The Division reminds carriers that carriers will be expected to provide verbal, as well as written documentation, when a “specialing” service is authorized - with appropriate details, including an authorization number - in order to document that the services are covered by the insured health benefit plan. Special services are those services that have been identified by the facility or unit as needed to admit a patient and exceed the typical capabilities and competencies of the facility or unit. Since the EPIA process is expected to speed inpatient psychiatric admissions for persons who have been subject to lengthy ER stays, the Division of Insurance requests that all such notifications be made expeditiously based on the presenting symptoms of the patient in order to facilitate patient placement.
- At the time of verbal authorization, plans should be able to provide written authorization, an authorization number, or other identification of services, so that if any issues occur during claims processing, the provider is able to reference that specialing was authorized.
- Plan billing and payment policies should be updated to reflect how the plan’s specialing process works, and also to include the specialing codes established in the coding grid that are required by the plan.
- Finally, we ask that plans provide authorization of specialing as soon as possible as this will help reduce admissions time.
In order to facilitate reimbursement for “specialing” services, the Division acknowledges the benefits of developing a set of common codes that apply to EPIA “specialing” services. The Division recognizes that methods and rates of reimbursement are negotiated between carriers and providers; thus, no one method perfectly serves in all situations, especially where carriers and providers may bundle services into one common payment code. The Division has worked with carriers and providers to develop a standard set of claim codes, which include services that may be considered EPIA “specialing” services, and which can be used by carriers and providers when negotiating an appropriate development of methods and rates of reimbursement for covered members. The codes represent a baseline set of codes that may be used as carriers and providers negotiate contracts. As to the codes and payment policies utilized by an individual carrier’s health plan, network providers will need to refer to provisions included within their contracts with their payer. The Division expects that each health insurance carrier’s billing and payment policies will be updated to reflect a plan’s “specialing” process, including the codes the carrier is using to process approved “specialing” services.