NEW DIRECTIONS MANAGED BEHAVIORAL HEALTH PROVIDER AND FACILITY MANUAL

Transcription

1 NEW DIRECTIONS MANAGED BEHAVIORAL HEALTH PROVIDER AND FACILITY MANUAL 2014 PO BOX 6729 Leawood, KS

2 Table of Contents Table of Contents... 2 Preface... 4 About New Directions... 5 Communication... 6 Policies and Procedures... 7 Focus Areas Quality of Care and Member Safety... 7 Shared Information... 9 Information Changes... 9 Provider/Facility Update Form Privacy Policy and Privacy Practices Fraud and Abuse Excluded Persons Compliance Program Credentialing Criteria Provider WebPass HIPAA Information Provider Accessibility Availability Standards Management of Benefits Medical Necessity Criteria Quality Improvement, Utilization Management and Case Management Programs Request for Psychological/Neuropsychological Testing Billing Assistance Common Billable CPT and Revenue Codes Completing the CMS (HCFA) 1500 Claim Form Statement of Rights and Responsibilities of Providers Statement of Rights and Responsibilities for Members and Clients Commercial Member and Provider Denial and Appeal Rights Coordination of Care with Primary Care Physicians Clinical Guidelines Page 2

3 Blue Cross Blue Shield of Alabama Arkansas Blue Cross Blue Shield (ABCBS) HMO & PPO (Including Health Advantage).. 53 Arkansas Blue Cross Blue Shield (ABCBS) Federal Employee Program (FEP) Walmart through Arkansas Blue Cross Blue Shield (ABCBS)/Blue Advantage Administrators (BAA) Florida Blue PPO including Medicare Advantage Florida Blue HMO including Medicare Advantage Florida Blue Federal Employee Program (FEP) Blue Cross Blue Shield of Kansas (BCBSKS) PPO Blue Cross Blue Shield of Kansas (BCBSKS) Federal Employee Program (FEP) Blue Cross Blue Shield of Kansas City (Blue KC) Blue Care HMO Blue Cross Blue Shield of Kansas City (Blue KC) Preferred Care & Preferred Care Blue PPO Blue Cross Blue Shield of Kansas City (Blue KC) Federal Employee Program (FEP) Appendix for Employer groups contracted with New Directions Archer Daniels Midland (ADM) Ball s Food Cerner HCA Page 3

4 Preface New Directions Behavioral Health takes pride in the collaborative relationships developed with Network Providers and Facilities. Our Members and your patients/clients gain as a result of this collaboration. New Directions encourages Providers and Facilities to give us feedback about programs, policies and processes. Please consider this Provider and Facility Manual (Manual) as a general guide to programs, policies and processes. When updates to the Manual are made, New Directions makes every effort to communicate them to Providers and Facilities through , fax, our website, and our quarterly Provider Newsletter. The current version of the Manual is available on our website at New Directions offers Continuing Education (CEU) Workshops for Providers and Facilities. New information or changes may also be communicated at those events. Providers and Facilities are encouraged to contact the Network Operations (Provider Relations) department at for explanation and clarification. Page 4

5 About New Directions Since incorporation as a limited liability company in 1995, New Directions Behavioral Health (New Directions) has become a leading managed behavioral health care organization (MBHO), with national accreditations and recognition from Blue and non Blue organizations. In addition to MBHO services, New Directions provides Employee Assistance Programs (EAP) and health coaching. Behavioral health benefits are managed by New Directions to ensure that members have timely access to the most appropriate services in the least restrictive setting as medically necessary. We coordinate care among the member s primary care physician, psychiatrist, behavioral health therapist, and community resources, among others. Our close relationship with health plans has led to an unparalleled integration of behavioral health and medical service. Integration includes case finding, co case management, and work flows that encompass case and disease management, joint access to technology and data, shared planning relative to pharmacy, quality improvement and network operations. New Directions unique and effective population management paradigm, based upon a philosophy of proactive Member outreach, has led to consistently high satisfaction rates from Members, Providers and account surveys. New Directions has built a national reputation for innovative services focused on patient safety. In addition to recognition and awards from URAC, NCQA, and the Blue Association, New Directions has received honors for its Paradigm for the Telephonic Assessment of Suicide Program from URAC in the category, Best Practices in Health Care Consumer Empowerment Protection. New Directions has URAC accreditation for Utilization Management and Case Management, and full accreditation from NCQA (National Committee on Quality Assurance) as a Managed Behavioral Health Organization. Our clinical operations follow the standards set by these nationally recognized organizations, as well as state and federal laws. Providers and Members give New Directions high marks. The most recent surveys reflect satisfaction rates above 90%! Our reputation for quality and service is grounded in a philosophy of collaboration with the behavioral and medical providers caring for our Members. Page 5

6 Communication New Directions updates the Manual annually and as needed. The updated version is available online at Throughout the year, we convey policy changes and other pertinent information to Providers and Facilities through: Newsletters Broadcast s Office Manager Meetings Website at Educational workshops Contacting New Directions To contact our New Directions Service Center for utilization management, case management, case consultation, or administrative questions regarding eligibility, benefits and claims, please refer to health and group Plan specific information in the Appendix at the end of this Manual. Website New Directions provides detailed and easy to use information about many programs and services at Updates occur frequently to provide current information about behavioral health care and services. The Website includes the following: Most recent version of the Manual Sample Documentation Forms New Directions Medical Necessity Criteria for authorization of payment determinations Clinical Practice Guidelines for Adult Depression, Attention Deficient Hyperactivity Disorder (AD/HD) for Children/Adolescents, and Adult Substance Abuse Initial Assessment Provider WebPass (User name and password is needed) o Eligibility information for many New Directions contracts o Outpatient Quality Review Forms o Benefit information for many New Directions contracts Notice of Privacy Practices for New Directions Member Rights and Responsibilities Information about our Quality and Case Management programs Educational Materials that includes Guidebooks for ADHD, Depression, Bipolar Disorder, and Substance Abuse An Autism Resource Center for parents of a child with an autism spectrum disorder An Alcohol Resource Center to assist Members and families struggling with alcohol misuse or dependency Page 6

7 The Website also includes a Provider Search feature, allowing our Members to locate Providers by name, location, or specialization. A description of our Quality Improvement activities, results of Member Satisfaction Surveys, reports of access and appointment availability, and results and information about our Case Management Programs are reported in the Health Plan Member Section. These materials are also available in print upon request. Policies and Procedures Pursuant to the terms of the Provider/Facility Agreement, Providers and Facilities must comply with New Directions policies and this Manual. Certain policies may apply to only a designated line of business or type of benefit Plan or government sponsored health benefit program. You may find select policies and procedures at To obtain a written copy of New Directions policies and procedures, call us at Focus Areas Quality of Care and Member Safety Continuity and Coordination of Care and communication among Providers and primary care physicians (PCP) are important to promote effective and comprehensive care. HIPAA allows communication among health care providers without authorization. Clinical Peer Reviewers are available 24/7 to review and discuss clinical issues and concerns. You may contact a peer reviewer through the New Directions call center. It is not necessary for a claim to reach the formal denial or appeal process for such a dialogue to take place. Member Safety is monitored through various contact points between New Directions and Members. Providers will be contacted by New Directions when a safety concern, such as medication overdose or suicide attempt, is identified. This will allow the provider to coordinate appropriate care for the member, related to the concern. Medication Safety New Directions staff checks for medication discrepancies at critical points of transition and through ongoing case management. When members participate in our case management program, we fax a list of the medications reported by the Member or from facility discharge orders to their prescribing physicians. New Directions staff checks for medication discrepancies at critical points of transition and through ongoing case management. When a discrepancy is identified, a list of the medications reported by the Member or from facility discharge orders is faxed to the prescribing physicians. This enables the prescribing physician to review the medication list in order to identify and reconcile any discrepancies. Page 7

8 Medication Overdose Whenever possible, if a Member is hospitalized for a suicide attempt by overdosing with prescribed medications, New Directions Care Managers will notify the prescribing physician. This gives the physician greater knowledge of his/her patient s situation so a determination can be made whether a change in prescription is needed. Depression Severity Members with a Depression diagnosis or symptomology who are participating in New Directions Case Management program are screened routinely using the PHQ 9 screening tool. When a Member scores a 10 or above on the tool, we notify their Providers so treatment options or changes may be considered. Performance Measures collected by HEDIS (Health Care Effectiveness Data and Information Set) are tools used to gauge performance on important dimensions of care and service. The following measures, monitored by New Directions, involve Providers implementation of best practices in managing their patients behavioral health care. Antidepressant Medication Management Members, 18 years and older with a diagnosis of major depression and have been treated with antidepressant medication, are monitored for their continuation on the medication at 84 days (acute phase) and 180 days (continuation phase). Follow Up Care for Children Prescribed ADHD Medication Children, newly prescribed ADHD medication are monitored for completion of at least 3 follow up care visits within a 10 month period, one of which was within 30 days of when the first ADHD medication was dispensed and continuation on the medication prescribed. Follow Up after Hospitalization for Mental Illness Members, 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses, are monitored for completion of an outpatient visit, intensive outpatient encounter or partial hospitalization encounter within 7 days and 30 days of discharge. Diabetes Monitoring for People on Atypical Antipsychotics Members who were dispensed an antipsychotic medication are monitored for a diabetes screening test completed within the past 12 months. Page 8

9 Shared Information Geographical availability and access to appointments are measured at least annually, and the results shared with Providers. Member and Provider Satisfaction Surveys are conducted annually and the results shared with Providers. Preventive Health Programs are critical to Members. If you have Members you believe would benefit from these Programs, please contact us. Thorough treatment record documentation forms can be downloaded from our Website and may be customized to suit your specific needs. Website ( includes information such as Medical Necessity Criteria, Clinical Practice Guidelines, and New Directions Notice of Privacy Practices. Eligibility and benefit information is available online through WebPass. Information Changes To avoid a delay in reimbursement for submitted claims, you must notify New Directions 45 days prior to any change to your demographic or practice information, including: Primary practice location Billing address location Phone/Fax/ changes Name changes Social Security Number (SSN) or Tax Identification Number (TIN) National Provider Identifier (NPI) Practice panel status (open/closed) Provider status with group/facility Page 9

10 Provider/Facility Update Form Please note: This form must be accompanied by a W 9. Fields marked with an asterisk (*) are essential. *Name: Address: *Individual NPI: *Blue Number: *Organizational NPI: *Taxonomy Code: I am currently seeing members at the following location(s): *Street: *City/ST: Phone: Fax: *TIN: *Street: *City/ST: Phone: Fax: *TIN: *STE: *ZIP: *STE: *ZIP: The billing location(s) I currently utilize: *Street: *City/ST: Phone: Fax: *TIN: *Street: *City/ST: Phone: Fax: *TIN: *STE: *ZIP: *STE: *ZIP: Remove the following location(s) from my profile: *Street: *City/ST: Phone: Fax: *TIN: *Street: *City/ST: Phone: Fax: *TIN: *STE: *ZIP: *STE: *ZIP: Please return this form by fax ( ) or ([email protected]). Please note: This form must be accompanied by a W 9. Page 10

11 Privacy Policy and Privacy Practices Please refer to the Notice of Privacy Practices found at This notice explains how personal information and protected health information are collected, used and disclosed to third parties. New Directions has implemented security measures to prevent the unauthorized release or access to personal information. The confidentiality of any communication transmitted to or from New Directions via unsecured cannot be guaranteed. When a visitor performs a search on New Directions may record information identifying the visitor and/or linking the visitor to the search performed. New Directions may also record limited information for every search request and use that information only to solve technical problems with the service and to calculate overall usage statistics. Fraud and Abuse New Directions Policy New Directions is committed to preventing, identifying, investigating and reporting fraud and abuse. The Compliance Program provides education on what types of activities constitute fraud and abuse. New Directions regularly monitors and audits claims, and reports cases of fraud and/or abuse to the appropriate entity or governmental agency. New Directions expects its Providers and Facilities to comply with all applicable state and federal laws pertaining to fraud and abuse. Definitions Fraud means a deception or misrepresentation made by an entity or person that results in an unauthorized benefit or payment. Fraudulent insurance act means any oral or written statement submitted for payment, or other benefit pursuant to an insurance policy, when the person knows the statement contains materially false information or conceals a material fact. Abuse means practices that are inconsistent with sound fiscal, business, or health care practices and result in an unnecessary cost to a health care benefit program. Abuse may also mean reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Examples of fraud and abuse include: Billing for services or procedures that have not been provided Submitting false information about services performed Up coding services provided Making a false statement or misrepresenting a material fact in any application for any benefit or payment Page 11

12 Presenting a claim for services when the individual who furnished the service was not appropriately licensed Failing to return an overpayment within 60 days after the later of either the date on which the overpayment was identified or the date any corresponding cost report was due Providing or ordering medically unnecessary services or tests Excluded Persons Providers and Facilities who participate in Federal or State funded health care programs must determine whether their employees and contractors are excluded from participating in such programs. It is considered fraud for a Provider or Facility that has been excluded from a Federal or State funded program, to submit a claim for services. The Department of Health and Human Services (HHS), through the Office of Inspector General (OIG), maintains the List of Excluded Individuals/Entities (LEIE). This List may be accessed online at Providers and Facilities are required to search this website at least monthly. Compliance Program New Directions encourages Providers and Facilities to create a compliance program in order to proactively prevent the submission of incorrect claims and combat fraudulent conduct. Internal controls efficiently monitor adherence to applicable laws and Plan requirements. The OIG has developed compliance program guidance for individual and small group health care practices (Federal Register, Vol. 65, p , Oct. 5, Providers may also obtain guidance from other compliance programs on the OIG website at Reporting New Directions maintains a Compliance Reporting Line for anonymous reporting of suspected fraud or abuse. To report suspected fraud or abuse, please call An or letter can also be sent to [email protected] or Ethics and Compliance, P.O. Box 6729, Leawood, KS, New Directions will not retaliate against any person who, in good faith, reports suspected fraud or abuse to New Directions, the federal or state governments, or any other regulatory agency. Audits New Directions performs random audits of Provider and Facility claims and medical records to identify fraudulent billing practices. Other entities also conduct audits. No specific intent to defraud is required to find that a violation of a law occurred. The OIG has developed A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse, which is an excellent resource on fraud and abuse ( education/index.asp). Page 12

13 New Directions expects its providers and facilities will fully cooperate and participate with all audit requests. This includes, but is not limited to, allowing New Directions access to member treatment records and progress notes, and permitting New Directions to conduct on site audits or reviews. Some of the most common fraud and abuse practices include: Claims for services not rendered Up coding services Excessive use of units Add on codes billed without primary CPT Diagnosis and/or procedure code not consistent with the member s age/gender Use of exclusion codes Misuse of Benefits Unbundling of codes Credentialing Criteria New Directions credentials and re credentials Providers and Facilities in compliance with NCQA accreditation standards and applicable state and federal laws. Decisions regarding credentialing and recredentialing are made by the New Directions Credentialing Committee. Minimum criteria for consideration as a Provider in the New Directions Network include: Be licensed for independent practice Practice a minimum of fifteen hours per week Maintain acceptable level of professional liability insurance (preferred coverage is $1,000,000 occurrence/$3,000,000 aggregate but may vary according to State law or Plan requirements) Have at least five years experience, post masters Have an address and access to the internet Have 24 hour coverage Site Visits As part of the credentialing or re credentialing process, New Directions may conduct a structured site visit of offices/locations. Site visits include an evaluation using the New Directions site visit standards and New Directions clinical recordkeeping standards. Any site visit will be arranged in advance. The New Directions site visit tool is available on our website ( under the Provider section. New Directions clinical recordkeeping standards are found in this manual and on our website. Page 13

14 Provider WebPass Provider WebPass WebPass is available for the convenience of Providers, Office Administrators and Facilities. You will find membership eligibility and Plan benefits at in the Provider WebPass section. If you do not have a user name and password to enter this area of the website, please complete the Access Request Form, which can be located in this Manual (page 15) or on You may also contact us by at [email protected]. Please remember that the Internet is not secure. Protected health information should not be communicated by . Getting Started with WebPass To access the New Directions WebPass system you will need to obtain an Identification number and password. Complete the Provider WebPass Access Request Form and Agreement on the following page and fax it to Let Us Know How the System Works If you experience problems with obtaining timely eligibility and benefits information, please contact us toll free at or by at [email protected]. Page 14

15 Provider WebPass Access Request Form and Agreement Page 15

16 HIPAA Information NOTICE OF PRIVACY PRACTICES Effective September 23, 2013 Updated September 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS INFORMATION CAREFULLY. New Directions Behavioral Health (New Directions) cares deeply about your privacy and strives to promote an environment that keeps your protected health information (PHI) as secure as possible. PHI is health and nonpublic personal financial information that can reasonably be used to identify you, and that we maintain in the normal course of administering member services and benefits. Some examples of PHI are: name, address, Social Security Number, information about medical procedures and diagnoses, and payments made for health care provided by you. New Directions is required by federal and state laws to maintain the privacy of your PHI. We are also required to provide you with this Notice which describes our privacy practices, our legal duties, and your rights concerning your PHI. New Directions is required to follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make any change in our privacy practices and the new terms of our Notice applicable to all medical information we maintain, including medical information we obtained prior to making the change. Should a significant change be made to our privacy practices, New Directions will change this Notice and alert members to the change. Uses and Disclosure of Your Protected Health Information (PHI) New Directions may disclose your PHI in connection with your treatment, the payment of your health care, and our health care operations. New directions will limit such disclosures, to the extent practicable, to the minimum amount of PHI necessary to accomplish the intended purpose of such use. New Directions may use or disclose your PHI: As Permitted by Law: We may use or disclose your PHI when permitted to do so by law. For Treatment: We may disclose your medical information and other PHI to a physician or other health care provider in the course of treatment. Page 16

17 For Payment: We may use and disclose PHI to manage your account or benefits, to determine your eligibility for benefits, to coordinate your benefits with payers, to determine the medical necessity of care delivered to you, to issue explanations of benefits to the subscriber of the health plan in which you participate, to obtain funds for services rendered, and other similar activities. We may disclose your PHI to other providers or other plans to obtain payments or to engage in other payment activities. For Health Care Operations: We may use and disclose PHI for our health care operations and to support business activities. For example, we may use or disclose your PHI to conduct quality assessment and improvement activities; to authorize Business Associates to perform tasks on behalf of New Directions; to conduct fraud and abuse investigations; renewal and replacement negotiation of health insurance coverage for procedures and conditions; in business planning, development, management, and general administration, including customer service and grievance resolution; in member data aggregation and research; and to obtain legal services and conduct internal audits. We may disclose PHI to another health plan or provider as long as that entity has or had a relationship with you and the PHI is for that entity s health care quality assessment and improvement activities, fraud and abuse detection and prevention, or competence and qualification evaluation and review. New Directions will not use your genetic information for underwriting purposes. To You: You may give New Directions written authorization to use your PHI or to disclose it to anyone for any purpose. You may at any time after such authorization revoke the authorization in writing. New Directions maintains psychotherapy notes. If we have psychotherapy notes about you, most disclosures of these notes require your authorization. Also, to the extent that we utilize or disclose your information for fundraising practices and activities, we will provide you with the ability to opt out of future fundraising communications. Most uses and disclosures of medical information for marketing purposes, and disclosures that constitute a sale of PHI, require your written authorization. Unless you provide written authorization we cannot use or disclose your PHI for any reason except those provided in this Notice. To Family, Friends, or Others Involved in Your Care: You may authorize New Directions to disclose your information to others. We may disclose your PHI to a family member, friend, or any other person you involve in your health care, only to the extent that the information is relevant to their involvement. We may use or disclose your name, location, and condition to notify, or to assist an appropriate public or private entity to locate and notify a person responsible for your care in the case of an emergency, a natural disaster, or other appropriate situation. You will be provided an opportunity to object to such disclosures, unless you are not present, incapacitated, or in a disaster relief situation. New Directions will exercise professional judgment to determine the appropriateness of such a disclosure. To Business Associates: New Directions contracts with 3rd party entities to conduct business functions for New Directions that we are either incapable of doing due to organizational constraints, or the contracted entity can conduct the business function more efficiently. These contracted entities are deemed Business Associates. New Directions may allow Business Associates to create, maintain, Page 17

18 receive, transmit, and re disclose to subcontractors your PHI. All of New Directions Business Associates are contractually obligated to protect the privacy and integrity of your PHI. For Public Safety: We may disclose your PHI for the betterment of public health. For example PHI may be disclosed: for the report of child and adult abuse, neglect, or domestic violence to appropriate authorities; to avert a serious imminent threat to health or safety of the public; to law enforcement officials with regard to crime victims, criminal activities, the apprehension of a dangerous individual, or regarding persons already in lawful custody; to the military, federal officials, counterintelligence and counter terrorism agents, in regard to domestic security activates; to coroners, medical examiners, funeral directors, and organ donation and procurement services; and in accordance with workers compensation laws and regulations. For Judicial, Administrative, and Regulatory Process: New Directions may disclose your PHI in response to a court or administrative order or decree, discovery request, subpoena, legislative mandate, or other similar official process. We may disclose PHI to a government agency authorized to oversee the health care system or government programs. Your Rights Access: You may request to review and/or receive a copy of your PHI over which New Directions has dominion. This includes: medical records (except for fitness of duty evaluations, FMLA reviews, second opinion evaluations, and raw test data); health information from third parties; billing records; enrollment, payment, claims adjudication, and appeal records; OPTAMUM and EAP Expert notes; and any other information used to make decisions about your health care. Amendment: You may request that New Directions change PHI about you that you believe is incomplete, inaccurate, or false. New Directions will determine if the request is valid, and if deemed invalid, you will be notified in writing of the reason for denial. You may be able to appeal a denial. Restriction: You may request in writing that New Directions restrict our use or disclosure of your PHI for treatment, payment, or health care operational purposes. We may agree to restrict the use of your PHI, but are not required to do so in all circumstances. Even when we agree to restrict use, New Directions may still disclose your PHI for public health and safety purposes, in the case of medical emergencies, and for other reasons as dictated by law. Alternative Means of Communication & Confidential Communication: If you desire to be contacted via a different method than what New Direction chooses, you have the ability to request in writing that we contact you via any medium, and to any location, that affords reasonable protection of your PHI and which is acceptable and practical for both you and New Directions. If you request in writing that we communicate to you in confidentiality, New Directions will attempt to accommodate the request to the extent that is reasonable and practicable. Page 18

19 Breach Notification: In the event of breach of your PHI, as required by law, New Directions will provide you with notification that your PHI has been accessed, used, acquired, or disclosed to an unauthorized person or entity, and that the breach compromises the confidentiality of your PHI. Privacy Notice & Paper Copy: You may request and receive a paper or electronic copy of this Notice at any time. This Notice is always accessible via the New Directions website at State Law: In some circumstances state law affords greater protection of your PHI than federal regulation, and also might require that New Directions take extra precaution with certain kinds of PHI. In such cases New Directions will abide by all state level legal requirements that are applicable. To exercise any of your rights, or to discuss them further, you may contact the New Directions Behavioral Health Privacy Officer at P.O. Box 6729, Leawood, KS , or via telephone at , or via at [email protected]. Complaints We take the protection of your PHI very seriously, and have a number of policies and procedures in place to ensure that your PHI remains secure. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about your access to PHI, about amending your PHI, about restricting our use or disclosure of your PHI, or about how we communicate with you, you may issue a complaint to New Directions Behavioral Health Privacy Officer P.O. Box 6729, Leawood, KS , or via telephone at , or via at [email protected]. You may also submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, Room 509F, Washington D.C You may access the HHS website at We support your right to protect the privacy of your PHI. New Directions will not penalize you or retaliate against you in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Page 19

20 Provider Accessibility Overview New Directions is committed to assisting members obtain timely access to services with appropriate Network Providers. For routine referrals, Members may be given the names and contact information for 3 5 providers. For urgent or emergent appointments, New Directions obtains the appointment and links the Member with the Provider. Whenever possible, New Directions utilizes ReferralQuick, a proprietary scheduling system, to facilitate Member access to care. About ReferralQuick ReferralQuick is a proprietary, online scheduling system that allows New Directions to provide Members with real time assistance in scheduling appointments with Network providers. ReferralQuick is a voluntary and free service available to any Network provider who would like to offer appointments for scheduling. If you would like more information or to begin using the ReferralQuick system, please contact Network Operations at Availability Standards Emergent Care, Life Threatening In an emergency situation, the Member must be offered the opportunity to be seen in person immediately. Emergent Care, Non Life Threatening When there is a significant risk of serious life deterioration, the Member must be seen within six (6) hours of the request. Urgent In an urgent situation, a Member must be offered the opportunity to be seen within twenty four (24) hours of the request. Routine In a routine situation, a Member must be offered the opportunity to be seen within seven (7) days of a request. Page 20

21 Management of Benefits Behavioral health benefits are managed by New Directions to ensure that members have timely access to the most appropriate environment as medically necessary. We coordinate care among the member s primary care physician, psychiatrist, and behavioral health therapist. New Directions Utilization Management staff is available 24 hours a day, seven days a week, at to address questions about the UM process, send outbound communication regarding UM inquiries, connect Providers with Clinical Peers, or initiate reviews with external or independent review organizations. New Directions staff will identify themselves by name, title and organization when initiating or returning calls regarding UM issues. New Directions offers TDD/TYY and language assistance services for Members, Providers and Facilities to discuss UM issues. New Directions bases decisions about utilization of services only on eligibility, coverage and appropriateness of the care and service. There are no financial incentives for decisions that result in under utilization of services or care. New Directions does not reward, hire, promote or terminate individuals for issuing denials of coverage. Members may contact New Directions at the phone number on their insurance card for a referral to a Network Provider. New Directions will assist in identifying appropriate providers in the Member s area and may provide additional assistance with making a timely appointment with the appropriate Provider. Benefit information, eligibility, and any requirements for pre notification or authorization for coverage specific to the Plan are included on the Plan Fact Sheets in the Appendix. Outpatient Quality Review (previously called Outpatient Treatment Request) To request authorization for payment of outpatient treatment, please use the standard outpatient quality review form (OQR) accessible through WebPass. Not all Plans that New Directions manages will require authorization. Please visit WebPass to check the benefits and eligibility to see if and when authorization is required. The authorization/re authorization (reference number) number is only valid for the: 1. Member for whom services are authorized; 2. Provider authorized to see the Member; and 3. Family of codes that is authorized/pre certified. This unique authorization/reference number must be included on the CMS FORM (BOX 23) for claims processing. Any variance from the authorization procedure can result in a denial of that claim. Page 21

22 Availability of Clinical Peers Clinical Peers are available any time a Provider has a concern about access to services, an authorization for services, a utilization management decision, a level of care recommendation, or other matters relevant to Member care. It is not necessary for a claim to reach the formal denial or appeal process for such dialogue to take place. External and independent review organizations are also available. Page 22

23 Medical Necessity Criteria Medical necessity criteria can be located and downloaded at under the Provider link. A hard copy of the Medical Necessity Criteria can be requested by calling Network Operations toll free at Page 23

24 Quality Improvement, Utilization Management and Case Management Programs New Directions initiated the Quality Improvement Program in 1995 to evaluate and maintain the quality of services for Members and Clients. Goals are established, measured, and analyzed for our clinical and administrative services. Many of these goals are based on those established by national accrediting organizations and applicable laws. The Quality Improvement Program provides oversight for: Treatment services Quality, type and availability of Providers and Facilities Availability of appointments Continuity and coordination of care Case Management Services Complaints Appeals Confidentiality and privacy New Directions evaluates its Quality Improvement Program annually. Based on the results, a new Work Plan is created for the following year. Printed copies of the Quality Improvement Program Evaluation, Work Plan, and Description are available by calling toll free and asking for the Quality Management Department. Utilization Management Services The mission of the Utilization Management Program is to improve health through change and to provide support to individuals in need of behavioral health care. The Utilization Management Program (UM) promotes positive health outcomes by providing the structure and processes needed to provide UM services for all managed behavioral health (MBH) Members. The UM Program is a framework for making benefit determinations affecting the health care of members in a fair, impartial, and consistent manner. All UM services are provided either telephonically, secure fax or , mail, or through New Directions website ( The UM staff is available 24/7 to provide information about UM processes and to address requests for certification of care. Members have direct access to all behavioral health providers and can self refer to Providers for assessment. Members who contact New Directions for assistance to find a practitioner and obtain an appointment are asked a series of questions. These questions enable UM staff to determine the type of services needed, the acuity of the member s condition, and the appropriate time frame for the appointment. The acuity of the situation is evaluated and appropriate referrals are then provided. In urgent and emergent situations, the Member is assisted with access to services. The safety of the Member is the primary concern. The staff facilitates peer clinical reviews and appeals and coordinates services with other departments. Page 24

25 Case Management Services New Directions Case Management Program collaborates with providers and community health resources to assess, plan, facilitate services and advocate for Members. Such collaboration promotes optimal health outcomes. Our Program incorporates member education, improves physician awareness, minimizes fragmentation of care within the health care delivery system, and addresses the physical and behavioral health needs of the Member. By serving as a single point of contact, Care Managers use evidence based practices to engage Members and partner with Providers to assist with adherence to treatment and promote recovery. Case Management is a telephonic service with an emphasis on: Supporting Members efforts to take an active role in developing their health care Plans Using a Member centric holistic approach during transitions of levels of care Coordinating referrals to Providers, community resources and caregivers Improving Member resiliency, self management and self care Empowering Members to adhere to their treatment plan Assisting Members to achieve time limited, individualized, attainable goals Case Managers are licensed clinicians with expertise in care coordination who serve to empower members to understand and support access to high quality health care. As a New Directions Provider, you may request Case Management services for a Member. Please see health Plan or group specific contact information in the Appendix in the back of this Manual. Preventing Inpatient Readmissions: Care Transition Program Fifty percent of mental health admissions readmit within one year. Readmissions occur when members are: Unprepared for self management roles, Do not know their discharge plans, Cannot access providers when problems arise, Receive minimal input in the health plans, Suffer medication errors, and/or Do not have adequate follow up. New Directions Care Transition Program focuses on providing a better member experience, improving the health of populations, and reducing services costs. This results in avoided readmissions and improved quality of service to the Member. Page 25

26 Adequate care transition programming: Ensures that members and member support systems understand and are actively engaged in the member s individualized treatment plan, Coordinates care with member s out patient behavioral and medical providers, Addresses barriers to treatment adherence, Verifies that follow up care is timely and appropriate to the member s needs. New Directions Care Transitions Program Targets: Assist providers and member understand the importance of post hospitalization aftercare Increase the scheduling and attendance of post discharge follow up appointments within seven days Increase member understanding, participation, and adherence to their treatment plan Self Management and Prevention Education Programs Autism Spectrum Disorders Resource Center New Directions has developed two related support services: the ASD Resource Center and the Autism Resource Program. Core services include: Accurate and timely information on ASD available at Education on ASD for families with a member with an ASD Advocacy for individuals with ASD and their families Referral to appropriate services and resources Optimization of the available insurance benefit Effective coordination of care Service and outcome tracking Provider support For more information about this program, please contact the ASD Coaching Program at Alcohol Use Education, Support and Coaching Program The New Directions Alcohol Use Education, Support and Coaching Program is designed to provide alcohol use education, self help tools, resources and coaching directly to members. It also provides education on screening, brief intervention and treatment referral information and support to primary care and behavioral health providers. You can download the information from our website at in the Free Health Resources section. Page 26

27 Members to be targeted primarily are those age 10 and older who are: Curious about the level of their drinking Contemplating whether they have a problem and what they might do about it Preparing to address their drinking problem Heavy or abusive users who are not appropriate for a more formal treatment program Abusers or dependent, but unwilling to enter a formal treatment program Post treatment, but unwilling to engage in an active post treatment or relapse prevention program, and at risk of returning to problematic drinking Family members are a secondary audience. The Program: Emphasizes the individualized nature of behavior change Includes multiple evidence based approaches to alcohol use/abuse/dependence (e.g., educational, cognitive behavioral, motivational, twelve step) Presents the drinking continuum (e.g., moderate, heavy, binge, abuse, dependence), with corresponding interventions Has a strong self direction emphasis, with confidential consultation, coaching and referral as needed and accepted by the member Supplies education to primary care and other health providers to enhance the likelihood that they participate in screening and brief interventions with their patients, and know how to make a warm transfer to the Program or make a treatment referral Depression and AD/HD Preventive Health Programs New Directions has a series of educational materials that are mailed to Members recently diagnosed with AD/HD and depression. Since 2000, we have offered the materials free of charge. We also send them to any Member who requests them. You may also download the information from our website at in the Free Health Resources section. Bipolar Disorder Preventive Health Program Research indicates that three factors appear associated with improved outcomes for bipolar disorder: education, medication adherence, and social supports. Based on this data, New Directions developed an educational workbook designed to be used with or without a Bipolar Health Coach, which includes telephonic support and guidance from a licensed New Directions clinician. You may download the information from our website at in the Health Plan Member section. If you have a New Directions Member that you think might benefit from this program, please contact the Bipolar Disorder Program Coordinator toll free at Page 27

28 Request for Psychological/Neuropsychological Testing Some health Plans do not require authorization for psychological or neuropsychological testing. Please review the health Plan and group specific information in the Appendix at the back of this Manual. For health Plans that require authorization, please use the form found on The form is called Request for Psychological/Neuropsychological Testing. Complete all fields, including the date of request and testing start date. The total number of testing hours that you are planning should be filled in next to the appropriate CPT code(s) listed on the form. If you have requested multiple CPT codes, you may use the total number of units within these code groups. A Reference Number or Authorization of will be interchangeable with and A Reference Number or Authorization of will be interchangeable with 96118, 96119, and If you have any questions or want to check the status of your Request for Psychological Testing, please feel free to contact us. Contact information is found in the Appendix in the back of this Manual. Billing Assistance Billing and Missed Appointments New Directions does not authorize payment to Providers for missed appointments, nor may a Member be billed unless he or she has agreed, in writing, to pay out of pocket for any missed appointments at the start of treatment. Maximum Visits per Day Benefits will be authorized for only ONE professional unit per day unless a Plan specifies otherwise, except for the following: Outpatient psychotherapy or group therapy with a non psychiatrist Provider and medication management with a psychiatrist on the same day Outpatient psychotherapy or evaluation and psychological testing on the same day Providers should not bill concurrent services, including two or more direct services being delivered the same time to the same Member and delivering non group services to more than one Member at the same time. Only the provider rendering the face to face session with a member can bill for that service. Page 28

29 Common Billable CPT and Revenue Codes Service Code FREQUENTLY REQUESTED CODES Treatment Description Psychiatric diagnostic evaluation (no medical services) Psychiatric diagnostic evaluation (with medical services) Individual Psychotherapy, 30 minutes Individual Psychotherapy, 45 minutes Individual Psychotherapy, 60 minutes minute psychotherapy add on code (prescribers only) minute psychotherapy add on code (prescribers only) minute psychotherapy add on code (prescribers only) Family Session without Patient Present Family Psychotherapy Group Psychotherapy Psychotherapy for crisis, first 60 minutes Psychotherapy for crisis, each additional 30 minutes 96101, 96102, Psychological Testing CPT and REVENUE CODES IN NUMERICAL ORDER 124 Inpatient Day Mental Health 126 Inpatient Day Substance Abuse 129 Sub Acute/ Residential Rehabilitation 762 Observation Bed 900 Behavioral Health Treatment or Service (General Classification) 901 Electroconvulsive Therapy Facility Code 905 Intensive Outpatient (IOP) Psychiatric 906 Intensive Outpatient (IOP) Chemical Dependency 910 Community Behavioral Health Programs Day Tax 912 Partial Care (PHP) Less Intensive 913 Partial Care (PHP) Intensive 1001 Residential Care Psychiatric 1002 Residential Care Chemical Dependency Page 29

30 Service Code CPT Treatment Description CODES IN NUMERICAL ORDER Initial inpatient/residential evaluation 30 minutes Initial inpatient/residential evaluation 50 minutes Initial inpatient/residential evaluation 70 minutes Subsequent inpatient/residential visit 15 minutes Subsequent inpatient/residential visit 25 minutes Subsequent inpatient/residential visit 35 minutes Discharge Inpatient/residential visit Consultation 40 minutes Consultation 60 minutes Initial inpatient consultation 20 minutes Initial inpatient consultation 40 minutes Initial inpatient consultation 60 minutes Initial inpatient consultation 80 minutes Initial inpatient consultation 80+ minutes Follow up Consultation 20 minutes Nursing Home Evaluation 30 minutes Nursing Home Evaluation 40 minutes Nursing Home Evaluation 50 minutes Nursing Home Subsequent Visit 15 minutes Nursing Home Subsequent Visit 25 minutes Nursing Home Subsequent Visit 35 minutes Rest Home Visit Low Complexity Rest Home Visit Moderate Complexity Rest Home Visit High Complexity Rest Home Subsequent Visit Low Complexity Rest Home Subsequent Visit Moderate Complexity Rest Home Subsequent Visit High Complexity Case Management Page 30

31 Completing the CMS (HCFA) 1500 Claim Form All outpatient claims submitted to New Directions must be filed on the CMS claim form. The following is a description of each section of the CMS 1500 Claim Form, Version. Please see the Medicare Provider Manual when completing forms for Medicare patients. Please note that the claim form requests both a Rendering Provider and a Billing Provider. The Rendering Provider (Field 24J) is the Provider who delivered the service to the Member whose insurance is being billed. The Billing Provider (Field 33) is the Provider or Group who is to receive payment for the services that were billed. CMS VERSION Field Number/Name Instructions 1. Type of health insurance coverage Check appropriate box, usually group health Plan, Medicare, or other 1A. Insured s ID number Enter the certificate number shown on the Member s ID card, including any letters 2. Patient s name Last, first, middle initial as shown on the patient s insurance card 3. Patient s date of birth and sex Enter the patient s 8 digit birth date (MM/DD/CCYY) and sex 4. Insured s name List the name printed on the identification card. If the insured and the patient are the same, enter the word SAME 5. Patient s complete address Fill in the patient s mailing address and telephone number 6. Patient s relationship to insured The patient s relationship to insured when item 4 is completed 7. Insured s Address Fill in the Insured s address and telephone number. When the insured is the patient, use the word SAME 8. Patient status Check appropriate boxes 9A D. Other insurance coverage If the patient has a Madigan policy, enter information according to Medicare guidelines. If the patient has insurance with more than one company, enter as much information as is available to you. At minimum, enter the name and address of the employer through which the other coverage was obtained. 10A. Was condition related to patient s Check appropriate box employment Page 31

32 10B. Was condition related to an auto accident 10C. Was condition related to another accident Check appropriate box Check the appropriate box 10D. Reserved for local use Use this item exclusively for Medicaid information. If the patient is entitled to Medicaid, this item must show the patient s Medicaid number, preceded by MDC. 11A D. Insured s policy group number If the patient has health insurance coverage with more than one company, list as much 12 Patient s or authorized person s signature 13. Authorization of payment to physician information as possible The patient or authorized representative must sign and enter either a 6 or 8 digit date unless the signature is on file. If the patient s signature is on file, SIGNATURE ON FILE is acceptable. The signature in this item authorizes payment of mandated Madigan benefits. If the patient s signature is on file, SIGNATURE ON FILE is acceptable. 14. Date of illness, injury, accident Enter date of the current illness, injury or pregnancy. Do not repeat date of service for patients receiving continuing services; use date of onset. 15. If patient has had same or similar illness, give first date MM/DD/YY. 16. Dates patient unable to work in current occupation. 17A. Name and identification number. 17B. NPI 18. Hospitalization dates related to current services. Enter month, day and year the patient first consulted you for this condition. Leave blank. Enter the name of the referring physician or Primary Care Physician Use the NPI of the referring Provider The 6 or 8 digit date when a medical service is furnished as a result of or subsequent to a related hospitalization. 19. Reserved for local use. If this is a Medicare or Medicaid claim, the 6 or 8 digit date the patient was last seen and the UPIN of his/her attending physician should be listed. 20. Outside lab. As requested. 21. Diagnosis or nature of illness or injury. (Through 3/31/14) Enter the appropriate ICD 9 CM diagnosis code(s). Report codes to the fourth or fifth character, as defined by ICD 9. List primary diagnosis first. Page 32

33 Field Number/Name 21. Diagnosis or nature of illness or injury. (Effective 4/1/14) Instructions Enter the appropriate ICD 10 CM diagnosis code(s). Report codes to the fourth or fifth character, as defined by ICD 10. List primary diagnosis first. 22. Medicaid resubmission code. Leave blank. 23. Prior authorization number. When REQUIRED, obtain from New Directions Behavioral Health. 24A. Date of service. List the 6 or 8 digit date for each procedure or service. When from and to dates are shown for a series of identical services, enter the number of days or units in column C. 24B. Place of service. Identify the location, using place of service code for each item used or service performed. 24C. EMG 24D. Procedure code. Enter the appropriate code that best describes the services rendered; include any necessary modifiers. If you need to describe an unlisted code or an unusual circumstance, use an attachment. 24E. Diagnosis code. Reference the appropriate diagnosis code used in Box 21 for each procedure. 24F. Charges. List your total charge for each service. 24G. Days or units. This field is most commonly used for multiple visits or anesthesia minutes. If only one service is performed, the number 1 must be entered. 24H. EPDST. Leave blank. 24I. ID. QUAL. Leave blank. 24J. Rendering Provider ID # Use the ten (10) digit rendering provider number in the shaded area Use the performing Providers ten (10) digit NPI in the lower un shaded portion 25. Federal Tax ID Number. List the Provider or service or supplier s Federal Tax ID or Social Security Number. This information is required. 26. Your patient s account number. If you list this number, it will be printed on your voucher. 27. Accept assignment. The appropriate block must be checked to indicate whether the Provider of service accepts assignment of Medicare benefits. 28. Total charge. Enter the total of charges listed on 24F. 29. Amount paid. Enter the total amount the patient paid on the covered services only. This should include the Page 33

34 Field Number/Name Instructions co payment if applicable. 30. Balance due. Subtract other insurance payment from your total charge in Box Signature of physician. Physician s name (typed, stamped, or computer 32. Name and address of facility where services were rendered (if other than home or office). 33. Physician s name, address, zip code, and telephone number. printed), signature and date. Enter name and address of the facility if the services were furnished in a hospital, skilled nursing facility, nursing home, or other location if all or a portion of the services were rendered outside your office of the patient s home. Enter the NPI of the service location Enter the practitioner s billing name, address, zip code, and phone number. Enter the 10 digit billing Provider NPI. Page 34

35 New Directions CMS Minimum Required Fields Field Description Number 1 Type of Coverage 1A Insured s ID Number 2 Patient complete name 3 Patient s DOB 4 Insured s Name or SAME * 5 Patient s Address 6 Patient s Relationship to Insured 7 Insured s Address 8 Patient Status if 4 is other than patient 9 Other Insured s Name* 9A Other Insured s Policy or Group Number* 9B Other Insured s DOB* 9C Other Insured s Employer Name or School Name* 9D Other Insured s Insurance Plan or Program Name* 10A D Check appropriate boxes 11 Insured s Policy Group or FECA Number if patient has other coverage 11A Insured s DOB 11B Insured s Employer or School Name 11C Insured s Insurance Plan or Program Name 11D Is there another Health Plan Benefit? 12 Patient s Signature or SIGNATURE ON FILE 13 Insured s Signature or SIGNATURE ON FILE 21 Diagnosis using the appropriate ICD 9 CM Code (through ) 21 Diagnosis using the appropriate ICD 10 CM Code (beginning ) 23 Prior Authorization Number 24A J Service Information 25 Federal Tax ID Number 26 Patient s Account Number 27 Accept Assignment 28 Total Charge 29 Amount Paid 30 Balance Due 31 Signature of Provider Including Credentials 32 Name and Address of Facility Where Services Rendered 33 Physician/Supplier s Billing Name, Address, Zip Code * If applicable Page 35

36 CMS 1500 Claim Form (Use through March 31, 2014) Page 36

37 CMS 1500 Claim Form (Effective April 1, 2014) Page 37

38 Completing the UB 04 Claim Form All inpatient (higher levels of care) claims submitted to New Directions must be filed on the UB 04 claim form. Please see the Medicare Provider Manual when completing forms for Medicare patients. Description Inpatient Outpatient The authorization or pre certification number is required in field 63 on UB 04. To ensure timely processing, please complete the UB 04 with all required information. Page 38

39 UB 04 Form Sample form Page 39

40 Statement of Rights and Responsibilities of Providers Providers have the right to: 1. Access information contained in personal Credentials Files 2. Rectify erroneous information in personal Credentials Files 3. Be informed of their status in the credentialing/re credentialing process 4. Participate in activities and develop documents at New Directions, such as: Clinical Practice Guidelines Medical Necessity Criteria Credentials Committee Preventive Health Programs 5. Request a hearing (in accordance with the Policy, Fair Hearing with the policy Plan ), if an adverse recommendation regarding participation in the New Directions Network is made 6. Be credentialed in accordance with the Provider Appointment and Reappointment policy, which describes the processes for credentialing and re credentialing, including: Maintaining the confidentiality of Credentials Files to the extent permitted under state or federal laws and New Directions Policies Recommendations that are non discriminatory Right to be notified if information received during the credentialing/re credentialing process is substantially different from information received from a Provider Notification within 60 calendar days of credentialing/re credentialing decisions Providers have the responsibility to: 1. Use and disclose protected health information in accordance with federal and applicable state laws 2. Maintain health information (treatment records) in accordance with the New Directions Treatment Record Documentation policy; submit to reasonably requested audits of health information; implement action plans as required; and participate in follow up reviews of deficiencies 3. Participate when requested in quality improvement and professional review activities 4. Communicate with primary care physicians and other Providers about mutual Members Page 40

41 Statement of Rights and Responsibilities for Members and Clients Members/Clients have the right to: 1. Receive information about New Directions, its services, its Network Providers and Affiliates, and their rights and responsibilities 2. Be treated with respect and receive recognition of their dignity and right to privacy 3. Participate with Network Providers and Affiliates in decisions about their health care 4. Receive a candid discussion of appropriate or medically necessary treatment options for their health conditions, regardless of cost or benefit coverage 5. Voice complaints or appeals about New Directions or the care it provides, either verbally or in writing, and obtain prompt resolution 6. Make recommendations regarding this Statement of Rights and Responsibilities for Members and Clients Members/Clients accept the responsibility to: 1. Provide information (to the extent possible) that New Directions and its Providers and Affiliates need to provide health care 2. Follow the Plans and the instructions for care and treatment agreed upon by Plans, Providers and Affiliates 3. Understand their health conditions and participate in developing mutually agreed upon treatment goals, to the extent possible Commercial Member and Provider Denial and Appeal Rights The attending physician or other ordering provider can request a peer to peer conversation upon receipt of an adverse benefit determination. A peer to peer conversation can be requested by calling New Directions at The peer to peer conversation will occur with the original peer clinical reviewer or with a different clinical peer if the original clinical peer reviewer cannot be available within one business day. If the Peer Clinical Reviewer makes an adverse benefit determination to deny coverage for payment of the requested service, the requesting Provider/Facility and the Member are notified of the adverse benefit determination and appeal rights. Page 41

42 The right to appeal is available to the Member, the Member s representative, and the Member s Provider on behalf of the Member. New Directions Behavioral Health has written procedures for appeals of determinations not to certify payment for an admission, service, or extension of stay, including retrospective non certification determinations. These procedures are available to Providers and Members upon request. All medical necessity appeals are reviewed by a clinical peer, a physician or other health care professional who holds an unrestricted license or certificate to practice and is in the same or similar specialty as one who typically manages the health condition, procedures, or treatment under review. Members, families, and Providers can access New Directions UM staff to answer questions regarding access to services, UM issues and the UM process toll free, 24 hours a day, seven days a week at The Member also has the right to request an independent review when an adverse determination is based on lack of medical necessity. An independent review is a review completed by an external review organization. The external review organization will use a Provider peer who has similar education, certification and licensure as the treating Provider. New Directions role in appeals varies by health Plan and group. See Plan or group specific information and contact information in the Appendix in the back of this Manual. Written appeal and denial procedures are available upon request and can be found at Types of Appeals and Definitions Adverse benefit determination (denial) A denial, reduction, termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make a payment that is based on a Member's eligibility to participate in a Plan; A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review; A failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate; or Any rescission of coverage, including a cancellation or discontinuance of coverage that has retroactive effect. Appeal a verbal or written request by a Member, a representative on behalf of the Member (who may be any person), or a Provider, for a full investigation of the adverse benefit determination, including any aspect of clinical care involved. A grievance is an appeal. Expedited appeal a review of an adverse benefit determination of urgent services involving an admission, continued stay, or other health care services within a facility. Page 42

43 Coordination of Care with Primary Care Physicians Members benefit when all health care Providers share health information. New Directions encourages Network Providers to explain to Members the important reasons for sharing health information with their primary care physicians (PCP) and other health care Providers, both behavioral health and medical specialists. Under HIPAA, authorization from a Member isn t usually required when sharing health information with other treating health care Providers. The few exceptions may be for substance abuse, HIV/AIDS, genetic information, or because of a specific state law. Providers are also expected to comply with relevant state laws regarding contact with other health care Providers. For more information, call Network Operations toll free at Page 43

44 Guidelines for Treatment Record Documentation The following Guidelines have been developed as required by NCQA Standards for office treatment records. As part of the re credentialing process, Providers seeing a high number of New Directions Members may be asked to submit several outpatient records for audit in accordance with these Guidelines. A passing score is 80%. 1. Confidentiality: (a) Treatment records are securely stored; (b) only accessible by authorized personnel; and (c) office staff receives periodic training in confidentiality of patient information. 2. Personal/Biographical Information: Personal/biographical information is documented in a consistent location in the treatment record. Information includes: Name or ID number on each page Date of birth Home address Home/work telephone numbers Gender Employer or school Marital or legal status Appropriate consent forms/guardianship information Emergency contact information 3. Comprehensive Treatment Record Organization: A comprehensive treatment record is defined as a single all inclusive record of health information that is comprised of all clinical patient information available to the Provider or group practice. The internal information from the Provider office is integrated with external information. Practices that have satellite offices have at least one location that maintains a comprehensive treatment record. Providers must establish a separate file for each Member. All contents of the paper or hard copy treatment record are in an established format and sequencing, either in chronological or reverse chronological order. The electronic treatment record may encompass multiple applications to form a comprehensive record. For example, if demographic information such as home/work phone number is stored in one application, and follow up visit information is stored separately from the main EMR, all applications must be accessible to the clinical staff from an individual work station. 4. Allergies: Documentation of medication allergies is clearly noted. If the patient has no known allergies, this is noted in the treatment record typically as NKA (no known allergies) or NKDA Page 44

45 (no known drug allergies). Physician and Nurse Practitioner records also clearly describe the reactions associated with allergies. 5. Special Status Situations: Special status situations include conditions where the patient is at imminent risk of harm, has suicidal or homicidal ideation with a plan, or is unable to conduct activities of daily living. Observations of these situations and prompt referral to the appropriate level of care are documented in the record. 6. Medication Management: Records contain information about medication. This information includes: Medication prescribed or documentation of no medication Dosages of each medication (physician and nurse practitioner records) Dates of initial prescription or refills (physician and nurse practitioner records) Herbal medications or over the counter medications 7. Alcohol, Tobacco, And Substance Use and/or Abuse: Documentation includes past and present use of cigarettes, alcohol, and prescribed, illicit, and over the counter drugs, including frequency and quantity. 8. Mental Status Evaluation: The treatment record contains evidence of at least one mental status evaluation/examination (e.g., patient s affect, speech, mood, thought content, judgment, insight, attention or concentration, memory and impulse control). 9. History: A psychiatric and medical history was obtained and documented in the record outlining the patient s past treatment and response (or lack thereof). The history consists of: Previous treatment dates Therapeutic interventions and responses Sources of clinical data (e.g., self, mother, spouse, past records) Relevant family information Consultation reports, if available/applicable (e.g., psychological testing) Lab test results, if applicable, in physician and nurse practitioner records (i.e., Lithium, Depakote, Tegretol levels) 10. Minor Patients Treatment Records: Records of minor patients (less than 18 years of age) contain documentation of prenatal and parental events, complete developmental histories (e.g., physical, psychological, social, intellectual, and academic) and evidence of family involvement in care within 60 days of the initial visit. 11. Treatment Plan: Within the first three visits, the treatment plan contains (a) specific measurable goals, (b) documentation the treatment plan and/or goals were discussed with the patient, (c) estimated time frames for goal attainment or problem resolution, and (d) documentation of the patient s strengths and limitations in achieving goals. This personalized treatment plan for each individual Member should guide the overall treatment process. Page 45

46 12. Diagnosis: The treatment record documents a DSM IV or ICD 9 diagnosis or clinical impression within the first three visits. Deferred or Rule out diagnosis is acceptable but must be revised within three (3) visits. In order to reflect the Member s appropriate Risk Adjustment Factor under the Affordable Care Act, the Member s diagnosis needs to include all of the diagnoses impacting the Member, reflecting the severity of the patient s overall illness. 13. Treatment Record Notes: Each face to face encounter note contains (a) reason for the Member s visit; (b) objective and subjective documentation of the patient s presentation; (c) goal of the service; (d) summary of the intervention/service provided with the Member response; and (e) an updated treatment plan. Treatment Record Notes must support the medical necessity of the service provided and support the code that is billed. Documentation for each visit must stand alone. 14. Legibility: The treatment record is legible to someone other than the writer. 15. Author Identification, Authentication, and Date and Time of Entries: All entries are dated, including the month and year, start and end times the member was seen; have the rendering provider clearly identified on the entry; and authenticated (signed) by the individual providing the services with professional degree (e.g., PhD, MD/DO, LCSW) and/or professional credentials. 16. Follow up Appointments: The treatment record documents dates of follow up appointments or, as appropriate, a discharge plan. Documentation of follow up with the patient has occurred if an appointment was missed. 17. Continuity and Coordination of Care: As applicable, the treatment record reflects continuity and coordination of care as evidenced by communication with, or review of information from, other behavioral health Providers, consultants, ancillary Providers, and health care institutions. 18. Coordinating Care with the PCP: Treatment records reflect contact with the patient s primary care physician (PCP), as applicable, and follow up contact as needed. 19. Appropriate edits to documentation: Providers should document the services rendered in the Member s medical record at the time of service. At times, a Provider may determine that the information entered into the medical record is not completely accurate. If revisions need to be made to an entry into a medical record, amendments and edits are made using the following steps: a. To remove information from the documentation, draw a single line through the words needing removed, ensuring the content is still readable. White out is not to be used. b. The individual adding or editing the documentation needs to sign and date the revision. Page 46

47 Clinical Guidelines Page 47

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51 Appendix for Blue Cross and Blue Shield Plans (Fully insured, Federal Employee Program and Self Funded accounts) Note: Information contained in the Appendix that is specific to each health Plan (i.e., not a New Directions process) may be subject to change. If you have questions, please verify with the health Plan. Blue Cross Blue Shield of Alabama Provider Network through Managed Health Care Administration (MHCA) MHCA Website: CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions No authorization required. Outpatient services may be reviewed retrospectively. Pre Certification for MHCA New Directions Contracted Facilities Benefits & Eligibility New Directions or benefits/eligibility are available at Provider Relations MHCA Claims Inquiries MHCA (205) or [email protected]. Deaf or hearing impaired Alabama relay phone numbers (Voice) (TTY/HCO) Or 711 in your service area. Medical Necessity Appeals New Directions Primary Requirements Authorizations No authorization required for outpatient services, including Psychological testing. ABA Therapy requires authorization for all visits. Pre Certification required for ALL Inpatient services when provided in a facility that contracts with MHCA, and for services outside of Alabama. Pre Certification is required for partial hospitalization and intensive outpatient services when required by the Member s contract. Page 51

52 Timely Filing Timely filing of claims is 180 days. Benefits If you have any questions about Member benefits, please call New Directions Customer Service at Online eligibility and benefits information is available at Claims Electronic Claims Providers interested in filing electronic claims should [email protected]. Paper Claims Paper claims should be mailed to: MHCA ATTN: Claims Processing 2868 Acton Road Birmingham, Alabama Change in Demographics Evelyn Barbee, RN, MPPM, Director of Network Development MHCA 2868 Acton Road Birmingham, Alabama [email protected] Medical Records Medical records, if requested, are to be provided without charge. Page 52

53 Arkansas Blue Cross Blue Shield (ABCBS) HMO & PPO (Including Health Advantage) CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or Fax to: Pre Certification Eligibility & Benefits and Claims Questions New Directions Use Provider WebPass or Call: Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Arkansas Relay Service Provider Appeals New Directions Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations Authorizations for outpatient services are required after the 8 th visit. MD/DO s and ARNP s do not require an authorization. Pre Notification required for ALL inpatient, Pre Certification for partial hospital and intensive outpatient services. No authorization required for psychological or neuropsychological testing. Timely Filing Timely filing of claims is 180 days. Benefits New Directions will quote benefits. Claims Claims must meet ABCBS filing requirements. Page 53

54 Clean claims will be processed within 10 to 30 days. To check the status of a claim, please call customer service at Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: ABCBS PO Box 2181 Little Rock, AR ABCBS Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 54

55 Arkansas Blue Cross Blue Shield (ABCBS) Federal Employee Program (FEP) CONTACT INFORMATION Toll Free Number Pre Certification New Directions Use Provider WebPass or Call: Eligibility & Benefits and ABCBS Claims Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Arkansas Relay Service Reconsideration/inquiries New Directions Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations No authorization required for outpatient services. Pre Certification required for ALL inpatient services. No authorization required for psychological or neuropsychological testing. Timely Filing Timely filing of claims is 180 days. Benefits ABCBS FEP department will quote benefits. If you have any questions about Member benefits, please call FEP customer service at Claims Claims must meet FEP/ABCBS filing requirements. Clean claims will be processed within 10 to 30 days. To check the status of a claim, please call FEP customer service at Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Page 55 Arkansas Blue Cross Blue Shield FEP PO Box 2181 Little Rock, AR 72203

56 ABCBS FEP Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 56

57 Walmart through Arkansas Blue Cross Blue Shield (ABCBS)/Blue Advantage Administrators (BAA) CONTACT INFORMATION Toll Free Number Pre Notification Eligibility & Benefits and Claims Questions New Directions Use Provider WebPass or Call: Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Relay Services Dial 711 for state relay service toll free number Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations No authorization required on outpatient services or intensive outpatient services. Pre Notification recommended for ALL inpatient services and Partial Services. No authorization required for psychological or neuropsychological testing Timely Filing Timely filing of claims is 365 days. Benefits If you have any questions about Member benefits, please use Provider WebPass or call New Directions Customer Service at Claims Claims must meet ABCBS filing requirements. Clean claims will be processed within 10 to 30 days. Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Blue Advantage Administrators PO Box 1460 Little Rock, AR Page 57

58 New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 58

59 Florida Blue PPO including Medicare Advantage Effective December 1, 2011 CONTACT INFORMATION Outpatient Authorizations Authorizations for ABA Therapy only Pre Certification Eligibility & Benefits and Claims Questions New Directions New Directions Toll Free Number Use Provider WebPass or fax to: Fax to: Attn: T&R Clinical Use Provider WebPass or Call: Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired State relay services Call 711 to identify the correct toll free number for your location. Provider Appeals New Directions Primary Requirements Please be advised: Due to a recent update to the claims payment system at FL Blue, the requirement to utilize a type 2 NPI number is now being enforced. If you are billing using a Tax ID number, you will need to register for a type 2 NPI number. If you are billing using your Social Security number, you will NOT have to register for a Type 2 NPI number. To avoid payment delays and or claim denials, please access the following link to register for your type 2 NPI number Using your new group/type 2 NPI number in the billing process The group/type 2 NPI number will be used as the billing provider on a claim The individual NPI number will be used as the rendering provider on a claim Page 59

60 Authorizations Effective July 1, 2014, no authorization required for outpatient services with the exception of Autism Services (see below). ABA requires prior authorization from first visit. A reference number will then be assigned. (For Authorizations related to Autism services, please refer to the Autism Provider manual located under the provider section of Failure to get prior authorization may result in denial of payment. Refer to the member s plan for specific benefits and authorization requirements. No authorization required for psychological or neuropsychological testing. After eight (8) hours, medical records need to be sent to FL Blue. Pre Certification required for ALL Inpatient, residential, partial hospitalization and intensive outpatient services (including ABA therapy). Note: some self funded Plans may not have this requirement. Timely Filing Timely filing of claims is 180 days. Benefits Benefits vary by group and Plan. Claims Claims must meet timely filing requirements. Clean claims will be processed within 10 to 30 days. To check the status of a claim, please check Availity, or call New Directions Customer Service at Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Florida Blue PO Box 1798 Jacksonville, FL BCBSFL PPO Customer Service: See Member s ID card New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 60

61 Florida Blue HMO including Medicare Advantage Effective January 1, 2012 CONTACT INFORMATION Outpatient Authorizations New Directions Toll Free Number Use Provider WebPass or fax to: Authorizations for ABA Therapy only Fax to: Attn: T&R Clinical Pre Certification New Directions Eligibility & Benefits and Claims Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired State relay services Call 711 to identify the correct toll free number for your location. Provider Appeals New Directions Primary Requirements Please be advised: Due to a recent update to the claims payment system at FL Blue, the requirement to utilize a type 2 NPI number is now being enforced. If you are billing using a Tax ID number, you will need to register for a type 2 NPI number. If you are billing using your Social Security number, you will NOT have to register for a Type 2 NPI number. To avoid payment delays and or claim denials, please access the following link to register for your type 2 NPI number Using your new group/type 2 NPI number in the billing process The group/type 2 NPI number will be used as the billing provider on a claim The individual NPI number will be used as the rendering provider on a claim Page 61

62 Authorizations Effective July 1, 2014, no authorization required for outpatient services with the exception of Autism Services (see below). ABA requires prior authorization from first visit. A reference number will then be assigned. (For Authorizations related to Autism services, please refer to the Autism Provider manual located under the provider section of Failure to get prior authorization may result in denial of payment. Refer to the member s plan for specific benefits and authorization requirements. No authorization required for psychological or neuropsychological testing. After eight (8) hours, medical records need to be sent to FL Blue. Pre Certification required for ALL Inpatient, residential, partial hospitalization and intensive outpatient services (including ABA therapy). Note: some self funded Plans may not have this requirement. Timely Filing Timely filing of claims is 180 days. Benefits Varies by group No out of network benefit unless group has a POS Rider Claims Claims must meet timely filing requirements. Clean claims will be processed within 10 to 30 days. To check the status of a claim, please check Availity or call New Directions Customer Service at Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Florida Blue PO Box 1798 Jacksonville, FL BCBSFL Customer Service: See Member s ID card. New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 62

63 Florida Blue Federal Employee Program (FEP) Effective January 1, 2012 CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or fax to: Pre Certification New Directions Eligibility & Benefits and Claims Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired State relay services Call 711 to identify the correct toll free number for your location. Reconsideration/ Inquiries New Directions Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations No authorization is required for outpatient services Pre Certification is required for ALL Inpatient services No authorization is required for psychological or neuropsychological testing Timely Filing Timely filing of claims is 180 days. Benefits Contact New Directions toll free at Page 63

64 Claims Claims must meet timely filing requirements. Clean claims will be processed within 10 to 30 days. To check the status of a claim, please check Availity or call New Directions Customer Service at Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Florida Blue PO Box 1798 Jacksonville, FL BCBSFL Customer Service: See Member s ID card New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 64

65 Blue Cross Blue Shield of Kansas (BCBSKS) PPO CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or fax to: Pre Certification New Directions Benefits, Eligibility and BCBSKS Claims Other Inquiries New Directions Provider Relations BCBSKS Deaf or hearing impaired Kansas relay services Toll Free Provider Appeals New Directions Network BCBSKS provides the network Authorizations Authorization is required for outpatient services after the 8 th visit. Authorization is required for Psychological testing after the 8 th hour. Pre Certification is required for ALL higher levels of care. 180 day timely filing requirement Benefits BCBSKS will quote benefits. If you have any questions about Member benefits, please call customer service at Timely Filing BCBSKS does not follow a strict filing requirement and performs retrospective reviews on claims if they are filed. Claims Claims must meet BCBSKS filing requirements. Electronic Claims Providers interested in filing electronic claims should refer to BCBSKC.com. Paper Claims Paper claims should be mailed to: Blue Cross Blue Shield Kansas 1133 SW Topeka Blvd Topeka, KS Page 65

66 Blue Cross Blue Shield of Kansas (BCBSKS) Federal Employee Program (FEP) CONTACT INFORMATION Pre Certification of Inpatient Toll Free Number New Directions Benefits, Eligibility and BCBSKS Claims Other Inquiries New Directions Provider Relations BCBSKS Deaf or hearing impaired Kansas relay services Reconsiderations New Directions Network BCBSKS provides the network. Authorizations Advanced benefit determination is required for outpatient services after eight (8) visits. Pre Certification is required for ALL inpatient services. No authorization is required for psychological or neuropsychological testing. Benefits BCBSKS will quote benefits. If you have any questions about Member benefits, please call FEP customer service at Timely Filing BCBSKS does not follow a strict filing requirement and performs retrospective reviews on claims if they are filed. Claims Claims must meet BCBSKS filing requirements. Electronic Claims Providers interested in filing electronic claims should refer to BCBSKC.com. Paper Claims Paper claims should be mailed to: Page 66 Blue Cross Blue Shield Kansas 1133 SW Topeka Blvd Topeka, KS

67 Blue Cross Blue Shield of Kansas City (Blue KC) Blue Care HMO CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or fax to: Pre Certification New Directions Eligibility & Benefits and Claims Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Kansas relay phone number Deaf or hearing impaired Missouri relay Phone number Provider Appeals New Directions Primary Requirements Providers must have a Blue KC Provider number. This is assigned after credentialing is complete. If you do not already have a 5 digit Blue KC Provider ID, please contact customer service at Providers/Facilities must use an NPI number in billing. Authorizations No authorization required for outpatient services. ABA requires prior authorization from first visit. A reference number will then be assigned. (For Authorizations related to Autism services, please refer to the Autism Provider manual located under the provider section of Failure to get prior authorization may result in denial of payment. Refer to the member s plan for specific benefits and authorization requirements. Pre Certification is required for ALL Inpatient, residential, partial hospitalization and intensive outpatient services. Authorization is required for psychological testing after three (3) hours of testing. Authorization required for neuropsychological testing after 8 hours of testing. Page 67

68 Timely Filing Timely filing of claims is 180 days. Benefits If you have any questions about Member benefits, please use Provider WebPass or call New Directions Customer Service at Blue KC s automated system, Blue Touch, will walk you through the process to obtain eligibility and benefits information. You will need your Blue KC Provider number and the member s ID number and date of birth. The phone numbers for Blue Touch are or Online eligibility and benefits information is available at Click on the Provider icon. Blue KC may also be contacted at Claims Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Blue Cross Blue Shield Kansas City PO Box Kansas City, MO Blue KC Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 68

69 Blue Cross Blue Shield of Kansas City (Blue KC) Preferred Care & Preferred Care Blue PPO CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or fax to: Pre Certification New Directions Eligibility & Benefits and Claims Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Kansas relay phone number Deaf or hearing impaired Missouri relay Phone number Provider Appeals New Directions Primary Requirements Providers must have a Blue KC Provider number. This is assigned after credentialing is complete. If you do not already have a 5 digit Blue KC Provider ID, please contact customer service at Providers/Facilities must use an NPI number in billing. Authorizations No authorization is required for outpatient services. ABA requires prior authorization from first visit. A reference number will then be assigned. (For Authorizations related to Autism services, please refer to the Autism Provider manual located under the provider section of Failure to get prior authorization may result in denial of payment. Refer to the member s plan for specific benefits and authorization requirements. Pre Certification is required for ALL Inpatient, residential, partial hospitalization and intensive outpatient services. Authorization is required for psychological testing after five (5) hours of testing. Authorization is required for neuropsychological testing after five (5) hours of testing. Page 69

70 Timely Filing Timely filing of claims is 180 days. Benefits If you have any questions about Member benefits, please use Provider WebPass or call New Directions Customer Service at Blue KC s automated system, Blue Touch, will walk you through the process to obtain eligibility and benefits information. You will need your Blue KC Provider number and the member s ID number and date of birth. The phone numbers for Blue Touch are or Online eligibility and benefits information is available at Click on the Provider icon. Blue KC may also be contacted at Claims Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Blue Cross Blue Shield Kansas City PO Box Kansas City, MO Blue KC Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 70

71 Blue Cross Blue Shield of Kansas City (Blue KC) Federal Employee Program (FEP) Effective January 1, 2011 CONTACT INFORMATION Toll Free Number Pre Certification New Directions Eligibility, Benefits and Claim Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Kansas relay phone number Deaf or hearing impaired Missouri relay Phone number Reconsideration/inquiries New Directions Primary Requirements Providers must have a Blue KC Provider number. This is assigned after credentialing is complete. If you do not already have a 5 digit Blue KC Provider ID, please contact customer service at Providers/Facilities must use an NPI number in billing. Authorizations No authorization is required for outpatient services. Pre Certification is required for ALL inpatient services. No authorization is required for psychological or neuropsychological testing. Timely Filing Timely filing of claims is 180 days. Page 71

72 Benefits If you have any questions about Member benefits, please use Provider WebPass or call New Directions Customer Service at Blue KC s automated system, Blue Touch, will walk you through the process to obtain eligibility and benefits information. You will need your Blue KC Provider number and the member s ID number and date of birth. The phone numbers for Blue Touch are or Online eligibility and benefits information is available at Click on the Provider icon. Blue KC may also be contacted at Claims Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Blue Cross Blue Shield Kansas City PO Box Kansas City, MO Blue KC Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 72

73 Appendix for Employer groups contracted with New Directions Note: Information contained in the Appendix that is specific to each health Plan (i.e., not a New Directions process) may be subject to change. If you have questions, please verify with the health Plan. Archer Daniels Midland (ADM) Blue Cross Blue Shield of Illinois provides the network CONTACT INFORMATION Toll Free Number Pre Certification New Directions Other Inquiries New Directions Provider Relations New Directions or [email protected] Deaf or hearing impaired Contact your state relay Dial 711 services for the toll free number Provider Appeals New Directions Network: BCBSIL PPO Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations No authorization is required for outpatient services. Pre Certification is required for ALL inpatient services. No authorization is required for psychological or neuropsychological testing. Timely Filing Timely filing of claims is 180 days. Page 73

74 Claims Paper Claims Paper claims should be mailed to: BCBS of Illinois 1400 North 30 th St Quincy, IL BCBSIL Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 74

75 Ball s Food Price Chopper & Hen House Market Employees CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or fax to: Pre Certification New Directions Eligibility & Benefits and Claims Questions Other Inquiries New Directions Provider Relations New Directions or [email protected] Deaf or hearing impaired Kansas relay phone number Deaf or hearing impaired Missouri relay Phone number Provider Appeals New Directions Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations Authorizations for outpatient services are required after the 8 th visit. MD/DO s and ARNP s do not require an authorization. Pre Certification is required for ALL inpatient services, including Partial and Intensive Outpatient services. No authorization is required for neuropsychological testing. Timely Filing Timely filing of claims is 365 days. Benefits Psychological testing is not a covered benefit. Neuropsychological testing is covered under the medical benefit. If you have any questions about Member benefits, please call Ball s Food customer service at Page 75

76 Claims Clean claims will be processed within 10 to 30 days. Paper Claims Paper claims should be mailed to: Freedom Network Select C/O Preferred Health Professionals PO Box Shawnee Mission, KS Ball s Food Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 76

77 Cerner CONTACT INFORMATION Toll Free Number Outpatient Notification New Directions Use Provider WebPass or fax to: Pre Notification Eligibility, Benefits and New Directions Use Provider WebPass or call: Claim Questions Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Kansas relay phone number Deaf or hearing impaired Missouri relay Phone number Provider Appeals New Directions Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations Pre notification is required after eight (8) outpatient visits will result in a reference number. ABA requires prior authorization from first visit. A reference number will then be assigned. (For Authorizations related to Autism services, please refer to the Autism Provider manual located under the provider section of Failure to get prior authorization may result in denial of payment. Refer to the member s plan for specific benefits and authorization requirements. Pre notification is required for inpatient services. No authorization is required for psychological or neuropsychological testing. Timely Filing Timely filing of claims is 365 days. Benefits If you have any questions about Member benefits, please use Provider WebPass or call New Directions Customer Service at Page 77

78 Claims: Clean claims will be processed within 10 to 30 days. To check the status of a claim, please call Health Exchange customer service at Electronic Claims Providers interested in filing electronic claims should use payer ID Paper Claims Paper claims should be mailed to: Health Exchange PO Box Kansas City, MO Health Exchange Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 78

79 HCA CONTACT INFORMATION Toll Free Number Outpatient Authorizations New Directions Use Provider WebPass or fax to: Pre Certification New Directions Use Provider WebPass or Call: Benefits, Eligibility and Claim Inquiries New Directions Use Provider WebPass or Call: Other Inquiries New Directions Provider Relations New Directions or Deaf or hearing impaired Kansas relay services Deaf or hearing impaired Missouri relay Phone number Provider Appeals New Directions Primary Requirements Providers/Facilities must use an NPI number in billing. Authorizations Authorization is required for all outpatient services after the twentieth (20 th ) visit. Pre Certification is required for ALL inpatient, residential, partial hospitalization and intensive outpatient services. Authorization is required for psychological testing after three (3) hours of testing. Authorization is required for neuropsychological testing after eight (8) hours of testing. Timely Filing Timely filing of claims is 180 days. Benefits If you have any questions about Member benefits, please use Provider WebPass or call New Directions Customer Service at Page 79

80 Claims To check the status of a claim, please call New Directions Customer Service at Electronic Claim: Use payer ID Paper Claim: Use Address: PHP/New Directions PO Box Shawnee Mission, KS HCA Customer Service: New Directions Behavioral Health Customer Service: Change in Demographics Please provide 45 days notice of any planned demographic changes, using the Provider/Facility update form. This form is found in the New Directions Provider and Facility Manual at Medical Records Medical records, if requested, are to be provided without charge. Page 80