Eureka | Fairfield | Redding | Santa Rosa
Overview Rates Payment Methodology
Visit Types Exceptions to OMB Rate PHC Enhanced Benefits
Authorization Requests Billing Information
Claim Form / Format Code Set Other Health Insurance Electronic Claims / Paper Claims
Agenda
Eureka | Fairfield | Redding | Santa Rosa
Overview
Effective 1/1/2018, Managed Care Plans are required to reimburse Indian Health Service (IHS), Memorandum of Agreement (MOA) 638 Clinics for eligible services at the applicable Office of Management and Budget (OMB) encounter rates. This is an updated presentation as of September 2020 with increased rates.
Eureka | Fairfield | Redding | Santa Rosa
Overview - Rates
The OMB encounter rates are all-inclusive for eligible services. There are 2 applicable encounter rates.2020 outpatient per visit rates, lower 48 states:
Excluding Medicare
Medicare Primary $336.74
$479
Effective Date for Calendar Year 2020:The rates will be effective for services provided on/or after January 1, 2020.
Eureka | Fairfield | Redding | Santa Rosa
Overview – New Payment Methodology
Services that are included in the Medi-Cal benefit and billed to PHC will be reimbursed on a fee-for-service basis at the OMB rate.
Providers continue to be eligible for our Quality Improvement Program (QIP).
Eureka | Fairfield | Redding | Santa Rosa
Visit Types
Medical Health Visit• Face-to-face encounter occurring at a clinic or center between an American
Indian Health Program recipient and physician, physician assistant, nurse practitioner, nurse midwife or visiting nurse in certain circumstances.
Mental Health Visit• Face-to-face encounter between an American Indian Health Program recipient
and a psychiatrist, clinical psychologist, clinical social worker, or other health professional for therapeutic mental health services.
• Note: Bill mild-to-moderate Mental Health services to PHC, not Beacon.
Ambulatory Visit• Face-to-face encounter between an American Indian Health Program recipient
and a health care professional other than a physician or mid-level practitioner which is included in California’s Medi-Cal State Plan.
• Note: Bill Vision services to PHC, not VSP.
One OMB encounter rate payment will be allowed, per day, per the following categories. A maximum of three OMB encounter payments are allowed per day, as long as there is only one in each of the categories.
Eureka | Fairfield | Redding | Santa Rosa
Exceptions to OMB Rate
Non-medical Transportation Non-emergency Medical Transportation
Pharmacy Adverse Childhood Experiences (ACEs)
Eureka | Fairfield | Redding | Santa Rosa
PHC Enhanced Benefits
PHC contracts with clinics to provide certain services to adults that are not covered by Medi-Cal or are considered subject to optional benefits exclusion.
The PHC enhanced benefits do not qualify for OMB reimbursement.
Services are reimbursed per contract.
Bill services on a separate claim.
Acceptable billing types for PHC enhanced benefits:
UB-04
837I Format
CMS-1500 Form
837p Format
Eureka | Fairfield | Redding | Santa Rosa
Authorization Requests
Note: A RAF is not required for services that qualify for OMB reimbursement
A TAR is required for
OMB Ambulatory encounters
PHC enhanced benefits services
A TAR is not required
Medical OMB encounters
Mental Health OMB encounters
A TAR is required for
A TAR is notrequired for
Eureka | Fairfield | Redding | Santa Rosa
Claim Form/Format
Submit OMB line with revenue code, procedure code and modifier, if appropriate.
Add information line with traditional CPT or HCPCS Code.
Submit information line with zero billed amount.
Bill OMB rate(s) using UB-04 Form or 837I Electronic Format. This is consistent with billing to the State since October 2017.
Eureka | Fairfield | Redding | Santa Rosa
Information lines are required to document the visit. Enter Procedure Code and charges of zero.
Example UB-04 Form
*Do not use a decimal point.
Eureka | Fairfield | Redding | Santa Rosa
Discussion: In October 2017, DHCS required a new code set. It assumed the provider was also billing for the MCP differential rate.
Code Set
If you believe your claim was processed incorrectly, please reach out to our Claims Department. We want to address issues as they arise.
The Code Set for OMB services is attached to this webinar.
The 01/01/2018 Code Set reflects the complete OMB rate.
There will be no additional billing to the State.
Eureka | Fairfield | Redding | Santa Rosa
Other Health Insurance - Medicare
Providers can bill concurrently to Medicare and PHC.
Bill PHC for OMB rate using the appropriate revenue code and Medicare-specific HCPCS code.
Medicare EOMB is not required for reimbursement by PHC.
PHC will reimburse up to the allowable California modified rate of $336.74.
Eureka | Fairfield | Redding | Santa Rosa
Bill PHC for OMB rate using the appropriate revenue code and procedure code.
Primary EOMB is not required for reimbursement from PHC.
PHC will reimburse the full OMB rate of $479.00.
Other Health Insurance - Commercial
Eureka | Fairfield | Redding | Santa Rosa
Trauma Screening
G9919Once in 11 months per provider for children 0-20 yrs.One in a lifetime per provider for members 21 years and older
G9920Once in 11 months per provider for children 0-20 yrs.Once in a lifetime per provider for members 21 years and older.
Developmental Screening
96110Payable per year of age (0 to <20) without TARMay only be used with one of the DHCS approved screening tools.Autism only screening; socio-emotional screens and other must use 96110.KX.
96110.KXPayable per year of age (0 to <20) without TAR.May be used for screening that does not include one of the nine screening tools approved by DHCS.
Adverse Childhood Experiences (ACES)
Eureka | Fairfield | Redding | Santa Rosa
Electronic Claims
It is recommended that all providers who currently submit claims electronically, submit test claims, even if currently in production. This is not a requirement.
We encourage you to use electronic billing.
Contact InformationPHC EDI Enrollment & TestingInformation Technology DepartmentPhone: (707) 863-4527 | Fax: (707) 863-4390Email: [email protected]
Eureka | Fairfield | Redding | Santa Rosa
Paper Claims
To avoid processing errors when submitting paper claims, we suggest configuring your system to fill in a number 1 in the Unit Field for all lines.
If you cannot fill in the units of service, please send the paper claim for special review to:
PHC/Medi-CalP.O. Box 1368Suisun City, CA 94585-1368Attention: Nicholas Thompson
Eureka | Fairfield | Redding | Santa Rosa
Resources
Monday - Friday8 a.m. - 5 p.m.
Claims Telephone Support(707) 863-4130
Contact your Assigned PR Representative
PHC Online Serviceshttps://provider.partnershiphp.org
Partnership HealthPlan of Californiawww.partnershiphp.org
Our Mission: To help our members, and the communities we serve, be healthy.
Indian Health Services (IHS) Clinics
Billing for OMB Services
Revenue Code Procedure Code and Modifier Description
0520 T1015 PHC Primary Medical, per visit
0520 G0466 Medicare Crossover Claims - New Patient
0520 G0467 Medicare Crossover Claims - Established Patient
0520 G0468Medicare Crossover Claims - Initial Preventive Physical Exam, (IPPE) or
Annual Wellness Visit (AWV)
0420 T1015 PHC Primary Ambulatory Visit - Physical Therapy
0430 T1015 PHC Primary Ambulatory Visit - Occupational Therapy
*0440 T1015 PHC Primary Ambulatory Visit - Speech Pathology
*0470 T1015 PHC Primary Ambulatory Visit - Audiology
*0510 T1015 PHC Primary Ambulatory Visit - Podiatry
0520 H0047 PHC Primary Ambulatory Visit - Drug and Alcohol
0520 92004 Optometry Services, per visit - New Patient
0520 92014 Optometry services, per visit - Established Patient
*0940 98940PHC Primary Ambulatory Visit - Chiropractic manipulative treatment.
Spinal, one to two regions
*0940 98941PHC Primary Ambulatory Visit - Chiropractic manipulative treatment.
Spinal, three to four regions
*0940 98942PHC Primary Ambulatory Visit - Chiropractic manipulative treatment.
Spinal, five regions
2101 97810PHC Primary Ambulatory Visit - Acupuncture one or more needles.
Without electrical stimulation initial 15 minute service
2101 97811PHC Primary Ambulatory Visit - Acupuncture one or more needles.
Without electrical stimulation. Each additional 15 minute service
2101 97813PHC Primary Ambulatory Visit - Acupuncture one or more needles. With
electrical stimulation. Initial 15 minute service
2101 97814PHC Primary Ambulatory Visit - Acupuncture one or more needles. With
electrical stimulation. Each additional 15 minute service
0900 G0469 Medicare Crossover Claims - Mental Health Visit – New Patient
0900 G0470 Medicare Crossover Claims - Mental Health Visit – Established Patient
0561 T1015 - AG Modifier Medical Other Health Visit - Psychiatrist
0561 T1015 - AH Modifier Medical Other Health Visit - Clinical Psychologist
0561 T1015 - AJ Modifier Medical Other Health Visit - Clinical Social Worker
0561 T1015 - HR Modifier Medical Other Health Visit - Marriage and Family Therapist
*Subject to Optional Benefits Exclusions
MEDICAL SERVICES - Bill PHC
AMBULATORY SERVICES - Bill PHC
MENTAL HEALTH SERVICES - Bill PHC
April 2018