ABC’S OF ABA BILLING

BILLING BASICS

FOR THE ABA PROVIDER

By Yvonne Mc Namee, YMC Consulting P.O. BOX 3065 WAYNE, NJ 07470

AUTHORIZE

AUTHORIZATION OF ABA IS REQUIRED BY MOST INSURANCE PLANS

v  NO AUTHORIZATION ON FILE WILL RESULT IN TWO DENIALS

1.  FULL DENIAL OF SERVICE REIMBURSEMENT DUE TO LACK OF AUTHORIZATION

AND/OR

2.  REQUEST FOR EVERY SERVICE NOTE FOR EACH DATE OF SERVICE BILLED

By Yvonne Mc Namee, YMC Consulting

HOW TO AUTHORIZE v  CALL THE INSURANCE COMPANY

§  PHONE NUMBER FOR PROVIDERS IS ON BACK OF THE INSURANCE CARD

ALWAYS CALL THE PROVIDER LINE

PRESS PROMPT OR ASK FOR THE AUTHORIZATION DEPARTMENT

§  BE SPECIFIC:

SPECIFY YOU NEED APPLIED BEHAVIOR ANALYSIS AUTHORIZATION FOR TREATMENT OF AUTISM

ABA IS USUALLY COVERED UNDER THE MENTAL HEALTH

PROVISIONS OF THE POLICY

§  CONFIRM YOU ARE SPEAKING WITH THE CORRECT DEPARTMENT

§  ASK FOR THE SPECIFIC AUTHORIZATION FORMS TO BE FAXED OR EMAILED TO YOU

§  PROPERLY COMPLETE ALL FORMS

By Yvonne Mc Namee, YMC Consulting

BENEFITS

CHECK AND CONFIRM BENEFITS

v  CALL THE PROVIDER SERVICE NUMBER ON THE CARD §  YOU NEED:

a)   I.D. OF THE CHILD (FRONT OF THE INSURANCE CARD)

b)   DATE OF BIRTH OF CHILD

c)   PROVIDER TAX I.D. AND NPI

d)   PROVIDER NAME (MUST MATCH TAX I.D.) ADDRESS AND PHONE NUMBER

By Yvonne Mc Namee, YMC Consulting

TEN TOP QUESTIONS FOR BENEFITS

1.  IS THIS POLICY SELF FUNDED OR FULLY INSURED?

2.  WHICH STATE GOVERNS THE POLICY?

3.  IS ABA SPECIFICALLY COVERED IN THE POLICY LANGUAGE FOR THE TREATMENT OF AUTISM?

4.  If RESPONSE IS ABA IS NOT COVERED AND POLICY IS FULLY INSURED CITE THE STATE INSURANCE MANDATE ( Resource: https://www.autismspeaks.org/state-initiatives)

5.  DOES THIS POLICY HAVE OUT OF NETWORK COVERAGE?

6.  HOW MUCH IS DEDUCTIBLE?

7.  HOW MUCH IS OUT OF POCKET LIMIT? o  ARE DEDUCTIBLE AND OUT OF POCKET PER CALENDAR YEAR OR POLICY YEAR?

o  IS DEDUCTIBLE APPLIED TOWARD OUT OF POCKET LIMITS?

8.  WHAT IS COINSURANCE? (USUALLY A %) o  IS DEDUCTIBLE AND OUT OF POCKET PER CALENDAR YEAR OR POLICY YEAR

By Yvonne Mc Namee, YMC Consulting

9. CONFIRM MENTAL HEALTH CLAIM MAILING ADDRESS?

•  IS THERE A CLAIM FAX NUMBER – CAN CLAIMS BE FAXED?

10. KEEP THIS INFORMATION SAFE FOR FUTURE REFERENCE:

v  NOTE THE DATE AND TIME YOU MADE THE CALL

v  GET THE NAME OF THE REPRESENTATIVE YOU SPOKE WITH

v  GET A REFERENCE NUMBER FOR THE CALL

By Yvonne Mc Namee YMC Consulting

CODING

v  VERIFY THE CODES YOU WILL BILL WITH EVERY AUTHORIZATION

§  MOST INSURANCE CARRIERS WILL SWITCH TO NEW AMA CPT CODES FOR ABA DURING 2015

§  CONFIRM THE CODES WITH EACH INSURANCE COMPANY WHEN YOU AUTHORIZE SERVICES.

§  VERIFY THAT THE CARRIER RECOGNIZES THE CODE IN THE SAME WAY YOU INTEND TO USE IT

§  VERIFY TIME INCREMENTS FOR EACH CODE

By Yvonne Mc Namee, YMC Consulting

USE THE PROPER DIAGNOSIS CODE

u  DIAGNOSIS CODING IS ABOUT TO CHANGE

v  CURRENT AUTISM DIAGNOSIS CODES ARE ICD-9 FORMAT THIS WILL CHANGE AS OF OCTOBER 15, 2015.

v  CODES OF 299.xx WILL NO LONGER BE VALID FOR MAJOR CARRIERS

§  SOME LOCAL UNION CONTRACTS WILL CONTINUE TO USE ICD-9

§  CONFIRM WITH NON MAJOR INSURANCE CARRIERS

By Yvonne Mc Namee, YMC Consulting

CLAIMS SUBMITTAL IF YOU ARE IN NETWORK:

§  YOU ARE REQUIRED TO SUBMIT CLAIMS IN PROPER CMS 1500 FORMAT DIRECTLY TO THE INSURANCE COMPANY

§  COMPLETE THE FORMS PROPERLY – INFORMATION NOT PROPERLY SUBMITTED WILL RESULT IN A DENIAL AND NEED TO RESUBMIT OR APPEAL

§  READ YOUR PROVIDER AGREEMENT – YOU MAY BE REQUIRED TO SUBMIT CLAIMS ELECTRONICALLY

By Yvonne Mc Namee, YMC Consulting

u  IF YOU ARE NOT IN NETWORK

§  YOU MAY COLLECT YOUR FEES DIRECTLY FROM THE PARENTS

§  YOU ARE NOT REQUIRED TO COMPLETE CLAIMS FORMS OR SUBMIT

§  YOU MAY INVOICE PARENTS WITH PROPER CODING ON INVOICE OR WITH A DESCRIPTION OF SERVICES FOR PARENT SUBMITTAL TO INSURANCE

•  INVOICE MUST DOCUMENT:

•  NAME ADDRESS DATE OF BIRTH OF CHILD INSURANCE I.D.

•  REFERRING PROVIDER AND DIAGNOSIS CODE

•  DATE OF SERVICE (ONE DATE PER LINE)

•  DESCRIPTION OF SERVICE AND/OR CPT CODE (REFER TO YOUR AUTHORIZATION) ONE CODE FOR EACH LINE OF SERVICE. IF TWO CODES ON SAME DATE, THIS IS TWO LINES

•  NUMBER OF UNITS (REFER TO YOUR INSURANCE CALL)

•  PRICE PER UNIT

•  TOTAL COST FOR EACH SERVICE

•  PROVIDER NAME, ADDRESS, PHONE NUMBER, NPI, TAX I.D.

•  IF REIMBURSEMENT TO BE MADE TO FAMILY MARK THIS INVOICE AS PAID

By Yvonne Mc Namee, YMC Consulting

DOCUMENT ALL SERVICES BILLED MUST BE PROPERLY DOCUMENTED

v  INSURANCE CARRIERS MAY ASK FOR YOUR DOCUMENTATION TO VALIDATE SERVICES WERE PROPERLY SUBMITTED

§  IF YOUR DOCUMENTATION DOES NOT ADEQUATELY DEPICT OR REPRESENT THE SERVICES PROVIDED THE REIMBURSEMENT CAN BE DENIED. IF SERVICES HAVE BEEN PAID PRIOR, INSURANCE CAN RECOUP THE AMOUNTS PAID AND DENY FUTURE CLAIMS

§  ABA DOCUMENTATION MUST BE COMPLIANT WITH THE INSURANCE CARRIER GUIDELINES.

§  IF YOU ARE IN NETWORK, YOUR CONTRACT WILL OUTLINE THE DOCUMENTATION REQUIREMENTS.

§  IF YOU ARE NOT IN NETWORK, YOU MAY FIND THE REQUIREMENTS ONLINE AT THE CARRIER WEBSITE.

By Yvonne Mc Namee, YMC Consulting

BASIC DOCUMENTATION REQUIREMENTS

v  ON EVERY PAGE

ü  NAME AND DATE OF BIRTH OF CHILD

ü  DATE OF SERVICE

§  INFORMATION TO INCLUDE:

ü  NAME AND CREDENTIALS OF PROVIDER OF SERVICE

ü  NAME AND CREDENTIALS OF SUPERVISOR OF SERVICES (MUST BE BCBA)

ü  DIAGNOSIS CODE AND REFERRING PROVIDER NAME

ü  CODE(S) FOR THE SERVICE YOU PERFORMED (MUST MATCH CODES SUBMITTED)

ü  TIME IN AND TIME OUT

ü  PROGRAMS WORKED THIS SESSION – IDENTIFY EACH PROGRAM (MUST BE PART OF TREATMENT PLAN SUBMITTED IN PRE-AUTHORIZATION REQUEST.

ü  INCLUDE NARRATIVE OVERVIEW PROGRAM INCLUDING PROGRESS TO DATE, DATE FOR NEXT SESSION AND PLAN OF TREATMENT

ü  SIGNATURE AND CREDENTIALS OF PROVIDER AND SIGNATURE AND CREDENTIALS OF SUPERVISING BCBA IF PROVIDER IS NON BCBA FOR THIS DATE.

By Yvonne Mc Namee, YMC Consulting

u THANK YOU

Learn more about how Rethink can support best practices in ABA Billing at rethinkbh.com

Yvonne Mc Namee YMC Consulting

ymcnamee@aol.com

Jamie Pagliaro Rethink Behavioral Health

jamie@rethinkbh.com