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Act 62 Frequently Asked Questions

July 19, 2010

Clinical Questions

Are the Best Practice Evaluations considered an initial evaluation?  Do these have to be sent to the commercial insurance company as the primary payer?  (NEW)

Providers who are contracted to complete the level of care called Best Practice Evaluations should send those claims to Community Care as the primary payer. The modified codes that should be billed as primary are 90801-HA & 90801-EP. For providers contracted to deliver the evaluation service that is billed with an “SC” modifier (90801-SC), that service code should also be billed as primary for Community Care members. 

Should providers continue to send packets to Community Care when they send the treatment request to the commercial insurer? 

Yes, we are recommending that providers submit a packet to Community Care when they send the treatment request to the primary payer. Packets received, will be processed as usual by Community Care, including the timing and duration of the BHRS prescriptions. As packets are received, they will be reviewed for medical necessity and the resulting authorizations entered into the care management system. If providers receive claims denials for services by the primary/commercial insured, the authorization will then be in the system so that the secondary claim can be processed.    

Do providers still have to submit the various reports on services completed if the primary payer is authorizing the care?

If you have submitted a packet to Community Care, you will be included in the various BHRS reports that we are required to send to DPW. Therefore, if you have received an authorization from us, we are still requiring that you submit the various reports and follow the same policies as if we were the primary payer.

What if the provider gets a medical necessity criteria denial (a clinical denial) by the primary insurance?   What should the provider do at that point? 

Community Care is able to authorize and pay after the initial medical appeal has been done.  The insurance companies are being asked to offer families (the subscriber) a 2 day expedited appeal process. Please note that these types of appeals are available only for the covered member so providers will have to ask families to request these appeals. After the appeal has begun, and/or if there is another appeal, Community Care can authorize and pay. If the appeal is eventually overturned and the provider gets paid by the primary payer, that provider should refund any monies paid by Community Care during that time period.    

Do providers have to submit evaluations in the life domain format? 

When providers submit packets to Community Care, the same standards as are used now will still be in place. For any request for a Community Care authorization, providers are expected to follow all of our procedures and forms requirements prior to that authorization being granted. 

How will Community Care  handle the request for authorization for an initial evaluation if the member has not yet been diagnosed on the Autism spectrum?  (CHANGED)

The basic evaluation, 90801, is a service that is covered under Act 62. Community Care is not changing its authorization policies regarding evaluations, however, in most cases, the initial (pre-ASD diagnosis) can be billed to the primary insurer. Members can get an evaluation regardless of outcome. However, many commercial insurers already pay for evaluations too so this is not a service that is exempt from coordination of benefits rules. If the provider gets a denial on an evaluation service, then Community Care will be happy to pay it when we receive the secondary claim with the appropriate claims attachment. Please note that this answer pertains to the standard evaluation and not the evaluation that is modified to indicate the Best Practice Evaluation. BP evaluations occur after the initial diagnostic evaluation has been completed. 

For an Act 62 eligible child, will Community Care pay for providers to attend ISPT meetings even when they are not paying for the care of the child yet because they haven’t reached their $36K limit?

Since we feel that attendance at the ISPT meetings is so important, we are going to continue to cover the ISPT meeting code. Providers should continue to attend ISPT meetings and to bill Community Care for those sessions. Authorizations must be in the system for these claims to pay, so providers should submit a packet to Community Care if they are planning on billing for the ISPT meeting attendance. 

Insurance/Claims/Payment Questions

I have received denials for COB but I attached the EOB from the primary insurance company.  What should I do? (NEW)

Community Care is aware that there are some providers who have experienced this issue.  In order to minimize claims denials for our providers, while we are working with our TPA vendor to fix the problem, we’d like to ask that providers send their paper COB claims and the attachments to: Community Care Claims Department, Attention: David Solenday, One Chatham Center, Suite 700, Pittsburgh PA 15219.

How is Community Care going to handle co-pays and deductibles for members covered under Act 62? 

We were under the impression that our TPA claims vendor was able to pay claims for copayments and deductibles without an authorization, however, we recently discovered that this process is not working correctly. Therefore, please make sure that you have an authorization in the system so that we can pay your coordinating claims correctly. To submit a claim for a copay or deductible, the provider should bill the commercial insurance company and get a remittance that shows the total paid less the withhold for copayment or deductible. The provider sends a secondary claim to Community Care with that information as an attachment. We will then pay the amount up to our fee schedule for that service. If we get a claim for a copayment or deductible without evidence that the primary insurer has been billed, that claim will be denied.

What if the child lives in PA but has his/her insurance from out of state?

Act 62 only applies to insurance companies/products licensed in Pennsylvania so in that case, Act 62 does not apply.

I have received a claims denial from Community Care for a child who I know does not have Act 62. 

Please send an email to Sharon Hicks, hickssr@ccbh.com, that includes: the MA ID, date of birth, the dates of service and the reason for Act 62 forgiveness (e.g., insurance is self-funded, Act 62 eligibility is in the future, etc.). Sharon will follow our internal processes to correct the child’s flag in the claims system and will work with claims to reprocess your claims denial.   

I know that a child will be Act 62 eligible on a future date. 

For a child who you discover will be Act 62 eligible in the future, send the information above and the date of eligibility.  Sharon will add to the claims flag. 

What if a service that a child is getting is not covered by the commercial insurer under Act 62?

There are some services that certain insurers are not covering. Providers must either bill the primary payer at least once per member per benefit year and get a denial, or they can obtain a letter from the primary payer during each benefit year that documents that that insurance company is not covering the service in question. They need to send a denial to us and we will pay from that point forward. Community Care authorizations are still required before these services can pay. That means that providers must follow our guidelines re: packet submission, etc. to get these services authorized. 

How are we going to know who is in Act 62 moving forward?

DPW and the Department of Third Party Liability are working on making this type of information available electronically. In the interim, we are working on various ways to get that information into the system. Providers should get this information directly from families and commercial insurance companies. Providers should make sure to ask families if they are eligible so that the provider can avoid getting claims denials from Community Care.  

How will providers know when a child is getting close to the $36K limit?

Some insurance companies are going to let providers know but some will only know because they are tracking their own spending. One way is that providers will get a denial from the primary insurer.  For members getting many services from more than one provider, it is possible that a provider won’t know until the claim is denied. Providers should always ask the family when their commercial benefit year begins. At the point where a provider gets to the middle of the benefit year, depending on the utilization patterns of the child, it is probably prudent to request a Community Care authorization in addition to the commercial authorization (Please see #2 in the clinical FAQ section for more information about authorization requirements). For example, if a child’s benefit year is July 1, then in December, the provider may want to submit a packet to Community Care in addition to the treatment plan submitted to the commercial insurer.   

What should the provider do to assure that they get paid from Community Care as soon as the child’s primary insurance reaches the limit?

We are going to work very hard to make sure that members don’t have their care disrupted because of insurance issues. So the providers must contact us as quickly as possible. We understand that there may be transition actions that will take time and so will work with the provider during that time to assure that children don’t lose their services. For example, if the primary insurance didn’t require an ISPT meeting or a packet, the provider will use that transition time to have the meeting, complete the packet, and send it to us. 

Can Community Care pay as primary if the provider gets a denial because the provider is not in the network of the commercial insurance company?

No, if a provider chooses not to contract with a commercial insurance network, we are not allowed to pay them as primary. They must be in the commercial network in order for us to coordinate benefits. 

To which insurance company does the provider submit the claim if Autism is the secondary and not the primary diagnosis?

The Department of Public Welfare has indicated that if there is a diagnosis of Autism on the claim form, regardless of what order, then it is an Act 62 claim and should be submitted to the commercial payer. 

Will Community Care make up the difference if the commercial payer’s fees are less than paid by the HealthChoices program?

No, Community Care may not use HealthChoices dollars to increase the amount paid to a provider when that provider has a contract with the primary payer to accept a specific amount. In other words, if the provider agreed to accept that fee, then Community Care is not able to use public program dollars to pay more than they’ve agreed to accept. 

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