Health Homes Program: Billing Guidelines

Transcription

1 Health Homes Program: Billing Guidelines Welcome, Sunflower HH Partners!

2 Billing Agenda Sunflower rates Top 7 claim rules Pre-checking HH status prior to performing service Claims troubleshooting 2

3 SMI-HH PMPM Rate LEVEL State Rate HHP PMPM Sunflower Rate 1 $ % $ $ % $ $ % $ $ % $ Look for the Sunflower rates on your Remittance Advice. 3

4 Top 7 Health Home Claim Rules 1. Bill only health home services together, do not include other services. (State rule, all MCOS the same) For example, bill S0280 and S0281 together but not with Always include a modifier with each service Claims without a modifier will be denied Modifier HE indicates SMI so always include HE 3. Only one service per member per month will be paid Additional services will have a paid status and a $0 payment EX ha will be applied 4. Authorization: NOT required 5. Coordination of Benefits: NOT required 6. Use Payer ID for all Health Home claims (never use Payer ID for health home claims) 7. TCM services no longer available for health home members (expect for spenddown members) 4

5 Claims Rule 1: bill only health home services Bill only health home services together, do not include other services. (State rule, all MCOS the same) For example, bill S0280 and S0281 together but not with After reviewing the following reasons for requiring separate claims for Health Homes billing, we [State of Kansas} have decided that it is best to make it mandatory that MCOs require providers to bill their Health Home claims on separate forms than their other claims. If the claim needs to be voided for the non-health Home service on the claim, there is the potential the per member per month Health Home payment will be recouped. Front End Billing (FEB) routes claims based on detail line 1 of the claim, so if the Health Home service is not on line 1, it appears that per testing the Health Home service will be processed as FFS and deny. Also because FEB routes claims based on detail line 1 of the claim, if the Health Home service is on line 1, the claim will be routed to the MCO and other service lines could be carved out of KanCare. These services should be denied by the MCO. FEB routes claims based on detail line 1 of the claim, so if the Health Home service is on line 1, the claim will be routed to the MCO and other service lines could be carved out of KanCare. These services should be denied by the MCO. 5

6 Claims Rule 2: always include modifiers Official CPT descriptions: S0280 Medical home, initial plan S0281 Medical home, maintenance Although the official description of the S0280 and S0281 CPT codes implies initial and maintenance, both codes will represent maintenance. In other words, there is no requirement that S0280 Initial occur prior to S0281 Maintenance. Nor is there a requirement that S0281 Maintenance occur after S0280 Initial. UC This modifier will be defined as maintenance of plan when billed with procedure code S0280 (rather than initial plan). Also, S0280 will be defined as Comprehensive Care Management and S0280 as Care Coordination when billed with modifier UC. U1 This modifier will be defined as maintenance of plan when billed with procedure code S0280 (rather than initial plan). Also, S0280 will be defined as Health Promotion and S0281 as Comprehensive Transitional Care when billed with modifier U1. U8 This modifier will be defined as maintenance of plan when billed with procedure code S0280 (rather than initial plan). Also, S0280 will be defined as Patient and Family Support and S0281 as Referral to Community and Social Support Services when billed with modifier U8. 6

7 Claims Rule 2: always include modifiers (Contd.) Always include a modifier with each service Claims without a modifier will be denied. Modifier HE indicates SMI so always include HE Procedure Modifier Modifier Core Service S0280 UC HE Comprehensive Care Management S0280 U1 HE Health Promotion S0280 U8 HE Patient and Family Support S0281 UC HE Care Coordination S0281 U1 HE Comprehensive Transitional Care S0281 U8 HE Referral to Community and Social Support 7

8 Claims Rule 3: only 1 service paid Only one service per member per month will be paid Example below, SMI Level 1, received all 6 core services Sunflower will pay for one core service per member per month $99.63 Suggestion: submit one claim per month with all services (example below) 8

9 Claims Rule 4, 5 & 6 4. Authorization: NOT required A1 denials will not apply to S0280 or S Coordination of Benefits: NOT required L6 denials will not apply to S0280 or S Use Payer ID for all Health Home claims (never use Payer ID for health home claims) 9

10 Claims Rule 7: TCM no longer available (except for spenddown) Providers should use KMAP to determine whether a member is assigned to a Health Home and if the member has an unmet spend down amount. Providers will bill only Health Homes services for members assigned to a Health Home who have met his or her spend down. If a member has an unmet spend down amount, claims for targeted case management (TCM) can be submitted until the member s unmet spend down amount has been met. In this situation only, there is the possibility that claims for TCM and HH services may be submitted in the same month. In no other situation will TCM claims be allowed for Health Home members. Rule of thumb: TCM services will not be paid for health home members, except those with spenddown, when spenddown is not met at the time of adjudication. 10

11 Spenddown status and health home claims Providers should check spend down status on the KMAP website prior to performing services since spend down members are not eligible to receive Health Home services until their spend down is met. Spend down members will be assigned to Health Homes but it is the provider s responsibility to check spend down status prior to performing services per the state. Rule of thumb for spenddown members in health homes: When spenddown is met > eligible for HH When spenddown is UNmet > not eligible for HH 11

12 Claims pre-check Remember to check member eligibility prior to performing health home services (via KMAP) Health home actions and where to view: Member opt out: check KMAP Member change to health home partner: Sunflower portal Member newly eligible for health home: KMAP or Sunflower portal 12

13 Pre-check: step 1 search 13

14 Pre-check: step 2 review 14

15 Claims Troubleshooting Missing modifier denial Solution: verify that modifiers are included More than health home services included denial Solution: verify that only S0280 and S0281 submitted Member not eligible for services denial Solution: check eligibility via KMAP Provider on claim not assigned to member denial Solution: verify that member is assigned to your health home and that the correct NPI/TAX ID combination was billed 15

16 Secure Provider Website The Sunflower portal will offer a Wizard for Health Home billing. Click on Provider Login. 16

17 Secure Provider Website (Cont.) Click on Create An Account. 17

18 Registration Start your registration. Enter Tax ID, your name, address and create your own password. Hover over the? for more details. Click Register. If you receive error message We could not find your Tax ID in our system please return to our public site Become a Provider page to join the network. Once your data is in our systems you ll be able to create your account. Every provider needs his/her own user name and password. Please do not share you user name with others. You can access the instruction manual through the secure provider portal. 18

19 Start registration 19

20 Registration complete! An will be sent to your mailbox. Click the link in the to sign in and finish setting up your account. If you do not receive your check your junk file or click click here to have another one sent to you. 20

21 Account Setup Now that you ve signed into the site you select your secret questions and answers. You will use these if you forget your password or accidently lock your account. Click Submit once you enter your telephone and fax numbers. Your request for an account has now been sent to the Health Plan for approval. If you do not receive an within 2 work days please call the plan or send a secure message. 21

22 System Requirements System Requirements: Access the secure provider website using Internet Explorer 8.0 or higher, Firefox and/or Google Chrome. Each browser should be updated to the most recent version available for optimal performance 22

23 Key HH Program Contacts Sunflower HH Correspondence: Phone: (877) Fax: (866) HH Team Leads: Health Home Director: Marc Shiff Operational Project Manager: Jeanine Meiers Contracting: Debra Whited Burnham or Kami Toben Provider Relations: Bryan Swan Billing: Ashley Hackman 23

24 On the web KanCare website: Program Manual Documentation requirement Rates & claims direction Sunflower website: 24