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Billing for Habilitation Services

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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, 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.

4 Provider Billing Codes
IA Medicaid HAB Service Name Time Unit/Basis Old W Code New HIPAA Code HIPAA Modifier* Day Habilitation Per 15 Min W1206 T2021 UC Per Day W1204 T2020 Home-based habilitation W1207 H2015 W1208 H2016 Pre-Vocational Services Per Hour W4425 T2015 W1425 T2014 Supported Employment: Maintain employment/job coaching W1431 H2025 Maintain employment/enclave W1433 H2023 Job Development Per Unit W5019 T2018 Employer Development W5020 H2024 Enhanced Job Search W5021 H2019 *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
Code Description 290 Senile and presenile organic psychotic conditions 291 Alcoholic psychoses 292 Drug psychoses 293 Transient organic psychotic conditions 294 Other organic psychotic conditions (chronic) 295 Schizophrenic disorders 296 Affective psychosis 297 Paranoid states 298 Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology) 299 Psychoses with origin specific to childhood 300 Anxiety states 301 Personality disorders 302 Sexual deviations and disorders 306 Physiology malfunction arising from mental factors 307 Special symptoms or syndromes, not elsewhere classified 308 Acute reaction to stress 309 Adjustment reaction 311 Depressive disorder, not elsewhere classified 312 Disturbance of conduct, not elsewhere classified 313 Disturbance of emotions specific to childhood and adolescence 314 Attention deficit disorder Note: – Mental Retardation is NOT covered.

6 Place of Service (POS) Codes
Definition 03 School 32 Nursing Facility 04 Homeless Shelter 33 Custodial Care Facility 11 Office 49 Independent Clinic 12 Home 50 Federally Qualified Health Center 13 Assisted Living Facility 53 Community Mental Health Center 14 Group Home 54 Intermediate Care Facility 22 Outpatient Hospital 57 Non-residential SA Treatment Facility 23 Emergency Room 71 State or Local Health Clinic 31 Skilled Nursing Facility 72 Rural 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 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.

11 Getting Paid Claim Submission Submit a “Clean” Claim
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 What’s 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 – Magellan’s Web Option Small volume submitters Direct Submission to Magellan Medium to high volume submitters Clearinghouse Large volume submitters

15 Website Resources

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 EDI Technical Assistance General Website Technical Assistance
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 63043 Customer Service address: PO Box 71129 Des Moines, IA 50325

21 Questions?

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