Molina Healthcare of Ohio Behavioral and Mental Health Molina Dual Options MyCare Ohio 2014

Transcription

1 Molina Healthcare of Ohio Behavioral and Mental Health Molina Dual Options MyCare Ohio

2 Headline Goes Here Mental Health/Behavioral Health Services Cont. Mental and emotional well-being is essential to overall health. Sound mental health allows people to realize their full potential, live more independent lives, and make meaningful contributions to their communities. Reducing the stigma Item 1 associated with behavioral health diagnoses is important to utilization of Item 2 health treatment. Identifying and integrating behavioral effective behavioral health needs into3care coordination, traditional health care, social services, Item person-focused care and community resources, is particularly important. The following benefits are available to Molina Dual Options members and are a responsibility of the Health Plan: Behavioral Health Counseling Individual and Group Community Psychiatric Support Treatment Individual and Group Crisis Intervention Mental Health Assessment Physician and non-physician Partial Hospitalization Pharmacological Management For Molina Dual Options members, rehabilitative mental health services, including crisis intervention, stabilization and residential, Molina Healthcare works with and refers to county-administered behavioral health services to coordinate care for Molina Healthcare members. 2

3 Headline Goes Here Mental Health/Behavioral Health Services Cont. Molina Dual Options MyCare Ohio Behavioral Health Services Item 1 Item 2 Item 3 May be billed by Providers Certified by the Department of Mental Health (ODMH) (PT 84) and Ohio Department of Mental Health & Addiction Services (ODMHAS) (PT 95) Ohio Department of Mental Health Services Ohio Department of Alcohol and Drug Addiction Services Pharmacologic Management Mental Health Assessment (non-physician) Psychiatric Diagnostic Interview (physician) Counseling & Therapy (Ind) Counseling & Therapy (Grp) Crisis Intervention Partial Hospitalization Community Psychiatric Support Treatment (Ind) Community Psychiatric Support Treatment (Grp) Alcohol/Drug Screening Analysis/Lab Urinalysis Assessment Case Management Group Counseling Individual Counseling Ambulatory Detoxification Crisis Intervention Intensive Outpatient Medical/Somatic Methadone Administration 3

4 Headline Goes Here Mental Health/Behavioral Health Services Cont. Item 1 Item 2 Item 3 Eligible Service Providers and Eligible Service Supervisors 4

5 Headline Goes Here Mental Health/Behavioral Health Services Cont. Item 1 Item 2 Item 3 5

6 Headline Goes Here Mental Health/Behavioral Health Services Cont. Item 1 Item 2 Item 3 6

7 Headline Goes Here Mental Health/Behavioral Health Services Cont. Billing Community Alcohol and Other Drug Treatment Services Item 1 Item 2 Item 3 Alcohol and other Drug Treatment Service Fee Schedule HCPCS/CPT Code Distinguishing Modifier Unit Definition Billing Increment Reportable In Ambulatory Detoxification $ H0014 HA or HF Day Day Whole Unit Assessment $ H0001 HA or HF Hour Six Minutes.1,.2, etc. Case Management $ H0006 HA or HF Hour Six Minutes.1,.2, etc. Crisis Intervention $ H0007 HA or HF Hour Six Minutes.1,.2, etc. Group Counseling $ 9.52 H0005 HA or HF 15 Minutes 15 Minutes Whole Unit Individual Counseling $ H0004 HA or HF 15 Minutes 15 Minutes Whole Unit Intensive Outpatient $ H0015 HA or HF Day Day Whole Unit Laboratory Urinalysis $ H0003 HA or HF Screen Screen Whole Unit Medical/Somatic $ H0016 HA or HF Hour Six Minutes.1,.2, etc. Methadone Administration $ H0020 HA or HF Dose Dose Whole Unit 7

8 Mental Health/Behavioral Health Services Cont. Billing Community Mental Health Services Mental Health Service Fee Schedule HCPCS/CPT Code Distinguishing Modifier Unit Definition Billing Increment Reportable In BH Counseling-Group $ 9.87 H0004 Fee HCPCS/CPT HQ Distinguishing 15 Minutes 15 Minutes Billing Whole Unit BH Counseling-Individual Mental Health Service $ Schedule H0004 Code HE or Modifier GT 15 Unit Minutes Definition 15 Increment Minutes Reportable Whole Unit In CPST-Group BH Counseling-Group $ 9.81 $ 9.87 H0036 H0004 HQ HQ Minutes Minutes Minutes Minutes Whole Whole Unit Unit BH Counseling-Individual $ H0004 HE or GT 15 Minutes 15 Minutes Whole Unit CPST-Individual CPST-Group $ $ 9.81 H0036 H0036 HE or GT HQ Minutes Minutes Minutes Minutes Whole Whole Unit Unit Crisis Intervention CPST-Individual $ $ S9484 H0036 HE HE or GT 15 Hour Minutes 15 Six Minutes Whole.1,.2, Unit etc. Crisis Intervention $ S9484 HE Hour Six Minutes.1,.2, etc. Mental Health Assessment $ H0031 HE or GT Hour Six Minutes.1,.2, etc. Mental Health Assessment $ H0031 HE or GT Hour Six Minutes.1,.2, etc. Partial Hospitalization Partial Hospitalization $ $ S0201 S0201 HE HE Day Day Day Whole Whole Unit Unit Pharmacological Management Pharmacological Management $ $ HE, HQ HE, or HQ GT or GT Hour Hour Six Six Minutes.1,.2,.1, etc..2, etc. Pharmacological Management $ HE, HQ or GT Hour Six Minutes.1,.2, etc. Pharmacological Management $ HE, HQ or GT Hour Six Minutes.1,.2, etc. Psychiatric Diagnostic Interview $ HE or GT Hour Six Minutes.1,.2, etc. Psychiatric Diagnostic Psychiatric Interview Diagnostic $ HE or GT Hour Six Minutes.1,.2, etc. Interview $ HE or GT Hour Six Minutes.1,.2, etc. Psychiatric Diagnostic Interview SPMI Health Home $ MCR S0281 HE or GT None Hour Month Six Month Minutes Whole.1,.2, Unit etc. *TJ billed with kids bypass annual benefit limit w/out the provider having to get a prior authorization for S0201 and H0036 8

9 Mental Health/Behavioral Health Services Cont. Billing Medications Alcohol and other Drug Medications Fee HCPCS/CPT Unit Billing Reportable In Alcohol and other Drug Medications Fee Schedule HCPCS/CPT Code Distinguishing Definition Increment Billing Generic Buprenorphine Mental Health Service Schedule $.55/mg Code J8499 Modifier Milligram Unit Definition N/A Increment Whole Unit Reportable In Vivitrol BH Counseling-Group $ 9.87 $2.83/mg H0004 J2315 HQ Milligram 15 Minutes N/A 15 Minutes Whole Unit Whole Unit BH Counseling-Individual Mental $ Health H0004 Medications HE or GT 15 Minutes 15 Minutes Whole Unit CPST-Group $ 9.81 H0036 HQ 15 Minutes 15 Minutes Whole Unit CPST-Individual $ Fee H0036 HCPCS/CPT HE or GT Unit 15 Minutes Billing 15 Minutes Whole Unit Mental Health Medications Crisis Intervention $ Schedule S9484 Code HE Definition Hour Increment Six Reportable Minutes In.1,.2, etc. Fluphenazine Decanoate Mental Injection Health Assessment 25 mg $ H0031 J2680 HE or GT 25 Mg Hour Six Minutes 25.1,.2, etc. Haloperidol Decanoate Partial Injection Hospitalization $ S0201 J1631 HE 50 Mg Day Day 50 or 100 Whole Unit Haloperidol Injecton Pharmacological Management $ J1630 HE, HQ or GT 1 Mg Hour Six Minutes.1,.2, etc. Lorazepam Injection Pharmacological Management $ J2060 HE, HQ or GT 2 Mg Hour Six Minutes.1,.2, etc. Olanzapine Long Acting Psychiatric Injectable Diagnostic 1 mg J Mg 210, 300, 405 Paliperidone Palmitate Injection Interview $ HE or GT Hour Six Minutes 39, 78, 117,.1,.2, etc. Psychiatric Diagnostic Prescription Drug, Injection Interview Non-Chemotherapeutic $ J2426 J Mg HE or GT Hour 156, 234 Six Minutes.1,.2, etc. Risperidone, Long Acting SPMI Health Home MCR S0281 None Month 12.5, Month 25, 37.5, Whole Unit J Mg 50 Valium Injection J Mg 9

10 Mental Health/Behavioral Health Services Cont. Partial Hospitalization Partial hospitalization services includes activity therapies, group activities, or other services and programs designed to enhance skills needed for living in the least restrictive environment are allowable. A partial hospitalization program day shall consist of a minimum of two hours and up to a maximum of seven hours of scheduled intensive activities Unallowable partial hospitalization activities include, but are not limited to, crafts, general non-therapeutic art projects, recreational outings purely for recreational purposes, exercise groups, etc

11 Mental Health/Behavioral Health Services Cont. Crisis Intervention Crisis intervention is the process of responding to emergent situations and may include: Assessment, Immediate stabilization, The determination of level of care in the least restrictive environment in a manner that is timely, responsive, and therapeutic. Outcomes may include: De-escalating and/or stabilizing the individual and/or environment, Linking the individual to the appropriate level of care and services including peer support, Assuring safety, Developing a crisis plan, Providing information as appropriate to family/significant others, and Resolving the emergent situation. A crisis plan will be established that includes referral and linkages to appropriate services and coordination with other systems. A crisis plan should also address safety issues, follow-up instructions, alternative actions/steps to implement should the crisis recur, voluntary/involuntary procedures and the wishes/preferences of the individual and parent/guardian, as appropriate. *Please contact our Nurse Advice Line available 24 hours a day, 7 days a week 888)

12 Mental Health/Behavioral Health Services Cont. Community Psychiatric Supportive Treatment Community psychiatric supportive treatment (CPST) service s purpose is to provide specific, measurable, and individualized services to each person served. CPST services should be focused on the individual's ability to succeed in the community; to identify and access needed services; and to show improvement in school, work and family, and integration and contributions within the community. A combined maximum of one-hundred and four hours (416 units) of individual and group CPST services are allowed per twelve month period. In accordance with the Healthchek benefit, children up to age of twenty-one may receive services beyond established limits when medically necessary and approved through the prior authorization process (modifier TJ). Adults may receive services beyond established limits when medically necessary and approved through the prior authorization process. After the first 6 units (90 minutes) of service provided to the same consumer by the same provider on the same day, additional units will be reimbursed at 50% of the rate. CPST services are not covered under this rule when provided to an adult or child in a hospital setting, except for the purpose of coordinating admission to the inpatient hospital or facilitating discharge to the community following inpatient treatment for an acute episode of care. Providers may use POS 99 (other place of service) when billing CPST for this particular circumstance

13 Headline Goes Here Mental Health/Behavioral Health Services Cont. How to refer Molina Healthcare members in need of Mental Health/Behavioral Health services Refer to Molina Healthcare Prior Authorization requirements at Item 1 Item 2 Item 3 Behavioral health participating providers should fax the Molina Healthcare Inpatient/PHP/IOP/Outpatient Behavioral Health Treatment Request form to Molina Healthcare as soon as possible to (866) For both participating and non-participating providers, if the request is for Inpatient Behavioral Health, Partial Hospitalization, or an Intensive Outpatient Program for psychiatric and substance use disorders, the Molina Healthcare Inpatient/PHP/IOP/Outpatient Behavioral Health Treatment Request form should be faxed as soon as possible to the same number at (866) If the admission to Inpatient Behavioral Health is an emergency, prior authorization is not needed but the form should be faxed as soon as possible to (866) The Molina Healthcare Behavioral Health RN may call the behavioral health provider for additional clinical information, particularly if the Molina Healthcare Inpatient/PHP/IOP/Outpatient Behavioral Health Treatment Request form is not completely filled out. Interqual medical necessity criteria is used to review the provided clinical information. The Molina Healthcare psychiatrist may also contact the behavioral health provider for a peer-to-peer discussion of the member behavioral health needs. All Requests for Prior Authorization will require the current and existing treatment plan that identifies all medical and behavior health services known. Crisis Prevention and Behavioral Health Emergencies Please contact our Nurse Advice Line available 24 hours a day, 7 days a week at (888) / TTY: (866)

14 Frequently Used Phone Numbers DEPARTMENT NUMBER Case Management (855) (follow phone prompts) Claims Reconsideration (855) / fax (800) Claims Inquiry Customer Service (855) (follow phone prompts) Community Outreach (855) Fraud, Waste, and Abuse Tip Line (866) / fax (888) Member Eligibility Ohio Medicaid (800) Member Services Duals (855) /fax: (855) Member Services Medicare (866) Pharmacy (Medicare/Duals) (855) / fax: (888) Prior Authorization (Inpatient) (855) Prior Authorization (Outpatient) (855) Provider Services (855) / fax: (866) Provider Services Web Portal Help Desk (866) Utilization Management (855) / fax: (866) Hour Nurse Advise Line (888) / TTY: (866) Behavioral Health (855) / fax(866) Main Phone (855) TTY 711 Member Services 8 a.m. to 8 p.m. Monday - Friday Provider Services 8 a.m. to 8 p.m. Monday - Friday 14 14

15 Headline Goes Here Questions and Comments Item 1 Item 2 Item