dasa - overview
TRANSCRIPT
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions
Terriana Clark
Brenda Brown &
Tracy Crump-Ermon
DASA - Overview
Agenda
Welcome and Introduction
Objectives
Provide an overview of Aetna Better Health of Illinois and its programs:
Integrated Care Program (ICP),
Medicare Medicaid Alignment Initiative (MMAI)
Premier Plan, & Family Health Plan (includes Affordable Care Act)
Credentialing Process (New facilities & additional staff)
Identify member eligibility and enrollment process
Billing Process, Claims- Submission, Timely Filing Guidelines & Prior
authorization
Case Management
Secure Web Portal
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Aetna Better Health of Illinois
• Aetna has over 150 years of experience in meeting members’ health care needs
• Aetna Better Health is an experienced Medicaid Managed Care Organization (MCO)
that shares the philosophical principles and business strengths of our parent company,
Aetna Inc.
• Aetna Better Health and our affiliates have 25 years of Medicaid managed care
experience
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Aetna Better Health Programs
We provide services for over 3 million members in 17 states and manage over $7 billion worth of health care expenses each year.
Aetna Better Health- Programs Lines of Businesses
Lines of Business Inception Date
Integrated Care Program 05/01/2011
MMAI-Premier Plan 10/01/2013
Family Health Plan 09/01/2014
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Integrated Care Program- Benefits and Eligibility
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ICP- Benefits •All Medical Benefits
•Pharmacy
•Dental
•Vision
•Behavioral Health Services
•Transportation
•24/7 nurse line
•Short-Term Post Acute rehabilitation stays in Nursing Facilities
•Nursing Facility Services/Long Term-Care Services
•Home and Community Based Services waivers
•Excludes the waivers servicing individuals with Developmental Disability
Service Counties: Boone, Cook, DuPage, Kane, Kankakee, Lake, McHenry, Will and Winnebago
Eligible Members: • Adults age 19 years of age and older
• Are not Medicare eligible
Sample ID Card- ICP
Front
Back
MMAI- Premier Plan Benefits and Eligibility
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MMAI- Benefits • All Medical Benefits
• 24/7 nurse line
• Behavioral health services
• Eye care services
• Hearing services
• Home health care
• Hospital services
• Lab tests and x-rays
• Medical supplies
• Pharmacy
• Therapy
• Transportation
Service Counties: Kane, DuPage, Cook, Will and Kankakee
Eligible Members: Age 21 and older;
Entitled to benefits under Medicare Part A and B and receive full Medicaid benefits;
And may be in the following Medicaid waivers:
• Elderly;
• Persons with disabilities;
• Persons with HIV/AIDS
• Persons with Brain Injury; and
• Persons residing in Supportive Living Facilities (SLFs)
• Individuals with End Stage Renal Disease (ESRD)
Sample ID Card-MMAI (Premier Plan)
Front
Back
Family Health Plan (ACA/TANF)- Benefits and Eligibility
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FHP Benefits •All Medical Benefits
•Pharmacy
•Dental
•Vision
•Behavioral Health Services
•Transportation
•24/7 nurse line
•Short-Term Post Acute rehabilitation stays in Nursing Facilities
•Nursing Facility Services/Long Term-Care Services
•Home and Community Based Services waivers
•Family planning services and supplies
•Early and Periodic Screening, Diagnostic and Treatment services for enrollees under age 21
Service Counties: Boone, Cook, DuPage, Kane, Kankakee, Lake, McHenry, Will and Winnebago
Eligible Members: • FHP- Age 0-and older
• ACA- Adults age 19 years of age and older
• Are not Medicare eligible
Sample ID Card- Family Health Plan
Front
Back
Eligibility Verification Options
• Use Aetna Better Health’s 24/7 options:
Call 1.866.212.2851 option 1 ICP or FHP
1-866-600-2139 option 1 MMAI-Premier Plan
Aetna Better Health’s secure web portal at www.aetnabetterhealth.com
• Providers may continue to use the existing Medicaid eligibility verification methods set up by the State:
MEDI information is available at: www.myhfs.illinois.gov/
The MEDI system is available 24 hours a day, 7 days a week
CREDENTIALING PROCESS
Credentialing Process New Facilities and/or New Staff
• Contact your Network Account Manager and request for a Facility Application and/or Provider Screening Form (Individual Providers)
• Please submit all documents to our Provider Services Department email address: [email protected]
• Credentialing Process takes up to 60 days to complete
• Once credentialing has been completed it will take another 30 days for the loading process.
• During this process please contact our UM department (866.212.2851, Option 2, then Option 2) to obtain authorizations if you are servicing our members during this time.
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Claims- Submission &
Timely Filing Guidelines
Claims Submission
• Aetna Better Health accepts claims submitted on the New CMS 1500 (02/12) form or on a UB04 Form (no other forms will be accepted)
• Processes over 90% of initial “clean claims” within 30 days of receipt
• Most “clean claims” are processed in 15 business days or even quicker if submitted electronically through EMDEON Clearing House- Payer Id 26337
• Providers administering drugs to patients are required to submit NDC codes on the claims otherwise will result in claim denials.
“Clean Claim” defines as a claim that can be processed to adjudication without obtaining additional information from the provider of service or from another party.
Claims Submission Information • Electronic Claims Submission:
Emdeon
Aetna Payer ID: 26337
www.emdeon.com
• EFT and ERA is now available (request for forms if you’re not set up)
• Paper Claims Submission address:
Aetna Better Health
PO Box 66545
Phoenix, AZ 85082
• Check Claims Status via Secure Web Portal:
http://www.aetnabetterhealth.com/illinois/providers/portal
www.aetnabetterhealth.com
Claims: Timely Filing Guidelines
• Initial claims must be received within 120 days of the date of service or date of discharge
• Claims that have a primary payer must be received within 120 days from the EOB receipt day and within 180 days of the original date of service
• Resubmission of a corrected claim and claims disputes must be received within 180 days of the original date of service
• Providers are required to submit valid, current HIPAA compliant codes that most accurately identify the member’s condition or service(s) rendered
Paper Claims and Resubmission address:
Aetna Better Health
PO Box 66545
Phoenix, AZ 85082
Provider Disputes
• The provider dispute process allows providers to express dissatisfaction with a decision based on contractual provisions inclusive of claim disputes
• To file a dispute, the provider must complete and submit the Provider Dispute Form and any appropriate supporting documentation
• The Provider Dispute Forms can be obtained via our website
• In the event the provider remains dissatisfied with the dispute determination, the provider may file a complaint
Provider Dispute address:
Aetna Better Health
Attention: Provider Dispute
333 W Wacker Drive 21st Flr. Mail Stop F646
Chicago, IL 60606
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Division of Alcoholism and Substance Abuse that is regulated
by DHS (Department of Human Services)
DHS/DASA administers a network of community based
facilities that provide alcohol and other drug treatment
programs
Treatment services are delivered through a network of
agencies at over 200 community-based sites.
Group of Behavioral Health Providers
Open to admissions 24 hours a day, 365 days a year, and are
most often furnished in a residential setting.
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Detoxification- Provides immediate and short-term clinical support for a person in the withdrawal process
Early Intervention- is pre-treatment services for individuals whose problems or risk factors appear to be related to substance abuse but who do not meet any diagnostic criteria for substance abuse related disorders.
Case Management is the provision, coordination, or arrangement of ancillary services designed to support a specific patient's treatment with the goal of improving clinical outcomes.
Outpatient Counseling
Intensive Outpatient Counseling- provides a variety of diagnostic and highly structured clinical services on a scheduled basis. Activities include individual, group and family counseling and patient education
Residential Rehabilitation provides clinical and treatment rehabilitation services 24 hours a day
Residential Aftercare is offered in two levels: halfway houses and recovery homes. Halfway houses provide living opportunities to patients in need of additional services, usually following residential rehabilitation. Services are designed to support the patients' productive return into the community. Recovery homes provide extended residential support services and the mutual support of living in a sober environment with other recovering individuals.
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Claim submission on HCFA & UB-04
DASA residential/institutional services are to be billed as one global rate on a single 837I claim – domiciliary (room and board costs) and treatment costs should not be split nor should they be billed to the MCOs separately.
Bill at Group Level not by Individual Providers Multiple services can be performed daily and are billable
DASA services are only Billable thru Medicaid
As of 01/01/2015 H2010 have replaced M0064 (Medication
Monitoring)
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There must be a fully executed contractual agreement with DHS/DASA that outlines the type of services that are reimbursable along with the rates for those respective services
Please reach out to your Network Account Manager when adding new DASA locations and Services to make sure that our system is updated and current with your information
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Please call 1-800-722-4004
This line will be managed daily from 8am – 5PM by clinicians who are able to take the inpatient information and work to make clinical determination while the caller is on the line.
If approval cannot be made, the caller will be directed to the next steps to complete the authorization process.
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DASA: Department of Alcohol and Substance Abuse
Substance abuse treatments are offered at varying degrees of intensity based on
the level of care.
Level 0.5 – Early Intervention
Level 1 – Outpatient
Level 2 – Intensive outpatient/partial hospitalization
Level 3 – Inpatient Sub acute/Residential
Level 4 – Medically managed intensive inpatient
Service codes and rates are provided to us by the State. Reference can be
found on the DASA Contractual manual:
http://www.dhs.state.il.us/OneNetLibrary/27896/documents/By_Division/OASA/2016/DASA_Contractual_Policy_Manual_FY_2016.pdf
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Services Overview
The required DASA services covered by HFS contracted Managed Care Plans are listed in Table 1 below, along with the corresponding ASAM level(s) and general billing structure overview:
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Service Name ASAM Level (s) Claim Type Unit Per Unit Rate
Admission and
Discharge Assessment
All levels 837P 1/4 hour $16.32
Psychiatric
Evaluation
All levels 837P Event $81.31
Psychotropic
Medication
Monitoring
All levels 837P 1/4 hour $15.53
Individual -
Therapy/Counseling,
Substance Abuse
Level I 837P 1/4 hour $15.53
Group -
Therapy/Counseling,
Substance Abuse
Level I 837P 1/4 hour $5.87
Individual - Intensive
Outpatient,
Substance Abuse
Level II 837P 1/4 hour $15.53
Group - Intensive
Outpatient,
Substance Abuse
Level II 837P 1/4 hour $5.87
Rehabilitation -
Adult (age 21+)
Level III.5 837I Per Diem Provider Specific
Rehabilitation - Child
(age 20 or under)
Level III.5 837I Per Diem Provider Specific
Adolescent
Residential
Level III.5 837I Per Diem Provider Specific
Detoxification Level III.7D 837I Per Diem Provider Specific
Admission and
Discharge Assessment
All levels 837P 1/4 hour $16.32
Psychiatric
Evaluation
All levels 837P Event $81.31
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1. DASA services may only be rendered from a site that is certified by the Department of Human Services’ Division of Alcohol and Substance Abuse (DASA). The NPI providers bill Managed Care Plans under must correspond to a DASA certified site.
2. Providers offering both substance abuse and mental health services from the same site may not utilize the same NPI number for billing substance abuse and mental health services. Mental health services must be billed under a separate NPI number from substance abuse services.
3. All outpatient DASA services are to be submitted on an 837P claim. All inpatient/residential DASA services are to be submitted on an 837I claim, in line with the Claim Type listed in Table 1.
4. As with all other encounter data submissions, the HCP and K3 segments are required on all DASA claims.
5. MCO will follow these guidelines on their historical DASA claims.
6. Any valid DASA services not listed but paid by MCOs will be accepted but default priced at $0 on encounters reported to HFS.
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Table 2. Acceptable Primary Diagnosis Codes for DASA
Services ICD-9
(services rendered prior to
October 2015)
ICD-10
(services rendered on or after
October 2015)
303 – 305.93 F10-F19.19
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Service Name
Billing Code Modifier Taxonomy Unit Per Unit Rate Place of Service
Admission
and
Discharge Assessment
H0002
261QR005X,
276400000X
¼ hour $16.32 21, 22, 55,
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Psychiatric
Evaluation 90791 Event $81.31 21, 22, 55,
57 Psychotropic
Medication
Monitoring
H2010 ¼ hour $15.53 21, 22, 55,
57
Individual –
Therapy/Cou
nseling, SA
H0004 ¼ hour $15.53 22, 57
Group –
Therapy/Cou
nseling, SA
H0005 ¼ hour $5.87 22, 57
Individual –
Intensive
Outpatient,
SA
H0004 TF ¼ hour $15.53 22, 57
Group –
Intensive
Outpatient,
SA
H0005 TF ¼ hour $5.87 22, 57
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Table 4. DASA 837I Billing Codes
Service Name Revenue Code Billing Code Modifier Taxonomy Type of
Bill
Rehabilitation – Adult (age 21+) 944 or 945 H0047 324500000
X,
3245S0500
X
086X, 089X
Rehabilitation – Child (age 20 or under) 944 or 945 H0047 HA
Adolescent Residential 944 or 945 H2036
Detoxification 944 or 945 H0010
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1. DASA residential/institutional services are to be billed as one global rate on a single 837I claim – domiciliary (room and board costs) and treatment costs should not be split nor should they be billed to the MCOs separately.
2. A Value Code of 80 is required on all 837I claims for the number of covered treatment days.
3. If a member is being dually treated for both alcohol and substance abuse, the primary admitting diagnosis code should be utilized to determine the appropriate Revenue Code (944 or 945) for the claim.
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Case Management
Case Management at a Glance
Aetna Better Health of Illinois’ Case Management is a collaborative process of Assessment, Planning, Facilitation, Care Coordination, Evaluation and Advocacy services.
With the goal to:
Meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
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Case Management Professionals
Aetna Better Health of Illinois’ Care Coordination interdisciplinary teams are comprised of:
• Physicians
• Registered Nurses
• Licensed Clinical Social Workers
• Licensed Clinical Professional Counselors
• Non-clinical Professionals
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Aetna Better Health Secure Web Portal
The Aetna Better Health Secure Web Portal will allow the providers to:
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• Request Portal Access – To submit your request for registration, please fax your completed form and attached agreement to Aetna Better Health Provider Services at
(860) 754-0435. (Application is found on the Aetna Better Health Website) • http://www.aetnabetterhealth.com/illinois/assets/pdf/providers/ProviderWebPortal
Registration-IL.pdf
• Provide and Designate level of access as Administrator or Staff
• Verify eligibility of your members
• Check Claims Status
• Access evidence-based clinical practice guidelines
• View Gaps in Care reports for members
• Available 24 Hours a Day
Secure Provider Web Portal
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Log in screen
Secure Provider Web Portal
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• Research and view member claims by Claim ID, Claim Type, Claim Status or Check Number.
The Provider Report Management Tool
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Benefits to Providers Safe, secure online tool gives providers access to plan-generated reports through your secure web portal
Gives the provider secure, direct access to view, download, save and print any report generated for your practice
• Provider Report Management Tool access is linked to the provider’s secure web portal log-in and password
No additional sign-on information required ensuring ease of access
• The tool is agnostic allowing plans to upload reports and provider communications in PDF, Microsoft Excel and Microsoft Word
• Versatility for health plan to distribute reports based on different levels of provider affiliation
Individual provider reports/communications
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