S
BHC
Behavioral Health Compliance
Solutions, LLC
Behavioral Health Medicaid Training
7 AAC 135
S
BHC
Staff Qualifications
Behavioral Health Medicaid Training
7 AAC 135
Staff Qualifications
Program Staff
•Program Staff are professionals who render behavioral
health services directly to a recipient.
•Required staff qualifications depend on the service
category.
•Service Categories are
–Clinic
–Rehabilitation
–Residential
–Detoxification
–Day Treatment
3
Staff Qualifications
Staff Types
•Substance Use Disorder Counselor
•Behavioral Health Clinical Associate
-includes Peer Support Specialists
•Mental Health Professional Clinician
•Directing Clinician
4
Staff Qualifications
Behavioral Health Clinical Associate
•May have less than a master’s degree in psychology, social work,
counseling, or a related field with specialization or experience in
providing rehabilitation services to recipients with severe behavioral
health conditions.
•Responsibilities may include a provision of psychosocial evaluation,
education related to a recipient’s behavioral health condition,
encouraging and coaching, counseling, and teaching of needed life
skills.
•Works within the scope of the their training, experience, and
education.
5
Staff Qualifications
Substance Use Disorder Counselor
•Subject to the limits of the their education,
training, and experience. They may provide
behavioral health rehabilitation services with a
focus on the treatment of substance use
disorders, while working for a community
behavioral health services provider.
6
Staff Qualifications
Mental Health Professional Clinician
• Working for a community behavioral health services provider;
• Performing limited behavioral health services that are within field of
expertise;
• Not working in a capacity that requires licensure under AS 08; and
• Has a master's degree or more advanced degree in psychology, counseling,
child guidance, community mental health, marriage and family therapy,
social work, or nursing;
Note: there are licensure requirements for mental health professional
clinicians that are not working for a community behavioral health service
provider
7
Staff Qualifications
Directing Clinician
•A substance use disorder counselor or mental health
professional clinician working within the scope of their
education, training, and experience who, with respect to the
recipient’s treatment plan:
–Develops or oversees the development of the plan
–Periodically reviews and revises the plan as needed
–Signs the plan each time a change is made to the plan
–Monitors and supervises the delivery of all services
identified in the plan
8
Staff Qualifications
Directing Clinician
• By signing a treatment plan, a directing clinician attests that (in their
professional judgment) the services prescribed in the plan are appropriate
to the recipient’s needs, delivered at an adequate skill level, and are
achieving treatment goals.
• Responsible for monitoring recipients’ care across all programs within an
agency as identified on a treatment plan.
• May bill Medicaid for 1hr per week/per recipient of case management
services for the monitoring by direct observation the delivery of services
as those services are provided to the recipient
9
Staff Qualifications
Clinic Services
Staff Qualifications
Integrated assessments
Mental health assessments
Psychotherapy
Psychological testing and evaluation
Short-term crisis intervention
Mental Health Professional Clinician
Psychiatric assessment
Physician, Physician Assistant,
Advance Nurse Practitioner
Pharmacologic management
Physician, Physician Assistant,
Advance Nurse Practitioner with
prescriptive authority
10
Staff Qualifications
Rehabilitation Services
AST
Screening and Brief Intervention (SBIRT)
Client Status Review (CSR)
Substance Abuse Assessment
Case Management
Comprehensive Community Support
Therapeutic Behavioral Health
Recipient Support
Daily Behavioral Health Rehabilitation
Day Treatment for Children
Facilitation of Telemedicine
BH Tx Plan Rvw for Methadone Recipient
Staff Qualifications
Behavioral Health Clinical Associate
Substance Use Disorder Counselor
11
Staff Qualifications
Rehabilitation Services
Staff Qualifications
Short-Term Crisis Stabilization
Behavioral Health Clinical Associate
(BHCA), Substance Use Disorder
Counselor (SUDC)
Note: If the BHCA or SUDC is unable to
resolve the crisis, a mental health
professional clinician may assume
responsibility for the case and begin
providing short-term crisis intervention
services.
12
Staff Qualifications
Rehabilitation Services
Staff Qualifications
Short-Term Crisis Stabilization
Behavioral Health Clinical Associate
(BHCA) Substance Use Disorder Counselor
(SUDC)
Note: If the BHCA or SUDC is unable to
resolve the crisis, a mental health
professional clinician may assume
responsibility for the case and begin
providing short-term crisis intervention
services.
Medication Administration, On/ Off Site
physician, physician assistant, advanced
nurse practitioner, registered nurse, or
licensed practical nurse.
13
Staff Qualifications
Rehabilitation Services
Staff Qualifications
Peer Support Services
You must be a behavioral
health clinical
associate or substance use
disorder counselor. You must
have experienced behavioral
health issues in your life or
within your family. Note: Must
be supervised by a mental
health clinician, determined by
your employer to be
competent to supervise peer
support.
14
Staff Qualifications
Peer Support Specialists
•Peer support staff must be employed by the Provider as a
behavioral health associate.
•Minimum age is determined by labor laws for employment
and agency policy.
•Good practice indicates that all employees, and particularly
peer support staff should be aware of the prohibition of dual
relationships with clients and maintain appropriate
boundaries.
15
S
BHC
Recipient Eligibility
Behavioral Health Medicaid Training
7 AAC 135
Recipient Eligibility
There are five categories of recipient eligibility for Medicaid services.
Recipients who are eligible to receive behavioral health clinic services
include:
1)
A child experiencing an emotional disturbance– a recipient is under the age of 21
who is experiencing on non-persistent mental, emotional, or behavioral health
disorder that:
a) Is identified and diagnosed during a professional behavioral health
assessment; and
b) Is not the result of an intellectual, physical, or sensory deficit
2)
An adult experiencing an emotional disturbance – a recipient is 21 years of age or
older who is experiencing on non-persistent mental, emotional, or behavioral
disorder that:
a) Is identified and diagnosed during a professional behavioral health
assessment; and
b) Is not the result of an intellectual, physical, or sensory deficit
17
Recipient Eligibility
Behavioral health clinic services
3) A child or adult experiencing a substance use disorder – a recipient of any
age experiencing a disorder that is identified by a diagnostic code found in
the American psychiatric Association’s diagnostic and statistical manual of
mental disorders that is related to:
a) alcohol, amphetamine, or similar acting sympathomimetics;
b) cannabis, cocaine, hallucinogens, inhalants, nicotine or
opioids
c) analogues of phencyclidine (PCP) or similar
arylcyclohexylamines;or
d) sedatives, hypnotics, or anxiolytics
18
Recipient Eligibility
Behavioral health clinic services
4) A child experiencing a severe emotional disturbance– a recipient is under the age of
21 who:
a) has or had a diagnosable mental, emotional, or behavioral health disorder
any time in the past year that resulted it in a functional impairment (that is
not a result of response to stressful situations) which substantially interferes
with the child’s role functioning in family, school, or community activities as
indicated by a global assessment of functioning score of 50 or less
b) exhibits specific mental, emotional, or behavioral disorders that
i) place them at imminent risk for out of home placement
ii) place the individual at imminent risk for being placed in the
custody of the Division of Juvenile Justice
iii) have resulted in the individual being placed in the protective
custody of the Office of Children’s Services
19
Recipient Eligibility
Behavioral health clinic services
5) An adult experiencing a serious mental illness– a recipient that is 21 years
of age or older who
a) has or had a diagnosable mental, emotional, or behavioral health
disorder any time in the past year that resulted it in a functional
impairment (that is not a result of response to stressful situations)
which substantially interferes with or limits one or more life
activities including
i) basic daily living skills
ii) instrumental living skills such as managing money
iii) functioning and social, family, or vocational/educational
contexts
20
Recipient Eligibility
Three of the five categories of recipient eligibility for
Medicaid service are eligible to receive behavioral
health rehabilitation services including:
1) A child or adult experiencing a substance use
disorder
2) A child experiencing a severe emotional disturbance
3) An adult experiencing a serious mental illness
21
S
BHC
Clinical Documentation
Requirements
Behavioral Health Medicaid Training
7 AAC 135
Clinical Documentation Requirements
Community behavioral health services providers (CBHS) “must maintain a
clinical record for each recipient in accordance with the standards used for
the Medicaid Program” [7 AAC 70.100(a)(6)]
7 AAC 135.130 Clinical Record
A CBHS must maintain a clinical record that contains the following:
–Screening using AST
–Client Status Review
–Behavioral Health Assessment
–Treatment Plan
–Progress Notes (for each service / each day service provided)
23
Clinical Documentation Requirements
•A Medicaid provider must retain a record of
service for each recipient according to
requirements noted in 7 AAC 105.230
•To document active treatment a Medicaid
provider must describe or list active
interventions provided to a recipient
•All changes to assessments and treatment
plans must be noted in the recipient’s clinical
record
24
Clinical Documentation Requirements
•A provider shall maintain accurate records necessary to
support the services for which the provider requests
payment, and ensures that the provider’s staff meet the
requirements of this section 7 AAC 105.230
•A provider’s record must identify all the following:
–Recipient name
–Specific services provided
–Extent of each service provided
–Date of service
–Individual who provided service
25
Clinical Documentation Requirements
• A Provider shall maintain a clinical record for each
recipient in accordance with professional
standards applicable to the provider that
includes:
–Recipient’s diagnosis
–Medical need for each service
–Prescribed Service or Plan of Care
–List of prescription drugs
–Stop and start times for time-based codes
–Progress notes of services provided signed / dated by
person who provided service
26
Clinical Documentation Requirements
Behavioral Health Screening
Alaska Screening Tool (AST)
•A CBHS must complete the AST for each new or returning
recipient of behavioral health services before a behavioral
health assessment is conducted [7 AAC 135.100(a)]
•AST does NOT have to be completed for recipients
receiving:
–SBIRT
–Short-term Crisis Intervention / Crisis Stabilization
•AST is a reimbursable Medicaid service [7 AAC 145.580]
27
Clinical Documentation Requirements
Behavioral Health Screening
Client Status Review
The Department will pay a CBHS for completing a client status
review with the client present if:
1. it is used as relevant clinical information concurrent with
an initial Behavioral Health Assessment
2. Conducted Every 90-135 Days
3. Conducted at discharge from treatment [7 AAC 135.100(b)]
4. Administered using the Dept. CSR Form
28
Clinical Documentation Requirements
Behavioral Health Screening
Client Status Review
6. Documented in the clinical record
7. CSR data reported to Department
8. Used to help determine recipient’s level of functioning
9. Used by Directing Clinician to:
a. Measure Treatment Outcomes
b. Make Treatment Decisions
c. Revise Treatment Plan
29
Clinical Documentation Requirements
Professional Behavioral Health Assessments
If a behavioral health screening (AST), or a referral by a court or
other agency, has identified an individual suspected of having a
behavioral health disorder that could require behavioral health
services, the Dept. will pay a CBHS for one of the following
behavioral health intake assessments [7 AAC 135.110]:
1.Mental Health intake assessment
2.Substance Use intake assessment
3.Integrated MH and Substance Use intake assessment
4.Psychiatric Assessment (used as Intake Assessment)
30
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Mental Health Intake Assessment
• Are conducted by a Mental Health Professional Clinician
for the purpose of determining:
–Recipient’s Mental Status, Social & Medical Histories
–Nature & Severity of Mental Health Disorder(s)
–Complete DSM Multi-axial Diagnosis
31
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Elements of ALL Behavioral Health Assessments:
• Finalizes in a written report
• Documents that results of AST and CSR were reviewed and
considered
• Documents information on functional impairment
• Documents treatment recommendations that form basis of a
treatment plan
• Identifies the need for Recipient Support Services (if
appropriate) that includes Hx of violence/need for vigilance &
location/frequency of RSS
• Is updated as new information becomes available
32
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Substance Use Intake Assessment
•Conducted by a Substance Use Disorder Counselor, Social
Worker, or other Qualified Staff Member working within the
scope of their authority, training, and job description
•Conducted to Determine:
–If recipient has substance use disorder
–Nature & severity of disorder
–Correct diagnosis
33
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Integrated Mental Health and Substance Use Intake
Assessment
•Conducted by a Mental Health Professional Clinician
(able to diagnose BOTH Mental Health & Substance Use
Disorders)
•Documents
–All Requirements for Mental Health Intake
Assessment
–All Requirements for Substance Use Intake
Assessment
34
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Psychiatric Assessments
• The department will pay a community behavioral health services provider
for a psychiatric assessment that is to serve as the professional behavioral
health assessment if the recipient's condition indicates the need for a
more intensive assessment, including an assessment to evaluate the need
for medication. [7 AAC 135.110(f)]
• A psychiatric assessment must be conducted by a licensed practitioner
working within the scope of their education, training, and experience, if
the provider has prescriptive authority, and if the provider is enrolled
under 7 AAC 120.100(c) as a dispensing provider:
•Physician
•Physician Assistant
•Advanced Nurse Practitioner
35
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Psychiatric Assessments
•2 Types of Psychiatric Assessments:
1.Psychiatric Assessment Interview
2.Interactive Psychiatric Assessment (uses equipment and devices)
•Both Types must include:
– Review of medical & psychiatric history or problem;
– Relevant recipient history;
– Mental Status Examination;
–Complete Multi-axial DSM diagnosis
–Listing of identified psychiatric problems
36
Clinical Documentation Requirements
Professional Behavioral Health Assessments
Psychological Testing and Evaluation
The Dept. will pay a CBHS, or psychologist for psychological testing and
evaluation to assist in the diagnosis and treatment of mental and emotional
disorders [7 AAC 135.110(g)]
•Psychological testing and evaluation must be conducted by a Mental Health
Professional Clinician working within the scope of their education, training,
and experience.
•Psychological Testing and Evaluation includes:
–assessment of functional capabilities
–administration of standardized psychological tests
–interpretation of findings
37
Clinical Documentation Requirements
Behavioral Health Treatment Plan
• Based on Behavioral Health Assessment recommendations
• Developed with recipient or
–Recipient’s representative if recipient 18 & older
–Treatment team if recipient is under 18
• Supervised by Directing Clinician
• Remains current based on Client Status Review conducted
every 90-135 days
38
Clinical Documentation Requirements
Behavioral Health Treatment Plan
Documentation Requirements [7 AAC 135.130(a)(7)]:
•Recipient’s identifying information
•Date that plan will be implemented
•Treatment goals related to assessment findings
•Services & interventions employed to address goals
•Frequency and duration of services & interventions
•Name, signature & credentials of Directing Clinician
•Signature of recipient or recipient’s representative
39
Clinical Documentation Requirements
Behavioral Health Treatment Plan
Treatment Team for Recipient under 18 MUST include:
•Recipient
•Recipient’s Family Members (including parents,
guardians, or others providing general oversight of
Recipient)
•OCS Staff Member if Recipient in State Custody
•DJJ Staff Member if Recipient in DJJ Custody
•Directing Clinician
•Case Manager, if Recipient is SED
40
Clinical Documentation Requirements
Behavioral Health Treatment Plan
Treatment Team for Recipient under 18 MAY
include:
•Representative(s) from Foster Care, Residential
Child Care, or Institutional Care
•Representative(s) from Recipient's Educational
System
41
Clinical Documentation Requirements
Behavioral Health Treatment Plan
ALL treatment team members shall:
• Attend team meetings In-person or by telephone
• Be involved in team decisions unless the clinical record
documents –
(1 ) that participation by Recipient or other Individual involved with
Recipient care is detrimental to Recipient's well-being
(2) family members, school district employees, or government agency
employees refuse or unable to participate after provider's responsible
efforts to encourage participation or
(3) weather, illness, or other circumstances beyond member's control
prohibits participation
42
Clinical Documentation Requirements
Behavioral Health Treatment Plan
Directing Clinician- Substance Use Disorder Counselor or Mental Health
Professional Clinician working within the scope of their education, training,
and experience who, with respect to the recipient’s Treatment Plan:
1.Develops or oversees treatment planning process
2.Periodically reviews & revises plan
3.Signs plan each time plan is changed
4.Monitors & directs delivery of services identified in plan
• By signing treatment plan, directing clinicians attest (in their professional
judgment) that services prescribed are:
• Appropriate to recipient’s needs
• Delivered at adequate skill level
• Achieving treatment goals
43
Clinical Documentation Requirements
Progress Notes
Requirements: [7AAC 135.130(a)(8)]
•Progress note is written for each service/each day service is
provided
•Date service was provided
•Duration of service expressed in service units or clock time
•Description of “active treatment” provided
•Treatment goals that service targeted
•Description of recipient’s progress toward treatment goals
•Name, signature & credentials of individual who rendered
service
44
Clinical Documentation Requirements
Short-term Crisis Intervention
Provided by a Mental Health Professional Clinician who:
1.Conducts initial assessment to determine:
a. Nature of Crisis
b. Recipient's Mental, Emotional, & Behavioral Status
c. Recipient's overall Functioning related to Crisis
2. Develops Crisis Intervention Plan
a. Uses Dept. Form
3.Directs ALL Services (except Pharmacologic Management
Services)
45
Clinical Documentation Requirements
Short-term Crisis Intervention
Clinician may order & deliver ANY Medically
Necessary and Clinically Appropriate Behavioral
Health Clinic or Rehabilitation Service or
intervention to:
• Reduce Symptoms
• Prevent Harm
• Prevent further Relapse or Deterioration
• Stabilize the Recipient
46
Clinical Documentation Requirements
Short-term Crisis Intervention
ST Crisis Intervention Plan MUST Contain:
•Treatment goals derived from assessment
•Description of Medically Necessary and
Clinically Appropriate Services
•Documentation by individual who delivered
service
47
Clinical Documentation Requirements
Short-term Crisis Stabilization
Provided by a Substance Use Disorder Counselor or
Behavioral Health Clinical Associate who:
1.Conducts initial assessment of recipient's overall
functioning in relation to crisis
2.Develops Short-term Crisis Stabilization Plan
3.Orders ANY Medically Necessary and Clinically
Appropriate Rehabilitation Service to return recipient
to level of functioning before crisis occurred
4.Documents Assessment, Stabilization Plan, and
Services on Dept. Form
48
Clinical Documentation Requirements
Short-term Crisis Stabilization
ST Crisis Stabilization includes:
• Individual or Family Counseling
• Individual or Family Training & Education related to Crisis and Preventing
Future Crisis
• Monitoring Recipient for Safety Purposes
• Any other Rehab Service
ST Crisis Stabilization May be Provided:
• Any Appropriate Outpatient or Community Setting
• Premises of CBHS
• Crisis Respite Facility
• Recipient’s Residence, Workplace or School
• Documented by Individual who Provides the Service
49
Clinical Documentation Requirements
Short-term Crisis Stabilization
ST Crisis Stabilization includes:
• Individual or Family Counseling
• Individual or Family Training & Education related to crisis and preventing
future crisis
• Monitoring recipient for safety purposes
• Any other Rehab Service
ST Crisis Stabilization may be provided:
• Any appropriate outpatient or community setting
• On the premises of CBHS
• Crisis Respite Facility
• Recipient’s residence, workplace or school
• Documented by individual who provides the service
50
S
BHC
Covered Services
Service Authorization
Medical Assistance Billing &
Payment
Post-Payment Activities (Appeals,
Audits)
Behavioral Health Medicaid Training
7 AAC 135
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Refer to Alaska Medical Assistance Program Policies and Claim Billing
Procedures Manuals
•Section I, Part B – Service Detail Sheets –
–Service Definition/Description – from regulations
–Service Code/Code Set Description – from national code sets
•Current Procedural Terminology – CPT
•Health Care Procedure Coding System – HCPCS
•Section I, Appendix I-D – Claims Billing & Payment Information
–List of Procedure Codes & Modifiers, Adult/Child Coverage, Brief
Descriptions, Unit Values, Payment Rates, Service Limits, Program
Approval Categories
52
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Coverage EXCLUSIONS & LIMITATIONS
•EXCLUSIONS
–Persons in the custody of Federal, State, or Local Law
Enforcement (including juveniles in detention) Authority: 42 CFR
435.1009, 42 CFR 436.1005, 7 AAC 105.110
–Persons between age 22 and 65 who are residents of an
Institution for Mental Diseases (IMD) Authority: 42 CFR 436.1005
•IMD is a hospital, nursing facility, or other institution of
more than 16 beds that is primarily engaged in providing
diagnosis, treatment, or care to patients with mental diseases
–Persons of any age who are residents of a Skilled Nursing or
Intermediate Care Facility (SNF/ICF) Authority: 7 AAC 140.505, 7
AAC 140.580
53
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Coverage EXCLUSIONS & LIMITATIONS
•LIMITATIONS
–Persons who are inpatients of an acute care
hospital or a residential psychiatric treatment center
are limited to coverage of assessment and case
management services for treatment planning or
preparation for transition to lower level of care within
30 days of discharge from the acute care hospital
54
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Service Authorization
 Annual Service Limits changed from CALENDAR year to STATE
FISCAL year (July 1 through June 30)
 NEW Service Authorization request forms are available in
provider manuals and via DBH and fiscal agent websites
 Requests are to be made in correlation with Client Status
Review requirements
 Requests limited to a maximum of 90 to 135 days of planned
services (to be submitted approximately 3 to 4 times annually)
 Requires signature of directing clinician
 ALL Requests to be submitted to the fiscal agent for
capture/control and entry into Medicaid Management
55
Information System (MMIS).
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Claims Billing - General
ALL CLAIMS MUST BE FILED WITHIN 12 MONTHS OF THE DATE SERVICE
• The 12-month timely filing limit applies to all claims, including those that
must first be filed with a third party carrier.
• Submit on paper form or electronically; complete required fields
–Use Paper CMS-1500 Claim Form for Professional Services - Set B
for billing behavioral health services
–Use Electronic Claim Transaction (837-Professional)
–Include Service Authorization number as required if services billed
exceed annual service limits
Ensure services are:
–Performed as active treatment, documented in treatment plan, stated as
a need in assessments, etc.
–Performed by staff qualified
56
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Claims Adjudication, Editing & Response All claims submitted are processed
according to program rules which will result in one of the following outcomes:
• adjudicated claim (paid or denied)
• reduction in payment
• denial of service
• in-process claims (further internal review or information needed)
• pending status requiring internal staff review
• additional information requested from the provider (via RTD)
• Remittance Advice (RA) statement includes the claims processing details
that include three-digit claims edit codes each with a unique explanation
of how the claim was processed. These edit codes are listed on the
Explanation of Benefit (EOB) description page of the RA and lists all EOB
codes and a brief description of each code used within that specific
Remittance Advice statement.
• Contact the fiscal agent’s Provider Inquiry for clarification as needed 57
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Medical Assistance Appeals for Providers (7 AAC 105.270)
REASONS for Providers to Request an Appeal
–Denied or reduced claims (180 days)
–Denied or reduced service authorization (180 days)
–Disputed recovery of overpayment (60 days)
Three Levels of Appeals
–First level appeals
–Second level appeals
–Commissioner level appeals
58
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Medical Assistance Appeals for Providers (7 AAC 105.270)
First Level Appeals- Fiscal Agent Must be submitted in writing
within 180 days of remittance advice for claim or other
notification (service authorization decision, request for recovery
of funds) Appeal form is available in provider manual, include:
•A copy of the Claim or Disputed Authorization Decision
•A copy of the Remittance Advice Statement
•Supporting Documentation
•Completed Adjustment Request, if applicable
•Mail to: Xerox Provider Services Unit
P. O. Box 240808, Anchorage, AK 99524-0808
59
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Medical Assistance Appeals for Providers (7 AAC
105.270)
Second Level Appeals – DBH, Must be submitted in
writing to Division of Behavioral Health within 60 days
of First Level Appeal Decision. Include:
–Reason for Appeal including a description of the issue or
decision being appealed
–Copy of decision from First Level Appeal
–Copy of denial or payment notice (Remittance Advice)
–Copy of Original Claim
–All other information and materials for consideration
60
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Medical Assistance Appeals for Providers (7 AAC
105.270)
Commissioner Level Appeals
•ONLY used to challenge/appeal adverse timely filing
denials/reductions
•Must be submitted in writing to the DHSS
Commissioner within 60 days of Second Level Appeal
decision
•Include clear description of the reason for appeal (the
issue or decision being appealed)
61
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Recommended Keys to Achieve Success in Billing/Payment:
•Read and maintain your
billing manual
•File your license renewals
•Verify recipient eligibility and/or
certification/permits timely
•Verify eligibility code
(keep
your
enrollment
•Verify dates of eligibility
current)
•Verify Third Party Liability
• Ensure completion of
•Verify the services you are claim forms
eligible to provide
•Verify procedure codes
62
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Recommended Keys to Achieve Success in Billing/Payment:
• Document Third Party
Liability payment on claim,
if applicable
• Include attachments as
required
• FILE TIMELY
• RECONCILE PAYMENTS
(Remittance Advice (RA)
Statements)
• Read and distribute RA
messages
• Address problems/issues
promptly
• Call Provider Inquiry with
questions
63
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Alaska Medical Assistance Regulations Request for Records
7 AAC 105.240 – Request for records
At the request of a DHSS representative or authorized federal, or
other representative, including an employee of the Department
of Law, a provider shall provide records, including financial,
clinical, and other records, that relate to the provision of goods
or services on behalf of a recipient:
– To the person making the request at the address
specified in the request
– No later than the deadline specified in the request
– Without charge and in the format stated in the request
64
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Audits
• Federal Audits
–
–
–
–
Department of Health and Human Services (DHHS)
Office of Inspector General
Department of Justice
U. S. Government Accountability Office (GAO)
• State Audits
–
–
–
–
Department of Health and Social Services (DHSS)
Department of Law
Legislative Audits
Fiscal Audits
65
Covered Services, Service Authorization, Medical Assistance
Billing & Payment, Post-Payment Activities (Appeals, Audits)
Previous Audit Findings
•
•
•
•
•
•
•
•
•
•
•
No client signature on treatment plan
No treatment plan reviews to cover dates of service
No documentation to match billed services
Progress notes do not match service billed
Duplicates of notes for the same service on a different day
Units billed and documented do not match notes
Duration of service is not supported by content of note
No treatment plan
Insufficient documentation to support units of service billed
Wrong service code submitted
Agency forms that contained check boxes that were unchecked and the
missing information was not supported by a narrative explanation
elsewhere in the note
66
Resources
Alaska Medical Assistance Provider Billing
Manuals
•
Section I: Community Behavioral Health Clinic Services, Policies and
Procedures:
https://medicaidalaska.com/dnld/PBM_CBHC.pdf
•
Section II: Professional Claims Management:
https://medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf
• Section III: General Program Information:
https://medicaidalaska.com/dnld/PBM_Gen_Program_Info.pdf
State of Alaska Division of Behavioral Health
• http://dhss.alaska.gov/dbh/Pages/Resources/Regulations.aspx
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Behavioral Health Medicaid Training
7 AAC 135
Behavioral Health Compliance Solutions, LLC
Contact information
• Connie Greco
E-mail: cgreco@gci.net
Phone: 907-522-8170
• Pam Miller
E-mail: pmillerbhcs@yahoo.com
Phone: 907-717-9180
Blog site address: www.bhcompliance.com
Facebook page: https://www.facebook.com/pages/Behavioral-HealthCompliance-Solutions-LLC/185142004863501
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