Weekly Provider Q&A Session 1 st Quarter 2016

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1 Weekly Provider Q&A Session 1 st Quarter 2016 Type Provider Issue/Agenda Item Response/Outcome/Updates Norfolk CSB What is the timely filing limit on a corrected claim and for appeals? You have one year from the date on the Explanation of Benefits (EOB) to resubmit a corrected claim. You have 30 days from the date on the EOB or date on the denial letter to submit a claim reconsideration. You may reference the Magellan Provider Handbook Supplement, pages for Unidentified Can I bill for case management services while a member is receiving intensive community treatment (ICT)? Blue Ridge CSB Do you have any updates on billing to Magellan as a secondary payer when a Medicare Advantage Plan is paid primary? more detailed information. Yes. Magellan supports the ICT model to provide all necessary behavioral health services within the program. However, members have the right to refuse case management even if bundled into the service or they may decide to receive case management services either from their current ICT provider or they may choose to receive case management services from their local Community Services Board (CSB) outside of ICT. Effective January 30, 2015, if the member chooses to receive CSB case management services outside of ICT, and in this unique circumstance, providers may bill for both services. Providers need to document the reason for the change. Magellan trends these instances to assess the potential need for changes to the ICT model or ICT rate decreases. Providers should refer to the DMAS October 1, 2014 Medicaid Memo on fee-for-service cross over billing instructions as posted in the 2014 Medicaid Memo. At this time, there are three exceptions to bill Magellan (instead of DMAS) when Medicare is primary: 1. When a member has maxed their benefit through Medicare, per the Medicare EOB 2. If the rendered service is non-covered by Medicare 3. When the provider is not contracted by Medicare or does not qualify as a Medicare provider (i.e. LPC, etc.) Chesapeake CSB We are a non-physician directed organization billing outpatient codes with degree level modifiers. If I am billing a telemedicine visit completed by a nurse practitioner, in what position do I list the GT modifier? Magellan is working on a comprehensive communication to provide further clarification on billing instructions. You should refer to the Magellan provider communication posted on April 1, 2015 regarding degree level modifiers. For claims in which multiple modifiers are appropriate, claims should be billed with the degree level modifier in the first position, for accurate processing and pricing. The GT modifier would be in the second position. 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 1 of 9

2 Western Tidewater CSB We are moving from a clearinghouse to submitting batch claims to Magellan and need to know how to get a submitter ID. Magellan offers an EDI Support Center for providers. Providers may contact this resource at EDISupport@magellanhealth.com or X Representatives are available to assist individual providers with set-up and the testing for the submission process. Lewis Gale Medical Center Can the service specific provider intake (SSPI) for case management be billed separately from the service? If so, what code do I use? We billed an inpatient claim 9/29/15-10/8/15. It denied for ICD-9/ICD-10 reasons. My understanding for inpatient claims that span from September to October, we should bill as one claim for ICD-10, however, the claim denied. No. The case management service specific provider assessment (SSPI) is included as part of the first month of the case management services. There is no separate assessment code for mental health case management. For more information, refer to the Community Mental Health Rehabilitation Services (CMHRS) manual, chapter 4, and page 79. Dates of service prior to October 1, 2015 should be billed with ICD-9 codes. Dates of service October 1, 2015 and later are billed with ICD-10 codes. Both codes cannot be used on the same claim; therefore, two claims will need to be submitted. For more information, please refer to the Magellan provider communication posted October 8, Keystone Newport News We have been doing some audits and have found some overpayments that are over a year old. I want to get clarification on how to send Magellan a refund check without initiating an automatic retraction. It is recommended you contact the Magellan Cost Containment team, which can be reached at to assist you with this process. They can put the account on hold during the time period you give them, so that they don t also retract a payment. In general, there are two ways in which a provider can refund money to Magellan: 1. For EDI transactions, providers may submit voided claims electronically using the value 8 (VOID) in CLM05-3. A Magellan claims processor will review and initiate the retraction process internally. 2. For refunds via check, please send documentation to identify the claim (member ID, claim number(s) and date(s) of service) and the reason for the refund. Mail the check and the documentation to: Magellan Health (VA DMAS) Attn: Recoveries Lockbox P.O. Box Philadelphia, PA st Quarter 2016: Weekly Friday Provider Call FAQs Page 2 of 9

3 Western Can we bill crisis intervention for kids who are also Tidewater CSB receiving intensive in home services? If we are collaborating with the intensive in home provider, who gets to bill when both services occur during the same moment in time? Please re-research the answer to this question and submit a revised response. Unidentified What should I do for claims that were submitted while a member was enrolled in GAP and then switched to fee-for-service? Confirming with GAP You can only bill for crisis intervention and intensive in-home services on the date of admission and discharge. Magellan recommends that you coordinate for your services and billing, if there is another provider conducting the other service. Your documentation should clearly support the separation of services with clear distinct treatment goals. You may want to refer to the CMHRS Manual, Chapter 4, page 57 and Chapter 6, page 14. It states that if other clinic services are billed at the same time as crisis intervention, documentation must clearly support the separation of services with distinct treatment goals. Disclaimer: Medicaid prohibits the duplication of services. If you have questions about providing services that could be considered duplicative, please contact Magellan at and ask to speak with a care manager to assist you with this matter. If the member was in a GAP plan and claims were paid and they now have FFS that was retroactive, the provider would need to submit a corrected claim (removing the GAP modifier) as there is a difference in payment for GAP CM and FFS CM. must be must be submitted within one year from the date of service to be considered timely. Unidentified Can you appeal claims on the Magellan website? Yes. On the Magellan of Virginia website, under For Providers, click Forms. The Reconsideration form is the link at the bottom of the page. Additionally, the form allows you to submit attachments along with the requested information. You may access the Reconsideration Form here: If you disagree with the reconsideration decision, you may file an appeal with DMAS. The details to file an appeal with DMAS are outlined in the reconsideration letter. Phoenix House We have some residential claims that are billed to DMAS and the ancillary services we bill to Magellan. Do these ancillary services need a special authorization? I am having claims that are denying for non-authorization for outpatient. How many sessions are they allowed without authorization and where can I find this information? In this case, the member has already used their first 26 sessions for outpatient. After the first 26 sessions are used, an authorization is required. The claims denied because we do not have an authorization in our system for that member. You can find this requirement outlined in the Psychiatric Service Manual: Chapter 4 page st Quarter 2016: Weekly Friday Provider Call FAQs Page 3 of 9

4 Unidentified We received a notice from Magellan stating all behavioral technicians will need to become registered behavior technicians (RBT) by the end of September Can you confirm if this is true? Magellan did send a notification to ABA providers contracted for Commercial accounts. It does not apply to Medicaid (VA DMAS) at this time. Providers that are contracted with Commercial, non-virginia Medicaid, Magellan, ABA services will need to meet this new requirement, per the notice. Unidentified I have a question about submitting a VICAP authorization. The child was referred to us from the school and the parent brought him in. After the assessment there is no actual diagnosis for us to use and just the generic code of academic or educational problems. Is there a generic type code that we can use? Unidentified Will the provider website be updated so that we can submit an autism diagnosis online for case management services instead of faxing? Unidentified On the continued stayed review form for intensive community treatment (ICT) services, it asks was an individual service plan (ISP) initiated at the time of admission and fully developed within 30 days of the initiation of services and approved LMHP type. Can you clarify if this means if it was approved by or developed by an LMHP type? Can you point me to where I could find the manual reference that states notes for intensive community treatment need to be signed within 1 business day? Yes. You would use the R69 ICD-10 code. At this time, our website is unable to accept that diagnosis For ICD-10 diagnoses F84.0, F84.5 and F84.8 You must fax in the allowable diagnosis for mental health case management. Please indicate on the fax cover page unable to submit diagnosis online. It is referring to an approval by the LMHP type. For more information, refer to the CMHRS manual, chapter 4, and page 59. An individual service plan must be fully developed by either the LMHP, LMHP supervisee, LMHP-resident, LMHP-RP, QMHP-A, QMHP-C, or QMHP-E and approved by the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP within 30days of the initiation of services. In Chapter 6 of the CMHRS Manual, page 13. Providers shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in providers' care. Such documentation shall fully disclose the extent of services provided in order to support providers' claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered or within one business day from the time the services were rendered. Mt. Rodgers What is the caseload limit per clinician for therapeutic day treatment (TDT) services? The ratio and staffing assignments is referenced in the CMHRS Manual, chapter 2. On page 8 of the manual, it states that the minimum staff to youth ratios shall ensure that adequate staff is available to meet the needs 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 4 of 9

5 of the youth on the service plan. For more information on staff assignments, please contact the Department of Behavioral Health and Developmental Services (DBHDS). Unidentified I have a question concerning the PCP notification. The DMAS Manual states that we need to send notification at the receipt of services. Care coordination outlined in the Magellan Provider Handbook Supplement for VA DMAS is more detailed. Are we supposed to do this, even though it is not required by DMAS? Western Tidewater We are non-physician directed for outpatient services. Can we bill for the outpatient counselor services if a non-licensed person completes the intake? What if the intake is performed by an intern and remaining portion of the service is performed by a qualified staff person? In Chapter 6, page 10 of the CMHRS Manual, it states that care coordination is still required and the provider should be engaging in this practice. As a best practice, we encourage providers to coordinate with the PCP at the start of services, end of services, medication changes or significant changes in service provision. Providers should ensure that current medications along with the prescriber are listed on the Service Request Authorization (SRA) and in the member s medical record. Care Coordination with the PCP should also be clearly documented in the member s medical record. The Magellan Provider Handbook Supplement outlines best practices which providers are expected to follow. It is lack of appropriate care coordination may result in a quality of care concern. The Psychiatric Service Manual, Chapter 2 on the beginning of page 6 through page 7 describes the provider qualifications for psychiatric and substance abuse services. On page 7, it states that an individual who has completed his or her graduate degree and is under the direct supervision of an individual licensed under Virginia state law may be allowed to perform services. They must be working towards licensure in accordance with the requirement of the regulations of the individual profession which is listed. Additionally, within the same manual on page 8, it describes what needs to occur regarding direct supervision when services are provided by an unlicensed professional. Regarding whether an intern (nonqualified provider of psychiatric services) can provide the intake/assessment and the qualified provider can bill for the outpatient psychiatric services, this is not permitted: the services would be subject to retractions. The assessment is clinically essential to the initiation of services. The plan of care is based from the assessment and guides the provision of services. The assessment or evaluation is fundamental. The regulations state that psychiatric services must be directly and specifically related to an active treatment plan and are appropriate when meeting certain medical necessity criteria. Determining if medical necessity criteria are met and the appropriateness of the plan of care begins with an assessment of the individual s condition and diagnosis. 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 5 of 9

6 The Psychiatric Services Manual, Chapter 4 and Appendix C, references the expectation regarding an evaluation. As of December 1, 2015 the old eligibility criteria was replaced with Magellan Medical Necessity Criteria. You can access that information on Magellan Medical Necessity Criteria on magellanofvirginia.com. Magellan defines medical necessity as: Services by a provider to identify or treat an illness that has been diagnosed or suspected. The services are: 1. consistent with the diagnosis and treatment of a condition and the standards of good medical practice; 2. required for other than convenience; and 3. the most appropriate supply or level of service. All medical necessity decisions about proposed admission and/or treatment made by the Magellan care manager after receiving a sufficient description of the current clinical features of the individual s condition that have been gathered from a face-to-face evaluation of the individual by a qualified clinician. Evaluations are also referenced with consideration of service limits and billing procedures. Although DMAS or Magellan does not advise providers how to code or bill for the services they provided, providers should use the AMA CPT code book for clarification of the codes and how they are to be used. Since the evaluation is fundamental to the initiation of services, the code specified for this type of session would be the most appropriate to use in order to validate the clinical practice standards are being met. The reimbursement rate is higher for this session so there is no adverse reason to support a provider not using the evaluation code. Additionally, we would encourage you to contact the Department of Health Professionals about their licensing requirements. I have a clarification question regarding injectables. On a previous call we were told that the actual medication is billed to DMAS but we can continue to bill the administration of the injection to Magellan. I just want to confirm this is correct. Yes. When appropriate, providers may bill or directly to Magellan. DMAS published a clarification Medicaid Memo on this topic dated February 11, You may access the memo by clicking the following link: tent?vsid={ccf0855d ea-af17- F5F0DE20254E}&impersonate=true&objectType=document&id={940CB0C3 -EECE-4C83-81E3-07C06A46BBDF}&objectStoreName=VAPRODOS1 Horizon CSB I have a question regarding crisis stabilization. One day our agency was closed due to inclement weather. Do we have to discharge the registration No. In this example, if for one day services were not provided due to inclement weather, you do not need to discharge the registration. We encourage you to document your inability to provide service to the 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 6 of 9

7 to account for the closure since no services occurred and then submit another registration? member due to the inclement weather in the member s record. As this is a crisis service, we would encourage you to have pre-arranged measures in place to ensure the safety of members during inclement weather. This CSB Mt. Rodgers CSB Can the member call in to discharge themselves from services? Does the annual SSPI for mental health case management need to be completed and signed during a face-to- face visit? Blue Ridge We are trying to get an authorization for outpatient services; however, we are having an issue with the client s anniversary date and getting an end date with Magellan to match. What is the process? Can you explain it so we can know what to do on this end? Highland Springs In the Medicaid Manual Chapter 2 page 12, it talks about the required supervision of the QMHP eligible staff and it has to be provided by only LMHP staff. I think somewhere along the way I read they can also be supervised by LMHP eligible staff is that correct? would include a risk assessment and safety plan. Yes. The member may contact our customer service center at to discharge themselves from services for any reason. Common reasons for member discharging themselves include wanting to go with a different provider or no longer wanting to receive the particular service. In cases when a member calls dissatisfied with a particular service or provider, Magellan may work with the member to resolve issues related to service delivery. This may involve helping them find a different level of care or provider, or addressing concerns with the current provider. Yes. You can refer to the CMHRS Manual, Chapter 4, page 14 which covers the service specific provider intake requirements. It does state that the assessment SSPI needs to be face-to-face. Any subsequent reassessment or subsequent SSPI would need to include all of those same elements required on the initial, such as the mental status profile. Magellan posted an alert to our provider web portal regarding technical issues with the anniversary date display function. While we are correcting these issues, you may contact our customer service center at to confirm the anniversary date. No. That is not correct. The CMHRS manual states that an LMHP has to provide supervision to a QMHP, not an LMHP type. Regarding the QMHPA and QMHPC, is this credential only for services in the Community Mental Health Manual and is it not used in the Mental Health Clinic Manual. Is that correct? Unidentified I have a question about requesting an EPSDT - request from the memo that was sent out by Magellan on December 4, In the second Yes, that is correct. The QMHP-A and the QMHP-C are only credentialed for services in the CMHRS manual and not services in the Mental Health Clinic Manual. If any portion of the dates that you are requesting require an EPSDT request, you should answer yes to that question on the SRA and specify the dates. You would only submit one SRA request. If a request is 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 7 of 9

8 paragraph, it mentions when we need to request EPSDT. It gets confusing to me as to whether or not the authorizations are split or should simply be explained in the clinical portion. We were told that you actually split the authorization for EPSDT. One authorization for the first two weeks and a separate for the rest. Is that accurate? and Billing Norfolk CSB Is there a limit to the number of GAP SMI screenings an individual can have, if the member did not previously meet eligibility criteria? Or will they be considered as duplicates when the claims are submitted? incorrectly identified as EPSDT on the SRA, Magellan will process as an automatic non-authorization and will place a courtesy call out to provider for those authorizations. We encourage intensive in- home providers with questions regarding how many weeks of services your member has received to contact our customer service center at They can identify and tell you how many weeks that member has been in intensive in-home services so you can answer the question correctly. There is no limit on the number of GAP SMI screenings an individual can have, if the result of the previous screenings showed the member did not meet eligibility criteria. These will not be considered as duplicate claims. GAP Unidentified I need to access the member s financial screening information. Do I need to call Cover VA if I need to be listed as a representative on the authorization to release information? GAP GAP County There are a couple ICD-10 diagnoses that we were having trouble submitting online for the GAP limited SMI screenings, so we are submitting them by fax. Should we continue to fax these in? Do we just continue to fax those? When is a GAP treatment plan review due for case management services? Is it within 30 calendar days or the end of the calendar month? The member will first need to have you listed as a representative. The member must contact Cover VA in order to get you added Cover VA s contact number is Magellan does not accept GAP SMI screenings by fax. They have to come through the secure provider website, in order to be processed. If you experience an issue when you submit the SMI screening and get a response stating the diagnosis is not accurate and you believe it is an acceptable diagnosis, please contact our customer service center at and ask to speak to a GAP care manager for assistance. The ISP must be fully completed within 30 days of the initiation of services. For more information, refer to the GAP Manual on page 11. GAP Norfolk CSB We have a GAP client for whom we need to purchase injectable drugs. We are being told to bill Medicaid but it seems to be some confusion. We bill DMAS for the J codes, correct? Yes you bill J codes to DMAS. Refer to the DMAS Medicaid Memo posted on February 11, 2016 to clarify the injectable billing processes at DMAS and Magellan. In addition, DMAS corrected an error that prevented the processing of injectable medication claims for GAP members. GAP Rappahannock I have denied claims for GAP screenings. When I If any provider has GAP screenings submitted with the member s social 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 8 of 9

9 Area CSB called, a representative said it was denied because we did not put VAD in front of the social security number. Is this something new? We have needed to do this in the past and been paid for GAP screenings. GAP Mount Rodgers If we are providing case management services and our case manager makes contact with the GAP care coordinator would that be acceptable to be billed as a collateral contact as relevant to the ISP. GAP Unidentified If someone has GAP and also has another insurance that doesn t include mental health are they still eligible for GAP? His anniversary date was just up and he is now employed. The insurance through his employer does not include mental health services and he is continuing to come in and see us. We are wondering if he can still apply and get GAP coverage even when he has other insurance that doesn t include mental health services. Could the member cancel is insurance and apply for GAP? security number, our teams have been educated to handle those types of calls. You do not need to put VAD in front of the social security number when billing for the GAP screening. You may contact our customer service center at if you continue to experience this issue. If that is the only activity that is being done in that months time span, just speaking to a Magellan care manager doesn t appear to meet the required activities in the GAP Manual under case management. If the provider is completing coordination of care activities about services, resources, and activities related to the ISP that are member specific, this would be a part of case management. I would direct you to the GAP Manual page 10 to the required activities for case management. No, if that person has a comprehensive insurance, then they are not eligible for GAP benefits. GAP members who have no insurance at the time of GAP eligibility but then get other insurance would maintain their GAP eligibility for 12 continuous months or until the annual eligibility review occurs, whichever comes first. It would be the member s decision about what to do regarding their existing coverage. If the member does not have any insurance coverage at the time of the application, they may apply for GAP, however, the member would still have to meet the eligibility criteria for GAP GAP We are having difficulty with providers accepting our GAP clients because they are being told that they don t accept GAP. I am not sure how we can get this addressed. If you and/or your members are experiencing this issue, please contact one of the Magellan GAP care managers, so we can help reach out to those providers and clarify that if they are Medicaid fee-for-service, they can take GAP and we can help with any barriers that keep members from getting service in your area. 1 st Quarter 2016: Weekly Friday Provider Call FAQs Page 9 of 9