MAPS-MD Claims Readjudication Process - MAPS-MD is in the process of finalizing a complete readjudication of all pended claims for all HCFA 1500 claim submitters. This project will be completed by 12/18/98. The final results of this project will appear on EOP 554, which subsequently will be a very large volume of claims, as this project is on target to release 80-85% of all claims pending in the MAPS-MD system. You will then need to work any remaining denials for appropriate resolution and payment.

GUIDELINES FOR CLEANING UP MAJOR DENIAL CATERGORIES

Eligibility Denials (C28 & QG3)

• Gray Zone Consumer denied as ineligible (QG3) - check Gray Zone Web Site (www.gzmd.com) for eligibility.
• If consumer is not GZ eligible on DOS, has DCW and Income Verification been submitted to MAPS-MD prior to third visit? These claims must be rebilled once the appropriate information has been submitted.
• If consumer has lost MA eligibility, even for a short term period, has the consumer been registered as GZ
• Verify Consumer eligibility with EVS (C28)
• Is consumer eligible for MA on DOS?
• Is consumer only eligible for "Pharmacy Assistance" or "Family Planning" on DOS? (You must listen to entire EVS message to obtain this information). If so you must register the consumer as GZ and rebill the services.

Authorization Denials (C18, C21, C23, & C35 )

• Has Authorization been requested and issued by MAPS-MD? (C21)
• Does the authorization period begin after the dates of service billed? (C18)
• Have you requested and been authorized for appropriate number of units and billed for the number of units authorized? (C23)
• Is the amount of time authorized appropriate? (C35)
• If Authorization request is greater than 90 days retroactive, you must contact your CSA to obtain approval for MAPS-MD to authorize services.

Once your authorization issues have been resolved, you will need to rebill to receive reimbursement.

Invalid and/or missing diagnoses codes, billing modifiers, and invalid procedure codes (QSC, QDC, & QSV )

• Have you billed with a diagnoses code covered by the Public Mental Health System (Provider Manual p. 16-2-0)? (QDC)
• Have you used an appropriate billing modifier?* (i.e.: C modifier for children’s services) (QSC)
• Inappropriate procedure codes* (i.e.: billing 1998 dates of service with 1997 CPT codes) (QSV)

*You can reference the "Service Matrix" section of the Provider Manual for correct information on billing and coding

Other Frequent Denials (QPR & QNR)

• Are the providers in your group practice linked to the group appropriately (QPR) - call MAPS-MD Provider Relations to verify
• Have you included the rendering provider MA# in Box 19 of the HCFA 1500 (QNR)

FOR CLARIFICATION ON ANY DENIAL YOU CAN CALL THE MAPS-MD CLAIMS CUSTOMER DEPARTMENT AT 800-565-9688. CLARIFICATION OF ALL CLINCIAL AND AUTHORIZATION DENIALS SHOULD BE DIRECTED TO THE CLINICAL LINE AT 800-888-1965.

Authorization Letters - Just a reminder, if you bill for services at the same time you submit a request for authorization, your claims will deny in most instances for "No Authorization". Therefore, you need to wait until you received the Authorization Letter from MAPS-MD before you bill. This will ensure that the Claims system has been updated with the Authorization and allow your claims to pay.

PRP (Housing/Intensive Level Staffing) - Effective 12/7/98, there will be a new code (W9550) - Combined Housing/Intensive Level Staffing. This code can be used in lieu of W9507 and W9508. The billing modifiers for the new code will remain the same. Any previous/existing authorizations, for Intensive Staffing, will still enable you to bill the new code (W9550). Furthermore, if you bill the old codes (W9507 & W9508) you will be reimbursed the correct rate.

Enhanced Support - must be paper billed (includes Enhanced Support when providing Respite services for children)

New Mobile Treatment CPT Code – The new Mobile Treatment CPT code for consumers receiving mobile treatment services who have Medicare coverage is W9549 (W9549-S for deaf consumers).

Unlicensed Clinicians – Private practitioners of any discipline are not allowed to bill for services delivered by unlicensed clinicians (i.e. students, LGSW’s or interns). Only Outpatient Mental Health Centers and Hospitals with formalized training programs are allowed to utilize students, LGSW’s and interns and bill for their services.

Overlapping Services – Providers cannot bill for outpatient clinical services while a consumer is in a hospital, except for one psychiatrist visit per day and certain pre-authorized transition services..

Pharmacy Benefits Management – Effective January 4, 1999, the Maryland Medical Care Operations Administration, using First Health as its pharmacy benefits manager, will assume responsibility for the processing and payment of prescriptions for all Medical Assistance Fee-For-Service prescriptions filled on behalf of the Public Mental Health System.

Provider Manual Corrections:

Mid-Shore Mental Health (p. 1-5-0) - correct address: 8706 Commerce Drive, Suite 3, Easton, Maryland 21601