The purpose of this assignment is to apply course concepts related to record keeping, third party reimbursement, and other practice management issues in clinical mental health counseling (CMHC 5.C.2.m.) and to understand clinical mental health counselors’ roles, relationships, and collaborations with other community agency personnel (2.F.1.b.). Additionally, students will apply legislative and governmental policy relevant to clinical mental health counseling (CMHC 5.C.2.i.) and understand advocacy processes needed to address institutional and social barriers that impede access, equity, and success for clients (2.F.l.e.) for working with clients across mental health service delivery modalities within the continuum of care, such as inpatient, outpatient, partial treatment and aftercare, and the mental health counseling services networks (CMHC 5.C.2.c.).
Students will review the ‘Third Party Payor and Service Financing Video Fall 2023’ Links to an external site. and complete the two sample billing forms (Part 1 and Part 2) Links to an external site. using the provided case. Upload both completed billing forms to the Canvas Assignment Box. See rubric for assignment details (12 points).
Please note that the following two links are also referenced in the video:
https://www.cms.gov/medicare/physician-fee-schedule/search/overview
Case Example Part 1:
Maria Rodriguez
DOB: 4/21/67
Address: 925 Beacon Place; Apopka, FL 33490
Phone #: 407-998-1212
Maria is a 55yo Hispanic, cisgender female who self-refers for counseling due to trouble sleeping and concentrating. Her symptoms began after she separated from her husband of 20 years, Joseph, last month. She has no history of any mental health issues or treatment.
You are a counselor at Crossroads Community Mental Health Center, an outpatient provider near her home. You complete an intake on January 10, where you provisionally diagnose Maria with an Adjustment Disorder with depressed mood (F43.21). You then see her weekly (January 18 and January 25) for individual sessions for two weeks prior to your treatment plan review.
You learn from your Utilization Review (UR) Department that prior to the appointment, Maria called her insurance company, where she was approved for an intake assessment and 3 individual sessions with you. She brought along her Prior Authorization number for these sessions: 123XXX789. UR also informs you that Maria has no deductible for her mental health treatment, as you are an in-network provided for her insurance. Maria has a $40.00 copay per session.
The UR Department also collected the following information from Maria:
Insurance Name: Florida Blue
Insurance ID #: XYZ999666333
Primary Insured: Joseph Rodriguez
Insured’s DOB: 12/1/65
Insured’s Address: 1122 Templeton Lane; Daytona Beach, FL 33147
Insured’s Phone #: 407-223-5577
Insured’s Employer: Baptist Health of Osceola County
Additional Information about Crossroads Community Mental Health Center:
Office Address/Phone Number: 223 Main Street; Orlando, FL 33555; 407-885-2222
Tax ID: 333227777
Your personal NPI number is: 111222333
Your Florida Blue Provider Number is: FBLMHC888
In accordance with the No Surprises Act, your agency’s published fees are as follows:
60-minute Intake Assessment: $150.00
50-minute Individual Counseling Session: $100.00
90-minute Group Counseling Session: $75.00
75-minute Family Counseling Session: $130.00
Your agency’s contracted rates with Florida Blue are as follows:
60-minute Intake Assessment: $90.00
50-minute Individual Counseling Session: $65.00
90-minute Group Counseling Session: $30.00
75-minute Family Counseling Session: $75.00
Part 1 Instructions: Using the information provided above, complete a CMS-1500 billing form for Maria’s Intake Assessment and the 2 dates of service for individual counseling.
Case Example Part 2:
Maria completed 12 individual sessions to treat her adjustment disorder, and successfully terminated individual counseling with you. However, she continued seeing Crossroads Community Mental Health Center’s Psychiatric Nurse Practitioner, who diagnosed Maria with Persistent Depressive Disorder (F34.1) and prescribed her Prozac 20mg po daily.
After 6 months on the medication, the Nurse Practitioner noticed increased alcohol use with unsuccessful efforts to control her use. She diagnosed Maria with Alcohol Use Disorder, Mild (F10.10), and referred her back to you for counseling to address both the substance use and the depressive symptoms.
You learn from your Utilization Review (UR) Department that since Maria’s first counseling sessions, her divorce has been finalized, and she now has her own personal insurance policy with Cigna insurance through the Affordable Care Act. UR informs you that you are an Out-of-Network provider with Cigna but has not yet informed Maria of this information. While Maria has prior authorization for 3 individual and 3 group sessions with you (PA # 987ZZZ321), she has not yet met her $1000.00 deductible, and has a $25.00 copay for both individual and group counseling sessions. You proceed to see Maria for 2 more individual sessions on August 2 and August 9.
The UR Department also collected the following updated information from Maria:
Insurance Name: Cigna
Insurance ID #: ABC222999888
Primary Insured: Maria Rodriguez
Insured’s DOB: 4/21/67
Insured’s Address: 925 Beacon Place; Apopka, FL 33490
Insured’s Phone #: 407-998-1212
Insured’s Employer: None
Your Cigna Provider Number is: CIGLMHC222
Your agency’s contracted rates with Cigna are as follows:
60-minute Intake Assessment: $90.00
50-minute Individual Counseling Session: $65.00
90-minute Group Counseling Session: $30.00
75-minute Family Counseling Session: $75.00
Part 2 Instructions: Using the information provided above, complete a second CMS-1500 billing form for Maria’s 2 dates of service for individual counseling in August.
