Baltimore Substance Abuse Systems, LLC has compiled this resource to answer questions that have been asked by providers related to billing Medicaid MCOs and the PAC transition. These answers have been reviewed by the Maryland Department of Health and Mental Hygiene. If you have a question that is not addressed here, please email us and bSAS staff will research and post an answer. 

Common Questions and Answers for
Substance Abuse Providers
Preparing for the PAC Transition

PAC and Medicaid Overview    top

Q: What is PAC and who does it cover?

A: PAC is the Primary Adult Care Program. PAC is an eligibility group in the Medicaid program. PAC is available to adults without dependent children who have incomes below 116% of the federal poverty level (FPL) or $12,552 annually. Adults with dependent children who have incomes below 116% of the FPL are eligible for more comprehensive health care benefits under Medical Assistance for Families. Baltimore Health Care Access provides information on eligibility for these programs and applications. DHMH funds Baltimore Health Care Access to help individuals enroll in the PAC program and to determine eligibility for the PAC program for Baltimore City residents.

Q: What is the difference between Medicaid, PAC, Medical Assistance for Families and HealthChoice?

A: These are all terms used to describe different aspects of the state Medicaid program, which provides health care coverage for low-income individuals. Medicaid is funded with both state and federal funds. Medical Assistance for Families is the expansion of Medicaid to parents that began in 2008. PAC is an eligibility group in the Medicaid program for adults without dependent children which also receives state and federal funds. PAC does not provide the comprehensive benefits that are covered by the Medicaid program. HealthChoice is the name of Maryland ’s managed care program which contracts with Managed Care organizations (MCOs) to provide health care to individuals enrolled in Medicaid. Most individuals with Medicaid and all individuals enrolled in PAC are enrolled in MCOs.

Q: What substance abuse services are currently covered by the Primary Adult Care Program (PAC)?

A: Currently, the only addictions service covered by PAC is Buprenorphine administration. This is changing in January 2010, when PAC will be expanded to provide coverage for certain substance abuse services: However, HealthChoice currently pays for some substance abuse treatment. If a provider is currently serving individuals enrolled in HealthChoice they can bill for those services now.

Q: What is changing in January 2010?

A: The PAC program will begin covering most substance abuse services provided by Medicaid (HealthChoice). These services include: Substance Abuse Assessment, Individual Outpatient Therapy, Group Outpatient Therapy, Intensive Outpatient, and Methadone Maintenance. The only Medicaid substance abuse services that will not be covered by PAC are those provided by a hospital based provider in a setting that is regulated by the Health Services Cost Review Commission (HSCRC). There are only a few of these providers in Baltimore City.

Q: What is the Substance Abuse Improvement Initiative?

A: Currently, the Substance Abuse Improvement Initiative (SAII) is a voluntary agreement between providers and MCOs to develop common procedures and rules for Medicaid coverage of substance abuse treatment. Within the SAII, the self-referral protocol allows an individual to receive treatment for certain services from providers, regardless of whether they have a contract with the MCO, if the provider meets the requirements laid out in the SAII. Under this agreement, MCOs voluntarily pay the Medicaid fee schedule to non-participating providers for these self-referred substance abuse services. This voluntary agreement is being incorporated in regulation by DHMH in January 2010. The DHMH website provides information on the SAII and the self-referral protocol and related forms.

Q: Do all the MCOs participate in the PAC program?

A: Not all of the MCOs participate in the PAC program, but most do. The only MCOs that do not currently participate in PAC are Diamond (a Coventry MCO) and MedStar.

Q: Which MCOs serve Baltimore City?

A: All of the MCOs serve Baltimore City, but they vary in the number of people they serve.

Baltimore City HealthChoice and PAC Enrollment

Substance Abuse Treatment
in Hospital-Based Settings   top

Q: When will hospital-based substance abuse services be covered by PAC?

A: A law passed in 2007 laid out a plan for expanding Medicaid and PAC to adults. The first phase of this expansion, providing Medicaid coverage to parents with family incomes below 116% of FPL is already in effect. Health coverage for adults without children was supposed to be phased in over several years by expanding the benefits covered by the PAC program until they reached the same level of benefits covered under Medicaid. The final phases of the expansion of benefits covered hospital based services. Presumably, the PAC substance abuse benefit would include hospital based services when the final phase of the expansion of benefits occurs. It is not clear when there will be sufficient funding for this to happen.

Q: What does a hospital-based substance abuse provider do if it is serving a PAC enrolled individual after January 2010.

A: ADAA and bSAS have updated our guidance on the admission guidelines beginning 1/1/2010 to be the following.

MCO Contracts   top

Q: Do providers need MCO contracts to bill for services provided to Medicaid or PAC enrollees?

A: Under the SAII, non-participating providers (providers without MCO contracts) can bill for services as long as they follow the self-referral protocol. The self-referral protocol outlines the specific authorization and notification requirements and timelines.

Q: Do providers need to contract separately with MCOs for PAC and Medicaid program?

A: No. If a provider has a contract with an MCO to provide coverage for its Medicaid (HealthChoice) clients, it will cover PAC unless the contract specifically states otherwise.

Q: Why should I contract with an MCO?

A: You don’t have to contract with an MCO because the SAII allows providers to bill MCOs as non-participating providers as long as they follow the protocols outlined in the self-referral protocol.

There may be advantages to contracting with MCOs, including:

-          MCOs may direct clients to the provider;

-          A contracted provider may have a closer working relationship with the MCOs and may get more assistance from the MCO in troubleshooting issues;

-          A contracted provider may be more likely to be reimbursed for continued services provided after the services described in the self-referral protocol are completed; and

-          A contracted provider may negotiate coverage for additional services.

In the past, one of the advantages to contracting with an MCO was to negotiate better rates; however, when the Medicaid fee increases in January 2010, MCOs will be required to pay at least this fee and it is unlikely MCOs will pay more to contracted providers.

Q: Does an MCO have to contract with all OHCQ-Certified Addictions Providers?

A: No, MCOs are not required to contract with all OHCQ-certified addictions providers. There are minimum standards for the qualifications of an MCO’s provider network and OHCQ-certified addictions providers meet the minimum standard, but MCOs are allowed to require providers to meet their own credentialing standards before contracting with a provider. MCOs may require their contracted providers to be licensed and meet their individual credentialing requirements or they credential the OHCQ-certified addictions provider as an organization rather than an individual provider. MCOs may also make exceptions to the credentialing requirements.

Q: Does a provider need to meet MCOs’ credentialing requirements to be reimbursed for services under the SAII?

A: No. The SAII allows all OHCQ-certified addictions providers to be reimbursed for self-referred services.

Q: Do I have to be JCAHO accredited to contract with an MCO?

A: No. While many MCOs prefer that providers be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), they typically will not reject an application solely due to lack of JCAHO certification. If a provider is not JCAHO accredited, the MCO may require additional information, such as a provider’s quality improvement plan, and they will likely conduct a site visit as part of the credentialing process.

Q: How do I start the process of contracting with MCOs?

A: Contact each MCO and request a provider application. You should call the provider relations contact listed on the DHMH website and make this request. You can let the MCO staff person know that you are an OHCQ certified addictions program and would like an application for an organization. The MCO may have an “organizational” or “facility application.” Applications for the MCOs can also be found on DHMH’s website. at. The provider may also want to focus on those MCOs that will be participating in the PAC program – Amerigroup, Jai, Maryland Physicians Care, Priority Partners and United HealthCare (also known as Americhoice).

Treatment Plans    top

Q: Can I just use the Treatment Plan required by MCOs through the SAII?

A: The Treatment Plans currently included in the SAII do not meet all the requirements of ADAA. There may be an effort to change these treatment plans to make them consistent with the minimum requirements of ADAA. Until that happens, the provider will need to maintain two treatment plans for their Medicaid and PAC Clients – one that meets the requirements of ADAA and another that is the treatment plan form of the SAII.

Medicaid Provider Numbers and MCO Provider Numbers    top

Q: Do I need a Medicaid Provider Number and how do I get one?

A: Yes, you will need to have a Medicaid Provider Number to access the DHMH Eligibility Verification System (EVS). EVS will provide information on whether individuals you are serving are currently enrolled in PAC or Medicaid. To get a Medicaid Provider Number, you need to complete and mail in an application. DHMH recently mailed provider applications with special instructions for substance abuse providers to all OHCQ-certified providers who do not have a Medicaid provider number. If you need a provider application, contact Susan Harrison in the DHMH Office of Health Services at 410-767-1434. You will need to attach your OHCQ certification form. You will need to sign the attestations, as well as the attached contract. An accurately completed application takes about 3 to 4 weeks to process.

Q: How do I get a Medicaid Provider Number if my OHCQ certification is not current?

A: The Office of Health Care Quality (OHCQ) is currently running behind schedule on renewals for OHCQ-certified addictions providers. If you are a provider that has timely submitted an application for renewal with OHCQ, but it has not occurred for reasons of administrative delay (not concerns about quality of services), you can request a letter from OHCQ that states that you are a provider in good standing. This letter should be included in your application for a Medicaid provider number.

Eligibility Verification    top

Q: How do I identify whether individuals I am serving are enrolled in Medicaid or PAC?

A: Providers with a Medicaid provider number can access the DHMH Eligibility Verification System (EVS) to determine whether an individual is enrolled in PAC or Medicaid and to which MCO they are assigned. EVS is available by phone or via the web. You will have to register to use the EVS web access.

Q: What do the terms in EVS mean?

A: DHMH has a brochure which helps providers use the Eligibility Verification System (EVS). The EVS system will say “eligible, federal” for those individuals enrolled in Medicaid or PAC and then provide the name of the member’s MCO. The “invalid social security number” can also mean that an individual was never enrolled in Medicaid or PAC and the EVS system does not recognize their social security number. These individuals are not enrolled in Medicaid or PAC. EVS will only provide information on whether an individual is currently enrolled. It will not provide information on whether they may be eligible for Medicaid or PAC. If a provider thinks an individual may have an income that is below the PAC threshold of $12,552, they should provide information about enrolling in PAC. This information is available through Baltimore Health Care Access.

Q: How often do I need to verify eligibility through EVS?

A: While providers are not required to verify eligibility through EVS, it is strongly recommended that providers EVS for each service in order to validate that the patient is eligible with the MCO and or Medicaid/PAC. Eligibility within the Medicaid program can change at any time, and providers can use EVS to verify eligibility on a real time basis without waiting for an EOB to learn that a patient was no longer eligible.

Q: Is MCO authorization for future services a guarantee of payment?

A: No, an MCO authorization for future services is not a guarantee of payment. Any authorizations given by an MCO are contingent upon the patient being eligible with the MCO at the time of the actual service.

Q: What is retroactive eligibility and can I back bill for services?

A: Under Medicaid, individuals can be determined eligible back to the date of their original application for coverage. This period of time is called the retroactive eligibility period. There is no retroactive coverage under the PAC program so coverage will only begin after the individual is determined eligible and enrolled in the program. Providers can be reimbursed for Medicaid services during the retroactive period; however, the individual may not have been assigned to an MCO for the retroactive period and it will not be possible to secure necessary authorizations retroactively. Therefore, providers will only be able to bill prospectively for Medicaid individuals enrolled in MCOs. However, providers may bill Medicaid fee-for-service (FFS) for the period prior to MCO coverage for Medicaid recipients that were in the HealthChoice program. Since the fee-for-service benefit package is expanding at the same time that the PAC benefit package is expanding this opens up new reimbursement sources for Medicaid enrolled OHCQ-certified addictions providers.

MCO Reimbursement   top

Q: What services will MCOs pay for and how much will they pay?

A: Medicaid will pay for an assessment, individual counseling, group counseling, intensive outpatient and methadone maintenance. In January 2010, PAC will pay for all of these services as long as they are provided outside of a HSCRC-regulated setting. The individual must meet the ASAM criteria and all the other criteria described in the SAII.

DHMH just announced that it will be increasing the Medicaid fee schedule for substance abuse services. MCOs must pay at least this amount to non contracted providers under the self-referral protocol. It is possible that a contracted provider could negotiate a different payment rate.

CODES AND RATES FOR COMMUNITY-BASED SUBSTANCE ABUSE SERVICES

Q: Can I bill the MCO when a client does not show up for an appointment?

A: No, MCOs will not reimburse a provider for missed appointments.

Q: How long do I have to bill an MCO?

A: Typically, an MCO will have a filing limit requirement of 180 days from the date of service. The filing limit will be specifically referenced in the contract and/or provider manual. The provider should make certain that its contractual agreement stipulates the timelines, since MCOs are free to negotiate their own claim filing guidelines.

Q: What is a CMS 1500 and where do I get one?

A: The CMS-1500 form is the standard Medicare claim form used by non-institutional providers to bill for services. Providers are required to use this form to bill the Medicaid program and all of the MCOs. The form will require that you provide a procedure code to bill for services (see question related to MCO payment) and provide the date of service, as well as other information. A PDF version of the CMS 1500 is available through many websites. Most billing software packages allow a provider to print a CMS 1500 and some allow them to be electronically filed. Through an internet search, providers can find basic software packages to help them format and print a CMS 1500 form. Many MCOs allow CMS 1500 to be electronically filed through their websites.

Q: Can I bill the MCO for an assessment of Medicaid or PAC enrolled individuals if I don’t charge sliding scale clients for this service?

A: Providers cannot bill Medicaid or PAC for a free service Therefore, if you want to bill Medicaid or PAC for this service, you either need to bill the uninsured clients on a sliding fee scale or bill the client’s insurance company for the service if the client has third party coverage. All services supported through ADAA grant funds must also be provided on a sliding scale.

Budget and Accounting   top

Q:How can I determine how this change may affect my revenue?

A: Providers can identify the number of Medicaid and PAC enrolled individuals by checking the eligibility status of individuals on the Eligibility Verification System (EVS) (see question related to EVS). A provider may assess how many individuals they serve may be Medicaid or PAC eligible, but not enrolled by looking at the income of individuals they serve reported through their intake process. A provider can assess the services that they provide to these PAC and Medicaid clients and determine their possible revenue by looking at the new Medicaid fee schedule (see question related to how much a provider will be paid).

Q: How do I account for services that the MCO will not reimburse for a Medicaid or PAC covered individual?

A: MCOs are not required to cover some treatment services. These include residential services for adults or halfway house services. Providers should continue to bill their grant for non-Medicaid covered services provided to PAC or Medicaid enrolled individuals that meet ASAM criteria for that level of care. If an MCO denies a service as not meeting the ASAM criteria for the level of care requested, the service should not be billed to the bSAS grant.

Other   top

Q: How is urinalysis reimbursed under Medicaid and PAC?

A: Urinalysis is a Medicaid and PAC covered service. Each MCO will have their own requirements for how they pay for lab services. The Friends Lab, used by BSAS, does not currently have contracts with the MCOs. Therefore, providers should not expect MCOs to reimburse them if they use the Friends Lab for urinalysis for their MCO clients. For MCO enrollees, any lab tests must go through a lab contracted with the enrollee’s MCO. All MCOs currently have contracts with LabCorp.