Newsletter Vol. 27, No.15

REQUIREMENTS: 1. Before January 1, 2018: Billing team must update claims routing rules to assign emergency air transport codes A0431 (Air Ambulance – Rotary Wing) and A0436 (Rotary Wing Mileage) to MCOs rather than FFS. Update billing software to reflect MCO responsibility for these transports. 2. Before July 1, 2018: Update billing system to route all behavioral health service claims (mental health, substance use disorder, inpatient psychiatric admissions) for MLTSS, FIDE SNP, and DDD managed care beneficiaries to MCOs instead of FFS. Maintain FFS routing ONLY for: Targeted Case Management (JIS, CSOC CMOs, ICMS, PATH), PACT, Behavioral Health Homes, and Community Support Services. 3. Before July 1, 2018: Update billing system to route ALL general acute care hospital admissions (all diagnoses, all ages) for NJFC MCO-enrolled beneficiaries to MCOs. Exception: Admissions to Institutions of Mental Diseases (stand-alone psychiatric hospitals, psychiatric specialty hospitals, State/County facilities) for MLTSS, D-SNP, and DDD beneficiaries remain FFS. 4. Billing team must update claim submission protocols and provider communication materials to clarify MCO vs. FFS responsibility for follow-up care. Per case examples: MCOs are responsible for hospital discharge planning and connecting patients to community-based providers for follow-up, even when outpatient services are FFS-covered. 5. Providers and front desk staff must be trained on the new benefit structure to avoid claim routing errors and patient billing issues. Failure to properly route claims will result in denials and delays.