What are some strategies for providers to use to figure out their costs?

Work with your CFO or budget team to calculate your staffing, administrative and unit of service costs. For a sample model, utilize the CTAC benchmarking tool.

If someone is denied due to medical necessity or if managed care is refusing to pay, is there an appeals process?

Yes. The first step in the appeals process would be to initiate a discussion with the managed care company. If this is unsuccessful, a formal appeals process can then be instituted. Managed care has created external and internal appeals processes. It's important to recognize that the formal appeals process can be lengthy and time-consuming.

Contact information for a specific plan's appeals department can be found on the MCO matrix at matrix.ctacny.org. 

What should providers do when clean claims differ across payers?

Most times, 80%-90% of claims will be the same. MCTAC has developed a Billing tool and a Chargemaster Webinar to help with this. 

If a field on the claims form is not required and you complete it anyway, what will happen? For example if a field is required for one plan but not others and you set your default to fill it the way it is required for that one plan will the others deny you because you have completed a field that is not required?

Many plans will just ignore it and it will not disrupt the claim, but for some plans, it could lead to a denial. 

Claim testing is a great opportunity to determine the appropriate system set up to reduce denials. 

How will clinicians know which codes to use?

It can be beneficial to create a Chargemaster that everyone at your organization has access to so that they understand which codes are used for which services as well as who (in terms of licensure) can provide and bill for each service.

For more information, view the Creating a Chargemaster webinar.

Where can claims testing contact information be found for each Medicaid Managed Care Plan?

Providers should contact each MMCP to get instructions on claims testing. The MCTAC Matrix below includes a tab for contacts at each MMCP related to billing: https://matrix.ctacny.org/

Can agencies be reimbursed for completing the LPHA Recommendation for CORE Services?

If the LPHA is a member of the CORE Services staff, time spent with the member (in-person or via approved telehealth) for the purposes of completing an LPHA recommendation may be billed under the service specific rate codes. 

If the LPHA recommendation for Empowerment Services – Peer Support is completed by a member of the CORE staff, the time spent by the LPHA with the individual for the purposes of making an initial recommendation may be billed at the service-specific rate code, even if the LPHA is not otherwise qualified to deliver the service. For example, if an LPHA meets with an individual face-to-face to determine medical necessity for Empowerment Services – Peer Support, that time would be billable in 15- minute increments using rate code 7794, even if the LPHA is not also a certified peer.

Can we bill for communication w/ outside providers related to CORE services?

The CORE provider can bill for synchronous (real time, two-way)
communication with outside providers as a collateral if it is for the benefit of the individual (i.e., advances their service plan or goal). See the Operations Manual for specific documentation requirements and information on consent. Synchronous communication with collaterals may be provided in person or via telehealth modalities. Emails, text messages, and instant messages with collaterals are not Medicaid reimbursable activities. The minimum service duration (15 min. per unit) applies to collateral contacts.

Can you provide a telehealth and in-person CORE Service for the same person on the same day and be able to bill for both services appropriately?

Yes, Providers serving an enrollee may submit one claim per day for each rate code/procedure code/modifier combination. In accordance with the CORE Services Operations Manual, and if clinically indicated, providers may submit claims for an in-person visit and telehealth visit for the same rate code in the same day.

Please see page 17 from CORE Benefit and Billing Guidance.

Will rate codes stay the same or change for services transitioning from Adult BH HCBS to CORE?

Rates and rate code combinations will remain the same for CPST, FST, and Peer Support. Some PSR rate code combinations, rates, and other billing-related information will change as a result of the transition to CORE, including the addition of two new PSR rate codes and the discontinuation of the PSR per diem rate code. There will be two new provider travel supplement rate codes for CORE.

Are Adult Personalized Recovery Oriented Services (PROS) clients, dual eligible clients, etc. designated as Fee-for-Service (FFS) or managed care?

PROS clients are included in, or carved-in to, Medicaid managed care.

Dual eligible clients are now excluded, or carved out, from Medicaid managed care but have an option for managed Medicare. Dual eligible clients who are not in Fully Integrated Dual Advantage (FIDA) programs will remain in FFS. Agencies should not dismantle FFS as clients are still enrolled in it (e.g. non-FIDA dual eligible clients).

Are clinicians mandated to code their own sessions?

Yes, clinicians are mandated to code their own sessions.

Can billing departments or billing systems automate codes based on keywords?

No, billing departments or billing systems cannot automate codes based on keywords.