WELCOME IHCP Providers

Transcription

1 WELCOME IHCP Providers 1 #234 7/2007

2 What topics will we cover today? Why Managed Care? What does this mean for me? PMP Communication Pharmacy Services Common Claim Issues NPI Quick Reference Guide OTR Intensive Case Management 2

3 Why Managed Care? Managed Care Provides: A medical home from which all types of care can be coordinated and managed Increased coordination between the PMP, the MCO and the behavioral health care provider An opportunity to better manage utilization of behavioral health care services GOAL: Improve Outcomes While Managing Costs 3

4 What does this mean for me as an IHCP Provider? In order to bill CBH for services provided to MHS Hoosier Healthwise members: Contracted Credentialed Loaded as Par Psychiatrists are not required to join CBH in order to see MHS members 4

5 Coordination with Physical Health Provider Coordination with the member s Primary Medical Provider (PMP) should occur within five days of the initial visit with a new patient. Note: Make sure to complete this section on the OTR form. 5

6 Pharmacy Program Benefit Managed by the healthplan - Managed Health Services (MHS) Preferred Drug List (PDL) available at Any script not within the recommended utilization edit (on PDL) will be subject to prior authorization. 6

7 Common Claim Issues Billing non-behavioral health diagnosis codes BH diagnosis must be primary. When resubmitting a claim, claim should be sent on paper with Resubmission at the top. Resubmissions/challenges to original payments/denials must be made within 60 days 7

8 Common Claim Issues Billing CPT codes not included on the fee schedule Authorizations for outpatient therapy visits will not overlap Not including the 4 th or 5 th digit on the DSM when required Member s name, DOB, number not matching New CMS 1500 claim form required as of 11/1/07 8

9 Modifiers Common Claim Issues AH provided by a clinical psychologist AJ provided by a clinical social worker HE in conjunction with SA provided by a nurse practitioner or clinical nurse specialist HE provided by any other mid-level practitioner HO provided by Master s Level SA NP/CNS 9

10 Reporting your NPI CBH Web site (Follow the provider link) Very Important Must be reported by 12/31/07 Bill with Medicaid (Legacy) number and NPI until

11 Quick Reference Guide Does not replace the CBH Provider Manual Intended as a quick guide Applies to participating CBH providers If Provider is non-par* all services require authorization and should see existing patients only *Does not apply to Psychiatrists 11

12 Outpatient Treatment Request (OTR)... a means to show a picture of the client s needs, level of functioning and progress to the Care Manager (CM). Outpatient sessions beyond the initial assessment (1) and (5) therapy visits require authorization Eff 9/15/07 Toll-free fax #

13 Intensive Case Management Who Qualifies for ICM? Any member discharged from a BH related, inpatient acute hospitalization for at least 180 days Any member assessed and meeting criteria ICM will contact members during an inpatient hospitalization to insure member is scheduled for OP appt. within seven days of discharge. 13

14 Intensive Case Management What is the ICM s role? Consult with both the member s physical and behavioral health providers Facilitate the sharing of clinical information Development and maintenance of a coordinated physical health and BH treatment plan for the member. 14

15 Objective of ICM Maintaining members in appropriate, least restrictive level of care Improve treatment compliance Relapse reduction Improve coordination of care among multiple providers Facilitate progress in treatment 15

16 Intensive Case Managers and Care Coordinators Area Managed Northern IN (877) Mid & Southern IN (317) ICM (clinical) Cynthia Jakacki-Null x20303 Dellmus Porter X20276 ICC (non-clinical) Rhonda McDonald X20309 Julie Montgomery X

17 Clinical Training Bart Marshall, LCSW CBH Clinical Provider Trainer OTR Completion Crisis Management Ethics Training 17

18 Provider Complaints An expression of dissatisfaction about a given matter Via Phone: CBH Customer Service at MHS-4U4U (follow prompts for auth/cbh) Via Letter: CBH Complaint, 504 Lavaca, Ste 850, Austin, TX Your complaint will be researched and CBH will respond within 30 days. 18

19 How can we help you? QUESTIONS? 19