Medi-Cal Managed Care CBAS Program Transition
|
|
- Betty Washington
- 5 years ago
- Views:
Transcription
1 Medi-Cal Managed Care CBAS Program Transition Presented to: The Sacramento Medi-Cal Managed Care Stakeholder s Advisory Committee By: the Sacramento GMC Plans Revised 01/25/13 1
2 Outline What is CBAS? Who is Eligible for CBAS Services? What is Available for those Who Aren t Eligible for CBAS? How are Beneficiaries Enrolled in CBAS? CBAS Participant Protections Preparation by the Health Plans The First Month Numbers Challenges The Months Ahead Opportunities 2
3 What is CBAS?- Basic Benefits The following services will be provided to all eligible CBAS beneficiaries: Nutrition service one balanced, safe, and appetizing meal that meets the nutritional needs of the individual including beverage and/or other hydration. Special meals will be provided by the CBAS Center when required by the enrollee s physician. Professional nursing care, including RN and LVN services. Professional nursing will be organized, appropriately staffed, and equipped to provide skilled nursing care to CBAS Beneficiaries receiving CBAS services. Therapeutic activities aimed at enhancement of the social, physical, or cognitive functioning of the CBAS Beneficiary. Facilitated participation in group or individual activities for CBAS Beneficiaries whose physical frailty or cognitive function precludes them from independent participation in activities. Social services provided by a social worker to facilitate and assist the CBAS Beneficiary and his/her family and/or caregivers in providing necessary home care and to cope with issues related to aging and disability. Personal care services provided primarily by program aides to assist the CBAS Beneficiary with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). Source: Transition/California STCs ( ).pdf 3
4 What is CBAS? Community-Based Adult Services (CBAS) Community Based Adult Services is an outpatient, facilitybased program that delivers skilled nursing care, social services, therapies, personal care, family/caregiver training and support, nutrition services, and transportation to certain State Plan beneficiaries. Source: Transition/California STCs ( ).pdf 4
5 What is CBAS?- Additional Benefits The following additional benefits will be provided to all eligible CBAS beneficiaries when specified on the person s IPC: Physical therapy provided by a licensed, certified, or recognized physical therapist within his/her scope of practice. Occupational therapy provided by a licensed, certified, or recognized occupational therapist within his/her scope of practice. Speech therapy provided by a licensed, certified, or recognized speech therapist within his/her scope of practice. Behavioral health services for treatment or stabilization of a diagnosed mental disorder provided by licensed, certified, or recognized mental health specialist under scope of practice statutes. Individuals experiencing symptoms that are particularly severe or whose symptoms result in marked impairment in social functioning will be referred by CBAS staff to County Mental Health programs, or psychiatrists or psychologists, other mental health specialists, or emergency mental health services. Registered dietician services provided by a registered dietician for the purpose of assisting the CBAS Beneficiary and/or family caregivers in assuring proper nutrition and good nutritional habits in the CBAS center and in the recipient s home. Transportation to and from the CBAS Beneficiary s place of residence and the CBAS center through its transportation, or via a transportation service in vehicles accessible to the CBAS Beneficiary that are properly licensed and maintained pursuant to applicable laws. Drivers will be appropriately licensed and maintain a good driving record which will be verified by the CBAS administrative staff at least annually. Source: Transition/California STCs ( ).pdf 5
6 Who is Eligible for CBAS Services? Individuals who: Are age 18 years and older; Derive their Medicaid eligibility from the State Plan and are either aged, blind, or disabled; including those who are recipients of Medicare. 6
7 What is the Enrollment Criteria for CBAS Services? The CBAS benefit will be available to all CBAS beneficiaries who qualify based on the following medical criteria and comply with the requirement to enroll in managed care for CBAS services: Meet medical necessity criteria as established by the State; Meet Nursing Facility Level of Care (NF-A) criteria as set forth in the California Code of Regulations, or above NF-A Level of Care; or Have a moderate to severe cognitive disorder such as Dementia, including Dementia characterized by the descriptors of, or equivalent to, Stages 5, 6, or 7 of the Alzheimer s Type; or Have a mild cognitive disorder such as Dementia, including Dementia of the Alzheimer s Type, AND needs assistance or supervision with two of the following: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management, or hygiene, or; Have a developmental disability. Developmental disability means a disability which originates before the individual attains age 18, continues, or can be expected to continue, indefinitely, and constitutes a substantial disability for that individual as defined in the California Code of Regulations, or; Have a chronic mental disorder or acquired, organic, or traumatic brain injury. Chronic mental disorder means the enrollee shall have one or more of the following diagnoses or Source: Transition/California STCs ( ).pdf 7
8 What is the Enrollment Criteria for Cont. CBAS Services? Cont. Have a developmental disability. Developmental disability means a disability which originates before the individual attains age 18, continues, or can be expected to continue, indefinitely, and constitutes a substantial disability for that individual as defined in the California Code of Regulations, or; Have a chronic mental disorder or acquired, organic, or traumatic brain injury. Chronic mental disorder means the enrollee shall have one or more of the following diagnoses or its successor diagnoses included in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association: (a) Pervasive Developmental Disorders, (b) Attention Deficit and Disruptive Behavior Disorders, (c) Feeding & Eating Disorder of Infancy, Childhood, or Adolescence (d) Elimination Disorders, (f) Schizophrenia and Other Psychiatric Disorders, (g) Mood Disorders, (h) Anxiety Disorders, (i) Somatoform Disorders, (j) Factitious Disorders, (k) Dissociative Disorders, (l) Paraphilias, (m) Gender Identity Disorders, (n) Eating Disorders, (o) Impulse Control Disorders Not Elsewhere Classified (p) Adjustment Disorders, (q) Personality Disorders, or (r) Medication-Induced Movement Disorders. In addition to the presence of a chronic mental disorder or acquired, organic, or traumatic brain injury, the enrollee shall need assistance or supervision with either: Two of the following: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management, or hygiene; or One need from the above list and one of the following: money management; accessing community and health resources; meal preparation, or transportation. Source: Transition/California STCs ( ).pdf 8
9 What is available for those who aren t t eligible for CBAS? Enhanced Case Management (ECM) Enhanced Case Management is a service consisting of Complex Case Management and Person-Centered Planning services including the coordination of eligible Medi-Cal beneficiaries individual needs for the full array of necessary long-term services and supports including medical, social, educational, and other services, whether covered or not under the Medicaid program, and periodic in-person consultation with the enrollees and/or his designees. Source: Transition/California STCs ( ).pdf 9
10 Enhanced Case Management (ECM) cont. From April 1, 2012, through August 31, 2014, the ECM benefit will be available to all Medi-Cal beneficiaries who: Received ADHC services through the California Medicaid program at any time from July 1, 2011 through February 29, Have been determined to be ineligible for CBAS or who are eligible for CBAS but exempted from enrolling in managed care and choose to receive ECM as a fee-forservice benefit rather than the CBAS benefit through a managed care plan. A Medi-Cal beneficiary determined to be eligible for ECM may, at a later date, be determined eligible for CBAS. If the enrollee then receives CBAS, he/she will no longer receive ECM. If at a later time the enrollee no longer receives CBAS, he/she will be eligible to receive ECM. An ECM-eligible enrollee who receives CBAS at some time between April 1, 2012, and August 31, 2014, is eligible to receive ECM for any time period during which they do not receive the CBAS benefit. A beneficiary shall not receive ECM and CBAS concurrently. Source: Transition/California STCs ( ).pdf 10
11 How are Beneficiaries Enrolled in CBAS? Existing ADHC Participant A. CBAS Center Re-Assesses participant and sends Prior authorization request, including IPC with Level of Service recommendation is created and sent to Plan. B. Plan receives Prior Authorization request from CBAS center, which includes a completed IPC and Level of Service recommendation. Plan will handle recommendation through existing prior authorization process which includes: Plan will approve, modify or deny prior authorization request within 5 business days, in accordance with Health and Safety Code If Plan cannot make a decision within 5 business days a 14-day delay letter will be sent to the member and center. Plan notifies Center within 24 hours of decision. Plan notifies member within 48 hours of decision. C. To deny or decrease the Prior Authorization request, the plan must conduct a F2F with the member. Process must be completed in accordance with Health and Safety Code and ensure timelines are met. D. CBAS services begin 11
12 How are Beneficiaries Enrolled in CBAS? New Participant A. Provider identifies a potential need for CBAS services and submits a request for inquiry to begin the CBAS assessment process B. Plan schedules Face to Face (F2F) with member using the following process Plan acknowledges, in writing, to requestor and member, the inquiry and makes first attempt to schedule F2F within 5 business days. Plan makes two additional attempts via telephone to schedule between 5 and 8 business days of request. Plan makes final attempt in writing giving the member until 14th calendar day to schedule F2F. If m ember does not schedule within 14 days from inquiry, plan will send a follow-up letter to member and requestor that if services are still needed a new inquiry must be submitted to begin the process again. Managed Care Plan conducts Face to Face (F2F) with member using the following guidelines Plan must schedule F2F within 14 calendar days. F2F must be completed, using CEDT tool, with in 30 days from initial inquiry. Approval or denial of eligibility for CBAS to conduct IPC will be sent to the Center with in 1business day of decision. Member has the right to choose a center. 12
13 How are Beneficiaries Enrolled in CBAS? New Participant cont. C. CBAS Center Completes & Submits Prior Authorization Request Receives authorization from Plan to conduct I PC/LOS assessment CBAS center multi-disciplinary team performs assessment Prior authorization request, including IPC with level of Service recommendation is created and sent to Plan. D. Plan receives Prior Authorization request from CBAS center, which includes a completed IPC and Level of Service recommendation. Plan will handle recommendation through existing prior authorization process which includes: Plan will approve, modify or deny prior authorization request within 5 business days, in accordance with Health and Safety Code If Plan cannot make a decision with in 5 business days a 14-day delay letter will be sent to the member and center. Plan notifies Center within 24 hours of decision. Plan notifies member within 48 hours of decision. E. CBAS services begin 13
14 How are Beneficiaries Enrolled in CBAS? Expedited Participation Request A. Nursing Facility or Hospital identifies a potential need for expedited CBAS services within the discharge plan and provider submits a request for inquiry to begin the CBAS assessment process. Expedited process will be conducted with 5 business days. B. Managed Care Plan schedules Face to Face at the Nursing Facility or Hospital with member/facility immediately Managed Care Plan conducts F ace to Face with member using the following guidelines Plan must complete F2 F within 5 business days. F2F must be completed, u sing CE DT tool, within 5 business days from initial inquiry. Approval or denial of C BAS eligibility to conduct IPC will be sent to the Center within 1business day of decision. Member has the right to chose a center. C. CBAS Center Receives approval from Plan to conduct IPC assessment CBAS center multi-disciplinary team performs IPC assessment Prior authorization request, including IPC with Level of Service recommendation is created and sent to Plan. 14
15 How are Beneficiaries Enrolled in CBAS? Expedited Participation Request cont. D. Plan receives Prior Authorization request from CBAS center, which includes a completed IPC and Level of Service recommendation. Plan will handle recommendation through existing prior authorization process which includes: Plan will approve, modify or deny prior authorization request within 72 hours, in accordance with Health and Safety Code (h)(2) Plan notifies Center within 24 hours of decision. Plan notifies member within 48 hours of decision. E. CBAS services begin 15
16 CBAS Participant Protections No Disruptions in Care Beneficiaries who previously received Adult Day Health Care Services between July 1, 2011 and February 29, 2012 must have a face to face assessment to determine CBAS enrollment qualification, but there will be no disruption in care until the face to face assessment has been conducted. Second Level Review Beneficiaries who previously received Adult Day Care Services between July 1, 2011, and February 29, 2012 and have been determined not to meet the level of care for CBAS by the Department or a managed care plan may request a second level review. The second level review may be requested by the beneficiary, their family or guardian. An individual must continue to receive CBAS services if the individual was receiving CBAS prior to being determined ineligible for CBAS until the second level review has been completed by an entity/agency independent of the initial assessment reviewer. Individuals determined not eligible must have a Discharge Plan of Care completed and provided in writing to the individual, family member or guardian. Continuity of Care In referring a beneficiary for CBAS services consideration will be given to the CBAS beneficiary s relationship with previous providers of similar services Source: Transition/California STCs ( ).pdf 16
17 CBAS Participant Protections cont. Discharge Plan of Care State Plan and CBAS beneficiaries determined not in need of CBAS services will be provided a written Discharge Plan of care to be completed by a CBAS center. The Discharge Plan of care must contain: a) The name(s) of the patient s physician(s) and the patient s ID number. b) The date the Notice was issued. c) The date the CBAS services are to end. d) Specific information about the patient s current medical condition, treatments and medication regime. e) A statement about Enhanced Case Management Services and how they will be provided to those eligible State plan beneficiaries f) A statement of the right to file a Grievance or Appeal, or to request a second level review. g) A space for the beneficiary or representative to sign and date the document. Grievances and Appeals Individuals who receive a notice of adverse action are entitled to file a Grievance or Appeal as they are entitled under State and Federal law. Source: Transition/California STCs ( ).pdf 17
18 Preparation by the Health Plans CAADS Partnership GMC Coalition/ ADHC Center Partnership ADHC Center Meet and Greet Visits Provider Education/ Communication Member Education/ Communication Executed Contracts with CBAS Centers WEBINAR Trainings for ADHC staff Review of sampletars, IPCs Claims system modifications 18
19 Our First Month Enrollment November 2012 Existing New Total ECM CBAS (10/12) CBAS CBAS Anthem Health Net Molina Kaiser
20 The First Month- Challenges Health Net s Perspective Things have been quiet out of Sacramento County but overall first month challenges are: Higher than expected opt out rate back into FFS Medi-Cal CBAS software and clearing house issues with errors and rejections Medicare FFS Providers guiding beneficiaries back into FFS Medi-Cal and cancelling appointments for colonoscopies, doctor appointments, cataract surgeries, and collecting copays Plan s response: Dedicated Health Net associates for CBAS Increase the number of providers for transportation, Durable Medical Equipment to maintain access to care Performed 6 webinars with 4 more scheduled Outreach to 300 physicians and 3 hospital systems Health Net has been able to get appointments and surgeries rescheduled, and have been able to get copays refunded 20
21 The Months Ahead In the Months Ahead the Plans will: Continue with provider outreach Use webinars as temperature check to assess the needs of CBAS centers Continue to communicate and collaborate with the CBAS centers collectively and individually as needed to indentify problems and initiate timely resolution. Convene a workgroup of internal staff from each of the plans to discuss program implementation and identify best practices/ successful models of practice that me be shared, replicated and or modified. 21
22 CBAS Transition: The Trouble Shooters Members are encouraged to contact their Plan Member Services Department first Available via toll-free number 24hours a day, 7 days/wk, 365 days/yr Multi-lingual staff that can communicate with Member in their preferred language. Have all the needed resources and tools to facilitate Member requests (ie: appointment scheduling, PCP change, Member grievance, link with after hours nurse advice line, new ID card, health education resources, information about programs/services in the community.) Sacramento GMC Plan Member Services Departments can be reach at:
23 CBAS Transition: The Trouble Shooters Provider Services WriteFax for IPCs Status for DME Ambulatory Case Mgmt (status of service notifications) Contracts or CBAS- Renewal- t.com or ellpoint.com or Point.com Cora Ross point.com Lissette Mendoza Lissette.x.men et.com Ext ext ext Linda Baez olinahealthcar e.com
24 Questions? 24 24
BH Medical Group Providers IEHP Provider Relations Date: January 16, 2014 Subject: Expanded Mental Health Benefits
To: From: BH Medical Group Providers IEHP Provider Relations Date: Subject: Expanded Mental Health Benefits The New Year has begun and the expanded mental health benefit for IEHP Medi-Cal Members is in
More informationCommunity Based Adult Services (CBAS) Manual
Community Based Adult Services (CBAS) Manual Revised October 2016 TABLE OF CONTENTS Policies and Procedures CBAS Initial Assessment and Reassessment... 3 CBAS Authorization Requests... 5 CBAS Claim Procedures...
More informationREAD THIS NOTICE CAREFULLY.
United States District Court For The Northern District Of California If you are in Medi-Cal and receive (or recently received) Adult Day Health Care (ADHC), this is a Notice of a Class Action Settlement
More informationProvider Certification Standards Adult Day Care
Provider Certification Standards Adult Day Care December 2015 1 Definitions: Activities of Daily Living (ADL s)- Includes but is not limited to the following personal care activities: bathing, dressing,
More informationBasic Training in Medi-Cal Documentation
Basic Training in Medi-Cal Documentation Sara Kashing, J.D. Staff Attorney The Therapist May/June 2012 Since 1998, Medi-Cal mental health services have been provided through county-based Mental Health
More informationUpdate June, 2013 Medi-Cal Mental Health Services General Statewide Information Why Is It Important To Read This Booklet? The first section of this booklet tells you how to get Medi-Cal mental
More informationCommunity Based Adult Services (Adult Day Health Care)
4/25/2013 Adult Day Care and Community Based Adult Services (Adult Day Health Care) Snack & Learn April 30, 2013 1 Supported by the California Department of Health and Human Services Agency and U.S. Department
More informationMEMBER GRIEVANCE FORM
MEMBER GRIEVANCE FORM Please Return: Partnership HealthPlan of California Attention: Grievance Unit 4665 Business Center Drive Fairfield, CA 94534 Phone: (800) 863-4155 Fax: (707) 863-4351 Partnership
More informationGUIDE TO Medi-Cal Medi-Cal M ental Health Mental Health S ervices Services Updated 2010
GUIDE TO Medi-Cal Mental Health Services Updated 2010 Disponible en Español What Is A Mental Health Emergency? An emergency is a serious mental or emotional problem, such as: When a person is a danger
More informationManaged Long Term Services and Supports (MLTSS)
Cal MediConnect 2017 Managed Long Term Services and Supports (MLTSS) 2017 CMC Annual Training Topics of Discussion What are MLTSS services? Overview of MLTSS programs MLTSS Referrals Services covered Eligibility
More informationExhibit A. Part 1 Statement of Work
Exhibit A Part 1 Statement of Work Contractor shall provide Basic Neurological services as described herein to Medicaid eligible Clients who are authorized to receive services at the Contractor s owned
More informationCoordinated Care Initiative DRAFT Assessment and Care Coordination Standards November 20, 2012
Coordinated Care Initiative DRAFT Assessment and Care Coordination Standards November 20, 2012 Table of Contents CARE COORDINATION GENERAL REQUIREMENTS...4 RISK STRATIFICATION AND HEALTH ASSESSMENT PROCESS...6
More informationSolano County Mental Health Managed Care Provider Manual August 2011
Solano County Health & Social Services Solano County Mental Health Managed Care Provider Manual August 2011 Revised August 2011 Revised August 2011 This page left blank intentionally Table of Contents
More informationPresenters. Kathy Hughes President/Chief Executive Officer, ChildNet Youth and Family Services
Intensive Treatment Foster Care, Intensive Services Foster Care and Therapeutic Foster Care ITFC, ISFC and TFC Differences in Policies and Practices (September 6, 2017, 4:00 5:30) Presenters Kathy Hughes
More informationOther languages and formats
Dear member, We re glad you re part of our health plan! It s important to us that you have the most up-to-date information about your benefits. We re sending you the following notices with this letter:
More informationCMHPSM Organizational Credentialing/Re-credentialing Application Instructions
CMHPSM Organizational Credentialing/Re-credentialing Application Instructions Overview The CMHPSM credentialing/re-credentialing form is to be used for initially applying to become a CMHPSM Mental Health
More informationMEDI-CAL MANAGED CARE OVERVIEW
MEDI-CAL MANAGED CARE OVERVIEW September 2016 Sandy Damiano, PhD Deputy Director DHHS Primary Health Eligibility & Enrollment Open year round Based on income and family size Simplified procedures Income
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR DATE: September 15, 2014 All Plan Letter 14-011 TO: ALL MEDI-CAL
More informationMEDI-CAL MANAGED CARE OVERVIEW
MEDI-CAL MANAGED CARE OVERVIEW July 2018 Sandy Damiano, PhD Deputy Director DHS Primary Health Eligibility & Enrollment Apply for Medi-Cal year round: County Department of Human Assistance (DHA) Online,
More informationMississippi Medicaid Autism Spectrum Disorder Services for EPSDT Eligible Beneficiaries Provider Manual
Mississippi Medicaid Services for EPSDT Eligible Beneficiaries Provider Manual Effective Date: July 1, 2017 Services for Introduction: eqhealth Solutions Services (ASD) Utilization Management Program includes
More informationNew provider orientation
New provider orientation Welcome 2 Agenda Introduction to Amerigroup Provider resources Contact numbers and questions Provider responsibilities Member benefits and services Claims and billing Preservice
More informationIn Arkansas 02/20/2014 1
In Arkansas 02/20/2014 1 Procedures for Determination of Medical Need for Nursing Home Services I. Medical Need Assessments A. Nursing Facility Procedures B. OLTC Procedures II. Pre-Admission Screening
More informationCAL MEDICONNECT: Working with In-Home Supportive Services (IHSS) Physician Webinar Series
CAL MEDICONNECT: Working with In-Home Supportive Services (IHSS) Physician Webinar Series Today s Webinar This webinar is part of a series designed specifically for physicians. For a general overview of
More informationI. General Instructions
Contra Costa Behavioral Health Services Request for Proposals (RFP) Outpatient Mental Health Services September 30, 2015 I. General Instructions Contra Costa Behavioral Health Services (CCBHS, or the County)
More informationOneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) OneCare Connect Program Overview
OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) OneCare Connect Program Overview 2018 1 Learning Objectives After completing this module you will: Have gained an awareness and knowledge about
More informationPROVIDER POLICIES & PROCEDURES
PROVIDER POLICIES & PROCEDURES EXTENDED NURSING SERVICES The purpose of this document is to provide guidance to providers enrolled in the Connecticut Medical Assistance Program (CMAP) on the requirements
More informationCHILDREN S PERSONAL CARE SERVICES (CPCS): OVERVIEW & UPDATE VERMONT FAMILY NETWORK WEBINAR OCTOBER 28, 2015
1 CHILDREN S PERSONAL CARE SERVICES (CPCS): OVERVIEW & UPDATE VERMONT FAMILY NETWORK WEBINAR OCTOBER 28, 2015 2 PROGRAM OVERVIEW: WHAT CPCS IS Medicaid benefit for children diagnosed with verifiable longterm
More informationINPATIENT OPERATIONS HANDBOOK
INPATIENT OPERATIONS HANDBOOK County of San Diego Health & Human Services Agency Behavioral Health Services Updated September 2012 2 TABLE OF CONTENTS Page Overview..5 1. General Guidelines 6 2. Notification
More informationAmendment Sheet to the Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Evidence of Coverage/Member Handbook
Amendment Sheet to the Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Evidence of Coverage/Member Handbook November 2017 Dear Member, This is important information on changes in your Health
More informationDate of Last Review. Policy applies to Medicaid products offered by health plans operating in the following State(s) Arkansas California
POLICY: Anthem Medicaid (Anthem) is responsible for providing Access to Care/Continuity of Care and coordination of medically necessary medical and mental health services. Members who are, or will be,
More informationMolina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)
Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience
More informationDefinitions Used in Managed Care
Adult Day Health Care (ADHC) means an organized day program of therapeutic, social and health activities and services provided to persons 55 years or older or other adults with functional impairments,
More informationExtended Continuity of Care for Seniors and Persons with Disabilities Frequently Asked Questions. September 2011
Extended Continuity of Care for Seniors and Persons with Disabilities Frequently Asked Questions September 2011 Question #1: If a beneficiary s current fee-for-service (FFS) Medi-Cal doctor does not accept
More informationLong-Term Care Glossary
Long-Term Care Glossary Adjudicated Claim Activities of Daily Living (ADL) A claim that has reached final disposition such that it is either paid or denied. Basic tasks individuals perform in the course
More informationSection 4 - Referrals and Authorizations: UM Department
Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation
More informationOverview and Current Status of Program of All-inclusive Care for the Elderly (PACE) Dr. Cheryl Phillips, M.D. Chief Medical Officer, On Lok Lifeways
Overview and Current Status of Program of All-inclusive Care for the Elderly (PACE) Dr. Cheryl Phillips, M.D. Chief Medical Officer, On Lok Lifeways 1 What is On Lok? Original Vision: Help the low-income
More informationNovember 14, Chief Clinical Operating Officer Division of Medical Assistance Department of Health and Human Services
Department of Health and Human Services Division of Medical Assistance Response To Questions from the Adult Care Home Transition Subcommittee of the Blue Ribbon Commission November 14, 2012 Presenter:
More informationREQUEST FOR PROPOSALS Community Placement Plan Fiscal Year
REQUEST FOR PROPOSALS Community Placement Plan Fiscal Year 2015-2016 North Bay Regional Center (NBRC) is a community- based, private non-profit corporation that is funded by the State of California to
More informationThe Budget: Maximizing Federal Reimbursement For Parolee Mental Health Care Summary
The 2013-14 Budget: Maximizing Federal Reimbursement For Parolee Mental Health Care MAC Taylor Legislative Analyst MAY 6, 2013 Summary Historically, the state has spent tens of millions of dollars annually
More informationService Review Criteria
Client Name: SAR#: Administrative Review Process notes: When documenting call outs to provider, please document the call in a patient note in Alpha the day the call is made. tes should be coded as Care
More informationNotice of Adverse Benefit Determination Training
Notice of Adverse Benefit Determination Training Santa Cruz County Behavioral Health Quality Improvement Mental Health Plan / Drug Medi-Cal Plan From here-out to be referred to as Plans 05/1/18 Goal Training
More informationContra Costa County. Drug Medi-Cal Organized Delivery System (DMC-ODS) Program BENEFICIARY HANDBOOK
Contra Costa County Drug Medi-Cal Organized Delivery System (DMC-ODS) Program BENEFICIARY HANDBOOK DMC-ODS Beneficiary Handbook 1 TABLE OF CONTENTS Table of Contents GENERAL INFORMATION... 4 Emergency
More informationA. Members Rights and Responsibilities
APPLIES TO: A. This policy applies to all IEHP Medi-Cal Members. POLICY: A. For the purpose of this policy, a Delegate is defined as a medical group, IPA or any contracted organization delegated to provide
More informationSanta Clara County, California Medicare- Medicaid Plan (MMP)
Santa Clara County, California Medicare- Medicaid Plan (MMP) Behavioral health overview topics Topics covered: o Behavioral health (BH) covered services overview o BH noncovered services o Early and Periodic
More informationStatewide Inpatient Psychiatric Programs Admission Process and Level of Care Criteria. Effective August 1, 2014
Statewide Inpatient Psychiatric Programs Admission Process and Level of Care Criteria Effective August 1, 2014 1 Table of Contents Florida Medicaid Handbook... 3 Clinical Practice Guidelines... 3 Description
More informationDEPARTMENT OF COMMUNITY SERVICES. Services for Persons with Disabilities
DEPARTMENT OF COMMUNITY SERVICES Services for Persons with Disabilities Alternative Family Support Program Policy Effective: July 28, 2006 Table of Contents Section 1. Introduction Page 2 Section 2. Eligibility
More information65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically
65G-4.0213 Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically validated relationships between individual characteristics
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services JENNIFER KENT DIRECTOR EDMUND G. BROWN JR. GOVERNOR DATE: December 3, 2015 ALL PLAN LETTER 15-025 (SUPERSEDES ALL
More informationUnderstanding and Leveraging Continuity of Care
Understanding and Leveraging Continuity of Care Cal MediConnect Providers Summit January 21, 2015 Moderator: Jane Ogle, Consultant, Harbage Consulting www.chcs.org An Overview of Continuity of Care in
More informationMedical Care Meets Long-Term Services and Supports (LTSS)
Medical Care Meets Long-Term Services and Supports (LTSS) Cal MediConnect Providers Summit January 21, 2015 Moderator: Rebecca Malberg von Lowenfeldt, Director LTSS Practice, Harbage Consulting www.chcs.org
More informationADULT LONG-TERM CARE SERVICES
ADULT LONG-TERM CARE SERVICES Long-term care is a broad range of supportive medical, personal, and social services needed by people who are unable to meet their basic living needs for an extended period
More informationNew provider orientation. IAPEC December 2015
New provider orientation IAPEC-0109-15 December 2015 Welcome 2 Agenda Introduction to Amerigroup Provider resources Preservice processes Member benefits and services Claims and billing Provider responsibilities
More informationMichelle P Waiver Training
Michelle P Waiver Training Presented by Department for Medicaid Services and Department for Mental Health, Developmental Disabilities and Addiction Services 1 Workshop Outline I. History and Overview of
More information2015 CMS National Training Program Workshop Monika Vega, MSW Harbage Consulting, LLC Representing California s Department of Health Care Services
California s Coordinated Care Initiative 2015 CMS National Training Program Workshop Monika Vega, MSW Harbage Consulting, LLC Representing California s Department of Health Care Services Roadmap Nationally
More informationVoluntary Services as Alternative to Involuntary Detention under LPS Act
California s Protection & Advocacy System Toll-Free (800) 776-5746 Voluntary Services as Alternative to Involuntary Detention under LPS Act March 2010, Pub #5487.01 This memo outlines often overlooked
More informationFlorida Medicaid. Therapeutic Group Care Services Coverage Policy
Florida Medicaid Therapeutic Group Care Services Coverage Policy Agency for Health Care Administration July 2017 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal
More informationCAL MEDICONNECT: Understanding the Health Risk Assessment. Physician Webinar Series
CAL MEDICONNECT: Understanding the Health Risk Assessment Physician Webinar Series Today s Webinar This webinar is part of a series designed specifically for CAPG members. For a general overview of the
More information#14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT)
COUNTY OF SANTA BARBARA ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES Section - Policy- QUALITY ASSURANCE #14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT) Director's /{A A.. \
More informationGERIATRIC SERVICES CAPACITY ASSESSMENT DOMAIN 4 ALTERNATE LIVING ARRANGEMENTS
GERIATRIC SERVICES CAPACITY ASSESSMENT DOMAIN 4 ALTERNATE LIVING ARRANGEMENTS Table of Contents Introduction... 2 Purpose... 2 Serving Senior Medicare-Medicaid Enrollees... 2 How to Use This Tool... 2
More informationCoordinated Care Initiative Frequently Asked Questions for Physicians
What is the Coordinated Care Initiative? California's Coordinated Care Initiative (CCI) changes the focus and delivery of health care for seniors and people with disabilities. Coordinated care offers participants
More informationPASRR: What You Need to Know Now HHS PASRR Staff
PASRR: What You Need to Know Now - 2017 HHS PASRR Staff Session Objectives At the conclusion of this session participants will: Be familiar with recent and upcoming PASRR enhancements Know how to respond
More informationService Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note:
Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note: If you are a Medicaid beneficiary and have a serious mental illness, or serious emotional disturbance, or developmental
More informationBeneficiary Any person certified as eligible under the Medi-Cal program according to Title 22, Section (CCR, Section ).
right to appeal the SFMHP s decision within 90 days of the date on the Notice of Action. There are no filing deadlines if a Notice of Action is not issued. The Grievance Officer or his or her designee
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS Director EDMUND G. BROWN JR. Governor DATE: OCTOBER 28, 2013 ALL PLAN LETTER 13-014 SUPERSEDES ALL PLAN
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA H3237_2015_0291 CMS Accepted 09082014 Health Net Cal MediConnect Summary of Benefits! This is a
More informationMedi-Cal Managed Care Advisory Committee Split Benefit Overview
Medi-Cal Managed Care Advisory Committee Split Benefit Overview Division of Mental Health Services Stephanie Kelly, MS, LMFT October 23, 2017 1 Molina Anthem Blue Cross Health Net Kaiser Permanente United
More informationE. Guiding To show, indicate, or influence a course of action for an individual in order to promote independence.
D. Direct Assistance Hands-on physical care provided to an individual in need of assistance with Activities of Daily Living or Instrumental Activities of Daily Living. E. Guiding To show, indicate, or
More informationCalifornia Children s Services (CCS) Program Medi-Cal Managed Care CCS Whole-Child Model Comparison Chart January 6, 2016
California Children s Services (CCS) Program Medi-Cal Managed Care CCS Whole-Child Model Comparison Chart January 6, 2016 Authorization for Services Plan to adjudicate authorization request. Authorization
More informationOverview for Acute, Hospital & Ancillary Care Providers
Overview for Acute, Hospital & Ancillary Care Providers Agenda Overview Medicaid Waivers and Plan Network Services Prior Authorization and Clinical Information Billing and Claims Information Resources
More informationRevised: November 2005 Regulation of Health and Human Services Facilities
Revised: November 2005 Regulation of Health and Human Services Facilities This guidebook provides an overview of state regulation of residential facilities that provide support services for their residents.
More informationTRANSITION OF NURSING HOME POPULATIONS AND BENEFITS TO MEDICAID MANAGED CARE
ANDREW M. CUOMO Governor HOWARD A. ZUCKER, M.D., J.D. Acting Commissioner SALLY DRESLIN, M.S., R.N. Executive Deputy Commissioner TRANSITION OF NURSING HOME POPULATIONS AND BENEFITS TO MEDICAID MANAGED
More informationNORTH DAKOTA LEVEL OF CARE FORM INSTRUCTIONS TO BE USED WITH LOC FORM ND
For this section, select which type of LOC screen is to be reviewed Requested Screen Type NORTH DAKOTA LEVEL OF CARE FORM INSTRUCTIONS Nursing Facility Swingbed CMFN PACE MFP Provisional MFP Final Tech.
More informationFlorida Medicaid. Early Intervention Services Coverage Policy. Agency for Health Care Administration August 2017
+ Florida Medicaid Early Intervention Services Coverage Policy Agency for Health Care Administration August 2017 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal
More informationHOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101
HOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101 Medicaid Background Federal and State Roles Whom Does Medicaid Serve? What Does Medicaid Cover? Medicaid Waiver Programs and Services In 1965, Medicare
More informationDisability Rights California
Disability Rights California California s protection and advocacy system BAY AREA REGIONAL OFFICE 1330 Broadway, Suite 500 Oakland, CA 94612 Tel: (510) 267-1200 TTY: (800) 719-5798 Toll Free: (800) 776-5746
More informationDIVISION CIRCULAR #3 (N.J.A.C. 10:46) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES
DIVISION CIRCULAR #3 (N.J.A.C. 10:46) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES EFFECTIVE DATE: March 24, 2011 DATE ISSUED: April 27, 2011 (Rescinds Division Circular #3, Determination
More informationApplicant Name Last, First Social Security Number Date of Birth. Applicant s Address City State Zip Code
MAP-409 COMMONWEALTH OF KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASRR) NURSING FACILITY IDENTIFICATION SCREEN (LEVEL I) Revised March 2007 Applicant Name
More informationWakeMed Rehab Hospital Stroke Rehabilitation Scope of Service
WakeMed Rehab Hospital Stroke Rehabilitation Scope of Service WakeMed Rehab Hospital provides an integrated, comprehensive delivery of rehabilitation services utilizing evidenced-based practice directed
More informationPrior Authorization and Continued Stay Criteria for Adult Serious Mentally Ill (SMI) Behavioral Health Residential Facility
Prior Authorization and Continued Stay Criteria for Adult Serious Mentally Ill (SMI) Behavioral Health Residential Facility AUTHORIZATION CRITERIA FOR BEHAVIORAL HEALTH RESIDENTIAL FACILITY, ADULT Title
More informationPASRR LEVEL I INSTRUCTIONS FOR OHCA FORM LTC-300A PURPOSE
PLEASE READ THE FOLLOWING INSTRUCTIONS THOROUGHLY. IF YOU HAVE ANY QUESTIONS OR IF ANY PART IS NOT UNDERSTOOD, PLEASE CONTACT OHCA/LOCEU. PURPOSE The LTC-300A is used to meet Federal requirements for PASRR
More informationAssessment Content Map
Purpose: Provides an outline of the MnCHOICES Assessment to help certified assessors locate and become familiar with the content of the Assessment document. A Person Information Reason for Contact & Referral
More information65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically
65G-4.0213 Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically validated relationships between individual characteristics
More informationClinical Utilization Management Guideline
Clinical Utilization Management Guideline Subject: Therapeutic Behavioral On-Site Services for Recipients Under the Age of 21 Years Status: New Current Effective Date: January 2018 Description Last Review
More informationGUIDE TO. Medi-Cal Mental Health Services
GUIDE TO Medi-Cal Mental Health Services Fresno County English Revised July 2017 If you are having a medical or psychiatric emergency, please call 9-1-1. If you or a family member is experiencing a mental
More informationPRESCRIBED PEDIATRIC EXTENDED CARE CENTERS CSHCN SERVICES PROGRAM PROVIDER MANUAL
PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS CSHCN SERVICES PROGRAM PROVIDER MANUAL SEPTEMBER 2018 CSHCN PROVIDER PROCEDURES MANUAL SEPTEMBER 2018 PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS Table of Contents
More informationOverview of the Prior Authorization Process for Home Health Aide Services. June 27, 2018
Overview of the Prior Authorization Process for Home Health Aide Services June 27, 2018 Objectives Understand the HUSKY Health program s Prior Authorization (PA) process for home health aide (HHA) services
More information# December 29, 2000
#00-53-3 December 29, 2000 Minnesota Department of Human Services 444 Lafayette Rd. St. Paul, MN 55155 OF INTEREST TO! County Social Service Directors/Supervisors! County Designated LMHA for PASRR! County
More informationAnthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, provider orientation presentation
Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, provider orientation presentation Anthem HealthKeepers MMP HealthKeepers, Inc. participates in the Virginia Commonwealth
More informationNYC HEALTH + HOSPITALS/QUEENS Mount Sinai Services
NYC HEALTH + HOSPITALS/QUEENS Mount Sinai Services Psychology Externship Brochure 2018-19 Revised 10/25/17 NYC HEALTH + HOSPITALS/QUEENS PSYCHOLOGY EXTERNSHIP PROGRAM NYC Health + Hospitals/Queens 2018-19
More informationTitle 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 07 Medical Day Care Services Authority: Health-General Article, 2-104(b), 15-103, 15-105, and 15-111, Annotated
More informationOASIS-B1 and OASIS-C Items Unchanged, Items Modified, Items Dropped, and New Items Added.
Items Added. OASIS-B1 Items UNCHANGED on OASIS-C OASIS-C Item # M0014 M0016 M0020 M0030 M0032 M0040 M0050 M0060 M0063 M0064 M0065 M0066 M0069 M0080 M0090 M0100 M0110 M0220 M1005 M1030 M1200 M1230 M1324
More informationCAADS California Association for Adult Day Services
CAADS California Association for Adult Day Services A Study of Patient Discharge Outcomes Resulting from California s Elimination of Adult Day Health Care on December 1, 2011 by the California Association
More information(c) A small client to staff caseload, typically 10:1, to consistently provide necessary staffing diversity and coverage;
309-019-0225 Assertive Community Treatment (ACT) Overview (1) The Substance Abuse and Mental Health Services Administration (SAMHSA) characterizes ACT as an evidence-based practice for individuals with
More information1. SMHS Section of CCR Title 9 (Division 1, Chapter 11): this is the regulation created by the California Department of Health Care Services (DHCS).
Clinical Documentation Tool This tool compares the definitions of outpatient Specialty Mental Health s (SMHS) that appear in two different sources: 1. SMHS Section of CCR Title 9 (Division 1, Chapter 11):
More informationNEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES PROCEDURE CODES & FEE SCHEDULE
NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES PROCEDURE CODES & FEE SCHEDULE Table of Contents General Rules and Information... 3 Occupational Therapist, Physical Therapist and Speech Language
More informationFlorida Medicaid. Statewide Inpatient Psychiatric Program Coverage Policy
Florida Medicaid Statewide Inpatient Psychiatric Program Coverage Policy Agency for Health Care Administration December 2015 Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority...
More informationWYOMING MEDICAID PROGRAM
WYOMING MEDICAID PROGRAM COMMUNITY MENTAL HEALTH & SUBSTANCE USE TREATMENT SERVICES MANUAL MENTAL HEALTH/SUBSTANCE USE REHABILITATION OPTION EPSDT CHILD & ADOLESCENT MENTAL HEALTH SERVICES TARGETED CASE
More informationS a n F r a n c i s c o C o u n t y
BAYVIEW HUNTERS POINT S a n F r a n c i s c o As of 3/11/2015 ADULT DAY HEALTH CENTER 1250 LaSalle Avenue San Francisco, CA 94124-2414 (415) 826-4774 Email: Bayviewadhc@aol.com Bayview Hunter's Point Multipurpose
More informationLONG TERM CARE SETTINGS
LONG TERM CARE SETTINGS Long term care facilities assist aged, ill or disabled persons who can no longer live independently. In this section, we will briefly examine the history of long term care facilities
More informationPENNSYLVANIA PREADMISSION SCREENING RESIDENT REVIEW (PASRR) IDENTIFICATION LEVEL I FORM (Revised 9/1/2018)
PENNSYLVANIA PREADMISSION SCREENING RESIDENT REVIEW (PASRR) IDENTIFICATION LEVEL I FORM (Revised 9/1/2018) This process applies to all nursing facility (NF) applicants, regardless of payer source. All
More information