EI Medicaid Billing Manual. Revised 8/18/14

EI Medicaid Billing Manual Revised 8/18/14

Table of Contents Section I: Enrollment... 3 Section II: Training... 4 Section III: Eligibility... 4 Section IV: Submission of PARs... 5 Section V: Billing 1500 only for paper claims, 837P is for online... 7 Section VI: Claims Processing Common Terms... 12 Section VII: Required Paperwork... 12 Section VIII: Resources... 13 Section IX: Appendices... 14 2

Section I: Enrollment 1) Standard Enrollment Needed for all providers: a) You will need BOTH a National Provider Identification (NPI) number AND a state Medicaid identification number. b) You will first need to submit an application to obtain an NPI. Go to the website https://nppes.cms.hhs.gov/nppes/welcome.do and apply for a number. c) The Colorado Medicaid Enrollment Forms are on the Department of Health Care Policy and Financing (HCPF) website www.colorado.gov/hcpf; click on Provider Services / Provider Enrollment. d) You will need to fill out both the Standard and Rendering provider applications if you will be providing direct services to a child and if you will be submitting billing. If another agency will be processing your billing, you will only need to fill out the Rendering provider application. i) Unless you are changing the name of your organization, skip #1 and go to #2, Name and Business Organization Information. ii) If you had a Medicaid number in another state that has been discontinued, you will need to fill out the last question on #3, including which state(s) the Medicaid number was in and the date that you left that state. iii) If you have seen a child with Medicaid within the past 120 days and are planning on billing for the services you have provided, you will need to check the box on question #4. iv) #5, sign and provide the requested information. v) #6, use your home address. vi) #7 & #8 are self-explanatory. vii) #9 is for receiving Fax Back for eligibility (which you can also check through the web portal), so you do not need to put anything in here, if you do not want. viii) For #10, you only need to worry about this if you are using a billing agent or a clearinghouse. Otherwise, just skip to question #13. ix) #13 is self-explanatory. x) #14 is only for those agencies that are doing the billing for providers, so if you are an independent provider who will be billing for yourself, you do not need to fill this out. If you are using a billing agent, however, you will need to use this to authorize that agency to have access to the information they will need to be able to process your billing for you. xi) #15 you can only indicate ONE provider type per enrollment. xii) #16 - #18 are self-explanatory. xiii) #19 - #21 are not necessary for EI Providers. xiv) #22 - fill in NPI number, indicate pending if you do not have a number yet - however, your application will be considered incomplete until you supply your NPI number, so it is best to wait until you have that number before filling out this application. xv) #23 is not necessary for EI providers. xvi) #24 is self-explanatory (Entity completing document is Provider ). For A., check the box that says I am an individual using my SSN for enrollment and ownership/control interest does not apply. xvii) #25 is only for those agencies that will be doing the billing for several providers. 3

xviii) #26 is self-explanatory. xix) #27 is only for those agencies that are doing the billing for a provider. xx) Page 17 24 are self-explanatory. xxi) EI Providers do not need to worry about page 25. xxii) Fill out your preferences for how reports are formatted. Reports contain VERY important information. xxiii) Indicate how you want to access the monthly Provider Bulletins (again, very important information). xxiv) Pages A1-A6 are for your information only. You must fill out the W9 form. xxv) On the Authorization Agreement for Automatic Deposits (ACH Credits), where it asks for Medicaid Provider # and NPI #, just indicate pending. xxvi) After the instructions on how to fill out the ACH form are the instructions on how/where to submit the Enrollment form. 2) Rendering Provider Needed only for those providers who are serving the child. Most of the information is already on the Standard Enrollment Form, but you will need to copy the information onto the Rendering Provider Form. a) #4, put your home/office address in for where the services will be rendered. b) #8, you can only select one provider type. i) #12, if you do not have your NPI number yet, put pending on the line - however, your application will be considered incomplete until you supply your NPI number, so it is best to wait until you have that number before filling out this application. c) Appendix A, page 3 this only needs to be filled out by Registered Nurses submitting this enrollment. Section II: Training It is recommended that all providers attend trainings on how to bill. All trainings are conducted by Xerox. Topics covered are: the Provider Enrollment Application, Beginning Billing, Using the Web Portal, and Occupational/Physical/Speech Therapy Billing. The training calendar can be found through a link to the Provider Bulletins that is found on the state Medicaid website: www.colorado.gov/hcpf. Click on Provider Services/Provider Bulletin, click on the most current Bulletin and scroll to the end. Near the end of the Bulletin, there is a listing of the trainings being offered for that month and the next month. Below the list of trainings is a link to sign up for a workshop. The workshops are free and typically last about two hours. Some of the trainings are web-based, so are easier for those providers located outside of the Denver metro area. Providers may also view archived presentations by going to the Training and Workshops section under the Provider Services part of the website. Section III: Eligibility Prior to billing for any Medicaid activity (therapy or Targeted Case Management (TCM)), a provider should check the eligibility of a child. Use the date of service (DOS) to ensure that the child was eligible on the date the activity (therapy or TCM) occurred. Eligibility may be verified in various ways. The two most common ways are: 1. Through the web portal, or 2. Fax Back 1-800-493-0920. 4

There is a great deal of important information that is included on the Eligibility Response: 1. Eligibility dates this is important to know that the child was eligible for the DOS of the activity (therapy); 2. Co-pay information; 3. Third Party Liability (Behavioral Health Organization (BHO) or Accountable Care Collaborative (ACC)); a. The name of the responsible BHO, so that the mental health provider can bill the correct organization; or the responsible ACC so the provider can bill that organization directly. To view the fact sheet for ACCs, go to: http://www.colorado.gov/cs/satellite?blobcol=urldata&blobheader=application%2fpdf& blobkey=id&blobtable=mungoblobs&blobwhere=1251900153680&ssbinary=true 4. Guarantee Number this is critical, as even if Medicaid denies a particular billing due to a child being not eligible, if you have the Guarantee Number for that particular DOS, Medicaid must pay Section IV: Submission of PARs 1) A Prior Authorization Request (PAR) is not required for the first 24 units of Occupational Therapy (OT) or Physical Therapy (PT) in a 365-day period. 2) It is important for the new therapist to check the PAR status to determine if there is an open PAR or to determine how many of the 24 units have already been used within the previous 365 days. You can do this by calling the Xerox Customer Service line. You will need the child s Medicaid ID and the Common Procedure Treatment (CPT) codes you will be billing under. Xerox can pull up the billings for that child, for those codes for the previous 365 days. 3) PARs are needed only for PT and OT services and all PARs are processed by the Colorado PAR Program and must be submitted using the CareWebQI: http://coloradopar.com/carewebqi/carewebqi-portal-access. 4) If another EI provider holds a PAR that needs to be closed, there is a form on the Medicaid website that must be completed: http://www.colorado.gov/cs/satellite?c=page&childpagename=hcpf%2fhcpflayout &cid=1201542696550&pagename=hcpfwrapper Go to Update Forms, then Change of Provider Form. It then gets submitted to the CareWebQI, requesting that the PAR be closed so that the new provider can open a new PAR. 5) PAR requirements are: a) Legibly written and signed ordering practitioner prescription, to include diagnosis with ICD 9 (through September 30, 2015) or ICD 10 (on and after October 1, 2015) code and reason for therapy, the number of requested therapy sessions per week and total duration of therapy. The modifier for PT is GP and for OT is GO. The modifier TL is used as a second modifier for all children in early intervention. For a PAR renewal, complete an evaluation to be signed by the Primary Care Practitioner (PCP) and submitted with the PAR. While a speech therapist is not required to submit a PAR, the therapist should maintain current assessment and evaluation information in the child s file. 5

b) Evaluation report to include history, current assessment and treatment, previous services, plan of care, and diagnosis. c) Documentation supporting medical (physical, NOT developmental) necessity for the course and duration of treatment being requested. d) Course of treatment, measurable goals and reasonable expectation of completed treatment. The IFSP shows that it is an Early Intervention client. e) Assessment or progress notes submitted for documentation with the PAR, must be dated less than sixty (60) days prior to submission of PAR request. f) If the PAR is submitted for services delivered by an independent therapist, the name and address of the individual therapist providing the treatment must be present in field #24 of the PAR. g) The billing provider name and address needs to be present in field #25 on the PAR (if different from the rendering provider). h) The Colorado Medical Assistance Program provider number of the independent therapist must be present in PAR field #28. i) The billing provider s Colorado Medical Assistance Program number must be present in field #29 of the PAR. j) A child MAY receive PT & OT services during the same time period/service dates. (Have PARs that cover the same time period, but the same CPT codes with no modifier or the same modifier cannot be billed on the same day). k) Duplicate therapy MAY NOT be performed on the same dates of service (DOS) l) Clients may not receive the same service for habilitative & rehabilitative therapy on the same DOS (i.e., a child who is having rehab for a broken arm may not also see his EI PT on the same day). m) Separate PAR and necessary documentation is required for each request. n) A PAR can only be for a maximum 12 month span (364 days). o) Approval of the PAR is based on medical necessity, deemed by the authorizing agent. In most cases, the IFSP serves as proof of medical necessity. 6) If a child s condition requires more visits than listed and authorized on the original PAR, a new PAR is required. 7) The new PAR must include all the required information that was on the original PAR and must show continued need, ongoing deficits and progress toward the treatment goals. A new evaluation is required if not current within 60 days, and a new RX required if not current within six months. 8) Common PAR errors are: a) If the billing provider is not the rendering provider, all the following information must be on the PAR: i) Name/address of prescribing provider in Box 24 (corresponds with Medicaid number in box 28); ii) Billing provider name and address in field #25; and iii) Billing provider number in field #29. b) If any necessary information is missing or invalid, the PAR may be returned to the provider or denied for lack of information. 9) Use the Web Portal for PAR letter retrieval/par status inquiries (just open the blue link to the PAR and it will indicate what was approved on the PAR) https://sp0.hcpf.state.co.us/mercury/login.aspx. 6

10) The PAR number on a PAR letter is the only number accepted when submitting claims 11) If a PAR Inquiry is performed and you cannot retrieve the information: a) Contact the Colorado PAR Program (CareWebQI); and, b) Ensure that you have the right PAR type (e.g., a Medical PAR may have been requested, but processed as a Supply PAR), so make sure that you carefully check over the PAR letter when you receive it. Section V: Billing - 1500 only for paper claims, 837P for online Providers can bill through the Web Portal Medicaid Secured Sites (HCPF website/providers/ secured site tab at the top) or by using the paper Colorado 1500 form. If using the Web Portal to bill, you must first set up your user information and add all providers who you will be billing for. You can add them under data maintenance/provider maintenance. You will need to select the provider and put in their start date and NPI. If you are experiencing difficulty, it is most helpful if you call HCPF technical support line to have them walk you through the process. Call 1-888-538-4275 or e-mail HelpDeskHCG.central.us@cgi.com. Timely Filing 1. All services must be billed within 120 days from the DOS a. The 120 days is determined by the date of receipt of the billing paperwork, not postmark; b. PARs are not proof of timely filing; and, c. Certified mail is not proof of timely filing. 2. Documentation for Timely Filing: a. 60 days from the date on: i. the Provider Claim Report (PCR) Denial; or, ii. Rejected or returned claim b. Use delay reason codes on the 837P transaction (electronic filing form); c. Keep all supporting documentation; d. Extensions may be allowed when: i. Commercial insurance has yet to pay/deny. The private insurance (e.g., United Health Care) must be billed and the provider must have received a denial that is then submitted to Medicaid. If you submit paper claims, you need to send the paper denial from the insurance company with your paper claim. If you submit through the web portal, you pick a late bill override code and just keep the paper denial on file; ii. Delayed client eligibility notification (use the Delayed Eligibility Notification Form Certification & Request for Timely Filing Extension). Must use the paper Colorado 1500 form to file this claim; or, iii. Backdated eligibility (use the Delayed Eligibility Notification Form and clearly identify the late bill override date LBOD). e. Extensions for commercial insurance may occur: i. up to 365 days from the date of service; ii. iii. 60 days from the payment/denial date; or, When nearing the 365 day cut off: 1. File a claim with Colorado Medicaid and receive denial or rejection; and, 7

2. Continue re filing every 60 days until insurance information is available. f. Extensions for Delayed Notification may occur: i. 60 days from eligibility notification date; and, ii. Use the Delayed Eligibility Notification Form, located in the Forms section of the HCPF website/provider page and make sure that you complete and retain this form for a record of Late Bill Override Date (LBOD). g. Bill electronically; h. Bill using Form CMS 1500 i. This form is the paper form and can be obtained through the US Government Printing Office or you can purchase a downloadable form online in a Word or Excel format; and, ii. The downloadable form can be pre populated with all of the patient information and saved to your desktop, so all you have to do is fill in the treatment dates, codes, amounts and totals. i. Steps you can take to receive payment: i. Review past records to ensure that you have followed all the necessary steps and timeline required to receive payment. j. Extensions Backdated Eligibility: i. 120 days from the date that the county enters eligibility into the system; and, ii. You can prepare the Backdated Eligibility Report by obtaining a Stateauthorized letter identifying 1. County technician 2. Client name 3. If the eligibility was delayed or backdated; and, 4. The date the eligibility was updated. Medical Necessity 1. In order to determine Medical Necessity, the following must be true: a. Therapy must be in accordance with generally accepted standards of medical practice, as outlined by the therapists professional organization; b. Must be clinically appropriate in terms of type, frequency & duration, as determined by the therapists professional organization; c. Must not be primarily for the convenience of the child, parent or legal guardian, physician, or other health care provider; d. Must be cost effective; and, e. A therapist must have a medical (physiological) reason to perform the service. 2. Benefits that are not covered are: a. Education; b. Personal need; and, c. Comfort therapy. Units of Service and Billing Codes 1. PTs and OTs have a combined daily limit of five (5) units, which is separate from the Speech therapy (ST) daily limit of five (5) units. One unit is equivalent to 15 minutes. a. A child may receive five (5) units of PT or OT and five (5) units of ST on the same DOS as long as they are not duplicative services. The most common code for ST 8

(92507) is untimed (one (1) unit), but some of the other codes that can be billed by a speech pathologist are timed. 2. Below is a table of possible codes, modifiers and the number of units each may be billed, and which codes may be billed together. This information is accurate as of April 17, 2014 and may change over time. In the References section, there are links to websites where a therapist can obtain information on the most current codes and what is acceptable to be billed together. Remember that any code used must be supported by the documentation in the treatment notes and plan (IFSP), which must be retained for six (6) years for audit purposes. Much of this information is also available in the OT/PT and Speech Billing manuals in the Providers section of the HCPF website. This list of CPT codes is not exhaustive, so it is recommended that for further information, you consult your professional organization for guidance. Beginning July 1, 2014, every EI service will also need the EI modifier, TL. Possible Codes for PT (remember that there can be no more than five (5) units billed per day). Any of these codes may be billed together (with the proper modifiers), as long as there is justification in the treatment plan and notes. Code Description Max Number of Medicaid Rate Modifier(s) Units Possible as of 1/1/14 97110 Therapeutic 4 $10.95 per unit GP, TL procedure 97116 Gait training 3 $8.74 per unit GP, TL (includes stair climbing) 97124 Massage $12.04 per unit GP, TL 97530 Therapeutic 3 $10.95 per unit GP, TL activities direct 97532 Cognitive 3 $20.58 per unit GP, TL and 59 (indicating that it is a distinctive activity, separate from the activities of PT) Possible Codes for OT (remember that there can be no more than five (5) units billed per day). Any of these codes may be billed together, as long as there is justification in the treatment plan and notes. Code Description Max Number of Medicaid Rate Modifier(s) 92526 Swallowing or Oral Motor/feeding Units Possible as of 1/1/14 1 $24.08 GO, TL 97110 Therapeutic 4 $10.95 per unit GO, TL 9

procedure 97530 Therapeutic 3 $10.95 per unit GO, TL activities direct 97532 Cognitive 3 $20.58 per unit GO, TL 97533 Sensory 4 $21.70 per unit GO, TL 97535 Self care/ Activities of Daily Living 4 $16.43 per unit GO, TL Possible Codes for Speech (remember that there can be no more than five (5) units billed per day). Any of these codes may be billed together (with the proper modifiers), as long as there is justification in the treatment plan and notes. Code Description Max Number of Medicaid Rate Modifier(s) Units Possible as of 1/1/14 92507 Treatment of 1 $59.08 GN, TL speech 92522 Evaluation of 1 $32.19 GN, TL speech sound production 92523 Evaluation of 1 $32.19 GN, TL speech sound production with evaluation of language comprehension and expression 92524 Behavioral and 1 $32.19 GN, TL qualitative analysis of voice and resonance 92526 Swallowing or 1 $24.08 GN, TL Oral Motor 92609 Use of speech 1 $39.48 GN, TL device service 96111 Developmental 1 $97.62 GN, TL testing; extended with interpretation and report, per hour 97532 Cognitive 3 $20.58 per unit GN, TL and 59 (indicating that it is a distinctive 10

activity, separate from the activities of speech therapy) 97533 Sensory 4 $21.70 per unit GN, TL 3. Common Reasons for Denials: a. The 24 units have been used before the PAR is in place; b. The claim was submitted more than 120 days after the DOS without a Late Bill Override Date (LBOD) form; c. The claim is a duplicate, which is sometimes related to a provider not reconciling their Provider Claim Reports (PCRs) to see what claims had been paid and which were still outstanding; d. The claim was submitted without the Referring Provider Number; e. Other insurance should have been billed prior to billing Medicaid; f. There is no PAR on file for the services (the CPT codes being billed), or there are no units remaining on the PAR for the CPT code being billed; g. The line item charges do not match the claim total; or, h. Appropriate modifiers not used. 4. Adjusting Claims a. Adjustments create a replacement claim. b. This is a two step process consisting of Credit and Repayment. c. Adjust a claim when the provider billed the incorrect services or charges or the claim was paid incorrectly. d. Do not adjust a claim when the claim was denied, the claim is in process or the claim is suspended. e. Adjustments can be made through the Web Portal. 5. Provider Claim Reports (PCRs) a. These are very important reports that a provider can pull weekly and contain the following claim information: i. Accept/Reject Report; ii. Claims paid; iii. Claims denied (there is always a reason code/explanation as to why the claim was denied); iv. Claims adjusted; v. Claims voided; and, vi. Claims in process. b. Providers are required to retrieve the PCR through the File and Report Service (FRS), via the Web Portal. c. PCRs are available through the FRS for 60 days. 11

d. There are two options to obtain duplicate PCRs: i. The fiscal agent (FRS) will send an encrypted e mail with a copy of the PCR attached for $2 per page; or ii. iii. The fiscal agent will mail a copy of the PCR via FedEx; and, The charge is assessed regardless of whether the request for a duplicate is made within one (1) month of the PCR issue date or not. Section VI: Claims Processing Common Terms 1. Reject the claim has primary data edits and is not accepted by the claims processing system 2. Denied the claim was processed and denied by the claims processing system 3. Accept the claim was accepted by the claims processing system 4. Paid the claim was processed and paid by the claims processing system 5. Adjustment there are corrections to under/overpayments, claims paid at zero and claims history information 6. Rebill rebilling a previously denied claim 7. Suspend the claim must be manually reviewed before adjudication 8. Void Cancelling a paid claim. The provider must wait at least 48 hours to rebill Section VII: Required Paperwork 1. At the initial visit, an evaluation must be completed and must contain the following components: a. Diagnosis; b. Treatment plan; c. Frequency of recommended services (4x/mo, 1x/week, etc.); d. Planned interventions; e. Goals; f. Rehabilitation potential; g. Background; h. Observation and Testing (used for OT & PT evaluations, ST evaluations do not use these criteria): i. Strength, Motor Control, Endurance; ii. Joint Mobility/stability; and, iii. Skills; and i. Criteria for discharge. 2. All records must be retained for at least six (6) years beyond the year in which the activity occurred. 3. Records might need to be retained longer than 6 years if required by regulation or if there is a specific contract between a provider and Colorado Medical Assistance Program 4. All records must be furnished upon request about payments claimed for the Colorado Medical Assistance Program services. 5. Records must: a. Substantiate submitted claim information; and, 12

b. Be signed and dated by the person ordering and providing the service computerized signatures and dates may be used if electronic record keeping system meets Colorado Medical Assistance Program security requirements. Section VIII: Resources HCPF: www.colorado.gov/hcpf Provider Bulletins come out the first of every month and contain very important information, so a provider should read these every month Provider Billing Manuals All forms/training/medicaid rates and other Provider resources PAR Submission/Issues (CareWebQI): www.coloradopar.com Prior Authorization Request, 55 N. Robinson Ave., Suite 600, Oklahoma City, OK 73102 1 888 454 7686 (phone); 1 866 492 3176 (fax) Xerox CGI 1 800 237 0757 Checking the number of units for possible codes that have already been used within the past 365 days (for the purposes of billing prior to the PAR being issued) Claims/Billing/Payment Forms/Website issues EDI (electronic data interface) Enrolling New Providers Updating existing provider profile 1 888 538 4275 Helpdesk.HCG.central.us@cgi.com Web Portal technical support Password resets Colburn, J. (2011). The small patient practice. Colorado Springs, CO: Three Leaf Press. This is a wonderful, comprehensive resource for how to bill for therapy services Free CMS 1500 electronic transmission Office Ally www.officeally.com CMS 1500 Form Resources www.medicalformsoftware.com (for downloadable form) http://www.cms.gov/electronicbillingeditrans/16_1500.asp 13

ASHA APTA AOTA NCCI www.asha.org Guidance on diagnosis (ICD 9 and ICD 10) codes Guidance on CPT codes www.apta.org Guidance on diagnosis (ICD 9 and ICD 10) codes Guidance on CPT codes www.aota.org Guidance on diagnosis (ICD 9 and ICD 10) codes Guidance on CPT codes http://www.medicaid.gov/medicaid CHIP Program Information/By Topics/Dataand Systems/National Correct Coding Initiative.html Guidance on what codes may be billed together look at the PTP edits for outpatient services codes used for OT, PT and Speech are in Part 2 For more complete explanation of CPT codes https://ocm.ama assn.org/ocm/cptrelativevaluesearch.do?submitbutton=accept Section IX: Appendices A. Sample Physician Signature Request B. Sample Treatment Plan for Medicaid C. Sample Initial Evaluation 14