ACMS PWP Billing Form version 2022.b

Physician Wellness Program Contract Counselors Billing and Demographics Submission

Submit a separate bill for each 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 another/unreported one of those indicators to mask them fully. If you have trouble with the form, call Melanie at 412-321-5030 x100 or email mmayer@acms.org.
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.
Counselor Name*

Eligibility Verification Instructions
- Please verify the physician status of all new clients when scheduling intake appointments and at the beginning of each 12-month benefit period. Check eligibility by confirming their Medical ID card. Clients are entitled to a maximum of 4 sessions per year. The duration of each session will be determined by the therapist's recommendation.
What if I can't verify their membership?
- If a new client claims to be a physician but cannot provide identification, please see them if the issue is urgent. However, before the next appointment, please call the ACMS office to determine the best way to verify their membership while maintaining confidentiality.

Eligibility
I saw evidence confirming the physician's status*

YesNo, it was urgent and I need to follow up.
Subcontract Billed

MonthDayYear
Date
Allowed Billable Hours per 12 Month Benefit Period

Appointments
Appointments: How many sessions (irrespective of sessions billed) have you scheduled with this client THIS month?*
INCLUDING 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*
Please indicate the number of appointments for which you will bill $75 because theclient did not cancel the scheduled appointment in time or did not show upwithout adequate notice. Reporting such no-show appointments will reduce thenumber 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 PWP 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 PWP 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 PWP before or

b) the client has used PWP before with a different PWP contracted MHP in the past 12 months.
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 PWP 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.
After entering the number of no-shows in the above question, the system will automatically adjust and round to the nearest 0.5 increment, corresponding to the $75 payment for each no-show.
Enter total KEPT regular appointment sessions billed for this client this month (do not include No Shows.)*
Total hours billed this month for this client
Intake Modifier
The system will auto-populate if you indicated "yes" for completing client intake paperwork, related to the $25 payment.
Calculated Sub Total $*
Prior to this billing month, how many PWP billed sessions had THIS client used during the current 12-month benefit period?*
(inclusive of prior PWP MHP utilization during the same period.)
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 Melanie at 412-321-5030 x100 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
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?
Age*
Physician Type*
Gender*
Specialty*
Employment Type*
Primary Initial Challenge*

Billing Summary and Submission

The fields below are calculated based on previous answers. If you believe they are incorrect or need to be edited, please return to the appointments section to make changes accordingly.
Unique ID (Optional)
This field is OPTIONAL and can be used as an internal record code to distinguish this billingfrom others submitted during the same month. For example, you can use"1/22 Client 245" or "Jan 22/1 of 3". You can use any format that makes sense to you, but it should not in any way identify the client to ACMS. This will also help me ensure that duplicate billings are not submitted accidentally.
Invoice Total $*
Anything we should know about your billing this month?
By signing and submitting below, I certify that the appointments are billed in agreement with my contract with Allegheny County Medical Society and that membership in {eligibility} was verified before initial appointments and the first appointment after January 1st of each year.

Contractors will bill the ACMS monthly 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 the invoice for each calendar month of the Agreement Term. All monthly demographics must add up appropriately before payment is processed.

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

Please call Melanie Mayer at 412-321-5030 x 100 or email mmayer@acms.org 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 Wellness Program Contract Counselors Billing and Demographics Submission