■ We are Acadia Family Center

Acadia Family Center provides prevention, education, and outpatient treatment services for adolescents, adults, andfamilies affected by substance use, chemical dependency,and related mental health disorders

■ My name is Laura Shelby & I am the Billing Manager for this agency.

■ We provide Non-Intensive Out-Patient Substance Abuse & Mental Health Counseling. Currently serving 60-80 clients per month.

■We are a non-profit Behavioral Health Services Agency in the State of Maine with 4 clinicians & 3 Administrative Staff, focusing on Substance Abuse.

■ Our clinicians include: an Art therapist ATR-BC, LCPC; Ph.D, LCSW; LMSW-CC; & LADC.

■ In the State of Maine, Medicare does not cover our out-patient Substance Abuse services, so we do not bill Medicare. We cannot take clients that have Medicare unless they want to self-pay. Check with your state as to whether you can bill Medicare the services you provide in your particular setting.

■ We take MaineCare, which is our state’s Medicaid & Commercial Insurances (Blue Cross, AETNA, Cigna & Harvard Pilgrim). We also offer a sliding fee scale, treatment scholarships & have many self-pay clients.

■ Today we will focus on third party billing…And let me start by saying that it is not hard or expensive to do!

■ Billing Basics

■ What is an NPI? This is your National Provider Identifier. This number is required by all Insurance Companies. Agencies & individual clinicians need their own unique NPI’s that stay with them forever.

■ How do you get one? Google “National Provider Identifier” & a web site will come up. There is a 6 page application that takes about ½ hour to fill out & submit.

■ Billing Basics

■ What is an NPI? This is your National Provider Identifier. This number is required by all Insurance Companies. Agencies & individual clinicians need their own unique NPI’s that stay with them forever.

■ How do you get one? Google “National Provider Identifier” & a web site will come up. There is a 6 page application that takes about ½ hour to fill out & submit.

■ You will need your EIN or Tax ID # & a “Taxonomy” code for your type of practice. You can find this by Googling “Taxonomy Codes”. I found it at www.adldata.com/Downloads/provider-taxonomy.html or www.wpc-edi.com/taxonomy

AFC’s TaxonomyCode

■ Credentialing/Contracting

■ This verifies to the Insurance Companies that your providers are licensed & who they say they are!

■ You will need to call each Insurance Company that you would like to bill. Ask for the “Provider Relations Department” for the forms/applications to be “Credentialed”.

■ You will need to gather some info, you may want to start a file for each Insurance Company that has a copy of the Agency License, Clinicians’ License & Certificate of Liability Insurance & necessary NPI #’s.

■ Once Credentialed, you are “In-Network” with that carrier also known as “Participating”. This also means that you will accept the “Contractual Rate” from that Insurance Company.

■ Insurance Information

■ When the client comes in, get a copy of their Insurance Card, front & back.

■ Call the Insurance Company for “Behavioral Health” benefits & eligibility… you’ll need the Client Member/ID #, DOB & probably the Social Security #. You will also need your agency NPI #.

■ Ask if there are any Pre-Authorization or on-going Authorization requirements.

■ You can give the client an Idea of what their co-pay or charge will be, but until it is processed there is no way to know for sure.

■ It may say on the card there is a $20.00 co-pay, but they may not yet have met their Deductable. So, I always preface it with “Depending on your policy, this is what we estimate the Insurance Company will pay”.

Member ID #Call # for Information

We use this CMS-1500 form.

I order them on-line at www.databusinesssystems.com

Customer Service # 1-800-778-6247

Can be submitted handwritten – you have to fill in all required fields/blocks. Keep a copy for your files, then send in the original.

This is how we started!!

Billing Codes (Block 24D on this form)

I have a list/chart of “Service/Procedure Codes” from the Insurance Companies called a “Fee Schedule” that I choose from to bill a certain service.

For example, Commercial Insurances use:

90801 - Psychiatric Evaluation (Assessment)90806 - Psychotherapy 45-50 Minutes90808 - Psychotherapy 75-80 Minutes90847 – Family Psychotherapy (w/Client)90846 – Family Psychotherapy (w/o Client)90853 - Group Psychotherapy 120 Minutes

For MaineCare (Medicaid), I have different codes that come from what they call a “Cross Walk”. They are:

H2000 – Evaluation (Assessment)H0004 – Individual TherapyH0004 HH – Individual Co-Occurring TherapyH0004 HQ – Group TherapyH0004 HQ HH – Group Co-Occurring Therapy

Co-Occurring = Having a S.A. diagnosis & M.H. diagnosis.

The HQ & HH are modifiers

■ Getting Remittance Advice

■ Remit

■ EOB – Explaination of Benefits

“Service/Procedure Codes”

Amount Covered“Contractual Rate”does not always equal theAmount Charged.

The difference is the “Contractual Adjustment”.

■ Is your head spinning? Take a deep breath…

■ You can submit the claims by hand.

■ Also Practice Management Software is available.

■ We use Psych Advantage by Compulink, which runs in the $2000 - $10,000 range with an annual service agreement fee of $$? It fills in the blocks/fields with the info entered in the system.

■ To bill electronically, which we have just started doing; we use a clearinghouse called Emdeon. Our software works to verify the claims then sends them on to each Insurance Company.

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