Administrative Guide

Transcription

1 Community Plan KanCare Program Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide UHCCommunityPlan.com

2 Welcome to UnitedHealthcare This administrative guide is designed as a comprehensive reference source for the information you and your staff need to conduct your interactions and transactions with us in the quickest and most efficient manner possible. Much of this material, as well as operational policy changes and additional electronic tools, are available on our website at UHCCommunityPlan.com. Our goal is to ensure our members have convenient access to high quality care provided according to the most current and efficacious treatment protocols available. We are committed to working with and supporting you and your staff to achieve the best possible health outcomes for our members. If you have any questions about the information or material in this administrative guide or about any of our policies or procedures, please do not hesitate to contact Provider Services at We greatly appreciate your participation in our program and the care you provide to our members. Important Information Regarding the Use of This Guide In the event of a conflict or inconsistency between your applicable Provider Agreement and this Guide, the terms of the Provider Agreement shall control. In the event of a conflict or inconsistency between your participation agreement, this Guide and applicable federal and state statutes and regulations, applicable federal and state statutes and regulations will control. UnitedHealthcare reserves the right to supplement this Guide to ensure that its terms and conditions remain in compliance with relevant federal and state statutes and regulations. This Guide will be amended as operational policies change.

3 Table of Contents Introduction to Health Homes Health Home Provider Requirements Contact Information for Health Homes Onboarding Process Member Eligibility Billing, Claim Filing and Payment Oversight/Documentation/Standards of Care Non-Health Home Partners

4 12.1 Introduction to Health Homes Medicaid Health Home The new statutory definition of the term Health Home, a goal of implementing section 2703 of the Affordable Care Act, will be to expand the traditional medical home models to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care, in keeping with the needs of persons with multiple chronic illnesses. The whole-person philosophy described below is fundamental to a Health Home model of service delivery. The Centers for Medicare and Medicaid Services (CMS) expects Health Homes to build on the expertise and experience of medical home models, when appropriate to deliver Health Home services. Who They Impact: The state of Kansas has defined 2 target populations; members with serious mental illness (SMI) and chronic conditions (CC) to include asthma and diabetes. Health Homes do not replace care already being received, like doctor visits, medicine, hospital care, therapies, etc. Health Homes are in addition to the services already being provided to individuals. Providers may continue to provide services as they currently are AND provide additional Health Homes services. Health Homes are considered to be duplicative of Targeted Case Management Services and the member cannot receive both simultaneously. The Six Core Services Comprehensive Care Management: The Health Home staff provides an assessment and creates a plan with the member, to provide a roadmap for care with specific goals that includes the member, their doctors and other providers Care Coordination: The Health Home staff provides coordination and collaboration of services for the member in a timely manner Health Promotion: The Health Home staff provides ongoing education regarding conditions, motivation towards health action goals and tips for maintaining health Comprehensive Transitional Care: The Health Home staff provides support during and following discharge from a hospital or other care facility, inpatient or emergency room visit Individual & Family Supports: The Health Home staff provides a coordinated approach to health goals, including the role of family, caregiver and the member Referral to Community & Social Support Services: The Health Home staff provides members access to the services and supports needed to stay in their homes For a more detailed description of the Six Core Services, and the professionals who are qualified to provide each service, please access the KanCare Health Homes Program Manuals for SMI and CC at 2

5 Benefits of Health Homes Health Homes are designed for a complex group of Medicaid members that have been identified as vulnerable and costly. Providing this group of members additional resources in the form of additional care coordination services will improve the adherence of members to the physician lead plan of care and improve the ease of access to needed health care services for a population that may have low health literacy. The state has set four goals for Health Homes: 1. Reduce utilization associated with avoidable (preventable) inpatient stays 2. Improve management of chronic conditions 3. Improve care coordination 4. Improve transitions of care between primary care providers and inpatient facilities In addition to the above goals targeted by the state of Kansas, we will also have the following goals for UnitedHealthcare Health Homes: 1. Decrease emergency room use 2. Improve quality outcomes 3. Improve patient and provider experience 4. Promote use of health information technology (HIT) through an interactive community based plan of care 5. Improve access to primary care and behavioral health care and promote appropriate use Health Home Members In Kansas, the state has submitted two separate Medicaid State Plan Amendments (SPAs) to allow the implementation of Health Homes for two target member populations. Serious Mental Illness Members with a primary diagnosis of one or more of the following: Schizophrenia Bipolar and major depression Delusional disorders Personality disorders Psychosis not otherwise specified Obsessive-compulsive disorder Post-traumatic stress disorder This target population will also include anyone who may have a substance use disorder who also has one of the above-listed diagnoses. 3

6 Chronic Conditions Members with asthma or diabetes who are also at risk for: Substance use disorder Hypertension Coronary artery disease Depression Being overweight or obese Health Home Benefits to Providers When a provider chooses to contract with UnitedHealthcare to become a Health Home Partner (HHP), providers receive additional tools and resources at no cost to the practice that enables full participation. These resources include: An RN Care Manager to train and support the provider s office-based care coordinators. A consultant analyst to provide measurement analytics and reporting to support practice transformation. A fully-developed model of clinical care coordination based on evidence-based best practices. The Community Care Platform, a web-based community health record that allows interactive access to all assigned members by anyone on the patient s care team for full transparency to the plan of care. This is NOT duplicative of data in the electronic medical record. The Population Registry, a web-based tool that gives a Health Home provider access to two years of health care utilization history and known gaps in care for the patient panel eliminating the knowledge silos and fragmentation of the current health care system. Collaboration and support for the management of very complex and vulnerable patients in the panel. 4

7 12.2 Health Home Provider Requirements Provider Partner Requirements for Serious Mental Illness (SMI) The requirements for Health Home Partners (HHPs) vary, depending upon the target population served by the Health Home; however, every Health Home must include the targeted case management (TCM) provider for any Health Home member who has an intellectual or developmental disability (I/DD). The Lead Entity or the HHP must contract with the TCM provider if the I/DD member wishes to continue the relationship with that provider. The TCM provider will be responsible for various components of the six core Health Homes services and these will be determined at the time the Health Action Plan is developed. For Health Home members with SMI, the HHP must: 1. Meet State licensing standards or Medicaid provider certification and enrollment requirements as one of the following: A. Center for independent living B. Community developmental disability organization C. Community mental health center D. Community service provider for people with intellectual/developmental disabilities (I/DD) E. Federally qualified health center/primary care safety net clinic F. Home health agency G. Hospital-based physician group H. Local health department I. Physician-based clinic J. Physician or physician practice K. Rural health clinics 2. Substance use disorder provider 3. Enroll or be enrolled in the KanCare program and agree to comply with all KanCare program requirements 4. Have strong, engaged organizational leadership who agree to participate in learning activities, including in-person sessions and regularly scheduled calls 5. Provide appropriate and timely in-person care coordination activities. Alternative communication methods in addition to in-person such as telemedicine or telephonic contacts may also be utilized if culturally appropriate and accessible for the member to enhance access to services for members and families where geographic or other barriers exist 6. Have the capacity to accompany members to critical appointments, when necessary, to assist in achieving Health Action Plan goals 7. Agree to accept any eligible members, except for reasons published in Section 12.5 of this Manual 8. Demonstrate engagement and cooperation of area hospitals, primary care practices and behavioral health providers to collaborate with the HHP on care coordination and hospital/emergency room notification 5

8 9. Commit to the use of an interoperable electronic health records (EHR) through the following: A Submission of a plan, within 90 days of contracting as a HHP, to implement the EHR B. Full implementation of the EHR within a timeline approved by the lead entity C. Connection to one of the certified state Health Information Exchange (HIE), Kansas Health Information Network (KHIN) or Lewis and Clark Information Exchange (LACIE), within a timeline by the lead entity Provider Partner Requirements for Chronic Conditions The requirements for Health Home Partners (HHPs) vary, depending upon the target population served by the Health Home; however, every Health Home must include the targeted case management (TCM) provider for any Health Home member who has an intellectual or developmental disability (I/DD). The lead entity or the HHP must contract with the TCM provider if the I/DD member wishes to continue the relationship with that provider. The TCM provider will be responsible for various components of the six core Health Homes services and these will be determined at the time the health action plan (HAP) is developed. For Health Home members with CC, the HHP must: 1. Meet State licensing standards or Medicaid provider certification and enrollment requirements as one of the following: A. Center for independent living B. Community developmental disability organization C. Community mental health center D. Community service provider for people with intellectual/developmental disabilities (I/DD) E. Federally qualified health center/primary care safety net clinic F. Home health agency G. Hospital-based physician group H. Local health department I. Physician-based clinic J. Physician or physician practice K. Rural health clinics 2. Substance Use Disorder Provider 3. Enroll or be enrolled in the KanCare program and agree to comply with all KanCare program requirements 4. Have strong, engaged organizational leadership who agree to participate in learning activities, including in-person sessions and regularly scheduled calls 5. Provide appropriate and timely in-person care coordination activities. Alternative communication methods in addition to in-person such as telemedicine or telephonic contacts may also be utilized if culturally appropriate and accessible for the enrollee to enhance access to services for members and families where geographic or other barriers exist 6. Have the capacity to accompany enrollees to critical appointments, when necessary, to assist in achieving Health Action Plan goals 6

9 7. Agree to accept any eligible enrollees, except for reasons published in Section 12.5 of this Manual 8. Demonstrate engagement and cooperation of area hospitals, primary care practices and behavioral health providers to collaborate with the HHP on care coordination and hospital/emergency room notification; and 9. Commit to the use of an interoperable electronic health records (EHR) through the following: A. Submission of a plan, within 90 days of contracting as a HHP, to implement the EHR B. Full implementation of the EHR within a timeline approved by the Lead Entity C. Connection to one of the certified state Health Information Exchange (HIE), Kansas Health Information Network (KHIN) or Lewis and Clark Information Exchange (LACIE), within a timeline by the Lead Entity Provider/Member Relationship Requirements Engage with the Health Home member to complete the HAP and establishment of health action goals. The HAP is repeated annually, with updating of the health action plan (HAP). Obtain Health Home member consent to receive additional Health Home services. Strive to meet the clinical best practice standards set forth by UnitedHealthcare s clinical model (refer to Section 12.7 for more information). Completion and progress of the above standards clinical model of care will be entered by the HHPs into the Community Based Care Coordination Tool (CBCCT) in order to track, document, develop and maintain a comprehensive Health Home member record. The CBCCT tool enables UnitedHealthcare Community Plan to extract data in order to monitor utilization of Health Home services, monitor referrals, engagement of family and other support systems, track HHP engagement with Health Home members and ensure the members needs are being met and progress is monitored. The CBCCT enables progress notes to be documented and maintained in a central record. HHPs whose outcomes first fall short of the specified goals on 50 percent of the processes listed above will immediately be alerted within 7 days after the reporting period. Three consecutive months of failing to meet outcome goals on half of the processes listed above will place a HHP under corrective action for 30 days. The HHP s leadership will be required to outline specific measures to correct its failure to meet standards and begin to raise its performance by submitting a corrective action plan (CAP) to UnitedHealthcare Community Plan. The HHP will engage face to face with Health Home members who require intensive care management and either face to face or telephonically for members with lower intensity care management needs once the health action plan has been created. The health action plan will be completed during face to face contact with the member. The HHP will communicate with the member in a culturally competent manner by engaging interpreter services or use of telephonic translation as appropriate, depending on the member s needs. 7

10 Kancare Serious Mental Illness (SMI) Health Homes Services Professional Requirements 6 CORE SERVICES Physician Psychiatrist 1. Comprehensive Care Management Social Worker/Care Coordinator Nurse Care Coordinator 2. Care Coordination 3. Health Promotion 4. Comprehensive Transitional Care 5. Member and Family Support 6. Referral to Community Supports and Services Peer Support Specialist/Peer Mentor/Recovery Advocate * Physician - MD/DO who must be actively licensed to practice medicine in Kansas. For children, pediatricians are preferred * Psychiatrist - Licensed to practice psychiatry in Kansas * Social Worker/Care Coordinator - Must be a BSW actively licensed in Kansas or BS/BA in a related field or a MH (Mental Health) Targeted Case Manager (TCM) or an I/DD (Intellectual/Developmentally Disabled) Targeted Case Manager (TCM) or a substance use disorder person centered case manager to support the Health Home in meeting the Provider Standards and deliver Health Home services to enrollees. Case Managers must meet the requirements specified in the Kansas Medicaid State Plan and Provider Manuals, and can either be employed directly or contracted with HHP. * Nurse Care Coordinator - RN, APRN, BSN or LPN actively licensed to practice in Kansas to support the Health Home in meeting the Provider Standards. Although the preference is for the HHP to have an RN, APRN, BSN or LPN, some HHP s in rural areas may need to rely on the Lead Entity to provide a nurse care coordinator. * Certified Peer Support Specialist (mental illness) - Must meet the defined KDADS Behavioral Health requirements for mental illness, be employed by a licensed mental health provider, meet education and age requirements, pass state approved training through a state contractor and complete criminal, state abuse/neglect registry, and professional background checks. The Certified Peer Support Specialist must self-identify as active in stable recovery and be a present or former primary recipient of mental health services. * Recovery Advocate - Must meet the defined KDADS Behavioral Health requirements for mental illness and/or substance use disorder, meet age, training, and supervision requirements, and self-identify as active in stable recovery for a minimum of one year. 8

11 Kancare Chronic Conditions Health Homes Services Professional Requirements 6 CORE SERVICES Physician/PA/APRN Nurse Care Coordinator Social Worker/Care Coordinator 1. Comprehensive Care Management 2. Care Coordination 3. Health Promotion 4. Comprehensive Transitional Care 5. Member and Family Support 6. Referral to Community Supports and Services * Physician - MD/DO who must be actively licensed to practice medicine in Kansas. For children, pediatricians are preferred. * PA/ARNP - May be substituted in rural areas if the HHP can demonstrate the PA or ARNP is employed by the HHP and the signed protocol from the supervising physician covers provisions of Health Home Services by the PA or APRN. The PA or ARNP must be licensed to practice in Kansas. * Nurse Care Coordinator - RN, APRN, BSN or LPN actively licensed to practice in Kansas to support the Health Home in meeting the Provider Standards. * Social Worker/Care Coordinator - Must be a BSW actively licensed in Kansas or BS/BA in a related field or a Mental Health or I/DD TCM or a substance use disorder person centered case manager to support the Health Home in meeting the Provider Standards and deliver Health Home services to enrollees. Case Managers must meet the requirements specified in the Kansas Medicaid State Plan and Provider Manuals, and can either be employed directly or contracted with HHP. Sample job descriptions can also be found on the Kancare website at: Additional information is available: For detailed information, please reference the CC Health Homes Provider Requirement document on the KanCare website at: Additional details are also available in the KanCare Health Homes Program Manual for CC at: For detailed information, please reference the SMI Health Homes Provider Requirement document on the KanCare website at: Additional details are also available in the KanCare Health Homes Program Manual for SMI at: 9

12 12.3 Contact Information for Health Homes Questions can be submitted to our Health Home mailbox at: Designated Health Home fax number is also available to providers at: Questions or Claim Issues can be directed to our Provider Call Center at: Call with Tax ID, Member ID, date of service or claim number. Providers may check the status of claims through our online provider website: UnitedHealthcareOnline.com For member specific questions, please contact Member Services at: Benefits of using UnitedHealthcareOnline.com No hold times 24-hour access to information Printable information (benefits & eligibility and claims status) Faster adjustment turnaround time for claim reviews responses to claims review requests within 48 hours Please refer to UHCCommunityPlan.com for specific contact information related to Health Homes Onboarding Process The Preparedness and Planning Tool (PPT) can be located on the Kancare website at: Step 1: Interested Providers can complete PPT at: Step 2: The State forwards the PPT to UnitedHealthcare; UnitedHealthcare Reviews PPT, Estimates Provider Model Step 3: UnitedHealthcare schedules a meeting with the provider to review the PPT, estimates the provider s alignment with our model, determine which counties the provider is interested in serving, discuss estimated capacity and desired membership, and also share our readiness assessment tool with the provider. We may also discuss the number of estimated members in the area to help the provider understand their opportunities to serve. Step 4: Review and complete the readiness assessment tool of the provider practice. Determine what level of health home model the provider is interested in participating in. When complete, the provider returns the Readiness Assessment to UnitedHealthcare. 10

13 Step 5: Upon receipt, UnitedHealthcare will review the tool and make a determination as to whether the readiness demonstrated is appropriate for the model requested. If UnitedHealthcare determines that a provider is adequately prepared and appropriate for the model requested, a contract amendment will be offered. In the event that UnitedHealthcare determines a Health Home Partner is not ready, we will offer feedback on any areas of concern. We will ask that the provider review the deficient areas, work to address them, and submit an updated Readiness Assessment after completion of this work. Step 6: Contract amendment is executed. UnitedHealthcare conducts or assists in any training needs, including the use of our available clinical application and how to engage UnitedHealthcare resources for assistance. Step 7: Membership is assigned and services begin. UnitedHealthcare and the provider will work together to schedule joint oversight sessions on a recurring basis to review reporting and ensure that high quality services are being consistently provided to the members served Member Eligibility To be eligible for Health Homes, a person must first be eligible for Medicaid. Health Homes are not available to children in the Children s Health Program (CHIP) portion of KanCare because Health Homes are a State Medicaid Plan service. Eligibility for Medicaid is determined by state staff at either the KanCare Eligibility Clearinghouse or at Department of Children and Families (DCF) offices throughout the state. Medically Needy Medicaid beneficiaries are eligible for Health Home services only as long as their spend down amounts are met for the applicable spend down periods. Members will initially be identified as eligible for either the serious mental illness or chronic conditions Health Home by United through analysis of claims data. All 3 MCOs have agreed to a consistent methodology for identifying eligible members to ensure that members who move from one MCO to another during open enrollment periods, will maintain their Health Home eligibility Member Assignment Member Choice is ALWAYS honored Provider capacity and panel limit is always considered State Plan Amendments served by the provider are always considered 11

14 Members have the right to choose from among available Health Home Partners (HHP) in their area, with certain limits. Members who are eligible for both types of Health Homes, SMI and CC, may choose which type of Health Home they want to participate in, but the Lead Entity will make a default assignment to the type of Health Home which seems most appropriate for the member, based on the member s conditions and claims and other data available. When a Health Homes member is identified, United (the Lead Entity) will send an assignment letter explaining: Health Homes and their benefits Why the member is eligible Which HHP the member has been assigned How to choose a different HHP How to opt out of Health Homes Eligibility begin date Members may opt out of Health Homes or change Health Home partners (HHPs) at any time. Eligible members will receive a letter in July, 2014 notifying them of their Health Home eligibility and assignment. Health Home Services will be initiated by HHPs beginning in August An HHP may not refuse to accept a member assigned by any Lead Entity with which the HHP contracts for Health Homes services, except for some limited reasons. These reasons include, but are not limited to: The member has been previously discharged by the HHP with applicable notice in writing provided The member resides outside the geographic range served by the HHP, e.g. a Community Mental Health Center The member is outside the age range parameters established by the HHP, e.g. a pediatrician is not required to serve adults The HHP has reached its capacity to provide Health Home services The HHP is a Tribal 638/Indian Health facility and wishes to limit its HH activities to Native Americans The HHP is a provider of services to people with intellectual or developmental disabilities (I/DD), and wishes to limit its HH activities to those with I/DD Any other reason for refusing to serve a potential Health Home member must be approved by both the State Health Homes Manager and the Lead Entity. For additional information, please reference the SMI and CC program manuals at: 12

15 Member Eligibility Verification Health Home eligibility and Health Home partner (HHP) assignment is determined monthly changes are effective the first of following month. Information about the members assigned to a specific HHP each month is available from several resources: The Community Care Platform: Allows interactive access to all assigned members by anyone on the member s care team for full transparency to the plan of care This is NOT duplicative of data in the electronic medical record Population Registry (for providers not utilizing the Community Care Platform): A secure web application that will be used by UnitedHealthcare to notify providers of assigned members A specific training webinar will be scheduled for providers relative to registering for access and established user IDs and passwords for Population Registry Population Registry will provide a list of eligible members assigned to the Health Home Partner for the month In addition, a monthly list of eligible members will be provided to HHPs by the Health Plan: List to include SPA type (SMI or CC) and level assignment The list will also identify newly eligible members and terminated members for the month Providers may call the Provider Call Center at for information on which Health Home (SMI or CC) a member is assigned to, and to get the rate for that member Billing, Claim Filing and Payment Health Home Payments A Health Home is considered a bundled service, so individual core services provided within any month will not be paid for as fee-for-service. Payment to the Lead Entity, from the State, is a per member per month (PMPM) payment made retrospectively each month. UnitedHealthcare will pay HHPs a PMPM for Health Home services as negotiated in the provider contract. In order for an HHP to receive the Health Home PMPM payment agreed upon between the Lead Entity and the HHP, the HHP must provide the member with at least one Health Home service during the month for which the claim is submitted. All Health Home services should be documented per the information provided in the Health Homes program manuals at: 13

16 Billing Codes/Modifiers Health Home Services will be billed with two procedure codes and four modifiers: Core Services Serious Mental Illness Billing Chronic Condition Billing Comprehensive Care Management S0280 UC HE S0280 UC Care Coordination S0281 UC HE S0281 UC Health Promotion S0280 U1 HE S0280 U1 Comprehensive Transitional Care S0281 U1 HE S0281 U1 Patient and Family Support S0280 U8 HE S0280 U8 Referral to Community Support Services S0281 U8 HE S0281 U8 For additional description of the 6 Core Services, please reference the SMI and CC program manuals at: Billing Guidelines Health Home Partners (HHPs) must file claims using the appropriate code and modifier for the actual date the health home service was rendered. For example, if a Health Home provider provided the following core services to a Chronic Conditions member in the month of August: Comprehensive Care Management on 8/12/14 Care Coordination on 8/20/14 Patient and Family Support on 8/28/14 The HHP would file a claims for: S0280 UC with a date of service 8/12/14 for 1 unit S0281 UC with a date of service 8/20/14 for 1 unit S0281 U8 with a date of service 8/28/14 for 1 unit These services can either be billed on three different claim forms (one for each date of service) or they may be billed on one claim form with three separate claims lines as long as the appropriate date of service is defined for each of the core services. All Health Home services should be billed with one unit for the date of service rendered. Health Home services cannot be billed on the same claim form as other medical/behavioral/waiver services. To ensure correct payment, Health Home services should be billed on separate claims from other services. 14

17 Monthly Payment Although providers must bill each of the Core Services for the date of service provided, the full monthly health home payment will be made on the first claim processed each month. Subsequent claims for that month must be billed, even though the payment was made for the month. After the first claim is paid with the monthly health home payment, the remittance advice for subsequent services rendered for the month will show a $0 allowed and paid amount. This will be an indicator that the monthly payment for the health home service was already rendered for the month on a previous claim. To ensure the monthly payment is processed correctly, providers cannot bill services across multiple months on one claim form. Services for separate months must be billed on separate claims. Provider Charge To ensure appropriate payment, the base charge billed for procedure codes S0280 and S0281 must have a billed amount that is equal to or greater than the highest rate available for that member s SPA and assigned rate level. If a provider files a claim with a billed amount below the monthly Health Homes payment, our claim system may apply logic which would result in a limitation of payment to the billed charge amount. As a result, claims with a billed amount below the monthly Health Home payment may process at the provider s billed charge. Providers are encouraged to follow this guideline for all services billed throughout the month, as the claim that processes first each month may not necessarily be the claim that was filed first by the provider. Upon receipt of the remittance advice, providers will post the monthly Health Home payment and write off the charges for the subsequent services for that month. Providers may not bill members for Health Home services. NPI/POS/Dx Codes NPI - Providers must file all health home claims with the agency or medical group NPI number in box 33A of the CMS 1500 claim form (loop 2010AA for electronic claim submission). Providers do not have to include a rendering provider NPI number in box 24J of the CMS 1500 claim form (loop 2310B for electronic claim submission). Health Home services are billed by the Health Home Partner and not all of the six core services have to be provided by a licensed professional. Providers should report their group NPI number in box 24J. Place of Service (POS) Codes - There are not specific Place of Service codes that are required for billing health home services. Providers should bill with the most appropriate Place of Service code for the service rendered. Diagnosis Code - There are no diagnosis code restrictions for health home services. Providers should bill the diagnosis code(s) appropriate for the member. 15

18 Obtaining SPA/Payment Rates The monthly rate Health Home Partners will be paid for health home services is dependent upon the SPA the member is assigned to (SMI or CC) and the member s level within the SPA. Health Home members are placed into one of four levels based on their KanCare Rate Cohort. For detailed information regarding the four levels and KanCare Rate Cohorts, please reference the SMI and CC program manuals at: Providers can call the Provider Service Call Center at to get information on: The SPA a member is assigned to (either SMI or CC) The applicable monthly payment rate for a specific member In addition, a monthly list of eligible members will be provided to Health Home Partners by the Health Plan: List to include SPA type (SMI or CC) and level assignment The list will also identify newly eligible members and terminated members for the month Payment Rates For the Chronic Conditions SPA the highest monthly payment rates can be found below: KanCare Rate Cohort Level Level 1 Level 2 Level 3 Level 4 Contract Rate $97.48 per month $ per month $ per month $ per month For the Serious Mental Illness SPA the highest monthly payment rates can be found below: KanCare Rate Cohort Level Level 1 Level 2 Level 3 Level 4 Contract Rate $ per month $ per month $ per month $ per month Notes: The rates above are the highest rate that will be paid for Heath Home members, and reflect the rates to be paid to Health Home Partners who provide all 6 Core Services. Providers who contract to provide fewer than all 6 Core Services will be paid a percentage of the above rates as outlined in the payment appendix offered to the provider during the contracting process All rates are reflective of the full PMPM, less admin of 10 percent for CC and 12 percent for SMI. 16

19 Targeted Case Management I/DD Targeted Case Management: Targeted Case Management cannot be provided to people in Health Homes, however HHPs must include the Targeted Case Management (TCM) provider as part of the Health Home team for any member who has an intellectual or developmental disability (I/DD). The MCO or the HHP must: Contract with the TCM provider if the I/DD member wishes to continue the relationship with that provider Provide a minimum PMPM payment to TCM providers serving I/DD health home members Minimum PMPM payment I/DD SMI Members $ I/DD CC Members $ The TCM provider will be responsible for various components of the six core Health Homes services and these will be determined at the time the health action plan (HAP) is developed. Members with intellectual/developmental disabilities have the right to continue to receive services from their established Targeted Case Manager (TCM). If a HHP has assigned health home members with intellectual/developmental disabilities, the HHP must: Coordinate with the member to determine if the member wants their historic TCM to continue to provide services Contract with the TCM Coordinate services for the member with the TCM If a member is participating in a health home, the TCM cannot bill for TCM services directly to UnitedHealthcare using T1017. In this case, the HHP will bill for the health home service for that month, receive the monthly PMPM payment from United, and then pay the TCM at least the minimum monthly TCM payment for that month. The HHP must partner and coordinate with the TCM regarding the amount of services to be provided in a given month. Claim Submission Options Options for Health Home claim submission are the same as for other Medicaid services: Electronically through your established claim clearinghouse Our electronic payer ID is

20 Electronically through the KanCare Provider Web Portal On paper the paper claim address is: KMAP P.O. Box 3571, Topeka, KS The state converts the paper claim to an electronic file and sends to UnitedHealthcare CMS-1500 billers can also file claims directly through UnitedHealthcareOnline.com Providers may submit claim corrections for Health Home services in the same manner used to submit corrected claims for other medical/behavioral health/waiver services For additional information on claim filing, please refer to Chapter 15 of the Provider Administrative Guide. Claim Reconsiderations If your claim was filed correctly but you feel it was not paid correctly, you may submit a claim reconsideration to request we review the payment of the claim: Reconsideration Requests for Health Home services should be directed to the following: Call the Provider Services Call Center at Call your Provider Advocate Claim Appeals If you have filed a Claim Reconsideration Request and are dissatisfied with the outcome, you may file an appeal: File a formal appeal by sending it to: UnitedHealthcare Attention: Formal Claim Appeals P.O. Box Salt Lake City, UT Note: The cover letter should state that a formal claim appeal is being made. Third Party Liability Third Party Liability (TPL) does not apply to the Health Homes services. If a member has primary insurance, providers do not need to bill the primary carrier or submit a primary carrier s explanation of benefits or other documentation. UnitedHealthcare will pay Health Home claims as the primary carrier regardless of other coverage. 18

21 Date Span Billing Date span billing is not allowed for health home claims. Each of the Health Home services must be billed using the correct service code/modifier combination and must be billed for the date of service on which the service was actually rendered. If a provider wants to file a claim for the month, the claim must include separate claim lines for each health home service provided for the month, and the date for each service must be consistent with the actual date the service was rendered to the member. Client Obligation Client obligation (for Health Home members who are also on one of the HCBS waivers) will not be applied to health home providers. The client obligation will continue to be assigned to the provider that has the largest cost of HCBS waiver services for the month. Client obligation assignment letters will continue to be mailed to the member and the assigned provider each month. Checks and Remittance Advices All Health Home Partners will also be contracted providers for other medical, behavioral or waiver services. Payments for Health Home services will be paid to the tax identification number (TIN) and billing address already loaded in UnitedHealthcare s claim payment system. Payments for Health Home services will be co-mingled with payments for other, non-health home services, on the same checks and remittance advices. UnitedHealthcare is not able to break out Health Home payments and provide a separate check and/or remittance advice for health home services Oversight/Documentation/Standards of Care The following shall be implemented in the oversight, documentation and evaluation of standards of care for Health Homes in accordance with the policies of UnitedHealthcare: Standards of Care 1. Health Home partners (HHPs) will be responsible for delivering or sub-contracting the six Health Home Care Coordination services to the member. 2. Data on the members Care Plan shall be provided by the HHP twice every month for analysis by UnitedHealthcare Health Home consultant in the reoccurring Joint Operations Committee ( JOC) meeting between the HHP and UnitedHealthcare Community Plan s Health Home leadership. 19

22 3. HHPs may refer to the following grid for an increased understanding of UnitedHealthcare Health Homes Quality Monitoring in relation to the six core services. 6 Core Service Example Requirements Expectations Measure Comprehensive Care Management Member assessment for complex care needs and development of Health Action Plan; indication that plan was shared with multidisciplinary care team. Assessments performed on all Health Home members within 30 days of enrollment and annually. Document HAP for all members including goals w/ time frames % members assessed within required time frame % of patients with a face-to-face encounter with a care coordinator in last 30 days % of patients who have goals with timeframes % members with no PCP visits % PCP visits every 90 days % behavioral health visits every 90 days % m e m b e r s w i t h B M I o n r e c o r d % members with preventive measures complete (no gaps in care) Care Coordination Facilitate completion of activities between and among members of the community based care team assuring interactive participation with whole person plan of care. PCP visits q 90 days for members. Behavioral health visits q 90 with leading behavioral health condition. Health Promotion Documented assessment of health promotion needs and addition of problems to health action plan including obesity, health literacy assessment, educational discussions All members will have their BMI recorded at least annually. All members receive information on health promotion including gaps in care for chronic illness. PCP visit is provided within 7 days of any discharge from ED or inpatient service. Comprehensive Transitional Care Coordination of services across various providers, with a transition of place or level of care. Ensure PCP visit within 7 days of inpatient or emergency room visits Assessment of individual and family psych-social or community support needs including gap identification and plan development; documentation regarding services for member of family Management of referrals including transparency of tracking when referrals are made, completed, reported and changes to plan of care resulting from referrals. Documentation and information sharing through community based health information exchange required for all services above % PCP follow up visit within 7 days of ER visit % PCP follow-up within 7 days of inpatient discharge Individual & Family Support Individuals name a primary caregiver. % of patients with substance abuse disorders in active treatment programs % patients who identified a primary caregiver Referral to Comm/Social Support Services All referrals are tracked for completion of visit, completion of referral report or CDC and follow-up up by PCP visit. Use of UnitedHealthcare tools for care coordination. % referrals completed by evidence of report tracking Use of HIT If using an independent system must provide access to UnitedHealthcare to that system and provide data field extracts. 20

23 4. Customer satisfaction survey results from members will be analyzed, reported and trended for each HHP. 5. The following standardized tools will be used, as appropriate, to determine each member s individual needs in the completion of the health action plan (HAP): a. CAM 13 Caregiver Activation Measure b. PAM Patient Activation Measure c. History and Physical d. FACT Health Home survey assessment e. GAD7 General Anxiety Disorder Scale f. PHQ-9 Depression Patient Health Questions g. CAGE Alcohol Detection Questionnaire h. DAST-10 Drug Abuse Screening Test i. Fall Free Plan j. FLACC Pain Assessment k. Katz Index of Independence in Activities of Daily Living l. Wong-Baker Faces Outcome goals will be specified and agreed upon by UnitedHealthcare Community Plan and all contracted HHPs for the following processes: Assessments will be performed on all Health Home members within 30 days of enrollment and annually. HHPs opting to use their own community based electronic tool will be responsible for ensuring the above assessments are used according to member specific needs. Minimum assessments will include the FACT Health Home assessment, PAM and the first section of the History and Physical tool. All other assessment tools are available for member-specific needs. Engage with the Health Home member to complete the HAP and establishment of health action goals. The HAP is repeated annually, with updating of the HAP as necessary. Documentation of the HAP should include goals and time frames. Ensure individuals name a primary caregiver. Obtain Health Home member consent to receive additional Health Home services. Ensure Health Home members are seen by their PCP regularly, at least every 90 days. Ensure Health Home members are seen by a behavioral health clinician at least every 90 days when a behavioral health problem exists and for all members eligible under the serious mental illness (SMI) SPA. Ensure Health Home members who are discharged from an inpatient admission see a clinician for follow up within 7 days of discharge. Ensure Health Home members who are discharged from skilled nursing facility (SNF) admission, acute psychiatric facility admission or an emergency department are seen by a clinician (or by a behavioral health clinician) for follow up within 7 days of discharge. 21

24 Ensure pre-visit planning is completed for all Health Home members to ensure all open care opportunities are completed during visits to PCP/behavioral health providers. Ensure Health Home members who are referred to specialists and community resources are completed (patient seen and report received) within 30 days of the referral date. Ensure adult (18 years and older) Health Home members are screened for clinical depression using PHQ-9 Patient Questionnaire within 60 days of enrollment. Ensure young adult (13-17 years old) Health Home members with initiation and engagement of alcohol and other drug (AOD) dependence treatment. Adult (18 years and older) Health Home members with initiation and engagement of AOD Dependence Treatment. Ensure Health Home members are screened and their BMI indicator is collected within 30 days of enrollment. All members will have their BMI recorded annually. All members shall receive information on health promotion including gaps in care for chronic illnesses. All referrals will be tracked for completion of visit, completion of referral report and follow up by primary care visit. Documentation 1. Completion and progress of the above standards will be entered by the HHPs into the Community Based Care Coordination Tool in order to track, document, develop and maintain a comprehensive Health Home member record. 2. The Community Based Care Coordination Tool enables UnitedHealthcare Community Plan to extract data in order to monitor utilization of Health Home services, monitor referrals, engagement of family and other support systems, track HHP engagement with Health Home beneficiaries and ensure the member s needs are being met and progress is monitored. 3. The Community Based Care Coordination Tool enables progress notes to be documented and maintained in a central record. HHPs whose outcomes first fall short of the specified goals on 50 percent of the processes listed above will immediately be alerted within 7 days after the reporting period. 4. Three consecutive months of failing to meet outcome goals on half of the processes listed above will place a HHP under corrective action for 30 days. The HHPs leadership will be required to outline specific measures to correct its failure to meet standards and begin to raise its performance by submitting a corrective action plan (CAP) to UnitedHealthcare Community Plan. 5. The HHP will engage face to face with Health Home members who require intensive care management and either face to face or telephonically for members with lower intensity care management needs once the HAP has been created. The HAP will be completed during face to face contact with the member. 6. The HHP will communicate with the member in a culturally competent manner by engaging interpreter services or use of telephonic translation as appropriate, depending on the member s needs. 22

25 Oversight UnitedHealthcare Community Plan provides support through a combination of modern technology and high touch. 1. Tools and technology infrastructure are provided to HHPs to provide data transparency at the point of service: a. Population Registry for PCPs for transparency of claims, authorization and gaps in care. The Population Registry will be available to community based health centers (CBHCs) by third quarter b. Web-based software tool to provide community based interactive plan of care for all members of the care team. 2. Evidence-based clinical model of care. 3. Experienced Care Managers for care coordination oversight and support. a. Clinical model of care with clearly defined expectations. b. Regular follow up by RN Care Managers to the HHPs to provide oversight and support of Health Home. c. Training provided by RN Care Manager to the HHP care coordination staff. 4. Joint Operations Committees. a. Routine data collection and analysis delivered to the HHP for process improvement and management of the Health Home Program Non-Health Home Partners Hospitals Hospitals are required to refer members into Health Homes; Section 2703 of the Affordable Care Act requires that hospitals participating under the state Medicaid Plan or waiver of such plan must refer individuals with chronic conditions who seek or need treatment in an emergency department to a Health Home. Hospital referrals must be made using the Kansas Health Homes Referral Form, found in Appendix B of the Health Homes Program Manuals found at: Subcontractors Subcontractors are not subject to the same requirements as the Health Home partner (HHP). These might include use of an EMR/ HER and connection to KHIN or LACIE. UnitedHealthcare does expect that subcontractors utilize the Community Based Care Coordination tool in order to ensure effective, completes, and documented coordination of services and activities for the member. Other Providers UnitedHealthcare expects that other providers in the community engage with Care Coordination staff from the HHP in order to ensure the consistent delivery of high-quality care to the member. The care coordinators should be viewed and treated as additional resources to improve member appointment attendance and engagement. Other providers may refer Medicaid members to Health Homes through their MCO. Providers must use the Kansas Health Homes Referral Form, found in Appendix B of the Health Homes Program Manuals found at: 23