Claims Billing Guide
- Tracy Archuleta
- Emily Goleski
Introduction
This Billing Guide is intended to serve as a resource for Vendors submitting Claims to Falling Colors for Non-Medicaid Services. It outlines the process of submitting claims, the billing rules applied, and instructions on how to correct and re-submit claims.
Submitting Claims
Claims can be submitted to Falling Colors through our Clearinghouse Claim MD. http://www.claim.md
Vendors can enroll with Claim MD at BHSD StarOnline Claim Portal and submit claims via manual entry or electronic upload of an 837P or 837I. There is No Cost to the vendor for submitting claims directly to Falling Colors via Claim MD. (existing Claim MD customers do not need to re-enroll, but will just submit a claim using payer ID FCC20)
Vendors can also submit claims to Claim MD via an already established relationship with their own Clearinghouse. Please ask your Clearinghouse to contact Claim MD at (855) 757-6060. Our Payer ID is FCC20.
Vendors that will be submitting claims must have completed Vendor Registration with Falling Colors and will need STAR system access for the Claims Project to pre-register the claims clients. Please submit a request to support@fallingcolors.com to register vendors.
If you have any questions regarding Vendor Registration or about the STAR application, contact us at support@fallingcolors.com
If you have questions about the Claim MD application, contact their support team at (855) 757-6060 x2
For details on 837 P and I required fields refer to the 837 Companion Guide here: 837 Companion Guide .
Client Eligibility and Registration
Vendors are responsible for determining the eligibility of a client at the time service is rendered. Non-Medicaid funds are intended for services for individuals not covered by Medicaid, who do not have commercial insurance, or any other source of funding (e.g. county indigent funds). Vendors must check the Medicaid portal before administering a service for non-Medicaid reimbursement. By submitting a service for non-Medicaid reimbursement, Vendors are attesting that they have verified a client’s non-Medicaid eligibility. Done here: https://nmmedicaid.portal.conduent.com/static/providerlogin.htm
Depending on specific scopes of work, additional eligibility criteria may exist. If you are unsure of the eligibility of a client for the non-Medicaid funding you are receiving, please contact your State Agency Program Manager.
Before submitting claims, you must also register your client in STAR. To register a client, review our guide here: Client Registration
Billing Rules
No Shows
Vendors cannot bill for no-shows.
Vendors should not charge a deposit or advance payment for a potential missed appointment or no-show.
Vendors may not bill for services not rendered.
Required Claim Fields
Each Claim submitted to Falling Colors must have the Client ID from the STAR system to indicate what client received the service(s), a Billing NPI to indicate where payment is to be made, only Service Codes from a Vendor’s Fee Schedule, an indication of who, when, and where the service(s) was/were performed, and Mental Health and/or Substance Abuse ICD-10 code Diagnosis(es).
All Staff rendering services and all Vendor locations must be kept up-to-date in STAR Vendor Registration. Each Claim processed will be validated against the information in STAR Vendor Registration.
Rendering/Attending NPI Requirements
A Rendering NPI is not required for Service Codes: 0124, 0459, Q3014, H0010, H0015, H0018, H0019, H2012, H2017, T1005, or T1016.
An Attending NPI is required for Service Codes: 0114, 0124, 0134, 0144, or 0459.
Mental Health and Substance Abuse Modifiers/Diagnosis(es)
Modifiers HE, HI, and HK can only be used with an ICD-10 Mental Health Diagnosis (F1-F99)
Modifiers HF and HV can only be used with an ICD-10 Substance Abuse Diagnosis (F10-F19)
Invalid Service Code Combinations and Max Units
| 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 a Max of 4 Units for the same date of service |
| 41 | H2011 U2 can only be billed Max of 4 Units for the same date of service |
| 42 | H2011 U3 can only be billed a Max of 4 Units for the same date of service |
| 43 | H2011 U4 can only be billed a 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 a Max of 4 Units for the same date of service |
| 51 | The Start and End dates 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 |
Timely Filing
Falling Colors must enforce the following timeframes for Vendors to submit all Claims:
Vendors have:
Until Midnight on the last day of the month following the month the service was rendered to submit claims.
Thirty (30) days from the date a correction was required to submit the corrections.
Falling Colors cannot accept Claims for Services rendered for a previous State Fiscal Year outside of the timely filing limits.
Payments
All submitted claims will be bundled into a STAR invoice on the 1st and 15th of each month for payment. Claims invoices are pre-approved by Member Agencies for payment but will be reviewed by Falling Colors and processed for payment.
All payments will be made no later than 30 days from the date of invoice approval.
Fixing Rejected Claims or Claim Lines
If the Error States: | Possible Ways to Fix: |
Activity amount cannot exceed the available funds (allocated amount - (paid + outstanding)) | Correct the amount submitted to be less than the Remaining Balance located on your Project Home Page |
The amount must be greater than $0.00 | Correct the amount submitted to be greater than $0.00 |
The service dates must fall within the service billable window. | Ensure the service dates are for the current or previous month and not before 7/1/2021 for Claims |
The amount entered exceeds the total amount allocated for this project | Correct the amount submitted to be less than the Remaining Balance located on your Project Home Page |
The amount entered exceeds the service amount allowed for this project | Correct the amount submitted to be less than the Remaining Balance located on your Project Home Page |
The client is not registered in Star | Ensure the client is registered at your organization |
This procedure code is not on the approved fee schedule. | Correct the service code to a code on your Vendor Fee Schedule |
The billing provider is not registered in Star | Ensure the Billing NPI on the claims matches the Billing NPI in Vendor Registration |
The facility/site was missing or could not be matched in BHSDStar. | Ensure the Facility NPI and Name match the Facility NPI and Name in Vendor Registration |
This provider has not been authorized to submit claims. | Contact support@fallingcolors.com to determine what steps still need to be completed |
The rendering provider is not registered in Star | Ensure the Rendering NPI on the claims matches the Rendering NPI in Vendor Registration |
The fee schedule for this service could not be determined | Ensure the Rendering Provider and their Licensure are entered in Vendor Registration and they are allowed to provide the service based on the Service Definition. |
The billing NPI cannot be found in Star | Ensure the Billing NPI on the claims matches the Billing NPI in Vendor Registration |
This service is not on the approved fee schedule | Correct the service code to a code on your Vendor Fee Schedule |
The rendering provider is either not registered or not active at this location | Ensure the Rendering Provider and their Licensure are entered in Vendor Registration |
Per diem services can only be billed one unit per day per client | Correct the Units on the Claim to be the allowable # of Units per Service Date |
H0020 cannot be billed for Clients <18 | Ensure the client's DOB is correct and the client is over 18 |
H2015 cannot be billed more than 16 units for the same date of service | Correct the Units on the Claim to be less than 17 per Service Date |
H0019 cannot be billed for greater than 180 Units per client | Correct the Units on the Claim to be less than 180 for the client |
90863 must be billed with 90832, 90834, and 90837 | Correct the Claim to ensure the codes are billed together for the client for the same date of service |
90791 or 90792 cannot be billed with 99201-99215 for the same date of service | Correct the Claim to ensure the codes are NOT billed together for the client for the same date of service |
96101 cannot be billed with 96102 or 96103 for the same date of service | |
96118 cannot be billed with 96119 or 96120 for the same date of service | |
H0015 cannot be billed with H0018,0114,0124,0134,0144, H0010, H2033, H2017, S9480 for the same date of service | |
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 | |
H0019 cannot be billed with H0018 or S9480 or 99201-99205 or 99355 for the same date of service | |
H0031 cannot be billed with H2033 or T1007 for the same date of service | |
H2011 cannot be billed with H2033 for the same date of service | |
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 | |
H2015 cannot be billed with H2033, H0010, or H0018 for the same date of service | |
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 | |
H2033 cannot be billed with 99221-99223 or 99231-99236 for the same date of service | |
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 | |
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 | |
T1007 cannot be billed with H2033 or H0010 or H0018 for the same date of service | |
T1016 cannot be billed with H2015 for the same date of service | |
T1502 cannot be billed with 90862 or H0020 for the same date of service | |
A claim line for this service has already been submitted within this date range | |
This service does not support a date range | Correct the claim to indicate the correct date of service |
The number of days in the date range is not equal to the number of units submitted | Correct the claim to ensure the # of days in the date range is equal to the # of Units and the Date correctly reflects when the client received the actual service |
Disputes and Grievances
Should the Vendor have questions regarding payment the Vendor should address their questions, comments, or concerns to support@fallingcolors.com. Falling Colors will provide reasonable help to the Vendor in these types of requests or will forward those requests to the Collaborative. If the Vendor is dissatisfied with any decision related to payment, the Vendor agrees to address its grievance or dissatisfaction solely with the Collaborative Member Agency.