unisys louisiana medicaid dhh – bureau of primary care practice management technical assistance...

LOUISIANA

Department ofHEALTH and

HOSPITALS

UNISYS

Louisiana Medicaid

DHH – Bureau of Primary CarePractice Management Technical Assistance Workshop

August 14th , 2008

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Billing for Independent Mental Health Providers

Independently Practicing Psychologists and Social Workers Medicaid covers services provided to

Medicare/Medicaid recipients ONLY Medicaid uses a cost-comparison methodology to

make payments up to the Medicare coinsurance/or deductible

Claims should crossover electronically from Medicare Psychological and Behavioral Services (PBS)

Must be an enrolled Psychologist participating in the PBS program

Covers recipients under the age of 21 Services covered include necessary assessments,

evaluations, individual therapy, and family therapy Reimbursement is based on fee-for-service

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Ind. Social Worker Claim Form Example

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PBS Claim Form Example

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Common Billing Errors

General Claim Form Completion Codes 003 – Recipient # invalid or less than 13 digits 028 – Invalid or missing CPT code

Recipient Eligibility Error Codes 215/216/222/223 – Recipient not on file/not eligible on one or more DOS 217 – Name/# on claim does not match file

Timely Filing Error Codes 272/371 – Claim exceeds 1 year filing limit/attachment requires review

Misc. Error Codes 433/020 – Missing/invalid diagnosis 131 – Primary diagnosis not on file 234 – P/F age restriction 739 – Recipient has exceeded maximum allowed services per year

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Timely Filing Guidelines

Initial Filing Limits

Dates of Service Past Initial Filing

Limit

Two-Year Filing Limit

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Appeals Process

Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys

Appeals may be filed when all efforts to get the claim paid have been exhausted

Requests must be submitted in writing to DHH Bureau of Appeals P.O. Box 4183 Baton Rouge, La. 70821-4182

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CommunityCARE

Program Description

Exempt Recipients

Primary Care Physician (PCP)

Non-PCP Providers

Exempt Services

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Types of Services Covered Mental Health Rehabilitation Services

Private providers Assessment Service Planning Community Support Medication Management Individual Intervention/Supportive Counseling Group Counseling Parent/Family Intervention Counseling Psychosocial Skills Group Training

All services must be Prior Authorized through SRI

Reimbursement is based on fee-for-service

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Types of Services Covered Mental Health Clinics

Only State Operated Clinics Covered Services include:

Evaluations/Assessments Treatment Counseling Services Medication Management Injections

Reimbursement is based on fee-for-service

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MHC Claim Form Example

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Common Billing Errors General Claim Form Completion Codes

003 – Recipient # invalid or less than 13 digits 028 – Invalid or missing CPT code

Recipient Eligibility Error Codes 215/216/222/223 – Recipient not on file/not eligible on one or more DOS 217 – Name/# on claim does not match file

Timely Filing Error Codes 272/371 – Claim exceeds 1 year filing limit/attachment requires review

TPL Error Codes 273 – TPL carrier code missing 290 – No EOB from primary carrier attached

Miscellaneous Error Codes 194 – Claim exceeds prior authorized limits 191 – Procedure requires prior authorization 299/232 - Procedure not covered by Medicaid/type of service not covered

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Timely Filing Guidelines

Initial Filing Limits

Dates of Service Past Initial Filing

Limit

Two-Year Filing Limit

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Appeals Process

Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys

Appeals may be filed when all efforts to get the claim paid have been exhausted

Requests must be submitted in writing to DHH Bureau of Appeals P.O. Box 4183 Baton Rouge, La. 70821-4182

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CommunityCARE

Program Description

Exempt Recipients

Primary Care Physician (PCP)

Non-PCP Providers

Exempt Services

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Outpatient Visit Limits

If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP

Can either treat the recipient and not bill Medicaid

Offer to see the recipient as a private pay patient (enrollee pays out of pocket)

Request an extension using the 158-A form Issue a referral to a physician who will treat the

recipient

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Provider AssistanceProvider Assistance Provider Relations Telephone Unit:Provider Relations Telephone Unit:

800-473-2783 OR 225-924-5040800-473-2783 OR 225-924-5040 Provider Enrollment Department:Provider Enrollment Department:

225-216-6370225-216-6370 Correspondence Unit:Correspondence Unit: Unisys-Provider RelationsUnisys-Provider Relations

P.O. Box 91024P.O. Box 91024 Baton Rouge, LA. 70821Baton Rouge, LA. 70821 Field Analysts Field Analysts

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For Attending This 2008 Provider

Workshop

THANK YOU!THANK YOU!