Billing Clinic SHP_

Transcription

1 Billing Clinic SHP_

2 Introductions & Agenda Verifying Eligibility Authorization Process Establishing Medical Necessity (after an adverse determination) Submitting Clean Claims Billing Tips and Reminders Electronic Funds Transfer Superior HealthPlan (Contacts, Website and Secure Portal) FQHC/RHC Billing Information

3 Verifying Eligibility Correctly identifying a Member s Medicaid Plan

4 Verify Eligibility Texas Medicaid Benefit Card (TMBC) TexMedConnect - Superior HealthPlan Identification Card Superior HealthPlan Website: Contact Member Services: STAR, CHIP: CHIP RSA: STAR Health: STAR+PLUS: MRSA (Medicaid Rural Service Area): Verify eligibility the 1 st of each month using our website or by contacting Member Services

5 Member ID Cards: STAR /MRSA STAR STAR MRSA (Rural Service Area)

6 Member ID Cards: STAR+PLUS STAR+PLUS STAR+PLUS Dallas

7 Member ID Cards: STAR HEALTH

8 Member ID Cards: CHIP/ PERINATE CHIP CHIP Perinatal CHIP Perinate Newborn

9 Member ID Cards: CHIP RSA CHIP RSA CHIP RSA Perinatal CHIP RSA Perinate Newborn

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11 Authorization Process Ensuring proper authorizations are in place

12 Medical Management Authorizations Prescheduled elective admissions must have authorization prior to admission Note: Emergent inpatient admissions to any level of acute or sub acute care, skilled nursing facilities, rehabilitation admission, and all other inpatient facility type require notification by the close of the next business day All out of network services require an authorization Please initiate authorizations 5 working days in advance for non-emergency services Please escalate your requests to the Medical Management Supervisors or Managers if needed If additional documentation is requested from Medical Management you may submit via fax or through the SHP Website. If additional information is required, you must submit in a timely fashion or Medical Management will not be able to establish Medical Necessity per NCQA Guidelines Or Call: Fax:

13 Services Requiring Prior Authorization The most current list of services requiring authorization is found on our website under Provider Resources:

14 Prior Authorization Form Interactive form is located on-line (Provider Resources ---Forms)

15 High Tech Imaging: NIA National Imaging Associates (NIA) is contracted with Superior to perform utilization review for High Tech imaging services CT/CTA MRI/MRA PET Scan CCTA Nuclear Cardiology/MPI Stress Echo Echocardiography* (STAR+PLUS, Advantage & Ambetter) Inpatient and ER procedures will not require authorization All claims should be submitted to SHP through the normal processes, electronic submission or paper claim submission

16 High Tech Imaging: NIA The servicing provider (PCP or Specialist) will be responsible for obtaining authorization for the procedures. Servicing providers may request authorization and check status of an authorization by: Accessing Utilizing the toll free number Providers can contact Kevin Apgar, Provider Relations Manager at

17 Establishing Medical Necessity After an adverse determination

18 Medical Management Denials Adverse determination (denial ) - a reduction, suspension, denial or termination of any service based on medical necessity or benefit limitations Type of Denial Administrative Denials (non-clinical reasons) Medical Necessity Administrative: Member ineligibility; and/or Member has exceeded annual benefit limit as specified in the member s Schedule of Benefits as defined by the State; and/or, requested service specifically excluded from the benefits package as stated in the Certificate of Coverage as defined by the State (Non-covered Benefit). No prior authorization Late Notification Medical Necessity: Medical Director or appropriate practitioner reviewer may make an adverse determination (organization determination) to deny, terminate, or reduce services when insufficient clinical information is received to determine medical necessity for requested service(s)

19 Appealing Medical Management Denials Peer to Peer Review When medical necessity cannot be established, a peer to peer review is offered. A peer to peer discussion is available to the ordering physician, nurse practitioner, physician assistant during the prior authorization, denial or appeal process with regard to Medical Necessity Communication of Denials Denial letters will be sent to Member, Requesting Provider and Servicing Provider to include: The clinical basis for the denial (will be indicated) Member appeal rights fully explained OR Provider may request an appeal on behalf of Member, if authorized to do so Medical Necessity Appeal Address: Attn: Appeal Coordinator 2100 S. IH-35, Suite 200 Austin, TX Phone: Fax: TTY:

20 Appealing Medical Management Denials Authorized representatives of members acting on their behalf, may appeal adverse determinations regarding their care and service (designation of a member s authorized representative must be submitted in writing). Types of Medical Necessity Appeals: Level 1: Internal/standard appeal (appeal to Superior HealthPlan) Level 2: External appeal (appealing to a third party) CHIP IRO (independent review organization) STAR/STAR+/STAR Health FH (fair hearing HHSC) Claims medical necessity appeals only (Note: Administrative denials only have Complaint Rights) Appeals must be submitted to SHP within 120 days from the date of the last denial

21 Appeal Timeframe by Product Medicaid (STAR & STAR+PLUS, STAR Health) Provider or Member has 30 calendar days from the date of the notification of adverse determination (date of denial letter) to file an appeal 90 calendar days from the date of notification of adverse determination to file a Fair Hearing (Non-covered Benefit denial also has Fair Hearing rights) Do have Compliant rights Superior HealthPlan will review and respond to the appeal within 30 calendar days

22 Appeal Timeframe by Product CHIP/CHIP RSA Provider or Member has 90 calendar days from the date of the notification of adverse determination to file an appeal Do have IRO rights Do not have Fair Hearing rights Do have complaint rights Appeal completed within 30 calendar days

23 Expedited Appeals Expedited Appeals IP expedited are processed within 1 working day of appeal request All other expedited appeals are completed within 3 days Expedited Appeals Criteria Will it cause severe pain if not processed within 30 day time frame Is it life/limb threatening if not process within 30 days time frame Reviewed by Medical Director

24 Provider Complaints Superior requires complaints be submitted in: Writing: Superior HealthPlan 2100 South IH-35, Suite 202 Austin, Texas ATTN: Complaint Department Fax: Superior s website address for the online complaint submission feature is: The website also contains a complaint form that can be printed, completed and faxed or mailed to Superior for resolution response. Link at: Download.pdf

25 Claims Submitting Clean Claims

26 Clean Claims Clean claims will be paid within thirty (30) days Each claim payment check will be accompanied by an Explanation of Payment, which itemizes your charges for that reimbursement and the amount of your check from Superior. For electronic pharmacy claim submissions, claims will be paid in eighteen (18) days Once a clean claim is received, Superior will either pay the total amount of the claim or part of the claim in accordance with the contract, or deny the entire claim or part of the claim, and notify the Provider why the claim will not be paid within the 30-day claim payment period Payment is considered to have been paid on the date of issue of a check for payment and its corresponding EOB to the Provider by the MCO, or the date of electronic transmission, if payment is made electronically STAR, STAR+PLUS, and STAR Health Institutional Claims must contain Present on Admission (POA) indicators, and Superior will utilize the POA information submitted on claims to reduce and/or deny payment for Provider Preventable Conditions. For per diem hospital payments, Superior utilizes a methodology for reduction and/or denial of payment for services related to a Provider Preventable Condition that was not POA

27 Claims Filing: Initial Submission Claims must be filed within 95 days from the Date of Service (DOS) Filed on CMS 1500 or UB04 Filed electronically through clearinghouse Filed directly through website Filed on paper claim 1 ST time paper claims, mailed to: Superior HealthPlan P.O. Box 3003 Farmington, MO Claims must be completed in accordance with Medicaid billing guidelines All member and provider information completed Providers should include a copy of the Explanation of Payment (EOP) when other insurance is involved

28 Electronic Claims Filing If provider uses EDI software but is not setup with a clearinghouse, they must bill SHP via paper claims or through our website until the provider has established a relationship with a clearinghouse listed on our website To send claim adjustments via EDI, the CLM05-3 "Claim Frequency Type Code" must be "7" and in the 2300 loop a REF *F8* must be sent with the original claim number (or the claim will reject). Claims can also be submitted through the Superior HealthPlan website Claims submitted through our website are considered Electronic Claims We will cover more on our Secure Web Portal at the end of this training FILE ONLINE AT

29 EDI: Payor ID by Product Superior HealthPlan Product MEDICAL CLAIMS BEHAVIORAL CLAIMS ADVANTAGE by Superior HealthPlan AMBETTER from Superior HealthPlan Superior STAR Superior STAR HEALTH Superior STAR+PLUS Superior CHIP

30 EDI: Current Trading Partners List Allscripts/ Payerpath Availity Capario Claim Remedi Trading Partners IGI MD On-Line Physicians CC Practice Insight Contact EDI Telephone: (800) , ext Claimsource CPSI DeKalb Emdeon First Health Care GHNonline Relay/ McKesson Smarta Data SSI Trizetto Provider Solutions, LLC. Viatrack

31 Paper Claims Filing To assist our mail center in improving the speed and accuracy to complete scanning please take the following steps: Remove all staples from pages Do not fold the forms Claim must be typed using a 12pt font or larger and submitted on original CMS 1500 or UB04 red form (not a copy). Handwritten Claim forms are no longer accepted When information is submitted on a red form, our Optical Character Recognition ORC scanner can put the information directly into our system. This speeds up the process and eliminates potential sources for errors and helps us to process your claims faster

32 Billing Tips & Reminders Submitting Claims Corrections, Addressing Denials & Rejections

33 Billing Tips & Reminders Superior HealthPlan s Provider Manual provides guidelines on how to submit clean claims and highlights the requirements for completing UB04 or CMS 1500 Forms Some items to remember! National Provider Identifier (NPI) of a Referring or Ordering Physician on a claim Appropriate 2 digit location code must be listed Appropriate Modifiers must be billed when applicable Taxonomy codes are required on encounter submissions effective 12/13/2013 for the Referring or Ordering Physician ZZ qualifier for HCFA or B3 qualifier for UB04 to indicate taxonomy

34 Claims - CMS 1500 Referring Provider: [C] 17 Name of the referring Provider and 17b NPI Rendering Provider: [R] Place your NPI in box 24J (Unshaded) and Taxonomy Code in box 24J (shaded). These are required fields when billing Superior claims. If you do not have an NPI, place your API (atypical provider number/ltss #) in Box 33b Billing Provider: [R] Billing NPI# in box 33a and Billing Taxonomy # (or API # if no NPI) in 33b 34

35 Sterilization Form Providers must complete all sections of the Sterilization Consent Form as applicable. All of the fields must be completed legibly in order for the consent form to be valid. Any illegible field will result in a denial of the submitted consent form. Providers must resubmit denied consent forms with all required fields on the consent form itself completed legibly; resubmission with information indicated on a cover page or letter will not be accepted

36 Corrected Claim Form A corrected claim is a correction or a change of information to a previously finalized clean claim in which additional information from the Provider is required to perform the adjustment. Corrections can be made, but are not limited to: Patient Control Number (PCN) Date of Birth (DOB) Date of Onset X-Ray Date Place of Service (POS) Present on Admission (POA) Quality Billed Prior Authorization Number (PAN) Beginning Date of Service (DOS) Ending Date of Service or Discharge Date

37 Corrected Claims Filing Must reference original claim # on EOP Must be submitted within 120 days of adjudication paid date Resubmission of claims is now a function of EDI. You must provide the following information to your billing company: To send claim adjustments via EDI, the CLM05-3 must be 7 and in the 2300 loop a REF *F8* must be sent with the original claim number (or the claim will reject) OR Submit claim adjustments through the secure SHP web portal! At this time, batch adjustments are not an option via the SHP secure portal. Corrected or Adjusted paper claims can also be submitted to: Superior HealthPlan Attn: Claims PO Box 3003 Farmington, MO

38 Claims Appeal Form A claims appeal is a request for reconsideration of a claim for anything other than medical necessity and/or any request that would require review of medical records to make a determination.

39 Claim Adjustments, Reconsiderations & Disputes All claim adjustments (corrected claims), or requests for reconsideration, or disputes must be received within 120 days from the date of notification or denial Adjusted or Corrected Claim The Provider is CHANGING the original claim. Correction to a prior- finalized claim that was in need of correction as a result of a denied or paid claim Claim Appeals Often require additional information from the Provider Request for Reconsideration: Provider disagrees with the original claim outcome (payment amount, denial reason, etc.) Claim Dispute: Provider disagrees with the outcome of the Request for Reconsideration Visit for easy to fill Corrected Claim or Claim Appeal Forms!

40 Appealing Denied Claims Submit appeal within 120 days from the date of adjudication or denial Attach & complete the claim appeal form from the website Include sufficient documentation to support appeal Include copy of UB04 or CMS1500 (corrected or original) or EOP copy with claim # identified Claims appeals must be in writing and submitted to: Superior Health Plan Attn: Claims Appeals P.O. Box 3000 Farmington, MO

41 Appeals Documentation Examples of supporting documentation may include but are not limited to: A copy of the SHP EOP (required) A letter from the provider stating why they feel the claim payment is incorrect required A copy of the original claim An EOP from another insurance company Documentation of eligibility verification such as copy of ID card, TMBC, TMHP documentation, call log, etc. Overnight or certified mail receipt as proof of timely filing Centene EDI acceptance reports showing the claim was accepted by Superior Prior authorization number and/or form or fax

42 **Remember** If a provider bills for procedure codes not identified as valid encounter services (identified specifically in the TMHP manual available at the service will not pay as the services are considered to be informational only

43 Common Billing- Denials Denial Code Definition EXNB SERVICE IS NOT A COVERED BENEFIT OF TEXAS MEDICAID EX18 DUPLICATE CLAIM SERVICE EXA1 AUTHORIZATION NOT ON FILE Exya DENIED AFTER REVIEW OF PATIENT S CLAIM HISTORY EX29 THE TIME LIMIT FOR FILING HAS EXPIRED EXMA PROVIDER MEDICAID ID# NOT ON FILE EXN5 NDC MISSING/INVALID OR NOT APPROPRIATE FOR PROCEDURE EX46 THIS SERVICE IS NOT COVERED EX35 BENEFIT MAXIMUM HAS BEEN REACHED EXDV PROCEDURE IS INAPPROPRIATE FOR PROVIDER SPECIALTY EXx3 PROCEDURE CODE UNBUNDLED FROM GLOBAL PROCEDURE CODE EXL6 BILL PRIMARY INSURER 1ST RESUBMIT WITH EOB EXx9 PROCEDURE CODE PAIRS INCIDENTAL, MUTUALLY EXCLUSIVE OR UNBUNDLED EX86 INVALID DELETED MISSING MODIFIER EXCP COVERED UNDER PRIMARY PROCEDURE EXK6 CLAIM IS THE RESPONSIBILITY OF MEDICARE EXDX SERVICES FOR THE DIAGNOSIS SUBMITTED ARE NOT COVERED EXM5 IMMUNIZATION ADMINISTRATION NOT PAYABLE WITHOUT CPT FOR VACCINE EXDZ SERVICE HAS EXCEEDED THE AUTHORIZED LIMIT EXHT NO AUTH ON FILE FOR SERVICES BILLED This is not an all inclusive list- Your EOP provides you with the Denial Code and explanation

44 Common Billing - Rejections Rejection Code Definition 06 THE PROVIDER IDENTIFICATION AND TAX IDENTIFICATION NUMBERS ARE EITHER MISSING OR DO NOT MATCH THE RECORDS ON FILE. B7 RE A5 DATA NOT PROPERLY ALIGNED WITHIN NEW CLAIM FORM FIELDS. ENSURE UPDATED PRACTICE MANAGEMENT SOFTWARE/PRINTER IS UTILIZED TO SUPPORT THE SUBMISSION OF THE NEW CMS 1500 (02/12) VERSION THE CLAIM(S) SUBMITTED WAS BLACK AND WHITE OR HANDWRITTEN. ONLY CLAIM FORMS THAT ARE PRINTED IN FLINT OCR RED, J6983 (OR EXACT MATCH) INK ARE ACCEPTED AS OF 4/1/13. PLEASE SUBMIT YOUR CLAIMS VIA THE CENTENE WEB PORTAL, ELECTRONIC CLEARING HOUSE OR THE NDC INFORMATION MISSING/INVALID 09 MEMBER NOT ELIGIBLE FOR DATE OF SERVICE. AV PATIENT REASON FOR VISIT SHOULD NOT BE USED WHEN CLAIM IS INPATIENT. 15 MEMBER NOT ELIGIBLE FOR DATE OF SERVICE; THE PROVIDER IDENTIFICATION AND TAX IDENTIFICATION NUMBERS ARE EITHER MISSING OR DO NOT MATCH THE RECORDS ON FILE. This is not an all inclusive list. Rejections are not in our system because the missing or invalid information prevents the system from recognizing the claim. EDI Submission will need to occur within 95 days of DOS but you can Appeal a rejection in writing within 120 days from the date of letter. You do not receive an EOP with a rejection- You will receive a letter that details the rejection reason

45 Authorizations & Billing Reminder Avoid Denials- remember to use the right Tax ID LTSS Number when requesting authorizations! If your authorization denies because you billed with a different combination than was authorized You CAN appeal Rebill with correct combo Request Reconsideration by providing the authorization number you did obtain and ask it be assigned to the correct combination When calling in to request an authorization or to notify of a patient admission, please have available the Tax Identification Number (TIN) and National Provider Identifier (NPI) or LTSS ID Number (Atypical ID) that you will use to bill your claim. The representative handling your call will be requesting the numbers from you. If you do not have your identifiers available, your request will not be processed and you will be asked to call back with the necessary information. It will be very important that the numbers you use to request your authorization match the numbers you will use to bill your claim or your claim will deny.

46 Recurring Bills Reminder Superior HealthPlan may issue authorizations that extend to multiple dates of service In order for the claim to process correctly, Dates of Services billed on a claim must be covered under a single authorization Bill must reflect the services under the authorization- including billing period 1 claim per authorization period Superior HealthPlan frequently issues authorizations that span over multiple dates of service. To avoid claim denials, the dates of service billed on a claim must be covered under one single authorization. If the dates of service billed are covered by multiple authorizations, the claim should be split and billed on separate claims for each authorization. HHSC Form #

47 Elective Delivery Policy Superior HealthPlan will review all NICU admissions delivered prior to 39 weeks to determine whether the delivery was elective or medically necessary If elective, we will deny the delivering physician and the facility (for both the delivery and the NICU) We will not deny other Physicians (Anesthesia, Neonatology) or other facilities (if the infant is transferred due to medical necessity) If you have any questions regarding this new procedure, please contact Provider Services at

48 Obstetrics: Delivery Claim Requirements Effective Delivery & Postpartum services must be billed separately for all Products This improves our ability to report HEDIS quality outcomes for Postpartum Care Corrected claims can be submitted within 120 days from the Explanation of Payment date for payment with the separate procedures codes Procedure Code Reimbursable Codes Code Description Vaginal Delivery Only C-Section Delivery Only Postpartum Outpatient Visit Non-reimbursable codes Vaginal Delivery including Postpartum Care C-Section Delivery & Postpartum Care Superior HealthPlan will reimburse for two postpartum visits Delivery after C-Section including Postpartum Care

49 Electronic Funds Transfer Signing up for EFT and Retrieving your EOPs

50 Outgoing Providers receive the information back from us in two ways: Via Paper: EOP (via Emdeon) Electronically: ERA/835- Electronic Remittance Advice PaySpan (EFT and ERA) Providers may be set up to receive via their Clearinghouse/Trading Partners (and still receive a paper check)

51 EFT or Paper Check Providers will receive a paper check unless they are signed up for EFT via PaySpan. Did you know? A provider can submit claims via paper and still enroll for EFT/ERA. A provider that likes their EDI Vendor can still go through their vendor to submit their claims We simply divert the return file aka the ERA (835) through PaySpan along with EFT

52 PaySpan Health SHP has partnered with PaySpan Health to offer expanded claim payment services Electronic Claim Payments (EFT) Online remittance advices (ERA s/eops) HIPAA 835 electronic remittance files for download directly to HIPAA-compliant Practice Management or Patient Accounting System Register at: For further information contact , or or contact your local Provider Relations office or Provider Services at

53 Superior HealthPlan Our Contact Information, Our Website, & Our Secure Portal

54 Secure Site SUBMIT: VERIFY: VIEW: Public Site ACCESS: Claims Resubmit corrected claims Submit COB Claims Online Authorization Requests Request for EOPs Provider Complaints Notification of Pregnancy (NOP) Eligibility Claim Status Claim Editing Software Care Gap Lists Contract Requests Provider Directory Provider Manual Provider Training Schedule Links for Additional Provider Resources

55 Provider Services If you have claims status or payment questions OR If you need instructions on how to complete claims CALL Provider Services Department (Please have Tax ID, NPI or Claim Number available)

56 Provider Relations Responsible for Provider Orientation and Education Billing Requirements New Products, Programs or Processes Liaison for claims issues or concerns Provider Relations now offers online webinar trainings along with local group training sessions (See for the orientation calendar)

57 Participating Provider Request For Existing Contracted Providers Only Adding a New Location Adding a New Product Adding a New Provider Request can be completed online:

58 Provider Complaints Superior requires complaints be submitted in: Writing: Superior HealthPlan 2100 South IH-35, Suite 202 Austin, Texas ATTN: Complaint Department Fax: Superior s website address for the online complaint submission feature is: The website also contains a complaint form that can be printed, completed and faxed or mailed to Superior for resolution response. Link at: Download.pdf

59 Secure Provider Portal: Registration A user account is required to access the Provider Secure area. If you do not have a user account, click Register to complete the 4-step registration process. For Providers

60 Claims Status Claims status could be viewed on claims that have been sent EDI, Paper or Web portal

61 Select the Claims Audit Tool Click Accept to enter Clear Claim Connection Page

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63 Submitting Claims Online Submitting a claim via No charges or fees Batch claims now accepted UB04 (facility claims)

64 Create Professional Claim From the navigation menu: Select Claims at the top of the landing page Create Claim

65 Create Professional Claim Enter the Member s Medicaid ID or Last Name and Birthdate. Click the Find button

66 Create Professional Claim Chose a Claim Type Select Professional Claims

67 General Info * required Enter Patient Account Number. Note: This is your internal patient account number.

68 General Info

69 Coordination of Benefits If applicable select Coordination of Benefits

70 Coordination of Benefits In the Referring Provider section, enter information as needed.

71 STAR+PLUS Claims Helpful Hints: Only item to be added will be the Prior Authorization Number found on the authorization summary sent from the STAR+PLUS Service Coordination Team. *Auth # starts with OP followed by 7 digits (Ex: OP ) If provider bills less than contracted amount, the claim will pay the lesser of. In the Diagnosis Codes section, enter Diagnosis Code 1 (required). This DX code is found on the Authorization Summary In the Service Line #1 section, enter required information. (All info is found on the authorization summary) From Date To Date, Place of Service, Procedure Code, Use the Diagnosis Pointer checkboxes to associate the previously entered Diagnosis Code 1, 2, 3 & 4 with the Service Line as needed. Charges, Days/Units Rendering provider information.

72 Rendering Provider Section In the Rendering Provider section, Enter your NPI number Select the provider info from the drop-down list associated with your location and taxonomy code

73 Billing Provider Section In the Billing Provider section, Enter required information or click Same as Rendering Provider to automatically copy the rendering provider information into the service facility fields

74 Service Facility Location Section In the Service Facility Location section, enter information as needed. Click Same as Billing Provider to automatically copy the billing provider information into the service facility fields. Click the Next Step button

75 Finalize & Submit Review to ensure that all information is correct. If information is incorrect, click Previous Step to move to the section that needs changes and change the information within the section If all information is correct, click Submit Claim and the claim will be transmitted. A Claim Submitted confirmation will be displayed.

76 Claim Submitted Successfully! Take note of the Web Reference Number, which may be used to identify the claim while using the View Web Claim feature. The Web Reference Number may also be useful in discussing a claim with your Provider Relations/Services Representative.

77 Additional Features Eligibility section for Providers Primary Care Physicians Panel- Texas Health Steps Last Exam Date: View the date of the member's last Texas Health Steps Exam Alerts: Alerts section indicates whether a member has a gap in care. If a member has a gap in care (preventative service not rendered within the allotted time frame), you will see an alert symbol on the left side of the member s name on the Patient List Search page. Provider Relations does have the ability to shadow provider to show how Care Gaps can be pulled Care Gap Alert Categories and descriptions Adult Preventive No mammogram in most recent 12 month No Chlamydia test in past 12 months in patient years. No PAP in past 12 months Diabetes DM - Not seen in past 6 months DM - No retinal eye exam in past 12 months DM - No HbA1C screening in past 12 months Flu Vaccine No flu vaccine in past 12 months. Child Preventive Immunizations not current for age Texas Health Steps Non-compliant for well child visits Cardiac CAD - Not seen in past 12 months HTN - Not seen in past 12 months

78 FQHC & RHC Billing Information

79 FQHC Medicaid & CHIP Billing Procedures FQHC Medicaid & CHIP Services The FQHC must bill a T1015 procedure code and applicable modifier for general medical services Exception claims ( other health visits e.g. Well-Child, Vision Care and Mental Health) must be billed with appropriate or applicable CPT codes An FQHC is paid their full encounter rate for medical services directly from Superior HealthPlan An FQHC is paid a contracted rate by the CHIP Dental MCO for dental services All Optometry Provider claims should be billed directly to TVHP using the standard billing formats Behavioral health services should be billed directly to Cenpatico

80 RHC Medicaid Billing Procedures RHC Medicaid Services The RHC must bill a T1015 procedure code for general medical services Exceptions claims ( other health visits e.g. Texas Health Steps and Family Planning) must be billed with appropriate or applicable CPT codes An RHC is paid their full encounter rate directly from Superior HealthPlan All services provided at an RHC and billed on a CMS 1500 form must be submitted using a location (POS) code 72. This includes Texas Health Steps/Well visits, and Family Planning Services Services rendered at an RHC facility and billed with a location code other than 72 may be denied Providers must use the appropriate modifiers in order to receive payment for services All Optometry Provider claims should be billed directly to TVHP using the standard billing formats. Behavioral health services should be billed directly to Cenpatico

81 RHC CHIP Billing Procedures RHC CHIP Services The RHC must bill a T1015 procedure code for general medical services Well Child visits must be billed with appropriate or applicable CPT codes An RHC is paid their full encounter rate directly from Superior HealthPlan All services provided at an RHC and billed on a CMS 1500 form must be submitted using a location (POS) code 72. This includes Texas Health Steps/Well visits, and Family Planning Services Services provided at an RHC and billed with a location code other than 72 may be denied Providers must use the appropriate modifiers in order to receive payment for services A RHC is paid a contracted rate by the CHIP Dental MCO for dental services All Optometry Provider claims should be billed directly to Opticare using the standard billing formats. Behavioral health services should be billed directly to Cenpatico *Important Note: CHIP coverage is secondary when coordinating benefits with all other insurance coverage. Coverage provided under CHIP will pay benefits for Covered Services that remain unpaid after all other insurance coverage has been applied

82 Questions & Answers