ValueOptions Presents:

Transcription

1 ValueOptions Presents: Applied Behavior Analysts (ABA) Provider Orientation August

2 Discussion Topics Overview of ValueOptions Overview of Operational Areas ABA Service Implementation Clinical Interface & Workflow Administrative Interface & Workflow ProviderConnect Questions and Answers 2

3 3 Overview of ValueOptions

4 ValueOptions Founded in 1983 Committed to principles of recovery and resiliency Diverse client base covering 32 million lives Commercial Division Employer Groups Health Plans Federal Division Public Sector Division 4

5 Our Mission, Vision and Values Our Mission We help people live their lives to the fullest potential. Our Business Focus We are a health improvement company specializing in mental and emotional wellbeing and recovery Our Values Consumer Engagement Integrity Innovation Listen and Respect People Development Joint Accountability 5

6 ValueOptions National Presence 6 Commercial Membership Only Shared Commercial and Public Program/ Medicaid Membership Major service centers Regional support, EAP staff and corporate support offices

7 7 Overview of Operational Areas

8 ValueOptions National Network Services Provider Relations Meeting members behavioral health care needs through a geographically and clinically robust network of providers Engaging in timely and appropriate recruitment to meet member and client needs Collaborative provider partnerships Education and Communication Provider Connect Quality of Service and Access & Availability monitoring Provider Credentialing Must meet ValueOptions minimum criteria for ABA network consideration Completion of the ValueOptions Credentialing Application required for ABA network participation Credentialing Department is NCQA accredited Oversight by the Californian and National Credentialing Committees 8

9 Customer Service Clinical Customer Service Provides the following services to Members and Providers as the front end to the Clinical Department: Claims Customer Service Provides the following services to both Members and Providers: Responds to routine eligibility questions Responds to requests for authorizations Responds to referral requests Education assistance Responds to routine claims, benefits and eligibility questions via telephone, correspondence and web inquiries Facilitates the resolution of complex claims issues via telephone, correspondence and web inquiries Responds to all Administrative Complaints and Appeals via a dedicated Appeal and Complaint Unit Provides dedicated Liaisons to investigate and resolve complex client and provider issues 9

10 ValueOptions Quality Management Quality Management Program Oversight is provided by Medical Director. Key Quality Indicators include but are not limited to: Satisfaction Survey measures Access and Availability of Services geographic access; phone statistics; appointment availability; etc Complaints and Grievances tracking and reporting Patient Safety (adverse incidents and quality of care) Coordination of Care Quality Improvement Activities/Projects Compliance with URAC Standards Compliance with NCQA Standards 10

11 Clinical Referral Assistance Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management Member referral process: Emergencies are followed until disposition Urgent referrals are offered appointments within 48 hours and are called to ensure appointment is kept Providers can contact ValueOptions for referral assistance if needed Providers should contact ValueOptions 24 hours a day/seven (7) days a week if members require higher level of care or increased visit frequency Care Management staff will assist with referral to inpatient or specialty programs 11

12 2 ABA Service Implementation

13 Qualified Autism Service (QAS) Professionals QAS Provider: BCBA-D, BCBA, SLP, LMHP with specialization DUTIES: Designs, Supervises, or Provides Treatment QAS Professional: BCBA, BCaBA DUTIES: Provides Treatment, Assessment, Supervision QAS Paraprofessional: (HS Diploma, BA) DUTIES: Direct Intervention 13

14 Qualified Autism Services Effective, January 1, 2012, ValueOptions, began covering applied behavior analysis (ABA) for all PG&E employees, eligible dependents and retirees Covered diagnoses include Autism, developmental brain disorders known as Pervasive Developmental Disorders (PDD) Other covered pervasive developmental disorders not otherwise specified include: Asperger Syndrome Rett Syndrome Childhood Disintegrative Disorder *These diagnoses along with a diagnosis of being at risk of Autism or PDD will be covered 14

15 Covered Diagnoses Autistic Disorder Atypical Autism Childhood Disintegrative Disorder Asperger's Disorder Rett's Disorder Pervasive Development Disorder not otherwise specified (PPD- NOS) Pervasive Development Disorder At Risk of Autism or PDD 15

16 Covered ABA Codes 16

17 7 Clinical Operations & Referral

18 Assessment and Referral A Customer Services Representative will review benefits, eligibility and transfer the caller to a Licensed Care Manager The Care Manager conducts a clinical assessment, including assessing for any high risk and provides a referral for ABA services The Care Manager continues to work with the family/member to confirm the referral was successful and that member has an appointment for an assessment Once the member is assessed the care manager coordinates with the ABA program to obtain the treatment plan request and clinical information. The request is then reviewed for medical necessity 18

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21 21 Administrative Operations & Workflows

22 Billing & Claims Submission Claims should be submitted using a standard CMS 1500 claim form ABA covered services should be billed directly to ValueOptions For general information regarding eligibility and benefit verifications, pre-certification requests, and claim inquiries please call the member s dedicated toll-free number 22

23 ValueOptions Website ( ValueOptions website contains information about ValueOptions and its business Offers links to information and documents important to providers are located here at the Provider section Access to ProviderConnect ProviderConnect is a secure, password protected site where participating providers may conduct certain online activities with ValueOptions directly twenty four (24) hours a day, seven (7) days a week (excluding scheduled maintenance and unforeseen systems issues) 23

24 ABA Network Specific Site 24

25 25 ProviderConnect

26 ValueOptions Connect System NETWORKCONNECT SM Robust network management and provider relations PROVIDERCONNECT SM Secure, online administrative self-service for providers CARECONNECT SM Superior clinical case management and data collection TELECONNECT SM Easy-to-access telephonic selfservice for providers and members SERVICECONNECT SM Industry-best customer service and issue resolution MEMBERCONNECT SM Online self-service and awardwinning content for members 26

27 ProviderConnect (Provider Online Services) What is ProviderConnect? An online tool where providers can: Verify member eligibility Access ProviderConnect message center Access and print forms 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 re-credentialing applications Increased convenience, decreased administrative processes Disclaimer: Please note that ProviderConnect SM may look different and have different functionalities based on individual contract needs, therefore some functions may not be available or may look different for your specific contract. 27

28 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 28

29 How to Access ProviderConnect? Go to choose Providers. All in-network providers can self register for ProviderConnect using their provider ID number. Self-registration is only available to providers that do not have an existing ProviderConnect electronic account 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 ProviderConnect registration questions or questions about the form referenced above please contact the ValueOptions EDI Helpdesk at (Monday - Friday, 8 am - 6 pm ET) 29

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31 ProviderConnect SM Login Screen 31

32 User Agreement Page 32

33 Search/View Member Eligibility 33

34 Member Eligibility Search 34

35 Member Eligibility Results 35

36 Review an Authorization 36

37 Search Authorizations 37

38 Authorization Search Results 38

39 Authorization Summary 39

40 Recent Authorization Letters 40

41 New Authorization Letters 41

42 Authorization Letter Sample 42

43 Direct Claim Submission 43

44 Direct Claim Submission 44

45 Direct Claim Submission 45

46 Direct Claim Submission 46

47 Direct Claim Submission 47

48 Direct Claim Submission 48

49 View Provider Summary Voucher 49

50 View Provider Summary Voucher 50

51 Provider Summary Voucher Results 51

52 52 Provider Summary Voucher Sample

53 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 For PaySpan Registration Instructions please visit: Provider Support contact information: providersupport@payspanhealth.com Provider Support is available from 8am to 8pm Eastern time, Monday through Friday. 53

54 Provider Contacts California Service Center ABA Provider Network Specific Website Provider Relations, Credentialing and Contracting Questions (8 am - 5 pm ET Monday - Friday) Electronic Claims & ProviderConnect Technical Questions (EDI Help Desk) (8 am - 6 pm ET Monday - Friday) 54

55 55 Questions & Answers

56 56 Thank You