Behavioral Health Professional Refresher Workshop Presented by The Department of Social Services & HP 1
Training Topics Client Eligibility Verification Policy Review Fee Schedule Updates Provider Bulletins Re-Enrollment Web Claim Inquiry / Submission Third Party Liability Frequent Claim Denials Claim Resolution Guide ICD-10 Time for Questions 2
Client Eligibility Verification DSS recommends that providers verify a client s eligibility on the date of service prior to providing services. To verify a client s eligibility through the secure Web site www.ctdssmap.com click on the Eligibility tab on the main menu. 3
Client Eligibility Verification Enter enough data to satisfy at least one of the valid search combinations; click search When entering a full name as part of your search, a middle initial is required if present in his/her Connecticut Medical Assistance Program (CMAP) profile. 4
Web Eligibility Screen Enhancements Search by Service Type Codes Providers will now be able to search by up to five (5) different service type codes. The service type codes allow providers to verify the client s eligibility benefit coverage for specific services. The first service type code field defaults to 30 Health Benefit Plan Coverage. If the provider searches by that default selection, it will return with all the service type codes that are covered for the client s benefit plan. The specific service type codes for behavioral health providers is A6 Psychotherapy. 5
Web Eligibility Screen Enhancements Search by Service Type Codes 6
Web Eligibility Screen Enhancements Search by Service Type Codes A6 Psychotherapy 7
Web Eligibility Screen Enhancements The eligibility verification request screen has been enhanced to verify eligibility to the end of the current month. The eligibility response is based on current eligibility and is subject to change. Please validate again on the actual date of service. 8
Web Eligibility Screen Enhancements HUSKY B client eligibility search response HUSKY B copay amounts will not show on the eligibility screen. 9
Web Eligibility Screen Enhancements HUSKY B copay amounts Provider should refer to the CTBHP Web site www.ctbhp.com for HUSKY B co-pay amounts. From www.ctbhp.com Web site, select For Providers, then Covered Services then click on the link for New: HUSKY B Client Cost-Share Services. 10
Web Eligibility Screen Enhancements HUSKY C client eligibility search response 11
Policy Review Provider Bulletin 2012-04 Behavioral Health Clinician Coverage for Individuals Under Age 21 in Fee-For-Service Medicaid (HUSKY C) and Medicaid for Low Income Adults (HUSKY D). Effective January 1, 2012 behavioral health assessment and treatment services provided by the following independent practitioners to individuals covered by HUSKY C and HUSKY D who are under twenty-one (21) years of age will be reimbursed as optional services by Connecticut Medicaid. Licensed Clinical Social Workers (LCSWs) Licensed Marital and Family Therapists (LMFTs) Licensed Professional Counselors (LPCs) Licensed Alcohol and Drug Counselors (LADCs) Certified Alcohol and Drug Counselors (CADCs) 12
Policy Review Behavioral Health Clinicians and Psychologists cannot see HUSKY C & D clients that are over 21. Prior Authorization (PA) from the Connecticut Behavioral Health Partnership is required for these services. Refer to the www.ctbhp.com Web site for providers and select covered services. Under Authorization Schedule select your provider type based on Independent Group Practitioners. Prior Authorization does not guarantee benefits. Behavioral Health Clinicians and Psychologists can see HUSKY A, HUSKY B and Charter Oak clients regardless of age. 13
Policy Review Provider Bulletin 2013-02 Requirements for Payment of Services Provided by Licensed Behavioral Health Clinicians in Independent Practice. Policy regulations for payment are posted on the www.ctdssmap.com Web site, go to publications, then to Provider manuals to chapter 7 and from the drop down box choose Behavioral Health Clinicians Services. These regulations: (1) define licensed behavioral health clinicians ; (2) identify the individuals to whom licensed behavioral health clinicians may provide reimbursable services; (3) identify the services covered, service limitations and services not covered; (4) describe the prior authorization and registration requirements; (5) identify the rules for billing procedures and payments; and (6) describe documentation requirements. 14
Fee Schedule Updates Behavioral Health Clinicians fee schedules have been updated for claims with dates of service January 1, 2013 and forward. Accessing Behavioral Health Clinicians fee schedule: From www.ctdssmap.com Web site, go to Provider, then to Provider Fee Schedule Download, click on I Accept scroll to Behavioral Health Clinicians and click on the PDF link. From www.ctbhp.com Web site, select For Providers, then Covered Services then click on the link for CT BHP Proposed Fees/Rates. Behavioral health clinicians can only bill for those services that are on their fee schedule and which they personally provide. 15
Fee Schedule Updates Behavioral Health Clinicians fee schedules 16
Fee Schedule Updates Psychologists have been updated for claims with dates of service January 1, 2013 and forward. Accessing Psychologists fee schedule: From www.ctdssmap.com Web site, go to Provider, then to Provider Fee Schedule Download, click on I Accept scroll to Behavioral Health Psychologist and click on the PDF link. From www.ctbhp.com Web site, select For Providers, then Covered Services then click on the link for CT BHP Proposed Fees/Rates. 17
Fee Schedule Updates Behavioral Health Psychologists fee schedules 18
Fee Schedule Updates www.ctbhp.com screen shot 19
Provider Bulletins Provider Bulletins Access the Publications page via our Web site www.ctdssmap.com and select Publications from either the Information box on the left hand side of the home page or from the Information drop-down menu. The Bulletin Search menu allows you to search for specific bulletins (by year, number, or title) as well as for all bulletins relevant to your provider type. When searching by title, you can search by any word as long as that word is in the title of the bulletin. 20
Provider Bulletins Provider bulletin search by Year 12 and Number 04 to pull up a specific bulletin. Provider bulletins numbers are located on the actual document. 21
Provider Bulletins Provider bulletin search by Year 13 and Provider Type Behavioral Health Clinician to pull up all the bulletins for 2013 pertaining to Behavioral Health Clinicians and Psychologists. 22
Provider Bulletins Provider Bulletin 2013-04 Elimination of Paper Re-enrollment Applications As of March 1, 2013, paper provider re-enrollment applications submitted to HP will no longer be accepted. If a paper application is received from a provider who is required to submit their re-enrollment application via the Wizard, the paper application will not be processed and will be returned to the provider with instructions to use the online Wizard. Behavioral Health providers must submit their provider reenrollment application via the online Wizard located on the www.ctdssmap.com Web site. 23
Provider Re-enrollment Re-enrollment Period Behavioral Health Clinicians and Groups, Psychologists and Groups, who complete their re-enrollment on or after January 1, 2012 will be required to re-enroll every five years. Providers will receive a reminder letter when the provider is due for re-enrollment (30 days prior to the end of their previous enrollment contract). This letter contains the Application Tracking Number (ATN). The ATN and NPI or AVRS ID are required to access re-enrollment application. 24
Provider Re-Enrollment Select Provider Re-Enrollment from the Provider dropdown menu To log-in to your Re-Enrollment Application, enter the ATN and NPI or AVRS ID 25
Web Claim Inquiry At the claims menu select claims inquiry to view claims processed regardless of the submission method. Search by: Internal Control Number (ICN) Client ID and date of service (no greater range than 93 days) Date of payment (no greater range than 93 days) Pending claims 26
Web Claim Inquiry Web Claim function buttons Paid claim Denied claim Suspended claim 27
Web Claim Submission Claim submission Professional 28
Web Claim Submission Claim submission Professional (Cont.) 29
Web Claim Submission Claim submission Professional (Cont.) 30
Third Party Liability Medicaid is the Payer of last resort. The three digit Carrier Code of the Other Insurance (OI) is required to be submitted on the claim when OI is primary. The three digit code can be found on the client eligibility verification screen under TPL. It can also be found on the claim submission screen under the TPL panel in the Client Carriers field. Other Insurance and Medicare Billing Guides are located Web site www.ctdssmap.com; under publications, scroll to provider manual chapter 11 and select Professional Other Insurance/Medicare Billing Guide. 31
Third Party Liability Update To correct or update Third Party Liability (TPL) information: Obtain TPL forms Print out form located on Web site at www.ctdssmap.com under Information Publications Forms Other Forms TPL Information Form. Call Health Management System, Inc. (HMS) 1-866-277-4271. HMS staff will mail or fax the form to the provider. E-mail request to ctinsurance@hms.com and form will be e- mailed back to provider. Submit completed forms Fax to HMS with HIPAA compliant letter to 1-214-560-3932 Scan completed forms and submit through e-mail to ctinsurance@hms.com. * Provider Manual Chapter 5 - Claim Submission Information 32
Dual Eligible / Medicare Prime Dual Eligible is when a client is eligible for Medicare and Medicaid. Medicaid is always the payer of last resort and claims must be submitted to Medicare first for Medicare eligible services. At this time for behavioral health clinician claims we will only cover claims if the provider has already received payment from Medicare. If Medicare is prime and makes a payment we will pay coinsurance and/or deductible up to your Medicaid rate. If Medicare s payment is greater than or equal to your Medicaid rate, Medicaid will pay zero. Medicare Billing Guides are located under Provider Manual chapter 11 on the www.ctdssmap.com Web site. 33
Web Claim Submission 34
Claim Resolution Guide Provider Manual Chapter 12 Claim Resolution Guide This guide lists commonly posted Explanation of Benefit (EOB) codes and provides a brief explanation of the reason why claims were either suspended or denied. This guide provides a detailed description of the cause of each EOB and more importantly, the necessary correction to the claim, if appropriate, in order to resolve the error condition. This guide also provides tips by identifying where providers can go to find additional information to assist with correcting their claims. 35
Claim Resolution Guide EOB 4801 Procedure not covered. Check: Prior Authorization, FTC, Referring Provider, Quantity Restrictions. Cause The procedure billed is not permitted to be paid to the billing provider on the date of service. Resolution If the procedure billed is not a covered procedure on the provider's fee schedule for the date of service, the service is not payable. If the procedure billed is present on the provider's fee schedule, contact the Provider Assistance Center to request an update to the procedure code in question. 36
Most Frequent Claim Denials EOB 4140 The Services Submitted are not Covered Under the Client s Benefit Plan and EOB 4250 No Reimbursement Rule for the Associated Provider Type/Provider Specialty. The provider should verify client eligibility to determine if services are covered for provider type and specialty. If the services are covered under client s benefit plan, client eligibility could have been updated at some point. Providers should re-submit the claim for processing or verify by calling the Provider Assistance Center (PAC). 37
ICD-10 Changes ICD (International Statistical Classification of Diseases and Related Health Problems)-10 Changes On October 1, 2014 the ICD-9 code set used to report medical diagnosis and inpatient procedures will be replaced by ICD-10 code sets. The transition to ICD-10 is required for all providers, payers and vendors. Please start paying attention to information about ICD-10 and that we will use that coding instead of the DSM-5 codes on Medicaid claims. 38
Training Session Wrap Up Where to go for more information: www.ctdssmap.com www.ctbhp.com For questions on authorizations and the authorization processing contact: Value Options 1-877-552-8247 For questions on claim and enrollment questions you can contact: HP Provider Assistance Center (PAC) 1-800-842-8440 Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays. 39
Time for Questions Questions & Answers 40