Health Home Billing Questions and Answers

1. HealthHome Billing Questions and Answers An overview of billing, potential issues, and best practices Health Home Biweekly Implementation Webinar, Session 15 April 24, 2013

2. Who can bill for HH services? • For the first two years of each phase, converting OMH TCM, COBRA, and MATS programs bill Medicaid directly for ALL Health Home services they provide. • Converting programs bill for both their existing members AND all new Health Home members. • Converting programs can bill a limited number of claims per month under their legacy rate codes (1800 series) and bill the remaining claims under the 1386/1387 rate codes.

3. Who can bill for services? • Health Homes are responsible for billing Medicaid for fee for service members that are NOT receiving services from a converting provider • Managed Care Plans are responsible for billing Medicaid for their plan members that are NOT receiving services from a converting provider. • After the first two years of each phase, Health Homes and Managed Care Plans will bill directly for ALL members regardless of the entity providing Health Home services.

4. Billing for Health Home Services • The entity responsible for billing must submit a claim to eMedNY in addition to submitting member information to the HHTS Portal. • 1386/1387 claim payments are calculated by multiplying a member’s acuity score by the appropriate base rate. • If a member does not have an acuity score on file, the claim will pend until the average statewide acuity score can be loaded at which time the claim will pay. • Legacy rates (1800 series) are loaded with an average rate based on past billing. Acuity scores do not factor into payment of legacy claims.

5. Acuity Scores • Acuity is a weighted average based on total Medicaid fee-for-service and managed care encounter costs associated with the Clinical Risk Groups™ (CRG). • Acuity calculations are not real time, so a patient’s acuity score may not always reflect the member’s current health status. • Updated acuity scores will eventually be released quarterly. • The statewide acuity score is the average acuity score of the high risk high need HH eligible members.

6. What is Duplicate Billing? • Duplicate billing is when two entities bill for Health Home services for the same member in the same month. • The system will only allow for the billing of one service per member per month • If two entities attempt to bill for Health Home services for the same member during the same month, the first claim submitted will be accepted by the system and the second claim will be denied.

7. Why Does Duplicate Billing Occur? • Confusion over which entity is responsible for billing Medicaid for HH services. • Correct member enrollment information is not submitted to the HHTS Portal in a timely manner. • Health Home partners have not yet completed DEAA subcontractor packets enabling them to share patient information.

8. Determining Entity Responsible for Health Home Billing Yes No Yes No Yes No NOTE: Converting programs (OMH TCM, MATS, and COBRA) bill directly for members that were enrolled in their programs prior to Health Home conversion AND new members assigned to their programs by Health Homes.

9. What can be done to avoid duplicate billing? • Complete agreements ASAP to allow member information exchange. • Submit correct records to the tracking system in a timely manner. • Look up a member’s HH enrollment status using the Portal member search function before providing services. • CMAs must contact the member’s MCP or a HH for FFS members to determine if a referred member is already enrolled.

10. What can be done to avoid duplicate billing? • DOH is implementing enhancements to the HHTS Portal Member Lookup Function: • Making HH enrollment history available to all Portal users • New flag indicating if a member has recently received a converting service. • HH/MCP should be available to look up members’ HH enrollment in the portal for downstream providers and should share all info downloaded from the portal with CMAs they are working with.

11. Health Home Communication • All regional Health Home partners (Managed Care Plans, Health Homes, and Care Management Agencies) should establish communication to better facilitate Health Home services. • Please see the following power points regarding sharing patient information. • http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2013-03-27_hh_medicaid_webinar_session13.ppt • http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2013-04-10_hh_cmart_weekly_support_call_session14.ppt