Provider Handbook Supplement for Blue Shield of California (BSC)

Transcription

1 Magellan Healthcare, Inc. * Provider Handbook Supplement for Blue Shield of California (BSC) *In California, Magellan does business as Human Affairs International of California, Inc. and/or Magellan Health Services of California, Inc. Employer Services. Other Magellan entities include Magellan Healthcare, Inc. f/k/a Magellan Behavioral Health, Inc.; Merit Behavioral Care; Magellan Health Services of Arizona, Inc.; Magellan Behavioral Care of Iowa, Inc.; Magellan Behavioral Health of Florida, Inc.; Magellan Behavioral of Michigan, Inc.; Magellan Behavioral Health of Nebraska, Inc.; Magellan Behavioral Health of New Jersey, LLC; Magellan Behavioral Health of Pennsylvania, Inc.; Magellan Behavioral Health Providers of Texas, Inc.; and their respective affiliates and subsidiaries; all of which are affiliates of Magellan Health, Inc. (collectively Magellan ) Magellan Health, Inc. 11/14

2 Table of Contents SECTION 1: INTRODUCTION... 3 Welcome... 3 Covered Services... 3 Contact Information... 4 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN.5 Before Services Begin... 5 Concurrent Review... 7 Member Access to Care... 9 Advance Directives - Medicare SECTION 4: THE QUALITY PARTNERSHIP A Commitment to Quality Provider Input Appeals Appeals - Medicare SECTION 5: PROVIDER REIMBURSEMENT Claims Filing Procedures Appendix H to the California Provider Handbook Supplement Magellan Health, Inc. 11/14

3 SECTION 1: INTRODUCTION Welcome Welcome to the Human Affairs International of California (HAI-CA) Provider Handbook Supplement for Blue Shield of California (BSC). This document supplements the Magellan Provider Handbook for the National Provider Network and the California provider handbook supplement, addressing policies and procedures specific for the BSC plan. This provider handbook supplement for BSC is to be used in conjunction with the Magellan national provider handbook and with the California provider handbook supplement. When information in the BSC supplement conflicts with the national handbook, or when specific information does not appear in the national handbook, policies and procedures in the BSC supplement prevail. Covered Services HAI-CA will manage the provision of medically necessary services pursuant to BSC plans. Providers should furnish medically necessary services in an amount, duration and scope that meet members needs. HAI-CA will not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or condition. Covered services may vary based on the member s benefit plan. Covered services, when medically necessary, include: Emergency room consultations Outpatient psychotherapy (individual, family and group) Outpatient psychiatric evaluations Outpatient hospital services Inpatient treatment for mental health and substance abuse (if patient s benefit plan has a substance abuse rider)* Office emergency visits Partial hospitalization for mental health and substance abuse* Intensive outpatient program for mental health and substance abuse* Electroconvulsive therapy (ECT) Psychological testing Therapeutic or diagnostic injections Home services Consultations Telehealth services ABA - Applied Behavior Analysis for Autism TMS Transcranial Magnetic Stimulation Treatment OBOT Office Based Opioid Treatment *Substance abuse services are covered only when the member s benefit plan has a substance abuse rider Magellan Health, Inc. 11/14

4 Contact Information If you have questions about covered services, you may contact HAI-CA at the following numbers: DMHC plan members: HMO, HMO Inpatient Substance Abuse Rider HMO/POS PPO, PPO Inpatient Substance Abuse Rider IFP HMO & PPO Healthy Families DOI plan members: PPO, PPO Inpatient Substance Abuse Rider IFP ASO BSC Buy-Up Product plan members: CalPERS plan members: City and County of San Francisco plan members: Medicare plan members: Magellan Health, Inc. 11/14

5 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Before Services Begin Our Philosophy Our Policy What You Need to Do HAI-CA joins with our members, providers and customers to make sure members receive the most appropriate services and experience the most desirable treatment outcomes for their benefit dollar. Our policy is to refer members to providers who best fit their needs and preferences based on member information shared with HAI-CA at the time of the call. We also confirm member eligibility and conduct reviews for initial requests for clinical services upon request. Your responsibility is to: (Facility-Based Care) Understand federal and state standards applicable to providers. Comply with federal and state standards. Contact HAI-CA for prior authorization of all facility-based care services: DMHC plan members: DOI plan members: ASO BSC Buy-Up Product plan members: CalPERS plan members: City and County of San Francisco plan members: Medicare plan members: Not require a primary care physician (PCP) referral from members. Not require prior authorization of emergency services or urgent care services. Your responsibility is to: (Outpatient Care) Not require a primary care physician (PCP) referral from members. Not require prior authorization of emergency services or urgent care services. Contact HAI-CA for prior authorization for outpatient ECT; TMS; OBOT; ABA; biofeedback and psychological testing (all provider types). Contact HAI-CA to confirm member eligibilty, member benefits, applicable member copayments/coinsurance/deductibles, and timely filing timeline prior to the member s visit. For routine outpatient codes, initiate services to the member. Prior authorization is not required. Psychiatrists do not need authorization for routine outpatient codes at any time. Acquire the applicable copayment/coinsurance/deductible from the member at the time of the each visit. Submit all claims to HAI-CA on behalf of the member and follow billing procedures detailed in Appendix H to the California Provider Handbook Supplement Magellan Health, Inc. 11/14

6 What Magellan Will Do HAI-CA s responsibility to you is to: (Facility-Based Care) Operate a toll-free telephone number to respond to provider questions, comments and inquiries. Those numbers are listed above. Establish a multi-disciplinary Utilization Management Oversight Committee to oversee all utilization functions and activities. Make decisions about expedited prior authorizations and give verbal notification within 24 hours of receipt of the request. Written notification will be sent within the shorter of two business days from when the determination is made or 72 hours of receipt of the request. Understand federal and state standards applicable to providers. Comply with federal and state standards. Contact HAI-CA for eligibility and benefits prior to outpatient services beginning, as applicable: DMHC plan members: DOI plan members: ASO BSC Buy-Up Product plan members: CalPERS plan members: City and County of San Francisco plan members: Medicare plan members: HAI-CA s responsibility to you is to: (Outpatient Care) Operate toll-free telephone numbers to respond to provider questions, comments and inquiries. Those numbers are listed above. Establish a multi-disciplinary Utilization Management Oversight Committee to oversee all utilization functions and activities. Conduct an expedited coverage review when the member s condition is such that he/she faces an imminent and serious threat to his or her health, including, but not limited to the potential loss of life, limb, or other major bodily function, or the standard time frame for the decision-making process would be detrimental to the member s life or health or could jeopardize the member s ability to regain maximum function. Upon receipt of a request that is complete, a medical necessity review of requested services is initiated and verbal notification of the determination is given to the provider in a timely fashion appropriate for the member s condition not to exceed 72 hours after receipt of the request Magellan Health, Inc. 11/14

7 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Concurrent Review Our Philosophy Our Policy HAI-CA believes in supporting the most appropriate services to improve health care outcomes for members. We look to our providers to notify us if additional services beyond those initially authorized are needed, including a second opinion for complex cases. Concurrent utilization management review is required for all services, including but not limited to: Inpatient Intermediate ambulatory services such as residential treatment, partial hospital programs (PHP) or intensive outpatient (IOP) programs What You Need to Do If, after evaluating and treating the member, you determine that additional services are necessary: (Facility-based Care) Call the designated HAI-CA care management team member at least one day before the end of the authorization period for inpatient and intermediate ambulatory services, at the following numbers: DMHC plan members: DOI plan members: ASO BSC Buy-Up Product plan members: CalPERS plan members: City and County of San Francisco plan members: Medicare plan members: Be prepared to provide the HAI-CA care manager or physician advisor with an assessment of the member s clinical condition, including any changes since the previous clinical review and discharge plan. Request a second opinion if you feel it would be clinically beneficial. Understand federal and state standards applicable to providers. Comply with federal and state standards. Respond promptly to requests for additional clinical information. If, after evaluating and treating the member, you determine that additional nonroutine outpatient services are necessary: (Outpatient Care) Request a second opinion if you believe it would be clinically beneficial. Understand federal and state standards applicable to providers. Comply with federal and state standards. Contact HAI-CA for authorization of all non-emergent out-of-network services at the applicable number listed above. Respond promptly to requests for additional clinical information Magellan Health, Inc. 11/14

8 What Magellan Will Do HAI-CA s responsibility to you is to: (Facility-based Care) Be available 24 hours a day, seven days a week, 365 days a year to respond to requests for authorization of care. Promptly review your request for additional days or visits in accordance with the applicable medical necessity criteria. Have a physician advisor available to conduct a clinical review in a timely manner if the care manager is unable to authorize the requested services. Respond in a timely manner to your request, verbally and in writing, for additional days. Make a decision and give verbal notification within 24 hours of receipt of the request. Written notification is sent within the shorter of two business days from when the determination is made or 72 hours of receipt of the request. Operate toll-free telephone numbers to respond to provider questions, comments and inquiries. Those numbers are: DMHC plan members: DOI plan members: ASO BSC Buy-Up Product plan members: CalPERS plan members: City and County of San Francisco plan members: Medicare plan members: Establish a multi-disciplinary Utilization Management Oversight Committee to oversee all utilization functions and activities. HAI-CA s responsibility to you is to: (Outpatient Care) Make a physician advisor or clinician advisor available to conduct a clinical review in a timely manner if the care manager is unable to authorize the requested services. Make a decision within five business days of receipt of the request. The determination will be communicated via phone or fax to the requesting provider within 24 hours of making the determination and written notification will be sent within two business days of making the determination. Operate toll-free telephone numbers to respond to provider questions, comments and inquiries. Those numbers are: DMHC plan members: DOI plan members: ASO BSC Buy-Up Product plan members: CalPERS plan members: City and County of San Francisco plan members: Medicare plan members: Establish a multi-disciplinary Utilization Management Oversight Committee to oversee all utilization functions and activities Magellan Health, Inc. 11/14

9 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Member Access to Care Our Philosophy Our Policy What You Need to Do Members are to have timely access to appropriate mental health, substance abuse, and/or Employee Assistance Program (EAP) services from an in-network provider 24 hours a day, seven days a week. Our access-to-care standards allow members to obtain behavioral health services from an in-network provider within a time frame that reflects the clinical urgency of the situation. In support of that commitment, we have established appointment and telephone access standards. We strongly encourage you to follow these standards. Appointment Access Standards Life-Threatening Emergency Access If you are unable to see a member who has a life-threatening emergency immediately, we ask that you immediately refer the member to the nearest emergency room or advise the member to call 911. Non-Life-Threatening Emergency Access We expect you to see members with non-life-threatening emergencies within six hours of contact. Urgent Access We expect you to see health plan and other managed care members with urgent situations within 48 hours of contact and EAP members with urgent situations within 24 hours of contact. Routine Access We expect you to see health plan and other managed care members for routine care within 14 calendar days of contact, Medicare members within 10 business days of contact, and EAP members within three business days of contact. Unavailability - Notify us immediately when you become unavailable for new referrals by updating your appointment availability and/or requesting a hold of referrals for any date span via the provider website. Any hold request beyond 90 days will need to be received in writing and reviewed for approval by the Network and CNCC committee. Telephone Access Standards If you are unavailable when a member calls, we expect you to return the member s call within one business day and to communicate your telephone response time to members via your phone message and/or answering service. Of course, if a member message indicates urgency, please respond immediately or in accordance with good professional practice guidelines. We also ask that your phone message or answering service informs members that if they believe their situation requires immediate intervention, they should: Go to the nearest emergency room Hang up and call 911 Hang up and call 911 or go to the nearest emergency room Magellan Health, Inc. 11/14

10 In-Office Wait Times Members should not have to wait more than 15 minutes after the scheduled appointment time except when an emergency interrupts your schedule. Referral Supplement California Provider Specialty Information Providers can update and maintain their specialties and appointment availability via the site using the online Provider Data Change Form as explained in the National Provider Handbook. This information is requested to meet regulatory requirements of the California Department of Managed Health Care. What Magellan Will Do In support of our commitment to these standards and to meet our regulatory obligations, we may contact you through random audits to gauge your ability to meet these standards. Failure to meet these standards may result in sanctions, up to and including termination of your provider participation agreement. If you have any concerns or comments, please contact us toll-free at Magellan Health, Inc. 11/14

11 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Advance Directives - Medicare Our Philosophy Our Policy What You Need to Do What Magellan Will Do HAI-CA believes in a member s right to self-determination in making health care decisions. As appropriate, HAI-CA will inform adult members 18 years of age or older about their rights to refuse, withhold or withdraw mental health and/or substance abuse treatment through advance directives. HAI-CA supports the state and federal regulations that provide for adherence to a member s psychiatric advance directive. Your responsibility is to: Understand and comply with federal Medicare standards regarding psychiatric advance directives. Maintain a copy of the psychiatric advance directive in the member s file, if applicable. Understand and follow a member s declaration of preferences or instructions regarding behavioral health treatment. Use professional judgment to provide care believed to be in the best interest of the member. HAI-CA s responsibility to you is to: Comply with federal advance directive laws. Document the execution of a member s psychiatric advance directive. Not discriminate against a member based on whether the member has executed an advance directive. Provide information to the member s family or surrogate if the member is incapacitated and unable to articulate whether or not an advance directive has been executed Magellan Health, Inc. 11/14

12 SECTION 4: THE QUALITY PARTNERSHIP A Commitment to Quality Our Philosophy Our Policy What You Need to Do HAI-CA supports the delivery of quality care, with the primary goal of improving the health status of members and, where the member s condition is not amenable to improvement, maintaining the member s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. This includes identifying members at risk of developing conditions, implementing appropriate interventions, and designating adequate resources to support the intervention(s). In support of our Quality Improvement Program, our providers are required to be familiar with HAI-CA guidelines and standards and apply them in clinical work with members. To comply with this policy, your responsibility is to: Understand and comply with regulatory standards applicable to providers. Provide input and feedback to HAI-CA to actively improve the quality of care provided to members. Participate in quality improvement activities if requested by HAI-CA. What Magellan Will Do HAI-CA s responsibility to you is to: Actively request input and feedback regarding member care. Work with members, providers, community resources and agencies to improve the quality of care provided to members. Operate a toll-free telephone hotline to respond to provider questions, comments and inquiries. Establish a multi-disciplinary Quality Oversight Committee to oversee all quality functions and activities. Maintain a health information system sufficient to support the collection, integration, tracking, analysis and reporting of data. Provide designated staff with expertise in quality assessment, utilization management and continuous quality improvement Magellan Health, Inc. 11/14

13 SECTION 4: THE QUALITY PARTNERSHIP Provider Input Our Philosophy Our Policy What You Need to Do What Magellan Will Do HAI-CA believes that provider input concerning our programs and services is a vital component of our quality programs. HAI-CA obtains provider input through provider participation in various workgroups and committees of the San Diego Care Management Center. We offer providers opportunities to give feedback through participation in our quality programs, or via requests for feedback in provider publications. To comply with this policy, your responsibility is to: Understand and comply with regulatory requirements and standards applicable to providers. Provide input and feedback to HAI-CA to actively improve the quality of care provided to members. Participate in quality improvement and utilization oversight activities if requested by HAI-CA. HAI-CA s responsibility to you is to: Actively request input and feedback regarding member care. Operate a toll-free telephone number to respond to provider questions, comments and inquiries. Establish a multi-disciplinary Quality Oversight Committee to oversee all quality functions and activities. Maintain a health information system sufficient to support the collection, integration, tracking, analysis and reporting of data. Provide designated staff with expertise in quality assessment, utilization management and continuous quality improvement. Develop and evaluate reports, indicate recommendations to be implemented, and facilitate feedback to providers and members. Participate in annual performance improvement projects (PIPs) that focus on clinical and non-clinical areas, and provide annual reports on performance improvement project results using a valid process for evaluation of the impact and assessment of the quality improvement activities Magellan Health, Inc. 11/14

14 SECTION 4: THE QUALITY PARTNERSHIP Appeals Our Philosophy Our Policy HAI-CA supports the right of members and providers acting on the behalf of members to appeal adverse determinations. Our customer organizations and applicable federal and state laws impact the clinical appeals process. The applicable procedure for appealing a clinical determination is outlined fully in the adverse determination notification letter. An appeal is a formal request by a member for reconsideration of a nonauthorization decision or adverse claim determination with the goal of finding a mutually acceptable solution. For an appeal prior to the provision of the services, the member may submit the appeal or the provider, acting on the member s behalf, may submit an appeal. Examples of actions that can be appealed include, but are not limited to, the following: Denial or limited authorization of a requested service, including the type or level of service Reduction, suspension or termination of a previously authorized service Denial, in whole or in part, of payment for a service. An expedited appeal is a request that is made when the routine decision-making process might seriously jeopardize the life or health of a member, or when the member is experiencing severe pain. An expedited decision may involve an admission, continued stay, or other health care services. What You Need to Do To comply with this policy, your responsibility is to: Follow the instructions listed in the notification of an adverse determination to submit an appeal for services that have not been provided, by: Submitting the appeal verbally by contacting the customer service number on the back of the member s benefit card for appeals, or Faxing the appeal to , or Mailing the appeal and supporting documentation to: Blue Shield of California Mental Health Service Administrator P.O. Box San Diego, CA Members must follow the instructions for submitting an appeal described on the notification of the adverse decision and contact HAI-CA directly. Providers and other individuals filing on the member s behalf should refer to the adverse determination notification letter for the specific procedures for appealing a clinical determination Magellan Health, Inc. 11/14

15 What Magellan Will Do HAI-CA s responsibility to you is to: Notify you verbally within 24 hours of our determination when we decide to reverse our non-authorization decision Notify you in writing of our determination to reverse our non-authorization decision. Forward appeals to BSC for further review and a determination when we decide to uphold our non-authorization decision. Not take any punitive action against any provider who requests or supports an appeal Magellan Health, Inc. 11/14

16 SECTION 4: THE QUALITY PARTNERSHIP Appeals - Medicare Our Philosophy Our Policy What You Need to Do What Magellan Will Do HAI-CA supports the right of members and their providers acting on the member s behalf to appeal adverse determinations. In the event of a dispute regarding coverage of mental health/substance abuse services under a Medicare Advantage Full-Risk Benefit Plan, HAI-CA will refer members to BSC for response and resolution. Should medical necessity be an issue during the review, BSC will consider HAI-CA s medical necessity criteria when reviewing and rendering a decision. If HAI-CA s criteria conflicts with BSC medical policy, BSC medical policy will govern. All final decisions regarding coverage are reserved to BSC. To comply with this policy, your responsibility is to: Contact the BSC Appeals and Grievance department to request an appeal for a Medicare Advantage member. Members must follow the instructions for filing an appeal listed on the notification of an adverse decision and contact BSC directly. Providers and other individuals filing on the member s behalf should refer to the adverse determination (non-authorization) notification letter for the specific procedures for appealing a clinical determination, and contact BSC directly. HAI-CA s responsibility is to: Refer you to BSC for handling of your Medicare Advantage appeal determinations Magellan Health, Inc. 11/14

17 SECTION 5: PROVIDER REIMBURSEMENT Claims Filing Procedures Our Philosophy Our Policy What You Need to Do HAI-CA is committed to reimbursing our providers promptly and accurately in accordance with our provider contracts. HAI-CA reimburses mental health and substance abuse treatment providers in accordance with reimbursement schedules for professional services. The reimbursement schedules contain current procedural terminology (CPT) codes for traditional outpatient providers, and a combination of CPT and Healthcare Common Procedure Coding System (HCPCS) codes. The reimbursement schedule(s) is attached to your provider participation agreement. Your responsibility is to: Collect the applicable copayment/coinsurance/deductible from the member at the time of the each visit. Contact the San Diego Care Management Center at the applicable number to verify eligibility, obtain information on copayment amounts, and prior authorization for all higher levels of care and, except for routine outpatient care. Sign up for online claims submission and electronic funds transfer (EFT) through Submit a clean claim form for the services that you have provided through an accepted clearinghouse, or via paper claim. Include Magellan submitter ID # on EDI claims. Claim address: Human Affairs International of California, Inc. (A Magellan Health Services Company) P.O. Box San Diego, CA In accordance with Centers for Medicare and Medicaid Services (CMS) requirements, HAI-CA requires Medicare claims to be submitted by the 90 th calendar day. HAI-CA encourages providers to submit claims within 60 calendar days of date of service or discharge; however, claims will be accepted until the 90 th calendar day from date of service or discharge. Bill using the Taxpayer Identification Number under which you are contracted. Refrain from billing the member for any amount, including the difference between HAI-CA s reimbursement amount and your standard rate, other than applicable deductibles and copayment. This practice is called balance billing and is prohibited. Contact the San Diego Care Management Center if you are not certain which services require pre-authorization, what your reimbursement rate is, or for any questions that you have concerning the member in care. See Appendix H to the California Provider Handbook Supplement for our Claims Settlement Practices Magellan Health, Inc. 11/14

18 What Magellan Will Do HAI-CA s responsibility to you is to: Provide verbal notice, send an authorization letter and/or provide electronic authorization when we authorize services. Process your claim promptly upon receipt, and complete all transactions within regulatory and contractual standards. Inform you of any reasons for administrative denials and action steps required to resolve the administrative denial. Send you or make available online an Explanation of Payment (EOP) or other notification for each claim submitted, including procedures for appealing. Provide appropriate notice regarding corrective action or information required if a claim is denied. Re-open your claim and process to final payment upon receipt of requested information. Regularly update the Universal Services List and HIPAA-compliant billing codes on our provider website. Review our reimbursement schedules periodically in consideration of industry-standard reimbursement rates and revise them when indicated. Include all applicable reimbursement schedules as exhibits to your contract. Communicate changes to reimbursement rates in writing prior to their effective date. Comply with applicable state and federal regulatory requirements regarding claims payment. Communicate changes to claims filing requirements and reimbursement rates in writing prior to the effective date Magellan Health, Inc. 11/14