Objective: Provide information to Admin users to help in their understanding about the unit limit being placed on the cost configuration.

The Pear Suite platform will now have limits on billing for Community Health Worker (CHW) services. This means that users can only bill up to 12 units of CHW services before more steps are required. The Pear Suite team has placed unit limitations into each of the insurance configurations that Pear Suite is in-network with and that codes for CHW services. The limitations have been installed to support compliance with the Plan of Care policy of the All Plan Letter from DHCS. According to All Plan Letter, once a member receives 12 units of CHW services, they must have a Plan of Care in place. Providers will need to submit this Plan of Care if they want to continue billing for CHW services beyond the 12 units. Pear Suite has installed the 12 unit limitation as a way to remain compliant and to make it clear when a request for more units is needed so that members can continue receiving care in the right way.

As an Admin user, you will be able to see all claims on the claims page, including those that have reached their billing limits. This page is an important tool because it helps you track which members have already reached the 12-unit limit. Once the limit has been met or passed for a member, the next claim for CHW services will automatically show an error status. Along with the error status, you will also see an error message explaining that the billing limit for that procedure code has already been reached. This means no additional units can be billed for that member until a Plan of Care is submitted and approved.

To resolve this error the Admin/user will need to submit a request for Authorization for Additional Units to the health plan. You can now do that through Pear Suite with the use of the Review Request feature on the member’s profile. Read the following:

• Speak with CHW and complete the Community Health Worker Supervising Provider Authorization Form for Additional Units. The form and the Plan of Care must be filled out correctly.
• It's best practice to write the Plan of Care with a lot of information to be comprehensive.
• When on the member’s profile the Review Request section is on the right side of the member’s profile, click on the “Create Review Request”, button and select the “Request for Additional CHW Billing Units” template from the dropdown menu. Then select create.
   

• The Review Request window will open. Select “+ File”, and upload the Authorization form from step 1. Enter the number of units you are requesting and select “Save and Submit for Review”.

• The next step of the process is for the Pear Suite Billing Team to review the request for quality and then submission directly to the health plans via the health plan’s provider portal.
• Once the Health Plan has decided on the authorization request, the Pear Suite Billing Team will either move onto the next step of the process or send the request back to the user and requesting more information.
• If the authorization request is approved, the Pear Suite Billing team will enter the number of units that the request was approved for. By doing so the initial billing limitation that was set for the first 12 units of CHW services has been removed.
• In its place is a new billing limitation tied to the specific procedure code that was requested on the form. With the new billing limitation in place, the user will be able to continue billing CHW services for that member.
• The new billing limitation will trigger; if the user has billed the maximum amount of units or if the time/date on the limitation has expired and it is possible for both to occur, triggering the limitation.
• As the billing limitation triggers once again, the error message on the claims that exceed the limitation will appear once again.

• The solution is to simply repeat the process detailed above. The process will allow for all parties involved to be in compliance with state policy, as well as keep a track of rendered CHW services and improve on the quality of documentation of the member’s care.