Report Objective To assess the types of Behavioral Health services the most fragile members (SMI, SED, SUD) are receiving by member county. General Instructions The managed care organization (MCO) is required to submit the Behavioral Health Members Services/Core Services Agencies (CSA) report on a ly basis. This report is due on April 30, July 30, October 30, and January 30 of each year. If a report due date falls on a weekend or a State of New Mexico holiday, receipt of the report the next business day is acceptable. An annual supplement is also required for this report. The annual supplement is a restatement of all four ly report submissions related to the reporting periods within the particular calendar year. The restated reports are to reflect data as of March 30 of the following year, thus benefiting from the additional paid claims run out. Please adhere to the following reporting periods and due dates. Quarter Reporting Period Report Due Date 1 January 1 March 31 April 30 2 April 1 June 30 July 30 3 July 1 September 30 October 30 4 October 1 December 31 January 30 Annual Supplement January 1 December 31 April 30 (following year) An Excel workbook is provided as a separate attachment for submission. Quantitative data and any qualitative data must be entered in the Excel workbook. The MCO must ensure that data is entered in all fields. The report will be considered incomplete if any field is left blank. Use ND if there is no data available to report for the applicable reporting period. Use N/A if the data field is not applicable. All formulas provided in the workbook shall not be altered by the MCO. An electronic version of the report in Excel must be submitted to the New Mexico Human Services Department (HSD) by the report due date listed above. The report shall be submitted via the State s secure DMZ FTP site. The date of receipt of the electronic version will serve as the date of receipt of the report. To assist the MCO with the use of the template, all cells within the template are viewable. This allows the user to move the cursor into any cell of the template and enables the user to see the formulas in the cells that calculate automatically. Although certain cells are locked and protected, the user s ability to view the formulas should assist in the MCO s understanding of the template and calculations performed. It is important to note that when populating the templates with data, users are not to use the cut and paste function in Excel, as this may cause errors to the cell formulas. Additionally, certain cells have been shaded and locked to prevent data entry where data is not required or not applicable to the particular item or category. Each time the report is submitted, the MCO shall use the same template that was submitted in previous s. For example, the report due on July 30 will include data for the first and second s. The reporting period for the first two sections of the report will be 1/1/16 through 06/30/16. The reporting period for the remaining sections of the report would be entered as stated in the table above. For BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 1 of 9
sections of this report that capture data for multiple reporting periods, the MCO is required to restate previously submitted data. Amounts entered into this report are to be based on actual data and exclude any estimates or accruals. Note that this report captures information based on paid claims with dates of service within the applicable reporting period. The MCO shall submit the electronic version of the report using the following file name labeling format: MCOName.HSD45.Q#CY##.v#. With each report submission, please change the reporting period reference (e.g., Q2), the calendar year (e.g., CY16), and the version number (e.g., v1), as appropriate. The MCO s name, reporting period, and report run date must be entered on the top portion of the first worksheet in the report. The report run date refers to the date that data was retrieved from the MCO s system. The MCO name entered on the top of the first worksheet will automatically appear on the top of Sections I, II, and III of the report, but the reporting period and report run date must be entered manually in Sections II and III. The start and end of the reporting period must be entered in the format illustrated below. Reporting Period 1/1/2016 through 3/31/2016 MCO Name MCO Report Run Date 4/1/2016 Attestation and Penalties The MCO shall ensure that all data is accurate and appropriately formatted in the workbook prior to submitting the report. Per Section 7.3 of the centennial Care contract, failure to submit accurate reports and/or failure to submit properly formatted reports in accordance with the contract may result in liquidated damages of $5,000 per report, per occurrence. The MCO shall include a signed attestation with each report. Failure to submit a signed attestation form by the report due date will result in the entire report being late. Per Section 7.3 of the contract, failure to submit timely reports in accordance with the contract may result in liquidated damages of $1,000 per report, per calendar day. The $1,000 per calendar day damage amounts will double every ten calendar days. Related Contract and Reporting Requirements 1. Section 4.21 Reporting Requirements 2. Section 4.4.12.5 Care Coordination Staff Requirements 3. Section 4.8.10 Core Service Agencies 4. Section 7.3 Failure to Meet Agreement Requirements Definitions Severe Emotional Disturbance (SED) Refer to Appendix 2 - SED (attached separately) for behavioral health determination criteria. For SED, include all the listed diagnoses BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 2 of 9
Substance Use Disorder (SUD) Serious Mental Illness (SMI) For Adult SUD, include the diagnoses listed in the chronic substance dependency checklist. For Child SUD, include the substance-related disorders contained within the Appendix 2 SED (attached separately) criteria. Refer to Appendix 1 - SMI (attached separately) for SMI behavioral health determination criteria. Unduplicated Member Count Level: Satellite Offices Level: County Description Level: All Members Example Count Members only once for each satellite office. Members who received services from multiple satellite offices during the applicable reporting period should be counted once for each satellite office that provided services. Count members only once per the member s county information. Count members only once regardless of the number of times the member received a BH service. This report is based on member s county information. Provided below is an example for determining unduplicated member counts for a member who received services for SUD, SMI, and SME in the fourth : An MCO member in Care Coordination Level 2 received services from Tri County Community Services (Taos) on October 10 and October 24. In addition, the same MCO member received services on November 1 from PMS (Espanola). The member would be counted as an unduplicated member at the following levels: Level: All Members Total for ALL Members 1 count due to this report being based on the member s county location. Section I: Analysis Before entering data in the workbook, ensure that the Analysis tab is selected. Respond to the following questions taking into consideration the data reported for the reporting period. For each question, identify any changes compared to previous reporting periods and trends over time and provide an explanation of the identified changes. Additionally, describe any action plans or performance improvement activities addressing any negative changes found during the current reporting period or previous reporting periods. Note that the MCO must use information from claims data. BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 3 of 9
By analyzing the units of service provided by each member s county for SED, SUD, and SMI, complete the following questions After reviewing the CC Members Tab After reviewing the CC Members Tab Explain if the method used to reach members has changed compared to previous reporting periods. Explain any significant differences that happened in the from previous (s). Explain any significant differences that happened in the from previous (s). What contributed to the change(s)? What trends appear in the over 21 population? What services are under-utilized and what might contribute to this? After analyzing the Overall Findings After analyzing the Overall Findings After analyzing the Overall Findings What services are over-utilized and what might contribute to this? What actions have been taken to address identified trends? Were there other services members received that were not captured in this report? Are there any other topics, issues, or concerns in response to the report findings this? Describe any outliers or member services not captured. Section II: CC Members - SED, SUD and SMI Before entering data in the workbook, ensure that the CC Members tab is selected. This section of the report captures information for SED, SUD, and SMI members who received services from BH facilities. Count members who had a paid claim with dates of service within the applicable reporting period. Report member counts based on the member s age as of the last day of the reporting period. This report is prepared per each member s county for SED, SUD, and SMI. BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 4 of 9
The MCO must use all relevant systems (e.g. care coordination system, claims system, membership information, etc.) to complete this report. Please refer to separate appendices referenced in the last section of these instructions for determination criteria for SMI, SED, and SUD populations. Refer to guidance provided above regarding reporting unduplicated member counts. New Mexico Counties are listed on this tab in the template. If additional space is needed for new locations, please include them at the bottom of the report in the space provided. If needed, additional rows may be added. Note that this section of the report captures data for all s in the applicable calendar year. Each time the report is submitted, the MCO must use the same template submitted in previous reporting periods and restate data for previous reporting periods. Row Header Row Descriptions Total 8 From the member counts entered within each of the columns detailed below, identify and enter the corresponding total unduplicated count of CC members for the particular column. Column Header Column Criteria / Descriptions who received a BH Service by county in identified as SED/SMI/SUD who received a BH Service by county in identified as SED/SMI/SUD in Care Coordination Level 2 who Received a BH Service by member county in identified as SED/SMI/SUD in Care Coordination Level 3 who Received a BH Service by member county in E, O, Y, AI Based on list of services. F, P, Z, AJ Based on diagnosis: Based on SED/SMI/SUD criteria. G, Q, AA, AK Based on SED/SMI/SUD criteria for members in Care Coordination Level 2. H, R, AB, AL Based on SED/SMI/SUD criteria for members in Care Coordination Level 3. BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 5 of 9
Column Header Column Criteria / Descriptions identified as SED/SMI/SUD who refused Care Coordination and Received a BH Service in identified as SED/SMI/SUD who were unable to contact or engage and a received a BH Service Identified as SMI who Received BH Services in the Identified as SED who Received BH Services in the Identified as SUD under the age of 21 who Received BH Services in the Identified as SUD over the age of 21 who Received BH Services in the who Received BH Services from a CSA - Annual Total I, S, AC, AM Based on SED/SMI/SUD criteria for members who have refused Care Coordination. J, T, AD, AN Based on SED/SMI/SUD criteria for members the MCO is unable to contact or engage. K, U, AE, AO Based on SMI criteria. L, V, AF, AP Based on SED criteria. M, W, AG, AQ Based on SUD criteria for members who are under the age of 21. N, X, AH, AR Based on SUD criteria for members who are age 21 and older. AS Total unique count of members reported in the calendar year. This is not a sum of all four s. A member should only be counted once for the CY total, even if that member is included within the counts of more than one within the CY. Section III: County and Services (for each ) Before entering data in the workbook, ensure that the County & Services tab is selected for the stated. This section of the report captures information for SED, SUD, and SMI members who received the listed services from BH facilities. Count members who had a paid claim with dates of service within the applicable reporting period. Report member counts based on the member s age as of the last day of the reporting period. This report is prepared per each member s county for SED, SUD, and SMI. BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 6 of 9
The MCO must use all relevant systems (e.g. care coordination system, claims system, membership information, etc.) to complete this report. Please refer to separate appendices referenced in the last section of these instructions for determination criteria for SMI, SED, and SUD populations. Refer to guidance provided above regarding reporting unduplicated member counts. Please use the listed codes for each section in the description grid. New Mexico counties are listed on this tab in the template. If additional space is needed for new locations, please include them at the bottom of the report in the space provided. Note that this section of the report captures data for each in the applicable calendar year. Each time the report is submitted, the MCO must use the same template submitted in previous reporting periods and restate data for previous reporting periods. The MCO will enter the following information for each in cells B5 and B6 respectively: Count of CSA Contracts Terminated: The number of CSA contracts terminated with an effective date of termination that occurs in the applicable reporting period. Count of Newly Contracted CSAs: The number of CSAs contracted for which the contract start date occurs in the applicable reporting period. Fill out the template via the following -- The number of unique CC members: Who are identified as SMI/SED/SUD Who were admitted to a freestanding psychiatric hospital, psychiatric unit, or any other BH Facility within a general hospital during the applicable reporting period Who received service for the facility during the applicable reporting period Using the Description and Codes stated Row Header Row Descriptions Total Members Served 10 From the member counts entered within each of the columns detailed below, identify and enter the corresponding total unduplicated count of CC members for the particular column. Column Header Column Description and Codes County/CSA Provider A-D All NM Counties Out of State providers and additional CSAs should be added manually. Total Male and Female E Total Male and Female Members Male F Total Male Members Female G Total Female Members Under the Age of 21 H Members Under the Age of 21 Age 21 and Over I Members Age 21 and Over BMS J H2014 BH Day Treatment K H2012 BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 7 of 9
Column Header Column Description and Codes Intensive Outpatient Ages 13 to 17, Adolescent L H0015 MST M H2033 HO or HN Note: modifier is required; modifiers indicate profess level; tied to rates BH Respite N T1005 Residential Under 21 O 0190, 0191, 0194, and 1000 - Desert Hills, 1001, 1002, 1005 - GH, TFC I & II S5145 with or without U1 modifier. Includes RTC, non-accredited, GH, sub-acute and specialty units and Treatment Foster Care I & II. Intensive Outpatient Ages 18 and Over, Adult P H0015 ACT Q H0039 U1 (F2F), U2 (Collateral) or U3 (assertive outreach) Modifiers are required. PSR - Group or Classroom with or without the modifier Psychiatric or Substance Abuse Inpatient Services 24/7 Crisis Intervention Billing w/o a modifier R H2017 HQ H2017 H2017 U8 S 0114, 0124, 0126, 0134, 0144, 0154, 0204;0900-0903; 0911, 0914-0916, 0918,0944, 0945, 0961 T H2011 24/7 Crisis Intervention U H2011 U2 or U3, 90839 (first hour), 90840 additional 30 mins 24/7 Crisis Intervention - phone V H2011-U1 Medication Management W +90863, OP Visit New patient - 99201, 99202, 99203, 99204, 99205, OP Office Visit Established Patient - 99211, 99212, 99213, 99214, 99215; H2010 w/ or w/o U8; 90792 Note: Limit to BH providers All CCSS X H2015 HO, HN or HM; H2016 HO, HN or HM (IHS) Note: modifier is required; modifier defines level of provider Behavioral Health Assessment Y H0031, H0031 U8, and 90791 Psych Testing Z 96101, 96102 96103, 96105, Neuro: 96116, 96118,96119, 96120 BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 8 of 9
Column Header Column Description and Codes Service Plan Developments/Updates AA T1007 T1007 HV T1007 U8 ER Services AB Pull data based on POS 23 and Bill type 013 or 085 Revenue code "like" 045 or 45, but not 459, 456, 451, 452, 0459, 0456, 0451, 0452 Medication Assisted Treatment AC H0020 H0033 H0001 Also include medication information: Partial Opioid Agonist: Subutex (Buprenorphine), Suboxone (Buprenorphine/naloxone) Opiate antagonist: Naltrexone extended release injection Opioid antagonist: Revia (naltrexone), Vivitrol (naltrexone extended release injection), GABA/taurine analogue: Campral (acamprosate) Aldehyde Dehydrogenase Inhibitors: Antabuse (disulfiram) Anticonvulsant: Topiramate (Topamax ) Antispasmodic, muscle relaxant: Baclofen (Lioresal ) Psychiatric or Substance Abuse Outpatient Therapy Crisis Triage AE Placeholder AD 90832, 90834, 90837, +90833, +90836, +90838, 90846, 90847, 90849, 90853; also 0914,0915, 0196, H0014 outpt detox; Report 45 - Appendices Behavioral health determination criteria are detailed within the following appendices (attached separately): Appendix 1 SMI Appendix 2 SED A map of the New Mexico Behavioral Health Local Collaboratives is located in the following appendix (attached separately): Appendix 3 Collaborative Map BH Member Services/CSA - Report #45 Rev. v7 2016-08 Page 9 of 9