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| 1 | Claims Rules |
| 2 | The activity amount cannot exceed the available funds (allocated amount - (paid + outstanding)) |
| 3 | The amount must be greater than $0.00 |
| 4 | The service dates must fall within the service billable window |
| 5 | The client must be registered in Star at the Vendor organization |
| 6 | The procedure code must be on the Vendor's approved fee schedule |
| 7 | The billing facility/site NPI cannot be missing or not be a match to BHSDStar Vendor Registration |
| 8 | The facility/site NPI and Name cannot be missing or not be a match to BHSDStar Vendor Registration |
| 9 | The Vendor's Vendor Registration must be approved to submit claims |
| 10 | The Rendering Provider must be registered in Star at the Facility/Site where the Service was Rendered |
| 11 | H0019 cannot be billed for greater than 180 Units per client |
| 12 | H0020 cannot be billed for Clients under 18 |
| 13 | 90791 or 90792 cannot be billed with 99201-99215 for the same date of service |
| 14 | 96101 cannot be billed with 96102 or 96103 for the same date of service |
| 15 | 96118 cannot be billed with 96119 or 96120 for the same date of service |
| 16 | H0015 cannot be billed with H0018,0114,0124,0134,0144,H0010,H2033,H2017,S9480 for the same date of service |
| 17 | H0018 cannot be billed with H0019 or H2017 or S9480 or H0015 or 99201-99205 or 99211-99215 or 99354 or 99355 for the same date of service |
| 18 | H0019 cannot be billed with H0018 or S9480 or 99201-99205 or 99355 for the same date of service |
| 19 | H0031 cannot be billed with H2033 or T1007 for the same date of service |
| 20 | H2011 cannot be billed with H2033 for the same date of service |
| 21 | H2012 cannot be billed with 99221-99223 or 99231-99233 or H0018 or H0010 or H0015 or 96150 or 99201-99205 or S9480 for the same date of service |
| 22 | H2015 cannot be billed with H2033, H0010 or H0018 for the same date of service |
| 23 | H2030 cannot be billed with H2015 or H2033 or H0018 or H0019 or H0010 or 0114 or 0124 or 0134 or 0144 or 99221-99223 or 99231-99236 or 99251-99255 for the same date of service |
| 24 | H2033 cannot be billed with 99221-99223 or 99231-99236 for the same date of service |
| 25 | H2033 cannot be billed with S9482 or H2012 or T1005 or 96150 or 96151 or T1007 or H0002 or H0015 or S9480 or 99354 or 99355 or H0018 or H0019 for the same date of service |
| 26 | T1005 cannot be billed with H0041 or H0010 or H0018 or H0019 or 0114 or 0124 or 0134 or 0144 or 99234-99236 or 99251-99257 for the same date of service |
| 27 | T1007 cannot be billed with H2033 or H0010 or H0018 for the same date of service |
| 28 | T1016 cannot be billed with H2015 for the same date of service |
| 29 | T1502 cannot be billed with 90862 or H0020 for the same date of service |
| 30 | 90785 can only be billed with 90791, 90792, 90832, 90834, 90837, 90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350, and 90853 |
| 31 | H2015 cannot be billed more than 16 units for the same date of service |
| 32 | Services with a “15 min” unit type cannot exceed 32 units (8 hours) per day/client |
| 33 | Services with a “Per Hour” unit type cannot exceed 8 units (8 hours) per day/client |
| 34 | Services with a “Session”, “Product” or “Per Dose” unit type cannot exceed 1 unit per day/client |
| 35 | 90836 must be billed with 99201-99255, 99304-99337, 99341-99350 |
| 36 | 90838 must be billed with 99201-99255, 99304-99337, 99341-99350 |
| 37 | 90863 must be billed with 90832 or 90834 or 90837 or 90846 or 90847 or 90849, or 90853 for a client on a date of service |
| 38 | The claim cannot have already been accepted |
| 39 | T1007 can only be billed once every 90 days |
| 40 | H2011 U1 can only be billed Max of 8 Units for the same date of service |
| 41 | H2011 U2 can only be billed Max of 8 Units for the same date of service |
| 42 | H2011 U3 can only be billed Max of 8 Units for the same date of service |
| 43 | H2011 U4 can only be billed Max of 8 Units for the same date of service |
| 44 | H0031 cannot be billed with H2000 for the same date of service |
| 45 | H2000 cannot be billed with H0031 for the same date of service |
| 46 | H2000 cannot be billed with T1007 for the same date of service |
| 47 | T1007 cannot be billed with H2000 for the same date of service |
| 48 | T1007 cannot be billed less than 90 days from H2000 |
| 49 | H2000 cannot be billed with H2033 for the same date of service |
| 50 | 90853, 90863, and 90834 can only be billed Max of 4 Units for the same date of service |
| 51 | Start and End date must be in the same Service month |
| 52 | CYFD only pays claims for clients 21 and under |
| 53 | BHSD will only pay claims for clients 18 and older |
| 54 | H0047 cannot be billed with H0018 or H0019 |
| 55 | H0047 cannot be billed more than 90 consecutive days |
Timely Filing
Falling Colors must enforce the following timeframes for Vendors to submit all Claims:
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