San Diego County Mental Health Services. Financial Eligibility and Billing Procedures - Organizational Providers Manual (No Screen Prints)

Transcription

1 San Dieg Cunty Mental Health Services Financial Eligibility and Billing Prcedures - Organizatinal Prviders Manual (N Screen Prints)

2 Financial Eligibility and Billing Prcedures Organizatinal Prviders Manual Table f Cntents INTRODUCTION... 4 GENERAL WORKFLOW... 4 NEW CLIENTS... 4 EXISTING CLIENTS WHO ARE NEW TO THE PROGRAM... 4 ONGOING CLIENTS... 5 WEEKLY AND MONTHLY SELF MONITORING... 5 CLIENT FINANCIAL RESPONSIBILITY FOR PUBLIC MENTAL HEALTH SERVICES... 5 DETERMINING FINANCIAL ELIGIBILITY... 6 CLIENT SCREENING/FINANCIAL INTERVIEW... 6 CLIENT 3RD PARTY COVERAGE (INSURANCE, MEDICARE AND MEDI-CAL)... 7 Insurance Cverage Entry... 7 T Edit Insurance Cverage... 9 T Expire Insurance Cverage... 9 T Reactivate Insurance Cverage T Delete Insurance Cverage Medicare Plicy Cverage Entry T Edit Medicare Cverage T Expire Medicare Cverage T Reactivate Medicare Cverage T Delete Medicare Cverage Prcess fr Determining Medi-Cal Eligibility Mnthly Medi-Cal Eligibility File (MMEF) Match Maintenance Medi-Cal Plicy Cverage Entry T Edit Medi-Cal Cverage T Delete Medi-Cal Cverage CALIFORNIA CLIENT FINANCIAL REVIEW FORM (UMDAP) T Initiate a Client Financial Review (UMDAP) Full Pay (UMDAP) T Edit a Client Financial T Delete a Client Financial Review Link Family Members Client Financial Reviews MEDI-CAL REFERRAL REVIEW ASSIGNMENT OF BENEFITS MEDI-CAL CLIENTS WITH SHARE OF COST (SOC) Share f Cst Clearance Prcess Califrnia Share f Cst Claiming Reprt MINOR CONSENT MEDI-CAL MEDI-CAL HMO HEALTHY FAMILIES (SED) Mental Health Services Prvided t NON-SED Healthy Families Clients... Errr! Bkmark nt defined. Healthy Families (SED) -- ESU Staff Only... Errr! Bkmark nt defined. T View an Authrizatin in the MH MIS System CALWORKS ELIGIBILITY BILLING, COLLECTIONS AND PAYMENT PROCEDURES BILLING RATE SET UP BILLING PROCESS MEDICARE Page 2 f 84 8/27/2013

3 INSURANCE MEDI-CAL CLIENT PAYMENTS OF UMDAPS AT COUNTY AND CONTRACT PROGRAMS ACCOUNT COLLECTIONS- INSURANCE AND MEDICARE Insurance and Medicare Payment Entry Prcess CORRECTIONS, ADJUSTMENTS AND SPECIAL REQUIREMENTS INVALID SERVICES- FORMERLY SERVICE DELETIONS VOID CORRECTION AND REPLACE PROVIDER SELF MONITORING REPORTS CORRECTING ITEMS IN SUSPENSE TROUBLE SHOOTING AND QUESTIONS SERVICE QUESTION PAYER SOURCE QUESTIONS WHAT IS A BIC CARD? Benefits Identificatin Card (BIC) Temprary Benefits Identificatin Card (BIC) PATIENT ASSISTANCE PROGRAM (PAP) FISCAL PROCESS... ERROR! BOOKMARK NOT DEFINED.7 QUICK REFERENCE LIST FORMS MEDI-CAL INFORMATION NUMBERS... ERROR! BOOKMARK NOT DEFINED.3 HEALTHCARE BILLING TERMS INDEX Page 3 f 84 8/27/2013

4 Intrductin The Cunty f San Dieg Health and Human Services Agency (HHSA) Mental Health Divisin is respnsible fr management f the public mental health system. The HHSA Financial Services Divisin is respnsible fr management f mental health financial eligibility, billing and reimbursement. The public mental health system prvider netwrk includes Cunty perated prgrams and cntract prviders, which are knwn as rganizatinal prviders; private practitiners such as psychiatrists and psychlgists, which are knwn as individual fee fr service (FFS) prviders; and private hspitals, which are knwn as FFS hspitals. Each f these prvider grups is respnsible fr specific functins related t determining client financial eligibility, billing and cllectins. This manual prvides standardized prcedures fr rganizatinal prviders, wh may be Cunty r cntract prviders. Separate manuals utline prcedures fr individual FFS and FFS hspital prviders. The Organizatinal Prviders Operatins Handbk Vlume II, MIS User Manual prvides detailed instructins fr cmpletin f MIS related nn-financial administrative prcesses including entry f new clients, entry f demgraphic infrmatin and diagnses, assignments and services. This Financial Eligibility and Billing Prcedures Organizatinal Prviders Manual prvides detailed instructins fr cmpletin f financial eligibility and billing prcesses including entry f third party cverage and financial reviews (UMDAP), billing and recrding f payments. General Wrkflw The fllwing is a summary f a typical wrkflw fr new clients, existing clients wh are new t the prgram and nging clients. Please refer t this manual fr further detail regarding financial eligibility billing and payment functins and t the Organizatinal Prviders Operatins Handbk Vlume II, MIS User s Manual fr ther tasks. New Clients (nt fund in client lk-up) Add the client Enter a Demgraphic review Enter a Diagnstic review Assign client t prgram and staff Cnduct a financial interview Enter 3 rd party cverage (Insurance, Medicare and Medi-Cal) File signed AOB (Authrizatin f Benefits) and Authrizatin t Release Infrmatin if applicable Enter Califrnia Client Financial review (UMDAP) File signed Califrnia Client Financial Review Maintenance frm (financial respnsibility frm) Enter services Cntract Prviders nly if client has Insurance r Medicare Submit billing t insurance cmpany r Medicare carrier Submit Explanatin f Benefits (EOB) t MH Billing Unit t recrd payments r denials. Existing clients wh are new t the prgram Cnfirm/update the Demgraphic review Cnfirm/update the Diagnstic review Assign client t prgram and staff Page 4 f 84 8/27/2013

5 Cnduct a financial interview Cnfirm/update 3 rd party cverage (Insurance, Medicare & Medi-Cal) File signed AOB and Authrizatin t Release Infrmatin if applicable Cnfirm/update Financial review (UMDAP) File signed Financial respnsibility frm Enter services Cntract Prviders nly if client has Insurance r Medicare Submit billing t insurance cmpany r Medicare carrier Submit Explanatin f Benefits (EOB) t MH Billing Unit t recrd payments r denials. Onging Clients Cnfirm/update applicable fields n Demgraphic review at the time f the Annual Review, as changes ccur r becme knwn- the address, telephne, emergency cntact and living arrangements fields shuld be cnfirmed r updated at each visit. Update the Diagnstic review each time diagnsis is changed by a server Update assigned staff if applicable Cnduct a financial interview annually and whenever clients financial situatin changes Cnfirm/update 3 rd party cverage (Insurance, Medicare & Medi-Cal) Cnfirm/update and file signed AOB and Authrizatin t Release Infrmatin if applicable Cnfirm/update Financial review (UMDAP) Enter services Cntract Prviders nly if client has Insurance r Medicare Submit billing t insurance cmpany r Medicare carrier Submit Explanatin f Benefits (EOB) t MH Billing Unit t recrd payments r denials. Weekly and Mnthly Self-Mnitring All prgrams are respnsible fr mnitring, crrecting and updating the financial reviews; 3 rd party insurance entry, Medi-Cal eligibility determinatin, etc. that are dcumented in the MH MIS in accrdance with the instructins in this manual. The Prvider Self-Mnitring Reprts sectin includes summary infrmatin abut reprts available t facilitate the mnitring and crrecting prcess. Client Financial Respnsibility fr Public Mental Health Services In accrdance with the State f Califrnia Welfare and Institutins Cde, Regardless f the funding surce invlved, fees shall be charged in accrdance with the ability t pay fr specialty mental health services rendered but nt in excess f actual csts in accrdance with Sectin Clients wh are residents f the State and wh are receiving cmmunity mental health services, including invluntary admissins, are t be charged a fee accrding t their ability t pay, utilizing the Unifrm Methd t Determine Ability t Pay (UMDAP) Fee Schedule. Organizatinal prviders must enter the financial eligibility infrmatin int the MH MIS t ensure accurate billing f services. Nte that clients residing in residential and lng term care prgrams may be respnsible fr rm and bard csts, which are nt billed via the MH MIS. Mental Health services prvided by the fllwing areas are nt chargeable t the client and are therefre exempt frm the entry f UMDAP in the MH MIS system: Page 5 f 84 8/27/2013

6 Adult Frensic Services Cal-Wrks Clubhuses Residential Prgrams (Des nt include Day Treatment Services) Lng Term Care Institutins Outreach and Cmmunity Services Lw Incme Health Prgram (LIHP) In rder t be eligible fr UMDAP, residency in the state is required. Residency is defined as intent t reside based n the clients verbal declaratin. Withut intent t reside in the state, the client is nt eligible fr UMDAP and must be billed at full cst. This means that clients wh reside ut f state (including freign natinals) are respnsible fr full cst f services. Nte that, in accrdance with Federal, State and Cunty plicy, persns wh are knwn t be undcumented immigrants are eligible nly fr emergency services, i.e., services prvided by an acute hspital r Emergency Psychiatric Unit (EPU) r the Emergency Screening Unit (ESU). Any service that is nt reimbursable by Shrt-Dyle/Medi-Cal is chargeable t the client. Determining Financial Eligibility Organizatinal Prviders are respnsible fr cnducting a client screening/ financial interview with new clients and existing clients wh are new t the prgram prir t prviding nn-emergency r crisis services. If clients are prvided emergency r crisis services in advance, the client screening/ financial interview shall be cmpleted befre the client leaves the facility r as sn as pssible thereafter. Onging clients shuld receive a financial interview at least nce per year and whenever there is a change in the client s financial situatin, e.g. change in incme r Insurance cverage. In rder t take full advantage f the sftware functinality, prgram staff shuld gather the infrmatin frm the client and enter it directly int MH MIS as an interactive prcess. This manual includes frms designed fr use if the financial infrmatin must be gathered frm clients by direct service staff in situatins when it is nt pssible t enter infrmatin directly int the MH MIS. Client Screening/Financial Interview The purpse f a client screening/financial interview is t identify and dcument any third party cverage that the client may have and t determine the client s respnsibility fr payment fr services. In additin, as part f this prcess, clients wh appear t be eligible fr Medi-Cal shuld be referred fr assistance with applicatins fr Medi-Cal. The screening prcess cnsists f a Client 3 rd Party Cverage review which includes Insurance and Medicare, Medi-Cal Eligibility Review, and Client Financial Review r UMDAP. It is recmmended that entry is made directly int the MH MIS. In situatins when that is nt pssible, the fllwing MH MIS frms shuld be cmpleted fr later entry int the MH MIS: Client 3 rd Party Cverage Screen Califrnia Client Financial Review Screen Assignment f Benefits and Release f Medical Infrmatin Frm Page 6 f 84 8/27/2013

7 Client 3rd Party Cverage (Insurance, Medicare and Medi-Cal) When a client visits a prgram and has been determined t have Insurance, Medicare, r Medi-Cal, the cverage shall be entered in MH MIS in the Client 3 rd Party Cverage view. Insurance Cverage Entry Ask the client fr his/her Insurance card. Make a cpy f the card and file in the client s chart. In the Client 3 rd Party Cverage screen: Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T cmplete 3 rd Party Cverage Main (1) Search fr Pay Surce Insurance = Check drp dwn list fr apprpriate Insurance cmpany number Enter Benefit Plan: Benefit Plan #1 Standard This is used fr standard insurance plicies. Benefit Plan 9020 Inpatient Only This benefit plan is cnsidered a 9000 series benefit plan. Therefre, this des nt require selectin; all clients are autmatically set up with a 9000 benefit plan s based n the Pay Surce selectin (insurance cmpany selectin inpatient services can be billed if apprpriate) Cautin: Many insurance cmpanies have similar names. Carefully chse the insurance cmpany that matches the client s insurance card. Please cnsult a cpy f the Pay Surce Listing with addresses, t ensure that the crrect pay surce is selected. In the event yu cannt find the insurance cmpany, please cntact the MH Billing Unit at (619) fr assistance.. If the Pay Surce is Insurance: Enter the plicy number frm the card Enter the effective date: Use the first date f service r effective date f Insurance, whichever is later Example: If a client presents fr the first time fr treatment n Octber 10, 2007, and their Insurance card reflects that they have Insurance cverage since January 1, 2000, the effective date entered int the MH MIS system wuld be Octber 10, By using the latest date, yu prevent any ptential issues surrunding in apprpriate r inaccurate service billing. Enter the apprpriate Pay Surce Pririty number frm this table fr billing purpses : Insurance - Primary = 1 Insurance Secndary = 2 Insurance Tertiary = 3 Medicare = 4 Page 7 f 84 8/27/2013

8 Insurance Secndary t Medicare = 5 Medi-Cal = 6 Insurance Secndary t Medi-Cal = 7 Victims f Crime = 8 The pririty number is used t determine which payer will be billed first. In mst cases, insurances shuld be entered with a pririty # 2. This will allw fr the entry f an additinal insurance cmpany as the primary, if it is fund that the client had ther Insurance. If the client has mre than ne insurance, the primary cverage shuld be entered as # 1 and the secndary cverage shuld be entered as # 2. Exceptins include insurance plicies that are Medicare supplements. These shuld be entered with a pririty #5. If yu have questins abut the crrect pririty number, please cntact the MH Billing Unit at (619) fr assistance. Grup Number: Enter grup number r name frm the card Plicy Hlder: Relatinship t Insured: Search t select apprpriate relatinship If ther than the client, cmplete name, address, DOB and sex. Example: If the insured is a parent and the client is a child, then the relatinship t insured is Child. Main (2) The Ok t Bill bx shuld be checked at all times. In the event that the bx is unchecked, ntificatin t the MH Billing Unit will be necessary fr apprval and dcumentatin within the system is necessary in the cmments field. The Alias field in the 3 rd party cverage view is used t recrd an alternate name that is used n client s insurance recrds. If the name n the clients insurance card is different than the client s name in MH MIS, enter the name n the insurance card in the alias field fr that insurance cverage. Example: Client name is Smith-Jhnsn, Susan hwever, with her insurance cmpany she is knwn nly as Jhnsn, Susan. We can place the Jhnsn in the last name f the alias field t be used fr billing t this particular insurance cmpany, and the riginal name Smith-Jhnsn, Susan bills t all ther insurance cmpanies Once the infrmatin has been entered, please prvide the alias infrmatin t staff respnsible fr cmpleting the demgraphics in the prgram t allw fr entry int the alias sectin f the demgraphics mdule. Once the alias infrmatin has been cmpleted, pen the Cmments tab (4) and dcument the alias infrmatin and identify where the infrmatin was gathered and identified with the date, emplyee name and prgram name. State Specific (3) N Entry required fr insurance clients Cmments (4) Additinal cmments cncerning client insurance may be entered. When making entries int any Cmment field, each cmment shall be identified with the date, emplyee name, and Unit/sub-unit. Page 8 f 84 8/27/2013

9 After all entry has been cmpleted click SAVE. T add anther insurance click buttn marked CLEAR at the bttm f the screen and repeat the prcess fr insurance cverage entry. T Edit Insurance Cverage It may be necessary t edit previusly entered insurance cverage due t a data entry errr r terminatin f cverage. An effective date and reasn fr the change must be entered t keep an audit trail f the client s cverage infrmatin any time a change is entered. Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 - T Edit r Update Insurance Cverage Main (1) The fllwing areas may be edited: Insurance Plicy Number Expiratin Date (may be entered) Main (2) Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change Please nte: If the effective date r name f insurance cverage needs t be edited, yu must cntact the Mental Health Billing Unit at (619) fr assistance. Please refer t the Trubleshting sectin in the manual fr mre infrmatin. T Expire Insurance Cverage If the Insurance cverage has expired, the Prgram staff shall enter the expiratin date int the MH MIS. Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T Expire Insurance Cverage Main (1) Type in the Expiratin Date f the Plicy int the field designated. If the date entered is cnsidered a future date, the pririty bx will reflect an I fr inactive. Even thugh the plicy will be effective until the expiratin date arrives and will technically lk as if it is inactive, billing will still ccur apprpriately. Main (2) Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change. State Specific (3) N Entry fr Medicare Clients Page 9 f 84 8/27/2013

10 Cmments (4) Cmments regarding client insurance may be entered. Identify cmments with the date f entry, emplyee name, and unit/sub-unit. After all entry has been cmpleted click SAVE. T Reactivate Insurance Cverage If a client s insurance plicy is reactivated after it has been already expired in the MH MIS, the Prgram staff can reactivate the plicy with a new effective date. Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T Reactivate Insurance Cverage Main (1) Click n ALL buttn belw the Insurance listing fr the client. This will allw the prgram t see all f the active and inactive plicies fr the client. Click n the apprpriate insurance plicy t be reactivated. Press Reactivate at the bttm f the screen Cnfirm the apprpriate plicy number fr the client Type in the new effective date fr the plicy in the Effective Date bx. Type in the apprpriate Pay Surce pririty number Press Save Main (2) Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change. State Specific (3) N Entry fr Insurance Clients Cmments (4) Cmments regarding client insurance may be entered. Identify cmments with the date f entry, emplyee name, and unit/sub-unit. After all entry has been cmpleted click SAVE T Delete Insurance Cverage Deletin f insurance Cverage shall nly be cmpleted by the Mental Health Billing Unit. Please cntact the Mental Health Billing Unit at (619) fr assistance. The Billing Unit will require a reasn fr the prpsed deletin. Medicare Plicy Cverage Entry Page 10 f 84 8/27/2013

11 Ask the client fr his/her Medicare card. Make a cpy f the card and place in the client s chart. In the Client 3 rd Party Cverage view: Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T cmplete 3 rd Party Cverage Main (1) Search fr Pay Surce Medicare A nly = 200 Medicare B nly = 201 Medicare A & B = 202 Medicare plicies must be dcumented apprpriately. When the client has Medicare Cverage, they have cverage with ne and nly ne f the Medicare Pay Surces. If the client has Medicare Part A nly, use the plicy number 200 (Medicare Part A); if the client has Medicare Part B nly, use the plicy number 201; and if the client has Medicare Part A and Part B, use the plicy number 202 (Medicare Part A & B). Medicare Pay Surce entry is nt based n services prvided, but is based n the client s cverage. Fr example, if yu are an utpatient prgram, and the client has Medicare Part A and Part B, the pay surce entered int the MH MIS system is 202 Medicare A & B. If the Pay Surce is Medicare: Enter the plicy number frm the card. The Plicy Number must be a minimum f 10 characters and must use capital letters. Enter the effective date: Use the first date f service r effective date f insurance, whichever is later. Pririty: Enter the apprpriate Pririty number fr billing purpses: Medicare = 4 Main (2) The Alias field in the 3 rd party cverage view is used t recrd an alternate name that is used n client s insurance recrds. If the name n the clients insurance card is different than the client s name in MH MIS, enter the name n the insurance card in the alias field fr that insurance cverage. Example: Client name is Smith-Jhnsn, Susan hwever, with her insurance cmpany she is knwn nly as Jhnsn, Susan. We can place the Jhnsn in the last name f the alias field t be used fr billing t this particular insurance cmpany, and the riginal name Smith-Jhnsn, Susan bills t all ther insurance cmpanies. Once the infrmatin has been entered, please prvide the alias infrmatin t whever cmpletes the demgraphics in the prgram t allw fr entry in the demgraphics mdule QMB (Qualified Medicare Beneficiary) D nt place a check mark in the bx marked QMB, as this will affect the Medi-Cal billing in a negative manner. QMB is a special prgram fr lw incme Medicare beneficiaries that d nt apply t San Dieg Cunty Mental Health services. State Specific (3) Page 11 f 84 8/27/2013

12 N Entry fr Medicare Clients Cmments (4) Dcument the alias infrmatin, identifying where the infrmatin was gathered, the date, emplyee name and unit/sub-unit. When making entries int any Cmment fields, each cmment shall be identified with the date, emplyee name and unit/sub-unit. After all entry has been cmpleted click SAVE. T Edit Medicare Cverage It may be necessary t edit previusly entered Medicare cverage due t a data entry errr r terminatin f cverage. Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T Edit r Update Medicare Cverage Main (1) The fllwing areas may be edited: Medicare Plicy Number - The Plicy Number must be a minimum f 10 characters and must use capital letters Expiratin Date (may be entered) Main (2) Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change. State Specific (3) N Entry fr Medicare Clients Cmments (4) Any cmments can be entered cncerning the client. After all entry has been cmpleted click SAVE. T Expire Medicare Cverage If the Medicare cverage has expired, the Prgram staff shall enter the expiratin date int the MH MIS. Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T Expire Medicare Cverage Main (1) Page 12 f 84 8/27/2013

13 Type in the Expiratin Date f the Plicy int the field designated. If the date typed in is cnsidered a future date, then the pririty bx will reflect an I fr inactive. Even thugh the plicy will still be effective until the expiratin date arrives and will technically lk as if it is inactive, billing will still ccur apprpriately. Main (2) Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change. State Specific (3) N Entry fr Medicare Clients Cmments (4) Any cmments can be entered cncerning the client. After all entry has been cmpleted click SAVE. T Reactivate Medicare Cverage If a client s Medicare plicy is reactivated after it has been already expired in the MH MIS, the Prgram staff can reactivate the plicy with a new effective date. Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T Reactivate Medicare Cverage Main (1) Click n ALL buttn belw the Insurance listing fr the client. This will allw the prgram t see all f the active and inactive plicies fr the client. Click n the apprpriate insurance plicy t be reactivated. Press Reactivate at the bttm f the screen Cnfirm the apprpriate plicy number fr the client Type in the new effective date fr the plicy in the Effective Date bx. Type in the apprpriate pririty number Press Save Main (2) Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change. State Specific (3) N Entry fr Medicare Clients Cmments (4) Any cmments can be entered cncerning the client. After all entry has been cmpleted click SAVE Page 13 f 84 8/27/2013

14 T Delete Medicare Cverage Deletin f Medicare Cverage shall nly be cmpleted by the Mental Health Billing Unit. Please cntact the Mental Health Billing Unit at (619) fr assistance. The Billing Unit will require a reasn fr the prpsed deletin. Prcess fr Determining Medi-Cal Eligibility Client eligibility indicates whether an individual is qualified t receive services as part f the Medi- Cal prgram. Prgram staff is respnsible fr ensuring that current Medi-Cal eligibility infrmatin is recrded fr all clients wh are Medi-Cal beneficiaries. Fr new clients, Medi-Cal eligibility shuld be entered prir t the delivery f services. In additin, Medi-Cal eligibility shuld be verified each time a client receives Medi-Cal cvered services The MH MIS system includes an uplad f the State s Mnthly Medi-Cal Eligibility File (MMEF) which includes all f the Medi-Cal beneficiaries within the State f CA. As anther way t ensure that Medi-Cal eligibility is captured fr all clients, this file is dwnladed each mnth and matched against the clients registered in MH MIS. This prcess is cmpleted by the Mental Health Billing Unit n a mnthly basis and prgrams are ntified each mnth via frm OPTUM nce the prcess is cmplete. Mnthly Medi-Cal Eligibility File (MMEF) The Mnthly Medi-Cal Eligibility File (MMEF) file is dwnladed each mnth and matched against the clients registered in MH MIS. This prcess is cmpleted by the Mental Health Billing Unit n a mnthly basis. The MMEF is received tward the end f the mnth and includes sixteen mnths f cverage infrmatin which equates t the current mnth and fifteen prir mnths data. The current mnth is the mnth fllwing the mnth in which the MMEF file is received. An example: when MMEF is received in late Nvember, the current mnth is cnsidered t be December. This means that Medi-Cal eligibility will be autmatically entered thrugh this prcess fr mst existing clients. Hwever, since the match prcess may smetimes cntain errrs, prgrams shuld nt rely n this methd f updating Medi-Cal eligibility. Match Maintenance The MMEF Match Maintenance is a mnthly prcess cnducted by the MH Billing Unit. The MMEF file includes all the Medi-Cal clients within the Cunty, nt just thse wh are clients f the Cunty MH system. Therefre, the MH MIS allws a prcess by which the system can attempt t match each f the MMEF client recrds with a client in the MH MIS system. Each client recrded in the MMEF file will be categrized as: Match: The MMEF recrd can be autmatically matched t a client in the MH MIS system (i.e. with n human interventin required) Ptential Match: The MMEF recrd ptentially matches a client in the MH MIS system pending a manual determinatin (i.e. human interventin required) N Match: The MMEF recrd des nt match a client in the MH MIS. Fr the client wh can be matched using this MMEF utility, the client cverage in the MH MIS will be autmatically updated t reflect the apprpriate infrmatin. Nte: prir t updating the client cverage recrd, a snapsht f the existing client cverage infrmatin will be permanently recrded t facilitate auditing. Page 14 f 84 8/27/2013

15 Medi-Cal Plicy Cverage Entry Medi-Cal cverage shall be entered using infrmatin frm the client s Medi-Cal card, either by ging t lgin t Medi-Cal Eligibility r by matching t Mnthly Medi-Cal Eligibility File (MMEF). Ask the client fr his/her Medi-Cal card. The fllwing prcedure shuld be used if the client has their Medi-Cal card. In the Client 3 rd Party Cverage view: Step 1 T select Client Search fr client using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Enter Pay Surce as Medi-Cal Step 2 T cmplete Medi-Cal Cverage Main (1) Search fr Pay Surce Medi-Cal = 100 Enter the plicy number frm the card Enter the effective date: Use the first date f service r effective date f Medi-Cal, whichever is later Pririty: Enter the apprpriate Pririty number fr billing purpses: Medi-Cal = 6 d Step 4: T Save Updated Infrmatin Step 5: Click Update at the bttm f the respnse screen t save infrmatin t MH MIS. Main (2) The Alias field in the 3 rd party cverage view is used t recrd an alternate name that is used n client s insurance recrds. If the name n the clients insurance card is different than the client s name in MH MIS, enter the name n the insurance card in the alias field fr that insurance cverage. Example: Client name is Smith-Jhnsn, Susan hwever, with her insurance cmpany she is knwn nly as Jhnsn, Susan. We can place the Jhnsn in the last name f the alias field t be used fr billing t this particular insurance cmpany, and the riginal name Smith-Jhnsn, Susan bills t all ther insurance cmpanies. Once the infrmatin has been entered, please prvide the alias infrmatin t whever cmpletes the demgraphics in the prgram t allw fr entry in the demgraphics mdule. Once the alias infrmatin has been cmpleted, pen the Cmment tab (4) and dcument the alias infrmatin, where the infrmatin was gathered, date, emplyee name and unit/sub-unit. Page 15 f 84 8/27/2013

16 Step 6: State Specific (3) Share f Cst (SOC) is determined by checking the client s Medi-Cal cverage either thrugh the checking Medi-Cal eligibility thru the internet r matching t the Mnthly Medi-Cal Eligibility File (MMEF). The utstanding SOC balance will be nted and this infrmatin is then entered int the Share f Cst/Spend Dwn view lcated n tab 3 under Califrnia/New Yrk. Share f Cst/Spend Dwn Subject t Share f Cst/Spend Dwn: Mark this bx if client is subject t share f cst/spend dwn amunts. This is determined thrugh the client s Medi-Cal eligibility. Mnthly Share f Cst/Spend Dwn Amunt: N entry needed. This field will be autmatically filled in by either the RTIE r MMEF uplad. The prcess fr the clearing f Share f Cst is nted belw under the heading: Share f Cst Clearance Prcess page 28. Share f Cst met by ther Prviders fr the Mnth: Enter the dllar amunt f the share f cst amunt that has been met fr the mnth by ther prviders based n infrmatin frm the State website. Cunty f Respnsibility: The state identified Cunty cde (e.g. 37 = San Dieg) will be ppulated based n the infrmatin prvided frm the client s Medi-Cal eligibility. Primary Aid Cde: The state identified primary aid cde will be ppulated by the client s Medi-Cal eligibility, hwever, in the event that the Aid Cde sectin is nt ppulated, the Medi-Cal claim will nt be claimed t the state. T Edit Medi-Cal Cverage The majrity f edits fr Medi-Cal cverage ccur with the MMEF file uplad. Therefre, it may be a rare ccurrence that a persn wuld need t edit Medi-Cal cverage. If editing Medi-Cal cverage becmes necessary, please cntact the MH Billing Unit at (619) fr assistance. Step 2 T Edit r Update Medi-Cal Cverage Main (1) The fllwing areas may be edited: Medi-Cal Plicy Number (Prgram staff shall check Medi-Cal eligibility via the internet verify the accuracy f the Medi- Cal Plicy number t ensure the client is Medi-Cal eligible. D nt just enter a plicy number and save; Expiratin Date (may be entered) Pririty: Medi-Cal = 6 Main (2) The Alias field in the 3 rd party cverage view is used t recrd an alternate name that is used n client s insurance recrds. If the name n the clients Insurance card is different than the client s name in MH MIS, enter the name n the Insurance card in the alias field fr that insurance cverage. Example: Client name is Smith-Jhnsn, Susan hwever, with her Insurance cmpany she is knwn nly as Jhnsn, Susan. We can place the Jhnsn in the last name f the alias field t be used fr billing t this particular insurance cmpany, and the riginal name Smith-Jhnsn, Susan bills Page 16 f 84 8/27/2013

17 t all ther Insurance cmpanies. Once the infrmatin has been entered, please prvide the alias infrmatin t whever cmpletes the demgraphics in the prgram t allw fr entry in the demgraphics mdule Once the alias infrmatin has been cmpleted, pen the Cmment tab (4) and dcument the alias infrmatin, where the infrmatin was gathered, the date, emplyee name, and unit/sub-unit. Change Date: Enter date f entry fr change Dcument the reasn fr the change. Include the unit/subunit Include the name f the persn making the change. Ok t Bill bx must remain checked State Specific (3) Share f Cst is determined by checking the client s Medi-Cal cverage Medi-Cal eligibility via internet r matching t the Mnthly Medi-Cal Eligibility File (MMEF). The utstanding SOC balance will be nted and this infrmatin is then entered int the Share f Cst/Spend Dwn view lcated n tab 3 under State Specific. Share f Cst/Spend Dwn Subject t Share f Cst/Spend Dwn: Mark this bx if client is subject t share f cst/spend dwn amunts. This is determined thrugh the client s Medi-Cal eligibility. Mnthly Share f Cst/Spend Dwn Amunt: N entry is needed. This field will be autmatically filled in MMEF uplad. The prcess fr the clearing f Share f Cst is nted belw under the heading: Share f Cst Clearance Prcess. Share f Cst met by ther Prviders fr the Mnth: Enter the dllar amunt f the share f cst amunt that has been met fr the mnth by ther prviders. This must be a cnfirmed amunt. Cunty f Respnsibility: The state identified cunty cde (e.g. 37 = San Dieg) will be ppulated based n the infrmatin prvided frm the client s Medi-Cal eligibility. Primary Aid Cde: The state identified primary aid cde will be ppulated by the client s Medi-Cal eligibility. Hwever, if the Aid Cde sectin is nt ppulated, the Medi-Cal claim will nt be claimed t the state. Cmments (4) Additinal cmments can be entered cncerning the client. Nte that cmments must include date, name f staff, and unit/sub-unit number. After all entry has been cmpleted click SAVE. T Delete Medi-Cal Cverage Page 17 f 84 8/27/2013

18 Deletin f Medi-Cal Cverage shall nly be cmpleted by the Mental Health Billing Unit. Please cntact the Mental Health Billing Unit at (619) fr assistance. The Billing Unit will require a reasn fr the prpsed deletin. Califrnia Client Financial Review Frm (UMDAP) The Califrnia Client Financial Review Frm is used t determine the amunt the client r respnsible party is bligated t pay fr services under the Unifrmed Methd fr Determining the Ability t Pay (UMDAP) requirements. Prgrams shuld rutinely calculate UMDAP fr their clients prir t r during the first visit, as the annual UMDAP liability is due and payable by the client at the time f service. Medi-Cal clients with n Share f Cst are required t have the UMDAP perid updated in the MH MIS system fr CSI reprting requirements. Clients with Full Scpe Medi-Cal r under the Lwer Incme Health Plan (LIHP) will nt be required t pay an UMDAP. It will be necessary t recrd that the Assignment f Benefits has been signed in Califrnia Client Financial Review fr all clients if they have Medicare r Insurance. Medi-Cal clients wh have been determined by the State t have a Share f Cst shall be UMDAP ed in the MH MIS system in rder t bill the client fr their UMDAP in lieu f their share f cst amunt (whichever is less). Prgram staff is respnsible fr verifying, cmmunicating, and cllecting the client s financial respnsibility. The financial screening prcess is required fr all clients wh are nt full Scpe Medi-Cal r LIHP whenever there is a change in the client r family incme r allwed expenses. At minimum, an UMDAP must be cmpleted annually within 30 days prir t r after the anniversary f the UMDAP date. Failing t assess the UMDAP date within the parameters identified abve, the prgram will need t cntact the Mental Health Billing Unit at (619) fr entry. UMDAP is determined by incme, asset determinatin, allwable expenses, and family size, s it is imperative that it be as accurate as pssible. Nte: When calculating an UMDAP in the MH MIS, the number f dependents must include all children under 18 and parents. Incme includes grss mnthly wages and/r salaries f all members f the family grup. Under ther incme be sure t recrd ttal incmes frm dividends, interest, rentals, supprt payments, and any ther surce f incme. Asset determinatin includes recrding all liquid assets, such as savings accunts, stcks, bnds, and mutual funds. Althugh the MH MIS system autmatically calculates the excess liquid assets, the prcess t manually calculate assets has been included t assist thse individuals wh may be wrking in the field. Excess Liquid Asset Calculatin : T determine the amunt f the excess liquid assets, determine the ttal value f all f the liquid assets. Subtract the allwance frm the Schedule f Asset Allwances included n the State Department f Mental Health Unifrm Patient Fee and Asset Allwance Schedule. Divide the remaining ttal f the liquid assets by 12 and apply the result t the mnthly incme f the family unit. A cpy f the schedule is lcated n page 66 in the Frms sectin f this handbk. The nly deductins frm grss incme allwed are: Curt rdered bligatins paid mnthly Mnthly child care expenses necessary t maintain emplyment Mnthly dependent supprt payments Mnthly medical expense payments Mnthly mandated deductins frm grss incme fr retirement plans Page 18 f 84 8/27/2013

19 The manual calculatins prcess has been prvided fr thse staff that may nt have access t Anasazi. Subtract the ttal f the allwable mnthly deductins frm the ttal mnthly incme. The result is the mnthly-adjusted grss incme f the family unit. Use this infrmatin, as well as the number in the family unit t determine the UMDAP liability using the State Department f Mental Health Unifrm Patient Fee and Asset Allwance Schedule included in the frms sectin f this handbk. Prgram staff has the authrity t request verificatin f any financial infrmatin given by a client r respnsible party. Verificatin shuld be requested when staff has reasn t suspect that the infrmatin prvided is nt accurate. In making an inquiry t surces ther than the client r respnsible persns, care must be exercised t prtect the cnfidentiality f the client. (Welfare and Institutins Cde, Sectin 5328). A signed Authrizatin t Release Infrmatin shuld be btained befre requesting infrmatin frm surces ther than the client because by making the request fr infrmatin, the prgram is revealing that the client is seeking mental health treatment. The State Department f Mental Health Revenue Manual lists the fllwing surces fr verificatin f financial data: Incme Tax Returns Driver s License r State-issued Identificatin Unemplyment Dcuments Current Earnings Statements Emplyer Identificatin Card A client r respnsible party has the right t refuse t give financial infrmatin; hwever, if such refusal is made, the client r respnsible party shall be liable fr the full cst f services received. After the UMDAP is cmpleted, the client r respnsible party must be infrmed f the amunt f the financial respnsibility assessed. If the client requests a payment plan t be established, the Prgram shall establish a payment plan in accrdance with the requirements belw: Payment plans must be at a minimum the ttal UMDAP amunt divided by 12 mnths. Example: If a client s financial UMDAP amunt is $250.00, the payment plan can be set up fr $ divided by 12 = $20.85 (apprximately) per mnth. If the client requires a payment plan that is less than 12 equal payments fr the year, then the prgram staff shuld refer the client t the Mental Health Billing Unit at (619) fr apprval f the payment amunt. Prgrams are nly authrized t apprve payment plans that are equal t 12 payments fr a year t pay ff the UMDAP amunt r balance f the client s accunt. Agreed Upn Payment Amunt: Enter the amunt f the payment plan amunt that was agreed upn by the client. Identify that the payment is mnthly. D nt establish a payment plan n a per visit basis. Nte: In rder t view hw much a client wes after the UMDAP has been cmpleted and services have been prvided, prgram staff shall use the Client Abstract view. T Initiate a Client Financial Review (UMDAP) Page 19 f 84 8/27/2013

20 Nte: Prir t cmpleting a financial review, it is imprtant t determine if anther family member is receiving services. If s please refer t the Financial Review Type sectin belw fr specifics n handling individual and family UMDAP s. In Califrnia Client Financial Review Maintenance view Step 1 T Select Client Search fr client using magnifying glass r enter client identifying infrmatin int selectin field (Case Number r Scial Security Number) Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 - T Cmplete a Financial Review Click (Add) t add a new financial review fr the client Review Date: Enter the date the infrmatin was cllected. The MH MIS defaults tday s date, but date can be changed t accurately reflect the date the infrmatin was cllected. Fr Users withut Administratr Access: The review date must be later than the last Client Financial Review saved fr the client. The review date must be n mre than 30 days befre r 30 days after the start date fr the UMDAP perid. See Page 23 fr mre infrmatin abut start date. Financial reviews that d nt adhere t these parameters will need t be cmpleted by staff with Administratr Access t this view. Reviewed by: Enter the name f the staff that cllected the infrmatin. This is nt necessarily the same persn as the staff entering the infrmatin int the system. The system defaults t the staff persn entering the data, and shuld be changed t accurately reflect the staff persn that cllected the data. Financial Review Type: Individual: indicates nly ne persn in the family is receiving mental health services r there is nly ne persn attached t the UMDAP. Family: indicates mre than ne persn in the family is receiving mental health services r that the UMDAP is applicable t multiple family members. Click (Add) t add the apprpriate family members t the financial review. Search fr family member using magnifying glass Click n ALL buttn Highlight apprpriate client and click OK r duble click Please refer t the Link Family Members Client Financials sectin if multiple Individual Reviews have been entered fr a single family. Prgram: Always use M fr Mental Health Bill T: Select the huse tab and check the apprpriate bill t address fr accuracy. This address shuld be the respnsible party s address fr mailing purpses. If this is an Individual Review this infrmatin can be selected frm the client s address as it is entered n Page 20 f 84 8/27/2013

21 the Demgraphic r can be manually entered. If this is a Family Review, the address fr billing must be manually entered. Assignment f Benefits (AOB): Fr Medicare and Insurance, if there is a signed AOB, mark this bx, click n the Cmment (4) tab and add a nte that states the date the Assignment f Benefits was signed and the unit/subunit that has the AOB n file. Mre infrmatin regarding the AOB is fund n page 26. If the client des nt have Medicare r Insurance, d nt mark the Assignment f Benefits bx. Instead, click n the Cmment (4) tab and add a nte that states AOB nt Needed, including reviewer initials and date. Financial Infrmatin Prvided/Verified: If the financial infrmatin was verified, mark the bx and prceed t Financial (Tab 2). If financial infrmatin is nt prvided r nt verified, click n the drp dwn bx t identify a reasn: N = N/A (use if verificatin was nt requested) P = Dcumentatin Pending R = Dc nt prvided/refused U = Unemplyed Identify the apprpriate reasn frm the list. If the reasn is R- Dc nt prvided/refused, the client r respnsible party becmes respnsible fr the full cst f services. When the client r respnsible party becmes respnsible fr the full cst f services, the UMDAP, when viewed thrugh the Client Financial Screen will reflect $37.00; hwever, the client s actual balance is reflected n the Client Abstract View. Suppress Printing Statements: Check this bx if statements are nt t be mailed t the client. Please nte that checking this bx means the client/respnsible party will still be respnsible fr charges incurred, althugh a billing statement will nt be printed and mailed. Suppress Reasn: If the Suppress Printing Statements Bx is checked, select the apprpriate reasn frm the drp dwn menu: H = Hmeless N = N Permanent Mailing Address B = Bad Address BK = Bankruptcy CR = Client Request Financial (2) Step 3 T calculate the UMDAP Number f Dependents: The number f dependents must include parent(s) and all children under the age f 18 wh the parent/legally respnsible party is financially supprting ver 50% Grss Family Incme: Grss family incme means the ttal family incme befre allwances fr taxes and ther deductins. In the case f self-emplyed persns, this is the Page 21 f 84 8/27/2013

22 ttal incme after business expenses have been deducted. Nte: If client claims n incme, ask hw they are supprting themselves. Respnsible Party: Enter client s mnthly r annual grss incme, if they are selfsupprting. If the client is a child, enter parent s/legal guardian s mnthly r annual grss incme. Spuse: Enter spuse s incme, if any. Leave blank if nne. Other: This may include SSA, Cal-Win, child supprt, spusal supprt, dividends, and interest and rental incme. Ttal Grss: Autmatic calculatin by MH MIS based n incme identified frm abve. Liquid Assets: Checking Accunt: Enter the average checking accunt balance, if nne enter zer. Savings Accunt: Enter the average savings accunt balance, if nne enter zer. Other: Enter any assets that are persnal r real prperty which can readily be cnverted int cash. This includes stcks, bnds and mutual funds. Ttal Liquid Assets: Autmatic calculatin by MH MIS based n liquid assets frm abve. Asset Allwance: Asset allwance is autmatically calculated by MH MIS based n the State apprved Asset Allwance schedule f Allwable Expenses: Curt Ordered Obligatins: Enter any deductins rdered by the curt. This can include child supprt. Child Care: Enter child care amunt when parent r client is seeking emplyment r is necessary t maintain emplyment. Dependent Supprt: Enter the financial supprt amunt being expended n supprting a dependent mre than 50%. Medical Expenses: Enter the mnthly cst fr medical, dental and visin. This may include medical Insurance premiums. Medical Expenses in Excess f 3% Grss Incme: This sectin autmatically calculates in MH MIS based n the medical expenses entered and the grss incme already identified in the system. Mandated Deductins fr Retirement Plans: Enter the mnthly mandated deductins frm grss incme fr retirement plans. This may include 401K and Deferred Cmpensatin Page 22 f 84 8/27/2013

23 Ttal Allwable Expenses: Autmatic calculatin by MH MIS based n the expenses identified abve. Max Annual Liability: This yearly amunt is autmatically calculated frm the UMDAP scale based n the infrmatin nted abve. Fr Perid: This is the beginning date f the UMDAP year. The MH MIS system autmatically defaults t the first day f the mnth that the review is entered. If this is nt the crrect UMDAP perid, the date must be changed by smene with administratr access t this view. Nte: Once the date is established, this becmes the UMDAP date fr all subsequent UMDAP anniversary perids. Payment Plan (3) Payment Plan: Check this bx if a payment plan is being set up fr the client. A minimum payment plan is the Maximum Annual Liability divided by 12 mnths. Example: If a client s Maximum Annual Liability is $ the payment plan can be set up fr $ divided by 12 = $20.85 (apprximately) per mnth Prgrams are nly authrized t apprve payment plans fr 12 equal payments per year t pay ff the UMDAP amunt r balance f the client s accunt. If the client requires a payment plan that is less than 12 equal payments per year, the prgram staff must refer the client t the Mental Health Billing Unit at (619) fr apprval f the payment amunt. Agreed Upn Payment Amunt: Enter the payment plan amunt that was agreed upn by the client. Identify that the payment is mnthly. D nt establish a payment plan n a per visit basis. Infrm the client that the Maximum Annual Liability amunt will be reflected n the client statement as the amunt due and that the actual amunt due will be reflected in the payment plan infrmatin at the bttm f the statement. Cmments (4) Identify the date f the Assignment f Benefits was signed and the unit/subunit that has the AOB n file r if client des nt have insurance r Medicare, indicate AOB nt required. Include yur name and date f the cmment entry fr recrdkeeping purpses. After all entry has been cmpleted click SAVE. Full Pay (UMDAP) In the MH MIS system a client is cnsidered t be a Full Pay client if he/she des nt respnd t request fr financial infrmatin r refuses t prvide financial infrmatin r verificatin, if requested. This is recrded by nt placing a checkmark in the bx fr the financial infrmatin prvided/verified and entering R= nt prvided/refused in the reasn list. Page 23 f 84 8/27/2013

24 When the client r respnsible party becmes respnsible fr the full cst f services, the UMDAP, when viewed thrugh the Client Financial Screen will reflect $37.00; hwever, the client s actual balance will be the full cst f services received and will be reflected n the Client Abstract View. T Edit a Client Financial Step 1 T Select Client Search fr client using magnifying glass r enter client identifying infrmatin int selectin field (Case Number r Scial Security Number) Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 - T Edit a Financial Review Click Edit t access the current financial review that requires editing. In the Edit mde yu have the ability t update the fllwing infrmatin pertaining t the Client s Financial Review. Bill T: Check the bill t address sectin fr accuracy. This address shuld be the respnsible party s address fr mailing purpses. The editing f a Client Financial Review by prgram staff is intentinally very limited. This prevents the entry f inaccurate infrmatin that may affect the clients UMDAP balance and/r client accunt. Therefre, if additinal edits are needed, the prgram staff must cntact the Cunty f San Dieg Mental Health Billing Unit at (619) fr further assistance. T Delete a Client Financial Review It may be necessary t delete a Client Financial Review if an entry was made fr the wrng client. T delete a Client Financial Review frm the MH MIS, yu must cntact the Cunty f San Dieg Mental Health Billing Unit fr assistance at (619) Link Family Members Client Financial Reviews If separate financial reviews have been established fr clients wh are members f the same family unit, it will be necessary t link their financial reviews. Per Sectin 5718 f the Califrnia Welfare and Institutins Cde, a family unit is defined as a husband (man) and/r wife (wman) and their dependent minr children. A dependent is defined as a persn wh is dependent n the family incme fr ver 50% f their supprt. Therefre, family members must meet the abve criteria in rder t link their financial reviews. Access the Client Financial Review in MH MIS Step 1 T Select fr Client Search fr client using magnifying glass r enter client identifying infrmatin int selectin field (Case Number r Scial Security Number) Click n ALL buttn Highlight apprpriate client and click OK r duble click Step 2 T Link Client t ther Family Members Click (LINK) which intrduces anther screen entitled, Link Client t Financial Review The current client is displayed n the tp line Search fr Family Member Page 24 f 84 8/27/2013

25 Search fr family member using magnifying glass r enter client identifying infrmatin int selectin field (Case Number r Scial Security Number) Click n ALL buttn Highlight apprpriate client and click OK r duble click The Family Members Client Financial will appear in the bx belw the clients. If this is the apprpriate family member and client financial then check the bx entitled, Select. Once the Select buttn has been marked, the OK buttn will be enabled t cmplete the transitin. Select OK t save the Linkage f Client Financials. Linking Family Members verwrites the current UMDAP and applies the linked t family members UMDAP as active. Medi-Cal Referral Review During the curse f cnducting the financial screening, prgram staff are respnsible fr reviewing the infrmatin prvided t determine if the client may be eligible fr a third party pay surce such as Medi-Cal Any client wh may fit int the fllwing categries may als have the ptential fr Medi-Cal eligibility and therefre, a referral shuld be made t ne f the resurces identified n Page Individuals under the age f 21 withut any ther health insurance may qualify fr Medi-Cal. 2. A parent r caretaker relative with dependent children under the age f 21 living in the hme and sme type f deprivatin exists, e.g. a. Absence b. Deceased c. A disabled parent d. Unemplyed r (underemplyed depends n hurs wrked and incme earned). 3. Individuals between the ages f 21 and 64 wh have cnsistently received mental health services fr ne year r lnger and cntinues t be disabled and has nt been denied SSI r Medi-Cal within the last year. a. A referral t SSI/SSP b. A referral t Medi-Cal and r LHIP 4. Individuals wh are disabled r blind and/r receiving Scial Security Disability Benefits wh d nt have Medi-Cal. 5. Anyne age 65 and ver. 6. Anyne wh is pregnant. 7. See attached listing n page 73 fr infrmatin regarding phne numbers and lcatins t apply fr Medi-Cal, and SSI/SSP. SSI Advcacy Services assist clients with cmpletin f the SSI and Medi-Cal applicatin prcess. Clients wh receive case management services may als be referred t their case manager fr assistance with applicatins fr benefits. Page 25 f 84 8/27/2013

26 Assignment f Benefits In accrdance with Califrnia State regulatins, Medicare and/r ther insurance must be billed prir t billing Medi-Cal. Cntracted Prgram Prviders are respnsible fr all billing t Medicare and insurance. The Cunty f San Dieg Mental Health Billing Unit is respnsible fr billing Medicare and insurance fr Cunty perated prgrams nly. In rder t bill Medicare and/r ther insurance cmpanies, a signed Assignment f Benefits (AOB) is required. The client r respnsible party has the right t refuse t sign the assignment f benefits. Hwever, if such a refusal is made the client r respnsible party shall be liable fr the full cst f services received. An AOB authrizes all Cunty and cntracted rganizatinal prviders t submit claims fr reimbursement n behalf f the client and t receive payment directly. Once the AOB has been cmpleted and signed by the client r respnsible persn, the prgram staff must nte the cmpletin f this frm in the MH MIS system. In the Califrnia Client Financial Review Maintenance view, there is a check bx which identifies if the AOB has been signed. Place a checkmark in this bx. Failure t mark this bx apprpriately affects the billing f the services. A Release f Infrmatin frm shuld als be cmpleted t allw the prvider f service, cunty r Cntract Prvider, t prvide any clinical infrmatin required fr claims prcessing by the third party payer. A cpy f the frnt and back f the Insurance/Medicare card shuld be made fr bth the Medical Recrd and fr the Cunty r cntracted prvider-billing unit. As a general guideline, the AOB shuld be btained during the first visit and updated every tw years n the anniversary f the client s first visit r whenever a change in Insurance has ccurred. Please nte: Prgrams are respnsible fr determining if an AOB is needed prir t the tw years nted abve. An insurance cmpany may have a different requirement than what is nted here; s it remains as the respnsibility f the prgrams t ask the insurance cmpany fr their specific requirements. Each Cunty and Cntracted site is required t have the client fill ut an AOB when the client first begins receiving services at the prgram unless an AOB is already n file. If a signed AOB is already n file, a cpy f the signed AOB can be requested when the client begins receiving services frm anther Cunty r Cntracted Prvider. Fr the fllwing payer types, please use these guidelines in cmpleting the AOB: Insurance Cpy the frnt and back f the insurance card. Please review card t determine where mental health billing will be sent. It is nrmally different than the medical claims address. Cmplete the AOB frm in full. Ensure that the cmpany address fr the mailing f Mental Health claims is accurate and the apprpriate plicy numbers and grup numbers are identified n the frm. Verify the insurance cmpany s requirements regarding the effective perid fr the Assignment f Benefits/Release f Infrmatin. Sme carriers require an Assignment f Benefits/Release f Infrmatin signed at each visit, while ther carriers require it annually. This verificatin can be accmplished by calling the telephne number listed n the client s insurance identificatin card. Page 26 f 84 8/27/2013

27 Medicare Obtain the client s/respnsible party s signature n Assignment f Benefits and Release f Infrmatin frms. T ensure the validity f the client s identity, btaining a cpy f the client s State issued identificatin is recmmended. If an authrizatin fr treatment is required, please cntact the insurance cmpany directly fr authrizatin prir t the prvisin f Services. Cpy the frnt and back f the client s Medicare card; Verify eligibility date f Part A and B cverage. If the client has nly part A r part B cverage, it must be cnsistent with the service being prvided in rder t receive reimbursement frm Medicare. Part A cverage is nly fr inpatient treatment and Part B is fr utpatient treatment; Obtain the client s/respnsible party s signature n Assignment f Benefits and Release f Infrmatin frms. T ensure the validity f the client s identity, btaining a cpy f the client s State issued identificatin is recmmended. A current address is needed in rder t bill Medicare. The client r respnsible party is required t cmplete and sign an Assignment f Benefits & Authrizatin t Release Medical Infrmatin frm which is used t apprve the electrnic claiming f services t insurance cmpanies and t allw fr the release f medical infrmatin t said insurance cmpanies fr billing purpses. Cpies f these frms are in English lcated n page 56. There are cpies in ther languages n pages in the Frms sectin f this handbk. Medi-Cal Clients with Share f Cst (SOC) Medi-Cal ffers health care cverage t individuals and families whse incme exceeds the maximum allwable by requiring these beneficiaries t cntribute t their health care by paying a share f the cst fr the services they received. Share f Cst is a term that refers t the amunt f health care expenses a beneficiary must accumulate each mnth befre Medi-Cal begins t ffer assistance. Once a beneficiary s health care expenses reach a predetermined amunt Medi-Cal will pay fr any additinal cvered expenses fr that mnth. Share f Cst is an amunt that is wed t the prvider f health care services, nt t the State. "Share f cst" requires beneficiaries t take full respnsibility fr health care expenses up t a predetermined amunt. Share f cst is nt a premium; it is an amunt that a beneficiary is financially respnsible fr each mnth in which Medi-Cal assistance fr health care expenses is needed. The amunt f the Medi-Cal Share f cst is determined by the Department f Scial Services. The State Department f Mental Health plicy n the certificatin f Medi-Cal share f cst allws the Medi-Cal Share f Cst t be certified, r cleared, by using the full cst f services received by a client during a mnth. The client is nly held financially respnsible fr the amunt f their UMDAP liability. If the clients mnthly share f cst is less than their UMDAP, then the mnthly share f cst amunt is cllected until the ttal amunt f their UMDAP has been satisfied. If the Page 27 f 84 8/27/2013

28 client has received services in which the ttal cst meets r exceeds the share f cst, it shuld be certified. Each case must be reviewed t determine if the share f cst will be certified. If the client s share f cst is nt certified then the client is nt cnsidered Medi-Cal eligible. Share f Cst Clearance Prcess This is a centralized prcess in the Cunty f San Dieg Mental Health Billing Unit. A client wh has a share f cst (SOC) respnsibility must have their SOC cleared in the State system and MH MIS in rder t facilitate billing t the State fr services apprpriately. Please nte that the services that are used t clear the SOC are nt reimbursed by Medi-Cal. The services used t clear a Medi-Cal SOC are based n the dates f service (i.e. clearance begins with the first service date f that particular mnth t be certified.) Therefre, multiple services frm different prgrams may be used t meet a share f cst amunt. Cunty and Cntracted Prgrams that have clients wh have a Share f Cst (SOC) and require clearance will be required t submit a Share f Cst clearance frm t the Cunty f San Dieg Mental Health Billing Unit and cmplete the UMDAP. The Share f Cst clearance frm will be required t be cmpleted at the beginning f the client s services with the Prgram and a cpy f the frm can be fund n page 49 f this manual. Califrnia Share f Cst Claiming Reprt On a weekly basis, the Cunty f San Dieg Mental Health Billing Unit will run the Califrnia Share f Cst Claiming Reprt frm the MH MIS system. The reprt will be used t identify the clients wh have an utstanding Share f Cst balance and have received Services within the identified claiming perid. This reprt will shw the prcedure cdes and dates f services fr the time perid requested. The Cunty f San Dieg Mental Health Billing Unit will use the infrmatin frm the reprt t determine the apprpriate accunts t be cleared f their share f cst balance thrugh the State system and the dcumenting f that clearance in MH MIS fr the entire system f care. This prcess mves the apprpriate balances frm the Medi-Cal Pay Surce t the Client fr cllectin. Any amunt ver and abve the Client s Share f Cst amunt will then be claimed t Medi-Cal. The Share f Cst Claiming Reprt is used in cnjunctin with the Share f Cst Clearance frm prvided by the Cunty r Cntracted prgram Minr Cnsent Medi-Cal Califrnia Family Cde prvides that minrs between the ages f 12 thrugh 20 wh may be eligible fr Medi-Cal services may receive a number f sensitive services including utpatient mental health treatment withut parental cnsent due t: Being in danger f causing harm t self r thers; r Being an alleged victim f incest r child abuse. Page 28 f 84 8/27/2013

29 New Clients: Clients meeting the definitin f sensitive services as defined abve shuld be referred t a Family Resurce Center (FRC) t apply fr minr cnsent Medi-Cal. A list f FRC s may be fund n page 71 f this manual. Onging Clients: Mental health services fr clients identified as minr cnsent are nt billed t Shrt/Dyle Medi-Cal. Hwever, labratry and pharmacy services are still a benefit f the minr cnsent prgram and are cvered thrugh the minr cnsent client s Medi-Cal. Therefre, prgrams may refer clients t receive pharmacy and labratry services using their Medi-Cal cverage. Minr cnsent clients d nt need t be UMDAP ed. Nte: Entry f minr cnsent eligibility is nt required, as the services are nt billable t Shrt/Dyle Medi-Cal. Hwever, eligibility may be entered autmatically thrugh the MMEF file r by staff wh were unaware that the client had minr cnsent Medi-Cal. The MH MIS billing has been set up t prevent billing f these services. Medi-Cal HMO Medi-Cal beneficiaries enrlled in a Prepaid Health Plan (PHP) are eligible t receive medical services thrugh their HMO. These HMO plicies d nt cver specialty mental health services. Therefre, these particular HMO s shuld nt be entered int MH MIS as a pay surce r insurance cmpany. T learn mre abut the Medi-Cal Managed Care plans, prgram staff can visit Califrnia s Medi- Cal Managed Care website at: The fllwing lcal Medi-Cal HMO s cver medical services nly: 1. Cmmunity Health Grup Partnership Plan 2. Care 1 st Partner Plan, LLC 3. Health Net Cmmunity Slutins 4. Kaiser Permanente Cal, LLC 5. Mlina Healthcare f Califrnia Partner Healthy Families (SED) The Healthy Families Prgram (HFP) is ging away and is being transitin int Medi-Cal under the new Targeted Lw Incme Children s Prgram (TLICP) up t age 19 with new aid cdes f 5C and 5D in a fur phase prcess. The first 3 Healthy Families Prviders t terminate Healthy Families enrllees as f are Cmmunity Health Grup Kaiser Mlina As f the next HFP t transitin t TLICP Medi-Cal Health Nets As f the final HFP t transitin t TLICP Medi-Cal Blue Crss. Page 29 f 84 8/27/2013

30 Final Phase is the annual determinatin review and the new aid cdes f H1,H2,H3,H4 and H5 has been implemented. Funding fr these children are under Title XX1(MCHIP) and reimbursed at 65% FFP. SED determinatins will still need t be prcessed ay ESU until the child has transitined t the TLICP Fr thse HFP children and yuth wh meet the qualificatins fr being designated Seriusly Emtinally Disturbed (SED), specialty mental health services are prvided by the Cunty and cntracted prgrams. Upn determinatin by Children s Mental Health Emergency Services Unit (ESU) that the enrllee is SED, the full range f medically necessary mental health services cvered by Shrt Dyle/Medi-Cal are available. The billing fr Healthy Families fr Mental Health services will be cnducted by the Mental Health Billing Unit t the State Department f Mental Health Shrt/Dyle Medi-Cal system. The Human Service Specialist (HSS) at ESU will cnfirm HFP SED eligibility. The HSS will enter the Healthy Families SED Pay Surce in the MH MIS system fr the client. Healthy Family clients can be identified thrugh their aid cde, 9H,9R. Each Cunty and cntracted prgram is required t cnfirm eligibility mnthly by verifying that the client is still an active HFP with an aid type f 9H r 9R. Only thse Healthy Family clients wh have been designated SED by the ESU shuld have Healthy Families cverage recrded. Medi-Cal Reimbursement Requirements Specific t Day Treatment Day treatment is reimbursable thrugh Shrt-Dyle/Medi-Cal when the client meets medical necessity criteria and the ASO has determined that service necessity criteria have been met. Day treatment prviders must submit a Day Prgram Request frm t the ASO t request authrizatin fr day treatment services and any ancillary services that may be required. If the ASO determines that the client meets day treatment service necessity criteria, ASO staff will enter an authrizatin in the MH MIS. Day treatment prviders shuld review the client s recrd t verify that an authrizatin has been entered prir t prviding services. If the authrizatin has nt been entered t cver the dates f service, the day treatment services will be held in suspense and will nt be billed t Medi-Cal. Ancillary services withut an authrizatin will nt be autmatically suspended. T View an Authrizatin fr HF and Day Treatment in the MH MIS System Prgrams that prvide services t Healthy Family SED clients and Day Treatment services can verify authrizatin f services by viewing ne f three screens in the MH MIS: Client Chart Client Abstract Client Authrizatin Maintenance View CalWORKs Eligibility Califrnia s public cash assistance prgram is called the Califrnia Wrk Opprtunity and Respnsibility t Kids (CalWORKs). CalWORKs applicants must meet state and federal regulatin requirements t qualify fr cash assistance. Caretaker relatives may als be eligible fr benefits. Verificatin f the relatin t the child will be required. Ptential CalWORKs eligible clients shuld be referred t their lcal Family Resurce Center. Page 30 f 84 8/27/2013

31 Nn-citizens are subject t specific regulatin requirements and may wish t inquire abut ptential eligibility t CalWORKs. If a family prvides all the necessary facts, eligibility shuld be determined within 45 days f the date f applicatin. Persns with drug related felny cnvictins since January l, l998 are nt eligible fr CalWORKs. CalWORKs mental health services are prvided nly by designated prgrams identified by specific Unit/Subunits. Services prvided by ther prgrams are nt eligible fr CalWORKs reimbursement. Billing, Cllectins and Payment Prcedures Cunty and Cntracted prgrams are respnsible fr ensuring accurate and apprpriate claiming fr all reimbursable services. All allwable payers must be billed sequentially and any primary payer, such as Medicare r insurance must be billed prir t Medi-Cal. The Mental Health Billing Unit is respnsible fr claiming t Medicare and insurance carriers fr all cunty perated prgrams. Cntracted prviders are respnsible fr prducing claims t Medicare and insurance carriers at least mnthly thrugh their wn business system and must als enter payment and denial infrmatin int the MH MIS system fr crdinatin f benefits and accurate billing t Medi-Cal as the secndary insurance. When Medicare and/r an insurance cverage has been entered fr a client wh receives cvered services frm a cntracted prvider, the MH MIS system stages the service t that payer pending the entry f payment and denial infrmatin by the prvider. Services will nt mve t a secndary payer until the primary payer has been satisfied in the MH MIS. Billing Rate Set Up Billing rates fr MH MIS are established in the fllwing manner: Medi-Cal Rate: The rate in the Anasazi system is determined by BHS admin. wh prvides the billing unit with the rate t bill fr cntractrs each year. The State determines the CMA rate fr each Cunty every year, BHS prvides the infrmatin t the billing unit t update in the system Medicare and Insurance Rate: The rates are being lked at, it is the intentin t use the rate prvided by CMS. Client Rate: The client rate is based n the current billing rate that is in the system. The Billing rates used in the MH MIS are nt intended t represent r replace Cntract Prvider published charges. Cntract Prviders shuld fllw their wn business practices fr the billing f insurance and Medicare. Based n the rate setups, cntract prviders may experience a discrepancy in the dllar amunt f claims billed frm their wn billing system and the amunt shwn in the MH MIS system. Billing Prcess The guidelines prvided belw are intended t assist cntracted prgrams with the billing prcess, but d nt cnstitute billing prcedures. Cntracted prgrams are respnsible fr the develpment and implementatin f internal prgram plicies, prcedures that cnfrm t mental health billing rules and regulatins, fr implementing mnitring systems t ensure the accurate claiming and fr maintaining adequately trained billing staff. Cntracted prviders are subject t mnitring by the Cunty t ensure that cntract prgrams are in cmpliance with regulatins including crdinatin f benefits fr Medi-Cal services. This mnitring may include but is nt limited t review f payment explanatin f benefits fr services, review f 3 rd party cverage ledgers, etc. Page 31 f 84 8/27/2013

32 Belw are general guidelines which apply t mst third party payer billing: The subscriber identificatin number n the claim must match the number n the member s insurance identificatin card. The claim must clearly indicate that the Assignment f Benefits frm is cmpleted by entering Signature n File in the Assignment area f the CMS If the prvider f service is enrlled as a prvider in an HMO r PPO and has been assigned an identificatin number, that number shuld be referenced n the claim. Claims shuld be submitted n later than 30 days frm the date f service. Prgram managers are respnsible fr develpment and implementatin f internal prgram plicies, prcedures, and mnitring systems which may include but are nt limited t the fllwing: Identify staff that are Medicare-eligible prviders and ensure that these identified staff btains necessary certificatin as Medicare Prviders. Medicare/Medi-Cal (Medi-Medi) insured clients shall be identified at the time f enrllment fr prgram services Medi-Medi insured clients shall be prvided and/r referred t Medicare-apprved prviders fr Medicare-apprved services Reimbursable Mental Health Services shall be claimed in a timely and accurate manner with Medicare and/r Other Health Cverage (OHC) billed first as the primary payer. Ensuring that Medicare and OHC are billed prir t claiming Medi-Cal. Reviewing the Explanatin f Benefits (EOB) and ensuring that EOBs are submitted timely t the Mental Health Billing Unit fr psting f payments and denials. If yu have billed the OHC and have nt received a respnse within 90 days frm the date the claim was submitted and apprpriate fllw-up was cnducted (n payment r denial), yu must cntact the MHBU t cnfirm that a respnse has nt been received s that Medi-Cal can be billed. Medicare Medicare Part B prvides benefits fr psychiatric services which are medically necessary fr the diagnsis r treatment f an illness r injury. Physicians, psychiatrists, clinical psychlgists, clinical scial wrkers, clinical nurse specialists, nurse practitiners and physician assistants are recgnized by Medicare Part B t prvide diagnstic and therapeutic treatment. Cverage is limited t thse services that the mental health prfessinal is legally authrized t perfrm under State law (r the State regulatry mechanism prvided by State law) f the state in which such services are perfrmed fr the diagnsis and treatment f mental illnesses. In accrdance with the Omnibus Budget Recnciliatin Act f 1989, all prviders f services and suppliers must submit cmplete and valid claims n behalf f Medicare beneficiaries fr services furnished n r after September 1, Therefre, cunty and Cntract Prvider perated prgrams are required t submit claims fr services in an apprpriate and timely manner. Belw are general guidelines which apply t the claiming f Medicare services: Medicare must be billed prir t billing Medi-Cal fr services that have been identified by the State as billable t Medicare. The system is set-up t bypass Medicare fr services that are billable directly t Medi-Cal. Page 32 f 84 8/27/2013

33 The Assignment f Benefits (AOB) frm must be updated in the system t allw the services t stage t billing Medicare. Medicare claims may either be billed electrnically thrugh an electrnic 837P (utpatient) prtcl r claims can be billed manually n an riginal CMS-1500 claim frm that is printed in red ink. Phtcpies f the CMS-1500 claim frm cannt be accepted. Medicare prvides a curse that will prvide a cmplete verview f the CMS 1500 frm instructins. Prviders are required t resubmit claims rejected due t incmplete and/r invalid claim data. A denial based n invalid r incmplete infrmatin is nt cnsidered t be valid fr entry in the MH MIS system. Prgrams must re-submit the claim accurately fr prcessing. Benefits fr all claims will be based n the patient s eligibility, prvisins f the Law, and regulatins and instructins frm Centers fr Medicare & Medicaid Services (CMS). It is the respnsibility f each prvider r practitiner submitting claims t becme familiar with Medicare cverage and requirements. All infrmatin is subject t change as federal regulatins and Medicare plicy guidelines, mandated by the Centers fr Medicare & Medicaid Services (CMS), are revised r implemented. If a client shws enrlled in a Medicare Risk prgram (HMO), services shuld n lnger be billed t Medicare. The prgram shuld terminate Medicare and update the system and enter the Medicare Risk HMO prvider as the Health care prvider. Prgrams shuld fllw the nrmal prtcl fr billing OHC when billing the Medicare Risk prvider and prvide EOBs t the MHBU. Insurance Many insurance carriers prvide benefits fr mental health services which are medically necessary fr the diagnsis r treatment f an illness r injury. Generally, insurance carriers will reimburse fr services prvided by licensed mental health practitiners. Cvered services are generally mre limited than the array f services cvered by Shrt-Dyle/Medi-Cal. Belw are general guidelines, which apply t mst insurance claiming: Verify the insurance plicy prir t services being prvided t determine apprpriate start date fr plicy r terminatin date. Obtain pre-authrizatin fr services by cntacting the insurance cmpany at the number nted n the card. If the card is unavailable, request specific insurance carrier infrmatin frm the client prir t the first appintment. Identify the crrect address fr submitting claims fr mental health services. The address may be different fr medical claims and mental health claims. Make a cpy f the insurance card fr the client s recrd. A signed Assignment f Benefits (AOB) frm must be btained frm the client prir t billing insurance. Page 33 f 84 8/27/2013

34 Depending upn the prgrams billing system set up, claims may either be billed electrnically thrugh an electrnic 837P (utpatient) prtcl r claims may be billed manually n a CMS-1500 claim frm. Medi-Cal The Cunty f San Dieg Mental Health Billing Unit is respnsible fr prcessing all data fr Medi- Cal claims fr all rganizatinal prviders. Fr clients wh have Medi-Cal as a secndary payer, the residual amunt may be claimed t Medi-Cal after payments r denials have been entered int the MH MIS system fr claims submitted t Medicare and insurance carriers. If the client des nt have a primary payer surce, the services are billed directly t Medi-Cal whenever a client has eligibility fr the mnth f service recrded in MH MIS. Prgrams are respnsible fr crrecting services that are suspended due t incrrect r missing data. The Cunty Mnitring reprts that include suspense items and missing elements will either be given t the prgrams t cmplete, r the prgrams will be instructed t print the dcumentatin at their facility. Additinal infrmatin cncerning reprts that can be used by prgrams t mnitr their financial wrklad can be fund in the sectin entitled, Prvider Self-Mnitring Reprts in this manual. Client Effective July 1, 2008, the Cunty f San Dieg s Health and Human Services Agency (HHSA), Financial Supprt Services Divisin (FSSD) Mental Health Billing Unit assumed the respnsibility f billing mental health clients f cntract prviders fr their UMDAP balances. Hwever, Cntract Prviders will cntinue t be respnsible fr billing and cllecting client rm and bard fees fr residential services. UMDAP client billing statements will be generated mnthly by the Mental Health Billing Unit, which will als cllect utstanding patient accunts (UMDAPS) until they becme delinquent. When UMDAP patient accunts have been determined t be delinquent, the accunts will then be transferred t the Cunty s Office f Revenue and Recvery (ORR) fr cntinued cllectin effrts. All Cunty and Cntract Prvider perated prgrams are respnsible fr assisting with the cllectin f any UMDAP balances fr clients served by their prgram. Prgrams shuld discuss the client s financial bligatin with them at least nce every 30 days when a client presents fr treatment. Payments f UMDAPS at Cunty and Cntract Prgrams Mental Health Prgrams are the first-line and smetimes the nly cnnectin a client may have cntact with; therefre, it is in the clients best interest t pay fr services where the services are rendered. As indicated abve, Cntract prviders will nt be required t send a patient statement t the client. A new bank accunt has been pened with Wells Farg fr the depsit f cllectins frm bth Cunty-perated and cntract prviders. Depsit slips will be identified by Legal Entity name and Legal Entity Number. Please d nt use any ther bank depsit slip ther than the nes issued specifically fr yur prgram. It is imperative that client payments are entered int the Mental Health MIS system in a timely manner, s that client accunts reflect a crrect balance due. Therefre, depsits f client payments will be made n a daily basis, r weekly as apprpriate and cpies f the depsit Page 34 f 84 8/27/2013

35 infrmatin, client payment infrmatin, etc., will be frwarded t the FSSD MH Billing Unit daily, r weekly, as well. The fllwing prcedures fr depsiting cllectins apply t bth Cunty and Cntract prgrams: 1. Upn receipt f payment fr client fees (cash, check r mney rder), indicate the client s number in the upper right hand crner f the check, mney rder r cash payment receipt. 2. Prepare a depsit slip and make a cpy. 3. Depsit the cllectins t the nearest Wells Farg Bank in yur area. 4. Submit the fllwing t HHSA/FSSD MH Billing Unit at the fllwing address: HHSA/FSSD MH Billing Unit PO Bx San Dieg, CA Or at Mail Stp W403 a. Cpy f the check, mney rder r cash receipts b. Cpy f depsit slip c. Cllectin f Client Accunts Lg (fund n page 64) 5. Cllectins shuld be depsited t the bank n a daily basis, r weekly if: a. The aggregate f mney cllected is less than $100. b. The headquarters f the ffice r emplyee making cllectins is c-lcated as t make daily depsit infeasible. Cntract Prvider Optins fr Cllectin f Client Balances (UMDAP s) Optin 1: Client pays the Cntract Prvider fr client balance r UMDAP and the Cntractr depsits the mney int the Cunty s Wells Farg Bank Accunt. Requirement: The Cntract Prvider wuld prvide a cpy f the depsit slip, cllectin lg (fund n page 64) and cpy f the checks/mney rders t the Cunty Mental Health Billing Unit fr prcessing. Optin 2: Client pays the Cntract Prvider fr client balance r UMDAP and the Cntractr depsits the mney int their wn private bank accunt and writes a check t the Cunty fr the mney received. Requirement: The Cntractr wuld prvide their riginal check, cllectin lg and cpy f the client s checks/mney rders t the Cunty Mental Health Billing Unit fr prcessing. Optin 3: Client presents at the Cntract Prvider with a client payment and the Cntract Prvider prvides the client with a self-stamped envelpe fr the payment t be mailed t the Cunty Mental Health Billing Unit. Offices r emplyees exempted frm the daily depsit requirements will depsit accumulated cllectins n the last wrk day f each week, and by the last wrk day f the mnth. Checks and mney rders shuld be made ut t the Cunty f San Dieg. Page 35 f 84 8/27/2013

36 Yu may cntact the Mental Health Billing Unit at (619) fr questins and when yur supply f depsit slips runs lw. Client Accunt Adjustment Requests/Therapeutic Adjustments Clients must be re-evaluated fr their ability t pay the UMDAP amunt each year. When a clinician determines that a client s financial bligatin needs t be altered frm the UMDAP fee schedule due t clinical reasns, the client s accunt may be adjusted accrdingly the clinician must determine the amunt f the therapeutic adjustment and dcument the reasn in the client recrd. The fllwing are reasns a therapeutic adjustment may be cnsidered: The client r respnsible party has verbally expressed an inability t pay the UMDAP and is exhibiting mental r emtinal distress ver cntinued pursuit f cllectins. The client r respnsible party will nt return fr treatment, participate r allw the client t participate with the fllw-up recmmended treatment because f his/her inability t pay the UMDAP, and withut treatment the client s mental health will diminish. Based n the clinician s assessment f the client, cntinued cllectin effrts may result in the client, r the client s immediate family/caregivers suffering a serius crisis. The Deductible Adjustment Request frm must be cmpleted and apprved by the Prgram Manager/Directr. This frm is then submitted t the Mental Health Billing Unit fr prcessing. A cpy f this frm can be fund in the Frms sectin page 53 f this manual. Enter current annual/mnthly UMDAP amunt and cntract year. An adjustment f a crrectly determined annual deductible r UMDAP liability can nly be made fr therapeutic reasns and must be dcumented in the client recrd. The clinician r their designee will discuss with the client r respnsible party the circumstance that may require a therapeutic adjustment and determine the amunt the client r respnsible party is able t pay. The clinician r their designee may request dcumentatin f prf f hardship frm the client. Once the frm is cmpleted and signed by all required staff, it shall be frwarded t the Cunty Mental Health Billing Unit fr prcessing: Cunty f San Dieg/HHSA Mental Health Billing Unit P.O. Bx San Dieg, CA (619) MS W403 A cpy f the submitted Deductible Adjustment Request Frm must be filed in the client chart. If the request fr a therapeutic adjustment is denied by the clinician r prgram manager, the client may appeal the decisin t the Lcal Mental Health Directr r his/her designee. Page 36 f 84 8/27/2013

37 All therapeutic adjustments shall expire at the end f the client s UMDAP liability perid. The Deductible Adjustment Request prcess must be re-initiated fr any extensins. Accunt Cllectins- Insurance and Medicare The mst effective way t reslve utstanding accunts receivable balances is t fllw up billings with a telephne call t the insurance carrier. At minimum, fllw up shuld ccur fr all utstanding claims every 30 days. Belw are sme general guidelines that may assist in this prcess: If the insurance carrier indicates they did nt receive the claim, ask if the claim can be faxed. This will alleviate an unnecessary delay f re-submitting the claim by mail. If the insurance carrier states they culd nt identify the client, prvide them with the infrmatin frm the client s identificatin card. If necessary, fax a cpy f the insurance card. If the insurance carrier indicates the client was nt eligible fr benefits, prvide them with the name f the individual in their rganizatin that verified benefits and eligibility (if applicable). If the insurance carrier indicates the services were nt authrized, determine if prgram staff btained authrizatin. If s, prvide the carrier with the authrizatin infrmatin. If the insurance carrier indicates there is a primary payer, btain that infrmatin. Cntact the carrier they indicated was primary t determine if the client is eligible fr cverage, and submit claims accrdingly. The business standard fr reslving utstanding claims is 90 days frm the date f service r the date the claim was submitted. Insurance and Medicare Payment Entry Prcess Insurance and Medicare payments and denials fr Cunty and Cntract Prvider services are managed by the Cunty Mental Health Billing Unit. Fr each payment r denial, Cntract Prviders are required t submit the fllwing t the Mental Health Billing Unit n a weekly basis: cpy f the Explanatin f Benefits (EOB) received frm Medicare r Private Insurance cpy f the MH MIS Accunts Receivable Reprt shwing the service(s) cvered by the EOB. services shuld be crss referenced between the tw dcuments by identifying with letters. Fr example, an item n the EOB shuld be labeled A and the crrespnding item n the MH MIS Accunts Receivable Reprt shuld als be labeled A. Mental Health Billing Unit staff will enter the payments and denials. Prgrams can review the payment tab in display client services fr psting f payments and denials. If the client has Medi- Cal the pay surce will change t 100 in the pay surce clumn. Page 37 f 84 8/27/2013

38 Crrectins, Adjustments and Special Requirements Invalid Services- frmerly Service Deletins In rder t maintain a cmplete audit trail, services entered in MH MIS cannt be deleted. An invalid service can be crrected as lng as it is in its riginal state, meaning that it has nt been claimed t a payer r had a payment r denial psted t it, this can be crrected by the prgram. If an invalid service has billing activity; such as clearing a SOC, and r crssed ver t OHC r Medicare, the prgram must cmplete a deletin frm t invalidate the service. The service shuld be reprcessed as nn-billable if the service shuld be cunted in the TUOS. If the service was denied and shuld nt cunt in TUOS such as a denial fr a cde 18 duplicate service, the prgram shuld submit the deletin frm t mark the service as invalid. If the service is attached t a prgress nte, review the prcess t vid prgress ntes packet, it can be fund in the OPTUM Web-site. Nte that vided services and services marked as an invalid service will be filtered ut f all reprting f ttal units, including thse used fr the cst reprt. If a service has been denied by Medi-Cal and subsequently determined t be an invalid service, the billing unit staff will require the prgram t submit the deletin frm and will mark the service with the denial cde 33 t identify that the service is invalid and the units shuld be excluded frm the ttal units f service. Deletin A request t remve a nn-medical service that has been disallwed r Medi-Cal denied service because f a prviders review and the service desn t qualify as a valid service. See frm t submit t MHBU see page 69 Vid r Replace Replacement A replacement is an actin taken t address a service that was entered incrrectly- fr example the numbers were reversed and 12 minutes is entered instead f 21 minutes. In rder t replace a claim the billing prvider EIN and Subscriber CIN must be the same between the riginal claim and the replacement claim and at least tw f the fllwing fur elements must be the same- Prcedure Cde Place f service Date f Service Prvider ID Page 38 f 84 8/27/2013

39 Vid A vid is an actin taken t address a service that is nt Medi-Cal billable that is being disallwed because the dcumentatin des nt meet the standards f billing fr that service. MHBU fllws the infrmatin prvided by the prgrams that is utlined in the reasn fr disallwances, the standard State criteria t determine which services d nt meet the criteria t be billed and must be vided. Services must have been already claimed and paid by the State befre a service can be vided. If it is nted n the reasn fr disallwance instructin frm that the vided service can be re-entered as nn-billable, nce the MHBU has ntified the prgram that the service has been vided, the prgram may re-enter the service as nn-billable using the apprpriate nn-billable cde fr that service. The State implemented Vid r Replace functinality fr the SD/MC claiming system. Using existing HIPAA 837/835 transactins, cunties have the ability t perfrm the fllwing: 1. Vid errneus apprved claims (disallw r adjust Medi-Cal units) using an electrnic claim transactin (HIPAA 837 P/I). This transactin eliminates the need fr using the manual Disallw Claims System (DCS) prcess prgrams must cmpleted the enclsed vid request frm befre the MHBU will prcess a vid. Page Replace paid r denied claims by using an electrnic claim transactin (HIPAA 837 P/I) while utilizing the riginal claim s received date up t 15 mnths frm the mnth f service. The MHBU will replace services based n the replaced frm request. Page Crrect previusly denied claims by using an electrnic claim transactin (HIPAA 837 P/I) while utilizing the riginal claim s received date up t 15 mnths frm the mnth f service. This transactin eliminates the need fr using the manual Errr Crrectin Reprt (ECR) prcess. Prgrams must submit a replace frm request t the MHBU alng with the denial reprt t identify denied services t be replaces. If service denied fr cde 22 an EOB must be submitted with the request. Medi-Cal Denied Services Run the Payment Applicatin reprt denied services template. The State eliminated the prcess f suspending services that d nt meet the edit/eligibility requirements. If a service is deemed by the State t be ineligibility fr reimbursement, the service is denied right away. The fllwing are denied reasn cdes and steps that a prgram must cmpleted in rder t replace a denied service. Denial cde 18 The service appears t be a duplicate. The prgram will need t review the chart and if the service was nt a duplicate cmplete the replacement frm and prvide a cpy f the denial reprt indicating which services shuld be replaced and the crrect prcedure mdifier cde that needs t be n the claim t replace. See mdifiers belw 59 Distinct prcedure cde - There was 2 different services prvided (different service cdes fr the same date and amunt f time) when the services were billed t the State, they appeared t be the same because f the same HCPCS cdes such as (cllateral and a psychtherapy bth H2015 MHS) 76 Repeat prcedure cde by the same persn (rendering prvider) The service cde is the same and was prvided by the same prvider fr the same date, amunt f time and service cde. Page 39 f 84 8/27/2013

40 77 Repeat prcedure by different persn (rendering prvider) The service cde is the same and was prvided by 2 different prviders n the same date and amunt f time. Nte If the service is truly a duplicate service and the wrng service was paid by the State and is nt attached t the prgress nte, the paid service must be vided and the denied service must be prcessed as a replacement. Denial Cde 22 Accrding t MEDS the client has OHC, Medicare r a Medicare Risk HMO and the State denied the claim because the insurance was nt billed prir t Medi-Cal being billed. The Health Insurance must be billed and the prgram must prvide the MHBU with an EOB that either denied r paid the claim. In rder fr the claim t be replaced, the prgram must submit a replacement frm alng with a cpy f the denial reprt identifying each claim that needs t be replaced and the crrespnding EOB. Nte- In rder t avid future cde 22 denials prgrams shuld fllw the steps belw: Get a signed AOB frm the client and enter int Anasazi and bill the OHC If n signed AOB and n verificatin f OHC, g t the State s eligibility respnse web-site and verify what insurance cmpany is listed fr the client Enter the insurance infrmatin n the Third party screen, this prevents future claims frm being denied and the services will suspend Cntact the client and verify whether the insurance is still active. If client still has cverage, schedule the client t cme in t sign AOB. If client n lnger has cverage, instruct the client t bring terminatin letter. Once terminatin letter is received, fax a cpy t the State t remve the insurance frm the State s database. Please g t MediCalEligibilityDataSystem(MEDS).aspx fr OHC Reprting/Crrectin Prcedures frm the State. Denial Cde 31 Aid Cde Invalid. In mst f these cases the client has a SOC and the services were billed withut the SOC being met. These cannt be fixed. Denial cde 119 Services exceed maximum allwed fr a day. Make sure the ttal amunt billed in ne day fr MEDs services d nt exceed 4 hurs, fr crisis interventin 8 hurs and fr crisis stabilizatin 20 hurs. Check the chart and the time entered int the system. Generally this happens when there is an errr with the time entered int the system. Submit replacement frm with the crrect time. If the time truly went ver the billable time, after submitting replacement t crrect the billable time any excess time shuld be recrded as nn-billable. Denial Cde 177 Beneficiary nt eligible. MEDS is nt shwing that the client is eligible t Medi- Cal fr the mnth billed. Re-verify eligibility by checking Medi-Cal eligibility via the internet and ensure that all infrmatin such as CIN, DOB is crrect in the system. If there is an errr and the infrmatin is nt crrect n the claim cntact MHBU fr further instructins. Wrng CIN, the service wuld need t be marked as invalid and new services data entered int the system and rebilled t the State. A nte will need t be made in the prgress ntes f the rebilling. (This may change when new plicy is updated by the State). Denial Cde 185 Health Families Participant and n SED verificatin. Review services and cnfirm whether client has an SED authrizatin fr the denied services. If the system cnfirms that there is an SED authrizatin fr services denied, submit a replacement frm alng with the Page 40 f 84 8/27/2013

41 denied service reprt indicating next t the denied services the date perid that the SED authrizatin cvers. There shuld be n mre denials fr cde 185 fr service dates n r after Denial Cde 204 Under the present aid cde, the client is nly eligible while pregnant (pstpartum) r emergency services nly. Emergency services are prvided at EPU/ESU nly. Therefre prgrams shuld nly be treating clients under these aid cdes if pregnant, please verify scpe f eligibility based n aid cde listing. Prgrams need t cmplete the replacement frm and prvide a cpy f the denial reprt stating the client was pregnant r pstpartum at the time f services. The demgraphics have been updated t include a questin n whether the client is pregnant. This shuld prevent services frm being denied fr clients that are pregnant in the future. If the client is shwing multiple aid cdes fr emergency services and fster care cntact the MHBU fr review. Denial Cde 9998/9999 Services are denied shwing these cdes when there is a set-up issue such as the place f service, NPI r prgram is nt shwing Medi-Cal certified with the State. Or if a prgram billed fr a service at the time f lckut (see lckut regulatins), The MHBU will try t reslve set-up issues and will replace services that are deemed t be replaceable. If yu have any questins, please cntact the MHBU at Nte - please submit replacement frms and any dcumentatin fr the replacement t the MHBU via mhbillingunit.hhsa@sdcunty.ca.gv r fax t Prvider Self-Mnitring Reprts Cunty and Cntract Prvider perated prgrams are required t run the fllwing reprts and cmplete fllw up wrk n a weekly r mnthly basis, as nted fr each reprt. The reprts are designed t assist prgrams t self-mnitr and imprve their prgram s perfrmance n prgram financial functins. Sme reprts are designated fr Cntract Prviders nly. Detailed instructins fr running the reprts are included in the MH MIS Reprts Manual which can be fund n the OPTUM web-site. The fllwing is a summary f each reprt. Accunt Receivable Reprt - Other Health Cverage (OHC) and Medicare Outstanding Receivables Reprt (Mnthly) Cntract Prviders Only This reprt identifies utstanding receivables fr Private Insurance and Medicare. Cntract Prviders are required t bill these payers within 30 days f prviding the services and actively fllw up until payer has paid r has issued a final denial fr the claim. The summary reprt is a tl fr managers t versee this prcess and determine whether additinal actin is required. Managers shuld fllw up with staff regarding any services that are mre than 120 days ld. This reprt is fund n page 19 f the Anasazi Reprts Manual. Aged Accunts receivable reprt Other Health Cverage (OHC) and Medicare Outstanding Receivables Detailed Reprt (Mnthly) Cntract Prviders Only This reprt identifies utstanding receivables fr Private Insurance and Medicare. Cntract Prviders are required t bill these payers within 30 days f prviding the services and actively fllw up until payer has paid r has issued a final denial fr the claim. The detailed reprt is a tl fr billing staff t fllw up with payers n utstanding claims. In additin, the detailed reprt may Page 41 f 84 8/27/2013

42 be used t identify services that have nt yet been billed and shuld be billed ASAP. This reprt is fund n page 19 f the Anasazi Reprts Manual. An enhancement has been requested t allw the reprt t identify clients with Medi-Cal and Private Insurance r Medicare as primary cverage. When this enhancement is available, Cntract Prviders shuld priritize the billing/appeals prcess fr services prvided t clients with Medi-Cal. Califrnia Client Financial Review Reprt (UMDAP Anniversary Reprt (Mnthly) This reprt identifies clients with an upcming UMDAP Review Anniversary. Prgram staff respnsible fr cmpleting UMDAPs shuld run this reprt mnthly t identify thse clients whse UMDAP shuld be scheduled. Only the mst recent review will shw. Prgrams will need t verify that the review date shwing is the actual UMDAP date. The riginal UMDAP date will remain the same as when the client was riginally pened fr the first time. This reprt is fund n page 27 f the Anasazi Reprts Manual. Califrnia Client Financial Review Reprt UMDAP Outstanding Review Reprt (Mnthly) This reprt identifies clients wh need an UMDAP, including thse wh d nt have Medi-Cal (withut a Share f Cst) that d nt have a Financial Review (UMDAP) entered int the system r wh have an expired UMDAP. Prgram staff respnsible fr cmpleting UMDAPs shuld run this reprt mnthly t identify thse clients whse UMDAP shuld be cmpleted ASAP. This reprt is fund n page 27 f the Anasazi Reprts Manual. Client Services Management Reprt (Mnthly) This reprt prvides a mechanism fr Prgram Managers and COTRs t review dllar amunts f Services currently in Suspense t mnitr the vlume f errrs causing services t suspend and timeliness f crrectins. Tw reprt templates were created, ne mnthly that prvides a summary f the verall vlume f errrs and the secnd pririty mnthly that fcuses n services that lder than 90. These items shuld be priritized fr crrectin. This reprt is fund n page 68 f the Anasazi Reprts Manual. Client Insurance Eligibility Reprt (Mnthly) This reprt identifies clients wh, may have insurance cverage that has nt been entered int the system. Prgram staff shuld run this reprt mnthly and then cntact clients t verify that the client is nt eligible fr cverage r update the client s cverage. Regular wrking f this reprt will reduce denials fr failure t bill the client s primary cverage prir t Medi-Cal. This reprt is fund n page 45 f the Anasazi Reprts Manual. Medicare Eligibility Reprt (Mnthly) This reprt identifies clients, wh based n their age, may have Medicare cverage that has nt been entered int the system. Prgram staff shuld run this reprt mnthly and then cntact clients t verify that the client is nt eligible fr cverage r update the client s cverage. Regular wrking f this reprt will reduce denials fr failure t bill the client s primary cverage prir t Medi-Cal. This reprt is fund n page 45 f the Anasazi Reprts Manual. Page 42 f 84 8/27/2013

43 Client Third Party Cverage Reprt This reprt identifies clients that may have had a change in Medi-Cal Cverage in the specified date range. Prgram staff shuld run this reprt mnthly and then cntact the client t cmplete an UMDAP and, if apprpriate, prvide assistance in reacquiring their Medi-Cal cverage. This reprt is fund n page 32 f the Anasazi Reprts Manual. Duplicate Services Mnthly Reprt (Weekly) This reprt identifies clients wh have had mre than ne service f the same type recrded n the same day. Prgram staff shuld run this reprt weekly and review services t assure they have nt been recrded twice. Services that have been entered twice (true duplicates) shuld be vided. Fr the remainder f the services n the reprt that may appear t be duplicates but are in fact valid services, e.g. mre than ne case management service prvided in the same day, prgrams are required t send an t the MH Billing Unit t certify the validity f the services. This reprt is fund n page 90 f the Anasazi Reprts Manual. Authrizatin Ntificatin Reprt (Weekly) - Day Treatment Services withut Authrizatin This reprt prvides a listing f clients wh have had Day Treatment Services withut an authrizatin r with an expired authrizatin. This reprt is fund n page 25 f the Anasazi Reprts Manual. Payment Applicatin Reprt Select Medi-Cal Denied Claims Reprt Template Prvide mechanism t identify denied Medi-Cal claims that may need t be replaced. This reprt is fund n page 94 f the Anasazi Reprts Manual. 3rd Party Billing Suspense Reprt (Weekly) This reprt lists services that are suspended frm billing fr ne r mre reasns. Prgram staff shuld review each item and make necessary crrectins t client s recrd in MH MIS n a weekly basis. Once the data has been crrected the service will be ready fr billing and will nt appear n the next suspense reprt. Crrectins fr Items in Suspense can be fund n page belw(see instructins fr crrecting errrs identified by each suspense cde). Crrecting Items in Suspense The fllwing table summarizes hw t crrect errrs identified by each suspense cde listed in the Prgram Billing Suspense Reprt. The table nly includes thse suspense cdes activated fr current use r planned fr future use in MH MIS. Suspense Cde Suspense Descriptin Hw t crrect A N Valid Diagnsis Enter Diagnstic Review with a valid diagnsis cvering date f service. If unable t fix, call Optum B N Diagnsis f Billing Type help desk at (800) D N Final - Apprved Prgress Nte Future Use Page 43 f 84 8/27/2013

44 Suspense Cde Suspense Descriptin Hw t crrect E F J L N Plicy Number Service is lder than X days N Active Insurance Cverage Server 3rd Party Billing Suspended Prgram can fix. Enter Plicy # fr all payers in 3rd Party Cverage Maintenance. N crrectin fr this item but indicates anther suspense items that needs t be crrected ASAP. Call Mental Health Billing Unit (MHBU) at (619) Prgram can fix. Enter cverage in 3rd Party Cverage Maintenance View with effective dates cvering date f service. Find ut why QI rdered suspensin f billing fr the server, crrect prblem and request resumptin f billing. Call MH-MIS at (619) M Unit 3rd Party Billing Suspended Find ut why Cunty rdered suspensin f billing. Call assigned COTR V W Z N Assignment f Benefits (AOB) Signed Insurance Flagged as Unbillable Nt Authrized 1 N Server Prvider Number 2 Requires Re-Calculatin 3 N NPI! Duplicate Service Obtain signed AOB fr Private Insurance and Fax t MHBU an updated CA Client Financial Review Frm with AOB bx checked. Indicate what insurance the AOB is fr in the cmments sectin. MHBU FAX # (858) Prgram can fix. Determine why insurance flagged as unbillable, if dne in errr, turn ff flag in 3 rd Party Cverage Maintenance screen. If unable t crrect call MHBU at (619) Fr Medi-Cal Day Treatment fllw up t btain authrizatin frm ASO/ OPTUM. Prgram t check Display Client Services t verify there is an authrizatin. If a day treatment authrizatin is shwing r nt shwing fr yur prgram, cntact the Optum Health Prvider Line phne at 1(800) Optin 4 t find ut why the services are in suspense. Fr Medicare Prgram must btain Medicare Server prvider number and Fax t MH MIS Unit at (858) t be recrded in staff recrd. May be crrected when MHBU runs mnthly Re- Calculatin prcess. If unsuspended after tw (2) cnsecutive mnths, please call MHBU at (619) Prgram needs t btain server NPI and fax t MH MIS Unit at (858) t be recrded in staff recrd. Prgrams can fix. Fr 24-hur prgrams nlyresearch why client is shwing pen t tw 24-hur prgrams at the same time. Make crrectins as needed t assignments. p Service Nt Authrized Prgram shuld FAX the suspense reprt with cde P t the MHBU fr crrectin. MHBU FAX # (858) Page 44 f 84 8/27/2013

45 Suspense Cde Suspense Descriptin Hw t crrect r t Authrized Limits Exceeded Mre than 20 hurs f Service Billed fr Crisis Stabilizatin t this Benefit Plan. Mre than 4 hurs f medicatin services prvided n the same day Fr Medi-Cal Day Treatment fllw up t btain authrizatin frm ASO/ OPTUM. Prgram is authrized t prvide day treatment services fr a specific number f days. If yu feel there is an errr check with the Optum Health Prvider Line phne # (800) Optin 4, t ensure yur prgram is authrized t prvide day treatment fr the days that are suspending Fr Crisis Stabilizatin, if ttal hurs exceed 20 hurs in a day, crrect data entry f service duratin by re-entering up t a ttal f 20 hurs f billable service. Anything ver 20 hurs can be fixed by re-entering service as nn-billable. Fr Medicatin Services, prgram shuld check the ttal medicatin services fr the day. If ttal exceeds 4 hurs, prgram shuld crrect and nly re-enter the service time that ttals up t 4 hurs fr the day. All ther medicatin services that exceed the 4 hurs ttal, shuld be re-entered as nn-billable. y Service cncurrent with an Admissin Assignment Indicates client is pen t 24-hur prgram at same time as receiving utpatient treatment service. Prgram must research and make crrectins t the assignment r services as needed. If assignments and services are crrect, identify services n the reprt t be claimed with CLAIM IT ANYWAY and fax t QI Matters at Fax # fr determinatin. QI Matters will frward the apprved reprt t MHBU fr prcessing. Once prcessed, MHBU will fax the cmpleted reprt t the Prgram fr cntinuatin f internal prcess, if needed. Truble Shting and Questins Service Questin The service fr my prgram did nt bill t crrect payer surce. Hw can I crrect this? Step 1: Check the effective date f the plicy t ensure it is within the time frame fr the service; if this is accurate, then mve t step 2 belw: Step 2: If a service was entered int the MH MIS befre the insurance plicy was cmpleted, the service will nt bill t the insurance cmpany until the MH Billing Unit runs a prcess knwn as re-calc. prir t claiming fr services. Infrm the MH Billing Unit f the issue s re-calc. culd be run earlier if apprpriate. If this still des nt answer yur questin, mve t step 3 belw: Page 45 f 84 8/27/2013

46 Step 3: Cntact the MH Billing Unit fr assistance at (619) Payer Surce Questins I m trying t enter an insurance cmpany, and it is nt in the payer surce drp dwn menu what d I d? Cmplete the Add Insurance Cmpany Request frm page 65 f this manual and fax it t the MH Billing Unit using the number n the frm. The MH Billing Unit will ntify yu when the insurance has been added. I m lking fr an insurance cmpany, and it desn t shw in the MH MIS what d I d? Check t ensure yu clicked the ALL buttn. This will allw yu t see active and inactive insurance plicies. An insurance cmpany plicy was entered in the MH MIS with a future expiratin date; hwever I can n lnger see the plicy even thugh the terminatin date is nt effective yet. Step 1: Click t ensure yu clicked the ALL buttn, t view all payer surces whether they are active r inactive plicies. Step 2: If the future date is used the pririty will reflect I fr inactive even thugh the plicy is technically still active and will bill apprpriately till the terminatin date. It can nly be viewed when yu click either ALL r Inactive. What is a BIC Card and what number d I use t verify eligibility? Prgram Staff shuld enter the first 8 digits and the alpha character as the plicy number, this is the CIN that is used t verify Medi-Cal eligibility thru the internet. The Benefits Identificatin Card is a white plastic card with blue lettering and the State seal. It has the client s name, date f birth, Medi-Cal identificatin number, and the card issue date n the frnt. The Department f Health Care Services (DHCS) issues a plastic Benefits Identificatin Card (BIC) t each Medi-Cal recipient. In exceptinal situatins, cunty welfare departments may issue paper cards t individuals. It is the prvider s respnsibility t verify that the persn is eligible fr services and is the individual t whm the card was issued. Eligibility verificatin shuld be perfrmed prir t rendering a service. Benefits Identificatin Card (BIC) Pssessin f a BIC is nt prf f Medi-Cal eligibility because it is permanent frm f identificatin and is retained by the recipient even if he r she is nt eligible fr the current mnth. See sample BIC belw. Page 46 f 84 8/27/2013

47 Sue G. Recipient Signature Gender This card is fr identificatin nly. It des nt guarantee eligibility. Misuse f this card is unlawful. Date f Birth Sample Benefits Identificatin Card (BIC). (Actual card size = 3 ⅛ x 2 ⅜ inches; white card with blue letters n frnt, black letters n back.) Secnd ID Helps Cnfirm Recipient s Identificatin If a recipient is unknwn t a prvider, the prvider must make a gd faith effrt t verify the recipient s identificatin befre rendering Medi-Cal services. A gd faith effrt means verifying the recipient s ID by matching the name and signature n the Benefits Identificatin Card against the signature n a valid Califrnia driver s license, a Califrnia identificatin card issued by the Department f Mtr Vehicles, anther acceptable picture ID card, r ther credible dcument f identificatin. Exceptin: The requirement des nt apply when a recipient is receiving emergency services, is 17 years f age r yunger r is in a Lng Term Care facility. Temprary Benefits Identificatin Card (BIC) Senate Bill (SB) 25 ( Statutes f 2003, Chapter 907) required the remval f the Scial Security Number (SSN) frm the Medi-Cal BIC s and prhibits the use f the SSN in certain situatins and n certain dcuments. Assembly Bill (AB) 3029 (Statutes f 2004, Chapter 584) prhibits the use f the SSN when billing Medi-Cal. As a part f the expanded BIC-Identificatin (ID) number prject, in Nvember 2005 the Medi-Cal paper card was changed t display the new 14-digit BIC ID when the beneficiary was already knwn t the Medi-Cal Eligibility Data System (MEDS) r the client index number (CIN) was entered n the transactin. Fr new beneficiaries withut CIN s, the nine-digit MEDS-ID (SSN r pseud-id plus check digit), is currently printed. Because AB 3029 prhibits the use f SSN s, the paper card prcess is being changed t display nly the BIC-ID. And, since in mst cases prviders will need the BIC-ID when billing Medi-Cal, the beneficiary must have either a plastic r paper BIC cntaining the BIC-ID t receive services. Page 47 f 84 8/27/2013

48 Patient Assistance Prgram (PAP) Fiscal Prcess If applicable t the prgram, Pharmacy Healthcare Slutins (PHS) staff cmplete and submit applicatins fr Patient Assistance Prgram (PAP) medicatins fr mental health clients. Medicatins are received at Health & Human Services Agency (HHSA) Pharmacy and are checked in by designated pharmacy staff. PHS includes cntract prgram s PAP Recvery Fee f 12.5% n a mnthly invice sent t the HHSA Pharmacy. The HHSA Pharmacy pays PHS invice using the accunting infrmatin (Prjects, Organizatin Number, Expenditure Type, Task and Award Number als called as POETA) prvided by Behaviral Health Services (BHS) Cntract Supprt Unit (CSU). Upn receipt f the mnthly invice frm PHS, the HHSA Pharmacy verifies that the crrect fee accunt is reflected and prcess payment f the invices. HHSA Pharmacy als cnducts a cash transfer f the amunts used fr each relevant prgram mnthly. PHS sends PHS PAP Meds invice fr Cunty cmpletes & received at recvery fee Pharmacy submits PAP designated t the Cunty pays PHS applicatins pharmacy Pharmacy invice BHS Admin frwards cpy f invice t cntractr Cntractr includes PHS PAP recvery fee n mnthly cst reprt BHS Admin deducts fee via credit mem frm cntractr mnthly payment Page 48 f 84 8/27/2013

49 Quick Reference List COUNTY OF SAN DIEGO MENTAL HEALTH BILLING UNIT PHONE: (619) FAX: (858) MIS CUSTOMER SERVICE DESK Phne: (619) Fax: (858) QI MATTERS Fax: (619) PATIENT ADVOCACY PROGRAM PHONE: (619) SAN DIEGO MHP MENTAL HEALTH ADMIN PHONE: (619) OPTUM HEALTH ACCESS AND CRISIS LINE PHONE: (888) PROVIDER LINE PHONE: (800) OPTUM HELP DESK PHONE: (800) Fax: (619) Page 49 f 84 8/27/2013

50 Frms Share f Cst Clearance Request Date Share f Cst Amunt Unit/Subunit Requested By Clients Name MH MIS Clients Number Clients DOB Service Cde Date f Service Price Cmments Staff Signature Mental Health Billing Unit nly Cmpleted by: Date prcessed: Page 50 f 84 8/27/2013

51 Share f Cst Clearance Request Instructins A client that has a share f cst (SOC) respnsibility must have their SOC cleared in the State system and MH MIS in rder t facilitate billing t the State fr services apprpriately. Please nte that the services that are used t clear the SOC are nt payable by the State. Cunty and Cntracted Prgrams that have clients wh have a Share f Cst (SOC) and require clearance, will need t cntact the Cunty f San Dieg Mental Health Billing Unit at (619) Date The date submitting yur requesting Unit/Subunit (Reprting Unit) Share f Cst Amunt Ttal amunt f share f cst Requested By Name f the persn requesting clearance Clients Name Name f the client MH MIS Clients Number Client number prvided by MH MIS Clients DOB Birth date f client Services Cde Enter the service cde used in MH MIS Date f Service Service date Price Price f service shwn in MH MIS Cmments Any cmments needed t clarify SOC clearance Mental Health Billing Unit Only DO NOT USE THIS SECTION Page 51 f 84 8/27/2013

52 MH MIS Case Number Cllectin f Client Accunts Client Payment Recrd Prgram Name: Unit/Subunits: Date Sent t MH Billing Unit: Client Name Date Amunt Received Check#/ Mney Order Fiscal Use ONLY Check Re cd 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ 7. $ 8. $ 9. $ 10. $ 11. $ 12. $ 13. $ 14. $ 15. $ Cntract Prviders will be expected t accept payments frm clients. Checks shuld be mailed t Cunty within a week f receipt. Cash cllected frm clients shuld be reprted t the Cunty within a week and paid t the Cunty via check n less frequently than mnthly. Page 52 f 84 8/27/2013

53 Cllectin f Client Accunts Instructins Client fee cllectin fr cntracted prviders shuld be cnducted, at minimum, nce every 30 days. The mst effective cllectin methd fr patient fees is t discuss their financial bligatin with them when they are present fr treatment. In n case shuld the client be denied treatment based n financial issues. All client payments must be captured in MH MIS t ensure clients are held financially respnsible nly up t their UMDAP liability and t ensure accurate revenue reprting. The Mental Health Billing Unit is respnsible fr psting client payments fr all prgrams. Cntract perated prgrams must reprt client payments received t the Mental Health Billing Unit via the Cllectin f Client Accunts frm fr psting t the MH MIS system r via depsit infrmatin. MH MIS Case Number This is number issued by MH MIS Client Name Last Name, First Date Received Date prgram received payment frm client Amunt Dllar amunt received by prgram Check # / Mney Order Check number r mney rder numbers. Fiscal Use ONLY Check Re cd DO NOT USE THIS FIELD Cunty f San Dieg/HHSA Mental Health Billing Unit P.O. Bx San Dieg, CA (619) MS W403 Page 53 f 84 8/27/2013

54 DEDUCTIBLE ADJUSTMENT REQUEST T: Prgram/Regin Mgr Mail Stp (MS#) Date Frm: Title (MS#) RE: Client Name Anasazi Case # UMDAP Annual Deductible $ Mnthly Rate $ Cntract Yr CRITERIA: (Check thse applicable fr Deductible Adjustment) Stated inability t pay due t Will nt return fr recmmended treatment and withut treatment the client s mental health will diminish Withut treatment, patient may becme suicidal and/r injure self r thers. Recmmended by Therapist that reductin be granted. Therapist Signature Amunt Patient will pay: Annual $ Mnthly $ STATEMENT:(Further justificatin) Cntinue n attached sheet if necessary Human Service Specialist Recmmendatin (If Needed): APPROVAL DISAPPROVAL NO RECOMMENDATION HSS Signature Adjustment Review: Disapprved Apprved Fr Prgram/Regin Mgr. Signature Annual Deductible $ Payable Mnthly at $ Request Unjustified Denied Request Justified Reduce T Recmmended Amunt Final and/r Appeal Review: ADMINSTRATOR ANNUAL Fax T: Mental Health Billing Unit (619) Rute cc: Human Service Specialist Review MONTHLY AT $ HHSA: MHS-661 (11/2007) Page 54 f 84 8/27/2013

55 Deductible Adjustment Request Instructins T: Name f Prgram/Reginal Manager f the clinician seeking adjustment Mail Stp: Mail Stp f prgram/reginal manager Date: Date submitting adjustment Frm: Persn requesting adjustment Title: Title f persn requesting adjustment Mail Stp: Mail Stp f persn requesting adjustment RE: Client Name Last Name, First MH MIS case number: Client number issued in MH MIS UMDAP Annual Deductible $: Current UMDAP Annual amunt Mnthly Rate$: Current UMDAP Mnthly amunt Cntract Yr: Year fr cntract Criteria: State reasn why patient nt able t pay in accrdance with plicy and prcedures if nt listed belw. Therapist Signature: Therapist wh apprves exceptin Amunt Client will pay: Annual $: Re-determined UMDAP Annual amunt Mnthly $: Re-determined UMDAP Mnthly amunt STATEMENT: (Further justificatin if needed) Any cmments needed t clarify adjustment Human Service Specialist Recmmendatin: (If needed) HSS will apprve, disapprve, r give n recmmendatin then sign. Adjustment Review This sectin is fr the prgram/reginal mgr t apprve r disapprve then sign. Final and/r Appeal Review: recmmended UMDAP amunt. The frm must be signed by the administratr with the Cunty f San Dieg/HHSA Mental Health Billing Unit P.O. Bx San Dieg, CA (619) MS W403 Rute cc: Eligibility Review: A cpy shall be prvided t the HSS Fax t: Mental Health Billing Unit at (619) Page 55 f 84 8/27/2013

56 Ntice f Payment Plan Date: Name: Address: City: State: Zip Cde: Fr Services Rendered T: MH MIS Case Number: UMDAP AMOUNT $ Cntract Year This payment plan will cnsist f cnsecutive mnthly payments f $ each. The first mnthly payment is due and the final payment is due. All payments shall be sent t: Cunty f San Dieg Mental Health Billing Unit P.O. Bx San Dieg, CA (619) In the event f nn-payment, yur accunt may be referred t the Cunty f San Dieg Office f Revenue and Recvery fr additinal cllectin activities. By signing belw yu are acknwledging that yu understand that yu we fr services prvided. Respnsible Party Signature Prgram Staff Signature Date Date Page 56 f 84 8/27/2013

57 Cunty f San Dieg Health and Human Services Agency Mental Health Services ASSIGNMENT OF INSURANCE BENEFITS AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION I/We Patient M.R. Plicyhlder Relatinship t Patient I d hereby assign t the Cunty f San Dieg, r agencies cntracted by the Cunty f San Dieg, any cvered Insurance Benefits payable. (Please refer t yur insurance plicy r cntact yur insurance agent fr assistance in cmpleting the fllwing.) INSURANCE COMPANY COMPANY ADDRESS POLICY NUMBER CERTIFICATE/MEMBERSHIP NUMBER EFFECTIVE DATE ENROLLMENT CODE PATIENT S BIRTHDATE PATIENT S SOCIAL SECURITY NUMBER POLICYHOLDER S SOCIAL SECURITY NUMBER UNION LOCAL NUMBER FOR GROUP INSURANCE PLEASE SIGN IN BOTH PLACES BELOW Plicy Hlder DOB: Insurance cmpanies must have the fllwing infrmatin, in additin t any f the abve that may apply, befre payment n insurance claim can be made. Name f Emplyer Address f Emplyer Grup Plicy Number Certificatin/Membership Number I understand and agree that I/We are respnsible t the Cunty f San Dieg r Cntracted Agency fr all charges nt paid by this agreement r as determined by Unifrm Methd f Determining Ability t Pay (UMDAP). I/We authrize the release f infrmatin regarding care received at the Cunty f San Dieg Mental Health Services r a Cntracted Agency in San Dieg Cunty, as requested by the Insuring Agency. By signing this frm, yu are giving permissin fr all mental health prgrams prvided by the Cunty f San Dieg, r its Cntract Prviders, t bill yur insurance fr services rendered. A cpy f this release will be frwarded t each prgram within the Cunty f San Dieg frm which yu receive services. Date Date Patient s Signature Plicyhlder s Signature Cunty f San Dieg Health and Human Services Agency Mental Health Services ASSIGNMENT OF BENEFITS HHSA: MHS-071 (03/2006) Client: MR/Client ID#: Prgram: Page 57 f 84 8/27/2013

58 Cndad de San Dieg Agencia de Servicis Humans y de Salud Servicis de Salud Mental CESIÓN DE BENEFICIOS DE SEGURO MÉDICO Y AUTORIZACIÓN PARA LIBERAR INFORMACIÓN MÉDICA Y/Nstrs Paciente M.R. Asegurad Relación cn el paciente Pr este medi ced/cedems al cndad de San Dieg, a las agencias cntratadas pr el cndad de San Dieg, cualquier benefici de segur médic cubiert pagader. (Pr favr cnsulte su póliza de segur cntacte a su agente de segurs para que le ayude a cmpletar ls siguientes dats.) COMPAÑÍA DE SEGUROS DOMICILIO DE LA COMPAÑÍA NÚMERO DE PÓLIZA CERTIFICADO/NÚMERO DE MEMBRESÍA FECHA DE VIGENCIA CÓDIGO DE INSCRIPCION FECHA DE NACIMIENTO DEL PACIENTE NÚMERO DE SEGURO SOCIAL DEL PACIENTE NÚMERO DE SEGURO SOCIAL DEL ASEGURADO NÚMERO DEL SINDICATO LOCAL POR FAVOR FIRME EN LOS DOS LUGARES A CONTINUACIÓN PARA SEGURO DE GRUPO Además de la infrmación anterir que crrespnda, las cmpañías de segurs deben cntar cn la siguiente infrmación antes de que se efectúe un pag a una reclamación de segur. Nmbre del empleadr Dmicili del empleadr Númer de la póliza de grup Certificación/ Númer de membresía Entiend y esty de acuerd en que Y/Nstrs sms respnsables ante el cndad de San Dieg agencia cntratada de tds ls cargs que n sean pagads pr este acuerd cm se determina pr el Métd Unifrme de Determinación de Habilidad de Pag (UMDAP, pr sus siglas en ingles: Unifrm Methd f Determining Ability t Pay). Y/Nstrs autrizams que se divulgue infrmación en relación a la atención recibida de ls Servicis de Salud Mental del cndad de San Dieg de la agencia cntratada en el cndad de San Dieg, cm l slicitó la agencia de segurs. Al firmar este frmulari usted está dand su autrización para que tds ls prgramas de salud mental que el cndad de San Dieg prprcina, sus cntratistas, envíen a su cmpañía de segurs la factura pr servicis prestads. Una cpia de este frmulari de autrización será enviada a cada prgrama del cual usted recibe servicis y que se encuentre dentr del Cndad de San Dieg. Fecha Fecha Cunty f San Dieg Health and Human Services Agency Mental Health Services ASSIGNMENT OF BENEFITS HHSA: MHS-071 (03/2006) Firma del paciente Firma del asegurad Client: MR/Client ID#: Prgram: Page 58 f 84 8/27/2013

59 Quận Hạt San Dieg Cơ Quan Sức Khỏe và Nhân Sinh Dịch Vụ Sức Khỏe Tâm Thần CHỈ ĐỊNH CÁC QUYỀN LỢI BẢO HIỂM VÀ GIẤY ỦY QUYỀN TIẾT LỘ CHI TIẾT Y KHOA Tôi/Chúng tôi Bệnh nhân M.R. Tên người đứng tên hợp đồng bả hiểm Liên hệ gì với bệnh nhân Xin chỉ định ch Quận Hat San Dieg, hay các cơ quan hợp đồng với Quận Hạt San Dieg, được nhận lãnh bất cứ phúc lợi trả từ bả hiểm. (Xin vui lòng đưa số hợp đồng hay liên lạc với nhân viên bả hiểm để đuợc giúp đỡ điền đơn dưới đây) TÊN CÔNG TY BẢO HIỂM ĐỊA CHỈ CÔNG TY SỐ HỢP ĐỒNG SỐ THẺ HỘI VIÊN CÓ HIỆU LỰC NGÀY MÃ SỐ GHI DANH SỐ AN SINH XÃ HỘI CỦA THÂN CHỦ SỐ AN SINH XÃ HỘI CỦA NGƯỜI ĐỨNG TÊN HỢP ĐỒNG MÃ SỐ CỦA CÔNG ĐÒAN ĐỊA PHƯƠNG XIN VUI LÒNG KÝ TÊN VÀO HAI CHỖ DƯỚI ĐÂY ĐỐI VỚI NHÓM BẢO HIỂM Ngòai những chi tiết bên trên, các hãng bả hiểm phải có thêm những thông tin dưới đây, trước khi hóa đơn của hãng được trả tiền. Tên của Chủ Nhân Địa chỉ của Chủ Nhân Số Hợp đồng của Nhóm Bả Hiểm Số Chứng chỉ/hội viên Tôi hiểu rõ và đồng ý là Tôi/Chúng tôi có trách nhiệm với Quận Hạt San Dieg hay Cơ quan có Hợp đồng về những chi phí không được thanh tóan căn cứ và bản thỏa hiệp này hặc được quyết định của Phương Cách Trả Tiền Dựa Và Khà Năng (UMDAP). Tôi/Chúng tôi ch phép được tiết lộ chi tiết về việc chăm sóc mà tôi đã nhận tại Dịch Vụ Tâm Thần của Quận Hạt San Dieg hay từ một Cơ quan Hợp dồng ở Quận hạt San Dieg, dưa và yêu cầu của Bả Hiểm.. Ngày tháng Ngày tháng Chữ ký của thân chủ Chữ ký của người đứng tên hợp đồng Cunty f San Dieg Health and Human Services Agency Mental Health Services ASSIGNMENT OF BENEFITS HHSA: MHS-071 (09/2004) Client: MR/Client ID#: Prgram: Page 59 f 84 8/27/2013

60 Unifrm Methd f Determining Ability t Pay (UMDAP) Cunty f San Dieg Health and Human Services Agency Mental Health Services ASSIGNMENT OF BENEFITS Client: MR/Client ID#: Prgram: Page 60 f 84 8/27/2013

61 HHSA: MHS-071 (03/2006) Distrit ng San Dieg Ahensiya ng Kalusugan at ng Makatang Serbisy Serbisy sa Kalusugan ng Pangkaisipan PAGTATALAGA NG BENIPISYO NG SEGURO AT PAGPAPAHINTULOT NA IPAHAYAG ANG KAALAMANG MEDIKAL Ak/Kami M.R. ng Pasyente Humahawak sa Patakaran Kaugnayan sa Pasyente Ay itinatalaga sa Cunty ng San Dieg, mga ahensiyang kinntrata ng Cunty ng San Dieg, and alinmang bayarin na sakp ng Benepisy ng Segur. (Tingnan ang plicy ng segur, tawagan makipagkita sa iyng kinatawan ng segur para sa tulng sa pagkmplet ng mga sumusund na imprmasyn.) KOMPANYA NG SEGURO ADRES NG KOMPANYA NUMERO NG POLICY SERTIPIKO/NUMERO NG PAGKAKASAPI PETSA NG PAGKAROON NG BISA KODIGO NG PAGPAPALISTA PETSA NG PAGSILANG NG PASYENTE NUMERO NG SOSYAL SEKYURITI NG PASYENTE NUMERO NG SOSYAL SEKYURITI NG HUMAHAWAK SA POLICY LOKAL NA NUMERO NG UNYON PAKIPIRMA SA MGA KAPWA LUGAR SA IBABA PARA SA SEGURO NG GRUPO Ang mga kmpanya ng segur ay dapat magkarn ng sumusund na imprmasyn, karagdagan ng anmang imprmasyn na magagamit sa taas ng papel na it, bag gawin ang anumang hinihinging kabayaran ng segurl Pangalan ng Pinagtrabahuhan Adres ng Pinagtrabahuhan Numer ng Grup ng Segur Sertipik/Numer ng pagkakasapi Aking naiintindihan at sang-ayn na Ak/Kami ay may pananagutan sa Cunty ng San Dieg Nakakntratang Ahensiya para sa lahat na mga na hindi nabayaran kasunduang it ang napagpasiyahang kabayaran sa pamamagitan ng Magkatulad na Paraan ng Pagpapasiya sa Kakayanang Kabayara-Unifrm Methd f Determining Ability t Pay (UMDAP). Aking/Aming pinahintulutan ang pagpahayag ng imprmasyn tungkl sa natatanggap sa Cunty ng San Dieg ng mga Serbisy ng Kalusugang Pangkaisipan ang Nakakntratang Ahensya sa Cunty ng San Dieg, na hiniling sa pamamagitan ng Nagpasegur na Ahensiya. Sa pagpirma ng prmang it, ikaw ay nagbibigay ng pahintult para sa lahat ng mga prgrama ng kalusugang pangkaisipan na pinagkalb ng Cunty ng San Dieg, nitng mga nangngntratang ahensya, upang mapadalhan ng kuwenta ang iyng kmpaniya ng segur para sa mga serbisyng ibinigay sa iy. Ang kpya nitng pahayag ay ipapadala sa bawat prgrama sa lb ng Cunty ng San Dieg na kung saan ka tumanggap ng serbisy Petsa Petsa Cunty f San Dieg Health and Human Services Agency Mental Health Services ASSIGNMENT OF BENEFITS HHSA: MHS-071 (03/2006) Pirma ng Pasyente Pirma ng Humahawak ng Patakaran Client: MR/Client ID#: Prgram: Page 61 f 84 8/27/2013

62 San Dieg Mental Health Services Califrnia Client Financial Review Maintenance Client Name: Case Number: SSN: DOB: Review Date: Status: New Update Annual Main [1] Financial Type: Individual Family (Cmplete Family Members sectin belw): Prgram: Mental Health Name: Family Members: Case#: Bill T: Name: Relatinship t Client: Address: City: State: Zip Cde: Phne: Assignment f Benefits Signed? Yes If YES, Nte date signed and lcatin where AOB is n file in the Cmments Sectin n page 2. N If NO, Insurance will nt be billed. Financial Inf Prvided/Verified Yes N If NO, Select Reasn frm Table: N Nt Applicable P Dcumentatin Pending R Dcumentatin nt Prvided/Refused U Unemplyed Suppress printing statements? Yes N A. Grss Family Incme If YES, Select Reasn frm Table: CR Client Request H Hmeless N N Permanent Mailing Address Financial [2] Number dependent(s) n incme: 1. Respnsible Persn: 2. Spuse: 3. Other (Name f Surce): 4. Ttal Grss Incme: Califrnia Client Financial Review Maintenance - Page 2 Mnthly Annual Page 62 f 84 8/27/2013

63 Client Name: Case Number: SSN: B. Liquid Assets C. Allwable Expenses Mnthly Annual 1. Savings Accunts 1. Curt Ordered Obligatins 2. Checking Accunts 2. Child Care (necessary fr emplyment) 3. Other 3. Dependent Supprt 4. Ttal Liquid Assets 4. Medical Expenses 5. Asset Allwance 5. Medical Expenses in excess f 3% Grss Incme 6. Net Assets 6. Mandated Deductins fr Retirement Plans 7. Mnthly Liquid Assets 7. Ttal Allwable Expenses UMDAP Calculatins Ttal Mnthly Grss Incme (Frm pg. 1) $ Subtract Ttal Allwable Expenses $ Bx A4 C7 (-) Subttal $ (=) Add Adjusted Mnthly Liquid Assets $ B7 (+) D. Adjusted Grss Incme $ D (=) Max Annual Liability: $ Fr Liability Perid: Fr an Override, fllw Therapeutic Adjustment P&P # and/r Financial Eligibility and Billing Manual, page 24. Thrugh: Payment Plan: Yes Payment Plan [3] Agreed upn Payment Amunt: $ Per: Mnth Visit Cmments [4] Name f Insurance AOB is signed fr: Date AOB Signed: AOB n file at (Unit/Subunit): Signatures [5] I understand that I am bligated t pay the established UMDAP deductible r the actual cst f services received during the UMDAP cntract year, whichever is less. I understand that I am bligated t pay fr the cst f care up t the UMDAP deductible regardless f when treatment is terminated. Respnsible Party Name (Print) Signature f Respnsible Party Date Interviewer s Signature Anasazi ID# Page 63 f 84 8/27/2013

64 Califrnia Client Financial Review Maintenance Main (1) Client Name Case Number SSN DOB Status Date Financial Type Individual vs. Family Ntes: The UMDAP will cver the whle family fr a year f mental health services as lng as the family members are U.S. Citizens r Registered Legal Aliens. Undcumented clients are nly eligible t receive emergency services at EPU and ESU. The UMDAP will cver the whle family fr a year f emergency mental health services nly. Prgram Family Members Bill t Assignment f Benefits signed Financial Infrmatin Prvided Reasn Nt Verified Suppress Printing Statements Suppress Reasn Nte: Client can request suppress printing statement des NOT mean client will nt be respnsible fr UMDAP. Last Name, First Client Number Scial Security Number Date f Birth New, update, r annual UMDAP Date infrmatin was cllected, maybe different frm UMDAP date. Individual meaning nly ne persn receiving Mental Health Services. Family meaning mre than ne persn receiving Mental Health Services. (If yu mark Individual and find ut later that they have smene in their family receiving services yu can link the tw acct. this is an Anasazi feature.) Always Mental health All family members in the mental health system and write their case number beside their name. (If knwn) The respnsible party that wuld receive the bill. This includes client. Mark if yu have an AOB n file with signature. Als, AOB is NOT needed fr Med-Cal clients. If the financial infrmatin was verified, check this bx. If the financial infrmatin bx is nt checked, please indicate reasn: N-N/A P-Dcumentatin Pending R-Dc nt Prvided/Refused U-Unemplyed Check this bx if statements are nt t be printed/sent t client. If Suppress Printing Statements bx is checked, please indicate reasn: CR- Client Request H-Hmeless N-N Perm Mail Address MC- Minr Cnsent FINANCIAL (2) TAB Page 64 f 84 8/27/2013

65 Number f Dependents Grss Family Incme (Bx A) Ntes: NOTES: Grss Incme means ttal family incme befre allwances fr taxes and ther deductins. In the case f self-emplyed persns, it is ttal incme after business expenses have been deducted. If client claims n incme, ask hw they are supprting themselves. Liquid Assets (Bx B) Nte: The clients incme maybe depsited in the acct. S always use the average balance when using checking r saving accunts t avid cunting the clients incme twice. The number f dependents must include parent(s) and all children under the age 18 which the parent is financially supprting ver 50%. (Line 1) Respnsible persn, if self-enter client s mnthly r annual grss incme. If client is a child enter parents/legal guardian s mnthly r annual grss incme. (Line 2) Spuse s incme, if any. Leave blank if nne. (Line 3) Other incme. This can include incme frm SSA, CalWIN, Child supprt, Spusal supprt, Dividends, Interest & Rental incme. (Line 4) Ttal Grss incme. Add lines 1, 2 and 3 t get yur grss incme. (Line 1) Savings Accunt. Average Savings balance, if nne enter zer. (Line 2) Checking Accunt. Average Checking balance, if nne enter zer. (Line 3) Other Assets. Any Assets persnal r real prperty which can readily be cnverted int cash and may increase ability t pay. This can include stcks, bnds and mutual funds (Line 4) Ttal Liquid Assets. Add lines 1, 2 and 3 t get yur ttal. (Line 5) Asset Allwance. Refer t 1989 Asset Schedule. It is based n family size. Enter the Asset Allwance amunt n line 5. If the amunt n line 5 (Asset Allwance) is greater than line 4 (Ttal Liquid Assets) put a zer n line 6 (Net Assets) and a zer n line 7 (Liquid Mnthly Assets). This means that their assets are nt ging t affect their mnthly grss incme. (See Example 1) If the amunt n line 5 (Asset Allwance) is less than line 4 (Ttal Liquid Assets) subtract line 5 frm line 4 t get the amunt that will g int line 6 (Net Assets). Nw divide the Net Asset amunt by 12 t get the amunt that will g int line 7 (Mnthly Liquid Assets). Yu will need t rund ff the amunt n line 7 t the nearest dllar. Nw add the amunt frm Bx B line 7 t Bx A line 3 as ther incme. This will give yu yur new ttal grss incme. (See Example 2). Page 65 f 84 8/27/2013

66 UNIFORM PATIENT FEE SCHEDULE COMMUNITY MENTAL HEALTH SERVICES EFFECTIVE OCTOBER 1, 1989 MONTHLY ADJUSTED GROSS INCOME* PERSONS DEPENDENT ON INCOME ANNUAL DEDUCTIBLES r mre MEDI-CAL ELIGIBLE AREA** MONTHLY ADJUSTED GROSS INCOME* PERSONS DEPENDENT ON INCOME ANNUAL DEDUCTIBLES r mre $ 4200 and abve add $ 400 fr each $ 100 additinal incme *Mnthly Grss Incme after adjustments fr allwable expenses and asset determinatin frm cmputatin made n the financial intake frm. ** Medi-Cal eligible. The shaded Medi-Cal eligible area identifies incme levels presumed eligible if client meets Medi-Cal eligibility requirements. Prepared and published by the Califrnia Department f Mental Health in accrdance with Sectins 5717 and 5718 f the Welfare and Institutins Cde. (ATTACHMENT C) 10/20/89 Page 66 f 84 8/27/2013

67 QUICK REFERENCE MEDI-CAL ELIGIBILITY All clients with mnthly inc me at r bel w the Medi -Cal Family Budget Unit (MFBU) and h ave assets at r bel w th e asset all wan ce area are presu med eligible if they meet aid eligibility requirements. Mainten ance n eed levels b y Medi -Cal Family Bud get Unit (MFBU) are: MFBU 1. $ $ $ 1, $ 1, $ $ 1, $ 1, $ 1, $ 934 (Adults) 5. $ 1, $ 1,692 Asset allw ances fr 1989 are : Persns 1. $ $ $ $ $ $ $ $ $ 4050 Aid categ ries c mmnly fund in c mmun ity mental health are: R E F U G E E - First 18 mnth s in the U.S. D I S A B L E D- Meetin g Fed eral definitin f disability. A G E D- 65 years f age and ver AFDC- Aid t Family with Dep endent Child ren. M E D I-CAL SHARE - OF-C O S T Persns with an extend ed treatment pr gnsis wh are within a few hundred dllars f asset all wan ce an d mainten ance need levels may be eligible fr Medi -Cal with a sh are-f-cst and/r real r p ersnal prp erty spend d wn. Fr Examp le: A single 70 -years f age man wuld be eligible fr Medi -Cal except his inc me is t high. He has a $ 1,000 medical bill. He meets l w asset levels, but his in c me fr m retirement is $1,000 per mnth. His in c me is $ 1,000 min us the stand ard $20 disregard and th e $ payme nt f r the Medicare Part B, leavin g a net f $ His share -f-c st fr Medi-Cal is $ min us $ 602 ( need level ) r $ Medi-Cal will pay th e remainder f th e $ 1,000 medical bill fr that mnth and ther mnth s when he bligates th e sh are-f-cst abve $ His eligibility will be re -d etermined b y Scial Servi ces each year. All persns with prp erty and inc me within a few h undred dllars f th e Medi -Cal limits and are expected t have substantial treatment cst must be referred t Scial Services fr eligibility d eterminatin. Persns n Medi-Cal, SSI r in c mes in the sh aded area dn nt have an annual deductible. Page 67 f 84 8/27/2013

68 ADD INSURANCE COMPANY REQUEST Insurance Cmpany Name: Street Address 1: Street Address 2: City: State: Zip Cde: Cntact Name: Telephne Number: ( ) Requested By: Tel. N.: Please fax this request t: MENTAL HEALTH BILLING UNIT (619) (Fax) Shuld yu have any questins, please cntact MH Billing Unit directly at (619) Yu will be ntified as sn as the insurance plicy is inserted. Date: Time: Persn Ntified: Page 68 f 84 8/27/2013

69 Page 69 f 84 8/27/2013

70 Page 70 f 84 8/27/2013

71 Page 71 f 84 8/27/2013

72 Page 72 f 84 8/27/2013