1. Texas Public Sector Behavioral Health Claims Update
July 16, 2015
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2. Introduction
This presentation is a high level summary of claim issues identified for the Texas MHMR’s:
12 providers impacted (detailed on slide 7)
Root Cause analysis findings thus far
Adjustment claim volume by provider validated
Adjustment claim status provided*
We are unable to provide the impacted volume by issue since a provider’s claim could be impacted by multiple different issues (outlined on slides 3 – 6)
Your Network Manager will work with you to reconcile any remaining claims that are outstanding once the initial adjustments are completed and payment is received.
*Adjustments began 6/23/2015, targeted completion date is 8/17/15.
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3. Claim Updates
Project
Root Cause Solution
System Update
Claims with medical liability which initially routed to behavioral health incorrectly
H2011 with diagnosis code
CPT codes:
For these two codes, claims have been incorrectly routing to the behavioral health platform when they should instead be paid by medical.
Automated logic has been created to correctly move these claims to the medical claims platform effective July 24, 2015.
All claims that have been denied on the behavioral platform have been moved to the medical platform and are being reprocessed.
Target Date
Medicaid
7/24/15
Medicare & Commercial
8/17/15
J codes:
The resolution for the J codes will be the same as above. All claims that have been denied on the behavioral platform have been moved to the medical platform and are being reprocessed.
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4. Claim Updates
Project
Root Cause Solution
System Update
Claims with behavioral health liability which initially routed to medical incorrectly
PSR/TCM
These claims have been incorrectly routing to the medical platform when they should instead be paid by behavioral health.
Logic is being created to correctly move these claims to the behavioral claims platform effective July 24, 2015.
All claims that have been denied on the medical platform will be moved to the behavioral platform and be reprocessed.
Target Date
Medicaid
7/24/15
Claims denial for multiple services on the same date of service
PSR/TCM claims processed under Optum. Some claims were incorrectly denied. These claims are being reprocessed. Processor refresher training was completed by Optum on 7/1/15.
Complete
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5. Claim Updates Group vs. Individual clinician billing practices Project
Root Cause Solution
System Update
Group vs. Individual clinician billing practices
PSR/TCM services:
Clarification received from the State that PSR/TCM benefits are allowed for CHIP members. Optum to proceed with creating automated logic. We are reviewing if any claims need to be reprocessed.
Target Date
Medicaid
7/31/15
SUD services:
CMHC’s that are billing for SUD services will be allowed to bill at the group level. Automated logic is being created to allow the CMHCs to submit SUD services at the group level instead of the rendering provider. We are reviewing if any claims need to be reprocessed.
Note: Clarification received from the State has now allowed Optum to proceed with implementing automated logic.
Methadone/H0020 with U1 modifier:
Based on clarification from the State, Optum is in the process of updating our benefit configuration. There is an impact to claims and some claims will need to be reprocessed.
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6. Education provided the week of July 6th
Claim Updates
Project
Root Cause Solution
System Update
Authorization
J codes:
Processer education on the medical claims platform was needed to ensure that claims with J codes are processed correctly.
Education provided the week of July 6th
PSR/TCM processed under Optum:
Some claims were incorrectly denied during the waiver period (9/1/14 through 11/30/14). Processor refresher training was completed by Optum on 7/1/15.
Claims denied for authorization not on file: Root cause analysis identified an initial issue with a crossover of timing for receiving and loading authorization requests while claims were submitted. This has been remediated.
The claims for both issues are being reprocessed.
Target Date
Medicaid
8/17/15
Cost Share
5 issues have been reported by 4 providers as Cost Share, however only 1 issue for 1 provider has been Cost Share related.
Provider education has been shared with the providers to help them understand which members are eligible for cost share.
Complete
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7. Number of Claims Submitted/Processed
As of July 15, 2015
Provider
# of Submissions
# of Submissions Completed
Total # of Claims
Total # of Claims Reprocessed
% Reprocessed
Andrews Center 2 -
427 58
13.6%
Behavioral Health Center of Nueces 1 60
100.0%
Bluebonnet Trails 61 55
90.2%
Burke Center 4 11
18.2%
MHMRA Harris County 3
768
506
65.9%
Sabine
408
406
99.5%
Spindletop 7 5
71.4%
Texana MHMR
567
456
80.4%
Texoma
0.0%
Tri County 64 44
68.8%
Tropical Texas Behavioral
175 36
20.6%
TX Gulf Coast
213 38
17.8%
Total 29 9
2,763
1,666
60.3%
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8. THANK YOU
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