Other Health Coverage OHC AOD Provider Training February

Other Health Coverage (OHC) AOD Provider Training February 2011 1

Training Topics I. Other Health Coverage (OHC) claiming process Ø Ø Processing of OHC claims after 90 days Acceptable OHC Denials Use of denial notice for one year Timely Notification of payment or denial II. Minor Consent services, with and without Minor Consent aid code III. Reminders and Report Changes IV. Training Highlights and Contact Information Topics included in the Network Office Training -Invoice adjustments -Changes to contract payment terms 2

I. Other Health Coverage (OHC) Claiming Process Payment Determination Prior to Service § It is the responsibility of the AOD provider to assess whether a client has private insurance/other health insurance (OHC) with their Medi-Cal plan. If the AOD provider chooses to provide services without assessing OHC/Medi-Cal first, they go at risk of not obtaining Medi. Cal reimbursement. § During your new client intake process ask your client what type of insurance coverage they have to pay for their services. 3

Payment Determination Prior to Service Medi-Cal n. Use the Medi-Cal internet method to verify the client’s Medi-Cal for the month of service. OHC with Medi-Cal n. When a client’s Medi-Cal eligibility response indicates the client has OHC, follow the OHC claiming process described later in this training. n. Contact the client to obtain insurance information as needed. Follow the OHC claiming process described later in this training. Medicare with Medi-Cal n. Medicare does not reimburse alcohol and drug services. Follow the standard Medi-Cal claiming process. n. EXCEPTION: Medicare clients enrolled in a “Medicare Risk HMO” plan, sometimes referred to as “F” are considered an OHC, providers are expected to follow the OHC claiming process described later in this training. 4

Sample Eligibility Response Message with an OHC Code Name of OHC Carrier 5

Sample Eligibility Response Message with a Medicare OHC Code Clients with Code (F) will have this message displaye d when verifying 6

Medi-Cal Eligibility Quick Reference Guide Follow the OHC claiming process described later in this training for clients with OHC coverage other than (D) Dental, (P) Prescriptio 7

Correcting OHC Information n When a client reports a termination of their OHC, but it is still reflected on their Medi-Cal Eligibility record, the record must be corrected. Contact the client’s Eligibility Technician to request a correction of the OHC. n The Medi-Cal eligibility response must reflect the change prior to claiming to Medi-Cal or services may be denied. 8

OHC Claiming Requirements 9

Follow these steps for claiming of clients with OHC: 1 Obtain OHC information from the client and OHC carrier 5 Enter services in In. Syst and bill OHC carrier 2 Obtain prior authorization for services from OHC carrier. 3 Notify BHCS Billing Dept. Develop a process to record and monitor authorization expiration dates 6 7 Follow-up timely with OHC carrier for: claim corrections, denial, or 90 Day rule. Receipt of valid denial or payment from OHC carrier. Notify BHCS Billing Dept. 4 Provide services, meet chart documentation standards of clients’ insurance plan 8 Adjust monthly invoice with OHC revenue received amount. § Details for each step of this process are on the following slides. 10

Step 1 – Obtain OHC Information n Once you’ve determined the client has OHC ask the client to provide you with insurance information and retain a copy of their insurance card for your records. n If the client has multiple OHC’s, collect information from all carriers. n As a tutorial to gather the client’s specific insurance information use the “AOD Insurance Plan Verification and Authorization form. ” The form is located on the BHCS Provider Website at: www. acbhcs. org/providers/Main/Index. htm in the forms section under Insurance Verification. 11

Sample BHCS “AOD Insurance Plan Verification and Authorization Form” 12

Step 1 cont’– Obtain OHC Information In addition gather the following information to assist with your claiming decisions: n Does the client's coverage include Substance Abuse services? n Does the client have a co-pay? n Does the client have an annual deductible? Amount of remaining deductible? n How can our agency obtain an out of network authorization? 13

Step 1 cont’– Obtain OHC Information § What are the claim submission deadlines? (BHCS recommends claiming within 30 days from month of service. ) § Billing address for substance abuse services? § Which billing form is required? (CMS 1500 or UB 04) Follow instructions for completion of claim form to meet the insurance carrier’s billing requirements. The following is one of the websites for the CMS 1500, the most commonly used billing form for outpatient services: nucc. org/index. php? Itemid=42&id=33&option=com_content&task=view 14

Step 2 – Obtain Prior Authorization for Services § Contact the insurance carrier to verify the client’s scope of coverage and obtain prior authorization of services. (Prior authorization is the process of obtaining approval to provide specific services under a client’s OHC plan. ) Most OHC carriers require you to get authorization before you deliver services. Requirements vary for each OHC carrier, so make sure to follow their rules. § Be sure to stay in contact and develop a relationship with the OHC carrier, so you do not go at risk of loosing revenue. 15

Step 2 cont’ – Obtain Prior Authorization for Services n After completing the “AOD Insurance Plan Verification and Authorization” form fax it to the BHCS Provider Relations Billing Unit at (510) 777 -2225 by the end of the following workday. § This form enables BHCS to put a process in place to prevent the client’s services from claiming directly to Medi-Cal until a payment or valid denial is received from the OHC carrier. § Provider Relations reviews the AOD Insurance Plan Verification and Authorization form when received. If we have any questions concerning the information on this form we will contact the sender for clarification. 16

Step 3 - Develop a Process to Record and Monitor Authorization Dates § Develop a process to record and monitor authorization expiration dates. § Re-authorization requests should be made prior to the expiration date of the initial authorization. § For small agencies the authorization and reauthorization process may be managed by the clinical supervisor or program manager. Note: Having staff devoted to the authorization process increases revenue collection. 17

Steps 4 -5 - Provide, Enter and Bill Services to OHC § Provide services to the client and enter the service into In. Syst, making sure to meet appropriate chart documentation standards. § Prepare the appropriate claim form CMS 1500 or UB 04 per insurance carriers request. And forward the claim to the OHC carrier. (BHCS recommends claiming within 30 days from month of service. ) § If the client has multiple OHC carriers ADP expects all OHC carriers to be billed prior to claiming to Medi-Cal. § Standard insurance billing codes are CPT 4 or HCPC codes. A BHCS translation chart from In. Syst procedure code to HCPC is included on the next page. If CPT 4 codes are required consult the insurance carrier for the appropriate codes to use. 18

Crosswalk Table In. Syst Code - HCPC Code 19

Step 6 - Follow-up with the OHC Carrier § BHCS strongly recommends the development of an internal process to monitor and follow-up on submitted OHC claims. § Claim follow-up should occur after initial claim submission. BHCS recommends following up on claims within 30 days of the mailing date, which is the standard timeline. § Developing an “Aged Open Receivable” report will assist your agency with timely follow-up to minimize revenue delays. § Claims returned by the OHC for billing errors should be corrected and resubmitted to the OHC as soon as possible to secure reimbursement. 20

Step 6 cont’- Follow-up with the OHC Carrier § Per ADP Bulletin 11 -01, providers may presume that a claim for reimbursement submitted to an OHC carrier has been denied, and may submit a claim to Medi-Cal on that basis, when ALL of the following are true: ØProvider billed as required by the carrier ØAt least 90 calendar days have elapsed since the submission of the claim to the OHC carrier AND the provider has received none of the following: Ø Payment for the claim Ø A report of the results of the OHC’s adjudication of the claim, (either hardcopy, electronic or other form) this includes a denial, or claim correction request 21

Step 6 cont’- Follow-up with the OHC Carrier § ADP Bulletin 11 -01 denied requirements Cont’ Ø Any communication, in any form, indicating that the claim submission was in an unacceptable form or otherwise in need of correction prior to adjudication by the OHC carrier. ØProviders shall report this service as denied to ACBHCS within (6) months of the claims submission to the OHC carrier. Claims received more than (10) months from the service date may result in revenue loss. ØProviders must complete the BHCS “AOD Insurance Payment Notification” form attesting to the above 90 day rule. A delegated official within your agency must sign the attestation and enter the 91 st date after the initial OHC billing date. ØClaims exceeding the 90 day rule must only be reported to BHCS when they exceed the 90 day timeframe. 22

Step 7 - Receipt of Valid Denial or Payment from OHC Carrier (This slide replaces slide 23 from the February 22, 2011 presentation. ) § Per the ADP bulletin 11 -01 review the following appropriate denial information. (This document can be found on the following California Alcohol and Drug Programs website @ http: //www. adp. ca. gov/ ) Appropriate OHC Denials: ¨ The client’s OHC coverage has been exhausted or terminated, or q The specific service is not a benefit of the OHC. n When the OHC carrier accepts claims from your agency and sends your agency one of the appropriate denials above, ADP requires a unique denial when providing the same type of service to the client and does not currently allow the use of a denial for one year. 23

Step 7 - Receipt of Valid Denial or Payment from OHC Carrier (This slide was added to the February 22, 2011 presentation and updated subsequently to the February 25, 2011 presentation. ) Appropriate OHC Denials cont’: § You may use a written or electronic notification from an OHC carrier from the date on the notification as a valid denial when all of the following are true : ¨ ¨ Your agency has made an attempt to bill the OHC carrier in the past 12 months. In response to your agency’s attempt to bill the OHC carrier, your agency receives a dated written or electronic notification from the OHC carrier that clearly states : (Note: n Note: EOB’s and Remittance Advices do not apply in this situation) The OHC carrier will not accept claims for reimbursement from your agency in general or for specific types of circumstances or services. The OHC carrier’s notification must indicate a specific period of time the notification is valid and that the claim is being denied for an appropriate denial reason. (See slide 23 for valid denial reasons. ) ¨ The services your agency will provide or have provided are within the scope specified in the OHC carrier’s notification, in which the OHC carrier will not accept claims for. ¨ The services your agency will provide or have provided are within the specified period of time indicated in the OHC carrier’s notification, in which the OHC carrier will not accept claims for. It is up to the provider to put in place a method to monitor the expiration of this one year date and to obtain a new denial when the time period exhaust. 24

Step 7 cont’- Receipt of Valid Denial or Payment from OHC Carrier § Inappropriate OHC Denials: ¨ Services were not rendered by an: • OHC facility • OHC approved provider • HMO facility/provider • In-network provider ¨ Services were not authorized according to the OHC coverage requirements or ordered or authorized by the OHC carriers physician. ¨ Services were not claimed timely in accordance with the OHC carrier guidelines. ¨ Claims were submitted with incorrect or missing data to the OHC carrier. NOTE: If you have submitted any inappropriate denials for Medi-Cal claiming as listed above and have received Medi-Cal payment you must request a void of that payment by completing a “BHCS Alcohol & Drug Void and Replace” form. 25

Step 7 cont’- Receipt of Valid Denial or Payment from OHC Carrier § n Appropriate denials and payments must be reported to BHCS within one week of receipt from the OHC carrier. Notification should be reported on the “AOD Insurance Payment Notification” form located on the BHCS Provider Website at: www. acbhcs. org/providers/Main/Index. htm in the forms section under Insurance Verification. Include with the form: §A copy of the RA/EOB or §A copy of a valid denial letter §A copy of the original claim form submitted to the OHC § In addition, use this form to notify BHCS of annual denial letter, ADP 90 day attestation, and minor consent which is discussed later in this presentation. NOTE: HIPAA regulations apply when submitting RA/EOB’s. Please be sure that only BHCS client information is included on any supporting documentation. If other client information is legible on the EOB/RA please 26 black it out.

Sample BHCS “AOD Insurance Payment Notification” Form 27

Step 7 cont’- Receipt of Valid Denial or Payment from OHC Carrier n Provider Relations reviews the AOD Insurance Payment Notification form with the information on the EOB/RA or denial when received. If we have any questions concerning the information on this form we will contact the sender for clarification. n Once the OHC denial or payment is received and posted in In. Syst, the service will be claimed to ADP. At this point the service will appear on the next ADP 1584 Medi-Cal Test Claim. § Services for clients with OHC will not be claimed to ADP until an insurance payment or valid denial is sent to BHCS. 28

Step 8 - OHC Revenue Adjustments to Monthly BHCS Invoice n Steps for this process will be covered in the Network Office portion of this presentation. 29

II. Minor Consent Services, with and without Minor Consent Medi-Cal aid codes Minors with Minor Consent Medi-Cal aid codes and OHC § The Minor Consent program permits youth under 21 year of age who are living with their parent/guardian access to confidential, limited alcohol and other drug treatment services without regard to the parental income/resources or OHC. n Services for Minors with Minor Consent Medi-Cal aid codes of 7 M or 7 P do not require claiming to the OHC prior to Medi-Cal claiming. n It is not necessary to report OHC to BHCS for clients in this circumstance. n If the client is already known to ACBHCS as having OHC, this information may prevent the service from billing directly to Medi-Cal. If you are aware of this and the services do not appear on your Medi. Cal test claim, contact Provider Relations at (800) 878 -1313. It may be necessary to coordinate the receipt of a “AOD Insurance Payment Notification” form with the Minor Consent box checked to post a OHC denial to allow the service to bill to Medi-Cal. 30

Minor Consent Services for clients without Minor Consent Medi-Cal aid codes n n Services for Minors without Minor Consent aid codes will be denied when the OHC is not billed first. ADP recognizes that this is an issue. Providers are NOT expected to bill OHC for minor consent services. When you have a client with services falling under this circumstance: ØComplete the “AOD Insurance Payment Notification” form indicating Minor Consent in the check box on the form and BHCS will post a special denial reason code to allow the service to claim to Medi-Cal. If ADP announces a different method to identify these circumstances providers will be informed at that point. 31

III. Reminders and Report Changes Records Retention n Providers shall retain all records relevant to the application of the processes described in this training consistent with the records retention requirements identified in the State Administrative Manual for trading partners. This includes retaining documentation supporting confidential Minor Consent services to clients without Minor Consent aid codes for those with OHC. 32

Reminder n Medi-Cal clients whose benefits are restricted to pregnancy or emergency services will have services denied by ADP when the indicator is missing from the Medi-Cal claim. When providing a service to a client with these restrictions you must enter a “Y” in the applicable In. Syst field when the service is an emergency or the client is pregnant. (Note: The Pregnancy indicator field is now available on all service entry screens. ) n Enter late reason codes only when appropriate. A service is not considered late prior to 30 days after the month of service. (For example: February 2011 services are not considered late until April 1, 2011. Indicating a late reason code prior to that date causes errors in claiming to ADP. ) n Make sure the CIN number you enter is 9 digits and no longer. 33

Reminder of System Upgrades Sample Eligibility Response Pregnancy Restricted Benefits 34

Reminder of System Upgrades Sample Eligibility Response Emergency/Pregnancy Restricted Benefits 35

Medi-Cal Benefits Help Desk The Medi-Cal Benefits Help Desk is intended for Providers Only, NOT MEDI-CAL BENEFICIARIES. 36

Test Medi-Cal Claim ADP 1584 Report Changes 37

ADP 1584 Test Claim Report Changes n Provider Relations is continuing to attempt to update the ADP 1584 Test Claim report. Watch for upcoming information on the report. 38

Sample of updates to come on the ADP 1584 Test Claim Report 39

Resource Links & Information q BHCS Provider Website: www. acbhcs. org/providers Training – copy of this training will be available soon Forms Insurance Verification Ø AOD Insurance Plan Verification and Authorization form Ø AOD Insurance Payment Notification Form q CMS 1500 Billing Form and Guide Website: www. nucc. org/index. php? Itemid=42&id=33&option=comcontent&task =view 40

Training Highlights Minor Consent services, with or without Minor Consent aid code Other Health Coverage (OHC) Claiming Process q Payment Determination Prior to service (Slides 3 -8) q Minors with Minor Consent Medi-Cal aid codes and OHC (Slide 29) q Sample Eligibility Response Message for clients with an OHC Code (Slides 5 -6) q Minors without Minor Consent Medi-Cal aid codes and OHC (Slide 30) q Medi-Cal Eligibility Quick Reference Guide (Slide 7) q Correcting OHC Information on Medi-Cal Eligibility Record (Slide 8) q OHC Claiming Requirements (Slides 9 -28) - Processing of OHC Claims after 90 days 22) Reminders and Report Changes q Record Retention (Slide 31) q Client Emergency and Pregnancy Restricted Aid Codes (Slide 32 -34) q Medi-Cal Benefits Help Desk (Slides 21 - - OHC Denials (Appropriate vs. Non-approp. ) (Slides 23 -24) Call center to assist providers with basic Medi-Cal benefit questions @ 1 -(888) 346 -0605. (Slide 35) - Use of Denial notice for one year (Slide 23) q ADP 1584 Test Medi-Claim Report Changes (Slides 36 -38) 41