Version Summary New Questions Added Answers Revised Answers Archived 08/25/2017 1 thru 42 n/a n/a 1. Acronyms 2. BPA Health Network Process 3. Prescriber Agreements 4. Funding 5. Medications 6. Screening / Eligibility 7. SUD or General Referral/Authorization/Service 8. MAT Services Referral/Authorization/Service 9. Documentation 10. Claim Submission 11. Contact Information Page 1 of 9
CARF Commission on Accreditation of Rehabilitation Facilities IROC Idaho Response to Opioid Crisis MAT Medication Assisted Treatment OTA Opioid Treatment Addendum Question 1: Where can I find the "Opioid Treatment Addendum" (OTA)? Answer: Please contact BPA Health Provider Network Management. Question 2: What will be required of the SUD Treatment Provider regarding the claims withhold and related performance measures? Answer: The 5% withhold amount will be applied to the IROC funded clients. The current measure to have "encounters notes entered within 5 days" will apply to SUD Treatment claims. It will not be applied to bundled rate for the MAT Services. If the client is enrolled in MAT Services and is authorized MAT Bundled Services and MAT Management Fee, the "encounter notes entered within 5 days" will not be measured for encounters entered against these two authorized services. Question 3: Are there requirements for providers to partner with a non-profit? Answer: No. There are no requirements to work with non-profit or for profit. There is a requirement for the Prescriber to be an approved Data Waiver 2000 Prescriber. Question 4: Who is the contact person for prescribers about being on the list of available Data Waiver 2000 providers? Answer: Prescribers may contact Dan Canfield with Idaho Department of Health and Welfare at Daniel.Canfield@dhw.idaho.gov or (208) 334-0466. Question 5: I am a SUD Treatment Provider interested in engaging and contracting with a prescriber in my area. Does BPA Health have a sample contract I could use to do this? Answer: Yes. Please contact BPA Health Provider Network Management. Question 6: Can SUD Treatment Providers contract with more than one prescriber? Answer Yes. SUD Treatment Providers may enter into a contract or agreement with one or more Prescribers. Question 7: Can Prescribers contract with more than one SUD Treatment Provider? Answer: Yes. Prescribers may enter into a contract or agreement with one or more SUD Treatment Providers. Page 2 of 9
Question 8: What is the length of the IROC grant? Answer: The IROC grant is for 1 year. The first year of IROC runs from 5/1/17 to 4/30/18 with a possible 2nd year. Question 9: What types of medications are available to clients through IROC funding? Answer: IROC funding will reimburse for Methadone, Suboxone or Buprenorphine medications. It will not reimburse for Naltrexone (brand name Vivitrol). Question 10: Does Medicaid reimburse for the prescription cost for the 3 medications under MAT Services for Medicaid covered clients? (Methadone, Suboxone, or Buprenorphine) Answer Buprenorphine containing prescriptions (includes Suboxone film (buprenorphine/naloxone), generic buprenorphine/naloxone tablets, and generic buprenorphine tablets) must be from an authorized prescriber for treatment of documented opioid dependence or opioid abuse. Oral buprenorphine/naloxone combination products are preferred except in pregnant women to minimize the possibility of diversion of buprenorphine single entity via the injection route. Methadone can only be dispensed through on opioid treatment program certified by SAMSHA (Substance Abuse and Mental Health Services Administration). Refer to medicaidpharmacy.idaho.gov for more information on the Preferred Drug List (PDL). Question 11: Is Naltrexone an allowable medication? Answer: No. Naltrexone is not a medication that IDHW IROC funding will reimburse. Methadone, Suboxone or Buprenorphine are the approved medications under IROC Funding. Question 12: Is a client eligible for MAT Services if they have legal charges pending, or are on probation or parole? Answer: No. A client does not qualify for IROC funding if they are currently on probation or parole, or if they have legal charges pending. Question 13: Can a SUD Treatment Provider limit the number of clients under IROC funding and MAT Services? Answer Yes. SUD Treatment Providers may limit the number of clients for whom they coordinate MAT Services. Question 14: Will clients authorized for IROC funding be authorized for MAT Services first? Page 3 of 9
Answer: No. Clients will be authorized under IROC funding for SUD Treatment first. The initial authorization will include a GAIN Assessment and the initial MAT Services evaluation. The client and the SUD Treatment Provider will determine if MAT Services is a treatment that would benefit the client s recovery. At that time, the SUD Treatment Provider would be able to refer the client to a prescriber for the MAT Services Evaluation. Question 15: I know that the population for the PWWC and IVDU is higher in the hierarchy than IROC. Does that mean that those populations do not get IROC funding? Answer: Yes. If a client qualifies for another population (such as PWWC and IVDU) they will be placed in that population for their SUD Treatment. Through the course of treatment, if the client would benefit from the service of Medication Assisted Treatment, the provider can ask to have the client transferred to IROC (the population that would cover for that service). The client would still need to meet the eligibility criteria for IROC to be transferred by BPA Health. Question 16: Who determines if a client qualifies for IROC funding? Answer: BPA Health completes the eligibility determination with individuals seeking SUD Treatment and funding. To be eligible for MAT Services an individual must be 18 years of age or older, not be on probation or parole, and have an opiate as their primary drug of choice. An authorization is created for "Alcohol and Drug Assessment" to a SUD Treatment Provider. Question 17: Who determines if a client qualifies for Medication Assisted Treatment (MAT) Services? Answer: The SUD Treatment provider and the client will assess if MAT Services are a treatment approach that would be beneficial for the client. The Prescriber would evaluate the client for MAT Services. Question 18: Can a client go to one SUD Treatment Provider for treatment and another SUD Treatment Provider for MAT Services management/coordination? Answer: No. A client must go to the same SUD Treatment Provider for treatment and coordination of MAT Services. Question 19: Can a client transfer into IROC funding from another IDHW funding source? Answer: Yes. If it is appropriate for a client to transfer into IROC population/funding because exploring MAT Services would benefit the client, the SUD Treatment Provider may request the client be transferred. As with other population/funding transfers, the provider must explicitly ask in their request to move the client to another population/funding source and Page 4 of 9
identify which one (when possible). An updated ASAM or other clinical information may be requested to support the request. Question 20: Do clients covered under IROC funding have access to Residential services? Answer: No. IROC funded clients are not covered for Halfway House, Residential, or Medically Monitored Residential. IROC funded clients do have access to Adult Social Detox. Question 21: Since Residential is not a covered service under IROC funding, can the client be transferred to another funding source to receive Residential Treatment? Answer: Similar to the processes in place today, if the client is in a funding source that does not cover for Residential, the client case may be reviewed for transfer to another funding source (if client meets eligibility for another population). Important to understand is the client will lose the funding for MAT Services when a transfer from IROC funding occurs. Question 22: Can an existing client transition into IROC funding? Answer: Yes. If it is appropriate for a client to transfer into IROC population/funding because exploring MAT Services would benefit the client, the SUD Treatment Provider may request the client be transferred. As with other population/funding transfers, the provider must explicitly ask in their request to move client to another population/funding source and identify which one (when possible). An updated ASAM or other clinical information may be requested to support the request. Question 23 Is Case Management separate from the monthly $50 management fee? Answer: Yes. Case Management is a separate authorization. SUD Treatment Providers should ensure that they have an authorization that meets the case needs and is within the authorization maximums. Question 24: Is Outpatient or Intensive Outpatient also limited to 6 months of treatment? Answer: No. Other SUD Treatment is not limited to 6 months. Current processes for clinical review will be used for SUD Treatment and RSS. Question 25: If clients are not participating in their SUD Treatment (Outpatient or Intensive Outpatient) can they continue to receive MAT Services? Answer: No. Clients must be actively participating and engaged in SUD Treatment in order receive MAT Services. The SUD Treatment Provider would follow discharge processes if the client has not engaged in at least the last 30 days. The SUD Treatment Provider must inform the Prescriber the client is not participating in treatment and will be discharged. BPA Health will not monitor or fund services after discharge. Page 5 of 9
Question 26: Is there any limitation on how much Case Management is allowed per month for clients with IROC funding? Answer: Yes. The existing frequency of Case Management services apply to the IROC funded clients. The existing allowable frequency is up to 4 hours of Case Management per week. Question 27: Is there any limitation on how much Recovery Coaching is allowed per month for clients with IROC funding? Answer: Yes. The existing frequency of Recovery Coaching apply to the IROC funded clients. The existing allowable frequency is up to 192 units (48 hours) of Recovery Coaching for 6 months. Question 28: How will Treatment, RSS, and MAT Services be authorized? Will they be separate authorizations? Answer: The MAT Services will always be a separate authorization from RSS and SUD Treatment. There will be two services on one authorization: MAT Bundled Services (the services performed by the prescriber, visits and medication) and MAT Management fee (the services performed by the SUD Treatment Provider to coordinate the MAT service). SUD Treatment and RSS may be on the same authorization depending on who is providing the service and if the services were requested at the same time or a different time. These will be authorized together or independently as they are today under all funding. Question 29: What is the maximum amount of MAT Services a client may have? What are the readmission rules? Answer: A client may only have 180 days ( 6 months) of MAT Services in the project year. If a client admits to MAT Services for 30 days ( 1 month) and leaves MAT Services, they can return in the same project year and receive the remaining 150 days ( 5 months). If a client admits to MAT Services and utilizes 180 days ( 6 months), they cannot access MAT Services in the same project year. Question 30: Why is the initial authorization for MAT Services only 14 days long? What if I need more time? Answer: It is preferred that the client receives the "MAT Evaluation" with a prescriber within 14 days of being referred by the SUD Treatment Provider for the evaluation. We understand that not all evaluations can happen in 14 days. Simply call BPA Health to inform them of the scheduled date of the prescriber appointment and to get an extension of the authorization. The initial authorization cannot exceed 30-days from start date. Question 31: Are MAT Services available under other funding sources/populations? Page 6 of 9
Answer: No. MAT Services are only available for clients who are funded under IROC funding. Question 32: What if the client needs continued MAT Services after the conclusion of the 6 months of state funding? Answer: The client, SUD Treatment Provider, and Prescriber may discuss the best course of action for continued MAT Services. For example, the client may stay in SUD Treatment Services and arrange to self-pay the Prescriber for the MAT Services. Question 33: Will the SUD Treatment Provider be required to document the treatment and progress, including the MAT Services, in the ASAM for reviews? Answer: Yes. The client's progress and engagement in the MAT Services is important to clinical reviews. Please include it in ASAM Reviews. Question 34: May I bill for the management fee if the client is found not eligible for MAT Services? Answer: Yes. A SUD Treatment Provider may enter an encounter and bill for the $50 MAT Management Fee for the first 30 days even if the client is found to not be eligible for continued MAT Services after prescriber determination. Question 35: I am a SUD Treatment Provider and I have contracts or agreements with a Prescriber for the office visits with Prescriber, and a contract or agreement with a Pharmacy for the medication. How much is the reimbursement for me as the coordinator of the service, the prescriber, and the medications? Answer: The MAT Services is a bundled rate established to pay the Prescriber for all MAT Services and include the necessary visits at their clinic and the medications. Because this is a bundled amount, the SUD Treatment Provider and the Prescriber are encouraged to outline the costs and reimbursement expectations in their contract or agreement. Question 36: Is there a screening process to determine if the client has ability to pay 50% of the MAT Services cost in the final 3 months? Answer: No. There is not a formal screening process established to determine the clients ability to pay. There is a 50% copay in the final 3 months to be paid directly to the Prescriber for the MAT Services. SUD Treatment Providers and the Prescriber are both encouraged to work with clients in the first 3 months of the MAT Services to prepare the client for their 50% cost-share in the final 3 months. NOTE: The 50% client cost-share applies to the MAT Services; it does not apply to other SUD Treatment services. Page 7 of 9
Question 37: I am a SUD Treatment Provider who is coordinating MAT Services for a client. How do I bill BPA Health for the MAT Services? Answer: The SUD Treatment Provider may use their current business processes to bill BPA Health for the MAT Services. There are few general rules to consider: All claims must be entered and billed in WITS by the SUD Treatment Provider The SUD Treatment Provider may submit the claim for the $50.00 Management Fee one time in a 30-day period. The SUD Treatment Provider may submit a claim for one MAT Services Evaluation up to $250.00 in the first 30-day period. The SUD Treatment Provider should require and receive invoices from the Prescriber(s) for their services and submit the claim in WITS for the appropriate bundled rate for each 30-day period. It is recommended that the SUD Treatment Provider submit the claim(s) in WITS at least every 30 days (to prevent authorization closure by the WITS system) The SUD Treatment Provider will need to manage the 30-day period cost and could be responsible for costs over the 30-day allowable. Question 38: For MAT Bundled Services, what does the rate cover? Answer: The bundled rate per 30 days includes reimbursement for all of the Prescribers services. The following definitions apply to services delivered by the prescriber under MAT Services: 1. Initial MAT Evaluation. Office visit to evaluation if the client is a candidate for MAT Services. Includes patient history, medical exam, establish as a new patient with prescriber, etc. 2. Monthly Bundle for MAT Services. Medication checks, medication, drug tests, on call services in emergencies, interface with the SUD Treatment Provider, and case management to ensure client compliance. Question 39: Are SUD Treatment Services separate from MAT Services? Answer: Yes. SUD Treatment services and the related costs are separate from MAT Services and paid under the appropriate bundled rate. Question 40: If a SUD Treatment Provider is CARF certified, will an annual audit now be required based on the addition of the MAT Services? Answer: No. Established BPA Health audit schedules and requirements will not change as a result of a SUD Treatment Provider participating in IROC funding. Page 8 of 9
Should IDHW request any information regarding services or payment with a CARF certified provider organizations, the Regional Coordinator will work with the organization directly on the requested information. Question 41: I am a SUD Treatment Provider who is audited by BPA Health. What documentation do I need to be prepared to have about prescribers visits and medication for clients receiving MAT Services? Answer: BPA Health will include IROC specific clients in the annual audit processes. Audit items will include documentation to support the MAT Services claims for Prescriber services. It will also include documentation supporting Evidence Based Programs included in treatment (Matrix Model, Cognitive Behavioral Therapy (CBT)). Question 42: What is the SUD Treatment Provider required to have in their records to ensure back-up document is available for the claims submitted in WITS? Answer: The invoice(s) from the Prescribers that report the dates of service for the MAT Services evaluation; and the invoice(s) for the bundled services that report medication type and the 30-day time period covered by the bundled rate. Idaho Department of Health and Welfare Program Specialist Crystal Campbell 208-334-6506, Crystal.Campbell@dhw.idaho.gov IROC Project Coordinator Dan Canfield 208-334-0466, Daniel.Canfield@dhw.idaho.gov WITS WITS Help Desk 208-332-7316, Toll-Free: 844-726-7493, dbhwitshd@dhw.idaho.gov BPA Health Call Center 208-947-4393, Toll Free: 800-922-3406 Provider Services 208-947-4377, Toll Free: 800-688-4013 Regional Coordinators o Region 1 Nancy Irvin 208-964-4868, Nancy.Irvin@bpahealth.com o Region 2 Dean Allen 208-305-4439, Dean.Allen@bpahealth.com o Region 3 & 4 LaDessa Foster 208-284-4511, LaDessa.Foster@bpahealth.com o Region 5 & 6 Lisa Bell 208-484-0093, Lisa.Bell@bpahealth.com o Region 7 Doug Hulett 208-921-8923, Doug.Hulett@bpahealth.com Page 9 of 9