October 5 th & 6th, The Managed Care Technical Assistance Center of New York

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1 October 5 th & 6th, 2015 The Managed Care Technical Assistance Center of New York

2 What is MCTAC? MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC s Goal Provide training and intensive support on quality improvement strategies including business, organizational and clinical practices, to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care.

3 Who is MCTAC?

4 MCTAC Partners

5 Overall guidelines Access to services Care Coordination/Notification Outlier Management

6 Inpatient psychiatric services in Article 28 facilities Part 599 clinic services Behavioral health services in Part 598 integrated clinics Personalized Recovery Oriented Services (PROS) programs operated under Part 512 Continuing Day Treatment (CDT) programs operated under Part 587 Intensive Psychiatric Rehabilitation Treatment (IPRT) programs operated under Part 587 Assertive Community Treatment (ACT) programs operated under Part 508 Partial Hospitalization (PH) programs operated under Part 587 Inpatient Psychiatric Hospitalization Services operated under Parts 580 or 582 Comprehensive Psychiatric Emergency Programs (CPEPs) operated under Part 590 Crisis Intervention Behavioral Health Home and Community Based Services (BHHCBS): available to eligible Health and Recovery Plan (HARP) and HARP-eligible HIV Special Needs Plan (SNP) enrollees only

7 OASAS Clinic OASAS Opioid Treatment Program OASAS Outpatient Rehab

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10 Definition: A course of ambulatory behavioral health treatment, other than ambulatory detoxification and withdrawal services, which began prior to the Effective Date of the Behavioral Health Benefit Inclusion in each geographic service area in which services had been provided at least twice during the six months preceding the Behavioral Health Benefit Inclusion Date by the same provider to an Enrollee for the treatment of the same or related a behavioral health condition.

11 90 day transition language prohibits plans from applying utilization review criteria for a period of 90 days from the effective date of the Behavioral Health benefit inclusion in either NYC or the rest of state, respectively. Accordingly, plans must accept existing plans of care. 2 year continuity of care language affirms plans must permit enrollees to continue receiving services from their current provider(s) for Continuous Behavioral Health Episodes of Care (as defined in the Model Contract) for up to 24 months from the date of the Behavioral Health benefit inclusion in either NYC or the rest of state, respectively. Notwithstanding, plans may use OMHapproved UR criteria to review duration and intensity of such episodes of care.

12 Utilization Management: This guidance regards utilization management for ambulatory behavioral health (BH) services that will be effective when the MCOs, including MMCPs, HARPs, and HIV SNPs assume management of these services in the adult Medicaid Managed Care Program. These services include routine outpatient office and clinic care as well as the full range of BH specialty services. MCOs will not use prior authorization for Medicaid BH outpatient office and clinic services as of the implementation of the behavioral health carve-in. MCO responses to the RFQ indicated the intent to minimize use of prior authorization for routine BH outpatient office and clinic services as it has proven an inefficient form of utilization management. In addition, parity requirements prohibit the imposition of non-quantitative treatment limits or benefit exclusions based on medical necessity or medical appropriateness when there are no such limits for similar medical/surgical services.

13 Prior Authorization Request is a Service Authorization Request by the enrollee, or a provider on the enrollee s behalf, for coverage of a new service, whether for a new authorization period or within an existing authorization period, made before such service is provided to the enrollee. Concurrent Review Request is a Service Authorization Request by an enrollee, or a provider on Enrollee s behalf for continued, extended or additional authorized services beyond what is currently authorized by the Contractor within an existing authorization period.

14 OASAS will not allow Plan routine requests for outpatient approvals for admission or continuing stay. Clinic includes Intensive Outpatient Service all admissions to IOS should be reported to the plan. Most programs will use the LOCADTR report to notify.

15 Programs are required to complete a LOCADTR for all admissions within 3 visits. Plans may not require calls, reports or other routine requests for authorization for clinic admission. Programs may be reviewed by plans for clinic admission standards if practices trigger an approved admission review target. An example of this may be that the plan determines anomalies in admissions related to diagnosis. This type of review will occur on a program level.

16 Plans are not allowed to request routine treatment reviews for continued stay. Plans may request additional clinical information for individual or program level that meet an approved review clinic. Examples of this may include an intensity, frequency or duration of treatment that is inconsistent with a diagnosis or a pattern of care that indicates that all members receive the same number and duration of service.

17 There is no routine concurrent review for the purpose of determining discharge. Patients should be discharged when treatment goals are met. 822 regulations allow for ongoing aftercare services for medication management and check-ins for individuals are not in active treatment. Plans may request clinical information for program level clinical review triggers for anomalies in discharge practices. An example of this may be outlier lengths of stay.

18 See OASAS guidance regarding use of LOCATDR tool to inform level of care determinations. OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; visits per year are within an average expected frequency for OASAS clinic visits. The contractor will allow enrollees to make unlimited self referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee s primary care provider. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

19 Plan Prior Authorization Concurrent Review Empire Blue Cross Blue Shield HealthPlus No No Fidelis No No Healthfirst No No UnitedHealthcare No Yes, outlier management Wellcare No Yes Affinity (Beacon) No No Metro Plus (Beacon) No No VNS Select (Beacon) No No Emblem (Beacon) No No Amida Care (Beacon) No No

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21 OASAS will not allow Plan routine requests for outpatient approvals for admission or continuing stay. Clinic includes Intensive Outpatient Service all admissions to IOS should be reported to the plan. Most programs will use the LOCADTR report to notify.

22 Programs are required to complete a LOCADTR for all admissions within 3 visits. Plans may not require calls, reports or other routine requests for authorization for clinic admission. Programs may be reviewed by plans for clinic admission standards if practices trigger an approved admission review target. An example of this may be that the plan determines anomalies in admissions related to diagnosis. This type of review will occur on a program level.

23 Plans are not allowed to request routine treatment reviews for continued stay. Plans may request additional clinical information for individual or program level that meet an approved review clinic. Examples of this may include admissions for other than opioid dependence.

24 Plans are not allowed to request routine treatment reviews for continued stay. Plans may request additional clinical information for individual or program level that meet an approved review clinic. Examples of this may include individual or program level pick-up schedules that are outliers or inconsistent with patient functioning.

25 There is no routine concurrent review for the purpose of determining discharge. Patients should be discharged when treatment goals are met. 822 regulations allow for ongoing aftercare services for medication management and check-ins for individuals are not in active treatment. Plans may request clinical information for program level clinical review triggers for anomalies in discharge practices. An example of this may be outlier lengths of stay.

26 OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; visits per year are within an average expected frequency for opioid treatment clinic visits. The contractor will allow enrollees to make unlimited selfreferrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee s primary care provider. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law. No to Prior Authorization and Yes to Concurrent Review

27 Plan Prior Authorization Concurrent Review Empire Blue Cross Blue Shield HealthPlus No No Fidelis No Yes Healthfirst No No UnitedHealthcare No Yes, Concurrent review due on last covered day. Review every 6 months. Wellcare No Yes Affinity (Beacon) No No Metro Plus (Beacon) No No VNS Select (Beacon) No No Emblem (Beacon) No No Amida Care (Beacon) No No

28 OASAS will not allow for prior authorization for outpatient rehabilitation. Programs must complete a LOCADTR at admission. Programs must inform the plan of an admission to this level of care, most programs will send the LOCADTR report programs should talk with plans about their process and expectations.

29 Programs are required to complete a LOCADTR for all admissions within 3 visits. Plans may not require calls, or other routine requests for authorization for clinic admission. Programs may be reviewed by plans for rehab admission standards if practices trigger an approved admission review target. An example of this may be that the plan determines anomalies in admissions related to diagnosis or severity.

30 Plans are not allowed to request routine treatment reviews for continued stay. Plans may request additional clinical information for individual or program level that meet an approved review clinic. Examples of this may include duration of treatment that is uniform for all patients indicating care that is not individualized.

31 There is no routine concurrent review for the purpose of determining discharge. Patients should be discharged when treatment goals are met. Programs should utilize LOCADTR to determine appropriate step-down following discharge. Plans may require a report for discharge from this level of care.

32 Plans may require notification through a completed LOCADTR report for admissions to this service within a reasonable time frame. The contractor will allow enrollees to make unlimited self-referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee s primary care provider. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law. No to Prior Authorization and Yes to Concurrent Review

33 Plan Prior Authorization Concurrent Review Empire Blue Cross Blue Shield HealthPlus No Yes Fidelis No Yes Healthfirst No No UnitedHealthcare No Yes, Concurrent review due on last covered day of 3 months. Wellcare No Yes Affinity (Beacon) No No Metro Plus (Beacon) No No VNS Select (Beacon) No No Emblem (Beacon) No No Amida Care (Beacon) No No

34 Plans may utilize outlier management on an individual participant or program level. Plans must get OASAS approval for outlier management triggers. Examples include diagnosis and frequency are incongruent, program has same pattern of care for all individuals in program, opioid treatment with no MAT.

35 Service OASAS-certified Part 822 clinic services, including off-site clinic services Prior Auth Concurrant Review Authorization State: Additional Guidance No Yes See OASAS guidance regarding use of LOCATDR tool to inform level of care determinations. OASAS encourages plans to identify individual or program but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; visits per year are within an average expected frequency for OASAS clinic visits. The contractor will allow enrollees to make unlimited self referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee s primary care provider. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law. Medically supervised outpatient substance withdrawal No Yes Plans may require notification through a completed LOCADTR report for admissions to this service within a reasonable time frame.

36 Service Prior Auth Concurrant Review Authorization State: Additional Guidance OASAS Certified Part 822 Opioid Treatment Program (OTP) services No Yes OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; visits per year are within an average expected frequency for opioid treatment clinic visits. The contractor will allow enrollees to make unlimited self-referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee s primary care provider. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law. OASAS Certified Part 822 Outpatient Rehabilitation No Yes Plans may require notification through a completed LOCADTR report for admissions to this service within a reasonable time frame. The contractor will allow enrollees to make unlimited selfreferrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee s primary care provider. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

37 Plan Notification Prior Authorization Concurrent Review Appeals Process Grievances Empire Blue Cross Blue Shield HealthPlus or for or for non acute levels of non acute levels of care care (PROS, ACT, CDT, (PROS, ACT, CDT, IPRT, IPRT, OP Rehab) fax to OP Rehab) fax to or for non acute levels of care (PROS, ACT, CDT, IPRT, OP Rehab) fax to Expedited appeal ; or (member appeals) Member complaints or Provider Complaints (standard appeals) Fidelis FIDELIS and follow the appropriate prompts FIDELIS and follow the appropriate prompts FIDELIS and follow the appropriate prompts FIDELIS and follow the appropriate prompts FIDELIS and follow the appropriate prompts Healthfirst Mainstream Medicaid: HARP: Same as Appeals #'s UnitedHealthcare Provider portal: unitedhealthcareonlin e.com Call Center for UnitedHealthcare: Fax# Provider portal: unitedhealthcareonline.c om Call Center for UnitedHealthcare: Fax# Provider portal: unitedhealthcareonline.c om Call Center for UnitedHealthcare: Fax# UnitedHealthcare Community Plan Appeals P.O. Box Salt Lake City, UT UnitedHealthcare Community Plan Grievances P.O. Box Salt Lake City, UT Wellcare Customer/Provider Support line Customer/Provider Support line Customer/Provider Support line Customer/Provider Support line Customer/Provider Support line

38 Plan Notification Prior Authorization Concurrent Review Appeals Process Grievances Affinity (Beacon) Metro Plus (Beacon) VNS Select (Beacon) Emblem (Beacon) Amida Care (Beacon)

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41 Managed Care Mailbox Form NOTE DO NOT include any patient identifying information on this form, elsewhere in your , in the subject line or any attachments. Thank you.

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44 Updating Your Registration Information 1. Log on to our CTAC/MCTAC Registration Site: MentalHealthNYS.Org using your registered and password. 2. Select the Update Demographics Link

45 Updating Your Registration Information 3. Update your demographics including your role, region, agency and program. When you are done, make sure to hit Save at the bottom of page! Have questions? Need help? us at for assistance.

46 The Managed Care Technical Assistance Center of New York

47 Coordinated Specialty Care (CSC) Services (OnTrackNY) Identification of FEP Network staff identifies client presenting with FEP in any service setting or through client s direct outreach to network plan Checks network to determine nearby programs meeting OMH CSC criteria and facilitates referral Networks must include providers of specialized FEP programs Per 2015 OMH guidance, members with first episode psychosis (FEP) should preferentially be referred to teams such as OnTrackNY For more information about OnTrackNY: Webinar on FEP and referral to OnTrackNY to follow

48 Intensive Utilization Management Learning Community Effective Clinical Practices to Support Utilization Management (UM) Starts November 3 rd 6 webinars plus 3 Applied Learning Discussions Intended audience The applied nature of the content is intended to support providers and their immediate supervisors Examples discussed will be most applicable to providers working with adults in PROS, ACT, and SUD settings Topics Case conceptualization: Informing the care pathway and setting the foundation for successful UM review Tracking adherence to the treatment plan by adding measurable outcomes How a clinical supervisor can be successful in a world with Utilization Management Tracking and documentation to support successful communication with the MCO s UM staff Client education in the world of MCO UM: Explaining what can be accomplished with a set number of visits Family Engagement as a tool to support improved client outcomes Visit MCTAC.org for more information

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