Early Intervention Services Billing Guide Statewide Medicaid Managed Care

Transcription

1 Aetna Better Health of Florida Early Intervention Services Billing Guide Statewide Medicaid Managed Care FL aetnabetterhealth.com/florida

2 Table of Contents Early Intervention Services Statewide Medicaid Managed Care Program (SMMC)... 4 Why is Medicaid adding this service to the list of SMMC health plan covered services?... 4 What are Early Intervention Services (EIS)?... 4 Who can receive EIS?... 4 What is DOH s Early Steps program?... 4 What are screenings, evaluations, and Individualized Family Support Plans?... 5 Aetna Better Health s Responsibilities... 5 Screening and Evaluation services... 5 Multidisciplinary team meeting (also known as an IFSP staffing)... 5 Service delivery model... 5 Service Authorization of EIS... 6 Targeted Case Management/Care Coordination... 6 Provider Network... 6 Continuity of care at enrollment... 6 Provider reimbursement... 6 Where can additional information be located?... 6 Billing Procedure Codes and Limits Early Intervention Services Physical Therapy Services Occupational Therapy Services Speech-Language Pathology Services Child Health Targeted Case Management Services Claim Submission Protocols and Standards... 7 National provider Identifier (NPI)... 7 Medicaid ID... 7 Timely Filing and Prompt Pay Guidelines Grid... 8 Clean claims... 8 How to file a claim... 9 Modifiers

3 How to submit a corrected claim Paper Claims Electronically (EDI Claims)

4 Early Intervention Services Statewide Medicaid Managed Care Program (SMMC) With the implementation of the new SMMC contracts, health plans will be responsible for covering Early Intervention Services for its members. Why is Medicaid adding this service to the list of SMMC health plan covered services? This collaboration is intended to facilitate an integrated health care delivery system where the health plan is responsible for the coordination and payment of Early Intervention Services for children participating in the SMMC program. What are Early Intervention Services (EIS)? Early intervention services (EIS) provide for the early detection and treatment of recipients from 0-36 months of age who exhibit developmental delays or related conditions. EIS promotes a parent-coaching model intended to support the child in meeting certain developmental milestones. Reimbursable services include: Screenings to identify the need for more intensive evaluation and assessment activities, if necessary Evaluations conducted by a multidisciplinary team to identify the presence of a developmental delay or disability Weekly individual or group EIS sessions that include: Family and caregiver support and education Parent training to implement intervention strategies Who can receive EIS? Children ages 0-36 months of age enrolled in the Florida Department of Health s (DOH) Early Steps program. Anyone can refer a child to the Early Steps program; however, being referred does not necessarily mean that a child is eligible for EIS. An eligible member must be enrolled in the Florida Medicaid program on the date of service and meet the criteria provided in Early Intervention Services Medicaid Policy. Provider(s) must verify each recipient s eligibility each time a service is rendered. What is DOH s Early Steps program? Early Steps is Florida's Part C early intervention system that offers EIS to eligible infants and toddlers, age birth to 36 months, who have or are at-risk for developmental disabilities or delays. This federalstate partnership offers services to both Medicaid and non-medicaid eligible children. Administered by DOH, Early Steps coordinates the delivery of EIS to eligible children across the state through 15 local provider groups. These groups receive referrals and deliver services either directly or through subcontractors. Early Steps supports families and caregivers to increase their child s participation in daily activities and routines that are important to the family. For a list of these provider groups, please refer 4

5 to DOH s statewide directory. More information on eligibility criteria for Early Steps can be found in the Early Steps Policy at: What are screenings, evaluations, and Individualized Family Support Plans? Once a child is referred by an individual (e.g., family member, physician, or child care provider), he or she undergoes a screening and/or evaluation to determine the child s developmental status in one or more of the following domains: Physical: Moving, walking, grasping, and coordination (including hearing and vision) Cognitive: Thinking, learning, and problem solving Communication: Babbling, languages, speech, and conversation Social/Emotional: Playing and interacting with others Adaptive environment: Self-help skills (e.g., feeding, toileting, or dressing) The initial evaluation must be completed within 45 days of a child s referral. (See Title 34 Code of Federal Regulation ) If a child is determined eligible, a team of EIS providers then create an Individualized Family Support Plan (IFSP). IFSPs are similar to Individualized Education Plans (IEP) that document Exceptional Student Education children s individual needs and services. IFSPs, however, are only for children under three who meet eligibility criteria. They emphasize the family s role in treatment, which can vary depending on the affected domains. EIS providers must provide services within 30 days from the date the family consents to the services listed in the IFSP. (See 34 CFR (f).) EIS providers deliver services as indicated on the IFSP. Aetna Better Health s Responsibilities Screening and Evaluation services Screening and/or evaluation is an essential part of the process for determining if a child needs EIS. Aetna Better Health will not require prior authorization or a prescription before a child can access EIS screening and/or evaluation services. Multidisciplinary team meeting (also known as an IFSP staffing) Aetna Better Health will participate in the multidisciplinary team meetings where the IFSP is developed to facilitate quick and timely authorization of medically necessary services. Service delivery model Aetna Better Health will ensure that services are provided to the family and child where they live, learn, and play to enable the family to implement developmentally appropriate learning opportunities during every day activities and routines. Most services will be provided in the home. 5

6 Aetna Better Health will work with the DOH Early Steps program to ascertain best practices and evidence-based guidelines that support the delivery of EIS when developing clinical protocols or service authorization criteria. The Agency will host a joint training with DOH and the plans in October to further discuss the service delivery model. Service Authorization of EIS Aetna Better Health of Florida does not require an authorization for the evaluation and management of therapies provided under the Early Steps program by approved providers participating in the program. Aetna Better Health will accept the IFSP as the authorizing document to authorize therapies in lieu of having the provider go through a separate authorization process. Please fax the current Individualized Family Support Plan (IFSP) to Targeted Case Management/Care Coordination Children receiving EIS are eligible for targeted case management (TCM)services. Aetna Better Health is required to cover the TCM services for children receiving EIS using case managers who are certified by the DOH Early Steps program. Provider network Aetna Better Health will contract with EIS and TCM providers that are certified through the DOH Early Steps program, or its designee. If all EIS and TCM provider network agreements are not in place when the new health plan contracts are implemented in a region, Aetna Better Health will enter into single case agreements with existing providers to honor continuity of care requirements for any EIS member who was receiving EIS at the time of transition. A single case agreement is a contract between the health plan and an out-of-network provider for a specific service or patient, to ensure services are continued. Continuity of care at enrollment Aetna Better Health is responsible for continuing to provide services already in place for all members. This includes EIS. In the event a new member is receiving prior authorized ongoing course of treatment with any provider, including those services previously authorized under the fee-for-service delivery system, Aetna Better Health will continue that course of treatment and pay the existing provider for that treatment, without any form of authorization and without regard to whether such services are being provided by participating or non-participating providers for up to 60 days after the effective date of enrollment. Provider reimbursement Aetna Better Health will continue to reimburse EIS services at the current Medicaid rate. Where can additional information be located? For Florida Medicaid s policies and reimbursement rates, please refer to the Early Intervention Services Coverage Policy and Early Intervention Services Fee Schedule. The coverage policy also provides information on services that are excluded from this benefit. Health plans cannot be more restrictive than what is stipulated in the coverage policy. 6

7 Additional information can be located at: Kids/home/resources/es_policy/es_Policy.html Claim Submission Protocols and Standards Providers shall submit claims in accordance with applicable state and federal laws. Provider shall submit timely, complete, and accurate claims to the Plan in accordance with the requirements of Section X.D., Information Management and Systems of the SMMC contract. Untimely claims will be denied when they are submitted past the timely filing deadline. Unless otherwise stated in the Provider agreement, the following guidelines apply. National provider Identifier (NPI) NPI is the standard unique health identifier for health care Providers adopted by the Secretary of Health and Human Services under the Health Insurance Portability and Accountability Act of You may apply for an NPI number online at Providers are required to submit their NPI on every claim. Medicaid ID If you provide direct health care services to members, you need to add your national provider identifier (NPI) number to claims. Claims may be rejected or denied when submitted without an NPI or with an invalid NPI, depending on the method of submission. Be sure to: Use the NPI you registered with Florida Medicaid Bill for services as you are registered on the Florida PML You can verify this information: Online: mymedicaid-florida.com Phone: Florida Medicaid Provider Enrollment Call Center at , Option 4. Providers must have a nine-digit Medicaid ID prior to submitting claims/encounters to the Plan. Providers can register with the State of Florida at Enrollment_EnrollmentForms/tabid/58/Default.aspx?desktopdefault=%20. Providers who do not currently hold a Medicaid ID have three options for requesting one. They can register through a plan, apply directly to Medicaid via the online enrollment wizard for Limited Enrollment, or apply directly to Medicaid via the online enrollment wizard for Full Enrollment. Any of these three options would result in assignment of a Medicaid ID which can be used by the plans to submit encounter data. To apply directly to Medicaid, providers can submit either a Limited Enrollment or a Full Enrollment application via the online Provider Enrollment Wizard. NOTE: Full Enrollment is 7

8 required if the provider is to bill Medicaid as fee-for-service. Alternatively, providers can register for a Medicaid ID by downloading and completing the Florida Medicaid Provider Registration Form. Completed forms must be submitted to a Medicaid health plan prior to submission to Medicaid. See the Florida Medicaid Provider Registration Guide for directions for successfully completing the form. Timely Filing and Prompt Pay Guidelines Grid Provider / Claim Type Plan Participating Providers Non-Participating Providers Plan as Secondary Payor Corrected Claims Return of requested additional information (itemized bill, ER records, med records, attachments) Guideline Provider shall mail or electronically transfer (submit) the claim within 180 days after the date of service or discharge from an inpatient admission. (F.S ) Provider shall mail or electronically transfer (submit) the claim within 365 days after the date of service or discharge from an inpatient admission. (SMMC Contract) (Section VIII.D)(E)(2) When the Managed Care Plan is the secondary payer, the provider must submit the claim within ninety (90) calendar days after the final determination of the primary payer. (SMMC Contract) (Section VIII)( E)(1)(h) Provider shall mail or electronically transfer (submit) the corrected claim within 180 days from the date of service or discharge from an inpatient admission. (F.S ) A Provider must submit any additional information or documentation as specified, within thirty-five (35) days after receipt of the notification. Additional information is considered received on the date it is electronically transferred or mailed. Aetna Better Health cannot request duplicate documents. (F.S (2)(c)(2) Clean claims In order for a claim to be paid, it must be a clean claim. Per Rule 59G (42), F.A.C., clean claim means a claim that: Has been completed properly according to Medicaid billing guidelines; Is accompanied by all necessary documentation required by federal law, state law, or state administrative rule for payment; and Can be processed and adjudicated without obtaining additional information from the provider or from a third party. A clean claim includes a claim with errors originating in the claim system. It does not include a claim from a provider who is under investigation for fraud, abuse, or violation of state or federal Medicaid laws, rules, regulations, policies, or directives or a claim under review for medical necessity. Aetna Better Health of Florida will comply with the following standards regarding timely claims 8

9 processing: Aetna Better Health of Florida will pay 50% of all clean claims submitted within 7 days. Aetna Better Health of Florida will pay 70% of all clean claims submitted within 10 days. Aetna Better Health of Florida will pay 90% of all clean claims submitted within 20 days. How to file a claim Select the appropriate claim form and complete the claim form. Service Claim Form Medical and professional services CMS 1500 Form Instructions on how to fill out the claim forms can be found on our website at: aetnabetterhealth.com/florida. Claims must be legible and suitable for imaging and microfilming for permanent record retention. Complete ALL required fields and include additional documentation when necessary. The claim form may be returned unprocessed (unaccepted) if illegible or poor-quality copies are submitted or required documentation is missing. This could result in the claim being denied for untimely filing. Submit original copies of claims electronically or through the mail (do NOT fax). To include supporting documentation, such as members medical records, clearly label and send to Aetna Better Health of Florida at the correct address. Claim may be filed using the following methods. o o Electronic Clearing House Providers who are contracted with us can use electronic billing software. Electronic billing ensures faster processing and payment of claims, eliminates the cost of sending paper claims, allows tracking of each claim sent, and minimizes clerical data entry errors. Additionally, a Level Two report is provided to your vendor, which is the only accepted proof of timely filing for electronic claims. Change Healthcare (Emdeon) is the EDI vendor we use Contact your software vendor directly for further questions about your electronic billing. Contact our Provider Relations department at (800) for more information about electronic billing. All electronic submission will be submitted in compliance with applicable law including HIPAA regulations and Aetna Better Health of Florida policies and procedures. Through the mail: Aetna Better Health of Florida P.O. Box Phoenix, AZ

10 Modifiers Appropriate modifiers must be billed in order to reflect services provided and for claims to pay appropriately. Aetna Better Health of Florida can request copies of operative reports or office notes to verify services provided. Please refer to your Current Procedural Terminology (CPT) Manual for further detail on all modifier usage. How to submit a corrected claim Corrected and/or Voided Claims are subject to Timely Claims Submission (i.e., Timely Filing) guidelines. Paper Claims For Professional claims, Provider must include the original Aetna Better Health of Florida claim number and bill frequency code per billing standards. When submitting a Corrected or Voided claim, enter the appropriate bill frequency code left justified in the left-hand side of Box 22. Example: Any missing, incomplete or invalid information in any field may cause the claim to be rejected. Please Note: If the Provider handwrites, stamps, or types Corrected Claim on the claim form without entering the appropriate Frequency Code (7 or 8) along with the Original Reference Number as indicated above, the claim will be considered a first-time claim submission. When processing a Corrected or Voided Claim, a Payment Reversal may be generated which may produce a negative amount, which will be seen on a later Remittance Advice than the Remittance Advice that is sent for the newly submitted corrected claim. Electronically (EDI Claims) Loop 2300 Segment CLM composite element CLM05-3 should be 7 or 8 indicating to replace 7 or void 8 Loop 2300 Segment REF element REF01 should be F8 indicating the following number is the control number assigned to the original bill (original claim reference number) Loop 2300 Segment REF element REF02 should be the original claim number the control number assigned to the original bill (original claim reference number for the claim to be replaced.) Example: REF F8 Aetna Better Health of Florida Claim number here~ 10

11 Procedure Codes and Modifiers Early Intervention Services Code Mod 1 Mod 2 Description of Service and Limits T1023 Screening (Maximum 3 per calendar year per child) T1024 GP UK T1024 GN UK T1024 GO UK T1024 TL T1024 HN UK T1024 GP TS T1024 GN TS T1024 GO TS T1024 TL TS T1024 TS Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Physical Therapist (Maximum 1 per lifetime per child) Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Speech Therapist (Maximum 1 per lifetime per child) Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by an Occupational Therapist (Maximum 1 per lifetime per child) Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Licensed Early Intervention Professional (Maximum 1 per lifetime per child) Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by an ITDS (Maximum 1 per lifetime per child) Follow-up Psychosocial and Developmental Evaluation rendered by a Physical Therapist (Maximum 3 per calendar year per child) Follow-up Psychosocial and Developmental Evaluation rendered by a Speech Therapist (Maximum 3 per calendar year per child) Follow-up Psychosocial and Developmental Evaluation rendered by an Occupational Therapist (Maximum 3 per calendar year per child) Follow-up Psychosocial and Developmental Evaluation rendered by a licensed Early Intervention professional (Maximum 3 per calendar year per child) Follow-up Psychosocial and Developmental Evaluation rendered by an ITDS (Maximum 3 per calendar year per child) T1027 SC Early Intervention Individual Session Provided by an EIS professional (Maximum 1 hour per day) T1027 TT SC Early Intervention Group Session Provided by an EIS professional (Maximum 1 hour per day) 11

12 Physical Therapy Services Code Modifier Description of Service Physical Therapy Evaluation, Low Complexity Physical Therapy Evaluation, Moderate Complexity Physical Therapy Evaluation, High Complexity Physical Therapy Re-Evaluation Physical Therapy Treatment Visit HM Physical Therapy Visit Provided by a Physical Therapy Assistant GP Wheelchair Evaluation and Fitting by a Physical Therapist GP AAC Initial Evaluation Provided by a Physical Therapist HA Application of Casting or Strapping Occupational Therapy Services Code Modifier Description of Service Occupational Therapy Evaluation, Low Complexity Occupational Therapy Evaluation, Moderate Complexity Occupational Therapy Evaluation, High Complexity Occupational Therapy Re- Evaluation Occupational Therapy Treatment Visit HM Occupational Therapy Visit Provided by an Occupational Therapy Assistant GO AAC Initial Evaluation Provided by an Occupational Therapist HA Application of Casting or Strapping GO Wheelchair Evaluation and Fitting by an Occupational Therapist 12

13 Speech-Language Pathology Services Code Modifier Description Evaluation/ Re-evaluation of speech fluency (e.g., stuttering, cluttering) Evaluation/ Re-evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) Evaluation/ Re-evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) Evaluation/ Re-evaluation Behavioral and qualitative analysis of voice and resonance Evaluation of oral and pharyngeal swallowing function Speech Therapy Visit HA Group Speech Therapy per child in the group per 15 minutes HM Speech Therapy Visit Provided by a Speech Therapy Assistant AAC Initial Evaluation Provided by a Speech-Language Pathologist GN AAC Re-Evaluation Provided by a Speech-Language Pathologist AAC Fitting, Adjustment, and Training Visit 13

14 Child Health Targeted Case Management Services Code Modifier Description of Service T1017 TL TL Targeted Case Management for Children s Medical Services Early Steps Providers T1017 SE SE Targeted Case Management for Children s Medical Services - Medical Foster Care Contractors 14