Behavioral Health Outpatient Authorization Request Self Service. User Guide

Transcription

1 Behavioral Health Self Behavioral Health Outpatient Authorization Request Self Service User Guide

2 Introduction Tufts Health Plan Network Health has created this user guide to illustrate how to navigate and use the online self-service tool for behavioral health clinicians to submit outpatient behavioral health authorization requests for Tufts Health Plan Network Health members. This guide will provide valuable information on the Tufts Health Plan Network Health secure provider website, Network Health Connect. Within this guide you will find general guidelines, helpful hints, and instructions on how to submit an authorization request for outpatient behavioral health services and view prior authorizations. We hope you find this guide useful. For additional information, visit Tufts Health Plan Network Health s public provider website at network-health.org/providers or call us at

3 Table of Contents General Guidelines and Helpful Hints 5 Submitting an Outpatient Behavioral Health Authorization Request 8 Viewing System Authorization Number 21 Behavioral Health Outpatient Psychotherapy Worksheet 23 3

4 General Guidelines and Helpful Hints 1. Whenever you finish a session, be sure to click the Log out button located at the top of the screen. 2. As a security measure, passwords expire every 90 days. After the 90 days has passed, you will be prompted next time you log in to create a new password. Passwords must be at least eight characters in length and contain a combination of letters, numbers, and at least one mixed case letter. 3. Tufts Health Unify members are excluded from this automated authorization request submission process. Authorization requests for these members should follow the current fax process. The current fax form can be found on the provider section of the website under behavioral health forms (Behavioral Health Outpatient Psychotherapy Authorization Form). 4. Out-of-network behavioral health providers must continue to use the current fax process. The fax form can be found on the provider section of the website under behavioral health forms (Out-of-network Outpatient Prior Authorization Request Form). 5. Authorization requests cannot be back-dated. The requested start date must be on or after the date submitted. (Example: today s date is July 1, 2015; requested start date must be July 1, 2015 or later to continue with submission). 6. The authorization end date will default to 180 days (approximately six months) from the current date. It may be manually changed to three months from the start date but should be at least 90 days from the start date. (Example: today s date is July 14, 2015; the requested start date for the authorization request is today; system will default request end date to January 9, 2016 but it may be manually changed to October 12, 2015 or later if desired). Please note that the end date can be changed to less than three months, however this may require your request to pend for review by a clinician. 7. Authorization requests may be submitted for active Tufts Health Network Health members. If a member is currently active but has a termination date in the near future, the authorization request must be submitted for only the date period that the member is eligible. 8. Authorization requests may only be submitted for the following outpatient CPT procedure codes: Psychiatric diagnostic evaluation (includes the assessment of the patient's psychosocial history, current mental status, review, and ordering of diagnostic studies 4

5 followed by appropriate treatment recommendations) Individual psychotherapy, minutes Individual psychotherapy, 45 minutes Family psychotherapy without patient present Family psychotherapy with patient present Multifamily group therapy NOTE: the following CPT/HCPCS codes currently do not require an authorization: Psychiatric Diagnostic Examination with medical services Group psychotherapy Environmental Intervention for Medical Management Purposes on a Psychiatric Patient s Behalf With Agencies, Employers, or Institutions Interpretation or Explanation of Results of Psychiatric, Other Medical Examinations and Procedures Office visits Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components 9. Behavioral health outpatient authorization requests may only be submitted if the servicing provider is a behavioral health provider and is in-network for the member s plan. 10. In order to be considered for automatic approval, outpatient authorization requests must meet the following requirements: requested start date must be within 21 days of the date submitted (Example: request submitted on June 1, 2015 must have a requested start date no later than June 21, 2015) requested start date must be 75 days after the start date on the last authorization request submitted (Example: Last authorization request was submitted on May 25, 2015 with a requested start date of June 1, 2015; the requested start date on the next authorization request must be on or after August 16, 2015) the total number of units requests must be less than or equal to 12 (if patient age 21 years or over on requested start date) the total number of units requests must be less than or equal to 15 (if patient age less than 21 years on requested start date) If the above requirements are not met, you will receive a warning message but will still be allowed to submit the request. However, the request will be ineligible for an automatic approval and will be pended for clinician review. 5

6 (Example: Authorization requests submitted on June 1, 2015 with a requested start date of June 21, 2015 or prior will be considered for automatic approval. If the requested start date is after June 21, 2015, you may still submit the request however it will be pended for clinician review.) 6

7 Submitting a behavioral health outpatient authorization request The secure provider portal allows you to submit an authorization request for outpatient behavioral health services. Upon submission, the request may be automatically approved if it meets criteria and a confirmation number will be provided. This will be your authorization to provide the services requested. You will be instructed to print a copy of the screen for your records. If your request does not meet criteria for auto-approval, your request will be submitted and pended for review by a behavioral health clinician. You may be contacted by a clinician at the contact telephone number provided on your request if additional clinical information is needed. You will be notified of the decision via fax. 1. Log in to the Network Health Connect, our provider portal with your assigned username and password. 2. Select Referrals/Auths from the list of options on the left side of the screen. 7

8 The following screen will display. This is the screen used to request a summary of all approved and pended authorization requests for a particular member for the date period specified. This screen is not needed to submit a request for behavioral health outpatient services. 8

9 1. Click on Outpatient tab and the following screen will display. This is where the behavioral health outpatient request will be submitted. 2. Enter the member s last name, member ID or SSN to search for and select the desired member. Helpful hint: note the member s end date; some contracts automatically have an end date of 12/31 of the current year if the member needs to re-enroll in order to continue eligibility; authorization requests cannot have a start or end date before or after the member s eligibility start or end date 3. Enter the requesting provider last name, provider ID, provider UPIN, or provider NPI to search for and select the correct provider. Generally the requesting and servicing provider will be the same, however please note that the servicing provider must be the behavioral health provider who will be providing services to the member. Note: providers may notice their names and locations listed multiple times in the search results screen. Each NPI # and location will be listed separately. Pay attention to the NPI number and location for the provider ID # that you select. 4. Enter either the ICD diagnosis code or a partial description of the diagnosis to search for the appropriate primary member diagnosis. Please enter any additional diagnosis codes for this 9

10 member. Only one diagnosis is required with a maximum of four diagnosis codes allowed. Note: for a requested start date prior to 10/1/2015, a valid ICD-9 diagnosis code must be submitted. For a requested start date on or after 10/1/2015, a valid ICD-10 diagnosis code must be submitted. 5. Enter the servicing provider s last name, provider ID, provider UPIN or provider NPI to search for and select the correct provider. Generally for behavioral health providers, the requesting and servicing providers will be the same. Note: providers may notice their names and locations listed multiple times in the search results screen. Each NPI # and location will be listed separately. Pay attention to the NPI number and location for the provider ID # that you select. The servicing provider ID # submitted on the authorization request must match the provider ID # on the claim that providers will submit for payment. Helpful hint: providers may have several provider ID s assigned where some are out of network and some are in network based on the plan. Provider ID # s highlighted in red are out of network and will not be allowed on requests through this process. 6. Enter your contact name and phone number in the field Provider Contact Name/Phone. This information is required in the event there is a question about your submitted authorization request and a clinician needs to contact you to obtain further clinical information. This field is free-text so both a contact name and phone number should be entered in this field. Note: please limit your response to 50 characters or less. Helpful Hint: to avoid delay if your request does not meet criteria to auto-approve, double check the contact name and phone number for accuracy as this is the number the clinician will call if there are any questions on your request. 7. Enter your fax number in the field Contact number field. In the event your request is pended for manual review, a letter will be faxed to you indicating the final determination for your request (approved, denied, etc.) Helpful Hint: double check the fax number entered for accuracy as this is the number the clinician will attempt to fax the letter notifying you of the determination. If you do not have a working fax number, enter in the fax contact number field. Include your mailing address in the remarks section at the bottom of the screen if you wish to have your letter mailed. 8. Select Psychotherapy from list of options in the requested service field. This is the only option that should be selected to submit a behavioral health outpatient authorization request. Helpful hint: the system will default to Home Health Care so be sure you select the value Psychotherapy. 10

11 9. Enter the total number of requested visits in the requested units field. Reminder: in order for your request to be considered for auto-approval, the requested number of visits must not exceed 12 (for patients 21 years and older) or 15 (for patients under age 21). 10. Select the appropriate location for the visits from the drop down in Location field. Note: the selected location will not affect the determination process. 11. Enter the CPT procedure code or first few characters of the procedure description in procedure field and select the appropriate CPT code from the list displayed. You may enter up to six unique behavioral health outpatient procedure codes. Reminder: outpatient behavioral health authorization requests are limited to the specific codes listed in the Helpful Hints section of this manual. 12. Enter the number of units requested for each procedure code selected. Note: the number of units requested for each procedure code submitted must equal the total number of units requested in step Select Routine/Elective or Urgent from the Level of Service field. Note: Urgent is defined as requiring immediate action or attention. 14. Enter Start Date of requested service. Refer to Helpful Hints section for rules regarding edits on this field. 15. The End Date field will default to 180 days (approximately six months) from the current date. It may be manually changed to three months from the start date if desired but must be at least 90 days from the requested start date in order for the request to be considered for auto-approval. Helpful hint: some members may have future termination dates of 12/31/2015. The request End Date may not be greater than the member termination date or you will receive an error message. To avoid this edit, change the request End Date to a date equal to or prior to the member termination date. 16. You may enter any additional information in the remarks section that you think would be helpful in processing this request. This field is not required. Maximum is 225 characters. 17. Click on Submit when you have completed entering all information on the screen. Note: see sample completed screen below: 11

12 18. If there are any required fields that are missing or any other issues with the request, a message will be displayed with a list of errors to be corrected. 19. Once all fields have been successfully validated, the Behavioral Health Questionnaire screen(s) will be displayed to allow you to enter a series of questions providing clinical information regarding the member s current medications and conditions. All questions must be answered. 20. Medication Questions - a series of yes/no questions must be answered regarding psychotropic medications the member is currently taking. 12

13 Note: if the member is not currently taking any psychotropic medications, please enter none in the box. Otherwise, list any psychotropic medications, known doses and frequency the member is taking. 21. Acuity questions - a series of yes/no questions must be answered regarding the member s acuity. 13

14 You must answer all questions. There are a few questions that require a free-text response based on the response provided. Please limit your response to 225 characters or less. 14

15 22. Functional Impairment Questions at this point, you may receive a series of yes/no questions that must be answered regarding the member s level of functional impairment. If you receive a summary screen, you can ignore this step as the system has determined there is enough information submitted on the medication and acuity screens to make a determination if the request can be approved. Progress Bar use this if you need to go back You must answer all questions. There are a few questions that require a free-text response based on the response provided. Please limit your response to 225 characters or less. 23. Upon successful entry of all required fields on the medications, acuity and functional impairment tabs, you will be prompted at this point with a screen displaying the information previously entered. 15

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17 If all answers are correct, click Submit at the bottom of the screen to enter your request. If you need to change any of your responses, click on the appropriate bar on the progress bar at the top of the screen (medication, acuity or functional impairments) to go back to that screen and re-enter the information. Helpful hint: DO NOT CLICK ON THE BACK ARROW in your browser to go back and change any responses or you will receive an application error and will need to start over entering your request. The system will automatically provide an immediate approved or pended response based on the clinical information submitted and past history for this member. 24. If the request is approved, the following screen will be displayed with confirmation # and approved # of units displayed on the screen. Note: you will no longer receive an authorization letter faxed or mailed to you if your request is automatically approved. 17

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19 25. If the request does not meet criteria for auto-approval, your request will be submitted and pended for clinical review by a Behavioral Health clinician. A confirmation # will be displayed on the screen for reference. You will receive a faxed letter with the final determination as you currently receive today. The fax will be sent to the fax number submitted on your request, so please ensure it is correct. 26. The confirmation # received on either the pended or approved request is a temporary number. You may use this request confirmation number in any communication required with Tufts Health Plan Network Health. If your request was approved, you may see the member on or after the start date of your request. 27. If you wish to print a copy of the response screen, use your browser print button. If you use the print form button on the response screen, it will print a copy of the screen but will NOT print the confirmation #. Viewing System Authorization Number 19

20 The actual system authorization number will be available within 1 2 business days on the Summary Referrals/Auths screen. To access this number, click on the Status tab at the top of the screen to display the Referral/Auths status screen. 20

21 Enter the last name, member ID, or member SSN of the member in the patient field. The following Service Request Search Results screen will be displayed. Note the system authorization number. You may use either confirmation number in any communications with Tufts Health Plan Network Health. 21

22 Behavioral Health Outpatient Psychotherapy Online Authorization Preparation Worksheet This worksheet is intended to be used as a guide to assist providers when preparing the necessary clinical information that is required for completing behavioral health outpatient requests using the online automated system. This form is only to be used for preparation purposes and CANNOT be submitted as a request for treatment authorization. Member Name: ID#: ICD 9/10 Diagnosis Codes (ICD-10 required after 10/1/2015): Date range of requested sessions from / / to / / Level of Service: Routine/Elective Urgent Please complete this table with your requested number of sessions for the next three months. CPT Code Session Type # of Sessions Psychiatric Diagnostic Evaluation (no medical/medication services) Individual psychotherapy, minutes Individual psychotherapy, 45 minutes Family psychotherapy without patient present Family psychotherapy with patient present Multifamily group therapy Remarks Please provide any additional information that might be relevant (this information can be entered into the Remarks section on the first screen of the outpatient request page). Section 1 Medications Please check off which type of medications this member is currently taking, if applicable. List the names, dosages and frequency of any psychotropic medications member is currently taking: Anti-depressants Anti-anxiety Stimulants Hypnotic/sedatives Mood stabilizers/anti-convulsants Anti-psychotics Medication list Section 2 Acuity Please answer these questions as accurately as possible and elaborate when applicable. Has the patient been hospitalized for MH (mental health) treatment in the past 3 months? Yes No Has the patient been hospitalized for SA (substance abuse) treatment in the past 3 months? Yes No

23 Member Name: ID#: Section 2 Acuity (cont.) Is the patient at risk for hospitalization in the next 2 weeks? Yes No If yes, please describe Has the patient physically and/or sexually assaulted another in the past 3 months? Yes No Has the patient expressed homicidal intent in the past 3 months? Yes No Has the patient made a suicide attempt in the past 3 months? Yes No Has the patient been the victim of physical/domestic/sexual violence in the past 3 months? Yes No Has the patient exhibited self-injurious behavior in the past 3 months? Yes No Has the patient experienced a recent traumatic event in the past 3 months (e.g., house fire, death of spouse/child, etc.)? Yes No If yes, please describe Has the patient abused drugs or alcohol within the past 2 weeks? Yes No Has the patient been newly diagnosed in the past 3 months with a catastrophic medical condition? Yes No Has the patient exhibited fire-setting behaviors in the past 3 months? Yes No Has the patient been in therapy more than one (1) year? Yes No If yes, how long has the patient been in therapy? Section 3 Functional Impairment Please answer these questions as accurately as possible and elaborate when applicable. Is the patient currently unable to attend work or school full or part-time due to psychiatric or substance abuse issues? Yes No Has the patient shown a decrease in the past 3 months in their baseline abilities to perform ADL s or IADL s such as bathing, feeding, dressing, toileting, grocery shopping, paying bills, etc.? Yes No Has the patient shown a decrease in their baseline level of social interaction in the past 3 months? Yes No Has there been a new marital or family crisis in the past 3 months? Yes No Has the patient displayed active eating disorder behaviors in the past 3 months? Yes No Has the patient experienced frequent episodes of feeling hopeless or worthless in the past 3 months? Yes No Has the patient experienced frequent episodes of sleep or appetite disturbance in the past 3 months? Yes No Has the patient had a significant increase in baseline anxiety or panic in the past 3 months? Yes No Has the patient had a significant decrease in their ability to control impulsive behavior in the past 3 months? Yes No Has the patient received a suspension or warning at school or work in the past 3 months? Yes No Is the patient currently involved with the legal system or a state agency (e.g., DYS, DMH, DDS, DCF)? Yes No Have you considered group therapy, every other week sessions, or referrals to community supports for this patient? Yes No If no, please elaborate on why these have not been considered V1.1 08/06/2015

24 Contact Information If you have any questions, please call us at Revised August 2015