Billing/Program Defaults - Glossary

Enter all company information.

• A nine-digit zip code must be used.
• For the Tax ID, enter the Tax ID for the Program, which is required for billing purposes.
• For the Taxonomy, enter the taxonomy for the Program, which is required if being sent.
• For the National Provider Identifier (NPI), enter the NPI for the Program, which is required for billing purposes.
• For the Managing Organization OID, New Jersey Health Information Network.
• For the Managing Organization Type, choose from the drop-down menu.
• For the Provider One ID, this is used in BHDS reporting. Talk to your Project Manager for details.

The fields in this tab are identical to the fields in the Company Info tab. If you receive remittances differently than how they are set up in the Company Info tab, then in the Pay-To-Info tab:

1. Enter the new or different address.
2. Click Save.

If you receive remittances under the same name/address that you entered in the Company info tab, leave this tab blank.

1. ICD-9 Dx is a legacy feature and no longer applicable to billing.
2. In the ICD-10 Dx field, enter an ICD-10 diagnosis to set a default ICD-10 Code for patients in the program.
3. In the Procedure field, enter a procedure code to set a default Procedure for patients in the program.
4. In the Facility Name field, select a facility name from the drop-down menu to set a default Facility for patients in the program.
5. Check the box for Use Normal Business Hours to use normal business hours and select your clinic's hours using the start and end times.
   • Any service set up for After Hours will apply the after-hours Add-On if provided outside of these hours.
6. The selections under Autoposting are used to differentiate between APG billing and individual charges.
   • Check the box for Rate Based Claims (For Non-APG Billing) to create charges as separate claims. They will not bundle.
   • Check the box for Fee-for-Service (For APG Billing) for APG Billing which will bundle claims by Date of Service.
7. The selections under COPS/CSP will differentiate the Program as a COPS or CSP Program.
8. Select Yes or No under Additional Billing info - Copay Exempt to determine if Copays report to Patient Billing Statements.

1. Check the box for Use Atypical Provider Billing to use a legacy ID number instead of an NPI.
2. Check the box for Create Separate Transaction set in 837 File to create a separate Transaction Set (TS) in the 837 file for this program.
3. Check the box for Include Issuing Provider on Auth as Referring Provider on Visit to include the Referring Provider.
4. Check the box for Save Covered Days to save covered days.
5. Send location code (REF LU) for 02 Billing Format Medicaid in 837 is a Medicaid-only setting.
6. Send Provider Name Only in Medicaid 837 files is a Medicaid-only setting.
7. APG is a billing method that allows the user to bundle claims.
   • Check the box for Use APG Billing to make the program use APG Billing.
   • Enter a number in the Day Cap on Claim field, to cap the number of services provided in a day to that number.

     NOTE: The Day Cap must be the same for all programs using APG for APG billing to work correctly.

8. Check the box for Effective DOS for APG Rate Codes to set an effective date for APG Rate Codes.
9. From the Admission Type Code drop-down menu, select the code indicating the type and priority of an inpatient admission associated with the service on an intermediary submitted claim.
10. From the Admission Source Code drop-down menu, select the code indicating the source of the referral for the admission or visit.
11. From the Admission Frequency drop-down menu, select the third digit of the type of bill submitted on an institutional claim record to indicate the sequence of a claim in the beneficiary's current episode of care at the time of Admission.
12. From the Patient Status Code drop-down menu, select the code used to identify the status of the patient at discharge.
13. From the Ongoing Frequency drop-down menu, select the third digit of the type of bill submitted on an institutional claim record to indicate the sequence of a claim in the beneficiary's current episode of care for continued care.
14. Transportation Options apply to HCBS or CORE billing. Talk to your Program Manager for details.

Treatment Plan/Review is used to define the regulatory treatment plan/review due dates.

This setting will auto-set the next due date on the treatment plan and establish a basis for a rule flag setting that can be turned on at the visit level requiring a valid treatment plan to select a billable visit type on a progress note.

1. Use Treatment Plan/Review Option #1 will calculate the Due Date of Reviews based on the Date Completed of the previous Treatment Plan or Review.
2. Use Treatment Plan/Review Option #2 will calculate the Due Date and Date of the next review of Treatment Plans and Reviews based off of the Admit Date on the Chart.
3. Use Treatment Plan/Review Option #3 (NYSCRI Phase 2 IAPs) will calculate the Due Date of the first IAP and IAPR based off of the Admit Date of the Chart.
   • The Due Date of the subsequent IAPRs are based off of the Completed Date of the previous IAPR.
4. Use Treatment Plan/Review Option #4 (Custom) to allow you to set a custom date with the option to review a specified number of days after the Admit date and/or Last Review date for a specific frequency over a set duration.

1. Under Assessment, enter the number of days after admission that the assessment must be completed.
2. Check the box for TA07A_12 to enable all signatures on the review or hide certain signatures.
3. Check the box for NYSCRI to leave the Supervisor Signature on Review open, if it isn't captured at the time of the other signatures.
4. For the TP Due Date > Warning Period, entering a number will color the entry in the status list and the chart header differently if the treatment plan is due within this number of days.
5. Check the box under Progress Notes to use the last saved goals if there isn't a completed treatment plan.
6. Under TGI Treatment Plan (TGI_TP), check the boxes to hide or add signature tabs.
7. Under Valid Treatment Plan, select a treatment plan from the drop-down menu to require a specified treatment plan within a certain number of days after the Admit Date.

1. The Call Center Intake (CCI) Youth Age Range is used to determine if a patient is a youth when scheduling an appointment through the CCI.
2. When the box is checked for SA018_UA, the UA will not require an IHP Budget in order to be signed.
3. The checkboxes under PAS are used to hide the last tab, Orientation to Change on the PAS 44, Pas 45 Forms and exclude visits from PAS 45 count and only count from other notes.
4. Check the box for Service Thresholds to enable service thresholds at the program level.
5. Check the box for Send DFT Transactions to indicate that the program should send a DFT message when charges are processed under that program in My Billing.
6. Check the boxes under Scheduler to have the pop box for signature auto-open at the time of check-in for the Individual, Group or Copay Screen.
7. The Group Note Settings Note drop-down menu allows you to select the group note template for the program.
   • Check the box for Allow Non-Billable Visit Type with Client Attended to allow a non-billable visit type to be selected on a billable group.

MAR stands for Medication Administration Record.

1. Enter the allowable Minutes before a medication can be signed.
2. Enter the allowable Minutes after a medication won’t be late.
3. Check the desired boxes to create your MAR preferences.
   • Recommended settings:
     • Check the box for Use Current Dates as Start Date instead of Admit Date.
     • Check the box for Make MARS for a calendar month.
     • Check the box for Enable Warnings of expiring meds.
     • Check the box for Pull all meds instead of only meds since Start Date.
     • Check the box for Enable Dispensed Times until signed.
     • Enter a number in the Days to warn of expiring meds field to have advanced notice of expiring medications.
4. Enter the desired times that correspond with each frequency.

1. In the Days ends at time field, select when the day ends.
2. In the table, enter the desired days.
   • Frequency corresponds with days rather than times. Use the 1st Day, 2nd Day, and 3rd Day columns to specify what days of the week it corresponds to.

This tab allows you to add or remove headers, with a description, to the patient's chart header.

1. Check the box for Use Hours to use the table to select to define Crisis Hours and Non-Crisis Hours for the program.
   • These settings, along with the scheduled appointment time, determine whether a service occurs within Crisis Hours (After Hours) or within normal business hours.
   • In the screenshot example, Crisis Hours vs. Non Crisis Hours:
     • For Monday:
       • Crisis Hours are 8 am to 10 am and 5 pm to 9 pm.
       • Non Crisis Hours do not occur on Mondays.
   • After Hours Setup Example:
      

     After Hours		Standard Business Hours		After Hours
     12 AM	8 AM	8 AM	5 PM	5 PM	12 AM
     Start Time Before	End Time Before			Start Time After	End Time After

2. Check the box for Use Total Service Time Limit to enter the maximum minutes allowed per provider per day.
3. Check the box for Use After Hours Service Limit to enter the maximum after-hours services allowed per patient per day.

1. The Day Treatment Setup section is regarding billing.
   • Check the box for Use Day Treatment to utilize.
   • This type of billing is based on the minimum number of minutes per day.
   • The procedure is to be defined with the minimum and maximum minutes.
   • The bill is completed based on the sum of daily Progress Note durations.
2. Check to box for Use BHRS Billing under BHRS Setup to set the program as a BHRS Program and enabled BHRS Billing functionality.
3. Check the box for Use Case Management under Case Management Settings to bill specific to Mental Health and the use of Medicaid.
   • It is a form of billing for Case Management where you will need to set a threshold of Progress notes to be completed before you can bill.

PROS (Personalized Recovery Oriented Services) is unique to the PROS (NYS OMH) program.
 

1. The PROS Unit Conversion section calculates the minutes accrued and the unit assignment for the number of services.
2. The PROS Tier Setup section allows you to create billable tiers based on procedure type and units.
   • The Procedure column Identifies the type of procedure done.
   • This table allows you to establish the procedure that correlates with each billable tier.
   • This table allows you to create accrued max and min units per tier.
3. The PROS Time Exclusions section allows the user to create non-billable exclusion times.
   • The Exclusion Time column is the non-billable minutes in a day when minimum accrued.
   • eCR will subtract the exclusion minutes when calculating the total minutes for the day.

1. Check the box for Use OMH ActBilling under OMH ACT (Assertive Community Treatment) Setup if using OMH Act Billing.
   • Enter the Full Month Procedure and Half Month Procedure.
2. Check the box for Use ACTT Billing under ACTT Setup to set the program as an ACTT Program.
   • ACTT Billing is a fee-for-service program that caps billing so that only 4 charges can be billed per month per patient.
   • Additionally, no more than one charge can be created in a day.
   • Regardless of how the user screen is set up, for example if some users are set up to bill their own NPI, this program needs to always bill the NPI as the rendering provider.
3. Check the box for Use Prevention Billing under Prevention Setup to set the program as a Prevention program using Prevention billing.
   • Enter the Procedure, Minutes Per Unit and Rate per unit according to Prevention Rules.

1. Under Inpatient Daily, check the box for Use Inpatient Daily Billing to set the program as an Inpatient Billing Program, creating a billable charge daily.
   • Check the box for Include progress notes on inpatient charges to bill an Inpatient charge and a 2nd charge to My Billing.
   • Under Charge Creation:
     • Select the radio button to Bill Monthly on a Single Line or Daily Lines of service.
     • Or select the radio button to Bill All on a Single Line, Monthly Lines, or Daily Lines of service.
2. Under Inpatient Monthly, check the box for Use Inpatient Monthly Billing to do Inpatient Monthly Billing.
   • Enter the CPT Code in the Full Month Visit Type field.
   • Select the radio button for Use actual days in a month to count the actual days.
   • Or select the radio button for Use configurable days in a month and enter a number in the field.

1. HCBS/CFTSS Setup is for state reporting specific to Colorado. Talk to your Project Manager for details if you are in Colorado.
2. Check the box for Use CCBHC Setup to use CCBHC Billing.
   • Select a Procedure from the drop-down menu.
   • Choose any procedure Modifiers by clicking in the box.
     • A maximum of four modifiers can be selected.
3. Check the box for Use MOMS Setup to use MOMS Billing.
4. DARTS Billing is specific to Indiana. Talk to your Project Manager for details if you are in Indiana.
5. BHDS Setup is specific to billing to Beacon. Talk to your Project Manager for details.

E&M stands for Evaluation & Management, to be used with E&M + Assessment Progress Note (TGI_EMPNA) & E&M + Psychotherapy Progress Note v3 (TGI_EMPPNV3).

• Select an E&M Code from the drop-down menu.
• >Enter a Procedure name.

1. For IOS (Intensive Outpatient Services), set the time and procedure code requirements and thresholds for IOS program billing.
   • Using the radio buttons, select Hours or Minutes. 
   • In the Minimum Time/Day field, enter the minimum accumulated hours or minutes, depending on your select above, in a day of the specified service in order to bill that specific procedure code.
   • Select the IOS Procedure code from the drop-down menu.
2. For IOP (Intensive Outpatient Program), set the time, procedure code, visit requirements and thresholds for IOP program billing.
   • Using the radio buttons, select Hours or Minutes. 
   • In the Minimum Time/Day field, enter the minimum accumulated hours or minutes, depending on your select above, in a day of the specified service in order to bill that specific procedure code.
   • Select the IOS Procedure code from the drop-down menu.
   • Check the box for Ignore Visit Combinations if applicable.
   • The Visit Combination Name field is used to input the visit types that can be combined to meet the minimum hour threshold.
   • In the Quantity column, enter the number of visits per visit type required for IOP billing.
   • In the Visit Type column, select the visit type from the drop-down menu.

HCBSW stands for Home and Community-Based Services Waiver.

• An HCBS Waiver provides services and supports for adults and children of all ages and their families in their own home or community rather than institutions or other isolated settings.
• An HCBS Waiver allows Medicaid to pay for some services not normally provided through Medicaid.
• The waiver is ONLY available in all of the New York state’s counties and the boroughs of New York City.

ICC stands for Individualized Care Coordinating.

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