Provider Resources

This section includes the most commonly needed information for providers.

Provider Manual

Jackson Care Connect providers are contracted with CareOregon, the health insurance provider that works with Jackson Care Connect. Below you will find the CareOregon Provider Manual, which also applies to CareOregon Advantage/Medicare contracted providers.

This manual has information on the following topics:

  • Membership
  • Benefits
  • Referrals and authorizations
  • Billing and payment
  • Interpretation
  • Transportation for OHP members
  • Provider relations specialists
  • Primary care
  • Medical record
  • Quality improvement
  • Credentialing
  • Medicare Advantage
  • Clinical practice guidelines

If you have questions, please contact your provider relations specialist.

Becoming a CareOregon Provider

CareOregon provides plan services to three Coordinated Care Organizations (CCO) and offers a Medicare Advantage plan supporting and enhancing sensible, localized, coordinated care.

If you are interested in becoming a contracted provider, please review our credentialing requirements (outlined in our CareOregon Provider Manual).

If you have additional questions, or would like to learn more about requesting consideration for a contract, please contact Customer Service at 800-224-4840 or 503-416-4100. You may also complete the New Contract Requests form here. Please be certain to include all applicable fields for consideration.

Thank you for your interest in joining CareOregon’s provider panel!

Policies and Forms

This section includes medical policies, forms and medical management guidelines for physical and behavioral health. Some documents are provided by CareOregon, the health insurance provider that works with Jackson Care Connect. For dental health information, visit the provider page of the appropriate plan:

Behavioral health guidelines and forms

 

Behavioral Health Delegated Credentialing

 

Policies: General

 

Policies: Pharmacy

  1. OHP Prior Authorization Use criteria

 

Forms: Pharmacy

 

Policy updates and other forms: Pharmacy

 

Authorization guidelines and forms

Eligibility

Use the Provider Portal to verify a member’s eligibility with Jackson Care Connect.

 

Authorization guidelines 

Changes are posted on the 15th day of the calendar month (or the next business day).

 

Diagnostic and treatment procedures: CPT code grid

 

DME: Authorization and code lists

 

Frequently asked questions (FAQs)

 

Authorization request forms

 

Miscellaneous policies and forms

Where to send claims

To submit claims electronically, use EDI Payer ID #93975. Paper claims can be mailed to:

Jackson Care Connect
c/o CareOregon Claims
PO Box 40328
Portland, OR 97240

Drug list (Formulary)

Click here to read an update about Bi-Mart pharmacy closures.

The drug list (or formulary) is a directory of all preferred medications approved for Jackson Care Connect members. This list is administered and provided by CareOregon. To download and view the drug list, click on the link or thumbnail below.


You can search for a drug in one of the following ways:

  1. Find the drug listed in the formulary/PDF index.
  2. In the PDF file, enter the drug name into the search box located in the menu.
  3. Call Customer Service for assistance in finding a drug.

 

Formulary updates

Jackson Care Connect makes formulary updates when necessary. These usually occur monthly.

Interpretation Services

Jackson Care Connect wants to help you and your patients have the best experience, which is why we help you coordinate live interpreters for patients who speak a language other than English. Click here to learn about our resources.

Health-Related Services

When members have health needs that aren’t covered by a health plan or other services, Jackson Care Connect offers funds for health-related services (HRS). HRS must be consistent with a member’s treatment plan, as developed by their primary care team or other treatment providers. The services will be documented in the member’s treatment plan and clinical record. For that reason, members without a current provider relationship need to establish one in order to receive health-related services funds.

What HRS covers

These funds cover items or services that aren’t covered under standard health plan services, but will improve a person’s health. Health plans cover provider visits, pharmacy benefits and durable medical equipment. Durable medical equipment (DME) is a covered benefit, which means equipment that would be covered as DME is not eligible for HRS funds. (For a list of items covered by DME with no authorization required, click here.)

Health-related services funds cover services like:

  • Helping a person get a cell phone if having one will give them better access to their providers.
  • Transit passes for members who need transportation for health-related needs beyond covered appointments.
  • Buying an air conditioner for a person whose health is affected by the warmth and airflow in their home.
  • Vouchers for a yoga studio for a person whose back pain will be helped by an exercise class.
  • A class on cooking healthy meals for a person with diabetes.

This is not an exhaustive list. Any requested items will be evaluated for consistency with a member’s health needs and treatment plan.

Requesting HRS funds

Limitations of health-related services: The Oregon Administrative Rules restrict health-related services to items not paid for with grant money, funding separate from CCO contract revenue, or normal clinical service billing. In other words, health-related services may be used only if other funding is not available. Before you make a request, please be sure there is no other funding available.

Making a health-related services request: Any health care provider, primary care team, care coordination staff member working directly with members, or other subcontractors of Jackson Care Connect's network may request the use of HRS for a member. Jackson Care Connect encourages our community-based organization (CBO) partners to help our shared members access HRS. CBOs can work with members and their treatment providers to identify the need, and the provider can submit a request.

All HRS requests must include medical documentation (care plan, progress notes, chart notes, etc.) and information about the member’s diagnosis.

There are two ways to submit requests for health-related services:

  1. Use our standard Health-Related Services Flexible Services Funding Request form to make requests for cell phones, hotel rooms or other health-related services for individual members:
    • Items that are needed on a repeating basis — like monthly transit passes or gym memberships, extensions of hotel stays, etc. — require the submission of a Funding Request form each month.
    • Urgent requests will be fulfilled in two to five business days. Standard requests will be fulfilled in 10-14 business days.
    • For hotel stays, click here to download our hotel liability form that members must fill out and click here to download our hotel request checklist.
    • If a member lives in an area being impacted by a current state of emergency and needs a hotel, our State of Emergency Flex Request may be the quickest way to assist the member. Please see the instructions for more information.
  2. Bulk items are available to help clinics and providers ensure a constant supply of the following items:
    • Cell phones and phone minutes
    • Transit passes
    • Sleeping bags
    • Shelter materials (tents and tarps)
    • City Team shelter vouchers
    • Personal hygiene products
      • This includes (but is not limited to) shampoo, conditioner, body and face washes, soap and feminine hygiene products
      • Some items are not included, like (but not limited to) PPE, incontinence supplies, diapers, sunscreen, sanitary wipes, disinfectant wipes, thermometers, durable medical equipment (DME) or COVID-19-specific items, as described above
    If these bulk items are purchased by providers/clinics, you must submit a Bulk Request Tracking document and itemized invoices to be reimbursed. To request that items be purchased by Jackson Care Connect (and then delivered to providers or clinics), fill out our Bulk Purchase Request form.
    • Bulk requests may take up to 14 business days for review and delivery.
    • Clinics and county teams may make bulk requests one time per month.
    • Requests should be submitted by supervisors or managers.
    • Clinics/teams are required to submit a Bulk Request Tracking document with member details before new orders can be fulfilled.

Evaluating requests

Jackson Care Connect evaluates all completed request forms based on:

  • The member’s eligibility and whether the request fits their treatment plan.
  • A sustainability plan to support the member’s ongoing needs, because CCOs may not be able to support these needs in the long term.
  • Whether other community resources or safety net funds (besides HRS) were pursued before the request was made.

We provide members with a written outcome and copy the requesting provider (and member representatives, if applicable). Often, this involves asking for more information about the member, which may include the member's budget information. Requests cannot be fulfilled until all information is received.

Depending on the nature of the request, if more details about the budget is indicated, this form can be used to provide that information.

Questions? Email us at social.determinants@careoregon.org.

Behavioral Health provider frequently asked questions

You asked. JCC’s external consultant and expert, Dr. Derek Jones, answered.

About the Expert: Dr. Derek Jones is a board-certified fraud examiner (CFE), forensic consultant (CFC), and medical investigator (CMI-V). He is a member of the Advisory Council to the Association of Certified Fraud Examiners and is a fellow of the American Board of Forensic Examiners. Dr. Jones holds a PhD in Forensic Psychology, specializing in behavioral analysis.

Dr. Jones is the principal and co-founder at The Compliance Consortium. His experience includes conducting risk analyses, performing due diligence and leading internal investigations for large companies in health care and government. He consults directly to state Medicaid authorities, health lawyers, health plans and provider trade associations. His publications include three recent books and dozens of articles in peer-reviewed journals.

 

Billing/coding definitions

Q: What is the CPT code for treatment planning? Can it be billed for on the same date of service (DOS) as a 90837/90834, as they often occur concurrently?

A: Initial service planning is a “process,” a service, that includes assigning certain providers and treatment to address specific client issues, as determined during a comprehensive assessment. Service planning also requires the participation of others, including the participation of the client and family. It is not anticipated that all the work of service planning be completed during a single encounter with the client or family. If both therapy and the face-to-face portion of service planning occurs on the same day, there’s one client and one session and your documentation should reflect this.

Q: What is the definition of case management and environmental intervention and when to use them? For example, what to use when a therapist is speaking to a teacher in a school-based setting?

A: 90882, environmental intervention, is often used as a catchall code for medical management interactions on a psychiatric patient's behalf with agencies, employers or institutions. Typically, a discussion of medications is included. Oregon identifies case management/care coordination (CM/CC) at OAR 410-120-0000(39) with the following definitions: “case management services” means services provided to ensure that CCO members obtain health services necessary to maintain physical, mental and emotional development and oral health. 

Case management services include a comprehensive, ongoing assessment of medical, mental health, substance use treatment or dental needs plus the development and implementation of a plan to obtain or make referrals for needed medical, mental, chemical dependency or dental services, referring members to community services and supports that may include referrals to allied agencies. 

If you are an agency with a certificate of approval, an additional definition of case management is (309-019-0105(16)): "Case management" means the services provided to assist individuals who reside in a community setting or are transitioning to a community setting in gaining access to needed medical, social, educational, entitlement and other applicable services. 

We suggest that one of the CM/CC codes will more closely describe this encounter with the teacher. The provider’s credential will determine the specific code.

Q: I need to know how to use emergency (90839) and the add-on codes for one or two additional 30-minutes — a total of 90 minutes or 120 minutes.

A: The first thing to remember is that this is a psychotherapy for crisis service and not a crisis intervention service such as h2011, s9484 or one of the other crisis codes that are often used. If the alphanumeric codes more accurately describe the service, they should be the first choice.  

If indeed psychotherapy is needed for crisis, the process is to claim 90839 for the first 30-74 minutes, then 90840 for the next 30 minutes. So, in your example, a single claim for 90839 and 90840. Consider this: The alphanumeric codes are often more descriptive of the service and flexible with billable units. Take a close look at those codes. Of course, if it is psychotherapy you are providing, the answer is 90839 and appending 90840 (90840 should never be used alone).

Q: When is it appropriate to use the 02 telehealth place of service code and does the documentation need to explain why it is being used? For example, a phone session was done because the client couldn’t get transportation or was feeling ill. 

A: The telehealth site of service code (02) has a very specific definition and requirement, as defined by CMS. It does not refer to routine services as you describe in your example and it is not intended for telephonic services. 

For a telehealth place of service code to be appropriate, the client would have to be in a health care professional shortage area (HPSA, as determined by the U.S. Department of Health and Human Services) and a non-metropolitan statistical area, by a clinician delivering a covered service from a “distant” site (the location of the provider which has the correct telehealth equipment) and to a client in a facility that qualifies as an “originating” site (also defined by DHHS).

Phone calls to or from your office for a client who is temporarily unable to keep a regularly scheduled appointment, or who may need temporary crisis/emergency contact by phone, would not qualify.

Consider using your typical place of service (POS) code (e.g., 11). Depending on the credential of the provider and the content of the call, there are generally or HCPCS codes your payer has agreed to reimburse when provided by phone. These will be payer-specific. On each occurrence, the documentation should describe the circumstance(s) necessitating the call, especially if the call replaces a face-to-face visit.

Q: What do the feds say about the minimum number of minutes of service that need to occur to justify a per occurrence CPT? HCPCS code? Is there is still a minimum amount of services needed to support a per occurrence code? For example, would a two-minute service substantiate a per occurrence billing?

A: Assuming “per occurrence” refers to any service you provide and get paid for that does not have time attached to it (as psychotherapy and some others do), it’s fairly simple: you get paid for what you do as required by the CPT/HCPCS l-ii or payer manuals for that specific service, and the description of which will reside in the medical record.

The time-based codes are self-explanatory: 30-minutes; per diem; per 15 minutes, etc.

Consider this: I’ve been at this for 40+ years and have defended many providers who got themselves in significant trouble with federal and/or state oversight bodies. Even with that experience, I would have a very hard time defending a provider who was delivering a two-minute service.

Q: What CPT code to use for consultations with other providers without the patient present?

A: In this instance, the question does not contain enough information about what type of consultation is happening. We are not able to guess or cover all scenarios. The act of consultation is not in and of itself a covered service — the content of the consultation is what matters when billing for these services.

Q: What is the difference between 90837 and 90838 for billing outpatient codes?

A: 90837 is 60 minutes of standalone psychotherapy. 90838 is 60 minutes of psychotherapy with an Evaluation and Management service/code on the same day by the same provider. 90838, along with 90836 and 90833, should never be reported alone, nor should they be used by someone who is not licensed to practice medicine.

Q: Can 90839 only be used for current clients in crisis?

A: There is no requirement in the CPT description of this service limiting it to established clients.

Q: When and how should T1013 (Sign Language/ Oral Interpreter Service) be billed?

A: This code should only ever be used in conjunction with a code for the service delivered and only when the client cannot communicate with the provider without assistance. The interpreter must also be an employee of the provider or employed for the service at the providers expense. CareOregon/JCC offers free interpreter/sign language services to all members and providers. Details are in the provider handbook.

Q: Do we have to use the telemedicine modifier (GT) for telephone services?

A: The GT modifier is not intended for telephone services. Telemedicine requires face-to-face interaction, which services provided by telephone would not meet. Telephone services that are provided on a routine basis would not be covered by JCC since psychotherapy codes include a requirement that services are provided face to face.

Q: What is the difference between Group Therapy and Multi-Family Group Therapy codes?

A: Groups (CPT 90853) are comprised of clients only. Multi-family group (CPT 90849) is comprised of clients and their family member(s).

 

How do I bill, and when?

Q: I am providing therapy for a child, and both parents meet with me separately on the same day for the same member — mom with the child for 45-50 minutes (without dad present), then dad with the child for 45-50 minutes (without mom present).

I have been billing for one session of family psychotherapy with the client present, but I am wondering if it’s okay to bill for two units of family psychotherapy with the client present? Can one bill for two units of 90847 on the same day? Or would it be more appropriate to bill for two units of 90834, psychotherapy, 45 minutes with patient and/or family member?

A: In general, payers do not cover two family psychotherapy services with the patient present in one day. Try thinking of it this way: there is one client (the child); there isn’t an upper limit time for billing one unit of the service (though some payers have a minimum). So, you are seeing the client for 90 minutes and bringing in one family member at a time. And, that’s the way a payer or auditor would see it.

Q: A client was in crisis when she came in for her regular appointment. A second 60-minute session was scheduled with her the same day to utilize the crisis to move her forward in her therapy.  How would the second hour be coded to get paid for it (90839 +90840 +90840)?

A: The CPT codes 90839 and 90840 are used for emergency sessions with patients who are in high distress and under complex or life-threatening circumstances that demand immediate attention. It's important to note that 90840 is an add-on code that must be used in conjunction with 90839. 

In a crisis scenario, 90839 is billed for the first 60 minutes (though it can be used for 30-74-minute sessions), and 90840 is billed for each additional 30 minutes. Using both of these codes together requires that the session lasts 75 minutes or longer. 

If you don't meet the time required to bill one or both of these two crisis codes, you can bill the standard CPT code for the session, such as 90832 (individual psychotherapy, 30 minutes). In this description, it seems as if the patient came for a regularly scheduled session of one hour, during which the crisis situation was discovered. 

The crisis necessitated a second one-hour encounter. The recommended coding is 90837 for the regularly scheduled hour (at which the crisis elements were prominent) and 90839 for the encounter prompted by the crisis. Due to national correct coding initiative (NCCI) auto-edits, it may be necessary to append the 90837 with the modifier -59.

Q: I have a provider that is seeing patients for an initial visit, plus a 60-minute psychotherapy on the same day. Can he bill out a 90791 and a 90837? He's not a prescriber so can't bill e/m codes.

A: Billed without modifier, a psychotherapy by the same provider on the same day as a diagnostic visit is not allowable (wouldn’t pass NCCI edits). The theory (the AMA, not me) is that 90791 has no minimum or maximum time attached, therefore is only content based, and that any counseling (or psychotherapy) provided adjunct to the visit is included in the time spent and payment.

I think the only way to be paid for this would be to add the modifier 59 to the 90791 and submit both services on the same claim. It’s not clear how one would document the need for this immediate psychotherapy based on the outcome (one assumes) of a just completed diagnostic interview. It would certainly have to be an unusual occurrence and not a pattern of diagnostic visits followed by an hour of psychotherapy. 

If the services are provided by two different providers, the 59 modifier would be appended and both claims would/should be paid whether on the same or different claims.

Consider this: If the patient’s appointment is for a diagnostic interview (90791) and there is need for additional time due to challenges (e.g., high anxiety, high reactivity, repeated questions or disagreement), adding the code for interactive complexity (90785) may be more.

Q: We are starting a weekly drop-in group facilitated by an LCSW for existing patients. The group will be art-focused, with an emphasis on interventions that reduce stress, improve emotion regulation, encourage problem-solving skills and boost mood. During the group, patients will also have the opportunity to meet with a medical provider, and he will bill appropriately for those visits. We are hoping this group will help patients access medical care promptly and provide a therapeutic benefit in the process. For JCC members who attend this group, would it be appropriate for me to use g0176 (activity therapy)?  Do you know whether g0176 requires a linked mental health assessment and treatment plan? Is it for Medicare only? I think the alternative is 96153.

A: The easy part, first: I think it would be very difficult to make the case that anything you are calling a “drop-in” service will meet the federal definition of psychotherapy. My 40 years of experience doing this leads me to believe that you can no longer order psychotherapy on a “PRN” or as needed basis — those days have long passed. Nearly every service beyond emergent care, or a very temporary change in modality, requires all the regulatory bells and whistles.

Consider this: Regarding the G-code part of the question, what’s the activity? What you describe is a care coordination model, with emergent/urgent medical care available. If that’s an accurate understanding of what you’ve outlined, I’d be willing to bet the farm (probably yours, not mine) that we could work with JCC to find a way if this is truly doing as advertised.

Q: When counselors are required to appear in court after being subpoenaed, since there is no billable code to compensate for the time and the occasional stipend from the court does not cover costs, can the provider bill the attorney directly some fee that is more in line with the cost of the service and is there any rule (similar to not being able to bill a no-show fee) for OHP clients? Does it matter if it’s a criminal case or permanency hearing? And, if attorneys are just being excessive and are unwilling to work with the provider (i.e., being OK with records and an affidavit versus having to actually appear in court), do they have any recourse? Wondering if there's just a general way to deter what seems to be developing into a growing issue and what our rights as agencies are within this process.

A: In most cases, it is either the state vs. our client or our client vs. the state. In some straight parent/parent or parent/family custody battles, it may be that we get pulled in via subpoena to testify for one side or the other. In the latter (straight custody) you may be able to negotiate some sort of appearance fee if you are willing to risk fighting a subpoena and the testimony is so valuable to one party, they consider paying you a fee. But I would recommend you consider the impact this stance would have on opinions regarding the impartiality of your clinical practice.

The two caveats in this one:

  1. I have been called in both civil and criminal cases as an expert witness and, in turn, been paid for my time. But, to be clear, that’s not what we’re talking about.
  2. I’m not your lawyer.

In most cases, if you are handling the subpoena for records correctly, there is some negotiation room in the appearance factor. But you should have someone else in your organization be arguing that for you and that’s going to be very dependent on the lawyers. If you are in private practice, feel free to make your own argument against appearance, but it is not wise to refuse or to refuse unless you are compensated. In the eyes of the court, there is very little difference — you are simply in violation of the subpoena.

Consider having your own policy and process regarding how subpoenas for paper and appearance are handled. Make part of it that someone reaches out to the issuer of the subpoena. I think JCC made available some suggestions for how to respond to subpoena through the training sessions from last year. Check it out. 

Most of the time, clinicians are appearing for their clients in one capacity or another and get paid by an agency unless in private practice. 

If you are in private practice, you can sometimes negotiate your way out of an appearance if they have the records. I don’t know of any prohibition about negotiating a fee, but it’s a subpoena.

In either case, entity or private practice, there are rules about charging for copies of the record.

Q: How do I bill when I provide multiple services provided in one session like service planning, psychotherapy and case management?

A: Multiple services must be separately identifiable encounters, or they are not billable. For instance, a client may receive medication management and psychotherapy on the same day. As long as those processes occur at distinctly separate encounters, they can be billed separately and should both be payable. The phrase “in one session” implies a single encounter and would not qualify for separate claims.

Q: How do I bill for treatment planning as well as an initial comprehensive assessment? Would it be 90791 and H0032 and can I bill for them on the same day if a session lasts 90 or 120 minutes?

A: H0032 is intended to be used when a separate encounter is required for coordinating/discussing/completing a treatment plan with your client. It is not intended to be used solely for the completion of a document by the provider. On rare occasions, it may be necessary to have a separately identifiable encounter for coordinating/discussing/completing a treatment plan with the client on the same day as another encounter. In such cases, the documentation for both encounters should clearly indicate the need for the separate encounters.

Multiple services must be separately identifiable encounters or they are not billable. For instance, a client may receive medication management and psychotherapy on the same day. As long as those processes occur at distinctly separate encounters, they can be billed separately and should both be payable. The phrase “a session” implies a single encounter and would not qualify for separate claims for these two services.

Q: When there are co-facilitators of a group, which one should be included as the rendering provider on the claim?

A: If both providers are eligible to bill for the service, the rendering provider could be either co-facilitator though not both. If only one co-facilitator is eligible to bill for the service, or if one provider has a higher credential level than the other, then the claim would include that provider as the rendering provider.

Note:

  1. It is assumed that “co-facilitator” indicates that both participated for the full group session.
  2. While not a violation of a rule, it might be difficult to support that a claim is filed by one provider while another documented the service.

Q: If you can’t use the telemedicine modifier with routine phone calls, can you use the modifier with the usual outpatient office as the POS code and 90837 for an online session? And, is it OK to conduct secure, HIPAA-compliant online sessions in each of these situations that will also be reimbursed?

A: Oregon’s rule for defining telemedicine is quite expansive. It does cover telephone calls when they can be considered “patient consulting.” That is not to say that calls made to make or confirm an appointment, ask or answer simple questions or deal with an issue that is not clinical in nature fit into that category. But, if the phone call can accurately be described as consultation (in the medical definition of the term) in content, then it could be covered. However, the psychotherapy codes should only be used for that purpose. They are not catchall codes. You should code the call using the CPT/HCPCS code that is most accurate to describe the work done:

  1. Client is ill and cannot travel to office, but we have a session via Zoom.
    • In my opinion, as long as the session is medically necessary, it would fit the definition of telemedicine.
  2. Client is traveling, so have a Zoom session.
    • In my opinion, as long as the session is medically necessary, it would fit the definition of telemedicine.
  3. Client is moving, establishing services and eligibility for Medicaid-funded services or other mechanisms to pay for therapy will take a while and they are very much in need of transitional support.
    • Until some sort of coverage is established, this is a self-pay client. Payer rules do not necessarily apply. But state licensing rules do apply, and you’d want to be aware of any jurisdictional practice issues, such as crossing state lines.

Q: A psychologist embedded in a primary care setting will be expanding his code set to psychotherapy codes. He is looking to track incident to billing and had questions for two scenarios:

(Assuming here that the billing is done by the PCP office or clinic.)

  1. The PCP has a well-child check and calls the Psychologist in to the room to address a positive depression screen. Is there a modifier code that can be added to the well-child check by the PCP so that it can be flagged as a BHC visit?
    • There is no modifier established as of yet for integrated care. However, assuming the PCP reviews the psychologist’s comments or stays in the room, the E/M level increases and/or a prolonged service code is appended to the E/M.
  2. The PCP has an illness visit and calls the psychologist in and, based on time and complexity, bills the appropriate E&M code. Is there a modifier that can be added to the illness visit that can flag that visit as one where a BHC was involved?
    • Same as the previous question.

Q: If I am called to serve as a witness in a case involving a JCC member, can it be billed and, if so, under what code?

A: No. It is part of the professional responsibility of the therapist and the legal responsibility of a citizen to respond to a subpoena. If there was no subpoena, it is up to the therapist to decide if they want to comply with a request. 

Q: If a therapist completed training in Neurofeedback, which reimbursable code would be best to use since the CPT codes for Neurofeedback are not covered? Would 90834/90837 (psychotherapy) be appropriate even though Neurofeedback isn’t a “talk therapy”?

A: In Oregon, we cover services that are paired with a diagnosis above the line on the prioritized list. The neurofeedback codes (90901 and 90876) are not included on the prioritized list so they are not a covered benefit. In addition, we do not believe that neurofeedback meets the requirements of psychotherapy, so it would not be appropriate to code neurofeedback as psychotherapy. So, it’s not a covered benefit that we pay for at this time.

 

Corrected claims

Q: Is there compliance risk around submitting corrected claims for a modifier issue vs. just re-submitting the claim without flagging it as a corrected claim?

A: The simple answer is yes. Without knowing the status of the original claim (paid, denied, pended, appealed, etc.), any answer is general. But you can’t have two claim numbers in any system for the same service, even for a modifier issue. 

The proper way of dealing with this (financial and billing systems aside) is to make sure the initial claim is fully adjudicated and not create a new claim until/unless instructed to do so by the payer. Complete adjudication may mean denial-appeal-payment/denial-whatever is next, or, payment (of the incorrect claim) and adjustment based on the payer’s instructions. 

Consider this: It’s very good that you caught this and are dealing with it. Best practice is to learn how the modifier issue occurred and make whatever systemic changes you need to make to ensure it doesn’t happen again. Turn an issue into a model for how well your compliance process works.

 

Billing services

Q: Am I able to charge providers for my services as a billing company on a percent-based fee based on the provider’s collections (patient, private insurance and Medicaid)? OAR 410-12-0130 section (12) is rather gray and I want to make sure I am understanding it correctly. I have contacted the state directly and was told this OAR does not apply to the way I charge for my services, and only applies to billing for a rate that had been increased if a service was transferred to a collection agency, etc. For example: The provider bills a 90837 to Medicaid, I submit the claim and Medicaid then reimburses the provider directly the DMAP rate of $144.41. Are there any restrictions that prohibit me from charging a percent of the $144.41 collected for the services I provided in billing this for the provider?

A: I’m not immediately aware of any state restrictions on what a private company can charge for its services. There are many, many billing companies offering a variety of package services from claims submission only all the way to providing one-stop shopping for everything from claims scrubbing to handling appeals. I’d look around at my colleagues/competition as a starting place. 

Also, be aware there will be some common-sense rules related to what a provider will pay to have someone else file claims. That would be important information, too.

Consider this: The U.S. Department of Health and Human Services, Office of the Inspector General (commonly referred to as the OIG), issued guidance for third-party billing companies that deal with government health care programs (primarily Medicare and Medicaid) about 20 years ago. It may have been updated and you’d find that on the OIG compliance homepage. Here’s a link to the federal register guidance document: oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf

 

Record keeping

Q: Do psychotherapy notes need to be kept separate in the medical record, and how separate should they be?

A: The original language of HIPAA and the preamble of the Final Privacy Rule refer to psychotherapy notes, not progress notes. Psychotherapy notes are recognized as a therapist’s personal notes to remember a specific session and are of little to no use to others. These notes are to be kept separate from the medical record. A progress note is a part of the medical record and includes: start and stop time of session, modalities of treatment, frequency of treatment, results from clinical tests, medical prescription and monitoring, diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.

 

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Contacts and Meetings

Contacts

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Meetings

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Quality Metrics Toolkit

Individual measures

 

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