Transcript Slide 1

Mental Health
Presented by
EDS Provider Field Consultants
October 2009
Agenda
• Session Objectives
• Outpatient Mental Health
• Medicaid Rehabilitation Option
• Somatic Treatment
• Assertive Community Treatment
• Psychiatric Residential Treatment
Facilities
• Edit 2017
• Risk-Based Managed Care
• Common Mental Health Claim
Denials
• Helpful Tools
• Questions
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Objectives
• At the end of this session, providers will:
–Understand outpatient coverage requirements
–Understand the meaning of rolling 12-month period
–Understand the role of the health service provider in
psychology (HSPP)
–Understand services covered under:
•
Medicaid Rehabilitation Option
•
Assertive Community Treatment
•
Psychiatric Residential Treatment Facility
–Understand the impact of the managed care carve-in
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Outpatient Mental Health
• The Indiana Health Coverage
Programs (IHCP) reimburses for
outpatient mental health services
provided by:
–Licensed physicians
–Psychiatric hospitals
–Psychiatric wings of acute care
hospitals
–Outpatient mental health facilities
–Licensed psychologists with the
HSPP designation
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Outpatient Mental Health
• The IHCP also reimburses for psychiatrist or HSPP-directed
outpatient mental health services when provided by midlevel practitioners:
– ACSW, CCSW, LCSW, MSW
– Advanced practice nurses, credentialed in psychiatric or mental
health nursing
– Licensed psychologist
– Licensed independent practice school psychologist
– Licensed marriage and family therapist
– Licensed mental health counselor
– Psychologist with basic certificate
– Registered nurse (RN) with master’s degree in nursing with
major in psychiatric and mental health nursing
•
Mid-level practitioners are not enrolled by the IHCP
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Outpatient Mental Health
Psychiatrist or HSPP Requirements
• Psychiatrist or HSPP responsibilities:
– Must certify the diagnosis and supervise the plan of treatment
– Must see the patient or review information obtained by mid-level
within seven days of intake
– Must see the patient or review documentation to certify
treatment plan and specific modalities at intervals not to exceed
90 days
– Must document and personally sign all reviews
– Must be available for emergencies
•
An emergency is a sudden onset of a psychiatric condition
manifesting itself by acute symptoms of such severity that the
absence of immediate medical attention could reasonably
expect to result in (1) danger to the individual, (2) danger to
others, or (3) death of the individual
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Outpatient Mental Health
Rolling 12-Month Period
• Is not:
– Based on a 12-month calendar year
– Based on a fiscal year
– Renewable on January 1 of each year
• Is:
– Based on the first date that services are
rendered by a particular provider
– Renewable one unit at a time beginning
365 days after the date that services are
rendered by a particular provider
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Outpatient Mental Health
PA Requirements
• Prior authorization (PA) is required for units in excess
of 20 per member, per rendering provider, per rolling
12-month period:
– Codes subject to limitation
• 90801 through 90802
•
•
•
90804 through 90815
90845 through 90857
96151 through 96153
• Requests for PA should include a current plan of
treatment and progress notes to support the
effectiveness of therapy
• Reference BT200901 for Prior Authorization instructions
– Managed care organizations may have different PA
requirements
MENTAL HEALTH UPDATES
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Outpatient Mental Health
PA Requirements
• Package C members are allowed 30 units per member, per
rendering provider, per rolling 12-month period. The IHCP
may cover an additional 20 units with PA, for a maximum of
50 units per year.
• PA is always required for neuropsychological and
psychological testing
– 96101 – Psychological Testing
– 96110 – Developmental Testing
– 96111 – Developmental Testing – Extended
– 96118 – Neuropsychological Testing Battery
• These services must always be performed by a psychiatrist
or HSPP.
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Outpatient Mental Health
PA Requirements
• One unit of psychiatric diagnostic
interview (90801) is allowed per
member, per provider, per rolling
12-month period
• Additional units require PA
• Exception: Two units are allowed
without PA if a separate evaluation
is performed by both a psychiatrist
or HSPP and a mid-level
practitioner
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Outpatient Mental Health-Prior Authorization
Mail or Fax PA requests to:
ADVANTAGE Health Solutions-FFS
P.O. Box 40789
Indianapolis, IN 46240
• Fax number 1-800-689-2759
• For questions or inquiries call 1-800-269-5720
• For RBMC members, contact the appropriate MCO
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Care Management Organizations – Prior
Authorization
ADVANTAGE Health Solutions
•
www.advantageplan.com
•
Fax 1-800-689-2759
•
1-866-504-6708
MDwise
•
www.mdwise.org
•
Fax 1-877-822-7186
•
1-866-440-2449
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Outpatient Mental Health
Noncovered Services
• The IHCP does not cover:
– Biofeedback
– Broken or missed appointments
– Day care
– Hypnosis
– Partial hospitalization (except as set forth
in 405 IAC 5-21)
– Medical services by mid-level practitioners
• 90805
• 90807
• 90809
• 90811
• 90813
• 90815
• 90862
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Outpatient Mental Health
Billing Overview
• Services are billed on the CMS-1500 (08/05) claim
form
• Services are billed using the National Provider
Identifier (NPI) of the facility or clinic, and the
rendering NPI of the supervising psychiatrist or HSPP
• Medical records must document the services and the
length of time of each therapy session
• Psychiatrists and HSPPs are reimbursed at 100
percent of the allowed amount
• Mid-level practitioners are reimbursed at 75 percent
of allowed amount
– Services rendered by mid-level practitioners are
billed using the rendering NPI of the HSPP
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Outpatient Mental Health
Billing Overview
• Appropriate modifiers must be used for mid-
level practitioners
–AH – Clinical Psychologist
–AJ – Clinical Social Worker
–HE and SA – Nurse Practitioner or Nurse
Specialist
–HE – Masters degree in nursing with major
in psychiatric and mental health nursing
–HE – Any other mid-level practitioner
–HO – Masters degree level
–SA – Nurse practitioner or clinical nursing
specialist (CNS) in a nonmental health
arena
• Refer to IHCP provider bulletin BT200603 for
recommended internal audit guidelines
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Outpatient Mental Health
TPL Exception
• Mental health services may bypass being billed to Medicare
for dually eligible members
–Applies to members who have Medicare and Medicaid
–Applies to services billed with modifiers HE or HO
• Utilize the Notes feature of Web interChange (or the 837P
equivalent) to indicate, “Provider not approved to bill
services to Medicare”
NOTE: This TPL exception applies when Medicare does not
recognize the educational level of the mid-level practitioner
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Medicaid Rehabilitation Option
• Medicaid Rehabilitation Option (MRO) services remain
carved out of the risk-based managed care (RBMC)
delivery system
• MRO services remain reimbursable only to providers
enrolled as community mental health centers (CMHCs)
• Clinical mental health services are provided for individuals,
families, or groups living in the community who need aid
intermittently for emotional disturbances or mental illness
• Services may include attention in member’s home,
workplace, mental health facility, or wherever needed
• Services must be rendered by a qualified mental health
professional (QMHP)
• MRO is not covered for Package C members
• Services must be reported with an HW modifier
– Also report modifiers to identify specialty of the mid-level
practitioner
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Medicaid Rehabilitation Option
• Covered MRO procedure codes:
– 97535
Self Care/Home Management Training
– 97537
Community Work Reintegration
– H0002
Behavioral Health Screening
– H0004
Behavioral Health Counseling
– H0031
Mental Health Assessment (nonphysician)
– H0033
Oral Medication Administration
– H0035
Partial Hospitalization
– H0040
ACT Program
– H2011
Crisis Intervention
– H2014
Skills Training Development
– T1016
Case Management
•
Add the appropriate modifier(s): HW, HQ, HR, HS, and TG
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Somatic Treatment
Somatic treatment includes responding to a physician’s orders,
dispensing or administering prescribed medications, monitoring
medication side effects, and conducting medication groups or
classes
• CMHCs report procedure code
H0033 with the HW modifier for
somatic treatment
• Report additional modifiers for
mid-level practitioners
• These services are billed on the
CMS 1500 claim form
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Assertive Community Treatment
• Assertive Community Treatment (ACT) services are
coordinated by an interdisciplinary team (ACT Team)
responsible for the direct provision of:
– Community-based psychiatric treatment
– Assertive outreach
– Rehabilitation
– Support services
• Intensive mental health services for consumers with serious
mental illness with co-occurring problems or multiple
hospitalizations
• Member’s level of functioning must be low or moderate as
defined by the Division of Mental Health and Addiction
• PA is established by the team psychiatrist/HSPP
• Services must be available 24 hours a day, seven days a
week, with emergency response coverage
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Assertive Community Treatment
• Reimbursement is based on a per diem
for procedure code H0040 HW
• Reimbursement is at 75 percent if the
ACT team psychiatrist or HSPP is not in
attendance at daily team meeting
– Refer to IHCP Provider Manual,
Chapter 8, Section 4, Outpatient
Mental Health
• Billing on CMS-1500 (08/05)
• ACT remains carved out of RBMC
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Psychiatric Residential Treatment Facilities
• What is a psychiatric residential treatment facility
(PRTF)?
–A facility licensed as a private secure facility under
465 IAC 2-11
•
Private Secure Facility – A locked living unit of an
institution for gravely disabled children with chronic
behavior that harms themselves or others
–A facility accredited by one of the following:
•
The Joint Commission on Accreditation of
Healthcare Organizations
•
The Council on Accreditation of Services for
Families and Children
MENTAL HEALTH UPDATES
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Psychiatric Residential Treatment Facilities
Covered Services
• The IHCP reimburses for services provided
to children younger than 21 years of age
• The IHCP requires PA for admission to a
psychiatric residential treatment facility
(PRTF).
– Patient must show need for long-term
treatment modalities
• See Chapter 6 of the IHCP Provider
Manual for details
• Medical leave days ordered by a physician
are reimbursed at 50 percent for as many
as four days per admission, unless the
occupancy rate is less than 90 percent
• Therapeutic leave days ordered by a
physician are reimbursed at 50 percent, for
as many as 14 days per calendar year,
unless the occupancy rate is less than 90
percent
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Psychiatric Residential Treatment Facilities
• PRTF services are billed on the CMS-1500 (08/05)
claim form using the following procedure codes:
– T2048 – Per Diem
– T2048 U1 – Medical Leave
– T2048 U2 – Therapeutic Leave
• One unit equals a 24-hour day of care (midnight to
midnight)
• PRTF services are reimbursed on a per diem, which
includes:
– All IHCP-covered psychiatric services performed in a
PRTF
– All IHCP-covered services not related to the psychiatric
condition that are performed at the PRTF
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Psychiatric Residential Treatment Facilities
Non-Covered Services
• Hoosier Healthwise Package C does not cover PRTF
services
• PRTF services remain carved out of RBMC
– The MCO retains responsibility for services outside the
PRTF, including transportation, pharmacy, and other
related healthcare services
• The PRTF per diem does not include:
–Pharmaceutical supplies
–Nonpsychiatric physician services not available at
the PRTF and performed at another location
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Psychiatric Residential Treatment Facilities
Patient Liability
• Some residents of PRTF and State hospitals are
assigned a patient liability
–The patient liability must be paid to the facility by
the member each month
• IndianaAIM systematically deducts the patient liability
during claims processing
–Providers can identify the patient liability deduction
on the remittance advice
•
EOB 2014 Claim adjusted by the monthly
Medicaid patient liability amount
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Edit 2017
• Providers billing psychiatric services for
members residing in a PRTF that are receiving
Edit 2017 – Recipient ineligible on the date(s)
of service due to enrollment in a managed care
organization are instructed to send their claims
for in-house processing to:
– EDS Provider Written Correspondence Unit
P. O. Box 7263
Indianapolis, IN 46207-7263
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Risk-Based Managed Care
• Effective January 1, 2007, outpatient mental health
services were carved in to the RBMC delivery system
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Risk-Based Managed Care
• Services provided to RBMC members by the following
specialty types are the responsibility of the MCOs:
– Freestanding Psychiatric Hospital (011)
– Outpatient Mental Health Clinic (110)
– Community Mental Health Center (111)
– Psychologist (112)
– Certified Psychologist (113)
– HSPP (114)
– Certified Clinical Social Worker (115)
– Certified Social Worker (116)
– Psychiatric Nurse (117)
– Psychiatrist (339)
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Risk-Based Managed Care
• Services that are the MCO’s
responsibility:
–Office visits with a mental health
diagnosis
–Services ordered by a provider
enrolled in a mental health
specialty, but provided by a
nonmental health specialty, such
as a laboratory and radiology
–Mental health services provided
in an acute care hospital
–Inpatient stays in an acute care
hospital or freestanding
psychiatric facility for treatment
of substance abuse or chemical
dependency
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Risk-Based Managed Care
• MCOs
– Anthem www.anthem.com
– Managed Health Services (MHS)
www.managedhealthservices.com
– MDwise www.mdwise.org
• Behavioral Health Organizations (BHO)
– Magellan (Anthem)
www.magellanhealth.com
– Cenpatico (MHS) www.cenpatico.com
– MDwise www.mdwise.org
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Risk-Based Managed Care
• The MCO or BHO may have
different rules for PA, timely
filing limits, claims processing,
and so forth
• MCO or BHO and EDS must
honor PAs approved by the
original for a period of 30 days
following a change from the
originating entity to the
receiving entity
• Providers should verify eligibility
before providing service
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Common Mental Health
Claim Denials
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EOB 1120- Rendering NPI Submitted Is Not
Reported to an LPI
Cause
NPI has not been linked to the provider’s
Legacy Provider Identifier (LPI) in the provider
file
Resolution
Verify that the correct NPI was submitted or
submit NPI to IHCP using the NPI reporting too.
MENTAL HEALTH UPDATES
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EOB 2502- Recipient is Covered by
Medicare B or D
Cause
Recipient is covered by Medicare Part B or the MRN was
not submitted with the claim
Resolution
Verify Medicare eligibility and bill Medicare first or submit
a Medicare MRN
MENTAL HEALTH UPDATES
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EOB 3001- Dates of Service Not on PA
Database
Cause
Code billed requires PA for the program, such as Medicaid,
Care Select, and RBMC, of which the recipient is enrolled,
and the date(s) of service indicated on the claim for the
code that needs prior authorization, do not fall within the
start/stop dates prior authorized for that code
Resolution
Acquire PA for procedure and dates of service being billed
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EOB 4021- Procedure Code Vs Program
Indicator
Cause
Procedure code billed is restricted to a specific program
for the date of service, and it has not been prior
authorized
Resolution
The procedure code billed is not authorized for the
recipient’s program – acquire PA for service
MENTAL HEALTH UPDATES
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EOB 1008- Rendering Provider Must Have an
Individual Number
Cause
The rendering provider is not an individual provider
Resolution
The rendering provider must have an individual number;
verify NPI and resubmit
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2029 Non-IHCP member ineligible for dates of
service
• Cause
–For MRT claims the eligibility effective date is
after the service date or the eligibility
effective date terminated prior to the date of
service
–For PASRR claims the eligibility effective date
or end date is not within the date range of
the dates of service billed
• Resolution
• For MRT submit the request from the DFR with
the claim in order to update the eligibility
effective date
• For PASRR contact the AAA to verify they have
entered the correct eligibility information
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2037 Member not on file for non-IHCP
program
• Cause
–The MRT or PASRR eligibility segment is not
on the eligibility file
• Resolution
–For MRT submit the request from the DFR
with the claim in order to update the
eligibility effective date
–For PASRR contact the AAA to verify they
have entered the correct eligibility
information
MENTAL HEALTH UPDATES
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Helpful Tools
• IHCP Web site at
www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or
paper)
• MRO Provider Manual
• Customer Assistance
–1-800-577-1278, or
–(317) 655-3240 in the Indianapolis local
area
• Written Correspondence
–P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
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Questions
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Office of Medicaid Policy and Planning (OMPP)
402 W. Washington St, Room W374
Indianapolis, IN 46204
EDS, an HP Company
950 N. Meridian St., Suite 1150
Indianapolis, IN 46204
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October 2009