Do all Trigon Member Handbooks contain information about the Early Intervention Services (EIS), and where is this information located in the handbooks?
For groups with the early intervention benefits, the benefit books that are mailed to members when their group first enrolls (or each year at the group’s renewal) contain a section about EIS. The exact location of the EIS information varies, depending on what product the group has. Usually, it is found in the Outpatient Benefits section of the book (see the Table of Contents).
Will any "pre-existing condition" clauses impact the availability of these Early Intervention benefits for new Trigon groups?
If a group has pre-existing condition waiting periods, these would apply just as they would to any other benefits under the policy. The pre-ex waiting periods vary by market size and product. For example, HMO products don’t have pre-ex waiting periods, however all Trigon (non-HMO) products could, depending on the market segment. 100+ size groups have the option of removing the waiting period if they choose to buy that option.
With Personal Health Care policies, if policy is in the first year and does not have portability, does the pre-existing condition clause apply?
Yes. Pre-existing condition clauses may be applied to Personal Health Care policies.
What kind of information is being shared with self-insured groups about HB 1413 and the early intervention benefits?
As with all our group communications to fully or self-insured groups, the sales reps present Early Intervention Services as one of the July 1, 1998 state legislative and benefit changes that we, as a company, have added to our standard products. The information is outlined in our sales literature as well as our renewal letters that are mailed to our group customers several months prior to their renewal date.
As you are probably aware, self-funded groups are not under the jurisdiction of Virginia mandates; therefore, adding these benefits is optional for them. To understand this, over 50% of the non-HMO business on the books was self-insured, as of fall, 1998 when training sessions were conducted.
We have been told that the HMO network in Central Virginia is closed. Can the HMO networks be expanded if there is an identified need – if there are no HMO pediatric therapists in a particular area? What about other areas of the state?
The Network Administrator for Ancillary Provider Contracting manages the Trigon HealthKeepers (HMO) rehab networks for central and northern Virginia. The western region network (limited service area) is administered by the Carilion Health System facilities. Other Trigon affiliated HMOs - Trigon HealthKeepers by Priority Health Care and Trigon HealthKeepers by Peninsula Health Care – manage these networks in South Hampton Roads and on the Peninsula, respectively. Inquiries regarding network participation should be directed to the appropriate regional network administrator.
The Network Administrator (central/northern Va.) recently added a number of new Part C providers to the central region commercial and Medicaid networks. This effort was largely the result of mandated benefits for early intervention services as well as the Medallion II central Virginia expansion effective April 1, 1999. All Part C providers expressing an interest in network participation were requested to submit formal, written requests for consideration. Subsequently, Part C providers submitting executed agreements were accepted into the network(s), and the network expansion is currently complete for the central Virginia region.
Can a non-HMO provider render services for a Part C child and be reimbursed?
No. If the member is covered by an HMO product that does not provide out of network benefits, the member is be responsible for reimbursing the provider, not HealthKeepers. If the member has an HMO Point of Service product, they are eligible for out of network benefits but at a reduced payment level.
What is the Blue Card Program, and does HB 1413 apply to members who are insured by other Blue cross Blue Shield plans?
The BlueCard and BlueCard PPO programs allow persons living in other Blue Cross Blue Shield plan areas to access Trigon’s Par (with the BlueCard program) or PPO (with the BlueCard PPO program) networks for care. The benefits for the covered persons are the benefits sold to them by the Blue Cross Blue Shield plan where their company is located. Likewise, when a group in Virginia has employees living in another plan’s service area, if their group is covered under a KeyCare 10 product, the employee living out of state also is eligible for the KeyCare 10 benefits and they receive the higher level, in-plan benefits by using the PPO network of the state in which they live. This also applies for KeyCare and BlueCare members traveling, as opposed to living, outside the Trigon service area. Therefore if an employee of a Virginia group that has the EIS benefits lives in Colorado, that person is eligible for these benefits because their group is insured with a contract written based on Virginia law.
What is the definition of certification? What is the intent of authorization?
The definition of Certification: The Code of Virginia, Sections 38.2-3418.5 and 2.1-20.1 state that the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) must certify children as eligible for Part H [C] of the Individuals with Disabilities Education Act in order to access the benefits of the early intervention mandate. DMHMRSAS has determined that the Individualized Family Service Plan (IFSP) is the document that certifies eligibility for Part H[C]. In order to provide proof of certification, Part H[C] early intervention providers must submit a complete IFSP to Trigon (or its affiliated HMOs). Submitting the IFSP will help ensure that the early intervention benefit (if available to the child) is applied to claims for early intervention services indicated on the IFSP.
The intent of authorization: Some of Trigon’s benefit plans (Trigon Point of Service Plans, for example) require authorization for all therapy services, for services rendered by a Home Health Agency (HHA), and for durable medical equipment (DME). For any Part C candidate, Trigon is substituting the certification of eligibility (copy of IFSP) by the local interagency coordinating council as the medical necessity review portion of the authorization process.
What is the definition of medical necessity?
For the purposes of Early Intervention Services, House Bill 1413 defines medically necessary early intervention services as speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices designed to help an individual attain or retain the capability to function age-appropriately within his environment, and includes services that enhance functional ability without affecting a cure. Please refer to the preceding question for clarification about Trigon’s requirement of the IFSP, as proof of Part H [C] certification and medical necessity.
How will we know whether or not a child’s group has added this benefit for early intervention services? Is there a way that a non-Trigon provider (an agency Service Coordinator) can contact Member Services to access a child’s benefits? Can a release form be developed that allows agency personnel to contact Trigon? (Our Service Coordinators have not been able to access benefit information.)
The providers can call Trigon’s Member Services to obtain information on whether the child is eligible for the EIS benefits. They will need to have the information on the child’s ID card in order to complete the call. A non-Trigon provider can call as long as they have the same information. Under the Privacy Act we are able to provide member benefit information to "medical care institutions, which includes rehab agencies and public health agencies".
Sometimes the child is seen in the home and a copy of the member’s ID Card cannot be made (and we cannot get a copy from the child’s physician). What information can be submitted to Trigon instead of a copy of the card?
You may write down all the information on the card and submit it with the copy of the IFSP. The purpose of having a copy of the card is to be able to match the IFSP’s we might have on file with the person whose name the policy is under, i.e. a child under a parent’s policy. Having the name, identification number, group number, date Covered Since, and type of contract (Employee Only, Employee-Spouse, Family, etc.) will help us match the IFSP to the claims we receive.
Do we need to identify the provider on the IFSP form?
If available, Trigon would like to have the name of the therapist(s) rendering services, or the name of the provider group at a minimum.
For Trigon Point of Service Plans, we need to obtain pre-authorization. If we are accustomed to faxing pre-auth requests, may we fax the IFSP for Point of Service Plans?
Yes. For Point of Service, you may fax the IFSP to (804) 354-2578.
For Point of Service, if we mail the IFSP how long should we wait before calling to request pre-authorization?
Depending on where the form is being mailed from, the providers should allow a week for us to receive the form and have the information entered into the processing system. The authorization will be entered beginning with the effective date of the IFSP.
Does the actual provider need to call to request pre-auth for Point of Service, or is the Service Coordinator able to call?
The Service Coordinator, servicing provider or parent may call to request pre-authorization for Point of Service plans.
Will pre-authorization be required for infants?
Trigon Point of Service Programs require pre-authorization for therapy, regardless of the child’s age. If Home Health Services are rendered by a Home Health Agency (HHA), these services also require pre-authorization for all Trigon benefit plans. Trigon Personal Healthcare policies do not require pre-authorization for therapy (except when rendered by HHA). Trigon’s affiliated HMO’s require a primary care physician referral to a specialist (and a corresponding HealthKeeper’s referral number) as well as prior authorization for therapy services.
For Point of Service, if a different therapist begins treating the child (from the therapist indicated on IFSP), do we need to call pre-auth again?
No, you do not need to call again if the new therapist is in the same provider group and at the same location as the therapist indicated on the IFSP. If the new therapist is part of a different group, or part of the same group but at a different location, then you do need to call.
My agency has satellite clinics so putting the therapist’s name on IFSP will be difficult since we don’t schedule with a specific therapist until after we have pre-authorization for services. Is this a problem for Point of Service plans?
We need to get the exact location where services are to be rendered in order to load the authorization. See preceding question.
If the provider is not indicated on the IFSP, how will Trigon know whether or not the claim being filed is for an early intervention service? (If the child has an injury or accident and needs physical therapy, will those services also be applied to the $5,000 EI benefit cap?)
Since the claim for a non-EIS therapy service will include a different diagnosis code, i.e. accident diagnosis, the claim will be processed under the regular, non-EIS contract benefits that apply in this situation, i.e. physical therapy, DME, etc.
Do we need to send in the physician’s written prescription for therapy?
No. Trigon will not require a copy of the paper prescription prepared by the primary care physician or specialist. A prescription from a physician (M.D., D.O., etc.) is of course required for therapy according to the Virginia Board of Medicine, and we would expect to see a copy of the prescription for therapy in the child’s record.
For Point of Service Plans, do we have to have a Trigon referral number or just a pre-authorization number?
Just a pre-auth number is required.
When is the pre-authorization confirmation letter mailed to the member and to the provider?
The next working day following the day the pre-auth is given.
Where do we mail the IFSP?
For Trigon traditional programs: Trigon Blue Cross Blue Shield, P. O. Box 27401, Richmond, VA 23279, Attn: Early Intervention Services, Mail Drop 04M. Or, if you usually fax your authorization requests, that option is available. For HMOs – see documentation from EIS training seminars
For Trigon HMOs, is it true that a PCP referral must be performed before the child is seen and evaluated?
The normal medical management processes must be followed for HMO members; i.e., the primary care physician must perform a referral by calling Trigon HealthKeepers. If the request involves a covered benefit, the referral number will be given. If the request is for a non-covered benefit (for example, developmental delay) we will not assign a referral number until we receive a copy of the child’s IFSP specifying what services are required.
Will medical necessity criteria be applied? Will we need to send any additional medical documentation other than the IFSP?
No. The initial IFSP and updated IFSPs are all that is required. See Pre-Treatment Process – question #1.
Whose responsibility is it to notify Trigon when a child is taken out of the program?
Anne Lucas, Part C Coordinator, has indicated that it is up to each local council to determine wherein this responsibility lies. The local council may identify the service coordinators or other provider as the responsible party, if deemed appropriate.
When services change on the IFSP, what does Trigon do?
Trigon will load on the child’s file information regarding what services are indicated, i.e., physical, speech and/or occupational therapy, and assistive technology devices if required. Each time an updated IFSP is received, the child’s file will be updated.
How are services rendered by a home health agency (HHA) distinguished from services rendered by a physical therapist (not employed by a HHA) that visits the child’s home and renders care? Are the HHA services reimbursable under the early intervention program and will they accrue toward the annual cap?
Home Health Agencies must meet Trigon’s credentialing criteria in order to be reimbursed for services, and HHA’s only render services in the member’s home setting. In addition, all HHA services require pre-authorization.
Provider specialty type and place of treatment are the two distinguishing factors that are required data elements on every claim. Home health services are reimbursable if they are received for a service (physical therapy, speech, etc.) listed on the IFSP as a requirement for this child and will accrue to the $5,000 annual cap.
Once a child is taken out of Early Intervention Program, what happens then?
The agency would notify Trigon in writing that the child has been removed. Trigon would remove flag from child’s file, and the child would be eligible to receive covered services according to the terms of his/her existing benefits with Trigon. Most benefit plans have caps on physical, occupational and speech therapy as well as DME. Early Intervention benefits could no longer be utilized.
If a provider changes frequency of services, what has to happen (with IFSP)?
The agency must submit a new IFSP or Trigon will not know that the services have been authorized through the agency for this child to receive.
Based on HB 1413 and Trigon’s use of the IFSP, are speech-language pathology services covered?
Whatever speech, physical, occupational therapy or assistive technology services are indicated on the IFSP will be covered and applied toward the EI benefit, up to the $5,000 cap.
Can we file claims electronically?
Yes.
If provider chooses not to send in IFSP, then will services be covered?
Not under the Early Intervention benefits provided under House Bill 1413 or 2716. Trigon requires the IFSP as proof of the child’s eligibility under Part C. Without an IFSP, the child’s basic healthcare plan coverage would be accessed (and medical necessity requirements would also apply).
What place of service is used for the child’s home, or grandparent’s/other relative’s home?
Use HCFA place of service code 12.
What place of service code is used for services rendered in the child’s daycare center?
If the Part C eligible child is not enrolled in a school program but is enrolled in a daycare center as a form of childcare while the parents are working, then the providers should bill this as place of treatment 99, defined as other unlisted facility.
Can COTA’s be reimbursed for services?
No, Certified Occupational Therapy Assistants are not covered providers under Trigon’s contracts.
What provider number should be used for billing services? Is it ok for a speech therapist to bill for physical and/or occupational therapy services?
The individual provider number of the therapist rendering the service must be used for non-HMO claims (and not the group number). Speech, occupational and physical therapists are assigned individual provider numbers for each physical location at which they render services. HMO providers use the provider number(s) assigned by the regional Network Administrator.
Where are POS claims mailed?
All claims should be mailed to the address indicated on the member’s identification card, or may be mailed to Trigon Blue Cross Blue Shield, P. O. Box 27401, Richmond, VA 23279
Since occupational therapists are instructed to bill Trigon code W0043, can we use this code for first 15 minutes and then bill physical medicine CPT codes for the rest of the therapy?
No. Use W0043 for all occupational therapy (15 minutes per unit) and bill multiple units if more than 15 minutes.
Will Trigon’s usual "Exclusions" (such as developmental delay) be denied for services under the Early Intervention Program?
No. As long as Trigon has received a copy of the child’s IFSP, then Trigon’s medical exclusions will not be applied.
If an evaluation is performed by a non-Part C provider who is in the HealthKeepers network, can that provider bill HealthKeepers for the evaluation?
Therapy evaluations that are conducted by non-Part C providers do not fall under Part C requirements nor the early intervention benefit. Therefore, non-Part C therapy evaluations may be billed to Trigon, and coverage will be based upon the child’s basic healthcare plan benefits.
What happens if a provider submits a HCFA-1500 claim form without a Trigon provider number in block 33?
Claims without a Trigon provider number are returned to the provider. (You may contact our Provider Network Operations Department at (804) 354-7378 to request an application for a provider number. You do not have to participate in our traditional networks to get a provider number.)
We were told that we may use provider number "000000" for providers who do not have a Trigon provider number. Is this true?
No. If you do not have a 6 digit Trigon provider number, put "PAY SUB" in block 33 under PIN# on the HCFA-1500 claim form.
Are there separate billing guidelines for HMOs?
Information regarding filing claims and completing the HCFA-1500 was discussed at the training sessions. For additional information regarding filing claims for Trigon HMOs, contact the Network Administrator at (804) 354-2338.
What is the "timely filing requirement" for submitting claims?
For all Trigon traditional programs, submit claims within 15 months of the date of service. If a claim is denied for timely filing, the member is not responsible for the bill, if the services were performed by a participating provider. For HMO programs, submit all claims within 90 days of the date of service.
If a child wanted to continue therapy services with a private provider, does insurance cover this?
If the child has been taken out of the Early Intervention Program or if a child has exhausted the $5,000 available benefits for that year, then the child’s contractual benefits for therapy and DME would be accessed and the normal medical necessity criteria would be applied. So, non-covered services (such as maintenance therapy) would be denied.
Do the standard contract deductibles apply to these services under the Early Intervention Program and HB 1413, or are they exempt from any deductibles?
The EIS Benefit is subject to all applicable contract deductibles, coinsurance, and copayments. The member’s deductible must be met, and the member must pay copayments and/or coinsurance as provided in the contract.
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