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

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Presentation on theme: "Billing for Habilitation Services Magellan Health Services June 11, 2013."— Presentation transcript:

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, 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 NameTime Unit/BasisOld W Code New HIPAA Code HIPAA Modifier* Day HabilitationPer 15 MinW1206T2021UC Day HabilitationPer DayW1204T2020UC Home-based habilitationPer 15 MinW1207H2015UC Home-based habilitationPer DayW1208H2016UC Pre-Vocational ServicesPer HourW4425T2015UC Pre-Vocational ServicesPer DayW1425T2014UC Supported Employment: Maintain employment/job coachingPer 15 MinW1431H2025UC Supported Employment: Maintain employment/enclavePer 15 MinW1433H2023UC Supported Employment: Job DevelopmentPer UnitW5019T2018UC Supported Employment: Employer DevelopmentPer UnitW5020H2024UC Supported Employment: Enhanced Job SearchPer 15 MinW5021H2019UC *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 CodeDescription 290Senile and presenile organic psychotic conditions 291Alcoholic psychoses 292Drug psychoses 293Transient organic psychotic conditions 294Other organic psychotic conditions (chronic) 295Schizophrenic disorders 296Affective psychosis 297Paranoid states 298 Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology) 299Psychoses with origin specific to childhood 300Anxiety states 301Personality disorders 302Sexual deviations and disorders 306Physiology malfunction arising from mental factors 307Special symptoms or syndromes, not elsewhere classified 308Acute reaction to stress 309Adjustment reaction 311Depressive disorder, not elsewhere classified 312Disturbance of conduct, not elsewhere classified 313Disturbance of emotions specific to childhood and adolescence 314Attention deficit disorder Note: – Mental Retardation is NOT covered.

6 Place of Service (POS) Codes CodeDefinitionCodeDefinition 03School32Nursing Facility 04Homeless Shelter33Custodial Care Facility 11Office49Independent Clinic 12Home50Federally Qualified Health Center 13Assisted Living Facility53Community Mental Health Center 14Group Home54Intermediate Care Facility 22Outpatient Hospital57Non-residential SA Treatment Facility 23Emergency Room71State or Local Health Clinic 31Skilled Nursing Facility72Rural 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 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 – 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 Whats 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 – Magellans Web Option – Small volume submitters Direct Submission to Magellan – Medium to high volume submitters Clearinghouse – Large volume submitters

15 Website Resources com com com com

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 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 Customer Service address: PO Box Des Moines, IA 50325

21 Questions?


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