Service Budgets › Mental Health Services Outpatient Mental Health Services Group Home TBS › Triple P › Budget Transfers Advance Request in writing No Transfers from Triple P to Mental Health Services
Provider submits DCFs to County County verifies Authorization for services Provider submits Invoice to County County verifies services against DCFs County submits invoice to Auditor/Controller for payment County enters services & submits billing to DMH DMH adjudicates claim and submits to DHCS DHCS submits to CMS (Fed) CMS pays DHCS DMH pays County DHCS pays DMH
Short Doyle Medi-Cal Phase II requires billing primary insurance prior to billing Medi-Cal Bill Medi-Cal following denial › Provide EOB with acceptable denial code Bill Medi-Cal if no response from primary insurance in 90 days › Provide copy of HCFA to confirm OHC was billed timely Services billed direct to Medi-Cal (without billing to OHC) › T1017 – Case Management › H2019 – TBS (not H0031TG – TBS functional behavior analysis) Medi-Cal Code V › County can request removal › If code changes to A, OHC must be billed
Review EOB for denial reason Requested additional information must be provided to insurance Acceptable denial code › Not a covered service › Paid a portion Bill remaining amount to Medi-Cal › Not a contracted provider
Annual fiscal report reconciling total costs and total units › Establishes actual rate Actual rate is used as interim rate › Medi-Cal Units are settled to actual rate with providers Up to Statewide Maximum Allowance (SMA) Up to total Contract Amount Service Categories still apply › All Triple P units are settled to actual rate
Costs by Service Category should never exceed Contract Max › Consistent costs Keeping costs within the contract budget ensures providers will be kept whole as long as: Settled rate is less than SMA All units are paid by Medi-Cal Increased/Decreased total units affect rate but do not affect settled reimbursement.
Example 1 – Consistent Costs & Units › Provider Contract - $120,000 max › Provider actual expenditures - $10,000/month ($120,000 total) › Provider units of service – 10,000/month › Interim Rate - $1.00 › Settled Rate - $1.00 › Provider receives total reimbursement by June › Total paid - $120,000 Example 2 – Consistent Costs & Increased Units › Provider Contract - $120,000 max › Provider actual expenditures - $10,000/month ($120,000 total) › Provider units of service – 15,000/month › Interim Rate - $1.00 › Settled Rate - $.67 › Provider receives total reimbursement by March › Total paid - $120,000
Example 3 – Increased Cost & Units › Provider Contract - $120,000 max › Provider actual expenditures - $11,000/month ($132,000 total) › Provider units of service – 11,000/month › Interim Rate - $1.00 › Settled Rate - $1.00 › Provider reimbursement does not cover actual expenditures › Total paid - $120,000
Definition › The amount of time spent providing direct service as a percentage of total hours paid Purpose › Ensures we provide as many quality services as we can within the resources we have available
Total Productive Hours/Total Paid Hours › Productive Hours Direct Client Service Hours (billed time) › Total Paid Hours All paid hours Regular Hours Worked Paid Time Off Overtime
Triple P – Billing private insurance Transitioning youth at 21 Notification of major incident Referrals › Medi-Cal › Triple P Medi-Cal Walk In HHSA
Annual TAR Process › Start Date September 1 TARS submitted prior to September 1 TARS that had an initial authorization period prior to September 1 Coordinating Assessments with TARS Do another assessment with TAR regardless of when the new assessment is due TAR authorization period to match assessment due date
Updated Contact Information Updated Org Provider Manual › In process Updated version will be provided by the QM meeting in October Billing Codes
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