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Beyond Medical Necessity Days for YouthCare Members

Date: 08/02/21

Effective for claims date of service (DOS) September 1, 2020, YouthCare HealthChoice Illinois (YouthCare) will be paying for Beyond Medical Necessity (BMN) days for YouthCare members.

The following billing guidance should be followed:

  • Claims for the Medically Necessary admission require prior authorization and should be billed per billing guidelines for DOS of the medical stay. Claims should be billed once the medical stay has ended.
  • BMN claims should be billed starting with the day after discharge for the medical stay with the appropriate TOB – 114/117.
  • Claims will be reimbursed as follows:
    • Behavioral Facility day 1-30 – $400 per diem
    • Behavioral Facility day 31+ – $600 per diem
    • Acute Care Facility – $289.48 per diem
  • All BMN claims should be billed with a Revenue Code 0169 – Room and Board Other. Any additional services billed on the claim will not be reimbursed.
  • The primary medical health (PH) or behavioral health (BH) diagnosis utilized for the prior inpatient claim should submitted diagnosis position 1 to ensure the appropriate reimbursement. If a diagnosis is considered shared by medical or BH, for example – depression, the claims will be reimbursed at the BH rate.
  • YouthCare request that Z62.21 – Child in welfare custody be utilized in the second diagnosis field.
  • Claims are subject to the 180 days filing limit from the date of final placement. However, YouthCare understands that there will be several initial claims with DOS in late 2020 and early 2021 that may be past timely filing. YouthCare will override timely filing on these claims during the initial submission of the older DOS.
  • While BMN days do not require authorization, if a YouthCare member returns to a medical admission status while waiting for placement, facilities will need to request prior authorization for those days in accordance to established procedures.
  • When YouthCare members move between medical admission and BMN while waiting for placement, a claim will need to be specific to the status of the member and inclusive of the days in each status.
  • Clinical reviews will occur every seven days for all BMN youth. Clinical documentation should be submitted to Utilization Management via fax: BH 1-833-387-3173 or PH 1-844-989-0154.

We thank you for your patience and for helping our members live better, healthier lives. For more information or if you have any questions or concerns, please call YouthCare at 1-844-289-2264.