ACMS PVP Billing Form version 2022.b

Physician Vitality Program Contract Mental Health Provider Billing and Demographics Submission

Submit a separate bill for each individual client for each month on this form. Do not submit any client names on this form. If the combination of the client's age, gender, specialty, employment status and credentials is so specific, it could compromise their identity, choose other/unreported on one of those indicators to mask them fully. If you have trouble with the form, text or call (415) PVP-ACMS (415-787-2267) or call 208-336-2930
Billing Period Ends*

MonthDayYear
Chose the last day of the month this billing period represents and only bill for appointments within a one month period.
Mental Health Provider Name*

Eligibility Verification Instructions
- Please confirm membership on all new clients upon making intake appointments and in each subsequent 12-month benefit period.
- Determine eligibility based on who the client says they learned about the program from - this will determine which membership association will be billed. Please stay consistent between billings on any one client.
- Client members who may be eligible under more than one medical society/association may still have the same maximum allotment of 5.0 appointment hours per year (booked in 1/2 hour increments), regardless of dual or triple eligibility.
Ada County Medical Society Members
All medically licensed members of ACMS whose primary workplace (or homebase) is Ada or Elmore County.

Verified via https://www.adamedicalsociety.org/pvp-qualified-members-directory

Idaho Medical Association

All medically licensed members of IMA verified via: https://www.idmed.org/idaho/Idaho_Public/Physician_Finder/Idaho_Public/Physician_Finder/Search.aspx

IAFP - Idaho Academy of Family Physicians
All currently licensed members of IAFP are eligible, including attending physicians and medical residents, as well as retirees, verified via current membership list. Please email ACMS for a current membership list.

MIEC - Medical Insurance Exchange of California

All current malpractice insurance policy holders (physicians); ancillary medical or non-medical staff of the physician are not eligible. Mental Health Provider should ask physician making an appointment to show a Certificate of Insurance available from MIEC to validate their eligibility.

What if I can't verify their membership?

If a new client insists they are a member of one of the above associations, but cannot be verified this route, please see them if the issue is urgent. Before the next appointment, however, please call the ACMS office to find how to best verify their membership while maintaining confidentiality.

There may be alternate ways to verify this while maintaining their confidentiality, their membership may have lapsed, they may be confused about membership coverage.

Eligibility
Eligibility*

ACMSIAFPIdaho Medical AssociationMIEC
Subcontract Billed

MonthDayYear
Date
Allowed Billable Hours per 12 Month Benefit Period

Appointments
Appointments: How many appointments (irrespective of hours billed) did you have scheduled with this client THIS month?*
INCLUDING Resident Meet and Greets prior to establishing as client, kept client appointments, and no-shows
Meet and Greets*
How many of the Appointments above were Resident Meet and Greets. (Half hour appointment and didn't establish as a client.) These will be paid at $75. Do not count any Resident Meet and Greets that were No Shows. Report those below.
No-Shows*
How many of the appointments above will you be billing at $75, because the client did not cancel the scheduled appointment in time or no-showed without adequate warning. Reporting no shows that you will bill for does reduce the number of covered sessions for the member for the Benefit Year.
Were any of these a "First Time" (of the Benefit Year) Appointment (definition below)?*

YesNo
FIRST TIME DEFINITION: When an appointment is marked as "First Time" it allows us to count discreet # of members seen each year AND determine which types of members by reported demographics are utilizing the service each year.

Mark an appointment as first time if any of these are true
- The client has never used ACMS PVP services before OR
- The client is starting a new 12-month benefit year.
Do NOT count this as a first-time appointment if they have seen another PVP contract counselor and are finishing an existing 12-month benefit period.
Did you do INTAKE paperwork with this client for YOUR very first time? (definition below)*

YesNo
Intake Appointment Definition: Intake appointment is usually a first-time-ever appointment, but not always. It allows for an additional $25 reimbursement for completing initial consent to treat and demographic paperwork.

Mark YES if you are meeting with a client for the first time. You would do this if

a) the client has NOT used PVP before or

b) the client has used PVP before with a different PVP contracted MHP in the past 12 months.

You may also mark YES if it has been at least three years since you have last seen the client. Do NOT mark YES each year you need to renew the consent to treat and update demographics.
It looks like you are trying to bill for a no-show on a single appointment this month that was scheduled to be an intake appointment. You can do that, but you just won't be able to bill for the modified intake amount of $25 since you didn't have the appointment.

Please mark the intake field above as NO before proceeding.
It looks like you are trying to bill for a meet and greet and an intake with only a single appointment this month. The meet and greet should not be marked as intake since no paperwork should have been completed. If it was, do not mark it as a meet and greet.

You can charge for an intake appointment subsequent to a first-appointment meet and greet.

Please make the appropriate changes before proceeding.
Telehealth*
How many of the appointments billed for this month were conducted via phone/web/video?
Prior Year Utilization*
Mark YES if the client has utilized PVP services with you OR another counselor that you know of PRIOR to this 12-month benefit period (not just prior to this calendar year)? We use this data point to determine how much utilization is year over year.

Billing Hours
Billed meet and greet hours calculated
Billed No Show hours calculated.
Enter total KEPT regular appointment HOURS billed for this client this month (do not include Meet and Greets or No Shows.)*
(in 1/2 hour increments, e.g. .5, 1.0, 1.5, 2.0, etc)
Total hours billed this month for this client
Intake Modifier
Calculated Sub Total $*
Prior to this billing month, how many PVP billed hours had THIS client used during the current 12-month benefit period?*
(in 1/2 hour increments, e.g. .5, 1.0, 1.5, 2.0, etc), inclusive of prior PVP MHP utilization during the same period.
Based on the hours reported for this client for the current benefit year, please be sure to remind them to fill out an evaluation of the program at this link. You can also provide this to clients who are finishing with you even if they use less than the maximum number of appointments.

https://form.jotform.com/213464794079063

A printable version is available here
Total hours reported for this client for current "benefit year:"*
First Time Appointments Billed
Follow-up Appointment Hours Billed
It looks like the total hours you are billing for this month ({TotalHoursBilled}) plus any prior appointments in the clients "Benefit Year" ({priorTo}) will push them over the number of hours allowed by qualification type ({AllowedBillableHours}).

Please make the appropriate changes before proceeding or call Steve at 208-336-2930 to assist with your billing.
Please proceed and fill out demographics for all client, whether "first time" appointment or otherwise. We count statistics of demographics once per benefit year per client, but for repeat clients having these demographics allows us to see the higher count utilizers.

Client Demographics
Member Type*
It looks like you are trying to bill for a Resident meet and greet but are marking the member type as other than Resident.

Please make the appropriate changes before proceeding.
Primary County*
In which county is the member practicing or institution located?
Slow down. Did you really mean IDAHO county? If so, proceed, but unless you're serving somebody from Grangeville, Kamiah, or Kooskie, you probably mean a different county.
You marked this as an ACMS eligible member, but didn't mark their county as Ada or Elmore. If the person practices outside of Ada or Elmore county, you should qualify them under Idaho Medical Association or Idaho Academy of Family Physicians as appropriate.
Age*
Gender*
Specialty*
Employment Type*
Primary Initial Challenge*

Billing Summary and Submission

Fields below are calculated based on previous answers. If you feel they are not correct or need to be edited, please go back to the appointments section to edit accordingly.
Unique ID (Optional)
This OPTIONAL field may be an internal record code which you use to distinguish this billing from others you submit during the same month. For example ("1/22 Client 245" or "Jan 22/1 of 3") You may use anything that makes sense to you but it should not in any way identify client member to ACMS in part or in whole. This also helps me know you have not accidently submitted duplicate billings.
Invoice Total $*
Since you indicated this client has had five appointments, please invite them to fill out the anonymous feedback form for the PVP program located here.
Anything we should know about your billing this month?
Random Invoice ID
Invoice ID
By signing and submitting below I certify that the appointments are billed in agreement with my contract with Ada County Medical Society, that membership in {eligibility} was verified prior to initial appointments and the first appointment after April 1 of each year.

Contractors will bill the ACMS on a monthly basis for all counseling sessions provided during a calendar month within 15 days. Payments will be made within thirty (30) days of the ACMS’s receipt of invoice for each calendar month of the Agreement Term. All monthly demographics must add up appropriately before processing for payment.

A confirmation email will be sent to you upon successful submission.

Please call Steve Reames at 208-336-2930 should you have any questions
Submitted by (billing agent) *

First NameLast Name
Email*
example@example.com
Signature*

Clear
Submission Date

MonthDayYear
Date
Paid Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Physician Vitality Program Contract Mental Health Provider Billing and Demographics Submission