ALLEGHENY COUNTY DEPARTMENT OF HUMAN SERVICES

Transcription

1 ALLEGHENY COUNTY DEPARTMENT OF HUMAN SERVICES OFFICE OF BEHAVIORAL HEALTH CLIENT INFORMATION AND PAYMENT SYSTEM (CIPS) BUSINESS PROCESS GUIDE June 1, 2015 Versin 1.0

2 Overview CIPS prviders will be able t: register new clients and lk up relevant infrmatin fr existing clients manage client demgraphics enter current diagnsis cdes submit, adjust and vid services rendered claims fr their agency assciate service fferings t a client receiving services frm the agency review mnthly invices fr claims infrmatin have new Master Prvider Enterprise Repsitry (MPER) service fferings mapped autmatically t CIPS questins t: dhs-cipsprject@alleghenycunty.us Terminlgy Client ID Number is the number assigned t a client. MCI (Master Client Index) Number is the Department f Human Services (DHS) client ID used acrss multiple areas f invlvement (bth internal and external). Primary Prvider is the respnsible service crdinatin / case management service prvider determined thrugh the Primary Prvider algrithm and will take the lead in crisis situatins. Services Rendered Claim is an encunter recrd describing a service prvided t a specific client. Diagnsis Cde is an alphanumeric Internatinal Classificatin f Disease (ICD) cde assigned t a specific diagnsis and used fr claims and billing purpses. CIPS user accunt is the persnal accunt which will enable each user t access the system. Service Offering is the cmbinatin f cst center, prvider, and the physical lcatin f a service (e.g. Administrative Management Services prvided by the Department f Human Services at One Smithfield Street, Pittsburgh, PA) t which all services rendered claims are assciated. Cnversely, in MPER, service fferings are assciated t a specific specialized service; therefre, an agency may have multiple service fferings in MPER which map t ne CIPS service ffering. Specialized Service Cde: A standardized prcedure/service cde t identify the service prvided when reprting an encunter. (i.e. M0064 is used t identify Medicatin visit- CRNP and PA service ). 1

3 Acrnyms AHCI: Allegheny HealthChices, Inc. CCBHO: Cmmunity Care Behaviral Health Organizatin CCRI: Cnslidated Cmmunity Reprting Initiative CIPS: Client Infrmatin and Payment System D&A: Drug & Alchl DHS: (Allegheny Cunty) Department f Human Services DSM: Diagnstic and Statistical Manual ecaps: Electrnic Client and Prvider System EI: Early Interventin FFP: Federal Financial Participatin HC: HealthChices ICD: Internatinal Classificatin f Disease ICF: Intermediate Care Facilities MA: Medical Assistance MCI: Master Client Index MH: Mental Health MPER: Master Prvider Enterprise Repsitry OBH: Office f Behaviral Health OID: Office f Intellectual Disability SCU: Service Crdinatin Unit SOID: Service Offering Identificatin (number) SSN: Scial Security Number Client Data Cnversin Fur (4) fiscal years f client data has been cnverted frm ecaps t CIPS. The fllwing client infrmatin will be available in CIPS. Clients with a diagnses Clients with services rendered Clients with SCU assciatins (active r clsed) and wh have had an at least ne service rendered at least n diagnsis an assciatin t an SCU n r after July 1, 2014 If a clsed (end-dated) SCU assciatin was brught ver frm ecaps, it shuld remain clsed. Histrical data (2010 and prir) can be made be available upn request. 2

4 Searching and Creating Client ID Numbers If a client has nt been registered in CIPS (by anther prvider), the current prvider can register a new client in CIPS. Befre registering a new client, there will be a screen prmpt t search fr an existing client recrd in CIPS. Thrugh searches are necessary t avid duplicatin, that is, creating anther client ID fr a client. Multiple searches may be necessary t ensure the client is nt already registered in CIPS. It is expected prvider staff will be diligent in this task t avid duplicatin. If a client search reveals a match t an existing client recrd (a client ID number and infrmatin already exist in CIPS), the prvider user will use that existing ID number t dcument the client s demgraphics, diagnsis cde(s), pririty grup, and services rendered claims. ecaps Client ID cnverted t a new CIPS Client ID Prviders will be able t search fr a client wh was cnverted frm ecaps t CIPS by entering the letter e befre the ecaps client ID number n the Client Search Screen. The system will return the new client ID number that the prvider will use ging frward in CIPS. The new batch prcess will require a CIPS client ID fr all services rendered submissins. When a claim has been submitted with the ecaps client ID number instead f the CIPS ID number, the submitter will receive a warning. The subsequent batch reprt will prvide the new CIPS client ID. Primary Prvider Prvider Invlvement and the Primary Prvider Algrithm A primary prvider is the designated entity respnsible fr ensuring that a client has his r her needs met thrugh apprpriate services. The primary prvider assists the client during a crisis, during a hspitalizatin r incarceratin, and either thrugh direct treatment/services r by cnnecting the client t ther/additinal needed services n an nging basis. The primary prvider is determined by an algrithm (Appendix A) that is based n a hierarchy f case management services defined belw: Cmmunity Treatment Team (CTT) Family Based Mental Health Service Crdinatin r Enhanced Clinical Service Crdinatin (ECSC) Justice Related Services Transitin and Cmmunity Integratin Services Administrative Service Crdinatin In the event n prvider is identified by the algrithm as having prvided any f the abve services, and the client is unable t make his r her wn selectin f a prvider, designated staff with the Office f Behaviral Health will review the client recrd/histry f services t determine which prvider will be the primary prvider. If there is n histry f services, the decisin will be made by OBH staff accrding t what is mst apprpriate given the client s current circumstances. All MH prviders will have the ability t view the MH primary prvider fr a client whether r nt they have submitted services rendered claims fr that client. Once they have entered a claim fr a client, prviders will have the ability t view all MH prviders assciated t a client. 3

5 Prviders will have the ability t view services rendered claims frm all MH prviders nce they have submitted a services rendered claim. Prviders will n lnger be able t view services rendered claims frm ther MH prviders if they have nt submitted services rendered claims in the past six mnths. Primary Prvider Algrithm An algrithm will calculate the primary prvider during the fllwing events: When a service rendered claim is submitted fr a client via n-line r via batch submissin f claims (837p prfessinal). When the prvider end dates its invlvement as primary prvider fr a client. The algrithm will calculate wh the primary prvider is based n the next case management service(s) entered after the previus prvider has end-dated its invlvement as the primary prvider. CIPS will shw a warning ntificatin in the ntificatin panel n the Hme Page if there is ne r mre clients with whm the prvider has invlvement, but fr whm n Base r HealthChices service rendered claims have been submitted fr the previus tw (2) fiscal years. The warning ntificatin will disappear nce the prvider has end-dated their invlvement with the client (see appendix A) r nce a new service has been reprted. Prvider Invlvement Scenaris If a client is brught ver frm ecaps with an active SCU and the CIPS primary prvider algrithm des nt find a newer prvider t assciate, the active SCU is designated as the primary prvider If the client is brught ver with nly a clsed SCU affiliatin and algrithm des nt find a newer prvider t assciate The client shuld chse their primary prvider If the client des nt wish t have a primary prvider The OBH prgram ffice will make decisins as needed. If the client chses a primary prvider The primary prvider wuld then prvide a service and submit a service rendered claim in CIPS and the algrithm wuld autmatically assciate them as the primary prvider. Client has n prvider affiliatin the algrithm des nt find a prvider t assciate A client with n prir invlvement receives a service after July 1 The prvider wh created a client is alerted that n diagnses r services rendered have been entered. Client chses a primary prvider which the algrithm will then autmatically assciate nce the chsen prvider enters a service in CIPS. If the client had an SCU assciatin prir t 2014 but was nt part f the cnversin (e.g. n services r n diagnsis) Client will chse a primary prvider and algrithm will autmatically assciate nce the chsen prvider enters a services rendered claim in CIPS. Prvider will dcument the client s chice f primary prvider. 4

6 Client Service Histry Screen If the assciated prvider agency has prvided any Mental Health services t the client within the last six (6) mnths, based n the service recrd end date fr the client, the prvider will be able t see all Mental Health service recrds. Drug & Alchl services will nt be visible in CIPS. Entering Demgraphic infrmatin All demgraphic screens shuld be cmpleted upn initial registratin. It is the respnsibility f each prvider wh is serving a client t maintain current demgraphic infrmatin in CIPS. There are several mandatry fields that must be entered t save infrmatin n each screen thugh nt all demgraphic infrmatin is mandatry. Hwever, cmpleting all knwn/applicable demgraphic fields is strngly recmmended as will prevent the need fr later client cleanup activities due t CCRI reprting requirements. DHS is required by the state t reprt the fllwing client infrmatin fr CCRI. CCRI FIELDS: Scial Security Number (SSN) Last Name First Name Citizenship Status Race Date f Birth Living situatin Living Situatin qualifier (child residence) depending n the Living Situatin selected Living Situatin qualifier (private ICF/ID) depending n the Living Situatin selected Language Pririty Grup Educatin and Vcatinal Status Veteran Status Marital Status Address State Zip Cde Address Type Effective Address Begin Date CIPS is designed t check fields identified as CCRI-required left vacant and display a warning message n the hme page. T avid warning messages listing regarding missing CCRI infrmatin; the prvider user shuld update the fields whenever there is new r mre accurate infrmatin. (See screenshts) 5

7 Address infrmatin shuld be maintained by each prvider serving a client. D nt use the Save Withut Verificatin buttn unless the Search buttn is clicked first. If an alternate address has been fund, and the address suggested is the crrect address, select the crrect address by clicking int the rw which shws the crrect address. If the suggested address is nt the crrect address, and it has been cnfirmed t be the client s crrect address, ONLY then shuld Save withut Verificatin be used. * *When Save Withut Verificatin is used befre cnducting an address search, the Cunty, Municipality, Schl District, Residency etc. cdes d nt ppulate (fields cannt be entered manually). These fields are required fr CCRI reprting. A reprt will be generated each mnth fr each prvider identifying the missing infrmatin. Prviders will be ntified f the missing fields and asked t supply the infrmatin needed. 6

8 Entering a Diagnsis Cde A prvider with a relevant/current diagnsis cde fr the client shuld enter it alng with the pririty grup n the diagnsis screen and n the services rendered screen whenever submitting services rendered claims. All prviders submitting services rendered claims shuld use ICD-9 CM cdes t reprt services that ccurred prir t Octber 1, All prviders submitting services rendered claims shuld use ICD-10 CM cdes t reprt services ccurring n r after Octber 1, Prviders will have access t view histrical diagnses frm mental health assessments and services rendered. Diagnses entered in ecaps/cips fr services/assessments prir t Octber 1, 2015 using ICD-9 r DSM-IV will nt autmatically cnvert t ICD-10. Prvider will have t determine and enter the apprpriate ICD-10 cde. If a prvider cannt determine an ICD-10 diagnsis cde fr a services rendered claim dated after Octber 1, 2015, please refer t the Center fr Medicare and Medicaid Services General Equivalence Mappings (GEMs): Claims will nt be accepted withut a current diagnsis cde. The system CIPS will shw a warning in the ntificatin panel n the hme page if there is a deferred diagnsis in the current diagnsis set with a prmpt requiring an update t the diagnsis cde. A deferred diagnsis cde cannt be entered if there is a valid diagnsis cde previusly entered. Entering a Pririty Grup The services rendered claim will be rejected if the client s MH Pririty Grup is missing and it has been mre than 45 days between the client s start date and the service rendered start date. The service rendered claim will be accepted if the client s MH Pririty Grup is missing, and it has been less than r equal t 45 days between the client s start date and the service rendered date. Hwever, a warning message will be generated t infrm the prvider user that future service rendered recrds will be rejected unless the Pririty Grup is entered. If a client has been assciated with multiple prviders, the 45 day grace perid is calculated based n the client s earliest start date. Adult and Child & Adlescent Mental Health Target Ppulatin descriptins can be fund n the fllwing site: Service Offering Mapping When a prvider creates a new service ffering ID in MPER, the service ffering will autmatically map t CIPS. The request will n lnger have t g thrugh the Service Desk. All existing ecaps service ffering IDs will be cnverted and remain the same in CIPS. 7

9 When a new service ffering is created in MPER fr an existing facility and can be assciated t an existing CIPS service ffering ID, it will be mapped by the system (e.g. when adding a new specialized service t an established CIPS service ffering ID) When a new facility and service ffering ID is created in MPER, it will be mapped by the system and assigned a new service ffering ID number in CIPS. If a new facility is created and there are multiple service ffering ID s created in MPER that are assciated with ne cst center all f thse will be assigned t ne new service ffering ID number in CIPS. Assciate a Client t a Service Offering Befre a prvider can submit service rendered claims fr a client, the client must be assciated t a prvider s CIPS service ffering (service and lcatin site) using the Client Service Offerings screen. Submitting Services Rendered Claims Prviders can submit services rendered claims thrugh the 837p batching prcess and/r n-line directly int CIPS. Submitting services rendered will n lnger be a tw-step prcess. Changes t services rendered batch prcesses are listed belw: Create a Prvider Claim ID this user-created claim ID can be used t trace services back t the riginal system f recrd and/r identify any changes t riginal claims. Prviders submitting the 837 claims submissin file must have the ability t indicate the type f recrd: Original specifies that the claim recrd is a new/riginal recrd. Adjustment specifies that the claim recrd is an adjustment t a previusly prcessed recrd. A recrd with this indicatr must have an existing prvider claim ID that matches the recrd being adjusted. Vid specifies that the riginal claim is being vided. A recrd with this indicatr must have an existing prvider claim ID that matches the recrd being vided. Please dhs-cipsprject@alleghenycunty.us if yu have any questins abut the 837p batching prcess. A services rendered claim must be submitted fr each date the client received a service(s). Fr example, if the client received a service n July 5, 9, and the 20, this requires three separate entries. A cpy functin, fr n-line submissins, is available t submit multiple dates fr services rendered claims within the same mnth. FFP- Federal Financial Participatin Prviders will have the ability t indicate any claim as an FFP claim in 837 Batch submissins. If the claim is indicated as an FFP claim, the prvider has t enter the FFP rate. The system will cmpare the FFP rate entered by the prvider with the rate in the Rate Card and prcess the payment with the lwer f the tw rates. Prviders will als be able t indicate any claim as an FFP claim n the Services Rendered screen in the CIPS applicatin by checking the FFP Claim check bx. If any claim is indicated as an FFP claim, the prvider has t enter the FFP rate. The system will cmpare the FFP rate 8

10 entered by the prvider with the rate in the Rate Card and prcess the payment with the lwer f the tw rates. A client shuld be MA eligible fr FFP claims. Please refer t the website address belw fr further infrmatin abut FFP claims: C_ MA Eligibility Check CIPS will check fr a client s MA enrllment befre prcessing the claims fr payments. Claims will be upladed t the State Client Infrmatin system thrugh a prcess called 270/271 data exchange. If a client has MA, CIPS will reject all MA reimbursable claims fr that client. The prviders shuld bill MA fr reimbursement fr the rejected claims. The system will check fr retr-eligibility up t 90 days frm the date f service, s that prviders can meet 180 days timely filing requirement t bill MA. HealthChices Eligibility Check CIPS will check fr HealthChices (HC) Eligibility. DHS will get an HC Eligibility file frm AHCI. Claims will be checked fr HC eligibility and reject claims fr services t be paid by HC (CCBHO). Payment Prcess There are currently three (3) payment scenaris in CIPS as fllws: 1. All claims with n adjustments will be paid at the rate maintained by DHS in a Rate Card. 2. If a claim is marked as FFP, as discussed abve, the system will cmpare the FFP rate entered with the rate in the Rate Card and prcess the payment using the lwer f the tw rates. 3. Prviders will be able t enter the client liability received, and private health insurance infrmatin as shwn belw. The prvider shuld als enter the Ttal Amunt Due fr these claims in the Ttal field which is a free text field. If an amunt is entered in this field, the system will calculate the payment amunt by multiplying the rate frm the Rate Card and the number f units entered; cmparing it with the amunt entered by the prvider and paying the lwer f the tw ttals. (See screensht) 9

11 Submit Services Rendered Claims by 10 th f each mnth Claims shuld be submitted by the 10 th f the mnth in rder t be prcessed n the 15 th f the mnth. Timely Submissins f Services Rendered Claims (90 day cut-ff date) The services rendered claims cut-ff date is nw 90 days frm the date f service. If the current date is later than the 90 day cut-ff date, the claim will be put n hld status. The claim will nt be prcessed fr payment unless authrized by DHS/OBH. Prviders shuld request a waiver f timely filing fr these claims. Prgram funded services will nt be put n hld. Year-end clsing fr FY 14-15: Prviders will be able t submit FY services rendered claims in CIPS beginning July 1, Prviders can submit FY claims until December 31, DHS Fiscal will be using the August 8 run date reprt t clse the FY All f the reprts will be generated frm CIPS nly. Year-end clsing cut-ff is December 15: The services rendered claims submissin batch will accept riginal services rendered claims and put them n hld status if they are received beynd year-end clsing. i.e., service rendered start date is in the previus fiscal year and current date is after December 15 f the fllwing the fiscal year. The claims submissin batch will accept adjustment/vid recrds and put them n hld status if they are received after the cut-ff date. The claims/payment prcessing batch will nt pick up recrds in n hld status. 10

12 CTT N? Appendix A Family Based Mental Health (FBMH) N? CIPS Primary Prvider Algrithm Service Crdinatin r ECSC N? Justice Related Services N? Yes? Yes? Transitin and Cmmunity Integratin N? Yes? Yes? Administrative Service Crdinatin N? Yes Yes Office f Behaviral Health Adult Mental Health Services Respnsible Service Prvider Respnsible Service Prvider Respnsible Service Prvider Respnsible Service Prvider Respnsible Service Prvider Respnsible Service Prvider 5/29/15