Health Home Billing Guide

Transcription

1 Health Home Billing Guide A nonprofit independent licensee of the Blue Cross Blue Shield Association

2 Excellus BlueCross BlueShield Billing Guide for Health Homes All Health Home services with service dates on or after July 1, 2018, must be billed through Excellus BlueCross BlueShield ( Excellus BCBS ). This guide will assist your organization with billing and submitting claims to the Excellus BCBS. In the event of a conflict between the provisions of this guide and the Lead Health Home Services Agreement ( Agreement ), the Agreement supersedes this guide. In the event of a conflict between the provisions of this guide and all applicable New York State Department of Health ( NYSDOH ) policy guidance, NYSDOH policy guidance supersedes this billing guidance. Please contact your Behavioral Health Provider Relations representative if you have any questions regarding this guidance. Click here to access our contact list, or visit ExcellusBCBS.com/Provider and select the Contact Us tab. Electronic Submission of Claims Required The NYSDOH Medicaid Managed Care Plan Billing and Payment Protocol for Health Home Service requires Health Homes to submit claims to MMCP using electronic formats. Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), Public Law , institutional providers who submit claims electronically are required to use the HIPAA 837 Institutional (837i) transaction. This is the preferred method of claims transmission by most Medicaid Managed Care Plans and is strongly encouraged for all Medicaid Health Home claims transmission. The UB-04 may be used when applicable and in accordance with plan-specific guidance. See paragraphs under heading How to Submit Electronic Claims for more information about submitting claims electronically. General Requirements for Claims Submissions Claims must be completed accurately and in full, in accordance with the instructions presented in this guide. Excellus BCBS cannot pay claims that are inaccurate or incomplete. Claims should be submitted following NYSDOH guidelines using the codes identified in Appendix A, which is included at the end of this guide. All required supporting material must be made available to Excellus BCBS upon request. Claims submitted to all payors must include an NPI to identify each Health Home for which data is reported on the claim. Excellus BCBS cannot accept any claims that do not include an NPI and Tax ID. Taxonomy codes are required on all claim submissions. Claims submitted without taxonomy codes will be returned. You may have multiple taxonomy codes, but June

3 Health Home Billing Guide Excellus BlueCross BlueShield to ensure that your claim is successfully processed, it is imperative that you use the following taxonomy code for health home services billing: 251B00000X. For the ANSI 837 electronic claim, care management agency (CMA) information should be indicated in loop 2310D and the CMA s NPI should be included in loop 2310D, segment NM1.09. Timely and Accurate Filing Excellus BCBS requires that Health Homes submit claims in a timely manner. Medicaid regulations require that claims for payment of Health Home services to eligible beneficiaries be initially submitted within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the Health Home. All such claims submitted after 90 days must be submitted within 30 days from the time submission came within the control of the Health Home. Claims submitted after that time limit may be denied for late filing. In the event of a declared pandemic, Excellus BCBS may extend the time limit to one year from the date of service. Excellus BCBS will reject claims with incorrect or incomplete entries in required fields outlined in later paragraphs regarding submittal of electronic claims and paper claims. For example, Excellus BCBS will reject all claims submitted without proper member identification information. You may access the Request for Timely Filing Review form on our website, ExcellusBCBS.com/Provider. Select Print Forms from the Quick Links menu, and refer to the Billing and Remittance section. Accurate and Complete ICD-CM Diagnosis & ICD-PCS Procedure Coding To ensure that claims process appropriately, it is important that all claim submissions contain accurate and complete ICD-CM diagnosis and ICD-PCS procedure codes. If a specific diagnosis code is unavailable for the service rendered, please use diagnosis Z71.89 for outreach services and Z76.89 for enrollment services, per instructions from the NYSDOH. Using Modifiers Please refer to Appendix A, which is included at the end of this guide. How to Submit Electronic Claims Excellus BCBS accepts claims from Health Home who choose to use a clearinghouse or other third party, as well as Health Homes who choose to submit claims to us directly. Please review the sample 837i information at the end of this billing guidance. For information about how to submit electronic claims, including information about HIPAA claims formats and standards, contact us via at EDI.Solutions@excellus.com. 2 June 2018

4 Excellus BlueCross BlueShield Health Home Billing Guide Filing Tips To support accurate and prompt claims processing, Health Homes must use the correct Payor Identification Number (Payor ID), which is 00302, when submitting claims electronically. All required fields must be populated. If any required field has no entry, the clearinghouse will reject the claim. Use valid codes in fields such as those defining relationship, gender and place of service. If the code entered does not match the type of service being billed, the claim may pend and require manual intervention to be processed. Claims submitted to all payors must include an NPI and taxonomy code (251B00000X), with the proper qualifier to identify each Health Home and/or Health Home services provider for which data is reported on the claim. Response Reports Following submission of electronic claims, the Health Home will receive three reports: 1. Clearinghouse Acknowledgment (999) Report. This report indicates whether the transmission was accepted, rejected or accepted with errors. A claim accepted on the 999 report will move on to the next step. 2. Clearinghouse Response (277CA) Report. This report provides you with claims accepted for processing from the 999 report. Each claim, accepted or rejected, is issued a clearinghouse claim identification (ID) number. 3. Payor Response Report. This report is available within 24 hours after submission and will list accepted and rejected claims. Once the claim enters our payor system, it is renumbered with a new claim ID number, and this ID number is what will be returned on the 835. Health Homes must review these reports, identify those claims that were rejected and correct the errors and resubmit the claims, if appropriate. A Health Home should not consider that the clearinghouse has accepted an electronic claim until it has received all three reports, and the Payor Response Report shows that the claim was accepted. Health Homes are encouraged to keep copies of these reports to help verify claims submission. Paper Claim Submissions In limited circumstances, submission of papers claims will be accepted on Form UB-04, in accordance with plan-specific guidance. Health Homes that submit on paper must do so according to the general requirements listed below under the heading General Paper Claim Requirements. June

5 Health Home Billing Guide Excellus BlueCross BlueShield As stated in those requirements, claims submitted to all payors must include an NPI and taxonomy to identify each Health Home and/or Health Home services provider for which data is reported on the claim. Paper Claim Requirements Paper claims are subject to the same edits as electronic claims. Excellus BCBS uses Optical Character Recognition (OCR) technology to read most paper claims. Please review the following points to ensure that a paper claim is processed using OCR rather than manually. Following these guidelines helps ensure timely processing. Use original forms that are printed in red. Do not use photocopies. Do not use red ink to fill in data field or attachment information. OCR equipment does not recognize red ink. Entries should be typed and dark enough to be legible. Change the toner cartridge in your printer regularly. So that information prints in the appropriate field, forms should be properly aligned prior to printing. When submitting multi-page paper claims, submitters must ensure that identifying information for both the health home services provider and patient (Health Home ID, NPI, taxonomy code preceded by B3, patient account number, etc.) is reproduced and consistent on all pages. Use these guidelines when including attachments, such as medical records or primary payor information. Submit paper claims to Attn: Claims, P.O. Box 21146, Eagan, MN Retrospective Claim Review The purpose of the claim review is to analyze whether a claim reflects services rendered, and to verify that the services rendered are billed in accordance to the DOH Outreach guidelines for each service billed, Medicaid Managed Care and/or HARP benefits and terms of the Agreement. This review includes: Reviewing supporting documentation to determine face to face contact for the second billed month Reviewing coding/pricing as appropriate Review of Care Manager notes Review of the Medicaid Analytics Performance Portal Health Home Tracking System (MAPP-HHTS) monthly attestation of core service provisions Inquiries about Claim Status Health Homes may contact Customer Care at to inquire about the status of a claim. When you contact Customer Care, you will need to provide your NPI as well as the member s subscriber identification number and date of service. 4 June 2018

6 Excellus BlueCross BlueShield Health Home Billing Guide You may also register for secure access to our website to check claim status at your convenience, 24 hours a day, seven days a week. Visit ExcellusBCBS.com/Provider and select the Login or Register button to get started. Remittance Advice A Health Home that submits claims for Excellus BCBS Medicaid Managed Care or HARP benefits plan receives a remittance advice that summarizes all claims processed since the last payment was made to the submitter. Paper remittances may come in multiple envelopes. This occurs when a remittance exceeds the number of pages that Excellus BCBS s remittance processing system is able to mail in a single envelope. When Additional Information is Required For some claims, Excellus BCBS may need additional information before it can make a determination to cover or deny the service. These claims will be so marked on the remittance with a message asking submitter to provide additional information. A Health Home has 45 days from the date printed on the remittance to submit supporting documentation related to the service in question. Understanding the Remittance The remittance includes details about each claim, as well as: Explanation Codes. Providing the reasons why a specific claim has not been paid. Reasons for non-payment include denials and the need for more information. Explanation codes associated with a specific claim are on the claim line; descriptions of what the codes mean are presented at the end of the remittance. Adjustments. All adjustments made to previously submitted claims are listed at the end of the remittance. Recoupments. All recoupments related to a remittance check will appear in the adjustment section, and the total dollars recovered will be shown. Procedure and Revenue Codes. All codes will appear in the field labeled SERVICE. If both a procedure and revenue code was submitted for a claim, the SERVICE field will display the procedure code first, followed by the revenue code. Electronic Remittance Advice and Electronic Funds Transfer We are pleased to offer InstaMed for Electronic Payments (EFTs), Remittance Advice (ERA) and more, as a free service to our Health Homes. Visit instamed.com/eraeft and complete the online registration process. June

7 Health Home Billing Guide Excellus BlueCross BlueShield Benefits of InstaMed: Possible reduction in accounting expenses - By importing electronic remittance advice from the Web directly into practice management or patient accounting systems, the need for manual re-keying is reduced or eliminated. Improvement in cash flow - Electronic payments can mean faster payments, resulting in improved cash flow. Paper checks will be discontinued upon enrollment. Control of bank accounts - Maintain total control of the destination of claim payment funds; multiple practices and accounts are supported. Prompt match of payments to remittance advice - Immediately associate electronic payments with electronic remittance advice. View remittance advice online and print it at your convenience. Increase in reporting functionality - Ability to create functional reports that support your internal needs. Easier management of multiple payors- Reuse enrollment information to connect with multiple payors. Assign different payors to different bank accounts, as desired. Reduction of paper usage - Paper checks will be discontinued by the next pay cycle after enrollment. Paper remittances will be discontinued four weeks after enrollment with electronic funds transfer. Requesting a Change in Claim Payment There are a number of circumstances after a claim has been processed that may require Excellus BCBS to take another look. These include incorrect payments or denials, or services billed incorrectly or in error. Adjustments Excellus BCBS has a claims adjustment process that providers may initiate after the claim has been processed. Please note that claims returned to the submitter because they were inaccurate or incomplete have not been processed and consequently cannot be adjusted. This includes electronically submitted claims that don t pass edits at the clearinghouse or payor system. In addition, Excellus BCBS cannot adjust a claim when the dollar amounts change due to the Health Home s corrections, such as adding a service line or a modifier. A corrected claim must be submitted. 6 June 2018

8 Excellus BlueCross BlueShield Health Home Billing Guide Excellus BCBS will make adjustments when a claim is paid incorrectly due to Excellus BCBS error, but only if the original claim was clean. If Excellus BCBS mistakenly underpays a Health Home for a claim, Excellus BCBS will make an adjustment on a subsequent remittance. If Excellus BCBS mistakenly overpays a claim to a Health Home, Excellus BCBS will make an adjustment and deduct that amount from future payments. Review of a claim does not guarantee a change in payment disposition. Note: Health Homes may also return overpayments to Excellus BCBS. See the paragraph below titled Overpayments. Adjustments may be requested via: Website. Health Homes who are registered users of Excellus BCBS s website may request an adjustment electronically via an interactive form available on the website. Health Homes may also submit related additional information, such as medical records, electronically. To access go to ExcellusBCBS.com/ProviderCodingBilling > Request an Adjustment. Paper Request for Research/Claim Adjustment form. This form is available on the Excellus BCBS website or from Customer Care. To access via the website, go to ExcellusBCBS.com/ProviderCodingBilling > Request an Adjustment > Request a Claim Adjustment by Mail or Fax. Attach a copy of the remittance advice that included the claim, a copy of the original claim form, and other relevant supporting documentation. If a claim denied for timely filing, the Health Home should submit the Request for Timely Filing Review form with supporting documentation. A timely filing denial may be overturned if one of the situations listed on the Request for Timely Filing Review form applies, and the Health Home has sufficient supporting documentation for the situation. Please note: The Request for Research/Claim Adjustment form is not appropriate for questioning timely filing denials. Customer Care. Representatives may be able to take information over the phone, in limited amounts, to initiate an adjustment. If documentation is required, the Health Home may be advised to use the Request for Research/Claim Adjustment form. Overpayments Reminder In accordance with the Agreement, Health Homes will promptly: (i) notify Excellus BCBS of, and return to Excellus BCBS, any overpayment of which Excellus BCBS notifies the Health Home, or of which the Health Home becomes aware, regardless of the reason for such overpayment, and (ii) subject to the requirements set forth in New York State Insurance June

9 Health Home Billing Guide Excellus BlueCross BlueShield Law 3224-b(b), the Health Home acknowledges that Excellus BCBS may recover any overpayment made to the Health Home by offsetting it against future payments due to Health Home, with notice prior to recovery. Excellus BCBS has a process for receiving returned overpayments in lieu of an adjustment on a subsequent claim. In order to credit the returned payment properly, Excellus BCBS requires the claim number, member identification information and the date of service. Health Homes may supply this information separately or by including a copy of the applicable remittance. Overpayments must be mailed directly to the Credit and Collections Department at Excellus BlueCross BlueShield, Attn: Credit and Collection, 333 Butternut Drive, Syracuse, NY The process and address are also available on the website, as well as from Customer Care. To access online go to ExcellusBCBS.com/ProviderPrintForms> Overpayment Return Form. As a reminder, if Excellus BCBS mistakenly overpays a claim to a Health Home, it will make an adjustment and deduct that amount from future payments. If the Health Home disagrees with Excellus BCBS's decision regarding the adjustment, the Health Home should contact its regional Customer Care department. False Claims Act Reminder Excellus BCBS expects participating Health Homes to understand the state and federal requirements regarding false claims recovery. Health Homes participating with Medicaid Managed Care are obligated to report and return overpayments to Excellus BCBS within 60 days of the time when the overpayments are identified. Information about our policies on false claims and overpayment procedures is available on our website. Claim Form Completion Health Home services are billed on a biweekly or monthly basis. In order to be reimbursed for a billable unit of service, Health Homes must, at a minimum, provide one of the core Health Home services in a given month. The monthly payment will be paid via the outreach and active care management services. Once an Excellus BCBS member has been assigned a care manager and is enrolled in the Health Home program, the active care management services may be billed. Health Home should submit one service per claim using the first of the month as the date of service, regardless of when the service was provided during the month. As an example, for a member enrolled in a Health Home on June 14, 2018; the corresponding claim would have a date of service of June 1. 8 June 2018

10 Excellus BlueCross BlueShield Health Home Billing Guide Claim Form Completion Tools The following field descriptions will assist you in completing the Form UB-04. UB-04 Field Descriptions See notes at the end of this chart. Field Name Entry 1 Unlabeled 4 lines for Provider Name, Address, Telephone, Fax, Country Code (only if address/phone outside the U.S.) 2 Unlabeled 4 lines for Pay-to Name, Address, etc. 3a PAT CTL # Patient Control Number assigned to patient by provider 3b MED REC # 4 TYPE OF BILL 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD (From/Through) 7 Unlabeled (2 lines) 2 lines not used 8a PATIENT NAME - ID 8b PATIENT NAME Enter name of patient 9 PATIENT ADDRESS Medical record number assigned to patient s medical record by provider 4-digit code that identifies type of facility, bill classification (variations for hospital, clinic or special facilities), and frequency (indicates sequence of bill in particular episode of care). Bill 034 plus frequency code Tax identification number (TIN) or employer identification number (EIN) Enter beginning and ending dates of the period included on the claim Patient ID number (depending on primary, secondary, tertiary in field 60) 10 BIRTHDATE Enter patient s date of birth 11 SEX Enter F or M Lines a through e for street and number or box number, city, state, zip code and country code (if address outside the U.S.) 12 ADMISSION DATE Date of admission or commencement of services 13 ADMISSION HOUR Time of day of admission or commencement of services 14 ADMISSION TYPE Appropriate code for emergency, urgent, elective, newborn, etc. 15 ADMISSION SRC Source of admission code June

11 Health Home Billing Guide Excellus BlueCross BlueShield UB-04 Field Descriptions See notes at the end of this chart. Field Name Entry 16 DHR Discharge hour 17 STAT Patient discharge status code CONDITION CODES Relate to type or lack of coverage 29 ACDT STATE Accident state 30 Unlabeled (2 lines) Not used 2 lines OCCURRENCE CODE and DATE OCCURRENCE CODE and SPAN (FROM/ THROUGH) 37 Unlabeled Unused lines a and b 38 Unlabeled VALUE CODES and AMOUNTS (lines a through d) Enter applicable occurrence code(s) and associated date in lines a and b Enter applicable occurrence code(s) and associated date span in lines a and b 5 lines for responsible party/subscriber name and address Lines a through d. Value codes and amounts, including those for covered days (80), non-covered days (81), coinsurance days (82) or lifetime reserve days (83) should be placed here. 42 REV CODE Revenue code for each service billed 22 lines 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE Revenue code description for each service billed 22 lines HCPCS or HIPPS code corresponding to each service billed 22 lines 45a SERV. DATE Service date of each service billed 22 lines 45b CREATION DATE Date claim form is completed 46 SERV. UNITS Service units corresponding to each service billed 22 lines 47 TOTAL CHARGES Total charges for each service billed 22 lines 48 NON-COVERED CHARGES Non-covered charges for each service billed 22 lines 49 Unlabeled 22 lines not used TOTALS 50 PAYOR NAME Total amount of charges and total amount of noncovered charges 3 lines, one each for primary, secondary and tertiary payors. 10 June 2018

12 Excellus BlueCross BlueShield Health Home Billing Guide UB-04 Field Descriptions See notes at the end of this chart. Field Name Entry 51 HEALTH PLAN ID This spot reserved for the national health plan identifier when one is established. 3 lines, one each for primary, secondary and tertiary payors. Health Plan ID for Excellus BCBS is REL INFO 53 ASG BEN 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI NPI for billing provider. 57 OTHER PRV ID 58 INSURED S NAME 59 P REL 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. 63 TREATMENT AUTHORIZATION CODES Release of information certification indicator (Y or I). 3 lines, one each for primary, secondary and tertiary payors. Assignment of benefits certification indicator. 3 lines, one each for primary, secondary and tertiary payors. Payments from other payors or patient. 3 lines, one each for primary, secondary and tertiary payors. Estimated amount due from patient. 3 lines, one each for primary, secondary and tertiary payors. Other provider identifier (non-npi assigned by Excellus BCBS). 3 lines, one each for primary, secondary and tertiary payors. Do NOT include non-npi provider number after May 22, Name of holder of the insurance contract. 3 lines, one each for primary, secondary and tertiary payors. Patient s relationship to insured. 3 lines, one each for primary, secondary and tertiary payors. Insured s insurance identification number. 3 lines, one each for primary, secondary and tertiary payors. Insured s group name. 3 lines, one each for primary, secondary and tertiary payors. Insured s group number(s), if available. 3 lines, one each for primary, secondary and tertiary payors. Excellus BCBS authorization number. 3 lines, one each for primary, secondary and tertiary payors. 64 DOCUMENT CONTROL NUMBER Area for Excellus BCBS to assign claim number 65 EMPLOYER NAME Insured s employer name. 3 lines, one each for primary, secondary and tertiary payors. June

13 Health Home Billing Guide Excellus BlueCross BlueShield UB-04 Field Descriptions See notes at the end of this chart. Field Name Entry 66 DX 67 Label is 67 Qualifier code reflecting ICD revision. Enter the number 0 to indicate ICD-10 or 9 to indicate ICD-9. Enter principal diagnosis code. Include all digits (4-5) where applicable. 67 A through Q Other diagnosis codes. Include all digits (4-5) where applicable. 68 Unlabeled 2 lines not used 69 ADMIT DX Admitting diagnosis code (if inpatient claim) 70 PATIENT REASON DX Patient s reason for visit (diagnosis) code(s) (3 blocks) 71 PPS CODE Prospective Payment System code 72 ECI External cause of injury code(s) (3 blocks) 73 Unlabeled Input DRG code here. 74 PRINCIPAL PROCEDURE CODE and DATE Enter principal procedure code and date of procedure (see current ICD-PCS codes beginning with the 10 th Revision) 74a-e OTHER PROCEDURE CODE and DATE As applicable, enter other procedure codes and dates 75 Unlabeled 4 lines - not used ATTENDING NPI, QUAL, LAST, FIRST OPERATING NPI, QUAL, LAST, FIRST 5 boxes. Enter NPI of attending provider and last and first names of attending provider. Use for Care Management Agency (CMA) information. 5 boxes. Enter NPI of operating provider and last and first names of operating provider 78 OTHER NPI, QUAL, LAST, FIRST 5 boxes. Enter NPI of other provider and last and first names of other provider. 79 OTHER NPI, QUAL, LAST, FIRST Same as above 80 REMARKS 4 lines for notation that doesn t go elsewhere 81 CC Code-Code (lines a through d, 3 boxes each) 81a Taxonomy code qualifier and taxonomy code(s) In first box, enter qualifier code B3 for field 56 billing provider taxonomy code. In second (and third, if applicable) boxes, enter taxonomy code(s) for the field 56 billing provider. 81b Other code qualifier and other code As needed 12 June 2018

14 Excellus BlueCross BlueShield Health Home Billing Guide UB-04 Field Descriptions See notes at the end of this chart. Field Name Entry 81c Other code qualifier and other code As needed 81d Other code qualifier and other code As needed Note: Excellus BCBS requires information in certain other fields before it can adjudicate the claim. These fields may vary with the type of service being billed. Completion of all fields does not guarantee payment. June

15 APPENDIX A Health Homes must submit claims to Excellus BCBS in an electronic format using the HIPAA 837 Institutional transaction claim form in accordance with the HCPCS codes and modifiers set forth below. Health Homes and their billing vendors must use the appropriate rate codes when direct billing. All Medicaid Managed Care Plan billing instances must contain the applicable procedure code and modifier where applicable. Health Homes are required to validate that all claims meet the requirements for the rate billed and supported by the MAPP-HHTS Billing Support Download. (Continued on the next page)

16 The chart below includes the proper rate code, revenue codes and modifiers to be implemented and used by Health Homes with respect to billing for health home services under the Agreement. Rate Code 1862 Rate Code Description Category of Service Provider Specialty Code Health Home Outreach (Adult) Health Home Outreach (Children) Health Home Services Children (Low) Health Home Services - Children (Medium) Health Home Services - Children (High) Rates Apply to Revenue Code Procedure Code Health Homes Serving Adults 0500 G9001 Health Homes Serving Children 0500 G9001 Health Homes Serving Children 0500 T2022 Health Homes Serving Children 0500 T2022 Health Homes Serving Children 0500 T2022 Procedure Code Description Coordinated care fee, initial rate Coordinated care fee, initial rate Case management, per month Case management, per month Case management, per month Modifier U1 U1 U2 U Health Home Services - Children (Low) (Inc FFP) Health Homes Serving Children 0500 T2022 Case management, per month U Health Home Services - Children (Med) (Inc FFP) Health Homes Serving Children 0500 T2022 Case management, per month U Health Home Services - Children (High) (Inc FFP) Health Homes Serving Children 0500 T2022 Case management, per month U Health Home-CANS Assessment (Children) Health Home Plus/Care Management Health Homes Serving Children Health Homes Serving Adults Health Home Services - Adult Home Transition ** HHs Serving Adult Home Class Adult Home Assessment and Management Fee*** Direct HH billing through emedny Health Home Care Management Health Home Serving Adults 0500 G G G G9005 Comprehensive assessment, care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service) Coordinated care fee, risk adjusted maintenance Case Managemt, per month Case Management, per month U4 U3 U Health Home High Risk/Need Care Management Health Home Serving Adults 0500 G9005 Case Management, per month U2

17 Health Homes Serving Adults Health Home Care Management (1873/G9005-U1) This risk adjusted category must be billed at this rate if the clinical and functional assessment yield a medium or low risk and do not meet: HARP/ HIVSNP (HARP Eligible),or Adult Home Plus criteria, or Health Home Plus criteria Health Home High Risk/Need Care Management (1874/ G9005-U2) This risk adjusted category will include all HARP and HIV/SNP (HARP eligible) Plan enrolled members. These members can be identified by the following restriction exemption codes: H1 H2, H3, H4, H5, or H6. In addition, any member who scores High on the clinical and functional assessment can bill at this rate. Adult Home Plus (1860/G9005-U3) (This code is designated for NYC not to be billed to BCBS) This risk adjusted category is applicable only to the five boroughs of NYC and is guided by separate guidance. Health Homes are responsible for attesting and verifying that the Care Management Agency is approved to serve this population. This subset of Health Home population represents a group of members transitioning from Adult Homes to the community. Health Homes are required to produce documentation to Medicaid Managed Care Plans as requested for the purposes of billing audits. Care Management agencies must indicate that the member meets the Adult Home Plus rate category when completing the MAPP-HHTS clinical and functional assessment Health Home Plus (1853/G9005-U4) This risk adjusted category is guided by separate guidance distributed in partnership with the Office of Mental Health and the AIDS Institute. This category serves the highest risk members who meet the single qualifying conditions of Severe Mental Illness (SMI) and HIV/AIDS. Meeting the single qualifying condition criteria alone, however, is not enough to bill at this rate. Members who meet criteria for Health Home Plus must also meet additional clinical criteria. In addition, Health Homes must attest that the Care Management agency employs staff that have the credentials and meet the supervisory qualifications to serve this population. This attestation also requires that Health Homes are verifying that care managers are meeting a minimum of two (2) face-to-face contacts per member per month*. Care Management agencies must indicate that the member meets the Health Home Plus rate category when completing the MAPP-HHTS clinical and functional assessment. If the care manager has met the minimum contact requirements this will be documented in the MAPP-HHTS by attesting to a core service and indicating that the member meets HH + criteria. *Health Home Plus guiding members with an Assisted Outpatient Treatment (AOT) order must meet the requirement of four (4) face-to-face contacts to bill at this rate.

18 SAMPLE 837i segment segment description notes example ISA Interchange Control Header ISA.06 IS A VALUE ASSIGNED BY EXCELLUS BCBS AND WILL BE GIVEN N/A TO YOU UPON SETUP TO SUBMIT ELECTRONICALLY. IF YOU WILL BE SUBMITTING VIA A THIRD PARTY CLEARINGHOUSE, PLEASE CONTACT THEM FOR THE APPROPRIATE VALUE. ISA.08=00304 GS Functional Group Header GS.02 IS A VALUE ASSIGNED BY EXCELLUS BCBS AND WILL BE GIVEN N/A TO YOU UPON SETUP TO SUBMIT ELECTRONICALLY. IF YOU WILL BE SUBMITTING VIA A THIRD PARTY CLEARINGHOUSE, PLEASE CONTACT THEM FOR THE APPROPRIATE VALUE. GS.03=00304 ST Transaction Set Header submit a single transaction set per file (containing claims for multiple HHs and/or multiple payers when allowed by the recipient) ST*837*0123*005010X223A2~ BHT Beginning of Hierarchical Transaction BHT*0019*00*123* * Loop 1000A - Submitter Name NM1 Submitter Name NM1*41*2*PROVIDER PER Submitter EDI Contact Information PER*IC*EMILY Loop 1000B - Receiver Name NM1 Receiver Name identify the file recipient (e.g. clearinghouse) here 46*00304~ EXCELLUSBCBS=00304 Loop 2000A - Billing Provider Hierarchical Level HL Billing Provider Hierarchical Level HL*1**20*1~ PRV Billing Provider Specialty Information HH taxonomy code (always 251B00000X) PRV*BI*PXC*251B00000X~ Loop 2010AA - Billing Provider Name NM1 Billing Provider Name HH name and NPI Home*****XX* ~ N3 Billing Provider Address HH address Homes*Floor 4~ N4 Billing Provider City, State, ZIP Code HH city, state, zip N4*New York*NY* ~ REF*EI Billing Provider Tax Identification HH tax id (without hyphen) REF*EI* ~ Loop 2000B - Subscriber Hierarchical Level HL Subscriber Hierarchical Level HL*2*1*22*0~ SBR Subscriber Information BL for claim filing indicator code BL Loop 2010BA - Subscriber Name NM1 Subscriber Name patient name and Medicaid id NAME & CIN N3 Subscriber Address patient address N3*987 Dinosaur St.*Apt. #6F~ N4 Subscriber City, State, ZIP Code patient city, state, zip N4*Brooklyn*NY*11217~ DMG Subscriber Demographic Information patient DOB and gender DMG*D8* *M~ Loop 2010BB - Payer Name NM1 Payer Name payer name and payer ID (payer ID is usually 5 digits) EXCELLUS BCBS=00302 Payer*****PI*00302~ N3 Payer Address payer address OR blank (usually blank) N3*12 Payer Way*Floor 34~ optional N4 Payer City, State, ZIP Code payer city, state, zip OR blank (usually blank) N4*Albany*NY*10024~ optional Loop Claim Information CLM Claim Information our internal claim id, charge amount, bill type (always 34) (1 original; 7 correction; 8 void) DTP*434 Statement Dates DOS-DOS (e.g ) DTP*434*RD8* ~ DTP*435 Admission Date Use DOS for admission/start date DTP*435*D8* ~ CL1 Institutional Claim Code X12 transaction segment type that applies to claim CL1.01=9 CL1.02=9,CL1.03=01 REF*EA Medical Record Number our internal patient id vendors for internal tracking HI*ABK Principal Diagnosis Z outreach ; Z76.89 enrollment or valid dx code on BSD HI*ABK:R69~ HI*APR Patient's Reason For Visit Z outreach ; Z76.89 enrollment or valid dx code on BSD HI*APR:R69~ HI*BE Value Information rate code HI*BE:24:::1873~ Loop 2310A - Attending Provider Name NM1 Attending Provider Name "UNKNOWN" for the attending provider name NM1*71*1*UNKNOWN~ REF*G2 Attending Provider Secondary Identification NYS DOH HH unlicensed practitioner ID ( to be issued at later date ) Loop Service Line Number LX Service Line Number LX*1~ REF*G2* ~ SV2 Institutional Service Line revenue code, procedure code, modifier, charge amount SV2*0500*HC:G9005:U1*213*UN*1~ DTP*472 Date - Service Date DOS DTP*472*D8* ~ REF*6R Line Item Control Number vendors SE Transaction Set Trailer SE*35*0123~ GE Functional Group Trailer GE*1*123~ IEA Interchange Control Trailer IEA*1* ~

19 Save Time, Check Online Online resources are fast, easy to use and convenient self-service at your fingertips! We know how busy your work day can be. That s why we remind you about time-saving tools available via our website, ExcellusBCBS.com/Provider. Before placing a call to Customer Care, check to see if the information you need is online! Coverage & Claims View benefits, coverage & check claims Look up members of other Blue Plans (BlueCard ) Submit member adjustment requests View remittances Referrals & Auths Access Clear Coverage Request authorization Check authorization status Enter an emergency admission Attach clinical review requirements Coding & Billing Clinical Editing (CE) Dispute Request Access clinical editing policies Download or print our fee schedules (regional password required) Access procedure code modifiers Review medical record submission requirements Keep informed about telemedicine Download Forms Request Claim Adjustment or Retraction Form Request for Out-of-Area Member Claim Appeal (BlueCard) Form Request for Grievance or Appeal Form And access to so much more Connect patients to health resources Opt in to receive the monthly Connection newsletter ealert Read the latest news and updates Contact your Provider Relations Representative Request training for your staff Review helpful tip sheets and trainings Search Tool Feature And more If you re not currently registered to use our website, register today! It only takes a few minutes and gives you complete access to our online tools and resources. Here s how to register: 1. Visit ExcellusBCBS.com/Provider. 2. Scroll to Register Now! 3. Select the role that applies from the I am a drop-down menu, then click GO. 4. Enter your information and then click Submit. ExcellusBCBS.com/Provider If you need assistance with the ExcellusBCBS.com website related to technical issues, please contact Monday - Thursday 8-4:30, Friday 9-4:30. B-xxxx / CC