CLAIMS PROCESSING AND PAYMENT

This section describes the process for submitting a claim, including procedures and requirements for processing and payment of mental health service claims.

The SFMHP Claims Unit processes claims for authorized specialty mental health services provided to SFMHP members. Claims will come from Individual Licensed Mental Health Practitioners, Group Practitioners, and from Organizational Providers and Skilled Nursing Facilities/IMDs. Private hospitals will continue submitting their claims to Electronic Data Systems (EDS).

Submitting a Claim to SFMHP

Organizational Providers and Skilled Nursing Facilities/IMDs will continue to enter their services directly into the CMHS Billing and Information System (BIS) through network terminals located at their clinics.

Individual Practitioner Providers submit claims to the SFMHP Claims Unit for authorized mental health services rendered to plan members after April 1, 1998.

Services provided prior to this date should be sent to the EDS Fee-for-Service Claims Processing Unit.

Claims Forms and Procedure Codes

Claims will be paid only if they are submitted to the SFMHP within 60 calendar days after the date the authorized service was rendered. Individual and Group Practitioner Providers must use the HCFA 1500 Claim Form when submitting services for payment under the Plan. An original, two part, completed claim form must be submitted. Claim form copies are not accepted. Directions on how to complete the HCFA 1500 and a copy of the claim form are in Appendix 12.

Providers must use current HCFA Common Procedure Coding System (HCPCS) service codes on their claims. Any claim submitted with a procedure code(s) other than the authorized service(s) will result in the claim being pended or may result in denial of payment.

Only specialty mental health services that are covered under the SFMHP and are prior authorized will be paid. Emergency services do not require prior authorization. These will be ajudicated by the Claims Unit according to State regulations and SFMHP rules. Claims for non-emergency services that are submitted to the SFMHP require an authorization number. The SFMHP Claims Unit will make its best efforts to process claims within 15 days of its receipt. Clean claims will be paid within 30 calendar days of submission by the Provider.

FFS Providers' Medicare/Medi-Cal Beneficiary Claims

The SFMHP does not process claims from Fee-for-Service Providers for individuals who are covered by Medicare and Medi-Cal. Send these to the Medicare Fiscal Intermediary or to EDS.

Claims Submission Charges

By law, you are not allowed to charge the member for completing paperwork and sending claims to the SFMHP.

How to Send In Your Claim

All claims must be postmarked. Hand delivered mail or faxed forms for the SFMHP Claims Unit will not be accepted. Individual and Group Practitioner Providers should send claims and attachments, related forms, and documentation for authorized specialty mental health services to the following address:

SF Mental Health Plan Claims Unit
P. O. Box 423180
San Francisco, CA 94142

Inquiring About a Claim that has been Submitted

For information regarding the status or disposition of a claim submitted for payment, providers may call:

Provider Systems Office: (415) 255-3773
SFMHP Claims Unit Supervisor at (415) 255-3785
Claim Inquiry Line at (415) 252-3029 and leave a voice mail message about your claim, payment, or other billing question. Claims Unit staff will return your call within 24 hours.

Please do not call about a claim or Claim Resubmission Document (CRD) until at least 5 business days have elapsed since the date it was sent to the SFMHP Claims Unit.

Same Day Reporting

To ensure proper consideration of same day services in relationship to each other, items and services furnished to a specific member, on the same day, and by the same provider group should be reported on the same claim. We realize that in some cases, this may not be possible. For example, if more than six services were rendered to a member on the same day, it may be necessary to report these services on two or more claims.

Reporting same day provider services on separate claims can result in erroneous denial of some services, requiring expensive and time consuming appeals. Similarly, other services can be over-paid, resulting in time consuming post-payment recovery of incorrectly paid funds.

Tips for submitting Paper Claims

Do not bill more than six lines of service on a paper claim.
Use typewritten characters, standard 10-pitch typeface. Do not use Italics or Script fonts.
Please do use upper-case (CAPITAL) letters for all alpha characters.
Please enter all information within the designated field.
Do not print, write, or stamp extraneous data on the form.
Use only black or dark blue ink. If you are using a typewriter or printer, please make sure the print is dark. Replace worn ribbons or printer toner.
Review your claim form for completeness and readability before sending it.
Make sure the form is signed by the provider. This certifies the information contained on the claim is true and accurate.

Electronic Claims Submission

The SFMHP will begin to accept electronically submitted claims starting in July, 1998. These claims are subject to the same information, processing, and audit requirements as paper claims.

Providers may submit electronic claims directly, or through billing services, or selected claims networks/clearinghouses. Requirements for an electronic data interface with SFMHP must first be met by providers before commencing electronic claims submissions. To discuss how to initiate electronic claims submission with the SFMHP, please contact the SFMHP Claims Unit Supervisor at (415) 255-3785.

Processing Timelines

Claims submitted for payment by Individual and Group Practitioner Providers will be processed by the SFMHP Claims Processing Unit. All properly prepared or "Clean" claims that are accepted for payment will:

be entered in the claims processing system within 2 working days of receipt
have payment status determined within 3 working days
be paid within 30 calendar days of submission

Unprocessable Claims

Claims Returned to the Provider

The following conditions will result in the rejection of the claim for processing or payment and return to the sender:

Prior authorization or timely notification (for urgent care services) requirement was not met
Diagnosis listed is not covered under the Mental Health Plan
Place of Service is not authorized or not covered under the SFMHP
Service provided or the procedure code listed is not covered
Provider of Service has not met SFMHP credentialing requirements
A form other than the HCFA 1500 Claim Form was used to submit services for payment
Claim was submitted late. We can only accept claims submitted within 60 days after the authorized service was rendered.
Other Insurance Coverage indicated but no Explanation of Benefits form is attached showing how much the other carrier paid
Claim is for a Medicare covered beneficiary and should be submitted to EDS.
Claim is for a Medi-Cal beneficiary who was a resident of another county at the time services were rendered.
SFMHP is not responsible for the services, laboratory charges, prescription or supplies being claimed.

Claims in "Pending" Status

Any claim items that require additional information are also placed in "Pending" status. The Claim Examiner will attempt to get the missing information by contacting the provider directly if it is possible and reasonable to do so. Otherwise, the claim will be returned with a Claim Resubmission Document (CRD).

The provider should check the questionable data items identified on the CRD and make any necessary corrections or additions, then return the CRD to the Claim Examiner at the SFMHP Claims Unit. The corrected information will be entered and matched to the original claim for correction or verification.

Providers have 30 calendar days from the date of the CRD to submit the missing or corrected information. If the CRD is not returned within the 30 day period allowed, the claim will be sent back with a claims denial letter. A provider may resubmit the denied claim with the missing or additional information included within the original 60 day claim submission time limit.

Claims which are incomplete, illegible or otherwise cannot be processed because of errors in completing the form will be returned to the provider. Claim submissions without data or authorization errors will enter the claims adjudication process.

Claims Adjudication

Coordination of Benefits

Providers must bill all other health coverage and/or the patient's primary insurance carriers prior to submitting claims to SFMHP. Coordination of Benefit rules apply if the patient is covered under another insurance plan and has Medi-cal benefits under the SFMHP. After receipt of the Insurance payment or denial, submit a claim for authorized services with a copy of the Insurance Explanation of Benefit. SFMHP's payment liability can then be determined. Reimbursement of services is limited to the unpaid balance of the Provider's charge, up to the contracted rate for the service or the Standard Rate Schedule. All information necessary for the SFMHP to bill Medi-Cal for the authorized services must also be provided.

Medication and Lab Services

As described in the Pharmacy section of this manual, the SFMHP will not pay for any prescription charges or laboratory tests for patients who are covered by Medi-Cal, whether through Fee-for -Service or those enrolled in a health plan. It is the provider's responsibility to ensure these patients receive their prescriptions or laboratory tests through the health plan or Fee-for-Service Medi-Cal.

For SFMHP members who are not covered by Medi-Cal, SFMHP will only pay for prescriptions and laboratory tests that are prescribed and dispensed according to the SFMHP Pharmacy Services guidelines and that are listed on the SFMHP Formulary.

Providers do not submit claims for prescription or laboratory services. Please refer to Section VI of this manual for more information.

Charges to SFMHP Members

Some members who are referred to providers may be required under State law to contribute to the cost of their services. A member's financial obligation is also known as either an "UMDAP" (Uniform Method of Determining Ability to Pay) liability or a Medi-Cal Share of Cost amount. Providers will be informed of the member's copayment or UMDAP amount when the treatment authorization is issued. The provider shall bill the patient or their responsible party for this amount.

Patient copayment amounts received by the provider must be noted on the HCFA 1500 Claim Form under block number 29, "Amount paid". Reimbursement of services is limited to the unpaid balance of the provider's charge, up to the contracted rate of the service or the Standard Rate Schedule.

Claim Inquiries

Providers may complete a Claims Review Request (CRR) if a further review of their paid or denied claim is desired. A CRR is submitted whenever a provider feels an administrative error has occurred on the part of the Claims Processing Unit. The form must be received by the SFMHP Claims Unit within 30 calendar days of the Claim Explanation of Benefits date. All CRR's are reviewed by the Unit Supervisor or Manager and responded to within 10 days of receipt.

Filing a CRR is offered as a preliminary step before a formal Provider Appeal is made because it is a quicker, more efficient way to resolve administrative claim problems that may have occurred. The CRR process does not impinge on any further Appeal rights or remedies a Provider might have. A copy of the form and field description can be found on Appendix 13.

A Provider may file a formal appeal if he/she does not agree with the CRR process results or findings. Furthermore, an appeal can be filed concerning the processing or payment of a claim for services rendered to SFMHP members, or for a denied request for reimbursement of psychiatric services under the SFMHP. Please refer to Section IX of this manual for information about Provider Appeals.