Presentation on theme: "Thom Biller User Group October 28, 2013. Program Welcome from Peter Woodbury, Group Activity – Questions and Suggestions Break 3 Types of Autism Coverage."— Presentation transcript:
Thom Biller User Group October 28, 2013
Program Welcome from Peter Woodbury, Group Activity – Questions and Suggestions Break 3 Types of Autism Coverage SSP Spreadsheet Entry Demo Questions and Discussion Lunch
Group Activity Generate 3 questions on blue cards Generate 3 suggestions on red cards
3 Levels of Complexity Simple: (ex: MED) ◦ Single autism service code and rate ◦ Single payer Moderate: (ex: HPO) ◦ Single autism service code and rate ◦ Two “payers” (one primary and one subcontracted for autism coverage) Very: (ex: BCB) ◦ Multiple service codes and rates ◦ Single payer ◦ Contractual adjustments with DPH
Simple Cases Single autism service code and rate Single payer May or may not require PA Special cases ◦ Parent present Examples ◦ Straight MED
Simple Rate File Example: MED
Simple Autism Client Setup Single Coverage (MED) ◦ MED coverage needs authorization record in Thom Biller, but may or may not need PCC
Simple Autism Client Demo
Moderately Complicated Case Examples ◦ MCO with MED Secondary ◦ Third-party insurer with behavioral health subcontractor for autism service (e.g., Harvard Pilgrim + United Behavioral Health) Primary payer rate file must not have autism service codes Secondary payer rate file must have autism service codes
MCO Rate File Example no autism services So autism services drop down to the MED secondary that does have autism rate codes.
MCO with MED Secondary Client Demo
Third Party Rate File when behavioral health arm handles autism claims No autism services in rate file. Autism services will be picked up by the secondary behavioral health payer (such as UBH)
Behavioral Health Provider Rate File for autism services No EI services codes. Only autism services.
Third Party with Behavioral Health Secondary: Client Demo
Complicated: Blue Cross High and low rates. Overbill for low rate services so balance can be transferred to DPH. “Low rate supervision” is really a direct service H2019 to Blue Cross; it is only “supervision” to DPH.
Blue Cross Client Demo
SSP Spreadsheet Load Open spreadsheet in Excel “Save As” CSV Load CSV into Thom Biller ◦ Pre-screening report warns of problems ◦ Cancel if you need to fix problems or return spreadsheet Proceed to load ◦ Each spreadsheet record is used to pre-fill an event record in Thom Biller