TRICARE West Region. Behavioral Health. Basics for the Provider

Transcription

1 TRICARE West Region Behavioral Health Basics for the Provider Doc#: UHCMV1177_

2 Presentation Outline Introduction to TRICARE Eligibility Programs Behavioral Health Benefits Provider Types Referrals and Authorizations Claims Provider Resources Behavioral Provider Directory Important Contact Information 2

3 Introduction to TRICARE

4 What is TRICARE? TRICARE is the health care program for Active Duty Service Members, National Guard and Reserve members, retirees, family members, young adults, survivors and certain former spouses worldwide. a network of Military Health System resources and civilian health care professionals working together to foster, protect, sustain, and restore health for those entrusted to their care. 4

5 TRICARE West Region TRICARE is available worldwide and managed regionally. HealthNet Federal Services North Region UnitedHealthcare Military & Veterans West Region Humana Military Healthcare Services South Region 5

6 TRICARE West Region Contractor UnitedHealth Group National, diversified health and well-being company dedicated to making the health care system work better UnitedHealthcare Military & Veterans A division of UnitedHealth Group An administrator/managed care support contractor for the Department of Defense (DOD) Behavioral health and specialty networks provided through our vendor Optum 6

7 The Role of Optum Optum works as a vendor to UnitedHealthcare and provides a network of clinicians and facilities to serve the mental health needs of TRICARE beneficiaries. Optum contracts with clinicians and facilities in the 21 states of the West Region Optum will manage various contractual needs of this specialized network 7

8 Military Treatment Facilities Military Treatment Facilities (MTFs) provide care for Active Duty Service Members and other beneficiaries depending on available space MTFs vary from large teaching facilities, such as Naval Medical Center San Diego, to smaller primary care clinics with no specialty care TRICARE network providers augment the care available at the MTFs 8

9 TRICARE Eligibility

10 Eligible TRICARE Populations Active Duty Service Member (ADSM) & Active Duty Family Member (ADFM) Retired Service Member and dependents Young adult (up to age 26) Activated National Guard/Reserve and family Retired National Guard/Reserve (age 60+) and family Medal of Honor recipient and family Other eligible beneficiaries: survivors eligible former spouses eligible National Oceanic and Atmospheric Administration (NOAA) and U. S. Public Health Service personnel 10

11 TRICARE Eligibility Verify Patient Status: Check Military ID or Common Access Card (CAC) on Date of Service Use sponsor s social security number (SSN) or unique Defense benefit number (DBN) located on back of the ID card Validate benefits and eligibility Check expiration date Resources: UnitedHealthcare Military & Veterans: Provider service: Secure website* UHCMilitaryWest.com PGBA Claims Administrator Secure website* *Secure portion requires registration 11

12 Transition from SSN to DBN Newly formatted military and family member ID cards: 11-digit DoD Benefits Number (DBN) replaces 9-digit Social Security Number (SSN) 10-digit DOD ID Number is not used for claims billing H65 edit alert (invalid Member ID): numbers with 10 digits or dashes 12 TRICARE West Region Customer Service: (WEST) - UHCMilitaryWest.com. TRICARE, TRICARE Prime, TRICARE Reserve Select, and TRICARE Retired Reserve Doc#: are UHC2146v.2_ registered trademarks

13 TRICARE Programs

14 TRICARE Programs (product types) TRICARE Prime: Managed care option Offered in Prime Service Areas (PSAs) within a 40 mile radius of a MTF Beneficiary enrolled to Primary Care Manager (PCM) at the MTF or network provider Referrals made to network specialty providers Authorizations required if on the Prior Authorization List Lowest out-of-pocket costs Point of Service (POS) option: Deductible: $300 individual, $600 family 50 percent cost share 14

15 TRICARE Programs (product types) TRICARE Prime Remote (TPR): Managed care option Similar to Prime, TRICARE Prime Remote (TPR) is for the ADSM and the TRICARE Prime Remote Active Duty Family Member (TPRADFM) Prime Remote is for ADSMs: While assigned to remote US duty stations Who live and work more than 50 miles or one hour drive from an MTF National Guard/Reserve called to Active Duty Status and their families may be eligible 15

16 TRICARE Programs (product types) TRICARE Standard and TRICARE Extra: TRICARE Standard (like a traditional fee-for-service option) Care from a TRICARE-authorized non-network provider Most expensive out-of-pocket fiscal year (FY) deductible and cost-shares TRICARE Extra (like a preferred provider option) Care from a network provider Reduced five percent FY deductibles and cost shares No PCM enrollment required No referrals required Prior authorization required before performing services on the Prior Authorization List 16

17 TRICARE Programs (product types) TRICARE Young Adult (TYA): Similar to TRICARE Standard/Extra/Prime Eligible dependent age 21 (or 23 if full time student), up to age 26 Need to meet specific criteria to be eligible Premium-based health plan 17

18 TRICARE Programs (product types) TRICARE Reserve Select (TRS): Similar to TRICARE Standard/Extra (deductible and cost share) TRS coverage for National Guard/Reserve eligible members Premium-based health plan Authorizations required for services listed on the Prior Authorization List Prior authorizations required before performing services on the Prior Authorization List 18

19 TRICARE Programs (product types) TRICARE Retired Reserve (TRR): Similar to TRICARE Reserve Select (deductible and cost share) Premium-base health plan Specific criteria for eligible Retired Reservist Prior authorization required for services on the Prior Authorization list 19

20 TRICARE Programs (product types) TRICARE for Life (TFL): (NOT Administered by UnitedHealthcare) TRICARE s Medicare-wraparound coverage Available to all TRICARE and Medicare (Part A & B) dual-eligible beneficiaries Contact Wisconsin Physicians Service (WPS) or for: Benefits Claims Requirements Claims filed with Medicare are electronically forwarded to WPS/TFL 20

21 TRICARE Programs (product types) Extended Care Health Option (ECHO): Provides additional healthcare coverage benefits to ADFMs with special needs Beneficiaries must qualify based on specific mental or physical disabilities and register with their military branch Exceptional Family Member Plan (EFMP) Offers integrated set of services and supplies beyond basic TRICARE benefits Requires prior authorizations for all services 21

22 TRICARE Benefits Information - Behavioral Health Focus

23 TRICARE Behavioral Health Benefits Psychiatric Diagnostic Interview Examination Outpatient Psychotherapy Psychological and Neuropsychological Testing Medication Management Electroconvulsive Therapy Acute Hospital Psychiatric Care Residential Treatment Center Psychiatric Partial Hospitalization Program Substance Use Disorder Detoxification, Rehabilitation and Outpatient Services Autism Program 23 Doc#: PCA12480_

24 Outpatient Services Outpatient Services (one diagnostic interview per beneficiary, per provider, per fiscal year): Initial eight routine mental health visits per fiscal year do not require referrals Medication Management: Covered as an independent procedure by a TRICARE-authorized provider for up to two sessions per month More than two sessions per month require prior authorization When provided in conjunction with therapy, medication requires prior authorization after the initial eight behavioral health visits Note: ADSMs always need referrals and prior authorizations from their PCM for care outside of the MTF. 24 Doc#: PCA12480_

25 Outpatient Services Marriage Counseling and Family Therapy: Marriage counseling without DSM diagnosis is not covered Family therapy is covered in the treatment of a diagnosed medical or psychological condition: considered outpatient psychotherapy may occur if spouse/sponsor has diagnosed behavioral health disorder causing marital problems Note: ADSMs always need referrals and prior authorizations from their PCM for care outside of the MTF. 25 Doc#: PCA12480_

26 Outpatient Services Six units of psychological testing and 10 units of neuropsychological testing per beneficiary, per fiscal year Psychological Testing: Consideration for exceptions beyond the benefit limit need a medical review It is the in-network provider s responsibility to determine whether prior authorization is required for all or part of a testing request The following require prior authorization with an in-network provider: Outpatient Psychological Testing (96101, 96102, 96103) Neuropsychological Testing (96118, 96119, 96120) Neurobehavioral Status Exam (96116) 26 Doc#: PCA12480_

27 Intensive Outpatient Services Intensive Outpatient Programs (IOP) is covered when : Delivered through a facility based or free standing TRICARE certified PHP When billed as a ½ Day PHP can be provided as an interim level of care when delivered by a facility based program or a freestanding PHP that is KePro certified Intensive outpatient services can be designed to fill this gap when clinically indicated : This could include providing group therapy, individual therapy, and/or family therapy in the same day for multiple days in a week If a beneficiary needs more intensive care, please design a treatment plan and coordinate with Utilization Management to ensure clinical needs of the beneficiary are effectively met 27 Doc#: PCA12480_

28 Inpatient Services Acute Hospital Psychiatric Care Inpatient Limitation: 30 days ages 19 and older 45 days ages 18 and younger: per fiscal year (Oct. 1 to Sept. 30) Prior authorization is required for non-emergency admissions Emergency admissions require notification hours after admission Psychiatric Partial Hospital Programs Limitation: 60 days per benefit year 28 Doc#: PCA12480_

29 Residential Treatment Centers Children and adolescents only (ages 20 and younger) 150 day maximum per fiscal year or single admission: Medical necessity review is required Prior authorization required Center must be TRICARE-certified through KePro Not covered for a primary Substance Use Disorder except for ADSM 29 Doc#: PCA12480_

30 Substance Use Disorder Substance Use Disorder Treatment Services must be provided by: TRICARE-certified facilities TRICARE-certified hospital-based programs Treatment: Detoxification Up to seven (7) days per episode Rehabilitation Up to 21 days inpatient, partial hospitalization program or combination of both per benefit period Prior Authorization is Required: Non TRICARE certified IOP s may be covered under SHCP funds and when directed by a MTF for Active Duty Service Members Note: Free Standing Substance Use Disorder Rehabilitation Facilities must be TRICARE-certified through KePro. 30 Doc#: PCA12480_

31 Substance Use Disorder Rehabilitation: Benefits start the first day of covered treatment and end 365 days later One episode of care per year, three episodes of care per lifetime Limited to 21 days inpatient, partial or a combination of both Outpatient: Treatment is conducted in facility-based programs Coverage is limited to 60 group therapy sessions and 15 family therapy sessions per benefit year 31 Doc#: PCA12480_

32 TRICARE Behavioral Health Provider Types

33 TRICARE Provider Types All authorized providers meet state licensing and TRICARE certification requirements (e.g., physicians, hospitals, ancillary providers, pharmacies, et al.) Network Providers have signed a TRICARE agreement to accept assignment, file claims and other paperwork for TRICARE beneficiaries Non-Network Providers (out of network) have not signed a TRICARE agreement : Participating Non-Network Providers: participate on claim-by-claim basis accept allowable charge and direct payment from TRICARE Non-participating Non-Network Providers: do not accept TRICARE allowable charge or file claims for beneficiaries can legally charge up to 15 percent above TRICARE allowable charges 33

34 TRICARE Network Providers Network providers may only bill a beneficiary for: deductible cost-share copayment Network providers may not bill the beneficiary for: charges that exceed contracted rates Network Provider Hold Harmless Policy Payment is not required for any non-covered services except when: beneficiary did not inform provider of TRICARE status beneficiary informed the services were non-covered, agreed in advance to pay for specific services, and signed TRICARE Waiver of Non-Covered Services TRICARE Waiver of Non-Covered Services form : available at: UHCMilitaryWest.com > Find A Form 34

35 Eligible TRICARE Behavioral Health Provider Types Behavioral Health Professional Providers: Psychiatrists Clinical Psychologists Psychiatric Nurse Practitioners Clinical Social Workers Marriage and Family Therapists Mental Health Counselors, Licensed Professional Counselors, Pastoral Counselors Supervised MHC Autism Spectrum Disorder Providers: Board Certified Behavioral Analyst Technicians and others 35

36 Eligible TRICARE Behavioral Health Provider Types Institutional Providers: Hospitals, Acute Care and Psychiatric Facilities Residential Treatment Centers Psychiatric Partial Hospitalization Substance Use Disorder Rehabilitation Facilities 36

37 TRICARE Certified Mental Health Counselors The Defense Health Agency (DHA) changed requirements for licensed or certified mental health counselors: TRICARE will authorize TCMHCs as independent providers who meet specific qualification criteria: they must have a master s degree from a mental health counseling program accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP) and pass the National Clinical Mental Health Counseling Examination (NCMHCE) by Jan. 1, 2017 TCMHCs can independently treat TRICARE beneficiaries but Supervised Mental Health Counselors (SMHC) will continue to practice under the referral and supervision of TRICARE-authorized physicians Note: For more information please refer to the TRICARE Policy Manual, Chapter 11, Section 3.11 at 37

38 TRICARE Referrals and Authorizations

39 Referrals and Authorizations - defined Referral: The process of sending a patient to another professional provider for a consultation or health care service. Prior Authorization: A request for services, procedures or admission to a hospital or facility that is obtained before a service is provided. Prior authorization is not required for emergencies. Resources: Prior Authorization List: UHCMilitaryWest.com No Government Pay Procedure Code List: 39 Doc#: PCA12480_ TRICARE West Region Customer Service: (WEST) - UHCMilitaryWest.com. TRICARE, TRICARE Prime, TRICARE Reserve Select, and TRICARE Retired Reserve Doc#: are UHC2146v.2_ registered trademarks

40 Referrals and Authorizations Authorization requests for all behavioral services, including Autism: Send by automated fax transmission or paper fax to UnitedHealthcare Urgent/Routine authorization requests Call: (Online submission is not available for behavioral health providers) Providers receive responses via mail Outpatient Treatment Request: Both paper and online forms are available at UHCMilitaryWest.com > Provider Forms > Behavioral Health Note: No referrals are required for outpatient behavioral health (except for ADSMs) 40 Doc#: PCA12480_

41 Referrals and Authorizations For a complete list of services requiring authorization, please refer to the prior authorization list on UHCMilitaryWest.com. Generally, authorizations are not required if a beneficiary has other health insurance that provides primary coverage: Behavioral Health exceptions: TRICARE Prime beneficiaries may self-refer for an initial eight visits to a Mental Health Network Provider ONLY Extended Care Health Option Note: ADSMs always need referrals and prior authorizations from their PCM for care outside of MTFs. 41 Doc#: PCA12480_

42 Referrals and Authorizations Referral/Authorization Appointment Process: Beneficiary is notified via letter, , or text message to schedule an appointment and notify UnitedHealthcare Military & Veterans of the appointment date by calling: (WEST) Requesting specialist and facility receive a copy of the beneficiary letter and approved referral/authorization. Approvals are sent by mail, however, the rendering providers who are enrolled in the fax notification program will receive a faxed approval. Providers may check status at UHCMilitaryWest.com after registration Providers may request additional services by submitting Referral/Authorization form by fax Note: Specialty referrals are valid up to a 180 days. 42 Doc#: PCA12480_

43 Referrals and Authorizations Inpatient Notification: Fax: Needs cover sheet with notification Is required for any scheduled non-emergent admission Emergency care : In the event of a medical, maternity or psychiatric condition leading to life, limb, or eyesight threatening emergency, the beneficiary should go, or be taken, to the nearest emergency room or appropriate medical facility Notify within 24 hours of an emergency admission (including weekend notifications) Certain medical/surgical/behavioral health care services are reviewed for medical necessity and appropriateness of care prior to services being rendered or within 24 hours of an emergency admission 43 Doc#: PCA12480_

44 Search Referrals and Prior Authorizations After submitting a Referral or Authorization Request, you can then search for the request to view its status: If you are not already logged-in, log in to your UHCMilitaryWest.com account. From the left navigation under Secure Content > Search Referral and Prior Authorizations 44 Doc#: PCA12480_

45 Discharge Planning Objective: Military Treatment Facilities serve as the Medical Home to their beneficiaries. Coordination of care is critical to enhance patient safety, continuity of care and quality of care. Prior to discharge facilities should: Ensure a follow up appointment is scheduled for an inpatient beneficiary within seven (7) days of discharge Provide discharge information to the Utilization Management team Obtain appropriate patient releases and send discharge information to the MTF 45 Doc#: PCA12480_

46 TRICARE Claims

47 Electronic Data Interchange (EDI) and Claims Processing PGBA: Provides claims processing and customer service More than 30 years experience administering the military health care program and the current contractor for the TRICARE West, North and South Regions Available at: (WEST) Processes 99 percent of complete claims within 30 calendar days Timely Filing Notes for Network Providers: Bill all claims within 30 days and no later than one year from date of service, discharge or date of professional services billed by a facility Allow at least 30 days to receive payment Contract requires electronic claim submission (continued >) 47

48 EDI and Claims Processing PGBA EDI Contact Information: mytricare.com Phone: (option 2, EDI representative) PGBA Support: XPressClaim : a direct data entry option via PGBA website: mytricare.com Software options, billing services and clearinghouses coordinated upon request Electronic Funds Transfer (EFT) to EDI and ERA network providers: forms available at UHCMilitaryWest.com > Find a Form (continued >) 48

49 EDI and Claims Processing EDI Gateway Enrollment process through PGBA for TRICARE: 1. Contact Tech Support Center: Request copy of EDI Gateway Tech User Communication Manual and Trading Partner Agreement 3. Review manual and Trading Partner Enrollment 4. Complete and return forms appropriate for your connectivity choice Note: Return all forms to help ensure billing is not interrupted. An EDI Representative contact you when forms are received. For more information visit: mytricare.com (continued >) 49

50 TRICARE Provider Resources

51 Provider Resources TRICARE UnitedHealthcare Military & Veterans: Phone: (WEST) Extended hours 7 a.m. to 7 p.m. for all time zones: have your tax ID number ready when calling Routine answers for: Claims Benefits and eligibility Contracting Provider data updates 51

52 Dedicated Resource Site for Providers Objective: Develop a single resource page dedicated to access information to enhance provider knowledge of the unique needs of ADSM and ADFM especially for PTSD and TBI. We accomplished this in partnership with Defense Centers of Excellence and the TRICARE Regional Office West. Partner Resources descriptions: DCoE (Defense Center of Excellence) webinars with CEU s Trainings offered around the country by Center for Deployment Psychology Specific VA/DoD Evidence Based Guidelines Condition support tools and clinical information selected from Live and Work Well site (LAWW in UHCMilitaryWest.com) Best Practice articles for Integrated Medical/Behavioral Health from NICoE (National Intrepid Center of Excellence) T2 Mobile Apps from the National Center for Telehealth and Technology (12 mobile applications to download and support clinical services) 52

53 Dedicated Resource Site for Providers Partner Resources : Go to UHCMilitaryWest.com. From the main bar select Providers tab. From the left navigation under Resources > Behavioral Health > Partner Resources 53

54 Live and Work Well Includes both Medical and Behavioral Condition Support Tools (informational articles, health tips, exercises, etc.) Used by: Beneficiaries Network Providers UHC M&V Clinical Staff MTF Personnel Draws additional information from 6 public domain military sites:

55 Provider Resources TRICARE UHCMilitaryWest.com: Network Provider Directory TRICARE program updates and UnitedHealthcare Military & Veterans processes Link to TRICARE Manuals and policy information TRICARE Provider Handbook Downloadable forms Prior Authorization List Secure website information Check Status of: Claims Referrals and Authorizations Eligibility 55

56 Provider Resources - PGBA mytricare.com: Check status of TRICARE referrals, authorizations and claims Send confidential, secure questions through AskUs: prompt responses delivered to a personal, secure mytricare mailbox File TRICARE claims free online with XPressClaim and get instant claim results Check eligibility, other health insurance, catastrophic cap and deductibles Print reports from selected criteria with claims data reports mytricare Help Desk: Handles all incoming website issues Phone: a.m. to 7 p.m. CST 56

57 TRICARE Behavioral Health Provider Directory

58 Behavioral Health Provider Directory Live and Work Well Members cannot find Behavioral Health providers on the directory at UHCMilitaryWest.com Members need to use the LiveandWorkWell link, under Find a Provider LiveandWorkWell is designed for members and family. LiveandWorkWell is an educational resource to assist with recovery and personal resiliency 58 Doc#: PCA12480_

59 Behavioral Health Provider Directory Clinician Search on Live and Work Well 59 Doc#: PCA12480_

60 TRICARE Bi-annual Provider Data Validation Objective: Increase beneficiary, clinician and MTF satisfaction by validating behavioral provider data to ensure proper referrals and support accurate claims processing. Strategy: All clinician and group providers will be validated twice per year in strategically phased outreach and follow up attempts. Providers will receive via secure fax or USPS mail if no secure fax a letter introducing the process and prepopulated with the data as it exists in our systems. Providers are asked to review and return with either corrections or no indication of changes Optum will follow up with providers that have not completed the validation process in the following manners: Automated telephonic reminders Secondary mailing via , secure fax and or USPS Live telephonic outreach to providers Changes are updated posted in our system within 10 business days of receipt and then flow downstream to additional databases 60 Doc#: PCA12480_

61 TRICARE Contact Us

62 TRICARE Behavioral Health Network Managers 62

63 Autism Network Managers WA OR NV CA ID UT MT WY CO ND SD NE KS MN IA MO WI Justin Anderson (612) Chris Kulick (612) Gwen Miller (602) Carol Cremers (916) Rebecca Rupp (612) AZ NM GA AK TX HI El Paso area only 63

64 Thank you 64