1. Billing for Habilitation Services
Magellan Health Services
June 11, 2013

2. Billing for Services
Magellan providers billing for Iowa Medicaid Habilitation (HAB) services must bill with HIPAA-compliant codes for services rendered beginning July 1, Claims submitted with non-HIPAA compliant codes (e.g. old W codes) will be denied.

3. Provider Billing Tips Coding changes are effective July 1, 2013.
Billing the new HIPAA codes is mandatory; non-compliance is a HIPAA violation.
The switch to the new HIPAA codes is based on the date of service, not the date the claim was submitted.
Be sure to include required modifier.
Use covered diagnosis codes.
Use valid place of service codes.
Submit claims timely. Timely filing limit is 1 year from date of service.
These services require pre-authorization. To authorize services, please call to schedule an appointment.

4. Provider Billing Codes
IA Medicaid HAB Service Name
Time Unit/Basis
Old W Code
New
HIPAA Code
HIPAA Modifier*
Day Habilitation
Per 15 Min
W1206
T2021 UC
Per Day
W1204
T2020
Home-based habilitation
W1207
H2015
W1208
H2016
Pre-Vocational Services
Per Hour
W4425
T2015
W1425
T2014
Supported Employment:
Maintain employment/job coaching
W1431
H2025
Maintain employment/enclave
W1433
H2023
Job Development
Per Unit
W5019
T2018
Employer Development
W5020
H2024
Enhanced Job Search
W5021
H2019
*For all Iowa Medicaid Habilitation services, the UC modifier must be included on claims. Claims for this service submitted without this modifier will be denied.

5. Magellan Covered Diagnosis
Code
Description
290
Senile and presenile organic psychotic conditions
291
Alcoholic psychoses
292
Drug psychoses
293
Transient organic psychotic conditions
294
Other organic psychotic conditions (chronic)
295
Schizophrenic disorders
296
Affective psychosis
297
Paranoid states
298
Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology)
299
Psychoses with origin specific to childhood
300
Anxiety states
301
Personality disorders
302
Sexual deviations and disorders
306
Physiology malfunction arising from mental factors
307
Special symptoms or syndromes, not elsewhere classified
308
Acute reaction to stress
309
Adjustment reaction
311
Depressive disorder, not elsewhere classified
312
Disturbance of conduct, not elsewhere classified
313
Disturbance of emotions specific to childhood and adolescence
314
Attention deficit disorder
Note: – Mental Retardation is NOT covered.

6. Place of Service (POS) Codes
Definition 03
School 32
Nursing Facility 04
Homeless Shelter 33
Custodial Care Facility 11
Office 49
Independent Clinic 12
Home 50
Federally Qualified Health Center 13
Assisted Living Facility 53
Community Mental Health Center 14
Group Home 54
Intermediate Care Facility 22
Outpatient Hospital 57
Non-residential SA Treatment Facility 23
Emergency Room 71
State or Local Health Clinic 31
Skilled Nursing Facility 72
Rural Health Clinic

7. Rounding Rules – 15 Min. Unit
Add together the minutes spent on all billable activities during a calendar day for a daily total.
For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.
Round the remainder using these guidelines: round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.
Add the number of full and rounded units to determine the total number of units to bill for that day.
Providers will not determine daily units by the number of encounters they have with the member during a day, but by the total amount of time spent with the member.
Units will not be determined by adding the number of minutes of service for the month and then dividing; units are to be determined on a daily basis.

8. Rounding Rules – Hourly Units
Add all the minutes provided for a day.
When the total minutes for the day is less than 60, round up to one (1) whole unit.
When the total minutes for the day is more than 60, divide the total by 60 to get the number of hours for the day. This should be rounded to the nearest whole unit, by rounding down for 1-30 minutes, and rounding up for minutes.

9. Daily Units
Daily Home-Based HAB is defined as 8 or more hours per day, based on the average hours of service provided during a 24-hour period as an average over a calendar month.
Day HAB and Prevocational Services, the daily unit is defined as 4.25 to 8 hours per day. There is no averaging for these services.

10. Authorizations
Existing service plans for HAB services active as of July 1, 2013, will be honored by Magellan.
Magellan staff will be reviewing service plans for members whose plan has an end date of August 2013.
Magellan staff will be contacting HAB providers on any existing ETP needing renewal.
For new HAB clients July 1, 2013 or after – the case manager or Integrated Health Home (IHH) staff should contact Magellan at to make an appointment to review a new HAB request.

11. Getting Paid Claim Submission Submit a “Clean” Claim
Electronic Claim Submission
Paper Claim Submission
Submit a “Clean” Claim
Submit Within Timely Filing Guidelines
Claims must be completely adjudicated within one year of date of service.

12. Top Claim Denial Reasons
No authorization
Client not eligible for services
Duplicate claim submission
Invalid diagnosis codes
Invalid CPT/HCPCS codes
Invalid or missing modifier or place of service code
Missing name and degree of provider – CMS 1500 only
Site not contracted/credentialed
Sites ON contract means you should bill that rendering site.
Sites NOT on contract means you should bill the main site as the rendering site.

13. Electronic Claim Submission – Preferred Method What’s in it for you?
Improved Efficiency
No paper claims, envelopes or stamps.
Prompt confirmation of receipt or incomplete claim.
Faster Reimbursement – cuts out the mailman, “clean” claims processed within 36 hours.
Improved Quality
Up-front electronic review ensures higher
percentage of clean claims.
Secure process with encryption keys,
passwords, etc.

14. Electronic Claim Submission Options
Claims Courier – Magellan’s Web Option
Small volume submitters
Direct Submission to Magellan
Medium to high volume submitters
Clearinghouse
Large volume submitters

15. Website Resources

16. On-Line Resources

17. On-Line Resources, cont.

18. Electronic Claim Submission – On-Line Training Available
Go to .
Choose “Education”, and then “Online Training”.
The section on “Electronic Transactions” includes the following demos:
835 Transactions
Clearinghouse
Submit EDI Claims
EDI Testing Center
Electronic Funds Transfer

19. EDI Technical Assistance General Website Technical Assistance
Claims/Website Contact Information
General Billing Questions Customer Service at
EDI Technical Assistance
Getting Started – visit our EDI Testing Center at
EDI Hotline at , ext or
General Website Technical Assistance
For all other website technical assistance, call Provider Services at

20. Magellan Customer Service Contact Information
Customer Service – ; Fax
Christine Bryant, Customer Svc. Supervisor, –
Dennis Petersen, Director, Operations, –
Claims address:
PO Box 1869
Maryland Heights, MO 63043
Customer Service address:
PO Box 71129
Des Moines, IA 50325

21. Questions?