Provider Orientation. Magellan Providers of Applied Behavior Analysis (ABA) Services for Autism Spectrum Disorders (ASD) Members

Transcription

1 Provider Orientation Magellan Providers of Applied Behavior Analysis (ABA) Services for Autism Spectrum Disorders (ASD) Members CalOptima December 2016

2 Agenda Welcome to the Magellan Network! Who is CalOptima? Assessment and Treatment Planning, the Authorization Process Credentialing, Contracting and Recredentialing Claim Submission and Tracking Magellan Provider Service Center Website Wrapping Up: Supporting the Provider with First-Class Service 2

3 Welcome to the Magellan Network! You play an important role in serving CalOptima members. Magellan Healthcare, Inc.* is the leading behavioral health care management organization in the industry. With identification of children with autism spectrum disorders (ASD) increasing dramatically nationwide, coverage and services are expanding: A majority of states have passed or proposed legislation requiring health insurers to provide coverage for autism treatment. A smaller number of states have adopted more comprehensive legislation requiring coverage of specialized services including applied behavior analysis (ABA) services for the treatment of autism. Magellan s customers are looking to Magellan to provide full-service support for this disorder. *In California, Magellan does business as Human Affairs International of California, Inc. and/or Magellan Health Services of California, Inc. Employer Services 3

4 Who is CalOptima? CalOptima is one of six County Organized Health systems (COHS) in the state of California created as a public agency by County, State and Federal action. CalOptima started operations on Oct. 1, 1995 as the sole managed Medi-Cal health plan for individuals residing in Orange County. Today, CalOptima administers health benefits to approximately 800,000 members (about 775,000 Medi-Cal only and about 17,000 dual eligible) for the following programs: Medi-Cal (California s Medicaid program) for most members residing in Orange County In 2014, with the Affordable Care Act (ACA) Essential Health Benefits, a limited outpatient only Behavioral Health benefit was added for the Medi-Cal members. This was further expanded in September 2014 to include Applied Behavior Analysis that is medically necessary to treat Autism Spectrum Disorder (ASD). 4

5 Who is CalOptima? OneCare [Medicare Advantage Duals Special Needs Plan (D-SNP) available to members who are dually eligible for Medicare and Medi-Cal, Duals ] In 2005, CalOptima added OneCare, which has a more comprehensive behavioral health benefit (full outpatient and inpatient) than Medi-Cal managed care plans are responsible for. OneCare Connect (California s Coordinated Care Initiative, also known as the Duals Demonstration Program or Cal MediConnect) This program has the same behavioral health benefit as OneCare. 5

6 CalOptima s Mission To provide members with access to quality health care services delivered in a cost-effective and compassionate manner 6

7 CalOptima Applied Behavior Analysis Benefit Who is covered? Individuals ages 0-20 years old (up to the member s 21 st birthday) What is covered? Diagnosis and treatment of ASDs including: Applied behavioral analysis Psychiatric and psychological services 7

8 CalOptima Applied Behavior Analysis Benefit-Contd. What are the coverage limits? There is no coverage limit Services must not be duplicative to what is currently being offered at school. The member s most recent IEP may be requested for verification. Must be medically necessary 8

9 The Provider Role: Assessment and Treatment Planning, the Authorization Process

10 Expectations for ABA and Other Qualified ASD Providers: Assessment and Treatment Planning Magellan dedicated autism care managers refer members to you You conduct initial functional assessment, confirm diagnostic evaluation and develop treatment plan You conduct follow-up and reassessment Obtain authorizations for additional services as needed Follow Magellan medical necessity criteria and clinical practice guidelines In some regions, review of treatment plans for pre-existing cases is necessary 10

11 The Authorization and Review Process Purpose: To authorize care based on a thorough assessment of the member s unique needs, with services delivered at the least intensive, appropriate level of care Authorization is the responsibility of the provider/program/facility by calling All existing cases currently covered by CalOptima will have their current authorization honored. At the end of your current authorization we will provide you with a new auth contingent that the member continues to meet medical necessity. For newly diagnosed cases in need of an initial evaluation, Magellan will authorize an initial assessment and provide hours to complete a Functional Behavioral Assessment (FBA). The provider will need to complete the Magellan treatment planning template (available on the provider website in addition to the submission of the results of an ABAS, Vineland or other developmental assessment that has been accepted by Magellan. 11

12 Authorization Determinations Magellan will: Make an authorization decision based upon the completed care planning and assessment template, Vineland/ABAS and any telephonic review we do with you. Advise you of the ABA service type and units authorized, number of sessions or days authorized, and a start and end date for authorized services. Communicate authorization decisions by telephone and/or in writing. Offer the opportunity to discuss the determination with a physician advisor if we are unable to authorize the requested service(s) for clinical reasons. 12

13 Treatment Planning The provider develops the Autism Treatment Plan based on the findings of an assessment and evaluation; the plan will be reviewed by a Magellan care manager. The provider must submit a new treatment plan each time additional sessions are requested along with a new Vineland or ABAS evaluation. Autism Treatment Plan includes the following domains of focus (Speech/Language/Communication, Sociability, Sensory/Cognitive Awareness and Health/Physical Behavior), specific interventions, and measurable goals that have been developed based on the concerns identified through the assessment and evaluation process and family priorities. The treatment plan will be accessible on the Magellan provider website. 13

14 Sample Authorization for ABA Services* Treatment/Billing Code Description Number of Units Duration Total Hours Authorized H0031 Functional behavioral assessment by BCBA H2019 Direct ABA services by a BCBA or paraprofessional H2014 Skills training and development minute unit/duration minute unit/duration minute unit/duration 3 S5110 Home care training, family 4 15-minute unit/duration 1 * Covered services may differ by region and/or customer. 14

15 Magellan Clinical Policy Resources MNC Magellan medical necessity criteria for outpatient ABA:* Established DSM diagnosis of pervasive developmental disorder A severe challenging behavior that presents a health or safety risk or significantly interferes with home or community activities Less intensive behavior treatment or other therapy has been considered or has been insufficient Patient is medically stable and does not require 24-hour medical/nursing monitoring Treatment plan should be established upon individualized goals, with measurable objectives Treatment plan should include parent/caregiver training and support * Covered services may differ by region and/or customer. 15

16 Magellan Clinical Policy Resources MNC (continued) Magellan s medical necessity criteria are based on scientific evidence Magellan clinical leaders review the criteria annually, taking into consideration: Current scientific evidence Provider feedback MNC available at under Providing Care/Clinical Guidelines 16

17 Credentialing, Contracting and Recredentialing

18 Credentialing and Contracting To be a Magellan network provider, you must be both credentialed and contracted Magellan encourages the use of the Council for Affordable Healthcare (CAQH) credentialing application. If you do not have a CAQH profile, we can help you to create one Magellan s credentialing process reflects industry standard and is compliant with regulatory, state and customer requirements. The process includes, though is not limited to, the collection and/or verification of credentials including licensure, board certification, education and training, work history and malpractice insurance coverage The Regional Network and Credentialing Committee reviews completed credentialing applications and renders credentialing decisions Once credentialing and contracting are complete, notification will be sent to inform you that you may treat and bill for patient services. 18

19 Group Contracting To be an in-network group provider, the group must be contracted with Magellan AND certain practitioners within the group must be individually credentialed by Magellan A master s or doctoral-level practitioner who is a member of a contracted group must be individually credentialed by Magellan to be eligible to receive ABA referrals as an innetwork provider Paraprofessional who is a member of a contracted group, the group must attest that they hold a state-issued license, certificate, registration, credential or other designation as a behavior technician; or hold a certification as a Registered Behavior Technician (RBT TM ) through the Behavior Analyst Certification Board (BACB ) A group member who leaves the group practice is no longer considered a Magellan innetwork provider unless the practitioner is also contracted under an individual provider participation agreement with Magellan AND has an active Taxpayer Identification Number (TIN) Groups must notify Magellan when staff join or leave their practice Groups must attest that all Applied Behavioral Analysis providers have successfully completed a background screening at least every 5 years 19

20 Organizational Contracting To be an in-network provider, the agency/organization must be contracted with Magellan AND must be organizationally credentialed Agencies must be accredited and/or hold acceptable program/agency licensure to meet organizational credentialing standards. If an agency is not accredited, a site visit is required. A state or CMS survey may be accepted in lieu of a site visit conducted by Magellan staff. Organizations must provide roster information for all ABA service providers at the time of contracting and update Magellan when staffing changes Organizations must attest to staffing qualifications on the Network Organizational Credentialing Standards Attestation 20

21 Recredentialing Must be completed once every three years Magellan accepts CAQH for recredentialing of practitioners; please maintain your CAQH updates quarterly; you will NOT receive notification of the need to recredential when a CAQH application is utilized However, you will receive written notice prior to your credentialing anniversary date when no CAQH application is available or you have not completed a Magellan online recredentialing form Applications and recredentialing notifications are mailed to all agencies/organizations prior to the credentialing anniversary Return/complete recredentialing applications within 30 days of receipt 21

22 Paraprofessional Requirements Magellan will ask its CalOptima providers to meet the minimum requirement for paraprofessional certification in Date has not been established; will not be within the first few months of transition to Magellan Currently accepting either RBT or BCAT as the certification A minimum of 90 days notice will be provided to have your staff come under the minimum requirement of certification for direct level staff Your group will be required to provide self-attestation that the requirements are being met Groups are subject to audit/siu should there be suspicion that direct level staff are not certified at time of implementation 22

23 Helpful Hints for Credentialing and Contracting (Practitioners) If possible, use CAQH (Universal Provider DataSource ) Make sure you indicate the one TIN number with which you will complete your W-9 either your Social Security Number (SSN) OR Employer Identification Number (EIN) NOT BOTH Please note and explain in the comments section of the application any periods of unemployment of more than six months Keep copies of your completed contract and application 23

24 The Quality Partnership A commitment to quality: Magellan maintains a Continuous Quality Improvement (CQI) program Magellan s providers are an integral component of the quality program Magellan obtains meaningful input from providers through: Regional Network and Credentialing Committees Annual provider satisfaction surveys Provider Advisory Groups We provide information to providers through: Provider Focus newsletter Provider forums and webinars Magellan provider website 24

25 Claim Submission and Tracking

26 Magellan Claim Tips Claims with CPT or HCPCS procedures should be submitted on a 837P or CMS Timely filing requirements are 90 days from Date of Service. Hints for claim completion: Give complete information on the member (name, address, DOB) Give complete provider information TIN Individual provider name and degree Rendering provider name Billing pay to provider name and address National Provider Identification [NPI] number for both the rendering and billing provider Attach primary carrier s Explanation of Benefits when billing secondary insurer Include all HIPAA-compliant diagnosis codes (ICD-10 required) Include the appropriate billing modifier in conjunction with the HCPCS 26

27 Claim Submission Example Sample autism-related services fee schedule* Description Functional Behavioral Assessment per 15 min up to 4 hours Direct Applied Behavior Analysis (ABA) services by a BCBA or paraprofessional per 15 min Case oversight and management by treatment team by BCBA per 15 min CPT/HCP CS Codes Behavior Analyst (Modifier HO or HP) Assistant Behavior Analyst or Non-Certified Support Staff (Modifier HM or HN) H0031 $31.25 Not billed for HN or HM H2019 $18.00 $12.50 H0032 $18.00 $15.50, Not billed for HM *Schedules vary by region Modifier HO HN HM Description Board Certified Behavior Analyst (BCBA or BCBA-D), Licensed Master s Level Behavioral Health Professional, or Doctoral Level Clinician Board Certified Assistant Behavior Analyst or Tier 2 Program Manager (non-licensed Master s level) Non-Certified Support Staff or Registered Behavior Technician HQ Group Setting 27

28 Claim Submission Example (continued) Sample CMS-1500 claim form information to input Dates of Service Place of Service Procedures, Services or Supplies CPT/HCPCS Modifier Charges Units (Field 24A) (Field 24B) (Field 24D) (Field 24F) (Field 24G) 7/1/ H0031 HO $250.00* 8 7/28/ H2014 HN $50.00* 4 7/15/ H2019 HM $50.00* 4 Note: The above samples are not inclusive of all possible billing codes and/or unit durations utilized by Magellan for autism services, which are subject to the provisions and limitations of the member s benefit plan. Billing codes and unit durations may vary by region. For the applicable rates, refer to the fee schedule attached to your provider agreement. *Total charge should reflect the number of units in field 24G x the rate per unit for the billed procedure code (e.g., 4 = $72.00 total charge) 28

29 Claim Submission Options Magellan s Three Electronic Submission Options #1 Claims Courier Claims Courier (Submit a Claim Online) is a web-based data entry application for providers submitting professional claims on a claim-at-a-time basis Accessible after sign-in on Magellan s provider website Claims Courier streamlines the claims process by eliminating the middleman Claims Courier provides information on accepted or rejected claims No charge to the provider 29

30 Claim Submission Options (continued) #2 Direct Submit Primarily for high-volume claim submitters, but there is no minimum number necessary for submission Magellan offers our providers the EDI Direct Submit testing application, which is an electronic claims tool available on an EDIdedicated website at HIPAA-compliant 837 files can be sent directly to Magellan HIPAA-compliant 277 files can be sent directly to provider to review for accepted or rejected claims Direct Submit streamlines the process by eliminating the middleman No charge to the provider 30

31 Claim Submission Options (continued) #3 Claims Clearinghouses Act as a middleman between the provider and Magellan, and can transform non-hipaa compliant format to compliant 837 Magellan accepts 837 transactions from the following clearinghouses: PayerPath (formerly Mysis and also known as Allscripts) Capario (formerly MedAvant Healthcare Solutions and ProxyMed) Availity (formerly THIN) Emdeon Business Services (formerly WebMD) NaviNet Claims (also known as AmpMed Corporation) RelayHealth (also known as McKesson) Gateway EDI HIPAA-compliant 277 files enable providers to review for accepted or rejected claims Note that there may be charges from the clearinghouses. When submitting claims electronically, Magellan s submitter ID is

32 Electronic Funds Transfer (EFT) It is expected that providers/groups sign up for Electronic Funds Transfer for Magellan-paid claims The benefits of EFT are Claims payments get to your bank account more quickly than the standard process of mailing and cashing or depositing a check No risk of lost or misplaced checks More time to devote to your practice Explanation of Benefits (EOB) are available on Sign into the secure network Click on Check Claims Status from the left-hand menu Click on the EOB Search on the top tab 32

33 Contact Info & Assistance Offered for Electronic Claims Submitted EDI/EFT Support Telephonic Line: ext EDI/EFT Support via 33 Magellan Health, Inc.

34 Magellan Provider Service Center Website

35 MagellanProvider.com A secure location for your provider transactions sign in and get started! 35

36 Magellan Provider Service Center Access Initial sign-in for individual providers: User Name = MIS number (Magellan system identifier) Password = year of birth and last four digits of TIN/SSN (whichever number you bill under) Group users: User Name = Group MIS number Password = 2003 and last four digits of the group TIN Administrator grants access to other group personnel Facility users: Same process as Group users 36

37 Magellan Provider Service Center Features Check member eligibility (for most customer plans) Obtain an initial authorization for routine outpatient services (for specific customer plans) Check on authorization requests and download authorization reports Print authorization letters and EOBs online Submit a claim for professional services (CMS-1500) and check on claim payment status View your outcomes reports Complete your recredentialing application online Register for Electronic Funds Transfer Access MyMessages for secure communication with Magellan staff Check your credentialing status and contracting status 37

38 Magellan Provider Service Center Features (continued) Website demonstration on home page Online provider orientation program Provider Focus behavioral health newsletter Electronic claims submission information HIPAA billing code set guides MNC and CPGs Clinical and administrative forms Cultural competency resources Demos of all our online tools/applications: go to Education/Online Training Behavioral health information for members Plus Autism Resource Center on member site at 38

39 Updating Practice Information Updating your practice data is critical to all transactions with Magellan. Practice data impacts: Authorization notifications Recredentialing notifications Network/contractual-related communications Provider directories Claims payment Office managers/group administrators must be cautious when updating practitioner information, particularly when the provider maintains a solo practice and/or works for other group practices. 39

40 Updating Practice Information (continued) What You Need to Do Solo Clinicians Notify Magellan within ten business days of any changes in your individual practice information: General information Contact information Access Promptly notify us if you are unable to accept referrals for any reason including: o Illness o Practice not accepting new patients o Professional travel, sabbatical, vacation, leave of absence, etc. Specialties Service, mailing or financial address 40

41 Updating Practice Information (continued) What You Need to Do Group Practices Notify Magellan within ten business days of any changes in your practice information: General information Contact information Specialties Service, mailing or financial address Practitioners departing the group practice New practitioners joining the group practice Access o Promptly notify us if you are unable to accept referrals for any reason including: Illness Practice not accepting new patients Professional travel, sabbatical, vacation, leave of absence, etc. 41

42 Updating Practice Information (continued) What You Need to Do Magellan s mandatory online Provider Data Change Form (PDCF) allows you to update your information in real time Go to Sign in to the secure network Click Display/Edit Practice Information from left-hand menu Training is available online under the Education heading on the provider website Network staff members are also available to assist with provider training 42

43 Provider Data Change Form 43

44 Wrapping Up: Supporting the Provider with First-Class Service

45 Our Commitment to You, the Provider In providing first-class provider service to you, Magellan focuses on: Prompt, accurate claims payment Ease of credentialing and recredentialing Healthy referral volume Easily accessible provider resources (clinical, training, consultation, outcomes tools, etc.) Secure transactions on our provider website to ensure privacy Personalized service when you need assistance 45

46 The Quality Partnership A commitment to quality: Magellan maintains a Continuous Quality Improvement (CQI) program Magellan s providers are an integral component of the quality program Magellan obtains meaningful input from providers through: Regional Network and Credentialing Committees Annual provider satisfaction surveys Provider Advisory Groups We provide information to providers through: Provider Focus newsletter Provider forums and webinars Magellan provider website 46

47 Free Continuing Education Opportunities Continuing education (CE) credits available at no charge to our contracted providers through our online education partner, Essential Learning Sign in on the website to begin; navigate to Education/CEUs and CMEs Literally hundreds of specialized courses available to providers via Essential Learning No less than four courses on treating ASDs are available through our site 47

48 Provider Contacts and Help Magellan Provider Services Line: West Field Network Support: For ABA eligibility, authorization and claims questions, use the customer service # on the back of the member s card to reach the Magellan Care Management Center. 48 Magellan Health, Inc.

49 Thank You