Behavioral health provider overview

Transcription

1 Behavioral health provider overview KSPEC February 2018

2 Agenda Provider manual and provider website Behavioral Health (BH) program goals Access and availability standards Care coordination and communication Precertification, clinical criteria, Notice of Adverse Benefit Determination, treatment records and adverse incidents Pharmacy program Member resources and cultural competency Quality management and HEDIS Fraud, waste and abuse Your support system 2

3 Reference tools Provider Services:

4 BH program goals The BH program goals are to: Ensure adequate services are available and accessible to eligible members. Assist members and providers in utilizing and delivering the most appropriate, least restrictive medical and BH care services to our members in the right place and at the right time. Promote the integrated management and delivery of physical and BH services to members. 4

5 BH program goals (cont.) Achieve Amerigroup Kansas, Inc. quality initiatives, including those related to HEDIS, the National Committee for Quality Assurance (NCQA), and the Kansas Department of Health and Environment performance requirements. Work with members, providers and community supports to provide tools and an environment that supports members toward their recovery goals. 5

6 Access and availability standards Substance use disorder (SUD) services Emergent: On demand; ask member to go directly to an ER for services if the individual is either unsafe or if his or her condition is deteriorating. Urgent: Assessment within 24 hours of the initial contact; service delivery within 48 hours from initial contact without resultant deterioration in the individuals functioning or worsening of his or her condition; pregnant members considered urgent. 6

7 Access and availability standards (cont.) SUD services Routine: Assessment within 14 calendar days of initial contact; treatment within 14 calendar days of assessment without resultant deterioration in the individual s functioning or worsening of his or her condition Intravenous (IV) drug users: Pertains to members who have used IV drugs within the last six months; not in the emergent or urgent categories because of clinical need; treatment within 14 calendar days of initial contact (not assessment); no requirement for the assessment or IV drug user category in the Kansas client placement criteria (KCPC) 7

8 Access and availability standards (cont.) Mental health (MH) Post-Stabilization: Within one hour from referral for services (both inpatient and outpatient) in an ER Emergent: Within three hours for outpatient MH services and within one hour from referral for an emergent concurrent utilization review screen Urgent: Within 48 hours of referral for outpatient MH services and within 24 hours of referral for an urgent concurrent utilization review screen Routine outpatient: Referral within five days; assessment and/or treatment within nine working days from referral and/or 10 working days from previous treatment 8

9 Care coordination and communication Care coordination We will coordinate care for members with MH needs or substance use disorders. Care communication BH providers are required to send records of consultations, recommendations, etc. to the member s PCP for inclusion into the member s medical records. 9

10 Care coordination and communication (cont.) 10

11 Care coordination and communication (cont.) 11

12 Care coordination and communication It is especially important to: (cont.) o Gather information about other providers, services and medications o Follow-up on labs that have been ordered o Follow-up on referrals that have been made o Document all the coordination in the member record 12

13 Is precertification required? Our Precertification Lookup Tool lets you search by market, member s health care program and CPT code to determine if precertification is required for certain CPT codes. 13

14 Precertification status You can check the status of your precertification request on the provider website or contact Provider Services to speak with an associate. 14

15 Clinical criteria In addition to utilizing the Kansas definition of medical necessity, Amerigroup utilizes clinical criteria to evaluate the medical necessity of requests for care and services as follows: o MH BH medical policies and Clinical Utilization Management (UM) Guidelines o SUD KCPC is based on the American Society of Addiction Medicine (ASAM) patient-placement criteria Additional level-of-care criteria will be used for services not included in the BH medical policies, Clinical UM Guidelines or KCPC ASAM criteria sets (e.g., health care management services, waiver services). 15

16 Clinical criteria (cont.) For more information about additional criteria in use by Amerigroup, please visit All criteria used by Amerigroup are approved by the Amerigroup Medical Advisory Committee and the Amerigroup National Medical Policy Committee. For information about how to access BH medical policies and Clinical UM Guidelines, please call Provider Services or go to 16

17 Psychiatric observation The code for this outpatient observation code has been changed from H2013 to S9485 Reimbursable up to three days per KMAP provider bulletin from June 2017 KMAP HOSPITAL BULLETIN Primary or secondary BH diagnosis is required No authorization is required; Prior authorization look up tool is being updated 17

18 Inpatient MH services Precertification or initial/concurrent/continued stay review inpatient requests may be requested 24 hours a day, 365 days a year by phone or fax. o Phone: o Fax: Precertification or initial inpatient requests for services require authorization. A concurrent or continued stay review for inpatient is required for additional authorization and expected on last day authorized. Amerigroup will fax authorization of services to the facility. Provider will fax a discharge summary to Amerigroup within one business day of discharge. 18

19 Psychiatric residential treatment facility (PRTF) PRTF* requests may be made by contacting the BH Utilization Management team. Phone: , ext Fax: KMAP Bulletin MCO PRTF Bulletin PRTF Admission Assessment PRTF Prior Authorization Request Form 19

20 Serious Emotional Disturbance waiver Providers must submit service authorization requests to the Kansas Assessment Management Information System (KAMIS). Community Mental Health Centers (CMHC) work in coordination with the Amerigroup BH case managers to conduct wraparound and plan of care reviews. If there is a delay in receiving the authorization notice (10 business days or more), contact Provider Services at to notify us of the delay. 20

21 Outpatient MH services To request additional services beyond the prespecified authorization limits, submit a request utilizing one of the following forms: CMHCs utilize KanCare Service Authorization Form All other outpatient behavioral health providers utilize Precertification Request Form. Please allow up to 14 days from day of receipt to process request per National Committee for Quality Assurance standards for all outpatient requests. 21

22 Outpatient MH services (cont.) Psychological/neuropsychological testing six hours per year; To request services utilize the Psychological Testing Request Form located on our provider website. Admission evaluation July 2017 removed the annual limit for procedures codes and

23 SUD services SUD providers must utilize the KCPC screening and assessment tool.* SUD treatment includes the following levels of care: Outpatient level I individual and group counseling Intensive outpatient level II Residential reintegration level III.1 Residential intermediate levels III.3 and III.5 Auxiliary services (assessment and referral, Medicaid case management, peer support, and crisis intervention) * Services after the initial authorization require approval of continued stay review. 23

24 SUD services (cont.) For inquiries, contact call Jason Keezer at , ext or BH at , ext BH ROI form is the form for SUD providers to complete when they are needing the Kansas Client Placement Criteria sent to them. Due to CFR 42 Part II, SUD information is redacted from being able to be shared in systems like Patient360. Providers also need to ensure that they have the appropriate releases on file to share SUD information about members they receive information about. 24

25 Authorization process Providers should only include one member per fax being sent so that the members health information is protected when we process the request. When a provider submits a request for authorization we process and review the request. We will respond to inpatient requests within X 1 calendar days and outpatient requests within 14 days. If we have questions pertaining to the request submitted, we will contact the person noted on the request. If we are unable to reach the requestor, we will leave a message. Please note timely response of the requestor is important so that the request can be fully vetted. 25

26 Clinical and administrative denials The denial is known as a Notice of Adverse Benefit Determination That means our medical director denied or reduced coverage of the service you requested. A copy of the NOA including the members appeal rights, will be mailed to the requesting provider, the member s PCP and/or the attending physician and the member. Providers have a right to discuss this decision with our medical director by calling Providers Services at

27 Clinical vs administrative denials An administrative NOA may include: o Late notification of admission Providers must notify Amerigroup within 24 hours, or the next business day, of any inpatient admission of an Amerigroup member. o Failure to request precertification of a service that requires prior precertification. o Member ineligibility on the date of service. o Notification that requested service/benefit was a noncovered service/benefit. o Notification that the limit on the benefit has been reached. A medical necessity NOA may include: o Lack of clinical documentation. o Failure of the clinical information to meet medical necessity definition. 27

28 Peer-to-peer Amerigroup is committed to working with all providers to ensure such guidelines are understood. Providers have a right to discuss this decision with our medical director by calling Providers Services at Peer-to-peer conversations (between an Amerigroup medical director and the provider clinicians) are one way that Amerigroup is able to ensure the completeness and accuracy of the clinical information and provide a one-on-one communication about the guidelines as necessary. Medical record reviews are another way to ensure that clinical information is complete and accurate. Providers that are able to appropriately respond in a timely fashion to peer-peer and medical record requests are less likely to encounter dissatisfaction with the utilization management process. Amerigroup is committed to ensuring a process that is quick and easy and will work with participating providers to ensure a mutually satisfying process where possible. 28

29 Appealing an NOA If your request for services is reduced or denied, you may file an appeal within 30 calendar days of receipt of the NOA. An additional three days is allowed if the notice is mailed. A provider may appeal on behalf of a member upon receipt of written authorization from the member. When the health of a member requires a quick response or a decision is less than 30 calendar days, a provider, at the request of the member, can ask Amerigroup for an expedited appeal. Call Member Services toll free at for help filing an expedited appeal. 29

30 Treatment records Member records* must contain the following documentation elements to permit effective service provision and quality reviews: Signed consent for MH treatment Comprehensive assessment Patient-centered support and care plan Progress notes * For the documentation specifics, please refer to the provider manual. 30

31 Comprehensive assessment A psychiatric assessment that includes: o Description of the presenting problem o Psychiatric history and history of the member s response to crisis situations o Psychiatric symptoms o Multiaxial diagnosis using the most current edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) o Mental status exam o History of alcohol and drug abuse A medical assessment that includes: o Screening for medical problems o Medical history o Present medications o Medication history 31

32 Comprehensive assessment (cont.) A substance use assessment that includes: o Frequently used over-the-counter medications o Alcohol and other drug use, including history of prior alcohol and drug treatment episodes o Impact of substance use in the domains of the community functioning assessment A community functioning assessment or an assessment of the member s functioning in the following domains: o Living arrangements and daily activities (vocational/educational) o Social support o Financial o Leisure/recreational o Physical health o Emotional health/bh o Member s strengths, current life status, personal goals and needs 32

33 Patient-centered support and care plan Support and care plans are based on psychiatric, medical, substance use and community functioning assessments. Care plans must be completed within the first 14 days of admission to BH services and updated every 90 days or more frequently as necessary based on the member s progress toward goals or a significant change in psychiatric symptoms, medical condition and/or community functioning. The member and, as appropriate, his or her family members, caregivers or legal guardian participate in the development and subsequent reviews of the treatment plan. 33

34 Patient-centered support and care plan (cont.) For providers of multiple services, one comprehensive treatment/care/support plan is acceptable as long as at least one goal is written and updated as appropriate for each of the different services that are being provided to the member. The treatment/support/care plan must contain the following elements: o Identified problem(s) for which the member is seeking treatment. o Member goals related to problem(s) identified are written in memberfriendly language. o Measurable objectives to address the goals are identified. o There are target dates for completion of objectives. o There are responsible parties for each objective. 34

35 Patient-centered support and care plan (cont.) o Specific measurable action steps to accomplish each objective. o Individualized steps for prevention and/or resolution of crisis, which includes identification of crisis triggers (situations, signs and increased symptoms); active steps or self-help methods to prevent, de-escalate or defuse crisis situations; names and phone numbers of contacts that can assist the member in resolving crisis; and the member s preferred treatment options, to include psychopharmacology, in the event of a mental health crisis o Signature of the member is required as well as signatures of family members, caregivers or legal guardian as appropriate. 35

36 Progress notes Progress notes are written to document status related to goals and objectives indicated on the treatment plans to include: o Correspondence concerning the member s treatment and signed and dated notations of telephone calls concerning the member s treatment. o A brief discharge summary must be completed within 15 calendar days following discharge from services or death. o Discharge summaries for psychiatric hospital and residential treatment facility admissions that occur while the member is receiving BH services should be included. 36

37 Adverse incidents Adverse occurrence (e.g., sentinel events or major critical events) reports must be made by each participating provider to all appropriate agencies as required by licensure, state and federal laws within the specified time frames required immediately following the event. Within 24 hours, these events must be reported into the Adverse Incident Reporting (AIR) system. State information on AIR: Reporting link User manual Provider-Pages/manuals/AIR/air-instructions-for-kdads-mcov2.pdf?sfvrsn=6 37

38 Adverse incidents (cont.) Examples of adverse incidents include but are not limited to the following: Treatment complications (including medication errors and adverse medication reactions) Accidents or injuries to a member Morbidity Suicide attempts Death of a consumer Allegations of physical abuse, sexual abuse, neglect and mistreatment, and/or verbal abuse 38

39 Adverse incidents (cont.) Use of isolation, mechanical restraint or physical holding restraint Any clear and serious breach of accepted professional standards of care that could endanger the safety or health of a member or members 39

40 Pharmacy program Amerigroup follows the state s Preferred Drug List and formulary list. Links to both lists are available on our website. Amerigroup uses state prior authorization criteria: Prior authorization is required for the following: o Brand-name medications when generics are available o High-cost injectable and specialty drugs o Any other drugs identified in the formulary as needing prior authorization Note: This list is not all-inclusive and is subject to change. 40

41 Psychotropic medications Providers must inform all members being considered for prescription of psychotropic medications of the benefits, risks and side effects of the medication; alternate medications; and other forms of treatment. The medical record is expected to reflect such conversations as having occurred. Members on psychotropic medications may be at increased risk for various disorders. As such, it is expected that providers are knowledgeable about side effects and risks of medications and regularly inquire about and seek treatment for any side effects from medications. 41

42 Member resources Translation services Transportation services Access2Care: KSKS_Transportation_ENG.pdf Value-added benefits KSKS_CAID_ValueaddedBenefits_ENG.pdf Taking Care of Baby and Me cuments/ksks_tcobam_program_flier.pdf 42

43 Cultural competency We expect our providers and their staff to gain and continually increase in knowledge, skill, attitudes and sensitivities to diverse cultures. This results in the effective delivery of care and services for all people, taking into consideration each person s values, reality conditions and linguistic needs. 43

44 Quality management Our Quality Management team continually analyzes provider performance and member outcomes for improvement opportunities. 44

45 HEDIS Healthcare Effectiveness Data Information Set 45

46 HEDIS (cont.) 46

47 Fraud, waste and abuse Help us prevent it, and tell us if you suspect it! Verify patient identity. Ensure services are medically necessary. Document medical records completely. Bill accurately. 47

48 Your support system Provider Services:

49 Thank you for partnering with Amerigroup to offer quality health care to our members. 49