HAPPY NEW YEAR

The staffs of MHA, MAPS-MD, and the CSAs would like to extend to all providers a Happy New Year's greeting.

We appreciate your efforts in providing services to consumers of the Public Mental Health System. This will be a challenging year given the changes that need to be implemented in 2004. We believe that a public-private partnership in providing services to consumers is in the best interests of all and we will strive to provide the support services you need to carry out the public mental health programs as effectively as possible.

UPDATE

MHA has concluded that the Public Mental Health System (PMHS) is currently in a budget crisis. The carry-over deficit from FY 2003 is $54 million. The projected deficit for FY 2004 is over $40 million. The growth in the PMHS for adults and children getting services has been impressive. However, the budget crisis has to be resolved. As a result, MHA has implemented cost containment measures that are outlined below.

Rate regulations have been submitted to move rehabilitation services to a monthly rate, effective February 1, 2004, as an attempt to cut costs and control growth. The strategy is to move towards the next generation of managed care by giving providers more flexibility in how the service is provided. Over the next several years, MHA will focus on Evidence-Based Practices and Clinical Outcomes to continue the goal of improving the quality of care in the PMHS.

PROGRAM CHANGES

Gray Zone Consumers
Effective February 1, 2004, the PMHS will no longer reimburse HSCRC hospitals for outpatient mental health services for gray zone consumers.

Treatment Team Planning and Community Prevention
Effective February 1, 2004, the PMHS will no longer pay for W9510, Treatment Team Planning, or W9511, Community Prevention. The Treatment Team Planning code will be replaced with a new HIPAA code requiring the consumer to be present for individual treatment team planning.

Authorizations for RTC Services
MAPS-MD will contact the CSA to discuss any requests for authorization for Residential Treatment Center (RTC) services in order to facilitate access to a less restrictive setting.

Retroactive Authorizations
Retroactive authorizations are no longer permitted, as was discussed in the November 2003 Web Issues Bulletin. The following is an excerpt from that policy statement, to which you should refer if you need the entire discussion:

One exception to this announcement: For consumers who are admitted for RRP services, a Rehabilitation Assessment service (old code W9547, new code H0002) may be retroactively authorized by MAPS-MD when the request is contained on the RRP Authorization Form with the request to begin RRP services. This exception is valid for assessments provided July 1, 2003 to December 31, 2003.

This exception does not apply in those cases where the assessment results in the consumer not being admitted for services. No backdates are allowed at all for such assessments.

OMHC
For new OMHC authorizations, providers should register the consumer with MAPS-MD for 12 pre-approved OMHC visits. When the initial OMHC service is provided on a weekend, the OMHC shall register the consumer on the next business day.

Extended Service OMHC Codes
Effective February 1, 2004, MAPS-MD will issue a single authorization only for an extended OMHC code. This will be issued for urgent care only. The extended codes are no longer available for regular and routine OMHC treatment services. The affected codes are 90808, 90809, 99354, 99355, and 90853.

Eligibility of Gray Zone Consumers
This is a re-iteration of policy published in the July 2003 Web Issue Bulletin. In order to be eligible, consumers must have a PMHS psychiatric diagnosis, meet medical necessity and also meet one of six other requirements.

Current or former consumers who lose MA or gray zone status prior to July 1, 2002, and do not meet the new requirements, are still eligible for gray zone benefits for a period of two years dating from July 1, 2003.

PSYCHIATRIC REHAB PROGRAM (PRP) RATE CHANGES

The following changes to PRP and Residential Rehabilitation Programs (RRP) are planned for February 1, 2004. If the rate change is delayed the current system for authorization and payment will remain in effect.

Utilization Management
Based upon age, an individual shall meet priority population criteria by diagnoses and functional criteria.

RRP/PRP Services
For individuals requesting RRP services, Core Service Agencies (CSAs) will review, and when indicated, authorize or reauthorize RRP and Psychiatric Rehabilitation Program (PRP) services. The length of time of the authorization period is one year.

CSAs may authorize a one-month block of on-site PRP services for a transition period when an individual is preparing for discharge from the state hospital to community.

For individuals not eligible for Medicaid and meeting criteria for gray zone, the CSA will review, and when indicated, authorize services. The length of authorization period may vary since funds are limited and are to be directed to the most in need. MHA will provide previous year's expenditure data to CSAs and they will be expected to manage within these parameters.

Eligibility for gray zone remains the same.

CSAs must fax the authorization to MAPS-MD within 48 working hours and provide copies to the providers.

CSAs will continue to review and approve enhanced client support services based upon criteria established by MHA (to be completed). The amount of funds available for this service is based upon FY 03 claims paid.

Authorizations will be based upon the first day of the month.

When services are no longer medically necessary, a one-month transition may be authorized.

PRP Services Only
For Medicaid recipients requesting PRP services only, MAPS-MD will review and when indicated, authorize or reauthorize services. The length of time of the authorization period is 6 months.

Supported Employment
For individuals requesting Supported Employment (SE) services, the CSA will review and when indicated, authorize or reauthorize SE and the PRP services associated with SE at the job site.

Appeals Process
The Appeals Process remains the same for all of the above services.

Documentation
The program shall meet all current requirements in COMAR Chapters 10.09.59 Medicaid and 10.21 Mental Hygiene Administration for documentation. This includes a written contact note when the individual is seen for PRP services. This shall include the date of service, time in and time out, location, goal of service (reason for visit), brief description of service provided, and signed by the individual providing the service (provider). The time documentation for the service may be documented in the medical record or on the billing service ticket.

Billing
Providers may submit bills, after the provider has met the minimum amount of service required by the respective rates. The provider will submit a bill that includes the date of service when the minimum services are met or any subsequent date. Providers will in addition, submit clean claims, which will be paid at $0, for each service encounter for the entire month.

Billing for services that do not meet the minimum amount of services required for a specific monthly case rate - In the event the provider does not meet the service level minimum encounters for the authorized level of service, but does meet the minimum encounters for a lower level of service, the provider will bill using the originally authorized modifier but will bill at the lower "allowed charge." It is the responsibility of the provider to ensure that the billed amount corresponds to the level of service that has been delivered.

Advance Payments
MHA cannot provide advance payments of State general funds or Medicaid reimbursement. A transition process to alleviate provider issues is still under discussion.

Minimum Service Requirements
The minimum service requirements for the respective monthly rate may not be met by including visits to individuals in hospitals (private or state).

RRP Room and Board
RRP room and board will be billed on a daily basis.

Encounter Data
MHA requires all PRPs participating in the public mental health system to submit encounter data. The encounter data will verify the number of face-to-face contacts, by date of service, when the PRP provided services to an individual within the month. This data shall be submitted to MAPS-MD within 30 days after the end of the billing month.

CSA Monitoring
MHA will provide instructions (to be developed) to CSAs to review encounter data. The review will be based upon outliers and any significant changes from previous year. MAPS-MD will provide statewide encounter data to MHA for analysis. MHA will review the CSA monitoring of the encounter data during the regularly scheduled MHA site visits.

Consumer Education and Communication
A communication will be sent to consumers currently receiving PRP services, describing the changes to the PRP/RRP program and how the changes will impact the services the consumer receives. This communication will also be sent to advocacy and consumer and family organizations to distribute to their memberships. In addition, forums to discuss changes with consumers and other interested parties will be hosted by CSAs, MHA, and advocacy groups

Proposed PMHS PRP/RRP Monthly Case Rate Overview

*Community Clients: Children or adults living with parents, guardians, or relatives who are legally responsible for the care of the individual or children living in foster homes in which psychiatric services are not part of the day rate. Foster parents are legally responsible for the care of their foster children.

**Supported/Independent Living Clients: Individuals who are living alone or with other individuals who are not legally responsible for their care.

HIPAA CODES

Attached is the link to the new HIPAA compliant codes, which are effective February 1, 2004. These codes are presented with a crosswalk to the former codes. If the codes have no crosswalk, they are no longer valid codes for the public mental health system.

PRP/RRP codes will be changed to a monthly case rate. These changes are planned for a February 1, 2004, implementation. If this change is delayed, continue billing using the old codes. All other codes are in effect as of February 1, 2004.

Please note the following major changes to the way claims are billed as you go through the new codes:

• At this point we are not requiring all modifiers required under HIPAA, but may do so in the future. Two that will not be used include HW (mental health) and HA (child-adolescent). MAPS-MD will be adding these modifiers to the claims as they are transmitted to MMIS for FFP (Federal Funds Participation) funding. The HW will be added based upon all claims being mental health and the HA will be calculated based up the date of birth provided on the claim form. Do not submit these codes or the claims will be denied.
• PRP codes have been changed from fee-for-service to monthly case rates with encounter data being submitted. A minimum number of services must be rendered in order to bill the case rate. Providers will be expected to bill the number of encounters (services rendered) under H2016 with a $0.00 charge in addition to the H2018 code which is payable. The encounter data must be submitted by the end of the month following the month when services were rendered. For example, if services were rendered in February, then the encounter data for February must be submitted no later than March 30, 2004. The minimum number of services to qualify for the case rate must be provided prior to billing the case rate.
• The payment rate for H2108 will be dependent upon the U1-U5 modifiers, the Place of Service Codes, and charges billed. Examples follow here and in the next section which is devoted to the PRP changes:
• Intensive Residential Clients-If you obtain an authorization for the intensive rate and provide >13 services and <19 services (which is the minimum number required for intensive), you may bill H2018, U5 modifier, 15 place of service. However, you may only charge $1,074 instead of the intensive case rate of $2,580.
• Community Client-On-Site Rehab only (Must provide a minimum of 2 encounters to bill). Bill H2108 with U2 modifier, 52 place of service and charge of $122. Payment is $122.
• Community Client--Off-Site Rehab only (Must provide a minimum of 2 encounters to bill). Bill H2108 with U2 modifier, 15 place of service and charge of $175. Payment is $175.
• Community Client-When provided by one provider, On- and off-site Rehab only (Must provide a minimum of 3 encounters to bill). Bill H2108 with U2 modifier, either 15 or 52 place of service code, and charge of $297. Payment is $297.
• Supported employment codes have changed substantially as well. The pre-placement phases 1-3 have been replaced with H2024, which is billable and payable in one lump sum.
• PRP Code H0002 for the Behavioral health screening (formerly W9547 Rehabilitation Assessment) is authorized by registering the service with MAPS-MD. The authorization is not contingent upon whether or not the consumer is authorized for PRP services. For an adult, this registration may occur when the PRP calls in for the authorization requesting rehab. For a child, the treating mental health clinician (any licensed mental health professional registered with MAPS-MD) must call in to confirm the need for PRP services, and this call will in effect serve as the registration for the screening.

CHECK DISTRIBUTION BY COMPTROLLER

The date for the Maryland Comptroller to begin sending out checks is still under review and will be on or about January-February, 2004. We will publish the instructions for enrolling for electronic funds transfer in a future Issues Bulletin after the transition has successfully occurred.

DAY LIMITS--REVISED

Effective, January 1, 2004, the following day limits by DRG are applicable to adults in acute care hospitals in MD and DC. There will be no change in the authorization process. Authorization will continue to be based on medical necessity and may be over or under the day limit.

For the public mental health sector, some of the mental health DRG's day limits were revised. Please refer to this current table. Other DRG's may be billed as determined by specific circumstances.

PAPER CLAIMS INSTRUCTIONS:

• Block 11-Include DRG.
• Block 7-Covered days should not exceed day limit for the DRG billed or claim will deny.
• Blocks 7 & 8 should equal the number of days in Block 6.
• Block 46-The service units for the R&B Rev Code should include all covered and non-covered days.
• Blocks 47 & 48-Allocate the charges for the covered and non-covered days between the two blocks as appropriate.
• Ancillaries on the non-covered days should be reported as non-covered services.

ELECTRONIC CLAIMS:

Electronic claims must include the DRG and non-covered services. Please enter the data and verify whether your clearinghouse can transmit this to MAPS-MD/APS healthcare via WebMD. If you encounter problems, please submit claims on paper until the problem is resolved.

DENIAL CODES:

• If claim exceeds the day limits:        S7
• If the claim has no DRG:                   8N
• If claim exceeds the authorization: J3 or 3J

RETRACTIONS: Appropriate use of DRG's will be subject to post payment audits.

TRANSFERS BETWEEN HOSPITALS: Each hospital should bill separately using appropriate DRG and day limits.

CHANGE IN TREATMENT DURING STAY: Discharge patient from med/surg service if psychiatric care is needed & vice versa.

ONE CLAIM PER STAY: Hospitals may only bill one claim per inpatient stay. This means that the hospital must submit a corrected bill if the number of covered days changes. MAPS-MD would then retract and repay the entire stay.

CLINICAL UPDATE

ECT AUTHORIZATIONS
Both inpatient and outpatient claims require a separate and distinct ECT authorization. Only one provider (i.e., facility, psychiatrist, or anesthesiologist) needs to call to for the authorization per episode of care. Our systems will link the authorization to all of the treating providers for the same date(s) of service. If you have an inpatient authorization for a hospital stay, you also need a separate authorization for any ECT treatment. The codes involved are 90780, 90781 (psychiatry), 00104 (anesthesiology) and R0901 (facility).

CLAIMS UPDATE

When submitting a corrected claim after the nine-month deadline, the claim must be resubmitted with a copy of the EOP that adjudicated the claim previously. This has been a standing Medicaid requirement. We anticipate that following this procedure will allow for more consistent adjudication of any corrected claims submitted in terms of determining whether the subsequent claim has been resubmitted within sixty days of the prior claim.

Mailing Addresses
MAPS-MD continues to receive claims using the incorrect mailing address printed on the claim form. Also, claims are not received even though the provider thinks they have sent them in. Please audit your claim forms and systems to assure that you are using the correct mailing address, which is MAPS-MD, P.O. Box 3000, Columbia, MD 21046. If an incorrect address is showing on the claim form, you run the risk of claims being sent to the wrong address. Claims from our old P.O. Box in Owings Mills are no longer being forwarded to MAPS-MD.

MAPS-MD uses Box 33 of the HCFA-1500 and Box 1 of the UB-92 as the address to which we return claims that are not clean. Please make certain that the address in is accurate for your organization's purposes.

Provider Eligibility
Please remember that there is a two-step process at the State of Maryland for renewing your license. First, you must notify the relevant Board of Licensing. Second, you must send the information to Medicaid's Provider Enrollment section. If both steps are not followed, MAPS-MD may disenroll you from participating in the public mental health system. MAPS-MD receives its provider eligibility information from the State's computer systems. If the State has terminated the provider for licensing reasons, MAPS-MD will follow suit. Such action will result in claim denials with the EX Code of X2 and/or retractions until all of the State of Maryland's licensing steps are completed.

www.apshealthcare.com
APS healthcare's new website which includes MAPS-MD information, is unified, recently redesigned, and greatly improved. (APS healthcare is MAPS-MD's parent company.) We invite all MAPS-MD providers to log on and visit the site. There is information of general value and also specific information that can help you manage your practice.

To access specific information on your consumers, you will need to obtain a log-on id and sign the user agreement. Please contact Bouveia Porter at 410-953-1836 if you need an agreement. These agreements were mailed out to every organization in September, but we have not yet signed up all of our providers.

If you currently are using the website www.gzmd, this site will be coming down during the first quarter of 2004. The inquiry function of gray zone eligibility is currently on the new website. The authorization inquiry function will soon be on the new website.

Other specific functions that you may wish to use on the website include claims inquiry and electronic submission of HCFA-1500 claims.

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