This document explains the logic and order of how service limitations are set. Although limitations can vary from one benefit plan to the next, most are set up the same across benefit plans. IF CLAIM IS ADJUDICATING W/OUT AN AUTH Limit Start/End Explanation Daily 12:00AM 11:59PM From the start of the day, to the last minute of the day – This is a date range, not rolling. Meaning if a “hard” Weekly Sunday Saturday consumer starts services on a Wednesday, MCS will still use – Sunday of that week as the beginning of the count Calendar Month: Even if a consumer starts services in the Monthly 1st - 30th (28th/31st) middle of a month, the monthly limit range is still from the 1st 28th, 30th or 31st. – Yearly July 1 June 30 Fiscal Year – IF CLAIM IS ADJUDICATING WITH AN AUTH Limit Start/End Explanation From the start of the day, to the last minute of the day Daily 12:00AM 11:59PM – **same as above This is a date not rolling. Meaning if a “hard” consumer starts services on a Wednesday, MCS will still use Weekly Sunday Saturday Sunday of that week as the beginning of the count. **this – limit does not use the auth eff date. This is in coordination with Medicaid limit policy. Uses the effective date of the auth. To adapt to the various days in a month, MCS takes the same day the following Monthly Rolling Month month minus 1. So if a consumer’s auth started 2/15, then the last day of the monthly count is 3/14. From the effective date of the authorization to year out (e.g. Yearly Rolling Year March 15, 2014 March 14, 2015). –
This document explains the logic and order of how service limitations are set. Although limitations can vary from one benefit plan to the next, most are set up the same across benefit plans. IF CLAIM IS ADJUDICATING W/OUT AN AUTH Limit Start/End Explanation Daily 12:00AM – 11:59PM From the start of the day, to the last minute of the day Weekly Sunday – Saturday This is a “hard” date range, not rolling. Meaning if a consumer starts services on a Wednesday, MCS will still use Sunday of that week as the beginning of the count Monthly 1st - 30th (28th/31st) Calendar Month: Even if a consumer starts services in the middle of a month, the monthly limit range is still from the 1st – 28th, 30th or 31st. Yearly July 1 – June 30 Fiscal Year IF CLAIM IS ADJUDICATING WITH AN AUTH Limit Start/End Explanation Daily 12:00AM – 11:59PM From the start of the day, to the last minute of the day **same as above Weekly Sunday – Saturday This is a “hard” date not rolling. Meaning if a consumer starts services on a Wednesday, MCS will still use Sunday of that week as the beginning of the count. **this limit does not use the auth eff date. This is in coordination with Medicaid limit policy. Monthly Rolling Month Uses the effective date of the auth. To adapt to the various days in a month, MCS takes the same day the following month minus 1. So if a consumer’s auth started 2/15, then the last day of the monthly count is 3/14. Yearly Rolling Year From the effective date of the authorization to year out (e.g. March 15, 2014 – March 14, 2015).
BP%20Limits%20Explained.docx