Billing for Habilitation Services Magellan Health Services June 11, 2013 Billing for Services Magellan providers billing for Iowa Medicaid Habilitation (HAB) services must bill with HIPAAcompliant codes for services rendered beginning July 1, 2013. Claims submitted with non-HIPAA compliant codes (e.g. old W codes) will be denied. 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 1-800-638-8820 to schedule an appointment. Provider Billing Codes Old W Code New HIPAA Code HIPAA Modifier* IA Medicaid HAB Service Name Time Unit/Basis Day Habilitation Per 15 Min W1206 T2021 UC Day Habilitation Per Day W1204 T2020 UC Home-based habilitation Per 15 Min W1207 H2015 UC Home-based habilitation Per Day W1208 H2016 UC Pre-Vocational Services Per Hour W4425 T2015 UC Pre-Vocational Services Per Day W1425 T2014 UC Supported Employment: Maintain employment/job coaching Per 15 Min W1431 H2025 UC Supported Employment: Maintain employment/enclave Per 15 Min W1433 H2023 UC Supported Employment: Job Development Per Unit W5019 T2018 UC Supported Employment: Employer Development Per Unit W5020 H2024 UC Supported Employment: Enhanced Job Search Per 15 Min W5021 H2019 UC *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. Magellan Covered Diagnosis Code 290 291 292 293 294 295 296 297 298 299 300 301 302 306 307 308 309 311 312 313 314 Description Senile and presenile organic psychotic conditions Alcoholic psychoses Drug psychoses Transient organic psychotic conditions Other organic psychotic conditions (chronic) Schizophrenic disorders Affective psychosis Paranoid states Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of etiology) Psychoses with origin specific to childhood Anxiety states Personality disorders Sexual deviations and disorders Physiology malfunction arising from mental factors Special symptoms or syndromes, not elsewhere classified Acute reaction to stress Adjustment reaction Depressive disorder, not elsewhere classified Disturbance of conduct, not elsewhere classified Disturbance of emotions specific to childhood and adolescence Attention deficit disorder Note: 310.00-310.99 – Mental Retardation is NOT covered. Place of Service (POS) Codes Code Definition Code 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 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. 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 31-59 minutes. 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. 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 1-800-638-8820 to make an appointment to review a new HAB request. Getting Paid • Claim Submission – 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. 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. 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. 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 Website Resources • www.MagellanProvider. com • www.MagellanofIowa. com On-Line Resources On-Line Resources, cont. Electronic Claim Submission – On-Line Training Available • Go to www.MagellanProvider.com . • 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 Claims/Website Contact Information General Billing Questions Customer Service at 1-800-638-8820. EDI Technical Assistance Getting Started – visit our EDI Testing Center at www.edi.MagellanProvider.com EDI Hotline at 877-326-7525, ext. 75841 or email [email protected] General Website Technical Assistance For all other website technical assistance, call Provider Services at 800-788-4005. Magellan Customer Service Contact Information Customer Service – 800-638-8820; Fax 888-656-5302 Christine Bryant, Customer Svc. Supervisor, 515-273-5009 Email – [email protected] Dennis Petersen, Director, Operations, 515-273-5044 Email – [email protected] Claims address: PO Box 1869 Maryland Heights, MO 63043 Customer Service address: PO Box 71129 Des Moines, IA 50325 Questions?