Mental Health Services Fee-for-Service Indiana Health Coverage Programs DXC Technology October 2017 1
Agenda Reference Materials Provider Healthcare Portal Outpatient Mental Health Inpatient Mental Health Medicaid Rehabilitation Option 1915(i) Home & Community Based Programs Updates Billing Secondary Claims on Portal Helpful Tools Q&A 2
Reference Materials Reference modules, code tables, fee schedules 3
Reference Materials Providers can stay abreast of current developments and research issues: Banners and bulletins News and announcements Provider Reference Materials Medical Policy Manual Mental Health & Addiction provider reference module Medicaid Rehabilitation Option (MRO) provider reference module Code Sets Subscribe to email notices Professional Fee Schedule 4
5 Reference Materials
6 Mental Health and Addictions Provider Reference Module
Mental Health Code Sets Table 1 Procedure Codes for Applied Behavioral Analysis Therapy Table 2 ICD-10 Codes for Bridge Appointments Table 3 Procedure Codes Linked to Revenue Code 513 Clinic/Psychiatric 7
8 Professional Fee Schedule
Provider Healthcare Portal Overview, what you can do, WBT (web-based training) 9
Provider Healthcare Portal What you can do in the Provider Healthcare Portal: Submit, copy, edit, void claims Check on status of claims Verify eligibility View, print remittance advices Request prior authorization Provider enrollment and revalidation Secure correspondence And more.. 10
11 Provider Healthcare Portal Login Page
Provider Healthcare Portal Web-based training available 12
13 Outpatient Mental Health
Outpatient Mental Health Physician/HSPP-directed services The Indiana Health Coverage Programs (IHCP) reimburses under 405 IAC 5-20-8 for physician or Health Service Provider in Psychology(HSPP)-directed outpatient mental health services for group, family, and individual outpatient psychotherapy when such services are provided by one of the following midlevel practitioners: Licensed independent practice school psychologist Licensed clinical social worker (LCSW) Licensed marital and family therapist (LMFT) Licensed mental health counselor (LMHC) A person holding a master's degree in social work, marital and family therapy, or mental health counseling Advanced practice nurse who is a licensed, registered nurse with a master's degree in nursing with a major in psychiatric or mental health nursing from an accredited school of nursing 14
Outpatient Mental Health Advanced Practice Nurses (APN) are allowed to oversee the treatment plan for outpatient mental health and substance abuse treatment Must be in APN s scope of practice Must be spelled out within APN s practice agreement with collaborating physician Indiana Code; Title 12-Human Services; Article 15-Medicaid; Chapter 5-Services Provided; Section 14 (d.) 15
Outpatient Mental Health Mid-level practitioners Mid-level practitioners may not be separately enrolled as individual providers to receive direct reimbursement Mid-level practitioners can be employed by: Outpatient mental health facility Clinic Physician HSPP enrolled in the IHCP Covered services rendered by mid-level practitioners must be billed using: Rendering National Provider Identifier (NPI) of the supervising practitioner Billing NPI of the outpatient mental health clinic or facility 16
Outpatient Mental Health Physician/HSPP responsibilities Must certify the diagnosis and supervise the plan of treatment as stated in 405 IAC 5-20-8 (3) (A) (B) Must see the patient or review information obtained by a mid-level practitioner within seven days of the initial assessment 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 No co-signatures on documentation 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 be expected to result in (1) danger to the individual, (2) danger to others, or (3) death of the individual 17
Outpatient Mental Health Modifiers 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 Any other mid-level practitioner as addressed in the 405 IAC 5-20-8, including master's degree 18
Outpatient Mental Health Providers not approved to bill Medicare Procedure codes billed with mid-level modifier HE for dually eligible Medicare/Medicaid members may use claim notes to indicate the provider has performed a service that is not approved to bill to Medicare Claims submitted using claim notes on each detail line must indicate in the claim notes on the 837P the following text: Provider not approved to bill services to Medicare The use of claim notes allows the claim to suspend for review of the claim note and be adjudicated appropriately This option is only available when Medicare is primary 19
Mental Health Therapy Services in Outpatient Facilities Outpatient claims for mental health therapy services must be billed on the UB-04 institutional claim form Must use revenue code 513-Clinic/Psychiatric, and an acceptable procedure code, and appropriate modifier Evaluation & Management (EM) codes such as 99212, 99213, 99214 may be billed with revenue code 510 Providers will be reimbursed up to two individual sessions and one group session on the same day of service These UB-04 claims are for the facility fee only and can only be provided in a hospital based outpatient facility In order to be reimbursed, the member must be physically present at the outpatient facility to bill for facility fees Professional fees are billed on the CMS-1500 professional claim form 20
21 Inpatient Mental Health
Inpatient Mental Health Prior authorization is required for all inpatient psychiatric admissions, including substance abuse admissions 405 IAC-50-20-1(d) The IHCP reimburses inpatient psychiatric services for recipients between 22 and 65 years old only in certified psychiatric hospitals with 16 beds or less Inpatient psychiatric services may be provided by freestanding psychiatric facilities or distinct parts of acute care facilities Reimbursement is at an all-inclusive Statewide Level of Care (LOC) per diem, which includes routine, ancillary and capital costs Direct care physician services are excluded from the LOC per diem and are billable separately on a CMS-1500 claim form 22
Inpatient Mental Health Freestanding psychiatric facilities are eligible for the Hospital Assessment Fee (HAF) payments; The HAF adjustment factor is 2.2 (multiplied by the LOC per diem) Diagnosis-related groups (DRGs) 424 through 432 are considered psychiatric and, therefore, are reimbursed on the LOC per diem All mental health admissions, including substance abuse and chemical dependency, require a Certificate of Need, Form 1261A Bridge appointments are covered benefits as a follow-up appointment after inpatient hospitalization for behavioral health issues, when no outpatient appointment is available within seven days of discharge. 23
24 Medicaid Rehabilitation Option MRO
Medicaid Rehabilitation Option (MRO) The Family and Social Services Administration (FSSA) Division of Mental Health and Addiction (DMHA), developed a benefit plan structure for Medicaid members receiving MRO services MRO services are designed to assist in the rehabilitation of the member s optimum functional ability in daily living activities Rehabilitation is accomplished by assessing the member s needs and strengths and developing an individualized plan of care MRO services can only be provided by DMHA approved community mental health centers (CMHCs) 25
MRO Providers Three predominant categories of providers may provide MRO services Licensed professional Qualified behavioral health professional (QBHP) An individual who has had at least two years of clinical experience treating persons with mental illness under the supervision of a licensed professional OR An individual who is under the supervision of a licensed professional, is eligible for and working toward licensure, and has completed a master s or doctoral degree Other behavioral health professional (OBHP) An individual with an associate or bachelor degree, and/or equivalent behavioral health experience, meeting minimum competency standards set forth by the CMHC and supervised by a licensed professional 26
MRO Diagnosis and Level of Need All Medicaid members who have a behavioral health need are eligible for Clinic Option services Only members with a qualifying diagnosis and level of need (LON) are eligible for a MRO service package The qualifying LON, is determined by DMHA-approved assessment tools Child and Adolescent Needs and Strengths (CANS)» LON of 2 or higher eligible for MRO service package Adult Needs and Strengths Assessment (ANSA)» LON of 3 or higher eligible for MRO service package 27
MRO Covered Services The following services are covered: Behavioral Health Counseling and Therapy (Individual and Group setting) Behavioral Health Level of Need Redetermination Case Management Psychiatric Assessment and Intervention Adult Intensive Rehabilitative Services (AIRS) Child and Adolescent Intensive Resiliency Services (CAIRS) Intensive Outpatient Treatment (IOT) Addiction Counseling (Individual and Group setting) Peer Recovery Services Skills Training and Development (Individual and Group setting) Medication Training and Support (Individual and Group setting) Crisis Intervention 28
MRO Service Packages The MRO service package comprises units of services that match the needs of a majority of MRO members Example - Adult LON 3 Individual Counseling and Therapy 32 units Group Counseling and Therapy 48 units Medication Training and Support 60 units Skills Training and Development 600 units Peer Recovery Services 104 units Addiction counseling 32 hours If a member does not have a qualifying diagnosis or LON, or has a service package but needs additional units of service, a prior authorization may be submitted for MRO services 29
1915(i) Home and Community- Based Services 30
Adult Mental Health Habilitation (AMHH) 31 Program for home and community-based services to adults with serious mental illness (SMI), who have specific mental health diagnoses Home and community-based services program will allow provision of intensive home and community-based services to eligible adults age 35 and older AMHH services include: Adult Day Services Respite Care Therapy and Behavioral Supports Peer Support Services Supported Community Engagement Services Care Coordination Medication Training and Support Home and Community-Based Habilitation and Support AMHH services can only be provided by DMHA-approved CMHCs enrolled with the IHCP, and cannot be billed simultaneously with MRO services.
Child Mental Health Wraparound (CMHW) Program for home and community-based services to youth with serious emotional disturbances (SED) Home and community-based services program that allows provision of intensive home and community-based wraparound services to eligible youth ages 6 to 17 CMHW services, based on the youth s approved individualized plan of care, include: Wraparound Facilitation Habilitation Respite Family Support and Training CMHW services must be provided by DMHA-approved providers enrolled with the IHCP 32
Behavioral and Primary Healthcare Coordination Behavioral and Primary Healthcare Coordination (BPHC) is designed to assist individuals with mental illness residing in a home or community-based setting with the coordination of the behavioral and physical healthcare needs Eligible individuals include those who are 19 years of age or older, have been diagnosed with mental health conditions, and have incomes below 300% of the federal poverty level Individuals must have an eligible LON and demonstrate difficulty managing their behavioral and physical health Includes those who previously qualified for Medicaid with a spend-down, who may have lost coverage due to eligibility changes implemented in June 2014 BPHC services can only be provided by DMHA-approved CMHCs enrolled in with IHCP 33
34 Updates
Intensive Outpatient Programs Effective February 1, 2017, coverage for intensive outpatient program (IOP) services was extended to all managed care benefit packages, including Hoosier Healthwise, Healthy Indiana Plan (HIP), and Hoosier Care Connect Prior authorization is required Refer to BT201739 for additional details 35
NCCI MUE Edits for ABA Therapy The IHCP received approval from CMS to deactivate the NCCI Practitioner Medically Unlikely Edit (MUE) edits for procedure codes 96150, 96151, 96152, 96154, 96155, when billed with appropriate ABA therapy modifiers Effective for claim DOS July 1, 2016 that are processed in CoreMMIS Edit still in place for procedure code 96153 Refer to BT201705 for additional details 36
Rendering Linkage (EOB 1010) The IHCP has temporarily converted EOB 1010, ARC B7, and Remark N570 to post-and-pay status, meaning that the system will allow claims and claim details to pay. However, the EOB 1010, ARC B7, and Remark N570 messages will continue to post on the RAs. The post-and-pay status will be in place through December 31, 2017, allowing providers ample time to link rendering providers to the appropriate group locations to support proper claims adjudication. Effective January 1, 2018, the EOB 1010, ARC B7, and Remark N570 will revert to a denial status. 37
Red-and-white claim form requirement Effective January 1, 2018 the IHCP will require the below claim types to be submitted for processing on the appropriate red and white forms. CMS-1500 (02-12) professional claims UB-04 (CMS-1450) institutional claims The IHCP will no longer accept copied (black and white) claim forms on or after January 1, 2018. Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider. Note: This requirement does not effect the ADA Form 1260 as that form is only available only in black and white. 38
Billing Secondary Claims on Provider Healthcare Portal 39
When is the primary EOB required for Other Insurance (TPL)? When the TPL has denied the service as non-covered Exception If the TPL primary EOB contains an acceptable denial ARC code, the secondary windows can be completed with the ARC code, and no EOB is required When TPL has applied the entire amount to the copay, coinsurance, or deductible Services that are NON-COVERED by the primary insurance are NOT filed as a secondary claim. The secondary windows may be completed to bypass the need for the primary EOB attachment for TPL CLAIMS only 40 40
When is the primary EOB for Other Insurance information (TPL) not needed? The primary insurance COVERS the service and has PAID on the claim Actual dollars were received 41 41
42 Step 1: Other Insurance (TPL) at the Header
43 Step 2: Other Insurance (TPL) Header
44 Step 3: Other Insurance (TPL) Header
45 Step 4: Other Insurance (TPL) Header
46 Step 1: Other Insurance (TPL) Detail
Step 2: Other Insurance (TPL) Detail 10/02/2017 47
48 Step 3: Other Insurance (TPL) Additional Details
49 Step 4: Other Insurance (TPL) Additional Details
When Is the Primary Medicare or Medicare Replacement Plan EOB Required? When Medicare or the Medicare Replacement Plan denies the service 50
When Is the Primary EOB for Medicare or Medicare Replacement Plans not Needed? The Medicare or Medicare Replacement Plan COVERS the service. Actual dollars were received Entire or partial amount was applied to deductible, co-insurance or copay 51
52 Step 1: Medicare or Medicare Replacement Plan Header
53 Step 2: Medicare or Medicare Replacement Plan Header
54 Step 3: Medicare or Medicare Replacement Plan Header
55 Step 4: Medicare or Medicare Replacement Plan Header
56 Step 5: Medicare or Medicare Replacement Plan Header
57 Step 6: Medicare or Medicare Replacement Plan Header
58 Step 1: Medicare or Medicare Replacement Plan at Detail
59 Step 2: Medicare or Medicare Replacement Plan at Detail
60 Step 3: Medicare or Medicare Replacement Plan at Detail
61 Step 4: Medicare or Medicare Replacement Plan at Detail
62 Step 5: Medicare or Medicare Replacement Plan at Detail
63 Step 6: Medicare or Medicare Replacement Plan at Additional Details
64 Step 7: Medicare or Medicare Replacement Plan at Additional Details
65 Step 8: Medicare or Medicare Replacement Plan at Additional Details
66 Step 9: Medicare or Medicare Replacement Plan at Additional Details
67 Step 10: Medicare or Medicare Replacement Plan at Additional Details
68 Helpful Tools
Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Reference Modules Medical Policy Manual Customer Assistance available 8am-6pm EST Monday Friday 1-800-457-4584 IHCP Provider Relations Field Consultants See the Provider Relations Field Consultants page at indianamedicaid.com Secure Correspondence via the Provider Healthcare Portal Written Correspondence DXC Technology Provider Written Correspondence P.O. Box 7263 Indianapolis, In 46207-7263 69 69
70 Questions Following this session please review your schedule for the next session you are registered to attend