Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars

Transcription

1 Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars 1. In the past we did precertifications for Residential Treatment Centers (RTC). Will this change in the future? Telephonic preauthorization (precertification) discussions will be required for all higher levels of care (HLOC) which include the following: Acute Inpatient, RTC (defined below) and Partial Hospitalization. Residential Treatment Center- a facility setting offering therapeutic intervention and special programming in a controlled environment which also offers a high degree of security, supervision and structure. Patients are medically monitored with 24-hour medical availability and 24-hour onsite nursing service for members with long term or severe mental disorders and patients with alcohol/substance abuse disorders. Facilities are licensed at the residential intermediate level or an intermediate care level. Licensure requirements for the facility vary by state. Credential requirements: Mental Health Residential Treatment Center- an institution appropriately licensed by state and accredited by the Joint Commission on Accreditation of Health care organizations (JCAHO), the American Association of Psychiatric Services for Children, Commission on the Accreditation of Rehabilitation Facilities (CARF), and/or Council on Accreditation (COA) Chemical Dependence Residential Treatment Center- any such facility must be licensed, certified or approved as a chemical dependency treatment center by the appropriate state agency and be accredited by the JCAHO, CARF and/or COA 2. Is there a different preauthorization and approval process for the two different levels of Intensive Outpatient Program (IOP), depending on whether the IOP is less than 20 hours or more than 20 hours a week? No, we recognize IOP as one level of care regardless of hours per week and authorize service days following medical necessity criteria. See the following definitions: Intensive Outpatient Program a free standing or hospital- based program appropriately licensed by the State and/or accredited by the Joint Commission (TJC), the American Association of Psychiatric Services for Children, the Council on Accreditation of Services for Families and Children, Inc. (COA), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Accreditation Association for Ambulatory Healthcare (AAAHC) or the National Integrated Accreditation for Healthcare Organizations (NIAHOSM) as a psychiatric or chemical dependency intensive outpatient program for the provision of mental health care, serious mental illness services and/or chemical dependency services. This behavioral healthcare is typically 3 to 4 hours per day, 3 to 5 days per week (not less than 9 hours of treatment services per week) and may typically run from 4 to 12 1

2 weeks duration. Treatment services are mostly performed using a structured group format and/or individual therapy and may include educational services and life skill training. An intensive outpatient program may or may not provide pharmacotherapy or nursing care. Participants at this level of care do not require 24 hour supervision and are not considered a resident at the Program. Partial Hospitalization or Day Treatment Program- an institution, either freestanding or hospital based, appropriately licensed by the State and/or accredited by the Joint Commission (TJC), the American Association of Psychiatric Services for Children, the Council on Accreditation of Services for Families and Children, Inc. (COA), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Accreditation Association for Ambulatory Healthcare (AAAHC) or the National Integrated Accreditation for Healthcare Organizations (NIAHOSM) as a psychiatric or chemical dependency intensive outpatient program for the provision of mental health care, serious mental illness services and/or chemical dependency services. This behavioral healthcare is typically 5 to 8 hours per day, 5 days per week (not less than 20 hours of treatment services per week) and may typically run from 1 to 8 weeks in duration. The program is staffed similarly to the day shift of an inpatient unit, i.e., medically supervised by a physician and nurse. The program shall ensure a psychiatrist sees the patient face-to-face at least once a week and is otherwise available, in person or by telephone, to provide assistance and direction to the program as needed. Participants at this level of care do not require 24 hour supervision and are not considered a resident at the program. 3. What is the approval process for IOP? For an Intensive Outpatient Program level of care, the following authorization processes will be followed: If member is in a HLOC, the BH UM clinician can authorize IOP service days without need to provide additional clinical until the last covered day. At this time if additional service days are requested, the IOP Request Form must be completed and faxed in for clinical review. If member is scheduled to admit to IOP from the community, the initial authorization of four (4) service days will be approved without providing clinical by contacting the BH Call Center at ( ). This will allow the provider an opportunity to gather and complete the form for continued visits if needed after the four visits are utilized and, if the member does not follow through and attend, the provider has not spent time unnecessarily filling out forms. The IOP Request Form is available on the bcbsmt.com website, under the FORMS tab. 4. What is the approval process for outpatient Electroconvulsive Therapy (ECT)? If member is in a HLOC receiving ECT and additional sessions continue to be necessary after discharge, the BH UM clinician can authorize additional sessions without providing additional clinical. If additional sessions may be indicated, an ECT Request Form must be completed and faxed in for clinical review. 2

3 5. What is the average turn-around time for a review of IOP and ECT services? Reviews are completed within 48 hours of receipt of the faxed request. The provider and member are notified by letter of the determination. You may contact the Behavioral Health Call Center at to inquire on the status of a request. 6. If an admission occurs on a weekend, can we wait until Monday to request authorization? The same process for medical admissions also applies to Behavioral Health admissions: (included in Provider manual on BCBSMT.com website) Scheduled Admissions The physician, facility, or member should notify BCBSMT when an inpatient admission is scheduled ahead of time. To the extent practical, precertification should be obtained at least five (5) days in advance of an admission or certain ancillary services. Precertification must always be obtained prior to the actual admission and/or treatment. Unscheduled Admissions Admission certification for emergency admission must be obtained within 48 hours of the actual admission. However, our BH UM clinicians are available 24 hours per day seven days per week, 365 days a year at to respond to acute inpatient authorization requests. 7. May we receive a copy of the slides from the December 2013 BH Provider webinar? The slide presentation is available on the bcbsmt.com website under the Behavioral Health tab within the Provider section. Also, you may contact: Susan Lasich, BCBSMT Provider Network Representative Susan_Lasich@bcbsmt.com Can you provide us with a copy of the Milliman Behavioral Health Care Guidelines for mental health conditions? We are not authorized to provide Milliman s guidelines to Providers. However, Clinical Review Criteria are available to physicians and other professional providers upon request relative to a specific care review decision. You may contact BCBSMT Behavioral Health at to initiate this request. Contact information to inquire about the guidelines: Milliman Care Guidelines, A Division of Milliman 3

4 Phone: Toll-Free: Will we have the current staff we have been communicating with at BCBSMT for BH Utilization Management (live reviews) and Case Management or will there be a new team? There will continue to be BH staff at the BCBSMT office to support the BH Utilization Management and Case Management programs. As MT membership transitions to its new information management system platform to match the other markets served, there will be additional BH clinicians you will interact with to support the MT membership. Adjustments in staffing will be made accordingly to best meet the needs of the membership. 10. Will HMK members work with a different BH team? Yes, a separate BH team will be designated to serve the HMK members. One of BCBSMT s current staff will be on that team. BH cases will be reviewed using the same processes and medical necessity criteria used for the other MT membership we serve. 11. Do you have any specialists in Addiction Medicine? What are the specific training requirements or qualifications for such specialists? All of the BH Medical Directors are Board Certified Psychiatrists who have extensive experience in managed care operations. Substance Abuse is a core component of their residency training. 12. Do members need a special benefit to their Plan to access these BH programs? Most members have BH services as part of their benefit plan. However, there may be some selffunded employer groups who may elect to exclude certain types of behavioral health services or programs. For example, a self-funded group may not cover RTCs. As another example, a selffunded group might choose a third party vendor to provide BH management programs such as Utilization Management (UM) and Case Management (CM). Please contact a BCBSMT Customer Advocate at or a BH Call Center Advocate at to verify benefits Are we going to be required to call (vs. currently typing and faxing) in for pre-authorization for members being admitted to our Crisis Stabilization Facility? If so, does BCBSMT require preauthorizations be requested by a licensed clinician? Additionally, does BCBSMT require that appropriate clinical information be provided by a licensed clinician? Yes, authorization for acute inpatient stays is required. The process applicable to medical admissions also applies to Behavioral Health admissions: (included in Provider manual on bcbsmt.com website) Admission certification for emergency admission must be obtained within 48 hours of the actual admission. 4

5 However, our BH UM clinicians are available 24 hours per day seven days per week, 365 days a year at to receive and respond to acute Inpatient authorization requests. The preference is for clinical information to be provided by a clinician but, if not possible/feasible, a non-clinician may provide the information from an assessment done by a licensed clinician. 14. Is a live discharge call going to be required as well? If so, are dates of follow-up appointments, providers, and provider contact info going to be required? If so, this may change the length of stay for some members as we cannot schedule appointments on the weekend. If a member is admitted on a Friday evening and wants to/is cleared for discharge on Sunday evening, do we have to keep them until Monday in order to have a follow-up with BCBSMT or can that be left to the member with the assistance of BCBSMT s Case Managers? The BH clinician will interact with the facility staff by telephone to confirm discharge plans. If discharge occurs during the weekend, contact on Monday is acceptable. In the situation you describe in the question, our BH Discharge Coordinator would reach out to the member to review their discharge plan, identify barriers in complying with treatment plan, confirm whether the member has a follow up appointment with his or her provider, (and if not, assist member in making a provider appointment), refer to our BH Case Management program as indicated, and provide other resources as indicated. 15. Does the fact that BCBSMT has now joined BCBSTX and four other Plans mean that treatment options in those states would be in-network for members? For instance, MT has no in-patient options for the treatment of trauma specifically. Members of BCBSMT have access to one of the largest networks of participating providers through the Blue Cross Blue Shield Association s BlueCard System. This network provides national coverage, which allows our membership to receive in- network coverage regardless of where they live. Because of the size of our national PPO network we have a very high in-network utilization rate. The in-network utilization rate for our 13+ million members is 95 percent. The BlueCard PPO program links participating health care providers and independent BCBS Plans across the country through a single electronic network for claims processing and reimbursement. The program ensures that members obtain consistent PPO benefits and access to BlueCard providers while traveling or residing in another Plan s service area. BlueCard PPO providers have agreed to file claims for members. Whether in or out of his or her home state, the BlueCard member is responsible only for any applicable copayment, coinsurance, and deductible. The steps below outline the claim payment process when out-of-state providers file claims: The participating provider files the claim with the local BCBS Plan. The local Plan prices the claim and transmits it to BCBSMT. BCBSMT determines eligibility and coverage, then adjudicates the claim and informs the local Plan of the amount to be paid. 5

6 The local Plan pays the provider and then reconciles with BCBSMT. Members file non-network provider claims directly with their local Plan. 16. What guidelines govern the length of coverage approved with a pre-authorization and the frequency of continued stay reviews? The Milliman BH Care Guidelines for Mental Health Conditions and ASAM criteria for Substance abuse are utilized to determine medical necessity for authorizing the initial and continued stay reviews. There is no defined length of coverage approval and frequency of continued stay reviews. This is unique to the individual s situation which includes review and evaluation of: Presenting symptoms Mental health treatment history and medications Alcohol/substance abuse treatment history Medical history, medications and treatment regimens Mental status (reported by a practitioner) Risk potential Current support systems Diagnosis (reported by a practitioner) 17. These following questions are similar and have one response below: What about discharge planning and the availability of community based services a significant issue for a number of our client families? Is there a consideration for lack of care in rural areas? If a member in a rural area does not have a residential coverage benefit, but has partial hospitalization, can you substitute two partial days for one residential day? We have a member who lives 200 miles away and has partial boarding benefits. He is currently paying for this out of pocket. Will this change? Many members in the markets we serve across the country reside in rural areas with lack of or minimal HLOC options, and in locations with limited community based services. Determinations for levels of care and appropriate discharge plans are made after evaluating the needs of the member and all potential treatment options for a successful outcome. The BH clinicians consult with the BH Medical Directors on a case by case basis when a lower level of care would be appropriate, but not available. Authorization for a higher level of care may continue to be necessary to provide a safe, therapeutic setting to meet the needs of the member, but all options will be thoroughly evaluated. In the event this situation arises, documentation in the record and claims system should indicate that inpatient level of care is authorized due to the unavailability of an alternative level of care. Billing must reflect the level of care being provided. Substituting two partial days for one residential day is not an option. If member is authorized for an inpatient level of care, there is no partial boarding benefit to be paid out of pocket by the member. The stay would be billed as inpatient. 6