2013 CMS Health Insurance Marketplace Workshops – in English & in Spanish

DATE:                    Thursday, September 19, 2013 – in English

TIME:                     8:30 am – 5:00 pm

LOCATION:          OneWorld Community Health Centers, 4920 S. 30th Street, Omaha, NE  68107

DATE:                    Spanish Language Workshop Wednesday, September 18th

TIME:                     1:30 – 4:00 pm

LOCATION:          OneWorld Community Health Centers, South Building/Women’s Health Center


–         An Overview of the Health Insurance Marketplace and the Small Business Health Options Program (SHOP)

–         Information on Health Insurance Literacy

–         An Overview of Consumer Assistance that will be available for People Using the Marketplace

–         The Marketplace Application Process

–         An Overview of Medicaid and the Children’s Health Insurance Program (CHIP)



REGISTRATION:        There will be no charge to you for the training.  To register for the English Workshop go to  http://necmsmarketplaceworkshop.eventbrite.com  Please register each workshop participant individually.  The number of attendees from the same organization may be limited.

To register for the Spanish Language Workshop email msmith@oneworldomaha.org

Lunch will be available for purchase for $10 for those that register by Friday the 13th through the CMS Web Site, for the English Language Workshop.

If you have any questions, please contact Marcia Smith at 402-502-8845 or at msmith@oneworldomaha.org.


SAVE THE DATE – Health Insurance Marketplace & Medicaid Expansion Outreach & Enrollment in Health Centers Part II Webinar

SAVE THE DATE: Health Insurance Marketplace & Medicaid Expansion Outreach & Enrollment in Health Centers Part II Tuesday, September 17, 2013, 12:30 pm – 2:30 pm CDT (11:30-1:30pm MDT). This session will include outreach and enrollment strategies for  targeting uninsured eligible populations and examples of successful initiatives as health centers prepare for the marketplace opening on October 1, 2013. Details on accessing the webinar next week.

Reimbursement for Select Behavioral Health Therapy CPT Codes – DHHS Provider Bulletin No. 13-56

Please share this information with administrative, clinical and billing staff.

Effective September 15, 2013 Nebraska Medicaid & Long-Term Care will implement a reduction in pricing for four behavioral health therapy CPT (Current Procedural Terminology) codes. The amended fee schedules will be posted at: http://dhhs.ne.gov/medicaid/Pages/med_practitioner_fee_schedule.aspx.

On January 1, 2013, Nebraska Medicaid implemented the American Medical Association (AMA) new psychiatric CPT code changes. For complete information regarding all CPT codes and descriptions, refer to the 2013 edition of Current Procedural Terminology, published by the American  Medical  Association.  These  CPT  changes  were  mandated  by  the  Centers  for Medicare and Medicaid Services (CMS); and providers and insurers are required to use these new CPT codes to identify the services they provide. Time specifications were changed to be consistent with CPT convention.

Nebraska Medicaid worked with behavioral health stakeholders to solicit input for the 2013 CPT code changes. Frequently Asked Questions and Answers were posted in January, 2013 from the discussions with the stakeholders. The implementation of these codes was to remain cost neutral to Nebraska Medicaid.

Currently, we are finding a substantial increase in utilization for therapy codes, based on analysis for the first six months of 2013. These changes have exceeded budget neutrality, and are being adjusted accordingly.

Pursuant to 471 NAC 20.002.11B and 32-002.11B, the Department may adjust the allowable amount  when  the  Medicaid  Division  determines that  the  current  allowable  amount  is  not appropriate for the service provided. In analyzing pricing for these codes, Medicare rates were evaluated, as well as regional Medicaid state pricing for the same codes. These are reductionsfrom current pricing; however, they are higher than the Medicare and neighboring states for the same services.

Effective September 15, 2013, pricing for physicians will be based on 120% of the Medicare rate for these CPT Codes. The remaining provider type rates will be based on the percentage of the MD/DO rate currently in effect. This change will better align the actual time spent with clients with the CPT codes, and bring the usage back into a cost neutral basis for Nebraska Medicaid.

As an example: In reporting, choose the code closest to the actual time (i.e. 38-52 minutes for 90834 or 90836, and 53 or more minutes for 90837 and 90838). Previously, the 45 minute code was used for all sessions that lasted from 35 minutes to 65 minutes.   Under the new code structure, the therapy code 90834 is used for therapy sessions lasting from 38-52 minutes, removing the time period of 50-65 minutes.   It should be recognized that the specific times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances.


Provider type 90834 90836 90837 90838
45 Min. 45 Min. + E&M 60 Min. 60 Min + E&M
MD/DO $ 93.22 $ 77.93 $ 136.55 $ 125.76
PA/APRN $ 74.64 $ 50.89 $ 109.34 $ 100.77
RN   / LIMHP/ LMHP/LDAC $ 64.27 $ 95.58
PLMHP/ PHD Cand. $ 61.06 $ 90.81
ProvisionalPsychiatrist/ S PhD $ 73.75 $ 108.03
PhD. $ 77.63 $ 113.72


If you have further questions or concerns about this information, please contact Cynthia Brammeier, at DHHS.MedicaidMHSU@nebraska.gov .


Behavioral Health Managed Care – Provider Bulletin No. 13-55

Please share this information with administrative, clinical, and billing staff.

This bulletin is intended to provide additional information relating to Behavioral Health Managed Care. Effective September 1, 2013 all behavioral health and substance use disorder services for managed care clients must be billed directly to Magellan Behavioral Health of Nebraska.  Payment for services provided to clients enrolled in managed care will not be paid by Medicaid Fee-For-Service for dates of service after September 1, 2013.

See the following “Frequently Asked Questions” for answers to most common questions.

Behavioral Health Managed Care Frequently Asked Questions

1. What is Behavioral Health Managed Care?

Managed care is a service delivery system where Nebraska Medicaid contracts with a managed care entity to operate a health plan that authorizes, arranges, provides, and pays for the delivery of behavioral health services to enrolled clients. The care of the clients enrolled in the health plan is managed by Magellan Behavioral Health, through its network of providers who contract directly with Magellan.

2. What happens if I choose not to be a provider in the Magellan network?

Providers not contracted through the Magellan network will not be paid for services rendered to clients enrolled in managed care.

3. If I am not currently in the Magellan network and want to be what do I do?

Please see Magellan’s website on “Becoming A Provider” http://www.magellanofnebraska.com/for-providers-ne/becoming-a-provider.aspx

4. What do I have to do to assure that I am ready to begin billing Magellan for managed care clients on September I, 2013?

Assure that you are enrolled as a Medicaid provider, credentialed in the Magellan network, and have responded to the amendment Magellan sent to all network providers. Please see Provider Implementation Updates on the Magellan web site: http://www.magellanofnebraska.com/for-providers-ne/provider-implementationupdates.aspx

5. How do I submit claims to Magellan?

There are several ways to attain this information: Magellan Web Site: http://www.magellanofnebraska.com

Provider Trainings & Events: http://www.magellanofnebraska.com/library-trainingne/trainings-events.aspx

Overview on Claims Submission Requirements, Electronic Billing Options, and Provider Website Features:


Call Magellan directly at 1-800-424-0333

6. What services will require prior-authorization for managed care?

For prior authorization questions, contact Magellan at 1-800-424-0333, or at: http://www.magellanofnebraska.com

7. What services require co-pay for managed care?

For co-pay questions contact Magellan at 1-800-424-0333, or at: http://www.magellanofnebraska.com

8. Are there new categories of individual members that will be eligible for Managed

Care, as a part of this change?

Yes, the populations that are new to Behavioral Health Managed Care include the following: Waiver Child Developmental Disabilities (DD), Aged & Disabled Waiver, Adult DD Comprehensive Waiver, Adult DD Day Waiver, TBI Waiver, residents of Nursing Facilities and Intermediate Care Facilities for Individuals with Developmental Disabilities (ICF/DD).

9. Is there a contract for Behavioral Health Managed Care that I can read?

Yes, please view the following link. http://das.nebraska.gov/materiel/purchasing/contracts/pdfs/55286(o4)awd.pdf

If you have questions regarding the information in the bulletin, please contact Lori Lewis at

Lori.Lewis@nebraska.gov or 402 471-6794.

Marketplace.cms.gov Outreach & Enrollment Materials

Marketplace.cms.gov offers multiple Outreach & Enrollment materials for use by community health centers here: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html .

On the Publications and Articles webpage you will find bi-fold brochures, fact sheets, drop-in articles, PSAs, toolkits, posters and the invaluable Health Insurance Marketplace Branding Guide available here: http://marketplace.cms.gov/getofficialresources/marketplace-brand-guide.pdf with guidelines for using any Health Insurance Marketplace information.

Keep checking the Communications section of HCAN’s Weekly eBrief for more Outreach & Enrollment materials.

SAVE THE DATE – HCAN to host UDS Training Nov. 8, 2013 in Kansas City

HCAN will be this year’s host for UDS Training to be held Friday, Nov. 8, 2013 in Kansas City.  Registration information and a link to book your hotel needs will be sent in next week’s eBrief.

Minority Mental Health: Lend Your Voice and Make a Difference

Mental illness affects one in four American families. The U.S. Surgeon General reports that minorities are less likely to receive diagnosis and treatment for their mental illness, have less access to and availability of mental health services, and often receive a poorer quality of mental health care. During National Minority Mental Health Awareness Month in July, the Office of Minority Health along with SAMHSA, the National Alliance and others came together to raise awareness about mental health in minority communities. Help keep the conversation going:

More on mental health:

DHHS Medicaid ICD-10 Implementation Project July 2013 Update

Please share this information with Clinical, Coding, Billing, and IT Staff The United States Department of Health and Human Services requires that all HIPAA covered entities use the International Classification of Diseases, 10th Revision (ICD-10) codes beginning October 1, 2014. This bulletin provides information regarding the Nebraska Medicaid ICD-10 Implementation Project.

CMS Frequently Asked Questions

CMS recently published the following questions and answers. Additional information is added as clarification for Nebraska Medicaid:

Question #1:

How long after the October 1, 2014, ICD-10 compliance date must I continue to report and/or process ICD-9 Codes?

CMS Answer

: Each payer determines their late filing requirements for standard transactions and ICD-10 does not require a change to these requirements. These deadline requirements vary among plans. Contact your payer for the current information regarding late filing for claims.

Nebraska Medicaid Answer:

Claims for dates of service prior to October 1, 2014, must be submitted with ICD-9 codes, regardless of the date submitted. Please note:

The Nebraska Medicaid claim filing deadline changes effective September 1, 2013, from within one (1) year to six (6) months of the date of service. See Provider Bulletin #13-50 for details.

A provider should also factor in how long they need to be able to report ICD-9 for claim adjustments that can be submitted up to 90 days from the payment date of the Remittance Advice and for exceptions to the 6 month timely filing rule. For exceptions to this rule, see 471 NAC 3-002.01A at Payment for Medicaid Services.

Claims for dates of service on or after October 1, 2014, must be submitted with ICD-10 codes.

When the dates of service span the implementation date, for example, the discharge date and/or through date is on or after October 1, 2014, the claim should contain only ICD-10 codes.

Question #2:

In current practice by the mental health field, many clinicians use the DSM-IV in diagnosing mental disorders. As of May 19, 2013, the DSM-5 was released. Can these clinicians continue current practice and use the DSM-IV and DSM-5 diagnostic criteria?

CMS Answer:

Yes. The Introductory material to the DSM-IV and DSM-5 code set indicates that the DSM-IV and DSM-5 are “compatible” with the ICD-9-CM diagnosis codes. The updated DSM-5 codes are crosswalked to both ICD-9-CM and ICD-10-CM. As of October 1, 2014, the ICD-10-CM code set is the HIPAA adopted standard and required for reporting diagnosis for dates of service on and after October 1, 2014.

Neither the DSM-IV nor DSM-5 is a HIPAA adopted code set and may not be used in HIPAA standard transactions. It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV/DSM-5 criteria, and, if so, to crosswalk those decisions to the appropriate ICD-9-CM and, as of October 1, 2014, ICD-10 CM codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV and DSM-5 codes, descriptors and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation and patient communications.

Dates when the DSM-IV may no longer be used by mental health providers will be determined by the maintainer of the DSM-IV/DSM-5 code set, the American Psychiatric Association, http://www.dsm5.org.

Nebraska Medicaid Answer: ICD-10 codes must be submitted for dates of service on or after October 1, 2014.

Providers should discuss with coders, billing staff, IT staff, office management software vendors, clearinghouses, trading partners, etc., to ensure that they will be prepared to code and submit ICD-10 on or after October 1, 2014.

See Provider Bulletin #13-36 for more detail.


The Nebraska Medicaid ICD-10 Project website has a number of Frequently Asked Questions. If you don’t see the answer to your question, please send it to DHHS.ICD10Implementation@nebraska.gov.

CMS has resources to help prepare for a smooth transition. Visit www.cms.gov/ICD10 to find out more.

Please submit questions about this bulletin or about ICD-10 to DHHS.ICD-10Implementation@nebraska.gov.

To stay informed of ICD-10 developments, please refer to the ICD-10 Implementation Project website at:




DHHS Breast Pump Policy Update


Please share this information with administration, sales, dispensing and billing staff.

This Provider Bulletin is to update Provider Bulletin 10-55.

Effective immediately, providers requesting Medicaid payment for breast pumps are no longer required to submit a physician order as supporting documentation with a claim.

Providers should continue to maintain federally and state required documentation in the client’s file and make it available to the Department or its designee upon request for audit purposes.

Nebraska Medicaid will rent hospital grade only breast pumps (E0604 KR and E0604 RR) on a short or long term basis due to one or more of the medical conditions listed below. The DME provider must obtain the physician’s order, including the diagnosis and length of time breast pump rental is necessary.

SHORT TERM RENTAL (up to 2 months)

1. Infant/neonate with abnormal weight loss

2. Hyperbilirubinemia

3. Inadequate milk supply

4. Mastitis

5. Acutely ill infant

6. Infant food allergy (to maintain milk supply for a limited period until off the

offending foods)

7. Medical condition of mother that precludes feeding infant at breast (examples

include, but not limited to: mom on radioactive compound or other medication

short term)

8. Maternal post-partum complications (examples but not limited to: excessive

fluids during delivery, maternal blood loss, D&C)

LONG TERM RENTAL (up to 6 months, with one additional 6 month period if medically necessary)

1. Congenital abnormality of the infant (examples, but not limited to: cleft lip/palate,

2. Down syndrome, other syndrome with poor suck/swallow, abnormal anatomy, congenital heart disease)

3. Neurologic abnormality of the infant (examples, but not limited to: low tone, poor suck/swallow reflex)

4. Prematurity (less than 37 weeks gestation)

5. Latch difficulties

Medicaid will pay claims for the breast pump kit with the first month’s rental, or in situations in which the client has access to the breast pump, and only is in need of the kit. The kit is to be submitted only under A9900 – “Misc DME supply, accessory, and/or service component of another HCPCS code”. Submission of the breast pump kit under other HCPCS codes will be denied.

For questions regarding this bulletin, please contact Kim Beedle at dhhs.dme@nebraska.gov or 402-471-9381.




Apply to Become a Certified Application Counselor (CAC) Organization

Health centers in Federally-Facilitated Marketplace and State Partnership Marketplace states receiving outreach and enrollment supplemental funds from BPHC must apply to CMS to become CAC organizations in order to certify appropriate health center staff and volunteers as CACs. Guidance on how to apply as a CAC can be found on marketplace.CMS.gov. To access the application to become a CAC organization, click here.