Limit Class


Elkhart, Indiana
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This is specific to Indiana Anthem Medicaid: We have one Care Connect client in behavioral health whose claims are being denied since August of 2015 for Ordering/Referring/Prescribing or Attending Provider's NPI is missing or invalid. We have billed group therapy done by an LCSW under the supervising MD with the MD's info in Boxes 17 and 24J. We have also billed E/M services provided by the same MD. All are denying. The only response from customer service is that the claims are missing the limit class. No one seems to be able to tell us what that is or where it goes on the claim; not even so much as information is missing in Box ... If anyone can please help us we would be very appreciative.
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I found this, although it doesn't mention what a Limit Class is; it DOES however discuss that members can't be referred by their primary medical provider (or be treated for the same condition by him/her) :confused: I don't understand why they wouldn't want a collaborative effort with the patient's PCP, but... okay I guess. (I also found something that mentioned restrictions for Care Connect and mental health services for certain age groups, a max benefits situation, but lost the link).

Coordination of Physical and Behavioral Health Services
As a network Provider, you are required to notify a Member’s Primary Medical Provider when a Member first enters behavioral health care and anytime there is a significant change in care, treatment, medications or need for medical services. You must secure the necessary release of information from the Member or the Member’s legal guardian. You should provide initial and summary reports to the Primary Medical Provider on at least a quarterly basis. The minimum elements to include are:
- Patient demographics
- Date of initial or most recent behavioral health evaluation
- Recommendation to see Primary Medical Provider, if medical condition identified or need for evaluation by a medical practitioner has been determined for the Member (e.g., EPSDT screen, complaint of physical ailments)
- Diagnosis and/or presenting behavioral health problem(s)
- Prescribed medication(s)
- Behavioral health clinician’s name and contact information

Psychologist or Licensed Clinical Social Worker (LCSW)
The following criteria should be met before directing a Member to a psychologist or Licensed Clinical Social Worker:
- Identifiable stressor is present
- Member is not taking psycho-actives
- Member not referred by Primary Medical Provider, not under Primary Medical Provider treatment for relevant problem
- Problem not recurrent, not greater than six months duration
- Problem not severe or disabling in any area of functioning

Hoosier Care Connect Members who would benefit from case management services, but either actively choose not to participate or are unable to participate, may be managed through a provider-focused program. Providers who serve Hoosier Care Connect Members engaged in care management shall participate in semiannual care conferences with an interdisciplinary care team. The goal is to coordinate services for Hoosier Care Connect Members across the care continuum. Providers may bill for the semiannual conference using HCPCS code 99211 SC.

Have you tried asking your provider representative?
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