Is insurance billing consuming your professional time and eating into your personal life? This presentation focuses on the basic insurance billing requirements for BCBAs, providing an overview of the components required to file a successful insurance claim. Yvonne McNamee reviews the prerequisites of the insurance carriers, including pre-authorization, documentation, and claims filing with follow up. She will also share tips for navigating the complexity of this process, based on her extensive experience in the medical billing industry.

1. ABC’S OF ABA BILLING
BILLING BASICS
FOR THE ABA PROVIDER
By Yvonne Mc Namee, YMC Consulting
P.O. BOX 3065
WAYNE, NJ 07470

2. AUTHORIZE
AUTHORIZATION OF ABA IS REQUIRED BY MOST INSURANCE PLANS
v NO AUTHORIZATION ON FILE WILL RESULT IN TWO DENIALS
1. FULL DENIAL OF SERVICE REIMBURSEMENT DUE TO LACK OF AUTHORIZATION
AND/OR
2. REQUEST FOR EVERY SERVICE NOTE FOR EACH DATE OF SERVICE BILLED
By Yvonne Mc Namee, YMC Consulting

3. HOW TO AUTHORIZE
v CALL THE INSURANCE COMPANY
§ PHONE NUMBER FOR PROVIDERS IS ON BACK OF THE INSURANCE CARD
ALWAYS CALL THE PROVIDER LINE
PRESS PROMPT OR ASK FOR THE AUTHORIZATION DEPARTMENT
§ BE SPECIFIC:
SPECIFY YOU NEED APPLIED BEHAVIOR ANALYSIS AUTHORIZATION FOR
TREATMENT OF AUTISM
ABA IS USUALLY COVERED UNDER THE MENTAL HEALTH
PROVISIONS OF THE POLICY
§ CONFIRM YOU ARE SPEAKING WITH THE CORRECT DEPARTMENT
§ ASK FOR THE SPECIFIC AUTHORIZATION FORMS TO BE FAXED OR EMAILED TO YOU
§ PROPERLY COMPLETE ALL FORMS
By Yvonne Mc Namee, YMC Consulting

4. BENEFITS
CHECK AND CONFIRM BENEFITS
v CALL THE PROVIDER SERVICE NUMBER ON THE CARD
§ YOU NEED:
a) I.D. OF THE CHILD (FRONT OF THE INSURANCE CARD)
b) DATE OF BIRTH OF CHILD
c) PROVIDER TAX I.D. AND NPI
d) PROVIDER NAME (MUST MATCH TAX I.D.) ADDRESS AND PHONE NUMBER
By Yvonne Mc Namee, YMC Consulting

5. TEN TOP QUESTIONS FOR
BENEFITS
1. IS THIS POLICY SELF FUNDED OR FULLY INSURED?
2. WHICH STATE GOVERNS THE POLICY?
3. IS ABA SPECIFICALLY COVERED IN THE POLICY LANGUAGE FOR THE TREATMENT OF
AUTISM?
4. If RESPONSE IS ABA IS NOT COVERED AND POLICY IS FULLY INSURED CITE THE STATE
INSURANCE MANDATE ( Resource: https://www.autismspeaks.org/state-initiatives)
5. DOES THIS POLICY HAVE OUT OF NETWORK COVERAGE?
6. HOW MUCH IS DEDUCTIBLE?
7. HOW MUCH IS OUT OF POCKET LIMIT?
o ARE DEDUCTIBLE AND OUT OF POCKET PER CALENDAR YEAR OR POLICY YEAR?
o IS DEDUCTIBLE APPLIED TOWARD OUT OF POCKET LIMITS?
8. WHAT IS COINSURANCE? (USUALLY A %)
o IS DEDUCTIBLE AND OUT OF POCKET PER CALENDAR YEAR OR POLICY YEAR
By Yvonne Mc Namee, YMC Consulting

6. 9. CONFIRM MENTAL HEALTH CLAIM MAILING ADDRESS?
• IS THERE A CLAIM FAX NUMBER – CAN CLAIMS BE FAXED?
10. KEEP THIS INFORMATION SAFE FOR FUTURE REFERENCE:
v NOTE THE DATE AND TIME YOU MADE THE CALL
v GET THE NAME OF THE REPRESENTATIVE YOU SPOKE WITH
v GET A REFERENCE NUMBER FOR THE CALL
By Yvonne Mc Namee YMC Consulting

7. CODING
v VERIFY THE CODES YOU WILL BILL WITH EVERY AUTHORIZATION
§ MOST INSURANCE CARRIERS WILL SWITCH TO NEW AMA CPT CODES FOR ABA
DURING 2015
§ CONFIRM THE CODES WITH EACH INSURANCE COMPANY WHEN YOU AUTHORIZE
SERVICES.
§ VERIFY THAT THE CARRIER RECOGNIZES THE CODE IN THE SAME WAY YOU
INTEND TO USE IT
§ VERIFY TIME INCREMENTS FOR EACH CODE
By Yvonne Mc Namee, YMC Consulting

8. USE THE PROPER DIAGNOSIS
CODE
u DIAGNOSIS CODING IS ABOUT TO CHANGE
v CURRENT AUTISM DIAGNOSIS CODES ARE ICD-9 FORMAT THIS WILL CHANGE AS OF
OCTOBER 15, 2015.
v CODES OF 299.xx WILL NO LONGER BE VALID FOR MAJOR CARRIERS
§ SOME LOCAL UNION CONTRACTS WILL CONTINUE TO USE ICD-9
§ CONFIRM WITH NON MAJOR INSURANCE CARRIERS
By Yvonne Mc Namee, YMC Consulting

9. CLAIMS SUBMITTAL
IF YOU ARE IN NETWORK:
§ YOU ARE REQUIRED TO SUBMIT CLAIMS IN PROPER CMS 1500 FORMAT DIRECTLY TO THE
INSURANCE COMPANY
§ COMPLETE THE FORMS PROPERLY – INFORMATION NOT PROPERLY SUBMITTED WILL RESULT
IN A DENIAL AND NEED TO RESUBMIT OR APPEAL
§ READ YOUR PROVIDER AGREEMENT – YOU MAY BE REQUIRED TO SUBMIT CLAIMS
ELECTRONICALLY
By Yvonne Mc Namee, YMC Consulting

10. u IF YOU ARE NOT IN NETWORK
§ YOU MAY COLLECT YOUR FEES DIRECTLY FROM THE PARENTS
§ YOU ARE NOT REQUIRED TO COMPLETE CLAIMS FORMS OR SUBMIT
§ YOU MAY INVOICE PARENTS WITH PROPER CODING ON INVOICE OR WITH A
DESCRIPTION OF SERVICES FOR PARENT SUBMITTAL TO INSURANCE
• INVOICE MUST DOCUMENT:
• NAME ADDRESS DATE OF BIRTH OF CHILD INSURANCE I.D.
• REFERRING PROVIDER AND DIAGNOSIS CODE
• DATE OF SERVICE (ONE DATE PER LINE)
• DESCRIPTION OF SERVICE AND/OR CPT CODE (REFER TO YOUR AUTHORIZATION) ONE CODE FOR
EACH LINE OF SERVICE. IF TWO CODES ON SAME DATE, THIS IS TWO LINES
• NUMBER OF UNITS (REFER TO YOUR INSURANCE CALL)
• PRICE PER UNIT
• TOTAL COST FOR EACH SERVICE
• PROVIDER NAME, ADDRESS, PHONE NUMBER, NPI, TAX I.D.
• IF REIMBURSEMENT TO BE MADE TO FAMILY MARK THIS INVOICE AS PAID
By Yvonne Mc Namee, YMC Consulting

11. DOCUMENT
ALL SERVICES BILLED MUST BE PROPERLY DOCUMENTED
v INSURANCE CARRIERS MAY ASK FOR YOUR DOCUMENTATION TO VALIDATE
SERVICES WERE PROPERLY SUBMITTED
§ IF YOUR DOCUMENTATION DOES NOT ADEQUATELY DEPICT OR REPRESENT THE
SERVICES PROVIDED THE REIMBURSEMENT CAN BE DENIED. IF SERVICES HAVE BEEN
PAID PRIOR, INSURANCE CAN RECOUP THE AMOUNTS PAID AND DENY FUTURE
CLAIMS
§ ABA DOCUMENTATION MUST BE COMPLIANT WITH THE INSURANCE CARRIER
GUIDELINES.
§ IF YOU ARE IN NETWORK, YOUR CONTRACT WILL OUTLINE THE DOCUMENTATION
REQUIREMENTS.
§ IF YOU ARE NOT IN NETWORK, YOU MAY FIND THE REQUIREMENTS ONLINE AT THE
CARRIER WEBSITE.
By Yvonne Mc Namee, YMC Consulting

12. BASIC DOCUMENTATION
REQUIREMENTS
v ON EVERY PAGE
ü NAME AND DATE OF BIRTH OF CHILD
ü DATE OF SERVICE
§ INFORMATION TO INCLUDE:
ü NAME AND CREDENTIALS OF PROVIDER OF SERVICE
ü NAME AND CREDENTIALS OF SUPERVISOR OF SERVICES (MUST BE BCBA)
ü DIAGNOSIS CODE AND REFERRING PROVIDER NAME
ü CODE(S) FOR THE SERVICE YOU PERFORMED (MUST MATCH CODES SUBMITTED)
ü TIME IN AND TIME OUT
ü PROGRAMS WORKED THIS SESSION – IDENTIFY EACH PROGRAM (MUST BE PART OF
TREATMENT PLAN SUBMITTED IN PRE-AUTHORIZATION REQUEST.
ü INCLUDE NARRATIVE OVERVIEW PROGRAM INCLUDING PROGRESS TO DATE, DATE FOR NEXT
SESSION AND PLAN OF TREATMENT
ü SIGNATURE AND CREDENTIALS OF PROVIDER AND SIGNATURE AND CREDENTIALS OF
SUPERVISING BCBA IF PROVIDER IS NON BCBA FOR THIS DATE.
By Yvonne Mc Namee, YMC Consulting

13. u THANK YOU
Learn more about how Rethink can support
best practices in ABA Billing at rethinkbh.com
Yvonne Mc Namee
YMC Consulting
ymcnamee@aol.com
Jamie Pagliaro
Rethink Behavioral Health
jamie@rethinkbh.com