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Terriana Clark

Brenda Brown &

Tracy Crump-Ermon

DASA - Overview

Agenda

Welcome and Introduction

Objectives

Provide an overview of Aetna Better Health of Illinois and its programs:

Integrated Care Program (ICP),

Medicare Medicaid Alignment Initiative (MMAI) Premier Plan, &

Family Health Plan (includes Affordable Care Act)

Credentialing Process (New facilities & additional staff)

Identify member eligibility and enrollment process

Billing Process, Claims- Submission, Timely Filing Guidelines & Prior authorization

DASA-Overview

Case Management

Secure Web Portal

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Aetna Better Health of Illinois

• Aetna has over 150 years of experience in meeting members’ health care needs

• Aetna Better Health is an experienced Medicaid Managed Care Organization (MCO)

that shares the philosophical principles and business strengths of our parent company,

Aetna Inc.

• Aetna Better Health and our affiliates have 25 years of Medicaid managed care

experience

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Aetna Better Health Programs

We provide services for over 3 million members in 17 states and manage over $7 billion worth of health care expenses each year.

Aetna Better Health- Programs Lines of Businesses

Lines of Business Inception Date

Integrated Care Program 05/01/2011

MMAI-Premier Plan 10/01/2013

Family Health Plan 09/01/2014

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Integrated Care Program- Benefits and Eligibility

ICP- Benefits •All Medical Benefits

•Pharmacy

•Dental

•Vision

•Behavioral Health Services

•Transportation

•24/7 nurse line

•Short-Term Post Acute rehabilitation stays in Nursing Facilities

•Nursing Facility Services/Long Term-Care Services

•Home and Community Based Services waivers

•Excludes the waivers servicing individuals with Developmental Disability

Service Counties: Boone, Cook, DuPage, Kane, Kankakee, Lake, McHenry, Will and Winnebago

Eligible Members: • Seniors & Persons w/Disabilities

• Adults age 19 years of age and older

• Not eligible for Medicare

• Waiver Program

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Sample ID Card- ICP

Front

Back

MMAI- Premier Plan Benefits and Eligibility

MMAI- Benefits • All Medical Benefits

• 24/7 nurse line

• Behavioral health services

• Eye care services

• Hearing services

• Home health care

• Hospital services

• Lab tests and x-rays

• Medical supplies

• Pharmacy

• Therapy

• Transportation

• Value add benefits

Service Counties: Kane, DuPage, Cook, Will and Kankakee

Eligible Members: Age 21 and older;

Entitled to benefits under Medicare Part A and B and receive full Medicaid benefits;

And may be in the following Medicaid waivers:

• Elderly;

• Persons with disabilities;

• Persons with HIV/AIDS

• Persons with Brain Injury; and

• Persons residing in Supportive Living Facilities (SLFs)

• Individuals with End Stage Renal Disease (ESRD)

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Sample ID Card-MMAI (Premier Plan)

Front

Back

Family Health Plan (ACA)- Benefits and Eligibility FHP Benefits •All Medical Benefits

•Pharmacy

•Dental

•Vision

•Behavioral Health Services

•Transportation

•24/7 nurse line

•Short-Term Post Acute rehabilitation stays in Nursing Facilities

•Nursing Facility Services/Long Term-Care Services

•Home and Community Based Services waivers

•Family planning services and supplies

•Early and Periodic Screening, Diagnostic and Treatment services for enrollees under age 21

Service Counties: Boone, Cook, DuPage, Kane, Kankakee, Lake, McHenry, Will and Winnebago

Eligible Members: • FHP- Children (through 18 years of age)

• ACA- Adults age 19 years of age and older

• Not Eligible for Medicare

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Sample ID Card- Family Health Plan

Front

Back

Eligibility Verification Options

• Use Aetna Better Health’s 24/7 options:

Call (866) 212-2851 option 1 ICP or FHP

(866) 600-2139 option 1 MMAI-Premier Plan

Aetna Better Health’s secure web portal at www.aetnabetterhealth.com

• Providers may continue to use the existing Medicaid eligibility verification methods set up by the State:

MEDI information is available at: www.myhfs.illinois.gov/

The MEDI system is available 24 hours a day, 7 days a week

CREDENTIALING PROCESS

Credentialing Process New Facilities and/or New Staff

• Contact your Network Account Manager and request for a Facility Application and/or Provider Screening Form (Individual Providers)

• Please submit all documents to our Provider Services Department email address: AetnaBetterHealthILProviderServices@aetna.com

• Credentialing Process takes up to 60 days to complete

• Once credentialing has been completed it will take another 30 days for the loading process.

• During this process please contact our UM department (866) 212-2851, Option 2, then Option 2) to obtain authorizations if you are servicing our members during this time.

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Claims- Submission &

Timely Filing Guidelines

Claims Submission

• Aetna Better Health accepts claims submitted on new CMS 1500 or 837p form or UB-04 or 837i

• Aetna Better Health processes over 90% of initial “clean claims” within 30 days of receipt

• Most “clean claims” are processed in 15 business days or even quicker if submitted electronically through EMDEON Clearing House- Payer Id 26337

• Providers administering drugs to patients are required to submit NDC codes on the claims otherwise will result in claim denials.

“Clean Claim” defines as a claim that can be processed to adjudication without obtaining additional information from the provider of service or from another party.

Claims Submission Information • Electronic Claims Submission:

“Change Healthcare”

as known as Emdeon

Aetna Payer ID: 26337

www.emdeon.com

• EFT (electronic funds transfer) and ERA (electronic remittance advice) is now available

• Paper Claims Submission address:

Aetna Better Health

PO Box 66545

Phoenix, AZ 85082

• Check Claims Status via Secure Web Portal:

http://www.aetnabetterhealth.com/illinois/providers/portal

www.aetnabetterhealth.com

Claims: Timely Filing Guidelines

• Initial claims must be received within 120 days of the date of service or date of discharge

• Claims that have a primary payer must be received within 120 days from the EOB receipt day and within 180 days of the original date of service

• Resubmission of a corrected claim and claims disputes must be received within 180 days of the original date of service

• Providers are required to submit valid, current HIPAA compliant codes that most accurately identify the member’s condition or service(s) rendered

Paper Claims and Resubmission address: Must indicate “corrected claim” on resubmissions.

Aetna Better Health

PO Box 66545

Phoenix, AZ 85082

Provider Disputes

• The provider dispute process allows providers to express dissatisfaction with a decision based on contractual provisions inclusive of claim disputes

• To file a dispute, the provider must complete and submit the Provider Dispute Form and any appropriate supporting documentation

• In the event the provider remains dissatisfied with the dispute determination, the provider may file a complaint

Provider Dispute address:

Aetna Better Health

Attention: Provider Dispute

333 W Wacker Drive 21st Flr. Mail Stop F646

Chicago, IL 60606

D.A.S.A. Division of Alcoholism and Substance Abuse

What is DASA? • DASA is a Division of DHS (Department of Human Services)

• DASA certifies Providers so they can provide alcohol and substance abuse services

• DHS/DASA administers a network of community based facilities that provide alcohol and other drug treatment programs

• Treatment services are delivered through a network of agencies at over 200 community-based sites.

• Group of Behavioral Health Providers

• Open to admissions 24 hours a day, 365 days a year, and are most often furnished in a residential setting.

What types of services does DASA provide?

Detoxification- Provides immediate and short-term clinical support for a person in the withdrawal process

Early Intervention- is pre-treatment services for individuals whose problems or risk factors appear to be related to substance abuse but who do not meet any diagnostic criteria for substance abuse related disorders.

Case Management -is the provision, coordination, or arrangement of ancillary services designed to support a specific patient's treatment with the goal of improving clinical outcomes.

Outpatient Counseling- Group or Individual Sessions

Intensive Outpatient -Counseling- provides a variety of diagnostic and highly structured clinical services on a scheduled basis. Activities include individual, group and family counseling and patient education

Residential Rehabilitation -provides clinical and treatment rehabilitation services 24 hours a day

Residential Aftercare -is offered in two levels: halfway houses and recovery homes. Halfway houses provide living opportunities to patients in need of additional services, usually following residential rehabilitation. Services are designed to support the patients' productive return into the community. Recovery homes provide extended residential support services and the mutual support of living in a sober environment with other recovering individuals.

In order to provide DASA Services….

• There must be a fully executed contractual agreement with DHS/DASA that outlines the type of services that are reimbursable along with the rates for those respective services

• Please reach out to your Network Account Manager when adding new DASA locations and Services to make sure that our system is updated and accurate with your information.

• Must obtain NPI#s and Medicaid #s from HFS for DASA Services (IMD facilities are not required to have a Medicaid ID#)

• IMD Facilities are only servicing ACA members at this time.

DASA HFS Billing Guidelines

Effective 06/01/2016- New DASA Billing Guidelines

The link to the 2016 billing guide: Please use the following information as a resource when billing

https://www.aetnabetterhealth.com/illinois/assets/pdf/providers/DASAILMCOBillingGuide1.pdf

The Billing Guide and other information is located on Aetna Better Health Website https://www.aetnabetterhealth.com/illinois/providers/

All claim submissions must be submitted to Aetna Better Health based on the new guidelines starting 06/01/2016

DASA Billing Guidelines

Historical Claim Resubmissions

• Aetna Better Health instructed DASA providers previously to submit claims using Rev code 0128 (Residential Room & Board) and 1002 for (Detox Service) on a UB-04 claim form or 837i (these codes are no longer billable for current claims effective 6/1/16).

• HCPC codes (outpatient services) should be billed on a HFCA 1500 (837p) claim

form

For any historical claim submissions please rebill claims based on the previous guidance in order to get reimbursed accordingly.

DASA Billing Requirements • All outpatient DASA services are to be submitted on an 837p claim.

• All inpatient/residential DASA services are to be submitted on an 837i claim

• DASA services may only be rendered from a site that is certified by the Department of Human Services’ (DHS) Division of Alcohol and Substance Abuse (DASA).

• DASA residential/institutional services are to be billed as one global rate on a single 837i claim – domiciliary (room and board costs) and treatment costs should not be split nor should they be billed to Aetna Better Health separately.

• A provider billing BOTH substance abuse AND mental health services from the same site may not utilize the same NPI for both services. Mental health must be billed using a separate NPI (other than the one used for substance abuse billing)

Aetna Better Health intends to follow the HFS published guidelines and the system will reject non-conforming claims

DASA Additional Billing Requirements

• A Value Code of 80 is required on all 837i claims for the number of covered

treatment days.

• If a member is being dually treated for both alcohol and substance abuse, the primary admitting diagnosis code should be utilized to determine the appropriate Revenue Code (944 or 945) for the claim.

DASA Diagnosis Codes

A primary diagnosis code is required on all DASA claims.

Acceptable primary diagnosis codes for DASA claims are listed

Table 2. Acceptable Primary Diagnosis Codes for DASA Services

ICD-9

(services rendered prior to October 2015)

ICD-10

(services rendered on or after October

2015)

303 – 305.93 F10-F19.19

DASA Institutional/Residential Services Billable Codes

Service Name

Revenue Code

Billing Code

Modifier

Taxonomy

Type of Bill

Rehabilitation – Adult (age 21+)

944 or 945

H0047

324500000X

3245S0500X

086X, 089X

Rehabilitation – Child (age 20 or under)

944 or 945

H0047

HA

Adolescent Residential

944 or 945

H2036

Detoxification

944 or 945

H0010

DASA Outpatient Services Billable Codes

Service Name

Billing Code

Modifier

Taxonomy

Unit

Per Unit Rate

Place of Service

Admission and

Discharge Assessment

H0002

261QR005X

276400000X

¼ hour

$16.32

21, 22, 55, 57

Psychiatric Evaluation

90791

Event

$81.31

21, 22, 55, 57

¼ hour

$15.53

21, 22, 55, 57

Psychotropic Medication

Monitoring

H2010

Individual –

Therapy/Counseling, SA

H0004

¼ hour

$15.53

22, 57

Group –

Therapy/Counseling, SA

H0005

¼ hour

$5.87

22, 57

Individual – Intensive

Outpatient, SA

H0004

TF

¼ hour

$15.53

22, 57

Group – Intensive

Outpatient, SA

H0005

TF

¼ hour

$5.87

22, 57

Aetna Better Health

Secure Web Portal

The Aetna Better Health Secure Web Portal will allow the providers to:

• Request Portal Access – To submit your request for registration, please fax your

completed form and attached agreement to Aetna Better Health Provider Services at (860) 754-0435. (Application is found on the Aetna Better Health Website)

• http://www.aetnabetterhealth.com/illinois/assets/pdf/providers/ProviderWebPortalRegistration-IL.pdf

• Provide and Designate level of access as Administrator or Staff

• Verify eligibility of your members

• Check Claims Status

• Access evidence-based clinical practice guidelines

• View Gaps in Care reports for members

• Available 24 Hours a Day

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Secure Provider Web Portal

Log in screen

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Secure Provider Web Portal

• Research and view member claims by Claim ID, Claim Type, Claim Status or Check Number.

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The Provider Report Management Tool

Benefits to Providers Safe, secure online tool gives providers access to plan-generated reports through your secure web portal

Gives the provider secure, direct access to view, download, save and print any report generated for your practice

• Provider Report Management Tool access is linked to the provider’s secure web portal log-in and password

No additional sign-on information required ensuring ease of access

• The tool is agnostic allowing plans to upload reports and provider communications in PDF, Microsoft Excel and Microsoft Word

• Versatility for health plan to distribute reports based on different levels of provider affiliation

Individual provider reports/communications

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Thank you

Copyright 20XX Aetna Inc.

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