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Limit the amount of time certain services may be provided to a beneficiary in a 24-hour period

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Claim Requirement 5.25.0

This claim requirement limits the amount of time certain services may be provided to a beneficiary in a 24-hour period.

There are three service categories that have limits on the amount of time provided in one 24-hour period per date:

Service category Amount of time Example
Crisis Intervention services Maximum 8 Hours in one 24-hour period Code H2011- Crisis Intervention
Medication Support services Maximum 4 hours in one 24-hour period Code 96372- Injection Administration
Crisis Stabilization services Maximum 20 Hours in one 24-hour period HCPCS code S9484- Crisis Stabilization

Set up an advanced billing rule for each service category that limits the services to the 24-hour period. The process is the same for all service categories; the only change is the values entered in the advanced billing rule.

Consult the Billing manual for a full list of codes for each service category and the duration of each code.

Prerequisites:

  • Refer to the Billing manual section 5.25.0 for the complete list of service codes.
  • In Dictionary Update, add the reason that a service did not meet the criteria for the advanced billing rule to this dictionary: (Other Tabled Files: data element 1262- Reason For Failed Compliance). Example: Crisis intervention exceeds 8 hours/day.

Set up advanced billing rule for Crisis Intervention services

These steps describe how to set up an advanced billing rule for Crisis Intervention services with a maximum of 8 hours per 24-hour period. 

  1. Go to: Avatar PM > System Maintenance > System Definition > Advanced Billing Rule Definition.
  2. Select Add for Add Or Edit Advanced Billing Rule.
  3. Select Yes for Active.
  4. For Advanced Billing Rule Description, enter a description that users can easily understand, such as 'Crisis Intervention 8 hour max'.
  5. Select Service Codes that the rule applies to; for this example, select (H2011) Crisis Intervention. 
    Note: The user can set up the service code for all relevant codes or for specific codes. 
  6. For the Guarantor select Medi-Cal.
  7. For the Effective Date, enter 07/01/2023. This is the date the new CalAIM processing requirements go into effect. 
  8. For Rule defines Conditions for, select Non-Compliance.
    Note: This selection creates logic for all Crisis Intervention Services that exceed 8 hours will appear on the Advanced Billing Rule Compliance Report.
  9. For Reason for failed Compliance, select the reason that was added to the dictionary mentioned in the prerequisites above.  
  10. For Rule Results In, select either ‘Message Only’ or ‘Liability Inhibit and Message’.
    Note: Selecting 'Liability Inhibit and Message’ prevents the liability from being placed on the guarantor defined in the advanced billing rule. Instead, the liability passes to the next valid guarantor in financial eligibility.
  11. Select File Advanced Billing Rule.
  12. Select Submit.
  13. Still in Advanced Billing Rule Definition, select Event Rules.
  14. For Event Table select Treatment History.
  15. For Event Field enter Duration(Minutes).
  16. For Specific Value (Other) enter 480.
    Note: This is the time requirement in minutes (8 hours * 60 minutes).
  17. Select Greater Than for the Relationship.
  18. Select Add Event Rule.
  19. Select Submit.

Set up advanced billing rule for Medication Support services or Crisis Stabilization services 

Follow the steps for creating an advanced billing rule for Crisis Intervention services, but make the following changes:

Medication Support services

  • Enter the Service Code defined for this type of service in the Billing Manual section 5.25.0.
  • In the Event Rules section, enter the Specific Value (Other) as 240 (4 Hours * 60 minutes).

Crisis Stabilization services

  • Enter the Service Code defined for this type of service in the Billing Manual section 5.25.0 (S9484 is the only service code for Crisis Stabilization Services).
  • In the Event Rules section, enter the Specific Value (Other) as 1,200 (20 Hours* 60 minutes).

Examples for H2011- Crisis Intervention services 

Example 1: This example shows a service that complies with the advanced billing rule. 

  • The advanced billing rule uses code H2011 with a maximum of 8 hours per day.
  • The service was created on 11-20-2022 with a total duration of 480 minutes. Each service is 15 minutes.

In Client Charge Input the Service Entry Details are:

  • Date Of Service - 11/20/2022
  • Client ID - Wexler,Kimberly (1859)
  • Episode Number - Episode #1
  • Program - O.P. Mental Health Services
  • Service Code - Crisis Intervention (H2011)
  • Practitioner - Greene,Sue (0000
  • Duration (Minutes) - 480
  • Cost Of Service - 1920.00
  • Location - Office
  • Discipline - Social Work

The Client Ledger shows the Crisis Intervention service with a maximum of 8 hours per 24-hour period, which complies with the advanced billing rule. 

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The 837 Professional Submission report shows the total amount billed for services that comply with the advanced billing rule. 

Note: If the advanced billing rule is set up to inhibit liability, the liability is passed to the next valid guarantor when the service is entered, according to the client’s financial eligibility.

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Example 2: This example shows a service for 540 minutes, or 9 hours, which does not comply with the advanced billing rule.

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The service exceeds the 8-hour limit and appears in the Advanced Billing Failed Compliance report.

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