Wiki Help with 99213 and F11.20

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RTabacco

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Hello Everyone -

My clinic is small and non-profit. We mostly run on grants. We are just now trying to figure out how to bill insurances.

Our clients are the forgotten folks in the community; people living with HIV + AIDS, un-homed folks, drug users. Our goal is to provide care for these folks, keep them out of the ER, keep them safe, and help them get to the point where they can go into a larger clinic in our area for primary care. We are not contracted with any insurance yet. So this is who we are.

I am struggling with Molina as they are finding our claims as behavioral health and not medical, then denying the claims saying the patient should go to the larger clinic that is contracted with them. For most of our clients that is not an option.

We are billing out CPT 99213 with most often ICD-10 F11.20. In these visits we are trying to help the patient manage their opioid addiction with Suboxone. The ICD-10 F11.20 feel the most appropriate but Molina sees it as behavioral health when we are designated for medical. We see it as medical. Does anyone know of a way to make this work? Is there another DX code or modifier that should be added? Or do you have any other ideas?

Thank you
 
RTabacco said:
Hello Everyone -

My clinic is small and non-profit. We mostly run on grants. We are just now trying to figure out how to bill insurances.

Our clients are the forgotten folks in the community; people living with HIV + AIDS, un-homed folks, drug users. Our goal is to provide care for these folks, keep them out of the ER, keep them safe, and help them get to the point where they can go into a larger clinic in our area for primary care. We are not contracted with any insurance yet. So this is who we are.

I am struggling with Molina as they are finding our claims as behavioral health and not medical, then denying the claims saying the patient should go to the larger clinic that is contracted with them. For most of our clients that is not an option.

We are billing out CPT 99213 with most often ICD-10 F11.20. In these visits we are trying to help the patient manage their opioid addiction with Suboxone. The ICD-10 F11.20 feel the most appropriate but Molina sees it as behavioral health when we are designated for medical. We see it as medical. Does anyone know of a way to make this work? Is there another DX code or modifier that should be added? Or do you have any other ideas?

Thank you
Click to expand...

This isn't a coding issue. The issue is that you're not contracted with Molina.

There is no benefit for out of network services, whether it's medical or behavioral health.

From Molina's enrollee handbook for Washington state:


Page 8:

You must go to Molina Healthcare doctors, pharmacies, behavioral health providers, and hospitals.

Page 9:
Payment for health care services

As an Apple Health client, you have no co-pays or deductibles for any covered services. You might have to pay for your services if:
  • You get a service that Apple Health does not cover, such as cosmetic surgery.
  • You get a service that is not medically necessary.
  • You don’t know the name of your health plan and a service provider you see does not know who to bill.
  • You get care from a service provider who is not in our network and it is not an emergency or pre-approved by your health plan.
  • You don’t follow our rules for getting care from a specialist.



FWIW, on the Molina Washington website, the services you're providing do fall under the behavioral health benefit.

Behavioral Health

www.molinahealthcare.com www.molinahealthcare.com

Substance use disorder treatment services may include:
  • Initial evaluation and specialty follow-up evaluation as needed
  • Individual, group and/or family treatment services
  • Other outpatient services such as: peer support, case management
  • Intensive outpatient programs (IOP)
  • Opiate use disorder treatment program services that includes medications and/or therapy services
  • Withdrawal management (detoxification)
  • Substance use disorder intensive residential treatment, long term residential treatment and recovery house residential treatment

Molina has a list of behavioral health providers that serve the Greater Columbia region/Walla Walla county:

Behavioral Health Providers by Region

www.molinahealthcare.com www.molinahealthcare.com

Unfortunately, I don't think you'll be able to get reimbursed for services for Molina Medicaid patients as a non-contracted provider. This leaves you with limited options:

  1. Get contracted with Molina for behavioral health/substance abuse services
  2. Continue to accept Molina patients knowing you won't get reimbursed and use grant money to cover their care
  3. Don't accept Molina patients and refer them to an in-network provider for services

If there is a specific reason why a specific patient absolutely cannot receive care from one of the in-network providers, you may be able to negotiate a single-case agreement for that individual patient.

I can't speak to the likelihood of Molina agreeing to do a single-case agreement, but you could inquire. Remember it would need to be pre-approved before services were rendered for that specific patient. Getting contracted would still be your best bet if you'd like to continue treating Molina patients.

Good luck!
 
Correct.

For the record, all the links I provided in my post above are specific to Molina Medicaid for Washington State.
 
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