Manual for Community Care Network Providers

Transcription

1 Manual for Community Care Network Providers Community Care Behavioral Health Organization 339 Sixth Avenue Suite 1300 Pittsburgh, PA Provider Line: CCBH (2224) Website: Welcome Community Care Provider Manual CCBH 2016 All Rights Reserved

2 Dear Network Provider, Welcome to Community Care Behavioral Health Organization (Community Care). This Provider Manual is designed to introduce you to Community Care and provide you with contact numbers; instructions regarding authorizations, billing, and quality of service; and access to our performance standards. As this Provider Manual is utilized for all of Community Care s HealthChoices contracts, we publish a companion guide within the manual for any contract where there are changes related to specific counties (please see Appendix E and Appendix F). The companion guide will identify additions and deletions to specific sections of the manual related to specific counties. Please be sure to review the appropriate document(s) in conjunction with this manual. We hope that you find this manual to be clear and easy to follow. If you have any questions, please call your assigned provider representative. Provider representatives contact information can be found at or call our provider toll-free telephone line, , for assistance. The Provider Line answers 24 hours a day/seven days a week. We look forward to working with you. Sincerely, Kristin Burns Senior Director, Network Management Community Care Community Care Provider Manual CCBH 2016 All Rights Reserved Page 1

3 Welcome to the Community Care HealthChoices Network Community Care is pleased to welcome you to our network. Since 1999, we have worked to serve HealthChoices* members and to create and support a strong network of providers and quality care. Our knowledge of managing care for highrisk populations combined with stakeholder input regarding program development has been the key to the successful management of our members care. Community Care s mission is to improve the health and well-being of the community by delivering effective, high-quality, and accessible behavioral health services in a nonprofit partnership with public agencies, experienced local providers, and involved members and their families. Community Care values: Excellence in customer service. Collegial relationships with managed care partners. Decision making based on criteria and data. Effective individualized care and service. Collaborative relationships with customers, stakeholders, and providers. Continuous quality improvement. This manual contains information about Community Care s commitment to acting responsibly and ethically and meeting the highest standards of care for members. It describes who we are, our HealthChoices members, what you need to know as a network provider, and our policies and procedures for providing care. This manual also contains instructions for claims submission (see the Billing section). Information is always changing; please tell us about any changes in your contact information or services. Also, watch for Provider Alerts from us; Provider Alerts amend the content of this manual and your contractual obligations. We welcome your suggestions about how Community Care can improve our service to you. Together we can present our members with a seamless system of high-quality behavioral health services and contribute to the communities and regions in which we work. *Community Care manages behavioral health services for Medicaid recipients (the program is known in Pennsylvania as HealthChoices) in counties throughout the Commonwealth of Pennsylvania. Community Care Provider Manual CCBH 2016 All Rights Reserved Page 2

4 HealthChoices Contact Information Corporate Office: Community Care Behavioral Health Organization 339 Sixth Avenue Suite 1300 Pittsburgh, PA Telephone: ; TTY: Fax: Provider Reference Materials: Appendix T for Mental Health Medical Necessity Criteria may be obtained from: Chemical Dependency Medical Necessity Criteria, Pennsylvania Client Placement Criteria (PCPC) may be obtained from: Department of Health, Bureau of Drug and Alcohol Programs, Room 929, Health and Welfare Building, Harrisburg, PA or from American Society for Addiction Medicine (ASAM) criteria may be obtained from: Patient Placement Criteria (PPC-2R) may be obtained from ASAM Publications Distribution Center, , or P.O. Box 101, Annapolis Junction, MD Provider Lines Provider Phone Line (Answers 24/7) Claims Questions opt 1, opt 2, opt 1 Fraud and Abuse Hotline Customer Service Lines for Members (24/7) by County: Adams Allegheny Berks Blair Bradford Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Elk Erie Forest Huntingdon Jefferson Juniata Lackawanna Luzerne Lycoming McKean Mifflin Monroe Montour Northumberland Pike Potter Schuylkill Snyder Sullivan Susquehanna Tioga Union Warren Wayne Wyoming York Community Care Provider Manual CCBH 2016 All Rights Reserved Page 3

5 Clinical Fax by County: Adams Allegheny Berks Blair Bradford Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Elk Erie Forest Huntingdon Jefferson Juniata Lackawanna Luzerne Lycoming McKean Mifflin Monroe Montour Northumberland Pike Potter Schuylkill Snyder Sullivan Susquehanna Tioga Union Warren Wayne Wyoming York TTY for people who are Deaf/Hard-of-Hearing Spanish Line Autism Support Line PA Child Abuse Hotline Community Care Provider Manual CCBH 2016 All Rights Reserved Page 4

6 Guidelines for Obtaining Approval for In-Plan and Supplemental Services Mental Health Service Emergency Evaluation Crisis Services: Mobile, Telephone, Walk-In Psychiatric Outpatient Evaluation or Initial Non-MD evaluation Best Practice / Life Domain Evaluation 2 Type via Request Center submission None Notification; Approved BHRSCA Providers and BHRSCA prescribers submit via Limits/Exclusions/Definitions Hospital not reimbursed separately if patient is admitted within 24 hours to the evaluating facility. Requests may be made up to 30 days before and 60 days after the start of service. Child: State-approved Best Practices format is required for Behavioral Health Rehabilitation Services for Children and Adolescent (BHRSCA) services and RTF. In some parts of the Commonwealth there is very limited access to licensed psychologists and nonlicensed providers sometimes complete evaluations without any face-to-face evaluation by the licensed psychologist. Community Care will allow this practice to continue. However, we encourage licensed prescribers to continue to participate in all Best Practice evaluations and re-evaluations unless access issues make that option impossible. Please note that, if doctoral or master's level clinicians who are non-prescribers are conducting parts of or the entire BP evaluation, these individuals must be designated by and directly supervised by the licensed prescriber. Please refer to Chapter 41 of the PA Code for Psychologists by the State Board of Psychology. Community Care advocates that prescribers review the case w/the doctoral or master s level clinicians who are conducting parts of or the entire evaluation. Request Form must be submitted following the initial evaluation; not to exceed the timely filing limits for Claims submission for the member s product coverage. Concurrent: must be submitted following the updated evaluation Request; not to exceed the timely filing limits for Claims submission for the member s product coverage. Community Care Provider Manual CCBH 2016 All Rights Reserved Page 5

7 Outpatient Therapy 1 MD Outpatient Medication Check RN Outpatient Medication Check 1 Service Coordination: Intensive Case Management Resource Coordination Blended Case Management Family-Based Mental Health Services Annual Registration Only None Annual Registration Only via Request Center submission Initial: Registration must be submitted following the initial outpatient visit, but within 60 days of that initial visit. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period. It may be submitted up to 30 days before the registration expiration date, but within 60 days of the new registration start date. Initial: Registration must be submitted following the initial outpatient visit, but within 60 days of that initial visit. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period. It may be submitted up to 30 days before the registration expiration date, but within 60 days of the new registration start date. Unit definition: 1 unit = 15 minutes. Requests may be made up to 30 days before and 60 days after the start of service. Unit definition: 1 unit = 15 minutes. Providers send/fax precert to their designated care manager who reviews and, if case meets medical necessity for the service, authorizes. The standard review schedule is to complete a Continued Stay Review at month 3 then again at month 6. The final review (Discharge Review) is completed within 5 business days of discharging the client from treatment. Of note, care managers always reserve the right to authorize and schedule reviews at their discretion based on such concerns as poor progress in treatment or high risk cases that require more care manager involvement and/or more frequent review. Community Care Provider Manual CCBH 2016 All Rights Reserved Page 6

8 Psychological Testing/ Neuropsychological Testing Electroconvulsive Therapy Non-Acute Partial Hospitalization Acute Partial Hospital Residential Treatment Facility Behavioral Health Rehabilitative Services (BHRS) 2 Inpatient Admission Clozaril (Monitoring /Evaluation and Support Services) 1 Psychiatric Rehabilitation; Site- Based, Mobile, Clubhouse Peer Support Multi-systemic Therapy (MST) ; for Outpatient only Notification; Telephonic exempt for Medicare Primary Annual Registration Only ; Notification; Mail Child or Adolescent: Authorized by testing group, peer review. Adult: Authorized by test, peer review. Peer review. Limit of 3 hours minimum to 6 hours maximum per day. Limit of 3 hours minimum to 6 hours maximum per day. Based on clinical necessity. Re-evaluation required every 90 days. Authorized by specific procedure; Community Care care manager to be invited to all interagency service planning team meetings. Packet is due one week after the ISPT meeting Based on medical necessity criteria. Requires diagnoses on all 5 Axes; no V-codes Notification of admissions and within 30 days of discharge for Medicare Primary. Initial: Registration must be submitted following the initial outpatient visit, but within 60 days of that initial visit. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period. It may be submitted up to 30 days before the registration expiration date, but within 60 days of the new registration start date. Based on clinical necessity. Initial: Two months authorized at pre-certification. Continued Stay: Three months authorized at continued stay. Unit definition: 1 unit = 15 minutes. Members must be age 18 or older or age 22 if in Special Education. Maximum six months authorized for each request. Packet is due one week after the ISPT meeting. Community Care Provider Manual CCBH 2016 All Rights Reserved Page 7

9 Functional Family therapy (FFT) Multidimensional Treatment Foster Care (MTFC ) Mobile Mental Health Treatment (MMHT) Tobacco/Smoking Cessation Mail Mail Notification; None Packet is due one week after the ISPT meeting. Packet is due one week after the ISPT meeting. Members must be age 21 or older. Maximum 30 units per 90 day authorization time frame. Based on clinical necessity and will be reviewed every 90 days. Individual and group delivery. Maximum 70 units per year, per member/provider. The maximum unit is calculated by the total number of combined units (individual and/or group). 1 Outpatient registration (OPR): Annual registration of Member required 2 Includes mental health, intellectual and developmental disabilities, and chemical dependency services Community Care Provider Manual CCBH 2016 All Rights Reserved Page 8

10 Guidelines for Obtaining Approval for In-Plan and Supplemental Services Chemical Dependency Service Emergency Evaluation Psychiatric Outpatient Evaluation or Initial Non-MD Evaluation Outpatient Therapy 1 Methadone Maintenance (Outpatient) 1 Intensive Outpatient Therapy Type None Annual Registration Only Annual Registration Only via Request Center submission Limits/Exclusions/Definitions For a hospital, not reimbursed separately if patient is admitted within 24 hours to the evaluating facility. Initial: Registration must be submitted following the initial outpatient visit, but within 60 days of that initial visit. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period. It may be submitted up to 30 days before the registration expiration date, but within 60 days of the new registration start date. Unit definition: Bundled = 1 week (methadone and treatment) Unbundled = 1 day (methadone only) Initial: Registration must be submitted following the initial outpatient visit, but within 60 days of that initial visit. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period. It may be submitted up to 30 days before the registration expiration date, but within 60 days of the new registration start date. Must meet PCPC or ASAM for adolescents. Requests may be made up to 30 days before and 60 days after the start of service. Community Care Provider Manual CCBH 2016 All Rights Reserved Page 9

11 Non-Acute Partial Hospitalization Notification via Must meet PCPC or ASAM for adolescents; at least 3 visits per week with a minimum of 10 hours per week. Acute Partial Hospitalization Must meet PCPC or ASAM for adolescents; at least 3 visits per week with a minimum of 10 hours per week. Halfway House Must meet PCPC or ASAM for adolescents for Medically Managed Rehabilitation Non-Hospital Residential Rehabilitation (3B; short-term or 3C; long term) Medically Managed Detoxification Non-Hospital Detoxification Drug & Alcohol Case Management (ICM/RC) Drug & Alcohol Level of Care Assessment level 2B. Must meet PCPC or ASAM for adolescents for Level 4B. Requires diagnoses on all 5 Axes; no V-codes. Must meet PCPC or ASAM for adolescents for level requested. Must meet PCPC for Level 4A. Requires diagnoses on all 5 Axes; no V-codes. Must meet PCPC for Level 3A. via Request Center submission via Request Center submission Unit definition: 1 unit = 15 minutes. Requests may be made up to 30 days before and 60 days after the start of service. Unit definition: 1 unit = 15 minutes. 1 Outpatient registration (OPR): Annual registration of Member required Requests may be made up to 30 days before and 60 days after the start of service. Community Care Provider Manual CCBH 2016 All Rights Reserved Page 10