LTSS Home and Community-Based Medical and Non-Medical
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1 LTSS Home and Community-Based Medical and Non-Medical New Jersey Department of Human Services Division of Medical Assistance and Health Services July 2014
2 Presentation Topics 1. Provider Enrollment Process 2. Service Billing codes include as part of MLTSS HCBS 1. Claim Submission Requirements 2. Prior Authorization Parameters 3. Questions 2
3 Provider Enrollment Process for Managed Care Managed Care Organization (MCO) offers an application for providers MCO completes credential/re-credential process of provider 3
4 Steps for Home and Community Based Medical and Non-Medical Providers to become Network Providers with the individual MCOs 1. Submit Application 2. Complete Credentialing Requirements 3. Secure contract if plan and provider reach agreement Note: Residential Providers-AL, CRS, NF SCNP any willing provider clause in MCO Contract till July
5 LTSS Home and Community Based Services Service and Billing Codes Refer to MLTSS Dictionary for specific information regarding contractual limits MLTSS HCBS Services below is sample of HCBS Services Former Waiver Service Adult Family Care (GO) Assisted Living Residence - 1 day (GO) Former Code (s) MLTSS Service MLTSS Code Code Mod Method/ Unit Y7573 Adult Family Care S5140 Per Diem Y9633, T2031 Assisted Living Services (ALR - Assisted Living Residence) T2031 Per Diem MLTSS Code Description Foster care, adult; per diem Assisted living, waiver; per diem Comprehensive Personal Care Home - 1 day (GO) Y7574 Assisted Living Services (CPCH-Comprehensive Personal Care Home) T2031 U1 Per Diem Assisted living, waiver; per diem 5
6 LTSS Home and Community Based Services Service and Billing Codes MLTSS Service MLTSS Code MLTSS Code Description Code Mod Method/ Unit Home Delivered Meals S5170 Per Home delivered meals, including Service - preparation; per meal One meal per day Medication Dispensing Device (Set Up) Medication Dispensing Device (Monthly Monitoring) T1505 S5185 Per Service Electronic medication compliance management device, includes all components and accessories, not otherwise classified Monthly Medication reminder service, nonface-toface; per month
7 Prior Authorization parameters must comply with "Health Claims Authorization, Processing and Payment Act (HCAPPA) P.L. 2005, c.352 PRIOR AUTHORIZATION PARAMETERS Draft April 2014 MLTSS Provider Workgroup 7
8 Prior Authorization Parameters Individual MCOs will identify Prior Authorization process and requirements for individual services Prior authorization denials and limitations must be provided in writing in accordance with the Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352. Prior authorization decisions for non-emergency services shall be made within 14 calendar days Source: Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352. MLTSS Provider Workgroup 8
9 Claims Processing Comply with "Health Claims Authorization, Processing and Payment Act (HCAPPA) P.L. 2005, c.352 for HCBS Medical Services Claim Submission Parameters 9
10 Claim Submission Requirement MCO claims are considered timely when submitted by providers within 180 days of the date of service as per (HCAPPA) P.L. 2005, c
11 UUniversal Billing Format for MLTSS Services Paper Submission Providers need to use the 1500 for AL facilities, HCBS service providers, and non-traditional providers such as home improvement contractors, emergency response system providers, meal delivery providers and more. Providers need to use the UB-04 lite for NFs and SCNFs. 11
12 Universal Billing Format for MLTSS Services Electronic Submission Providers need to use the 837 P for AL facilities, HCBS service providers, and non-traditional providers such as home improvement contractors, emergency response system providers, meal delivery providers and more. Providers need to use the 837 I for NFs and SCNFs. 12
13 Claim Submission Requirements with Explanation of Benefits Providers are to submit Coordination of Benefits (COB) claims within 60 days from the date of primary insurer s Explanation of Benefits (EOB) or 180 days from the dates of service, whichever is later. 13
14 MCO Claims Processing MCO contract specifies that MLTSS service claim should be processed by MCO within 15 days of clean submission MCO contract specifies that claims for non- MLTSS services should be processed by MCO within 30 days of clean submission 14
15 State Resources for Providers Department of Human Services Division of Aging Services Care Management Hotline Division of Disability Services Care Management Hotline NJ FamilyCare Member/Provider Hotline NJ FamilyCare Health Benefits Coordinator (HBC) NJ FamilyCare Office of Managed Health Care, Managed Provider Relations
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