Non-Medicaid Insured Changes Effective 7-1-03 (Formerly Gray Zone)

The following document highlights changes to the Public Mental Health System program covering the Non-Medicaid Insured population as of July 1, 2003. (Please note changes from the original document posted on the website.)

Public Mental Health System -- Uninsured Benefits Guide, Effective 7/1/03

Eligibility Requirements -- Providers

In order to meet eligibility requirements, providers must:

• be in the network of Maryland's Public Mental Health System (PMHS);
• be licensed or approved to provide the services they offer; and
• have an active Maryland Medicaid number.

Eligibility Requirements -- Consumers

In order to meet eligibility requirements, consumers must have a PMHS psychiatric diagnosis and meet medical necessity, and:

• be receiving Maryland Pharmacy Assistance; or
• be receiving SSDI for mental health reasons, or
• be homeless within the state of Maryland;
• be newly released from prison/jail/Department of Correction facility (w/in 3 months);
• be discharged (w/in 3 months) from a Maryland-based psychiatric hospital or residential crisis service; or
• receiving service as required by order of a Conditional Release.

Exceptions may be granted based on urgent need (Exceptions granted by MHA or CSAs).
[Providers treating new consumers that meet the above criteria after July 1, 2003, must contact MAPS-MD to register the new consumers and must request authorizations in accordance with the benefits package. In addition, under this benefits guide, providers must maintain income verifications of all consumers receiving services, which is subject to retrospective audit reviews.]

Summary of Benefits -- OMHC

Description Quantity of Visits Co-Payment

• 90862 & 90805 Unlimited* $2 Co-payment***
• All Other Outpatient Services 12 visits/year** $2 Co-payment***

* Medical management form must be submitted. The form will also trigger 12 unmanaged outpatient services visits (all other).
** No UTP needed for these services. UR will be completed retrospectively. UPT must be submitted to MAPS-MD for visit requests beyond 12.
*** Unless there is previously established co-pay greater than $2.00; the higher amount would apply.

Summary of Benefits -- PRP

Description Quantity of Visits Co-Payment

• Rehabilitative Services Up to 60 visits/year $2 Co-payment*
• In PRP receiving Sup.Emp. Up to 20(Additional) visits/year $2 Co-payment*

*Unless there is previously established co-pay greater than $2.00; then the higher amount would apply.

For the 60 visits providers will call MAPS-MD for authorization and there is no rehabilitation plan required for visit requests up to 60 per year (80 if in S.E). Providers requesting visits beyond the 60 but not exceeding 115 visits per year must submit a rehabilitation plan to MAPS-MD for approval. Providers requesting more than 115 visits must submit their request to MAPS-MD using form Uninsured PRP/RRP Authorization Extension. These should be rare requests. The expectation is for the provider to manage the visits and stay below the maximum of 115 visits. MAPS-MD will forward this information to the appropriate CSA for approval. If approved the CSA will forward the approval to MAPS-MD and copy provider on same. This process may take up to 10 business days, therefore, rehabilitation plans must be submitted prior to the end of treatment. The additional 20 supported employment visits are not counted toward the 60-115 visits.

If the provider does not agree with decision of the CSA, they may appeal to MHA.

Summary of Benefits- PRP W/RRP

• RESIDENTIAL REHABILITATION PROGRAM/Intensive Up to 10 visits PRP/per wk/ $2 Co-payment*
• RESIDENTIAL REHABILITATION PROGRAM /General Up to 5 visits PRP/per wk/ $2 Co-payment*

*Unless there is previously established co-pay greater than $2.00; the higher amount would apply.

For visit requests beyond the 5 per week for general and 10 per week for intensive, providers must submit a rehabilitation plan to MAPS-MD. These should be rare requests. The expectation is for the provider to manage the visits and stay below the 5/week or 10/week. MAPS-MD will forward this information to the appropriate CSA for approval. If approved, the CSA will forward the approval to MAPS-MD, and copy provider on same.

If the provider does not agree with decision of the CSA, they may appeal to MHA.

The above benefits package is subject to change based on funding availability.

Public Mental Health System -- Grant Transition Plan, Effective 7/1/03

There are 2,700 PRP/RRP consumers currently enrolled in the 2002 grant carve-out who will be transitioned back into the fee-for-service system by July 1, 2003.

Process

All consumers' currently enrolled and receiving services (based on claims activity) as of June 1, 2003, will be automatically enrolled back into the fee-for-service system with an eligibility period beginning July 1, 2003 through June 30, 2004. The total number of authorizations will be granted in accordance with the new uninsured benefits package to be implemented on July 1, 2003.

By July 11, 2003, providers currently treating consumers as of June 1, 2003, will receive an authorization letter verifying the new authorized service period.

OMHC

Twelve (12) unmanaged visits will be granted as usual. A treatment plan will be submitted for visit requests beyond 12.

PRP

Consumers meeting the above criteria will receive up to 60 visits per year with 20 additional visits if currently receiving supported employment.

RRP

Consumers meeting the above criteria will receive up to 5 general PRP or 10 Intensive PRP visits per week.

For additional visits all transition consumers will follow the new uninsured benefits guide.
NOTE: This "benefits guide" is for authorization only; regulatory requirements must continue to be met.

Questions and Answers Regarding the New Gray Zone Policy

Q: What is the status of gray zone consumers currently being treated in the Public Mental Health system who do not meet the new requirements for gray zone, i.e. a PMHS psychiatric diagnosis, medical necessity, and one of the 6 other requirements listed above?

A: Current consumers who lose Medical Assistance and do not meet the new requirements for uninsured benefits for the Public Mental Health system (i.e., Gray Zone) as of 7-1-02 are still eligible for gray zone benefits for a period of two years. In addition, any former (as of 7/1/02) Gray Zone or Medicaid consumer re-entering the system is also eligible to be returned to GZ status with an effective date of 7/01/03 for a period of 2 years. The benefit package for this population is subject to change.

Q: What are the procedures for obtaining authorizations for PRP benefits?
A: The individual must be registered with MAPS-MD and the individual must meet the requirements for presumptive authorizations, including medical necessity. Providers are encouraged to manage a client's symptoms within the number of visits provided in the new benefit plan for uninsured clients. If a client cannot be supported within the initial 60 visits per year in the guidelines, the provider should submit a rehabilitation plan requesting additional visits 2-4 weeks prior to exceeding the original allocations of authorizations. It is not appropriate for MAPS-MD to review rehabilitation plans with clinical information older than 2-4 weeks. Providers should indicate on the rehabilitation plan the estimated start date of the additional treatments.

If the consumer needs services that exceed 115 units, Providers should submit a rehabilitation plan requesting additional visits to MAPS-MD 2-4 weeks prior to the expected start date, attaching the Uninsured PRP/RRP Authorization Extension Request.

MAPS-MD will review the request for medical necessity and forward the request to the appropriate Core Service Agency for approval or denial. Denials may be appealed to MHA. The expectation is these will be rare requests and that providers will manage the visits to stay within the 60 or 115 authorized.

Q: Are Targeted Case Management-Medicaid consumers eligible for gray zone if they lose their Medicaid eligibility?

A: Yes


Medication Management

Requirements for Medication Management (Procedure Codes 90862 and 90805) have changed for all consumers, both Medicaid and Non-Medicaid Insured populations. A pre-authorization is no longer required.

However, a Medication Management form should be submitted to MAPS-MD and the Primary Care Physician (PCP) on all persons newly entering the Public Mental Health System. Specifically, the form applies to all new Medical Assistance, Pharmacy Assistance, and non-Medically Insured consumers. It should also be submitted when all previously authorized services have been used. It is the responsibility of the treating psychiatrist to keep both MAPS-MD and the PCP informed since coordination of care is a physician-to-physician responsibility. The form should be submitted annually to trigger the medication management visits and the other 12 preauthorized visits.

This form is intended to register the fact that the consumer is using the two following benefits: 90862 Pharmacological Management and 90805 Individual Therapy w/Medical Evaluation and Management Services benefits and to share information with the Primary Care Physicians.

The form does not need to be completed and resubmitted to MAPS-MD when there are changes in the consumer's medications. However, medication changes should be reported to the PCP as part of coordination of care.

Please note that this form was recently revised. All new medication management requests must use the 7/1/03 revised form. Medication management visits are distinct and separate from all other outpatient services and do not count towards the 12 unmanaged outpatient visits allowed consumers. The form will automatically authorize the 12 unmanaged visits and the medication management visits.

Grant Funding Transition

The grant funding of gray zone consumers for RRP and PRP services ended June 30, 2003. Fee-for-service payment to Providers will begin with 7-1-03 dates of service. The 8G edits no longer are applicable. Providers should note that you will need to obtain authorizations for the services prior to treating the patients. If authorizations are not on file, the claims will deny. See the official announcement from Dr. Brian Hepburn.

Treatment Plan Follow-Up

We are committed to processing your treatment/rehabilitation plans as expeditiously as possible. If you need feedback as to the status of your plan, please wait at least seven days for feedback from MAPS-MD. While we strive to process the treatment plans as quickly as possible, sometimes we have to coordinate our response with other parties or reviewers, which can add to processing time. If you have not received a fax or letter confirming approval after one week, please make your inquiry as follows:

• Check the website, www.gzmd.com for the approval.
• If you do not find the approval on the website, call 1-800-888-1965 for further information.

Medicare-Medicaid Crossover Claims

The Department of Health and Mental Hygiene's Medicaid Program has taken over the processing and payment of electronic and paper claims for individuals who received specialty mental health services and are covered by both Medicaid and Medicare (Medicare crossover claims).

The transition over to Medicaid is based on the Medicare payment date, not the service date. Medicaid will process and pay claims that have a Medicare payment date of June 30, 2003, or later.

ELECTRONIC CLAIMS

There is no change in the submission process of electronic claims for providers; however, providers now will receive payment checks from Medicaid rather than Maryland Health Partners (MAPS-MD). Providers can expect to begin receiving payments from Medicaid according to the timeframes described below.

Medicare Intermediary: CareFirst

All electronic claims (Medicare Part A and Part B outpatient only) transferred prior to June 30, 2003, by the Medicare Intermediary, CareFirst, reflected a Medicare payment date of June 29th or earlier. Claims transferred on June 30, 2003, reflected a Medicare payment date of July 1, 2003. Medicaid, therefore, began processing and paying electronic claims received from CareFirst on June 30, 2003.

Medicare Carrier: Trailblazers

Medicare Part B claims transferred electronically on July 7, 2003, by the Medicare Carrier, Trailblazers, reflected a Medicare payment date of June 30, 2003. Medicaid, therefore, began processing and paying electronic claims received from Trailblazers on July 7, 2003.

PAPER CLAIMS

Medicaid also is sending payment checks to providers for paper claims. The paper claim submission process for providers changed as well. Providers should submit their paper claims to Medicaid based on the Medicare payment date. Claims that have been paid by Medicare on or after June 30, 2003, should be submitted to Medicaid with a copy of the Explanation of Medicare Benefits. Providers should continue to send claims with Medicare payment dates prior to June 30, 2003 to MAPS-MD.

Please use the following addresses when submitting your claims.

Medicare Payment Dates Prior to June 30, 2003

Medicare Payment Dates On or After June 30, 2003

Claims submitted to MAPS-MD with Medicare payment dates on or after June 30, 2003, will be denied by MAPS-MD and will not be forwarded to Medicaid. Likewise, Medicaid will deny claims it receives with Medicare payment dates prior to June 30, 2003, and will not forward them to MAPS-MD.

Should you have any questions, please call Medicaid's Provider Relations Unit at 410-767-5503.

Provider Survey

The first mailing of the Provider Survey will be going out the week of July 21, 2003. We encourage all Providers receiving the survey to respond. Your organization may receive multiple surveys since we are trying to obtain the views of different programs involved with the Public Mental Health System. Please forward these surveys to the appropriate persons in your organization. Thank you for your assistance on this effort to obtain your views on the functioning of the Public Mental Health System.

Centralized Referral Center

The Central Admissions Referral Center located at the Walter P. Carter Center now handles all psychiatric preadmission authorizations of medical necessity to the State Hospitals, whether Medical Assistance, Non-Medical Assistance Insured, or uninsured consumers, if no placement is available in a private facility. This change was effective May 19, 2003. Admissions for individuals with Medicaid, should be approved for medical necessity by MAPS-MD. If no private bed is available, the Emergency Department shall contact the Central Referral Center for assistance in placement. If the consumer is not insured (Private or Medicaid) and no bed is available in the referring ED's hospital, the ED should contact the Central Admissions Center for authorization and placement. MAPS-MD will continue to provide concurrent reviews for consumers exceeding the initial authorizations. The contact number for the initial authorizations is 410-209-6354 or 1-800-MD-ADMIT. For Medicaid and private insurance consumers, the Central Admissions Referral Center should be contacted only after a reasonable effort to locate a placement in a non-State facility.

V4 EX Code

The EX code V4 that has begun to appear on the EOP's was started at the beginning of July and is intended to start informing providers that HIPAA compliant codes are soon going to be required. This is an informational only message and has no bearing on the adjudication process (i.e., payment or denial).

At this point, the final HIPAA compliant code sets for Maryland have not been released.

Provider Training Sessions-Questions and Answers

Approximately 150 persons from all parts of the State attended the June Training Sessions. We thank you for your participation and hope that you felt the training was useful. For those parties who did not attend and to document responses we are publishing many of the questions raised at the meetings and the answers.

Billing Questions

Q: If the consumer's finances have changed since a co-pay was established at 36% in 2000, how can the co-pay be changed.
A: Contact the CSA, and request a re-determination of the co-pay.

Q: Do DCW forms still need to be submitted?
A: No

Q: If a Medical Assistance consumer in a PRP program loses eligibility and is eligible for non-Medicaid insured (NMI)benefits, when does the provider begin collecting the co-pay?
A: As soon as the NMI status is established.

Q: What are the criteria for being homeless?
A: In general, the answer is anybody without a permanent fixed address where they can receive mail. A person in a shelter is considered homeless. A person living with parents is not considered homeless. The facts and circumstances of each case will determine homelessness.

Q: How should the provider handle the situation where a Medicaid consumer has private insurance and it is not listed in EVS?
A: Contact DSS with the details.

Q: Is diagnosis code 787.6, Incontinence of feces, payable?
A: Yes. There is an issue that responsibility for such claims be transferred back to Medical Assistance and the MCO's, but no decision has been reached in that regard at this point.

Q: Are CPT codes not on the approved MAPS-MD list payable by the Public Mental Health System?
A: No

Q: What is the location code for Hospice?
A: 34

Q: What is the code for one-on-one Behavioral Aide services?
A: One unit of W9115 is billed per hour of service. An OMHC or mobile treatment center may also bill a 90801 or 90806 for assessments. These codes all require pre-authorization.

Q: Can 90862 be billed with a C modifier?
A: Yes, this was allowed for OMHC's effective 7-1-2002.

Q: What are the WebMD contact numbers?
A: Customer Service is 1-888-305-3756 and Software Support is 1-800-836-6039

Q: What are the rules related to balanced billing?
A: Balance Billing is the practice of billing for the difference between the amount charged by the provider and the amount paid by the payor. Medicaid regulations require that a provider "Accept payment by the Program as payment in full for covered services rendered and make no additional charge to any person for covered services." Any Medicaid provider participating in balance billing is in violation of his/her agreement with the State's Medicaid Program, and is thus subject to sanctions, including termination from the Program. A provider is responsible for educating staff personnel on this issue and supervising staff so that balanced billing does not occur.

It is also imperative that providers obtain necessary pre-authorizations and bill the appropriate entity when a recipient is covered by Medical Assistance. The recipient should not be billed. The only exceptions to this statement are situations where a recipient knowingly chooses to be served by a provider, without the necessary preauthorization or referral, or requests an uncovered service. In such situations the provider must obtain a form, signed by the recipient or legal guardian, clearly stating that the recipient is on Medical Assistance and is knowingly choosing to be seen, even though EVS and/or their assigned MCO tells them it is an unauthorized procedure/visit and not covered under the Medical Assistance Program. (Source: Maryland MA Program, General Provider Transmittal #51, February 16, 1999.)

Clinical Questions

Q: For outpatient visits, what happens when a patient transfers to another provider for therapy after receiving the initial 12 unmanaged visits?
A: The consumer will receive the usual 4 unmanaged visits as before.

Q: Are on- and off- site PRP services combined as part of the initial 60 units or are they separate authorizations?
A: They are combined.

Q: Will there be documentation by the Customer Service Representative or Care Manager of the eligibility criteria that is met then unmanaged visits or other levels of care for the uninsured are being reviewed/entered?

A: The reason for eligibility will be listed when the CSR/CM builds the case.

Q: Will the PRP/RRP organizations automatically receive authorization letters from MAPS-MD for the non-Medicaid insured consumers?
A: Yes, MAPS-MD's Treatment Plans Unit will be sending these letters out.

Q: What should I do if I am not receiving authorization letters regularly?
A: Call Customer Service, 1-800-888-1965.

Q. What happened to consumers who receive PRP services from 2 different PRP's?
A. The benefit is for an amount of visits per consumer, not per agency. Both providers and the consumer must plan the utilization of the visits. The CSA is to mediate these situations when PRP's are not able to negotiate.

Q. Do providers still need to complete the IRP and the ITP for gray zone.
A. Yes. Programs are required to comply with all state and federal regulations.

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