The Washington State Health Care Authority (HCA) and Community Health Partnership Services (CHPS) have identified a technical issue affecting some Community Behavioral Health Support Services (CBHS) claims submitted by Adult Family Homes through the CBHS Clearinghouse.

This issue may help explain why some AFH providers have experienced rejected, delayed, or unpaid CBHS claims.

What happened?

The CBHS Clearinghouse receives billing information from Adult Family Homes through either direct data entry or the CBHS Supportive Supervision billing spreadsheet.

After a provider submits the billing information, the Clearinghouse converts that information into a standard electronic claim format known as an 837P, which is then sent to the appropriate managed care organization (MCO) for processing.

HCA reports that a technical issue was identified in how certain provider identification information was being placed within the 837P claim.

Most Adult Family Homes use an Atypical Provider Identifier (API) rather than a National Provider Identifier (NPI). According to HCA, the Clearinghouse-generated claim was not always placing these identifiers in the locations required by the 837P format.

As a result, some MCO systems have rejected claims because the provider did not have an NPI. Other systems may have accepted the claim but were unable to submit the corresponding encounter to HCA without changing the original claim information.

The issue occurs after the AFH submits its billing information and is not caused by how the provider entered the claim into the Clearinghouse.

What is being done?

HCA, CHPS, and the managed care organizations are working on changes to address the issue.

HCA reports that Coordinated Care, UnitedHealthcare, HCA, and Community Health Plan of Washington have indicated that changes may be possible that would allow providers to continue using either direct data entry or the CBHS billing spreadsheet once testing is successfully completed.

For Molina Healthcare and Wellpoint of Washington, HCA has indicated that Adult Family Homes will need to use the CBHS Supportive Supervision billing spreadsheet. CHPS would review the spreadsheet for minimum required information before forwarding it to the health plan for complete validation.

However, HCA has not yet provided final implementation instructions, and AFHC is seeking clarification before advising providers to change their current billing process.

What providers should do now

AFHC strongly encourages providers with unpaid, delayed, or rejected CBHS claims to keep complete records related to those claims.

Retain copies of:

• CBHS billing spreadsheets;
• Clearinghouse submission confirmations;
• Claim numbers and other claim information;
• Denial or rejection notices;
• Emails or other communications with CHPS or the managed care plan; and
• Any documentation showing when the service was provided and when the claim was submitted.

Providers may also want to maintain a simple record of affected claims that includes:

• Managed care plan;
• Resident or claim reference information, consistent with privacy requirements;
• Date of service;
• Date the claim was submitted;
• Amount billed;
• Current claim status; and
• Any denial or rejection reason received.

Keeping this documentation will be important if providers are later instructed to resubmit claims or take additional steps to address unpaid claims.

AFHC is seeking additional guidance

The Adult Family Home Council has asked HCA for clarification regarding:

• Whether providers working with Coordinated Care, UnitedHealthcare, HCA, and Community Health Plan of Washington should continue their current billing process while testing is underway;
• Whether Molina and Wellpoint providers should begin using the CBHS billing spreadsheet immediately or wait for final instructions;
• Whether rejected, delayed, or unpaid claims will need to be resubmitted;
• What process providers should use to correct previously affected claims;
• When testing and implementation are expected to be completed; and
• Whether HCA or CHPS will provide plan-specific instructions directly to affected providers.

Providers should not assume that a denied or unpaid claim must immediately be resubmitted until additional instructions are provided.

AFHC will share additional guidance as soon as HCA and CHPS provide final instructions.

Why this matters

AFHC knows that delayed or unpaid CBHS claims can create significant financial challenges for Adult Family Homes.

If you have been experiencing unexplained CBHS claim denials, delays, or nonpayment, this Clearinghouse issue may be a contributing factor. Continue documenting affected claims carefully while the technical changes are being completed.

AFHC will continue working with HCA and CHPS to obtain clear instructions for providers and information about how previously affected claims will be resolved.