Hawaii QUEST Integration (Medicaid)

Transcription

1 Hawaii QUEST Integration (Medicaid) ABA Provider Orientation Optum with UnitedHealthcare Community Plan of Hawaii

2 Today s Topics Agenda Optum Overview Member Information Provider Credentialing Criteria Provider Responsibilities Authorizations, Treatment Plans, Concurrent Reviews Coding, Billing and Reimbursement Resources Q & A 2

3 OPTUM Helping People Live Their Lives To The Fullest

4 Who is Optum? Optum is a collection of people, capabilities, competencies, technologies, perspectives and partners sharing the same simple goal: to make the health care system work better for everyone Optum works collaboratively across the health system to improve care delivery, quality and cost-effectiveness We focus on three key drivers of transformative change: engaging the consumer, aligning care delivery and modernizing the health system infrastructure 4

5 UnitedHealth Group Structure Helping make the health system work better for everyone Information and technologyenabled health services: Technology solutions Pharmacy solutions Intelligence and decision support tools Health management and interventions Administrative and financial services Helping people live healthier lives Health care coverage and benefits: Employer & Individual Medicare & Retirement Community & State Military & Veterans Global 5

6 Company Structure 6

7 Optum and You Our relationship with you is foundational to the recovery and well-being of the individuals and families we serve. We are driven by a compassion that we know you share. Together, we can set the standard for industry innovation and performance. Achieving our Mission: Starts with Providers Serves Members ~ Deb Adler, SVP Network Services Applies global solutions to support sustainable local health care needs From risk identification to integrated therapies, our mental health and substance abuse solutions help to ensure that people receive the right care at the right time from the right providers. 7

8 Specialty Network Services Customers we serve: 50% of the Fortune 100 and 34% of the Fortune 500 Largest provider of global Employee Assistance Programs (EAP), covering more than 19 million lives in over 140 countries Local, state and federal government contracts (Public Sector) Serving almost 43 million members: 1 in 6 insured Americans The largest network in the nation, delivering best in class density, discounts and quality segmentation More than 140,000 practitioners; 4,200 facilities with 9,000 facility locations Simultaneous NCQA and URAC accreditation Staff expertise: Multi-disciplinary team of 50 staff Medical Directors (e.g., child and adolescent, medical/psychiatric, Board Certified Behavior Analysts, and addiction specialists) just to name a few 8

9 Optum Autism/ABA Program Specialty Network Dedicated department responsible for building a network of autism specialty providers made up of Board Certified Behavior Analysts (BCBA) and licensed behavior clinicians with experience in intensive behavior therapies Extensive credentialing process/review of autism specialty providers that includes a site and medical record review Autism Corner on provider portal, Provider Express, offers network and clinical resource information for autism specialty providers. National network of over 1900 autism specialty provider locations Clinical Oversight Dedicated Autism Clinical Team consisting of masters and doctoral level, specialtytrained care advocates, led by a licensed Psychologists, who is also a BCBA Autism Clinical Team assists families with resources, education, care coordination and claims Clinical Technology Committee currently reviewing components of ABA to see which interventions are most successful National Institute of Mental Health Grant longitudinal study of Autism patient health data, including costs 9

10 Optum Autism/ABA Program (cont.) Operational Initiatives Autism coverage protocols and medical necessity guidelines in place Specialized team to assist members and facilitate authorizations and claims payment Kudos From Customers I wanted to send a letter out to all of our other clients encouraging them to switch to Optum when the open enrollments occur this fall as it has been such as great experience for us and the children are getting the services they so desperately need without a hassle. - Pat, Children Making Strides I wanted to let you know I attended the APBA s convention in Boston yesterday and people from all over the country attended. Everyone in the room had wonderful things to say about UBH! And I want to personally thank you, Debbie, for all the hard work and assistance. I could not have done it without you! Anne, Beacon 10

11 Hawaii QUEST Integration ABA Program Member Information 11

12 Who is eligible? To be eligible for ABA services, a client must meet both of the following criteria: Be younger than age 21 Be covered under Hawaii QUEST Integration Program AND: Have a documented Autism Spectrum Diagnosis, as defined by the most current version of the Diagnostic and Statistical Manual (DSM-5) 12

13 Member ID Card ID card is sent directly to the member The member s ID number is their Medicaid number All relevant contact information is on the back of the card for both medical and behavioral customer service Please note this image is for illustrative purposes only. 13

14 Member Rights and Responsibilities Members have the right to be treated with respect and recognition of his or her dignity, the right to personal privacy, and the right to receive care that is considerate and respectful of his or her personal values and belief system Members have the right to disability related access per the Americans with Disabilities Act A complete copy of Member Rights and Responsibilities is available in the Community Plan of Hawaii Provider Administrative Guide These can also be found on the website: providerexpress.com These rights and responsibilities are in keeping with industry standards. All members benefit from reviewing these standards in the treatment setting We request that you display the Rights and Responsibilities in your waiting room, or have some other means of documenting that these standards have been communicated to the members 14

15 Credentialing Criteria for Inclusion in the Hawaii QUEST Integration ABA Network 15

16 QUEST Integration Autism Provider Credentialing Criteria Individual Board Certified Behavior Analysts Solo Practitioner Board Certified Behavior Analyst (BCBA) with active certification from the national Behavior Analyst Certification Board, and State licensure Minimum of 6 months supervised experience or training in the treatment of applied behavior analysis/intensive behavior therapies Minimum professional liability coverage of $1 million per occurrence/ $1 million aggregate BCBAs must meet standards above ABA / IBT Groups Licensed behavioral health clinicians must have appropriate state licensure and state required training and experience BCBA or licensed behavioral health clinician on staff providing program oversight BCBA or licensed behavioral health clinician performs skills assessments and provides direct supervision of Behavioral Technicians in joint sessions with client and family Behavioral Technicians meet state requirements and receive appropriate training and supervision by BCBAs or licensed clinician $1 million per occurrence/$3 million aggregate of professional liability and $1m/$1m of general liability if services are provided in a clinic setting $1 million per occurrence/$3 million aggregate of professional liability and $1m/$1m of supplemental insurance if the agency provides ambulatory services only (in the patient s home) Successful completion of medical record and site audit, as applicable 16

17 Required: NPI, EIN/TIN, Liability Insurance National Provider Identifier (NPI) Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information We require that all claims submitted have an NPI number for reimbursement To obtain an NPI number, follow the instructions on the NPI web site Tax Identification Number (TIN), Employee Identification Number (EIN), or Social Security Number (SSN) information Professional Liability Insurance web site has coverage information; enter liability in the site s Search feature located in the left side of the menu 17

18 Provider Responsibility 18

19 Intake At Intake Copy front and back of the member s insurance card Record subscriber s name and date of birth Additional information to obtain from the member Consent for services Informed Consent: services, to leave voic , , etc. Release of Information to communicate with other providers Consent for billing using protected health information, including signature on file Information to provide to the member or subscriber Your HIPAA policies Your billing policies and procedures 19

20 Eligibility and Prior Approval Call the number on the back of the ID card to see if member is eligible for your services Check benefit coverage relating to both the service (e.g., is ABA-based therapy covered?) and the diagnosis (e.g., is autism covered?) Make sure services receive prior approval before beginning services, if needed (not all ABA services require prior approval for HI QUEST Integration ABA program) 20

21 Optum Authorizations, Treatment Plans, Concurrent Reviews 21

22 Clinical Team: Hawaii QUEST Integration ABA Enhanced Autism/ABA Clinical Team There is a dedicated, enhanced autism/aba clinical team that will be supporting the HI QUEST Integration ABA program Each team member is a licensed behavioral health clinician with experience in Autism and training in ABA Supervised by managers who are licensed psychologists and BCBA-Ds 22

23 Treatment Plan Requirements Fax #: Meet Medical Necessity this applies to initial and concurrent reviews Concurrent reviews - Due at least 10 days prior to the end of the authorization period but no more than 30 days in advance; should include how progress was assessed - this can include ABLLS-R or VBMAPP If the member is undergoing 26 week trial period of ABA, rendering provider will update and submit individual specific treatment plan at a minimum of 12 weeks (after the start of the approved ABA) Provider must submit the evaluation from the diagnosing provider and the treatment plan Find link for Treatment Request Form and Guidelines For ABA Services HI Medicaid in Resources section 23

24 Clinical Information Requirements for Each Review Confirmation member has an ASD diagnosis Must meet medical necessity Any medical or other mental health diagnoses Any other mental health or medical service member is enrolled in Any medications member is taking How many hours per week member is in school? Why ABA now? How long has member been in services? Goals must not be educational or academic in nature They must focus only on the core deficits of autism such as; imitation, social skills deficits and behavioral difficulties Discharge criteria (see next page for full criteria) Parent participation 24

25 Clinical Information Requirements for Each Review Discharge criteria More Information Anticipated date of discharge Objective, measurable goals that would need to be met for the child to discharged What the next level of care is for this child, e.g., school based services only, outpatient therapy (include contact info if appropriate) Resources in the community for the parents and member How discharge is coordinated with the school and other providers Member and/or parent agreement with plan How to resume services if needed Please see the Treatment Guidelines on the Autism/ABA page of Provider Express See Provider Express for the Level of Care Guidelines and Coverage Determination Guidelines for medical necessity criteria For concurrent requests, call in no more than 30 days in advance of the current approvals expiring 25

26 Re-evaluation & Prior Authorization Requirements Prior authorization not required for diagnostic evaluation (but referral may be required from the PCP) To avoid breaks in treatment, rendering provider shall submit a request for PA at least 2 weeks prior to the end of the approved treatment period If the diagnosing provider suspects ASD and requires further evaluation before making a definitive diagnosis, the patient may qualify for up to a 26-week trial of ABA. This trial period may be approved for an extension, or additional trial periods may be approved. Diagnoses that qualify for a trial of ABA include, but are not limited to: 1. Global Developmental Delay (F88) 2. Social (Pragmatic) Communication Disorder (F80.89) 3. Language Disorder (F80.9) 4. Unspecified Communication Disorder (F80.9) 5. Expressive Language Disorder (F80.1) 6. Receptive Language Disorder (F80.2) 26

27 Coding, Billing and Reimbursement 27

28 Diagnostic Coding Two Guides for Coding DSM-5 (Diagnostic and Statistical Manual, 5 th edition) ICD-10 (for dates of service beginning 10/1/2015) ASD Coverage ICD-10, F84.0 (effective 10/2015) 28

29 Claims Submission Submit claims through secure Transactions on providerexpress.com Electronic claim submission through Electronic Data Interchange (EDI) Electronic Claims Payer ID: Ingenix EDI Solutions via phone at , or and include: Your name, phone number & address Tax ID number(s) Entity name and contact information (phone and ) Approximate number of Optum claims you submit per month Whether your interest is in a single or multi-payer solution Paper Claims Requires CMS-1500 claim form (HCFA form) Mail to: UBH PO Box Salt Lake City, UT Claims Customer Service # :

30 Claim Tips To facilitate timely claims processing, please remember: The provider s NPI is required on all claims A complete diagnosis code is required on all claims (F84.0) Fully complete the online claim or claim form, including member ID or SSN Billing address on claim must match the address in our system Supervising provider must be on all claims as rendering provider Claims filing deadlines Claims must be submitted no more than 365 days from the date(s) of service Any correction requests must be submitted within 120 days on providerexpress.com (if claim was originally submitted on Provider Express) or on a paper claim via mail with CORRECTED CLAIM noted Claims and claim adjustments are generally adjudicated within 30 days of receipt of all required information Member cannot be balance-billed for behavioral services covered under the terms of the contractual agreement 30

31 CMS-1500 Claim Form All billable services must be coded. Coding is dependent on several factors: Type of service (assessment, treatment, etc.) Use appropriate modifier for specific provider type (ex. HP, HO, HN, HM) Rate per unit (BCBA vs. RBT) Place of service (home or clinic) Duration of therapy (1 hr vs. 15 min) One DOS per line CMS-1500 Claim Form formerly called HCFA You must select the code that most closely describes the service(s) provided. Please note: Field 31 must have a rendering provider name. Rendering supervisor (BCBA/Licensed Clinician) will bill for all services by them or the Registered Behavioral Technician under the supervisory protocol. 31

32 HI Medicaid Fee Schedule UNITED BEHAVIORAL HEALTH (OHBS) 2015 CPT Code Version Effective 01/01/2016 FS Name: HI ABA Medicaid Fee Schedule Billing Code Modifier Service Description Provider Unit/ Rate: Prior Auth Required (PA) 0359T HP HO Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s) /caregiver(s), and preparation of report BCBA-D BCBA 1 session = $ No Auth 0360T HP Observational behavioral follow-up assessment, includes physician BCBA-D or other qualified health care professional direction with interpretation 1 session = $62.50 HO and report, administered by one technician; first 30 minutes of BCBA technician time, face-to-face with the patient HN BCaBA 1 unit = 30 min = $37.50 No Auth 0361T 0362T 0363T HP Each addtional 30 minutes of technician time, face-to-face with the BCBA-D 1 unit = 30 min = $62.50 No Auth HO patient (List separately in addition to code for primary service) (Use BCBA 0361T in conjunction with 0360T) HN BCaBA 1 unit = 30 min = $37.50 No Auth HP Exposure behavioral follow-up assessment, includes physician or BCBA-D 1 unit = 30 min other qualified health care professional direction with interpretation HO BCBA MQD FFS rate = $62.50 and report, administered by physician or other qualified health care No Auth professional with the assistance of one or more technicians; first 30 HN minutes of technician(s) time, face-to-face with the patient BCaBA 1 unit = 30 min = $37.50 No Auth HP Each additional 30 minutes of BCBA-D HO technician(s) time, face-to-face with the patient (List separately in BCBA 1 unit = 30 min = $62.50 No Auth addition to code for primary procedure) (Use 0363T in conjunction HN with 0362T) BCaBA 1 unit = 30 min = $37.50 No Auth Adaptive Behavior Treatment 0364T HP HO Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of BCBA-D, BCBA time BCBA-D BCBA 1 unit = 30 min = $62.50 Prior Auth Required (PA) 0364T HN HM Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time BCaBAs RBT (Technician) 1 unit = 30 min = $25.00 Prior Auth Required (PA) 32

33 HI Medicaid Fee Schedule (cont.) UNITED BEHAVIORAL HEALTH (OHBS) 2015 CPT Code Version Effective 01/01/2016 FS Name: HI ABA Medicaid Fee Schedule Billing Code Modifier Service Description Prov. Unit/Rate: Prior Auth Required (PA) 0364T HP HO Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of BCBA-D, BCBA time BCBA-D BCBA 1 unit = 30 min = $62.50 Prior Auth Required (PA) 0364T HN HM Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time BCaBAs RBT (Technician) 1 unit = 30 min = $25.00 Prior Auth Required (PA) 0365T HP HO Each additional 30 minutes of technician time (List separately in addition to code for primary procedure) (Use 0365T in conjunction with 0364T) BCBA-D BCBA 1 unit = 30 min = $62.50 Prior Auth Required (PA) 0365T HN HM Each additional 30 minutes of technician time (List separately in addition to code for primary procedure) (Use 0365T in conjunction with 0364T) BCaBAs RBT (Technician) 1 unit = 30 min = $25.00 Prior Auth Required (PA) 0366T 0367T 0368T 0369T UN UP UQ UR US UN UP UQ UR US Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time, modifier designates group size Each additional 30 minutes of technician time (List separately in addition to code for primary procedure) (Use 0367T in conjunction with 0366T), modifier designates group size BCBA-D BCBA BCaBAs RBT (Technician) BCBA-D BCBA BCaBAs RBT (Technician) 1 unit = 30 min 2 patients/ less: $25/pt. 3 patients: $23/pt. 4 patients: $21/pt. 5 patients: $19/pt. 6 to 8 patients: $17/pt. HP Adaptive behavior treatment with protocol modification administered BCBA-D by physician or 1 unit = 30 min = $62.50 HO BCBA other qualified health care professional with one patient; first 30 HN minutes of patient face- to-face time BCaBA 1 unit = 30 min = $37.50 Prior Auth Required (PA) Prior Auth Required (PA) HP BCBA-D HO Each additional 30 minutes of patient face-to-face time (List 1 unit = 30 min = $62.50 Prior Auth Required (PA) BCBA separately in addition to code for primary procedure) HN (Use 0369T in conjunction with 0368T) BCaBA 1 unit = 30 min = $37.50 Prior Auth Required (PA) 33

34 HI Medicaid Fee Schedule (cont.) UNITED BEHAVIORAL HEALTH (OHBS) 2015 CPT Code Version Effective 01/01/2016 FS Name: HI ABA Medicaid Fee Schedule Billing Code Modifier Service Description Prov. Unit/Rate: Prior Auth Required (PA) 0370T HP HO HN Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) BCBA-D BCBA BCaBA 1 session = 45 min (minimum) =$ session = 45 min (minimum) =$75.00 Prior Auth Required (PA) 1 session = 45 min (minimum) 0371T UN UP UQ UR US Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) BCBA or BCBA-D BCaBA 2 families: $93.75/family 3 families: $88.75/family 4 families: $83.75/family 5 families: $78.75/family 6 families: $73.75/family Prior Auth Required (PA) 1 session = 45 min (minimum) 0372T UN UP UQ UR US Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients BCBA or BCBA-D BCaBA 2 patients: $93.75/pt. 3 patients: $88.75/pt. 4 patients: $83.75/pt. 5 patients: $78.75/pt. 6 to 8 patients: $73.75/pt. Prior Auth Required (PA) 0373T 0374T HP BCBA-D HO Exposure adaptive behavior treatment with protocol modification BCBA 1 unit = 60 min = $ HN requiring two or more technicians for severe maladaptive behavior(s); BCaBA 1 unit = 60 min = $75.00 HM first 60 minutes of technicians time, face-to-face with patient RBT (Technician) 1 unit = 60 min = $50.00 HP BCBA-D Each additional 30 minutes of technicians' time face-to-face with 1 unit = 30 min = $62.50 HO BCBA patient (List separately in addition to code for primary procedure) HN BCaBA 1 unit = 30 min = $37.50 (Use 0374T in conjunction with 0373T) HM RBT (Technician) 1 unit = 30 min = $25.00 Prior Auth Required (PA) 34

35 HI Medicaid Fee Schedule (cont.) UNITED BEHAVIORAL HEALTH (OHBS) 2015 CPT Code Version Effective 01/01/2016 FS Name: HI ABA Medicaid Fee Schedule 1) Units: The Reimbursement Rate made to Provider for each unit of service provided to a Member as defined by the definition of the Billing Code. Such payment shall be considered payment in full for all MH Services provided to the Member, included but not limited to nursing care, diagnostic and therapeutic services, and supplies. Such payment is exclusive of physician fees. If physician services are rendered, such services are included in the rate of reimbursement. 2) The MH Services authorized by UBH and provided to a Member on an outpatient basis of the diagnosis, testing, and/or treatment of a mental health condition, other than Emergency MH Services or as part of a partial hospitalization or day treatment program, Provider shall be paid by Payor the lesser of (a) Provider's Customary Charge for such MH Services, less any applicable Member Expenses; or (b) the Method of Payment set forth above, less any applicable Member Expense(s). 3) Proper billing: Proper billing form: CMS ) Modifiers: EP Services provided as part of Medicaid early periodic screening diagnosis and treatment (EPSDT) program HP-Doctoral level HO-Master s degree level HN-Bachelor s degree level HM-Less than bachelor degree level UN-Two patients or families served UP-Three patients or families served UQ-Four patients or families served UR-Five patients or families served 5) Modifiers for use when physician or other qualified health professional performs Assessment/Reassessment and Adaptive Behavior Treatment: AF =Specialty Physician, AH =Clinical Psychologist, TD = Advanced Practice Registered Nurse (APRN), AJ = Clinical Social Worker 35

36 Resources 36

37 Autism ABA Network by Practice/Group (updated 12/19/17) NH WA OR CA AK NV ID UT AZ MT WY CO NM ND SD NE KS OK TX MN IA MO AR LA WI IL MS IN TN AL MI OH KY GA WV SC NC PA VA VT ME NY MA RI NJ CT DE MD D.C. HI FL PR VI Carol Cremers Joslyn Gibbs Darlene Fitzpatrick Debbie Sills Jeanna Gonzales Chris Reinsberg Betty Rubin Courtney Banks-Turner 37

38 Provider Express On Optum s provider web site, providerexpress.com, you can find a wide variety of information and functions to enhance your interactions with us Level of Care, Best Practice and Coverage Determination Guidelines Optum Network Manual Contact Information Common Forms Eligibility and Benefits Claim Submission Claims Status 38

39 First-time Users Register for your Optum ID online for immediate access to secure Transactions No fees apply Provider Express Support Center available from 7 am to 9 pm Central time toll free at Live chat feature also available under Contact Us > Website Support 39

40 Hawaii Quest ABA Program Page Hawaii Quest ABA Program providers have their own page on providerexpress.com Materials on this page include: Hawaii Quest ABA Provider Quick Reference Guide Hawaii Quest ABA Treatment Plan/Authorization Request Form 40

41 Helpful Links Hawaii Med-QUEST Division (MQD) revised memorandum memos/qi-memos/qi-memos-2015/qi-1515_ffs-1510-coverage-of-ibt-for- Treatment-of-Children-with-ASD-Eff-Aug-2015.pdf Act 199 (Hawaii ABA Licensing Law) Dept. of Human Services Medicaid Eligibility Website To learn more about HIPAA 41

42 Q&A 42

43 BH515 3/1/16 43