STAR+PLUS through UnitedHealthcare Community Plan

Transcription

1 STAR+PLUS through UnitedHealthcare Community Plan Optum

2 Who We Are United Behavioral Health (UBH) was created February 2, 1997, through a merger of U.S. Behavioral Health, Inc. (USBH) and United Behavioral Systems, Inc. (UBS). Our company is a wholly owned subsidiary of UnitedHealth Group. We have been operating under the brand Optum since TM Optum is a service mark of United Behavioral Health. Optum is a leading health service business dedicated to making the health system work better for everyone. United Behavioral Health operating under the brand Optum Propriety and Confidential. Do not distribute. 2

3 Our Providers include the following: Psychiatrists Addictionologists Psychologists Master Level Clinicians include: Licensed Clinical Social Workers (LCSW) Licensed Marriage &Family Therapists (LMFT) Licensed Professional Counselors (LPC) Advanced Practice Registered Nurses (APRN) Network Providers Also Include: Federally Qualified Health Centers Community Mental Health Centers Chemical Dependency Treatment Facilities To Locate a Contracted Provider visit Liveandworkwell.com Propriety and Confidential. Do not distribute. 3

4 Behavioral Services Inpatient Hospitalization Partial Hospitalization Program / Extended Day Treatment Intensive Outpatient Treatment / Day Treatment Residential Care Residential substance use disorder treatment, including detoxification Psychiatry Services Outpatient substance use disorder treatment services including: Assessment, Detoxification Services, Counseling, Medication-assisted Therapy Individual, group and/or family therapy provided by a psychologist or behavioral health professional Targeted case managed and psychosocial rehabilitation services Propriety and Confidential. Do not distribute. 4

5 Member Verification Benefits Always verify member benefits and health plan designation. All relevant contact information will be on the back of the card for both medical and behavioral customer service. Sample ID Card Please note this image is for illustrative purposes only.. Propriety and Confidential. Do not distribute. 5

6 Who to Call for Utilization Management Phone Dedicated Intake Team Information is Gathered Benefits / Authorization Provided Optum staff are available 24 hours a day, 365 days a year. Propriety and Confidential. Do not distribute. 6

7 Authorization Non-emergent situations Emergent situations Member Initiated Optum assess the request over the phone with the Member (or representative) by addressing safety, collecting demographic information, explaining the services available under their benefit plan, and obtaining a brief description of the presenting problem. Clinician Initiated Optum assesses the request over the phone with a Clinician who has assessed Member safety and can verify demographic member information. Services are reviewed and a brief description of the presenting problem is documented. A medical professional in an emergency setting calls for prior authorization by identifying the need for behavioral health services. Conditions that warrant an emergency admission are situations in which there is a clear and immediate risk to the safety of the Member or another person as a direct result of mental illness or substance use. Optum is then contacted for a prior authorization Propriety and Confidential. Do not distribute. 7

8 Information Necessary for Authorization Request Necessary information includes: Member First and Last Name Member ID number as listed on UnitedHealthcare Community Plan ID card, or Date of Birth Date of Service Description of Services Number of Units Date Range Proposed for Service Delivery Supporting Clinical Information Name of Provider Contact Name Contact Phone Number Provider Texas Identification Number Propriety and Confidential. Do not distribute. 8

9 Authorization Process MDs and providers with prescriptive authority do not require prior authorization Master level and PhDs need to obtain prior authorization prior to rendering any services Authorizations for therapy are given in one-year increments. Details are available at providerexpress.com. See Alerts, then Eligibility and Certification. Propriety and Confidential. Do not distribute. 9

10 Authorization Process PRS/TCM For State Fiscal Year (SFY) 2015, Optum must cover Mental Health Rehabilitative Services and Targeted Case Management using the Department of State Health Services (DSHS) Resiliency and Recovery Utilization Management Guidelines (RRUMG) and the Adult Needs and Strengths Assessment (ANSA) or the Child and Adolescent Needs and Strengths (CANS) tools for assessing a Member s needs for services. The MCO is not responsible for providing any services listed in the RRUMG that are not Covered Services. Optum will ensure during SFY 2015 that Providers of Mental Health Rehabilitative Services and Targeted Case Management use, and are trained and certified to administer, the ANSA and CANS assessment tools to recommend a level of care to MCO by using the current DSHS Clinical Management for Behavioral Health Services (CMBHS) web based system Propriety and Confidential. Do not distribute. 10

11 Authorization Process PRS/TCM The following Mental Health Rehabilitative Services may be provided to individuals with an SPMI or a SED as defined in the DSM-IV-TR and who require rehabilitative services as determined by either the ANSA or the CANS: Adult Day Program Medication Training and Support Crisis Intervention * Skills Training and Development ** Psychosocial Rehabilitative Services The above-listed Mental Health Rehabilitative Services, as well as any limitations to these services, are described in the most current Texas Medicaid Provider Procedures Manual (TMPPM), including the Behavioral Health, Rehabilitation, and Case Management Services Handbook. Mental Health Rehabilitative Services must be billed using appropriate procedure codes and modifiers as listed in the TMPPM with the following exception. The MCO is not responsible for providing Criminal Justice Agency funded procedure codes with modifier HZ because these services are excluded from the capitation. Propriety and Confidential. Do not distribute. 11

12 Discharge Planning Effective discharge planning addresses how a Member s needs will be met during transition from one level of care to another or to a different treating clinician. Care Advocates begin this planning with the onset of care and it is documented and reviewed over the course of care. It includes, the Member, Member Representative, the Clinician at the next level of care, and/or relevant community resources. Involves assessment of the Member s needs including current functioning, resources, and barriers to treatment access or compliance. Discharge instructions are specific, clearly documented and provided to the Member prior to discharge. For discharge from an acute inpatient level of care, Optum expects that a patient s follow-up appointment will be scheduled prior to discharge and within seven (7) days of the date of discharge. Members have the right to decline permission to release information to other treating professionals, but should be informed about the potential risks and benefits of this decision and how it affects coordination of care. Propriety and Confidential. Do not distribute. 12

13 Treatment Record Documentation Member name or identification number on each page of the record Member address; employer or school; home and work telephone numbers, including emergency contacts; marital or legal status; appropriate consent forms; and guardianship information Date of service, start/stop time of service, CPT code billed, notation of session attendees, the responsible clinician s name, professional degree, license, and relevant identification number Medication allergies, adverse reactions and relevant medical conditions; if the Member has no known allergies, history of adverse reactions or relevant medical conditions Medication tracking that provides a thorough picture of all medications taken by the patient from the onset of care through discharge Presenting problems, the results of mental status exam's), relevant psychological and social conditions affecting the Member s medical and psychiatric status, and the source of such information Assessment and reassessment of special status situations, when present, including but not limited to imminent risk of harm, suicidal or homicidal ideation, self-injurious behaviors, or elopement potential. It is also important to document the absence of such conditions Propriety and Confidential. Do not distribute. 13

14 Treatment Record Documentation (continued) History: Medical and Psychiatric (previous treatment, clinician or facility identification, therapeutic interventions and responses, sources of clinical data, and relevant family information) Tobacco, alcohol and drug use (illicit, prescribed or over-the-counter) should be included past and present for Members 12 years and older Developmental (prenatal, perinatal through present age) for school-aged Members DSM Diagnosis (presenting problem(s), safety assessment, mental status examination, and other assessment data) Discharge Plan (beginning at the initiation of treatment and changing as approrpiate) Coordination of care (with PCP and other providers) Billing records should reflect the Member who was treated and the modality of care All non-electronic treatment records are written legibly in blue or black ink Visit for a complete description of expected Treatment Record Documentation Propriety and Confidential. Do not distribute. 14

15 Clinician Responsibilities Verify Member s eligibility prior to performing services Refer to in-network providers Adhere to the Optum s authorization policies appointment and accessibility standards medical record keeping and chart review standards Provide appropriate health education and instructions Provide services consistent with professional and ethical standards as set forth by national certification and state licensing boards, and applicable law and/or regulation regardless of a Member s Benefit Plan or terms of coverage Provide services that are accessible, family-centered, sensitive to cultural differences, comprehensive, coordinated, and compassionate. To ensure that all members receive the right services at the right time for their individual health care needs in a non discriminatory manner Determine if Members have medical benefits through other insurance coverage Advocate for members as needed Propriety and Confidential. Do not distribute. 15

16 Complaints: Quality and Non-Quality Send written complaint to: United Behavioral Health Appeals and Complaints P.O. Box Salt Lake City, UT Customer Service is available to assist with the complaint process at Written notification of receipt of the complaint will be forwarded to the Member or provider within five business days. The complaint will be fully investigated and resolved within 30 calendar days. A resolution letter will be sent to the Member and Clinician. Propriety and Confidential. Do not distribute. 16

17 Complaint Investigation and Resolution You are required to cooperate with OPTUM in the complaint investigation and resolution process. If Optum requests written records for the purpose of investigating a Member complaint, you must submit these to OPTUM within 14 business days, or sooner as requested. Complaints filed by Members should not interfere with the professional relationship between you and the Member. Optum requires the development and implementation of appropriate Corrective Action Plans (CAP) for legitimate problems discovered in the course of investigating complaints. Propriety and Confidential. Do not distribute. 17

18 Sentinel Events Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, or risk thereof, which occur during the course of a Member receiving behavioral health treatment. If you are aware of a sentinel event involving a Member, you must notify Optum Care Advocacy within one business day of the occurrence. You are required to cooperate with sentinel event investigations. Optum supports the Joint Commission s National Patient Safety Goals as they apply to behavioral health care. These Safety Goals are available on the Joint Commission web site at Propriety and Confidential. Do not distribute. 18

19 Appeals Non Urgent (Standard) Urgent (Expedited) Must be requested within 30 days from receipt of the notice of the complaint decision Pre-Service An Appeal of a service that has not yet been received by a Member. When a pre-service Appeal is requested, OPTUM will make an Appeal determination and notify the provider, facility, Member or authorized Member representative in writing within 15 calendar days of the request. Post-Service- An Appeal of a service after it has been received by a Member. When a post service Appeal is requested, OPTUM will make the Appeal determination and notify the provider, facility, Member or authorized Member representative in writing within 30 calendar days of the request. Must be requested within 10 days of the mailing of complaint decision notice or the intended effective date of the complaint decision, which ever is later. In Writing Unless the Appeal is urgent (expedited), an Appeal request must be in writing by the Member or Member Representative Propriety and Confidential. Do not distribute. 19

20 Services while in Appeal You may continue to provide service following an adverse determination, but the Member, or representative should be informed of the adverse determination by you in writing. The Member should be informed that the care will become the financial responsibility of the Member from the date of the adverse determination forward. The Member must agree in writing to these continued terms of care and acceptance of financial responsibility. You may charge no more than the Optum contracted fee for such services, although a lower fee may be charged. The consent of the Member to such care and responsibility will not impact the appeals determination, but will impact your ability to collect reimbursement from the Member for these services. If the Member does not consent in writing to continue to receive such care and Optum upholds the determination regarding the cessation of coverage for such care, you cannot collect reimbursement from the Member pursuant the terms of your Agreement. Propriety and Confidential. Do not distribute. 20

21 Texas Fair Hearing Process 90 Day Deadline A provider may be a representative for a Member. A fair hearing must be requested within 90 days of the date on the health plan s letter that tells of the decision you are challenging. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. 10 Day Deadline for Service Continuation If you ask for a fair hearing within 10 days from the time you get the hearing notice from the health plan, you have the right to keep getting any service the health plan denied, at least until the final hearing decision is made. If you do not request a fair hearing within 10 days from the time you get the hearing notice, the service the health plan denied will be stopped UnitedHealthcare Community Plan Southwest Freeway, Suite 800 Sugar Land, TX Propriety and Confidential. Do not distribute. 21

22 Important Reminders Verify benefits prior to rendering any services and receive authorization as appropriate Members may not be balanced billed No co-pay, no out of pocket maximum, no deductible Out-of-network benefits are not available for STAR+PLUS Notify Optum within 10 calendar days whenever you make changes to your office location, billing address, phone number, Tax ID number, your entity name, close your business or retire *Copy and paste this text box to enter notations/source information. 7pt type. Aligned to bottom. No need to move or resize this box. Propriety and Confidential. Do not distribute. 22

23 Optum Resources for Providers and Members Algorithms for Effective Reporting and Treatment (ALERT) ALERT incorporates Member responses to the Wellness Assessment (WA) together with claims data to measure behavioral health symptom severity, functional impairment and self-efficacy. Clinical Care Advocates use letters and/or phone calls to inform Clinicians in the event that a Member is identified with any targeted risk factors. Campaign for Excellence (CFE) Our Clinician recognition program enhances the partnership between Optum and network clinicians by recognizing and rewarding Clinicians for excellence in clinical care. *Copy and paste this text box to enter notations/source information. 7pt type. Aligned to bottom. No need to move or resize this box. Propriety and Confidential. Do not distribute. 23

24 Claims Required Claim forms are a CMS Form 1500 or a UB-04 (hospitals) Online Claims: Submit and check on the status of electronic claims online at providerexpress.com Call Support Line Chat Live at (then Contact Us, then Tech) Paper Claims: Submit claims by paper, by mailing to the following address: Optum P.O. Box Salt Lake City, UT Customer Service is available for paper claim questions Title of presentation goes here Propriety and Confidential. Do not distribute. 24

25 Claim Tips Always file clean claims Ensure complete diagnosis is listed Code to the highest specificity Claims filing deadline 95 days from date of service Clean Claims Paid within 30 days of receipt Appeal Deadline 120 days from date of explanation of benefits Title of presentation goes here Propriety and Confidential. Do not distribute. 25

26 Joining Our Network Clinicians can access the application and contract on our website: providerexpress.com Follow the prompts and answer all questions Providers must have a TPI number and an NPI number Licensed Clinicians must have an active professional license For practices that do not meet malpractice limits, submit the application and exceptions may be considered Fax or mail the entire application and contract signature page to: Texas Network Management 2000 West Loop South Ste 900 Houston, TX Main Number: Fax Number: Facilities should call their network manager for an application and contract. Propriety and Confidential. Do not distribute. 26

27 Thank you.