Participating Provider Manual

Transcription

1 Participating Provider Manual Revised November 2011

2 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER SERVICES Page 7 Intake Coordinators Referrals by member Referrals by providers Benefits eligibility 3. UTILIZATION MANAGEMENT Page 8 Utilization management program Appropriate treatment; no financial incentives Psychcare clinical criteria 24-hour access to UM inquiries Utilization management activities 4. NETWORK MANAGEMENT Page 15 Provider recruitment Request to join the network process Notification of Request to join process outcome Availability standards GeoAccess Network composition Provider training Provider complaints Accreditations 5. INITIAL CREDENTIALING & RECREDENTIALING Page 19 Application submission Basic credentialing elements for participation, based on government, accrediting agencies, and client standards Federal, state, and accreditation standards Time frame for completion of credentialing process Site visits prior to submission to Credentialing Committee Notification of Credentialing Committee decision Credentialing cycle/recredentialing Maintenance of credentialing file between cycles Ongoing monitoring PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 2

3 6. REVIEW OF KEY CONTRACT COMPONENTS Page 26 Missed appointments Breach of contract Billing members for covered services Billing members for non-covered services Termination Continuity of care for members following termination of member Provider Notification Responsibilities (i.e. Changes of address, TIN, holds, terminations, etc.) 7. CLAIMS Page 29 Claims Processing Timely submission Electronic claims Paper claim form types Paper claim forms submission address Clean claims Remittances Authorization numbers on claims Prompt payment Resubmission of clams Claim questions answered via Psychcare s online portal Claim questions not answered via Psychcare s online portal Address change notifications 8. QUALITY MANAGEMENT Page 33 Annual Quality Improvement Program Quality Improvement Program goals Scope of Quality Improvement Program Clinical management guidelines Outpatient treatment record documentation Collaborative activities Continuity and coordination of care activities Health literacy, cultural and linguistic needs of membership Member safety Potential quality of care and/or member safety instances Privacy Practices HIPAA, and federal and state confidentiality laws Members Rights and Responsibilities Access to care and availability standards Fraud, waste, and abuse activities Psychcare website 9. PREVENTIVE HEALTH Page 49 PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 3

4 10. LIFE S SOLUTIONS EAP EMPLOYEE ASSISTANCE PROGRAM Page 50 Access to EAP Services Treatment Beyond EAP Services 11. CONTACT LIST Page 52 Appendix A: Link to provider resources Page 53 Appendix B: Psychcare Website Page 54 Appendix C: Medicaid Addendum Page 55 Appendix D: Network Practitioner Outpatient Documentation Requirements and Review Tool Page 74 Appendix E: Practitioner s Statement of Receipt of Participating Practitioner Manual Page 76 PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 4

5 1. INTRODUCTION Psychcare, LLC s Management Team Rodolfo Hernandez, M.D., President & Chief Executive Officer, takes pleasure in announcing the management team of Psychcare, LLC (Psychcare) to you, and Dr. Hernandez joins with the management team in welcoming you to Psychcare s provider network! Daniel Hernandez, Senior Executive Vice President Rudy Hernandez, Executive Vice President Jordi Cuervo, Vice President, Operations Mission Statement Psychcare s mission is to establish and continue long-term partnerships with our clients through our commitment of providing quality behavioral healthcare and Employee Assistance Program (EAP) services, both of which meet the needs of our clients, as well as their members. Client satisfaction occurs through the collaboration of Psychcare s team of dedicated and ethical staff members, who work with skilled and professional practitioners, providers and community agencies (provider network) in Psychcare s network model. Psychcare s commitment to client retention and quality care increases the value our clients derive from services offered through both Psychcare s behavioral healthcare products, as well as from our EAP product, delivered through Psychcare s subsidiary, Life s Solutions EAP. Company Background Psychcare has experienced tremendous growth in recent years, and because of our growth, we have expanded our products to include: Life s Solutions EAP, a national EAP program Disease Management Programs Wellness Programs A Dependent Care Program PharmAssist Program Psychcare s President & Chief Executive Officer, Rodolfo Hernandez, MD, has served on various consulting boards in the area of psychopharmacological development and treatment. In addition, Dr. Hernandez previously served as the Medical Director for specialty hospitals, as well as for other Managed Behavioral Health Care Organizations (MBHO s). In the mid-80 s, Psychcare began as an EAP program, EmploAssist. Since that time, Psychcare has grown into an accredited MBHO, with a subsidiary called Life s Solutions EAP. Psychcare, a family-owned company, is a comprehensive MBHO that specializes in managing mental health and substance abuse benefits for HMOs, PPOs, and large employer groups. Psychcare also is experienced in providing EAP services to a wide variety of companies and governmental entities. Psychcare is proud of its strong history of client retention. Some of Psychcare s clients have been with the company for 15+ years, and others have returned to Psychcare after experiencing the differences in working PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 5

6 with other Managed Behavioral Healthcare Organizations. Psychcare s staff offers service that is consistently rated excellent in customer satisfaction surveys. Psychcare hopes that you will find this manual to be a helpful resource in learning the processes to follow when treating members managed by Psychcare. Hard copies are available for most of the resources, if you do not have the ability to download the information from a website. Accreditations Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare s commitment to quality is evident by its continuous full accreditation status with URAC since 1998, as well as its full accreditation status with the National Committee for Quality Assurance (NCQA) since These accreditations are evidence of Psychcare s ongoing measures which promote and provide for quality care and service to members managed by Psychcare. Provider Network Psychcare s provider network is very important to us! Psychcare s management team fosters a united effort between Psychcare and its provider entwork. The mutually-cohesive and collaborative work relationship between Psychcare s staff members and the contracted Psychcare provider network results in the provision of effective, efficient, timely, and appropriate treatment services, rendered to both the managed behavioral healthcare (MBHO) and the EAP members, all of whom are serviced by Psychcare. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 6

7 2. MEMBER SERVICES Intake Coordinators Intake Coordinators are bilingual (English/Spanish). Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call, a service which is available Monday through Friday, from 8:30 AM to 5:30 PM, Eastern Standard Time (EST). Intake Coordinators provide direct access to callers on eligibility information, routine referrals, and authorizations. Intake Coordinators transfer calls, as appropriate, to licensed clinicians and/or other departments for assistance. Member Referrals Members can access referrals by calling Psychcare s toll-free telephone number of ( ). Lists of providers are available electronically, by fax, or mail. In addition, referrals can be given telephonically at the member s request. Once an appointment is obtained, the member or the provider will receive an authorization telephonically or online. Provider Referrals For the purposes of coordination of care, providers are encouraged to contact Psychcare for network referrals for therapy and/or medication management. Benefits Eligibility Psychcare has updated benefit eligibility information and manages benefits based on clinical criteria, benefit plan coverage and service requests. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 7

8 3. UTILIZATION MANAGEMENT Philosophy Psychcare s philosophy is to monitor the quality, safety, and appropriateness of clinical care and services rendered by our provider network, to verify that accepted national and community standards are being provided within the scope of federal and state regulations and laws. Psychcare s Utilization Management (UM) program provides a mechanism for monitoring utilization of services, and ensuring delivery of quality and cost-effective behavioral healthcare. UM activities are an integral part of Psychcare s Quality Improvement Program. Psychcare makes decisions whether to approve or not approve payment for services based only on the appropriateness of the care or service, and on the coverage available in the member s benefit plan. Utilization Management (UM) Decision-Making Psychcare affirms the following: UM decision-making is based only on appropriateness of care and service and the existence of coverage; Psychcare does not specifically reward practitioners or other individuals for issuing denials of coverage or service care; Psychcare does not provide financial incentives for UM decision-makers, and Psychcare does not encourage decisions that result in underutilization. UM decisions are based on both the members benefit coverage, and: Psychcare s Level of Care Clinical Criteria for all Florida Commercial and Medicare members, as well as Medicaid members outside the State of Florida, and Florida s Medicaid Level of Care Guidelines for Florida Medicaid members. If you would like a hard copy of either UM decision-making criteria or guidelines, please contact Psychcare at our toll-free telephone number of ( ). The Scope of the Annual Utilization Management (UM) Program The scope of the annual UM Program includes the following the following core activities: Communication Services; Triage Processes; Acuity Level and Appropriate Level of Care; Referral and Clinical Review Processes; Interrater Reliability; Clinical Trainings; Over- and Underutilization Monitoring; Member Satisfaction with UM processes; Practitioner Satisfaction with UM processes, and PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 8

9 Continuity and Coordination of Care. Communication Services Regarding UM Processes and UM Inquiries Members and the provider network have access to Psychcare s clinical staff, 24 hours per day, 7 days per week, via our toll-free telephone number of ( ), to allow for questions regarding Psychcare s UM processes or any UM issues to be addressed. Psychcare s clinical staff is available to answer inquiries regarding Psychcare s UM processes or any UM issues,via telephone, fax, and/or , from both members and the provider network, Monday through Friday (excluding holidays), between 8:30 AM to 5:30 PM, EST. Following usual business hours, and on weekends and holidays, members and the provider network can contact an on-call Case Manager (a licensed clinician), via our toll-free telephone number of ( ). Psychcare s clinical staff addresses inquiries regarding Psychcare s UM processes or any UM issues received via telephone calls, faxes and/or within one (1) business day, Monday through Friday (excluding holidays), between 8:30 AM to 5:30 PM, unless otherwise agreed upon. Emergency telephone calls received afterusual business hours, on weekends or on holidays, are responded to within thirty (30) minutes from receipt of the call. Non-urgent telephone calls received Monday through Friday, between 5:30 PM to 8:30 AM, or on weekends and holidays, are responded to by a Case Manager, no later than one (1) business day from receipt of the call, unless otherwise agreed upon. Psychcare staff members identify themselves by name, title, and their affiliation with Psychcare, during both inbound and outbound communications to members and the provider network regarding Psychcare s UM processes, UM issues, and/or requests for services. Bilingual (English/Spanish) staff members are available to assist members and the provider network, both during and after usual business hours. Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call. Clinical Criteria Case Managers use a member s benefit coverage and one of the following: Psychcare s Mental Health Level of Care Clinical Criteria and/or Psychcare s Substance Abuse Level of Care Clinical Criteria for all Florida Commercial and Florida Medicare members, and for Medicaid members outside of the State of Florida; Florida Medicaid Level of Care Guidelines for Florida Medicaid members, or Applied Behavioral Analysis Criteria for Florida Commercial members. Psychcare believes that the determination of the level of care should be based upon presenting signs and symptoms, indicating that all lesser alternative levels of care would be detrimental to the safety and/or health of the member. It is the responsibility of the Psychcare clinical staff, which includes the Associate Medical Director, Psychcare Case Managers, and Clinical Peer Reviewers, to direct all members to the appropriate level of care, based on an acuity assessment. Psychcare s Level of Care Clinical Criteria and the Florida Medicaid Level of Care Guidelines are available to members and the provider network on the Psychcare website, or they may be obtained in hard copy, upon request, by calling Psychcare s toll-free telephone number of ( ). PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 9

10 Referral and Clinical Review Processes Pre-Service Non-Urgent Outpatient Referrals Members seeking initial non-urgent outpatient referrals can access services, Monday through Friday (excluding holidays), 8:30 AM to 5:30 PM, EST, via the toll-free telephone number of ( ). The call connects the members to Psychcare s state-of- the-art telephone system, whereby the members are provided with a menu selection, and from this menu, the members can select the menu option for nonurgent outpatient referrals. The referrals are then handled by a Psychcare Intake Coordinator. The Intake Coordinator verifies members benefits, confirms their addresses and telephone numbers, explains their financial obligations, such as copays, and completes Initial Intake Screening forms with the members. Referral considerations include the geographic, cultural, and/or linguistic preferences of the members. The Intake Coordinator provides the members with the names of network providers in their preferred area. Members are then advised that once they have made their selection, they should call Psychcare to have services authorized to the provider selected from the referral sources. Pre-service non-urgent care authorizations, inclusive of notification, are completed within fourteen (14) calendar days from the date of the request. Should the provider selected not be avilable within the non-urgent outpatient appointment standard, Intake Coordinators ask the provider to refer the members back to Psychcare, so that additional referral sources can be given to the members for selection. Use of Licensed Consultants Licensed specialty consultants are on Psychcare s Clinical Peer Reviewer panel. The panel consists of licensed behavioral health practitioners in active practices, who have both current and unrestricted licenses, and who are either board-certified psychiatrists, licensed doctorate-degree level psychologists, or master s level licensed clinicians with clinical expertise in all areas of behavioral health. The Medical Director and/or Associate Medical Director may consult with a Clinical Peer Reviewer in a like or similar specialty to the attending practitioner, whose case is being reviewed, to assist in making a determination of medical necessity or clinical appropriateness, and in other situations, as necessary. Initial Clinical Review Psychcare s Mental Health Level of Care Clinical Criteria, Psychcare s Substance Abuse Level of Care Clinical Criteria, the Florida Medicaid Level of Care Guidelines, and Psychcare s Clinical Management Guidelines are used by the Psychcare Case Managers during the initial clinical review. With oversight by the Associate Medical Director and supervision by the Vice President, Clinical Operations, actively- licensed Case Managers conduct both pre-service urgent care, as well as concurrent urgent and non-urgent care reviews. The Medical Director and/or Associate Medical Director are accessible for any clinical questions concerning authorization of services, 24 hours per day, 7 days per week. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 10

11 Medical necessity denial determinations are never issued during the initial clinical review. Medical necessity denial determinations are only issued during the peer clinical review, conducted by the Medical Director and/or Associate Medical Director, with the attending practitioner. Emergency Services and Urgent Care Review. Emergency mental health services are defined as those services that are required to meet the needs of an individual who is experiencing an acute crisis resulting from mental illness, which is at the level of severity that would meet the requirements for involuntary hospitalization, pursuant to Chapter , F.S., and who, in the absence of a suitable alternative or psychiatric medication, would require hospitalization. Emergency psychiatric services, necessary to screen and stabilize a member are authorized without prior approval, when a prudent layperson, acting reasonably, believes that an emergency exists or an authorized representative acting for the organization has authorized the provision of emergency services. Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member s benefit plan. Pre-service Care Review Pre-service reviews are conducted before treatment is provided to the member. A determination to authorize a particular service is based on the member s benefit coverage and the definition of medical necessity, based on Psychcare s Level of Care Clinical Criteria or Florida s Medicaid Level of Care Guidelines. Pre-service urgent care reviews, including verbal and written notifications, are completed as soon as possible, but no later than seventy-two (72) hours from the date and time of receipt of the request. Pre-service nonurgent review decisions, including verbal and written notifications, are completed within fourteen (14) calendar days from the date of receipt of the request. Concurrent Review Concurrent reviews are conducted during the course of treatment to ensure treatment continues to meet Psychcare s definition of medical necessity, based on Psychcare s Level of Care Clinical Criteria or Florida s Medicaid Level of Care Guidelines. Concurrent urgent care review decisions, including verbal and written notifications, are completed within twenty-four (24) hours of the date and time of the request. Concurrent non-urgent review decisions, including verbal and written notification, are completed within fourteen (14) calendar days from receipt of the request. Providers may request concurrent outpatient authorizations by completing the applicable form(s) available on the Psychcare website Both urgent and non-urgent concurrent care certification decision notifications include (1) the number of days or units of service authorized, (2) the next anticipated review point, (3) the new total of days or services approved, and (4) the date of admission or onset of services. Post-service Review PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 11

12 The Medical Director and/or Associate Medical Director make all post-service review determinations. Postservice reviews are conducted after the completion of a course of treatment. A post-service review occurs when services were neither authorized nor denied by Psychcare. The determination and written notification of the decision are provided within thirty (30) calendar days of the date of the receipt of the request and/or all clinical information necessary to make a medical necessity decision. When a request for a post-service review is received by Psychcare, and there is insufficient clinical information to determine the medical necessity of the case, Psychcare requests that the clinical information necessary to determine medical necessity is received within forty-five (45) calendar days from the date of the receipt of the notice requesting same. The requested clinical information includes, but is not limited to: The initial psychiatric evaluation; The physician s orders; The daily physician s progress notes; The daily nursing progress notes, and The discharge summary. Network Provider Utilization Management Processes for Post-Service Review of Emergency Services The post-service review process for emergency services is based on Federal and State regulatory standards; The definition of emergency services is based on (1) the member s certificate of coverage and (2) per Federal and State regulatory requirements; The submission and processing of a network provider request for a post-service review is based on (1) the individual network provider s executed Psychcare Participating Practitioner Agreement or Psychcare Participating Provider Agreement, and the section of the agreement pertaining to adherence to Psychcare s utilization management processes, (2) the member s certificate of coverage, (3) the emergency service definition as per the applicable line of business, and (4) national accrediting body standards; Psychcare will not process post-service review requests for routine outpatient services; Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member s benefit plan; It is the network provider s responsibility to contact Psychcare within twenty-four (24) hours of the member s admission, or, if unable to do so for circumstances beyond the provider s control, on the next business day. Although Psychcare cannot deny payment for emergency services based on the provider s failure to comply with the notification requirements, nothing shall alter any contractual responsibility of the member or provider to make contact with Psychcare subsequent to receiving treatment for the emergency condition; When the member is unable to provide insurance information upon admission, the network provider, in all circumstances, will obtain the member s insurance information prior to the member s discharge and will notify Psychcare of the member s hospitalization; When the network provider identifies the member s insurance information but was unable to contact Psychcare for authorization prior to the member s discharge, as evidenced by the provider s submission of a post-service review request to Psychcare, it is the network provider s responsibility to document in the member s treatment record, the provider s efforts to contact Psychcare and to obtain authorization upon receipt of the member s insurance information, prior to the member s discharge. The post-service review request will not be processed if there is a lack of this documentation, and the network provider will receive written notification within five (5) business days of Psychcare s review of the request, via mail and/or electronically of the decision, not to process the provider s request, with the specific reasons listed; PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 12

13 Requests for payment of post-service reviews follow the Federal and State submission time periods for postservice review requests. All requests received after the prescribed submission period shall be considered past the date of submission; When the network provider s utilization management process responsibilities are fulfilled, Psychcare s Medical Director or Associate Medical Director determines the medical necessity of the services previously rendered, based on; ü All clinical documentation submitted with the post-service review request, ü Psychcare s Level of Care Clinical Criteria, and when applicable, Florida s Medicaid Level of Care Guidelines, ü The member s benefit coverage, and ü The applicable definition for emergency services. When the network provider s utilization management processes are not fulfilled, the network provider shall be sent written notification via certified mail and/or , advising the provider that the post-service review will not be processed due to a breach in the agreement requring adherence to Psychcare s utilization management processes; The post-service review determination, including written notification via certified mail and/or , is completed within thirty (30) calendar days of the date of the receipt of the post-service review request; As per Chapter , F.S., Requirements for Providing Emergency Services and Care, the member is not held financially liable for the emergency services provided, except for any copayment or coinsurance; The timeliness of post-service medical necessity review determinations, are reported quarterly to the Utilization Management Committee; Peer Clinical Review The Medical Director or Associate Medical Director conducts all initial peer clinical reviews. Medical necessity denial decisions are based on the relevant clinical information provided by the attending practitioner or UM personnel, Psychcare s Level of Care Clinical Criteria, Florida s Medicaid Level of Care Guidelines, and the definition of medical necessity. Every reasonable opportunity is afforded to the member, member s legal representative, attending practitioner or provider to consult directly with the Medical Director or Associate Medical Director within one (1) business day of the decision, to discuss the determination via the toll-free telephone number of ( )..When the Associate Medical Director is unavailable within the specified time period for the peer clinical review, then a Psychcare Clinical Peer Reviewer, who is an actively practicing network practitioner of the same or similar specialty, conducts the peer clinical review within one (1) business day of the decision. Medical Necessity Appeals Commercial, Medicare, and Michigan Medicaid client health plan expedited, pre-service, and post-service member medical necessity appeals and network provider medical necessity appeals are contractually delegated to Psychcare by each client. Unless contractually delegated, Psychcare does not process Florida Medicaid medical necessity expedited, pre-service, and post-service member and network provider appeals. Second level appeals and/or external reviews of appeals by an Independent Review Organization (IRO) are not delegated to Psychcare by any of our clients. Expedited Appeals PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 13

14 An expedited appeal is a request to change a denial determination for urgent care, as per the urgent care definition, while the member is still undergoing treatment. A board-certified Clinical Peer Reviewer in the same or similar specialty as the attending practitioner, who was not involved in the initial denial determination, reviews the appeal. A determination is rendered, and the parties are given verbal and written notification of the decision as soon as possible, but no later than seventy-two (72) hours from receipt of the appeal request. Post-service Appeals A board-certified Clinical Peer Reviewer in the same or similar specialty as the attending practitioner, who was not involved in the initial denial determination, reviews the appeal. A post-service appeal is a request to change a denial determination for treatment that the member has already received. Post-service appeal determinations, inclusive of written notification, are completed within thirty (30) calendar days from receipt of the request. Practitioner Satisfaction with Psychcare UM Processes Annually, Psychcare conducts a Network Practitioner Satisfaction Survey with all of our network practitioners, and a Florida Medicaid Stakeholder Survey with our Florida Medicaid providers for each of our Florida Medicaid clients. The purpose of each survey is to find out our network s satisfaction with our clinical and administrative UM processes, and to identify opportunities to improve those areas of least satisfaction. UM Information Contained on the Psychcare Website Psychcare Mental Health Level of Care Clinical Criteria Psychcare Substance Abuse Level of Care Clinical Criteria Psychcare Applied Behavioral Analysis Criteria Psychcare Florida Medicaid Level of Care Guidelines Psychcare Neuropsychological Testing Criteria Accessibility to Customer Service Staff and Clinical Staff to discuss utilization management issues Ensuring appropriate utilization management Conflict of Interest Statement Pre-service, concurrent, and post-service review decision-making timeliness standards Authorization processes Post-service review processes for Psychcare network practitioners and providers The opportunity to request a Peer Clinical Review to discuss an initial medical necessity denial determination Psychcare s website address is Most of the information described herein can be downloaded from our website. If you would like a hard copy of the any of the documents and/or activities located on our website, please call Psychare s Quality Management Department at Psychcare s toll-free telephone number of ( ), Monday through Friday, 8:30 AM to 5:30 PM, EST. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 14

15 4. NETWORK MANAGEMENT Provider Recruitment If you or someone you know would like to be considered for inclusion in Psychcare, LLC s network, please refer to the Request to Join Network Process below in this section. Request to Join the Network Process Providers (practitioners) who have an interest in joining the network should print the Participating Provider Application, which can be downloaded from the Psychcare website at Recruitment Contracting. If you do not have access to a website, please contact the Network Development Department at the toll-free telephone number of ( , Ext. 3998). Once you have printed the application, please legibly complete the form, in full, then sign and return with all requested, supporting documentation, in one of three ways: Mail: Psychcare, LLC, Sunset Drive, Miami, FL Attention: Network Development Fax: Network partner@psychcare.com Upon receipt of a completed application, the following elements will be reviewed to assist Psychcare in determining initial eligibility for processing by the Credentialing Department: Specialty/area of expertise is needed in network; Location of practice is within network development-approved area; License must be current, valid, unrestricted, and in most geographic locations, independent; DEA/Controlled substance registration current, unrestricted; Board certification (ABMS or AOA ONLY) is current and verifiable (Physicians only); Residency training is completed and verifiable, if not board-certified. (Physicians only); Education is completed and verifiable. (Providers with Doctorate and Master s degrees); Work history must include five (5) current, consecutive years of experience in the field of interest. Gaps greater than one (1) year require a written explanation and will be reviewed. Gaps between six (6) months to one (1) year can be offered verbally, but the explanation is processed more efficiently when explained in writing, and Cultural, ethnic and linguistic needs of the network are considered and reviewed in each application. Note: If initial eligibility is not met, providers (practitioners) will be notified (See Notification of Request to Join Process Outcome ). If initial eligibility is met, providers (practitioners) will be sent application, or if already received, application will be processed by the Credentialing Department. Providers (facilities) with an interest in joining the network should contact the Network Development Department at the toll-free telephone number of ( , Ext. 3998). This department will handle all of your questions regarding the possibility of network inclusion. Notification of Request to Join Process Outcome PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 15

16 Upon receipt of a completed application, along with the supporting documentation, the provider (practitioner) will be notified within fifteen (15) business days following the next Credentialing Committee meeting, as to whether or not the application will be processed. The Credentialing Committee meets at least quarterly, typically on the 3 rd Thursday of the month the meeting will be held. Meetings are currently scheduled for the months of March, June, September, and December. Please note that completion and submission of a credentialing application, in and of itself, does not confirm that the Credentialing Committee allowed for the application to be sent to the applicant, nor does it constitute network acceptance by the Credentialing Committee. Availability Standards GeoAccess Psychcare s Credentialing Committee conducts network analyses, at least annually, but availability standards are analyzed on an ongoing basis throughout the year. Availability standards are reviewed annually and are determined, based on client needs, state and federal standards, accrediting standards, and network composition needs. Further, a network analysis is conducted prior to the processing of any initial credentialing application, to determine if there is a need in the network, based on GeoAccess-calculated availability standards, for a provider of the applicant s scope of practice, location, language(s) spoken, and cultural/ethnic background. Network Composition Psychcare s network is composed of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups. The size and the scope of the network is determined by the Credentialing Committee and is reviewed on an ongoing basis to assure the network is inclusive of the appropriate number and distribution of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups. Provider Training A Provider Training Module is available on our website at The Provider Relations Department is also available to conduct training with new providers at the time they are contracted. The Provider Training Module will include, but will not be limited to: Introduction to the Participating Provider Manual Provider Responsibilities Authorization process Claims submission, processing, and payment Electronic billing HIPAA Information Treatment plans Clinical summaries PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 16

17 Medication management forms Maintaining current credentialing file Change of address process Who to contact with general questions Contact list for Psychcare Provider Complaints Psychcare s Provider Partnerships Department maintains a Provider Complaint Log with the following components addressed for each Provider Complaint received: Date of complaint Date of response to complaint Name of health plan Practitioner name Practitioner license & state of issue for license Practice/Facility name Complaint type Access Authorizations Claims Service Other Complaint narrative Complaint resolution (i.e. who resolved, date resolved) The Provider Complaint Log is maintained on an internal shared location, so that any Psychcare staff member may access and input information, should a provider submit a complaint. If, however, the Provider Complaint is given directly to the Provider Partnerships Department via an internal staff member s notification, and the complaint was not logged, the Provider Partnerships Department will log the event, and The performance goal is to have 100% of provider complaints that are received, logged for review and resolution. Providers are encouraged to file provider complaints through the Provider Partnerships Department, incorporating one of the following delivery methods: (1) Partner@psychcare.com, (2) Fax: , (3) Telephone: (800) x 3904, or (4) Mail: Psychcare, LLC, Sunset Drive, Miami, FL Attn: Provider Partnerships. The Provider Complaint Log is reviewed on a daily basis, Monday through Friday, by the Provider Partnerships Department, and the complaints are given to the Vice President, Provider Partnerships, who will initiate the handling of the case. Each time a provider complaint is logged, the Vice President, Provider Partnerships, will assign a member of the Provider Partnerships Department to fully investigate the complaint received, with the assistance of other departments and key personnel, as needed. To prevent possible discrimination in any review of a provider complaint, no one staff member may determine the outcome or the resolution of same. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 17

18 All state, federal and contractual obligations are considered during review of the complaint. Once the provider complaint investigation is conducted, the Vice President of Provider Partnerships will present the complaint to the Credentialing Committee, a subcommittee of the Quality Improvement Committee. The Credentialing Committee will review the nature of the provider complaint and the data from the investigation. The Credentialing Committee will discuss and determine recommendations based on the outcome of the complaint investigation. The practitioner will be advised of the outcome, in writing, within ten (10) business days of the Credentialing Committee decision. If the practitioner wishes to dispute the outcome, a written letter of dispute with supporting documentation should be sent to the attention of the Credentialing Committee within forty-five (45) calendar days of the date of the outcome letter. The Credentialing Committee will convene an ad hoc meeting, and the dispute will be reviewed. If necessary, a conference call with the practitioner will be arranged. Following final review, a decision will be sent, in writing, to the practitioner, within ten (10) business days of the date the dispute was reviewed, either (1) in the ad hoc meeting, or (2) following the conference call with the practitioner, whichever comes last. Quarterly, the Vice President of Provider Partnerships will present a summary of provider complaints to the Quality Improvement Committee. The summary report will include the following: The total number of provider complaints received; A trending analysis to identify whether the provider complaints identify a particular area of dissatisfaction. When a trend is identified the quarterly report will contain the area(s) of dissatisfaction and, an analysis of the barriers, identification of opportunities for improvement, and recommended implemented interventions. Accreditations Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare s commitment to quality is evident by its continuous full accreditation status with URAC since 1998, as well as its full accreditation status with the National Committee for Quality Assurance (NCQA) since These accreditations are evidence of Psychcare s ongoing measures which promote and provide for quality care and service to members managed by Psychcare. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 18

19 5. INITIAL CREDENTIALING/RECREDENTIALING Application Submission The creation of the initial credentialing process begins when an applicant submits the completed, dated, and signed Participating Provider Application or the Participating Facility Application, along with copies of documents requested on the Attestation Page of the application, to Psychcare via mail to Psychcare, LLC, Sunset Drive, Miami, FL Attention: Network Development, or via fax to Network Documents requested include, but may not be limited to the following, as applicable to the provider: Curriculum vitae; Current license(s) to practice; Malpractice face sheet indicating amounts of coverage and expiration dates, or Financial Responsibility Statement ; DEA (if applicable), and controlled substance registration; Board certification by ABMS or AOA, and W-9. Basic credentialing elements for participation, based on government, accrediting agencies, and client standards DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA 1. Specialties/Areas of Expertise 2. Location(s) of Practice (See Availability Standards) REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA Specialties/areas of expertise are listed in Psychcare s credentialing applications. Providers complete this information and provide documentation to support the ability to provide such specialty or area of expertise. Location(s) of practice sites are reviewed and approved by the Credentialing Committee during the initial credentialing process. If any practice sites change, are deleted, or are added, Psychcare s Credentialing Committee will review same, and the committee will make a determination as to whether such modifications will be accepted, based on the network need for the location of the site(s), and on the cultural, ethnic, and linguistic needs of Psychcare s members in that area. Site visits will be required in all high-volume locations, as determined by an ongoing review of utilization data and claims history. 3. License(s) Providers must submit a legible copy of a current, valid, unrestricted, independent license(s) upon initial credentialing and upon each subsequent renewal of the licensure. Psychcare credentials its providers at the highest level of both education and licensure held by the provider, not merely by the highest level of education held by the provider. Therefore, if a provider has a doctorate degree (Ph.D, Psy.D., or Ed.D, etc.), but is licensed at the master s level, the provider will be credentialed at the master s level. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 19

20 DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA If a provider s level of licensure changes between credentialing cycles, it is the responsibility of the provider to notify Psychcare of the change for review by the Credentialing Committee at the next credentialing cycle. Psychcare verifies all state licenses from the state licensing agency, via the internet, in writing, or telephonically, whichever is applicable to the State. Disciplinary actions, if any, are indicated by the State during the verification. Psychcare requests further information from the State, when necessary. All providers complete an application at the time of initial credentialing and at the onset of each subsequent credentialing cycle, and providers answer questions as to whether or not their license(s) (current or any other in the past) are or have ever been disciplined. If a discrepancy is noted between the information given by the practitioner and by the State, the practitioner will be notified and will be given the opportunity to respond. The Credentialing Committee reviews these findings when the credentialing file is completed and presented for approval. 4. DEA/Controlled substance registration (Physicians and applicable providers only) 5. Residency Training (Physicians) or Education (Providers with Doctorate and Master s degrees) Providers must submit a copy of a legible, current, valid DEA registration upon initial credentialing and upon each subsequent renewal of the DEA. Psychcare verifies all DEA registrations from the NTIS (National Technical Information Service) internet database. Providers must also submit a copy of a legible, current, valid controlled substance registration, if applicable, upon initial credentialing, and upon each subsequent renewal of the controlled substance registration. Controlled substance registrations are verified from the primary source, whenever possible; however, the copy received from the provider is acceptable and is placed in the credentialing file. Physicians: If not board-certified, physicians must have completed a verifiable residency program. Psychiatrists must have completed a psychiatric residency program, and Addictionologists must have completed an internal medicine or other approved residency program. Psychcare verifies all residency programs (i.e. general, child and adolescent, addiction, forensic, and geriatric) completed by physicians, via the AMA Physician Profile Report or via a letter written to the residency program. Confirmation of the dates in the program and successful completion of the program is requested. If verification by the residency program is not possible, confirmation from the state licensing agency will suffice, ONLY if the agency PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 20

21 DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA can provide recent evidence that it conducts primary source verification of residency training. Physicians should be five (5) years post-graduate; this may include residency years. Doctorate and Master s Level Providers: These providers must submit proof of completion of their master s or doctorate level programs. Psychcare verifies all educational programs by doctorate and master s level providers, online via the NSCH (National Student Clearinghouse), or in writing, via a letter to the educational institutions from which they received their degrees. If verification by the educational program is not possible, confirmation from the state licensing agency will suffice, ONLY if the agency can provide recent evidence that it conducts primary source verification of education. 6. Board Certification - (ABMS or AOA) (Physicians only) Physicians who are board-certified by the ABMS or AOA must submit copies of any board-certifications in psychiatry upon initial credentialing, and they must submit any renewals or additional board-certifications, as they are granted. Verification of a provider s residency program(s) is not required if the provider is board-certified. Psychcare verifies all ABMS certifications via ABMS s CertiFacts service, an NCQA-approved source for verification of board-certifications. Psychcare verifies AOA certifications online, via the AOA Official Osteopathic Physician Profile Report. Verifications from these NCQA-approved sources are valid for up to one (1) year, but the verification must be obtained from the most current edition of the document source. 7. Work History Work history is collected at the time of initial credentialing via the application and/or the curriculum vitae. A current, continuous, five (5) year work history in the field is reviewed. Gaps of more than six (6) months must be explained by the provider, either telephonically, with a note in the credentialing file, or in writing. Gaps of one (1) year or more must be explained in writing by the provider. Psychcare is not required to verify work history, but at the discretion of the Credentialing Committee, may choose to do so, prior to rendering a decision on the status of the applicant. 8. Malpractice History All providers will attest to the absence or presence of malpractice history in their credentialing applications. Providers must submit a copy of a current, valid malpractice face sheet upon initial credentialing and upon subsequent renewals of the malpractice insurance; coverage must be in the amounts required as a minimum by state law, and/or as noted in the Provider Agreements. Physicians may issue a Financial Responsibility Statement in lieu of the PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 21

22 DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA malpractice coverage; these will be reviewed, on a case-by-base basis by the Credentialing Committee. Psychcare verifies the malpractice history of all providers via the NPDB (National Practitioner Data Bank). Additionally, Psychcare verifies the malpractice history for all doctorate and master s level providers, in writing, from their malpractice carriers, because the NPDB (National Practitioner Data Bank) does not necessarily contain information on providers at this level. However, if a response is not received prior to the required credentialing date, the file will be presented to the Credentialing Committee, using only the NPDB (National Practitioner Data Bank) information. If the claims history from the carrier reveals negative findings upon receipt, the provider will be asked to file an explanation. The contract will be held until the carrier s and the provider s responses are received. The Credentialing Committee will be given the findings for review. 9. Clinical Privileges (Physicians only) 10. Lack of present illegal drug use and/or felony convictions 11. Cultural, ethnic, and linguistic needs Physicians will attest to the absence or presence of a history of loss or limitation of privileges or disciplinary activity in their credentialing applications. Current clinical privileges will be listed and will be primary source verified. All providers will attest either to (1) the absence or presence of present illegal drug use and/or (2) felony convictions, in their credentialing applications. Cultural, ethnic, and linguistic needs are considered for each application presented, to assist in meeting the needs of all members. Federal, State, and Accreditation Standards Credentialing is conducted according to federal, state, and NCQA accreditation standards. Policies and procedures in credentialing are updated at least annually, or more often, if modifications become necessary during the year. Time Frame for Completion of Credentialing Process All credentialing files (initial and recredentialing), will be completed at least one hundred eighty (180) days prior to the presentation of the provider s file to the Credentialing Committee. The timeframe for completion is typically days from receipt of the application. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 22