Applied Behavior Analysts (ABA) Provider Orientation

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1 Applied Behavior Analysts (ABA) Provider Orientation

2 Objectives Overview of Horizon Behavioral Health and ValueOptions Qualified ABA Services and Covered Treatment Providers Covered ABA Codes/AMA CPT Codes Claim Submission Procedures Transition of Care and Authorizations Quality Management Credentialing, Recredentialing and Contracting Contact Information Questions and Answers 2

3 Overview of Horizon Behavioral Health and ValueOptions Effective July 1, 2014, Horizon Behavioral Health transitioned the management of its behavioral health services to ValueOptions Inc., from Magellan Behavioral Health, Inc. Transition allows you to better serve your patients, by offering a greater integration of all behavioral and medical health services, including benefits for Applied Behavior Analysis (ABA). Horizon Behavioral Health will: Provide utilization management for ABA services for Horizon BCBSNJ membership Have a specialized ABA team working with ABA providers to handle all requests for ABA services 3

4 Services Location Horizon Behavioral Health Operations Co-located Staff Customer Engagement Center National Operations Center Claims Processing Center 250 Century Parkway Mount Laurel, NJ Three Penn Plaza East Third Floor Newark, NJ Eisenhower Pkwy First Floor Roseland, NJ British American Blvd Latham, NY Paramount Pkwy Morrisville, NC Clinical Quality Management Clinical Account Management Medical Director Clinical Customer Service Provider Relations Claims Support Customer Service Grievance/Appeals Claims 4

5 ValueOptions National Footprint 34 Million Members 130,000 Provider locations Corporate Headquarters Engagement Centers National Technology Center National Operations Center Under 100,000 Members 100, ,000 Members 500,000 1,000,000 Members 1,000,000 2,500,000 Members Over 2,500,000 Members 5

6 Qualified ABA Services and Covered Treatment Providers 6

7 Autism Spectrum (ASD) Diagnosis Determinations Autism Spectrum Disorder (DSM-5) determined by a qualified provider, which is: MD; Licensed and credentialed psychologist; Nurse Practitioner; Physician Assistant, or as permitted by state and/or federal law 7

8 Covered Treatment Providers Qualified Autism Spectrum (QAS) Provider designs, supervises, or provides treatment Board Certified Behavior Analyst (BCBA) Board Certified Behavior Analyst Doctorate (BCBA-D) Licensed Mental Health Professional with specialization QAS Professional provides treatment, assessment, and supervision Board Certified Behavior Analyst (BCBA) Board Certified Assistant Behavior Analyst (BCaBA) QAS Technician provides care under the supervision of a BCBA Typically has a Bachelor degree in Social Work, Psychology, Counseling, teaching or closely related field with experience in applied behavior analysis 8

9 Covered ABA Codes/ AMA CPT Codes 9

10 Covered ABA Codes If authorization dates of service extend past July 1, claims will be paid if older codes are used. 10

11 Covered ABA Codes, cont d. 11

12 Covered ABA Codes, cont d. 12

13 New AMA CPT Codes American Medical Association (AMA) recently published CPT Category III temporary codes for Adaptive Behavior Assessments & Treatments Published as temporary to allow for data collection for emerging technology, services and procedures Becomes effective beginning on July 1, 2014 Features greater detail on services provided to patients Identifies provider type delivering services 13

14 New AMA CPT Codes New codes distinguish by provider type: Physician Qualified healthcare professional [Board Certified Behavior Analyst (BCBA)] Qualified technician under the direction of a physician or BCBA or protocol established within a treatment plan 14

15 New AMA CPT Codes Old Codes and [policy] Process: Using the prior HCPCS coding and consistent with the NJ Department of Banking and Insurance Bulletin, Horizon BCBSNJ provided coverage under the Autism Mandate for ABA services when provided by a BCBA. New [policy] Codes and Process Effective July 1, 2014: Given the new detailed AMA codes now available, Horizon Behavioral Health will begin honoring claims submitted for ABA services provided by qualified technicians for new treatment plans if they meet specific criteria. 15

16 Coverage Criteria for Qualified Technicians Services provided by a technician must be provided under the direction of a physician or qualified healthcare professional and consistent with the protocol established in the treatment plan. Claims must be submitted under Tax Identification Number (TIN) of supervising physician or BCBA. Six month treatment plan submitted by supervising provider indicates a qualified technician will be administering the services. ABA services provided by qualified technicians will be paid at a differential rate, reflecting the difference in expertise of the provider delivering the services. 16

17 Autism Code Resources Additional information on the Autism codes on NaviNet.net: Horizon BCBSNJ s Plan Central page Provider Reference Material page Future updates in Blue Review ValueOptions Network-specific Website: 17

18 Claim Submission Procedures 18

19 Claim Submission Timelines You may continue to submit ABA claims for treatment plans that were authorized by Magellan Behavioral Health prior to July 1, 2014 until those approved treatment plans expire using the following codes: Autism diagnoses codes (299.00, , , , , , , ) Healthcare Common Procedure Coding System Codes (H0031, H0032, H0046, H2019) Treatment plans that begin or are approved as of July 1, 2104 must use the new CPT Category III temporary codes. 19

20 Claim Submission Guidelines Submit claims with dates of services on or after July 1, 2014 to be electronically to Horizon. After logging into NaviNet.net, mouse over Claim Management and select CMS 1500 Claim Submission If you are not able to submit electronically, you can send paper claims to our new address: Horizon BCBSNJ Horizon Behavioral Health PO Box Newark, NJ (Current claims addresses should be used for services through June 30, 2014) 20

21 Transition of Care and Authorizations 21

22 Transition of Care All services currently approved by Magellan will be honored through expiration date of approval, even if extends beyond July 1, ValueOptions has received from Magellan a copy of your last submitted treatment plan. Contact Horizon Behavioral Health at least two weeks prior to the current approved treatment plan s expiration date or (for NJ State Health Benefits Program) 22

23 ABA Assessment Authorization Process Providers should contact Horizon Behavioral Health to: Check member eligibility and benefit coverage relating to Autism Spectrum Disorder and ABA services Verification of Horizon BCBSNJ member benefits and eligibility available at NaviNet.net Make sure all services receive review for medical necessity before beginning services (e.g., assessment, initial and concurrent authorization requests) Confirmation of an Autism Spectrum Disorder diagnosis is required 23

24 ABA Treatment Requests Providers requesting continued treatment should complete and submit an ABA Treatment Request and Treatment Plan Report via fax at at least 1 week prior to the end of the authorization period. ABA Treatment Request forms (initial and concurrent) and ABA Provider Progress Report Guidelines are accessible on the ValueOptions.com provider website. Medically necessary ABA treatment is authorized for a six month period. 24

25 ABA Treatment Request Form 25

26 Autism Case Management Program We are offering telephonic case management to members with ASD: Licensed clinicians who are trained in autism answer calls Ability to make referrals to other levels of care and community resources Members or providers can call with questions about a wide array of topics related to autism 26

27 Quality Management 27

28 Quality Management Successful program model Existing enterprise-wide linkages and relationships Complaint and grievance investigation and resolution NCQA and URAC Case Management compliant NCQA delegated entity Experience serving as the MBHO or as a delegated entity Work across systems Support integrated medical and behavioral health services for members Develop linkages for primary care physicians to access behavioral resources Cross reference with pharmacy data 28

29 Quality Management and Improvement National Quality Committee chaired by CEO Shared client committee responsibilities Chief Medical Officer nominated for and sits on the NCQA Standards Committee HEDIS monitoring, interventions and reporting STAR rating Monitoring and interventions for Medicare 29

30 Credentialing, Recredentialing and Contracting 30

31 Recredentialing and Credentialing ValueOptions will administer Recredentialing and Credentialing processes for Horizon Behavioral Health Credentialing standards comply with NCQA requirements Credentials Verification Organization certified for ten out of ten verification services Detailed credentialing process: Practitioners 30 days after a completed application is received Facilities 90 days after a completed application is received Primary source verification for all providers Recredentialing cycle on three-year intervals 31

32 Recredentialing Horizon Behavioral Health providers with recredentialing due dates on or after July 1, 2014 are receiving recredentialing notices from ValueOptions. Notices sent approximately 4-5 months prior to the renewal due date. All providers with recredentialing due dates between January 1, 2014 and June 30, 2014 will or have received recredentialing information from Magellan. Magellan will be completing recredentialing for these providers If providers are credentialed by both Horizon and ValueOptions, the earliest recredentialing date will apply. 32

33 Recredentialing Notification every three years through: CAQH-Universal Provider Datasource (UPD) (for CAQH members) Uses system reminders to prompt providers to update and attest to their information every 120 days Telephonic message via Provider Pulse 4 months prior to due date that application is available Telephone, fax, (for paper submitters) Telephonic message via Provider Pulse 4 months prior to due date that application is available Follow up or fax approximately 1 week later with instructions for accessing application in ProviderConnect (to access application, click on link titled Provider Data Sheet ) 60 and 90 day reminder notices Failure to respond to requests from CAQH or ValueOptions will result in disenrollment from the network 33

34 Credentialing Practitioners required to complete ValueOptions Credentialing Application Process, using one of following methods: Complete online universal credentialing application offered by Council for Affordable Quality Healthcare (CAQH) and give ValueOptions your identification number to access information Contact CAQH Help Desk with questions at Complete a ValueOptions paper application Application available by calling Provider Services Line at Complete a New Jersey Universal Application 34

35 Contracting New Providers joining Horizon network will sign Horizon contracts ValueOptions administers contracting process Providers interested in joining the Horizon BCBSNJ networks or with questions on contracting process can call , 8 a.m. to 8 p.m., Monday-Friday 35

36 Overview of Operational Areas: National Network Services (cont d.) 36

37 Overview of ProviderConnect 37

38 ProviderConnect Functionality ValueOptions secure and HIPAA-compliant provider portal: Verify Member Eligibility Download and Print Authorization Letters View Authorizations Note: Providers cannot use ProviderConnect to submit authorizations 38

39 ProviderConnect Registration Process New and Current ProviderConnect Users need to fax a completed Account Request form to Providers who already have a ProviderConnect account need to submit a new form to request an additional login id to access Horizon BCBSNJ member information Horizon BCBSNJ providers need to mark the box for Horizon Behavioral Health Authorizations Providers who do not know their Provider ID can contact the Provider Services Line at , 8 a.m. to 8 p.m., Monday through Friday Account Request form located at Services_Account_Request_Form-Editable.pdf If there are any questions on the form, providers can contact the EDI Helpdesk at , 8 a.m. to 6 p.m., Monday through Friday 39

40 ProviderConnect Resources ValueOptions.com > Providers>ProviderConnect Free demonstration: ct/pvd.html Quick Start Guide and Comprehensive User Guide Short Video Tutorials: Viewing Member s Eligibility, Submitting Authorizations, Submitting an Inpatient or Higher Level of Care Request, Responding to Requests for Additional Clinical Information, Recredentialing Upcoming webinars: July 16, 2014 / am Overview of ProviderConnect Customized training - Scheduled at your convenience 40

41 Contact Information 41

42 Communication Channels Alerts Webinars Video Tutorials Monthly Valued Provider enewsletter Provider Pulse SM Messages Fax Communications Onsite Presentations Provider Mailings 42

43 Provider Contacts Authorizations and Care Management or (for NJ State Health Benefits Program) ABA Treatment Request and Treatment Plan Report Submission: Fax: NaviNet or Navinet.net 43

44 Provider Contacts, cont d. Provider Relations, Credentialing and Contracting Questions: (8 am - 8 pm ET Monday Friday) com Complaints, appeals and/or general inquiries or (for NJ State Health Benefits Program) 44

45 Helpful Links Network-specific Website: NaviNet NaviNet.net ABA Website for Members: orizonbehavioralhealth/topic.do?centerid=370&topicid =532 45

46 Questions? 46

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