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Denials from BCBS PMAP

ahaugen 1 year ago in Payments/ERA Modules updated by Kayla Kenworthy 1 year ago 69

Is anyone else having issues with many denials on recent BCBS PMAP payments due to the "197" code.  Will pay the 9 code, but deny the travel due to the "197" code. Or won't pay on either code due to the "197" code. 

I am finding that even though the newletter saying we need to get auths for the H2014, H0046 and other codes (thank you for sending that by the way) doesn't hold true because in a recent ERA, we DID get paid for some of the very codes they are saying we need auths for. It is so inconsistent, hard to know what to believe.  

I also don't understand how they can go around the DHS rules;

I thought PMAPs had to follow DHS..


For CTSS services authorization is required after: 

· • 200 cumulative hours per calendar year for any combination of:

· • Psychotherapy (with patient or family member or both)

· • Skills training

· • Crisis assistance

· • Mental health behavioral aide (MHBA) services

· • Service Plan Development

They can require authorizations for whatever they want.

I'm not seeing on the document kimr sent anything about prior authorizations for ctss.

I've called our contract manager to provide clarification.

I just searched and couldn't find it either. I also checked out the Authorization link in Availity and it only allows authorization requests for future claims so what does that mean for all the claims denied? Very frustrating!

I did find a form "Pre-Authorization (PA) Request Form on BCBS of MN website, but even after it gets filled out it needs to be attached to the Availity site where auths are being requested. But then on the form it says:"Effective May 1, 2019, BCBS of MN and Blue Plus providers are required to use the Availity Provider Portal to submit preservice prior authorization requests. Faxes and phone calls for these requests will no longer be accepted by Blue Cross.  So what, for April, can fax requests in, but now in a week we have to do it all through Availity????  It really is confusing.  I have alerted our two managers about this as well, and if I hear anything from them, will let you know as well.  

I am following this thread very carefully.  I appreciate everyone posting what they are finding out about this.  BCBS PMAP is our 2nd largest payer so this has a profound impact on our business.  I'm going to make some phone calls this afternoon and will definitely let everyone know how my conversations go!

Thank you, Jill, for making those calls.  We have lots and lots of BCBS PMAP payers as well, so anything you can find out will be appreciated.  

I was working with someone who contacted me from Availity on the authorization portal.  They do not have it functional, as of the last time I spoke with him.  It does not complete the link to submit the authorization request or clinical support. 


I haven't had any issues with H2035 being paid; however, just today I had a bunch of T1016-Treatment Coord. come back as denied due to "not part of managed care contract". When I contacted them they stated we needed to submit a notification of admit...

We have never had to do this for OP services before. Also, we are not required to have auth for any of our services. 

Just when I thought I had it figured out -- this happens. 

When I had called they told me we didn't need the T1016 added as part of the contract.  This new company that took over is less than impressive.  Nobody knows what is going on there and I feel like they are hold our payments hostage.

Hi Kelly, they told me the same thing about T1016, so frustrating. Plus -- they are rude!

I just got a call from BCBS regarding authorizations I submitted for CTSS services for Blue Plus members.  He told me H2014 UA/UA HR does not require an authorization.  I told him that Amerigroup denied them stating they did and the representative faxed me a form to submit.  He said that is incorrect and would let his manager know.  I also told him about the other denials listed in this thread and he took the information to provide his manager.  

And they wonder why we can't get these issues resolved!!!  What was the form you were faxed to submit? Was this a form to submit to BCBS or Amerigroup?  Also, our operations director put in an email to our contract manager at BCBS, and will wait to hear what she says.  It's hard to know what to do at this point-appeal them as one of you was told?  Hold off until we get further word on this? Keep billing the denied codes?  Hopefully we will hear soon.  Thanks to all who have participated with comments in our confusion.  

I just got a call from Blue Cross.  I think the root of the problem is that there are some codes used in EIBDI (which DOES require an auth) that overlap with CTSS such as Provider Travel Time (which technically is not a ctss benefit), and Amerigroup is denying all claims using this code because they don't now the difference between the programs.  They are aware of the problem and are working on a fix from the Blue Cross side.

The form Amerigroup faxed me was a one page form that has Blue Cross and Blue Shield of Minnesota and Blue Plus in the top left corrner.  Prior Authorization/Precertification Request.  Fax to 1-800-964-3627

Has anybody heard anything back from Amerigroup on this issue? Also does anyone have a direct number for Amerigroup?

This is the phone number if you need to contact Blue Plus. 866-518-8448

We've had better luck here getting anything accomplished.  For our CD program, CO97 denials our CD biller talked with both Latisa @ BP and Michael @ Availity.  Michael was much more help, he found the claims right away and that the connection to Amerigroup was still not there.  He fixed that.  When you log in to Availity you can go to the top right of the screen to the drop down and pick MN, then click on Tx.  Go to the payer spaces drop down and select Amerigroup to get any remits you haven't gotten yet.  We found the remits, then called and asked BP to reprocess claims appropriately since they said CD claims denied with CO97 don't need an auth.  They did reprocess right away, no auth needed.  I believe Michael @ Availity also alerted his manager that this was happening and they were not happy.

Amerigroup - 866-518-8448

Shauna it me T

can you email me tvanovermeiren@northwoodchildren.org

I got this number when calling for a prior auth--administered through AmeriHealth, but was transferred at some point. 833-803-4459. 

We tried going into Availity to get auths for the H0046 codes alone, and could not. No place for Community Mental health, or home based services.  Called Amerigroup was transferred to the Behavioral Health side and she said the preauth form was on BCBSMN, under forms.  I believe the form is the Preauthorization Form listed (2 pages) and I was told to fax it to 1-800-505-1193 with clinicals.  Is that anyone else's experience.  Kimr, is that the form you found, except you were told a different fax number.  This truly is a huge headache. 

We were told by our contract manager at BCBS, that through April, needed to get auths for the H0046, skills codes, and the S5145 codes (these are ones we are using and of course, denied).  But starting in May, only need to get auths for the travel code.  When our manager over home based services tried to get these in Availity, wouldn't let her go back for earlier dates (I believe someone in this chat had that same issue).  Trying to figure all of this out, but no clear guidelines. Anyone else find success to get these? 

Had these issues again today on CTSS code H2014 and Travel. Is everyone doing authorizations or just sending back to be reprocessed? I'm hoping they will just fix everything on their side. Doing auths for all our patients would take a long time

From several calls to Amerigroup, the Hcodes and travel and the S5145 codes need auths through April.  Then May 1, only travel needs an auth.  Can ask up to 6 months for travel auths, and if need more, need to do new auths again.  

We bill H2014s for CTSS and H0046 for many services in addition to CTSS. After posting our BCBS PMAP remit we got today, there was about 10 H0046 denied with CO 197. Looks like only 1 H2014. When I run unpaid claims for H0046 and the H2014 codes, looks like all are April DOS that were likely recently billed, and then I have 1 H204 HR from Feb that denied. I have not tracked our denials for CTSS codes this year with this payer until now, so either some denied and recently reprocessed automatically and paid or we have not been getting too many denials for these codes. It will be a pain if we have to get prior auths for H0046 for BCBS PMAP clients. After reading all of the comments, it still seems unclear if we should attempt auths for travel time in Availity or not. What a pain!

From several calls to Amerigroup, and an email from a contract manager, the H2014, H0046, and S5145, H0032 codes all need auths starting in April.  We could not get onto Availity to enter auths for these clients, so have had to fill out the Pre/Auth form on BCBS MN's website and fax it in to Amerigroup.  Starting May 1 then, only the H0046 (travel) needs auths, so this will be an ongoing process. Can get auths for up to 6 months, and then need to get new ones once the 6 months are up.  It has been a laborious process and who knows if it will all shake out to get paid.  I was told the turnaround time for auths is 14 days.  But from everything called upon, H codes will need to get auths-at least for April, then only H0046 ongoing. 

I've searched for the Pre/Auth form and can't find it. Could one of you post it as a PDF on this thread please??? Thanks. 

Conflicting information on what form to use.

Any one have the link or PDF?

Here is the link on the BCBSMN website: https://www.bluecrossmn.com/providers/forms-and-publications. It is on the second page the "PreAuth Request Form"  I was told to fax it then to 1-800-505-1193-which is the "outpatient" side of things at Amerigroup.  Hope this helps.  

This is the form that Amerigroup faxed me.

Blue Plus Authorization

Additional information we learned today...

Again not sure if its accurate, as we getting conflicting information daily.

The rep provided me with the "outpatient expedited" fax line: 866-877-5229. I didn't get any more information about what this means exactly, but she said I can use either this or the "standard" fax number that is included on the form.

I asked her about the info already included in DA/Tx plan, and she said we can state "refer to" that documentation on the form. She advised us to specify on the cover sheet that requested information is included in supporting documentation.

Got this email from our BCBS network rep today, after I asked him about if certain codes need PAs. Not the greatest info but at least he responded. 

I was advised the following below in regards to Amerigroup yesterday.

I was advised now that Amerigroup is going to do a recovery on the following codes below that denied for no PA. They didn't give an ETA but thought I would let you know.

H0046

99213

90846

90834

90837

90785

90847

90791

99354

I spoke to my network manager and he says that we don't need an authorization for codes H2014 and H0046 since it is not EIDIBI services.

I've been following this thread, and thank everyone for posting detailed information.


Yesterday I received the following from a BCBSMN rep:

"I have heard the same message and concerns as well from BH providers in the last few weeks and have been forwarding them over to our contact with Amerigroup along with our BH contract manager. The CTSS issue and the H2035 I know are being reviewed as a high priority issue and they hope to have that one fixed by May 10th and start reprocessing we got advised".

I interpret "CTSS Issue" to mean H2014 and H0046 codes (facetime and travel).

I asked if we'd need to resubmit the denied transactions, or if they will be reprocessed automatically.

I also asked about the pre-auths, as the Availity portal doesn't allow us to do so.

Let's hope the May 10th date is good.

Did anyone get payments from BCBS for the denied services? We still have not done anything, so trying to see what the best course of action would be. The 10th is tomorrow, so maybe they will have everything fixed and they will start reprocessing. *Fingers crossed*

We have not anything either because we are not sure what to do.  No denied claims from April for the H0046, H2014, or S5145 have been reprocessed and paid yet.  Have held off billing for May now, because not sure if the travel will be denied or not.  We had faxed in many (and I mean many) of the Preauth forms to BCBS for H codes billed in April, and we received a cover sheet from BCBS saying no auths were needed for the H0046, H2014 and S5145.  So that is why all of this is so maddening and confusing.  If no auths are needed, why are these codes being denied!!!!  

According to what our BCBS Network rep said in an email to me after I asked last week, Amerigroup knows they are denying in error and are working on a recovery which I assume means they will be reprocessing and paying claims on there own. We all know this will make a long time...who knows when, but I have not submitted any prior auths yet as it's not clear and some of our CTSS codes are paying. 

from BCBS Rep: I was advised now that Amerigroup is going to do a recovery on the following codes below that denied for no PA. They didn't give an ETA but thought I would let you know.


I just spoke with BP and they have a "project open" and are reprocessing over 6000 claims from January 1, 2019.  She told me to allow 30 days for reprocessing and to call them if claims haven't reprocessed.



Has anyone started auths for H0046 – Travel Time
H2027 – Psycho-education
H2015 – Crisis Assistance Planning

We got three back saying we were INN and did not have to get auths for H0046. We have stopped submitting the auth requests.

How are you getting your authorizations for H2015, H2014, H0032 for CTSS?  We have a BCBS of Penn. Highmark policy and are having trouble finding the authorization form.  We got the run around this morning after making several phone calls.  We have an ERA that is denying these codes for authorization for the commercial policy.  Anyone else having this issue?

We originally sent in the form referenced above (in one of the comments) but it was the wrong form for us - we are Behavioral Health. I got the form link from the rep who called me about sending the wrong form. Here's the form for Behavioral Health:

https://www.bluecrossmn.com/sites/default/files/DAM/2019-04/X18509R07_Pre-Authorization%20Request%20Form.pdf

When we sent this one in - they replied telling us we are INN and do not need an auth for H0046. Hope that helps! Our H0032's are paying for both ARMHS and CTSS - we haven't needed an auth for those at all.

Has anyone gotten payment for the travel codes yet?  Or seen a reprocessing of denied codes in April.  I had billed a few travel dates out from May 1-May 3 and the H codes and the S5145 codes got paid, but travel is still being denied for auths, though it seems everyone is being told we don't need auths for that code.  

Has anyone gotten paid for the travel codes billed in May?  Just had a remit come through and BCBS is now paying on the H2014 and S5145 codes, but for the most part, the travels are all being denied still due to needing auths.   Does anyone have a clear idea about what to do with denials from April, and now continued denials for travel in May, when we are being told we don't need auths for those codes?  

I was told I needed to get authorization for H0046 but not H2014.

We have been submitting Auth requests for the following:

Skills codes

Travel

treatment plans

Claims for April with these services have only paid when resubmitted with  Auths.


May skills codes are paying without Auths, but travel and treatment plans for May are NOT.


Hope that helps..


Kim 

Kim, What do the auths look like that you have received to resubmit with the codes?  We faxed hundreds of pages to get auths in April, and got a cover sheet back saying auths weren't needed for the H0046, H2014, and S5145, unless Autism was the issue.  But then we received a couple of sheets on clients telling us that auths were accepted from 4-10-19 to 10-1-19 but we weren't given any auth numbers at all.  

How are you asking for the Travel code auths (being there are no units)? Are you just submitting dates?

The head of our home based department filled out the PreAuth form and just put dates from Aoril 1,2019 going forward. I don't think she put any amount of units needed-since so hard to predict.  But with some of those faxed in sheets, comes that front page telling us we don't need auths for the H0046, H2014.  So it is all so confusing.  

Thanks, Lily, for that update.  So it looks like the issue hasn't been resolved yet.  

Ann-


A member of our billing team  found it by going to https://www.bluecrossmn.com/providers/migration-minnesota-health-care-programs then clicking "forms" and selecting "mental health outpatient treatment request form". 

The Fax # used  is 800-505-1193. 

Addressed to  "Prior Authorization Department" at "Blue Plus".

Auth form is filled out  with sections "Identifying Data", "Provider Information", and "ICD-10 Diagnoses" filled out, and write "see attached documentation" for the rest. 

We include the most recent DA, two most recent Treatment Plans, and 6 most recent Progress Notes (signed by clinician and supervisor [if applicable]).

Then the approval form is typically one page double-sided and is faxed to the number I specified when faxing.

I will see if I can attach the form here.

Does anyone know or have experience with BCBS commercial plans paying travel code (H0046)? I was told when calling to check outpatient mental health benefits that it was covered however when I submit the claim, it comes back as B7 not a covered service.

It really depends on the benefits under the commercial BCBS plan.  But we have billed the commercial plan with the skills or 9 code with the 0046 (travel)  to then send to MA or a PMAP as secondary.  Some of the travels get denied with the 96 code or 204 code-meaning not a covered service and then it gets sent to MA and gets paid.  Other travel codes sometimes get paid partially by the BCBS commercial plan and the rest is adjusted out.  So it varies from client to client.  Sometimes, too, information from the various reps isn't always the same when the claim gets paid. We have been told we need to get auths for the code and travel on the commercial side, try to get them, and then are told by a different rep, we didn't need to get auths. 

How has everyone's claims been panning out? We are still getting sporatic payments and denials. Ugh! They said taht H0046, H2014, H0038 all require authorizations. This is going to take forever and I'm sooo frustrated about it