ICF-IID Provider Information Session Presented by: Alliance Behavioral Healthcare & Rubicon Management, Inc. January 29, 2013 Serving Durham, Wake, Cumberland and Johnston Counties
Session Objectives Providers will gain an understanding of: Procedure for initial ICF-IID eligibility determinations Procedure for ongoing determinations Use of Level of Care Eligibility Determination (LOC) Tool Process for vacancies and referrals Process for authorizations and claims (including Rubicon s involvement) Serving Durham, Wake, Cumberland and Johnston Counties
ICF-IID Eligibility Determination Alliance Behavioral Healthcare is responsible for determination decisions regarding ICF-IID level of care and follows a standardized process to determine an individual s eligibility for ICF-IID level of care. All reviews and decisions are tracked through the Alliance electronic consumer information system (AlphaMCS).
Initial Determinations Eligibility for ICF-IID level of care is determined by psychologist/psychological associate (PA) or Primary Care Physician (PCP) Psychologist/PA- Intellectual Disability PCP- Cerebral Palsy; Epilepsy; related condition Documentation required Completed/updated IQ and adaptive skills evaluation (Intellectual Disabilities) or completed/updated Medical Assessment (Medical Conditions) How current does psych need to be? For an initial request, 3 years for child, 5 years for adult. Completed MCO Level of Care Eligibility Determination Tool (LOC)
About the LOC LOC is replacing the MR-2 form This is a State form used for NC-Innovations and ICF-IID It is not a triplicate form and may be submitted electronically You may access the LOC on our website: http://www.alliancebhc.org/providers/forms-applications
LOC Instructions Instructions for Level of Care Determination This form is to be used for prior approval and utilization review of ICF-IID level of care. Demographics Name-Print last name, first name, middle initial. If no middle name or initial, use NMN. Address-Enter the complete address where the person lives. Date of Birth-Enter the month, day and year. Gender-Enter a capital F to indicate Female or a capital M to indicate Male. County of Medicaid Eligibility-List the county from which the person s Medicaid originates per the SIPPS system. Medicaid Number-Enter the Medicaid Number assigned to the person. Legally Responsible Person/Guardian-List the name of the person who is the legal guardian or responsible person for the individual who is being reviewed. Address of Legally Responsible Person/Guardian-Enter the complete address where the Legal Guardian/Responsible person lives.
LOC Instructions Living in ICF-IID facility Place a check in the space indicating whether or not the person lives in an ICF-IID residential facility. Diagnostic Information Check all of the disability areas that apply based on the documented disability. Check if the person has Mental Retardation/Intellectual Disability based on the documented assessment and document the IQ or the percentage of developmental delay. Check if the person has a Medical Condition and list the condition based on the documented assessment. If no diagnosis, list NA. Check if the person has a condition closely related to Mental Retardation based on the documented assessment and list the condition. If no diagnosis, list NA.
LOC Instructions Was the Disability manifested before the age of 22? Based on documented assessment, please check the correct box. Is the disability likely to continue indefinitely? Based on documented assessment, please check the correct Current Substantial Functional Limitations Place a check in the Yes box for each functional deficit the individual has based on documented assessment. If the individual does not have functional deficits in a specified area then check No. Skill acquisition Check the appropriate box to address if the person could benefit from Skill Acquisition.
LOC Instructions Level of Care Certification Based on assessment check the appropriate box to designate if the person meets the ICF-IID level of care. Get the Signature and Printed Name of a Licensed Psychologist/Psychological Associate or Physician as appropriate based on who completed the assessment. Medical doctor can sign anytime for ICF-IID Level of Care Recommendation (MCO Use Only) Based on review of information, check approved or denied for ICF-IID Level of Care List the month/day/year that the Level of Care became effective Document the Prior Approval Number Get the signature of the UM Clinical Care Manager and date of signature Get the signature of Medical Director and date of signature if needed
Initial Determinations If the psychologist or physician determines that the individual does not meet the ICF-IID eligibility criteria the decision is final and is not subject to appeal. If the individual would like a second opinion, Alliance can arrange for a different assessor to complete the evaluation.
Initial Determination The physician/psychologist forwards the LOC and a copy of the assessment/evaluation to the Alliance IDD Utilization Management (UM) Supervisor The LOC and assessment/evaluation is forwarded to an IDD UM Care Manager for review The LOC is valid for 30 days and decision eligibility must be made within 30 days of the signature date on the form The IDD UM Care Manager reviews the information from the assessment/evaluation and verifies that the documentation supports the eligibility criteria that are documented on the LOC
Initial Determination If eligibility is verified the IDD UM Care Manager builds a Service Authorization Request (SAR) in Alpha for the ICF-IID residential service The consumer/legal guardian, receiving facility and the appropriate Department of Social Services (DSS) receive written notification of the approval If the assessment/evaluations do not support that the person meets ICF-IID level of care, the Alliance Medical Director will review the information and make the final determination If the Medical Director determines that the individual is not eligible, Alliance notifies the individual/legal guardian in writing and offers appeal rights.
Ongoing Determinations Every 180 days, based on consumer s initial date of eligibility, the ICF-IID facility/agency must complete an LOC that is signed by the facility physician/psychologist Medical doctor can sign anytime for ICF-IID Will honor current MR2 until it expires We will be reviewing the reauths based on providers current 180 cycle. The facility/rubicon submits a SAR via the Alpha Provider Portal and uploads the LOC to the request Electronic submission of the LOC is fine, this is not a triplicate form and originals are not required for submission An Alliance IDD UM Care Manager reviews the SAR and LOC If the request is approved the consumer/legal guardian, IDD Care Coordinator, facility and appropriate DSS office are notified
Ongoing Determinations If eligibility cannot be determined, the case is forwarded to the Alliance Medical Director for review If ongoing eligibility is not determined by the Alliance Medical Director, the consumer/legal guardian and facility receive notification including appeal rights
Vacancies and Referrals If you have a vacancy: Contact the Alliance IDD Care Coordination Manager Local Care Coordination and IDD Access will determine appropriate referrals from the wait list for that county (individuals most urgently in need and residing in the county where the vacancy occurs) Target will be to make referrals within 3 days of notification of an opening If these referrals do not work out, contact the Alliance IDD Care Coordination Manager prior to considering referrals from Rubicon and/or other MCOs
ICF-IID Q&A s Q- What rates will be paid? A- Alliance has been directed by DMA as to what rates will be paid. Rates cannot change for 3 years. Q- What type of cost finds will be required? A- There will not be any cost finding. Q- Will there be any type of cost settlement as there is under the current Plan? A- There will not be any cost settlement Q- Who does a guardian contact if they have a complaint? A- Alliance 24-Hour Access and Information Line: (800) 510-9132 Q- Will Alliance be conducting on-site monitoring reviews? A- Yes, ICF-IID facilities are subject to monitoring and evaluation from Alliance, but we will not duplicate the State Surveys.
Alpha Provider Portal Training http://www.alliancebhc.org/alpha-provider-portaltraining February 15, 2013 and February 21, 2013 10:30am-Noon Claims Noon-1:00pm Lunch 1:00-4:00pm Clinical Available via webinar (Click on the join the live webinar link on the web address above) Pre-recorded webinars http://www.alliancebhc.org/providers/videoswebinars
Alpha Provider Portal Support Alpha Provider Portal Handbook http://www.alliancebhc.org/wp-content/uploads/alpha- Provider-Portal-Handbook.pdf Alpha Provider Helpdesk 919-651-8500 Talk with live staff about any Alpha related issue 8:30am- 5:15pm Monday-Friday Alpha Support via E-mail E-mail- alphasupport@alliancebhc.org
Alliance Weekly Claims Webinar Alliance is hosting weekly webinars for providers (not contracted with Rubicon) every Tuesday from 2:00-3:00pm to address how to bill CMS 1500 and UB04 claims and to review resources available on the Alliance website. There will be a Q&A period after each training. The schedule is as follows: February 5, February 12, February 19, February 26 March 5, March 12, March 19, March 26 To join a webinar follow this link: https://www1.gotomeeting.com/join/9704426 25/106813836
Example Alliance Checkwrite Schedule http://www.alliancebhc.org/providers/finance-and-claims-forms Claim Received Date January 11-17, 2013 January 18-24, 2013 January 25-31, 2013 ALPHA (Process To) Checkwrite Cycle Cutoff Date Checkwrite Date EFT's Effective 01/17/13 01/24/13 01/25/13 01/24/13 01/31/13 02/01/13 01/31/13 2/7/13 2/8/13
Rubicon Management Doing ICF/MR business with Alliance through Rubicon Management ASO Consolidated Billing and Collections Rubicon ICF Provider Members are able to bill and collect from Rubicon on a weekly basis for all MCOs under contract with Rubicon. Contracts to Date: Alliance Behavioral Health Cardinal (PBH) Centerpoint Coastal Care East Carolina Behavioral Health Eastpointe Sandhills Center Smoky Mountain Center
Joining Rubicon Provider membership in Rubicon is voluntary. Rubicon is a non-profit North Carolina corporation. Approximately 90% of non-state ICF consumers to be funded by Alliance are currently under contract with Rubicon Rubicon s goal is 100% MCO and Provider membership
Consolidated billing via Rubicon Provider files claims weekly through Rubicon Via 837-5010 or Rubicon proprietary software (free of charge) Claims paid via direct deposit each Tuesday PDF Remittance Advices and 835-5010 returned regardless of filing method Consolidated billing, consolidated deposit, consolidated remittance advice
Rubicon- Provider Training in Billing Process If already under Rubicon contract, add Alliance consumers to your demographic upload file, and continue billing as usual If new to Rubicon, training in new processes will be held near future, via WebEx
Rubicon Advantages At 100%, providers handle cash flow matters through Rubicon, and Alliance/Other MCO s only accept 837 s from Rubicon Transmissions from Rubicon to Alliance are bundled and submitted once a month to reduce claims processing burden for Alliance Rubicon clinical staff aid in maintaining state-wide waiting list, for use of MCOs and Providers after local MCO referrals from wait lists have been exhausted Rubicon will assist in SAR and LOC processing for Alliance s consumers Alliance will have Rubicon complete 180-day reauthorizations
Contact Information Johnston Provider Relations Cumberland Provider Relations Durham Provider Relations Wake Provider Relations Alliance UM Supervisor Alliance Care Coordination Manager Alliance Access & Information Line 800-510-9132 Lori Caviness 919-989-5557 lori.caviness@johnstonnc.com Rose-Ann Bryda 910 222-6074 rbryda@mail.ccmentalhealth.org Sara Wilson 919-651-0089 swilson@alliancebhc.org Tanya Held 919-664-7933 theld@alliancebhc.org Andrea Kinnaugh 919-651-8422 akinnaugh@alliancebhc.org Suzanne Goerger 919-651-8474 sgoerger@alliancebhc.org Rubicon Management Herb Whitesell H.Whitesell@RubiconNC.org Mike Harris M.Harris@RubiconNC.org 828-624-0001
Thank you for your time! Questions?