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Claims Processing and Reimbursement

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Complete and submit a CMS 1500 (formerly HCFA 1500) or spreadsheet within 30 days of the date of service. Use Common Procedural Terminology (CPT) and Health-Care Common Procedure Coding System (HCPCS) codes where applicable. A progress/session note for the specified service must accompany each completed claim.

The CMS 1500 or spreadsheet submitted must include:

  • Client's name
  • Social security number or BJCBH ID number
  • Date of service
  • The CPT code or DMH code when there is no applicable CPT code
  • Provider name and address
  • Total duration time; duration and start times should be on progress/session note
  • Amount paid by -- or due from -- third party

Send the completed CMS 1500 or spreadsheet and progress/session notes to:
BJC Behavioral Health
Suite 500
1430 Olive Street
St. Louis, Missouri 63103 USA

Reimbursement 
The BJCBH Business Office processes claims within 30 days of receipt. The period for processing a spreadsheet may be longer, depending upon its size. 

Claims are returned if:

  • Claim is incomplete
  • Claim is not accompanied by a progress/session note for specified service and date
  • Progress/session note does not meet basic requirements

Payment is withheld if:

  • There is delinquent or incomplete progress/session note or required documentation
  • Client is no longer eligible

Co-Pays for DMH Clients
Providers are not required to obtain co-pay amount from DMH clients.

Rounding Rules

Time of Service Rendered Unit of Service
7 minutes or less 0 units
8 to 22 minutes 1 unit
23 to 37 minutes 2 units
38 to 52 minutes 3 units
53 minutes to 1 hour and 7 minutes 4 units
  • Medication Services -- 81010H or 90862 -- includes services alone or with an injection; two 15-minute units per month are usually authorized for this service
  • An Injection -- 81010L or H2010 -- given the same day as medication service is included in these charges - 90862; an additional unit to cover same-day injections is not allowed; injections given on other days may be submitted for payment
  • Total service time includes time spent documenting the service
  • Time spent phoning in medications can be included in service time if related to the face-to-face visit just completed; if the call is made later in the day it should be considered medication administration

Third-Party Reimbursement
BJCBH requires providers to bill Medicare when there is a Medicare reimbursable service.

CPT Code Usual Number of Units DMH Code Type of Service
90801 4 (60 minutes) 90801 psychiatric evaluation
90805 2 (30 minutes) 90862 medication services with psychotherapy
90862 1 (15 minutes) 90862 medication services


When the client is on Medicare, it is indicated on the contract authorization. When Medicare is indicated and no Medicare Explanation of Benefits (EOB) is included with the claim, BJCBH automatically deducts the standard Medicare payment amount (50 percent of the maximum Medicare allowable rate) from the amount paid to the provider. For clients with Medicare with crossover, BJCBH deducts the full Medicare allowable rate from the provider payment, up to the contract rate. The coinsurance may be billed, up to the contracted rate, to BJCBH.

If you do not receive the expected Medicare reimbursement or payment is not received from Medicare or Medicaid, send a request to adjust your payment along with a copy of the Medicare EOB attached. Highlight the unpaid service on the EOB and send it to BJCBH. You'll be reimbursed for the balance of your contracted amount. Include the CMS 1500 or spreadsheet, and the progress/session note for accountability of services provided, and required record keeping.

Eligibility -- 314.206.3890
While BJCBH makes every effort to send providers authorizations and notice of discharge, continued verification of eligibility is the provider's responsibility.

Timely Filing
Please submit CMS 1500 or spreadsheets within 30 days of the date of service.

Per DMH guidelines, any claim submitted later than the last business day before July 10, for the prior fiscal year ending June 30, will be rejected without payment.

Claims Appeals -- 314.206.3890
If you believe a correction or adjustment is necessary to your payment, contact the accounts payable clerk for BJCBH. If you have contacted accounts payable and there is a need for further appeal of the claim, you may send a written appeal within 10 days of receipt to:

BJC Behavioral Health
Attention: Accounting Supervisor
Suite 400
1430 Olive Street
St. Louis, Missouri  63103 USA

A copy of any corrections will be mailed in advance of the payment, separately.

Standard Deductions for Medicare/Medicaid Payments Based on the 2005 Medicare Participating Provider Fee Schedule

     Medicare without crossover Medicare with crossover
CPT code Description Medicare
rate
Amount
deducted
Medicare
rate
Amount
deducted
90782 Therapeutic injection $18.82 $9.41 $18.82 $18.82
90801 Psychiatric diagnostic interview evaluation $150.56 $75.28 $150.56 $150.56
90804 Individual psychotherapy
-- face-to-face, 20-30 minutes
$64.49 $32.25 $64.49 $64.49
90805 Individual psychotherapy with medical evaluation
-- face-to-face, 20-30 minutes
$70.91 $35.46 $70.91 $70.91
90806 Individual psychotherapy
-- face-to-face, 45-50 minutes
$97.37 $48.69 $97.37 $97.37
90807 Individual psychotherapy with medical evaluation
-- face-to-face, 45-50 minutes
$103.43 $51.72 $103.43 $103.43
90808 Individual psychotherapy
-- face-to-face, 75-80 minutes
$145.16 $72.58 $145.16 $145.16
90809 Individual psychotherapy with medical evaluation
-- face-to-face, 75-80 minutes
$150.50 $75.25 $150.50 $150.50
90846 Family psychotherapy
-- without the patient present
$94.44 $47.22 $94.44 $94.44
90847 Family psychotherapy
-- with the patient present
$114.93 $57.47 $114.93 $114.93
90862 Pharmacologic management -- including prescription use -- and review of medication
with no more than minimal medical psychotherapy
$51.06 $25.53 $51.06 $51.06

Frequently Asked Questions
Q: Are the progress notes and CMS 1500 returned together?
A: Yes. Complete progress notes and CMS 1500 are required for payment. BJCBH returns incomplete progress notes and CMS 1500 for services with a letter explaining what is missing or wrong.
Q: Can bill processing be included in the service time?
A: No. Billing is limited to clinical services: the time the provider spends with the client, documenting the visit and working on behalf of the client.
Q: If the spreadsheet has the time on it, can it be sent to HIMS?
A: Yes. The spreadsheet is sent with the session notes to HIMS.
Q: How are payments reimbursed?
A: The business office processes payments at least monthly and more often when possible.
Q: Is a CMS claim still needed if the client has Medicare or Medicaid?
A: Yes. We still need to enter the service provided in our billing system.
Q: Can an injection be billed separately from the medication services?
A:  Total time spent administering the injection and providing medical service should be added together and billed as medication service when performed on the same date.
Q: Can a unit be billed with the medication service for injection?
A: Total time spent administering the injection and providing medical service should be added together and billed as medication service when performed on the same date.

  

 

 


    
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