily
Supported Employment: Job Development Per Unit W5019 T2018 UC Daily
Supported Employment: Employer Development Per Unit W5020 H2024 UC Daily
Supported Employment: Enhanced Job Search Per 15 Min W5021 H2019 UC Daily
Note: This is a list of all HAB services. Please check your contract for the services your site can provide.
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Magellan Covered Diagnosis
Code Description290 Senile and presenile organic psychotic conditions291 Alcoholic psychoses292 Drug psychoses293 Transient organic psychotic conditions294 Other organic psychotic conditions (chronic)295 Schizophrenic disorders296 Affective psychosis297 Paranoid states
298 Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology)
299 Psychoses with origin specific to childhood300 Anxiety states301 Personality disorders302 Sexual deviations and disorders306 Physiology malfunction arising from mental factors307 Special symptoms or syndromes, not elsewhere classified308 Acute reaction to stress309 Adjustment reaction311 Depressive disorder, not elsewhere classified312 Disturbance of conduct, not elsewhere classified314 Attention deficit disorder
Note: 310.00-310.99 – Mental Retardation is NOT covered.
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Place of Service (POS) Codes
Code Definition Code Definition
03 School 33 Custodial Care Facility
04 Homeless Shelter 49 Independent Clinic
11 Office 50 Federally Qualified Health Center
12 Home 53 Community Mental Health Center
13 Assisted Living Facility 54 Intermediate Care Facility
14 Group Home 57 Non-residential SA Treatment Facility
22 Outpatient Hospital 71 State or Local Health Clinic
23 Emergency Room 72 Rural Health Clinic
31 Skilled Nursing Facility 99 Other
32 Nursing Facility
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FACT: The majority of claims are processed within 24-48 hours.
• Electronic Claim Submission• Submit “Clean” Claim• Submit Within Timely Filing Guidelines• Sign Up For Electronic Funds Transfer (EFT)• Sign Up For Electronic Remittance Advice (ERA)
Claims – Expediting the Process
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Electronic Claim Submission Options
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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
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Claims/Website Contact Information
General Billing QuestionsCustomer Service 1-800-638-8820
EDI/Website Technical SupportGetting Started – visit our EDI Testing Center at
www.edi.magellanprovider.comEDI Hotline – 1-800-450-7281, ext. 75890 or email
General Website Technical AssistanceFor all other website technical assistance, call
Provider Services at 1-800-788-4005.
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Submit “Clean” Claims – Top Claim Denial Reasons
• Member Not Found – Be sure you are using the correct spelling of the member’s name and DOB that appears in eligibility. If this information does not match, it will cause the claim to reject and it will not be accepted for adjudication. If the information in eligibility is incorrect, contact IME to make a correction.
• No Authorization – Be sure you have an active authorization on file and units available to use.
• Not Eligible – Verify member eligibility each month of service. You can do this on our website at www.magellanprovider.com or via ELVS at 800-338-7752. Even if services are authorized, the member must still have active eligibility.
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Top Claim Denial Reasons, cont.
• Invalid/Non-Covered Dx Codes – Be sure the primary Dx you are billing is a covered Dx with Magellan. Be sure ALL the Dx codes you are billing are valid.
• Invalid CPT/HCPCS Codes – Confirm the code you are billing is the same code that was authorized for service. Refer to your authorization letter which can be accessed at www.magellanprovider.com.
• Invalid or Missing Modifier or Place of Service Code (POS)
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Top Claim Denial Reasons, cont.
• Missing Name and Degree of Provider – CMS 1500 only
• Site not contracted/credentialed – be sure the claim’s “rendering” site is contracted for the services you are billing for. Not all sites may be contracted for the same services. Be sure you are using the correct TIN/NPI number combination for that site.
• Duplicate Claim Submission – if you are submitting a CORRECTED CLAIM, be sure you indicate as such on the claim so that it doesn’t deny as a duplicate. When submitting a CORRECTED CLAIM, fill out the claim the way it should have been submitted.
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Submit Within Timely Filing Guidelines
• In accordance with State requirements, Magellan requires Medicaid claims to be resolved by the 365th calendar day from the date of service.
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Sign Up for EFT and ERA
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Website Resources
• www.MagellanofIowa.com
• www.MagellanProvider.com
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On-Line Resources
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On-Line Resources, cont.
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Magellan Customer Service Contact Information
Customer Service – 1-800-638-8820; Fax 1-888-656-5302
Donna Booth, Customer Service Supervisor – 1-800-638-8820, x85251Email – [email protected]
Christine Bryant, Customer Service Manager – 1-800-638-8820, x85009Email – [email protected]
Dennis Petersen, Chief Operations Officer – 1-800-638-8820, x85044Email – [email protected]
Customer Service AddressMagellan Health ServicesPO Box 71129Des Moines, IA 50325
Claims AddressMagellan Health ServicesPO Box 1869Maryland Heights, MO 63043
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Additional Contact Information
ELVS – Eligibility Verification System - 1-800-338-7752
Contracting/Rates questions, or to add an additional site – call Anne Thielking, Network Provider Relations Liaison at 1-800-638-8820 ext. 85045
How to file an appeal – Request should be made in writing and include all supporting documentation.
Email [email protected] 1-888-656-2658 or Mail to:Magellan Health ServicesAttn: Appeals, P.O. Box 71129Des Moines, IA 50325
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Q&A
Question(s) Magellan Response
I was hoping for some advice regarding recent interactions with Magellan. We have always been instructed to use full legal names for clients in our system, as per Iowa Code. We’ve had feedback from Magellan saying that for their records, they use the client’s name they receive from DHS each year when eligibility is reviewed. There have been instances where the name that Magellan has does not match the legal name in our system, therefore billing is denied. For example, our record may state “James Smith” and Magellan’s record may state “Jimmy Smith”. Apparently this is also an issue with maiden and married names. This has resulted in our billing department needing to manually resubmit billing for these clients, which is a tedious process. Any advice you can offer would be greatly appreciated.
This information is provided to us through the eligibility feeds we get regularly from the State. When you submit a claim, if the member’s name (including spelling) and DOB do not match exactly what’s in eligibility, the claim will reject. This means we cannot identify the member and the claim will not enter our system for adjudication. If the information contained in eligibility is incorrect, this must be corrected directly with IME. Usually the member’s worker can assist with this.
Regarding audits - Will Magellan be conducting their own audits of documentation pertaining to services provided and what kinds of things will they be looking for? Is a mental health statement necessary? ID SCL Hourly/Daily services specifically.
No. The reporting requirement of this QI process remains with Iowa Medicaid. For more information on these requirements, contact Provider Services at 1-800-338-7909.
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Q&A, cont.
Question(s) Magellan ResponseWill there be any electronic confirmation of when claims will be paid or have been paid? Right now I have to search the website for an EOB, or check with my bank for an ACH deposit.
If you receive paper checks from Magellan for claims payment, then an EOB or EOP would be included. However, if you are signed up for EFT, you will no longer receive these remits as indicated on the EFT form. In order to get EOB or EOP information, you would need to either view this information on the website, or you can sign up to receive Electronic Remittance Advice (ERA). This form can be found on our website. You may also contact customer service at 1-800-638-8820 for assistance.
Why is there no one to call to ask questions about claim denial or lack of response on submitted claims that have not yet appeared on an EOB? When I contact Magellan, I am referred back to the website that has no information about the submitted claim(s).
Our customer service department is here to assist you with things such as this. Our customer service associates can give you denial reasons and advise you if additional information is needed. If you are having difficulty getting this information, please ask to speak to a supervisor to further assist you.
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Q&A, cont.
Question(s) Magellan Response1) How is the timeframe determined for length of service? Sometimes it’s only approved for 3 months, and then the next time it might be 5 or 8 months. We are used to renewing annually and it becomes a tracking nightmare!2) Enhanced services do not seem to be consistent with number of hours/units for each individual. My understanding from the way we previously billed; was that individual had 26 hours (or 104 units) total. When that number had been used it was done, whether it took 6 months or a year. (the intent was that was meeting 1 hour per week for 6 months originally) The authorizations are not consistent…sometimes authorizing 104 units per month and others authorizing 104 units for 3 months, which is usually not possible.
Magellan staff members do make individual authorization decisions based on the needs of the member and overall need for the service. Some of these authorizations for exception rates have also been shorter as we try to move to a standardized rate process. As we are making adjustments in process and units, we will be moving more to a range of authorizations for high, medium and low need members. More to come out in the next 30 days.
How does your refund policy function? I have a payment from Magellan that needs to be returned but have no information on how to send it back properly.
If you have a payment that needs to be returned, call customer service at 1-800-638-8820. They will request an adjustment be done on the claim in question, and will also request that an overpayment letter be sent to you with instructions on returning the payment.
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Q&A, cont.Question(s) Magellan Response1. We had a case manager stop in last week and ask for a copy of a client’s Habilitation NOD from the Magellan website. Are case managers unable to pull a client’s NOD from the website themselves or does she just need to be shown how to do it?2. The authorization that I pull from the Magellan website does not have the approved rate on it. Am I doing something wrong or is this normal? Does the rate need to be on the NOD in case of an audit?
1. Due to privacy laws, access to our website is limited to those with granted access. Your company’s website administrator has the ability to grant access such as this to individuals within your office. If the case manager is not an employee, then they would not have access to this information and you would need to supply it as necessary.2. Magellan authorizations (NODs) do not list a rate, unless an Exception to Policy or Ad Hoc rate has been approved. If there is no rate listed on the auth form, then standard rates would apply.
Within Claims Courier on the Magellan Provider website, how do you “repay” a claim that was paid but was incomplete? And furthermore, if the previous question is possible, how do you correct that claim?
Claims Courier, through the Magellan Provider website, will only allow you to “correct” all aspects of a claim up until 3pm on the same day the claim was submitted. If you need to make any corrections after that, you may only do so to the Place of Service, Billed Amount and the Number of Units fields. Other corrections must be submitted on a hard copy corrected claim via postal mail, noting “Corrected Claim” at the top.
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