8 Steps to Ensuring Successful Billing Dec 2016

1 Health Home Provider Billing Readiness Manual – BTQ Financial

8 Steps to Ensuring Successful
Billing for Members in the
Health Home Program:

The Care Management Agency Billing Readiness Manual

Last Edited in December, 2016

2 Health Home Provider Billing Readiness Manual – BTQ Financial

3 Health Home Provider Billing Readiness Manual – BTQ Financial

Table of Contents

8 Steps to Ensuring Successful Billing for Members in the Health Home Program: .................. 1

Introduction .......................................................................................................................... 6
A Letter to Care Management Agencies ......................................................................................... 7
Who is BTQ Financial..................................................................................................................... 8
Services Offered....................................................................................................................................8

Billing ............................................................................................................................................................... 8
BTQ Portal........................................................................................................................................................ 8
Help Desk......................................................................................................................................................... 9

How This Manual Is Organized..................................................................................................... 10
Purpose and Recommendations.........................................................................................................10

The 8 Steps of the Tracking and Billing Process .................................................................... 12

........................................................................................................................................... 13
Step 1: Pre-Qualify New Member ................................................................................................ 14
Check Medicaid and Health Home Eligibility ......................................................................................15
Check If Member Is Already Working With Another Agency in MAPP ...............................................15

When looking up one member at a time using the “Member Search Report”:........................................ 15
When looking up multiple members at a time (up to 1,000) using the “Member CIN Search”: .............. 15

Step 2: Document Activity ........................................................................................................... 18
Perform Activity And Document Activity............................................................................................19
Complete Consent...............................................................................................................................19
*Directly Enter Encounter Information Into the BTQ Portal ..............................................................19

Step 3: Complete HML Survey...................................................................................................... 22
Complete HML Survey ........................................................................................................................23

Step 4: Review Tracking Submission and Resolve Errors ............................................................... 24
Review Tracking Submissions .............................................................................................................25
Resolve Errors .....................................................................................................................................26

Common Tracking Errors ............................................................................................................................... 26

Step 5: Review Eligibility and HML “Missed Claims” and Resolve Issues ........................................ 28
Review Issues With Eligibility..............................................................................................................29

Re-certification .............................................................................................................................................. 29

Review Issues with HML Surveys ........................................................................................................30

*Confirming HML........................................................................................................................................... 31

The Missed Claims Report...................................................................................................................31
The Enrollment File Report .................................................................................................................32
Step 6: Track Claims Submitted For Billing.................................................................................... 34
Review the Monthly Submissions and the NYS Billed Vs. Enrolled to track billing ............................35

*Specifics of the Medicaid Billing Cycle......................................................................................................... 36
Additional Program Billing............................................................................................................................. 37
Adult Homes .................................................................................................................................................. 38
HCBS Assessments......................................................................................................................................... 38
AOT Billing ..................................................................................................................................................... 38

Step 7: Track Payments and Accounts Receivables ....................................................................... 40

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Collection Targets .......................................................................................................................................... 41

Track Payments...................................................................................................................................41
Track Denials .......................................................................................................................................42

Denial Code Breakdown ................................................................................................................................ 42
Denial Types .................................................................................................................................................. 43
Denial Resolution........................................................................................................................................... 43

BTQ Steps .................................................................................................................................................. 43
CMA Steps ................................................................................................................................................. 43
Final Adjudication Denials......................................................................................................................... 43

Write Offs............................................................................................................................................44
Track Accounts Receivable..................................................................................................................44
Review the Health Home Snapshot ....................................................................................................44
Step 8: Track Disbursements........................................................................................................ 46
Track Disbursed Payments and Claim Level Detail .............................................................................47

Conclusion:.......................................................................................................................... 48

Glossary of Terms................................................................................................................ 50
Assertive Community Treatment (ACT): ....................................................................................... 51
Assisted Outpatient Treatment (AOT): ......................................................................................... 51
Behavioral Health Organization (BHO): ........................................................................................ 51
Care Management:...................................................................................................................... 51
Client Identification Number (CIN): .............................................................................................. 51
Claims Payment: ......................................................................................................................... 51
Data Exchange Agreement Application (DEAA):............................................................................ 51
Designated Health Home Provider: .............................................................................................. 51
Dually Eligible Individual:............................................................................................................. 51
eMedNY:..................................................................................................................................... 51
Fee-for-Service (FFS) Member:..................................................................................................... 52
Functional Assessment of Cancer Therapy for General Populations (FACT-GP©): .......................... 52
Health Home Service Provider: .................................................................................................... 52
Health Home Services:................................................................................................................. 52
Health Home Eligible: .................................................................................................................. 52
Health Information Exchange (HIE): ............................................................................................. 52
Managed Care Organization/Plan (MCO or MCP): ........................................................................ 52
Outreach and Engagement: ......................................................................................................... 52
Targeted Case Management (TCM): ............................................................................................. 52

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6 Health Home Provider Billing Readiness Manual – BTQ Financial

Introduction

7 Health Home Provider Billing Readiness Manual – BTQ Financial

A Letter to Care Management Agencies

Dear Partners,

From all of us here at BTQ Financial, we would like to welcome you to our organization and thank you
for entrusting us with your administrative and billing functions. We understand and truly value the
amazing work that your organizations do and are honored to be a part of the process on behalf of your
lead Health Homes.
As the Health Home program evolves and the future of care management unfolds, we would like to
assure you that BTQ will be standing by your side and ensuring that your agency can thrive financially.
We pride ourselves on providing the highest level of customer service to all of our clients as well as on
our ability to create the tools and systems necessary for our clients to succeed.
Throughout our tenure working in the public health sphere our motto has been, “Your mission is to
change the world. Ours is to help.” And that is exactly what we plan on doing with your wonderful
organizations.

Sincerely,
The Team at BTQ Financial

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Who is BTQ Financial

BTQ Financial has been providing solutions and serving the non-profit and public sectors for over thirty
years. Over the years BTQ has worked on various issues affecting the public health sphere in New York
City, including the HIV/AIDS epidemic, substance abuse programs, and various affordable housing
initiatives. In more recent years, BTQ has become the premier provider of outsourced fiscal and
accounting services for non-profit organizations, utilizing our vast industry experience to help support
our partners’ efforts.

In 2012, BTQ Financial first began working in the Health Home program, while it was still in the
beginning stages of implementation. The Health Home program, an initiative that came out of the
Affordable Care Act passed in 2010, aims to improve patient care and reduce unnecessary emergency
room visits by some of New York State’s most at risk populations. The program aims to do this through
expanded and standardized care management efforts, which is the main responsibility of the Health
Homes that take part in the program. A large part of this work revolves around successful
documentation, billing, and the financial management which BTQ Financial has been aiding Health
Homes with since the very beginning.

Within a few months of getting involved in the program, BTQ developed the BTQ Health Home Portal,
the leading Health Home billing and reporting software in the United States. The BTQ Portal is now
handling the billing and tracking of over 50% of all of the patients involved in the Health Home program,
a number which is still growing to this day.

Key Facts about BTQ:

• BTQ currently has over 50 clients, primarily non-profits, including 12 Health Homes

• BTQ is currently managing over $500 million per year in operations for its clients

• BTQ has over 120 full-time staff resources: direct staff and contracted staff

Services Offered
BTQ’s services include fiscal and accounting, revenue cycle management, administrative support and
consulting support on program expansion initiatives. This manual illustrates the process workflow BTQ
has developed specifically for the Health Home program.

Billing
BTQ primarily provides end to end revenue cycle management for the Health Home program and
beyond. The dedicated staff has expertise in billing at the CMA, MCO, and Health Home level. BTQ
provides collections and AR management, payer negotiations and follow up, disbursement services, and
more.

BTQ Portal
To maintain and report on all of these key functions, BTQ Financial provides a fully functional online
portal that transmits all Tracking information to New York State, which is built specifically to adhere to
technical specifications required by the NYSDOH.

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The BTQ Portal for the Health Home Program.
Help Desk
BTQ provides each of its clients, is an on-demand Help Desk platform. BTQ responds to all inquiries
within 4 hours with dedicated staff for answering all manners of questions related to the Health Home
program. Any questions that arise during the review of this manual should be directed to the Help Desk
which is available at [email protected] or by calling (646) 699-4969.

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How This Manual Is Organized

This manual is written for the Care Management Agencies contracted with the Health Homes that work
with BTQ Financial. As such, it describes the ideal process workflow that guarantees the successful
documentation and billing of each patient encounter, in 8 easy-to-follow steps.

Each section of the manual also contains the relevant reports and pages in the BTQ Portal that provide
insight into each of the processes described. At the back of the manual, readers will also find a
Frequently Asked Questions section, as well as an appendix of need-to-know terms.

Purpose and Recommendations
The purpose of this manual is to provide Care Management Agencies all of the tools they need to
successfully manage and bill for their patients through their lead Health Home. In addition this manual is
meant to be a reference guide to be reviewed when staff at Care Management agencies have questions
about BTQ Financial and/or the billing and tracking process.

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The 8 Steps of the Tracking and
Billing Process

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Step 1: Pre-Qualify New Member
• Check new member for Medicaid and Health Home Eligibility prior to activity in e-MedNY
• Check member to ensure another agency is not already working with them using MAPP

Step 2: Document Activity
• Document activity in the Health Home EMR/CMS according to the Health Home lead rules

Step 3: Complete HML Survey
• Complete HML survey no later than 2 weeks after the activity is performed in the EMR/CMS

Step 4: Review Tracking Submission and Resolve Errors
• Check any tracking errors using the “NYS Tracking Errors” report and resolve them

Step 5: Review Eligibility and HML “Missed Claims” and Resolve Issues
• Check the “Missed Claims” and the “Enrollment File” reports and resolve any issues

Step 6: Track Claims Submitted For Billing
• Review the “Monthly Billing Submissions” report and the “NYS Billed Vs. Enrolled” to track billing submissions

Step 7: Track Payments and Accounts Receivable
• Review the “Remittance Report,” the “A/R Report”, and the “Health Home Summary” report to track payments received by

the Health Home

Step 8: Track Disbursements
• Review disbursement reports to track payments deposited

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Step 1: Pre-Qualify New
Member

Check new member for Medicaid and Health Home Eligibility prior to activity in e-MedNY
Check member to ensure another agency is not already working with them using MAPP

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BTQ Financial strongly encourages all CMAs to at least check two factors before beginning work with a
patient, if they don’t already do so, in addition to following any specific Health Home policies.

Check Medicaid and Health Home Eligibility
Care managers should check a patients’ eligibility for Medicaid, as well as the Health Home program,
using the e-MedNY system before performing any billable work. Failure to do so means that work
performed will potentially not be billed until the eligibility has been re-certified. Problems with eligibility
are consistently one of the largest issues preventing billing, and it is BTQ’s recommendation that
eligibility be checked early and often. BTQ also provides information on members Health Home and
Medicaid eligibility, however, the BTQ Portal currently checks only members on the Enrollment File.
Since this may not apply to new members, this precautionary check in e-MedNY is highly recommended.

Check If Member Is Already Working With Another Agency in MAPP
Care managers should look up the members in MAPP to check if another HH is already working with the
member or might intend to work with the member.

When looking up one member at a time using the “Member Search Report”:
Check to see if another Health Home is already working with the member by clicking on the “Start Date”
column header in the “Health Home History” section to sort the rows in chronological order. Check to
see if the month in which you intend to begin services lies between the “Start Date” and “End Date” of
the most recent row. If it does, or if there is no “End Date” value, you cannot serve the member during
that month.

Note: These instructions assume another CMA or HH is associated with the most recent row. If it’s your
CMA within the correct Health Home, then BTQ has already reported your services with the member to
MAPP and there’s no issue.

Check to see if another Health Home might intend to work with the member by checking the “Assigned
Health Home” at the very top of the Member Search Report, to the right of their name and CIN. Do not
check the column header in the “Health Home History” section for this purpose.

When looking up multiple members at a time (up to 1,000) using the “Member CIN Search”:
Check to see if another HH is already working with the member by checking to see if the month in which
you intend to begin services lies between the “Begin Date” and “End Date” columns. If it does, or if there
is no “End Date” value, you cannot serve the member during that month.

Note: These instructions assume another CMA or HH is associated with the member. If it’s your CMA
within the correct Health Home, then BTQ has already reported your services with the member to MAPP
and there’s no issue.

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Check to see if another HH might intend to work with the member by checking the “Assigned Health
Home Name" column.

An example of a member’s history as it appears in MAPP.
Both of these pre-qualification checks will ensure that any data submitted to BTQ has the highest chance
of making it through to the billing process with no issues.
For additional questions regarding best practices for performing the care management work, please
consult your agency and Health Homes’ policies and procedures.

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Step 2: Document Activity

Document activity in the Health Home EMR/CMS according to the Health Home lead rules

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Perform Activity And Document Activity
Upon pre-qualification of the member’s Medicaid and Health Home eligibility status, the Care Manager
is free to work with the member. As per the rules of the program, each encounter must then be
documented properly in the Health Home’s designated EMR/CMS.

Patient demographic and encounter data is transmitted from the EMR/CMS into the BTQ patient portal.
This process is performed daily as long as the Health Homes or support staff send over the encounter
information in a timely fashion.

BTQ Financial runs a series of quality checks at the time of the upload to ensure that information coming
in to the BTQ Portal is accurate and can be interpreted by the State MAPP Portal. Issues with extracts
are generally rare and almost never require the intervention of the Care Management Agencies. Still,
occasionally CMA staff might be contacted by their lead Health Homes to correct certain information in
the EMR/CMS, in the case where there is not enough information available to be able to resolve a
problem with encounter.

Complete Consent
There are three different types of consent that can be given by, or on behalf of, a member: consent to
enroll, consent to share information, and consent to share information protected services. Consent, like
an Outreach or Enrolled service period, has a begin date and an end date. A member’s consent
information must be entered into the appropriate system per your Health Home’s workflow.

Please note: Before a child member (defined as a member under 18 or a member between 18 and 21
being served as a child) may be added to the Enrollment file in an Enrolled status, consent to enroll must
have already been recorded such that the member’s Enrolled service period is “covered” by the consent
period.

*Directly Enter Encounter Information In the BTQ Portal
If the Health Home does not yet have an EMR/CMS, the Care Management Agencies (CMAs) can input
patient demographic, HML, and encounter data directly into the BTQ Portal interface. Please consult
your lead Health Home for clarification on which system they have designated for patient management
and encounter entry.

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*For specific information on how to use the BTQ portal to enter in information, please see the attached
guide in the BTQ Portal FAQs section entitled, “BTQ Health Home Portal: User Manual for Care
Managers.”

The direct entry interface available in the BTQ Health Home portal.

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Step 3: Complete HML Survey

Complete HML survey no later than 2 weeks after the activity is performed

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Complete HML Survey
HML, which stands for High, Medium, and Low, is the replacement of the Acuity Score, and is used to
determine reimbursement rates owed to providers based on a patient’s medical condition. The HML
questionnaire must be filled out for all patients in order for billing to occur each month.

An example of the HML questionnaire available in the portal.
HML can be entered into the system in one of two ways. The direct entry method is available in the
portal and can easily be accessed for each patient. However, the majority of HML information is
transmitted to BTQ directly from the EMR/CMS by the Health Home.
Changes to HML surveys that are submitted after an initial entry will override the initial record. In
addition, it is recommended that HML surveys be submitted no later than 2 weeks after the activity was
performed.
For members that are part of any additional programs, such as Adult Home, HML should be filled out
after the appropriate number of required visits have been completed.
If you are unsure of where to enter in HML information, or have more specific questions about when
HML surveys should be entered, please consult your Health Home lead for additional guidance.

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Step 4: Review Tracking
Submission and Resolve Errors

Check any tracking errors using the “NYS Tracking Errors” report and resolve them

25 Health Home Provider Billing Readiness Manual – BTQ Financial
Once activities have been performed and documented, along with corresponding HML surveys, BTQ
submits the information it has received from the encounter extract to the State. It is by this process that
new patients get fully enrolled into the Health Home program.
The BTQ Portal pre-processes the information to ensure that submissions to MAPP follow the
appropriate Health Home guidelines. This ensures that any potential issues are caught as quickly as
possible so that CMAs have the ability to resolve those issues in a timely manner.
Review Tracking Submissions
Tracking data performs the following actions:
 Adds members to the MAPP Enrollment file in an Outreach or Enrolled status
 Dis-enrolls members from the MAPP Enrollment file
 Removes members from the MAPP Enrollment file (if they were submitted erroneously)
Tracking is submitted for each Health Home on a daily basis. The time that this takes is dependent on
the file size of the tracking submission. The State MAPP portal sends back 2 response files for each
submission. One consists of the accepted records, and the other consists of all the records that came
back with an error.
Once the responses come back from the State, BTQ uploads the State response file back into the BTQ
portal, thereby matching up all encounters received by the State to all the encounters submitted by
BTQ.

A screenshot of the Tracking Submission report follow.

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Resolve Errors
After the accepted records are uploaded back into the BTQ Health Home Portal, BTQ and the CMAs
resolve any “Tracking Errors” that occurred during this process.
Such errors occur when the MAPP QA validation identifies an issue in the data generated by the BTQ
Health Home Portal, and they prevent the above actions from succeeding.
These errors are displayed in the BTQ Health Home Portal’s Tracking Error Summary Report. The BTQ
portal automatically sweeps all errors each tracking cycle to see if error has been resolved. However, it
is vital that Care Management staff is constantly reviewing, investigating, and resolving issues
preventing members from getting onto the Enrollment File.

Tracking error report in the BTQ Portal.
Common Tracking Errors

• “As of <MMDDYYYY> the member is not eligible for Medicaid” – This error describes a
patient whose Medicaid Eligibility has run out. These errors only occurred in the HCS
portal and thus only affected some historical segments. In MAPP, eligibility issues no

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longer prevent patients from being added to the enrollment file. These are now caught
in the following step. BTQ resolves all new Eligiblity Errors on behalf of the Care
Management Agencies.

• “Overlapping segment w HH MMIS ID <12345678> <MMDDYYYY> to
<MMDDYYYY>” – This occurs when a part of the segment being submitted overlaps
with a segment submitted by a different Health Home. BTQ will submit all months that
do no overlap to maximize possible collections. Overlapping months are sent back to the
Health Homes and CMAs for attempted recovery.

• Demographic Errors – Issues with gender and date of birth are resolved by the BTQ staff
on behalf of all CMAs using information obtained from the MAPP portal.

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Step 5: Review Eligibility and
HML “Missed Claims” and
Resolve Issues

Check the “Missed Claims” and Enrollment File reports and resolve any issues

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Once activity information has been received and the member is on the Enrollment File, the activity is
queued up for the billing cycle. However, in order to avoid any unnecessary delays in billing due to
denials, the BTQ portal will do one final check for Medicaid and Health Home Eligibility as well as for a
completed HML survey and display any issues with either of those two things in the “Missed Claims”
report. It is important to note that the activities displayed in the “Missed Claims” report have never
been submitted for billing, so resolving those issues is extremely important in order to prevent any cash-
flow issues.
Review Issues With Eligibility
In preparation for billing, all data is swept for potentially billable activities and is compiled in the Billing
Roster file. BTQ then runs all potential claims on the Billing Roster file through eMedNY to check for
Medicaid and Health Home status as well. This is also done on the 1st of every month as well before
each weekly billing cycle. A report of all ineligible patients is available in the portal the following day. In
addition, the each time the eligibility is ran, an alert goes out from the Portal to all users.
Upon receipt of the eligibility status, the non-eligible claims are sent back to the Health Homes and
CMAs to be re-certified. Medicaid recertification retroactively re-instates Medicaid coverage for 3
months from the 1st of the current month. As such, it is imperative that patients are re-certified
immediately upon notice of the expiration. Any non-eligible claims that are older than 4 months are
unrecoverable.
The BTQ portal automatically sweeps for all re-certified patients and includes them in the following
billing cycle. Below is an excerpt of the report which details patients with Eligibility issues.

The Eligibility Managerial report as it appears in the BTQ Portal
Re-certification
A patient’s Medicaid can be re-certified by filling out the recertification form mailed to them, which is
the easiest option. If you do not have the recertification form, you can re-certify the patient online or

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over the phone through NY State of Health, which is New York State’s health exchange. Regardless of
the option you choose, you will need the following information:

 Social Security numbers (or document numbers for legal immigrants who need health insurance)

 Birth dates

 Employer and income information for everyone in the patient’s family

 Policy numbers for any current health insurance

 Information about any job-related health insurance available to the patient’s family
Re-certify online by following the steps below:

 Navigate to www.nystateofhealth.ny.gov.

 Click “Individuals & Families.”

 If the patient has a NY.gov ID, click the “Click Here to Login” button. If not, create an account for
them by clicking “Click Here to Register”. The patient will need an email address to which they
have access.

 Once logged in, follow the on-screen instructions to fill out and submit the health insurance
application.

To re-certify over the phone:

 Call 1-855-355-5777, and follow the spoken instructions.

 If necessary, you may refer the patient to their local Navigator. Navigators are certified in
helping people navigate the health exchanges and application processes. You can view
Navigator site locations here: http://info.nystateofhealth.ny.gov/IPANavigatorSiteLocations

Review Issues with HML Surveys
In the BTQ Health Home Portal, there are a number of reports available to admin personnel for the
purpose of identifying which patients currently do not have HML information filled out. Below is an
image of one of these reports. BTQ recommends that Care Management Agency staff review received
HML surveys and rectify any issues with missing information on a recurring basis.

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HML managerial reporting available in the BTQ Portal for CMAs.

*Confirming HML
HML surveys must be re-certified each month. If the information has not changed since last month, this
can simply be resubmitted on your behalf automatically. A batch confirmation option is also available in
the BTQ Health Home portal for easy re-confirmation. However, most EMR/CMSs will take care of this
process on the CMAs behalf.
The Missed Claims Report
Though issues with eligibility and HML are displayed in a number of places in the BTQ Portal, the
simplest way to review these issues are by checking the “Missed Claims Report.” This report is an at a
glance view of all work that is currently not able to be billed due to either of those two issues. It is
absolutely critical for agencies to be monitoring this report constantly and trying to keep the number of
these claims as close to zero as possible.

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As displayed here, the “Missed Claims” also estimates the amount of billing that is currently being held
back due to one of these issues.
BTQ Financial sends a notification out to all agencies as soon as the Medicaid Eligibility is run with
updated numbers on this report. It is crucial for agencies to make sure that the correct contacts at your
agencies receive this notification and can access this report.
The Enrollment File Report
One of the most comprehensive reports available in the BTQ Portal is the “Enrollment File Report” which
contains the detail-level data of a number of the summary reports discussed so far. The “Enrollment File
Report” can be used to resolve a number of different issues at the same time, as well as to get a high
level picture of your agencies’ current Enrollment File. In addition, its extensive filters allow for quick
views into specific segments of the Enrollment File.

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The Enrollment File Report as it appears in the BTQ Portal

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Step 6: Track Claims Submitted
For Billing

Review the “Monthly Billing Submissions” report and the “NYS Billed Vs. Enrolled” to track billing
submissions

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Once the activities that have passed all of the pre-requisites for billing have been compiled, BTQ sends
the roster of these claims to the Health Home for approval. In summary, claims to be billed must meet
the following minimum criteria, all of which should apply if all of the above steps have been followed:

 Patient must be enrolled in the Health Home program
 Patient must be Medicaid and Health Home eligible
 Patient must have at least one billable encounter
 Patient must have complete HML information

(with the Core Service Provided field marked as “Yes,” for certain Health Homes)
 Patient must be on the Enrollment File
The Health Home generally approves the Billing Roster within a few hours and gives BTQ the go-ahead
to bill.
Once approved, the Billing Roster is uploaded to the State MAPP portal. The MAPP portal then makes
the claims available for each of the MCOs to collect so that they may bill Medicaid.
**For the period of December 1st, 2016 to March 31st, 2017 BTQ will be submitting all claims to
Medicaid, until new guidance is provided from the State. However, since MCOs are slated to re-enter the
billing process in April, this section will discuss some of the details related to billing for them.
Review the Monthly Submissions and the NYS Billed Vs. Enrolled to track billing
BTQ Financial provides a whole suite of financial reports that detail various processes within the billing
workflow. At this step in the process, the key reports would be the Monthly Submissions Report and the
NYS Enrollment VS. Billing. The other reports are detailed at later points in this manual.

The Monthly Submissions Report as it appears in the BTQ Portal.

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The Monthly Submissions report pictured above shows a high level breakdown of the billing submitted
for the different payers. The member level detail is available in the “Detail” tab in the top left corner of
the report. This report is useful for anticipating the amount of billing revenue expected per month.

The NYS Enrolled Vs. Billed
The NYS Enrollment vs Billed report is a critical report for seeing the amount of billing that occurred
compared to all of the potential billing possible. This high level report is a good indicator of what can be
expected as far as revenue within a larger context. The estimated billable dollars can help agencies get a
fuller picture of what could potentially be collectable for a given month, if all of the billing criteria is met.
*Specifics of the Medicaid Billing Cycle
All approved activities for patients who are either Fee-For-Service Medicaid or any MLTC Provider, are
billed directly to Medicaid. Medicaid and MLTC claims are billed through eMedny using an 837 File
format. MLTC Claims are clearly marked with MLTC in the MCO name in the portal.
Every week BTQ downloads 835 Response Files from eMedny. Claims are paid in about three weeks as
per the usual Medicaid billing cycle. These 835 Remittances are posted in the BTQ Portal. BTQ bills all
claims each Monday and Tuesday. In order to meet that billing cutoff, activities must be entered by the
Thursday of the previous week.
Any claims not responded to after three weeks on an 835 File are re-billed by BTQ, as are any that can
be adjusted and re-billed.

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Schedule of Activity Entry Deadlines for Each Weekly Billing Submission starting December 2016
Additional Program Billing
Additional Billing for programs outside of the Health home are done on a monthly basis when a batch
file is sent to BTQ by the Health Homes. Some of the most important additional program procedures are
listed below.

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Adult Homes
The Adult Home rate codes are listed below:

1860- Health Home Services- Adult Home Transition (Billable by CMA)

1861- Adult Home Assessment and Management Fee (Billable by Health Home)

The Health Home Care Management Services – AH+ rates may be claimed by the Health Home or Care
Management Agency (CMA) if all of the following statements apply:

 The Health Home and CMA signed the required attestation form and returned to the
Department of Health;

 The class member enrolled in the Health Home and signed the Health Home consent form(s);

 The class member indicated an interest in transitioning from the adult home to the community;

 A care manager was assigned and the care plan was initiated within 7 business days of
enrollment;

The Adult Home Assessment and Management Fee (1861) is intended to support the lead Health Home
for the management of class members and may be claimed by the lead Health Home for class members
who are provided AH+ care management. BTQ bills these on behalf of the Health Homes.

Every Month the Health Home lead provides BTQ with a listing of all patients who have been seen and
qualify for each of the AH+ rates. It is the Health Home’s responsibility to ensure that all AH+
requirements are met as indicated as required by the DOH policy.

The Assessment and Management fee may be claimed by the lead Health Home for each month that a
Health Home Services – Adult Home Transition (1860) may be claimed (including months that four
contacts were not made as applicable.)

BTQ bills NYS Medicaid for all instances provided and ensures that regular Health Home services are not
simultaneously billed for the given month. BTQ reconciles to ensure that the 1861 code was billed in
each instance that a corresponding 1860 was billed.

HCBS Assessments
BTQ does not bill for directly for HARP Assessments (CMHA NYS Community Mental Health Assessment).
The state required workflow is that the CMHA are uploaded directly into the NYSDOH HCS portal and are
paid by the MCO/Medicaid from there.

BTQ does monitor the A/R Generated by the Assessments if provided the outstanding CMHA data by
either the Health Home or the Managed Care Plan.

AOT Billing
BTQ will bill any HH+ claims on behalf of the CMAs if the CMAs are currently contracted to do so.

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40 Health Home Provider Billing Readiness Manual – BTQ Financial

Step 7: Track Payments and
Accounts Receivables

Review the “Remittance Report,” the “A/R Report”, and the “Health Home Summary” report to track
payments received by the Health Home

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Once claims have been submitted, BTQ collects remittances from the payers as soon as they are
available. The remittances are then uploaded to the portal which keeps the record of all billed claims.
Often remittances come in without the corresponding payment or vice versa. In these cases, the BTQ
team will wait for both things to come in before posting.
The check details of any payments that come in are also posted to the Portal and can be viewed at any
time. All payments are monitored and reconciled in a timely fashion. Payments are generally deposited
electronically in a Health Home lockbox for easy access and reporting.
BTQ constantly strives to minimize the amount of time that claims and payments take to get through
our system. As such, BTQ posts remittances within 3 days of receipt at max. In general, remittances are
posted immediately if possible.
All claims are reconciled with the MCOs and Medicaid to ensure that no claims have been missed. At
each meeting with the MCOs, BTQ asks the payers to list all claims that it has received for each Health
Home. Any that have been sent but not received are immediately rebilled.
Collection Targets
With the announced changes to the billing process starting in December 2016, BTQ will be billing all
claims to Medicaid. For Medicaid billing the net collection target is 98% including denials.
Once MCO billing begins again in March, BTQ will update its billing targets accordingly.
Track Payments
Remittance reports are available in the BTQ Health Home portal to provide real time updates on any
payments coming in. A finance contact at the CMA should review these remittances to see what
payments are expected to come in.

The remittance report as it appears in the portal.

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Track Denials
Denial Code Breakdown
Denials are generally accompanied by a code that describes the reason for the denials was. g. In the
appendix, BTQ provides an abridged version of the State Denial crosswalk, which has the most common
denials as well as steps taken to resolve them. For an even more detailed look at all possible denials,
please contact BTQ for the “State Denial Crosswalk” which contains every single possible denial code, a
very large document.

Though the amount of denial codes are vast, they generally have the same overall reasons. Below is a
chart that explain the most common reasons.

Denial Reason Explanation

Claims denied due to eligibility are related to a patients Medicaid
status. As mentioned earlier, BTQ has put a new measure into place to
prevent this error by not billing (and thereby avoiding the long time
Eligibility delay) in an effort to encourage the speedy recertification of patients.
As such, any denials with this reason are likely to be for historical
claims submitted before the BTQ filter went into place in February of
2016.

Occasionally the MCOs will bill claims that are over 90 days old without
Modifier the proper modifier code. This denial is therefore a simple one that is

easily resolved by the MCOs with BTQs assistance.

Perhaps the largest denial issue is the paid to another provider. This
denial occurs when the claim which is being submitted has already
been paid to another provider and therefore, cannot be paid again.
Paid to Another Provider Largely a historical issue once again, it is the hope of BTQ, the State,
and the Health Homes that the amount of these denials will drop
significantly with the MAPP go-live, the implementation of daily
tracking, and the end to direct billing practices.

Rate code denials are simply caused by the incorrect submission of
Rate Code claims with the wrong rate code. These are rebilled and fixed

immediately.

A general “catch-all” category, these are the various different denials
which are a result of incorrect submissions. The number of specifics for
Pending Rebill
these are quite large but most importantly these are rebilled
immediately upon receipt.

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Denial Reason Explanation

Another general category, these denials are cause by incorrect
Demographics demographic information being submitted to Medicaid. These are

rebilled with the correct demographic information almost immediately.

Denial Types
BTQ categorizes denials into two broad categories, soft denials and hard denials. Soft denials can be
considered open, meaning that there are a numbers of ways in which the denial might be recoverable if
the appropriate action is taken. Hard denials on the other hand, are those that have gone through all of
the follow up steps and are considered non-recoverable. More on these denials and the write off
process below.

Denial Resolution
BTQ Steps
BTQ ensures that denied claims are rebilled numerous times until a resolution is achieved. Denials are
recognized and analyzed on a reoccurring basis. If a denial can be fixed and rebilled, rebilling occurs
twice a month. Examples of claims that can be adjusted and rebilled by BTQ involve:

 Demographics

 Missing Modifiers

 Rate Issues

 Pended Claims

CMA Steps
The only denials that requires CMA intervention are any that fall into the Eligibility Reason.
In order to prove an easy way of working these denial BTQ has developed the Missed Claims Report. It is
vital that a CMA assist patients on this report to get patients re-credentialed with Medicaid prior to 4
months passing from the Date of Service.
For a complete listing of patients not Eligible with Medicaid at any given time the CMA can also consult
the Medicaid Eligibility Report, covered earlier in the manual. Rebilling for Eligibility occurs automatically
once a patient is confirmed re-credentialed by BTQ.

Final Adjudication Denials
There are denials that cannot be fixed and rebilled as they are determined to be unrecoverable by
Medicaid. Examples of these are as follows:

 Paid to Another Health Home

 Timely Filing (Over 2 Years from Date of Service)

Paid to Another Health Home claims are those by which another provider has billed and been paid for
the activities prior to your Health Homes submission. At this time there is no recourse for successfully

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rebilling these. However- Medicaid has advised that such a mechanism may exist in the near future. At
that time BTQ will submit all of the claims that fit into this category to Medicaid for Payment.
Write Offs
Write offs are only processed after every other possible solution has been exhausted.
Quarterly (more frequent of requested) BTQ will submit to the Health Home lead all Denials for which a
final adjudication denial has occurred and recommend they are written off of the Open A/R.
These claims are submitted to the CMA for final approval and written off the Open A/R. The patient
activities that correspond with these are available in the Billing A/R Reports in the BTQ portal under the
Write Off category.
Track Accounts Receivable
Once claims have gone through the entire billing process and payments are coming in to the Health
Home accounts, CMAs should review the billing by checking the A/R Report in the portal.
The A/R Report is perhaps the most important financial report available in the portal, along with the NYS
Billed vs. Enrolled. The combination of these two reports allows the finance staff at any CMA to quickly
review their financial situation.

The A/R Report as it appears in the BTQ Portal
Review the Health Home Snapshot
A final report that is helpful in getting the overall “big picture” view of the CMAs current performance is
the “Health Home Snapshot.” This report pulls numbers from all of the other most important reports
found in the portal and puts them together in one place. Any administrative staff responsible for
monitoring enrollment, billing, and other issues should review this report on a recurring basis to ensure
that no anomalies appear anywhere in the report.

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The Health Home Snapshot as it appears in the Portal.

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Step 8: Track Disbursements

Review disbursement reports to track payments deposited

47 Health Home Provider Billing Readiness Manual – BTQ Financial
Once payments are received, reconciled, and posted, the BTQ Portal pulls together all recent payments
into a consolidated disbursement report. This report contains the high level breakdown of what was
received and for whom. CMAs can generally expect to get disbursement 35 days after the submission
date.
Track Disbursed Payments and Claim Level Detail
Agencies can track their disbursements and review claim level data in the BTQ Portal. The Disbursement
Report summarizes all checks and their corresponding amounts for each disbursement.
CMAs should review these disbursement reports and check their corresponding accounts to make sure
that all payments have in fact hit their bank.
Note: The Disbursement Report is currently being developed and will be available in the BTQ Portal on
December 30th, 2016

Example of disbursement reports.

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Conclusion:

The Health Home Billing process is complicated and involves multiple moving pieces and players. BTQ
hopes that this guide has clarified some of these pieces and that this has led to a greater level of
awareness and transparency into how billing through BTQ works. As we like to say at BTQ, “Your Mission
is to Create a Better World. Ours is to Help.” And we hope that this guide provides some of that help.
The rest of the manual contains a glossary of important terms.

For any additional questions that have not been answered by this manual or by the attached
documentation, or for any suggestions for improving upon this manual, please contact the BTQ Help
Desk available at [email protected] or by calling (646) 699-4969.

Otherwise, we look forward to serving your agencies in September and beyond.

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50 Health Home Provider Billing Readiness Manual – BTQ Financial

Glossary of Terms