OPTIMA HEALTH COMMUNITY CARE PROVIDER MANUAL

Transcription

1 OPTIMA HEALTH COMMUNITY CARE PROVIDER MANUAL SUPPLEMENTAL INFORMATION This supplement is provided for Providers that participate with Optima Health Community Care (OHCC). Information contained in this supplement details additional information and exceptions that are specific to the OHCC program as of January 1, Unless otherwise indicated in this supplement, information in the core Provider Manual applies to OHCC as well as Optima Health Commercial plans. Please continue to refer to the core Provider Manual for policies and procedures not addressed in this supplement and contact Provider Relations or your Network Educator for questions regarding OHCC. 1

2 OPTIMA HEALTH COMMUNITY CARE KEY CONTACTS The contacts listed below are for Optima Health Community Care Members only. Please see the Optima Health core Provider Manual, Key Contacts page, for other Optima Health product contacts and any Optima Health departments or services not listed here PROVIDER RELATIONS - OHCC Provider Relations & Eligibility Verification Phone: CLINICAL CARE SERVICES - OHCC Prior Authorization Fax numbers for specific services are located on the authorization fax form Phone: LTSS Authorizations Fax: Behavioral Health Phone: Inpatient Fax: Outpatient Fax: Care Coordination Phone: Medical Reports, etc. Fax: After Hours Program Phone: TELEPHONE FOR DEAF AND DISABLED OHCC Phone: CENTIPEDE Phone: Fax: E- Mail: joincentipede@heops.com CENTIPEDE Credentialing: CENTIPEDE Health P.O. Box Nashville, TN MEMBER TRANSPORATION Phone: OPTIMA HEALTH WEB SITE Provider Manual, Policies and Procedures, Credentialing Forms and Updates 2

3 TABLE OF CONTENTS PAGE Optima Health Community Care Program Overview 5 Managed Long Term Services and Supports Benefits 5 Enhanced Services 6 Carved Out Services 6 Dual Special Needs Plan (D-SNP) 7 OHCC Plus Requirements per DMAS Contract 7 Member Identification and Information 9 Sample ID Card 9 Eligible Individuals 10 Populations Excluded from CCC Plus 10 Enrollment and Assignment Process 11 CCC Plus Member Rights and Responsibilities 12 Cultural Competency 13 Member Services 14 Continuity of Care for New Members 14 Member Access to Care 15 CCC Plus Appointment Standards 15 Telemedicine Services 15 Transportation Program 16 CCC Plus Model of Care 17 Care Coordination 17 Person Centered Individualized Care Plan (ICP) 17 Interdisciplinary Care Team 18 Reassessments 18 Care Coordination with Transitions of Care 19 Utilization Management 20 Medical Necessity Criteria 20 Critical Incident Report 21 Additional/Ancillary Services (A-Z) 22 Addiction and Recovery Treatment Services (ARTS) 22 Audiology 22 Behavioral Health Service 22 Chiropractic 22 Community Mental Health Rehabiliation Services 22 Dental 25 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 26 Early Intervention Services 27 Gynecological Care 28 Obstetrical Services 28 Hospice 28 Immunizations / Vaccines 29 3

4 Medical Supplies and Medical Nutrition 30 Physical Therapy/Occupational Therapy/Speech Pathology 30 Preventive Care 30 Private Duty Nursing 30 Prosthetic Devices 31 Transplants 31 Vision 31 LTSS Services 32 LTSS Service Authorization 32 Patient pay for LTSS 32 Waivers 32 Home and Community Based Services 33 Developmental Disability (DD) waiver 33 Commonwealth Coordinated Care (CCC) Plus waiver 33 Adult Day Health Care (ADHC) 34 Personal Care Services 35 Respite Care Services 35 Consumer Direction 36 Service Facilitation (SF) 36 Environmental Modifications (EM) 36 Assistive Technology (AT) 36 Personal Electronic Response System (PERS) 37 Skilled Private Duty Nursing (PDN) 37 Transition Services 37 Nursing Facility and Long Stay Hospital Services 38 LTSS Provider Credentialing 38 Hospital/Ancillary 39 Hospital Payment Using DRG Methodology 39 Pharmacy 39 After Hours Urgent Outpatient Pharmacy Requests 39 Preferred Drug List 39 Benefit Exclusions 40 Long Acting Reversible Contraception (LARC) 40 Patient Utilization Management and Safety Program 40 Opioid Treatment Management 41 Specialty or Biotech Drugs 41 Claims and Coordination of Benefits 42 Payment Coordination with Medicare 42 Nursing Facility, LTSS, ARTS, CMHRS & EI Claim Payments 42 NDC Number 42 NPI 43 Member Complaints and Appeals 44 Member Complaint Procedure 44 Member Appeal Procedure 44 State Fair Hearing 45 4

5 OPTIMA HEALTH COMMUNITY CARE OVERVIEW The DMAS Commonwealth Coordinated Care Plus (CCC Plus) program incorporates medical, behavioral health and Long Term Services and Support (LTSS) services, including Home and Community Based Services (HCBS) waivers. It emphasizes care coordination and person centered care. Participation is mandatory for eligible populations. DMAS has chosen several managed care companies to participate in this program, including Optima Health. CCC Plus is a state-wide program and participation by managed care companies may vary by region. Optima Health participates in CCC Plus under the name, Optima Health Community Care (OHCC). OHCC operates in all six regions of the Commonwealth. OHCC offers fully integrated medical, social and behavioral health services to Members with intensive care coordination, including coordination with Medicare. OHCC provides timely access, enhanced capacity, improved quality management and aligns incentives for efficient outcomes. HMO Plan Type Primary Care Physician (PCP) selection required Member ID cards include PCP name and phone number No referrals required OHCC See Eligible Individuals in the MEMBER IDENTIFICATION INFORMATION section of this Supplement for a listing of Virginia residents who are included in OHCC No Copayments required Managed Long Term Services and Supports Benefits Managed Long Term Services and Supports (MLTSS) is designed to expand home and community-based services, promote community inclusion, and ensure quality and efficiency. The program provides comprehensive services and supports, whether at home, in an assisted living facility, in community residential services, or in a nursing home. OHCC coordinates all services for Members. Managed Long Term Services and Supports (MLTSS) include: Care Coordination Community Residential Services Home and Vehicle Modifications Community Mental Health Rehabilitation Services Mental Health and Addiction Treatment Services Nursing Home Care Personal Care Personal Emergency Response Systems Respite Care 5

6 Specific benefit information for OHCC is available 24 hours a day on the OHCC Provider Web Portal or by speaking with a Provider Service Representative during OHCC business hours. OHCC, Medallion 3.0 and FAMIS programs have separate benefits. Enhanced Services OHCC provides the following Enhanced Benefits that are not generally covered through Medicaid fee-for-service: Smoking cessation Assistive devices Extended respite care for caregivers Pest control Adult dental services Adult vision Adult hearing Diabetic foot care Wellness rewards Home delivered meals Weight management Home security memory care Free cell phones All enhanced benefits are coordinated through the Member s assigned Care Coordinator. Carved Out Services The following services are carved out of the contract between OHCC and DMAS. These services are reimbursed directly to Providers under the DMAS fee for service program: Dental Services (Smiles for Children) School Health Services Developmental Disabilities (DD) Waiver Services such as Building Independence Waiver, Family and Individual Support Waiver, Community Living Waiver, Targeted Case Management and Transportation to/from DD Waiver Services (non-waiver services are included in the CCC Plus Program) Preadmission screening for nursing facilities IACCT (Independent Assessment, Certification and Coordination Team) Therapeutic Group Home (formerly Level A and B Group Home) Treatment Foster Care Case Management 6

7 Dual Special Needs Plan (D-SNP) OHCC offers a Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP). Among the most important features of the D-SNP are: A team of doctors, specialists and Care Managers working together for the D-SNP Member A Model of Care (MOC) that calls for individual care plans for Members The same Member rights available to Medicare and Medicaid recipients Dual eligible Members enrolled in OHCC may receive their Medicare benefits from OHCC s companion D-SNP, Medicare fee-for-service, or through another Medicare Advantage (MA) Plan. Please reference the Optima Health Dual Eligible Special Needs Plan (D-SNP) Supplement for details regarding this Plan. OHCC Plus Requirements per DMAS Contract As a Participating OHCC Provider you have agreed to abide by all rules and regulations in the contract between OHCC and DMAS. Providers are required to: 1. Abide by all applicable provisions of Optima Health s CCC Plus Contract with the Department of Medical Assistance Services, CMS regulations and any other relevant state and federal laws or regulations 2. Have a National Provider Identifier (NPI) number 3. Meet the Optima Health standards for licensure, certification, and credentialing, as included in the Optima Health Provider Agreement 4. Comply with all applicable Federal and State laws and regulations including Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; the Americans with Disabilities Act of 1990 as amended; Health Insurance Portability and Accountability Act of 1996 (HIPAA) security and privacy standards, section 1557 of the Patient Protection and Affordable Care Act (including but not limited to, reporting overpayments pursuant to state or federal law) and the Deficit Reduction Act of 2005 (DRA) requiring that emergency services be paid in accordance with the DRA provisions [Pub. L. No , Section 6085], and as explained in CMS State Medicaid Director Letter SMDL # Maintain records for ten (10) years from the close of the Provider Agreement. For children under age 21 enrolled in the CCC Plus Waiver, records shall be maintained for the greater period of a minimum of ten (10) years or at least six (6) years after the minor has reached 21 years of age per 12VAC Provide copies of Member records and access to their premises to representatives of Optima Health, as well as duly authorized agents or representatives of the Department, the U.S. Department of Health and Human Services, and the State Medicaid Fraud Unit 7. Provide a copy of the Member s medical records to Members and their authorized representatives as required by law within no more than 10 business days of the 7

8 Member s request 8. Disclose the required information, at the time of application, credentialing, and/or recredentialing, and/or upon request, in accordance with 42 CFR 455 Subpart B, as related to ownership and control, business transactions, and criminal conviction for offenses against Medicare, Medicaid, CHIP and/or other Federal health care programs 9. Screen employees and contractors initially and on an ongoing monthly basis to determine whether any employees/contractors have been excluded from participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as defined in Section 1128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been excluded or debarred. Providers are required to immediately report to Optima Health any exclusion information discovered. Civil monetary penalties may be imposed against Providers who employ or enter into contracts with excluded individuals or entities to provide items or services to OHCC Members 10. Submit utilization data for Members enrolled with Optima Health in the format specified by Optima Health, consistent with Optima Health obligations to the Department as related to quality improvement and other assurance programs as required in the DMAS contract 11. Comply with corrective action plans initiated by Optima Health 12. Clearly specify referral approval requirements in any sub-subcontracts 13. Hold the Member harmless for charges for any Medicaid covered service, accept Optima Health payment as payment in full except for patient pay amounts and not bill or balance bill a Medicaid Member for Medicaid covered services provided during the Member s period of OHCC enrollment. The collection or receipt of any money, gift, donation or other consideration from or on behalf of an OHCC Member for any Medicaid covered service provided is expressly prohibited. This includes those circumstances where Providers fail to obtain necessary referrals, service authorization, or fail to perform other required administrative functions 14. Should an audit by Optima Health or an authorized state or federal official result in disallowance of amounts previously paid to the Provider, the Provider will reimburse Optima Health upon demand. The Provider cannot bill the Member in these instances 15. Provide services to CCC Plus waiver members in compliance with provider requirements as established in DMAS provider manuals: and Virginia regulations 12VAC through 12VAC Any conflict in the interpretation of Optima Health policies and the OHCC Provider Agreement shall be resolved in accordance with Federal and Virginia laws and regulations, including the State Plan for Medical Assistance Services and Department memos, notices and Provider manuals. Provider shall comply with Federal contracting requirements described in 42 CFR Part 438.3, including identification of/non-payment of Provider- preventable conditions, conflict of interest safeguards, inspection and audit of records requirements, physician incentive plans, recordkeeping requirements, etc. 8

9 MEMBER IDENTIFICATION INFORMATION Optima Health Community Care Member ID Card Sample Front Product Indicator for Optima Health Community Care Optima Health Community Care Member ID Number Starts with 2000 OPTIMA HEALTH COMMUNITY CARE Member Name: JOHN DOE Member Number: *01 Medicaid #: Group Number: DOB: Member Effective Date: PCP Name: PCP Phone: Detailed benefit information is available at optimahealth.com Back Contact Numbers Specific to Optima Health Community Care 9

10 Eligible Individuals The Virginia residents who fall into the following categories are included within OHCC: Dual eligible individuals with full Medicaid and any Medicare A and/or B coverage. Non-dual eligible individuals who receive LTSS, either through an institution or HCBS 1915 waivers. Individuals enrolled in the Building Independence, Community Living, and Family and Individual Supports Waivers will be enrolled in CCC Plus program for their non- waiver services only (e.g., acute, behavioral health, pharmacy, and non-ltss waiver transportation services). This includes individuals who will transition from the Medallion 3.0 health and acute care (HAP) program. Individuals enrolled in the Commonwealth Coordinated Care (CCC) program transition to CCC Plus program on January 1, Remaining ABD population (non-duals and those who do not receive LTSS) transition from DMAS s Medallion 3.0 program to the CCC Plus program on January 1, The CCC Plus program populations listed above may include individuals enrolled in the Medicaid Works program, Native Americans, individuals with other comprehensive insurance, children in foster care and adoption assistance, individuals with Alzheimer s disease and persons with dementia, and individuals approved by DMAS as inpatients in longstay hospitals (DMAS recognizes two facilities: Lake Taylor (Norfolk) and Hospital for Sick Children (Washington, DC). DMAS reserves the right to transition additional populations and services into the CCC Plus program in the future. Populations Excluded From CCC Plus Individuals in the following Programs are not eligible to participate with CCC Plus: Medicaid Medallion 3 and FAMIS Managed Care Members PACE (Program of All-Inclusive Care for the Elderly) Money Follows the Person (MFP) Alzheimer s Assisted Living Waiver (AAL) Health Insurance Premium Payment (HIPP) Individuals in Limited Coverage Groups are not eligible to participate with CCC Plus: Governor s Access Plan (GAP) Qualified Medicare Beneficiaries only Special Low-Income Medicare Beneficiaries Qualified Disabled Working Individuals Individuals in Specialized Settings are not eligible to participate with CCC Plus: Intermediate Care Facilities for Individuals with Intellectual Disability Veterans Nursing Facilities 10

11 Virginia Home Psychiatric Residential Treatment Facilities State Facilities: Piedmont, Catawba, and Hancock Local Government-Owned Nursing Facilities Please see the Hospice section of this Manual Supplement for information on Hospice enrolled individuals. Enrollment and Assignment Process DMAS has sole responsibility for determining the eligibility of an individual for Medicaid funded services; enrollment for eligible individuals is mandatory. There is no retroactive enrollment in the CCC Plus program. Providers can verify Medicaid Enrollment for CCC Plus on the DMAS website at To verify eligibility for OHCC, providers should utilize the Optima Health Interactive Voice Response System (IVR), the Optima Health Provider Web Portal or call OHCC Provider Relations. Enrollment Process for Newborns: When an OHCC Member gives birth during enrollment with OHCC, the newborn s related birth and subsequent charges are not covered by OHCC. In order for the newborn to be covered, the mother/parent/guardian must report the birth of the child by calling the Cover Virginia Call Center at (855) or by contacting the Member s local Department of Social Services. Once Medicaid enrolled, the newborn is the responsibility of FFS Medicaid until such time as the newborn is enrolled in one of the Department s Medicaid managed care programs. Enrollment Process for Foster Care and Adoption Assistance Children: OHCC provides services for enrolled foster care & adoption assistance children (designation codes 076 and 072, respectively). Foster Care and Adoption Assistance children are considered one of the OHCC vulnerable sub-populations. OHCC, and our Provider network, are required to comply with the following rules: For decisions regarding the foster care child s medical care, OHCC and our Provider network work directly with either the social worker or the foster care parent (or group home/residential staff person, if applicable). For decisions regarding the adoption assistance child s medical care, OHCC and our Provider network work directly with the adoptive parent The social worker is responsible for changes to MCO enrollment for foster care children. The adoptive parent is responsible for changes to MCO enrollment for adoption assistance children Coverage extends to all medically necessary EPSDT or required evaluation and treatment services of the foster care program 11

12 OHCC and our Provider network work with DMAS in all areas of care coordination. OHCC provides covered services until DMAS dis-enrolls the child from our plan. This includes circumstances where a child moves out of our service area. CCC Plus Member Rights and Responsibilities OHCC Members have the right to: Receive timely access to care and services; Take part in decisions about their health care, including their right to choose their Providers from OHCC network Providers and their right to refuse treatment; Choose to receive long term services and supports in their home or community or in a nursing facility; Confidentiality and privacy about their medical records and when they get treatment; Receive information and to discuss available treatment options and alternatives presented in a manner and language they understand; Get information in a language they understand - they can get oral translation services free of charge; Receive reasonable accommodations to ensure they can effectively access and communicate with Providers, including auxiliary aids, interpreters, flexible scheduling, and physically accessible buildings and services; Receive information necessary for them to give informed consent before the start of treatment; Be treated with respect and dignity; Get a copy of their medical records and ask that the records be amended or corrected; Be free from restraint or seclusion unless ordered by a physician when there is an imminent risk of bodily harm to themselves or others or when there is a specific medical necessity. Seclusion and restraint will never be used a s a means of coercion, discipline, retaliation, or convenience; Get care without regard to disability, gender, race, health status, color, age, national origin, sexual orientation, marital status or religion; Be informed of where, when and how to obtain the services they need from OHCC, including how they can receive benefits from out-of-network Providers if the services are not available in the OHCC network. Complain about OHCC to the State. Members can call the CCC Plus Helpline at or TDD to make a complaint about OHCC. Appoint someone to speak for them about their care and treatment and to represent them in an Appeal; Make advance directives and plans about their care in the instance that they are not able to make their own health care decisions; Change their CCC Plus health plan once a year for any reason during open enrollment or change their Managed Care Organization after open enrollment for an approved reason. Appeal any adverse benefit determination (decision) by OHCC that they disagree with that relates to coverage or payment of services; 12

13 File a complaint about any concerns they have with OHCC customer service, the services they have received, or the care and treatment they have received from an OHCC network Provider; To receive information from OHCC about their plan, covered services, Providers in the OHCC Network, and about their rights and responsibilities; To make recommendations regarding the OHCC Member rights and responsibility policy, for example by joining the OHCC Member Advisory Committee. OHCC Members have the responsibility to: Present their OHCC Membership card whenever they seek medical care Provide complete and accurate information to the best of their ability on their health and medical history Participate in their care team meetings, develop an understanding of their health condition, and provide input in developing mutually agreed upon treatment goals to the best of their ability Keep their appointments. If they must cancel, call as soon as they can Receive all of their covered services from the OHCC network Obtain authorization from OHCC prior to receiving services that require prior authorization Call OHCC whenever they have a question regarding their Membership or if they need assistance, toll-free at one of the numbers on their ID card Tell OHCC when they plan to be out of town so OHCC can help arrange their services Use the emergency room only for real emergencies Call their PCP when they need medical care, even if it is after hours Tell OHCC when they believe there is a need to change their plan of care Tell OHCC if they have problems with any health care staff. Members should call Member Services at one of the numbers listed on their ID card Call Member Services at one of the phone numbers listed on their ID card about any of the following: Changes to their name, their address, or their phone number. Members should also report these to their case worker at their local Department of Social Services If they have any changes in any other health insurance coverage, such as from their employer, their spouse s employer, or workers compensation If they have any liability claims, such as claims from an automobile accident If they are admitted to a nursing facility or hospital If they get care in an out-of-area or out-of-network hospital or emergency room If their caregiver or anyone responsible for them changes If they are part of a clinical research study Cultural Competency OHCC promotes the delivery of services in a culturally competent manner to all Members including those with limited English proficiency and diverse cultural, gender identity, and ethnic backgrounds. OHCC requires Providers demonstrate cultural competency in all forms of communication and ensure that cultural differences between Providers and Members do not impede access and quality health care. 13

14 All OHCC Providers must attest to completion of Cultural Competency training by either completing the Optima Health Cultural Diversity Training or The U.S. Department of Health & Human Services Think Cultural Health training at Member Services OHCC Members, Providers, their family members, caregivers or representatives, may contact Member Services through the phone number listed on the back of their Member ID card. Member Services Representatives are available to respond to various Member concerns, health crises, inquiries (e.g., covered services, Provider network), complaints, and questions regarding the OHCC program. Information for Members is also available on the Member website. Continuity of Care for New Members OHCC will provide or arrange for all medically necessary services during care transitions for new OHCC Members to prevent interrupted or discontinued services throughout the transition. 14

15 MEMBER ACCESS TO CARE OHCC network adequacy is an important component of quality care and is assessed on an ongoing and recurring basis along a number of dimensions, including: number of providers, mix of providers, hours of operation, accommodations for individuals with physical disabilities (wheelchair access) and barriers to communication (translation services); and geographic proximity to beneficiaries (provider to Members or Members to provider). OHCC Appointment Standards OHCC Emergency Urgent Routine Primary Care* Prenatal Care First Trimester Second Trimester Third Trimester High-Risk Pregnancy Immediately upon request 24 hours or as quickly as symptoms demand 30 days 14 days 7 days 3 days 3 days or immediately if emergency The standard for routine primary care does not apply to appointments for routine physical examinations, for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every thirty calendar days, or for routine specialty services like dermatology, allergy care, etc. Telemedicine Services OHCC provides coverage for telemedicine services for OHCC Members. Telemedicine is defined as the real time or near real time two-way transfer of medical data and information using an interactive audio/video connection for the purposes of medical diagnosis and treatment. Physicians, nurse practitioners, certified nurse midwives, clinical nurse specialists-psychiatric, clinical psychologists, clinical social workers, licensed and professional counselors are permitted to use medical telemedicine services and one of these types of providers at the main (hub) and satellite (spoke) sites is required for a telemedicine service to be reimbursed. Federal and state laws and regulations apply; including laws that prohibit debarred or suspended providers from participating in the Medicaid program. The decision to participate in a telemedicine encounter will be at the discretion of the OHCC Member and/or their authorized representative(s), for which informed consent must be provided, and all telehealth activities must be compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) and DMAS s program requirements. All telemedicine services must be provided in a manner that meets the needs of vulnerable and emerging high-risk populations and consistent with integrated care delivery. Telemedicine services can be provided in the home or another location if agreeable with the OHCC Member. 15

16 Transportation Program OHCC provides urgent and emergency transportation. Non-emergency transportation (NEMT) for covered services requires prior authorization, including air travel and services reimbursed by an out-of-network payer. 16

17 OHCC MODEL OF CARE The elements of the OHCC Model of Care include: Specific biopsychosocial approaches for subpopulations Staff and Provider training Provider networks with specialized expertise and use of clinical practice guidelines and protocols Comprehensive assessments Interdisciplinary care teams Individualized care plans Care coordination Transition programs The OHCC program: Provides for comprehensive care coordination that integrates the medical and social models of care through a person centered approach Promotes Member choice and rights Engages the Member and family members throughout the process Prioritizes continuity of care, and seamless transitions, for Members and providers, across the full continuum of physical health, behavioral health, and LTSS benefits. Care Coordination OHCC care coordination is locally and regionally based. Care coordinators are assigned to individual Members to conduct care coordination activities in every region across Virginia and act as advocates for Members and Providers helping Members. The Care Coordinator works closely with the Member as a point of contact to identify medical and behavioral health needs and Member strengths and supports. The Care Coordinator also works with the Member to develop an understanding of the services they are receiving, ensure appropriate authorizations are in place and to resolve barriers to care such as transportation issues. Person Centered Individualized Care Plan (ICP) The Care Coordinator works with the Member to develop a comprehensive individualized care plan (ICP). OHCC uses a Health Risk Assessment (HRA) as a tool to develop the OHCC Member s person-centered Individualized Care Plan (ICP). The ICP is tailored to the OHCC Member s needs and preferences and based on the results of OHCC s risk stratification analysis. The Health Risk Assessment must be completed and the ICP developed prior to the end of the Members service authorization. 17

18 Interdisciplinary Care Team OHCC will arrange the operation of an interdisciplinary care team (ICT) for each OHCC Member, in a manner that respects the needs and preferences of the Member. Each OHCC Member s care (e.g., medical, behavioral health, substance use, LTSS, early intervention and social needs) must be integrated and coordinated within the framework of an ICT and each ICT member must have a defined role appropriate to his/her licensure and relationship with the Member. The OHCC Member is encouraged to identify individuals that he/she would like to participate on the ICT. The ICT must be person-centered, built on the OHCC Member s specific preferences and needs, and deliver services with transparency, individualization, respect, linguistic and cultural competence, and dignity. An OHCC care coordinator will lead the ICT. The ICT must include the Member and/or their authorized representative(s) and may include the following as appropriate: PCP/Specialist Behavioral health clinician, if indicated LTSS provider(s) when the Member is receiving LTSS Targeted case manager, if applicable. TCM includes ARTS, mental health, developmental disabilities, early intervention, treatment foster care, and high risk prenatal and infant case management services Pharmacist, if indicated Registered nurse Specialist clinician Other professional and support disciplines, including social workers, community health workers, and qualified peers Family members Other informal caregivers or supports Advocates State agency or other case managers Reassessments The OHCC Care Coordinator will conduct reassessments to identify any changes in the specialized needs of OHCC Members. Re-assessments will be conducted pursuant to routine timeframes and upon triggering events. The ICT must be convened subsequent to all routine re-assessments, within 30 calendar days and in the following circumstances: Subsequent to triggering events requiring significant changes to the Member s ICP (e.g. initiation of LTSS, BH crisis services, etc.) Upon readmissions to acute or psychiatric hospitals or Nursing Facility within 30 calendar days of discharge; and, 18

19 Upon Member request. Care Coordination with Transitions of Care OHCC provides transition coordination services to include: the development of a transition plan; the provision of information about services that may be needed, prior to the discharge date, during and after transition; the coordination of community-based services with the care coordinator; linkage to services needed prior to transition such as housing, peer counseling, budget management training, and transportation. Transition support services will be provided to OHCC Members who are transitioning: From a Nursing Facility to the Community Between Levels of Care 19

20 UTILIZATION MANAGEMENT The OHCC Utilization Management (UM) program reflects the UM standards from the most current NCQA accreditation standards: Utilization Management decision-making is based only on appropriateness of care and service. OHCC does not compensate practitioners or others individuals conducting utilization review for denials of coverage or service. Financial incentives for UM decision-makers do not encourage denials of coverage or service. Members have access to all covered services, in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services as provided under FFS Medicaid. OHCC has mechanisms in place to detect and correct potential under and over utilization of services, including provider profiles. Processes include: Analytics reports bases on provider performance and accurate billing. Active committee review of clinical services and cost data. Authorizations based on evidenced-based criteria for clinical services. Medical Necessity Criteria OHCC uses evidence-based national standard(s) in making medical necessity determinations. Coverage decisions are based upon medical necessity and are in accordance with 42 CFR OHCC: 1. Will not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the Member 2. May place appropriate limits on a service on the basis of medical necessity criteria for the purpose of utilization control, provided that the services furnished can reasonably achieve their purpose 3. Will ensure that coverage decisions for individuals with ongoing or chronic conditions or who require long-term services and supports are authorized in a manner that fully supports the Member's ongoing need for such services and supports and considers the Member s functional limitations by providing services and supports to promote independence and enhance the Member s ability to live in the community 4. Will ensure that coverage decisions for family planning services are provided in a manner that protects and enables the Member's freedom to choose the method of family planning to be used consistent with 42 CFR Will ensure that services are authorized in a manner that supports: The prevention, diagnosis, and treatment of a Member s disease, condition, and/or disorder, health impairments and/or disability, 20

21 Ability for a Member to achieve age-appropriate growth and development, Ability for a Member to attain, maintain, or regain functional capacity, In the case of EPSDT, correct, maintain, or ameliorate a condition. Opportunity for a Member receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice. Critical Incident Reporting Critical incidents include the following incidents: medication errors, severe injury or fall, theft, suspected physical or mental abuse or neglect, financial exploitation, and death of a Member. OHCC requires its staff and contracted OHCC Providers to report, respond to, and document critical incidents to OHCC. The incident must be reported to OHCC within twenty-four hours. Providers should call the OHCC Care Coordination Department, fill out the Critical Incident Reporting Form on the Optima Health Provider Portal and FAX the form to Optima Health using the FAX number listed on the form. 21

22 Additional/Ancillary Services (A-Z) Addiction and Recovery Treatment Services (ARTS) The Addiction and Recovery Treatment Services program (ARTS) is an enhanced and comprehensive benefit package developed by DMAS to cover addiction and recovery treatment services. OHCC offers a variety of services through ARTS that help individuals struggling with substances, including drugs and alcohol. Services include inpatient, outpatient, residential, and community-based treatment. Medication assisted treatment options are available for Members using prescription or non-prescription drugs. Peer services and case management services are also available to Members. The ARTS program improves the benefit and delivery systems for individuals with a substance use disorder. Goals for the ARTS benefit and delivery system include ensuring that a sufficient continuum of care is available to effectively treat individuals with a substance abuse disorder. OHCC s criteria are consistent with the American Society for Addiction Medicine (ASAM) criteria as well as DMAS criteria for the Addiction and Recovery Treatment Services (ARTS) benefit as defined in 12 VAC et al. More information about ARTS is available in the ARTS Supplement to the Optima Health Provider Manual. Audiology Audiology services are provided as inpatient, outpatient hospital services, outpatient rehabilitation agencies, or home health services. Benefits include coverage for acute and nonacute conditions and are limited based upon medical necessity. There are no maximum benefit limits on audiology services. These services are covered regardless of where they are provided. Behavioral Health Services Behavioral health services, including inpatient and outpatient individual, family, and group psychotherapy services are covered. Services range from outpatient counseling to hospital care, including day treatment and crisis services. Community Mental Health Rehabilitation Services are provided through OHCC as of January 1, Chiropractic Chiropractic Services are not covered. 22

23 Community Mental Health Rehabilitation Services (CHMRS) Behavioral health services known as Community Mental Health Rehabilitation Services (CMHRS), listed in the table below may be provided in the Member s home or in the community. Community Mental Health Rehabilitation Services Procedure Code Mental Health Case Management H0023 Therapeutic Day Treatment (TDT) for Children H0035 HA/ H0032 U7 Day Treatment/ Partial Hospitalization for Adults H0035 HB / H0032 U7 Crisis Intervention and Stabilization H0036 Intensive Community Treatment H0039 / H0032 U9 Mental Health Skill-building Services (MHSS) H0046 / H0032 U8 Intensive In-Home H2012 / H0031 Psychosocial Rehab H2017 / H0032 U6 Crisis Stabilization H2019 Behavioral Therapy/Assessment H2033 / H0032 UA Mental Health Peer Support Services Individual H0025 Mental Health Peer Support Services Group H0024 Credentialing All CHMRS Providers are contracted as an organization (agency) type and all services are billed under the organization s NPI. Except for ABA practitioners, individuals do not complete Credentialing applications for CHMRS. CHMRS organizational Providers are required to submit the following documents: Completed OBH CMHRS Application A completed W-9 Clinical Staff Roster (must include last name, first name, DOB, NPI if applicable, and services provided) A copy of the DBHDS License and Licensed Services Addendum. Each service/location on the application requires verification by DBHDS Copies of all other licensure and/or certifications held by the organization A copy of their profession liability Certificate of Insurance (face sheet) Additional Locations Forms. In addition, Behavioral Therapy services require each ABA practitioner to complete a Behavioral Health Provider Credentialing Packet Detailed instructions and forms are available on the Optima Health website. Continuity of Care Prior to April 1, 2018, Members may maintain their current CMHRS Provider for up to 90 days (30 days after April 1, 2018). Service Authorizations issued prior to CCC Plus enrollment will 23

24 remain for up to 90 days or until the expiration date. Authorizations will be extended as necessary to ensure a safe and effective transition to a qualified In-Network Provider. Authorizations All CMHRS Services require authorization. OHCC utilizes the DMAS defined medical necessity criteria for CMHRS. Members must meet service specific medical necessity criteria. Requests are reviewed on an individual basis to determine the length of treatment and service limits based on the Member s most current clinical presentation. Forms may be submitted on the Optima Health Provider Web Portal or faxed to the Behavioral Health Authorization Outpatient FAX number. OHCC uses the following DMAS Standardized CMHRS Service Authorization /Registration forms for CCC Plus. These forms are specific to the service provided. They are available on the Optima Health Provider Portal and the DMAS Website. CCC Plus Service Registration Form CMHRS & Behavior Therapy Services CONTINUED STAY Service Authorization Request Form Day Treatment/Partial Hospitalization (H0035 HB) INITIAL Service Authorization Request Form EPSDT Behavioral Therapy INITIAL Authorization Request Form Intensive Community Treatment (ICT) H0039 INITIAL Service Authorization Request Form Intensive In-Home (IIH) H2012 INITIAL Service Authorization Form Mental Health Skill-Building (MHSS) H0046 INITIAL Service Authorization Request Form Psychosocial Rehabilitation (PSR) H2017 INITIAL Service Authorization Request Form Therapeutic Day Treatment (TDT) H0035 INITIAL Service Authorization Request Form The following chart indicates when a service requires a Registration Form and when the service requires an Authorization Form: CMHRS Service Code Initial Request Continued Stay Request Mental Health Case Management H0023 Registration Registration Mental Health Peer Support Services - Individual H0025 Registration Authorization Mental Health Peer Support Services - Group H0024 Registration Authorization Crisis Intervention H0036 Registration Authorization Crisis Stabilization H2019 Registration Authorization Intensive Community Treatment H0039 Authorization Registration Intensive In-Home H2012 Authorization Authorization Therapeutic Day Treatment for Children *TDT H0035 Authorization Authorization School Day *HA Therapeutic Day Treatment for Children *TDT H0035 Authorization Authorization After School *HA*UG Therapeutic Day Treatment for Children *TDT H0035 Authorization Authorization 24

25 Summer *HA*U7 Day Treatment/Partial Hospitalization *Adults H0035 Authorization Authorization *HB Mental Health Skill-building Services (MHSS) H0046 Authorization Authorization Psychosocial Rehab H2017 Authorization Authorization EPSDT Behavioral Therapy (ABA) H2033 Authorization Authorization Billing All CHMRS services may be billed using the CMS 1500 claim form for outpatient services. In addition, Therapeutic Day Treatment (TDT) for Children and Day Treatment /Partial Hospitalization for Adults may also utilize the UB-04 Claim Form for hospitals/facilities as appropriate. Providers may submit paper or electronic claims. CMHRS Providers may submit electronic claims through AllScripts/PayerPath or Availity. Residential Treatment Services Residential Treatment Services include Psychiatric Residential Treatment Facility Services (Level C) and Therapeutic Group Home Services (TGH) (Levels A & B) and are administered by the DMAS Behavioral Health Services Administrator (Magellan of Virginia). Members admitted to a Residential Treatment Facility will be temporarily excluded from the CCC Plus program until they are discharged. Members admitted to a Therapeutic Group Home (TGH) are not excluded from the CCC Plus Program and any professional medical service rendered to Members in a TGH are provided through OHCC. OHCC works closely with Magellan to coordinate care and provides coverage for transportation and pharmacy services for these carved out services. Members admitted to a Residential Treatment Center for Substance Use Disorder are not excluded from CCC Plus and all services continue to be provided through OHCC. Dental The Smiles for Children program covers diagnostic, preventive, restorative/surgical procedures, for OHCC children and pregnant women as well as orthodontia services for OHCC children. The program also provides coverage for limited medically necessary oral surgery services for adults (age 21 and older). Contact Smiles For Children at OHCC covers: Anesthesia and hospitalization services when deemed medically necessary to effectively and safely provide dental care. Services require prior authorization Transportation and medication related to all covered dental services CPT codes billed by an MD as a result of an accident, and CPT and non-cdt procedure codes billed for medically necessary procedures of the mouth for adults and children Dental fluoride varnish provided by a non-dental medical provider in accordance with the American Academy of Pediatrics guidelines and billed on a HCFA 1500 form Dental Screenings: An oral inspection must be performed by the EPSDT screening provider as part of each physical examination for a child screened at any age. Tooth eruption, caries, bottle 25

26 tooth decay, developmental anomalies, malocclusion, pathological conditions or dental injuries must be noted. The oral inspection is not a substitute for a complete dental evaluation provided through direct referral to a dentist. PCPs or other screening Providers must make an initial direct referral to a dentist when the child receives their six month/biannual screening. The dental referral must be provided at the initial medical screening regardless of the periodicity schedule on any child age three or older, unless it is known and documented that the child is already receiving regular dental care. When a screening indicates a need for dental services at any earlier age, referral must be made for dental services. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) All EPSDT services for Members under age twenty-one (21) are covered. OHCC complies with EPSDT requirements, including providing coverage for all medically necessary services for children needed to correct, ameliorate, or maintain health status. Where it is determined that otherwise excluded services/benefits for a child are medically necessary services that will correct, improve, or are needed to maintain the child's medical condition, OHCC will provide coverage through EPSDT for medically necessary benefits for children outside the basic Medicaid benefit package including, but not limited to: Extended behavioral health benefits Nursing care (including private duty) Personal care Pharmacy services Treatment of obesity Neurobehavioral treatment Other individualized treatments specific to developmental issues Per EPSDT guidelines, OHCC covers medical services for children if it is determined that the treatment or item would be effective to address the child s condition. The determination whether a service is experimental will be reasonable and based on the latest scientific information available. Providers are encouraged to contact care coordinators to explore alternative services, therapies, and resources for Members when necessary. No service provided to a child under EPSDT will be denied as out-of-network and/or experimental or non-covered, unless specifically noted as non-covered or carved out of this program. Documentation of screenings EPSDT services are subject to OHCC documentation requirements for network provider services. EPSDT services are also subject to the following additional documentation requirements: 26

27 The medical record must indicate which age-appropriate screening was provided in accordance with the AAP and Bright Futures periodicity schedule and all EPSDT related services whether provided by the PCP or another provider; and, Documentation of a comprehensive screening must, at a minimum, contain a description of the components utilized. Early Intervention Services Early Intervention (EI) services are covered. Children from birth to age three who have: A 25% developmental delay in one or more areas of development Atypical development; or, A diagnosed physical or mental condition that has a high probability of resulting in a developmental delay is eligible for EI services. EI services are designed to address developmental delay in one or more areas (physical, cognitive, communication, social or emotional, or adaptive). Children are first evaluated by the local lead agency to determine if they meet requirements. If determined eligible, the local lead agency enters the data in the Infant and Toddler Online Tracking System (ITOTS). Based upon ITOTS information, the Department of Behavioral Health and Developmental Services (DBHDS) staff enters the EI level of care (LOC) in the DMAS system. Once the LOC is entered, the EI services are billable based upon the Physician s order on the Individualized Family Service Plan (IFSP). All EI service Providers must be enrolled with OHCC prior to billing. Service authorization is not required. EI services are provided in accordance with the child s IFSP, developed by the multidisciplinary team, including the OHCC Care Coordinator and EI service team. The multidisciplinary team will address the developmental needs of the child while enhancing the capacity of families to meet the child s developmental needs through family centered treatment. EI services are performed by EI certified providers in the child s natural environment, to the maximum extent appropriate. Natural environments can include the child s home or a community based setting in which children without disabilities also participate. OHCC provides coverage for EI services as described in the Member s IFSP developed by the local lead agency. OHCC works collaboratively as part of the Member s multidisciplinary team to: Ensure the Member receives the necessary EI services timely and in accordance with Federal and State guidelines To coordinate other services needed by the Member, and To transition the Member to appropriate services. The child s Primary Care Provider approves the IFSP. The PCP signature on the IFSP or a letter accompanying the IFSP or an IFSP Summary letter within 30 days of the first visit for the IFSP service is required for reimbursement of those IFSP services. If PCP certification is delayed, services are reimbursed beginning the date of the PCP signature. 27