HP Provider Relations October 2011 Mental Health Industry From behind the scenes.

HP Provider Relations

October 2011

Mental Health IndustryFrom behind the scenes

2 Mental Health Industry October 2011

Agenda

– Session Objectives

– Outpatient Mental health

– Medicaid Rehabilitation Option (MRO) Transformation

– Psychiatric Residential Treatment Facilities (PRTF)

– Partial Hospitalization

– Brand Medically Necessary PA requirements

– Risk-Based Managed Care (RBMC)

– Common Denials for Mental Health

– Helpful Tools

– Questions


Objectives

At the end of this presentation, providers will understand the following:

– Outpatient coverage requirements

– Changes with MRO services

– Meaning of rolling 12-month period

– Role of the health service provider in psychology (HSPP)

– Managed care carve-in

– Services covered under:• Psychiatric Residential Treatment Facilities • Partial Hospitalization

– PA requirements for “Brand Medically Necessary” Mental Health Drugs

– How to review and resolve the most common Mental Health claim denials

UnderstandOutpatient Mental Health


Outpatient Mental Health

– The Indiana Health Coverage Programs (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


Outpatient Mental Health– The IHCP also reimburses under 405 IAC 5-20-8 for psychiatrist or HSPP-directed

outpatient mental health services for group, family, and individual outpatient psychotherapy when such services are provided by one (1) of the following practitioners:

– (A) A licensed psychologist.

– (B) A licensed independent practice school psychologist.

– (C) A licensed clinical social worker.

– (D) A licensed marital and family therapist.

– (E) A licensed mental health counselor.

– (F) A person holding a master's degree in social work, marital and family therapy, or mental health counseling, except that partial hospitalization services provided by such person shall not be reimbursed by Medicaid.

– (G) An advanced practice nurse who is a licensed, registered nurse with a master's

degree in nursing with a major in psychiatric or mental health nursing from an accredited school of 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 rendering

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 the IHCP Provider Manual Chapter 6 for prior authorization guidelines and instructions • Managed care entities (MCEs) may have different PA requirements; providers are

encouraged to contact each MCE for PA processes



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 Solutions• advantageplan.com

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

– MDwise• mdwise.org

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


Physician Covered Services

– Medical services provided by mid-level practitioners, such as clinical social workers, clinical psychologists, or any mid-level practitioners (excluding nurse practitioners and clinical nurse specialists) are not reimbursable for the following codes: • 90805

• 90807

• 90809

• 90811

• 90813

• 90815

• 90862

NOTE: These services are also not reimbursable if done by an HSPP


Physician, HSPP Covered Services

– PA is always required for neuropsychological and psychological testing• 96110 – Developmental Testing

• 96111 – Developmental Testing ExtendedAccording 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 837P or the CMS-1500 paper 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 – Master’s degree level

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



Billing overview

– Procedure codes billed with modifiers HE or HO for dually eligible Medicare/Medicaid members may utilize claim notes to indicate the provider has performed a service that is not approved to bill to Medicare• Claims submitted using claim notes must indicate in the claim notes on the 837P the

following text: “Provider not approved to bill services to Medicare”

• The use of claim notes allows the claim to suspend for review of the claim note and be adjudicated appropriately


LearnMRO Services


– 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 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 (Medicaid Rehabilitation Option)


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 for Medicaid on the date of service, the member can be billed• 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

– 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 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

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


Noncovered 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

• Physician and HSPP services provided at the PRTF



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

• Explanation of benefits (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 special handling to:

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

Edit 2017

ExplainPartial Hospitalization


Partial Hospitalization

– Partial hospital (PH) 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



– 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 five days, depending on the patient’s condition• Reauthorization criteria will be applied to stays that exceed five days

– Healthcare Common Procedure Coding System (HCPCS) code S0201, Partial Hospitalization Services, less than 24 hours, per diem, must be used• The current reimbursement rate is $219.86

– Services must be provided at least four to six hours each day for at least four days of that week

– Acute partial hospitalization is not an MRO service

– The IHCP requires that third-party insurance, including commercial carriers and Medicare, be billed prior to submission of the claim to Medicaid



Limitations and Restrictions – Prior authorization is required for S0201

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

– One unit allowed per date of service

– Inpatient and MRO services are not reimbursable on the same date as S0201

– Physician services and prescription drugs are reimbursed separately from S0201

– Service must be provided at least four days per week

DetailMental Health Drug – Prior Authorization

36 Mental Health October 2011

Prior Authorization for “Brand Medically Necessary” Mental Health Drug Prescriptions

• As of July 1, 2011, prior authorization (PA) is required for a prescriber’s specification of “brand medically necessary” for a mental health drug– Mental health drugs consist of anti-depressants, anti-psychotics, anxiolytics, and cross-indicated drugs

as defined in Indiana statute– The requirement applies to prescriptions written on or after July 1, 2011– The requirement applies to new prescriptions as well as refill prescriptions – Pharmacy claims cannot be paid without the required prior authorization

• Pharmacy benefit PA can be obtained by contacting– Affiliated Computer Services (ACS) Clinical Call Center

• 1-866-879-0106 Toll free phone number• 1-800-780-2198 FAX number

• Pharmacy Benefit PA forms are located on the Indiana Medicaid web site http://provider.indianamedicaid.com/media/29792/form%20pbm_call_center.pdf

• Pharmacy provider should follow the “emergency supply” procedures for instances in which a PA cannot be immediately obtained http://www.indianapbm.com/emergencySupply.htm

• Refer to BT201111 for specific details on BMN PA procedures http://provider.indianamedicaid.com/ihcp/Bulletins/BT201111.pdf

LearnRisk-Based Managed Care (RBMC)


Risk-Based Managed Care

– 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



– 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)



– MCEs• Anthem anthem.com

• Managed Health Services (MHS) managedhealthservices.com

• MDwise mdwise.org

– Behavioral Health Organizations (BHO)• Anthem anthem.com

• Cenpatico (MHS) cenpatico.com

• MDwise mdwise.org

DenyCommon Denials for Mental Health


Edit 5001

Exact Duplicate

– Cause• When the claim being processed is an exact duplicate of a claim(s) on the history file in

a paid status

– Resolution• Review claim(s) submitted to identify claim in paid status

Review Claims Inquiry on Web interChange

Review past-dated Remittance Advices


Edit 2502

Recipient Covered by Medicare B or D (no/attachment)

– Cause

• Recipient is covered by Medicare B; claim was submitted without Medicare EOB

– Resolution

• Submit Medicare EOB

• 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 6900

Outpatient Mental Health Services more than 20 per rolling calendar year without PA

–Cause• If more than 20 psychiatric services (90801-90815, 90846-90857, 96151-96151,

96152-96155, 96567-96567, and 99091-99091) are billed by the same provider (billing and/or rendering) for the same recipient, per rolling 12-month period

–Resolution • Obtain PA for services in excess of 20 per rolling 12-month period


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 time line

• 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 2017

Recipient Ineligible on Date(s) of Service Due to Enrollment in a Managed Care Entity

–Cause• Recipient is enrolled in an MCE

–Resolution• Check eligibility to obtain the MCE in which the member is enrolled

• Bill claim to the MCE in which the recipient is enrolled

Find HelpResources Available


Helpful Tools

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual

– MRO Provider Manual • 405 IAC 5-20 (Mental Health Services)• 405 IAC 5-21 (Community Mental Health Rehabilitation Services)• 405 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 2011 Mental Health Industry From behind the scenes.

Documents

Transcript of HP Provider Relations October 2011 Mental Health Industry From behind the scenes.