Michigan Medicaid Tribal Clinic Billing, Reimbursement, and Policy Updates Tyler Wise Policy Specialist Program Policy Division, Medical Services Administration Michigan Department of Health and Human Services

Overview Cost Settlement Background Billing and Reimbursement Facility Settlement System Interim Quarterly Payments Substance Use Disorder Services Initiatives Questions

Cost Settlement Background

Cost Settlement Background Prior to Institutional Billing (UB-04) Submitted on professional form Paid the Medicaid fee screen at adjudication All-Inclusive Rate (AIR) paid at cost settlement time Interim Quarterly Payments Paid throughout the fiscal period Estimate of most recently processed settlement amount Settlement occurs Qualifying Visit multiplied by AIR Less payments received via FFS, MC, and interim payments Liability less payments received HP, FFS, and third party payors. Multiply that total by .25% and round to the nearest 100th. Equals Estimated Medicaid quarterly payment for year

Billing and Reimbursement Methodology

Billing and Reimbursement Transition to UB-04 as of 08/01/2017 Align with other payors Crossover files Increase cash flow Medicaid FFS claims only Managed Care Encounters cost settled at the AIR Exceptions to UB-04: Dental services (837-D) MIHP services (Professional-1500)

Billing and Reimbursement Clinic Qualifying Visit Codes Available on State of Michigan website Clinic-PPS Visit Codes Payment Code Multiple Visit Codes Dentures, Partials and Antepartum Visit limits per date of service Modifier 59 for distinct services on same day Not required for dental services

Facility Settlement System CHAMPS

Facility Settlement System Cost Settlements 01/01/2017 forward Settlement system transitioned to Community Health Automated Medicaid Processing System (CHAMPS) Pulling FFS and Managed Care data directly Settlements after 01/01/2014 processed via FS Managed Care Encounters separate prior to 01/01/2017 Option to the clinic to submit cost report Cost settlement will be generated Utilize tool to verify claims and encounters

Interim Quarterly Payments Methodology

Interim Quarterly Payments Updated amounts effective 01/01/2018 Reflects the estimated quarterly amount for Managed Care Encounter data only FFS claims receiving AIR during successful adjudication Avoid overpayment and takebacks Liability less payments received HP, FFS, and third party payors. Multiply that total by .25% and round to the nearest 100th. Equals Estimated Medicaid quarterly payment for year. The new Interim Quarterly Payment amount will be based strictly off of the Managed Care Encounter claims data. This is because the fee-for-service claims will be receiving the AIR during successful adjudication. If we apply the a quarterly payment amount during the year and also pay the AIR for adjudicated claims, we would have a massive takeback come settlement time.

Substance Use Disorder Services Fee-For-Service

Behavioral Health Services - Policy 5.3 AMERICAN INDIAN AND ALASKA NATIVE SERVICES American Indians and Alaska Natives who are Medicaid beneficiaries can obtain mental health services directly from the THC. THC services are not included in the MDHHS §1915(b) Managed Specialty Services and Supports Waiver for PIHPs and substance use disorder services. 5.4 NON-NATIVE AMERICAN INDIAN SERVICES PIHPs/CMHSPs assume responsibility for community-based mental health and developmental disability services covered through Medicaid for non–Native American Indians. Refer to the Behavioral Health and Intellectual and Developmental Disability Supports and Services Chapter of this manual for policies and procedures. Non- American Indian mental health services must not be billed under CPT or HCPCS codes.

PIHP Waiver Language “Native American Indian beneficiaries may elect to obtain Medicaid mental health and substance abuse services directly from Medicaid enrolled Indian Health Service (IHS) facilities and Tribal Health Centers (THCs). For mental health and substance abuse services provided to Native American beneficiaries, the IHS facilities and THCs will be reimbursed directly for those services by MDCH under the memorandum of agreement (MOA) as specified in the Michigan Medicaid Provider Manual.”

PIHP Waiver Language “If the IHS facility or THC provides services to non-Native American persons, the IHS facility or THC must become part of the PIHP provider panel in order to receive reimbursement for specialty services provided to non-Native American persons from the PIHP. Any Native American Indian beneficiary who needs specialty mental health, developmental disability or substance abuse services may also elect to receive such care under this Waiver through the PIHP. The PIHPs have been specifically instructed by MDCH to assure that Indian health programs are included in the PIHP provider panel, to ensure culturally competent specialty care for the beneficiaries in those areas.”

Going Forward MDHHS policy interpretation Setting up billing for claims Identifying codes for services Input from THCs Thoughts?

Initiatives Future

Initiatives Tribal Pharmacy AIR Reimbursement Currently have ability to receive AIR for MTM services (99605, 99606) Seeking additional reimbursement per dispensed prescription Continuing additional cost analysis Tribal Services received ‘to-and-through’ (SHO 16-002) Bring discussions to the quarterly tribal meeting Additional guidance from CMS recommended

Questions

Contact Information Tyler Wise, Policy Specialist WiseT2@Michigan.Gov 517-284-1128 Lorna Elliot-Egan, Tribal Liaison Elliot-EganL@Michigan.Gov 517-284-4034