Addiction Recovery Treatment Services (ARTS): Billing Best Practices. December 2017

Transcription

1 Addiction Recovery Treatment Services (ARTS): Billing Best Practices December 2017

2 Substance Use Billing Best Practices Following the guidelines, requirements, and protocols for billing substance use services (ARTS) is essential to prompt, accurate payment of claims. So what happens when guidelines aren t followed? Claims are denied when charges are eligible expenses Payment cycle is elongated due to resubmissions, corrected claims, etc. Unnecessary cost is incurred due to additional man hours spent researching denials, resubmitting claims and making phone calls to insurance company Always review processing guidelines before submitting claims!

3 Submitting Claims: Electronic Claims Submission Option 1: Claims Courier Professional Claims can be submitted on Magellan Provider.com This service is free of charge and does not require a middle man Allows you to submit a claim at a time Option 2: Direct Submit Professional and Institutional Claims can be submitted This service is free of charge and does not require a middleman Allows you to submit claims in bulk Option 3: Clearinghouse Professional and Institutional Claims Acts as a middleman by taking non-hipaa complaint forms and translating them into hipaa compliant forms May require a fee For more information about these option you may go to the following site:

4 Top 5 Billing Errors for ARTS Services Using the incorrect claim form Using the incorrect service address Billing without using the referring provider s information Billing without the National Drug Code (NDC) if required Billing the incorrect payer

5 ARTS Best Billing Practice #1: Use the Correct Claim Form Make Sure you are using the correct form for the service being billed. You can find additional information about which forms to use for each ASAM level here Claim Form 1: CMS 1500 Claim Form 2: UB-04 The Electronic Version is called the 837 P Services are provided in a range of settings from home to inpatient For use by individual practitioners or group practices. National Uniform Claim Committee 1500 Claim Form Reference Instruction Manual The Electronic Version is called 837 I Services are provided within residential or inpatient settings For use by organizations (including clinics, facilities such as group homes / residential placements, or hospitals) National Uniform Billing Committee UB-04 Claim Form Manual

6 ARTS Best Billing Practice #2: Use the Correct Service Location Billing Requirement Always use the contracted service address for each licensed level of care. Not all service locations are licensed or contracted to render all levels care. Please review your provider agreement before claim submission. References and Additional Resources: Magellan Provider Communication DMAS ARTS Credentialing information

7 ARTS Billing Best Practice #3: Add the referring physician Some ARTS services (such as residential and inpatient) services require a referring physician. On the CMS-1500 the referring physician is indicated by adding the name and NPI number of the physician in field 17 and 17b. The attending physician s NPI number can be used for the referring NPI. On the UB-04 the referring physician is indicated by the qualifier DN in box 78 If billing the UB-04 electronically this will be loop 2301F. References and Additional Resources: ORP billing for residential services Provider Communication Example of where to enter the referral information on the UB-04

8 ARTS Best Billing Practice #4: Add National Drug Codes for Medication Assisted Treatment Are 10 digit three segment numbers Found on the medication packaging Must be submitted using the 11 digit format Are entered in BOX 24 of the CMS 1500 claim form Covered J codes which require the NDC number: J0571 Buprenorphine/Naloxone, one 1 mg tablet. J0572 Buprenorphine/Naloxone, oral, less than or equal to 3 mg buprenorphine J0573 Buprenorphine/Naloxone, oral, greater than 3 mg but less than or equal to 3.1 to 6 mg. buprenorphine J0574 Buprenorphine/Naloxone, oral, greater than 6 mg but less than or equal to 10 mg. buprenorphine J0575 Buprenorphine/Naloxone, oral, greater than 10mg buprenorphine J2315 Naltrexone injection administered in clinic by provider, 1mg S0109 (Oral) Methadone administered in a clinic by provider, 5mg (Medication only) Note: If the NDC is not submitted with these covered codes, claim will be denied.

9 Billing for Medication Assisted Treatment: Buprenorphine/Naloxone Scenario: A member receives a total of 2mg of Buprenorphine/Naloxone. The provider administers one 2mg tablet. Hypothetically, the NDC number on the medication box for the 2mg tablet is NDC: 2mg: because this is converted into the format. CPT code: J0572 because the dosage is less than or equal to 3mg. Number of units to bill: 1 because 1 unit=up to 3mg.

10 Billing for Multiple Units of Medication Assisted Treatment: Buprenorphine/Naloxone Scenario: A member receives a total of 10mg of Buprenorphine/Naloxone. The provider administers one 2mg tablet and one 8mg tablet. Hypothetically, the NDC number on the medication box for the 2mg tablet is Hypothetically, the NDC number on the medication box for the 8mg tablet is NDC: Line 1 for 2mg: because this is converted into the format. Line 2 for 8mg: because this is converted into the format. CPT code: Line 1 for 2mg: J0572 because the dosage is less than or equal to 3mg. Line 2 for 8mg: J0574 because the dosage is greater than 6 mg but less than or equal to 10mg. Number of units to bill: line 1 for 2mg: 1 because 1 unit=up to 3mg. 8mg: 1 because 1 unit is greater than 6 mg but less than 10mg.

11 ARTS Billing Best Practice # 5: Determine who is responsible for processing the claim Check eligibility before submitting a claim to determine what plan a member has. This can be done by using MediCall at or or by using the Virginia Medicaid Web Portal ( Not all ARTS claims are processed by the Magellan BHSA. Some claims are the responsibility of the State of VA or MCO and should be forwarded to them first. If a member has an MCO, the MCO is responsible for covering ARTS services. If a member has a Fee For Service Plan (FFS) or Governor's access plan (GAP) Magellan covers services with the exception of some of the labs. GAP does not cover inpatient substance use (ASAM 4.0). References and Additional Resources: ARTS Reimbursement Structure CMHRS Manual Chapter II page 4

12 References and Resources You may call Magellan of Virginia at if you have questions about denied claims.

13 LEADING HUMANITY TO HEALTHY, VIBRANT LIVES

14 Confidentiality statement for providers The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.