Community Partnership of Southern Arizona

Transcription

1 March 2014 Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines 4575 E. Broadway, Tucson AZ (520)

2 Table of Contents INTRODUCTION 2 STATEMENTS 3 CORPORATE AND ADMINISTRATIVE STRUCTURE 4 PROVIDER RESPONSIBILITY & CONTRACTOR EXPECTATIONS 5 CLAIMS PROCEDURE MANUAL OVERVIEW 8 CLAIMS & ENCOUNTER DATA 9 TIMEFRAMES 10 RESUBMISSIONS & RECONSIDERATIONS 12 THIRD PARTY LIABILITY 14 PIMA COUNTY TITLE DATA VALIDATION & CLAIM AUDITS 23 FINANCIAL 23 Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 1

3 INTRODUCTION Founded in February 1995, Community Partnership of Southern Arizona 1 administers public sector behavioral health services in southern Arizona (geographic service area 5) as a Regional Behavioral Health Authority (RBHA). In its role as a RBHA, CPSA works with its members, families, providers, state agencies, and other community stakeholders. CPSA believes that the achievement of high-quality outcomes is accomplished through the application of major principles of managed care. Within this context, financial and systems incentives are realigned so that the management of behavioral health care focuses primarily upon the number of people served and the quality of the outcomes of services provided. CPSA believes that qualified behavioral health providers can best design and carry out treatment processes that will produce positive results in the least intensive/restrictive environment and in the shortest amount of time. CPSA encourages providers to assume a significant amount of autonomy in the design and provision of care under carefully designed risk-based contracts. CPSA believes that with greater degrees of freedom to design and provide care, come greater degrees of responsibility and accountability. CPSA is guided by a focus on Continuous Quality Improvement (CQI) for members and in the overall management of the system. CPSA is dedicated to providing high-quality behavioral health services to residents of Southern Arizona and to a philosophy of care that is goal focused and improvement oriented. Critical Components of this philosophy include: Use of the most appropriate, least restrictive levels of care. Rapid, accurate diagnosis and effective treatment. Utilization of brief therapy treatment modalities. Treatment directed toward quality outcomes. Interventions designed to return the member to the highest possible level of functioning. Development and utilization of a full, creative, easily accessible continuum of care. Active involvement of members and their families in service planning and evaluation. Incorporation of evidence-based best practice models. Integration of services with other medical and social service providers. Within the philosophical context outlines above, CPSA has developed a Mission Statement, Vision Statement, and Statement of Values and Guiding Principles. 1 See About Us at for additional information. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 2

4 STATEMENTS Vision Statement CPSA believes in the importance of community involvement and community reinvestment. CPSA is dedicated to providing high-quality behavioral health services to residents of southern Arizona, and to a philosophy of care that is member and family driven, goal focused, and recovery oriented. Our mission, values and guiding principles developed within this philosophical context. Mission Statement Our mission is to ensure individuals and families receive accessible, high-quality behavioral health services that are member and family driven, recovery oriented, respectful of cultural differences, and foster hope and self-determination. Values & Guiding Principles 1. The focus of behavioral health services will be on the individual member and his/her family and on the development of services that support recovery and resiliency. 2. Every individual will receive the highest quality of service according to the best practice guidelines. 3. The rights of each individual and his/her family will be protected including the right to choice and involvement in decisions affecting them. 4. Behavioral health services will be provided following quick and simple entry procedures that are free of administrative, procedural, and geographic barriers. 5. The behavioral health system will be comprehensive in nature, providing a full continuum and array of services for adults and children. 6. The focus of the behavioral health system will be on those most in need. 7. Whenever possible, behavioral health services will be provided in the natural environment of the individual and his/her family. 8. Services will be linguistically and culturally relevant. 9. Members and families will have an integral role in determining services and will have ongoing input into system design and implementation. 10. The behavioral health service system will be evaluated regularly with accountability for producing positive outcomes. 11. The health and wellness of individuals and families will be enhanced through prevention and health promotion. 12. Technology will be utilized to increase the availability and accessibility of behavioral health information and to enhance service delivery. 13. The behavioral health system will actively support member advocacy and recovery selfmanagement. 14. Services will be designed and implemented based on the philosophies outlined in the DBHS Children s System of Care Vision and 12 Principles and the Adult System of Care Principles. 15. Individuals and families seeking services will be viewed as unique and resilient and will not be defined by their substance use or mental health disorders. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 3

5 CORPORATE & ADMINISTRATIVE STRUCTURE CPSA s administrate structure is designed so that functions are clearly identified and easily coordinated. The structure considers the diverse management needs of a sound managed behavioral healthcare organization and the many regulatory and contractual requirements that are placed on the RBHA. The administrative structure of CPSA includes three major components: Executive Office, Medical Management, Business Operations, and Network & Clinical Operations. The Executive Office includes: President/Chief Executive Officer Legal and Risk Management, and Grievance and Appeals Medical Management includes: Utilization Management Performance Improvement and Quality Management Business Operations includes: Claims Finance Analysis Accounting Utilization Analysis and Reporting Purchasing and Facilities Contracts Provider Services Information Technology & Information Systems, and; Human Resources Network & Clinical Operations is responsible for planning and monitoring the provider network. Functional areas within Network & Clinical Operations include: System Development and Evaluation Prevention, Training, and Health Promotion Network & Clinical Management Member Services Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 4

6 PROVIDER RESPONSIBILITY & CONTRACTOR EXPECTATIONS CPSA expects subcontracted providers to abide by and conform to all the requirements of: CPSA s subcontract with ADHS/DBHS, ADHS/DBHS, AHCCCS, and RBHA polices and procedures, CPSA s Provider Manual, Terms and conditions of subcontract agreement(s), ADHS/DBHS, AHCCCS, and CPSA credentialing criteria, Cooperation with the prior authorization, utilization review and quality management standards of the AHCCCS program and federal standards and ADHS/DBHS guidelines. Subcontracted providers will participate in all aspects of performance measurement established by ADHS/DBHS or CPSA. This includes the collection of data, analyses of this data, and implementation of improvements based on these analyses. Beyond this, subcontracted providers are required to participate in the development, adoption, implementation, and monitoring of best practices. Subcontracted providers are responsible for providing all covered services to CPSA members as authorized. Covered services are to be provided throughout the term of the subcontract agreement. Additional expectations for contracted or sub-contracted providers include but are not limited to the following: Provision of covered behavioral health services through a sufficient number of qualified staff including allocation of administrative coverage by a Medical Director, Adherence to professional qualifications requirements and best practices, Provision of accessible, available services including evening and weekend appointments, Provision for 24/7 availability for enrolled members for crisis/urgent situations, and the availability requires phone response, and face-to-face capability when appropriate, Use of community advisory board and stakeholder input, including family members and consumers, to improve the system of care, Development and implementation of continuous quality improvement program, Implementation of a utilization management program including admission certification and continued stay review, Assurance that the cultural needs of the members of addressed, Assurance of the appropriate licensure/certification and registration with AHCCCS is required by providers who operate within the scope of their practice, Compliance with appointment standards and referral; intake and first service standards (CPSA Policy #6.01, Intake and Enrollment ). A Trading Partner Agreement for all Electronic Data Interchange (EDI) transactions should be established with CPSA and the provider before electronic claims/encounters data can be processed. Please refer to the phone number below to get started. Moreover, HIPAA regulations specify a format for the submission of such data. HIPAA Format 837P is used for claims/encounters for non-facility services, including professional services, transportation, and independent laboratories. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 5

7 HIPAA Format 837I is used for claims/encounters for hospital inpatient, outpatient, emergency rooms, hospital-based clinics, and residential treatment center services. HIPAA Format NCPDP is used by pharmacies for claims/encounters for pharmaceutical services using NDC codes. If you need additional information or assistance regarding electronic submissions with CPSA 2, please contact the Data Processing Operations Manager at (520) Please note that providers are encouraged to submit clean claims/encounter data to CPSA for all covered behavioral health services. Dates of service must not span a contract/fiscal year. The date span for this begins on October 1 st, ending on September 30 th. A clean claim is defined as a claim that may be processed without obtaining any additional information from the provider or a third party. The clean claim(s) may not include claims that are under investigation for fraud or abuse, as well as those being reviewed for medical necessity. See A.R.S and search for Clean Claim. Please be sure to proofread your submissions to avoid delay. Coordination of Benefits for persons eligible for Medicare Part A, Part B, or Part D must follow the procedures established in 3.5 of the Provider Manual. To view specific billing guidelines, see Client Information System (CIS) File Layout and Specifications Manual and the ADHS/DBHS Office of Program Support Procedures Manual. Services to Providers Support to providers is offered through all areas of the organization. Specific areas offer ongoing support, training and technical assistance: Contract Supervision Claims Resolution Contracts Department Function/Responsibility The Contracts department duties and responsibilities are primarily post-award functions and include all phases of contract administration. The department is responsible for the preparation, maintenance, and monitoring of CPSA contract agreements for the provision of behavioral health services, in accordance with ADHS/DBHS and AHCCCS requirements. Responsibilities include contract monitoring for compliance with contract terms and conditions to include: credentialing, provider registration, and deliverables. Maintenance of contract files to ensure all documents regarding each contracting action are kept in a logical useable manner, sufficient to constitute a complete history of transactions. This department also provides technical assistance to individual contracts and/or provider networks, all of which are necessary actions for effective contracting. 2 Inquire about the CPSA IS File Layout & Specifications Manual to better understand the basic workflow of how our systems process your submissions. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 6

8 Financial Management CPSA is responsible for establishing and maintaining effective compliance with requirements of laws, regulations, contracts, and grants applicable to state and federal programs. In addition, CPSA is responsible for implementing proper accounting applications and internal control processes to mitigate on each annual financial audit. The CPSA annual budget and forecasts are presented to the Board Finance Committee and the Board of Directors for approval. All financial statements and results are reviewed internally monthly, quarterly, and annually. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 7

9 CLAIMS PROCEDURE MANUAL OVERVIEW The purpose of this manual is to: Identify general requirements for submitting encounter data; Identify procedures for submitting encounter data; Identify procedures for submitting claims; and Articulate the timelines for submitting billing information. Additional information for this manual may be found from the following: 45 CFR CFR A.A.C. 34 AHCCCS/ADHS Contract ADHS/RBHA Contract Section 3.18, Pre-Petition Screening, Court-Ordered Evaluation Section 3.4, Co-Payments Section 3.5, Third Party Liability and Coordination of Benefits Section 6.1, Submitting Tribal Fee-for-Service Claims to AHCCCS Section 6.2. Submitting Claims and Encounters Section 8.1, Encounter Validation Studies CMS 1500 UB 04 ICD-9-CM Manual First Data Bank Physicians Current Procedural Terminology (CPT) Manual Health Care Procedure Coding System (HCPCS) Manual ADHS/DBHS Office of Program Support Procedures Manual Client Information System (CIS) File Layout and Specifications Manual All documents are subject to change as they may be regularly updated on the Internet. Visit and click on Service Providers to browse the regularly updated Provider Manual. Need Assistance? For any inquiries, please note the following: Claims Customer Service Line: (520) We do not provide assistance to outsourced or third party collection agencies per HIPPA regulation. Claims Secure Fax: (520) Please include cover letters with attention to Claims. Claims.Inquiry@cpsaArizona.org Any transmission of PHI in an unsecure will result in corrective action. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 8

10 CLAIMS & ENCOUNTER DATA Your claims must be submitted electronically in the CMS 5010 format. You may be required to utilize EDI or CPSA s online form. Your submitted claims and encounters (may also be referred to as claims ) may be: Denied; Pended; or Adjudicated Denials Denials occur because of discrepancies between in your submitted data and claims system edit tables 3. A denied bill may be resubmitted as long as it has been performed in the established timeframe: 60 Days from the denial date as noted in the Weekly Response File (WRF). A resubmission cannot exceed 180 days from the last date of service, or day of discharge. Pended Claims may be pended by the HealthTrio claims system. CPSA works to resolve all pended claims within 120 days of the original processing date. Pended claims are also reported on the WRF. Once a pend condition is resolved, the claims will report to the provider response file as denied or accepted. Providers must monitor their claims that require correction and resubmission, including the date of resubmissions. Adjudication Claims that are on time 4, accurate, and pass all system edits are considered adjudicated/finalized. Claims for Non-Title 19/21 members are processed as any other claim. Adjudicated claims will then be processed by AHCCCS to be screened by their edits. 3 An edit table is a set of established rules and validation checks in place to ensure accuracy of all submissions in the system. Correct diagnosis codes, procedures, etc. 4 For timely filing guidelines, please see 6.2. Submitting Claims and Encounters of the Provider Manual. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 9

11 TIMEFRAMES Since encounters and claims (fee for service) are paid in different manners, here are timeframes for each. Encounter Submissions Encounters for services provided to a CPSA enrolled member must be received by CPSA within these guidelines: 45 Days from the DOS for professional contracted covered services. 45 Days from the date of discharge for facility contracted covered services. Encounters received beyond the 45 days from the DOS or date of discharge may be subject to timeliness sanctions. Initial encounters for CPSA direct contractors that receive claims from their subcontractors shall be submitted to CPSA within 90 days from the DOS for professional services and within 90 days from the date of discharge for facility services. Encounters involving Third Party Liability (TPL 5 ) must be submitted within 30 days from the date of the TPL EOB or EOMB. In no event shall an initial submission or resubmission of a denied encounter exceed 180 days from the DOS or date of discharge. Claim (Fee For Service) Submissions Claims for services provided to a CPSA enrolled member or a Title 36 6 patient must be received by CPSA following these guidelines: Fee for service claims are considered timely submissions if the initial claim is received by CPSA no later than 180 days from the DOS. For facility claims, DOS means the date of discharge of the patient or the service end date of the interim claim. Claims initially received by CPSA beyond the 180 day time frame will be denied as past timely filing. If a claim is originally received within the 180 day frame, the provider has up to 60 days from the date of initial denial notification to achieve clean claim status. In no event shall an initial submission or resubmission of a denied claim exceed 210 days from the DOS or the date of discharge. In the case of recoupment, the time frame for submission of a clean claim differs from the time frames described above. The time span allowed for a submission of a clean claim will be the greatest of: o 12 months from the DOS; o 12 months from the date of eligibility posting for a retro-eligibility claim; o 60 days from the date of the recoupment letter. If recoupment is initiated by CPSA, DBHS or ADHS/AHCCCS Office of Program Integrity as a result of identified misrepresentation, the provider may not be afforded additional time to resubmit a clean claim. Retro-Eligibility Claims A retro-eligibility claim is a claim where no eligibility was entered in the AHCCCS or RBHA system on the date(s) of service. At a later date, eligibility may be posted retroactively to cover the DOS. 5 For additional information, refer to the Third Party Liability and Coordination of Benefits document. 6 Pima County Title 36 encounters will follow the fee for service timelines above. Refer to the T36 section in this guide as well. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 10

12 Retro-eligibility fee for service claims are considered timely submissions if the initial claim is received by CPSA no later than 6 months from the AHCCCS date of eligibility. Retro-eligibility claims must attain clean claim status no later than 12 months from the AHCCCS date of eligibility posting. Adjustments to paid retro-eligibility claims must be received by CPSA no later than 12 months from the AHCCCS date of eligibility posting. This time limit does not apply to adjustments, which would decrease the original payment due to collections from Medicare or other third party payers. Out of Area Billing & One Time Billing If you are a provider that is outside of GSA 5, or for non-contracted covered services requires you to submit the claim to CPSA when you do not normally do so, your physicians and/or facilities may not be loaded into CPSA s HealthTrio system for claims adjudication. In this situation, you will need to speak to one of our contract specialists to coordinate an single service agreement and generate the appropriate fee schedules in the system before you are able to bill the claim(s). Failure to have the contract set completed may result in denial of your claim(s). You may also fax the claims and any associated documentation to the Claims department at (520) for appropriate routing to facilitate your contracting process. Please include a phone number and any extension number we may be able to reach you at. If you have any additional questions, please write Claims.Inquiry@cpsaArizona.org. Please note you must be registered with AHCCCS prior to any contract or claims processing. If you are terminated with AHCCCS, you must be re-instated. Visit for more information. Note: this process above for out of area providers is subject to change. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 11

13 RESUBMISSIONS & RECONSIDERATIONS Resubmission is defined as a claim originally denied because of missing documentation, incorrect coding, etc, which is now being resubmitted with the required information. Reconsideration is defined as a request for review of a claim that a provider feels was incorrectly paid or denied because of processing errors. When filing resubmissions or reconsiderations, please include: An updated electronic version of the claim. Original claim number in reference. A copy of the remittance advice on which the claim was denied or incorrectly paid. Any additional documentation needed. A brief note describing what is correction(s) need to be made. Each claim should be identified clearly as Resubmission or Reconsideration. You as the provider have 12 months from the DOS to request a resubmission or reconsideration of the claim. For prior authorization, Reconsideration is defined in this regard as a request for review of a prior authorization that a provider feels was incorrectly denied or prior authorized. This could include a change in tier status, missing documentation, incorrect CPT/HCPCS codes or units, or DOS change. When filing for reconsideration, please include: Any additional documentation required. A brief note describing what correction is needed. Each prior authorization should be identified as Reconsideration. Providers have 12 months from the DOS to request a reconsideration of the claim so prior authorizations must be updated prior to submission or resubmission. Adjustments After a claim has been paid, errors may be discovered in the amounts or services that were billed. These errors may require submission of an adjustment to the paid claim. For example, a provider may discover that additional services should be billed for a service span or that incorrect charges were entered on a paid claim. Similar to resubmissions, when performing an adjustment, you must: Submit a new claim containing all previously submitted lines. If they are omitted, the system will recoup payment. The original CPSA claim number must be included on the claim to enable the system to recognize the claim being adjusted; otherwise, the claim will be recognized as new and may be denied for being received beyond the initial submission timeframe or for being a duplicate of a previous claim. Recoupment Under certain circumstances, CPSA, ADHS or AHCCCS may find it necessary to recoup or take back money previously paid to a provider. Overpayments and erroneous payments are identified through reports, medical review, grievance and appeal decisions, internal audit review, and provider initiated recoupment. Upon completion of the recoupment, CPSA will send notification explaining the action on your FTP reports, date of the action, recipient, DOS, date of original remittance advice, and reason for the recoupment. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 12

14 If payment is recouped for a reason other than third party recovery (e.g., no medical documentation to substantiate services rendered), the provider will be afforded additional time to provide justification for repayment. Large dollar recoupment or adjustment to prior years may need approval by ADHS or AHCCCS see AHCCCS Contractors Operation Manual - ACOM 412 standard. Billing Limitations For billing limitations, please see the Covered Behavioral Health Services Guide, and the Procedure and Transportation Codes Billing Limitations Matrix. These guides provide a list of procedures/codes that cannot be billed the same day as other codes. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 13

15 THIRD PARTY LIABILITY Third party liability refers to situations where an enrolled member may also have coverage through another health insurance plan/program or third party 7. The third party may be liable or responsible for covering some or all of the behavioral health services a member receives, as well as medications. Additional information and references regarding Third Party Liability may be found in 3.5 Third Party Liability and Coordination of Benefits document. Service Providers are responsible for determining and verifying if a person has a third party before using state appropriated funds. Providers must cost avoid all claims or services that are subject to third party payments and may deny a service to a member if the third party will cover the services. CPSA may deny payment to a provider if they are aware of TPL and submits a bill to CPSA. In emergencies, the provider should coordinate payment with the third party when behavioral health providers render service. Postpayment recovery is necessary in cases where provider(s) were unaware of a third party when services were rendered, or unable to cost avoid. Providers must inquire about a member s other health insurance coverage during the initial appointment or intake process. When Providers attempt to verify a member s Title 19/21 eligibility, information regarding the existence of any third party coverage is provided through the automated systems described in 3.1, Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage and the Limited Income Subsidy Program. If the member is not eligible, there will be no information to verify the existence of a third party. It is the provider s responsibility to determine if there is third party coverage during the screening and application process. Providers must contact the third party directly to determine what coverage is available to the person, as third parties may cover all or a portion of behavioral health services. At times, T/RBHAs may incur the cost of co-payments or deductibles for a Title 19/21 eligible person, or a person that has a Serious Mental Illness (SMI), while the cost of the covered services is reimbursed through the third party payer. Title 19/21 funds cannot be used to pay for cost sharing of Medicare Part D. When it has been determined that there is third party coverage, a Provider must submit proper documentation to illustrate the third party has been delegated responsibility for the covered services 8. The following guidelines must be adhered to by Providers regarding a third party: ADHS/DBHS and the T/RBHA must be the payers of last resort for Title 19/21 covered services. Payment by another state agency is not considered third party and, in this circumstance, ADHS/DBHS and the T/RBHA are not the last resort. Benefits must be coordinated so that costs for services funded by ADHS/DBHS or the T/RBHA are cost avoided or recovered from a third party payer. Providers must bill claims for any covered services to any third party payer when information on that third party payer is available. Documentation that such billing has occurred must accompany the claim when submitted for payment. Such documentation includes a copy of the Remittance Advice or Explanation of Benefits from the third party payer. If a third party payer does not cover the service, or denies a service, the provider may submit directly to CPSA for reimbursement. Covered Behavioral Health Services for which Medicare indicates are non-covered codes should be submitted to CPSA for reimbursement. AHCCCS compiles a list of procedures that are not reimbursable by Medicare; these codes are not subject to COB edits. CPSA receives these codes from AHCCCS and are published to the CPSA Common folder via FTP. 7 Third parties include, but are not limited to, private health insurance, Medicare, employment related health insurance, medical support from non-custodial parents, court judgments or settlements from a liability insurer, State worker s compensation, first party probate-estate recoveries, long term care insurance and other Federal programs. 8 For specific billing instructions, see the ADHS/DBHS Program Support Procedures Manual and AHCCCS Provider Billing Manual. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 14

16 All Commercial and MCR Advantage plans should be verified and encountered to CPSA with the applicable TPL values, including non-coverage, or denied reported loops. Each carrier will need to be set up based on their benefit structure. Providers submitting electronic 837 claims/encounters with TPL transaction to CPSA shall maintain the appropriate audit trail to support the coordination of benefits data being reported on those claims/encounters. The only exceptions to this are: When a response from the third party payer has not been received within the timeframe established by the T/RBHA for claims submission or, in the absence of a subcontract, within 120 days of submission; When it is determined that the person had relevant third party coverage after services were rendered or reimbursed; or When a behavioral health recipient eligible for both Medicaid and Medicare (dual eligible) receives services in a Level I Sub-acute facility that is not Medicare certified. Non-Medicare certified facilities should only be utilized for dual-eligibles when a Medicare certified facility is not available. In an emergency situation, the provider must first provide any medically necessary behavioral health covered services and then coordinate payment with any third parties. Providers must cost avoid all claims or services that are subject to third party payment and may deny a service to a member, except for members determined to have a Serious Mental Illness, if providers know that the third party payer is financially responsible for providing the service. If the provider knows that the third party payer will not pay for or provide a medically necessary covered service then the provider must not deny the service nor require a written denial letter. If the provider does not know whether a particular medically necessary covered service is covered by the third party payer, the provider must contact the third party payer rather than requiring the person receiving services to do so. Providers must refer to the formulary of the behavioral health recipients Medicare Part D plan to determine if a specific drug will be covered under Medicare Part D. The Medicare Part D plan formularies are available at If it is determined that a person has third party liability after services were rendered or reimbursed, provider s must identify all potentially liable third party payers and pursue reimbursement from them. In instances of post-payment recovery, the Provider must submit an adjustment to the original claim, including a reference of the original claim number(s) on which payment was received. The CSP/provider must report any cases involving the above circumstances to the T/RBHA. Providers may be asked to cooperate with CPSA, ADHS/DBHS and/or AHCCCS in third party collection efforts. Co-Payments, Premiums, Co-insurance, and Deductibles If a third party insurer requires a person to pay a co-payment, co-insurance or deductibles, the T/RBHA is responsible for covering those costs for the Title 19/21 eligible persons (See PM Attachment 3.5.1, Third Partly Liability and Coordination of Benefits, Title XIX/XXI Eligible Persons; subsections G and H for specific cost sharing responsibilities for behavioral health recipients with Medicare Part A, B and D). The ADHS/DBHS co-payment assessed for non-title XIX/XXI persons determined SMI is intended to be payment by the member for services covered in the medication only benefit (e.g., psychiatric assessments, medication management, medications), but co-payments are only collected at the time of the psychiatric assessment and psychiatric follow up appointments. Non-Title XIX/XXI persons determined to have a Serious Mental Illness may be assessed the ADHS/DBHS co-payment in accordance with PM Section 3.4, Co-payments, or may be assessed co-payments, premiums, coinsurance and/or deductibles for services covered by the third party insurer.. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 15

17 When a Non-Title XIX/XXI person determined to have SMI is assessed the ADHS/DBHS co-payment, he/she will pay the ADHS/DBHS co-payment or the co-payment required by the third party insurer, whichever is less (see PM Attachment 3.5.2, Third Party Liability and Coordination of Benefits for NTXIX/XXI-eligible Persons Determined to Have a Serious Mental Illness). Additionally, when a Non-Title XIX/XXI person determined to have SMI is assessed a co-payment for a generic medication that is also on the ADHS/DBHS Non-Title XIX/XXI Formulary, he/she will pay the ADHS/DBHS co-payment or the copayment required by the third party insurer, whichever is less. T/RBHAs are responsible for covering the difference between the ADHS/DBHS co-payment and the third party co-payment when the third party copayment is greater than the ADHS/DBHS co-payment. Behavioral health recipients are responsible for third party co-payments for services that are not services that ADHS/DBHS covers (see ADHS/DBHS Guidelines for Services to Non-title XIX Members with Serious Mental Illness) and third party premiums, coinsurance and deductibles, if applicable. When Non-Title XIX/XXI persons determined to have SMI have difficulty paying co-payments, the provider must re-screen the individual for Title XIX/XXI eligibility. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 16

18 TITLE 36 COVERAGE GRID TITLE 36 TITLE 19 Days 1-4 (COE) Covered by Pima County After TPL Not Covered by ADHS/DBHS Funding Days 5-8 (COD (PEP); Post Evaluation Period) Covered by Pima County if the member is NT19 and no other payer source. Covered at the block purchase rate. COT/COW Not Covered by Pima County Member s other insurance (Medicare or commercial, if covered) must be the primary payer. All segments are subject to authorization before payment. Definitions: COE: Court Ordered Evaluation COD (PEP): Court Ordered Detention COT: Court Ordered Treatment (Voluntary) COW: Court Ordered Waiting Continue to the next section to read more on Pima County Title 36. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 17

19 PIMA COUNTY TITLE 36 Arizona state law permits any responsible person to submit an application for pre-petition screening when another person may have a mental illness and be a: Danger to Self (DTS); or Danger to Others (DTO) This screening includes an examination of the person s mental health status and other circumstances. If the screening process determines the person is either of the aforementioned status, an application for court ordered evaluation must be submitted. Based on the immediate safety of the person in question or others, emergency admission may be necessary. Otherwise, the evaluation will be arranged by a designated evaluating facility within the timeframes specified by state law. Upon completion of the evaluation, the facility may petition for further treatment if determined to be DTS/DTO. The court ordered treatment may include a combination of inpatient and outpatient treatment. At every stage of pre-petition, COE and COD, the patient will be provided an opportunity to change their status to voluntary. While under voluntary status, the patient is no longer considered to be DTS/DTO and agrees in writing to receive a voluntary evaluation. CPSA is responsible for the pre-petition screening services in Pima County under the terms of an intergovernmental agreement between AHS and Pima County. In turn, CPSA subcontracts that responsibility to SAMHC. The SAMHC Medical Director serves as the CPSA Medical Director s designee in performing the responsibility outlined below: Provide pre-petition screening within forty-eight hours excluding weekends and holidays; Prepare a report of opinions and conclusions. If pre-petition screening was not possible, the screening agency must report reasons why the screening was not possible, including opinions and conclusions of staff members who attempted to conduct the pre-petition screening; Have the medical director or designee of the CPSA review the report if it indicates that there is no reasonable cause to believe the allegations of the applicant for the court-ordered evaluation; Prepare a petition for court-ordered evaluation and file the petition if CPSA determines that the person, due to a mental disorder, including a primary diagnosis of dementia and other cognitive disorders, is DTS/DTO; If it is determined that there is reasonable cause to believe that the person, without immediate hospitalization, is likely to harm himself/herself or others, all reasonable steps to procure hospitalization on an emergency basis must be followed; Contact the county attorney prior to filing a petition if it alleges that a person is DTO. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 18

20 The intent of the contract between CPSA and Pima County is to reduce the number of unnecessary petitions presented to the court by continuously assessing whether the needs of the patient can be better met in a less restrictive community based environment. As such, Providers who are providing inpatient COE services must: 1. Have provided aggressive crisis services and identified and determined other less restrictive services will not meet the needs of the person prior to admitting the patient on an involuntary basis to a Level 1 acute psychiatric inpatient unit. 2. Obtain a completed PM Form , Court Ordered Evaluation Certification of Necessity for Admission, from CPSA s designated Diversion Liaison for each involuntary inpatient admission certifying that no other patient disposition or site of service was clinically appropriate and available and the patient continues to require involuntary commitment. 3. Document a psychiatrist or psychiatric and mental health nurse practitioner sees and assesses patients on a daily basis, including weekends and holidays, to determine whether patients continue to require involuntary commitment; 4. Ensure the psychiatric staff engage in treatment methods that appropriately seek opportunities to discontinue the use of the involuntary evaluation and treatment and refer individuals to appropriate and available follow-up care upon discharge; 5. Ensure psychiatric staff makes disposition decisions on a daily basis, including weekends and holidays; 6. Ensure psychiatric and other staff collaborates with CPSA s Court Ordered Evaluation Coordinator to facilitate coordination with Providers to discontinue the use of the involuntary evaluation and treatment process when appropriate; 7. Review and process all evaluation paperwork to ensure complete and accurate filing in the timelines specified by the Pima County Attorney's Office (PCAO). Provide staffing sufficient to comply with PCAO and Court deadlines and ensure patient and hospital staff are available for court appearances at the date, time and location ordered by the Court schedules; 8. Coordinate benefits as required in Section 3.5, Third Party Liability and Coordination of Benefits (with special emphasis on sub-section C, Billing Requirements). Additionally, Provider must exhaust all appeals of claims denied by payers and ensure the patient is not on an existing Court Order for Treatment, is a Pima County or out-of-state resident and is at least 18 years of age, prior to being reimbursed; and 8. Submit all claims for COE and COD in accordance with Section 6.2, Submitting Claims and Encounters to the RBHA. CPSA provides oversight in the evaluating hospitals as well as performs concurrent and retrospective utilization reviews. CPSA denies claims if Provider does not adhere to the requirements set out above and for any of the following reasons: 1. Claims submitted for medical services for patient; 2. Provider bills for services to patients after their status has changed to voluntary; 3. Failure to assure medical staff and management personnel attend initial and ongoing educational programs related to the Title 36 requirements as offered by Pima County or CPSA; 4. Failure to timely complete and file with the Court two (2) psychiatric evaluations; 5. Failure to provide accurate and timely Certification of Necessity for Admission that has been approved by CPSA or its delegated agency; 6. Dismissal of petition due to psychiatrist performing evaluations after the statutory timelines, including payments for evaluation and inpatient day(s) associated with the hospitalization; Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 19

21 7. Dismissal of a Petition for Court Ordered Treatment due to physician unavailability at the date, time and place of hearing; 8. Failure to file complete petitions with the PCAO within the timeframes set forth by PCAO; 9. Failure to file signed, legible evaluation paperwork that provides detail and specificity to meet statutory requirements; and/or 10. A lack of psychiatric staff documentation, on a daily basis, including on weekends and holidays that the individual continues to require involuntary commitment. To summarize the Court Ordered Evaluation/Court Ordered Detention/Court Ordered Waiting period: Transportation is covered from the ED (emergency department/room) to evaluation admittance only. The member is taken to an evaluating hospital for evaluation under application based on concerns that the member in question may be a danger to themselves or others. The member is evaluated by an Emergency Room Physician/Psychiatrist to determine if a petition needs to be started. If petition is approved, the patient is admitted up to four (4) days in an evaluating hospital. Two psych evaluations (coded 90801) are performed by an MD. The outcomes of the review can be: o Send to court if it is determined the member needs COE. o Discharge if it is determined that COE is not required. o Member consents to voluntary treatment. At which point services are covered by Title 19 (if eligible) and in accordance with any prior authorizations. Four day COD when approved by CPSA/UR. COE and COD services must be carried out within the timeframe of eight days. Upon completion of these services, the member is placed under COW, which is a period of time the member stays admitted at the facility waiting for a hearing at the court to evaluate the treatment and determine if further action is needed, or if the member is free to go. Along with COD, the waiting period of services are covered under Title 19 funding. Financial responsibility for T36 services are made as follows: Up to four days for Court Ordered Evaluation o Pima County T36 contract primary payer (after COB from Medicare/Commercial carriers). Days 5-8 (Detention/Mitigation Period) o If member is AHCCCS eligible, AHCCCS is the primary payer (after COB). o If member is not AHCCCS eligible and has no other insurance, T36 is the payer. o If member is Non-Title, Pima County T36 is the payer. o If the member is not AHCCCS eligible and has other insurance, no payment will be made by CPSA under Title 36 funds. Insurance deductibles and any patient liability are covered by CPSA. There is no financial responsibility under Pima County T36 contract for services provided beyond the 8 day limit. If COE is required, the members are transported to an evaluating hospital, which are covered to up four days in the hospital from date of determination, five if authorized. For these dates of service, the claim in the HT system adjudicates funding from Title 36 reimbursement. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 20

22 If the member is determined to display behaviors based on a mental illness, the member may be detained for COD for involuntary treatment. The petition is for a court signed authorization to hold the patient to keep them safe and to stabilize. As stated in legislature: That the patient is in need of a period of treatment because the patient, as a result of mental disorder, is a danger to self or to others, is persistently or acutely disabled or is gravely disabled; The treatment alternatives which are appropriate or available; That the patient is unwilling to accept or incapable of accepting treatment voluntarily. Regardless of how the member is admitted, these services are subject to reimbursement under Title 19 funds for AHCCCS eligible members assigned to CPSA; RBHA GSA5. Along with detention services, a COW period may also be billed and paid for. Title 36 Billing Requirements During the initial in-take process, service providers are responsible for discovering if the member has any other insurance coverage. Upon determining this, the service provider must submit proper documentation to demonstrate that the third party has been assigned responsibility for the covered services provided to the member. The following guidelines must be adhered to by service providers regarding third party payers: CPSA must be the payers of last resort for covered services. Payment by another state agency is not considered third party and, in this circumstance, AHCCCS and CPSA are not the payer of last resort. Benefits must be coordinated so that costs for services funded by CPSA are cost avoided or recovered from a third party payer. Providers must bill claims for any covered services to any third party payer when information on that third party payer is available. Documentation that such billing has occurred must accompany the claim when submitted for payment. Such documentation includes a copy of the Remittance Advise or Explanation of Benefits from the third party payer. Providers submitting electronic 837 claims or encounters with TPL transactions to CPSA shall maintain the appropriate audit trail to support the coordination of benefits data being reported on said claims and encounters. The only exceptions to this billing requirement are: When a response from the third party payer has not been received within the timeframe established by CPSA for claims submission, or, in the absence of a subcontract, within 120 days of submission; When it is determined that the person had relevant third party coverage after services were rendered or reimbursed; or When a behavioral health recipient eligible for both Medicaid and Medicare (dual eligible) receives services in a Level I sub-acute facility that is not Medicare certified. Non-Medicare certified facilities should only be utilized for dual eligible members when a Medicare certified facility is not available. In an emergency situation, the provider must first supply any medically necessary behavioral health covered services and then coordinate payment with any potential third party payers. Providers must cost avoid all claims or services that are subject to third party payment and may deny a service to a person, except for persons determined to have a Serious Mental Illness, if providers know that the third party payer is financially responsible for provider the service. If the provider knows that the Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 21

23 third party will not pay for or provider a medically necessary covered service, then the provider must neither deny the service nor require a written denial letter. If the provider does not know whether a particular medically necessary covered service is covered by the third party, the provider must contact the third party rather than requiring the person receiving services to do so. Providers must refer to the formulary of the behavioral health recipients Medicare Part D plan to determine if a specific drug will be covered under Medicare Part D. The Medicare Part D plan formularies are available at Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 22

24 DATA VALIDATION & CLAIM AUDITS Periodically, CPSA, its independent auditors, and/or its funders will audit provider claims and supporting documentation according to ADHS/CPSA Provider Manual, Section 8.1 Encounter Validation Studies. An audit may be performed off- or on-site at the provider s office. It is expected that all pieces of information on a claim can be substantiated in the member case file according to requirements established in contract (and other records) or that the claim for that service has been adjusted. If claims are found to be in error, the provider is required to correct or recoup, at a minimum, those claims identified. If a pattern of errors is suspected, the provider may be required to research and correct any claims showing the same type of error. Data Validation audits cover, but are not limited to: Third Party Liability (TPL) payment amounts and carrier information Co-pay amounts Member enrollment Total services rendered Denied claims have been worked and resubmitted successfully Encounter submission timeliness, correctness, and mission requirements Compliance with the Covered Behavioral Health Services Guide, applicable requirements in licensure rules, contract requirements, and the ADHS/DBHS/CPSA Provider Manual. Errors identified through the data validation audit process are to be corrected (adjusted and re-billed) using the procedures outlined in this manual, with the additional requirement that these adjustments and re-bills sent to CPSA must be identified as data validation errors. Identification of the reason for adjustment (data validation error) is necessary for timely and correct processing of these adjustments. If the provider sends an electronic file with requested adjustment or rebill data to CPSA, this file must only contain data validation error adjustments. Do not mix other adjustment or re-bill requests with data validation error adjustments. FINANCIAL Please refer to the CPSA Provider Financial Guide. Community Partnership of Southern Arizona Basic Billing Procedures & Guidelines Page 23