Health and Recovery Plan (HARP) Participating Provider Manual

Transcription

1 A nonprofit independent licensee of the Blue Cross Blue Shield Association Health and Recovery Plan (HARP) Participating Provider Manual Blue Option Plus and Premier Option Plus Products August 2017

2 Excellus BlueCross BlueShield Health and Recovery Plan (HARP) Participating Provider Manual Blue Option Plus and Premier Option Plus Products Table of Contents Transition of Behavioral Health Benefit into Medicaid Managed Care and Health and Recovery Program (HARP) Implementation... 1 HARP Services... 2 HARP Responsibilities... 2 Health Plan s HARP Products, Service Areas... 2 Member Eligibility for Enrollment in HARP... 2 Member Benefits... 4 Appointment Availability Standards... 5 Credentialing Requirements for BH Providers... 8 Web-Based System for Submitting Credentialing Information Provider Education and Training Delivering Care to our Members Interdisciplinary Care Team Quality Management Committee Utilization Management Home and Community-Based Services Eligibility Assessment Person-Centered Planning and Service Delivery Chart Documentation Requirements Billing and Claims Pharmacy Member Rights and Responsibilities Grievances and Appeals Care Management and Home and Community-Based Services BH HCBS Admissions, Continued Stay, Discharge Criteria BH HCBS Allowable Billing Combinations Appendix: Benefit Array for BH Services August 2017 i

3 Excellus BlueCross BlueShield Participating Provider Manual Health and Recovery Plan (HARP) Services Transition of Behavioral Health Benefit into Medicaid Managed Care (MMC) and Health and Recovery Program (HARP) Implementation The New York State Office of Mental Health (OMH), and the New York State Office of Alcohol and Substance Abuse Services (OASAS), in collaboration with the New York State Department of Health (DOH), have transitioned the full Medicaid behavioral health system to managed care. The goal is to create a fully integrated behavioral health (mental health and substance use disorder) and physical health service system that provides comprehensive, accessible, and recovery oriented services. There are three components of the transition: expansion of covered behavioral health services in Medicaid Managed Care (MMC), elimination of the exclusion for Social Security Income (SSI), and implementation of Health and Recovery Plans (HARPs). As part of the transition, eligible MMC enrollees will be transitioned into Health and Recovery Plans, or HARPs. HARPs are Special Needs Plans that include specialized staff with behavioral health expertise. HARPs will provide all covered services available through Medicaid Managed Care, in addition to an enhanced benefit package that includes Behavioral Health Home and Community-Based Services (BH HCBS) for eligible enrollees. These services are designed to provide the enrollee with specialized supports to remain in the community and assist with recovery. Enrollees must undergo an assessment to determine BH HCBS eligibility and, if eligible, the specific BH HCBS for which they are eligible. All HARP enrollees are eligible for individualized care management. The transition is designed to foster a partnership among MCOs, government, service providers, Medicaid members, and families that promotes an environment that is person centered, recovery-oriented, and integrated where enrollees receive the care that is necessary to achieve a successful recovery. For more information on the transition, please refer to the New York State Office of Mental Health website, the New York State Office of Alcoholism and Substance Abuse Services and the New York State Department of Health August

4 HARP Services Excellus BlueCross BlueShield (Excellus BCBS) strives to strengthen the health care experience for its members with chronic health conditions and those with serious mental illness and substance use disorders. To accomplish this, Excellus BCBS will collaborate with its participating providers, family members, communities and government agencies to encourage and inspire: Person-centered care: Care should reflect individualized goals while emphasizing shared decision-making approaches that empower participants, provide choice and minimize stigma. Recovery-oriented care: Care should be a fully integrated, comprehensive management approach that focuses on the recovery for mental health and substance use disorders. Integrated care: Care should be facilitated in an integrated care delivery model to address both physical health and behavioral health needs of members. The integrated model includes full participation of community-based and clinical providers for care coordination to improve both physical health and behavioral health outcomes. Data-driven results: Plans and providers should define data metrics to monitor and evaluate both performance and outcomes as they relate to improving health and well-being. Evidenced-based practices: Providers and practitioners should collaborate to implement and support the appropriate use of evidenced-based practices. HARP Responsibilities Health and Recovery Plans (HARPs) provide an integrated, enhanced benefit package to adults with serious mental illness and/or substance use disorders to improve health outcomes and promote recovery. The goals of the HARP Program are to reduce unnecessary emergency and inpatient care, increase network capacity to deliver community-based recovery-oriented services and supports, and provide enrollees with access to an enhanced benefit package, including care coordination and Behavioral Health Home and Community- Based Services, which will help support enrollees well-being and recovery. The HARP, contracting with Health Homes, will also provide care management for all services and assessments for Behavioral Health Home and Community-Based Services in compliance with federal and state standards and assurances. Health Plan s HARP Products and Service Areas The Excellus BCBS HARP services area includes the following counties: Broome, Herkimer, Livingston, Monroe, Oneida, Ontario, Otsego, Wayne, Seneca, and Yates (Blue Option Plus) and Orleans (Premier Option Plus). Member Eligibility for Enrollment in HARP HARP eligible members will be identified by the state on an ongoing basis and shared with the HARP Plans. Processes for community referrals for determination of HARP enrollment eligibility are currently under development by New York state. August

5 Adult Medicaid beneficiaries 21 and over who are eligible for mainstream Medicaid Managed Care are eligible for enrollment in the HARP if they meet either: 1. Target criteria and risk factors as defined below (Individuals meeting these criteria will be identified through quarterly Medicaid data reviews by Plans and/or New York state); or 2. Service system or service provider identification of individuals presenting with serious functional deficits as determined by: a. A case review of individual's usage history to determine if target criteria and risk factors are met; or b. Completion of HARP eligibility screen. New York state has determined that individuals in nursing homes for long-term care will not be eligible for enrollment in HARPs. HARP Target Criteria: New York state has chosen to define HARP targeting criteria as: 1. Medicaid enrolled individuals 21 and over; 2. SMI/SUD diagnoses; 3. Eligible to be enrolled in Mainstream MCOs; 4. Not Medicaid/Medicare enrolled ("duals"); 5. Not participating or enrolled in a program with the Office for People with Developmental Disabilities (OPWDD) (i.e., participating in an OPWDD program). HARP Risk Factors: For individuals meeting the targeting criteria, the HARP Risk Factor criteria include any of the following: a. Supplemental Security Income (SSI) individuals who received an "organized MH service in the year prior to enrollment. An organized MH service is one which is licensed by the NYS Office of Mental Health. b. Non SSI individuals with three or more months of Assertive Community Treatment (ACT) or Targeted Case Management (TCM), Personalized Recovery Oriented Services (PROS) or prepaid mental health plan (PMHP) services in the year prior to enrollment. c. SSI and non SSI individuals with more than 30 days of psychiatric inpatient services in the three years prior to enrollment. d. SSI and non SSI individuals with three or more psychiatric inpatient admissions in the three years prior to enrollment. e. SSI and non SSI individuals discharged from an OMH psychiatric center after an inpatient stay greater than 60 days in the year prior to enrollment. f. SSI and non SSI individuals with a current or expired Assisted Outpatient Treatment (AOT) order in the five years prior to enrollment. g. SSI and non SSI individuals discharged from correctional facilities with a history of inpatient or outpatient behavioral health treatment in the four years prior to enrollment. h. Residents in OMH funded housing for persons with serious mental illness in any of the three years prior to enrollment. i. Members with two or more services in an inpatient/outpatient chemical dependence detoxification program within the year prior to enrollment. August

6 j. Members with one inpatient stay with a SUD primary diagnosis within the year prior to enrollment. k. Members with two or more inpatient hospital admissions with SUD primary diagnosis or members with an inpatient hospital admission for an SUD related medical diagnosis related group and a secondary diagnosis of SUD within the year prior to enrollment. l. Members with two or more emergency department (ED) visits with primary substance use diagnosis or primary medical non-substance use that is related to a secondary substance use diagnosis within the year prior to enrollment. m. Individuals transitioning with a history of involvement in children s services (e.g., residential treatment facility, home and community-based services, Bridges to Health waiver). Member Benefits Note: Please refer to the appendix at the end of this document for a chart containing benefit/service information and preauthorization requirements. Behavioral health benefits for HARP services are listed below: Medically supervised outpatient withdrawal services Outpatient clinic and opioid treatment program Outpatient clinic services Comprehensive psychiatric emergency program (CPEP) Continuing day treatment program (CDTP) Partial hospitalization program (PHP) Personalized recovery oriented services (PROS) Assertive community treatment (ACT) Intensive case management/supportive case management Health home care coordination and management Inpatient hospital detoxification service Inpatient medically supervised inpatient detoxification Inpatient treatment services (OASAS) Rehabilitation services for residential substance use disorder treatment supports (OASAS) Inpatient psychiatric services (OMH) Rehabilitation services for residents of community residences Mobile crisis intervention Home and Community-Based Services (HCBS) are designed to provide the HARP member with specialized supports to remain in the community and assist with recovery. HCBS covered under the HARP benefit include: Psychosocial rehabilitation Community psychiatric support and treatment (CPST) Habilitation/residential support services Family support and training Educational support services Empowerment services, peer support Non-medical transportation Pre-vocational services Transitional employment Intensive supported employment Ongoing supported employment Short-term crisis respite Intensive crisis respite August

7 Please refer to the Care Management and Home and Community-Based Services section of this HARP manual for a description of HCBS services. Prior to rendering services, always check the member's identification card and visit our provider website, ExcellusBCBS.com/ProviderCoverageClaims, to verify eligibility and coverage, or contact Customer Care. Appointment Availability Standards Providers are required to adhere to the following appointment availability standards established by the New York State Department of Health. Providers must also have policies and procedures addressing enrollees who present for unscheduled non-urgent care with aim of promoting enrollee access to appropriate care. Maintaining these minimum standards ensure patient access to behavioral health care. Excellus BCBS will conduct an annual audit to ensure compliance with these standards. Appointment and availability time frames are included on the next two pages. August

8 Appointment Availability Standard by Behavioral Health Service Type Follow-up to Follow-up Nonurgent BH Emergency to Service Emergency Urgent Specialist or Hospital Jail/Prison MH/SUD Discharge Discharge Mental Health Outpatient Clinic/PROS Clinic ACT PROS Continuing Day Treatment IPRT Partial Hospitalization Inpatient Psyc. Services CPEP Crisis Intervention Community Mental Health Services (599 clinic services offered in the community) OASAS Outpatient Clinic Detoxification SUD Inpatient Rehab. Opioid Treatment Program Residential Addiction Services Upon presentation Upon presentation Upon presentation Upon presentation Upon presentation Within 24 hours of Within 24 hours of Within 24 hours of Within 24 hours for short-term respite Within 24 hours of Within 24 hours of Within 24 hours of Within 24 hours of Within 24 hours of Within one week Within one week Within one week of Within two weeks Two to four weeks Two to four weeks Two to four weeks Within five days of Within five days of Within five days of Within five days of Within five days of Immediate Within five days of Within five days of Within five days of Within five days of Within five days of Within five days of Within five days of Within five days of Within five days of August

9 Behavioral Health Home and Community-based Services Service Emergency Urgent Psychosocial Rehabilitation, Community Psychiatric Support and Treatment (CPST) Habilitation /Residential Support Services, Family Support and Training Nonurgent MH/SUD N/A N/A Within two weeks of BH Specialist Follow-up to Emergency or Hospital Discharge Within five days Follow-up to Jail/Prison Discharge Short-term and Intensive Crisis Respite Immediately Within 24 hours N/A Immediately Educational and Employment Support Services N/A N/A Within two weeks of N/A Peer Supports N/A Within 24 hours for symptom mgmt. Within one week of Within five days After-Hours Coverage BH providers are required to provide necessary telephonic services to members 24 hours a day, 7 days a week in case of telephone calls from established patients or patients family members concerning clinical mental health emergencies. This is critical for coordinating care when your patient has presented to the emergency room with an urgent/emergent or life threatening crisis. Providers must also arrange for complete backup coverage with other participating clinician(s) that can provide the same level of care in the event the practitioner is unable to provide covered services to established patients. Excellus BCBS members must be able to: Reach the practitioner or a person with the ability to patch the call through to the practitioner (i.e., answering service, pager); or Reach an answering machine or voice mail with instructions on how to contact the practitioner or his/her backup (i.e., message with number for home, cell phone or beeper) in case of a clinical urgent/emergent situation. Call forwarding may also be used, but the message must state that the call is being forwarded to the practitioner s contact number. August

10 The practitioners answering machine messages is automatically forwarded to a phone (i.e., practitioners cell phone, pager) where the practitioner retrieves and responds to those messages for life-threatening emergencies, after-hours, as soon as possible. Unacceptable answering for members when contacting you after-hours includes: Reaching an answering machine that instructs the active member to go to the nearest emergency room, crisis center hotline, lifeline and/or call 911. Reaching an answering machine with no instructions. Reaching an answering machine recommending the member call during business hours. No answer. A busy signal three times, within 30 minutes. To promote quality service to our membership, in conjunction with the delivery systems, Excellus BCBS needs to have compliance with this access standard. This standard is relevant to all lines of business. Failure to comply with the accessibility guidelines constitutes a material breach of your participating provider agreement, and may be cause for termination from the provider panel. Additionally, the New York Education Department Office of Professions and Code of Ethics for each discipline (i.e., psychiatrist, psychologist and licensed clinical social worker) support the after-hours accessibility guidelines for active members with a life-threatening emergency. Credentialing Requirements for Behavioral Health Providers OMH-licensed and OASAS-certified behavioral health providers When credentialing OMH-licensed, OMH-operated and OMH-certified providers, Excellus BCBS will accept OMH and OASAS licenses and certifications in place of any credentialing process for individual employees, subcontractors or agents of such providers. Excellus BCBS will collect and accept program integrity-related information as part of the credentialing process. Excellus BCBS requires that such providers not employ or contract with any employee, subcontractor or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in Medicare or Medicaid programs. Home and Community-Based providers The following guidelines outline the criteria/requirements for designated Home and Community-based Services to treat Excellus BCBS and Recovery Plan (HARP) members. 1. Complete an application for Designated Home and Community-based Services for approval by Health Plan. 2. Hold a valid and current license to practice specialty(ies) practiced by the provider. 3. Have a valid and current Participating Ancillary Services Provider Agreement ( Agreement ) with Health Plan. 4. Provide copy of current of license/certification, malpractice (liability) insurance and W Have completed the New York State HCBS Designation process, been approved and are listed on the NYS OMH website as a Designated Home and Community-based Services provider. August

11 6. Have sufficient facilities and support staff needed to provide all the services which may be required of members for the specialty or specialties practiced by the provider. 7. Have completed and certified the accuracy of the information provided in the application and provided documentation upon regarding previous and current challenges to licensure, loss of membership in any professional organization, and previous and current pending medical liability actions. 8. Be able to provide all services which may be required in a timely manner pursuant to the agreement for the designated appointment category, and in accordance with the New York State: Health and Recovery Plan (HARP) Home and Community-based Services (HCBS) Provider Manual available on the NYS OMH website. 9. Practitioner coverage must be provided by another Plan participating practitioner. 10. The provider must be willing to be listed as a participating provider in Plan literature. Individual behavioral health practitioners Providers who participate with Excellus BCBS must meet Excellus BCBS s credentialing requirements. Excellus BCBS credentials primary care physicians, most specialty physicians, certain allied health professionals and specific types of facilities. Excellus BCBS is responsible for assuring the provision of accessible, cost-efficient, quality care to its members. To that end, Excellus BCBS s Credentialing Committee reviews the credentials of all providers who apply for participation. The Credentialing Committee is composed of community providers, Excellus BCBS medical directors, and other such members as Excellus BCBS may appoint. The committee is responsible, as a peer group, for the review of all practitioner credentials and the review of all credentialing and recredentialing policies. Note: Excellus BCBS will not credential a trainee who does not maintain a separate practice from his/her training practice, nor does Excellus BCBS credential providers practicing on a limited permit. Excellus BCBS may not require credentialing of a provider who practices exclusively within an inpatient setting or freestanding facility, and who supplies health care services to an Excellus BCBS member only as a result of the member being admitted to the facility. Excellus BCBS makes credentialing decisions without regard to the applicant s race, ethnic/national identity, gender, age, sexual orientation, or the types of procedures or types of patients in whom the provider specializes. Excellus BCBS does not discriminate against providers who serve high-risk populations or who specialize in treating costly conditions. Note: Excellus BCBS reserves the right to disapprove credentials in accordance with federal and state law and regulation. The applicant has the burden of providing complete information sufficiently detailed for the Credentialing Committee to act. An applicant has the right upon to be informed of the status of his/her application. The method of communication used by the applicant will determine the method of response. (For example, a phone inquiry will receive a phone response; a letter inquiry will receive a response by letter.) Excellus BCBS will not provide benefits for services that a provider renders to a member covered under a program that requires providers to be credentialed until the provider is notified of Excellus BCBS s credentialing approval and execution of a participating provider agreement by both the provider and Excellus BCBS. Until he/she has received such an approval in writing and a participating agreement has been executed by both parties, a provider is not a member of the network and is not eligible for August

12 reimbursement. Providers must hold a member harmless if care is rendered prior to approval by the Credentialing Committee. Providers are recredentialed at least every three years. Provider s Right to Review Credentialing Information A provider has the right to review certain information Excellus BCBS uses when credentialing him or her. The information available for review is that obtained from primary source organizations such as the National Practitioner Data Bank, state licensing boards, medical professional insurance carriers and hospitals. Any provider wishing to review his/her personal information obtained from these primary sources must submit a signed (original signature of or), written to the Credentialing Department. (Credentialing Department contact information is included in the Contact List in this manual.) The provider has the right to correct erroneous information submitted by another party. The provider must notify credentialing staff in writing within 30 days of discovering the erroneous information. Excellus BCBS will include the explanation and/or correction as part of the provider's application when it is presented to the Credentialing Committee for review and recommendation. Web-Based System for Submitting Credentialing Information Excellus BCBS participates in a web-based system that providers must use to submit credentialing and recredentialing information. The system, called CAQH ProView TM, incorporates a nationwide universal credentialing application offered through the Council for Affordable Quality Healthcare (CAQH). This system enables a provider to complete his/her credentialing application online, store the information in a database he/she controls and can update, and authorize participating health plans to view the data. In addition to physicians, this policy applies to all non-physician health care providers for whom Excellus BCBS has credentialing responsibilities, including: Acupuncturists Optometrists Audiologists Oral maxillofacial surgeons Certified diabetic educators Physical therapists Chiropractors Podiatrists Dentists Psychiatry nurse practitioners Enterostomal therapists Psychologists Licensed mental health counselors Registered dieticians Nurse midwives Social workers Occupational therapists Speech and language therapists Note: For more information about the CAQH system, contact CAQH, Credentialing or Provider Relations. (For CAQH and Health Plan contact information, see the Contact List in Section 2 of the Excellus BCBS Participating Provider Manual.) Among the requirements of the credentialing process, physicians and non-physicians must: Maintain a practice within Excellus BCBS s service area. Demonstrate attainment of Excellus BCBS s specialty-specific requirements by providing copies of all applicable certificates regarding training, licensure, specialty certification and medical professional liability insurance. Possess and maintain at all times medical professional liability insurance in amounts specified by Excellus BCBS. The provider must have a certificate of medical professional liability insurance that names the provider, documents the limits of liability and specifies the effective date and the expiration date. August

13 Possess and maintain at all times a valid state license and current registration. Possess and maintain at all times a valid Drug Enforcement Agency (DEA) Certificate, if applicable to the provider s specialty. Be a member in good standing with a Health Plan-affiliated Article 28 or Article 40 facility, if applicable. Exemptions to this requirement may be available upon. All providers are required, by contract, to notify Excellus BCBS of any changes in their privilege status. Authorize release of information. Provide and update on an ongoing basis historical information regarding: physical or mental capacity impairments; criminal charges or convictions; loss, limitation or restriction of license; loss or limitation of DEA certification; loss or limitation of privileges in a hospital, facility, or managed care organization; professional disciplinary actions; or medical professional liability claims, among other information. Permit a site review of his/her office, if ed. See the paragraph headed Office Site Review in the Administrative Information section of this manual. Provide 24-hour coverage. In a managed care plan or a plan with managed care features, primary care physicians and specialists must provide continuous care of their patients through on-call coverage arrangements with other participating credentialed providers of the same or similar specialties. See the paragraph regarding Access to Care in the Administrative Information section of this manual. Practitioner Credentialing 1. When a physician or other health care practitioner is a first-time applicant for participation with Excellus BCBS, Excellus BCBS will send the practitioner a form that the practitioner must complete and return. The form includes a place for the practitioner to enter his or her CAQH ID if already registered in that database. 2. After processing the information, if the practitioner is not already registered with CAQH, Excellus BCBS will send the practitioner a letter with his/her CAQH ID number and the address of the CAQH website where he/she must start the application process. The letter also will explain that CAQH will soon be mailing the practitioner a welcome kit. Excellus BCBS then will forward the practitioner s name to CAQH. This service is provided at no cost to the practitioner. 3. The CAQH welcome kit will include detailed instructions for creating an electronic application on the CAQH website. The kit will also include information about how to and submit a paper application. 4. Once the practitioner completes the application and authorizes Excellus BCBS to view it, the practitioner s information will be available online through CAQH ProView TM. a. If the practitioner seeks to participate with another health plan that participates with the CAQH system, the practitioner may authorize that plan to view his/her information, thus eliminating the need to complete another credentialing application. b. Routinely, CAQH will ask the practitioner to update his/her information as necessary. A practitioner may also contact CAQH to update the information at any time. August

14 c. As required by Chapter 551 amendments to Public Health Law 4406-d(1) and Insurance Law 4803(a), Excellus BCBS will respond to a credentialing application within 90 days of receipt of the completed application. Excellus BCBS follows all applicable managed care legislation for any provider s credentialing application that is pending for more than 90 days. This includes notification to a provider when additional time is needed to complete processing of the application. Credentialing staff cannot process an incomplete application; if any information is missing, the practitioner will be notified as soon as possible, but no more than 90 days from receipt of the completed application. d. Credentialing staff shall notify the individual practitioner and/or the IPA(s)/Delivery System(s), if applicable, of the credentialing decision made by the committee within 30 days. Note: Practitioners must continue to notify Excellus BCBS directly in writing of changes to information, such as remit address, tax ID, etc. to keep claims processing systems accurate. Please use the Practitioner Demographic Changes form, available at ExcellusBCBS.com/Provider, or by calling Customer Care. Provisional Credentialing Excellus BCBS may offer provisional credentialing to physicians or other health care practitioners who join a group practice that already participates with Excellus BCBS. If the provider s complete credentialing application is not approved or declined within 90 days of receipt of a complete application by Excellus BCBS, the provider may to be provisionally credentialed. The provider may contact Excellus BCBS 60 days after submission of the credentialing application to determine the status of the application and/or provisional credentialing. If the is granted, the provider will be provisionally credentialed and paid as an in-network provider from the 91 st day of receipt of the application until the application is approved or declined. If the provider s application is declined, any amount paid by Excellus BCBS in excess of any out-of-network benefits payable under the member s coverage must be refunded to Excellus BCBS and neither the provider nor the group practice may pursue reimbursement from the member, other than applicable in-network cost-sharing amounts. Practitioner Recredentialing Excellus BCBS may recredential practitioners at any time, but in no circumstances less frequently than every three years. When a practitioner is due for recredentialing, Excellus BCBS will use the CAQH application if the practitioner has reviewed and refreshed the data in the last 90 days. If the on-line application has not been refreshed recently, Excellus BCBS will contact the practitioner to that the practitioner review, update and re-attest to his or her CAQH application data. Provider Education and Training Excellus BlueCross BlueShield offers a comprehensive provider training and support program for Health and Recovery Program service providers. The training program offers network providers an opportunity to gain appropriate knowledge, skills, and expertise as well as receive technical assistant to comply with the requirements under managed care. The provider training plan is reviewed annually and coordinated with the regional planning consortiums. An initial orientation and training shall be provided for all providers new to the Plan s network. Additional training opportunities will be made available (at least annually) at a variety of times and modalities to ensure that providers have an opportunity to participate. August

15 Materials and training schedules will be available at ExcellusBCBS.com/ProviderStaffTraining and communicated in our provider newsletter, Connection. Please refer to our Navigating Behavioral Health Services Expansion and the Health and Recovery Plan (HARP) guide, available at ExcellusBCBS.com/Provider. Training will include: Technical assistance on billing, coding, data interface, documentation requirements, utilization management requirements, credentialing and re-credentialing Training on person-centered planning Use of evidence-based practices and specific levels of quality outcomes Linguistically and culturally competent services Clinical training as appropriate by specialty and provider type Consistent with the guiding principles of the Health and Recovery Program (HARP), Excellus BCBS is committed to ensuring that its provider network adheres to recovery-oriented principles, including the delivery of person-centered services. Training opportunities will be coordinated with health homes and other resources. Additional Training Opportunities The New York State Office of Mental Health and the Department of Psychiatry at Columbia University established the Center for Practice Innovations at Columbia Psychiatry and New York State Psychiatric Institute to promote the widespread use of evidence-based practices throughout New York state. CPI uses innovative approaches to build stakeholder collaborations, develop and maintain practitioners expertise, build agency infrastructures that support implementing and sustaining evidence-based practices and direct staff competence. CPI is available to collaborate with agencies to increase the use of EBPs and improve staff clinical competencies. Licensed, non-licensed and certified peers who provide Home and Community-Based Services are encouraged to become trained on various evidence-based practices. Free training modules are available on the CPI website, CPI offers the following web-based training modules: Treating co-occurring mental health and substance use disorders (called Focus on Integrated Treatment or FIT) Assertive community treatment Supported employment/education via individual placement and support Wellness self-management First episode psychosis (called OnTrackNY) Increasing the use of clozapine Delivering Care to our Members Excellus BCBS administers Medicaid-approved benefits for members enrolled in our HARP programs. When rendering care to Excellus BCBS members, participating providers are expected to provide integrated treatment that helps move a patient toward his or her individual recovery goals, to monitor patient health status, manage co-occurring chronic diseases, avoid inappropriate hospitalizations and help patients to move from high risk to lower risk on the care continuum. August

16 Collaboration and Continuity of Care Excellus BCBS monitors continuity and coordination of general medical care with BH care. The goal is for members to receive a seamless, continuous and appropriate level of care, as well as strengthen system-wide continuity between medical and BH care. The Health Plan collaborates with BH care practitioners, PCPs, pharmacies, other health care facilities, and medical providers to monitor and improve coordination between medical care and BH care. The BH department annually collects data and assesses the following six areas for collaboration between medical and BH care: Exchange of information Appropriate diagnosis, treatment, and referral Psychopharmacological medication Access and follow up of coexisting medical and BH disorders Preventive BH guideline or program Special needs of members with severe and persistent mental illness Collaboration and communication among a BH practitioner, PCP and other appropriate treatment providers should occur no later than when the initial assessment is completed and a working diagnosis has been made; as well as when the initial plan of care has been completed. Providers are expected to document collaboration in the patient s chart. Collaboration encompasses coordination of care with the member s medical team. This may include, but is not limited to, the member s PCP, OB/GYN, surgeon, and/or other medical practitioner(s). A summary should be presented to the PCP with the patient s consent for release. Written consents are required by the NYSDOH. If the member is using behavioral health services in a clinic that also provides primary care services, enrollee may select the lead behavioral health provider to function as the PCP. Interdisciplinary Care Team The care management team provides a unique function to Excellus BCBS HARP members. The essential function is to increase community tenure, reduce recidivism, improve treatment compliance and facilitate positive treatment outcomes through the proactive identification of members with complex or chronic behavioral health conditions that require coordination of services and periodic monitoring in order to achieve desirable outcomes. Each member is assigned to a care manager who is responsible for establishing and leading the member s Interdisciplinary Care Team (IDT). The IDT can also include the member s assigned health home care manager, primary care physician, behavioral health provider, Home and Community-Based Service provider, the member s designee and other health care professionals needed to address the member s needs. The care manager, in conjunction with the IDT, are responsible for developing the Person-Centered Service Plan (PCSP), which is a written description in the care management record which specifies the member s specific health care goals to be achieved and the amount, duration, and scope of the covered services. Care manager duties include, but are not limited to, the following: Early identification of members who have special needs; Assessment of member s risk factors and needs; August

17 Contact with high-risk members discharging from hospitals to ensure appropriate discharge appointments are arranged and members are compliant with treatment; Active coordination of care linking members to behavioral health practitioners and needed medical services; including linkage with a physical health case manager for members with coexisting behavioral and physical health conditions; and residential, social and other support services where needed; Development of a care management person-centered service plan; Referrals and assistance to community resources and/or behavioral health practitioners. Quality Management Committee The Plan s Behavioral Health Quality Management Committee (BHQM) is responsible for carrying out the planned activities of the BHQM Program. The committee meets quarterly to review quality of care measures, accessibility to care and other issues of concern. Membership and attendance will be documented and include, at a minimum, the Behavioral Health Medical Director and Clinical Director, Director of Quality Improvement and peer, provider, family or member representation. Excellus BCBS will submit to OMH and OASAS a quarterly report of any deficiencies in performance and corrective action taken with respect to OMH and OASAS licensed, certified or designated providers. Excellus BCBS will report any serious or significant health and safety concerns to OMH and OASAS immediately upon discovery. Utilization Management Utilization management requirements help to ensure that a person-centered plan of care meets individual needs and that concurrent review protocols consider various factors. The Plan s utilization management program aims to ensure that treatment is specific to the member s condition, effective, and most clinically appropriate level of care. It also ensures that member care meets medical necessity criteria; treatment is specific to the member s condition, is effective and is provided at the least restrictive, most clinically appropriate level of care; services provided comply with our quality improvement requirements; and, utilization management policies and procedures are systematically and consistently applied; and focus for members and their families centers on promoting resiliency and hope. To accomplish these objectives, participating providers must collaborate with us and adhere to program requirements and guidelines. The utilization management team includes qualified behavioral health professionals with the appropriate level education, training and experience to conduct utilization management reviews. The team is under the direction of our licensed behavioral health medical directors, and staff meets regularly with the medical directors when there are any questions or concerns. Our utilization review decisions are made in accordance with currently accepted behavioral health care practices, taking into account special circumstances of each case that may require deviation from the screening criteria. Our medical necessity criteria are used for the approval of medical necessity; plans of care that do not meet medical necessity guidelines are referred to a licensed physician advisor or psychologist for review and peer-to-peer discussion. August

18 We conduct utilization management in a timely manner to minimize any disruption in the provision of behavioral health care services. The timeliness of decisions adheres to specific and standardized time frames, yet remains sufficiently flexible to accommodate urgent situations. The decision-making process is based on appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for issuing denials of coverage or services. Financial incentives for utilization management decision makers do not encourage decisions that result in under-utilization. Member coverage is not an entitlement to utilization of all covered benefits, but rather indicates services that are available when medical necessity is satisfied. Member benefit limits apply for a calendar year, regardless of the number of different behavioral health practitioners providing treatment for the member. Providers must work closely with our utilization management team to ensure judicious use of a member s benefit, and to carefully explain the treatment plan to the member in accordance with the member s benefit plan through Excellus BCBS. The plan uses McKesson s InterQual Level of Care Criteria for both inpatient and outpatient mental health services, as well as New York state guidelines, and the LOCADTR 3.0 for substance use services. This multi-faceted approach to medical necessity criteria allows staff and the department to facilitate services and develop programs that can address most aspects of the member s behavioral health experience. The NYS Medicaid Managed Care Model Contract requires that plans utilize the OASAS-provided LOCADTR tool for making substance use disorder level of care decisions. The tool is accessible through the Health Commerce System (HCS). The LOCADTR is a web-based tool that utilizes a series of clinical questions to determine individual risk and resources. Following the several logic pathways, answers to the questions lead to an initial LOCADTR recommended level of care. In most cases, this process will result in a level of care both recommended by the provider and approved by the Plan. In addition, the Health Plan has established evidenced-based UM criteria, workflows and processes for rehabilitation and recovery services, including ACT, CDT, PROS, and BH HCBS. This will be achieved through collaboration across the service delivery system, including provider participation on UM and QI committees, provider input on UM plan development and criteria, and enrollee feedback. For LOCADTR 3.0 resources, visit InterQual criteria sets are proprietary and cannot be distributed in full; however, a copy of the specific criteria relevant to any individual need for authorization is available upon. Both LOCADTR and InterQual criteria are reviewed annually. We are committed to the delivery of appropriate service and coverage, and offer no organizational incentives, including compensation, to any employed or contracted utilization management staff based on the quantity or type of utilization decisions rendered. Review decisions are based only on appropriateness of care and service criteria, and utilization management staff is encouraged to bring inappropriate care or service decisions to the attention of the medical director. Home and Community-Based Services Eligibility Assessment The eligibility assessment for Home and Community-Based Services includes the use of the Community Mental Health Assessment Eligibility (Brief) Assessment (InterRAI) tool, guidance on care planning process, guidance on care management, care coordination, and working with health homes. August

19 Assessments must be conducted by a health home or state-designated entity in compliance with conflict-free case management requirements. HARP enrollment will be open to Medicaid beneficiaries, 21 and older, with serious mental illness and/or substance use disorders. Individuals identified as HARP eligible must be offered care management through State-designated health homes. Individuals are identified as HARP- eligible based on their utilization of behavioral health services. Once identified, these individuals are referred to managed care plans and health homes to begin the process of engaging HARP-eligible members in care management. Going forward, HARP-eligible members will be identified by the State on an ongoing basis and shared with HARP Plans, which will make assignments to health homes. HARP members must be assessed for Home and Community-Based Service eligibility using an eligibility tool that contains items from New York state s community mental health suite of the InterRAI Functional Assessment. The eligibility assessment tool will determine if an individual is eligible for Tier 1 or Tier 2 services or not eligible for HCBS. Tier 1 services include employment, education and peer support services Tier 2 includes the full array of 1915i-like services If eligibility is determined based on the New York state Eligibility Community Mental Health Suite of the InterRAI a plan of care will be developed. The care plan must be developed in a conflict-free manner, meaning that the person conducting the assessment and developing the plan of care cannot direct referrals for service only to their agency or network; he or she must have a choice among available providers. Once the plan of care is completed, a health home care manager will work in collaboration with the individual to identify the Home and Community-Based Services to be included in the plan of care. At least one Home and Community-Based Service must be included in the plan of care for eligible individuals. If the individual does not meet the functional need for 1915i-like services through the eligibility tool, the plan of care cannot include 1915i-like services. Reassessment for HCBS is conducted on an annual basis, or after a significant change in the member s condition, such as an inpatient admission or a loss of housing. Health Homes will provide care management and will have a role in the assessment of individuals for Home and Community-Based Services. Provider agencies will deliver the HCBS services as described in this manual. Provider agreements should include procedures for monitoring HCBS utilization for each enrollee. CMS requires state oversight to determine that 1) the assessment is comprehensive, 2) the planning process is person-centered and addresses services and support needs in a manner that reflects individual preferences and goals, 3) the services were actually provided, and 4) the person is assessed at least annually or when there is a change in condition (e.g., loss of housing, inpatient admission) to appropriately reflect service needs. CMS requires that the state managed care plans and providers monitor and provide reporting for individuals enrolled in Home and Community-Based Service waivers to demonstrate that these individuals are receiving appropriate services. First Episode Psychosis The provider, in collaboration with Excellus BCBS and the Health Home will use available data to identify members with first episode psychosis. Appropriate resources, such as those available through OnTrack NY will be engaged to ensure comprehensive and integrated aftercare planning designed to facilitate prompt, extended follow-up with these members. August

20 For additional information and resources related to first episode psychosis, visit Person-Centered Planning and Service Delivery Based on an independent assessment of functioning and informed by the individual, the written service plan must meet the following requirements: 1. The service plan must include services chosen by the individual to support independent community living in the setting of his or her own choice and must support integration in the community, including opportunities to seek employment, engage in community life, control personal resources, and to receive services within the community; 2. Include the individual s strengths and weaknesses; 3. Be developed to include clinical and support needs that are indicated by the independent functional assessment; 4. Be comprised of goals and desired outcomes that are chosen by the individual; 5. Include services and supports (paid by Medicaid, natural supports and other community supports) that will enable the individual to meet the goals and outcomes identified in the service plan; 6. Identification of risk factors and barriers with strategies to overcome them; 7. Be written in a way that is clearly understandable by the individual; 8. Include the individual and the entity that is responsible for the oversight of the plan of care implementation, review of progress and need for modifications if desired outcomes are not being met or the individual s needs change; 9. Include an informed consent of the individual in writing along with signatures of all individuals responsible for the plan implementation; 10. Be sent to all of the individuals and others involved in implementing and monitoring the plan of care; and 11. The plan should not include services that are duplicative, unnecessary or inappropriate. Chart Documentation Requirements Chart notes for individuals enrolled in Home and Community-Based Services must include: Name of individual Type of service Date of service Location of service Duration of service, including start and end times Description of interventions to meet plan of care goals Outcome(s) or progress made toward goal achievement Follow up/next steps Provider s name, qualifications, signature and date August