Participating Provider Manual

Transcription

1 Participating Provider Manual Revised November 2012

2 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER SERVICES Page 7 Intake Coordinators Referrals by member Referrals by providers Benefits eligibility 3. UTILIZATION MANAGEMENT Page 8 Philosophy Authority Utilization Management (UM) Decision-Making Conflict of Interest The Scope of the Annual Utilization Management (UM) Program Communication Services Regarding UM Processes and UM Inquiries Clinical Criteria Medical Necessity Referral and Clinical Review Processes Emergency Services and Urgent Care Review Initial Clinical Review Pre-service Urgent Care Review Concurrent Urgent and Nonurgent Care Reviews Post-service Review Certification Determination Network Provider Utilization Management Processes for Post-Service Review of Emergency Services Peer Clinical Review Use of Clinical Consultants Medical Necessity Denials Medical Necessity Expedited (Urgent Care), and Standard (Pre-service and Post-service) Nonurgent Appeals Benefit Denials Practitioner Satisfaction with Psychcare UM Processes UM Information Contained on the Psychcare Website 4. NETWORK MANAGEMENT Page 18 Provider recruitment Request to join the network process Rev. November

3 Notification of Request to join process outcome Availability standards GeoAccess Network composition Provider training Provider complaints Accreditations 5. INITIAL CREDENTIALING & RECREDENTIALING Page 22 Application submission Basic credentialing elements for participation, based on government, accrediting agencies, and client standards Federal, state, and accreditation standards Time frame for completion of credentialing process Site visits prior to submission to Credentialing Committee Notification of Credentialing Committee decision Credentialing cycle/recredentialing Maintenance of credentialing file between cycles Ongoing monitoring 6. REVIEW OF KEY CONTRACT COMPONENTS Page 28 Missed appointments Breach of contract Billing members for covered services Billing members for non-covered services Termination Continuity of care for members following termination of member Provider Notification Responsibilities (i.e. Changes of address, TIN, holds, terminations, etc.) 7. CLAIMS Page 31 Claims Processing Timely submission Electronic claims Paper claim form types Paper claim forms submission address Clean claims Remittances Authorization numbers on claims Prompt payment Resubmission of clams Claim questions answered via Psychcare s online portal Claim questions not answered via Psychcare s online portal Address change notifications Rev. November

4 8. QUALITY MANAGEMENT Page 35 Philosophy Authority and Accountability Quality Improvement Program Goals Scope of the QI Program Psychcare Clinical Management Guidelines Management of Members with Complex Health Needs Psychcare Clinical Management Guidelines Psychcare Preventive Health Programs Continuity and Coordination of Care Continuity and Coordination of Care among Psychcare Practitioners Continuity and Coordination of Care between Behavioral Health and Medical Care Serving a Culturally and Linguistically Diverse Membership Health Literacy, Cultural and Linguistic (Limited English Proficiency) Resources Member Safety Potential Quality of Care and/or Member Safety Instances Investigation of a Potential Quality of Care and/or Member Safety Instance Confirmed Quality of Care or Member Safety Instances Follow-Up Risk Reporting Privacy Practices Members Rights and Responsibilities Member Satisfaction Member Complaint Reporting Annual Commercial, Medicare, and Michigan Medicaid Member Satisfaction Survey Annual Florida Medicaid Consumer Satisfaction Survey Accessibility and Availability and Acceptability of Care and Services Access to Care Medicare Performance Goals: Florida Medicaid Performance Goals: Commercial Performance Goals: Availability and Acceptability of Services Network Practitioner and Provider Confidentiality Fraud, Waste and Abuse Prevention 9. PREVENTIVE HEALTH Page LIFE S SOLUTIONS EMPLOYEE ASSISTANCE PROGRAM Page CONTACT LIST Page 53 Appendix A: Link to provider resources Page 54 Appendix B: Psychcare Website Page 56 Appendix C: Medicaid Addendum Page 57 Appendix D: Network Practitioner Outpatient Documentation Requirements and Review Tool Page 73 Appendix E: Practitioner s Statement of Receipt of Participating Practitioner Manual Page 75 Rev. November

5 1. INTRODUCTION Psychcare, LLC s Management Team Psychcare, LLC, founded by Rodolofo Hernandez, MD, joins with the following management team in welcoming you to Psychcare s provider network! Daniel Hernandez, Senior Executive Vice President, and Chief Operating Officer Jordi Cuervo, Vice President, Operations Mission Statement Psychcare s mission is to establish and continue long-term partnerships with our clients through our commitment of providing quality behavioral healthcare and Employee Assistance Program (EAP) services, both of which meet the needs of our clients, as well as their members. Client satisfaction occurs through the collaboration of Psychcare s team of dedicated and ethical staff members, who work with skilled and professional practitioners, providers and community agencies (provider network) in Psychcare s network model. Psychcare s commitment to client retention and quality care increases the value our clients derive from services offered through both Psychcare s behavioral healthcare products, as well as from our EAP product, delivered through Psychcare s subsidiary, Life s Solutions. Company Background Psychcare has experienced tremendous growth in recent years, and because of our growth, we have expanded our products to include: Life s Solutions, a national EAP program Disease Management Programs Wellness Programs A Dependent Care Program PharmAssist Program In the mid-80 s, Psychcare began as an EAP program, EmploAssist. Since that time, Psychcare has grown into an accredited MBHO, with a subsidiary called Life s Solutions.. Psychcare, LLC, is a comprehensive MBHO that specializes in managing mental health and substance abuse benefits for HMOs, PPOs, and large employer groups. Psychcare also is experienced in providing EAP services to a wide variety of companies and governmental entities. Psychcare is proud of its strong history of client retention. Some of Psychcare s clients have been with the company for 15+ years, and others have returned to Psychcare after experiencing the differences in working with other Managed Behavioral Healthcare Organizations. Psychcare s staff offers service that is consistently rated excellent in customer satisfaction surveys. Psychcare hopes that you will find this manual to be a helpful resource in learning the processes to follow when treating members managed by Psychcare. Hard copies are available for most of the resources, if you do not have the ability to download the information from a website. Accreditations Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare s commitment to quality is evident by its continuous full accreditation status with URAC since 1998, as well as its full accreditation status with the National Rev. November

6 Committee for Quality Assurance (NCQA) since These accreditations are evidence of Psychcare s ongoing measures which promote and provide for quality care and service to members managed by Psychcare. Provider Network Psychcare s provider network is very important to us! Psychcare s management team fosters a united effort between Psychcare and its provider entwork. The mutually-cohesive and collaborative work relationship between Psychcare s staff members and the contracted Psychcare provider network results in the provision of effective, efficient, timely, and appropriate treatment services, rendered to both the managed behavioral healthcare (MBHO) and the EAP members, all of whom are serviced by Psychcare. Rev. November

7 2. MEMBER SERVICES Intake Coordinators Intake Coordinators are bilingual (English/Spanish). Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call, a service which is available Monday through Friday, from 8:30 AM to 5:30 PM, Eastern Standard Time (EST). Intake Coordinators provide direct access to callers on eligibility information, routine referrals, and authorizations. Intake Coordinators transfer calls, as appropriate, to licensed clinicians and/or other departments for assistance. Member Referrals Members can access referrals by calling Psychcare s toll-free telephone number of ( ). Lists of providers are available electronically, by fax, or mail. In addition, referrals can be given telephonically at the member s request. Once an appointment is obtained, the member or the provider will receive an authorization telephonically or online. Provider Referrals For the purposes of coordination of care, providers are encouraged to contact Psychcare for network referrals for therapy and/or medication management. Benefits Eligibility Psychcare has updated benefit eligibility information and manages benefits based on clinical criteria, benefit plan coverage and service requests. Rev. November

8 3. UTILIZATION MANAGEMENT Philosophy Psychcare s philosophy is to monitor the quality, safety, and appropriateness of clinical care and services rendered by our provider network, to verify that accepted national and community standards are being provided within the scope of federal and state regulations and laws. Psychcare s Utilization Management (UM) program provides a mechanism for monitoring utilization of services, and ensuring delivery of quality and cost-effective behavioral healthcare. UM activities are an integral part of Psychcare s Quality Improvement Program. Psychcare makes decisions whether to approve or not approve payment for services based only on the appropriateness of the care or service, and on the coverage available in the member s benefit plan. Authority Our Board of Directors delegated approval authority of the annual Utilization Management Program, and policies related to key services and related programs to the Psychcare Medical Director, a Board Certified Psychiatrist who holds a valid, active, and unrestricted medical license to practice at a minimum in the State of Florida. Utilization Management (UM) Decision-Making Psychcare affirms the following: UM decision-making is based only on appropriateness of care and service and the existence of coverage; Psychcare does not specifically reward practitioners or other individuals for issuing denials of coverage or service care; Psychcare does not provide financial incentives for UM decision-makers, and Psychcare does not encourage decisions that result in underutilization. UM decisions are based on both the members benefit coverage, and: Psychcare s Level of Care Clinical Criteria for all Florida Commercial and Medicare members, as well as Medicaid members outside the State of Florida, and Florida s Medicaid Level of Care Guidelines for Florida Medicaid members. If you would like a hard copy of either UM decision-making criteria or guidelines, please contact Psychcare at our toll-free telephone number of ( ). Conflict of Interest Conflict of interest is defined as any relationship or affiliation on the part of the Psychcare staff or clinical peer reviewers that could compromise the independence or objectivity of the utilization management process. Conflict of interest includes, but is not limited to: An ownership interest of greater than 5% between any affected parties A material professional or business relationship A direct or indirect financial incentive for a particular determination Incentives to promote the use of a certain product of service Rev. November

9 A known familial relationship Any prior involvement in the specific case under review Conflicts of interest are reviewed as part of new hire training, and annual clinical staff trainings for all clinical peer reviewers, licensed clinical staff and non-licensed clinical staff. The Scope of the Annual Utilization Management (UM) Program The scope of the annual UM Program includes the following the following core activities: Communication Services Triage and Referral Processes Clinical Review Processes Complex Health Needs Serving a Culturally and Linguistically Diverse Membership Continuity and Coordination of Care Interrater Reliability Clinical Trainings Client-based Over and Underutilization Monitoring Member Satisfaction with UM processes Practitioner Satisfaction with UM processes Communication Services Regarding UM Processes and UM Inquiries Members, the member s authorized representative, practitioners and providers have access to our clinical staff 24 hours per day, 7 days per week via our toll free telephone number for questions about our UM processes or UM issues. The clinical staff is available for inbound communications from members, practitioners, and providers regarding UM issues and/or UM processes during business hours, Monday through Friday (excluding holidays), 8:30 AM to 5:30 PM Eastern Standard Time, via our toll free number, (800) or by accessing our TDD/TTY services through the Florida Relay Number, 711, a communications link for people who are Deaf, Hard of Hearing, Deaf/Blind, or Speech Impaired; and also by fax and . Bilingual (English/Spanish) staff members are available to assist members, practitioners, and providers, during business hours. Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call. After business hours, weekends, and holidays, members, practitioners, and providers can reach an on-call case manager, a licensed clinician, regarding questions about UM issues and/or UM processes, via our toll free number, (800) , or by accessing our TDD/TTY services through the Florida Relay Number, 711, a communications link for people who are Deaf, Hard of Hearing, Deaf/Blind, or Speech Impaired; and also by fax and . Bilingual (English/Spanish) on-call case managers are available to assist members, practitioners, and providers, after business hours, weekends and holidays. Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call. Upon request, the clinical staff informs members, network practitioners, network providers, including, but not limited to, the attending psychiatrist and utilization management staff, of specific utilization management requirements and procedures. The clinical staff returns calls, faxes and/or s regarding UM inquiries or UM issues during normal business hours within one (1) business day, unless otherwise agreed upon. Emergency after hour, weekend and holiday calls are Rev. November

10 responded to within 30 minutes from receipt of the call. Nonurgent calls received from 5:30 PM to 8:30 AM, Monday through Friday, along with calls received weekends and holidays, are responded to by a case manager no later than the next (1) business day from receipt the call, unless otherwise agreed upon. Clinical Criteria Psychcare developed objective and evidence-based Mental Health Level of Care Clinical Criteria and Substance Abuse Level of Care Clinical Criteria for all Commercial, Medicare members and Medicaid members outside of Florida; and Florida Medicaid Level of Care Guidelines for Florida Medicaid members. The licensed clinical staff and clinical peer reviewers utilize the criteria in coordination with the members benefit coverage for all medical necessity decisions. If you would like a hard copy of either UM decision-making criteria, please contact Psychcare at our toll-free telephone number of ( ). Medical Necessity Psychcare definition of medical necessity is adapted from the Agency for Health Care Administration (AHCA). Medically necessary services include, but are not limited to, the elements listed below: 1. Necessary to protect life, and prevent significant illness or significant disability 2. Specific and consistent with symptoms and a confirmed DSM IV diagnosis, and not in excess of the member s needs 3. Consistent with the generally accepted community standards as determined by Psychcare, and not experimental or investigational 4. Reflective of the level of service that can be effectively furnished, and for which no equally effective and more conservative, or less costly treatment is available 5. Furnished in a manner not intended for the convenience of the recipient, the recipient s caretaker or the practitioner/provider 6. Inadequate clinical information provided by the attending psychiatrist to make a medical necessity determination. 7. Clinical information indicates failure to improve despite acute inpatient treatment 8. Clinical information indicates a history of inpatient admissions with failure to sustain gains on discharge, and it is not likely that another acute inpatient admission is anticipated to significantly improve the member s condition or symptomatology Referral and Clinical Review Processes Pre-Service Non-Urgent Outpatient Referrals Intake Coordinators, under the supervision of the Vice President, Clinical Operations, conduct Non-clinical Administrative Staff Initial Screenings with all members, or the members authorized representative acting on behalf of the member, who request initial (pre-service) nonurgent outpatient services as per the menu selection on the Automatic Call Distributing (ACD) System. Psychcare Intake Coordinators are available to provide general benefit, policy, or UM process information during business hours, Monday through Friday between 8:30 AM to 5:30 PM on our toll free number or our TDD/TTY services through the Florida Relay Number, 711, a communications link for people who are Deaf, Hard of Hearing, Deaf/Blind, or Speech Impaired, to speak with an Intake Coordinator. Rev. November

11 The Intake Coordinator verifies members benefits, confirms their addresses and telephone numbers, explains their financial obligations, such as copays, and completes Initial Intake Screening forms with the members. Referral considerations include the geographic, cultural, and/or linguistic preferences of the members. The Intake Coordinator provides the members with the names of network providers in their preferred area. Members are then advised that once they have made their selection, they should call Psychcare to have services authorized to the provider selected from the referral sources. Pre-service non-urgent care authorizations, inclusive of notification, are completed within fourteen (14) calendar days from the date of the request. Should the provider selected not be avilable within the non-urgent outpatient appointment standard, Intake Coordinators ask the provider to refer the members back to Psychcare, so that additional referral sources can be given to the members for selection. Emergency Services and Urgent Care Review Emergency mental health services are defined as those services that are required to meet the needs of an individual who is experiencing an acute crisis resulting from mental illness, which is at the level of severity that would meet the requirements for involuntary hospitalization pursuant to Section , F.S., and who, in the absence of a suitable alternative or psychiatric medication, would require hospitalization. Emergency psychiatric services, necessary to screen and stabilize a member are authorized by the licensed clinical staff without prior approval, when a prudent layperson, acting reasonably, believes that an emergency exists or an authorized representative acting for the organization has authorized the provision of emergency services. Psychcare shall, at all times, authorize an emergency psychiatric evaluation as per the member s benefit plan. All members experiencing substance abuse withdrawal are directed to an inpatient setting. Psychcare does not credential outpatient detoxification programs. Initial Clinical Review Psychcare Mental Health Level of Care Clinical Criteria, Psychcare Substance Abuse Level of Care Clinical Criteria, Florida Medicaid Level of Care Guidelines, and Psychcare Clinical Management Guidelines are utilized by the Case Managers during the initial clinical review in coordination with the members benefit coverage. Case Managers have a valid, active, and unrestricted Doctorate Level Clinical License, Masters Level Clinical License or Registered Nurse Licensure to practice at a minimum in the State of Florida, and a minimum of 5 years experience post master and/or previous experience in direct patient behavioral health care, crisis intervention and/or discharge planning. With oversight by the Medical Director, and supervision by the Vice President, Clinical Operations, actively licensed case managers conduct telephonic pre-service urgent care, and concurrent urgent and nonurgent care reviews. Psychcare does not provide on-site review services. The Medical Director is accessible for any clinical questions concerning authorization of services, 24 hours per day, 7 days per week. Medical necessity denial determinations are never issued during the initial clinical review. Medical necessity denial determinations are only issued during the peer clinical review. Pre-service Urgent Care Review Rev. November

12 Psychcare licensed Case Managers conduct all pre-service urgent care reviews telephonically. Pre-service urgent care reviews are conducted before treatment is provided to the member. A determination to authorize a particular service is based on the member s benefit coverage, Psychcare Mental Health Level of Care Clinical Criteria, Psychcare Substance Abuse Level of Care Clinical Criteria or Florida Medicaid Level of Care Guidelines, and definition of medical necessity. A pre-service urgent care review is conducted when the application of the time-period for making a nonurgent care determination may result in the following circumstances: Could seriously jeopardize the life, health or safety of the member or others due to the members psychological state, or In the opinion of a practitioner, acting as the member s authorized representative, with knowledge of the members medical or behavioral health condition, would subject the member to adverse health consequences without the care or treatment that is subject to the request. Pre-service urgent care reviews, including verbal and electronic or written notification of the decision, are completed as soon as possible, but no later than seventy-two (72) hours of the request. Concurrent Urgent and Nonurgent Care Reviews Psychcare licensed Case Managers conduct all concurrent reviews telephonically. Concurrent reviews are conducted during the course of treatment to ensure treatment continues to meet Psychcare Mental Health Level of Care Clinical Criteria, Psychcare Substance Abuse Level of Care Clinical Criteria, Florida Medicaid Level of Care Guidelines, and definition of medical necessity in coordination with the member s benefit coverage. Concurrent nonurgent review decisions, including verbal and electronic or written notification, are completed within fourteen (14) calendar days from receipt of the request. A request for a concurrent urgent care review is conducted when the application of the time-period for making a concurrent nonurgent care determination: Could seriously jeopardize the life, health or safety of the member or others due to the members psychological state; or In the opinion of a practitioner, acting as the member s authorized representative, with knowledge of the members medical or behavioral health condition, would subject the member to adverse health consequences without the care or treatment that is subject to the request; and Consideration as to whether it is more reasonable to handle it as urgent if the application of a nonurgent time frame could involve an unnecessary interruption in the member s treatment that may jeopardize the member s life, health or ability to recover. Concurrent urgent care review decisions, including verbal and electronic or written notification are completed within twenty-four (24) hours of the request. Post-service Review The Medical Director makes all post-service review determinations. Post-service reviews are conducted after the completion of a course of treatment. A post-service review occurs when services were neither authorized nor denied by Rev. November

13 Psychcare. The completion of the determination and electronic or written notification of the decision are provided within thirty (30) calendar days of receipt of the request and/or all clinical information necessary to make a medical necessity decision. When a request for a post-service review is received by Psychcare, and there is insufficient clinical information to determine the medical necessity of the case, Psychcare requests that the clinical information necessary to determine medical necessity is received within forty-five (45) calendar days from the date of the receipt of the notice requesting same. The requested clinical information includes, but is not limited to: The initial psychiatric evaluation; The physician s orders; The daily physician s progress notes; The daily nursing progress notes, and The discharge summary. Certification Determinations Verbal notification of a pre-service or concurrent certification determination is given to the attending practitioner, other ordering provider, facility rendering the service, member, or members authorized representative; and upon request from the attending practitioner, other ordering provider, facility rendering the service, member, or members authorized representative, written notification is provided. Psychcare provides written notification of all post-service certifications. Network Provider Utilization Management Processes for Post-Service Review of Emergency Services The post-service review process for emergency services is based on Federal and State regulatory standards; The definition of emergency services is based on (1) the member s certificate of coverage and (2) per Federal and State regulatory requirements; The submission and processing of a network provider request for a post-service review is based on (1) the individual network provider s executed Psychcare Participating Practitioner Agreement or Psychcare Participating Provider Agreement, and the section of the agreement pertaining to adherence to Psychcare s utilization management processes, (2) the member s certificate of coverage, (3) the emergency service definition as per the applicable line of business, and (4) national accrediting body standards; Psychcare will not process post-service review requests for routine outpatient services; Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member s benefit plan; It is the network provider s responsibility to contact Psychcare within twenty-four (24) hours of the member s admission, or, if unable to do so for circumstances beyond the provider s control, on the next business day. Although Psychcare cannot deny payment for emergency services based on the provider s failure to comply with the notification requirements, nothing shall alter any contractual responsibility of the member or provider to make contact with Psychcare subsequent to receiving treatment for the emergency condition; When the member is unable to provide insurance information upon admission, the network provider, in all circumstances, will obtain the member s insurance information prior to the member s discharge and will notify Psychcare of the member s hospitalization; When the network provider identifies the member s insurance information but was unable to contact Psychcare for authorization prior to the member s discharge, as evidenced by the provider s submission of a post-service review request to Psychcare, it is the network provider s responsibility to document in the member s treatment record, the provider s efforts to contact Psychcare and to obtain authorization upon receipt of the member s insurance information, prior to the member s discharge. The post-service review request will not be processed if there is a lack of this documentation, and the network provider will receive written notification within five (5) business days of Rev. November

14 Psychcare s review of the request, via mail and/or electronically of the decision, not to process the provider s request, with the specific reasons listed; Requests for payment of post-service reviews follow the Federal and State submission time periods for postservice review requests. All requests received after the prescribed submission period shall be considered past the date of submission; When the network provider s utilization management process responsibilities are fulfilled, Psychcare s Medical Director or Associate Medical Director determines the medical necessity of the services previously rendered, based on; All clinical documentation submitted with the post-service review request, Psychcare s Level of Care Clinical Criteria, and when applicable, Florida s Medicaid Level of Care Guidelines, The member s benefit coverage, and The applicable definition for emergency services. When the network provider s utilization management processes are not fulfilled, the network provider shall be sent written notification via certified mail and/or , advising the provider that the post-service review will not be processed due to a breach in the agreement requring adherence to Psychcare s utilization management processes; The post-service review determination, including written notification via certified mail and/or , is completed within thirty (30) calendar days of the date of the receipt of the post-service review request; As per Chapter , F.S., Requirements for Providing Emergency Services and Care, the member is not held financially liable for the emergency services provided, except for any copayment or coinsurance; The timeliness of post-service medical necessity review determinations, are reported quarterly to the Utilization Management Committee; Peer Clinical Review The Medical Director conducts all initial peer clinical reviews. Medical necessity denial decisions are based on the relevant clinical information provided by the attending practitioner or UM personnel, Psychcare Substance Abuse Level of Care Criteria, Psychcare Mental Health Level of Care Clinical Criteria; and when applicable, Florida Medicaid Level of Care Guidelines, the definition of medical necessity, and the members benefit plan coverage. The frequency of a review for the extension of an initial determination is based on the severity or complexity of the members condition, or on necessary treatment and discharge planning. Use of Licensed Consultants Contracted licensed specialty consultants are part of our clinical peer reviewer panel. The panel consists of licensed behavioral health practitioners in active practices with current, valid, and unrestricted licenses to practice at a minimum in the State of Florida. Clinical Peer Reviewers are Board Certified Psychiatrists, Licensed Ph.D. psychologists, and Masters Level Licensed Clinicians with clinical expertise in all areas of behavioral health. At the discretion of the Medical Director, a Board Certified Psychiatrist Clinical Peer Reviewer may conduct concurrent initial clinical peer review with the attending physician, or post-service medical necessity review. The Medical Director may consult with a Clinical Peer Reviewer in a like or similar specialty to the attending practitioner whose case is being reviewed for the following reasons: Upon the request of the Medical Director and based on their clinical expertise, provides consultative support in a medical necessity determination prior to a medical necessity determination being made; Upon the request of the Medical Director, and based on their clinical expertise, reviews experimental or investigational behavioral health treatment or procedures; In the event the Medical Director is unavailable, conducts the peer-to-peer conversation with the attending practitioner regarding a medical necessity denial determination; or Rev. November

15 Conducts the medical necessity appeal review based on the submitted clinical documentation and Psychcare Level of Care Clinical Criteria. Medical Necessity Denials When requested by the Medical Director, a Board Certified Psychiatrist Clinical Peer Reviewer, is responsible for all initial medical necessity denial determinations. Member or out of network practitioner/provider medical necessity denials may place the member at financial risk. Network practitioner/provider medical necessity denials may result in a contractual dispute, and do not place the member at financial risk. Medical necessity denial decisions are based on the relevant clinical information provided by the member, or member s authorized representative acting on behalf of the member, and attending practitioner or UM personnel, Psychcare Mental Health Level of Care Clinical Criteria, Psychcare Substance Abuse Level of Care Clinical Criteria, Florida Medicaid Level of Care Guidelines, and definition of medical necessity. Within one (1) business day of a pre-service or concurrent verbal and/or written denial determination, via our toll free phone number, every reasonable opportunity is afforded to the attending practitioner or ordering provider to have a peer-to-peer conversation with the Medical Director concerning the denial decision. When the Medical Director is unavailable for the peer-to-peer conversation, a Board Certified Psychiatrist Clinical Peer Reviewer in active practice with a current, valid, and unrestricted license to practice at a minimum in the State of Florida of the same or similar specialty conducts the peer-to-peer conversation with the attending practitioner or ordering provider. If the peer-to-peer conversation or review of any additional information does not result in a certification, the attending practitioner, ordering provider, and in circumstances where the member may be at financial risk, the member or the members authorized representative are given their appeal rights and the process to file an appeal. The reviewer availability information is provided in all verbal and written denial notifications, and is posted on the Psychcare website. Quarterly members and network practitioners/providers are notified of the availability of this information as part of the website notifications. If a pre-service or concurrent peer clinical review was scheduled with the attending practitioner, but does not occur after there are two documented attempts to contact the attending practitioner; the Medical Director or a Board Certified Psychiatrist Clinical Peer Reviewer will determine whether there is sufficient clinical information to make a medical necessity determination. The Medical Director or a Board Certified Psychiatrist Clinical Peer Reviewer issues a preservice or concurrent medical necessity denial determination to the attending practitioner; and in circumstances where the member may be at financial risk, a copy of the letter is sent to the member, or the members authorized representative. The process is posted on the Psychcare website, and members and network practitioners/providers are notified of the availability of this information as part of the quarterly website notifications. Medical Necessity Expedited (Urgent Care), and Standard (Pre-service and Post-service) Nonurgent Appeals Commercial, Medicare, and Michigan Medicaid client health plan expedited, pre-service, and post-service member medical necessity appeals and network provider medical necessity appeals are contractually delegated to Psychcare by each client. Unless contractually delegated, Psychcare does not process Florida Medicaid medical necessity expedited, pre-service, and post-service member and network provider appeals. Rev. November

16 Member or out of network practitioner/provider medical necessity appeals may place the member at financial risk if the appeal determination is to partially or entirely uphold the initial denial determination. Psychcare internally processes one level of network provider expedited, pre-service or post-service medical necessity appeals. A network provider medical necessity appeal is contractually related, and does not hold the member financially responsible if the appeal determination is to partially or entirely uphold the initial denial determination. An expedited appeal is a verbal or written request to change an adverse determination for urgent care. Urgent care is any request for behavioral treatment which the absence of would seriously jeopardize the health or safety of the member or other individuals due to the member's psychological state. An urgent care condition has the potential to become an emergency in the absence of treatment. When delegated by each client health plan, Psychcare grants an expedited review for all requests concerning admissions, continued stay or other behavioral healthcare services for a member who has received emergency services but has not been discharged from a facility. An expedited appeal decision and verbal and electronic or written notification to the member, the member s authorized representative, and attending practitioner are rendered as expeditiously as possible, but no later than seventy-two (72) hours after the request. Psychcare allows a health care practitioner with knowledge of the member's behavioral health condition, for example the attending psychiatrist, to act as the members' authorized representative. A pre-service medical necessity appeal is a verbal or written nonurgent care request to change an adverse medical necessity determination for care, in whole or in part, in advance of the member obtaining care or services. A post-service medical necessity appeal is a verbal or written nonurgent care request for payment for care that the member has already received. Accordingly, a post-service request would never result in the need for an expedited review. The submission of pre-service and post-service medical necessity nonurgent appeal by a network practitioner or provider, in cases that the member is not at financial risk; and the submission of a delegated 1 st level post-service appeal request received from a Commercial member or the members' authorized representative is 180 calendar days following the denial determination. Psychcare notifies the member, or the member's authorized representative, of their appeal rights and the 180-calendar-day time limit for requesting an appeal at time of the initial denial notification. The submission of a delegated 1 st level pre-service and/or post-service nonurgent appeal by a Medicare member or the member s authorized representative is 60 calendar days following the denial determination. Psychcare notifies the member, or the member's authorized representative, of their appeal rights and the 60 calendar-day time limit for requesting an appeal at time of the initial denial notification. In compliance with the Federal legislation 42 CFR (b)(2), and the Florida Medicaid Contract, when a specific Florida Medicaid client delegates 1 st level member pre-service and/or post-service Medicaid medical necessity appeals, the appeal must be submitted by the member, or member s authorized representative, 90 calendar days following the denial determination. Psychcare notifies the member, or the member's authorized representative, of their appeal rights and the 90 calendar-day time limit for requesting an appeal at time of the initial denial notification. Pre-service and post-service nonurgent care appeal decisions and verbal and electronic or written notification to the member, or the members' authorized representative, are completed within thirty (30) calendar days from receipt of the request. All submitted clinical information for expedited (urgent care), pre-service or post-service (nonurgent care) appeals inclusive of written comments, documents, or other information related to the appeal is reviewed by a Psychcare Clinical Peer Reviewer. A Psychcare Clinical Peer Reviewer is a contracted Board Certified Psychiatrist in active practice, with a current, valid, and unrestricted license to practice medicine at a minimum in the State of Florida. The Rev. November

17 Psychcare Clinical Peer Reviewer must be of the same or similar specialty to the attending practitioner whose case is under review; was not involved in the initial denial determination; and is not a subordinate of any person who was involved in the initial denial determination. Medical necessity appeal decisions are based on the relevant clinical information, written comments, documents, records and other information relevant to the appeal provided by the member, or the member s authorized representative, and the Psychcare Mental Health Level of Care Clinical Criteria, Psychcare Substance Abuse Level of Care Clinical Criteria, Florida Medicaid Level of Care Guidelines, and definition of medical necessity. When the decision is completely overturned, notification includes the decision and the date. Benefit Denials Benefit denials are denials of a requested service that is specifically excluded from the member s benefit plan, and is not covered by Psychcare under any circumstance. Practitioner Satisfaction with Psychcare UM Processes Annually, Psychcare conducts a Network Practitioner Satisfaction Survey with all of our network practitioners, and a Florida Medicaid Stakeholder Survey with our Florida Medicaid providers for each of our Florida Medicaid clients. The purpose of each survey is to find out our network s satisfaction with our clinical and administrative UM processes, and to identify opportunities to improve those areas of least satisfaction. UM Information Contained on the Psychcare Website Psychcare s website address is The provider section of the website contains current quality improvement activities, clinical resources, prevention programs, utilization management processes, provider relations information, and claims processes. The provider files are secured due to the proprietary nature of the information. Please use the password PsychcareProviders_FYEO to open the files when prompted. The following utilization management information is available on the website: The Annual Utilization Management Program Psychcare Mental Health Level of Care Clinical Criteria Psychcare Substance Abuse Level of Care Clinical Criteria Psychcare Florida Medicaid Level of Care Guidelines Emergency, Urgent and Routine Access to Care Standards Accessibility to Customer Service Staff and Clinical Staff to discuss utilization management issues Ensuring appropriate utilization management Utilization management processes Emergency services and Network Provider post-service review processes The opportunity to request a Peer Clinical Review to discuss an initial medical necessity denial determination Most of the information described herein can be downloaded from our website. If you would like a hard copy of the any of the documents and/or activities located on our website, please call Psychare s Quality Management Department at Psychcare s toll-free telephone number of ( ), Monday through Friday, 8:30 AM to 5:30 PM, EST. Rev. November

18 4. NETWORK MANAGEMENT Provider Recruitment If you or someone you know would like to be considered for inclusion in Psychcare, LLC s network, please refer to the Request to Join Network Process below in this section. Request to Join the Network Process Providers (practitioners) who have an interest in joining the network should print the Participating Provider Application, which can be downloaded from the Psychcare website at Recruitment Contracting. If you do not have access to a website, please contact the Network Development Department at the toll-free telephone number of ( , Ext. 3998). Once you have printed the application, please legibly complete the form, in full, then sign and return with all requested, supporting documentation, in one of three ways: Mail: Psychcare, LLC, Sunset Drive, Miami, FL Attention: Network Development Fax: Network partner@psychcare.com Upon receipt of a completed application, the following elements will be reviewed to assist Psychcare in determining initial eligibility for processing by the Credentialing Department: Specialty/area of expertise is needed in network; Location of practice is within network development-approved area; License must be current, valid, unrestricted, and in most geographic locations, independent; DEA/Controlled substance registration current, unrestricted; Board certification (ABMS or AOA ONLY) is current and verifiable (Physicians only); Residency training is completed and verifiable, if not board-certified. (Physicians only); Education is completed and verifiable. (Providers with Doctorate and Master s degrees); Work history must include five (5) current, consecutive years of experience in the field of interest. Gaps greater than one (1) year require a written explanation and will be reviewed. Gaps between six (6) months to one (1) year can be offered verbally, but the explanation is processed more efficiently when explained in writing, and Cultural, ethnic and linguistic needs of the network are considered and reviewed in each application. Note: If initial eligibility is not met, providers (practitioners) will be notified (See Notification of Request to Join Process Outcome ). If initial eligibility is met, providers (practitioners) will be sent application, or if already received, application will be processed by the Credentialing Department. Providers (facilities) with an interest in joining the network should contact the Network Development Department at the toll-free telephone number of ( , Ext. 3998). This department will handle all of your questions regarding the possibility of network inclusion. Notification of Request to Join Process Outcome Upon receipt of a completed application, along with the supporting documentation, the provider (practitioner) will be notified within fifteen (15) business days following the next Credentialing Committee meeting, as to whether or not the application will be processed. The Credentialing Committee meets at least quarterly, typically on the 3 rd Thursday of Rev. November

19 the month the meeting will be held. Meetings are currently scheduled for the months of March, June, September, and December. Please note that completion and submission of a credentialing application, in and of itself, does not confirm that the Credentialing Committee allowed for the application to be sent to the applicant, nor does it constitute network acceptance by the Credentialing Committee. Availability Standards GeoAccess Psychcare s Credentialing Committee conducts network analyses, at least annually, but availability standards are analyzed on an ongoing basis throughout the year. Availability standards are reviewed annually and are determined, based on client needs, state and federal standards, accrediting standards, and network composition needs. Further, a network analysis is conducted prior to the processing of any initial credentialing application, to determine if there is a need in the network, based on GeoAccess-calculated availability standards, for a provider of the applicant s scope of practice, location, language(s) spoken, and cultural/ethnic background. Network Composition Psychcare s network is composed of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups. The size and the scope of the network is determined by the Credentialing Committee and is reviewed on an ongoing basis to assure the network is inclusive of the appropriate number and distribution of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups. Provider Training A Provider Training Module is available on our website at The Provider Relations Department is also available to conduct training with new providers at the time they are contracted. The Provider Training Module will include, but will not be limited to: Introduction to the Participating Provider Manual Provider Responsibilities Authorization process Claims submission, processing, and payment Electronic billing HIPAA Information Treatment plans Clinical summaries Medication management forms Maintaining current credentialing file Change of address process Who to contact with general questions Contact list for Psychcare Rev. November

20 Provider Complaints Psychcare s Provider Partnerships Department maintains a Provider Complaint Log with the following components addressed for each Provider Complaint received: Date of complaint Date of response to complaint Name of health plan Practitioner name Practitioner license & state of issue for license Practice/Facility name Complaint type Access Authorizations Claims Service Other Complaint narrative Complaint resolution (i.e. who resolved, date resolved) The Provider Complaint Log is maintained on an internal shared location, so that any Psychcare staff member may access and input information, should a provider submit a complaint. If, however, the Provider Complaint is given directly to the Provider Partnerships Department via an internal staff member s notification, and the complaint was not logged, the Provider Partnerships Department will log the event, and The performance goal is to have 100% of provider complaints that are received, logged for review and resolution. Providers are encouraged to file provider complaints through the Provider Partnerships Department, incorporating one of the following delivery methods: (1) Partner@psychcare.com, (2) Fax: , (3) Telephone: (800) x 3904, or (4) Mail: Psychcare, LLC, Sunset Drive, Miami, FL Attn: Provider Partnerships. The Provider Complaint Log is reviewed on a daily basis, Monday through Friday, by the Provider Partnerships Department, and the complaints are given to the Vice President, Provider Partnerships, who will initiate the handling of the case. Each time a provider complaint is logged, the Vice President, Provider Partnerships, will assign a member of the Provider Partnerships Department to fully investigate the complaint received, with the assistance of other departments and key personnel, as needed. To prevent possible discrimination in any review of a provider complaint, no one staff member may determine the outcome or the resolution of same. All state, federal and contractual obligations are considered during review of the complaint. Once the provider complaint investigation is conducted, the Vice President of Provider Partnerships will present the complaint to the Credentialing Committee, a subcommittee of the Quality Improvement Committee. The Credentialing Committee will review the nature of the provider complaint and the data from the investigation. The Credentialing Committee will discuss and determine recommendations based on the outcome of the complaint investigation. Rev. November