Billing & Insurance Use in Early Intervention May 2005

Training Objectives Participants will be made aware of the following: ICD-9 Code Usage; The Difference between Treatment and Eligibility Diagnosis Coding; Services that must be billed to insurance;

Training Objectives (Cont.) Length of time you have to bill CBO after services have been provided; Type of billing forms that are acceptable to bill CBO; and Private Insurance Use.

Agenda I. Diagnosis Coding II. Billing Requirements III. Responsibilities IV. Insurance Use V. Benefit Verification VI. Waivers & Exemptions VII. Provider Safety Net VIII. Technical Assistance IX. Resources

Billing & Insurance Use I. Diagnosis Coding

Diagnosis Coding Diagnosis coding discussed in this session does not refer to assigning a medical diagnosis but rather a billing diagnosis. A billing diagnosis tells us “why” you saw the child. Diagnosis codes submitted on claim forms (and on other medical documentation) are generally used to determine insurance coverage. Insurance payment is dependent upon meeting insurance company requirements. Knowledge of billing and coding requirements are professional development issues in which each provider must invest time and resources to ensure they can comply with insurance company guidelines.

Diagnosis Coding (Cont.) Specific questions regarding insurance denials relating to diagnosis coding should be addressed with the insurance company. Accurate diagnosis and procedure coding directly impacts correct and maximum benefit payment.

Diagnosis Coding (Cont.) Proper coding involves using the ICD-9-CM volumes to identify the appropriate codes for items or services provided (as recorded in the patient record), and using those codes correctly on the medical claim forms.

Diagnosis Coding (Cont.) Use the ICD-9-CM codes that describe the diagnosis, symptom, complaint, condition, or problem. Use the ICD-9-CM code that is chiefly responsible for the item or service provided. Assign codes to the highest level of specificity. Use the fourth and fifth digits when indicated as necessary in your ICD-9-CM volumes.

Diagnosis Coding (Cont.) Code a chronic condition as often as applicable to the patient's treatment. Code all documented conditions which coexist at the time of the visit that require or affect care or treatment. (Do not code conditions which no longer exist.)

Eligibility vs. Treatment Diagnosis Diagnosis coding is translating the medical terminology used for each service/item given by a provider into a code for billing purposes. The diagnosis determined for EI eligibility will not necessarily be the same diagnosis used for billing purposes.

Billing & Insurance Use II. Billing Requirements

Billing Requirements Bill using only CMS 1500 or UB92. Transportation providers may continue to use the DHS Transportation Billing Form. CMS 1500 forms can be obtained at most office stores or online. DHS Transportation Billing Forms are available through the Early Intervention website. *Copies are acceptable.

Billing Requirements (Cont.) Required on CMS 1500 Claim Form: Child’s name (last and first) (field 2); Child’s complete address (field 5); 6 digit EI number (field 1a); Date of birth (field 3); Payee name and address (field 33); Tax ID (field 25); Name of enrolled provider who performed the service (field 31) and, if applicable; Name of associate provider - listed under name of EI enrolled supervisor (field 19).

Billing Requirements (Cont.) Required on CMS 1500 Claim Form (cont.): Date of service (field 24A, lines 1-6); CPT or HCPCS codes (field 24D, lines 1-6); Treatment diagnosis code (field ); Place of service code (field 24B, lines 1-6); Length of session (field 24G, lines 1-6); Amount billed (field 24F, lines 1-6); Patient account number – if applicable (field 26), and; Total charge (field 28).

Billing Requirements (Cont.) Things to remember: Utilization of private insurance benefits is mandatory. You must accept insurance and/or CBO payment as payment in full for services and agree not to bill the family for further payment. Always notify the CFC immediately of any change of insurance for the family you are serving. Providers should not bill the family directly for any EI service unless the insurance payment was paid to the family versus the provider. CBO pays patient co-pays and deductible charges, up to the maximum allowed per service. An EOB from the insurance company must be attached to your claim. EI provider agreements specify you must send a claim to the CBO with the insurance EOB attached even if insurance has paid the claim in full.

Billing Time Period Beginning July 1, 2005, claims must be received by the CBO within 90 days of the date of service. When insurance billing is required, the CBO must receive the claim, with the insurance carrier’s EOB attached, within 90 days of the date of the most recent correspondence from the insurance company.

Acceptable Billing Forms Beginning July 1, 2005 all providers of service, with the exception of transportation providers, must submit all claims on either a CMS 1500 or UB92. Claims received at the CBO on any other type of form other than listed above beginning October 1, 2005, will be denied.

Billing & Insurance Use III. Responsibilities

Responsibilities Child & Family Connections Service Provider Family CBO

Child and Family Connections Responsibilities Assist family in completing Insurance, Affidavit, Assignment and Release Form. Provide copies of the family’s insurance card to the provider and CBO. Request approval of pre-billing waivers and exemptions from the CBO. Update CBO and provider of changes in insurance policy/benefits.

Provider Responsibilities Verify insurance benefits with all insurance companies covering the family. Verify that insurance coverage has not changed before each service is performed. The provider must be aware of who their payer will be and their requirements for each service provided. Bill the insurance company and CBO appropriately. Update CFC and CBO of changes in insurance policy/benefits. Follow up with insurance company per CBO instructions.

Family Responsibilities Assist the CFC and provider in determining insurance benefits and obtaining required documentation, if necessary. Provide timely notification of changes in insurance policy/benefits to CFC, CBO, and/or provider. Turn over recouped payments to the provider as appropriate.

CBO Responsibilities Benefit verification. Forward insurance data to CFC. Approval/denial of pre-billing waiver and exemption requests. Provide technical assistance to providers to help maximize insurance benefits.

Billing & Insurance Use IV. Insurance Use

Insurance Use All credentialed providers must bill insurance, whenever insurance exists, before submitting a claim to the CBO. *Unless a pre-billing waiver or exemption has been issued.

Insurance Use (Cont.) Assistive Technology (DME) Aural Rehabilitation Services Developmental Therapy Services (includes: DT Hearing and DT Vision) Health Services Nursing Services Nutrition Services Occupational Therapy Services Physical Therapy Services Psychological and Other Counseling Services Social Work and Other Counseling Services Speech Therapy Services Vision Services (including: optometric exam and dispensing fees) Providers performing the following services must bill private insurance before submitting their claims to the CBO:

Insurance Use (Cont.) Providers performing the following services are excluded from billing insurance: Assessment Services Audiology (examination by an Audiologist or a hearing aid assessment) Evaluation Services Family Training and Support IFSP Development Services Interpretation Medical Services for diagnostic/evaluation Parent Liaison Transportation

Billing & Insurance Use V. Benefit Verification

Insurance Benefit Verification CFC Distribute copy of insurance card (front and back) to the CBO and provider. Distribute copy of Insurance, Affidavit, Assignment and Release Form to the CBO and provider.

Insurance Benefit Verification (Cont.) Provider Verify benefits as they relate to specific services. Note: In consultation with insurance companies, EI services rendered in the natural environment most closely fall under the “outpatient” category of service. Confer with the insurance company to determine their preference on the appropriate service delivery billing classification. Determine and follow all pre-service requirements of the insurance policy. Bill the insurance company as soon as possible after the service has been provided.

Insurance Benefit Verification (Cont.) Provider Follow up with the Illinois Department of Financial and Professional Regulations if no response is received. Forward claim and copy of the insurance carrier’s EOB to the CBO once a response from insurance is received. Failure to follow insurance company policy guidelines will result in loss of payment from the insurance company and the CBO.

Insurance Benefit Verification (Cont.) Steps to Verify Benefits: Phone the benefits verification department of the insurance carrier - usually found on the back of the family’s insurance card. Identify yourself as a provider and that you want to verify benefit coverage. Give the representative any required information and define the type of benefits you are calling on. The representative will give you a “quote only” response. Final determination regarding payment will be made when your claim has been submitted.

Insurance Benefit Verification (Cont.) Steps to Verify Benefits: Ask about any policy limitations or provider restrictions. Below are a few examples of questions you may want to ask: Is a pre-certification or pre-authorization required? Is a referral from the primary care physician required? Are there a limited number of visits allowed per year? If so, what is the benefit year? Is there a maximum amount payable per year? Per lifetime? Are there out of network benefits available? Remember, it is the provider’s responsibility to know the policy guidelines to ensure payment for services.

Billing & Insurance Use VI. Waivers & Exemptions

Pre-Billing Insurance Waivers Pre-billing waivers will only be issued for the following situations: An insurance required provider is not available to receive the referral and begin services. No insurance required providers are credentialed in Early Intervention Travel to the insurance required Center based provider would be a hardship for the family. Pre-billing waiver requests will be submitted to the CBO by the CFC where they will be approved or denied.

Pre-Billing Insurance Waivers (Cont.) Approval/denial will be forwarded in writing to the CFC, provider, and family. Pre-billing waiver becomes void if the family’s insurance coverage changes or if provider receives payment from the insurance company. Pre-billing waivers are effective for the IFSP period in which the authorization was issued.

Post-Billing Insurance Waivers Will be issued by the CBO based on the denial reason listed on the EOB. Expire at the end of the insurance plan’s benefit year and the provider will be required to bill the insurance company according to program requirements. If the family’s insurance coverage changes, all waivers become void and the provider must bill the new insurance company.

Insurance Exemptions Exemptions may be issued by the CBO for the following reasons when the appropriate documentation has been forwarded by the CFC: Privately Purchased/Non-Group Plan Lifetime Cap (overall policy or service specific) Approval/denial will be forwarded to the family, CFC, and provider, if appropriate. Exemption becomes void if the family’s insurance coverage changes.

EI Insurance Use Insurance Billing Required CFC Receives Referral CBO Verifies Insurance Benefits CFC Refers to Insurance Approved Provider Provider Verifies Benefits and Provider Restrictions with Insurance Provider Renders Service and Bills Insurance Provider Bills CBO with Insurance EOB Attached

EI Insurance Use Pre-Billing Waiver/Exemption CFC Receives Referral CBO Verifies Insurance Benefits CFC Determines Pre-Billing Waiver or Exemption is Needed CFC Assists Family in Completing Pre-Billing Waiver or Exemption Request and Forwards to CBO CBO Approves and Forwards Determination to CFC and Family or CBO Denies and Forwards Determination to CFC and Family CFC Refers to EI Credentialed Provider to Begin Services Provider Performs Service And Bills CBO for Remainder of IFSP Period CFC Refers to Insurance Approved Provider Provider Bills Insurance and Then Bills CBO Claim with EOB Attached

Billing & Insurance Use VII. Provider Safety Net

Provider Safety Net Provider bills insurance and if no response is received within 30 days, they should follow up with the insurance company and document the method of contact. Provider complies with requests for any additional information and documents that submission. After 60 days, if the insurance company has not responded, the provider submits a complaint form to the Illinois Department of Financial & Professional Regulations – IDFPR (formerly IL Department of Insurance).

Provider Safety Net (Cont.) Once the IDFPR has received a response from the insurance company, they will notify the provider in writing of the outcome. If the insurance company agrees to pay, the provider submits the claim along with the insurance company EOB to the CBO. If the insurance company denies the claim, the provider submits the claim and denial within 90 days to the CBO. CBO will review based upon normal program requirements.

Billing & Insurance Use VIII. Technical Assistance

Technical Assistance Technical assistance to help providers with insurance issues will be available from the CBO. This insurance training will be available on the internet. DHS and CBO websites will contain the latest updates to insurance billing requirements and/or procedures.

Billing & Insurance Use IX. Resources

Early Intervention Resources Bureau of Early Intervention Provider Connections Illinois Office of the Comptroller Early Intervention Central Billing Office UCP – Greater Chicago Illinois Dept. of Financial & Professional Regulation Free ICD-9 Coding Website: