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Special Billing Procedures

Some claim types require specific attention, to ensure correct claim submission and reimbursement of services occur.  

Anesthesia 

HealthPlus follows Medicare methodology  for anesthesia payments.

The Medicare methodology includes:

  • Use of anesthesia CPT codes (00100-01999)
  • Use of the American Society of Anesthesiologists (ASA) 2001 Base Units
  • Calculation of Incremental Time Units, rather than Whole Time Units

Claims (all product lines) must include the modifier, anesthesia CPT code and actual time required to perform services, expressed in minutes.

The following universal billing modifiers apply to anesthesia claims:

Modifier

Explanation

AA

Physician personally performs anesthesia service

QK

Physician medically directs 1 to 4 cases

AD

Physician medically supervises 4 cases

QY

Medical direction of 1 CRNA

QX

CRNA medically directed by physician

QZ

CRNA personally performs service

Behavioral Health

Claims submitted for mental health and substance abuse outpatient counseling services require the following modifiers, to ensure accurate payment:

Modifier

Explanation

AH

The service was performed by a psychologist (PhD, EdD)

AJ

The service was performed by a social worker or licensed professional counselor (CSW, ACSW, LLP, LPC)

HO

The service was performed by a Master's level counselor.

Coordination of Benefits (COB) Recovery Timeframe Defined
Effective date: September 1, 2015 (discovery date)

HealthPlus audits claims paid to determine if any claims were paid as the primary insurer in error. This can occur when other primary insurance information is discovered after a claim is paid. Any claims paid in error with service date up to two years prior to the discovery date will be recovered from the next provider payment. Any claims paid in error with service date more than two years and up to three years prior to the discovery date will be recovered via a demand letter to the primary carrier requesting reimbursement.

Example 24 month negate
Discovery on 5/1/15
Claim date of service 5/31/13 - HealthPlus will negate from the next register

Example 25-36 month demand
Discovery on 6/1/15
Claim date of service 1/2/13 - HealthPlus will send a demand to the primary carrier for reimbursement for services HealthPlus paid

 Immunizations

Reimbursement of an immunization for HealthPlus members consists of two components:

  • Biological
  • Administration

Both components must be billed to receive correct reimbursement.

Billing for Administration Only:

When the biological has been obtained from the Health Department or is being billed by an outside supplier, the administration of the injection is billed alone. The biological must be submitted for reporting purposes.

Individual, Family and/or Group Therapy

It is important to bill the appropriate CPT code, to accurately reflect the various type(s) of therapy used.

Obstetrical and Gynecological Services

Effective October 1, 2012, HealthPlus will deny obstetrical deliveries billed with bundled (global) delivery codes. All obstetrical services must be submitted utilizing the appropriate individual CPT (unbundled) codes.  This change applies to the Commercial HMO, Commercial PPO, Medicare and Medicaid products.  

Reimbursement for unbundled delivery codes will be equivalent to the bundled code rate.

Maternal and Infant Health Program Services

Maternal and Infant Health Program Services (MIHP) are specialized services provided to pregnant women, mothers and infants. MIHP is designed to promote healthy pregnancies, good birth outcomes, and healthy infants.   

Services include:  

  • Maternal and infant health and psychosocial assessment completed by nurse or social worker 
  • Development of beneficiary care plans 
  • Coordination of MIHP services with the beneficiary's medical care provider and Medicaid Health Plan (who assist and supplement that care) 
  • Registered Nurse, Licensed Social Worker, Registered Dietitian and Infant Mental Health Specialist home or office visits provided with interventions based on the beneficiary's plan of care 
  • Transportation services arranged if needed.
  • Referrals are made to local community services  (e.g., mental health, substance abuse, domestic violence, basic needs assistance) as needed, and
  • Referral to local childbirth education or parenting classes.

MIHP services must be delivered by agencies certified by the State of Michigan. 

NOTE: Services are billed by the MIHP provider, directly to the State of Michigan.  These services are not included in the health plan benefit and therefore are not billable to HealthPlus. 

Reimbursement to Mid-Level Providers

 Lines of Business Physician Assistant (PA) Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Certified Nurse Midwife (CNM)
Commercial, HMO, PPO, Options 85% of fee schedule 85% of fee schedule 85% of fee schedule 100% of fee schedule
Medicare HMO, PPO 85% of fee schedule 85% of fee schedule 85% of fee schedule 100% of fee schedule
Medicaid 85% of fee schedule 85% of fee schedule NA 100% of fee schedule

Lines of Business Impacted:

  • Commercial HMO
  • Commercial PPO
  • Options
  • Medicare HMO
  • Medicare PPO
  • Medicaid
  • Healthy Michigan Plan
  • MIChild
Requirements:
  • Mid-level providers are required to submit claims with their Type I NPI as the rendering provider on the claim.
  • PCP mid-level providers are required to complete the credentialing process. Please contact providerenrollment@healthplus.org for enrollment.
  • Behavioral health mid-level providers are required to complete the credentialing process and can also contact providerenrollment@healthplus.org for enrollment.
  • All other specialist mid-levels are not required to complete the credentialing process.

Additional Resources: