NOTICE:

Please read this entire issues bulletin and share with your billing, finance, information technology, and clinical staff. There are important changes that affect all areas of your operation in this issue.

As more information becomes available related to HIPAA, it will be posted on this web site under the "What's New" section, so please check the web site at least weekly for the next couple of months.

Thank You for Your Commitment to the Consumers We Serve

The public mental health system has been successful in its goal of assuring consumers access to quality services because consumers, providers, CSAs, MAPS-MD and MHA have worked together. Continued commitment to consumers is needed even more during this time of fiscal restraint. Please continue. We thank you for continuing to deliver high quality consumer services as governed by the standards of your professional board and to manage within those services authorized.

Brian Hepburn, M.D.
Interim Executive Director
Mental Hygiene Administration

Rehabilitation Assessment (W9547) Authorizations

Effective 10-01-03, MAPS-MD will authorize one rehabilitation assessment service (W9547) per consumer, per provider, per episode of care. An authorization for this service will be approved even in those cases where, based upon the assessment, the consumer is found to be inappropriate for rehabilitation services and is not admitted to the provider’s program.

Revenue Code 914 and Authorizations

There is no change of policy vis-à-vis Revenue Code 914 and authorizations. You will need to obtain the necessary authorization for this code to pay. This applies to situations where medical management is being requested. If you are submitting a treatment plan, please include medical management in the plan if this is a service you are requesting.

If any hospital-based provider requested medical management visits for during the period July 1-September 30, 2003, the authorization was not entered into the system. MAPS-MD will go back and add authorizations for those visits to the provider’s request. If you have received any denials for this reason for DOS in this range, please resubmit your claims after November 1, 2003, for reprocessing.

Psychiatric Rehabilitation Program (PRP) Services-Child and Adolescents-Off Site Services

As stated in the August Bulletin, effective September 1, 2003, the Public Mental Health System will no longer reimburse off-site PRP services for children and adolescents under the off-site supported housing codes, namely W9541, W9542 and W9543. These services will be reimbursed only under the standard PRP off site service codes, W9500, W9501 and W9506. Please change your billing practices to correspond to this change.

As further clarification, there will be no retractions of payments made prior to September 1, 2003, to providers who billed off-site PRP services for children and adolescents using the off-site supported housing codes.

Review Criteria for Residential Rehabilitation Programs (RRP)—Intensive Level

The Mental Hygiene Administration has developed the following level of care criteria to be used when authorizing RRP services at the intensive level. These criteria supplement the protocols for review of RRP services in the Maryland Health Partners’ Provider Manual.

Please note: Eligibility for services in the PRP and RRP is limited to the priority population defined below and is applicable to adults. The children’s definition will be developed later. Eligibility for services will be based upon these definitions for individuals new to these services. These eligibility standards are not applicable to individuals currently being seen. Individuals currently being served in an RRP are grandfathered with existing criteria for the next six (6) months and those individuals currently being served in a PRP are grandfathered with existing criteria for the next three (3) months. The effective date of these changes is September 1, 2003.

LEVEL OF CARE CRITERIA

Residential Rehabilitation Program (RRP) - INTENSIVE

Individuals must meet each of the following three medical necessity criteria in order to be determined eligible for RRP Intensive services.

1. Diagnosis of Serious Mental Illness and meet priority population criteria (including impaired role functioning)
2. History of at least one of the following:
• Criminal behavior
• Treatment and/or medication noncompliance
• Substance Abuse
• Aggressive behavior
• Psychiatric hospitalization
• Psychosis
• Poor reality testing
3. Current Presentation of at least one of the following behaviors or risk factors that require daily structure and support in order to manage:
• Safety risk
• Active delusions
• Active psychosis
• Poor decision-making skills
• Impulsivity
• Inability to perform Activities of Daily Living (ADL) skills to maintain tasks necessary to live in the community environment
• Impaired judgment, including social boundaries
• Inability to self-protect in community situations
• Inability to safely self-medicate or otherwise self-manage the illness
• Aggression
• Inability to access community resources necessary for safety
• Impaired community living skills

SEVERELY MENTALLY ILL (SMI) PRIORITY POPULATION DEFINITION - ADULTS
REVISED 9/1/03

INCLUDED DIAGNOSES:

• 295.10 Schizophrenia, Disorganized Type
• 295.20 Schizophrenia, Catatonic Type
• 295.30 Schizophrenia, Paranoid Type
• 295.40 Schizophreniform Disorder
• 295.60 Schizophrenia, Residual Type
• 295.70 Schizoaffective Disorder
• 295.90 Schizophrenia, Undifferentiated Type
• 296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features
• 296.34 Major Depressive Disorder, Recurrent, Severe With Psychotic Features
• 297.1 Delusional Disorder
• 298.9 Psychotic Disorder, NOS
• 301.22 Schizotypal Personality Disorder
• 301.83 Borderline Personality Disorder
• 296.43 Bipolar I Disorder, Most Recent Episode, Manic, Severe Without Psychotic Features
• 296.44 Bipolar I Disorder, Most Recent Episode, Manic, Severe With Psychotic Features
• 296.53 Bipolar I Disorder, Most Recent Episode, Depressed, Severe Without Psychotic Features
• 296.54 Bipolar I Disorder, Most Recent Episode, Depressed, Severe With Psychotic Features
• 296.63 Bipolar I Disorder, Most Recent Episode, Mixed, Severe Without Psychotic Features
• 296.64 Bipolar I Disorder, Most Recent Episode, Mixed, Severe With Psychotic Features
• 296.80 Bipolar Disorder, NOS
• 296.89 Bipolar 11 Disorder

AND

In order to be included in the PRIORITY POPULATION, individuals must meet the target diagnostic criteria and meet the following functional limitations:

Serious mental illness is characterized by impaired role functioning, on a continuing or intermittent basis, for at least two years, including at least three of the following:

• Inability to maintain independent employment,
• Social behavior that results in interventions by the mental health system,
• Inability, due to cognitive disorganization, to procure financial assistance to support living in the community,
• Severe inability to establish or maintain a personal support system, or
• Need for assistance with basic living skills.

The diagnostic criteria may be waived for the following two conditions:

1. An individual committed as not criminally responsible who is conditionally released from a Mental Hygiene Administration facility, according to the provisions of Health General Article, Title 12, Annotated Code of Maryland. Or
2. An individual in a Mental Hygiene Administration facility with a length of stay of more than 6 months who requires RRP services, but who does not have a target diagnosis. This excludes individuals eligible for Developmental Disabilities services.

HIPAA

EDI Registration

Any providers wishing to sign up for EDI should contact a clearinghouse to enroll. You may find a list of clearinghouses doing business with MAPS-MD .

EDI Questions and Follow-Up

MAPS-MD’s parent company, APS healthcare, has established a web site in which there is extensive information related to HIPAA transactions and code sets. You should press the Provider Resources tab to access the HIPAA information.

If you have EDI issues, you should call your clearinghouse to resolve. If you cannot get your issue resolved, you may call Provider Relations for assistance.

Status Report-Transaction and Code Sets

October 16, 2003 is the official deadline for covered entities to comply with HIPAA’s electronic transaction and code sets provisions. However, until MHA/MAPS-MD implement the new claim format (837) and code sets, providers should continue to use the current formats and codes. Providers will receive the same ERA and paper EOP as they do now. When the 837 formats and code sets are implemented, providers will elect to receive the 835 (ERA). Until that time, there are no changes in submissions or responses.

Here is a status report on the various transactions that affect the HIPAA transition:

• Claims transactions—MAPS-MD is prepared to accept electronic transactions in the X-12 HIPAA transaction compliant format. For those providers submitting through WebMD, however, we will be operating on a contingency plan designed to assure the timely flow of provider payments as the clearinghouse converts clients using the existing systems over to the new format. Providers being set up currently should be HIPAA compliant in the X-12 format. Until you are implemented or are notified otherwise, the status quo continues.
• Payment and Remittance Advice—If you are currently receiving an electronic remittance advice through WebMD, you will continue to receive it until you are converted over to the new X-12 format. Once converted, you will need to apply to both the clearinghouse and to APS healthcare to register for an electronic remittance advice.
• Claim Status Inquiry and Response—This is an EDI function that you may be able to obtain through your clearinghouse. (WebMD expects to offer this and the other on-line services discussed below, but no implementation date is set at this point for MAPS-MD transactions.) There may be a charge for this service if you cannot submit the X-12 format. Alternatively, you may request access to APS healthcare’s web site for access to an internet-based claims inquiry system. See discussion below in On-Line Claims, Eligibility and Authorization Inquiry.
• Eligibility Inquiry and Response-- This is an EDI function that you may be able to obtain through your clearinghouse. There may be a charge for this service if you cannot submit the X-12 format. Alternatively, you may request access to APS healthcare’s web site for access to an internet-based eligibility inquiry system for “Gray Zone” (Non-Medicaid Insured) consumers. See discussion below in On-Line Claims, Eligibility and Authorization Inquiry.
• Authorization Inquiry and Response-- This is an EDI function that you may be able to obtain through your clearinghouse. There may be a charge for this service if you cannot submit the X-12 format. Alternatively, you may request access to APS healthcare’s web site for free access to an internet-based authorization inquiry system. See discussion below in On-Line Claims, Eligibility and Authorization Inquiry.

The code sets applicable to MAPS-MD and Providers include current versions of:

• Physician and other health services—HCPCS and CPT-4 The official procedural code sets have not yet been released for publication. MAPS-MD will publicize them as soon as they are available. We have been advised by the State that current codes will be used at least until November 1, 2003, and possibly beyond that date.
• Diagnosis Codes ICD-9-CM, Volumes 1 &2--Providers should be using the latest version of the codes. The 2004 edition will be available in October, 2003. The diagnoses available for payment under the Public Mental Health System were published in the April 2002 Bulletin.
• Inpatient Hospital Procedures—ICD-9-CM, Volume 3
• Revenue Codes - no change
• Occurrence Codes—These codes are found on the UB-92 instructions and remain the same as before. The specific MAPS-MD requirements did not change and are available in the Provider Manual.
• Place of Service Codes
• Modifiers—The Maryland Public Mental Health System will be using up to three (3) two-(2) digit modifiers per procedural code. Further details will be provided when the code sets are released.
• Remittance Advice Remark Codes and Claims Adjustment Reasons—These codes will change to be HIPAA compliant for those providers receiving claims remittances under the 835 standards. A complete list of these codes is available at www.wpc-edi.com under the HIPAA tab.
  

Paper Claims

MAPS-MD will require the use of HIPAA compliant industry standard codes on all claims, including paper, by January 1, 2004.

Companion Guide

Providers using WebMD as the clearinghouse for submitting electronic claims can request a copy of the Companion Guide from their Account Manager or they can go to WebMD’s web site and request it online. The companion guides tell you how to submit claims for all payers, including MAPS-MD.

Currently MAPS-MD only receives electronic claims directly through WebMD. By October 2003, you will also be able to use our two new contracted clearinghouses: Payerpath and ProxyMed. If you are using another clearinghouse, you should contact that organization for it’s companion guide. Your clearinghouse is the interface between MAPS-MD and MAPS-MD’s clearinghouses and is therefore responsible for assuring that your claims arrive at at WEBMD/MAPS-MD in HIPAA compliant formats.

Questions to Ask Vendors, TPAs, or Clearinghouses

The Center for Medicare and Medicaid Services has developed an excellent checklist for you to review with your software vendor and electronic clearinghouse about their progress towards HIPAA compliance. For example, your software vendor should supply you with upgraded software that allows you to submit electronic transactions following HIPAA standards. They should be testing this software with you and your clearinghouse. Likewise, if you are using a third party administrator (TPA) or electronic clearinghouse, you should assure yourself that the clearinghouse has made arrangements to be HIPAA compliant by October 16, 2003. For examples of questions that you should consider asking, please visit the CMS web site.

Claims Update

Community Support and Prevention Services W9511

Claims for this code should be directed to Provider Relations, PO Box 3190, Columbia, MD 21045-7190, for special handling.

The HCFA-1500 should be accompanied by the Special Clinic Services Authorization Form, which is completed by the CSA. Please ask the CSA to complete this form instead of another type, so that there is a consistent claims process in effect. If another form is received, it may result in the claim being processed incorrectly.

Please remember that the various blocks in Line 24 of the HCFA-1500 should parallel the Authorization. You only need to complete one line of information to satisfy the billing requirements. For example:

If you were authorized 20 units of a particular service in the Authorization for the month of August, 2003, and used 16 units, you should complete the claim as follows:

Block 2: Name of the CSA

Block 24

Block 31: Provider Name and signature

Block 33: Provider Name and MA#

Claims Address

Many providers are still mailing claims to the former MAPS-MD address. The correct address to mail claims effective June 1, 2002, is: P.O. Box 3000, Columbia, MD 21046. Please check your claims to make certain that the correct address is printing. Thank you.

Check Distribution by Comptroller

On or about November 1, 2003, the State of Maryland (Comptroller’s Office) will begin to distribute checks to the providers instead of MAPS-MD. You do not need to take any action at this point.

There is the option to sign up for electronic funds transfer. We will publish the specific directions for enrolling in a future issue of the Bulletin and advise that you do not initiate the change at this point. For those providers already enrolled for EFT with the State for other programs, you will receive your payment from the Comptroller as well on or about November 1.

Clinical Update

Child and Adolescent PRP

MHA requires providers to supply documentation demonstrating that PRP services are a part of the Individualized treatment plan. This applies to both the initial authorization and each subsequent request for ongoing services.

To comply with this requirement, the following procedures should be followed:

• The primary clinician should call 1-800-888-1965 at the time of referral to facilitate the authorization process.
• If preferred, the primary clinician can fax information to 410-953-1856, although this may delay the authorization process.
• When submitting an Authorization Plan (AP), please continue to include the name and telephone number of the primary clinician. Please fax AP’s to 410-953-1903.
• If MAPS-MD cannot determine that a consumer is in outpatient treatment, the AP will be returned. You should include documentation from the primary clinician that the consumer is still in outpatient treatment and return it with the AP.

Gray Zone

If a PRP provider requests a review of clinical material (AP) prior to using up the 60 gray zone visits, MAPS-MD may review at the time of the request and make a medical necessity determination. Cases that request additional visits beyond MAPS-MD’s limit of 115 will be referred to the appropriate CSA.

Partial Authorizations

If a provider does not receive the number of services requested on an AP, the provider has the right to appeal. The appeal must be in writing. The appeal should include a cover letter clearly stating what is being appealed and be attached to the AP. The AP may be adjusted to include additional clinical information.

Failure to Obtain Inpatient Continued Stay Authorization

The MAPS-MD Care Managers may make a courtesy call on the last certified day of an inpatient stay if a facility fails to call in for a concurrent review of an Inpatient stay. However, if the Care Manager is unable to make contact with an appropriate individual, the facility is required to send in the consumer’s medical record for a retrospective review after discharge. If there is no authorization in MAPS-MD’s system covering all of the days of the inpatient admission, claims will deny for no authorization if the days billed exceed the authorization.

Procedure for Obtaining Services on Urgent Need Basis when Consumer Is Not Gray Zone or Medicaid

Please use the following procedures:

1. Provider calls CSA for authorization for visits (2). They may grant exceptions on an emergency basis.
2. CSA faxes information to Manager of Customer Service, Italia Lewis-Pitts, at 410-953-1856.
3. Customer Service enters consumer and authorizations into system so claim can process. The authorization ultimately will be on the www.gzmd.com web site within approximately one week.
4. If consumer needs additional visits, Provider calls CSA for additional authorizations (10).
5. CSA faxes information to Manager of Customer Service.
   

On-Line Claims, Eligibility and Authorization Inquiry

MAPS-MD is very pleased to introduce an on-line claims inquiry capability for providers so that you can research the status of claims or review claims history using the internet. The system can be accessed through www.apshealthcare.com and will include the claims submitted by your organization to MAPS-MD. Claims availability will go back approximately 20 months from the date of processing.

You should have received a provider agreement in the mail in September that will allow your organization access to the site. Please review the document and return a signed copy to the APS healthcare address provided.

In addition to claims inquiry, there will be information related to gray zone eligibility and at a later date authorizations. The information now available on www.gzmd.com will be transferred to the www.apshealthcare.com web site, so we encourage you to sign up. The former web site will be phased out as the latter web site was developed to be HIPAA compliant. As of October 16, 2003, you will no longer be able to access the gray zone eligibility information on the www.gzmd.com web site.

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