Updated Billing Guidance

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Health Home Program

Updated Billing Guidance

November 30, 2016

Agenda

  • The following Updated Billing Guidance is effective for claims with a Date of Service on or after May 1, 2016.
  • Legacy Rates end effective 11/30/2016 for dates of service prior to 12/1/2016.
  • All billing for dates of service 12/1/2016 and after will be submitted by the Health Home directly to eMedNY.
  • MMCPs will continue to process claims prior to 12/1/2016 and address all payment lags.
  • Guidance forthcoming:
    • Reinstating Health Home claims submission through MMCPs. "Denied Duplicate Claims" for dates of service prior to 5/1/2016

Billing/tracking scenarios

Outreach services provided by two HHs but only one HH created segment in MAPP HHTS

HH1 provided outreach services and created an outreach segment in the MAPP HHTS. HH2 provided outreach services and submitted a claim without creating an outreach segment in the MAPP HHTS.

  Outreach Enrolled In HHTS Paid HH claim
HH1 X   X  
HH2 X     X

Resolution: HH2 will void the claim because the member is not in tracking. All members in outreach must have an outreach segment in tracking.

Outreach and Enrollment services provided by two HHs, but neither created a segment in MAPP HHTS

HH1 enrolled a member in September. HH2 provided outreach services and submitted a claim for September. Neither HH created a segment within MAPP HHTS.

  Outreach Enrolled In HHTS Paid HH claim
HH1   X    
HH2 X     X

Resolution: HH2 must void their claim and HH1 will enter enrollment segment, complete the monthly billing assessment, and submit claim for September.

Enrollment overrides outreach services.

Outreach and Enrollment involving two HHs but only one entered segment in MAPP HHTS

HH1 enrolled a member. HH2 provided outreach services, created a segment in the MAPP HHTS and submitted a claim.

  Outreach Enrolled In HHTS Paid HH claim
HH1   X    
HH2 X   X X

Resolution: HH2 must end date their outreach segment at the end of the month. HH1 will enter an enrollment segment for the following month and submit a claim. (If the Outreach segment with HH2 is in hiatus status, HH2 would need to delete the hiatus segment). All members must have a segment in tracking prior to submitting a claim.

HH Enrollments involving two HHs, only one created segment in MAPP HHTS

HH1 and HH2 both enrolled a member in their Health Home, both have had claims paid and denied, but HH2 created an Enrollment segment within MAPP HHTS.

  Outreach Enrolled In HHTS Paid HH claim
HH1   X    
HH2   X X  

Resolution: HH1 and HH2 will speak to each other and ask the member which HH they want to work with. If member chooses HH1, HH2 would need to end date their enrollment segment for the current month (i.e. September). HH1 will enter an enrollment segment and submit claim for future months (i.e. October 1).

HH Enrollments involving two HHs, neither created segments in MAPP HHTS In September, HH1 and HH2 find out they both enrolled a member in their Health Home but neither have created an enrolled segment within MAPP HHTS. HH1 enrolled in July and submitted claims for July and August. HH2 enrolled in August and submitted a claim but the claim was denied.

  Outreach Enrolled In HHTS Paid HH claim
HH1   X   X
HH2   X    

Resolution: HH1 and HH2 must speak to each other and ask the member which Health Home they want to work with. Member chooses HH2. HH1 must void claims for July and August. HH2 must enter an enrollment segment for September, complete the monthly billing assessment, and submit claim.

HH Outreach involving two HHs, neither created segments in MAPP HHTS

In September, HH1 and HH2 find out they both provided outreach to a member in their Health Home but neither have created an outreach segment within MAPP HHTS. HH1 began Outreach in July and submitted claims for July and August. HH2 began Outreach in August and submitted a claim but the claim was denied.

  Outreach Enrolled In HHTS Paid HH claim
HH1 X     X
HH2 X      

Resolution 1: HH1 and HH2 must speak to each other and ask the member which Health Home they want to work with. Member chooses HH2. HH1 must void their claims for July and August. HH2 must enter an outreach or enrollment segment for September, complete monthly billing assessment, and submit a claim.

HH Outreach involving two HHs, neither created segments in MAPP HHTS

In September, HH1 and HH2 find out they both provided outreach to a member in their Health Home neither have created an outreach segment within MAPP HHTS. HH1 began Outreach in July and submitted claims for July and August. HH2 began Outreach in August and submitted a claim but the claim was denied.

  Outreach Enrolled In HHTS Paid HH claim
HH1 X     X
HH2 X      

Resolution 2: HH1 and HH2 has no contact with the member. HH1 must void outreach claim for July and August since member was not in MAPP HHTS. HH1 and HH2 must review care notes and determine which CMA had a higher level of documented progressive outreach activities.

Steps for billing/tracking

Step 1: Check the member´s CIN in ePACES for Medicaid Coverage and Restrictions.

Step 2: Utilize the Member CIN Search Function within MAPP HHTS.

Step 2a: Within the Member CIN Search Function check: the last five claims, recent Care Management, RE Code, and Coverage for member. You may work with the member and add a segment into the MAPP HHTS if there is no CMA listed in the last five claims and/or recent Care Management, the member does not have an RE Code that is not compatible with the HH program, and the member has a coverage code that is compatible with the HH Program.

For RE and Coverage Codes:m

Step 3: Enter the outreach or enrollment segment into the MAPP HHTS.

Step 4: After a billable service has been performed complete the monthly billing assessment within the MAPP HHTS for the member.

Step 5: Submit claim for payment to eMedNY.

Please note:

If a member is not in the tracking system and a claim for payment is submitted, you may be required to void your claim.

If there is a conflict between two or more Care Management Agencies working with the same member, ALL agencies MUST work together to allow the member the choice of which agency he/she wants to continue to work with.

Questions?

Submit your questions to the Health Home BML and use the Subject: Health Home Policy + Billing Policy

Call the Health Home Provider Line at 518-473-5569.