Presentation on theme: "Billing for Habilitation Services"— Presentation transcript:
1Billing for Habilitation Services Magellan Health ServicesJune 11, 2013
2Billing for ServicesMagellan 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.
3Provider 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.
4Provider Billing Codes IA Medicaid HAB Service NameTime Unit/BasisOld W CodeNewHIPAA CodeHIPAA Modifier*Day HabilitationPer 15 MinW1206T2021UCPer DayW1204T2020Home-based habilitationW1207H2015W1208H2016Pre-Vocational ServicesPer HourW4425T2015W1425T2014Supported Employment:Maintain employment/job coachingW1431H2025Maintain employment/enclaveW1433H2023Job DevelopmentPer UnitW5019T2018Employer DevelopmentW5020H2024Enhanced Job SearchW5021H2019*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.
5Magellan Covered Diagnosis CodeDescription290Senile and presenile organic psychotic conditions291Alcoholic psychoses292Drug psychoses293Transient organic psychotic conditions294Other organic psychotic conditions (chronic)295Schizophrenic disorders296Affective psychosis297Paranoid states298Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology)299Psychoses with origin specific to childhood300Anxiety states301Personality disorders302Sexual deviations and disorders306Physiology malfunction arising from mental factors307Special symptoms or syndromes, not elsewhere classified308Acute reaction to stress309Adjustment reaction311Depressive disorder, not elsewhere classified312Disturbance of conduct, not elsewhere classified313Disturbance of emotions specific to childhood and adolescence314Attention deficit disorderNote: – Mental Retardation is NOT covered.
6Place of Service (POS) Codes Definition03School32Nursing Facility04Homeless Shelter33Custodial Care Facility11Office49Independent Clinic12Home50Federally Qualified Health Center13Assisted Living Facility53Community Mental Health Center14Group Home54Intermediate Care Facility22Outpatient Hospital57Non-residential SA Treatment Facility23Emergency Room71State or Local Health Clinic31Skilled Nursing Facility72Rural Health Clinic
7Rounding 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.
8Rounding 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.
9Daily UnitsDaily 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.
10AuthorizationsExisting 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.
11Getting Paid Claim Submission Submit a “Clean” Claim Electronic Claim SubmissionPaper Claim SubmissionSubmit a “Clean” ClaimSubmit Within Timely Filing GuidelinesClaims must be completely adjudicated within one year of date of service.
12Top Claim Denial Reasons No authorizationClient not eligible for servicesDuplicate claim submissionInvalid diagnosis codesInvalid CPT/HCPCS codesInvalid or missing modifier or place of service codeMissing name and degree of provider – CMS 1500 onlySite not contracted/credentialedSites ON contract means you should bill that rendering site.Sites NOT on contract means you should bill the main site as the rendering site.
13Electronic Claim Submission – Preferred Method What’s in it for you? Improved EfficiencyNo 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 QualityUp-front electronic review ensures higherpercentage of clean claims.Secure process with encryption keys,passwords, etc.
14Electronic Claim Submission Options Claims Courier – Magellan’s Web OptionSmall volume submittersDirect Submission to MagellanMedium to high volume submittersClearinghouseLarge volume submitters
18Electronic Claim Submission – On-Line Training Available Go to .Choose “Education”, and then “Online Training”.The section on “Electronic Transactions” includes the following demos:835 TransactionsClearinghouseSubmit EDI ClaimsEDI Testing CenterElectronic Funds Transfer
19EDI Technical Assistance General Website Technical Assistance Claims/Website Contact InformationGeneral Billing Questions Customer Service atEDI Technical AssistanceGetting Started – visit our EDI Testing Center atEDI Hotline at , ext orGeneral Website Technical AssistanceFor all other website technical assistance, call Provider Services at
20Magellan Customer Service Contact InformationCustomer Service – ; FaxChristine Bryant, Customer Svc. Supervisor, –Dennis Petersen, Director, Operations, –Claims address:PO Box 1869Maryland Heights, MO 63043Customer Service address:PO Box 71129Des Moines, IA 50325