Community Health Partnership

Transcription

1 Community Health Partnership Account Administrator and Biller Education May 2012

2 Agenda I. Welcome and Introductions II. Account Administrator Overview III. Account Administrator Workflows IV. Claims Overview V. Claims Workflows VI. Resources and Contact Information 2

3 Community Health Partnership I. Welcome and Introductions 3

4 Beacon CBHM Team Darren Xanthos, LCSW, Senior Director, Community Care Management Phone: Alice Kuchinskas, MFT, VP of Network Innovation & Management Phone: Kristen Slater, LCSW, Clinical Manager Phone: Kelly Coleman, Senior Network Coordinator Phone:

5 Community Health Partnership II. Account Administrator Overview 5

6 Role of Account Administrator Controls all eservice user accounts within his/her organization. Responsible for activating new users within the group. Determines which features are available to each user in eservices. Responsible for terminating accounts when staff leaves the group. Accepts and assigns cases. 6

7 Community Health Partnership III. Account Administrator Workflows 7

8 Activating new eservice Users Account Administrator receives an indicating that a new user has registered. Account Administrator logs into eservices to activate account for new user. 8

9 eservice Permission Levels To ensure protection of member confidentiality as required by HIPAA, set each user s permission level in accordance with their legitimate need to know for Treatment, Payment and/or health care Operations (TPO). Levels include: Account Administrator Community Care Supervisor Community Care Manager If user has administrative functions such as verifying eligibility or submitting claims only, assign roles specific to their responsibilities. 9

10 Account Administrator First registered eservice user for group Automatically registered with permission to use all eservices features Account Administrator role can be reassigned at any time by ing 10

11 Community Care Supervisor Must select supervisor and manager roles in order to function properly Role includes: Accept cases Assign cases Access to all case information Enrollment Assessment Care Plan Reassessment 11

12 Community Care Manager Select manager role Role includes: Access to only their assigned cases Enrollment Assessment Reassessment Care Plan 12

13 Assigning Permission Levels 13

14 Deactivating a User To protect member confidentiality, it is important to Lock the accounts of users who are no longer affiliated with the group. 14

15 Available Cases Queue Occasionally cases will be placed in the eservice s Available Case queue to self-select members based on geography, availability, and language capacity. 15

16 Accepted Cases Direct referrals based on the following trigger events will be placed into Accepted Cases on a daily basis: Recent ER and/or Inpatient visit Referral from Anthem case management Member self-referral in response to letter 16

17 Assigning Cases The Accepted Cases tab will generate a list of all cases assigned to the group. Members in eservices will have an asterisk next to their first name to indicate a trigger event such as a recent ER, inpatient stay, or a direct Case Management referral from Anthem. Reason for the asterisk can be located in the Enrollment notes. High priority cases should be assigned first to ensure they are engaged in a timely manner. Cases can be assigned to multiple users at the same time. 17

18 Assigning Cases (cont.) 18

19 Assigning Cases (cont.) 19

20 Assigned Cases (cont.) 20

21 Community Health Partnership IV. Claims Overview 21

22 Claims Overview Claims submission via Beacon s eservices. Claims for services submitted more than 90 days from the date of service will not be paid. A Behavioral Health diagnosis must be entered as the primary diagnosis in order for claims to process. Use modifiers for repeat procedures same day services. Search for members by using their date of birth and first or last name to ensure all accounts associated with the member appear. 22

23 eservices Claims Benefits No manual claims data entry errors and faster turnaround Fewer fields than paper claim forms Quick resubmission of denied claims Claim status available within 2 hours No postage Immediate confirmation of receipt 23

24 Allowable Units Tier I Narrative Time CPT Units Cap Umbrella Code Assessment FTF N/A Initial Eval Assessment Tel N/A Re-Assessment FTF N/A Re-Eval Re-Assessment Tel N/A Tier II Narrative Time CPT Units Cap Umbrella Code Assessment FTF N/A Initial Eval Assessment Tel N/A Re-Assessment FTF N/A Re-Eval Re-Assessment Tel N/A Member Care Management FTF 15 min per 6 mo (1 unit=15 min.) Member Care Management Tel 15 min CareMgmt Care Management - collateral, resource 15 min Tier III Narrative Time CPT Units Cap Umbrella Code Assessment FTF N/A Initial Eval Assessment Tel N/A Re-Assessment FTF N/A Re-Eval Re-Assessment Tel N/A Member Care Management FTF 15 min per 6 mo (1 unit=15 min.) Member Care Management Tel 15 min CareMgmt Care Management - collateral, resource 15 min

25 Allowable Unit Restrictions Face-to-Face Follow-up 16 unit cap per day Telephonic Follow-up 8 unit cap per day Care Management Collateral, Resource 8 unit cap per day 25

26 Approved Modifiers To avoid denials on repeat procedures with the same date of service, use the following modifiers: 76 Repeat procedure by same provider 77 Repeat procedure by another provider The modifiers will allow up to 3 claims per day for the same member-procedure (one claim per each procedure-modifier combination, no modifier being one of them). 26

27 Claim Tips A Behavioral Health diagnosis must be entered as the first diagnosis in order for claims to process. The following Behavioral Health ICD-9 codes include a non-exhaustive list of billable codes: Code Description Mood disorder in conditions classified elsewhere Anxiety disorder in conditions classified elsewhere Other transient mental disorders due to conditions classified elsewhere Unspecified transient mental disorder in other conditions 300 Anxiety state unspecified Other anxiety states Unspecified adjustment reaction 311 Depressive disorder other Other unknown/unspecified morbidity * Please note that this list is not to be used as a substitution to your clinical diagnosis, but as an additional reference. 27

28 Community Health Partnership V. Claims Workflows 28

29 Submitting a Claim Search for member by date of birth and first or last name. Ensures all active and inactive accounts associated with member populate. 29

30 Submitting a Claim (cont.) Select the appropriate record to avoid denial when submitting claim. 30

31 Submitting a Claim (cont.) Select Outpatient/Professional (CMS 1500) from drop down list and click Submit. 31

32 Submitting a Claim (cont.) Enter required fields: Dx Code 1 (Behavioral Health) Service Site (Provider location) Billing NPI (Group s NPI) Clinician (Rendering clinician) Date of Service POS Mod 1 (only if repeat a repeat procedure) Units Procedure Charges (manually calculate) 32

33 Claims Status Option to check claims status by either member or provider (group). 33

34 Claims Status (cont.) Search can be filtered by the month and year of the service or just by year. View detailed payment information by clicking on More. If claim was denied, click Resubmit. 34

35 Claim Resubmissions Make the necessary corrections and resubmit for processing. 35

36 Community Health Partnership VI. Resources and Contact Information 36

37 Resources The following resources are available on the CHIPA website, or by contacting our toll-free number, : Community Health Partnership Provider Manual eservices Manual Program forms and tools Provider bulletins And many more Log on to click on Providers, CCM Program, and Resources. 37

38 Contact Information Toll-Free Phone: (855) Secure Fax: (866) General 63