Diabetes Education Program Billing Guide

Washington Apple Health (Medicaid)

Diabetes Education Program Billing Guide

July 1, 2017

Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply.

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About this guide*

This publication takes effect July 1, 2017, and supersedes earlier guides to this program.

HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services.

Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the Children's Health Insurance Program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority.

What has changed?

Subject

Change

Entire Guide About the Program

Corrected DOH mailing address and fixed broken links. ? Included a telephone number and email

address for DOH

Reason for Change Housekeeping

To provide additional contact information

? Changed "What are the provider

Clarification

qualifications?" header to "What providers

and settings are eligible for this program?

Definitions Client Eligibility

Added FIMC "Fully Integrated Managed Care" definition Effective July 1, 2017, not all Apple Health clients will be enrolled in a BHO/FIMC/BHSO

Clarification Policy update

Effective July 1, 2017, AI/AN clients living in the FIMC regions have a change to services available

* This publication is a billing instruction. 2

Where can I download agency forms?

To download an agency provider form, go to HCA's Billers and provider's web page, select Forms & publications. Type the HCA form number into the Search box as shown below (Example: 13-835).

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Diabetes Education Program

Table of Contents

About this guide .........................................................................................................................2 What has changed? ....................................................................................................................2 Where can I download agency forms?.......................................................................................3

Resources Available .......................................................................................................................5

Definitions .......................................................................................................................................6

About the Program ........................................................................................................................7 What is the purpose of the Diabetes Education Program?.........................................................7 What providers and settings are eligible for this program? .......................................................7

Client Eligibility .............................................................................................................................8 How can I verify a patient's eligibility? ....................................................................................8 Are clients enrolled in an agency-contracted managed care plan eligible for diabetes education? ............................................................................................................................9 Primary care case management (PCCM) .............................................................................9 Effective July 1, 2017, not all Apple Health clients will be enrolled in a BHO/FIMC/BHSO. ...........................................................................................................10 Effective July 1, 2017, changes to services available to AI/AN clients living in the FIMC regions. ....................................................................................................................10 Effective January 1, 2017, some fee-for-service clients who have other primary health insurance were enrolled into managed care .......................................................................10 Effective April 1, 2016, important changes to Apple Health ..................................................11 New MCO enrollment policy ? earlier enrollment ............................................................11 How does this policy affect providers?..............................................................................11 Behavioral Health Organization (BHO) ............................................................................11 Fully Integrated Managed Care (FIMC) ............................................................................12 Apple Health Core Connections (AHCC)..........................................................................13 AHCC complex mental health and substance use disorder services .................................13 Contact Information for Southwest Washington ...............................................................14

Coverage .......................................................................................................................................15 What is covered?......................................................................................................................15 What is not covered?................................................................................................................15 How do I receive payment? .....................................................................................................16 How can I request a limitation extension (LE)? ......................................................................17

Coverage Table.............................................................................................................................18

Billing ............................................................................................................................................19 What are the general billing requirements? .............................................................................19 How do I bill claims electronically? ........................................................................................20

Alert! This Table of Contents is automated. Click on a page number to go directly to the page.

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Diabetes Education Program

Resources Available

Topic Information on becoming a provider or submitting a change of address or ownership

Contact Information

Information about payments, denials, claims processing, or agency-contracted managed care organizations

Electronic billing

See the agency ProviderOne Resources web page

Finding agency documents (e.g., billing instructions, # memos, fee schedules)

Private insurance or third-party liability, other than agencycontracted managed care

Information on becoming a diabetes education provider and obtaining an application

Department of Health Heart Disease, Stroke, and Diabetes Prevention Unit PO Box 47855 Olympia, WA 98504 360- 236-3750

Download and complete the reimbursement application from the Department of Health's Diabetes Prevention and Management web page

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