Certified Community Behavioral Health Clinic Demonstration Grant WRAP Supplemental Payment Reference Guide

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Imogene Wilkinson
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1 Certified Community Behavioral Health Clinic Demonstration Grant WRAP Supplemental Payment Reference Guide (Effective June 2017) Table of Contents WRAP Supplemental Payment Process Overview... 1 WRAP Supplemental Payment Submission Flowchart... 2 WRAP Supplemental Payment Submission Guidelines... 3 Valid Encounter CPT Code List Prepared 02/15/17

2 WRAP Supplemental Payment Process Overview A Medicaid Eligible patient who is assigned to a Managed Care Organization (MCO) is provided services by a CCBHC. The CCBHC bills the MCO for the services provided to the patient and is reimbursed the contracted amount from the MCO. The CCBHC gathers all such claims for the time period being submitted (quarterly, monthly) and submits the data via the secure FTP site to DHCFP. DHCFP calculates how many encounters the CCBHC provided to eligible members in the time period. This is used to calculate the total PPS rate due to the CCBHC. DHCFP then deducts the amounts already paid by the MCO from the total PPS rate. The balance is the WRAP Supplemental Payment. Example: 1. CCBHC submits a file containing 100 encounters. In this example, The CCBHC s PPS rate is $ per encounter. 2. The total PPS rate due is $13, (100 x $ each) 3. The MCO amount already paid on those encounters is $6, The WRAP payment is calculated: PPS Rate: MCO Paid: $13, (100 encounters x $ each) Less $6, (Total of Amounts already paid on the encounters) WRAP: $7, (WRAP Supplemental Payment) 1 Prepared 02/15/17

3 DHCFP - RAP WRAP Supplemental Payment Submission Process A Certified Community Behavioral Health Clinic (CCBHC) generates a monthly report based on paid claims exported from their billing system into an Excel file formatted per DHCFP guidelines. Prior to submitting the file, the CCBHC will review the data for blank and invalid fields (such as Medicaid ID listed as all zeros). The CCBHC will correct these errors and submit the file using the secure FTP site to DHCFP without altering any other data or creating any totals. * DHCFP will review the file for omissions or invalid data. Yes. File is complete and contains valid data. DHCFP accepts the file for processing. DHCFP Accepts File? NO. File is incomplete or contains invalid data. File is returned to CCBHC to correct the errors present. CCBHC resubmits the file to DHCFP. *This file must contain complete and valid information for every line item of every qualified encounter paid by the MCO during the time period, including: (1) Line Item #, (2) Provider Id NPI, (3) MCE Recipient ID, (4) Medicaid Recipient ID, (5) Date of Service, (6) CPT code, (7) MCE Name, (8) Total Amount Billed, (9) MCE Amount Paid, (10) Other Amount Paid, (11) Total Amount Paid, and (12) Date of Birth. DHCFP runs validations to produce an estimated reimbursement amount. The CCBHC is notified of the anticipated amount and has 5 business days to review the estimated totals. CCBHC will review the anticipated totals Yes. CCBHC agrees to the estimated totals. CCBHC Accepts Anticipated Totals? No. CCBHC disagrees with the estimated totals. The review and resulting resolution at this point would be based on the individual nature of the objection raised. CCBHC returns a signed copy of the Preliminary Totals report to DHCFP via the secure FTP site. DHCFP authorizes the WRAP payment. 2 Prepared 02/15/17

4 WRAP Supplemental Payment Guidelines June 2017 In an effort to fully reflect the Medicaid policy related to the submission, processing and payment of supplemental WRAP claims, the following guidelines will be effective June 30, 2017: 1. The data submitted for supplemental payment will contain only raw data, exported from the CCBHC s billing system into an Excel file following the guidelines below. The CCBHC will not make any calculations to the data submitted. The following information is required for all line items of all qualified medical encounters submitted for supplemental payment: (The corresponding Excel format required for each item is listed to the right) ITEM FORMAT a. Line Item # Number (NBR) (No Formulas or Macros) b. Provider ID (NPI) Text (TX) c. MCE Recipient ID Text (TX) d. Medicaid Recipient ID* Text (TX) e. Date of Service Date (mm/dd/yyyy) f. CPT code Text (TX) g. MCE Name Text (TX) h. Total Amount Billed Currency ($) i. MCE Paid Amount Currency ($) j. Other Paid Amount Currency ($) k. Total Paid Amount Currency ($) l. Date of Birth Date (mm/dd/yyyy) *The Medicaid Recipient ID must be 11 digits (characters) long. Leading zeros must be manually typed in if not present. It is important to ensure this number remains in text format. The Medicaid Recipient ID must be a valid ID (11 zeros is invalid data). Files that contain invalid or incorrect information will be returned to the CCBHC for corrections. 2. DCHFP will run the validation processes over the raw data submission and calculate the expected reimbursement based on the results. Once these validations are completed by DHCFP, the CCBHC will be notified of the resulting totals and will have five (5) business days to review the data. 3. After five (5) business days or upon notification from the CCBHC to proceed, DHCFP will authorize the appropriate supplemental payment to the CCBHC. 3 Prepared 02/15/17

5 36415 Routine venipuncture Metabolic Panel ionized ca Metabolic panel total ca General Health Panel Electrolyte Panel Compehen metabolic panel Obstetric Panel Lipid Panel Renal function panel Acute hepatitis panel Hepatic function panel Urinalysis nonauto w/scope Urinalysis auto w/scope Urinalysis non auto w/o scope Urinalysis auto w/o scope Microscopic exam of urine Urine pregnancy test Assay bld/serum cholesterol Assay glucose blood quant Reagent strip/blood glucose Glucose Test glucose tolerance test (gtt) glucose blood test Hemoglobin copper sulfate glycosylated hemoglobin test assay of lipoprotein assay of triglycerides chorionic gonadotropin test chorionic gonadotropin assay heterophile antibody screen Immunodiffusion ouchterlony TB intradermal test Syphilis test non-trep qual Syphillis test non-trep quant Chlamydia antibody Chlamydia IGM antibody HTLV/HIV CONFIRMJ ANTIBODY Hiv-1antibody Hiv-2 antibody 4 Prepared 02/15/17

6 86702 Hiv-2 antibody Hiv1/hiv-2 result antbdy Chlamydia culture Chlamydia trachmatis ag if Chylmd trach ag eia hepatitis b surface ag eia hepatitis b surface ag eia Chylmd trach dna dir probe Chylmd trach dna amp probe Chylmd trach dna quant N gonorrhoeae dna dir prob N gonorrhoeae dna amp prob N gonnorrhoeae dna quant Hpv dna dir probe HPV dna amp probe Hpv dna quant detect agnt mult dna direc detect agnt mult dna ampli chylmd trach assay w/optic N gonorrhoeae assay w/optic Strep a assay w/optic Im admin 1st/only component Immunization admin Immunization admin each add Immune admin oral/nasal Immune admin oran/nasal add Adenovirus vaccine type Adenovirus vaccine type Typhoid vaccine oral typhoid vaccine IM Hepb vacc ill pat 3 dose IM HEPB vacc ill pat 4 dose IM HIB-HEPB vaccine IM Psytx complex interactive Psych diagnostic evaluation Psych diag eval w/med srvcs Psytx pt&/family 30 Minutes Psytx pt&/fam w/e&m 30 min Psytx pt&/family 45 minutes Psytx pt&/fam w e/m 45 min Psytx pt&/family 60 minutes 5 Prepared 02/15/17

7 90838 Psytx pt&/fam w/e&m 60 Min Psytx crisis initial 60 min Psytx crisis ea addl 30 min Family psytx w/o patient Family psytx w/patient Multiple family group psytx Group Psychotherapy Psychophysiological therapy Psychophysiological therapy Biofeedback train any meth Biofeedback peri/uro/rectal Breathing capacity test Evaluation of wheezing Vital capacity test Airway Inhalation Treatment Psycho testing by psych/phys Psycho testing by technician Psycho testing by admin by comp Developmental screen w/score Developmental test extend Nuerobehavioral status exam Neuropsych tst by psych/phys Neuropsych tst admin w/comp Brief emotional/behav assmt Assess hlth/behave init Assess hlth/behave subseq Intervene hlth/behave indiv Intervene hlth/behave group Intern hlth/behav fam w/pt Interv hlth/behav fam no pt Ther/proph/diag inj sc/im OT Evaluation Ot Re-evaluation Therapeutic exercises Nueromuscular reeducation grouptherapeutic procedures Therapeutic activities Cognitive skills development Sensory integration Self care mngment training Wheelchair mngment training 6 Prepared 02/15/17

8 98961 Self-mgmt edic/train 2-4 pt self/mgmt educ/train 5-8 pt ocular instumnt screen bil app topical fluoride varnish office/outpatient visit new office/outpatient visit new office/outpatient visit new office/outpatient visit new office/outpatient visit new office/outpatient visit est office/outpatient visit est office/outpatient visit est office/outpatient visit est office/outpatient visit est Observation care discharge Initial observation care Initial observation care Initial observation care init pm e/m new pat infant init pm e/m new pat prev visit new age prev vist new age prev vist new age per pm reeval est pat infant prev visit est age prev visit est age prev visit est age prev visit est abe Preventive counseling indiv behav chng smoking 3-10 min behav chng smoking >10 min audit/dast min Audit/dast over 30 min Health risk assessment test Chron care mgmt srvc 20 min G0101 ca screen; pelvic/breast exam G0102 prostate ca screening; dre G0108 diab manage trn per indiv G0109 diab manage trn ind/group G0432 eia hiv-1/hiv-2 screen G0433 elisa hiv-1/hiv-2 screen 7 Prepared 02/15/17

9 G0435 G0438 G0439 G0477 G0478 G0479 G0480 G0481 G0482 G0483 H0001 H0002 H0004 H0006 H0007 H0015 H0020 H0031 H0034 H0035 H0038 H0047 H0049 H2011 H2012 H2014 H2017 H2023 H2025 Q3014 S9480 T1016 T1017 oral hiv-1/hiv2 screen ppps, initial visit ppps, subseq visit drug test presump optical drug test presump opt inst drug test presump not opt drug test def 1-7 classes drug test def 8-14 classes drug test def classes drug test def 22+ classes alcohol and/or drug assess alcohol and/or drug screening mh health asess by non-md med trng & support per 15 min mh partial hosp tx under 24h self-help/peer svc per 15min alcohol/drug abuse svc nos alcohol/drug screening crisis interven svc 15 min behav hlth day treat, per hr Skills train and dev, 15 min Psysoc rehab svc, per 15 min Supported employ, per 15 min Supp Maint Employ, 15 min Telehealth facility fee intensive outpatient psychia case management targeted case management 8 Prepared 02/15/17

Rural Health Clinic (RHC) Qualifying Visit List ( )

Rural Health Clinic (RHC) Qualifying Visit List (3-24-16) The RHC Qualifying Visit List is updated to include additional medically-necessary billable visits, effective April 1, 2016, but not payable until