Billing for Habilitation Services
Magellan Health Services
June 11, 2013
Billing for Services
Magellan providers billing for Iowa Medicaid
Habilitation (HAB) services must bill with HIPAAcompliant codes for services rendered beginning July
1, 2013. Claims submitted with non-HIPAA compliant
codes (e.g. old W codes) will be denied.
Provider Billing Tips
• Coding changes are effective July 1, 2013.
• Billing the new HIPAA codes is mandatory; non-compliance is a
HIPAA violation.
• The switch to the new HIPAA codes is based on the date of service,
not the date the claim was submitted.
• Be sure to include required modifier.
• Use covered diagnosis codes.
• Use valid place of service codes.
• Submit claims timely. Timely filing limit is 1 year from date of
service.
• These services require pre-authorization. To authorize services,
please call 1-800-638-8820 to schedule an appointment.
Provider Billing Codes
Old W Code
New
HIPAA Code
HIPAA
Modifier*
IA Medicaid HAB Service Name
Time Unit/Basis
Day Habilitation
Per 15 Min
W1206
T2021
UC
Day Habilitation
Per Day
W1204
T2020
UC
Home-based habilitation
Per 15 Min
W1207
H2015
UC
Home-based habilitation
Per Day
W1208
H2016
UC
Pre-Vocational Services
Per Hour
W4425
T2015
UC
Pre-Vocational Services
Per Day
W1425
T2014
UC
Supported Employment:
Maintain employment/job coaching
Per 15 Min
W1431
H2025
UC
Supported Employment:
Maintain employment/enclave
Per 15 Min
W1433
H2023
UC
Supported Employment:
Job Development
Per Unit
W5019
T2018
UC
Supported Employment:
Employer Development
Per Unit
W5020
H2024
UC
Supported Employment:
Enhanced Job Search
Per 15 Min
W5021
H2019
UC
*For all Iowa Medicaid Habilitation services, the UC modifier must be included on claims. Claims for this service
submitted without this modifier will be denied.
Magellan Covered Diagnosis
Code
290
291
292
293
294
295
296
297
298
299
300
301
302
306
307
308
309
311
312
313
314
Description
Senile and presenile organic psychotic conditions
Alcoholic psychoses
Drug psychoses
Transient organic psychotic conditions
Other organic psychotic conditions (chronic)
Schizophrenic disorders
Affective psychosis
Paranoid states
Other non-organic psychosis (i.e. emotional stress, environmental
factors as major part of etiology)
Psychoses with origin specific to childhood
Anxiety states
Personality disorders
Sexual deviations and disorders
Physiology malfunction arising from mental factors
Special symptoms or syndromes, not elsewhere classified
Acute reaction to stress
Adjustment reaction
Depressive disorder, not elsewhere classified
Disturbance of conduct, not elsewhere classified
Disturbance of emotions specific to childhood and adolescence
Attention deficit disorder
Note: 310.00-310.99 – Mental Retardation is NOT covered.
Place of Service (POS) Codes
Code
Definition
Code
Definition
03
School
32
Nursing Facility
04
Homeless Shelter
33
Custodial Care Facility
11
Office
49
Independent Clinic
12
Home
50
Federally Qualified Health Center
13
Assisted Living Facility
53
Community Mental Health Center
14
Group Home
54
Intermediate Care Facility
22
Outpatient Hospital
57
Non-residential SA Treatment Facility
23
Emergency Room
71
State or Local Health Clinic
31
Skilled Nursing Facility
72
Rural Health Clinic
Rounding Rules – 15 Min. Unit
• Add together the minutes spent on all billable activities during a
calendar day for a daily total.
• For each day, divide the total minutes spent on billable activities by 15
to determine the number of full 15-minute units for that day.
• Round the remainder using these guidelines: round 1 to 7 minutes
down to zero units; round 8 to 14 minutes up to one unit.
• Add the number of full and rounded units to determine the total
number of units to bill for that day.
• Providers will not determine daily units by the number of encounters
they have with the member during a day, but by the total amount of
time spent with the member.
• Units will not be determined by adding the number of minutes of
service for the month and then dividing; units are to be determined on
a daily basis.
Rounding Rules – Hourly Units
• Add all the minutes provided for a
day.
• When the total minutes for the day is
less than 60, round up to one (1)
whole unit.
• When the total minutes for the day is more than 60,
divide the total by 60 to get the number of hours for
the day. This should be rounded to the nearest whole
unit, by rounding down for 1-30 minutes, and rounding
up for 31-59 minutes.
Daily Units
• Daily Home-Based HAB is defined as 8 or more hours per
day, based on the average hours of service provided
during a 24-hour period as an average over a calendar
month.
• Day HAB and Prevocational Services, the daily unit is
defined as 4.25 to 8 hours per day. There is no averaging
for these services.
Authorizations
• Existing service plans for HAB services active as of July 1,
2013, will be honored by Magellan.
• Magellan staff will be reviewing service plans for members
whose plan has an end date of August 2013.
• Magellan staff will be contacting HAB providers on any
existing ETP needing renewal.
• For new HAB clients July 1, 2013 or after – the case manager
or Integrated Health Home (IHH) staff should contact
Magellan at 1-800-638-8820 to make an appointment to
review a new HAB request.
Getting Paid
• Claim Submission
– Electronic Claim Submission
– Paper Claim Submission
• Submit a “Clean” Claim
• Submit Within Timely Filing Guidelines
– Claims must be completely adjudicated within one year of date of
service.
Top Claim Denial Reasons
•
•
•
•
•
•
•
•
No authorization
Client not eligible for services
Duplicate claim submission
Invalid diagnosis codes
Invalid CPT/HCPCS codes
Invalid or missing modifier or place of service code
Missing name and degree of provider – CMS 1500 only
Site not contracted/credentialed
– Sites ON contract means you should bill that rendering site.
– Sites NOT on contract means you should bill the main site as the
rendering site.
Electronic Claim Submission – Preferred Method
What’s in it for you?
• Improved Efficiency
– No paper claims, envelopes or stamps.
– Prompt confirmation of receipt or incomplete claim.
• Faster Reimbursement – cuts out the mailman, “clean” claims
processed within 36 hours.
• Improved Quality
– Up-front electronic review ensures higher
percentage of clean claims.
– Secure process with encryption keys,
passwords, etc.
Electronic Claim Submission Options
• Claims Courier – Magellan’s Web Option
– Small volume submitters
• Direct Submission to Magellan
– Medium to high volume submitters
• Clearinghouse
– Large volume submitters
Website Resources
• www.MagellanProvider.
com
• www.MagellanofIowa.
com
On-Line Resources
On-Line Resources, cont.
Electronic Claim Submission – On-Line
Training Available
• Go to www.MagellanProvider.com .
• Choose “Education”, and then “Online Training”.
• The section on “Electronic Transactions” includes the
following demos:
–
–
–
–
–
835 Transactions
Clearinghouse
Submit EDI Claims
EDI Testing Center
Electronic Funds Transfer
Claims/Website Contact Information
General Billing Questions
Customer Service at 1-800-638-8820.
EDI Technical Assistance
Getting Started – visit our EDI Testing Center at
www.edi.MagellanProvider.com
EDI Hotline at 877-326-7525, ext. 75841 or
email edisupport@magellanhealth.com.
General Website Technical Assistance
For all other website technical assistance, call
Provider Services at 800-788-4005.
Magellan Customer Service Contact Information
Customer Service – 800-638-8820; Fax 888-656-5302
Christine Bryant, Customer Svc. Supervisor, 515-273-5009
Email – CRBryant@MagellanHealth.com
Dennis Petersen, Director, Operations, 515-273-5044
Email – DAPetersen@MagellanHealth.com
Claims address:
PO Box 1869
Maryland Heights, MO 63043
Customer Service address:
PO Box 71129
Des Moines, IA 50325
Questions?