Overview Of Billing Guidelines For Early Intervention .

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Overview of Billing Guidelinesfor Early Intervention Services (EIS)and Targeted Case Management (TCM)Servicesfor Children Ages 0 to 3November 19, 201812/18/2018

EIS and TCM ServicesImplementationSunshine Health is responsible for these services based on the SSMC contractrollout below:Phase 1:December 1, 2018Regions 9,10 and 11Phase 2:January 1, 2019Regions 5, 6, 7 and 8Phase 3:February 1, 2019Regions 1, 2, 3 and 412/18/20182

Early InterventionServices12/18/2018

Early Intervention Services (EIS) This service was added as a managed care covered benefit tofacilitate an integrated health care delivery to support coordination andpayment for all of the services a child needs. Sunshine Health recognizes that there are federal requirements tohave:– Referral to screening, evaluation, and Individualized FamilySupport Plan (IFSP) developed within 45 days– Services start no later than 30 days from the date of thefamily/caregiver consent on the IFSP12/18/2018

Contracting with EIS Providers Sunshine Health is in the process of contracting with the 15 local EarlySteps provider groups who provide EIS services. We acknowledge that the Department of Health provides an Infant andToddler Developmental Specialist (ITDS) certificate for providers whobecome specialized in children with special needs and their familiesunder the Early Steps Program. Confirmation of this certificate will be obtained upon the SunshineHealth credentialing process and ongoing. Sunshine Health will pay the Medicaid fee for service rates for EISservices.12/18/2018

EIS Provider Billing Providers who are not employees of the Early Stepagency, who are certified to perform EIS services, andhave an arrangement with the Early Steps program toprovide services can bill Sunshine Health under their taxidentification number and Medicaid provider number. EIS providers who are employees of an Early Step agencywill bill Sunshine Health under the Early Step’s taxidentification number and the Early Step’s Medicaidprovider number12/18/2018

Continuity of Care for New Members If Sunshine Health does not have contracts in place with all EIScertified providers when a region is implemented, we will do a singlecase agreement (SCA) with the child’s existing providers. The continuity of care (COC) period for these services are the samefor other services:– 60 days for MMA members– 90 days for Child Welfare members As part of COC, Sunshine Health will pay EIS providers at the ratethey were previously receiving for up to 30 days.12/18/2018

The IFSP The Individualized Family Support Plan (IFSP) process begins at thetime of referral, where the family’s identified resources, priorities,concerns, interests and daily activities are woven together throughoutthe process and is developed by a multidisciplinary team. A Plan of Care must be developed and updated every six months (orupon a change in services). Sunshine Health Case Management staff must participate in themultidisciplinary team meetings where the IFSP is developed in orderto facilitate quick and timely authorization of medically necessaryservices.12/18/2018

Covered EIS CodesThe following are the EIS codes with applicable modifiers that Sunshinewill reimburse for enrolled members.These services do not require a prior authorization from SunshineHealth.ServiceCodes with ModifiersDescriptionScreeningT1023Early Intervention ScreeningEvaluationT1024 with modifiers:Early Intervention EvaluationGP, UK, GN, GO, TL and HNFollow-up ServicesT1024 with modifiers:GP, TS, GN, GO, TLFollow-up psychosocial anddevelopmental evaluationsSessionsT1027 with modifiers:SC, TTEarly Intervention individualor group sessions12/18/2018

Prior Authorization of EIS Sunshine Health does not require prior authorization forEIS screening, evaluation and ongoing follow-up services. This includes the following codes:– T1023, T1024, T1027 with the applicable modifiers12/18/2018

Targeted CaseManagement Services12/18/2018

Targeted Case Management Providing targeted case management (TCM) services for childrenreceiving EIS is a federal requirement for children in Early Steps inorder for the child to have their services coordinated. Case managers providing EIS TCM must be certified/trained by theDOH Early Steps program, or their designee. Sunshine Health will contract with the providers who are deliveringTCM for these children. Providing the certification of training will be part of our credentialingprocess.12/18/2018

Management of TCM Continuity of Care rules also apply for TCM for new members.– 60 days after the new enrollment for MMA members– 90 days after the new enrollment for our Child Welfare SpecialtyPlan members. Single Case Agreements may be executed until the provider iscontracted. As part of the initial and ongoing credentialing process, proof ofCMS/DOH TCM certification will be obtained. Sunshine Health will pay the Medicaid fee for service rate for TCMservices.12/18/2018

Covered TCM CodesThe following are the TCM codes with applicable modifiers thatSunshine will reimburse for enrolled members.These services do not have to be prior authorized by Sunshine Healthfor reimbursement to occur.ServiceCodes with ModifiersTargeted Case Management for Children’sMedical Services Early Steps providersT1017 with modifier TLTargeted Case Management for Children’sMedical Services medical foster carecontractorsT1017 with modifier SE12/18/2018

Billing Guidelines12/18/2018

Timely FilingTimely Filing Guidelines: Initial Filing of a claim must be made in 180 calendar days from thedate of service.– Providers must submit claims within six months after the date ofdischarge or the date a non-participating provider was given thecorrect name and address of the applicable managed care plan.Resubmissions: Corrected, reconsiderations, or disputes must be filed within 90calendar days from the receipt of payment/denial notification.12/18/201816

Claims PaymentCoordination of Benefits: When Sunshine Health is secondary payer, and the primary payeris an entity other than Medicare, Sunshine Health requires theprovider to submit the claim within 90 calendar days after the finaldetermination of the primary payer. When the primary payer is Medicare, the timeline to submit theclaims is based on the Medicare Provider General Handbook.12/18/201817

Claims PaymentClaims Payment: Clean claims will be adjudicated (finalized paid or denied) within 15days (electronic), and 20 days (paper), following receipt of the claim.Processing standards: Pay 50% of clean claims within 7 days Pay 70% of clean claims within 10 days Pay 90% of clean claims within 20 days12/18/201818

Billing TipsThe following are essential data needed to ensure appropriatepayment: Provider Name (as noted on his/her current W-9 form)Provider nine-digit Medicaid NumberTax Identification NumberProvider National Provider Identifier (NPI)Physical location address (as noted on current W-9 form)Billing name and address (if different)Is the member effective with Sunshine Health on the date of serviceThe service provided is a covered benefit on the date of serviceA prior authorization was received if needed for that service12/18/201819

Billing Tips For EIS and TCM services, the provider should follow the Agency forHealth Care Administration’s (AHCA) Child Health Services applicableCoverage and Limitations Handbook. Sunshine Health hasestablished the same benefit limitations for EIS and TCM services asnoted in the AHCA Coverage and Limitations Handbook. The applicable modifiers for EIS and TCM must be billed with theprocedure code for appropriate payment to be made. For TCM services:– Only one TCM can bill per member per day.– Only one TCM claim per member per targeted care managershould be submitted per day.12/18/2018

Electronic Claims TransmissionNetwork providers are encouraged to participate in Sunshine Health’sElectronic Data Interchange Program.Five clearinghouses can be used for Electronic Data Interchange (EDI): Emdeon SSI Gateway EDI Medavant AvailityThe 5010-837 companion guides for EDI billing requirements, plus loopsegments, can be found on Sunshine Health’s c-transactions/edi/12/18/201821

Electronic ClaimsFor electronic filings use these payor IDs:Sunshine Health Payor ID #: 68069For Behavioral Health claims use Payor ID#: 68068 This would apply for the Targeted Case ManagementServices.For more information on electronic filing, contact:Sunshine Health Planc/o Centene EDI Department1-800-225-2573, extension 25525or by e-mail at: EDIBA@centene.com12/18/201822

Electronic ClaimsOther EDI Clearinghouses:Emdeon -4548www.availity.comUse the same Payor IDs:Sunshine Health Payor ID #: 68069For Behavioral Health claims use Payor ID#: 6806812/18/201823

Paper ClaimsAll paper claims should be submitted to:For medical claims:Sunshine Health PlanP.O. Box 3070Farmington, MO 63640-3823ATTN: Claims DepartmentFor behavioral health claims,including TCM:Sunshine Health PlanP.O. Box 6900Farmington, MO 63640-3818Paper submissions are subject to the same edits as electronic andWeb submissions.60

Paper ClaimsHere are some tips when filing paper claims:Do’s: Do use the correctPO Box number Do submit all claimsin a 9” x 12”, or largerenvelope Do type all fieldscompletely andcorrectly Do submit on aproper original redclaim form (CMS1500 or UB 04)Don’ts: Don’t submit handwritten claim forms Don’t use red ink on claim forms Don’t circle any data on claim forms Don’t add extraneous information to any claimform field Don’t use highlighter on any claim form field Don’t submit photocopied claim forms or blackand white claim forms as they will not beaccepted Don’t submit carbon copied claim forms Don’t submit claim forms via fax61

Direct DepositFor Direct Deposit contact Payspan:Phone: 1-877-331-7154Website: https://www.payspanhealth.com/12/18/201826

PaySpan –EFT/ERA12/18/201827

How to Get Access to theSunshine HealthSecure Provider Portal12/18/2018

Secure Portal InformationItems accessed in the secure web portal include: Member eligibilityClaim submission and claim statusClaim correctionsAuthorizations12/18/201829

Create an Account Click on create anaccount. Watch registrationvideo. Will need to registerwith TIN and workemail address. Access will beconfirmed andapproved.12/18/201830

Portal RegistrationRegister for the Provider Portal and gain access to many usefulreports and tools.12/18/201831

Account ManagerEach office should have an assigned account manager who will: Approve new accounts at the office. Unlock accounts. Disable accounts of employees who have left the practice.If your office does not have an account manager, please contactProvider Services at 844-477-8313.12/18/201832

Web Portal Instruction Guide12/18/201833

Secure Portal Landing Page12/18/201834

Provider Web Portal ProductLine and Eligibility12/18/201835

Provider Web Portal Claimsand Claims Audit Tool12/18/201836

Claims Status12/18/201837

Overview of theProvider Dispute Process12/18/2018

Provider DisputesSunshine Health is enhancing our provider dispute process based onnew contract requirements. The provider resolution unit will manageprovider disputes.Providers can submit disputes for two reasons: Non-claims related issues: Must be submitted within 45 days of theevent. These are to be resolved within 90 days of receipt. Claims related issues: Must be submitted within 90 days of thedetermination. These are to be resolved within 60 days of receipt.First-time claim adjustment requests are not part of the providerdispute process.12/18/201839

Provider DisputesTo file a dispute, a provider can:Call 1-844-477-8313orSend a written dispute using the Sunshine HealthProvider Claim Dispute Request Form to:Sunshine HealthPO Box 3070Farmington, MO 63640-3823The form can be found on our website SunshineHealth.com underprovider resources.12/18/201840

How to Reach Us12/18/2018

Provider Call CenterHow to Contact us:Our providers can now call one number to get answers totheir questions. This is for all our products.Call 1-844-477-8313– You can also select prompts to reach utilization management orcare management from this number.12/18/201842

Sunshine Health ContactsThe following Sunshine Health contracting team members maybecontacted for questions regarding contracts for EIS and TCMservices for members age 0 to 3:Primary Contact:Vonria BeckfordContract NegotiatorToll-Free: 1-866-796-0530Ext 41712Direct: 954-514-1712vbeckford@centene.comAdditional Contact:Carlos J. GonzalezContract NegotiatorToll-Free: 1-866-796-0530Ext 41310Direct: 813-286-6110cgonzalez@centene.com

Questions

case agreement (SCA) with the child’s existing providers. The continuity of care (COC) period for these services are the same for other services: – 60 days for MMA members – 90 days for Child Welfare members As part of COC, Sunshine Health will pay EIS providers at t

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