HIPAA

The following two notices on Contingency Plan and HIPAA Compliant Code Sets were distributed by the Maryland Mental Health Administration:

Public Mental Health System
Contingency Plan

HIPAA Compliance

The Mental Hygiene Administration (MHA) and Maryland Health Partners (MAPS-MD) will implement a contingency plan to accept and send certain Health Insurance Portability and Accountability Act (HIPAA) non-compliant electronic transactions for Public Mental Health System (PMHS) fee for service claims after the October 16, 2003 compliance deadline. To paraphrase the Centers for Medicare and Medicaid Services (CMS) announcement concerning Medicare, implementing this plan moves the PMHS towards HIPAA compliance and providers cash flow and operations so that consumers continue to receive the mental health services that they need. The authority to implement this contingency plan was provided by guidance issued from Health and Human Services on July 24, 2003. Implementing the contingency plans allows providers and our trading partners more time to test and successfully implement the transactions and new code sets.

The contingency plan allows the PMHS to continue to accept and process claims in the electronic formats and paper versions now in use as well as send the electronic remittance advice in the current format. Providers, and their billing companies or clearinghouses, should continue to test and move towards implementation of the HIPAA standard claim and remittance advice transactions as soon as possible. MHA will publish a preliminary set of HIPAA compliant codes prior to October 9, 2003. There will also be a publication of the final code set for PMHS claims within the next two months. There will be a minimum of 30 days between the publication of the final HIPAA compliant code set and the implementation of these codes and the new formats.

Public Mental Health System
Preliminary Listing
HIPAA Compliant Code Set

CPT Coding. For services that are currently billed using CPT codes, very little change is anticipated. The modifier "HW" will be added to every CPT code to allow the identification of the claim as one which is funded by the Public Mental Health System (PMHS). Modifiers currently in use will either be eliminated or replaced with modifiers which are contained in appropriate national code sets. It is expected that a maximum of three modifiers (i.e, two in addition to the HW modifier) will be required to bill any codes which are currently in use in the PMHS fee for service system.

Other Codes. Below please find a listing of several of the local codes which are currently in use in the Public Mental Health System. Associated with each of these codes is a Healthcare Common Procedure Coding System (HCPCS) code which will comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). This is a preliminary listing and does not fully represent the final code set. Psychiatric Rehabilitation Program codes and Residential Rehabilitation Program codes are still under development. However, this listing should allow planning for the changes that will be required to reconfigure billing and other software to meet the new requirements. The following guidelines should prove helpful in preparing the system and software changes necessary to bill using the new code sets. As with CPT codes, each new code will be modified by HW indicating that the claim is to be funded through the PMHS. A maximum of one additional modifier will be used to bill any codes which are or will be in use in the PMHS fee for service system.

PMHSpreliminary10031.pdf

Protected Health Information
Please do not e-mail claims status inquiries or other inquiries including consumer names or other identifiers such as social security number or MA number to MAPS-MD. We do not consider e-mail is sufficiently secure to protect the consumer's privacy rights. You should make your inquiry using our secure fax lines or telephone. If e-mail is necessary and there is no practical alternative, MAPS-MD expects providers to send the protected health information in an Excel or Word file that is password protected. Please do not include any patient identifiers in the body of the communication.

Claims Update

CODING CLARIFICATION - OMHC SERVICES
The following clarification on the appropriate use of CPT codes for OMHC services has been received from Dr. Brian Hepburn, Executive Director, Mental Hygiene Administration. These changes are effective December 1, 2003.

CPT codes 90808, 90808C, 90809, 90809C, 99354, 99355, 90853E and 90853CE are extended OMHC service codes and should not be considered interchangeable with other OMHC CPT codes. These services require separate authorizations. Additionally, MAPS-MD should consult with the CSA(s) before authorizations for these codes are granted.

This announcement also clarifies the language in the 2001 Provider Manual, pages 5-13-4: W9541, W9542, and W9543 are codes for off-site services delivered to persons living in an independent situation (i.e., their own apartment or home) without supports from others, such as: Parents, Foster Parents, RRP, Group Home, etc. The higher rate for these codes is to compensate for this higher level of support to persons who have no live-in, immediately available, or on-going assistance from others. The codes W9500, W9501 and W9506 are to be used for persons living in a supported environment (with parents in a care giver role, RRP, Group Home, etc.). It is anticipated that unless a minor is emancipated and living independently or married the lower rate, as seen in the second set of codes, would be used for minors.

MAPS-MD is instructed not to reimburse providers if an improper code is used.

Co-Pay Refunds

If a Gray Zone consumer is retroactively enrolled in Medical Assistance, the provider should refund the co-pays collected to the consumer. The procedure is:

• Mail/fax the name of the consumer, MA#, SS#, dates of service, and co-pay amounts made to Yolanda Dyer, Customer Service, MAPS-MD
• Yolanda will reprocess the claims involved, which will in effect reimburse the provider for the $2.00 (or other co-pay amount) not reimbursed to the provider by MAPS-MD at the time of the original processing of the claim.
• The provider refunds the consumer.

Paper Claims

If you are an electronic submitter, please remember to submit the following types of claims on paper:

• Corrected bills
• Non-covered days
• Claims for W9511

Retractions

If you need a retraction of an incorrectly paid claim (and no reprocessing of a new claim is involved), you should submit the request directly to the Recovery Unit. The request should include: Consumer Name, Medicaid Number, Date of Service, Service Paid and Payment Amount. It should also include the reason for the retraction, such as a duplicate payment, other insurance has paid in full, etc. These requests should be submitted to:

Maryland Health Partners
MAPS-MD Recovery Unit
P.O. Box 5150
Columbia, MD 21046-5150

If your claim has processed in error, resulting in either an overpayment or underpayment, and you need to have it reprocessed, please send it to Provider Relations with a copy of the corrected claim and a letter stating the reason for the reprocessing. The actual reprocessing of the claim will involve a retraction of the claim in error and the reprocessing of the new claim. If the number of claims involved exceeds twenty-five (25), please call Provider Relations to discuss other options that may be available.

For other retraction issues, please contact Customer Service first to discuss. If you dispute the retraction once you have discussed the issue, you should submit an appeal within 30 days of the date printed on the retraction notice to Retracted Claims Appeals, MAPS-MD, P.O. Box 3910, Columbia, MD 21045-7190. Your appeal should include a copy of the retraction notice and provide the necessary information to resolve the issue involved.

Emergency Petitions

Please do not contact Customer Service for payment or other information regarding Emergency Petition claims. These claims are handled separately from the normal claims processing operations, so C/S does not have access to the information you need. Please direct your inquiries to 410-953-1800 (tel.), 410-953-1856 (fax), or MAPS-MD, P.O. Box 3190, Columbia, MD 21045-7190, Attn: Emergency Petitions Dept.

EX Codes

The following link provides an updated listing of payment, denial and pend codes used by MAPS-MD.

ProcessorExCodes 10-20-03.pdf

Guidelines regarding Medicare-Medicaid Claims

We would like to take this opportunity to re-iterate and amplify upon policy related to Medicare-Medicaid consumers in the April 2001 Issues Bulletin. As originally published:

Guidelines when MAPS-MD is the Secondary Payer

Consumers with other Insurance

When consumers in the PMHS have other insurance, either commercial or Medicare, Maryland Health Partners is considered the secondary (or in some cases, the tertiary) carrier. There are some circumstances where MAPS-MD will become the primary carrier:

1. Benefits are exhausted under the other carriers.
2. The services are not covered under the primary carrier.
3. The member is not eligible through the primary insurance carrier on the date of service.

In all of the above cases, pre-authorization of treatment MUST be obtained from Maryland Health Partners for all services that require pre-authorization.

There are instances where the primary carrier denies the services and MAPS-MD will NOT become the primary carrier. These include but are not limited to:

1. Pre-authorization of services was not obtained from the primary carrier.
2. Claim for service was improperly billed.
3. Claim was not submitted timely.
4. Failure of consumer, provider, or other responsible party to comply with policies and procedures set forth by the primary carriers(s).
5. Private insurance denies the service as "not medically necessary."

   "In the cases above, MAPS-MD will not pay for the services even if pre-authorization has been given because the primary carrier is still responsible under these circumstances. The provider is expected to complete the primary carrier's full appeals process. "

As further guidance, the public mental health system will not reimburse non-physician providers for certain codes billed for Medicare-Medicaid consumers that require a physician to perform them. Neither Medicare nor Medicaid will allow payment for certain services unless performed by the physician. If any such services were paid to non-physicians, the claims will be retracted with an 8Z denial code. The codes include: 90805, 90807, 90809, 90811, 90813, 90814, and 90862.

Time Limits-Submitting Claims

Timely Filing of Claims

You must submit a clean claim that is received by MAPS-MD within nine months of the date of service (for acute hospitals, this is from date of discharge). A clean claim is an original, correctly completed claim that is ready to process.

Submit claims immediately after providing services. If a claim is denied, you then have time to correct any errors. A corrected, clean claim must be received by MAPS-MD within the nine-month timely filing requirement or within 60 days of the date of the denial, whichever is later.

Exceptions to the Time Statute

Exceptions to the claim submission statute can be made under the following circumstances:

• The claim was filed within statute previously but denied by MAPS-MD due to provider error.


Solution: Resubmit the corrected claim through normal claims processing channels within 60 days of the last rejection.


• Retroactive eligibility is determined by the local Department of Social Services.


Solution:Submit the claim via paper, not electronically, and attach documentation of retroactive eligibility if available. Claim must be received within 9 months of the eligibility determination date. If the claim is inpatient and requires an authorization, you must submit the medical records for retrospective review within 9 months after obtaining retroactive eligibility. If the claim is outpatient and requires an authorization, you must call Customer Service for discussion of the options available to you.

When submitting claims for retro eligibility (submit claim through normal claims processing channels), please have each claim stamped "Retro Eligibility Claim". This will assist our processors in identifying these claims and help to eliminate erroneously denied claims.


• A claim was submitted to Medicare as the primary payer.


Solution: Submit the claim with a copy of the Medicare EOMB through normal claims processing channels. Be sure to place the recipient and provider numbers in the required Medicaid fields. Claim must be received within 120 days from the date of Medicare EOMB.


• A claim has been retracted and you want to submit a corrected claim.


Solution: Submit the claim through normal claims processing channels within 60 days to MAPS-MD Retracted Claims Appeals, P.O. Box 3190, Columbia, MD 21045.

NOTE: Whenever a claim is past the 9 month from the date of service statute, documentation "MUST" be attached. If this is not done, the system automatically rejects that claim.

Timely Filing Appeals Process

Third Appeal:
Please submit the third appeal, along with supporting documents and the two denial appeal letters from MAPS-MD, to Mr. Ray Lewis (MHA) at the address listed below:

Final Appeal for MA Consumers:
Final appeals for MA consumers only go to the Office of Administrative Hearings through the Mental Hygiene Administration. This office does not handle any appeals for gray zone consumers.

(Please note that this does not replace the Clinical Appeals process)

Check Distribution by Comptroller

The estimated date for the Maryland Comptroller to begin sending out checks is mid-November 3, 2003. We will publish the instructions for enrolling for electronic funds transfer in a future Issues Bulletin after the transition has successfully occurred.

Clinical Update

Priority Population Criteria for Adults
MHA has added additional clarification to the Priority Population Criteria for Adults published in the September, 2003, Web Issues Bulletin:

The revised Priority Population Criteria for Adults is for authorizations for PRP and RRP services. Individuals may receive PRP services to augment Supported Employment services. Individuals currently in Supported Employment that do not meet new priority population criteria are to continue to be "grandfathered" for PRP services with CSA approval.

Authorizations

The Mental Hygiene Administration has provided the following clarification with respect to authorizations required when billing the public mental health system:

1. OMHC Pre-approved Visits
• MAPS-MD provides 12 pre-approved mental health treatment visits per year.
• When additional services are requested submit a written treatment plan for authorization to MAPS-MD. These 12 pre-approved visits do not include the medication management visits. The medication management visits do not require that a written treatment plan be submitted to MAPS-MD (It does require the annual written registration with a copy going to the Primary Care Physician), are pre-approved, and are expected to meet medical necessity criteria for the service.
• Additional visits may be reauthorized every six months upon submission of an updated treatment plan.
2. Authorization Process for PRP Services
• The provider should call MAPS-MD for an initial assessment.
• Once an initial assessment is documented, the initial authorization request for PRP services is made by a second telephone call. The initial authorizations may be for services for up to a 45-day period. The initial Individual Rehabilitation Plan (IRP) is to be submitted within 30 days of the initial authorization to MAPS-MD if continued authorizations are necessary.
• After the first authorization period, depending upon the length of time of the authorization submit the following:
  • For six month authorization time frame, submit the IRP review (6 month review)
  • For 1 - 4 month authorization time period submit a one page update that includes at a minimum, a progress summary, consumer response to IRP, and plans for continued service.
  • For any subsequent requests submit the most recent or a progress summary, including a consumer response to IRP, whichever is more recent and completed within 30 days of the request for authorization. If a summary is sent, also send the last IRP Review.
3. Authorizations and Service Benefits Are Tied to the Consumer Not the Provider
• When a consumer requests service from a new provider but has authorizations remaining from the previous service provider, the new provider is to receive written consent from the consumer to request information from MAPS-MD regarding the previous provider and remaining authorizations.
• The new provider shall request a discharge statement from the previous provider to indicate the number of services used in order to request a transfer of the authorizations from MAPS-MD.
• MAPS-MD will provide information that is available to the new provider. The lag times in the billing process may affect this information. MAPS-MD and MHA will not be responsible for any inability to obtain authorizations caused by a provider not submitting a discharge statement and thus allowing a transfer of the unused authorizations.
4. Individuals with pending MA or PA Applications
• Providers shall maintain documentation regarding application for appropriate entitlement.
• Providers will review the circumstances of the individual's applications with the CSA.
• The CSA will make determination of "financial eligibility" for the PMHS and notify MAPS-MD of decision.
• Provider shall call MAPS-MD to "register" client and provide appropriate information for MAPS-MD to make medical necessity decisions. These individuals shall be treated as gray zone for purposes of authorization and payment
5. Supported Employment (SE) and PRP Authorizations

The additional allocation of 20 PRP visits, when an individual is in Supported Employment, is one time per year per consumer. To receive these 20 visits, the SE providers need to document in the record that the individual is currently receiving SE services. The program is to send MAPS-MD a list of consumers active in SE.

Supported Employment

The Mental Hygiene Administration and Vocational Services have provided the following direction related to authorization spans for Pre-Placement Phases (W9530, W9531, W9532, and W9533) and Extended Services (W9535) in Supported Employment.

• The Core Service Agency (CSA) continues to authorize the service.
• MAPS-MD will only pay the provider based upon CSA authorization.
• Phases 1a and 1b (W9530 and W9531) are discrete services to be authorized and billed once during the authorization span.
• Phases 1c and 1d (W9532 and W9533) may be re-authorized, upon the discretion of the CSA, if the provider is seeking authorization for a new job, following job termination, or an alternate job secondary to career advancement.
• Phase 2 (W9534) - Intensive Job Coaching - is authorized up to a maximum benefit payment of $2,750. This code is only paid after receipt of a DORS denial for service.
• Phase 3 (W9535) - Extended Services - is an ongoing service to be authorized and billed monthly during the authorization span.
• When the new HIPPA codes become effective, we will combine Phases 1a, 1b, and 1c into one Pre-placement Phase billing code. Discrete billing codes will be assigned for Phase 1d - Placement in a Competitive Job and Phase 3- Extended Services. The same authorization rules will apply.
• If you have any further questions or require additional clarification, please consult Steve Reeder, Vocational Services, at 410-402-8476.

On-Line Claims, Eligibility and Authorization Inquiry

Please submit your agreements to use the www.apshealthcare.com website. The website will allow you to access claims inquiry for MA and gray zone consumers and eligibility inquiry for gray zone consumers.

The website www.gzmd.com will no longer provide the gray zone eligibility information on or about November 30, 2003, as the above website is the replacement. Please call Provider Relations at MAPS-MD if you have any questions.

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