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June 08, 2022, 05:39 EDT

Chapter 5: Billing Instructions (Psych)

Updated: 8/22/2018

 

Behavioral Health Services Administrator (BHSA)

Magellan of Virginia serves as the Behavioral Health Services Administrator or "BHSA" and is responsible for the management and direction of the Fee for Service (FFS) behavioral health benefits program under contract with DMAS. Magellan of Virginia is authorized to create, manage,  enroll, and train a provider network; perform service authorization; adjudicate claims; process claims; gather and maintain data; reimburse providers; perform quality assessment and improvement; conduct member outreach and education; resolve member and provider issues; and perform utilization management including care coordination for the provision of Medicaid-covered behavioral health services. Magellan of Virginia’s authority shall include entering into or terminating contracts with providers and imposing sanctions upon providers as described in any contract between a provider and Magellan of Virginia. DMAS shall retain authority for and oversight of Magellan of Virginia entity or entities.

Medicaid Managed Care

Most individuals enrolled in Medicaid and FAMIS receive their Medicaid services through Medicaid Managed Care Organizations (MCOs).  Providers must participate with the member’s MCO (or negotiate as an MCO out-of-network provider) in order to be reimbursed for MCO contracted services. Psychiatric services providers must contact the member’s MCO directly for information regarding the contractual coverage, and reimbursement guidelines for services provided through the MCO.

Billing Instructions

All providers must be under contract with Magellan of Virginia and/or a Medicaid MCO.  Providers must follow Current Procedural Terminology (CPT) guidelines for billing Psychiatric Services. 

Magellan of Virginia enrolled providers must contact Magellan of Virginia directly for information on reimbursement and claims processing instructions.   All claims processing and reimbursement information can be found by contacting Magellan of Virginia at 1-800-424-4046 or by email at VAProviderQuestions@MagellanHealth.com or by visiting the Magellan of Virginia website at https://www.magellanofvirginia.com/for-providers/.

Providers under contract with a Medallion 3.0, a Commonwealth Coordinated Care (CCC) Plus and/or Medallion 4.0 (effective 8/1/2018) MCO should contact the MCO for billing information.  Additional information is located on the DMAS website at:

ICD-10 (Psych)

In accordance with CMS requirements, DMAS and its contractors exclusively use ICD-10 CM diagnostic coding structure for electronic diagnosis and billing purposes. ICD-10CM is the only recognized HIPAA compliant coding system; therefore, it will be the only one accepted on electronic forms and transactions for Medicaid claims. In addition, in Section I of the DSM5 titled 'Use of the Manual' and in the subsection called the 'Coding and Reporting Procedure', the paragraph informs clinicians about ICD10. To assist providers, the corresponding ICD10 diagnosis codes are provided alongside the listed DSM5 diagnosis codes.

Billing Requirements for Services Under Arrangement

When a provider of services under arrangement submits a claim for their services to DMAS or one of its contractors, the NPI of the referring inpatient psychiatric provider must be submitted on the claim. The claim will deny or be retracted if no referring NPI is submitted. This  referral number will be required as indicated below.

Please refer to Magellan of Virginia or the MCO’s billing instructions for managing services provided under arrangement.

CMS-1500: Locator 17 - Name of Referring IPF Locator 17b - Enter the National Provider Identifier (NPI) of the inpatient psychiatric provider

UB 04: Locator 78 Other Provider Name and Identifiers - Enter the NPI for the inpatient psychiatric provider.

EDI 837 Professional:

 

Loop

Segment

Data Element

Comments

2310A-

Referring Provider Name

NM1

NM109-Referring Provider Identifier

Submit the referring inpatient psychiatric provider's NPI in this field.

2310A             –

Referring Provider Name

NM1

NM108 – Referring Provider

Identification Code

Use ‘XX’ for NPI

 

 

EDI 837 Institutional:

 

Loop

Segment

Data Element

Comments

2310F- Referring Provider Name

NM1

NM101 – Entity Identifier Code

Should always be ‘DN’ for the NPI of referring

provider.

2310 F – Referring Provider Name

NM1

NM108 –

Identification Code Qualifier

Use ‘XX’ for NPI

2310F- Referring Provider Name

NM1

NM109 –

Identification Code

Submit the referring inpatient psychiatric provider's NPI in this field.

 

Billing Requirements and Edits for Ordering, Referring and Prescribing (ORP) Providers

To ensure that DMAS is meeting the mandated requirements from CMS, edits related to the ORP providers have been created. DMAS has established these claim edits to ensure that all ORP and Attending provider NPI’s are submitted on claims and that the NPI listed is actively enrolled for the date(s) of service in the Virginia Medicaid program. Effective July 1, 2014, any claims submitted with invalid data will deny the claim.

The edits are:

 

DMAS

Edit/ESC

 

Description

HIPAA

Codes

Resol/Action Effective 04/01/2014

Resol/Action Effective 06/28/2014

 

Comments

0191

Provider Referral Required

CO/207/N286

EOB

Denial

This edit will validate that the ORP's NPI is enrolled in DMAS. Refer to the Attachment A for providers required to have referral.

0194

Attending Provider Not on File

CO/16/N253

EOB

Denial

This edit will validate that the attending NPI is valid and actively enrolled in DMAS. Attending Provider NPI must be on all UB/837I/DDE

institutional claims.

 

 

 

0195

Referring Provider Not on File

CO/207/N286

EOB

Denial

This edit will validate the referring NPI is valid and actively enrolled in DMAS

0196

Referring Provider Not Eligible on Date of

Service

CO/207/N286

EOB

Denial

This edit will set if the Referring NPI is not enrolled and active for the dates of service on the

claim.

0197

Attending

Provider Required

CO/16/N253

EOB

Denial

This edit will set if the

Attending NPI on claim is missing.

0198

Attending Provider Same as Billing Provider

CO/16/N253

EOB

Denial

This edit is checking to ensure the Attending NPI on the intuitional claim is not the billing provider. The Institution is expected to be the billing

provider.

0199

Attending Provider Not Eligible on Date of Service

CO/16/N253

EOB

Denial

This edit will validate that the attending NPI is valid and actively enrolled in DMAS for the dates of service(s) on claim. Attending Provider NPI must be on

all UB/837I/DDE institutional claims.