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Illinois Department of Human Services / Division of Mental Health and Illinois Mental Health Collaborative Present. March 2009. ICG Claims Submission Training. ICG Claims.
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Illinois Department of Human Services /Division of Mental Health and Illinois Mental Health Collaborative Present March 2009 ICG Claims Submission Training
ICG Claims ICG Residential and Community Service claims may be submitted to the Collaborative for dates of service 4/1/09 and after. Program Codes: Residential - ICG Community - ICGC 2
ICG Residential Per Diem and Community Services Workflow Provider submits claim to Collaborative Collaborative processes claim resulting in a Provider Voucher or 835 Collaborative sends claim information to DHS/DMH DHS/DMH issues payment to provider 3
ICG Residential ServicesClaim Submission Authorization is required Submit on 837P or Direct Claim Submission Quarterly Report is required timely. If not received, claims for dates of service after it is due will be denied Per Diem and Encounter Claims are submitted separately 4
ICG Residential ServicesClaim Submission Per Diem Codes – submit actual charges Always bill residential services with place of service code 11 Bill Per Diem Room & Board type codes with 1 unit/day 5
ICG Residential Services Encounter Services Claim Submission Encounter services are the professional services provided during residential stay Use Program Code ICG for encounter services during a residential stay Use Place of Service code 11 See Website http://www.illinoismentalhealthcollaborative.com 6
ICG Residential Encounter ServicesClaim Submission, continued Message code on Provider Voucher states that services were included in per diem 835 message code is 97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. 7
ICG Claims - Quarterly ReportResidential and Community Service Claims will reject if quarterly report is not submitted. Once submitted, provider is responsible to resubmit rejected claims. 8
ICG Community ServicesClaims Submission Use Program Code ICGC Follow Service Matrix for covered Community Service codes Follow same rules as submitting ABC services (rolling services, units, etc.) 13
ICG Community Services Two services require an authorization after maximum is met: W072M - ICG Child Support Services Authorization is required after $1570 in approved claims per consumer in the fiscal year W097M - ICG Behavior Management Authorization is required after $3500 in approved claims per consumer in the fiscal year 14
Questions? 16
Claims and Service Reporting Training Agenda • Billing and Service Reporting Guidelines • Direct Claim Submission on ProviderConnect • HIPAA 837P Technical Information • EDI Claims Set-up • Claim Helpful Hints • Billing with Psuedo-RINs • eClaims link on ProviderConnect
Service Reporting Under the Collaborative IT system, all services are submitted as claims. Mental Health claims must be submitted electronically and meet all HIPAA compliance standards • HIPAA standards govern both the file format and the codes used within the file • Some claims require data elements for which there are no standard fields. The notes fields will be used to submit these values
HIPAA 837P Software The Illinois Collaborative will accept all HIPAA compliant 837P formatted files Files must include all required DHS/DMH data elements The Illinois Collaborative provides free electronic claims submission software • eClaims Link, or • Direct Claims Submission (web-based)
Billing Guidelines Required Claims Data
Registration Requirement Before claim is submitted, consumer must be registered by the agency performing the service
Consumer Information • Standardized claims transactions require certain consumer information to verify the individual’s identity • The Collaborative has minimized the consumer information necessary for a claim to be submitted, while assuring that each service claim is correctly associated to the appropriate consumer
Claim Level Information Consumer Information Required • RIN • Consumer Name • Date of Birth • Gender • All must match exactly to the registration informationon file • Consumer address is optional
Claim Level Information(cont.) Pseudo RIN • Appropriate only for specific services when a specific consumer isn’t identified • A list of these pseudo RIN numbers, name, and date of birth is provided on-line at http://www.illinoismentalhealthcollaborative.com/ For example, ICG Application Assistance can be billed with a pseudo RIN if consumer information is not available.
Claim Level Information(cont.) Provider Information required on each claim • 10 digit NPI number that matches the NPI on file with the Collaborative • Tax ID Number (FEIN) • Service Location • Taxonomy Codes are optional Service code and modifier combinations will identify staff level
Claim Level Information(cont.) Subcontractors The Subcontractor’s Federal Employer ID Number (FEIN) must be provided when subcontracting services to a different agency
Claim Level Information (cont.) Program Codes • Submit the Program Code for the service provided: • Program Codes: Residential - ICG Community - ICGC
Claim Line Level Information Service Codes • Service codes must be valid HCPCS or CPT codes as shown on Service Matrix found at http://www.illinoismentalhealthcollaborative.com/ • Service code S9986 is used when a “W” code specifies the service. The W code is entered in claim line notes (LOOP 2400)
Claim Line Level Information (cont.) Modifiers • Staff Level Modifiers drive the allowable amount applied to a service • If no staff level modifier is submitted, the lowest allowable amount for the service code is assumed • Modifier Position is very important • Staff Level Modifier should always be in the last modifier position when multiple modifiers are submitted
Claim Line Level Information (cont.) Staff Level Modifiers • AH – LCP - Licensed Clinical Psychologist • HN – MHP - Mental Health Professional • HO – QMHP - Qualified Mental Health Professional • SA – APN -Advanced Practice Nurse • HM – RSA - Rehabilitative Services Associate • UA – MD, DO, DC
Claim Line Level Information (cont.) Diagnosis Codes • Must be ICD-9 and include 4th and 5th digit according to ICD-9 guidelines • Only Mental Health diagnoses that are DMH/DHS defined will be accepted.
Claim Line Level Information (cont.) Line Notes For all services, the following are required: • Delivery method • Service start time • Service duration • Staff ID Situational Requirements: • Activity code is required for S9986 services • For group based services show the group id, # clients in group, and # of staff in the group DMH considers these data elements to be important and necessary components of billing and service reporting
Review Services Matrix The Service Matrix provides the following information: Specific activities/services that are to be reported for S9986 Information regarding the use of specific pseudo-RINS for consumers who are not identifiable (previously referred to as unregistered consumers). This information will be posted on the Collaborative Website in an Excel Spreadsheet that youmay download. http://www.illinoismentalhealthcollaborative.com/
Direct Claim Submission For all providers
EDI Claims Link/Batch submissions • The Collaborative can receive your 837 Batch transaction directly • Access the Collaborative web site at www.valueoptions.com • Access “For Providers” on the left hand side of the screen • Access Handbooks – Administration- Online Services. • Required Forms referenced in Online Services are available by accessing the forms menu on the left side of the screen • EDIhelp is available from eSupport Services at 1.888.247.9311 (Mon-Fri. 8am – 6pm EST)
