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Department of Social Services Behavioral Health Claims Overview . Behavioral Health Transition Committee February 10, 2006. BH Medical Management and Claims Responsibilities. MCOs’ Provider Contract Requirements.
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Department of Social Services Behavioral Health Claims Overview Behavioral Health Transition Committee February 10, 2006
BH Medical Management and Claims Responsibilities
MCOs’ Provider Contract Requirements • Prior Authorization/Registration of Services are Required for Claim Payment • Claim Timely Filing Requirements • Anthem – 120 Days • CHN – 120 Days • HealthNet – 90 Days • WellCare – 60 Days • Clean ClaimPayment Requirements • Payment in 45 days
MCOs’ Provider Contract Requirements • Only codes described in the provider contracts are payable • Timely Appeals* from the date of remittance • Anthem – 60 Days • CHN – 60 Days • HealthNet – 60 Days • WellCare – 30 Days
Unclean Claim Does not make it into the claims processing system and is returned to the provider There is missing information on the claim e.g.. provider I.D./member I.D. There is incorrect information on the claim e.g. future dates of services When an unclean claim is returned, the resubmittal of that claim has to fall w/in the MCO’s timely filing limit. Clean Claim A clean claim is processed and adjudicated Information submitted is accurate and complete Accurate and complete information is accepted and adjudicated in the claims system Can be appealed within the MCO appeal time frames, if denied Claim Characteristics
Claims Responsibilities Summary • All MCO and provider rights and responsibilities related to claims apply to dates of service prior to January 1, 2006, including: • Timely Filing • Clean claim definitions • Appeal time frames • Timely payment requirements
DSS Requirements for all MCOs’ • Completion of all appropriate obligations for services prior to January 1, 2006 • Financial consequences for non compliance • Formal plans for service transition and coordination, subject to DSSs’ review and approval • The MCO shall be held directly accountable and liable for all of the contractual provisions under its contract regardless of whether the MCO chooses to subcontract their responsibilities to a third party.
