Billing for Habilitation ServicesMagellan Health Services

June 11, 2013

Billing for Services

Magellan providers billing for Iowa Medicaid Habilitation (HAB) services must bill with HIPAA-compliant codes for services rendered beginning July 1, 2013. Claims submitted with non-HIPAA compliant codes (e.g. old W codes) will be denied.

Provider Billing Tips

• Coding changes are effective July 1, 2013.• Billing the new HIPAA codes is mandatory; non-compliance is a

HIPAA violation.• The switch to the new HIPAA codes is based on the date of service,

not the date the claim was submitted.• Be sure to include required modifier.• Use covered diagnosis codes.• Use valid place of service codes.• Submit claims timely. Timely filing limit is 1 year from date of

service.• These services require pre-authorization. To authorize services,

please call 1-800-638-8820 to schedule an appointment.

Provider Billing Codes

IA Medicaid HAB Service Name Time Unit/Basis Old W CodeNew HIPAA Code

HIPAA Modifier*

Day Habilitation Per 15 Min W1206 T2021 UC

Day Habilitation Per Day W1204 T2020 UC

Home-based habilitation Per 15 Min W1207 H2015 UC

Home-based habilitation Per Day W1208 H2016 UC

Pre-Vocational Services Per Hour W4425 T2015 UC

Pre-Vocational Services Per Day W1425 T2014 UC

Supported Employment: Maintain employment/job coaching Per 15 Min W1431 H2025 UC

Supported Employment: Maintain employment/enclave Per 15 Min W1433 H2023 UC

Supported Employment: Job Development Per Unit W5019 T2018 UC

Supported Employment: Employer Development Per Unit W5020 H2024 UC

Supported Employment: Enhanced Job Search Per 15 Min W5021 H2019 UC

*For all Iowa Medicaid Habilitation services, the UC modifier must be included on claims. Claims for this service submitted without this modifier will be denied.

Magellan Covered Diagnosis

Code Description290 Senile and presenile organic psychotic conditions291 Alcoholic psychoses292 Drug psychoses293 Transient organic psychotic conditions294 Other organic psychotic conditions (chronic)295 Schizophrenic disorders296 Affective psychosis297 Paranoid states298 Other non-organic psychosis (i.e. emotional stress, environmental

factors as major part of etiology)299 Psychoses with origin specific to childhood300 Anxiety states301 Personality disorders302 Sexual deviations and disorders306 Physiology malfunction arising from mental factors307 Special symptoms or syndromes, not elsewhere classified308 Acute reaction to stress309 Adjustment reaction311 Depressive disorder, not elsewhere classified312 Disturbance of conduct, not elsewhere classified313 Disturbance of emotions specific to childhood and adolescence314 Attention deficit disorder

Note: 310.00-310.99 – Mental Retardation is NOT covered.

Place of Service (POS) Codes

Code Definition Code Definition

03 School 32 Nursing Facility

04 Homeless Shelter 33 Custodial Care Facility

11 Office 49 Independent Clinic

12 Home 50 Federally Qualified Health Center

13 Assisted Living Facility 53 Community Mental Health Center

14 Group Home 54 Intermediate Care Facility

22 Outpatient Hospital 57 Non-residential SA Treatment Facility

23 Emergency Room 71 State or Local Health Clinic

31 Skilled Nursing Facility 72 Rural Health Clinic

Rounding Rules – 15 Min. Unit

• Add together the minutes spent on all billable activities during a calendar day for a daily total.

• For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.

• Round the remainder using these guidelines: round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.

• Add the number of full and rounded units to determine the total number of units to bill for that day.

• Providers will not determine daily units by the number of encounters they have with the member during a day, but by the total amount of time spent with the member.

• Units will not be determined by adding the number of minutes of service for the month and then dividing; units are to be determined on a daily basis.

Rounding Rules – Hourly Units

• Add all the minutes provided for a day.

• When the total minutes for the day is less than 60, round up to one (1) whole unit.

When the total minutes for the day is more than 60, divide the total by 60 to get the number of hours for the day. This should be rounded to the nearest whole unit, by rounding down for 1-30 minutes, and rounding up for 31-59 minutes.

•

Daily Units

• Daily Home-Based HAB is defined as 8 or more hours per day, based on the average hours of service provided during a 24-hour period as an average over a calendar month.

• Day HAB and Prevocational Services, the daily unit is defined as 4.25 to 8 hours per day. There is no averaging for these services.

Authorizations

• Existing service plans for HAB services active as of July 1, 2013, will be honored by Magellan.

• Magellan staff will be reviewing service plans for members whose plan has an end date of August 2013.

• Magellan staff will be contacting HAB providers on any existing ETP needing renewal.

• For new HAB clients July 1, 2013 or after – the case manager or Integrated Health Home (IHH) staff should contact Magellan at 1-800-638-8820 to make an appointment to review a new HAB request.

Getting Paid• Claim Submission

– Electronic Claim Submission – Paper Claim Submission

• Submit a “Clean” Claim

• Submit Within Timely Filing Guidelines – Claims must be completely adjudicated within one year of date of

service.

Top Claim Denial Reasons

• No authorization• Client not eligible for services• Duplicate claim submission• Invalid diagnosis codes• Invalid CPT/HCPCS codes• Invalid or missing modifier or place of service code• Missing name and degree of provider – CMS 1500 only• Site not contracted/credentialed

– Sites ON contract means you should bill that rendering site.– Sites NOT on contract means you should bill the main site as the

rendering site.

Electronic Claim Submission – Preferred Method What’s in it for you?

• Improved Efficiency – No paper claims, envelopes or stamps. – Prompt confirmation of receipt or incomplete claim.

• Faster Reimbursement – cuts out the mailman, “clean” claims processed within 36 hours.

• Improved Quality – Up-front electronic review ensures higher

percentage of clean claims. – Secure process with encryption keys,

passwords, etc.

Electronic Claim Submission Options

• Claims Courier – Magellan’s Web Option – Small volume submitters

• Direct Submission to Magellan – Medium to high volume submitters

• Clearinghouse – Large volume submitters

Website Resources

• www.MagellanProvider.com

• www.MagellanofIowa.com

On-Line Resources

On-Line Resources, cont.

Electronic Claim Submission – On-Line Training Available

• Go to www.MagellanProvider.com .• Choose “Education”, and then “Online Training”. • The section on “Electronic Transactions” includes the

following demos: – 835 Transactions – Clearinghouse – Submit EDI Claims – EDI Testing Center – Electronic Funds Transfer

Claims/Website Contact Information

General Billing Questions Customer Service at 1-800-638-8820.

EDI Technical Assistance Getting Started – visit our EDI Testing Center at

www.edi.MagellanProvider.com EDI Hotline at 877-326-7525, ext. 75841 or

email edisupport@magellanhealth.com.

General Website Technical Assistance For all other website technical assistance, call

Provider Services at 800-788-4005.

Magellan Customer Service Contact Information

Customer Service – 800-638-8820; Fax 888-656-5302

Christine Bryant, Customer Svc. Supervisor, 515-273-5009 Email – CRBryant@MagellanHealth.com

Dennis Petersen, Director, Operations, 515-273-5044 Email – DAPetersen@MagellanHealth.com

Claims address:PO Box 1869Maryland Heights, MO 63043

Customer Service address: PO Box 71129 Des Moines, IA 50325

Questions?