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Information on Claim Modifiers for Special Populations

 If Special Populations add a Billing Modifier, Guidance on How to Use

  1. Based upon certain specific criteria, modifiers (HK) are added in the billing output (837) in both the Service Segment (SV1) and it creates another required segment in the 837 output.
  2. The criteria that the system looks at to determine whether the service should have the Modifier attached is:
    1. The client must be under 21 (This is calculated by the system based upon the client’s date of birth and the date of service)
    2. The client must have a “Special Population” record/document where the effective date and the data of service align.
      1. In the screen where Special Populations are assigned to the client, there are a number of different “Special Population” values that can be assigned to the client.  Of these, two of them have been configured to trigger the inclusion of the HK Modifier.  These are:
        1. ICC/IBHS
        2. Katie A – ICC/IBH
    3. The client must be covered by a Medi-Cal Plan.  In fact, what the system is looking for is whether or not the “Plan” that covers the service has the field “Katie A Eligible Plan” checked.  This field is on the “Custom Fields” tab of the “Plans (Administration)” menu/screen.  This field should only be checked for Medi-Cal Plans.
    4. Finally, the application of the HK Modifier (and additional segment) is only applicable to specific Procedures.  So, in the menu option where the Procedures are configured (“Procedure/Rates (Administration”) on the “Custom” tab, the applicable procedures need to be marked as “HighRiskPopulation”When all these variables are in place, the system will format the 837 output correctly to apply the “HK” modifier and the additional segment (as needed).  All of these elements have been configured in each County since the Plans, Procedures, and the applicable “Special Populations” were pre-configured by CalMHSA to assure this requirement works.  Counties should not be modifying any of these configurations, but there is some flexibility which would allow Counties to create their own “Special Populations”.  If your County creates a Special Population that should also have the “HK” modifier and the additional segment (as needed) applied in Medi-Cal 837 claims, please contact your Account Manager as there is a special setting/x-reference that will need to be added to the new “Special Population” value added by the County.”