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Illinois Department of Human Services / Division of Mental Health and Illinois Mental Health Collaborative Present. January 2010. CHP Direct Claims Submission Training. Claims Training Agenda. Overview of CHP Services Billing Guidelines Direct Claim Submission on ProviderConnect

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Illinois Department of Human Services /Division of Mental Health and Illinois Mental Health Collaborative Present

January 2010

CHP Direct Claims Submission Training


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Claims Training Agenda

  • Overview of CHP Services

  • Billing Guidelines

  • Direct Claim Submission on ProviderConnect

  • Claim Helpful Hints


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CHP Claims

Under the Collaborative IT system, all services are submitted as claims and all claims must be submitted electronically

Community Health and Prevention Service claims may be submitted to the Collaborative for dates of service 8/1/2009 and after.

Program Code: CHP

3






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Registration Requirement

Before claim is submitted, consumer must be registered by the agency performing the service


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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


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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


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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


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Claim Level Information (cont.)

Program Codes

  • Submit the Program Code for the service provided:

  • Program Code: CHP


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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/


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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 claim will be denied unless the service does not require a Staff Level Modifier

  • Modifier Position is very important

    • Staff Level Modifier should always be in the last modifier position when multiple modifiers are submitted


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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


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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.


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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:

  • 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


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Review Services Matrix

The Service Matrix is posted on the Collaborative Website in an Excel Spreadsheet that youmay download.

http://www.illinoismentalhealthcollaborative.com/




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Submitting Corrected/Replacement Claims

  • When an original claim was incorrectly billed, send a corrected or replacement claim by indicating the Claim Frequency Type Code

    • 6=Corrected

    • 7=Replacement

  • Enter the Collaborative’s original Claim Number




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    Helpful Hints to Faster Claim Processing

    • Submit the correct Consumer RIN in the Consumer ID field

      • if the RIN doesn’t match the DHS assigned number, the claim will be uploaded to our claims processing system identifying the Consumer as “UNKNOWN”


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    Helpful Hints to Faster Claim Processing (cont.)

    • Multiple units of service rendered by the same practitioner staff level, on the same day, for the same client, must be submitted on one claim.

      • All units for one service code must be submitted on one line.

      • If claims are submitted separately, claims will be denied as a duplicate service.


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    Helpful Hints to Faster Claim Processing (cont.)

    • Example:

      H2015 HN Community support, individual (MHP) For Consumer RIN 123456789

      • 10 AM 4 units, noon 2 units, 6PM 3 units

      • Submit H2015 HN on one line, with 9 units. Start time is 9999, duration: 135 minutes


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    Helpful Hints to Faster Claim Processing (cont.)

    A separate claim must be submitted for every different staff level rendering services (except for multiple disciplinary groups)


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    Most Common Reasons for Claim Denial

    Consumer Information:

    • RIN doesn’t match the RIN assigned by DHS or registration

    • Service code on the claim is not on the list of covered services

    • Service code billed is not one the provider is contracted to render (the service is not on the provider’s fee schedule).

    • Consumer is not eligible/registered on the date of service.


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    Most Common Reasons for Claim Denial (cont.)

    Codes/Modifiers

    • Place of service code on the claim is not a valid place of service code for the service rendered

    • Modifier code billed on the claim is not valid with the CPT or HCPCS code

    • Staff level modifier is not billed on the claim

    • Diagnosis code is not an ICD-9 code

    • Diagnosis code does not contain a required 4th or 5th digit


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    Most Common Reasons for Claim Denial (cont.)

    Billing

    - Duplicate/Non-Rolled Services

    - Third Party Liability

    - TPL not billed with claim

    - TPL information on claim incomplete


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    Timely Filing of Claims

    • Claims for all services must be received by the Collaborative within 365 days of the date of service

    • Claims Involving Third Party Liability (TPL)must be received by the Collaborative within 365 days of the date of the other carrier’s Explanation of Benefits (EOB), or notification of payment / denial.

    • Timely filing limit applies to replacement claims as well as original claims; claims must be received by the Collaborative within 365 days from date of service.



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    Thank you!

    Illinois Mental Health Collaborative for Access and Choice