Tips and Tools for Chemical Dependency Authorization & Claims. Last updated: September 2012

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1 Tips and Tools for Chemical Dependency Authorization & Claims Last updated: September 2012

2 Welcome and Purpose Welcome. We appreciate your willingness to join us today. UCare values positive, effective working relationships with our provider network We are aware there are CD providers that have had difficulty getting their claims paid accurately the first time, resulting in an significant administrative burden for the provider We have designed this training to give CD providers the resources to be appropriately reimbursed the first time the claim is submitted for services provided to our members Thank you for coming

3 Presenters Nancy Houlton UCare Behavioral Health Services Director Sandy DelCastillo UCare Behavioral Health Operations Specialist Quinn McBreen BHP Manager of CD Care Management Julie Dahl MMSI Provider Service Coordinator George UCare Claims Technical Lead Heidi UCare Provider Assistance Center Supervisor

4 Agenda Welcome / Purpose History and Changes to Policy and Procedures Communication of Policy and Procedure Changes - Past and Future Obtaining Authorizations Submitting Claims - Codes and Modifiers Denied Claims/ Adjustments Key Resources - UCare Provider Portal, MN-ITS Common Disconnects Future Changes to CD Billing Fall 2012 Resources

5 History 2009 legislative changes required uniformity in Chemical Dependency services rates. DHS led the Rate Reform process which determined the structure and set the rates for each service. Current rate reform allows a graduated reimbursement scale based on a patient s level of acuity and complexity. There is a potential for up to 160 combinations of codes and modifiers and rates for the three core Chemical Dependency services. DHS adopted the new rate structure on 7/1/11, implementing payment with the service agreement structure. UCare was required to adopt the new rates 1/1/12. Implementation was delayed until 3/15/12 due to a need for policy clarification and revision of systems. The new rate structure conflicts with an insurance billing system due to complexity of billing code combinations. As a result all CD claims require a manual process.

6 Communication In the past, UCare communicated changes via the UCare provider website and via HealthLines Bulletins and letters to providers as well as on-site meetings with providers Going forward, our plan is to continue to use those routes and in addition; Webinars and/or in-person trainings for major changes affecting providers Posting Bulletins, training slides and webinar recordings on UCare s provider website listserv to communicate future changes Advisory group of CD providers formed to work with UCare on an on-going basis.

7 UCare s Authorizing Entities: BHP and MMSI For UCare members with a Primary Care Clinic in the MMSI network (including the Mayo Clinic Health System): MMSI , Option 5 Fax: For all other UCare members please call BHP: BHP (Behavioral Healthcare Providers) or Fax:

8 All About BHP Authorizations BHP contact information: Phone: or Fax: Web: All Chemical Dependency services and authorizations are driven by the Rule 25 Assessment. BHP Substance Use Service Request Form available at

9 BHP Authorization Process Contact BHP for prior authorization of the Rule 25 assessment by phone or fax. BHP can assist members in scheduling a Rule 25. Submit the Rule 25 assessment and BHP Substance Use Service Request Form to BHP by fax to request authorization of the Rule 25 assessment itself and any CD treatment services. BHP contacts the assessor and treatment provider by phone regarding the treatment authorization decision. CD treatment provider notifies BHP of admission to treatment by phone or by faxing the Substance Use Service Request. At this time, BHP confirms quantity of services, HCPCS, revenue codes and modifiers, and duration of services. For concurrent requests, submit the Substance Use Service Request form. For termination of services, please fax a discharge summary.

10 Common Authorization Issues BHP Missing service details, such as date range of services, quantity of hours (outpatient), and modifiers. Regarding modifiers: be sure to request these, even if they are understood about your programs (such as HH for co-occurring or HA for adolescent). Initial requests missing DHS-required components of the Rule 25 assessment, such as collateral contacts and treatment recommendations. Concurrent request missing clinical information, such as discharge planning, current dimensions, and appropriate referrals for mental health (dimension III). See the Chemical Use Treatment Authorization Process handout for common authorization scenarios.

11 All About MMSI Authorizations MMSI contact information: Phone: Fax: Web: All Chemical Dependency services and authorizations are driven by the Rule 25 Assessment. MMSI Notification and Authorization Request Form available at and click on Government CD Admission Worksheet under Forms section in Provider site.

12 MMSI Authorization Process Member has a Rule 25 Assessment Rule 25 Assessor submits by fax the Government CD Request Worksheet and the complete 18 pg Rule 25 Assessment to MMSI for authorization for the assessment (H0001) and for preapproval for CD treatment. MMSI reviews and faxes back authorization. CD Provider submits by fax the Government CD Admission Worksheet with modifiers - when the member is admitted to either residential or outpatient care. MMSI reviews and faxes back authorization. Concurrent reviews for residential are faxed to MMSI with dimension ratings and clinical this can be submitted with the Rule 25 Assessment and Placement Summary or progress note from the provider which includes the dimension ratings and clinical. Indicate # of days requested for concurrent/continued stay review

13 MMSI Authorization Forms For the Rule 25 Assessor - DHS Full Rule 25 Assessment - Government CD Request Worksheet * For the CD Provider on Admit or at Start of Care - Government CD Admission Worksheet * (this form has all the modifiers and codes) For the CD Provider for Continued Stay (put # of days requested on fax cover sheet) - Rule 25 Assessment and Placement Summary * - OR progress note which contains dimension ratings/clinical (Forms marked * are found at )

14 Common Authorization Issues MMSI 1) Provider submits the wrong form for CD Admission (MMSI needs the form with the modifiers) 2) Provider does not correctly complete the CD Admission form: No modifiers Incorrect modifiers Duplicate modifiers (Ex: Medical U5 modifier listed for both treatment and lodging this is not allowed) 3) Clinical personnel complete the modifier section without knowing which modifiers DHS approved for the facility

15 Procedure and/or Revenue Codes 0101 is Hospital Based only- all inclusive 0944, 0945 or 0949 are used for Residential Treatment component if applicable 1002 is Room and Board at same location as treatment 1003 is used for Room and Board at a different location than treatment H2035 is used for Outpatient Individual H0005 is used for Outpatient Group H0001 is used for Alcohol/CD Assessment (per session only) and used with or without Rev code 0900 H0020 is Medication Assisted Therapy and used with or without Rev code 0900 Source:

16 All About Modifiers Modifiers and Complexity are needed to determine corresponding pricing Modifier Codes Description Modifier Code Co Occurring HH Special Populations U4 Adolescent HA MAT dosing all other U9 *Can be used with either H0020 or H2036 MAT Methadone PLUS UA MAT all other PLUS UB MAT Dosing Methadone U8 *Can be used with either H0020 or H2036 Residential Medium Intensity TF Residential Low Intensity UD Client with Child U6 Medical Services U5 Residential High Intensity TG Co-Occurring AND Med Services UC

17 Claim Type and Bill Type Service Description Unit Claim Type Claim Format Type of Bill Hospital-Based Residential Day Inpatient 837I 11X Bundled Room and Board and Treatment Hospital-Based Residential - Day Inpatient 837I 11X Room and Board Component Only Hospital-Based Residential- Day Inpatient 837I 11X Treatment Component Only Non-Hospital Based Residential Program - Day Inpatient 837I 86X Room and Board Component Only Non-Hospital Based Residential Program - Hour Inpatient 837I 86X Treatment Component Only Non-Residential Treatment Hour Outpatient 837I or 837P 89X or 13X Non-Residential Treatment - Day Outpatient 837I or 837P 89X or 13X Medication Assisted Therapy Source: MHCP Provider Manual- Alcohol and Drug Abuse Services

18 Common Claim Submission Errors Common claim submission errors Incorrect or missing NPI number- where the location of service occurred Incorrect bill type (first submission vs. replacement) What has been authorized is not consistent with what is billed (Reminder: all CD services require an authorization) Incorrect code (inpatient vs. outpatient) Incorrect modifiers used if needed Residential billing includes discharge date as date of service on claim (date of discharge is not billable) Rate on claim is inconsistent to rate in MN-ITS system (all UCare claims paid by verifying rate on MN-ITS and authorization in place)

19 Adjustments: Denied Claims Q: How to find out why a claim was denied A: Review EOP, review info on Provider Portal or call Provider Assistance Center Q: How to get new or modified authorization A: Call BHP or MMSI for adjustment Q: How to resubmit claim for adjustment A: See Chapter 6 of Provider Manual Q: Replacement claims and timeframe for payment A: Initial clean claims typically processed around 30 days or less Replacement claims typically processed around 45 days or less

20 Replacement Claim Tips To avoid duplicate claim submission, please consider the following: Allow 30 calendar days for claim processing. If you are inquiring about payment please utilize Provider Portal on UCare website or call our Provider Assistance Center at or toll free at If a claim has been processed and/or denied, resubmitting a duplicate claim will result in a denial. Use the status adjustment procedure or TOB XX7 to resubmit claims. Review your EOPs as you receive them. Address questions about an EOP to the Provider Assistance Center at or , not by resubmitting the claim.

21 Access to UCare Provider Portal Registration is quick and easy 1. Go to the UCare Website: 2. Select the provider log-in box 3. Follow instructions to create an account for your organization. One UCare Portal Administrator per account The administrator for your organization is the gatekeeper who approves and removes others who have access (a safeguard for your security).

22 UCare Provider Portal Claims & Payment Lookup Authorization Status Lookup Member Eligibility Verification Find In-Network Providers Manage your portal profile Administrator can create new users Update password, , security information Send secure messages to the UCare Provider Assistance Center. Provide portal feedback: Submit your suggestions and comments for Provider Portal enhancements. For technical support, call Provider Assistance Center

23 Verify Member Eligibility

24 Check Authorization Status

25 Claim Status EOP Access Search for EOPs by check number

26 Send Secure Messages You can use the Provider Portal to send secure messages (such as inquiries that include PHI). Get a response in 3-5 business days, often sooner.

27 MN-ITS Minnesota DHS MN ITS ("minutes") is a system for providers enrolled with Minnesota Health Care Programs (MHCP) and their affiliated billers Operated by the Minnesota Department of Human Services; not a UCare site. Register and use MN-ITS to verify eligibility and your CCDTF rates: Work directly with DHS on any questions you have about using MN-ITS. DHS provider call center at or

28 Contacting UCare for Assistance UCare Provider Assistance Center Claims/Billing/Benefit Questions or Monday Friday, 7 a.m. 5 p.m. UCare Member Enrollment Verification or

29 Common Disconnects and Challenges Clarity needed between clinicians and billing staff on services covered by your DHS contract When there is a change needed in services from what was initially authorized, contact BHP or MMSI to update the authorization Authorization needs to match claim submitted All CD services require a CD diagnosis as primary. Submitting Mental Health diagnosis code for CD service results in denial of claim

30 Proposed Coding changes in October 2012 Coding changes proposed from the AUC - Administrative Uniformity Committee go into effect on 10/1/12 This will substantially change your claims coding with all payers/mcos, not just UCare Changes proposed and new AUC companion guide can be found on AUC Website UCare will be updating systems with the changes after they are finalized, in fall 2012

31 Links to AUC resources Minnesota AUC Home Page AUC Companion Guides - Choose 837 P for HCFA 1500 form instructions Choose 837I for UB-04 claim information

32 Links to Key Resources UCare, BHP, MMSI UCare Provider Portal UCare Provider Home Page UCare Provider Manual BHP MMSI

33 Links to Key Resources DHS HINT: In general, you may have better success with a Google search for a DHS page or publication, rather than using the search box on the DHS site. MN-ITS mn-its.dhs.state.mn.us DHS Alcohol and Drug Abuse Division DHS Fee Schedule (or use Google search to find it) RevisionSelectionMethod=LatestReleased&dDocName=id_ DHS Provider Home Page DHS Provider Manual

34 Closing THANK YOU!