BILLING REVIEW SERVICES

Policy

Transformations contracts with independent providers to review provider bills/claims and corresponding documentation of services.  The reviewers shall approve claims that meet documentation guidelines and billing guidelines set forth by Medicaid and the Correct Coding Initiative established by CMS and the Department for Medicaid Services, any applicable Kentucky state regulation and any third party payer.  Once the bill and corresponding documentation is approved the claim will be submitted to the third party payer.

Procedure

Billing review services are not to be confused with clinical supervision and do not direct or prescribe provider care.

In accordance with 970 KAR 15:010 all behavioral health professional practitioners under clinical supervision shall have the bill/claims and corresponding documentation of services, approved by a billing reviewer.  

The billing reviewer shall be licensed in the same discipline as the service being provided.

The billing reviewer will provide documentation of the review services that include case consultation and evaluation and approval of the services as mandated by 907 KRS 15:010.  This is separate and in addition to licensing supervision.   Billing review professionals may separately contract with the behavioral health professional under clinical supervision for the purposes of licensing supervision.

In compliance with state regulations, all notes written by the behavioral health professional under clinical supervision shall be be co-signed and dated by the billing review professional with in 30 days of the service visit.

In accordance with state regulations, behavioral health professionals under clinical supervision shall receive a monthly billing review note recorded by the billing review professional concerning each individual case, and the billing review professional’s evaluation of the services being provided to the client. The note shall be signed by the billing review professional and stored in the agency electronic medical record system.

Bills and supporting documentation generated by Behavioral Health Professionals independently licensed may also receive a  billing review  .This peer billing reviewer shall approve documentation and claims for acceptance and submission to Medicaid, MCO plans, commercial plans and other payment sources.

Targeted Case Management bills and corresponding notes are also reviewed and approved by a billing reviewer prior to submission to the third party payer.