Illinois Department of Human Services Division of Mental

Illinois Department of Human Services / Division of Mental Health and Illinois Mental Health Collaborative Present ICG Claims Submission Training March 2009

ICG Claims l ICG Residential and Community Service claims may be submitted to the Collaborative for dates of service 4/1/09 and after. l Program Codes: Residential - ICG Community - ICGC 2

ICG Residential Per Diem and Community Services Workflow l l 3 Provider submits claim to Collaborative processes claim resulting in a Provider Voucher or 835 Collaborative sends claim information to DHS/DMH issues payment to provider

ICG Residential Services Claim Submission l l 4 Authorization is required Submit on 837 P or Direct Claim Submission Quarterly Report is required timely. If not received, claims for dates of service after it is due will be denied Per Diem and Encounter Claims are submitted separately

ICG Residential Services Claim Submission 5 l Per Diem Codes – submit actual charges l Always bill residential services with place of service code 11 l Bill Per Diem Room & Board type codes with 1 unit/day

ICG Residential Services Encounter Services Claim Submission l l 6 Encounter services are the professional services provided during residential stay Use Program Code ICG for encounter services during a residential stay Use Place of Service code 11 See Website http: //www. illinoismentalhealthcollaborative. c om

ICG Residential Encounter Services Claim Submission, continued 7 l Message code on Provider Voucher states that services were included in per diem l 835 message code is 97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

ICG Claims - Quarterly Report Residential and Community Service Claims will reject if quarterly report is not submitted. Once submitted, provider is responsible to resubmit rejected claims. 8

ICG Residential Per Diem (room & board) Service Codes CPT H C P CS 9 New Modifier Order W Code 1 2 3 Service Name Bill Unit (hrs) S 9986 W 017 B ICG services, group home, bedhold Day S 9986 W 017 M ICG services, group home, consumer present Day S 9986 W 019 B ICG services, residential, bedhold Day S 9986 W 019 M ICG services, residential, consumer present Day S 9986 W 020 B ICG services, special unit 1, residential, bedhold Day S 9986 W 020 M ICG services, special unit 1, residential, consumer present Day S 9986 W 021 B ICG services, special unit 2, residential, bedhold Day W 021 M ICG services, special unit 2, residential, consumer present Day S 9986

ICG Residential Encounter Service Codes CPT HCPCS 10 W Code New Modifier Order 1 2 Service Name 3 Bill Unit (hr s) H 0031 AH Mental health assessment (LCP) 0. 25 H 0031 HN Mental health assessment (MHP) 0. 25 H 0031 HO Mental health assessment (QMHP, AM/MA) 0. 25 H 0032 HN Treatment plan development, review, modification (MHP) 0. 25 H 0032 HO Treatment plan development, review, modification (QMHP) 0. 25 90862 52 Psychotropic medication monitoring 0. 25 90862 SA Psychotropic medication monitoring (APN) 0. 25 90862 UA Psychotropic medication monitoring (MD/DO/DC) 0. 25 H 0002 HE Case management - LOCUS H 0004 HN Therapy/counseling--individual (MHP) 0. 25 H 0004 HO Therapy/counseling--individual (QMHP) 0. 25 H 0004 HQ HN Therapy/counseling--group (MHP) 0. 25 H 0004 HQ HO Therapy/counseling--group (QMHP) 0. 25 H 0004 HR HN Therapy/counseling--family (MHP) 0. 25 H 0004 HR HO Therapy/counseling--family (QMHP) 0. 25 Event

ICG Residential Encounter Service Codes CPT HCPCS W Code New Modifier Order 1 2 Bill Unit (hr s) Psychotropic medication training--Individual 0. 25 Psychotropic medication training--group (APN) 0. 25 3 H 0034 HN H 0034 HQ Psychotropic medication training--group 0. 25 H 0034 SA Psychotropic medication training--Individual (APN) 0. 25 Crisis intervention--multiple staff 0. 25 SA H 2011 11 Service Name H 2011 HT H 2015 HE HM Community support, residential, individual (RSA) 0. 25 H 2015 HE HN Community support, residential, individual (MHP) 0. 25 H 2015 HE HO Community support, residential, individual (QMHP) 0. 25 H 2015 HQ HM HE Community support, residential, group (RSA) 0. 25 H 2015 HQ HN HE Community support, residential, group (MHP) 0. 25 H 2015 HQ HO HE Community support, residential, group (QMHP) 0. 25 H 2017 HM Psychosocial rehabilitation, individual (RSA) 0. 25 H 2017 HN Psychosocial rehabilitation, individual (MHP) 0. 25 H 2017 HO Psychosocial rehabilitation, individual (QMHP) 0. 25

ICG Residential Encounter Service Codes 12 New Modifier Order W Code S 9986 W 00 V 1 Vocational assessment 0. 25 S 9986 W 00 V 2 Vocational engagement, group 0. 25 S 9986 W 00 V 3 Vocational engagement, individual 0. 25 S 9986 W 00 V 4 Job finding supports, group 0. 25 S 9986 W 00 V 5 Job finding supports, individual 0. 25 S 9986 W 00 V 6 Job retention supports, group 0. 25 S 9986 W 00 V 7 Job retention supports, individual 0. 25 S 9986 W 00 V 8 Job leaving/termination supports, group 0. 25 S 9986 W 00 V 0 Job leaving/termination supports, individual 0. 25 1 2 3 Service Name Bill Unit (hrs) CPT HCPCS

ICG Community Services Claims Submission l l l 13 Use Program Code ICGC Follow Service Matrix for covered Community Service codes Follow same rules as submitting ABC services (rolling services, units, etc. )

ICG Community Services Two services require an authorization after maximum is met: W 072 M - ICG Child Support Services Authorization is required after $1570 in approved claims per consumer in the fiscal year l W 097 M - ICG Behavior Management Authorization is required after $3500 in approved claims per consumer in the fiscal year l 14

ICG Community New Service Codes 15 S 9986 W 051 M ICG application assistance S 9986 W 072 M ICG child support services S 9986 W 097 M ICG behavior management

Questions? 16

Claims Submission

Claims and Service Reporting Training Agenda l l l l 18 Billing and Service Reporting Guidelines Direct Claim Submission on Provider. Connect HIPAA 837 P Technical Information EDI Claims Set-up Claim Helpful Hints Billing with Psuedo-RINs e. Claims link on Provider. Connect

Service Reporting Under the Collaborative IT system, all services are submitted as claims. Mental Health claims must be submitted electronically and meet all HIPAA compliance standards l HIPAA standards govern both the file format and the codes used within the file l Some claims require data elements for which there are no standard fields. The notes fields will be used to submit these values 19

HIPAA 837 P Software The Illinois Collaborative will accept all HIPAA compliant 837 P formatted files Files must include all required DHS/DMH data elements The Illinois Collaborative provides free electronic claims submission software l e. Claims Link, or l Direct Claims Submission (web-based) 20

Billing Guidelines Required Claims Data

Registration Requirement Before claim is submitted, consumer must be registered by the agency performing the service 22

Consumer Information l l 23 Standardized claims transactions require certain consumer information to verify the individual’s identity The Collaborative has minimized the consumer information necessary for a claim to be submitted, while assuring that each service claim is correctly associated to the appropriate consumer

Claim Level Information Consumer Information Required • RIN Consumer Name Date of Birth • Gender • All must match exactly to the registration information on file Consumer address is optional • • • 24

Claim Level Information (cont. ) Pseudo RIN • • Appropriate only for specific services when a specific consumer isn’t identified A list of these pseudo RIN numbers, name, and date of birth is provided on-line at http: //www. illinoismentalhealthcollaborative. com/ For example, ICG Application Assistance can be billed with a pseudo RIN if consumer information is not available. 25

Claim Level Information (cont. ) Provider Information required on each claim l l 26 10 digit NPI number that matches the NPI on file with the Collaborative Tax ID Number (FEIN) Service Location Taxonomy Codes are optional Service code and modifier combinations will identify staff level

Claim Level Information (cont. ) Subcontractors The Subcontractor’s Federal Employer ID Number (FEIN) must be provided when subcontracting services to a different agency 27

Claim Level Information (cont. ) Program Codes Submit the Program Code for the service provided: l Program Codes: l Residential - ICG Community - ICGC 28

Claim Line Level Information Service Codes 29 l Service codes must be valid HCPCS or CPT codes as shown on Service Matrix found at http: //www. illinoismentalhealthcollaborative. com/ l Service code S 9986 is used when a “W” code specifies the service. The W code is entered in claim line notes (LOOP 2400)

Claim Line Level Information (cont. ) Modifiers l l 30 Staff Level Modifiers drive the allowable amount applied to a service – If no staff level modifier is submitted, the lowest allowable amount for the service code is assumed Modifier Position is very important – Staff Level Modifier should always be in the last modifier position when multiple modifiers are submitted

Claim Line Level Information (cont. ) Staff Level Modifiers l l l 31 l AH – LCP - Licensed Clinical Psychologist HN – MHP - Mental Health Professional HO – QMHP - Qualified Mental Health Professional SA – APN -Advanced Practice Nurse HM – RSA - Rehabilitative Services Associate UA – MD, DO, DC

Claim Line Level Information (cont. ) Diagnosis Codes 32 l Must be ICD-9 and include 4 th and 5 th digit according to ICD-9 guidelines l Only Mental Health diagnoses that are DMH/DHS defined will be accepted.

Claim Line Level Information (cont. ) Line Notes For all services, the following are required: l Delivery method l Service start time l Service duration l Staff ID Situational Requirements: l Activity code is required for S 9986 services l For group based services show the group id, # clients in group, and # of staff in the group 33 DMH considers these data elements to be important and necessary components of billing and service reporting

Review Services Matrix The Service Matrix provides the following information: Specific activities/services that are to be reported for S 9986 Information regarding the use of specific pseudo-RINS for consumers who are not identifiable (previously referred to as unregistered consumers). This information will be posted on the Collaborative Website in an Excel Spreadsheet that you may download. http: //www. illinoismentalhealthcollaborative. com/ 34

Questions? 35

Direct Claim Submission For all providers

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Provider. Connect 39

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EDI Claims Link/Batch submissions l l l 42 l The Collaborative can receive your 837 Batch transaction directly Access the Collaborative web site at www. valueoptions. com Access “For Providers” on the left hand side of the screen Access Handbooks – Administration- Online Services. Required Forms referenced in Online Services are available by accessing the forms menu on the left side of the screen EDI help is available from e. Support Services at 1. 888. 247. 9311 (Mon-Fri. 8 am – 6 pm EST)

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Technical Information Third Party Software 837 P submissions

Illinois Health Care Claim Companion Guide 837 Professional HIPAA 4010 Version The Companion Guide only applies to DHS/DMH specific services l l 51 The same requirements apply for third party software as well as the Collaborative’s free software The loops in this guide are in numerical order only to facilitate discussion

Standard Implementation Guide For complete technical information, please refer to the Standard Implementation Guide which contains the entire set of instructions for the EDI HIPAA 4010 version of the 837 P The Implementation Guide must be purchased. l 52 The sequencing of the loops should follow that specified within the Implementation Guide

Consumer Information l Loop 2000 B- Consumer Information – l Loop 2010 BA- Consumer Name – – 53 DMS/DMH Program Code Name should be shown as it is in the enrollment system RIN or Pseudo- RIN

Billing/Pay to Provider Information l Loop 2010 AA- Billing Provider Name – – l Loop 2010 AB- Pay- to- Provider Name – 54 Agency NPI (National Provider Identifier) FEIN Required if Pay-to is different than Billing Provider

Purchased Service Provider/Service Facility Location l Loop 2310 C- Purchased Service Provider – l Loop 2310 D- Service Facility Location – – 55 FEIN is required when Subcontractor is used If not using a subcontractor, and the service location is different than Billing Provider location this must be completed If Subcontractor is used, this field should be blank

Claim Level Information l Loop 2300 - Claim Information – – – 56 Individual Client. ID | Claim. ID POS (Place of Service) Assignment of Benefits Diagnosis Codes Claim Notes l Qualification Levels for staff – 01 = LPHA – 02 = QMHP – 03 = MHP – 04 = RSA

Service Line l Loop 2400 - Service Line – Procedure code l For Section E (capacity grant services) services use S 9986 – – Modifiers l – – – 57 Add appropriate W-code in note segment Maximum of four modifiers, last modifier must be staff level modifier Units Date of Service Line Control Number l up to 30 bytes

Service Line (cont. ) l Line Notes – This field is used for various data needs. Please be sure to include the pipe (|) between the identifiers. If pipe does not work in your software you can use a semi colon (; ). l W- code (non-standard codes for capacity grant services/Section E) – 58 Delivery Method l Face to face l Telephone l Video

Service Line (cont. ) l Time Service begin date (military time) – Duration in minutes (000) – l Group based services – Group ID – # clients in group – # staff in group l Staff ID 59

Coordination of benefit information l Loop 2320 - Other Consumer Information – Other insurance information l l Loop 2330 B- Claims adjudication date – 60 Insurance Code Carrier allowed amount Carrier paid amount Date of other insurance payment

Submitting Corrected/Replacement Claims LOOP 2300 – CLAIM INFORMATION l When an original claim was denied or incorrectly billed, send a corrected or replacement claim by indicating the Claim Frequency Type Code 6=Corrected – 7=Replacement – l 61 Enter the Collaborative’s original Claim Number prefixed with “RC” in the Reference Identification

EDI Claim Submission For all providers

EDI Claims Set-up Submit via http: //www. illinoismentalhealthcollaborative. com The same guidelines apply for all submitters regardless of the software used to submit a file l l All submitters must submit a completed Account Request Form Billing agents must also submit an Intermediary Form – – – 63 Fax forms to 866 -698 -6032 Allow 3 days for your submitter account to be set up You will receive an email with your ID and Password You will be set up in test mode After submitting a successful file, call to be taken out of test mode

EDI Claims Set-up cont. Submit file l 1 st email from e. Support confirms receipt of file l 2 nd email from e. Support confirms pass/failure of file – 64 If file fails email will give you the reason for failure EDI Helpdesk l 888 -247 -9311 l M-F 8 -6 EST

Collaborative’s Website for Claims Activities l l l 65 Access the Collaborative web site at www. illinoismentalhealthcollaborative. com Select “For Providers” on the left hand side of the screen Access Handbooks – Administration- Online Services. Required Forms referenced in Online Services are available by accessing the forms menu on the left side of the screen EDI help is available from e. Support Services at 1. 888. 247. 9311 (Mon-Fri. 8 am – 6 pm Eastern)

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Questions? 75

Claims Helpful Hints

Helpful Hints to Faster Claim Processing l Submit the Consumer’s RIN in the Patient ID field – 77 if the RIN doesn’t match the DHS assigned number, the claim will be uploaded to our claims processing system identifying the Consumer as “UNKNOWN” please submit the correct RIN

Helpful Hints to Faster Claim Processing (cont. ) l To be in compliance with HIPAA Regulations, the National Provider Identifier (NPI) must be submitted on all claims. The Agency NPI should be entered into the NPI field – If the NPI is not on the claim, the file will be rejected – 78 If the NPI submitted does not match the NPI we have on file for your agency, the claim will be delayed for resolution of the NPI discrepancy

Helpful Hints to Faster Claim Processing (cont. ) Examples Agency has multiple sub-NPIs for various service locations in addition to the Agency NPI: – – 79 Submit the Agency NPI in Billing Pay-to loop, enter the Service Location NPI in Service location loop All NPIs used on the 837 P must be on file with the Collaboration Agency has multiple sub-NPIs by Program. – Enter Agency NPI in Billing Pay-to loop, Program NPI in Service location loop

Helpful Hints to Faster Claim Processing (cont. ) When billing for specific services that allow or require a “pseudo- RIN” enter the pseudo RIN exactly as provided to you. Also enter the pseudo-name and date of birth associated to the pseudo- RIN exactly as shown. 80

Helpful Hints to Faster Claim Processing (cont. ) l Multiple units of service rendered by the same practitioner staff level, on the same day, for the same client, must be submitted on one claim. – – 81 All units for one service code must be submitted on one line. If claims are submitted separately, claims will be denied as a duplicate service.

Helpful Hints to Faster Claim Processing (cont. ) l 82 Example: H 2015 HN Community support, individual (MHP) For Consumer RIN 123456789 – 10 AM 4 units, noon 2 units, 6 PM 3 units – Submit H 2015 HN on one line, with 9 units. Start time is 10 AM, duration: 135 minutes

Helpful Hints to Faster Claim Processing (cont. ) A separate claim must be submitted for every different staff level rendering services (except for multiple disciplinary groups) 83

Most Common Reasons for Claim Denial Consumer Information: – – 84 RIN doesn’t match the RIN assigned by DHS or registration Service code on the claim is not on the list of covered service Service code billed is not one the provider is contracted to render (the service is not on the provider’s fee schedule). Consumer is not eligible on the date of service.

Most Common Reasons for Claim Denial (cont. ) Codes/Modifiers – – – 85 Service code is not a covered code Place of service code on the claim is not a valid place of service code for the service rendered Modifier code billed on the claim is not valid with the CPT or HCPCS code Staff level modifier is not billed on the claim Diagnosis code is not current ICD-9 standard Diagnosis code does not contain a required 4 th or 5 th digit

Most Common Reasons for Claim Denial (cont. ) Authorization – – 86 There is not an authorization in the system for the date of service billed or for the provider There is an authorization on the system but the dates of service on the claim are either before the effective date or after the expiration date of the authorization

Timely Filing of Claims 87 l Claims for all services must be received by the Collaborative within 365 days of the date of service l Claims Involving Third Party Liability (TPL) must be received by the Collaborative within 365 days of the date of the other carrier’s Explanation of Benefits (EOB), or notification of payment / denial. l Timely filing limit applies to replacement claims as well as original claims; claims must be received by the Collaborative within 365 days from date of service.

Billing with Pseudo-RIN

Reason for Pseudo-RINS The database has entries for pseudo consumers to be used for reporting services to consumers known in the current system as un-registered consumers. This helps to identify what populations (children/adolescents, adults, homeless persons) are served under capacity grants 89

Pseudo-RIN Example: if a provider is billing for Urban systems of Care (Program Code 140): – – – 90 for a child or adolescent use Pseudo-RIN 140001 for an adult use Pseudo-RIN 140002 for a group of consumers, or not consumer related use Pseudo-RIN 140000

Pseudo-RIN cont. Certain client information is required for all claims to help identify the claim for reporting purposes: Each Pseudo-RIN has a specific Pseudo-consumer name, date of birth (DOB), and gender: – – 91 DOB used for Any/All Groups Pseudo – 01 -01 -1980 DOB used for Child/adolescent- 01 -01 -2000 DOB used for Adult – 01 -01 -1970 Gender is always U

Pseudo-RIN (cont. ) l l The provider should always use the most definitive Pseudo-RIN available for the program. For example, there is a different Pseudo-RIN for a child or adult who is homeless or not, under the PATH Grant program. The following funds will always be associated to a Pseudo-RIN. There will never be a consumer attached to these funds. – – – 92 – Urban Systems of Care Geropsychiatric Services Co-Location Project Crisis Staffing Service 140 576 580

Pseudo-RIN (cont. ) The following funds will never be associated to a Pseudo. RIN. Provider can only bill with true RINs for services in these programs: 93 CHIPS ICG Medicaid/ non Medicaid FFS CILA Supported Res Permanent Supported Housing Supervised Res Crisis Residential 550 ICG ABC 620 821 830 860

Questions and Answers 94

Thank you! Illinois Mental Health Collaborative for Access and Choice

Comparison of Submission Methods Action/Fields 96 Direct Claim Submission (DCS) ECLW - Batch Claim Submission Provider access to claim submission method Via website Provider. Connect Downloaded to provider's computer desktop Claims Corrections As each claim is submitted through Provider. Connect it is immediately adjudicated in the Collaborative's system. Once submitted, no changes can be made to it. If an error was made, a corrected claim is required. Batches can be submitted at the provider's discretion, which offers the opportunity to correct claims entered before batch is submitted. Enter Consumer's RIN and date of birth on each claim One time set-up of Consumer demographics in member screen. Consumer is selected from drop-down box during claim entry Consumer Identification Pros and Cons DCS- Provider. Connect access allows for immediate availability of software updates ECLW- updates must be downloaded after receiving update message DCS - because submitted claims are adjudicate immediately, any corrections require a corrected claim ECLW - if an error is identified before batch submission the claim can be corrected without sending a new claim DCS - immediate consumer eligibility feedback. ECLW - eligibility feedback not received until claim is finalized and 835/ Provider Voucher is received