Common use of Disallowed Expenditures and Financial Repayments Clause in Contracts

Disallowed Expenditures and Financial Repayments. In the event that the MDHHS, the PAYOR, the State of Michigan, or the federal government ever determines in any final revenue and expenditure reconciliation and/or any final finance or service audit that the PROVIDER has been paid inappropriately per the PAYOR’s expenditures of federal, state, and/or local funds under this Agreement for Medicaid or non-Medicaid program supports/services claims, and/or cost claims which are later disallowed, the PROVIDER shall fully repay the PAYOR for such disallowed payments within sixty (60) days of the PAYOR’s final disposition notification of the disallowances, unless the PAYOR authorizes, in writing, additional time for repayment. Attachment B – Service Codes and Rates Code Service Description Modifiers Reporting Units PROVIDER Type BCBA BCaBA QBHP LP/LLP BT Notes 97151 ABA Behavior Identification Assessment AH, HN, HO, HP, ST, U5 Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 0362T Behavior Follow-Up Assessment AF, AG, AH, HN, HO, HP, SA Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97153 ABA Adaptive Behavior Treatment, individual AF, AG, AH, HM, HN, HO, HP, SA, TD Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT 97154 ABA Adaptive Behavior treatment, group AF, AG, AH, HM, HN, HO, HP, TD, SA Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT 97155 Clinical Observation and Supervision AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97156 Family training AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97157 Family training, multiple families AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97158 Adaptive Behavior Treatment Social skills group AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 0373T Direct treatment, requiring two or more technicians AF, AG, AH, HM, HN, HO, HP, SA Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT MODIFIERS: Modifier Description Applies To AF Specialty Physician 97153-54; 0362T; 0373T AG Physician 97153-54; 0362T; 0373T AH Clinical Psychologist provided service 97151-97158; 0362T; 0373T HM Less than Bachelor’s Level provided service 97153-54; 97158; 0373T HN Bachelor’s Level provided service 97151-97158; 0362T; 0373T HO Master’s Level provided service 97151-97158; 0362T; 0373T HP Doctoral Level provided service 97151-97158; 0362T; 0373T SA PA, NP, CNS 97153-54; 0362T; 0373T ST Related to Trauma or Injury 97151 TD Registered Nurse 97153-54; U5 Autism (State defined modifier) 97151 PLACE OF SERVICE CODES: Code Name Description

Disallowed Expenditures and Financial Repayments. In the event that the MDHHS, the PAYORPayor, the State of Michigan, or the federal government ever determines in any final revenue and expenditure reconciliation and/or any final finance or service audit that the PROVIDER Provider has been paid inappropriately per the PAYORPayor’s expenditures of federal, state, and/or local funds under this Agreement for Medicaid or non-Medicaid program supports/services claims, and/or cost claims which are later disallowed, the PROVIDER Provider shall fully repay the PAYOR Payor for such disallowed payments within sixty (60) days of the PAYORPayor’s final disposition notification of the disallowances, unless the PAYOR Payor authorizes, in writing, additional time for repayment. Attachment B – Service Codes and Rates Code Service Description Modifiers Reporting Units PROVIDER Type BCBA BCaBA QBHP LP/LLP BT Notes 97151 ABA Behavior Identification Assessment AH, HN, HO, HP, ST, U5 Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 0362T Functional Behavior Follow-Up Assessment AF, AG, AH, HN, HO, HP, SA Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97153 ABA Adaptive Behavior TreatmentDirect treatment, individual AF, AG, AH, HM, HN, HO, HP, SA, TD Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT 97154 ABA Adaptive Behavior Direct treatment, group AF, AG, AH, HM, HN, HO, HP, TD, SA Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT 97155 Clinical Observation and Supervision AHPer 15 minutes BCBA, HNBCaBA, HOQBHP, HP or LP/LLP 97155-GT Supervision, telepractice Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97156 Family training AHPer 15 minutes BCBA, HNBCaBA, HOQBHP, HP or LP/LLP 97156-GT Family training, telepractice Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97157 Family training, multiple families AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97158 Adaptive Behavior Treatment Social skills group AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 0373T Direct treatment, requiring two or more technicians AF, AG, AH, HM, HN, HO, HP, SA Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT MODIFIERS: Modifier Description Applies To AF Specialty Physician 97153-54; 0362T; 0373T AG Physician 97153-54; 0362T; 0373T U5, AH Clinical Psychologist provided service 97151-97158; 0362T; 0373T HM Less than Bachelor’s Level AJ Clinical Social Worker provided service 9715397151-5497158; 971580362T; 0373T HN Bachelor’s Bachelors Level provided service 97151-97158; 0362T; 0373T HO Master’s Other Masters Level provided service 97151-97158; 0362T; 0373T HP JP Other Doctoral Level provided service 97151-97158; 0362T; 0373T SA PA, NP, CNS 97153-54; 0362T; 0373T ST Related to Trauma or Injury 97151 TD Registered Nurse 97153-54; U5 Autism (State defined modifier) 97151 PLACE OF SERVICE CODES: Code Name Description

Disallowed Expenditures and Financial Repayments. In the event that the MDHHS, the PAYOR, the State of Michigan, or the federal government ever determines in any final revenue and expenditure reconciliation and/or any final finance or service audit that the PROVIDER has been paid inappropriately per the PAYOR’s expenditures of federal, state, and/or local funds under this Agreement for Medicaid or non-Medicaid program supports/services claims, and/or cost claims which are later disallowed, the PROVIDER shall fully repay the PAYOR for such disallowed payments within sixty (60) days of the PAYOR’s final disposition notification of the disallowances, unless the PAYOR authorizes, in writing, additional time for repayment. Commented [BG130R129]: Agreed. Commented [PF129]: Add U5. Modifier should be reported for behavior identification assessments completed on ABA enrollees. Commented [KJ131R129]: PNMC: Agreed; add U5 modifier Commented [KJ132R129]: Added Commented [BG127]: U5 has been added back to 97151 for autism enrollees Commented [AD128R127]: Noted below on Attachment B Attachment B – Service Codes and Rates Code Service Description Modifiers Reporting Units PROVIDER Type BCBA BCaBA QBHP LP/LLP BT Notes 97151 ABA Behavior Identification Assessment AH, HN, Per 15 BCBA, Behavior Identification Assessment HO, HP, ST, U5 Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 0362T Behavior Follow-Up Assessment AF, AG, AH, HN, HO, HP, SA Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97153 ABA Adaptive Behavior Treatment, individual AF, AG, AH, HM, HN, HO, HP, SA, TD Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT 97154 ABA Adaptive Behavior treatment, group AF, AG, AH, HM, HN, HO, HP, TD, SA Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT 97155 Clinical Observation and Supervision AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97156 Family training AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97157 Family training, multiple families AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 97158 Adaptive Behavior Treatment Social skills group AH, HN, HO, HP Per 15 minutes BCBA, BCaBA, QBHP, or LP/LLP 0373T Direct treatment, requiring two or more technicians AF, AG, AH, HM, HN, HO, HP, SA Per 15 minutes BCBA, BCaBA, QBHP, LP/LLP, or BT Commented [PF133]: Remove. GT modifier is obsolete effective May 11, 2023. Commented [BG134R133]: agreed. Commented [KJ135R133]: PNMC: Agreed GT can be removed MODIFIERS: Modifier Description Applies To AF Specialty Physician 97153-54; 0362T; 0373T AG Physician 97153-54; 0362T; 0373T AH Clinical Psychologist provided service 97151-97158; 0362T; 0373T HM Less than Bachelor’s Level provided service 97153-54; 97158; 0373T HN Bachelor’s Level provided service 97151-97158; 0362T; 0373T HO Master’s Level provided service 97151-97158; 0362T; 0373T HP Doctoral Level provided service 97151-97158; 0362T; 0373T SA PA, NP, CNS 97153-54; 0362T; 0373T ST Related to Trauma or Injury 97151 TD Registered Nurse 97153-54; U5 Autism (State defined modifier) 97151 “GT” Modifier may remain applicable for FY23 – in which case claims would need to be submitted in accordance with current MDHHS requirements PLACE OF SERVICE CODES: Code Name DescriptionDescription 02 & 10 Telemedicine As allowable as identified and in effect, in the Bureau_of_Specialty_Behavioral_Health_Services-Telemedicine_Database.pdf (xxxxxxxx.xxx) MICHIGAN PIHP/CMHSP COVID-19 Encounter Code Chart 03 School A facility whose primary purpose is education (effective January 1, 2003).