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Sign up for email and/or text notices of Medicaid and other FSSA news, reminders, and other important information. When registering your email, check the category on the drop-down list to receive notices of Medicaid updates check other areas of interest on the drop-down list to receive notices for other types of FSSA updates.
Time Limits For Filing Claims
Medicaid claims, except inpatient claims and nursing facility claims, must be received by NCTracks within 365 days of the first date of service to be accepted for processing and payment. Medicaid hospital inpatient and nursing facility claims must be received within 365 days of the last date of service on the claim.
NC Medicaid has checkwrites 50 weeks of the calendar year no checkwrites occur the week of June 30 and the week of Christmas. Claims are processed in real time. Please refer to checkwrite schedules available on NCTrack’s Providers page under Quick Links for cut-off timing for submitted claims.
What Original Medicare Doesnt Cover
Your health care provider may recommend you receive services more frequently than Medicare covers, or services that Medicare doesnt cover, and you may end up paying some or all of these costs. Ask your provider why they are recommending such services and whether Medicare will cover them.
You will have to pay for private duty nursing or a private room, unless its medically necessary. Other limits may apply.
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Telehealth Billing: Quick Guide
With telehealth becoming a popular if not required option for conducting therapy sessions in 2020, keep note of the following four points when billing telemedical therapy appointments:
If you are struggling to find out the place of service code or modifier to use for your insurance claims, this is something we provide as part of our billing service free of charge.
Our beginners guide to mental health billing doesnt make eligibility and benefits verification calls for you, but we do!
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Early And Periodic Screening Diagnostic And Treatment
8.280.4.E Other EPSDT Benefits
Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:
The following services are covered:
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How To Do Billing For Medicare And Medicaid
Just like when you bill to the private third-party payer, billers must send claims to Medicare and Medicaid. These claims are very similar to the claims youd send to a private third-party payer, with a few notable exceptions.
When you claim for Medicare and Medicaid, there is no need to go through a clearinghouse for these claims, and it also means that 100% clean claims submission. Make sure youre familiar with the Medicare contractors claim submission preference and submit claims accordingly because Medicare is not going to adapt to provider needs the provider does all of the adapting!
The Three Most Often Used Mental Health Cpt Codes
They are:
- 90791 Intake session to be billed for your first appointment with that patient exclusively
- 90834 45-55 Minute Individual Therapy Session
- 90837 56+ Minute Individual Therapy Session
Its as straight forward as it seems: bill the intake code for their first session, and bill either a 45 minute or 60 minute session for the rest, depending on the length of their sessions.
Dealing with family therapy, therapy with a family member with the patient not present, group therapy, or other cases? Review our definitive guide to CPT codes to get sorted!
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Does Medicare Pay For Therapy Services
As part of Medicares mental health care benefits, therapy, or counseling is typically covered under Part B as an outpatient service with Original Medicare. MA plans provide the same benefits as Part B does. Therapy generally can be for an individual or a group. Family therapy is covered if it is to support the Medicare beneficiarys mental health treatment goals.
As with all mental health services, you must receive therapy from a provider that accepts assignment for Original Medicare or is in-network with your MA plan. The provider must be licensed in your state. Copay or coinsurance and deductibles apply.
In 2022, for instance, for outpatient mental health care through a UnitedHealthcare MA HMO plan, you pay $25 copay for each Medicare-covered individual therapy session and $15 copay for group therapy. For a similar type of plan with Humana, you pay a $20 copay for mental health services received from a specialist, an outpatient hospital, or intensive therapy that is part of the day program in a hospital. For a similar plan with BCBS/Anthem, you pay $40 for each Medicare-covered visit, group, or individual.
Your copays vary depending on your MA plan. To find out what your out-of-pocket costs will be and precisely what your plan will cover based on Medicare rules, talk with your plans administrator, review your EOC, and talk with your healthcare provider. Allow for the time it takes to get a referral and prior authorization.
Special Provision: Epsdt Services Can Exceed Policy Limitations For Members Age 20 And Younger
Early and Periodic Screening, Diagnostic, and Treatment is a federal Health First Colorado) program that requires the state Health First Colorado agency to cover services, products, or procedures for Health First Colorado members ages 20 and younger if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination . EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
EPSDT does not require the state Health First Colorado agency to provide any service, product, or procedure that is:
- Unsafe, ineffective, or experimental/investigational.
- Not medical in nature or not generally recognized as an accepted method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, and/or other specific criteria described in the above screening policies may be exceeded or may not apply as long as the provider documentation shows how the service, product, or procedure will correct, improve or maintain the recipients health, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
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Does Medicare Cover Mental Health Services
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Medicare pays much of the cost of a wide range of mental health services, whether provided on an outpatient basis or for inpatients in a psychiatric or general hospital. But you need to be aware of limits on these benefits, including substantial copays, coinsurance and a lifetime maximum.
Mental health issues are common among older adults: Thirty-one percent of Original Medicare beneficiaries are living with mental illness, according to a July 2020 report by the Commonwealth Fund, a private foundation focused on health care. And in a July 2020 survey by the Kaiser Family Foundation, 46% of Americans ages 65 and up said that pandemic-related stress and worry were detrimental to their mental health.
| Annual depression screening 15 mins |
- Includes patient form completion, recording by medical assistant and physician discussion with patient
- Coinsurance and deductible waived
- Furnished by Psychiatrist or Psychologist only with clinical staff-assisted depression care supports in place
- Primary care settings only:
| Face-to-face behavioral counseling for alcohol misuse, 15 minutes |
What Part Of Medicare Covers Mental Health Care
Medicare Part A covers mental health care in an inpatient setting. Part A mental health care is in a general hospital or a psychiatric hospital only for people with mental health concerns. If you get inpatient care in a psychiatric hospital, Part A will cover up to 190 days in a lifetime. There is no limit to the number of benefit periods you can have for mental health care in a general hospital.
Part A covers your room , meals, nursing care , therapy and treatment, lab tests, medications, and other services and supplies you need. Part A does not cover personal items or a phone or TV in your room.
Part B helps pay for these outpatient mental health services:
Part D helps cover self-administered prescribed drugs.
Medicare Advantage plans cover all services offered through Original Medicare Part A, Part B, and usually Part D. Copays and coinsurance amounts vary, depending on your plan. Providers and services must be in-network and typically require referrals and prior authorizations before you can receive services.
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Where Do I Send The Claim
The address for where to send your claim can be found in 2 places:
- On the second page of the instructions for the type of claim youre filing .
- On your “Medicare Summary Notice” . You can also log into your Medicare account to sign up to get your MSNs electronically and view or download them anytime.
You need to fill out an “” if you want someone to be able to call 1-800-MEDICARE on your behalf or you want Medicare to give your personal information to someone other than you.
Get this form in Spanish.
You Should Only Need To File A Claim In Very Rare Cases
Medicare claims must be filed no later than 12 months after the date when the services were provided. If a claim isn’t filed within this time limit, Medicare can’t pay its share. For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020. Check the “Medicare Summary Notice” you get in the mail every 3 months, or log into your secure Medicare account to make sure claims are being filed in a timely way.
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The Role Of Medical Record Documentation
Private practice billing services must include proper documentation. Everything transpiring between a patient and the mental healthcare provider should be in the medical record. But why is mental health documentation important? A patients medical record determines what is billed for the mental health service, which means that all required information must be adequately documented. This medical record will help support the diagnosis and procedure code that is billed to insurance.
Essentially, an incomplete or inaccurate medical record would reflect that medical and mental health services are unnecessary for the patient. This error often results in insurance companies not paying for the service, making it difficult for behavioral health providers to do their job and patients to get the treatment they need. Proper note writing and documentation also play a huge role as a communication tool used between mental health providers and professionals.
When you have accurate, up-to-date medical record documentation, the risk of challenges to treatment and administrative litigation and penalties are reduced. Some of the essential things that need to be documented in these clinical records include:
If Your Claims Aren’t Being Filed In A Timely Way:
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Paper Claims Billing Manual
The Paper Claims Billing Manual, produced by Gainwell Technologies, is designed to offer guidance and assistance to providers submitting claims for reimbursement to the Mississippi Division of Medicaid . The Paper Claims Billing Manual includes detailed information specific to the submission of paper claims which includes Centers for Medicare and Medicaid -1500, Dental, and UB-04 claims. This manual must be used in conjunction with the General Policy and DOMs Provider Specific Administrative Code. DOM policy is located at Administrative Code and Mississippi Medicaid State Plan.
Why Is Medicare Hard To Bill For Mental Health Providers
Medicare subcontracts out to many different subcontractors like Noridian or Palmetto or Novitas or NGS or WPS or FCSO.
Each contractor has their own electronic claims submission enrollment requirements, forms, and process. Each system is clunky and the enrollments take quite some time. Most clients also have a secondary insurance company to bill alongside their Medicare coverage.
We take care of this enrollment process and secondary claims submission and follow-up for our providers at TheraThink.
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Demonstration Project To Increase Substance Use Provider Capacity
On October 24, 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act became law. Under section 1003 of the SUPPORT Act, the Centers for Medicare & Medicaid Services , in consultation with the Substance Abuse and Mental Health Services Administration and the Agency for Healthcare Research and Quality, is conducting a 54-month demonstration project to increase the treatment capacity of Medicaid providers to deliver substance use disorder treatment and recovery services. The demonstration project includes:
- Planning grants awarded to 15 states for 18 months and
- 36-month demonstrations with up to 5 states that received planning grants.
States participating in the 36-month demonstration will receive enhanced federal reimbursement for increases in Medicaid expenditures for substance use disorder treatment and recovery services.
Types Of Covered Mental Health Services
Its important to know the types of covered mental health services for your patients who may have varying insurance or medical coverage. For example, some insurance will only cover mental health services by specific providers, such as physicians, psychiatrists, clinical psychologists and clinical social workers. Additionally, some independent mental healthcare providers can only diagnose the patient with a mental disorder because insurance will not cover the actual treatment.
If you are part of a private practice, then physicians and psychiatrists diagnosis and treatment of the mental disorder will most likely be covered by insurance. These services are often some method of counseling, including a general form of:
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How Do I Become An Enrolled Provider
As a Health First Colorado provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.
The enrollment process is online and begins on the Provider Enrollment web page.
Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.
What Medicaid Helps Pay For
If you have Medicare and qualify for full Medicaid coverage:
- Your state will pay your Medicare Part B monthly premiums.
- Depending on the level of Medicaid you qualify for, your state might pay for:
- Your share of Medicare costs, like deductibles, coinsurance, and copayments.
- Part A premiums, if you have to pay a premium for that coverage.
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Billing Codes For Services Previously Denied
Certain nurse practitioner , physicians assistant and certified nurse midwives services have received denials due to incorrect billing codes since July 2013. NCTracks is updating the claims processing system as inappropriately denied codes are received.
Note: Certified Nurse Midwives are also called Advanced Practice Midwives and bill under that taxonomy code.
The procedure code list below includes NP, PA and CNM taxonomies that now can be billed through NCTracks. Codes currently in process for system updates will be added to this list, in red, once system modifications are completed. Newly identified codes will be addressed as they are received by the NC Medicaid Clinical section.
