IOWA HEALTH LINK TRAINING FOR ABA PROVIDERS UnitedHealthcare Community Plan

Transcription

1 IOWA HEALTH LINK TRAINING FOR ABA PROVIDERS UnitedHealthcare Community Plan

2 Our United Culture 2

3 APPLIED BEHAVIOR ANALYSIS (ABA) SERVICES 3 BH

4 Optum Autism/ABA Program Specialty Network Clinical Oversight Dedicated department responsible for building a network of autism specialty providers made up of Board Certified Behavior Analysts (BCBA) and licensed behavior clinicians with experience in intensive behavior therapies Extensive credentialing process/review of autism specialty providers that includes an onsite and medical record review In-depth provider orientations held monthly for all new and existing autism specialty providers Dedicated Autism Clinical Team consisting of specialty trained masters and doctoral level care advocates, led by a licensed psychologist who is also a BCBA-D Autism Clinical Team assists families with referrals, education, and care coordination Clinical Technology Committee currently reviewing components of ABA to see which interventions are most successful Autism Corner on provider portal, Provider Express, offers network and clinical resource information for autism specialty providers. National network of over 1900 autism specialty provider locations 4

5 Optum Autism/ABA Program (cont.) Operational Initiatives Kudos From Customers Autism coverage protocols and medical necessity guidelines in place Specialized team to assist members and facilitate authorizations and claims payment I wanted to send a letter out to all of our other clients encouraging them to switch to Optum when the open enrollments occur this fall as it has been such as great experience for us and the children are getting the services they so desperately need without a hassle. -Pat, Children Making Strides I wanted to let you know I attended the APBA s convention in Boston yesterday and people from all over the country attended. Everyone in the room had wonderful things to say about UBH! And I want to personally thank you, Debbie, for all the hard work and assistance. I could not have done it without you! Anne, Beacon 5

6 IOWA HEALTH LINK MEDICAID ABA PROGRAM MEMBER INFORMATION 6 BH

7 Member ID Card Will be sent directly to the member The member s ID number will be their Medicaid number All relevant contact information will be on the back of the card for both medical and behavioral customer service Please note these images are for illustrative purposes only. 7

8 Member Rights and Responsibilities Members have the right to be treated with respect and dignity, the right to personal privacy, and the right to receive care that is considerate and respectful of personal values and belief system Members have the right to disability-related access per the Americans with Disabilities Act You will find a complete copy of Member Rights and Responsibilities in the Network Manual These can also be found on the website: providerexpress.com These rights and responsibilities are in keeping with industry standards, and members will benefit greatly from reviewing these standards in the treatment setting We request that you display the Rights and Responsibilities in your waiting room, or have some other means of documenting that these standards have been communicated to the members 8

9 Who is eligible? To be eligible for ABA services, a client must meet the following criteria: Be younger than age 21 Be covered under Iowa Health Link Medicaid Have a diagnosis of an autism spectrum disorder, as defined by the most current version of the Diagnostic and Statistical Manual (DSM-5) 9

10 CREDENTIALING CRITERIA FOR INCLUSION IN THE IOWA HEALTH LINK MEDICAID ABA NETWORK 10 BH

11 Iowa Health Link Autism Provider Credentialing Criteria Individual Board Certified Behavior Analysts Solo Practitioner Board Certified Behavior Analyst (BCBA) with active certification from the national Behavior Analyst Certification Board, and Minimum of 6 months supervised experience or training in the treatment of applied behavior analysis/intensive behavior therapies Minimum professional liability coverage of $1 million per occurrence/$1 million aggregate ABA / IBT Groups BCBAs must meet standards above Licensed behavioral health clinicians must have appropriate state licensure and 6 months supervised experience or training in the treatment of applied behavior analysis/intensive behavior therapies BCBA or licensed behavioral health clinician on staff providing program oversight BCBA or licensed behavioral health clinician performs skills assessments and provides direct supervision of Behavioral Technicians in joint sessions with client and family Behavioral Technicians meet state requirements and receive appropriate training and supervision by BCBAs or licensed clinician $1 million per occurrence/$3 million aggregate of professional liability and $1m/$1m of general liability if services are provided in a clinical setting $1 million per occurrence/$3 million aggregate of professional liability and $1m/$1m of supplemental insurance if the agency provides ambulatory services only (in the patient s home) Successful completion of medical record and site audit, as applicable 11

12 Required: NPI, EIN/TIN, Liability Insurance National Provider Identifier (NPI) Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information We require that all claims submitted have an NPI number for reimbursement To obtain an NPI number, follow the instructions on the NPI web site Tax Identification Number (TIN), Employee Identification Number (EIN), or Social Security Number (SSN) information Professional Liability Insurance web site has coverage information use the term liability in the site s search field located in the left side of the menu 12

13 PROVIDER RESPONSIBILITIES 13 BH

14 Intake At Intake: Copy front and back of the member s insurance card Record subscriber s name and date of birth Suggested information: Provide subscriber with your HIPAA policies Provide subscriber with consent for billing using protected health information including signature on file Always obtain Informed Consent for services, permission to leave voice mail, contact, etc. Billing policies and procedures Release of Information to communicate with other providers 14

15 Eligibility and Prior Authorization Call the number on the back of the member s insurance card to see if member is eligible for your services Check benefit coverage relating to both the service (e.g., Is ABA-based therapy covered?) and the diagnosis (e.g., Is autism covered?) Make sure all services receive prior approval before beginning services 15

16 Abuse and Neglect Training Training For Mandatory Reporters in Iowa Licensed professionals are required to complete training that is required and approved by their respective licensing and examining boards or approved by the Iowa Abuse Education Review Panel The Abuse Education Review Panel website can be used for abuse education resources and can be accessed at: Report of suspected child abuse and dependent abuse shall be made by calling the Abuse hotline Mandatory reporters are required by law to complete two hours of training during their first six months of employment and two hours every five years thereafter. 16

17 STEPS IN PROVIDING TREATMENT Authorizations, Treatment Plans, Concurrent Reviews 17 BH

18 Clinical Team: Iowa Health Link ABA There is a dedicated, Enhanced enhanced Autism/ABA autism/aba Clinical clinical team Teamthat will be There is a dedicated, enhanced autism/aba clinical team that will be supporting the Iowa Health Link ABA program Each team member is a licensed behavioral health clinician or BCBA with experience in Autism and training in ABA Supervised by a manager who is a licensed psychologist and BCBA-D 18

19 Assessment Request Process The provider will need to submit a written request for the initial ABA assessment including write-up time Utilize the treatment plan request form to submit and indicate that this is an assessment request The initial assessment can include a Functional Behavioral Assessment of other skilled assessments Provider should include a copy of the diagnostic evaluation with the assessment request 19

20 Treatment Plan Requirements Fax number: Meet Medical Necessity this applies to initial and concurrent reviews Concurrent reviews - Due at least 10 days prior to the end of the authorization period but no more than 30 days in advance; should include how progress was assessed - this can include ABLLS-R or VBMAPP Provider must submit the evaluation from the diagnosing provider and the treatment plan 20

21 Treatment Plan Requirements Meet Medical Necessity Goals are: Related to the core deficits of autism Objective Measurable Individualized Includes: Baseline and mastery criteria Transition Plan to lower level of care Discharge Criteria Behavior Reduction Plan/Crisis Plan Parent Goals Supervision and treatment planning hours Relevant psychological information Coordination of care with other providers Not educational in nature For more information, please see the IA Treatment Plan guidelines on the Autism/Applied Behavior Analysis page of Provider Express. 21

22 Concurrent Reviews Due at least 10 days prior to the end of the authorization period but no more than 30 days in advance: Send treatment update with graphical display of progress: Mastered programs/targets Ongoing targets New goals/benchmarks Include behavior data and explanations of trends (if appropriate), especially if lack of progress Include: Goals Psychological update Hours/codes requesting for next period Transition plan Crisis management plan If Group: o Supervision protocol 22

23 Discharge Planning There Must is a dedicated, include enhanced the following autism/aba components clinical team in every that will plan be Anticipated date of discharge Objective, measurable goals that would need to be met for the child to be discharged Identify next level of care for the child, (e.g., school-based services only, outpatient therapy)---include contact info if appropriate Resources in the community for the parents and member How discharge is coordinated with the school and other providers Member and/or parent agreement with plan How to resume services if needed Contact the primary insurance company advocate to notify within 2 weeks Send a final summary treatment plan indicating: o The progress the child made o Reasons for discharge o What services 23

24 CODING, BILLING AND REIMBURSEMENT 24 BH

25 Claims Submission Required Claim Forms 1500 Claim Form Claims/Customer Service number : Electronic Claims Payer ID: Paper Claims: When submitting behavioral Claims by paper, please mail claims to: United Healthcare PO Box 5220 Kingston, NY

26 Claims Submission (Cont.) If not submitting claims online, providers must submit claims using the current 1500 Claim Form with appropriate coding UnitedHealthcare Community Plan requires that you initially submit your claim within 180 days of the date of service When a provider is contracted as a group, the payment is made to the group, not to an individual All claim submissions must include: o Member name, Medicaid identification number and date of birth o o o Provider s Federal Tax I.D. number National Provider Identifier (NPI) Providers are responsible for billing in accordance with nationally recognized CMS Correct Coding Initiative (CCI) standards. Additional information is available at 26

27 Claims Submission option 1 Online Log on to Secure HIPAA-compliant transaction features streamline the claim submission process Performs well on all connection speeds Submitting claims closely mirrors the process of manually completing a CMS-1500 form Allows claims to be paid quickly and accurately You must have a registered user ID and password to gain access to the online claim submission function: To obtain a user ID, call toll-free (866)

28 Claims Submission option 2 EDI/Electronically Electronic Data Interchange (EDI) is an exchange of information Performing claim submission electronically offers distinct benefits: Fast - eliminates mail and paper processing delays Convenient - easy set-up and intuitive process, even for those new to computers Secure - data security is higher than with paper-based claims Efficient - electronic processing helps catch and reduce presubmission errors, so more claims auto-adjudicate Notification - you get feedback that your claim was received by the payer; provides claim error reports for claims that fail submission Cost-efficient - you eliminate mailing costs, the solutions are free or low-cost 28

29 Claims Submission option 2 EDI/Electronically (Cont.) You may use any clearinghouse vendor to submit claims Payer ID for submitting claims is Additional information regarding EDI is available on and 29

30 Electronic Payment & Statements (EPS) With EPS, you receive electronic funds transfer (EFT) for claim payments, plus your EOBs are delivered online: Lessens administrative costs and simplifies bookkeeping Reduces reimbursement turnaround time Funds are available as soon as they are posted to your account To receive direct deposit and electronic statements through EPS you need to enroll at myservices.optumhealthpaymentservices.com. Here s what you ll need: Bank account information for direct deposit Either a voided check or a bank letter to verify bank account information A copy of your practice s W-9 form If you re already signed up for EPS with UnitedHealthcare Commercial or UnitedHealthcare Medicare Solutions, you will automatically receive direct deposit and electronic statements through EPS for UnitedHealthcare Community Plan when the program is deployed. Note: For more information, please call (866) , option 5, or go to UnitedHealthcareOnline.com > Quick Links > Electronic Payments and Statements. 30

31 Claims Tips To ensure clean claims remember: An NPI number is always required on all claims A complete diagnosis is also required on all claims Claims filing deadline Providers should refer to their contract with United to identify the timely filing deadline that applies Claims Processing Clean claims, including adjustments, will be adjudicated within 14 days of receipt Balance Billing The member cannot be balance billed for behavioral services covered under the contractual agreement 31

32 Claims Tips (Cont.) Member Eligibility Provider is responsible to verify member eligibility through DHS website Coding Issues Coding issues including incomplete or missing diagnosis Invalid or missing HCPC/CPT examples: Submitting claims with codes that are not covered services Required data elements missing, (i.e., number of units) Provider information missing/incorrect Example: provider information has not been completely entered on the claim form or place of service Prior Authorization Required Prior Authorization is required for all services or when additional units are being requested 32

33 Form Claim Form All billable services must be coded. Coding can be dependent on several factors: Type of service (assessment, treatment, etc.) Use appropriate modifier for specific provider type Rate per unit (BCBA vs. Paraprofessional) Place of service (home or clinic) Duration of therapy (1 hr vs. 15 min) One DOS per line Form 1500: formerly called CMS-1500 or HCFA You must select the code that most closely describes the service(s) provided. Please note: Field 31 must have a rendering provider name. Rendering supervisor (BCBA/Licensed Clinician) will bill for all services by them or the paraprofessional under the supervisory protocol. 33

34 CPT Codes CPT Code Modifier Description Unit H0031 HO Functional Behavioral Assessment (one hour) Direct Services for Assessment/Treatment Planning by BCBA or licensed MH clinician, per hour. Per Hour H0031 HP Functional Behavioral Assessment (one hour) Direct Services for Assessment/Treatment Planning by BCBA or licensed MH clinician, per hour. Per Hour H0032 HO Functional Behavioral Assessment (15 minutes) Direct Services for Assessment/Treatment Planning by BCBA or licensed MH clinician, per 15 minutes. Per 15 minutes H0032 HP Functional Behavioral Assessment (15 minutes) Direct Services for Assessment/Treatment Planning by BCBA or licensed MH clinician, per 15 minutes. Per 15 minutes H2014 HO MH Skills Training and Development (15 Min.) Social Skills Group (multi child & staff) Services by BCBA Per 15 minutes H2014 HP MH Skills Training and Development (15 Min.) Social Skills Group (multi child & staff) Services by BCBA Per 15 minutes H2014 HN MH Skills Training and Development (15 Min.) Social Skills Group (multi child & staff) Services by Board Certified Assistant Behavior Analyst (BCABA) or non-certified support staff Per 15 minutes H2019 HO MH Therapeutic Behavioral Services, (individual) (15 Min.) Services by BCBA Per 15 minutes H2019 HP MH Therapeutic Behavioral Services, (individual) (15 Min.) Services by BCBA Per 15 minutes H2019 HN MH Therapeutic Behavioral Services (individual) (15 Min.) Services by Board Certified Assistant Behavior Analyst (BCABA) or non-certified support staff Per 15 minutes 34

35 CPT Codes (Cont.) G9012 HO Care oversight and management of treatment team by licensed MH professional or certified BCBA, (15 Min.) Supervision of Paraprofessional by BCBA or licensed MH clinician; per 15 minutes (services rendered jointly, in-person, during directly supervised fieldwork of the Paraprofessional by the Supervisor) Per 15 minutes G9012 HP Care oversight and management of treatment team by licensed MH professional or certified BCBA, (15 Min.) Supervision of Paraprofessional by BCBA or licensed MH clinician; per 15 minutes (services rendered jointly, in-person, during directly supervised fieldwork of the Paraprofessional by the Supervisor) Per 15 minutes S5108 HO MH Home Care Training to home care client (parent training) (15 Min.) Services by Board Certified Behavior Analyst (BCBA) Per 15 minutes S5108 HP MH Home Care Training to home care client (parent training) (15 Min.) Services by Board Certified Behavior Analyst (BCBA) Per 15 minutes S5108 HN MH Home Care Training to home care client (parent training) (15 Min.) Services by Board Certified Assistant Behavior Analyst (BCABA) or non-certified support staff Per 15 minutes S5110 HO MH Home Care Training to home care client (family training) (15 Min.) Services by Board Certified Behavior Analyst (BCBA) Per 15 minutes S5110 HP MH Home Care Training to home care client (family training) (15 Min.) Services by Board Certified Behavior Analyst (BCBA) Per 15 minutes S5110 HN MH Home Care Training to home care client (family training) (15 Min.) Services by Board Certified Assistant Behavior Analyst (BCABA) or non-certified support staff Per 15 minutes HO - Masters degree level Board Certified Behavior Analyst (BCBA) HP - Doctoral level Board Certified Behavior Analyst (BCBA) HN - Board Certified Behavior Analyst (BCABA) or non-certified support staff 35

36 APPEALS AND COMPLAINTS 36 BH

37 Appeals Non-Urgent (Standard) Urgent (Expedited) Must be requested within 180 days from receipt of the notice of action letter. Pre-Service: is an appeal of a service that has not yet been received by a member. When a pre-service appeal is requested, we will make an appeal determination and notify the provider, facility, member or authorized member representative in writing within fourteen (14) calendar days of the request. Post-Service: is an appeal of a service after it has been received by a member. When a post service appeal is requested, we will make the appeal determination and notify the provider, facility, member or authorized member representative in writing within fourteen (14) calendar days of the request. Must be requested as soon as possible after the Adverse Determination. United will make a reasonable effort to contact you prior to making a determination on the appeal. If United is unsuccessful in reaching you, an urgent appeal determination will be made based on the information available to United at that time. Notification will occur as expeditiously as the member s health condition requires, within three (3) business days, unless the appeal is pertaining to an appeal relating to an ongoing emergency or denial of continued hospitalization, which we will complete investigation and resolution of no later than one (1) business day after receiving the request. Appeal requests can be made orally or in writing, however an oral request to appeal must be followed up by a written, signed, appeal. 37

38 Services while in Appeal You may continue to provide service following an adverse determination, but the member should also be informed of the adverse determination. The member or the member representative should be informed that the care will become the financial responsibility of the member from the date of the adverse determination forward. The member must agree in writing to these continued terms of care and acceptance of financial responsibility. You may charge no more than the United contracted fee for such services, although a lower fee may be charged. If, subsequent to the adverse benefit determination and in advance of receiving continued services, the member does not consent in writing to continue to receive such care and we uphold the determination regarding the cessation of coverage for such care, you cannot collect reimbursement from the member pursuant the terms of your Agreement. 38

39 Complaints We strive to deliver the best customer service possible but if you feel a complaint is necessary, please contact us at A Customer Service representative will assist with the complaint process. Or send a written complaint to: United Healthcare Community Plan of Iowa Appeals Department PO Box Salt Lake City, UT

40 Release of Information We release information only to the individual, or to other parties designated in writing by the individual, unless otherwise required or allowed by law Members must sign and date a Release of Information for each party that the individual grants permission to access their PHI, specifying what information may be disclosed, to whom, and during what period of time The member may decline to sign a Release of Information which must be noted in the Treatment Record; the decline of the release of information should be honored to the extent allowable by law PHI may be exchanged with a network clinician, facility or other entity designated by HIPAA for the purposes of Treatment, Payment, or Health Care Operations 40

41 RESOURCES 41 BH

42 Autism Network Managers State Assignments AK WA OR CA NV ID UT AZ MT WY CO NM ND SD NE KS TX OK MN IA MO AR LA WI IL MS IN TN AL MI KY OH GA WV VA SC NC PA NH VT NY NJ DE MD D.C. ME MA RI CT Carol Cremers HI FL PR Lisa Moore Jeanna Gonzales Joslyn Gibbs Chris Reinsberg Darlene Fitzpatrick Justin Anderson Betty Rubin Debbie Sills 42

43 UnitedHealthcare Provider Website unitedhealthcareonline.com Secure transactions for Medicaid include: Check eligibility and authorization or notification of benefits requirements Submit professional claims and view claim status Make claim adjustment requests Register for Electronic Payments and Statements (EPS) To request a user ID to the secure transactions on the unitedhealthcareonline.com, select New User from the home page You may also obtain additional information through the help desk at (866) For member eligibility, claim status, and reference materials, go to > Tools and Resources > UnitedHealthcare Community Plan Resources Customer Service for website support: (800)

44 UnitedHealthcare Online login page 44

45 Iowa Health Link ABA Program Page Iowa Health Link ABA Program providers have their own page on providerexpress.com Materials on this page include: Iowa Health Link ABA Provider Quick Reference Guide Iowa Health Link ABA Treatment Plan/ Authorization Request Form 45

46 Q&A 46

47 47 Thank You.