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Paramount Advantage Behavioral Health Redesign Resource Guide - Paramount Basics - Portal Functionality - Billing and Claims Submission - Forms
Always refer to the ODM site for updated material: https://bh.medicaid.ohio.gov/manuals *This link contains all relevant, updated provider information; materials are subject to change at the discretion of the Ohio Department of Medicaid.
Always refer to the latest ODM MITS BITS Newsletter: https://bh.medicaid.ohio.gov/Provider/Overview#55454-mits-bits
Ohio Behavioral Health Redesign The 2016/2017 state budget continued the Kasich Administration’s commitment to modernize Ohio’s Medicaid program. At the center of this effort is a proposal to rebuild community BH system capacity across the state. The legislation provided targeted investments to support initiatives such as:
Developing new services for individuals with high intensity service and support needs
Improving health outcomes through better care coordination’ and integration of physical and behavioral health care services to support individuals with substance use disorder or mental illness.
Recoding of all Medicaid behavioral health services to achieve alignment with national coding standards.
What’s Changing? Beginning in July 2018, Paramount Advantage (and all managed care plans) will have expanded service offerings for individuals with the highest, most intensive needs:
Assertive Community Treatment for Adults (New)
Assessment
Community Psychiatric Supportive Treatment (CPST)
Comprehensive Addiction Treatment Services
Counseling
Crisis Intervention
Day Treatment
Family Counseling (New)
Intensive Home-based Treatment for Youth (New)
Primary Medical Care – office visits, vaccinations, blood tests, etc., may now be given by your Behavioral Health provider (New)
The Behavioral Health Redesign Codes/Services only apply to the following provider types:
Provider Type 84: Ohio MHAS Certified Mental Health (MH) Example: Community Mental Health Centers
Provider Type 95: Ohio MHAS Certified Substance Use Disorder (SUD) Example: Alcohol and Drug Treatment Facility
Institutions for Mental Disease (IMD) Example: Nursing Facility, Hospital, or other institution of more than sixteen beds which primarily provides diagnosis, inpatient psychiatric treatment or care of persons with mental diseases, including medical attention, nursing care and related services.
Changes are being made in:
Claims submission requirements
NCCI guidelines for coding of services rendered (refer to ODM “Provider Requirements & Reimbursement Manual”)
NDC codes required for all medications along with J codes
Rendering providers must have an individual NPI number and valid Medicaid ID
Rendering provider ID must be provided with all claims
PARAMOUNT BASICS
Member Identification Card
Resource Center
www.ParamountHealthCare.com/BehavioralHealth
Description of the redesign project
Contact information for contracting, testing, training opportunities
Links to manuals, newsletters, claim testing forms, provider roster form
Link to contact our BH Rapid Response Team
Prior Authorization Requirements Inpatient admissions, some procedures, and drugs require Prior Authorization for Paramount
Advantage members. Prior Authorization is obtained by contacting Utilization Management:
- Phone 1-800-891-2520 - Fax 1-844-282-4901
A full Prior Authorization list can be found at: https://www.paramounthealthcare.com/PriorAuth Paramount also offers a variety of Prior Authorization tools/processes, including:
Automating authorization process and providing an instant determination InterQual® or ASAM Criteria sets for medical necessity determinations New users may obtain a login online at MyParamount.org
Paramount Case Management Strong, collaborative program between members, physicians, providers, and community
resources
Working collaboratively with Qualified Behavioral Health Entities (QBHEs) to support and assist the practices with members’ needs
Case managers specific to Advantage
Lab, pharmacy, claims data used to identify “at risk” patients
Real-time referrals for prompt assessment and intervention
Telephonic assessment, education and coaching
Paramount case management staff of certified case managers (both RNs and masters-prepared social workers) LISWs and LPCCs
Transitions of Care (TOC) Programs Members at high risk for complications
Goal is to reduce fragmentation of care and duplication of services to ensure member receives the support and services needed for a successful discharge
TOC programs include:
- Comprehensive discharge planning to reduce gaps in care - Post discharge follow-up - Facilitation of follow-up appointments - Referral services (home care, therapy, DME, medication)
MYPARAMOUNT.ORG - PORTAL
MyParamount.org – Provider Portal
Located at https://myparamount.org Providers can self-register for instant access (claim number required) – consult your
practice admin
View member’s real-time benefits and eligibility, including COB
Claim and authorization status
Submit questions with attachments to Paramount via Secure Messenger
Access to medical policies and frequently used forms
Fully compliant with all HIPAA privacy standards
Consult your practice administrator concerning portal access Registration
Follow our instructional guide on how to register.
MyParamount.org – Features
Dashboard: Eligibility Verification EOP Search Claims Search Authorization Search User Management
Tools and Resources: Eligibility Authorizations Manage My Provider List
o View Panel Roster o Manage Panel
Status Document Library
o Documents at your fingertips
Find a Provider: Search by: product type location distance type of provider name/group
Message Center: Send messages securely, with attachments.
BEHAVIORAL HEALTH BILLING
Billing Specifics – Claims Adjudication Explanation Document
For a full list of explanation codes describing why claims have Paid, Denied, or Pended –
specifically for Medicaid Behavioral Health Redesign, please visit the following site: https://www.paramounthealthcare.com/behavioralhealth
Billing Specifics – Rendering Provider On Claims
When billing Paramount Advantage, only ONE unique rendering provider is allowed on each
individual claim that is submitted. If more than one unique rendering provider is present on a claim, if appropriate, only services for one of the rendering providers on the claim can/will be processed – all other rendering providers and associated services on the claim beyond the initial ONE rendering provider will be denied/voided.
Billing Specifics – Billing with Modifiers
HE is for hospital use billing only. Not to be used on CMS1500 claims billed under the individual
practitioner. The order in which the modifiers are listed in each section of the ODM Manual for each code is
the order we prefer to have them billed on the claim to expedite payment. HK modifier is a required modifier When billing in a dual license capacity, bill the appropriate modifier that represents the specialty
of your dual license in the first modifier position followed by the procedures appropriate for that code.
Billing Specifics – Common Denials That Can Be Avoided
RN and LPN claims must be submitted with an ordering physician in order for your claim to be
paid.
H2036 is only payable for the specialties listed below:
The above grid can be found in the ODM Workbook overall coding tab: http://bh.medicaid.ohio.gov/Portals/0/Users/008/08/8/Unprotected_BHRedesign-Workbook_V5_12122017.xlsx
Only payable services for provider type 84 and 95 are those listed in the ODM Manual. Codes billed not in the ODM manual will be denied.
Codes categorized as MH in the ODM Manual must be billed with your 84 billing NPI or your claim will be denied. A corrected claim is required for consideration.
Codes categorized as SUD in the ODM manual must be billed with your 95 billing NPI or our claim will be denied. A corrected claim is required for consideration.
Codes categorized as MH/SUD in the ODM manual can be billed by either your 84 or 95 billing NPI.
Billing Considerations/Specifics – Opioid Treatment Program (OTP)
Please refer to the ODM Behavioral Health Provider Billing Manual for more information,
otherwise the following providers are approved to provide OTP services:
Please refer to the ODM Behavioral Health Provider Billing Manual for more information,
otherwise the following may be provided by Ohio MHAS Licensed Opioid Treatment Programs (Methadone).
Services provided by SAMHSA Certified Opioid Treatment Programs (Buprenorphine) (table
below).
Submitting Professional Claims Through MyParamount.org Providers must register for MyParamount.org Provider Portal prior to submitting professional claims through the Portal. Portal registration for claims submission requires that providers already have at least one claim processed in the Paramount claims system. Providers who have not previously submitted a claim can do so by submitting a claim electronically through their clearinghouse or mailing a hard copy on the approved CMS 1500 red claim form. Once the claim has processed, the claim number from the Explanation of Payment can be used in the registration process as indicated below.
Please note: Providers who are contracted and credentialed with Paramount but who have not filed any claims with Paramount may register to check member eligibility only by following the registration process except for supplying a claim number.
How to register Use the following guides to assist in the registration process:
How to register for MyParamount
Adding claims access in MyParamount
How to submit claims through MyParamount
Electronic Claims Submission Paramount encourages providers to bill claims electronically when possible
- Faster claim processing - Faster claim payment
Summary of Claims Submission Methods
Electronic Payment & Remittance Advice Paramount’s current payment vendor is RedCard RedCard issues checks Vpay issues electronic funds transfers or virtual credit card payments
Providers who wish to opt out of receiving virtual credit card payments may do so by contacting Vpay at 1-877-836-7586
Providers accepting VPay will enjoy the following benefits:
- Quick payments - VPay is delivered primarily via fax so you are receiving payments much sooner than by paper check.
- Easy reconciliation - the VPayment and EOP are delivered together in a single document. Enter the card number in your terminal and post the EOP to your billing system and you are done!
- No bank deposits - your funds will be delivered electronically to your merchant account.
- Fraud risk eliminated - delivery of funds to your account is guaranteed, regardless of any fraudulent attempt to process a VCard. No more stolen, lost or whitewashed checks.
- Customer support - VPay’s Call Center is staffed with knowledgeable, who can assist with any questions you have.
Third Party Payor (TPP) Coordination of Benefits (COB) Effective January 1, 2018
Federal Regulation requires states to deny Medicaid claims until after the application of available third party payor benefits since Medicaid is the payor of last resort.
A claim that has been submitted to a TPP using a CPT code cannot be recoded to a HCPCS code to bill Ohio Medicaid.
Paramount provides Medicaid services and, therefore, is the payer of last resort. Providers can verify a member’s eligibility through our provider portal before rendering services. Providers should also attempt to obtain other potential third party coverage from the member at time of service. Paramount receives coordination of benefit information from a variety of different sources, and although we attempt to maintain the most accurate information as we can, some information may not always be the most current information. Coordination of benefits information will only be displayed on our portal for members who have been active with Paramount within the last 24 months. Active coordination of benefit policies can be found on the provider portal. The presence of other coverage does not imply eligibility and provider should verify eligibility for services being rendered with the other carrier. ODM regulations require that the provider attempt to bill any other third party payers before billing Paramount. If for any reason the other payer denies coverage, provider would need to provide that information to Paramount to expedite the payment of any claims impacted.
FORMS
Many forms can be found on ParamountHealthCare.com under the Provider section of the website. We’ve also included more frequently used forms in this Guide.
If you need assistance, please contact our Provider Inquiry team at 419-887-2564 or 1-888-891-2564.
Paramount Health Care Provider Information Change Form
SAVE this form to your computer, then complete all applicable fields. When finished, print, sign (below) and return to Paramount Health Care by: Fax – 567-585-9403
Email – [email protected] Mail – Paramount Health Care, PO Box 928, Toledo, OH 43697-0928
Provider NPI ______________________ (Attach a list of additional providers & NPI’s, if applicable)
Provider Name ____________________________________ Today’s Date ___________________
Group Name ________________________________________________________________________
Contact Person (print) _______________________________ Job Title _______________________
Contact Signature __________________________________ Contact Phone __________________
Effective Date of Change(s) _________________
☐ NEW Office Location or Contact Information (attach additional pages if needed)
☐ New location/contact info ☐ Primary office ☐ Alternate Office
Street Address ___________________________________________ Ste #__________
City ____________________________________ State _______ Zip _____________
New Phone # __________________________ New Fax # ______________________________
New Office Hours ________________________________________________________________
Publish in directories? ☐ Yes ☐ No
☐ PREVIOUS Office Location or Contact Information
☐ No longer practicing here ☐ Primary office ☐ Alternate Office
Street Address ___________________________________________ Ste #__________
City ____________________________________ State _______ Zip _____________
Previous Phone # _________________________ Previous Fax # ________________________
☐ Billing Address / Tax ID / Group Name Changes (attach W-9 form)
New Tax ID __________________ (30-day notice required) TIN Effective Date ____________
New Group Name _______________________________________________________________
Street Address or PO Box _________________________________________________
City ____________________________________ State _______ Zip _____________
New Phone # _____________________________ New Fax # ___________________________
☐ Termination Effective Date _________________ Reason _________________________
☐ PCPs Only – Changes
Accepting new patients? ☐ Yes ☐ No
☐ Change in Hospital Affiliation ☐ Add hospital ☐ Remove hospital
Hospital ____________________________________________
FINANCIAL RESPONSIBILITY NOTIFICATION
PROVIDER NAME:
PROVIDER SECTION:
List specific service / product to be rendered:
Date of Service:
List amount member will be responsible for:
Ohio Model Medicaid Addendum Language
Provider may bill the member when Paramount Advantage has denied prior authorization or denied a referral, or the service is not covered. The following conditions must be met:
1. The member (your patient) must be notified that the service to be rendered is theirpersonal financial liability in advance of service delivery.
2. The notification by the provider was in writing, specific to the service being rendered,and clearly states that the member is financially responsible for the specific service.A general patient liability statement signed by all patients or for all services is notsufficient for this purpose.
MEMBER SECTION
I understand that the service to be provided has not been approved by Paramount Advantage OR, is not a covered service through ODJFS. I clearly understand that I will be billed by the provider for this service and that I am financially liable.
The provider may not submit a bill to Paramount Advantage.
Member Name:
Member Signature: Date:
CLAIMS FAX INQUIRY TO: PARAMOUNT – PROVIDER INQUIRY FAX: (419) 887-2014 (866) 768-5372 toll free
================================================= From: _____________________Phone: ________________Fax: _________________ Provider Name: ___________________________Paramount Provider #:____________ Regarding Claim Status Request Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ Member____________________________ ID#________________________________ Date of Service______________________ Billed Charges_______________________ Response from Paramount________________________________________________ ______________________________________________________________________ G:\USERS\PROVDEPT\CLAIMS FAX INQUIRY.doc Revised 8-02
Revised 11/7/16
CLAIM ADJUSTMENT/CODING REVIEW REQUEST
Please refer to reverse side for complete instructions
Section 1 - This section is required (PLEASE PRINT CLEARLY) Date of Request ELITE MEMBER Provider Name Provider ID Number
NPI Number Contact Name Phone Number
Member Name Member ID Number
Claim Number Date of Service
Section 2 – Please indicate the type of adjustment needed and include required documents. One form per request. CLAIM CORRECTION (corrected claim required) REFUND
Correction to units Overpayment (attach documentation)
Correction to diagnosis code Take back (attach documentation)
Correction to procedure code
Correction to modifier PAYMENT AMOUNT (corrected claim required)
Correction to date of service Additional or late charges
Correction to anesthesia time Correction to charge amount
Correction to DRG
Correction to place of service INVOICE
Denied for invoice
PROVIDER/MEMBER (corrected claim required)
Processed under incorrect provider number CODING REVIEW REQUEST
Processed under incorrect member number (Medical records and copy of EOP required)
Procedure code bundling logic denial
COB Denied for chart notes
Primary insurance (attach primary EOP) Unlisted procedure
Service is not a duplicate
PRIOR AUTHORIZATION
Copy of authorization attached
TIMELY FILING
Subrogation/workers’ compensation - copy of WC documentation attached
Paramount as secondary payer - copy of primary EOP attached
Originally submitted to another carrier - copy of other carrier EOP
Originally billed the member as self-pay - include information that indicates how/when notified that patient had Paramount
Other type of timely filing - copy of supporting documentation attached
STERILIZATION/HYSTERECTOMY/ABORTION CONSENT/CERTIFICATION - Advantage™ (Ohio Medicaid)
Explain codes “BG” or “BI” (requires a corrected completed consent form JFS 03198, JFS 03199, JFS 03197)
Additional explanation:
Revised 11/7/16
ADJUSTMENT/CODING SUBMISSION REVIEW FORM INSTRUCTIONS
If Paramount has denied your claim for additional information that you feel was submitted with the original claim, please contact Provider Inquiry at 419-887-2564
SECTION 1
1. All fields must be completed
2. The claim number from Paramount’s EOP
3. Paramount’s provider ID number and NPI number
4. Use one form per claim number
5. Identify if the member is an Elite member with the Plan.
SECTION 2
PLEASE CHECK THE MOST APPROPRIATE BOX
1. Claim Correction
Requires a corrected claim
2. Provider/Member Requires corrected claim with corrected provider or member number
3. COB
Requires a copy of primary payer EOP
4. Timely filing Requires proof of initial submission as outlined on front page
5. Sterilization/Hysterectomy/Abortion Consent/Certification
Requires a corrected completed consent form [sterilization JFS 03198, hysterectomy JFS03199, or abortion JFS03197 (Medicaid rule 5101:3-21-01/5101:3-17-01)] when denied specifically “BG” or “BI”
6. Prior Authorization
Requires a copy of correct authorization
7. Refunds Please provide full description for reason of overpayment or refund request Attach documentation
8. Payment Amount
Requires a corrected claim
9. Invoice Requires copy of invoice
10. Coding Review Request
Requires copy of coded chart, operative, or diagnostic reports Requires a copy of the Paramount EOP
Please return this form along with required attachments to: Paramount
P.O. Box 497 Toledo, OH 43697-0497
If you have questions concerning your submission, please contact: Provider Inquiry at 419-887-2564, or toll free at 888-891-2564
CONTACT US
DEPARTMENT ASSISTANCE AVAILABLE PHONE FAX
CREDENTIALING - New provider applications - Recredentialing questions 1-800-891-2542 1-855-896-0854
MEMBER SERVICES - Member questions - PCP change requests - Interpreter services
1-800-462-3589 1-888-740-5670 (TTY) 1-888-740-0222
PROVIDER INQUIRY 8:30 AM – 5:00 PM Monday – Friday
- Member benefits and eligibility - Claims inquiries - Claims processing questions - Referral and authorization verification
419-887-2564 1-888-891-2564
419-887-2014 1-855-448-4705
PROVIDER RELATIONS
- Education – provider and office staff - Contract issues - Orientations and webinars - New product participation requests - Office visit requests
1-800-891-2542 1-567-585-9403
UTILIZATION / CASE MANAGEMENT 8:00 AM – 6:00 PM Monday – Friday
- Obtaining in-plan and out-of-plan prior authorizations 1-800-891-2520
Toll-Free Numbers: 1-844-282-4901 BH, Chem Dep 1-844-282-4902 General Inquiry 1-844-282-4903 Home Health
1-844-282-4904 Imaging 1-844-282-4905 Inpatient / Acute 1-844-282-4906 Med/Surg, DME Genetics Pre-D 1-844-282-4907 Out of Plan 1-844-282-4908 SNF, Rehab and LTAC Precerts
TRANSPORTATION 7:00 AM – 7:00 PM Monday – Friday
- Issues and troubleshooting - Scheduling and pickups
1-866-837-9817 1-800-750-0750 (TTY) N/A
BEHAVIORAL HEALTH REDESIGN
Info on BH Redesign – http://www.paramounthealthcare.com/behavioralhealth Rapid Response Team email – [email protected] Contact number for questions regarding claims testing – 419-887-2532
