HP Provider Relations October 2010 Mental Health.

HP Provider Relations

October 2010

Mental Health

2 Mental Health October 2010

Agenda

– Session Objectives

– Outpatient Mental health

– Medicaid Rehabilitation Option (MRO) Transformation

– Psychiatric Residential Treatment Facilities (PRTF)

– Partial Hospitalization

– Package C

– Risk-based managed Care (RBMC)

– Common Denials for Mental Health

– Health Insurance Portability and Accountability Act (HIPAA) 5010

– Helpful Tools

– Questions


Objectives

At the end of this presentation providers will:

– Understand outpatient coverage requirements

– Understand the changes with MRO services

– Understand the meaning of rolling 12-month period

– Understand the role of the health service provider in psychology (HSPP)

– Understand managed care carve in

– Understand services covered under:• Psychiatric Residential Treatment Facilities

• Partial Hospitalization

• Package C

– Understand the upcoming HIPAA 5010 implementation

UnderstandOutpatient Mental Health


Outpatient Mental Health

– The Indiana Health Coverage Program (IHCP) under the direction of the Indiana Administrative Code (IAC) 405 IAC 5-20-8 reimburses for outpatient mental health services when provided by:• Licensed physicians

• Psychiatric hospitals

• Psychiatric wings of acute care hospitals

• Outpatient mental health facilities

• Licensed psychologists with the HSPP designation



– The IHCP also reimburses under 405 IAC 5-20-8 for psychiatrist or HSPP-directed outpatient mental health services when provided by mid-level practitioners:• Academy of Certified Social Workers (ACSW), certified clinical social worker (CCSW),

licensed clinical social worker (LCSW), master of social work (MSW)

• Advanced practice nurses (APN), credentialed in psychiatric or mental health nursing

• Licensed psychologist (without HSPP designation)

• Licensed independent practice school psychologist

• Licensed marriage and family therapist (LMFT)

• Licensed mental health counselor (LMHC)

• Psychologist

• Registered nurse (RN) with a master’s degree in nursing with a major in psychiatric and mental health nursing

– Mid-level practitioners are not enrolled by the IHCP


Outpatient Mental HealthPsychiatrist or HSPP responsibilities

– Must certify the diagnosis and supervise the plan of treatment as stated in 405 IAC 5-20-8 (3) (a) (b)

– Must see the patient or review information obtained by a mid-level practitioner within seven days of intake

– Must see the patient or review documentation to certify treatment plan and specific modalities at intervals not to exceed 90 days

– Must document and personally sign all reviews• No co-signatures on documentation

– Must be available for emergencies• An emergency is a sudden onset of a psychiatric condition manifesting itself by acute

symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in (1) danger to the individual, (2) danger to others, or (3) death of the individual


PA Requirements

– Prior authorization (PA) is required for units in excess of 20 per member, per rendering provider, per rolling 12-month period:• Codes below in combination are subject to 20 units per member, per provider, per rolling 12-month period: −90804 through 90815−90845 through 90857−96151 through 96153

– Requests for PA should include a current plan of treatment and progress notes to support the effectiveness of therapy

– Reference BT200901 for prior authorization instructions• Managed care organizations may have different PA requirements; providers are encouraged to contact each managed care entity (MCE) for PA processes


CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Outpatient Mental HealthWhat is a rolling 12-month period?

– A rolling 12-month period is:• Based on the first date that services are rendered by a particular provider

• Renewable one unit at a time beginning 365 days after the date that services are rendered by a particular provider

– It is not:• Based on a 12-month calendar year

• Based on a fiscal year

• Renewable on January 1 of each year


Outpatient Mental HealthPsychiatric Diagnostic Interview (90801)

– One unit of psychiatric diagnostic interview (90801) is allowed per member, per provider, per rolling 12-month period per IAC 405 IAC 5-20-8 (14)

– Additional units require PA

– Exception: Two units are allowed without PA if separate evaluations are performed by a psychiatrist or HSPP and a mid-level practitioner


Outpatient Mental Health Prior Authorization

– Mail or Fax PA requests to:

ADVANTAGE Health Solutions-FFSP.O. Box 40789 Indianapolis, IN 46240

– Fax number 1-800-689-2759

– For questions or inquiries call 1-800-269-5720

– For RBMC members, contact the appropriate MCE


Care Select Organizations – Prior Authorization

– ADVANTAGE Health Solution• www.advantageplan.com

P.O. Box 80068Indianapolis, IN 46280Phone 1-800-784-3981Fax request -1-800-689-2759

– MDwise• www.mdwise.org

P.O. Box 44214Indianapolis, IN 46244-0214Phone 1-866-440-2449Fax request 1-877-822-7186

http://www.advantageplan.com/

http://www.mdwise.org/


Physician, HSPP covered services

– Medical services provided by mid-level practitioners are not reimbursable i.e. clinical social workers, clinical psychologists, or any mid-level practitioners (excluding nurse practitioners and clinical nurse specialists) for the codes listed below

• 90805

• 90807

• 90809

• 90811

• 90813

• 90815

• 90862


Physician, HSPP covered services

– PA is always required for neuropsychological and psychological testing• 96101 – Psychological Testing

• 96110 – Developmental Testing

• 96111 – Developmental Testing Extended

• 96118 – Neuropsychological Testing Battery −According to 405 IAC 5-2-8(7), a physician or HSPP must provide these services


Noncovered Services

– Biofeedback

– Broken or missed appointments

– Day care

– Hypnosis



Billing overview

– Services are billed on the CMS-1500 claim form

– Services are billed using the National Provider Identifier (NPI) of the facility or clinic, and the rendering NPI of the supervising psychiatrist or HSPP

– Medical records must document the services and the length of time of each therapy session

– Psychiatrists and HSPPs are reimbursed at 100 percent of the allowed amount

– Mid-level practitioners are reimbursed at 75 percent of the allowed amount• Services rendered by mid-level practitioners are billed using the rendering NPI of the

HSPP



Billing Overview

– Appropriate modifiers must be used for mid-level practitioners• AH – Clinical Psychologist

• AJ – Clinical Social Worker

• HE and SA – Nurse Practitioner or Nurse Specialist

• HE – Any other mid-level practitioner as addressed in the 405 IAC 5-20-8

• HO – Masters degree level

• SA – Nurse practitioner or clinical nursing specialist (CNS) in a non-mental health arena


LearnMRO Transformation


Effective July 1, 2010

– The Office of Medicaid Policy and Planning (OMPP), in conjunction with the Division of Mental Health and Addiction (DMHA), developed a benefit plan structure for Medicaid members receiving MRO services.

– Prior to July 1, 2010 there were no prior authorization (PA) requirements and no benefit limitations imposed for members receiving MRO services during the benefit period.

– While members can continue to access MRO providers based on a self-referral, members who have a qualifying MRO diagnosis will be assigned a service package based on their individual level of need (LON).

MRO Transformation


Service Package Process


TPL Exception

– Mental health services may bypass being billed to Medicare for dually eligible members• Applies to members who have Medicare and Medicaid

• Applies to services billed with modifiers HE or HO

– Utilize the Notes feature of Web interChange (or the 837P equivalent) to indicate, “Provider not approved to bill services to Medicare”

– This TPL exception applies when Medicare does not recognize the educational level of the mid-level practitioner



Importance of Verifying Eligibility

– It is important that providers verify member eligibility on the date of service

– Viewing a Hoosier Healthwise card alone does not ensure member eligibility

– If a provider fails to verify eligibility on the date of service, the provider risks claim denial

– Claim denial could result if the member was not eligible on the date of service

– If the member is not eligible on the date of service, the member can be billed for services • If retroactive eligibility is later established, the provider must bill the IHCP and refund

any payment made to the provider by the member


MRO Inquiry


MRO Inquiry

– Providers can view past and present MRO service packages on the MRO Inquiry window

– MRO service packages are not assigned to the provider that requested the package. The services belong to the member which allows a member to seek treatment from more then one Community Mental Health Center (CMHC) at any time


MRO Denied Service Explanation

– If search results in no MRO service package, a message populates "No MRO Service Packages"

– If a member does not have an approved diagnosis, level of need (LON), or a current service package, the MRO inquiry displays the Status column with reason descriptions:• Denied: Diagnosis code does not meet the MRO program criteria

• Denied: LON does not meet the MRO program criteria

• Denied: Member has an active MRO service package

• Denied: Assessment date does not meet MRO program criteria


When to Submit a Prior Authorization

– If a member requires additional medically necessary services, a prior authorization (PA) request is required

– Please note that submitting a PA request for a full service package is not permitted

– Under the following four scenarios, an MRO service provider is required to submit a PA request to the PA vendor to be reimbursed:• Scenario 1: A member depletes units within his or her MRO service package and requires

additional units of a medically necessary MRO service.

• Scenario 2: A member requires a medically necessary MRO service not authorized in his or her MRO service package.

• Scenario 3: A member does not have one or more qualifying MRO diagnoses and/or LON for the assignment of an MRO service package, and has a significant behavioral health need that requires a medically necessary MRO service.

• Scenario 4: A member is newly eligible to the Medicaid program or had a lapse in his or her Medicaid eligibility, and was determined Medicaid eligible for a retroactive period. In this case, a retroactive PA request is appropriate for MRO services provided during the retroactive period.


Prior Authorization Prior Authorization by Telephone, Fax, or Mail

– ADVANTAGE Health SolutionsPrior Authorization DepartmentP.O. Box 40789Indianapolis, IN 46240

– Phone: 1-800-269-5720 Fax: 1-866-541-3977


PA Requests Via Web interChange

– To submit PA via Web interChange, the requesting provider must be an MD or HSPP enrolled with the IHCP as a billing or dual provider only

– A provider enrolled with the IHCP as a rendering provider does not have access to submit PA via Web interChange

– Community Mental Health Centers (CMHCs) enrolled as provider type 11 (Mental Health) and provider specialty 111 (CMHC) do not have access to submit PA requests via Web interChange


Medicaid Rehabilitation Option

– Medicaid Rehabilitation Option (MRO) services remain carved out of the risk-based managed care (RBMC) delivery system

– MRO services remain reimbursable only to providers enrolled as type 11 (mental health) with a specialty of 111 (community mental health center)

– Clinical mental health services are provided for individuals, families, or groups living in the community who need aid intermittently for emotional disturbances or mental illness

– Services must be reported with an HW modifier


MRO Covered Services

– The following services are covered:• Behavioral Health Counseling and Therapy (Individual and Group setting)• Behavioral Health Level of Need Redetermination• Case Management• Psychiatric Assessment and Intervention• Adult Intensive Rehabilitative Services (AIRS)• Child and Adolescent Intensive Resiliency Service (CAIRS)• Intensive Outpatient Treatment (IOT)• Addiction Counseling (Individual and Group setting)• Peer Recovery Services• Skills Training and Development (Individual and Group setting) • Medication Training and Support (Individual and Group setting) • Crisis Intervention

– Reminder: Do not use mid level modifiers when billing for MRO services


MRO Provider Qualifications

– Three categories of provider types can render MRO services:• Licensed Professional

• Qualified Behavioral Health Professional (QBHP)

• Other Behavioral Health Professional (OBHP)

– For a detailed list of qualified providers, please see the following resources:• MRO Provider Manual located on the www.indianamedicaid.com website under

manuals

• The Family Social Services Administration (FSSA) public Web site at https://myshare.in.gov/FSSA/ompp/MRO/default.aspx

http://www.indianamedicaid.com/

https://myshare.in.gov/FSSA/ompp/MRO/default.aspx

DescribePsychiatric Residential Treatment Facilities (PRTF)


What is a psychiatric residential treatment facility (PRTF)?

– A facility licensed as a private, secure facility under 465 IAC 2-11• Private secure facility – a locked living unit of an institution for gravely disabled children

with chronic behavior that harms themselves or others

– A facility accredited by one of the following:• The Joint Commission on Accreditation of Healthcare Organizations

• The Council on Accreditation of Services for Families and Children

Psychiatric Residential Treatment Facilities


Covered Services

– The IHCP reimburses for services provided to children younger than 21 years of age

– The IHCP requires PA for admission to a PRTF • Patient must show need for long-term treatment modalities

• See Chapter 6 of the IHCP Provider Manual for details

– Medical leave days ordered by a physician are reimbursed at 50 percent for as many as four days per admission, unless the occupancy rate is less than 90 percent

– Therapeutic leave days ordered by a physician are reimbursed at 50 percent, for as many as 14 days per calendar year, unless the occupancy rate is less than 90 percent



Psychiatric Residential Treatment Facilities Billing

– PRTF services are billed on the CMS-1500 claim form using the following procedure codes:• T2048 – Per Diem

• T2048 U1 – Medical Leave

• T2048 U2 – Therapeutic Leave

– One unit equals a 24-hour day of care (midnight to midnight)

– PRTF services are reimbursed on a per diem, which includes:• All IHCP-covered psychiatric services performed in a PRTF

• All IHCP-covered services not related to the psychiatric condition that are performed at the PRTF


Non-covered Services

– PRTF services remain carved out of RBMC• The MCE retains responsibility for services outside the PRTF including transportation, pharmacy, and other related healthcare services

– The PRTF per diem does not include:• Pharmaceutical supplies

• Non-psychiatric physician services not available at the PRTF and performed at another location



Patient Liability

– Some residents of PRTF and State hospitals are assigned a patient liability• The patient liability must be paid to the facility by the member each month

– IndianaAIM systematically deducts the patient liability during claims processing• Providers can identify the patient liability deduction on the remittance advice

• EOB 2014 Claim adjusted by the monthly Medicaid patient liability amount



Recipient ineligible on the date(s) of service due to enrollment in a managed care organization

– Providers billing psychiatric services for members residing in a PRTF that are receiving Edit 2017 are instructed to send their claims for in-house processing to:

HP Provider Written Correspondence UnitP. O. Box 7263Indianapolis, IN 46207-7263

Edit 2017


DescribePartial Hospitalization


Adult Partial Hospitalization

– Adult partial hospital programs are highly intensive, time limited medical services intended to either provide a transition from inpatient psychiatric hospitalization to community based care or, in some cases, substitute for an inpatient admission, per 405 IAC 5-20-8(4).

– Admission criteria for a PH program are essentially the same as for the inpatient level of care, with the exception that the patient does not require 24 hour nursing supervision. Patients must have the ability to reliably control themselves for safety. Patients with clear intent to seriously harm self or others are not candidates for Partial Hospitalization.

– The program is highly individualized with treatment goals that are measureable, functional, time framed, medically necessary and directly related to the reason for admission.


Adult Partial Hospitalization (continued)

– Providers must contact the health plan at the time of admission to a partial hospital program to provide notification of admission. Services will be authorized for up to 5 days, depending on the patient’s condition . Re-authorization criteria will be applied to stays that exceed 5 days

– HCPCS code S0201, Partial Hospitalization Services, less than 24 hours, per diem . The current reimbursement rate is $219.86 for four-six hours of active treatment


Adult Partial Hospitalization (continued)

– Limitations and Restrictions

Prior authorization is required for S0201

Providers will be audited to ensure they are providing an average of 6 hours per day for S0201

One unit allowed per date of service

Inpatient services are not reimbursable on the same date as S0201

Physician services and prescription drugs are reimbursed separately from S0201

Medicaid Rehab Option (MRO) services are not reimbursable on the same date as S0201

Service must be provided at least 4 days per week


Children Partial Hospitalization

– Partial hospital programs are highly intensive, time limited medical services intended to either provide a transition from inpatient psychiatric hospitalization to community based care or, in some cases, substitute for an inpatient admission per 405 IAC 5-20-8(4)

– Admission criteria for a PH program are essentially the same as for the inpatient level of care, with the exception that the patient does not require 24 hour nursing supervision. Patients must have the ability to reliably control themselves for safety. Patients with clear intent to seriously harm self or others are not candidates for Partial Hospitalization.

– The program is highly individualized with treatment goals that are measureable, functional, time framed, medically necessary and directly related to the reason for admission.


Children Partial Hospitalization (continued)

– Providers must contact the health plan at the time of admission to a partial hospital program to provide notification of admission. Services will be authorized for up to 5 days, depending on the patient’s condition Re-authorization criteria will be applied to stays that exceed 5 days

– HCPCS code S0201, Partial Hospitalization Services, less than 24 hours, per diem . The current reimbursement rate is $219.86 for four-six hours of active treatment


Children Partial Hospitalization (continued)

– Limitations and Restrictions

Prior authorization is required for S0201

Providers will be audited to ensure they are providing an average of 6 hours per day for S0201

One unit allowed per date of service

Inpatient services are not reimbursable on the same date as S0201

Physician services and prescription drugs are reimbursed separately from S0201

Medicaid Rehab Option (MRO) services are not reimbursable on the same date as S0201

Service must be provided at least 4 days per week


UnderstandPackage C - Outpatient, MRO and PRTF


Changes to Package C coverage

– Effective January 1, 2010 Package C (CHIPS) members have the same coverage for mental health, MRO and PRTF as traditional Package A members.

LearnRisk-Based Managed Care (RBMC)


Risk-Based Managed Care

– Effective January 1, 2007, outpatient mental health services were carved in to the RBMC delivery system

– Services provided to RBMC members by the following specialty types are the responsibility of the MCEs:• Freestanding Psychiatric Hospital (011)

• Outpatient Mental Health Clinic (110)

• Community Mental Health Center (111)

• Psychologist (112)

• Certified Psychologist (113)

• HSPP (114)

• Certified Clinical Social Worker (115)

• Certified Social Worker (116)

• Psychiatric Nurse (117)

• Psychiatrist (339)



– Services that are the responsibility of the MCEs:• Office visits with a mental health diagnosis

• Services ordered by a provider enrolled in a mental health specialty, but provided by a nonmental health specialty, such as a laboratory and radiology

• Mental health services provided in an acute care hospital

• Inpatient stays in an acute care hospital or freestanding psychiatric facility for treatment of substance abuse or chemical dependency



– MCEs• Anthem www.anthem.com

• Managed Health Services (MHS) www.managedhealthservices.com

• MDwise www.mdwise.org

– Behavioral Health Organizations (BHO)• Magellan (Anthem) www.magellanhealth.com

• Cenpatico (MHS) www.cenpatico.com

• MDwise www.mdwise.org

http://www.anthem.com/

http://www.managedhealthservices.com/

http://www.mdwise.org/

http://www.magellanhealth.com/

http://www.cenpatico.com/

http://www.mdwise.com/



– The MCE or BHO may have different rules for PA, timely filing limits, or claims processing

– The MCE or BHO and HP must honor PAs approved by the original IHCP entity for a period of 30 days following a change from the originating entity to the receiving entity

– Providers should verify eligibility before providing service

DenyCommon Denials for Mental Health


Edit 2503

Recipient Covered by Medicare B or D (w/attachment)

– Cause• Recipient is covered by Medicare B, claim was submitted with Medicare EOB but it

was not compatible with the information billed

– Resolution• Verify information on claim matches with Medicare EOB

• Verify claim was paid by Medicare and not denied. If so, the claim will need to be submitted as a Medicaid primary with a copy of the Medicare EOB to show the denial.


Edit 5000

Possible Duplicate

– Cause• There is a claim in history that was billed on the same date of service and matches

procedure, group and/or rendering provider

– Resolution• Verify if the claim was paid on a previous billing cycle

• Be sure to use appropriate modifiers for all rendering providers and mid-level providers for services rendered


Edit 0512

Claim Past Filing Limit

– Cause• Claim was billed more than 365 days after the date of service

– Resolution• Provider will need to submit proof of filing with each claim submission to show claim

was originally filed within the filing timeline.

• For a detailed listing of approved filing documentation please refer to the IHCP Provider Manual, Chapter 10, Section 5 under Past the Filing Limit Documentation.


Edit 2504

Recipient Covered by Private Insurance

– Cause• No primary payer information identified on the claim

– Resolution• Verify TPL payment and indicate the paid amount on claim in the appropriate field:

− CMS-1500 field 29

− UB-04 field 50B-54B

• If zero is paid by the TPL carrier or the TPL carrier denies the claim, be sure to include the primary EOB


Edit 2017

Recipient Ineligible on Date(s) of Service due to Enrollment in a Manage Care Organization

–Cause• Recipient is enrolled in an (MCE)

–Resolution• Provider must bill claim to the MCE in which the recipient is enrolled.


Edit 0346

Payer Prior Payment is Missing

– Cause• A payer code appears on the first payer line but no primary payment amount is listed

on the claim

– Resolution• Complete payer field with corresponding amount listed on the EOB

PlanHIPAA 5010


HIPAA 5010

– The mandatory compliance date for American National Standards Institute (ANSI) version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012

– If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delays in payment

– The IHCP and HP will test transactions on a schedule

– Specific transaction testing dates will be provided in the future


HIPAA 5010 Transactions affected by this upgrade

• Institutional claims (837I)

• Dental claims (837D)

• Medical claims (837P)

• Pharmacy claims (NCPDP)

• Eligibility verifications (270/271)

• Claim status inquiries (276/277)

• Electronic remittance advices (835)

• Prior authorizations (278)

• Managed care enrollments (834)

• Capitation payments (820)


Testing Information

– All trading partners currently approved to submit 4010A1 and NCPDP 5.1 version transactions will be required to be approved for 5010 and D.0 transaction compliance • All software products used to submit 4010 and NCPDP 5.1 versions must be tested

and approved for 5010 and D.0.

– Testing will begin January 2011 and include:• Clearinghouses, billing services, software vendors, individual providers, and provider

groups

– Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test

– Each trading partner will be required to submit a new Trading Partner Agreement


What You Need To Do

– If you bill IHCP directly• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions

– If you are using a billing service or clearinghouse• Find out if they are preparing for the HIPAA upgrades to ANSI 5010 and NCPDP D.0

• IHCP Companion Guides will be available during the fourth quarter of 2010

– Questions should be directed to the EDI Solutions Service Desk• By email at [email protected]

• By phone at 1-877-877-5182 or (317) 488-5160

– Watch for additional information on the testing process, revised IHCP Companion Guides, and the schedule for transaction testing on this mandated initiative in bulletins, banner pages, and newsletters at www.indianamedicaid.com

mailto:[email protected]



Helpful Tools

– IHCP Web site at www.indianamedicaid.com

– IHCP Provider Manual

– MRO Provider Manual o405 IAC 5-20 (Mental Health Services)o405 IAC 5-21 (Community Mental Health Rehabilitation Services)o405 IAC 5-21.5 (Medicaid Rehabilitation Option Services)

– Customer Assistance• 1-800-577-1278 toll-free• (317) 655-3240 in the Indianapolis local area

– HP Written Correspondence at the following address:HP Written Correspondence

P.O. Box 7263Indianapolis, IN 46207-7263

– Provider Relations Field Consultants


HP Provider Relations October 2010 Mental Health.

Documents

Transcript of HP Provider Relations October 2010 Mental Health.