Family Planning Eligibility and Billing

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Family Planning Eligibility and Billing

• Travis Duke

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Goals

• Understand changes to Title V, X, and XX
  eligibility guidelines
• Understand changes to Title V, X and XX billing
  policy
• Discuss Title V, X and XX payment for wrap
  around services provided to WHP clients.
• Discuss common billing issues

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Presentation Structure

• Eligibility Overview
• Changes to Eligibility Guidelines
• Billing Overview
• Changes to Billing Guidelines
• WHP Wrap Around Services
• New Procedures
• Common Billing Issues
• Q A

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Eligibility OverviewEligible Population

• Females (of childbearing age) and males, who
  have not had sterilization surgery or other
  condition resulting sterilization and who are
  seeking family planning services.

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Eligibility OverviewTitle V

• Income at or below 185 FPL
• Texas resident
• No fee or co-pay for clients at or below 100
  FPL.
• Co-pay may not exceed 25 of the authorized
  payment amount for services for clients between
  101-185 FPL.

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Eligibility OverviewTitle XX

• Income at or below 185 FPL
• Texas resident
• No co-pay for any client with zero income.
• Client co-pay may not exceed 25 of the
  authorized payment amount for services. (Note in
  a a X/XX clinic this requirement does not apply)

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Eligibility OverviewTitle X

• Income at or below 250 FPL
• No residency requirement
• No fee or co-pay for clients at or below 100
  FPL.
• A discounted fee schedule for clients between
  101 FPL and 250 FPL.

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Changes to Eligibility GuidelinesFamily
Composition

• The budget group consists of the applicant,
  his/her spouse, and all mutual and non-mutual
  children. If an unmarried applicant lives with a
  partner, ONLY count the partners income and
  children as part of the budget group IF the
  applicant and his/her partner have mutual
  children together. Treat applicants who are 18
  years of age as adults. No children aged 19 and
  older or other adults living in the household
  should be counted as part of the budget group.

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Changes to Eligibility GuidelinesIncome

• For unemancipated, unmarried clients UNDER 18
  years of age, if confidential services without
  the involvement of a principal family member are
  requested, only the client's income is used to
  assess eligibility.
• For clients who are married or are 18 years of
  age or older the income of all family members
  must be used.

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Changes to Eligibility GuidelinesIncome
Deductions

• Dependent Care Expenses
• 200 Per Month for Children Under 2
• 175 Per for Children Age 2 or Older

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Changes to Eligibility GuidelinesTitle XX
Co-payment at a Title X/XX Clinic

• Co-payment is no longer capped at 25 of the
  reimbursable cost of providing services
• Enables Title X/XX clinics to better implement
  the required sliding fee scale

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Billing Overview

• 2017 Family Planning Claim Form
• Filing Deadlines
• Initial Claims 60 days from date of service on
  the claim
• Appeals 120 days from date of the Remittance and
  Status report on which the claim reached a
  finalized status

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Billing Overview

• WHP claims must be held until the client is
  determined WHP eligible by HHSC
• If WHP eligibility has not been determined within
  35 calendar days from the date of service, a
  Title V or XX claim or a Title X encounter may be
  filed for the service

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Billing Overview

• Contractors must continue to file claims and
  encounters even if they have exhausted their
  budget

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Changes to Billing Guidelines

• After 35 days from the date of service
  contractors may file a Title V or XX claim or
  Title X encounter without verifying and
  documenting that a client is ineligible for WHP.
• Sterilization Complications

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WHP Wrap Around Services

• See Handout

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New Procedures

• J7303 Hormonal Vaginal ring, each - 35.80
  (9-1-07)
• S0180 Implantable contraceptive capsules
  (Implanon) - 585.11 (12-1-07)
• 11975 Insertion, implantable contraceptive
  capsules - 152.25 (12-1-07)
• 11977 Removal with reinsertion, implantable
  contraceptive capsules (12-1-07)

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New Procedures

• 87490 Chlamydia test, direct probe technique -
  27.71 (12-1-07)
• 87491 Chlamydia test, amplified probe technique
  - 27.71 (12-1-07)
• 87590 Gonorrhea test, direct probe technique -
  27.71 (12-1-07)
• 87591 Gonorrhea test, amplified probe technique
  - 27.71 (12-1-07)

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Rate Changes For IUDs

• J7300
• Rate prior to 4-1-07 321.13
• Rate after 4-1-07 387.60
• J7302
• Rate prior to 4-1-07 426.97
• Rate after 4-1-07 487.76

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Common Billing Issues

• CLIA Certification
• Family planning agencies can bill some lab codes
  to Title V and XX that can not be billed to Title
  XIX
• Most obvious when XIX retro-eligiblity occurs
• Retro-eligibility and rate differences between
  Title V/XX vs. XIX
• Appeals vs. Resubmission of New Claims

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Common Billing Issues

• Importance of submitting correct TPI/NPI at the
  beginning of the fiscal year
• NPI implementation and 3rd party billers
• Matching RS reports to payments

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• Questions
• Discussion

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• The End
• Travis Duke
• Travis.duke_at_dshs.state.tx.us