1. 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

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

3. Cost Settlement
Background

4. 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

5. Billing and Reimbursement
Methodology

6. 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)

7. 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

8. Facility Settlement System
CHAMPS

9. 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

10. Interim Quarterly Payments
Methodology

11. 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.

12. Substance Use Disorder Services
Fee-For-Service

13. 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.

14. 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.”

15. 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.”

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

17. Initiatives
Future

18. 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 )
Bring discussions to the quarterly tribal meeting
Additional guidance from CMS recommended

19. Questions

20. Contact Information
Tyler Wise, Policy Specialist
Lorna Elliot-Egan, Tribal Liaison