PROVIDER-LED INTEGRATED CARE COORDINATION (PLICC)

Transcription

1 PROVIDER-LED INTEGRATED CARE COORDINATION (PLICC) Program Requirements and Billing Guidelines

2 Table of Contents Overview... 3 What s Included in PLICC... 4 Identifying Eligible PLICC Members... 5 Special Health Care Needs Populations... 6 Member Participation... 6 PLICC Care Provider Activities... 7 Required PLICC Care Provider Activities in UHCTransitions (Health BI)... 7 Case Duration... 8 Data Availability... 8 Collaboration and Communication... 9 Physical and Behavioral Health Integration... 9 Transition Between Managed Care Organizations... 9 Whole Person Care Health Plan Care Management Healthify Coordinate Program Oversight Quality Assurance Established Threshold PLICC Billing Guidelines PLICC Auditing and Oversight Monitoring and Evaluation Measuring Care Coordination Effectiveness Definitions UHCTransitions (Health BI) User Registration UHCTransitions (Health BI) User Registration Instructions... 17

3 OVERVIEW We recognize the populations served under the Arizona Health Care Cost Containment System (AHCCCS) Complete Care contract face significant challenges, such as managing multiple behavioral and physical health conditions, food insecurity, unsafe housing, unemployment, under-employment and more. Studies and our own experience show that taking a holistic view of members circumstances is important, given that social and economic factors have a significant effect on health care outcomes. To encourage all providers to deliver integrated care, we developed a new, innovative strategy called Provider-Led Integrated Care Coordination (PLICC). This program is derived from evidence-based models which demonstrate that integration and collaboration between providers facilitates better outcomes and member experience, while affording providers an opportunity for additional compensation for leading care coordination efforts for members with higher levels of integrated care needs. Key components include: Identifying Members UnitedHealthcare Community Plan and/or the care provider may identify members with at least one physical and one behavioral health diagnosis, and evidence of increased risk of adverse health outcomes (see Identifying Eligible PLICC Members). Completing a Health Risk Assessment (HRA) Care providers complete a health risk assessment (HRA) and Social Determinants of Health (SDOH) screening. Results are documented in an integrated service plan within the UHCTransitions (Health BI) Platform (part of our CommunityCare Technology suite) and shared with the Interdisciplinary Care Team (ICT). Submitting a Designated Code Care providers submit a designated code subject to PLICC billing codes. Confirming the Claim UnitedHealthcare Community Plan confirms the claim is from a care provider contracted for PLICC. We also complete quarterly audits of UHCTransitions (Health BI) for PLICC care providers to confirm required services provided and completed documentation. Generating Reminders for Care Providers UHCTransitions (Health BI) will generate reminders for care providers to ensure timely completion of the required services. The following care providers are eligible for the PLICC program: Primary Care Providers (PCPs) Behavioral Health Providers Behavioral Health Homes Behavioral Health care providers that are part of a behavioral health home, physical health practice or integrated clinic (Psychologist; Social Worker; Marriage and Family Therapist; Professional Counselor) Integrated Clinics (ICs) (note specific billing instructions in section 16/Provider-led Integrated Care Coordination Billing Guidelines) Federally Qualified Healthcare Center (FQHC) (note specific billing instructions in section 16/Provider-led Integrated Care Coordination Billing Guidelines) Integrated Practices (co-located physical health and behavioral health practices) UnitedHealthcare Community Plan designated accountable care organizations (ACOs) Private practices Care Provider Eligibility 3

4 The program encourages care providers to work to their highest capacity to deliver integrated care for members, with our support. PLICC is aligned with what we heard care providers ask for: support payment strategies that adequately account for care coordination efforts between care providers and encourage PCPs and behavioral health only care providers to more effectively share data and collaborate. PLICC care providers are subject to both the Provider Administrative Manual and this PLICC Program Requirements and Billing Guideline. The PLICC Program Requirements and Billing Guidelines control if it conflicts with the information in the Provider Administrative Manual. If there are additional protocols, policies or procedures online you ll be directed to that location, when applicable. For protocols, policies and procedures not referenced here please refer to the appropriate chapter in the Provider Administrative Manual. Today with UHCTransitions (Health BI), care providers can communicate with us and with each other (including sending secure messaging) in member-consented care/service plan development. This is part of an interdisciplinary approach to improve data sharing, improve communication and virtually integrate care. Information Sharing PLICC uses two-way information sharing through UHCTransitions (Health BI), which is already used by UnitedHealthcare Community Plan staff and ACO provider partners. Our long-term goal is to leverage Arizona s Health Current as the underlying data exchange technology tool. We are committed to working with AHCCCS and care providers to further develop and expand the adoption of Health Current. PLICC care providers can access timely, actionable data (HIPAA/state compliant), like: Admissions, Discharges and Transfers (ADT) data Member risk stratification, including special health care needs designation and diagnosis information Quality care opportunities What s Included in PLICC PLICC focuses on three key PLICC care provider activities with the goal to generate care provider participation: Health Risk Assessment (HRA) Social Determinants of Health (SDOH) screening Integrated Service Plan Development Additionally, as part of holistic member engagement, PLICC care providers should: Outreach for inpatient discharge and follow-up appointments Outreach for emergency room use and follow-up appointments Offer post-stabilization care and support for individuals following a crisis event Submit internal referral to engage Health Plan Care Management or Specialty Liaisons as needed, based on member complexity and expertise needed Submit referrals to social service providers using Healthify and other resources based on the integrated service plan 4

5 Identifying Eligible PLICC Members A member is eligible for PLICC members if they meet the following criteria: A UnitedHealthcare Community Plan AHCCCS Complete Care member with at least one physical and one behavioral health diagnosis and evidence of increased risk of adverse health outcomes Require physical health and behavioral health care providers to co-manage their care Determined to be eligible by UnitedHealthcare Community Plan or a PLICC care provider using the following criteria: UnitedHealthcare Community Plan Criteria: we use a proprietary, industry-leading process that uses analytics and clinical expertise to stratify members by level of integrated clinical risk, including evidence-based gaps in care. Data inputs include behavioral, physical, and social determinant data (including ICD-10); continuity of care data, admit, discharge, and transfer; historical claims; other data such as AHCCCS supplemental data. PLICC Care Provider Criteria: not all PLICC eligible members will be identified through claims and utilization data due to day claims lag. We empower PLICC providers to use their expertise and relationship with the member to proactively identify PLICC eligible members when the member shows evidence of increased risk of adverse outcomes based on: A completed health risk assessment and social determinants of health screening A clinical determination based on patient encounters Recent admissions or emergency room utilization resulting from these diagnoses Increased risk of adverse events associated with medication adherence issues Being identified as Special Health Care Needs as defined by AHCCCS An integrated health profile is created for each member, which includes: An overall risk score Physical and behavioral health diagnoses Assessment results Claims history Care team members Gaps in care Information Sharing This information allows internal and external care managers, care providers and other constituents of the care team to easily access each person s individualized needs. A member is PLICC eligible if assigned to a PLICC participating PCP and/or a PLICC participating behavioral health home provider. MEDICAL RULE(S) Medical and Behavioral Cormorbidities Examples BEHAVIORAL RULE(S) Chronic Obstructive Pulmonary Disease (COPD) diagnosis on 2 or more inpatient/er events (Age > = 18) AND Schizophrenia non-adherence to antipsychotic medications Coronary Arterry Disease (CAD) diagnosis on 2 or more ER events AND Depression non-adherence to antidepressant CAD diagnosis on an inpatient event (claims) AND Drug interaction: opiates and benzodiazepines Asthma diagnosis on an inpatient event (Asthma out of control) AND 2 or more admissions for psychiatric condition without record of antipsychotic medications OR low adherence to antipsychotic medication Diabetes with renal condition but not on an ACE or ARB AND Evidence of high level of opioid use New ER visit with total of 4 or 5 ER visits in the last 6 months, without corresponding inpatient events AND Substance use disorder - Readmission in past 90 days 5

6 Special Health Care Needs Populations Defined by AHCCCS as a person with a serious and chronic physical, developmental, or behavioral conditions requiring medically necessary health and related services of a type or amount beyond that generally required by members. The services will last, or are expected to last, one year or more and may require ongoing care not generally provided by a PCP. When a PLICC care provider determines a member with special health care needs could/should benefit from further evaluation for Arizona Long Term Care System (ALTCS) a referral to the Health Plan ALTCS Coordinator should occur. AHCCCS has determined that the following populations meet this definition: Members with qualifying Children s Rehabilitative Services (CRS) conditions Members diagnosed with HIV/AIDS Members diagnosed with opioid use disorder, separately tracking pregnant members and members with comorbid pain and opioid use disorder Members who are being considered for, or are actively engaged in, a transplant process and for up to one year post transplant ALTCS members who are elderly and/or have a physical disability ALTCS members who have a developmental disability Members who are engaged in care or services through the Arizona Early Intervention Program (AzEIP) Members who are enrolled in the Comprehensive Medical and Dental Program (CMDP) Members who transition out of the CMDP up to one year post transition Members determined to have a serious mental illness Any child that has a Child and Adolescent Service Intensity Instrument score of 4+ Members who have a seriously emotionally disturbed diagnosis flag in the system Substance exposed newborns and infants diagnosed with neonatal abstinence syndrome Members diagnosed with severe combined immunodeficiency Members with a diagnosis of autism or at risk for autism Member Participation Members will be considered participating in PLICC unless they opt out. The goal of PLICC is for care providers to address unmet needs by developing strategies, in partnership with the member that will advance member self-management skills that improve quality of life. PLICC care providers will discuss the benefits of participating in PLICC and will document in UHCTransitions (Health BI) if the member has chosen not to participate. Once a member has chosen to participate, PLICC care providers will document an interdisciplinary care team (ICT), as well as what types of protected health information (PHI) the member agrees can be shared with the ICT. 6

7 PLICC CARE PROVIDER ACTIVITIES PLICC care providers agree to care coordination and data sharing activities required for payment, which includes, but is not limited to: Completion, review, update and attestation of a health risk assessment Completion, review, update and attestation of a social determinants of health assessment Development of an integrated service plan or plan of care and completion, review, update and attestation, as needed Referrals for needed services Required PLICC Provider Activities in UHCTransitions (Health BI) ACTIVITY DESCRIPTION MAXIMUM FREQUENCY (QUARTERLY) Completion of a Health Risk Assessment Completion of a Social Determinant of Health Screening Development of an Integrated Service Plan Captures baseline information that can determine if members need more in-depth evidencebased assessments or referrals for further evaluation. Timeline for Completion: Within 30 days of the member being identified as PLICC eligible If not completed within 60 days of member being identified, a system alert will be generated If not completed within 90 days of member being identified, a system alert will be generated and the health plan will outreach to determine if engagement support is necessary Captures factors that can influence health disparities and may impact the ability of a member to access adequate and timely care and services. This assessment will determine the types of formal and informal community supports that member may need, as well as identify any resources and referrals needed to address these concerns. Timeline for Completion: Within 30 days of the member being identified as PLICC eligible If not completed within 60 days of member being identified, a system alert will be generated If not completed within 90 days of member being identified, a system alert will be generated and the health plan will outreach to determine if engagement support is necessary Development of the service plan and ongoing care coordination include providing condition specific interventions, strategies, and education to members with identified targeted needs. This is a collaborative process. The care provider will ask for input from the member and/or their caregiver (with the member s permission), and the interdisciplinary care team, including but not limited to specialists, social workers, community program support, and behavioral health specialists. Member preferences and goals of care, including cultural and linguistic needs are included. Timeline for Completion: When the health risk assessment, social determinant of health screening and any other evidenced-based assessments are completed Within 30 days of the member being identified as PLICC eligible If not completed within 60 days of member being identified, a system alert will be generated If not completed within 90 days of member being identified, a system alert will be generated and the health plan will outreach to determine if engagement support is necessary Initial review, completion, attestation, and upon change in condition Review and attestation Initial review or completion, and upon change in condition Review and attestation Initial plan development or completion Review and attestation or when there is a change in condition 7

8 Data Availability Additional available data is in the UHCTransitions (Health BI) system. Care providers can use this data in an effort to efficiently manage PLICC eligible members. Information will include, but is not limited to: Inpatient discharges Emergency Room Utilization Laboratory Data Secure Messaging for Team Partners Care Opportunities Case Duration PLICC represents longitudinal care coordination, with the primary focus being on the relationship between the care provider and the member. The PLICC care provider will determine the frequency of the necessary activities to be billed, and will be reimbursed according to activities completed on a quarterly basis. 8

9 COLLABORATION AND COMMUNICATION An important approach to member-centric care is the collaborative and iterative service plan development process with the interdisciplinary care team. This team consists of the member, family/representatives, PCP, behavioral health providers, peer support specialists, behavioral community support worker and/or therapist, and any other individual or entity the member wishes to have as part of his or her care delivery. This addresses care coordination for members across the entire continuum of their care to not only meet the member s clinical needs but to provide bio-psychosocial coordination and integration critical to improving and maintaining their health status. Physical and Behavioral Health Integration Members identified as having comorbid (physical and behavioral) conditions and a care opportunity will receive an integrated approach to care. The PLICC care provider will assess the member s needs using evidence-based screening tools, as well as the health risk assessment and social determinants of health tools provided by UnitedHealthcare Community Plan. Development of an integrated service plan ensures the member s physical, behavioral health and social/environmental health care concerns are addressed holistically. As part of integrated care delivery, the team will focus on addressing physical and behavioral health, social determinants of health, wellness and recovery, trauma-informed care philosophies, and system of care principles that drive meaningful physical and behavioral health solutions for members that will help them achieve their goals. Transition Between Managed Care Organizations The health plan agrees to protocols for hand-offs and data sharing to ensure timeliness, quality of services, and continuity of care through: Care coordination initiated contacts to further evaluate member needs and services using the health risk assessment and social determinants of health screening tools Prioritization of high-risk members and addressing urgent concerns and needs Handoffs due to a member moving from one managed care organization to another will be completed through case conferences, as requested. The transfer of transitional care data will be based on the requirements outlined by AHCCCS. 9

10 Whole Person Care Health Plan Care Management The Whole Person Care program philosophy and structure helps ensure member needs are addressed holistically. Medical, behavioral and social/environmental concerns are targeted by engagement of members, community partners, and care providers working together. The primary goal is to ensure the person receives the right care from the right care providers in the right place and at the right time. The program targets members who have a higher persistency of healthcare utilization and may have chronic and complex emerging risk. The goal is to focus interventions on members with complex medical, behavioral, social, pharmacy and specialty needs. This should result in better quality of life for members, improved access to healthcare, and reduction of healthcare expenses. The Whole Person Care team will engage the physical and behavioral health care providers as part of the ICT to develop an integrated care plan. For members being managed by PLICC care providers, the Whole Person Care team may be engaged for members requiring more intensive care management solutions on a short-term basis. This would be on a case-by-case basis, and would include involvement of the PLICC care provider as part of the ICT, with the goal to transition the member back to the PLICC care provider for continued care coordination. Healthify Coordinate PLICC care providers will have access to Healthify, a web-based, mobile-friendly community resource tool. Healthify offers social services, empowering users to bridge the gap between health care and social needs. The search functions allow users to sort by type of service and preferred location. Every resource includes a map, contact information, eligibility requirements and service hours. An algorithm searches public websites and sources, such as 211 directories, to identify community resources. Each resource is validated before it is added it to the database. Detailed information for each resource, including services offered, contact information, intake requirements, service hours and languages spoken. Enables users to rate the community resource using a 5-star scale. Ratings are available to other users when searching for resources for a member. Users can also favorite community resources for convenient access as they log in to Healthify. Allows users to submit edits to the resource listing and add available resources to the database. The Healthify verification team validates all resources before adding them to the database. 10

11 PROGRAM OVERSIGHT Quality Assurance PLICC back-end reports will allow the health plan to monitor completion rates for PLICC activities as part of program oversight. At minimum these reports will include Participation rates (opt-in/opt-out) Activities completed or attested to: a. Health risk assessment b. Social determinants of health c. Integrated service plans Established Threshold The goal would be to establish an initial completion rate threshold for PLICC activities which will be utilized for baseline year of this pilot with the understanding that this pilot period (Year One Baseline) will include collaborative dialogue from PLICC participating providers to adjust the completion rate thresholds (Year Two Baseline to Re-measurement 1). Proposed Measurement period: Oct. 1, 2018 Sept. 30, 2019 Baseline Goals (see below) Rate/Results Medical and Behavioral Cormorbidities Examples VOLUME OF ELIGIBLE PLICC MEMBERS 1 TO BE MANAGED ACTIVITIES COMPLETION RATE (COUNT IS RELEVANT TO MEMBERS THAT ARE ELIGIBLE FOR PLICC AND HAVE CHOSEN TO PARTICIPATE) QUARTERLY COMPLETION RATES ANNUAL COMPLETION RATES STATISTICAL TEST SIGNIFICANCE 2 Less than percent TBD TBD TBD percent TBD TBD TBD percent TBD TBD TBD percent TBD TBD TBD More than percent TBD TBD TBD 1 UnitedHealthcare Community Plan estimates that approximately 10 percent of its members may be eligible for the program 2 If used, specify the test, p value, and specific measurements (e.g., baseline to re-measurement 1, re-measurement 1 to re-measurement 2, or baseline to final re-measurement, etc.) included in the calculations. 11

12 PLICC Billing Guidelines Care providers may bill the PLICC code on the claim and be paid once per quarter. For a payment to be valid, the following items must be completed: Medical and Behavioral Cormorbidities Examples PAID ACTIVITIES COMPLETED ATTESTATION DEFINITIONS Health Risk Assessment Must be on file in UHCTransitions (Health BI) within the calendar year One of the following must be true: Posted and attested Updated and attested Reviewed and attested Completed: all questions answered Reviewed: no update made Attested: was reviewed Updated: one or more question(s) updated in the quarter Social Determinants of Health Must be on file in UHCTransitions (Health BI) within the calendar year One of the following must be true: Posted and attested Updated and attested Reviewed and attested Completed: all questions answered Reviewed: no update made Attested: was reviewed Updated: one or more question(s) updated in the quarter Integrated Service Plan Must be on file in UHCTransitions (Health BI) within the calendar year One of the following must be true: Posted and attested with member s signature Updated and attested with member s signature Reviewed and attested with member s signature Completed: all questions answered Reviewed: no update made Attested: was reviewed Updated: one or more question(s) updated in the quarter PLICC claims must be submitted as follows: PLICC enhanced payment should only be billed for PLICC members identified by UnitedHealthcare Community Plan or a PLICC provider who determines the member meets the specific criteria as stated above. Only one unit may be billed per PLICC member, per quarter UnitedHealthcare Community Plan will not pay for more than four dates of service within the plan year per PLICC member PLICC claim must be submitted on the CMS 1500 Claim Form UnitedHealthcare Community Plan will reimburse providers per their contracted rate and in accordance with this guide. 12

13 For physical services, PLICC contracted providers must bill the CPT code, along with one of the following codes, within the same quarter. NEWPATIENT ESTABLISHED PATIENT For behavioral health services, PLICC contracted provider must bill HCPCS code H0025 with modifier 22, along with one of the following codes, within the same quarter: NEWPATIENT H H H H ESTABLISHED PATIENT For FQHC and Integrated Clinic care providers, claims must be submitted under the individual rendering care provider national provider ID number (NPI) and not the FQHC or IC NPI or claims will be denied. Physical/Medical Sample Claim , , Behavioral Health Sample Claim Behavioral Health Sample Claim , H ,

14 Payment Schedule Quarter 1 (January March) Quarter 2 (April June) Quarter 3 (July September) Quarter 4 (October December) Additional rules may apply and include, but are not limited to: Lessor of logic Timely filing guidelines Correct coding Reconsideration and dispute process Standard prior authorization guidelines Coordination of benefits rules Claims can be submitted electronically or mailed to the following addresses: For more information about submitting claims electronically, go to UHCprovider.com/EDI. Medical UnitedHealthcare Community Plan P.O. Box 5290 Kingston, NY Electronic Payer ID: Behavioral United Behavioral Health P.O. Box Salt Lake City, UT Electronic Payer ID: PLICC Auditing and Oversight The health plan will monitor timely completion of PLICC provider activities through claims submissions and audits of the attestation records to ensure alignment with the PLICC provider payments. Clinical staff are able to monitor timely completion of activities through system-generated alerts. These alerts will remind PLICC care providers and health plan staff to complete the quarterly PLICC care provider activities. Monitoring and oversight will include, but is not limited to: System generated alerts in UHCTransitions (Health BI) at 30, 60 and 90 days when PLICC care provider activities aren t completed System generated alerts in CommunityCare at 60 and 90 days when PLICC care provider activities aren t completed Health plan staff will outreach to the PLICC care provider when activities haven t been completed and determine what actions to take 14

15 MONITORING AND EVALUATION At a minimum, the PLICC care provider reviews the member s compliance with the service plan quarterly. Treatment, including medication adherence, is established as a health care goal and interventions and progress toward that goal are documented in each assessment session. At any point the PLICC care provider feels the member is not adhering to the service plan, the PLICC care provider will: Work to identify and understand the member s barriers to success Find alternative solutions Report non-adherence to the ICT and offer potential solutions and incorporate feedback Facilitate agreement for change between all parties and monitor progress Measuring Care Coordination Effectiveness UnitedHealthcare Community Plan uses quality, utilization, and operational indicators to determine effectiveness of the PLICC interventions. Through the annual review process, data is analyzed and goals will be established for the following year. The indicators will be measured against goals on an ongoing and annual basis. When performance is not favorable, a barrier analysis will be conducted to identify the root causes impacting performance. Based on this analysis, actions will be identified for implementation in the effort to reduce or remove barriers to improve performance. UnitedHealthcare Community Plan also analyzes utilization and operational metrics to determine the impact on PLICC effectiveness. Metrics measured include, but are not limited to, impact of PLICC on: A PCP visit in the last 90, 180 or 360 days Percent of eligible population engaged in PLICC Completion rates for PLICC care provider activities Member and provider satisfaction with PLICC Inpatient utilization Observation status Emergency room utilization Readmission rates Urgent care utilization 15

16 DEFINITIONS AHCCCS Complete Care: AHCCCS s new integrated system that joins physical and behavioral health services to treat all aspects of a member s health care needs. Begins Oct. 1, Health Current: Previously known as Arizona Health-e Connection, this is Arizona s health information exchange. Health Current connects hospitals, labs, behavioral and physical health care providers and allows them to securely share electronic health records for their members. Health Risk Assessment: A health questionnaire used to evaluate a member s health risks and quality of life. This form is available in UHCTransitions (Health BI). Interdisciplinary Care Team (ICT): A team of healthcare professionals from different professional disciplines who work together to manage the physical and psychological needs of the member. Provider-Led Integrated Care Coordination Program (PLICC): UnitedHealthcare Community Plan s integrated care model that emphasizes integration and collaboration between care providers to facilitate a better health outcome and member experience. Social Determinants of Health: Codes that identify the conditions in which people are born, grow, live, work and age. This form is available in UHCTransitions (Health BI). 16

17 UHCTRANSITIONS (HEALTH BI) USER REGISTRATION Group Registration A care provider group administrator can register individual users. PLICC contracted groups must provide the following information for each UHCTransitions (Health BI) user: First name Last name Group TIN Group name/organization name Individual Fill out the PLICCGroupMassRegistration.xls template and it to AZ_PLICC_Registration@uhc.com. The template is available at UHCprovider.com/plicc. Single Registration Individual users providing PLICC services under a group agreement must send an to AZ_PLICC_Registration@uhc.com with the following information to add, update or remove a user from UHCTransitions (Health BI): First name Last name Group TIN Group name/organization name Individual Questions? We can help. If you have questions, please contact your Provider Advocate. You can also call Provider Services at Doc#: PCA _ United HealthCare Services, Inc.