Effective 712009

1
Blue Cross of Northeastern Pennsylvania Act 62
Autism Mandate Orientation

• Effective 7/1/2009

2
Pennsylvania's Autism Insurance Act (Act 62-
2008)

• Act 62 requires private health insurance
  companies to cover the cost of diagnostic
  assessment and treatment of autism spectrum
  disorders (ASD).
• Act 62 coverage information
• Applies to children under the age of 21
• Insured employer groups having 51 or more
  employees upon group renewals
• Customer service can assist in determining if the
  group has 51 employees
• CHIP Program renews on February 1, 2010
• adultBasic Program renews on October 1, 2009
• Maximum benefit of 36,000 per year of our
  contracted rates
• Coverage is subject to copayment, deductible and
  coinsurance as they would be for other covered
  medical services and any other general exclusions
  or limitations
• Once the member reaches the 36,000 they may be
  eligible for additional Medical Assistance (MA)
  program benefits.

3
Pennsylvania's Autism Insurance Act (Act 62)
continued

• Pharmacy
• Prior authorization is required for employer
  groups that do not have a pharmacy benefit
• Prior authorization can be obtained by contacting
  Express Scripts at 1.877.603.8399
• If the group does have a pharmacy benefit, no
  prior authorization is required.
• Pharmacy charges will not accumulate towards the
  36,000 benefit cap
• Contact Customer Service Representatives at
  the following phone s to verify member
  benefits, eligibility and information on
  accumulated ASD services.
• FPLIC PPO 1-866-262-5635
• FPLIC Traditional/Major Medical 1-888-827-7117
  
• EPO 1-888-345-2353
• FPH 1-800-822-8752
• FEP (Federal Plan) Check back of card for phone
  number
• BlueCard Check back of card for phone number
  

4
BCNEPA Medical Policy and other resources

• Medical Policy
• The BlueCross of Northeastern Pennsylvania Autism
  Spectrum Disorder Medical Policy is attached and
  will be available on BCNEPAs Provider Center at
  www.bcnepa.com or via the link on Navinet on
  7/1/2009.
• Check your Provider Bulletins for updates
• Another resource is the DPWs site
• http//www.dpw.state.pa.us/servicesprograms/autism
  /act62/
• The Frequently Asked Question and Answers section
  maybe helpful.

5
Covered Diagnosis codes for Medical Management of
ASD
6
Pennsylvania's Autism Insurance Act (Act 62)
continued
7
Treatment Plan requirements

• Treatment of ASD must be identified in a
  treatment plan and should include any medically
  necessary pharmacy care, psychiatric care,
  psychological care, rehabilitative care including
  applied behavioral analysis, and therapeutic care
  that is
• Prescribed, ordered or provided by a licensed
  physician, licensed physician assistant, licensed
  psychologist, licensed clinical social worker or
  certified registered nurse practitioner.
• Provided by an autism provider.
• Provided by a person, entity or group that works
  under the direction of an autism service
  provider.

8
Treatment Plan and Continuity of care

• The provider is responsible for maintaining a
  copy of the autism assessment and treatment plan,
  to be made available upon request.
• Prior Authorizations will not currently be
  required for ASD services. Although we are not
  requiring prior authorization while the member is
  utilizing their private insurance coverage, we
  encourage providers to continue to request
  authorizations from Community Care Behavioral
  Health Organization/Medical Assistance (CCBHO/MA)
  to avoid possible claim rejections upon
  transition of care.
• Please be advised, some Highmark HMO
  Products may required prior authorizations
• In an effort to administer a smooth transition
  between plan coverages, a notice will be mailed
  to members advising them that they have
  accumulated 25,000 worth of ASD services.
• We encourage providers to work closely with
  the families to keep informed of the dollar
  amount accumulated. Providers can also contact
  customer service to obtain information regarding
  the members accumulated amount.

9
Provider Reimbursement

• BCNEPA/FPH/FPLIC will follow the current standard
  fee schedules and contract rates. These fee
  schedules will include
• Therapeutic Behavioral Services (H2019)
• Community Based Wrap Around Services (H2021)
• Mental Health Service Plan Development (H0032)

10
Billing Guidelines

• Professional Claims must be submitted on the
  NUCC-1500 Form
• When billing First Priority Health claims, please
  be sure to list the Autism Spectrum Disorder
  diagnosis codes as the primary diagnosis codes on
  claim.
• When billing for First Priority Life Insurance,
  line item procedure codes must ONLY reference an
  Autism Spectrum Disorder diagnosis code.
• Multiple diagnosis codes referenced via the
  diagnosis pointer (on 1500 form) will not process
  accurately.
• Please bill ASD claims according to CPT Code
  Standard Guidelines
• Providers billing for Behavioral Health
  Rehabilitation Services (BHRS) must list the
  supervising psychologist or psychiatrist in the
  rendering provider field.
• Attached is the BCNEPA Billing Guidelines

11
Billing Guidelines continued

• Facility claims are to be submitted on the NUBC
  UB-04 form. Remember to include the NPI and
  Taxonomy Code.
• Claims Addresses
• BlueCross/Major Medical/FPLIC
  First Priority Health- HMO
• Claims
  First Priority Health
• P.O. Box 890179
  P.O. Box 69699
• Camp Hill, PA 17089-0179
  Harrisburg, PA 17106-9699
• Federal Employee Program (FEP)
  BlueCard Claims
• Highmark Blue Shield
  Highmark Blue Shield
• P.O. Box 898854
  P.O. Box 890062
• Camp Hill, PA 17089-8854
  Camp Hill, PA 17089-0062
• Electronic billing- See attached billing
  guidelines

12
Rejection Codes/Messages once maximum 36,000
benefit cap has been met/exceeded

• Once a member has met or exceeded their ASD
  benefit limit of 36,000, the provider remittance
  advices will show the following rejection codes
  and description per product line
• For First Priority Health (FPH) -BL0
  Meets/exceeds the ASD benefit limit for service
  rendered and a ANSI (American National Standards
  Institute) adjustment reason code of PR 119
  (patient responsibility). PSO Not covered
  charge(s) and ANSI adjustment reason code of PR
  96 with a remark code of N174.
• For First Priority Life Insurance Company (FPLIC)
  and out of area claims- X8851 the maximum
  benefit available under the patients coverage
  for ASD services has been paid. Therefore, no
  payment can be made. Along with this an ANSI
  adjustment reason code of PR 119.
• Descriptions of adjustment reason codes can be
  found on the Washington Publishing Company at
  www.wpc-edi.com

13
Sample NUCC 1500 Form
14
Attachments

• Listing of the alpha prefixes utilized by Blue
  Cross of Northeastern Pennsylvania (BCNEPA),
  First Priority Health (FPH) and First Priority
  Life Insurance Company (FPLIC). Prefixes that do
  not appear in this listing should be considered
  out-of-area.
• Product Reference Guide
• BCNEPA Billing Guidelines
• ASD Medical Policy
• ASD Fee Schedules

15
Contact Information

• If you have any questions please contact your
  Provider Relations Consultant.
• If you do not know who your consultant is you can
  call our Provider Relations Department at
  570-200-4700