Short Doyle MediCal Phase II AOD Provider Training

Short Doyle Medi-Cal Phase II AOD Provider Training 1

Training Topics Ø Ø Ø 2 Reminder of System Upgrades Other Health Insurance Coverage (OHC) Medi-Cal Test Claim Resource Links and Information Training Highlights

Reminder of System Upgrades l l 3 Emergency Indicator Pregnancy Indicator Duplicate Override Medi-Cal Benefits Help Desk

Reminder of System Upgrades Emergency Indicator 4 Ø This indicator is required by the Department of Alcohol and Drug Program (ADP) when the service is known to be an emergency by the provider. Ø ADP defines emergency as: The patient requires immediate medical/mental health intervention as a result of severe, life threatening, or potentially disabling conditions. Note: There is no requirement that a service must be provided in a hospital setting to meet the definition of an emergency.

Reminder of System Upgrades l Title 9 CCR, Section 1810. 216 says: “’Emergency Psychiatric Condition’ means a condition that meets the criteria in Section 1820. 205 when the beneficiary with the condition, due to a mental disorder, is a danger to self or others, or immediately unable to provide for or utilize, food, shelter or clothing, and requires psychiatric inpatient or psychiatric health facility services. ” The Department of Health Care Services (DHCS) provided the following clarification regarding the definition of an emergency service for ADP services: Title 9 Section 1810. 216 defines "Emergency Psychiatric Condition" in terms of an inpatient. There is no separate definition for outpatients. The definition (with the exception of facility specifics) should be construed to apply to outpatients as well. 5

Reminder of System Upgrades When a service provided meets the above criteria of an EMERGENCY you must code the service with an emergency indicator of “Y” within the In. Syst system. l 6 Note: The Emergency indicator field is now available on all service entry screens.

Reminder of System Upgrades Pregnancy Indicator 7 Ø The pregnancy indicator is required when the client is known to the provider to be either pregnant or postpartum. Ø Clients enrolled in perinatal programs (program code 25) must have services coded with a Pregnancy indicator. Ø Per ADP Medi-Cal audit protocols, the individual must meet medical necessity criteria; the service must be driven by the client plan; and supported by the documentation.

Reminder of System Upgrades Pregnancy Restricted Benefits 8

Reminder of System Upgrades l 9 Emergency and Pregnancy Restricted Benefits

Reminder of System Upgrades !WARNING! 10 l Medi-Cal clients whose benefits are restricted to pregnancy or emergency services will have services denied by ADP when a pregnancy indicator is missing from the Medi-Cal claim. l Note: The Pregnancy indicator field is now available on all service entry screens.

Reminder of System Upgrades Pregnancy/Emergency Field on Multiple Service Entry Screen 11 Client Pregnant (CL PR) and Emergency Flag (EM FL)

Reminder of System Upgrades Duplicate Override l l 12 When entering services in In. Syst, an edit feature may identify possible Medi-Cal duplicate services. The service entry screen will propose an override code and display the 3 allowable override codes: – 59 Distinct Procedural Service – 76 Repeat Procedure by the Same Person – 77 Repeat Procedure by a Different Person

Reminder of System Upgrades l Data entry staff may need to consult with the clinician to determine whether the procedure is: – – – 13 A duplicate entry A separate and distinct service A repeated procedure by the same or different staff l Once the determination is made, data entry staff must select an appropriate override code and proceed with the service entry. l The selected override code is placed on the Medi-Cal claim and displayed on the Service Maintenance screen.

Reminder of System Upgrades Duplicate Override Codes on Multiple Service Entry Screen Enter appropriat e override code and “W” to write the service. 14 Override Codes

Medi-Cal Benefits Help Desk The Medi-Cal Benefits Help Desk is intended for Providers Only, NOT MEDI-CAL BENEFICIARIES. 15

Other Health Insurance Coverage (OHC) 16

Other Health Insurance Coverage (OHC) l l 17 ADP has installed a new Medi-Cal claiming system. Due to the new system’s enhanced capabilities ADP is enforcing the billing of OHC prior to claiming to Medi-Cal. The following slides are sections from the State’s Medi-Cal manual that address the requirements for handling of clients with OHC.

Excerpt from DHCS/EDS Medi-Cal Manual • Add State pages 18

Other Health Insurance Coverage (OHC) Sample Eligibility Response Message with an OHC Code 19 Name of Insurance Plan

IMPORTANT “HMO” also pertains to private insurance plans 20

Excerpt from DHCS/EDS Medi-Cal Manual IMPORTANT 21

Clients with Code “F” will have this message displayed when verifying eligibility. 22

E NO IMPORTANT 23 BL A C I PL T AP

IMPORTANT 24

Providers to use BHCS Insurance Payment Notification form 25

This will be reflected on the EOB. Payment amounts will be reported via In. Syst on the Medi-Cal claim. 26

These are the only valid Denial Reasons. 27

Sample Kaiser Denial Letter Remember #’s 2, 5, and 8 are not valid denials. Medi-Cal will not pay. 28

Other Health Insurance Coverage (OHC) l What 29 does this mean to you?

Other Health Insurance Coverage (OHC) 30 l When verifying a client’s Medi-Cal eligibility each month, if the eligibility response indicates the client has private insurance (OHC), you must bill the OHC. l DHCS/ADP will deny all Medi-Cal claims submitted without supporting documentation that the OHC was paid or denied. l If a client reports to you they no longer have OHC and it’s still reflecting on their Medi-Cal Eligibility record, the record must be corrected by contacting the client’s Eligibility Technician. This action must by taken prior to claiming to Medi-Cal.

Other Health Insurance Coverage (OHC) Prior to the client’s first visit: l l Verify the client’s Medi-Cal eligibility to determine if the client has OHC. For clients with Medi-Cal/OHC: – using the BHCS “AOD Insurance Plan Verification and Authorization form” your agency must contact the client to obtain insurance information. – Contact the insurance carrier to verify scope of coverage and obtain prior authorization. Note: Insurance authorization may require Dr. /Clinician to support diagnosis and treatment plan. l The BHCS “AOD Insurance Plan Verification and Authorization form” is located on the BHCS Provider Website at: www. acbhcs. org/providers/Main/Index. htm in the forms section under Insurance Verification. Note: HIPAA regulations apply when submitting the BHCS “AOD Insurance Plan Verification and Authorization form”. Please be sure that only BHCS client information is included on any supporting documentation. 31

Sample BHCS “AOD Insurance Plan Verification and Authorization Form” 32

Other Health Insurance Coverage (OHC) Suggested questions to ask the Insurance Carrier: 1. 2. 3. 4. 33 Does the client's coverage include Substance Abuse services? Does the client have a co-pay? Does the client have an annual deductible? Amount of remaining deductible? How can our agency obtain an out of network authorization?

Other Health Insurance Coverage (OHC) 34 l A completed BHCS “AOD Insurance Plan Verification and Authorization” form must be faxed to the BHCS Provider Relations Billing Unit by the end of the following workday. l BHCS staff will update In. Syst with the client’s insurance information. l Medi-Cal claims for client’s with OHC will be suppressed until verification of an insurance payment or valid denial is sent to BHCS.

Other Health Insurance Coverage (OHC) Suggested claims submission questions to ask the Insurance Carrier : 1. Contact the insurance carriers claims department for: a) Claim submission deadlines (BHCS recommends claiming within 30 days from month of service). b) Instructions for completion of claim form to meet the insurance carrier’s billing requirements. 2. Billing address for substance abuse services? 3. Which billing form is required? (CMS 1500 or UB 04) 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 35

Crosswalk Table In. Syst Code - HCPC Code 36

Other Health Insurance Coverage (OHC) Insurance Claim Follow-Up Ø Ø 37 BHCS strongly recommends each agency develop an internal process to monitor and follow-up on submitted insurance claims. Development of an “Aging”/open receivable reports will assist your agency with timely follow-up to minimize revenue delays. Medi-Cal services can not be claimed to ADP until an insurance payment or valid denial is reported to BHCS. Payments and/or denials should be reported to BHCS within one week of receipt.

Other Health Insurance Coverage (OHC) Clients with OHC whose services have been claimed to insurance will not appear on the Medi-Cal claim until an insurance payment or valid denial is sent to BHCS. The following information is required to be sent: l BHCS AOD Insurance Payment Notification form (located on the BHCS l A copy of the RA/EOB or A copy of a valid denial letter l 38 Provider Website at: www. acbhcs. org/providers/Main/Index. htm) in the forms section under Insurance Verification Note: HIPAA regulations apply when submitting RA/EOB’s. Please be sure that only BHCS client information is included on any supporting documentation.

Sample BHCS AOD Insurance Payment Notification Form 39

Test Medi-Cal Claim ADP 1584 Report Changes 40

Test Medi-Cal Claim ADP 1584 Report Changes l Effective April 20, 2010 the ADP 1584 Test and Real Medi-Cal Claim reports have the following changes: – 41 The MM YYYY and BG ND columns have been replaced with Serv Date. This field now displays the date of service in the following format: MMDDYYYY.

ADP 1584 Report Changes l The Prim Pay column has been replaced with Oth/SOC. l The Oth/SOC column will display: – – 42 All insurance payment amounts reported to BHCS on the BHCS AOD Insurance Payment Notification form. $ amount of service applied towards a client’s Medi-Cal Share of Cost.

SAMPLE ADP 1584 MEDI-CAL TEST CLAIM 43

Test Claim Review Process – Data Represented on the ADP 1584 l l l 44 Claim ID – Unique number automatically created by In. Syst to identify each claim line. l SFC – Service Function Code l Time – Duration (in minutes) l UOS – Units of Service = 1 l Amount – Ignore l Tot Chg –Ignore l Oth/SOC – $ amt. applied from other payment source or Share of Cost Clearance l X – Cross over indicator (service may be from a prior month). l L – Late reason code (All services with a Late Reason Code are required to have a completed 6065 A or B on file with your agency and BHCS. ) l D - Ignore Patient Name – Last Name, First Initial Number – Client’s In. Syst Number l Welfare ID – Client’s CIN l DOB – Client’s Birth Year l Sex – (M) Male (F) Female l Race - DMH ethnicity codes l DSM – Diagnosis Code from In. Syst l Serv Date - Service Month/Date/Year

Resource Links & Information v. BHCS Provider Website: www. acbhcs. org/providers In. Syst Medi-Cal Claim Ø Claim Schedule • Training Ø Provider Training Short Doyle Medi-Cal Phase II – AOD Ø FAQs (Updates Coming Soon) Forms • Insurance Verification Ø AOD Insurance Plan Verification and Authorization form Ø AOD Insurance Payment Notification Form • v. CMS 1500 Billing Form and Guide Website: www. nucc. org/index. php? Itemid=42&id=33&option=com_content&task=view 45

Training Highlights Client Emergency and Pregnancy Ø Reminder of the Emergency and Pregnancy definitions and indicator requirements. (slides 4 – 11) Ø Fields added to all service entry screens. (slides 6, 10, and 11) Duplicate Services Ø Reminder of the enhanced edit which identifies potential duplicate services on all service entry screens and requires entry of duplicate override codes. (slides 12 -14) 46 Medi-Cal Benefits Help Desk Ø New call center to assist providers with basic Medi-Cal benefit questions @ 1 -(888) 346 -0605 (slide 15). Other Health Coverage (OHC) Requirements Ø DMH requirements for handling of clients with OHC. (slides 17 -26) Sample Eligibility Response Message for clients with an OHC Code. (slides 19) Ø BHCS Provider requirements regarding billing for clients with OHC. (slides 28 -37) Ø Medi-Cal ADP 1584 Revision Ø New/Deleted columns on the Medi-Cal ADP 1584 Test Claim. (slides 3942)