Are the Best Practice Evaluations considered an initial evaluation? Do these have to be sent to the commercial insurance company as the primary payer?

Providers who are contracted to complete the level of care called Best Practice Evaluations should send those claims to Community Care as the primary payer. The modified codes that should be billed as primary are 90791-HA (Initial Best Practice Evaluation) & 90791-EP (Continued Stay Best Practice Evaluation). For providers contracted to deliver the evaluation service that is billed with an “SC” modifier 90791-SC (Best Practice Evaluation – Preferred Prescriber), that service code should also be billed as primary for Community Care members.

Should providers continue to send packets to Community Care when they send the treatment request to the commercial insurer?

Yes, we are recommending that providers submit a packet to Community Care when they send the treatment request to the primary payer. Packets received, will be processed as usual by Community Care, including the timing and duration of the BHRS prescriptions. As packets are received, they will be reviewed for medical necessity and the resulting authorizations entered into the care management system. If providers receive claims denials for services by the primary/commercial insured, the authorization will then be in the system so that the secondary claim can be processed.

Do providers still have to submit the various reports on services completed if the primary payer is authorizing the care?

If you have submitted a packet to Community Care, you will be included in the various BHRS reports that we are required to send to DHS. Therefore, if you have received an authorization from us, we are still requiring that you submit the various reports and follow the same policies as if we were the primary payer.

What if the provider gets a medical necessity denial (a clinical denial) by the primary insurance? What should the provider do at that point?

Community Care is able to authorize and pay, up to what was approved as medically indicated by Community Care, after the initial commercial MCO medical appeal has been completed. The insurance companies are being asked to offer families (the subscriber) a 2-day expedited appeal process. Please note that these types of appeals are available only for the covered member, so providers will have to ask families to request these appeals. After the appeal has begun, and/or if there is another appeal, Community Care can authorize and pay. If the appeal is eventually overturned and the provider gets paid by the primary payer, that provider should refund any monies paid by Community Care during that time period.

Do providers have to submit evaluations in the life domain format?

When providers submit packets to Community Care, the same standards as are used now will still be in place. For any request for a Community Care authorization, providers are expected to follow all of our procedures and forms requirements prior to that authorization being granted.

How will Community Care handle the request for authorization for an initial evaluation if the member has not yet been diagnosed on the Autism spectrum?

The basic evaluation, 90791, is a service that is covered under Act 62. Community Care is not changing its authorization policies regarding evaluations, however, in most cases, the initial (pre-ASD diagnosis) can be billed to the primary insurer. Members can get an evaluation regardless of outcome. However, many commercial insurers already pay for evaluations too, so this is not a service that is exempt from coordination of benefits rules. If the provider gets a denial on an evaluation service, then Community Care will be happy to pay it when we receive the secondary claim with the appropriate claims attachment. Please note that this answer pertains to the standard evaluation and not the evaluation that is modified to indicate the Best Practice Evaluation. BP evaluations occur after the initial diagnostic evaluation has been completed.

What if the child lives in PA but has his/her insurance from out of state?

Act 62 only applies to insurance companies/products licensed in Pennsylvania so in that case, Act 62 does not apply.

I have received a claims denial from Community Care for a child who I know does not have Act 62.

Please call the Provider Line at 1-888-251-2224. You will need: the MA ID, date of birth, the dates of service and the reason for Act 62 forgiveness (e.g., insurance is self-funded, Act 62 eligibility is in the future, etc.). We will follow our internal processes to correct the child's flag in the claims system and will work with claims to reprocess your claims denial.

I know that a child will be Act 62 eligible on a future date.

For a child who you discover will be Act 62 eligible in the future, call the Provider Line with the information above and the date of eligibility. We will add to the claims flag.

How will providers know when a child is getting close to the annual financial benefit limit?

The annual financial benefit limit changes based on the U.S. Dept of Labor Consumer Price Index for All Urban Consumers (CPI-U). Some insurance companies are going to let providers know but some will only know because they are tracking their own spending. One way is that providers will get a denial from the primary insurer. For members getting many services from more than one provider, it is possible that a provider won’t know until the claim is denied. Providers should always ask the family when their commercial benefit year begins. At the point where a provider gets to the middle of the benefit year, depending on the utilization patterns of the child, it is probably prudent to request a Community Care authorization in addition to the commercial authorization (Please see question 2 in the clinical FAQ section for more information about authorization requirements). For example, if a child’s benefit year is July 1, then in December, the provider may want to submit a packet to Community Care in addition to the treatment plan submitted to the commercial insurer.

To which insurance company does the provider submit the claim if Autism is the secondary and not the primary diagnosis?

The Department of Human Services has indicated that if there is a diagnosis of Autism on the claim form, regardless of what order, then it is an Act 62 claim and should be submitted to the commercial payer.

Will Community Care make up the difference if the commercial payer’s fees are less than paid by the HealthChoices program?

No, Community Care may not use HealthChoices dollars to increase the amount paid to a provider when that provider has a contract with the primary payer to accept a specific amount. In other words, if the provider agreed to accept that fee, then Community Care is not able to use public program dollars to pay more than they’ve agreed to accept.