 Contract Budgets  Invoice/Billing Process  Medi-Cal Billing  Cost Report  Productivity  Reports  Procedures  Resources Handout: PowerPoint Presentation Tab

 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