Anthem Path2Health / County Medical Services Program (CMSP) Non-Clinic Training. December 2011

Transcription

1 Anthem Path2Health / County Medical Services Program (CMSP) Non-Clinic Training December 2011

2 Welcome! Anthem Blue Cross thanks you for the time, commitment and dedication with which you serve the Path2Health / County Medical Services Program (CMSP) The goal of today s presentation is to share how we support your efforts to help your patients and our members to achieve better health outcomes and close gaps in behavioral health care We will be taking your questions through the use of the Q & A feature on the upper left portion of the toolbar. Please type your question and click the Ask box. We will break after the contracting section for contracting questions and again at the end for all other questions. Thanks so much! 2 2

3 Today s Topics Overview of Path2Health / Training Opportunities Provider Contracting An Innovative Solution for Path2Health / CMSP Members Integration of Care Covered Benefits through Anthem Covered Benefits through Path2Health / CMSP Members Excluded Benefits Behavioral Health Program Behavioral Health Benefits Behavioral Health Prior-Authorization Processes Anthem / Provider / Member Responsibilities Provider Resources Claim Filing Guidelines Grievances and Appeals Contact Information Questions and Answers 3 3

4 Background Low Income Health Program (LIHP) is created in California s Section 1115 Medicaid Demonstration Waiver. New 1115 Waiver seeks to leverage county-based coverage as a bridge to federal health reform. Waiver allows for a 50% federal match on county healthcare expenditures for LIHP eligible population. CMSP s program, Path2Health, will start January 1, All 34 CMSP counties will participate in Path2Health. 4

5 1) Alpine 2) Amador 3) Butte 4) Calaveras 5) Colusa 6) Del Norte 7) El Dorado 8) Glenn 9) Humboldt 10) Imperial 11) Inyo 12) Kings 13) Lake 14) Lassen 15) Madera 16) Marin 17) Mariposa 18) Mendocino 19) Modoc 20) Mono 21) Napa 22) Nevada 23) Plumas 24) San Benito 25) Shasta 26) Sierra 27) Siskiyou 28) Solano 29) Sonoma 30) Sutter 31) Tehama 32) Trinity 33) Tuolumne 34) Yuba

6 Background (continued) Path2Health will operate as a separate product under a time-limited pilot project in tandem with a residual CMSP program. Existing infrastructure will be utilized: CMSP eligibility infrastructure (through counties) Benefit administration infrastructure (through Anthem Blue Cross and MedImpact) Path2Health will not generate additional costs to CMSP counties in excess of their existing contributions to CMSP. Expanded benefit package to include mental health and substance abuse counseling 6

7 Background (continued) CMSP & Path2Health are structured uniquely and different than: Medi-Cal Fee for Service Medi-Cal Mental Health Drug Medi-Cal Anthem Blue Cross Commercial Plans 7 7

8 Additional Training Opportunities County Eligibility Trainings Path2Health Provider Trainings DentaQuest Clinic Dental Trainings For flyers & registration information, visit: 8

9 Behavioral Health Practitioners Contracting Practitioners must sign a new contract agreement New Behavioral Health benefits for Path2Health and CMSP will be effective 01/01/2012 These are new benefits are in addition to the current psychiatrist benefits which do not require prior authorization. Practitioner is fully licensed psychologist, clinical social worker, Marriage family therapist or Certified Substance Abuse Counselor. 9 9

10 Provider Contracting Practitioners/Clinics interested in joining PATH2HEALTH/CMSP or contracting questions can send an request to Rudolph Morales with Anthem Blue Cross: Contact Number for Inquiries: You may also submit your request via facsimile at

11 Behavioral Health Practitioners Billing Individual practitioners bill on a professional claim form CMS-1500 or electronic billing. Claim filing limit for Behavioral Health Benefit is 150 days. Reimbursement for each Medical Service rendered under this Agreement shall be at the lesser of PRACTITIONER s charge for such Medical Service or at the allowable unit amount. This reimbursement is subject for procedure codes identified below

12 Behavioral Health Practitioner Fee Schedule Procedure Codes Allowable $ $ $ $ $30.00 H0001 $90.00 H0004 $17.50 (2 unit minimum and 4 unit maximum) H0005 $

13 An Innovative Solution for Path2Health / CMSP Members Connecting everyone involved to help California members improve health outcomes Strive to develop strong collaborative relationships with our providers Care Management /Case Management programs to promote better health Members Anthem Providers Path2Health / CMSP Develop best practices 13 13

14 Program Objectives Our Objectives Making a difference in the lives of our California members Create health care efficiencies for Path2Health / CMSP members Implement a fully integrated quality-based managed care program Provide timely access to high quality healthcare Significantly improve quality of care Obtain innovative, results-oriented quality outcomes Provide care that promotes overall health and day to day functioning Our Goals Make fundamental differences in member health outcomes Integrate provider relationships Enhance care coordination Provide service excellence 14 14

15 Integration of Care for Member s Better Health Strive to develop strong collaborative relationships with our providers Providers are one of the most powerful forces in influencing our members care and health Our providers are team members, not vendors Develop best practices Provide comprehensive care for members Preventive Acute Chronic Case Management programs to promote better health Proactive Intervention Medical Management and Coordination Increase health literacy Help members overcome social and other barriers to seeking care 15 15

16 Why Integration? Integration is a vital part of Path2Health / CMSP Integration and Coordination of Care: Insures member health needs are addressed throughout all levels and types of care; Allows for the expeditious referral of members into one or more of the case management / condition care programs designed specifically for their needs; Prevents both under and over utilization of services; Mitigates multiple services / medications which are contraindicated; Assures the holistic treatment of each member 16 16

17 Benefits Covered by Path2Health / CMSP Acute inpatient hospital care Adult Day Health Care Dental services Emergency and non-emergent medical transportation Home Health Agency services Hospital outpatient and outpatient clinic services Laboratory and radiology services Medical supplies dispensed by physicians, licensed pharmacies, or durable medical equipment dealers and prosthetic or orthotic providers and durable medical equipment Optometry services Outpatient audiology services and hearing aids Outpatient heroin detoxification services (does not include methadone maintenance) No authorization needed until after 24 visits for in-network providers Outpatient occupational and physical therapy services Outpatient rehabilitation services in a rehabilitation facility Outpatient speech pathology services Prescription Medications Physician services Podiatry services Prosthetic and orthotic appliances Psychiatric services provided by a licensed psychiatrist 17 17

18 Behavioral Health Programs and Philosophy Tiered Case Management Program Tier I - Call Center and Outreach calls to members Tier II -Increased level of interaction with the member to assist with referral to provider or level of care and problem-solving with the member for any obstacles to receiving care, treatment, or ambulatory care follow-up services Tier III - Intensive Case Management offers interventions on an ongoing or episodic basis for members who have complex situations due to high risk, co-morbid medical and behavioral conditions placing the member in need of intensive support and treatment, and inpatient admissions for mental health or substance abuse 18 18

19 Behavioral Health Programs and Philosophy Case Management programs to promote better health Proactive Intervention Medical Management and Coordination Increase health literacy Help members overcome social and other barriers to seeking care Collaborating with Providers and Community 19 19

20 Behavioral Health and Medical Integration Provide a continuum of care management from initial contact to coordination of care and interventions Care Managers within the Utilization Management department support Behavioral Health Services They share the same medical information system Medical case managers refer members to behavioral health for coordination of care within our tiered Case Management Program An innovative and integrated approach with medical exists for those members with both behavioral health and medical problems as well as members with substance abuse difficulties 20 20

21 Behavioral Health and Medical Integration Behavioral Health case managers work closely with PCPs, specialists, behavioral health providers, members, and community resources to: Provide additional education and training for both behavioral health and primary care clinicians to enhance their knowledge and skills needed to provide integrated services Communicate directly with the PCP when any significant events occur in a member s treatment, i.e. hospitalization, emergency services, etc. for integrated care plan development Provide the PCP with the behavioral health notification form which includes significant findings from the initial assessment, medications prescribed, primary diagnosis, and other relevant information Assist the member in securing necessary community support Educate members and their family on services available within their community Encourage member and primary care provider (PCP) interaction 21 21

22 Behavioral Health Case Management Program Members may have behavioral health needs beyond the scope of the Care Management Programs and are eligible for the Behavioral Health Case Management Program The behavioral health care manager will work closely with the Clinical Team which includes the Medical Management Team, Primary Care Provider, and Behavioral Health Service Provider even if the member has exhausted their mental health / substance abuse benefit providing the member consents to this communication Based on the Tiered Case Management Format The Clinical Team will conduct clinical staffing as needed to develop treatment/care plans, develop community resources, and engage the member in treatment Members can and will move to the various tier levels based upon need 22 22

23 Mental Health / Substance Abuse Benefits Path2Health / CMSP Covers Outpatient Behavioral Health Treatment Services Effective 1/1/2012 This new benefit is separate from the current psychiatric benefit allowing services provided by a licensed psychiatrist with no authorization The new outpatient behavioral health treatment services benefit DOES NOT allow services to be provided by the following provider types: Licensed Psychiatric Nurses Licensed Registered Nurses Licensed Psychiatric Technicians Interim or Practicum Staff 23 23

24 Mental Health / Substance Abuse Benefits Mental Health (Per Calendar Year): One assessment (90801 or H0001) Up to 10 individual or group counseling sessions based on Medical Necessity (authorization is required) Group counseling sessions shall not exceed the ratio of eight patients per therapist or 10 patients per two therapists Eligible CPT / HCPC Codes are: H0004 (2, 3, or 4 units = 1 session) H0005 Allowed Provider Types: Licensed Psychologists, Licensed Clinical Social Workers (LCSW), Licensed Marriage /Family Therapists (LMFT) and Licensed Professional Clinical Counselors (LPCC), Certified Substance Abuse Counselors *Clinics (FQHC, RHC, THP) are not eligible to bill for the substance abuse group counseling sessions 24 24

25 Mental Health / Substance Abuse Benefits Substance Abuse (Per Calendar Year): One assessment (90801/ H0001) Two individual counseling sessions based on Medical Necessity (authorization is required) Eligible CPT / HCPC Codes are: H0004 (2, 3, or 4 units = 1 session) Up to 20 therapeutic group counseling sessions based on Medical Necessity based on Medical Necessity (authorization is required) Group counseling sessions shall not exceed the ratio of eight patients per therapist or 10 patients per two therapists Eligible CPT / HCPC Codes are: H0005 Allowed Provider Types: Licensed Psychologists, Licensed Clinical Social Workers (LCSW), Licensed Marriage /Family Therapists (LMFT) and Licensed Professional Clinical Counselors (LPCC), Certified Substance Abuse Counselors *Clinics (FQHC, RHC, THP) are not eligible to bill for the substance abuse group counseling sessions

26 Mental Health and Substance Abuse Covered Procedure Codes Procedure Code Description Diagnostic Psychological Assessment (may also be billed with substance abuse diagnosis) Individual Therapy, minutes Individual Therapy, minutes Group Therapy Other Interactive Group Therapy H0001 Alcohol and/or Drug Assessment [review like 90801] H0004 Behavioral Health Counseling and Therapy, per 15 minutes (all modifiers) 2,3, or 4 units = 1 session H0005 Alcohol and/or Drug Services; GROUP counseling by Clinician 26 26

27 Mental Health / Substance Abuse Benefits Inpatient Mental Health Treatment is authorized by the County Mental Health Plan and NOT Anthem. Path2Health / CMSP Covered Mental Health / Substance Abuse Diagnosis All major behavioral health diagnosis as listed in the DSM IV with the exception of the following range of codes: (except for initial assessment)

28 Behavioral Health Prior Authorization Prior authorization is not required for the first diagnostic interview session. Providers are strongly encouraged; however, to contact the behavioral health unit to determine if the diagnostic interview service is still available. The Behavioral Health Treatment Data Sharing Form is required within five calendar days of the initial assessment for non-risk members or within 24 hours for high risk members. The information which will be provided includes, but is not limited to: Significant findings from the initial assessment Primary and secondary diagnoses Medication(s) prescribed to the member Psychotherapy prescribed Any other relevant information The Behavioral Health Treatment Data Sharing Form is an easy to complete one page document which allows Anthem to better coordinate care and more effectively track the use of the initial assessment codes; therefore, time is really of the essence. The form itself should not require more than 20 to 25 minutes to complete. Continuation of services beyond the initial assessment protocol will require prior authorization. Prior authorization may be obtained by submitting the Outpatient Treatment Request form (OTR) via facsimile to Prior authorization for Emergency Services is not required; however, please notify Anthem within 24 hours of service 28 28

29 Behavioral Health Prior Authorization (Continued) Outpatient Treatment Request Form (OTR) Providers may list their P.O. Box on the form for mailing purposes. Please provide your telephone number as well in the event we would need to contact you. Anthem can return authorizations via facsimile if this is the provider s preference. Providers should list their facsimile number on the form with a note to return authorizations in this manner. Given the benefit available to the membership, Anthem is required to manage the care in the most responsible manner as possible in the event a client needs to be treated for more than one episode of care throughout the calendar year. It is for this reason we will not be authorizing the maximum visits allowed for the year at one time. Retrospective Enrollment If a member is retrospectively enrolled into Path2Health / CMSP and has been seeing a provider for services, please contact Anthem s Behavioral Health Unit immediately. If the provider was contracted for Path2Health / CMSP at the time of service, Anthem will grant an authorization for one or H0001 and two treatment sessions in this instance if there are remaining benefits

30 Provider Responsibilities Communicate and Coordinate Care with the member s PCP or other treating provider Encourage members to consent to the sharing of substance abuse treatment information Deliver services in a cultural sensitive manner Make appointments available to members consistent with their needs (emergent, urgent, routine care) Make a follow-up appointment available to all members within seven days of discharge from an Inpatient facility Seek authorization for all covered services Not Balance Bill the member for covered services 30 30

31 Member Rights / Responsibilities The right to be treated with respect and with due consideration for his or her dignity and privacy The right to receive information on available treatment options and alternatives, presented in a manner appropriate to his or her condition and ability to understand The right to participate in decisions regarding his or her health care, including the right to refuse treatment The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion The right to request and receive a copy of his or her medical records, and request that they be amended or corrected 31 31

32 Clinical Practice Guidelines/ On-line Training Materials / Medical Necessity Criteria Provider Resources Available On-Line at Path: ed%20business&rootlevel=2 Cultural Competency Co-Existing Disorders Anthem s Medical Necessity Guidelines Behavioral Health Clinical Guidelines Identification and Treatment of Adult Depressive Disorder Identification and Treatment of Antenatal Depression and Postpartum Depression and Postpartum Psychosis Identification and Treatment of Substance Use Disorders Preferred Practice Guidelines for the Evaluation and Treatment of Children with Attention Deficit/Hyperactivity Disorder Preferred Practice Guidelines for the Treatment of Bipolar Disorder 32 32

33 Claim Filing Guidelines For Behavioral Health Timely Filing: Professional Behavioral Health Claims: 150 days Billing Guidelines: It is important that you bill with the NPI number registered with the State of California or your claim will not be paid For information about registering your NPI with the State of California please see their website at: NPI / Taxonomy: Your NPI and Taxonomy number are required on all claims 33 33

34 Claim Filing Guidelines CLAIM ADDRESS: Attn: Claims Anthem Blue Cross P.O. Box Los Angeles, CA Providers may file claims via paper or electronically To file electronically contact Anthem at to: Learn how to get connected List of approved clearinghouses Submit Directly if system compatible Technical Assistance COB claims must include third party remittance advice and the third party letter explaining denial or reimbursement Electronic Funds Transfer (EFT) is available You may monitor the status of a claim on the provider website or through interactive voice response (IVR) at If you have questions about a claim, you may contact customer service at

35 Grievances and Appeals Path2Health / CMSP Grievances and Appeals should be mailed to the address below: Attn: Grievance and Appeals Department Anthem Blue Cross P.O. Box Los Angeles, CA You may also submit your grievances and appeals via facsimile at utilizing the provider form located at

36 Grievances and Appeals Timeframes for filing for your grievance and appeals are: Grievances: 60 calendar days calendar days from the receipt date of Anthem s correspondence or incident Appeals: 60 calendar days from the receipt date of Anthem s correspondence Contact Numbers for Inquiries: Facsimile:

37 Key Contacts for Behavioral Health Joe Garten, Ph.D. Director of Behavioral Health State Sponsored Business Keith Isenberg, MD Behavioral Health Medical Director Letitia Jackson, MS., EdS, LMHC Manager of Utilization/Care Management Behavioral Health / State Sponsored Business Christina Hurt, LCSW Provider Support Manager Prior Authorizations: Path2Health / CMSP: Facsimile (Data Sharing Form / OTR):

38 Important Numbers and Resources Anthem Provider Resources available at Anthem Provider Manual Clinical Practice Guidelines and Medical Necessity Criteria Member Eligibility Forms and Tools Path2Health Web Site: CMSP Web Site:

39 Thank you! Anthem Blue Cross appreciates the care and commitment with which you serve Path2Health / CMSP members! Do you have questions about today s presentation? Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association 39 39