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YourCare
Provider Orientation
History and Overview
2
• Since 1996 Beacon Health Strategies has been a leader in the managed behavioral
care industry.
• Locally owned and operated in the Boston area, Beacon has strived to provide
exceptional value to the plans and providers it has partnered with.
• Beacon started small, with regional health plans and began building relationships
and a strong reputation by working with and for our industry partners.
• Beacon is in full accreditation with both NCQA and URAQ.
• We have provided expertise in clinical, network, quality, operations and utilization
management services to those with which we have partnered.
• Beacon offers statewide networks that offer a full range of clinically appropriate
behavioral health services.
• We provide a cutting edge case management system that allows us to track and
authorize services appropriately and effectively.
• In 2014 Beacon Health Strategies acquired Value Options to form Beacon Health
Options.
Our Coverage Area
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Philosophy of Beacon Health
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• Improve the health care status of the members we cover
• Enhance continuity and coordination with behavioral health care providers
as well with physical health care providers
• Establish innovative preventive and screening programs to decrease the
incidence, emergence or worsening of behavioral health disorders
• Ensure members receive timely and satisfactory service from Beacon and
our network of providers
• Maintaining positive and collaborative working relationships with network
practitioners and ensure provider satisfaction with Beacon
• Responsibly contain health care costs
Beacon Provider Network Team
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Beacon Health Options
Operational Contacts
Fred Habib, GM and VP of Operations - Woburn Service Center
Bill Lavey, AVP Provider Network Operations – Woburn Service Center
Bill Carboni, AVP Provider Network Development – Woburn Service Center
Julie Fine, AVP Clinical – Woburn Service Center
Renee Abdou-Malta, Regional Vice President, Client Partnership
Debra Meyer, Program Director for YouCare
Maria Richter, Manager of Provider Relations– Woburn Service Center
Network Operations
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• Network Operations is responsible for many different functions at Beacon
beyond provider contracting and credentialing
• Our Network staff perform initial and re-credentialing site visits for our
provider network
• We also conduct Provider trainings for eServices
• Add providers and services (i.e languages, groups)
• Make changes to demographics or billing information
• Assist providers with any issues in a timely manner
Network Operations
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• Please contact us if you are updating your site information. This includes your
office address, mailing address or phone number.
• Also contact us if you are adding any clinicians, or updating your staff roster.
• It is important to keep rosters up to date, to provide the most accurate information to our members.
• Any updates can be sent to us at [email protected], or via fax at 781-994-7639
Joining the Network
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If you are not contracted with Beacon Health Options and are a Medicaid provider,
you may request participation through our website:
www.beaconhealthstrategies.com
Under the Provider section, please choose the “How to Become a Provider” link.
Complete the Letter of Interest form, and email it to
Applications and contracting materials will be sent to you in 7-14 business days.
For questions regarding this process please call Provider Relations at
844.265.7586
Maintaining Network Affiliation
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• Individual providers, groups and facilities are required to re-credential with
Beacon every three years. You will receive a notification in the mail.
• Providers are required to document continued compliance with eligibility
requirements through participation in a performance review process
including:
Utilization review
Chart review
Site Evaluations
Accreditation
• We ask providers to update Beacon regarding any provider additions or
deletions to your clinician roster and office contacts.
Level of Care Criteria
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• Developed from the comparison of national, scientific and
evidence based criteria sets
• Criteria are reviewed and updated, at least annually, and
as needed when new treatment applications and
technologies are adopted as generally accepted medical
practice.
• Beacon uses its LOC criteria as guidelines, not absolute
standards, and considers them in conjunction with other
indications of a member’s needs, strengths, and treatment
history in determining the best placement for a member.
• Level of Care Criteria is available to contracted providers
though eServices. Please go to
https://provider.beaconhs.com/ and choose the Provider
Materials link to review this criteria.
Model of Care
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Inpatient Psychiatric and Related Services
Inpatient Services Authorization
Required
Method
Inpatient Mental Health – Adult + Child Yes Telephonic
Inpatient Electroconvulsive Therapy (ECT)
Yes Telephonic
Extended Observation Bed No N/A
CPEP (Comprehensive Psychiatric Emergency
Program)
No N/A
Inpatient Professional Fee (99217 – 99239) If currently
admitted, No.
Otherwise Yes.
Mobile Emergency Services No N/A
Administratively Necessary Day Yes Telephonic
Model of Care
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Mental Health Diversionary and Outpatient Services
Mental Health Diversionary &
Outpatient Services
Authorization
Required
Method
Partial Hospitalization Yes Telephonic
Intensive Outpatient Program (IOP) Yes Telephonic
Day Treatment
Yes eServices
Continuing Day Treatment Yes Telephonic
Home Based Therapy (HBT) Yes Telephonic
Model of Care
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Outpatient Behavioral Health Services
Outpatient Services Authorization
Required
Method
Outpatient Electroconvulsive Therapy (ECT)
Yes Telephonically
Medication Management No N/A
Psychological and Neuropsychological Testing Yes eServices
eServices
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eServices home page
eServices
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eServices is simple to log into and use.
You create your own username and password.
eServices
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Choose to register if you don’t have an account.
eServices
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Enter your (or your organizations) NPI and tax identification number.
eServices
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Create your own user name, password and security question.
eServices
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Account administrators can determine the level of access.
eServices
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To locate inactive accounts, please uncheck the box circled above.
eServices
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Click on edit to assign level of access for the user account.
eServices
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You can assign the type of access by clicking on the checkboxes.
Please note that all accounts must have eligibility checked in order to work.
eServices
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Start by verifying your members eligibility by entering their plan ID,
date of birth, along with their last name.
Click here
eServices
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Once your member has been found, you can verify their benefits
by clicking on Yes.
Click here
eServices
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After you have clicked on the Yes button, this will allow you to view
their benefits. At the bottom you will see the number of outpatient
visits billed in the past twelve months. Click on More, for co-pay information.
Click here
eServices
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After clicking on the More link, there is additional eligibility information
of member co-pay details.
eServices
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Claim submission is simple and easy to complete.
Click here
eServices
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Choose the type of service from the drop down menu.
eServices
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Enter all of the appropriate and required fields for claims submission.
Enter diagnosis codes
Choose site and clinician NPI’s
from drop down menus
Enter date of service, place
of service code and procedure code
Diagnosis pointers indicate ICD
code which is primary
diagnosis code
Enter tax id number
Choose site of service
Add additional dates of services (if necessary)
Hit submit to complete transaction
eServices
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Now that your claim has been submitted, you will receive a transaction number.
You may also print the page for your records.
Transaction number
eServices
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Inpatient claims may also be submitted through eServices.
eServices
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Claim reconsiderations may be done
online, for claims that were submitted and
denied and require an in depth review.
eServices
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Once you have entered your claim info and explanation you can submit.
Use the free text box
to enter your explanation
Always make sure to enter
the original claim’s RecID
eServices
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Click here
Choose the month and year of the claim
Claims that may have denied for an incorrect procedure code
or diagnosis code may also be re-submitted electronically.
eServices
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Click here
Once the claim has been chosen, click on the resubmit link.
eServices
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After you have clicked on re-submit, the information will auto fill from the
previous submission. You can then make corrections and re-submit. Re-
submissions must be made within the timely filing limit.
Paper Claim Submission
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Member info
Diagnosis code
Complete the highlighted fields on the paper claim
Paper Claim Submission
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Member info
Diagnosis code
Complete the highlighted fields on the paper claim
Dates of service, place of
service code,
procedure code and modifier
Enter federal tax id
number, and
signature of clinician
Paper Claim Submission
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Member info
Diagnosis code
Complete the highlighted fields on the paper claim
Dates of service, place of
service code,
procedure code and modifier
Enter federal tax id
number, and
signature of clinician
Add charges, units and
rendering clinician NPI
Paper Claim Submission
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Member info
Diagnosis code
Complete the highlighted fields on the paper claim
Dates of service, place of
service code,
procedure code and modifier
Enter federal tax id
number, and
signature of clinician
Add charges, units and
rendering clinician NPI
Add service location
information, billing
provider info, and site
NPI number
Paper Claim Submission
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1 Yes Provider Name, Address, Telephone #
2 Yes Service Facility if different from box 1
3 No Provider’s Member Account Number
4 Yes Type of Bill (See Table 7-3 for 3-digit codes)
5 Yes Federal Tax ID Number
6 Yes Statement Covers Period (include date of discharge)
7 Yes Covered Days (do not include date of discharge)
8 Yes Member Name
9 Yes Member Address
10 Yes Member Birth Date
11 Yes Member Sex
12 Yes Admission Date
13 Yes Admission Hour
14 Yes Admission Type
15 Yes Admission Source
16 Yes Discharge Hour
17 Yes Discharge Status (See Table 7-2: Discharge Status Codes)
18 -28 No Condition Codes
29 No ACDT States
30 No Unassigned
31-34 No Occurrence Code and Date
35-36 No Occurrence Span
37 No Not used by Beacon.
38 No Untitled
39-41 Yes Value CD/AMT, Include “24” followed immediately by 4 digit
rate code based on facility type.
42 Yes Revenue Code (if applicable)
43 Yes Revenue Description
44 Yes Procedure Code (CPT) (Modifier may be placed here beside
the HCPCS code. See Table 7-4 for acceptable modifiers.)
45 Yes Service Date
46 Yes Units of Service
47 Yes Total Charges
48 No Non-Covered Charges
49 Yes Modifier (if applicable; see Table 7-4 for acceptable modifiers)
Using the highlighted fields, we can we what is required to be entered on the
claim form and what is not.
Paper Claim Submission
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50 Yes Payer Name
51 No Beacon Provider Id Number
52 Yes Release of Information Authorization Indicator
53 Yes Assignment of Benefits Authorization Indicator
54 Yes Prior Payments (if applicable)
55 No Estimated Amount Due
56 Yes Facility NPI
57 Yes Other ID (Rendering Taxonomy and/or Medicaid ID)
58 Yes Insured's Name
59 No Member's Relationship to Insured
60 Yes Member's Identification Number
61 No Group Name
62 No Insurance Group Number
63 No Prior Authorization Number (if applicable)
64 Yes RecID Number for Resubmitting a Claim (if applicable)
65 No Employer Name
66 No Employer Location
67 Yes Principal Diagnosis Code
68 No A-Q Other Diagnosis
69 No Admit Diagnosis. Not needed for outpatient claims
70 No Patient Reason Diagnosis
71 No PPS Code
72 No ECI
73 No Unassigned
74 No Principal Procedure
75 No Unassigned
76 Yes Attending Physician NPI/TPI, First and Last Name and NPI
77 No Operating Physician NPI/TPI
78 -79 No Other NPI
80 No Remarks
81 Yes Code-Code (Billing Taxonomy)
Using the highlighted fields, we can we what is required to be entered on the
claim form and what is not.
APG Rates
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Facilities that are Article 28 or Article 31 will be paid at the
APG rate.
The facility needs to identify to Beacon if they are Article 28
or Article 31.
Beacon has logic in our internal system so that claims will
pay at the APG rate through 3M.
Important Claims Reminders
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• Outpatient visits are one per day, per service.
• If multiple claims are billed for the same service on any date of
service, the first claim received will be paid and all others will deny.
• No balance billing is allowed. Member cannot be billed for denied
claims or no show appointments.
Paper Claim Submission
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Claims for Behavioral Health services can be mailed to
Beacon Health Options
500 Unicorn Park Dr, Suite 103
Woburn, MA 01801
Attention: YourCare Claims
Claims for medical services or with a medical diagnosis must be
sent to the health plan directly
Paper Claims Reconsiderations
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Reconsiderations for claim denials can be submitted either electronically
through eServices, or as paper submissions.
Reconsiderations have a filing limit of 180 days from the original date of service.
To send a reconsideration, with proof of timely filing or other applicable information, please mail
to us at:
Beacon Health Options
500 Unicorn Park Drive, Suite 103
Woburn, MA 01801
Attn: Reconsiderations
Reconsiderations will be reviewed by a committee who will make a determination on the claim.
Electronic Funds Transfer
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Beacon participates with PaySpan Health to administer EFT and to issue paper
checks. Provider may choose either method of payment, but we encourage you to
take advantage of EFT.
To become a user, please complete the enrollment process at
www.PaySpanhealth.com. Follow the instructions to select EFT or paper checks as
your preferred method.
You can also call the PaySpan Health provider hotline at 877.331.7154 for assistance
with registration.
Electronic Data Interchange (EDI)
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• For larger providers, EDI is the preferred method for receiving claims. We accept the standard HIPPA
837 format and provide 835 transactions.
• Beacon also uses 270/271 transactions for eligibility purposes.
• Beacon does allow EDI claims to be submitted from a Clearing House or Billing Agency
• EDI claims may also be submitted to Beacon via Emdeon. Beacon’s Emdeon payer ID is 43324.
• The plan id for YourCare is 156
• All EDI claims submitted via Emdeon must include the members Health Plan “Plan ID” and Beacon’s
Emdeon payer ID. Using just one or the other will cause claims to reject.
• EDI registration forms are on the Beacon web site at
http://www.beaconhealthstrategies.com/private/pdfs/forms/EDI_Trading_Partner_Setup.pdf
• After test submissions have been completed, contact EDI Operations to request a production setup.
They can be reached at 781-994-7500, or via email at [email protected].
Important Claims Reminders
49
• All claims must be received by Beacon within the plans timely filing limit. The filing
limit for YourCare is 120 days from the date of service for original filing, and 60
days for resubmissions. Out of Network claims have a filing period of 15 months.
Claims that require Coordination of Benefits (COB) have 120 days.
• All clean claim submissions (meaning no missing or incorrect numbers or
information) will be processed and paid by Beacon within 30 days.
• The top denial reasons for claims submitted to Beacon, are as follows:
• Timely filing (claim denied as it was not received within the plans timely
filing limit)
• Missing or incorrect NPI number (all claims must list the rendering
clinicians individual NPI number, along with the site NPI number. If either
of these numbers are missing or entered incorrectly, the claim will deny)
Contact Numbers
50
Beacon Health Options 844.265.7586
Main fax number 781.994.7600
TTY Number (for hearing impaired) 866.727.9441
Provider Relations 844.265.7586
Provider Relations fax 781.994.7639
Credentialing fax 781.994.7667
Provider Relations email: [email protected]
Claims Hotline 888.249.0478
eServices Helpline 866.206.6120
All departments can be reached at 844.265.7586
This is the main toll free number.
Copy of Presentation
51
For a copy of the presentation, please email: [email protected]
Please note, the Provider Training email does not handle day to day operational
issues. Please contact Provider Relations at [email protected], or at
844.265.7586 should you have an issue that needs to be resolved.
Thank you
52
Thank you
