ValueOptions Florida/First Coast Advantage, LLC. Provider Orientation

Transcription

1 ValueOptions Florida/First Coast Advantage, LLC Provider Orientation

2 Agenda and Objectives ValueOptions Florida and First Coast Advantage, LLC Medicaid Program, benefits and services ProviderConnect Authorization process Claims and Claims Status Other features Quality Management Questions 2

3 ValueOptions Overview Market leader in behavioral health care services Experienced and recognized leader in Medicaid program services Respected clinical programs and interventions Approximately 23 million lives under contract 4,600 employees nationwide National Presence with 20 service locations throughout the United States More than 50,000 providers, more than 5,000 facilities 3

4 4 First Coast Advantage LLC is a FFS Provider Service Network (PSN) for Medicaid Reform and Non-Reform counties in Regions 3 and 4. FCA s membership is over 74,000 for Managed Care (Medical Care and/or Integrated Medical and Behavioral Health services) to coordinate benefits for the Medicaid population for (Temporary Assistance for Needy Families (TANF), Aged, Blind and Disabled (ABD) and Dual Eligible.

5 Non Reform Counties: Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter Suwanee and Union Region 4: Flagler, St. Johns and Volusia 5

6 Veronica S. Walton, BA Contract Manager Ext

7 ValueOptions Credentialing & Contracting ValueOptions Florida Contracting & Credentialing Provider Credentialing Application Facility Program Specific Addendums ValueOptions Provider Agreement Florida Medicaid Addendum Fee Schedules Did you get your ValueOptions provider amendment for the First Coast Advantage network, or are you interested in joining the ValueOptions network? Questions about your contract? Call ext (8am 5pm EST) or us at 7

8 Provider Network Participation Requirements In order to participate in the First Coast Advantage, LLC network: Providers must either be participating in the Florida Medicaid program and have an existing Medicaid ID number; or Complete a Managed Care Treating Provider Registration Form to obtain a Medicaid Registration number If you have previously registered with another plan, there is no need to register again. 8

9 Utilization Management ValueOptions medical necessity criteria is available online at Via that website, there is 24 hour access to ProviderConnect which includes a lot of functionality, including a authorization request tool Emergency mental health services will not be denied and do not require prior authorization. Facilities are asked to notice ValueOptions within 24 hours of the emergency admission. Complete discharge planning and outcome assessment is a vital component of the ValueOptions process Care Managers are available 24 hours/day, 7 days/week, 365 days/year We are here to assist you with access to care, referrals and other related clinical questions. Just call

10 Behavioral Health Benefit Coverage Only certain diagnosis codes and procedure codes are covered under the behavioral health benefits for First Coast Advantage. All benefit coverage provisions follow the guidelines outlined within the Florida Medicaid Community Behavioral Health and Targeted Case Management Handbooks. Providers must bill in accordance with the above handbooks in order to obtain reimbursement for services. 10

11 Covered and Non-Covered Behavioral Health Services Covered Services Inpatient hospital care for psychiatric conditions Outpatient hospital care for psychiatric conditions Psychiatric physician services Community mental health services Behavioral Health Targeted Case Management Behavioral Health Intensive Targeted Case Management Psychosocial Rehabilitation Services Therapeutic Behavioral On-Site Services Day Treatment Services Self- Help/Peer Services Crisis Intervention Mental Health Services and Post-Stabilization Care Services Inpatient Substance Abuse Detox Services (members pregnant members only) Non-Covered Services Residential Care Statewide Inpatient Psychiatric Program Services (SIPP) Long- Term Care Institutional Services including Nursing Home, Institution for the Developmentally Disabled, State Mental Hospital. Services to enrollees assigned to a FACT team by DCF (SAMH) office Services for enrollees enrolled in the Child Welfare Prepaid Mental Health Plan (CWPMHP) Specialized Therapeutic Foster Care. Therapeutic Group Services (TGCS) Behavioral Health Overlay Services (BHOS) Comprehensive Assessments Community Substance Abuse Services (excluding members with Co-occurring medically complex diagnosis and pregnant members) 11

12 Behavioral Health Claim Submission Participating providers are encouraged to submit claims electronically through ProviderConnect on the Provider section of the ValueOptions website. Or via mail to the following address: ValueOptions P.O. Box 12699, Department FL Claims, Norfolk, VA Providers who participate with a Clearinghouse should call the EDI Help Desk at

13 13 ProviderConnect

14 ProviderConnect Benefits What are the benefits of ProviderConnect? Free and secure online application Access routine information 24 hours a day, 7 days a week Complete multiple transactions in single sitting View and print information Reduce calls for routine information 14

15 How to Access ProviderConnect? Go to choose Providers. All in-network providers are required to use ProviderConnect to request authorization for services. After registering, if additional ProviderConnect log ons for that same provider ID number are desired, please do the following: Fill out the Online Provider Services Account Request Form and fax the completed form to Additional log on turnaround time is 2 business days If your facility requires separate log ons for Clinical vs. Business Claims staff, a Role-Based Security options is available. ProviderConnect registration questions or questions about the form referenced above please contact the ValueOptions EDI Helpdesk at (Monday to Friday, 8:00 a.m. - 6:00 p.m. ET) 15

16 ProviderConnect (Provider Online Services) What is ProviderConnect? An online tool where providers can: Verify member eligibility Access ProviderConnect message center Access and print forms Request & view authorizations Download and print authorization letters Submit claims and view status Access Provider Summary Voucher Submit customer service inquiries Submit updates to provider demographic information Submit recredentialing applications 16

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19 ProviderConnect Login Screen 19

20 User Agreement Page 20

21 Search/View Member Eligibility 21

22 Member Eligibility Search 22

23 Member Eligibility Results 23

24 Member Eligibility Enrollment History 24

25 Member Eligibility - Benefits 25

26 Authorization Requests 26

27 Request for Authorization Outpatient Services 27

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40 ProviderConnect Service Request Guidelines The primary method for all service requests will be via the web on using ProviderConnect (with the exception of requests for ECT) beginning with an easy-to-use short web form that can be accessed 24/7/365. Providers can then: Log into ProviderConnect and track where the request is in the system, Store completed requests, or print them for paper files, Send messages back and forth to clinicians If a provider does not have online access, they can make telephonic or fax requests for services. Additional information on how to make a service request via ProviderConnect is included in this training as a separate attachment. 40

41 Service Requests Have Rules and Limitations Medicaid Community Mental Health and Targeted Case Management Handbook Rules Apply for Mental Health services only. Some services are deemed duplicative by ValueOptions if done by the same provider on the same day. ProviderConnect is set up to behave differently depending on the type of request made. 41

42 Service Request Protocols for FCA Some services pay without an authorization upon submission of a clean claim as long as Medicaid Handbook(s) Rules and Limitations are met: e.g.: covered evaluations and assessments Some services pay without an authorization upon submission of a clean claim e.g.: mental status exams done in the emergency rooms Some requests will not be denied but will require clinical data before claims come in so ValueOptions can register the event to facilitate claims payment e.g.: Emergency inpatient and post-stabilization services Some requests will pend for clinician review to assess medical necessity or manage high risk benefits e.g.: Non-Emergent hospital admissions, Day Treatment, Inpatient Detox for pregnant women, psych testing 42

43 Service Request Protocols for FCA (cont.) Some requests bounce up against auto-approval rules and the provider will get generous portions of the Medicaid annual limits without ever speaking to a clinician. (The remainder of the benefit will be given based on concurrent review of medical necessity) OP Services: including all therapy, medication management, TBOS, TCM, ICM, PSR These auto-approval rules renew every fiscal year (July 1 st ) Some requests can only be made by phone ECT 43

44 Authorization Requests from ProviderConnect Communication for Additional Clinical Information Overview At times clinicians may require additional information from providers to make medical necessity decisions. For authorization requests submitted via ProviderConnect the clinician can reach out to the provider to request this additional clinically sensitive information. A message is sent to the provider s Message Center on ProviderConnect. Attached to the detailed request for information is a copy of the original request for the provider to reference. The provider can respond back within defined turnaround times (TAT) with the additional information and any attachments they wish to provide. This information will be added to the authorization request for the clinician to complete the review process. If the information is not provided within the defined TAT the provider will need to contact the clinician telephonically to further discuss the authorization request. TAT varies by the type of services being requested. 44

45 ProviderConnect Message Center 45

46 Review an Authorization 46

47 Search Authorizations 47

48 Authorization Search Results 48

49 Authorization Detail 49

50 50 Recent Authorization Letters

51 New Authorization Letters 51

52 Authorization Letter Sample 52

53 Authorization File Download 53

54 Authorization File Download 54

55 Authorization File Download 55

56 Authorization File Download 56

57 Auto-Approval Overview 57

58 Auto-Approval Overview 58

59 Auto-Approval Overview 59

60 Auto-Approval Overview 60

61 Auto-Approval Overview 61

62 Auto-Approval Overview 62

63 63 Additional ProviderConnect Features

64 Direct Claim Submission 64

65 Direct Claim Submission 65

66 Direct Claim Submission 66

67 Direct Claim Submission 67

68 Direct Claim Submission 68

69 View Provider Summary Voucher 69

70 View Provider Summary Voucher 70

71 Provider Summary Voucher Results 71

72 Provider Summary Voucher Sample

73 My Practice Information 73

74 View Provider Practice Information 74

75 Provider Search Results 75

76 Provider Practice Details 76

77 Updating Provider Practice Info 77

78 My Online Registration Profile 78

79 Updating My Online Profile 79

80 ValueOptions EDI (Electronic Data Interchange) ValueOptions will accept claims files from any Practice Management System that outputs HIPAA formatted 837P or 837I files, as well as from EDI claims submission vendors. ValueOptions offers Direct Claims Submission on our website FREE to providers who do not have their own software, or who wish to submit certain claims outside their batch files. These claims are processed immediately, and you are provided the claim number. You may submit batch claims files or Direct Claims interchangeably. You can access our ProviderConnect Helpful Resources site to access additional claims resources. ValueOptions also has a dedicated Helpdesk (8am to 6pm ET) for EDI issues. 80

81 ProviderConnect Message Center (Personalized!) 81

82 Inquiry Details 82

83 ValueOptions Health Alert A program designed to enhance the follow-up care of members. Allows providers to request an automatic phone call reminder of an upcoming appointment for their members. The Health Alert functionality appears on several screens throughout ProviderConnect. Health Alert will also be used to alert providers telephonically about upcoming events, training opportunities and additional reminders. 83

84 PaySpan Health PaySpan Health is a tool that will enable you to do the following: Receive payments automatically in the bank account of your choice. Receive notifications immediately upon payment. View your remittance advice online. Download an 835 file to use for auto-posting purposes. 84

85 Why Register? PaySpan Health is a secure, self-service website. Improved cash flow through automated deposits. Access remittance data 24 hours a day. Access up to 18 months of historical remittance data. Ability to import payment data directly into the practice management systems. Mailbox functionality to automate the delivery of remittance data. Multi-payer solution. It s FREE! 85

86 Registering for PaySpan Health is easy! Register for PaySpan Health online using your registration code. The person who registers will become the Administrator of the account. The address entered during registration will be the Administrators User Name. Add additional users and set levels of access by user. Create additional receiving accounts. Your registration code currently prints on your ValueOptions Summary Vouchers If you do not have a registration code please corporatefinance@valueoptions.com You will receive your registration code within 3 business days 86

87 What do I need to register? Internet connection. Valid address. Your bank routing and account numbers. Registration Code. Your Pay-To Vendor Number (PIN). Tax ID Number. 87

88 How Do I Register? Visit our website at Select the Registration Now button. The New Registration screen will appear. Choose Partner Type: Provider Enter your Provider Identification Number (PIN) and Tax Identification Number (TIN). Select the Register button to continue with the registration process. 88

89 Visit our website at Select the Register Now Button 89

90 Get Started Screen Enter your RegCode, Provider Identification Number (PIN) and Tax Identification Number (TIN). Select the Start Registration button to continue with the registration process. 90

91 Step 1 of 4 Provider Information Screen Complete the required Registration Information questions. The address will become the user name when logging into PaySpan Health. Select the Next button 91

92 Organization Information Screen Complete the required Registration Information questions. The address will become the user name when logging into PaySpan Health. Select the Next button. 92

93 Step 2 of 4 Create a Password Complete the required fields. The password needs to contain at least 8 characters, at least one capital letter, at least one lower case letter and at least one number. Select the Next button. 93

94 Step 3 of 4 Accounting Information Enter an Account Name to identify the receiving account. Note: Providers typically use the Account Name to specify the payee designation. Each payee will have a separate registration code and can therefore have a separate receiving account established. The same routing and account number can be used for multiple receiving accounts. Enter the routing number and account number in the specified fields. Select the Next Button. 94

95 Step 4 of 4 Terms and Conditions Review the Registration Information. Select the Edit button to make any corrections. Read the Service Agreement then check the terms and conditions box if in agreement. Select the Submit/Confirm button. This will complete the registration. 95

96 Registration Success! You will receive an from PaySpan Health upon completing registration. In a few days you will need to verify with your bank that a minimal deposit has been made by PaySpan. This deposit amount will be used to confirm your electronic payments are set up appropriately through PaySpan Health and your bank. You will see this confirmation page the next time you login to using your User Id (your address) and your password. The deposit does not need to be returned to PaySpan. 96

97 How do I login to my account? Select the User Login button on our website and enter your address as your user name. 97

98 PaySpan Provider Support Provider Support contact information: Provider Support is available from 8am to 8pm Eastern time, Monday through Friday. 98

99 99 Quality Management

100 Purpose of our Program Quality Management The purpose of the ValueOptions Florida Clinical Quality Program is to totally integrate all functional operations and service center philosophies to include perspectives from all operational departments to facilitate good member outcomes. The ValueOptions Florida Quality Program has been established to monitor, evaluate and improve the continuity, quality, safety, accessibility and available of behavioral health care and service provided to Enrollees. This is accomplished by: Monitoring, evaluating and improving the quality and appropriateness of care and service delivery to Enrollees through performance improvement projects (PIPs), medical record audits, performance measures, surveys, and related activities; Promoting improvement in the quality of care provided to Enrollees through established processes; Adhering to all contractual federal, state, corporate and accreditation standards; Ensuring that all members of ValueOptions Florida s multi-disciplinary team participate in quality management and performance improvement processes; Identifying best practices for performance and quality improvement; and Ensuring local written policies and procedures address components of effective health care management including, but not limited to: anticipation, monitoring, measurement, evaluation of Enrollee s health care needs and effective action to promote quality of care. 100

101 PROGRAM OBJECTIVES Quality Management To define and implement improvements in processes that enhance clinical efficiency, provide effective utilization and focus on improved outcome management achieving the highest level of success To demonstrate in its care management, specific interventions to better manage the care and promote healthier enrollee outcomes; To establish assessment guidelines to determine if care by the Providers is rendered in a manner consistent with the highest community standards and practice; To maintain an integrated, system-wide reporting system to monitor and evaluate quality improvement activities at all levels and report results with recommendations in a systematic way both internally and externally, to Providers, the state of Florida and to Medicaid Enrollees; To identify methods to meet and exceed program expectations by ensuring continuous incorporation of results into program modifications; and To comply with all applicable Medicaid rules and regulations in the delivery of service to Enrollees. 101

102 SCOPE Quality Management Clinical Services/Utilization Management Programs; Quality Improvement Activities/Projects; Outcomes Measurements; Satisfaction Surveys; Clinical Treatment Record Evaluation; Services Available and Access to Care; Practitioner and Provider Quality Performance; Complaints and Grievances; 102

103 Quality Management SCOPE, con t Member Rights and Responsibilities; Patient Safety Activities; Clinical and Administrative Denials and Appeals; Quality Indicator development and monitoring activities; and, Health Literacy and Cultural Competency 103

104 Quality Management YOUR ROLE AS A PARTICIPATING PROVIDER Participation in the Provider Network requires the following quality activities: Complete all corrective action plan requests within specified timeframes; Submit all required datasets Develop and implement policies/procedures that are necessary to meet AHCA contract requirements; Participate in Performance Improvement Plans required by EQRO per AHCA contract; Submit all Critical Incidents for plan members as they occur complying with policy; Complete all actions necessary to resolve Grievances that are submitted by members related to the provider s performance; Maintain compliance with Access to Care standards and availability of mandatory services; and Cooperate and participate in regular Treatment Record Audits conducted by the Quality Department. 104

105 Treatment Record Audits Quality Management Providers will be required to participate in quarterly administrative monitoring and review of a random selection of records ValueOptions uses the Agency s audit tool for Clinical and Targeted Case Management records. This is in effort to enhance inter-rater reliability and standardize the review of the clinical record among ValueOptions, other Health Plans and the Agency. The Performance Standard for records reviewed at each Provider Agency is an overall score of 85% with no corrective action. If Inpatient, TCM and Outpatient records are all reviewed, a separate overall score will be given for each. Each individual category (in TRAT) reviewed must obtain an overall annual score of at least 85%. Again, a separate overall score will be given for specific types of record reviews. 105

106 Treatment Record Audits Quality Management Audit process and disputes. Soft copies of the results will be provided via encrypted to the provider agency. Results will be reviewed quarterly in FCA s Quality Improvement/Utilization Management Committee and will be discussed and used for quality improvement initiatives. Non-routine Targeted Reviews. Outcomes of NON-routine Targeted Reviews may lead to notification of the Compliance Manager. 106

107 Quality Management REQUIRED DATA SETS Critical Incidents ValueOptions manages the tracking, review and reporting of critical incident process as the MBHO for FCA. Analysis of adverse incidents is a confidential, internal risk management procedure working at the request of FCA, AHCA and for the purposes of Quality Management and related tracking. ValueOptions reports Critical Incidents immediately to FCA who in turn reports to AHCA as defined in the Contract. Network Providers are required to complete information related to all critical incidents. All critical incidents are forwarded to the Quality Improvement (QI) Department for review. QI staff review the report for required elements. When information is missing from the report, a request is sent to the provider for completion. The QI Department, the Medical Director and Director of Clinical Operations review the critical incident and may make recommendations regarding further actions necessary, including a further investigation of the incident and follow-up actions needed. The critical incident may also be forwarded to ValueOptions Quality of Care Committee for review, investigation and to recommend follow-up action(s). Please contact the ValueOptions Florida Quality Department for complete requirements. Critical Incidents are to be submitted on the AHCA-defined template and submitted to TampaQi@valueoptions.com upon notification or identification of the incident. 107

108 Critical Incidents Reportable Events Quality Management Death of an enrollee while the enrollee is in a facility operated or contracted by the health plan or in an acute care facility due to one of the following: - Suicide; - Homicide; - Abuse; - Neglect; or - An Accident or other incident that occurs while the enrollee is in a facility operated or contracted by the health plan or contracted by the health plan or in an acute care facility. Enrollee injury or illness A medical condition that requires medical treatment by a licensed health care professional and which is sustained, or allegedly is sustained, due to an accident, act of abuse, neglect or other incident occurring while an enrollee is in a facility operated or contracted by the health plan or while the enrollee is in an acute care facility. Sexual battery while the enrollee is in a facility operated or contracted by the health plan or in an acute care facility An allegation of sexual battery, as determined by medical evidence or law enforcement involvement, by: - An enrollee on another enrollee; - An employee of the health plan, a provider or a subcontractor, an enrollee; and/or - An employee on an employee of the health plan, a provider or subcontractor 108

109 Critical Incidents Reportable Events, con t Quality Management Medication errors in an acute care setting; and/or Medication errors involving children/adolescents in the care or custody of DCF. Enrollee suicide attempt An act which clearly reflects an attempt by an enrollee to cause his or her own death while an enrollee is in a facility operated or contracted by the health plan or while the enrollee is in an acute care facility, which results in bodily injury requiring medical treatment by a licensed health care professional. Altercations requiring medical intervention Any untoward or adverse event that requires medical intervention other than minimal first aid treatment occurring while an enrollee is in a facility operated or contracted by the health plan or while the enrollee is in an acute care facility. Enrollee escape To leave a locked or secured facility operated or contracted by the health plan or an acute care facility without notice or permission. Enrollee elopement To leave a facility operated or contracted by the health plan, an acute care facility, vehicle or supervised activity that would endanger an enrollee s personal safety. 109

110 REQUIRED DATA SETS, Con t Quality Management Children s Functional Assessment Rating Scales (CFARS) and Functional Assessment Rating Scales (FARS) Providers are required to administer/complete CFARS and FARS on all individuals receiving behavioral health services and upon termination of providing such services. Providers are required to maintain the results of the assessment tools in each individual s clinical record Required to submit to ValueOptions CFARS and FARS data in a ASCII flat, fixed-length record text file on a semi-annual basis. Providers will be required to submit Functional Assessment data (CFARS and FARS) semi-annually, every January and July 20 th of the previous six-month period. The file layout will be provided to participating providers to submit the data set. CFARS and FARS data will be submitted via to TampaQi@valueoptions.com Technical Assistance can be provided to Network Providers for the data submission. Please contact the Quality Department so that can be coordinated. 110

111 Quality Management Who we are and how to reach us.. Jaclyn Santucci Director, Quality Improvement Eileen Sims Quality Management Specialist Edmund Wonder Quality Improvement Analyst Gisela Vazquez-Soto Quality Improvement Analyst

112 112 Wrap Up

113 Contact Information- General For Claims, Eligibility, Authorizations and General Questions: Florida Provider Relations ext (8am 5pm EST) First Coast Advantage, LLC: Provider Customer Service:

114 Contact Information ValueOptions Florida: Ken Hacek Director, Provider Relations ext Michelle Clavecilla-Chan Director, Clinical Operations ext Jaclyn Santucci Director, Quality Improvement ext First Coast Advantage, LLC: Veronica S. Walton, BA Contract Manager: Ext

115 115 Questions?

116 116 Thank You