Treatment for Substance Use Disorders

Transcription

1 Treatment for Substance Use Disorders CHRISTUS Health Plan and CompCare HHSC: Posted CHRISTUS/Marketing/SFY 2013/ December 14, 2012 CHRISTUS and CompCare CHRISTUS Health Plan CHRISTUS Health Plan (CHP) contracts with the Texas Health and Human Services Commission (HHSC) to administer the Medicaid Managed Care and CHIP programs in the Nueces service area Nueces Service Area Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kennedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria STAR offers a wide range of free health care services to low income individuals including pregnant women and children No premiums or co-payments for doctor visits, eye glasses or prescriptions CHIP offers health care services for children 18 or under with little to no cost to their family CHRISTUS Subcontracts with CompCare for management of Behavioral Health Services 2

2 CHRISTUS and CompCare (Cont.) Comprehensive Behavioral Care, Inc. (CompCare) NCQA accredited Managed Behavioral Healthcare Organization (MBHO) Serving managed behavioral health needs of Texas STAR and CHIP members for more than 15 years CompCare provides full compliment of MBHO services to CHRISTUS members Access and Referral Utilization Management Credentialing and Contracting Claims Quality Reporting 3 Medicaid Enrollment Requirements for Facilities Enrollment Prerequisites: Typically, Medicaid provider enrollment requires enrollment as a Medicare provider as well. Medicare enrollment is not a requirement for Medicaid enrollment for any Facility or a Chemical Dependency Treatment Facilities (CDTFs). Treatment facilities must have a National Provider Identifier (NPI), as required in the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standards. Facilities must be actively licensed by DSHS as a Chemical Dependency Treatment Facility (CDTF). Facilities cannot be enrolled in Texas Medicaid if their licenses are due to expire within 30 days. 4

3 Medicaid Enrollment Requirements for Facilities (cont.) A Credentialing Application is required for the following: Facilities, CHMCs, CDTFs Individual Practitioners NOTE: CompCare considers delegating credentialing to organizations Other requirement include (see credentialing packet for additional information based on licensure type): Copies of all applicable Active Licenses Malpractice Insurance Site Visits, etc. Providers (practitioners or facilities) must possess both of the following to be considered for inclusion into the network. Active Texas Provider Identification number (TPI) National Practitioners ID number (NPI) 5 Medicaid Enrollment Requirements for Other (Non-Facility) Providers Enrollment Prerequisites: Providers (e.g., physicians such as psychiatrists) who are not affiliated with the following facilities must also be enrolled in Medicare in order to enroll as a Texas Medicaid provider: Substance Abuse Treatment Facilities, or Are affiliated with a facility but do not plan to bill through that facility Enrollment requirements as a provider of Texas Medicaid Providers dispensing opioid drugs for treatment of opioid addiction must be certified by the Substance Abuse and Mental Health Services Administration and must comply with the federal regulations of 42 C.F.R 8. Providers who want to prescribe Buprenorphine (a medication used in medication assisted therapy), must apply for a waiver that allows providers to dispense this drug for opioid addiction treatment. To apply for the waiver, contact the Center for Substance Abuse Treatment (CSAT) at BUP-CSAT( ). 6

4 Medicaid Enrollment Requirements for Other (Non-Facility) Providers (cont.) Enrollment Prerequisites (cont.): Eligible Providers for Reimbursement Physician/MD provider types A Licensed Professional Counselor (LPC) Can enroll as an individual provider May perform other counseling services Bill under BH codes Licensed Chemical Dependency Counselors (LCDCs) Not currently a recognized provider type Cannot enroll as independent Medicaid providers 7 Additional Information for Providers Who Plan to Serve STAR Medicaid Managed Care Clients Information on STAR Credentialing and Contracting: In addition to Medicaid enrollment, providers must be credentialed and contracted with the CompCare to receive reimbursement for treatment of CHRISTUS members Generally, credentialing involves verifications of qualifications and practice history, including an examination of appropriate licensure, a look at sanctions, limits on licensure, registration, and malpractice history. The credentialing process must be completed before the start date of a contract between the health plan and an individual provider. Contracts are negotiated between each provider and the health plans. 8

5 Additional Information for Providers Who Plan to Serve STAR Medicaid Managed Care Clients (Cont.) Information on STAR Credentialing and Contracting: STP status does not allow SUD providers to set different conditions than other providers. STPs must accept the terms and conditions for contracting with the health plan. Providers who have been credentialed by CompCare (CHRISTUS Health Plan) and have an existing contract with a health plan to serve children in Medicaid managed care may need to update their contracts or provider agreements, if they desire to serve adults. The credentialing and contracting process can take up to three months if all required information is not received upon initial submission. 9 How to become Contracted and Credentialed with CompCare to see CHRISTUS Members A contract and credentialing application can be obtained following the presentation Credentialing Timeframe days Less time if all information is received upon initial submission To obtain an application and contract: Contact Michelle Brochu, VP of Project Management [email protected] Office: Provide an or office address A packet will be sent 10

6 Substance Abuse Services for STAR (Medicaid) Reiterate the Statement of Benefits: Treatment for Substance Use Disorders (SUD) is a benefit of Texas Medicaid. SUD treatment services are age appropriate, medical, and psychotherapeutic services designed to treat an individual s substance disorder and restore function. Services and provider requirements associated with this benefit are found in Texas Department of Insurance (TDI) regulations (28 Texas Administrative Code (TAC), part 1chapter 3 subchapter HH) and TAC 448. Medical necessity for substance abuse services will be determined based on the TDI regulations and nationally recognized standards such as those from the American Society of Addiction Medicine (ASAM) or the Center for Substance Abuse Treatment (CSAT). 11 Overview of Substance Abuse Services for STAR (Medicaid) (cont.) SUD Covered Services for STAR Enrollees: An Assessment/Evaluation 1 per Episode of Care Ambulatory SUD treatment services Group Counseling provided by a CDTF Individual Counseling Medication Assisted Therapy Outpatient setting Detoxification Treatment Services Acute Care Hospital setting Residential or Ambulatory Services in a CDTF Setting Residential SUD treatment services SUD services provided by a CDTF are limited to those provided by facilities licensed and regulated by the Department of State Health Services (DSHS) to provide SUD services within the scope of that facility s DSHS license 12

7 Overview of Substance Abuse Services for STAR (Medicaid) (cont.) These SUD Services Require Prior Authorization Ambulatory SUD treatment services Benefit Limit per calendar year 135 hours (max.) of Group Counseling provided by a CDTF 26 hours of Individual Counseling Medication Assisted Therapy in an outpatient setting Detoxification Treatment services in Acute Care Hospital, Residential or Ambulatory CDTF Setting Benefit Limit Up to 21 days Residential SUD treatment services Benefit Limit Up to 21 days An Assessment is covered without prior authorization Benefit Limit 1 assessment per episode of care 13 Substance Abuse Services for STAR (Medicaid) (cont.) Assessment Assessment by a chemical dependency treatment facility (CDTF) for admission into a SUD treatment program. Assessment does not require prior authorization CDTF assessment must be performed by a qualified credentialed counselor (OCC) to determine the severity of an individual s SUD and identify their treatment needs. Assessments are limited to one per episode of care Use the following procedure code for assessment: H0001 (with HF Modifier) Alcohol and/or Drug Assessment 14

8 Substance Abuse Services for STAR (Medicaid) (cont.) Detoxification Ambulatory (outpatient) Detoxification Medical needs do not require close monitoring It is not a stand alone service and must be provided in conjunction with ambulatory substance abuse treatment services. Use H0014 (with HF Modifier) Alcohol and/or drug services to bill for ambulatory (outpatient) detox Codes are bundled in the H0014 per diem rate and negotiated with the provider. Include, but not limited to: H0050 (with HF Modifier) Alcohol and/or drug services; brief intervention, per 15 minutes S9445 (with HF Modifier) Patient Education, not otherwise classified, individual per session Residential Detoxification Medical needs do not warrant acute inpatient hospital admission Severity of the anticipated withdrawal requires close monitoring. Use H0047 (with HF Modifier) Alcohol and/or drug services procedure code Per diem rate for Residential Detoxification (acute detox residential addiction inpatient) Use H0031 (with HF Modifier) Mental Health Assessment by a Non- Physician Prior Authorization is Required by contacting CompCare 15 Substance Abuse Services for STAR (Medicaid) (cont.) Detoxification Continued Inpatient Detoxification (medically supervised hospital) is appropriate when one of the following criterion is met: Client has complex medical needs or complicated co-morbid conditions that necessitates hospitalization for stabilization. Services are provided to a client incidental to other medical services that are provided as a component of an acute care hospital stay Use the appropriate Revenue Codes for inpatient detoxification that are negotiated in the contract NOTE: Crisis stabilization is not a component of detoxification. Crisis stabilization for a mental health condition may be provided as needed when the service is medically necessary and the clinical criteria for psychiatric care are met. 16

9 Substance Abuse Services for STAR (Medicaid) (cont.) Residential Treatment Residential SUD services require prior authorization and are limited up to 21 days. The services include counseling, education and life skills. Use the following procedure codes for the residential treatment services H2036 (with HF Modifier) Alcohol and/or drug abuse treatment program, per diem 17 Substance Abuse Services for STAR (Medicaid) (cont.) Treatment Continued Ambulatory (outpatient) treatment services require prior authorization and are limited to 135 hours per year of group services and 26 hours of individual services per year when provided by a QCC. Use the following procedure codes for ambulatory (outpatient) treatment services: H0004 (with HF Modifier) Behavioral health counseling and therapy (per 15 minutes) H0005 (with HF Modifier) Alcohol and/or drug services, group counseling by a clinician (1 hour increments) NOTE: These codes are limited to the following diagnosis: , 291.9, 292.0, , 292.9, , , , , , , , , , , , , , , , ,

10 Substance Abuse Services for STAR (Medicaid) (cont.) Treatment Continued Medication Assisted Therapy (MAT) may be a benefit when using a drug or biological recognized in the treatment of SUD and provided as a component of a comprehensive treatment program as per TAC 448, or as a conjunctive treatment regimen for individuals addicted to abusable substances who meet the current DSM criteria for a SUD. MAT is limited to clients in ambulatory (outpatient) treatment. MAT is considered part of detoxification (residential and ambulatory (outpatient)) and residential treatment. Documentation requirements supporting the medical necessity for MAT must be maintained in the client s medical record as per 42 C.F.R. 8. No client under 18 years of age (age of majority) may be admitted to narcotic maintenance unless a parent or legal guardian, or responsible adult designated by the relevant State authority consents in writing to such treatment. To be eligible for narcotic maintenance treatment, clients 18 years of age or younger must have had 2 documented attempts at short-term detoxification or drug-free treatment. A waiting period of no less than 7 days is required between the first and the second short-term detoxification treatment. 19 Substance Abuse Services for STAR (Medicaid) (cont.) Treatment Continued Medication Assisted Therapy (MAT) for the treatment of opioid addiction must comply with the requirements in Federal Regulation 42 C.F.R. 8. Use the following procedure code for MAT for opioid addiction when using methadone: H0020 Alcohol and/or drug services, methadone administration and/or service provisions of the drug by a licensed program. H0020 UA Methadone given in person H0020 U1 Methadone take-home doses H2010 Comprehensive medication services, per 15 minutes H2010 HG, UA Nonmethadone given in person (opioid) H2010 HG, U1 Nonmethadone take-home doses (opioid) H2010 HF, UA Nonmethadone (non-opioid) 20

11 Substance Abuse Services for STAR (Medicaid) (cont.) Service that are not a covered benefit (exclusions): Aftercare Occupational therapy as part of a residential detoxification or treatment program. Services for which the client fails to meet the treatment eligibility or authorization criterion; or which are not clinically appropriate in the setting requested based on the client s medical condition. Services for tobacco and caffeine addiction. Detoxification services for hashish or marijuana addiction. Detoxification with an opioid when the client has had two or more unsuccessful opioid detoxification episodes (has left the program AMA) within a twelve month period (see 42 C.F.R Section 8). Substance abuse counseling or related services provided by electronic means such as telemedicine, , or telephone. 21 Substance Abuse Services for STAR (Medicaid) (cont.) Provider Type(s): 08 Chemical Dependency Treatment Facility (TCADA approved) 19 Physician (D.O.) 20 Physician (M.D.) 21 Physician Group (D.O.S only) 22 Physician Group (M.D.S only and multi specialty) Place(s) of Service 1 Office 3 Inpatient Hospital 5 Outpatient Hospital 9 Other Locations 22

12 Initial Outpatient Referral/Authorization The member does not need a PCP referral The member may self refer for treatment CompCare has a toll-free number available for members to use A member may call CompCare for assistance in locating an innetwork provider CompCare contracts and credentials with behavioral healthcare group practices, independent practitioners, agencies and facilities in the member s area Authorization is generated for follow up visits once a provider has been chosen The assessment does not require prior authorization A certification letter or auth mailer is sent to the provider and/or member The Authorization Number is also communicated over the phone to allow for immediate access 23 Concurrent Outpatient Authorization Network providers requiring additional outpatient services have the option of submitting an Outpatient Treatment Review (OTR) Form Fax Mail Portal on our Website Authorizations for concurrent outpatient services are reviewed and decisions rendered within 2 business days 24

13 Urgent Access/Referral/Authorization Urgent Access includes, but not limited to Situations of crisis, but not actively suicidal/homicidal Possible relapse that is causing significant distress Care Advocate transfers the call to a licensed Care Manager Our Care Management staff are master s prepared, licensed clinicians with at least 5 years post-graduate experience Urgent appointments are scheduled within 48 hours CompCare staff will set up a psychiatric consult with a network behavioral health care practitioner for the PCP at a medical or nursing home facility 25 Emergent Access/Referral/Authorization If the member is experiencing a very serious situation, perhaps wanting to hurt themselves or someone else, - do not hesitate to call or send (as appropriate) to the nearest emergency room or mental health center 26

14 Inpatient/Detox Authorization Members need inpatient behavioral health services Pre-certification services available 24 hours a day, 7 days a week Facility UR Staff contact CompCare s Central Triage Unit Licensed Care Managers obtain clinical information Review the clinical against the Level of Care Guidelines Authorize for services as appropriate Begin Coordinating a Discharge Plan The Care Management Department Care Managers Monitor the cases concurrently Further solidifies the follow up to discharge activity CompCare Physician Advisors Make denial and appeal decisions Conduct Peer to Peer conversations with the Attending MD Care Managers staff cases CompCare Discharge Planners Follow up with members upon discharge Ensure a follow up appointment is made and kept within 7 days and 30 days 27 Coordination of Care Primary Care Physician (PCP) Communication ~ Providers are required to attempt to obtain a signed consent form from members so that information about important aspects of care can be forwarded to the PCP Should the member refuse consent, documentation regarding the refusal should be placed in the member s chart PCP communication is monitored and targeted education is completed during outpatient concurrent review 28

15 Complaint Process All complaints should be directed to the Customer Service Department at CompCare Acknowledgement Letters are sent within 5 business days of receipt of complaint 30 Day Complaint Resolution and Notification Provider complaints are handled by CompCare Member complaints are registered by CompCare and then forwarded to the Health Plan for resolution CompCare is not delegated member complaints CompCare acts as a data gatherer Member also has the opportunity to complain HHSC 29 Complaint Appeal Process Complaint Appeals are handled through CHRISTUS s Complaint Appeal Panel The Complaint Appeal Panel has 30 Days Complaint Appeal Resolution Member Notification of Decision Member also has the opportunity to appeal the complaint decision to HHSC 30

16 Appeals Process Member Appeals are not delegated to CompCare Member has 30 days from date of the Notice of Action to appeal Member Advocates will document verbal appeal requests and send it to the member for review. The member needs to return the form to the Member Advocate. A written request can be sent to: CHRISTUS Health Plan Attention: Member Advocate PO Box Dallas, TX Acknowledgement letters sent within 5 business days 30 Day Appeal Resolution and Notification of Decision A State Fair Hearing request can occur any time during or after the appeal process Provider Appeals are sent to: CompCare Attn.: Appeals Dept W. Dr. Martin Luther King Jr. Blvd., Ste. 101 Tampa, FL The CompCare website provides helpful resources to include, but not limited to: Provider Resource Manual Level of Care Guidelines Clinical Practice Guidelines Preferred Practice Guidelines Current & Archive Provider Newsletters Faxblasts Informative materials and brochures Satisfaction survey results Executive summaries of the QI/UM Program Description, Work Plan, and Evaluation Providers who does not have internet access can request a copy of the documents to be mailed to them. Fax Blasts are used for all communications such as provider newsletters and are also posted on the CompCare website 32

17 Claims Submission Electronic Claims WebMD/Emdeon as the Clearinghouse Emdeon Payer ID: Paper Claims Submission Comprehensive Behavioral Care, Inc. Attention: Claims 3405 W. Dr. Martin Luther King Jr. Blvd.; Suite 101 Tampa, FL Clean Claims must be submitted within 95 days of the date of services to be considered for payment. Submit H-codes on CMS-1500 or UB 04 forms Revenue Codes are billed on UB 04 forms only CPT codes are billed on CMS 1500 forms 33 Contact Information for CHRISTUS Health Plan Provider Hotline Medicaid: CHIP:

18 CompCare Management Contacts Michelle Brochu Vice President of Project Management Lisa Smithers-Cambridge Vice President of Claims/Customer Service Bridgitt Scott-McCaughey, MSW, LLMSW Vice President of Quality and Compliance CompCare Quick Reference Contact CHRISTUS STAR Behavioral Health Prior Authorization Customer Service Referrals Claims Complaints Appeals CHRISTUS CHIP Behavioral Health All related items mentioned above 36