Encounter tidbits

              Arizona Dept. of
Health Services
Division of
Behavioral
Health Services Encounter Tidbits
May 2005
Encounter Tidbits is a monthly publication of the Arizona Department of Health Services, Division of Behavioral Health Services, Office of Program Support Services
150 North 18th Avenue, 2nd Floor, Phoenix, AZ 85007
www.azdhs.gov/bhs/index.htm
HIPAA Corner… … …
HHS Publishes Important Upcoming HIPAA Dates
The Department of Health and Human Service (HHS) published, in its Semiannual Regulatory Agenda in the December 13 Federal Register, important HIPAA implementation dates providers should know.
HHS plans to issue notices of proposed rulemaking on the follow-ing dates for the following items:
• January 2005, Claims Attachment standard
• February 2005, HIPAA enforcement
• April 2005, National Health Plan Identifiers
• June 2005, Transactions and code sets standards (modi-fications and revisions)
• August 2006, electronic Medicare claims submission
Go to the December 13 Federal Register (http://www.access.gpo.gov/su_docs/fedreg/a041213c.html) for more information. Are the JCAHO and other accrediting agencies con-sidered health oversight agencies such that we can disclose information to them without authorization? No. The definition of health oversight agency does not in-clude private organizations, such as private-sector accrediting groups.
Accreditation organizations perform healthcare operations func-tions on behalf of health plans and covered providers. Accordingly, to obtain PHI without individuals' authorizations, accrediting groups must enter into business associate agreements with health plans and covered providers.
Similarly, private entities (e.g., coding committees) that help gov-ernment agencies make coding and payment decisions perform healthcare payment functions on behalf those government agen-cies. Therefore, they must also enter into business associate agreements to receive PHI from the covered entity.
Editor's note: Attorneys from Bricker and Eckler LLP answered this question. For more information, go to Section 164.501 Definitions: Health Oversight Agency.
Important Information on Corporate Compliance Is a business associate agreement always required when disclosing patient information for healthcare operations? Although generally disclosures for healthcare operations will involve a business associate relationship with the recipient of the information, there are certain situations in which a business associate agreement would not be applicable. The test is whether the entity receiving the information is providing a service for the covered entity.
In this context, HHS notes in the commentary to the regulations: “Whether a disclosure is allowable for health care operations is determined separately from whether a business associate contract is required. These provisions of the rule operate independently. Disclosures for health care operations may be made to an entity that is neither a covered entity nor a business associate of the covered entity. For example, a covered academic medical center may disclose certain protected health information to community health care providers who participate in one of its continuing medical education programs, whether or not such providers are covered health care providers. A provider attending a continuing education program is not thereby performing services for the cov-ered entity sponsoring the program and, thus, is not a business associate for that purpose.”
Editor’s note: Attorneys from Bricker and Eckler LLP answered this question. For more information, see Section 164.501 Definitions: Health Care Operations.
User Access Request Forms
The Office of Program Support Services must authorize all requests for access to CIS, Office of Human Rights, Office of Grievance and Appeals, Issue Resolution System, and PMMIS (AHCCCS) databases. In order to obtain access to any of these databases, please fax or mail a copy of the er Access Request Form and User Affirmation Statement to Stacy Mobbs at (602) 364-4736.
appropriate Us
For questions or more information, please contact Stacy Mobbs by tele-phone at (602) 364-4708 or by e-mail at mobbss@azdhs.gov
Q
A
Q
APage 2 Encounter Tidbits May 2005
AHCCCS Billing for
Division of Health Care Management
Data Analysis & Research Unit
Encounter File Processing Schedule
May – June 2005
FILE PROCESSING ACTIVITY
May 2005
June 2005
Deadline for Corrected Pended Encoun-ter and New Day File Submission to AHCCCS
Fri
5/6/2005
12:00 PM
Fri
6/3/2005
12:00 PM
Work Days for AHCCCS
7
7
Encounter Pended and Adjudication Files Available to Health Plans.
Tue
5/16/2005
Tue
6/13/2005
Work Days for Health Plans
13
17
NOTE:
1. This schedule is subject to change. If untimely submission of an encounter is caused by an AHCCCS schedule change, a sanction against timeliness error will not be applied.
2. Health Plans are required to correct each pending encounter within 120 days.
3. On deadline days, encounter file(s) must arrive at AHCCCS by 12:00 p.m., Noon, unless otherwise noted
Travel vs.
Transportation
The Office of Program Support has recently received a high volume of questions regarding travel and transportation. The terms travel and transportation have been used interchangeably, however, provider travel is distinctly different from client transporta-tion. Please use the following guidelines when billing travel and transportation.
Travel
Travel occurs when the provider travels to the client to de-liver services.
The mileage cost of the first 25 miles of provider travel is included in the rate calculated for each service; therefore, provider travel mileage cannot be separately billed except when exceeding 25 miles.
To encounter additional mileage, use procedure code A0160 - Non-emergency Transportation: Per Mile/Case Worker or Social Worker, for the additional mileage when traveling in exceeds 25 miles per trip.
Transportation
Transportation is provided when the client or member is in the vehicle and is transported to a particular destination to receive services.
Transportation is encountered by billing the base rate code and the appropriate mileage code.
Remember: Travel is when the services are delivered to the client, and transportation is when the client is delivered to the services.
Services
In addition to the general principles related to the provision of services, there are also general guide-lines, which must be followed in billing for covered behavioral health services to ensure services will be reimbursed, and/or the encounters accepted.
There are two types of codes that can be billed for services provided:
• AHCCCS Allowable Codes may be paid for with Ti-tle XIX/XXI funds and/or non-XIX/XXI funds de-pending on the person’s eligibility status; and
• Codes not allowable under AHCCCS and can only be paid for with non-Title XIX/XXI funds.
1. AHCCCS Allowable Codes
AHCCCS allowable codes are to be used to bill for ser-vices provided to any person eligible to receive services through ADHS/DBHS, regardless of his/her eligibility status (e.g., Title XIX/XXI, non-Title XIX/XXI). To bill AHCCCS allowable codes the provider must be an AHCCCS registered provider.
AHCCCS allowable codes are further subdivided into the following categories:
(a) CPT
(b) HCPCS
(c) National Drug Codes (NDC)
(d) UB92 Revenue Codes
2. Codes not Allowable Under AHCCCS
Some codes are not reimbursable under Title XIX/XXI. Appendix B.2, ADHS/DBHS Allowable Procedure Code Matrix identifies the service codes not reimbursable through AHCCCS funding. If there is not an applicable AHCCCS allowable code, then these codes may be used to bill for the service. These codes may be billed regardless of the person’s Title XIX/XXI eligibility status. Depending on the code, these services may be billed by both AHCCCS registered providers and DBHS-only providers. These codes include: H0043, H0046 SE, H0046, S9986, T1013, 97780, and 97781.
Office of Program Support Staff
If you need assistance with eligibility, encounters, or coding ques-tions, please contact your assigned Technical Assistant at:
Michael Carter
Excel
(602) 364-4710
NARBHA
Eunice Argusta
CPSA-3
(602) 364-4711
CPSA-5
Gila River
Navajo Nation
Pascua Yaqui
Javier Higuera
PGBHA
(602) 364-4712
Value OptionsPage 3 Encounter Tidbits May 2005
AHCCCS Encounters Error Codes
R660 – DHS MHS Encounter Recipient must be on MHS En-rollment
Review encounter dates of service; verify the dates of service fall within an enrollment segment. Use the CIS application Enrollment Inquiry screen to verify enrollment segments. Also, verify an open behavioral health segment on the PMMIS using screen RP216 – Inquire BHS/FYI Data.
F105 – Procedure Code is Missing or Not on File for DOS
This field was left blank or contained an invalid procedure code. Verify the procedure code against screen H74988 – Procedure Code Maintenance or PMMIS screen RF110 - Procedure Codes and Descriptions.
R410 – Recipient not eligible for AHCCCS services on Service Dates
Review the AHCCCS ID and service begin and end dates for the encounter. The most common error involves the client’s termina-tion of enrollment in the health plan. Review the enrollment in-formation for the client using PMMIS screen RP216 – Inquire BHS/FYI Data, this screen indicates current or past enrollments and provides basic data for the client. If you are unable to resolve the issue, please contact the appropriate technical assistant.
Z725 – Exact Duplicate from Different Health Plans (Form A)
Z805 – Exact Duplicate from Different Health Plans (Form C)
Encounters are pending because at least one claim was found in the system from another health plan that matches the pended claim. These claims need to be researched by both health plans’ to deter-mine the cause for the exact duplicate. Each health plan must work together to resolve the issue and decide who should receive payment for the service. Your assigned technical assistant is avail-able to help you with your research.
R660 DHS MHS Encounter Recipient must be on MHS Enrollment
4,707
Z725 Exact Duplicate from Different Health Plans
4,016
Z805 Exact Duplicate from Different Health Plans
2,550
F105 Procedure Code is Missing or Not on File for DOS
2,268
R410 Recipient Not Eligible for AHCCCS Services on Service Dates
599
Total
14,140
These errors account for 44.93% of the pended en-counters at AHCCCS.
Edit Alerts
An Edit Alert is a faxed and e-mailed notice of system enhancements or changes. The Office of Program Support strives to ensure any system enhancements or changes are communicated to all program partici-pants in an accurate and reliable manner. Edit Alerts will be distributed when the information is first made available and again with the following monthly publication of the Encounter Tidbits.
Alert # 38
Effective July 20, 2005: Encounters will no longer be accepted by CIS for Title 19/21 Clients or services where the Service Provider is listed as an IHS Service Provider or is an otherwise FFS encoun-ter. This edit will not apply to Non-Title 19/21 Clients or services. Encounters for Non-Title 19/21 Clients or services will be ac-cepted into CIS regardless of the IHS flag indication in the Monthly Provider File Record Layout.
Examples:
An encounter submitted for a Client who has Behavioral Health En-rollment at AHCCCS on the date of service, and the provider is an IHS or otherwise FFS Provider: The encounter will not be accepted into CIS.
An encounter is submitted for a Client who does not have Behavioral Health Enrollment at AHCCCS on the date of service, and the pro-vider is an IHS or otherwise FFS Provider: The encounter will be ac-cepted into CIS as a subvention encounter.
Alert # 39
Effective April 20, 2005: In order to ensure timely processing of encounters and to monitor for data system issues, the Office of Program Support (OPS) monitors all RBHA encounter acceptance rates for all encounter files submitted to ADHS. At a minimum, RBHAs should maintain a 90% or greater acceptance rate on all encounters submitted. Percentages are derived each day for each file by dividing the number of encounters accepted by the total number of encounters submitted per each form type. When en-counter accepted rates do fall below the 90% minimum, the RBHAs should provide OPS with comments explaining why the rates fell below the norm. OPS will take into account RBHA comments when analyzing low acceptance rates.
Formulas:
UB Encounters: Accepted encounters divided by Header amount.
HCFA Encounters: Accepted encounters divided by Detail amount.
RX Encounters: Accepted encounters divided by Total Records Sub-mitted.
Alert # 40
Effective February 2, 2005: HCFA encounters with a date of service equal to the admit or discharge date of an inpatient UB already in the system will be accepted into CIS. HCFA encounters with a date of service within the admit or discharge date of an inpatient UB already in the system will be accepted unless the service code on the HCFA is included on the CIS Billing Limita-tions Table and is not end dated prior to the date of service.