Health Care Home (HCH)

Overview

Effective on or after July 1, 2010, the HCH program, authorized by the Minnesota Legislature in 2008 (MN Stat. sec. 256B.0625), allows qualified providers to receive HCH reimbursement for the delivery of care coordination services to members who have complex and chronic medical conditions.

The development of the HCH initiative is a coordinated effort between the Minnesota Department of Health (MDH) and DHS and is driven by the Institute for Healthcare Improvement’s Triple Aim, an initiative to simultaneously achieve the following goals:

Improve the individual experience of care
Improve the health of the population
Improve affordability by containing the per capita cost of providing care

Eligible Providers

Clinics and clinicians must meet a set of standards and criteria in order to be certified as an HCH provider in Minnesota. Use the MDH Health Care Homes certification process to become a certified HCH provider.

Providers must attest to PrimeWest Health that the facility and the primary care coordination team members meet the requirements of MN Rules Chap. 4764 (Health Care Homes) to provide services prior to submitting HCH claims to PrimeWest Health, including the following:

Patient-centered care coordination
Team
Communication
Access
Referral process
Care plan
Registry
Quality improvement

Clinics and clinicians must meet a set of standards and criteria in order to be certified as an HCH in Minnesota. Use the MDH HCHs certification process to become a certified HCH provider. To receive reimbursement for HCH services, providers must do the following:

Receive HCH certification from MDH
Determine which of their patients are eligible HCH recipients
Provide HCH services to eligible PrimeWest Health members according to stated requirements
Claim HCH reimbursement once a month for each eligible member
Coordinate with PrimeWest Health to provide a continuum of care

Effective December 6, 2012, HCH clinics and providers must fax a copy of their MDH HCH certification or recertification letters to MHCP that include the following required information:

HCH certification begin and end dates
NPI/UMPI for each MHCP-enrolled clinic
NPI/UMPI for each MHCP-enrolled individual provider

If the MDH HCH certification report does not include the NPI/UMPI for the clinic or individual providers, you must provide this information using one of the following methods:

Write the NPI/UMPI next to the clinician or clinic name
Attach a separate list of the NPIs/UMPIs with the MDH HCH certification report

Fax copies of the MDH HCH certification report that includes all required information to MHCP Provider Enrollment at 1-651-431-7462.

MHCP will not process requests without the NPI/UMPI and will add the certification dates to the provider record(s).

Before billing care coordination services S0281, access Minnesota Information Transfer System (MN–ITS) and verify the individual provider or clinic is listed on the HCH list accessible from the Provider Lists link in the left column.

Eligible Members

Providers can assess the overall complexity of members by grouping them into complexity tiers based on the number of major chronic condition groups that apply to them. Members with one or more major chronic condition are eligible for HCH. The Care Coordination Tier Assignment Tool was developed by MDH and DHS to support complexity assessments. Based on the above methodologies, members with major condition groups are scored as follows:

Tier 1: 1 – 3 major condition groups
Tier 2: 4 – 6 major condition groups
Tier 3: 7 – 9 major condition groups
Tier 4: 10 or more major condition groups

HCH reimbursement increases for care coordination when members (or caregivers of dependent members) have one of the following supplemental complexity factors:

Need sign or spoken language interpreter services
Have a serious and persistent mental illness

See the Care Coordination Tier Assignment Tool for how these factors are defined. There will be a 15 percent increase for each factor and a 30 percent increase when both apply. The corresponding procedure codes and modifiers for tier level and the presence of supplemental factors are described below.

Chronic Care Management Services

PrimeWest Health follows Medicare guidelines on reimbursement for chronic care management for non-face-to-face care coordination services furnished to members with multiple chronic conditions.

Billing Requirements

When billing for at least 20 minutes of chronic care management services (CPT code 99490) per month directed by a physician or other qualified health care professional, the following elements must be included:

The patient must have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
The patient must have chronic conditions that place him/her at significant risk of death, acute exacerbation/decompensation, or functional decline
The patient must have an established comprehensive care plan that has been implemented and that is revised or monitored

Complex county case management and non-complex county case management cannot be reported in the same calendar month for the same member (i.e., providers may not report CPT code 99491 in the same calendar month as CPT codes 99487, 99489, or 99490).

County case management CPT codes 99487, 99489, 99490, and 99491 can be reported by the same practitioner for services provided during the 30-day transitional care management service period (CPT codes 99495 and 99496).

County case management CPT codes cannot be billed during the same service period as Healthcare Common Procedure Coding System (HCPCS) codes G0181 or G0182 (home health care supervision/hospice care supervision), or CPT codes 90951 – 90970 (certain End-Stage Renal Disease services).

Effective January 1, 2018, Rural Health Clinics (RHC) and Federally Qualified Healthcare Centers (FQHC) are reimbursed for general care management services when G0511is billed alone or with other payable services on an RHC or FQHC claim. This code (G0511) can only be billed once per month per member, and cannot be billed if other care management services are billed for in the same time period. PrimeWest Health follows Medicare guidelines in the eligibility and billing requirements for this service.

The chronic care management or general care management fee is not reimbursable for providers who are participating in any PrimeWest Health programs that currently offer care management compensation.

HCH Provider Responsibilities

Providers wishing to bill for HCH services must follow and meet MN Rules part 4764.0040 (Health Care Home Standards).
Reimbursement will be dependent on verification that both the pay-to provider and treating provider are eligible for HCH and the member is actively enrolled in PrimeWest Health at the time HCH services are rendered.
Providers must demonstrate collaboration with PrimeWest Health care coordinators and county case managers. This is especially important with members who are currently enrolled in PrimeWest Health’s dual eligible programs—PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP)—in order to avoid unnecessary duplication of care management expectations.

For PrimeWest Health dual eligible members, providers agree to implement or use PrimeWest Health’s assessment, care plan, Medication Therapy Management (MTM) program requirements, transition of care forms, and other stated requirements when indicated.

Providers wishing to provide HCH services will agree to actively cooperate with PrimeWest Health initiatives for reducing unnecessary emergency room visits and unnecessary inpatient admissions and readmissions.

Provider Procedure for HCH Services

Verify member eligibility.
Provide member education about HCH services and obtain necessary consent according to regulations.
Submit an HCH claim according to specifications above.

PrimeWest Health retains the right to periodically request HCH medical records to ensure providers are meeting and following stated HCH requirements. Should PrimeWest Health determine that a provider is submitting HCH claims without supporting documentation, PrimeWest Health may exercise its right to refuse such payment or future payments for HCH services.

Billing for HCH Services

To claim care coordination payment:

Document all care coordination services provided and justification for complexity tier assignment in the member’s medical record
Use the 837P electronic claim transaction to submit all claims
Note that a single date of service represents the entire month. Bill on one claim transaction and enter one unit of Initial Care Coordination planning code S0280 for the first month. Enter Maintenance Care Coordination Planning code S0281 for each additional month. Bill the procedure code once a month with:
1. Modifier U1: Tier 1
2. Modifier TF: Tier 2
3. Modifier U2: Tier 3
4. Modifier TG: Tier 4

If necessary, include the following:

a. Modifier U3: If primary language is non-English
b. Modifier U4: If Severe and Persistent Mental Illness (SPMI)

For a provider to be eligible for reimbursement, the member must have an Evaluation and Management (E/M) visit with the care coordination provider within the last 12 months from the care coordination procedure code date of service. The appropriate E/M procedure code can occur on a different date of service and be billed separately from the care coordination procedure code. E/M visit procedure codes considered are 99201 – 99205, 99211 – 99215, 99324 – 99328, 99334 – 99337, 99339, 99340, 99341 – 99345, 99347 – 99350, 99381 – 99387, and 99391 – 99397.

Reimbursement is the lower of the submitted charge or, when the rendering enrolled provider is either a physician, NP, or PA, per the following tiers:

Physician                          NP or PA
Tier 1: $10.14                   Tier 1: $9.81
Tier 2: $20.27                   Tier 2: $19.61
Tier 3: $40.54                   Tier 3: $39.22
Tier 4: $60.81                   Tier 4: $58.83

Additional Resources

MN-ITS User Guide – Health Information Request (HIR)

MDH – Health Care Homes

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