Family Planning Eligibility and Billing by ZLFiPZN

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									Family Planning Eligibility
       and Billing

        Travis Duke
                  Goals
Understand changes to Title V, X, and XX
eligibility guidelines
Understand changes to Title V, X and XX billing
policy
Discuss Title V, X and XX payment for “wrap
around” services provided to WHP clients.
Discuss common billing issues
     Presentation Structure
Eligibility Overview
Changes to Eligibility Guidelines
Billing Overview
Changes to Billing Guidelines
WHP Wrap Around Services
New Procedures
Common Billing Issues
Q&A
        Eligibility Overview
          Eligible Population

Females (of childbearing age) and males,
who have not had sterilization surgery or
other condition resulting sterilization and
who are seeking family planning services.
        Eligibility Overview
                 Title V
Income at or below 185% FPL
Texas resident
No fee or co-pay for clients at or below
100% FPL.
Co-pay may not exceed 25% of the
authorized payment amount for services
for clients between 101-185% FPL.
        Eligibility Overview
                Title XX
Income at or below 185% FPL
Texas resident
No co-pay for any client with zero income.
Client co-pay may not exceed 25% of the
authorized payment amount for services.
(Note: in a a X/XX clinic this requirement
does not apply)
         Eligibility Overview
                 Title X
Income at or below 250% FPL
No residency requirement
No fee or co-pay for clients at or below
100% FPL.
A discounted fee schedule for clients
between 101% FPL and 250% FPL.
Changes to Eligibility Guidelines
             Family Composition

The budget group consists of the applicant, his/her
spouse, and all mutual and non-mutual children. If an
unmarried applicant lives with a partner, ONLY count the
partner’s income and children as part of the budget
group IF the applicant and his/her partner have mutual
children together. Treat applicants who are 18 years of
age as adults. No children aged 19 and older or other
adults living in the household should be counted as part
of the budget group.
 Changes to Eligibility Guidelines
                 Income
For unemancipated, unmarried clients
UNDER 18 years of age, if confidential
services without the involvement of a
principal family member are requested, only
the client's income is used to assess
eligibility.
For clients who are married or are 18 years
of age or older the income of all family
members must be used.
 Changes to Eligibility Guidelines
           Income Deductions

Dependent Care Expenses
$200 Per Month for Children Under 2
$175 Per for Children Age 2 or Older
 Changes to Eligibility Guidelines
Title XX Co-payment at a Title X/XX Clinic

Co-payment is no longer capped at 25% of
the reimbursable cost of providing services

Enables Title X/XX clinics to better
implement the required sliding fee scale
           Billing Overview
 2017 Family Planning Claim Form

Filing Deadlines
  Initial Claims: 60 days from date of service
  on the claim
  Appeals: 120 days from date of the
  Remittance and Status report on which the
  claim reached a finalized status
         Billing Overview
WHP claims must be held until the client is
determined WHP eligible by HHSC

If WHP eligibility has not been determined
within 35 calendar days from the date of
service, a Title V or XX claim or a Title X
encounter may be filed for the service
         Billing Overview
Contractors must continue to file claims
and encounters even if they have
exhausted their budget
Changes to Billing Guidelines
After 35 days from the date of service
contractors may file a Title V or XX claim
or Title X encounter without verifying and
documenting that a client is ineligible for
WHP.

Sterilization Complications
WHP Wrap Around Services



       See Handout
          New Procedures

J7303 – Hormonal Vaginal ring, each -
$35.80 (9-1-07)
S0180 – Implantable contraceptive
capsules (Implanon) - $585.11 (12-1-07)
11975 – Insertion, implantable
contraceptive capsules - $152.25 (12-1-07)
11977 – Removal with reinsertion,
implantable contraceptive capsules (12-1-07)
       New Procedures

87490 – Chlamydia test, direct probe
technique - $27.71 (12-1-07)
87491 – Chlamydia test, amplified probe
technique - $27.71 (12-1-07)
87590 – Gonorrhea test, direct probe
technique - $27.71 (12-1-07)
87591 – Gonorrhea test, amplified probe
technique - $27.71 (12-1-07)
     Rate Changes For IUDs

J7300
Rate prior to 4-1-07 = $321.13
Rate after 4-1-07 = $387.60
J7302
Rate prior to 4-1-07 = $426.97
Rate after 4-1-07 = $487.76
      Common Billing Issues

CLIA Certification
– Family planning agencies can bill some lab
  codes to Title V and XX that can not be billed
  to Title XIX
– Most obvious when XIX retro-eligiblity occurs
Retro-eligibility and rate differences
between Title V/XX vs. XIX
Appeals vs. Resubmission of New Claims
    Common Billing Issues

Importance of submitting correct TPI/NPI
at the beginning of the fiscal year
NPI implementation and 3rd party billers
Matching R&S reports to payments
Questions
    &
Discussion
        The End
         Travis Duke
Travis.duke@dshs.state.tx.us

								
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