Blue Cross of Northeastern Pennsylvania Act 62 Autism Mandate Orientation

Effective 7/1/2009Updated 5/5/2014

Blue Cross of Northeastern Pennsylvania Act 62 Autism Mandate Orientation

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Pennsylvania's Autism Insurance Act (Act 62- 2008)

• Act 62 requires private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorders (ASD).– Act 62 coverage information:

• Applies to children under the age of 21 • Insured employer groups having 51 or more employees upon group

renewals– Customer service can assist in determining if the group has 51+ employees

• CHIP Program renews on February 1, 2010 • Maximum benefit of $40,000 per year of our contracted rates

– Coverage is subject to copayment, deductible and coinsurance as they would be for other covered medical services and any other general exclusions or limitations

– Once the member reaches the $40,000 they may be eligible for additional Medical Assistance (MA) program benefits.

– The maximum benefit was increased from $36,000 to $40,000 on January 1, 2013. The increase applied on or after each affected group’s plan year renewal beginning January 1, 2013

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Pennsylvania's Autism Insurance Act (Act 62) continued

– Pharmacy• Prior authorization is required for employer groups that do not have a

pharmacy benefit– Prior authorization can be obtained by contacting Express Scripts at

1.877.603.8399• If the group does have a pharmacy benefit, no prior authorization is required.• Pharmacy charges will not accumulate towards the $40,000 benefit cap

Contact Customer Service Representatives at the following phone #’s to verify member benefits, eligibility and information on accumulated ASD services.

– FPLIC PPO – 1-866-262-5635 – FPLIC Custom PPO/EPO – 1-888-345-2353– FPLIC Traditional/Major Medical – 1-888-827-7117 – EPO – 1-888-345-2353– FPH – 1-800-822-8752 – FEP (Federal Plan) – Check back of card for phone number – BlueCard – Check back of card for phone number

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BCNEPA Medical Policy and other resources

• Medical Policy – The BlueCross of Northeastern Pennsylvania Autism

Spectrum Disorder Medical Policy is available on BCNEPA’s Provider Center at www.bcnepa.com or via the link on Navinet on 7/1/2009.

– Check your Provider Bulletins for updates– Another resource is the DPW’s site

• http://www.dpw.state.pa.us/forchildren/autism/index.htm• http://www.dpw.state.pa.us/foradults/autismservices/index.htm

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Covered Diagnosis codes for Medical Management of ASD

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Pennsylvania's Autism Insurance Act (Act 62) continued

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Treatment Plan requirements • Treatment of ASD must be identified in a treatment plan and should include

any medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care including applied behavioral analysis, and therapeutic care that is:

– Prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner.

– Provided by an autism provider.

– Provided by a person, entity or group that works under the direction of an autism

service provider.

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Treatment Plan and Continuity of care

• The provider is responsible for maintaining a copy of the autism assessment and treatment plan, to be made available upon request.

• Prior Authorizations will not currently be required for ASD services. Although we are not requiring prior authorization while the member is utilizing their private insurance coverage, we encourage providers to continue to request authorizations from Community Care Behavioral Health Organization/Medical Assistance

(CCBHO/MA) to avoid possible claim rejections upon transition of care. *Please be advised, some Highmark HMO Products may required prior

authorizations• In an effort to administer a smooth transition between plan coverages, a notice will

be mailed to members advising them that they have accumulated $25,000 worth of ASD services.

We encourage providers to work closely with the families to keep informed of the dollar amount accumulated. Providers can also contact customer service to obtain information regarding the member’s accumulated amount.

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Provider Reimbursement• BCNEPA/FPH/FPLIC will follow the current standard fee

schedules and contract rates. These fee schedules will include:

– Therapeutic Behavioral Services (H2019)– Community Based Wrap Around Services (H2021)– Mental Health Service Plan Development (H0032)

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Billing Guidelines• Professional Claims must be submitted on the

NUCC-1500 Form

– When billing First Priority Health claims, please be sure to list the Autism Spectrum Disorder diagnosis codes as the primary diagnosis codes on claim.

– When billing for First Priority Life Insurance, line item procedure codes must ONLY reference an Autism Spectrum Disorder diagnosis code.

• Multiple diagnosis codes referenced via the diagnosis pointer (on 1500 form) will not process accurately.

– Please bill ASD claims according to CPT Code Standard Guidelines– Providers billing for Behavioral Health Rehabilitation Services (BHRS) must

list the supervising psychologist or psychiatrist in the rendering provider field.– Attached is the BCNEPA Billing Guidelines

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Billing Guidelines continued • Facility claims are to be submitted on the NUBC UB-04 form.

Remember to include the NPI and Taxonomy Code.

Claims Addresses: BlueCross/Major Medical/FPLIC First Priority Health- HMO Claims First Priority Health P.O. Box 890179 P.O. Box 69699 Camp Hill, PA 17089-0179 Harrisburg, PA 17106-9699 Federal Employee Program (FEP) BlueCard Claims Highmark Blue Shield Highmark Blue Shield P.O. Box 898854 P.O. Box 890062 Camp Hill, PA 17089-8854 Camp Hill, PA 17089-0062

– Electronic billing- See attached billing guidelines

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Rejection Codes/Messages once maximum $40,000 benefit cap has been met/exceeded

• Once a member has met or exceeded their ASD benefit limit of $40,000, the provider remittance advices will show the following rejection codes and description per product line:

– For First Priority Health (FPH) -BL0 = Meets/exceeds the ASD benefit limit for

service rendered and a ANSI (American National Standards Institute) adjustment reason code of PR 119 (patient responsibility). PSO = Not covered charge(s) and ANSI adjustment reason code of PR 96 with a remark code of N174.

– For First Priority Life Insurance Company (FPLIC) and out of area claims- X8851= the maximum benefit available under the patient’s coverage for ASD services has been paid. Therefore, no payment can be made. Along with this an ANSI adjustment reason code of PR 119.

• Descriptions of adjustment reason codes can be found on the Washington Publishing Company at www.wpc-edi.com

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Sample NUCC 1500 Form

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Attachments

• Listing of the alpha prefixes utilized by Blue Cross of Northeastern Pennsylvania (BCNEPA), First Priority Health (FPH) and First Priority Life Insurance Company (FPLIC). Prefixes that do not appear in this listing should be considered out-of-area.

• Product Reference Guide• BCNEPA Billing Guidelines • ASD Medical Policy • ASD Fee Schedules

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Contact Information

• If you have any questions please contact your Provider Relations Consultant.

• If you do not know who your consultant is you can call our Provider Relations Department at 570-200-4700