Applied Behavior Analysis (ABA) Proper Billing Guidelines & Authorization Updates. January 2016
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1 Applied Behavior Analysis (ABA) Proper Billing Guidelines & Authorization Updates January 2016
2 The Way Forward 2
3 Objectives Overview of Claims-Proper Billing Procedures NPI Registration Authorization Updates ProviderConnect SM Contact Information Questions 3
4 Overview of Claims 4
5 Overview of Claims As of May 1, 2015, Horizon Blue Cross Blue Shield of New Jersey began processing all claims transactions with your National Provider Identifier (NPI) information rather than your Legacy Provider Identifier (TIN + suffix). Providers are no longer required to bill with the suffix - the 9 digit Tax ID Number should be submitted on all claims without the suffix. 5
6 Submitting Claims with Type 1 and Type 2 NPI INDIVIDUAL PROVIDERS Your Type 1 NPI# should be entered in the un-shaded area of the field in Box 24J of the claim form. You should also include your NPI# in Box 33a. GROUP PROVIDERS All claims submissions should include the Type 1 (individual) NPI information to identify the rendering provider and the Type 2 (organization) NPI information to identify the organization, corporation, group practice or facility. Type 1 NPI# should be entered in the un-shaded area of the field in Box 24J. This is the rendering provider s NPI# (BCBA responsible for the case). Type 2 NPI# should be entered in Box 33a. This is the group s NPI#. 6
7 Submitting Claims with Type 1 and Type 2 NPI (cont) To avoid rejections and/or delays in processing, please ensure that your claim submissions and electronic transactions include Type 1 and Type 2 NPI information as appropriate*. Talk with your clearinghouse or vendor to ensure that this information is always included on your electronic claim transactions. *Certain individual practitioners may only be eligible to obtain a Type 1 (individual) NPI. Sole proprietorships, a form of business in which one person owns all of the assets of the business and is solely liable for all the debts of the business in an individual capacity, are not considered organization health care providers for purposes of the NPI Final Rule and thus cannot obtain a Type 2 (organization) NPI. Practitioners who form a single-member LLC (i.e., disregarded entities) are also only eligible for a Type 1 NPI. These individual provider types should include their Type 1 NPI information in both the billing provider and rendering provider fields/loops. 7
8 Claim Example Box 24 J - Type 1 NPI# (Rendering Provider) Box 33a Individual Providers Enter Type 1 NPI Group Providers Enter Type 2 NPI 8
9 Tips for a Clean Claim The rendering provider s Type 1 NPI must be entered in Box 24J not the group s NPI#. Remember to bill with the primary codes as well as secondary codes as applicable. Be sure to include all digits in the insured s ID number, including alpha prefixes. Claims must be received within 180 days of date of service. For DOS on or after October 1, 2015, ICD 10 diagnosis codes are required. 9
10 NPI Registration 10
11 NPI Registration If you do not have an National Provider Identifier ( NPI ), please apply for one through the National Plan and Provider Enumeration System at or call NPI numbers are required, as this identifier is unique to each provider and will be the standard provider number that each provider will be required to use in all health care transactions. If you have not already registered your NPI# with us, please call Providers Services at Monday through Friday, between 8 a.m. and 8 p.m., Eastern Time (ET) for instructions on how to submit your NPI#. 11
12 ProviderConnect 12
13 ProviderConnect and Navinet Transaction NaviNet ProviderConnect Claim Submission X View Member Benefit Information X Verify Member Eligibility X X Access and Print Forms X X Download and Print Authorization Letters Request and View Authorizations Access to Message Center to Submit Customer Services Inquiries X May be available in the future X Submit Recredentialing Applications X INCREASED CONVENIENCE, DECREASED ADMINISTRATIVE PROCESSES Disclaimer: Please note that ProviderConnect may look different and have different functionalities based on individual contract needs, therefore some functions may not be available or may look different for your specific contract. 13
14 Authorization Process Update Effective November 17, 2015, the ABA Authorization Team began building authorizations using primary codes (e.g. 0364T) and add on codes (e.g. 0365T) to avoid claims issues. Authorizations may be done electronically in the future. Further training will be scheduled at that time. 14
15 ProviderConnect Registration Process New and current ProviderConnect users need to fax a completed Account Request form to Account Request form to register for ProviderConnect is located at Valueoptions.com/providers/Forms/Administrative/Online_Services_A ccount_request_form-editable.pdf Providers who already have a ProviderConnect account need to submit a new form to request an additional login ID to access Horizon BCBSNJ member information Horizon BCBSNJ providers need to mark the box for Horizon Behavioral Health Authorizations Providers who do not know their Provider ID can contact the Provider Services Line at , Monday through Friday, between 8 a.m. and 8 p.m., Eastern Time (ET) If there are any questions on the form, providers can contact the EDI Helpdesk at , Monday through Friday, between 8 a.m. and 6 p.m., Eastern Time (ET) 15
16 ProviderConnect Resources ValueOptions.com/Providers/Provider Connect Free demonstration: Valueoptions.com/PMC_prototype/ ProviderConnect/pvd.html Quick Start Guide and Comprehensive User Guide Short Video Tutorials: Viewing Member s Eligibility Submitting an Inpatient or Higher Level of Care Request Responding to Requests for Additional Clinical Information Recredentialing 16
17 ProviderConnect - Horizon BCBSNJ Providers 17
18 ProviderConnect - Horizon BCBSNJ Providers 18
19 Contact Information 19
20 Provider Contacts Authorizations, Care Management and Claim Inquiries: ABA Treatment Request and Treatment Plan Report Submission: Fax: NaviNet or NaviNet.net Provider Relations, Credentialing and Contracting Questions: Monday through Friday, between 8 a.m. and 8 p.m., Eastern Time (ET) 20
21 Helpful Links Network-specific Website: valueoptions.com/horizon valueoptions.com/horizon/aba NaviNet NaviNet.net 21
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