Rehabilitative Behavioral Health Providers Frequently Asked Questions

Transcription

1 Rehabilitative Behavioral Health Providers Frequently Asked Questions Q. What has changed regarding rehabilitative behavioral health services? A. Effective July 1, 2016, South Carolina Department of Health and Human Services (SCDHHS) rehabilitative behavioral health services provided by the Department of Mental Health (DMH), private rehabilitative behavioral health providers (RBHS), school districts, and the Department of Juvenile Justice (DJJ) will become part of the managed care organization s (MCO) covered responsibilities. Q. Will some services still be covered by Medicaid fee-for-service? A. Yes. Medicaid fee-for-service will still cover the services listed below. Medicaid fee-forservice will cover these services even if the member is participating with an MCO. Developmental evaluation centers (DEC). Adolescent treatment facilities (ATF). Waiver programs. Q. Which providers will be affected by this change? County mental health centers (DMH). Private RBHS providers. School districts. DJJ. Q. What are the covered benefits and authorization requirements? A. For participating providers, the grid below indicates services that can be rendered for each provider type and whether prior authorization (PA) is required. PA Psychiatric diagnostic evaluation X X Psychiatric diagnostic evaluation with medical services X Individual therapy 30 minutes X X X X Psychotherapy, 30 minutes with patient when performed with an evaluation and management (E and M) service 30 minutes X X

2 90834 Individual therapy 45 minutes X X X X Psychotherapy, 45 minutes with patient when performed with an E and M service 45 minutes X X Individual therapy 60 minutes X X X X Psychotherapy, 60 minutes with patient when performed with an E and M service E and M office or outpatient (OP) service, established patient level 4 E and M office or OP service, established patient level 5 60 minutes X X Office consult, new or established Office consult, new or establishedexpanded E and M consult, office consult level Office consult, new or established, comprehensive history E and M consult, office consult level Prolonged provider service office or OP, one hour Service plan development team conference with member Service plan development team conference without member Smoking or tobacco cessation counseling, 3 10 min Alcohol or substance use screening, brief intervention, min X X X X 10 minutes X X 30 minutes X X G0431 Drug screen, qualitative, single class H0001 Alcohol or drug assessment follow-up Page 2 of 6

3 H0002 Behavioral health screening 15 minutes X X X X H0004 Screening, brief intervention, and referral to treatment behavioral health counseling and therapy H0005 Substance use counseling group Yes H0010 Subacute social detoxification (detox) Daily X Yes H0011 Alcohol or drug subacute detox, residential Daily X Yes H0015 Alcohol or drug intense outpatient 15 minutes X Yes H0018 Behavioral health short-term residential Daily X Yes H0019 Behavioral health long-term residential Daily X Yes H2035 Substance use partial hospitalization Hourly X H0031 Mental health assessment, non-physician X X H0032 Mental health service plan development, non-physician X X H0034 Medication management 15 minutes X X X Yes H0038 Peer support services 15 minutes X X H2000 Child and Adolescent Level of Care Utilization System (CALOCUS) X H2011 Crisis management 15 minutes X X X X Yes H2014 Behavior modification 15 minutes X X X X Yes H2017 Psychosocial rehabilitation (PSR or PRS) 15 minutes X X X X Yes H2030 Community integration service (CIS) 15 minutes X X Page 3 of 6

4 Yes H2037 Therapeutic child care (TCC) 15 minutes X X J0401 Injection, pripiprazole extended release, 1 mg J0515 Benztropine, up to 1 mg J1200 Diphenhydramine, up to 50 mg J1630 Haldol, up to 5 mg J1631 Haldol decanoate, up to 50 mg intramuscular J2060 Ativan, up to 4 mg J2315 Injection, nalextron, depot form, 1 mg J2330 Navane, 1 mg up to 4 mg J2426 Paliperidone palmitate extended release, 1 mg J2680 Prolixin decanoate fluphenazine, up to 25 mg J2794 Injection, risperidone, long acting, 0.5 mg J3230 Thorazine chlorpromazine, up to 50 mg J3360 Valium up to 5 mg J3410 Vistaril up to 25 mg J3486 Injection, ziprasidone mesylate, 10 mg J3490 Unclassified drug documentation Yes S9482 Family support 15 minutes X X X X Page 4 of 6

5 T1002 Registered nurse services up to 15 minutes 15 minutes X X X Q. What is the turnaround time for authorizations? A. For routine non-urgent levels of care: Please allow 14 calendar days for authorization decisions. For acute (emergent or urgent) levels of care (behavioral health inpatient [BH IP], substance use disorder [SUD] residential, and SUD detox only): We will make a determination within 24 hours of receiving all clinical information. Q. What do I need to submit when obtaining authorization to begin services or for additional services or extension of services? A. Department of Alcohol and Other Drug Abuse Services (DAODAS) providers: The process for authorization requests (initial and continued stay) remains the same; there are no changes to the forms or the process. DMH providers: Please use the DMH RBHS Prior Authorization Request Form for both initial and additional services and extension of services requests. Private RBHS providers: Please use the Private RBHS Prior Authorization Request Form for both initial and additional services and extension of services requests. School districts: Please use the RBHS Prior Authorization Request Form for both initial and additional services and extension of services requests. DJJ: Please use the DJJ RBHS Prior Authorization Request Form for both initial and additional services and extension of services requests. For additional services and extension of services: In addition to the request forms specified above, providers should submit the diagnostic assessment (DA), individual plan of care (IPOC), and any testing results (e.g., psychological testing or ageappropriate assessment tools). It is a good practice to submit as much clinical information as possible. For all out-of-network providers: Prior authorization is required for any and all services. Contact Select Health Utilization Management at for information on authorization requirements. Q. Do copays apply to these services? A., there are no copays or deductibles for persons receiving behavioral health care. Q. Where are claims submitted? A. Submit claims to: Select Health of South Carolina Claims Processing Department P.O. Box 7120 London, KY Page 5 of 6

6 Q. Can a provisionally licensed clinician provide services and bill under a full independently licensed clinician? A. Yes. A provisionally licensed clinician can provide the services, but the full independently licensed clinician will be responsible for signing off on all notes and submitting claims. Q. What is the policy for certification of medical necessity by completing the DA? A. An independently licensed local public health agency (LPHA) must complete the DA for private RBHS providers or, if the DA is completed by a licensed master social worker (LMSW; the only non-independently licensed LPHA), an independently licensed LPHA must cosign. Q. Are there any special requirements for submitting claims? A. Yes. RBHS providers are assigned specific taxonomy codes by SCDHHS and must include the taxonomy code on the claim. RBHS providers are also considered facilities in the Select Health system and must bill using the facility national provider identifier (NPI) number in box 24J on the Centers for Medicare & Medicaid Services (CMS) 1500 claim form and the appropriate taxonomy code. Q. Whom do I contact if I would like to request training? A. If you are interested in requesting targeted training for your office or facility, contact Erin Garian at egarian@selecthealthofsc.com. Q. Do I have to inform Select Health if my provider demographics change or if additional providers are added to my facility? If yes, what do I need to do? A. Yes. If your provider demographics change (e.g., address, phone number, or name of facility) or if additional providers are added to your facility, you must notify Select Health in writing on your practice letterhead. Please include a W-9. Submit this information to your Provider Network Management Account Representative or to Provider Network Operations via fax at or at networkopsprovider@selecthealthofsc.com. Q. Who is my Provider Network Management Account Representative? A. Your representative is Erin Garian. She may be reached by: egarian@selecthealthofsc.com. Phone: Page 6 of 6