FAQs

CeltiCare Health Plan of Massachusetts, Inc. (CeltiCare) is the physical health vendor for Cenpatico’s Massachusetts membership.

You may contact CeltiCare by phone or website:

Yes, CeltiCare will provide each member with a Member Identification Card. A sample Member ID card looks as follows:

Cenpatico will send you a Welcome Packet which will include a Cenpatico Massachusetts Provider Manual, a copy of your fully-executed Agreement and a welcome letter notifying you of your effective date in our network. Welcome Packets are submitted after your credentialing application and contract have been approved and made effective in our system.

You will receive a copy of the Cenpatico Massachusetts Provider Manual in your Welcome Packet one you are made effective, or “PAR”, in our system. If you did not receive a copy of the Cenpatico Massachusetts Provider Manual in your Welcome Packet you can call the Cenpatico Internal Provider Relations department at 512-406-7200 or download a copy from our website at www.cenpatico.com.

You may obtain a Copy of the Comprehensive Cultural Competency Program by calling the Cenpatico Quality Improvement (QI) department at 512-406-7200 or online at www.cenpatico.com.

Cenpatico covers a comprehensive array of behavioral health and substance abuse services in Massachusetts. Services for CeltiCare members include, but are not limited to the following;

 

• Inpatient hospitalization
• Community Based Acute Residential Treatment
• Crisis Stabilization Services
• Partial Hospitalization
• Day Treatment
• Intensive Outpatient Treatment
• Outpatient Therapy (Individual, Family, and Group)
• Medication Management
• Methadone Maintenance
• Psychological Testing
• Electroconvulsive Therapy (ECT)
• Structured Outpatient Addiction Program (SOAP)
• Family Stabilization Team
• Community Support Services
• Diversionary Programs

For prior-authorizations during normal business hours, please call 866-896-5053. You may contact Cenpatico after hours to notify us of an inpatient admission via our after hours call center – Nursewise (calls to Cenpatico after hours are automatically routed to Nursewise). Member demographic information as well as admitting date, time, and diagnosis will be requested. Cenpatico UM staff will contact you the next business day to obtain full clinical information. You may also submit inpatient notification via our website at www.cenpatico.com.

When requesting authorization for covered outpatient services, you must complete an Outpatient Treatment Request (OTR) form and fax the completed form to Cenpatico at 866-694-3649 for clinical review. The OTR can be found in the Forms section of the Provider Manual and online at www.cenpatico.com. You may call the Customer Service department at 866-896-5053 to check status of an OTR. Treatment requests will be reviewed and responded to within two (2) days. If authorized, providers will receive a Notification of Authorization indicating code and units authorized via fax. If additional information is needed, the provider will be contacted via phone to discuss further.

You can use any of the following options to verify Member enrollment:

• Call 866-896-5053 to reach Cenpatico
• Verify online at www.cenpatico.com (You must have provider login to verify eligibility online)
• Providers who are registered MassHealth providers may also check eligibility through the Eligibility Verification System (EVS), of the new MMIS Eligibility, can be verified after hours via the Cenpatico website, or by contacting our afterhours nurse service – Nursewise (after-hours calls will automatically be routed to Nursewise).

If you render a non-covered service to a Member, you may bill the Member only if you have obtained written acknowledgement from the Member, prior to rendering such non-covered service, that the specific service is not a covered CeltiCare benefit, and that the Member understands they are financially responsible for such service.

Please use the Cenpatico Massachusetts Provider Information Update Form located in the Forms section of the Provider Manual to provide your information to Cenpatico. Completed Provider Information Update Forms should be sent to Cenpatico using one of the following methods:

Participating providers will be listed in the Cenpatico Massachusetts Provider Directory. You can find the Provider Directory online at www.cenpatico.com.

Please submit your claims to the following address:

Cenpatico
Attn: Claims
PO Box 7200
Farmington, MO 63640-3818

Cenpatico accepts transactions from the following vendors:

  • Emdeon/WebMD/Envoy
  • Relay Health/McKesson
  • Cenpario/ProxyMed

Cenpatico’s payer identification number is 68061.

Claims must be received within ninety (90) days of the date the service(s). Claims submitted after this period will be denied for payment.

An Explanation of Payment (EOP) is provided with each claim payment or denial. The EOP details each service being considered, the amount eligible for payment, copayments/deductibles from eligible amounts, and the amount reimbursed. If you have questions regarding your EOP, please contact Cenpatico’s Claims Customer Service department at 866-324-3632.

An EX code explains how the claim was processed and why a claim was adjusted or denied.
Common EX codes are as follows:

  • MF: DENY: INAPPROPRIATE MEDICAID# SUBMITTED FOR SVC PROVIDER, PLEASE RESUBMIT – The billed Medicaid# may not have been set up in our system, or may have been billed with additional alpha or numeric characters. Another common cause is inclusion of the Tax ID# in the fields where Medicaid# should be populated. Depending on provider type and state specific rules, this denial can also occur when the Medicaid number or NPI number of the rendering provider is put on the claim instead of the billing provider’s number.
  • A1: DENY: AUTHORIZATION NOT ON FILE –An authorization has not been obtained for the billing provider, the date of service falls outside the range of an existing authorization, the claim was submitted prior to request for authorization, or an authorization has been obtained but was not showing in the claim system at the time of processing.
  • 29: DENY: THE TIME LIMIT FOR FILING HAS EXPIRED – In the event that timely filing guidelines were not followed, this denial will apply. If effort was made to submit prior to the expiration of timely filing limits then documentation that demonstrates the same can be included with paper claims.
  • 18: DENY: DUPLICATE CLAIM/SERVICE – The claim payment system will attempt to match dates of service and procedures with previously processed claims. If a match is found then a duplicate denial code may be applied. Duplicate denials can occur when adjustment requests are submitted along with additional copies of the original claim or when part of a claim denies and a new claim with all services are resubmitted instead of just submitting an adjustment for the previously denied service lines. Another common submission error pertains to multiple submissions of the same electronic claims file “just to be sure.”
  • 28: DENY: COVERAGE NOT IN EFFECT WHEN SERVICE PROVIDED – Member eligibility should be verified prior to providing services to ensure payment. Additionally, careful keying of member information on the claim will help insure the correct member is selected in the claims system.
  • MQ: DENY: MEMBER NAME/NUMBER/DATE OF BIRTH DO NOT MATCH. PLEASE RESUBMIT – A common submission error pertains to member number containing extra digits, or too few digits. Additionally a restriction on the date of birth field circa March, 2007 now mandates that D.O.B. on claim must match the claim payment system exactly as opposed to a 2-day lenience or transposition of the numbers representing day of month (e.g. 06/12/1980 written as 06/21/1980).
  • 90: PAID: SERVICE IS PAID UNDER CAPITATION OR BLOCK AGREEMENT – This payment code is used to track encounter value for providers on block payment agreements.
  • VI: GLOBAL FEE PAID – A cash payment will not be made on this service as it has been already made on a primary service.

All CPT and HCPCS codes must be billed on a CMS-1500 form. All revenue codes must be billed on a CMS-1450 Form (“UB-04″) form.

If a claim discrepancy is discovered, in whole or in part, contact Cenpatico’s Claims Customer Service department at 866-324-3632 to speak with a Claims Support Liaison. The majority of issues regarding claims can be resolved through the Claims Department with the assistance of a Claims Support Liaison.

Under no circumstances is a Member to be balance billed for covered services or supplies. If you use an automatic billing system, bills must clearly state that they have been filed with the insurer and that the participant is not liable for anything other than specified un-met deductible or copayment (if any).

  • Submit claims immediately after providing services. Claims must be received within ninety (90) days of the date the service(s). Claims submitted after this period will be denied for payment.
  • Submit a Clean Claim on a CMS-1500 Form or a CMS-1450 Form (“UB-04″) or their successors. A Clean Claim is one in which every line item is completed in its entirety.
  • Ensure the billing provider’s NPI number is listed in field 24J if you are billing with a CMS- 1500 Form or field 56 if you are billing with a CMS-1450 Form.
  • Use the correct mailing address when submitting paper claims.

Plan Type I:

  • No copayments or out-of-pocket maximum for any covered behavioral health service.

Plan Type II:

  • $10.00 copayment for outpatient or office visits.
  • $50.00 copayment per stay for inpatient services*
  • No copayment for methadone maintenance
  • Maximum out-of-pocket cost per member per benefit year** is $750.00 (excluding prescriptions)

Plan Type III:

  • $15.00 copayment for outpatient or office visits.
  • $250.00 copayment per stay for inpatient services*
  • No copayment for methadone maintenance
  • Maximum out-of-pocket cost per member per benefit year** is $1500.00 (excluding prescriptions)

Note:
*Inpatient copayments are waived if transferred from another inpatient unit.
**Benefit year is July 1st through June 30th.