Provider Orientation. Providers of Applied Behavior Analysis (ABA) for Autism Spectrum Disorders (ASD)

Transcription

1 Provider Orientation Providers of Applied Behavior Analysis (ABA) for Autism Spectrum Disorders (ASD) August 2012

2 Agenda Welcome to the network for members of Magellan s California companies*! California Senate Bill 946 Assessment and Treatment Planning, the Authorization Process Credentialing, Contracting and Re-Credentialing Claim Submission and Tracking Magellan Provider website Wrapping Up: Supporting the Provider with First-Class Service *Magellan s California companies are Human Affairs International of California and Magellan Health Services of California, Inc. Employer Services Magellan Health Services, Inc. 2

3 Welcome to the Magellan Network! You play an important role in serving members of Magellan s California companies. The Magellan organization is the leading behavioral health care management organization in the industry. With identification of children with autism spectrum disorders (ASD) increasing dramatically nationwide, coverage and services are expanding. Our customers are looking to us to provide full-service support for this disorder. On July 1, 2012, a Magellan company, Human Affairs International of California (HAI) will begin managing the autism benefits for Blue Shield of California, Blue Shield of California Life & Health Insurance Company and Western Health Advantage. Magellan Health Services, Inc. 3

4 California Senate Bill 946

5 California Senate Bill 946 Effective July 1, 2012, health plans and insurers are required to cover behavioral health treatment, including applied behavior analysis (ABA), for insured individuals diagnosed with autism spectrum disorders. Behavioral health treatment for ASD services must meet the following criteria: Treatment is prescribed by a licensed MD or psychologist. A treatment plan is prescribed by a Qualified Autism Service (QAS) provider. Treatment is provided by a QAS provider, or a QAS professional or QAS paraprofessional under supervision and employed by a QAS provider. Treatment is not intended to provide respite, day care or education. Magellan Health Services, Inc. 5

6 The Provider Role: Assessment and Treatment Planning, the Authorization Process

7 Expectations for ABA and Other Qualified ASD Providers: Assessment and Treatment Planning HAI dedicated autism care managers refer members to you You conduct initial functional assessment, confirm diagnostic evaluation and develop treatment plan You conduct follow-up and reassessment Obtain authorizations for additional services as needed Follow HAI s Utilization Parameters for Outpatient Behavioral Health Treatment and clinical practice guidelines Magellan Health Services, Inc. 7

8 The Authorization and Review Process Purpose: To authorize care based on a thorough assessment of the member s unique needs, with services delivered at the least intensive, appropriate level of care Authorization is the responsibility of the provider/program/facility Initial assessment and plan development is authorized in one hour blocks up to 8 hours Follow-up and reassessment is authorized in 15-minute blocks Magellan Health Services, Inc. 8

9 Authorization Determinations HAI will: Make an authorization decision based upon the initial telephonic assessment with you. Advise you of the ABA or other behavioral rehabilitative service type and units authorized, number of sessions or days authorized, and a start and end date for authorized services. Communicate authorization decisions by telephone and in writing. Offer the opportunity to discuss the determination with a physician advisor if we are unable to authorize the requested service(s) for clinical reasons. Magellan Health Services, Inc. 9

10 The Authorization and Review Process Do NOT submit the Magellan Treatment Request Form (TRF) if you are an ABA/other behavioral health rehabilitative services provider. Complete and submit the Autism Treatment Evaluation Checklist (ATEC); see subsequent instructions. This tool can be found at on the My Practice Page. Use the ATEC to obtain authorization for continuing ABA/rehabilitative services based on the member s benefit plan. Magellan Health Services, Inc. 10

11 Autism Treatment Evaluation Checklist (ATEC) Usage Providers must submit the Autism Treatment Evaluation Checklist (ATEC) to measure clinical/functional outcomes after an initial 15 days of service and each time a new treatment plan is submitted to request additional sessions ATEC tool consists of four domains: Speech/Language/Communication, Sociability, Sensory/Cognitive Awareness and Health/Physical Behavior Providers can use ATEC results to monitor treatment progress and to discuss progress with member as appropriate Families of individuals with ASD will be asked to complete a satisfaction survey regarding the services provided Magellan Health Services, Inc. 11

12 The ATEC Tool The ATEC will be accessible on the Magellan provider website Complete the form online and submit As with all our Web-based provider applications, ATEC data on the website will be secure Magellan Health Services, Inc. 12

13 Sample Authorization for ABA Services Treatment/ Billing Code Description Number of Units Duration Total Hours Authorized H Initial Assessment and Plan Development 4 1-hour unit/duration 4 H2019 Follow-up and Reassessment minute unit/duration 4 G9012 Supervision of ABA follow-up per 15 minutes minute unit/duration 4 Magellan Health Services, Inc. 13

14 Clinical Policy Resources Our Utilization Management Parameters for Outpatient Behavioral Health Treatment (ABA/rehabilitative services) require: Established DSM-IV diagnosis of pervasive developmental disorder A severe challenging behavior that presents a health or safety risk or significantly interferes with home or community activities Less intensive behavior treatment or other therapy has been considered or has been insufficient Patient is medically stable and does not require 24-hour medical/nursing monitoring Treatment plan should be established upon individualized goals, with measurable objectives Treatment plan should include parent/caregiver training and support Magellan Health Services, Inc. 14

15 Clinical Policy Resources (continued) Our utilization management parameters are based on scientific evidence. Magellan clinical leaders review the parameters annually, taking into consideration: Current scientific evidence Provider feedback. The UM Parameters are available at under Providing Care/Clinical Guidelines/Medical Necessity Criteria. Magellan Health Services, Inc. 15

16 Clinical Policy Resources CPGs AAP Guidelines The primary goals of treatment are to minimize the core features and associated deficits, maximize functional independence and quality of life, and alleviate family distress. Management of Children with Autism Spectrum Disorders, Myers et al, Pediatrics Magellan clinical practice guidelines: Magellan has adopted American Academy of Pediatrics (AAP) guidelines AAP guidelines call for more research on ABA s effect on health outcomes, treatment efficacy CPGs are available online at under Providing Care/Clinical Guidelines Magellan Health Services, Inc. 16

17 Provider Level Distinctions for ABA and Other Behavioral Rehabilitative Providers Initial assessment and plan development performed by masters/doctoral-level provider (QAS Provider) Follow-up and reassessment oversight/supervision by masters/doctoral-level provider (QAS Provider) or Follow-up and reassessment follow up by bachelors/noncertified support staff-level provider (QAS Professional, QAS Paraprofessional) Magellan Health Services, Inc. 17

18 Credentialing, Contracting and Re-Credentialing

19 Credentialing and Contracting To be a network provider, you must be both credentialed by Magellan and contracted with Magellan s California companies. Magellan accepts Council for Affordable Quality Healthcare (CAQH) information for credentialing; please provide CAQH number when requesting applications. As an accredited CVO, Magellan verifies with state boards and agencies, national certification boards, accrediting bodies and other applicable entities the status of a provider s: license, certifications, malpractice insurance, education and training. The California Network and Credentialing Committee reviews completed credentialing applications and renders credentialing decisions. Magellan Health Services, Inc. 19

20 Qualified Autism Service (QAS) distinctions: QAS Provider: a BCBA or licensed physician, psychologist, marriage and family therapist, educational psychologist, clinical social worker, or professional clinical counselor meeting criteria for Behavioral Analyst Master s/doctoral. QAS Professional: Associate Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, Behavior Management Program. QAS Paraprofessional: an unlicensed and uncertified individual employed and supervised by a QAS Provider with training, experience, and education certified by the QAS Provider. Magellan Health Services, Inc. 20

21 Group Contracting To be an in-network group provider, the group must be contracted with Magellan s California companies AND certain practitioners within the group must be individually credentialed by Magellan. A master s or doctoral level practitioner who is a member of a contracted group must be individually credentialed by Magellan to be eligible to receive ABA/rehabilitative services referrals as an in-network provider. A group member who leaves the group practice is no longer considered an in-network provider unless the practitioner is also contracted under an individual provider participation agreement with Magellan s California companies AND has an active Taxpayer Identification Number (TIN). Groups must notify Magellan when staff join or leave their practice. Magellan Health Services, Inc. 21

22 Re-Credentialing Must be completed once every three years. Magellan accepts CAQH for re-credentialing of practitioners only; please maintain your CAQH updates. You will NOT receive notification of the need to re-credential when a CAQH application is utilized; you will receive a letter notifying you of successful recredentialing. You will receive written notice prior to your credentialing anniversary date if you have not already completed a Magellan online re-credentialing form. Applications and re-credentialing notifications are mailed to all agencies/organizations prior to the credentialing anniversary. Return/complete re-credentialing applications within 30 days of receipt. Magellan Health Services, Inc. 22

23 Helpful Hints for Credentialing and Contracting (Practitioners) If possible, use CAQH (Universal Provider DataSource ) Make sure you indicate the one TIN number with which you will bill on your W-9 either your Social Security Number (SSN) OR Employer Identification Number (EIN) NOT BOTH Please note and explain in the comments section of the application any periods of unemployment of more than six months Keep copies of your completed contract and application Magellan Health Services, Inc. 23

24 The Quality Partnership A commitment to quality Magellan s California companies maintain a Continuous Quality Improvement (CQI) program Our providers are an integral component of the quality program Magellan s California companies obtain meaningful input from providers through: California Network & Credentialing Committee Annual provider satisfaction survey Provider Advisory Group We provide information to providers through: Provider Focus newsletter Provider forums and webinars Magellan provider website Magellan Health Services, Inc. 24

25 Claim Submission and Tracking

26 Magellan Claim Tips Claims with CPT or HCPCS procedures should be submitted on a 837P or CMS-1500 Hints for claim completion: Give complete information on the member (name, address, DOB) Give complete provider information TIN Individual provider name and degree Rendering provider name Billing pay to provider name and address National Provider Identification [NPI] number for both the rendering and billing provider Attach primary carrier s Explanation of Benefits when billing secondary coverage Include all HIPAA-compliant diagnosis codes (ICD-9 required) Include the appropriate billing modifier in conjunction with the HCPCS Magellan Health Services, Inc. 26

27 Claim Tips (continued) Top reasons for claim rejection/denials: Missing or invalid CPT/HCPCS code Missing or invalid diagnosis code Missing or inaccurate place of service code (NOTE: School is not a covered place of service) Missing name and/or degree level of provider (when required) Missing or invalid NPI Timely filing claims must be submitted within 90 days of the date of service Claim submitted to incorrect payer Magellan Health Services, Inc. 27

28 Claim Submission Example Sample autism related services fee schedule* Description CPT/HCP CS Codes Behavior Analyst (Modifier HO or HP) Assistant Behavior Analyst or Non-Certified Support Staff (Modifier HM or HN) Applied Behavior Analysis (ABA) Initial Assessment and Plan Development per hour up to 4 hours Applied Behavior Analysis (ABA) Follow-up & Reassessment per 15 min H0032 $ Not billed for HM or HN H2019 $18.00 $12.50 Supervision of ABA follow-up per 15 min G9012 $18.00 Not billed for HM or HN *Schedules may vary Modifier HP HO HN HM Description Doctoral level (board certified behavior analyst) Master s degree level (board certified behavior analyst) Bachelor s degree level (board certified assistant behavior analyst) Less than bachelor s degree level (non-certified support staff) Magellan Health Services, Inc. 28

29 Claim Submission Example (continued) Sample CMS-1500 claim form information to input Dates of Service Place of Service Procedures, Services or Supplies CPT/HCPCS Modifier Charges Units (Field 24A) (Field 24B) (Field 24D) (Field 24F) (Field 24G) 7/1/ H0032 HO $250.00** 2 7/28/12-7/30/ H2019 HM $187.50** 15 7/15/12 12 H2019 HP $72.00** 4 Note: The above samples are not inclusive of all possible billing codes and/or unit durations utilized by Magellan companies for autism services, which are subject to the provisions and limitations of the member s benefit plan. Billing codes and unit durations may vary by region. For the applicable rates, refer to the fee schedule attached to your provider agreement. **Total charge should reflect the number of units in 24G x the rate per unit for the billed procedure code (i.e., 4 = total charge) Magellan Health Services, Inc. 29

30 Claim Submission Options Three electronic submission options #1 Claims Courier Claims Courier (Submit a Claim Online) is a Web-based data entry application for providers submitting professional claims on a claim-at-atime basis Accessible after sign-in on Magellan s provider website Claims Courier streamlines the claims process by eliminating the middleman Claims Courier provides information on accepted or rejected claims No charge to the provider Magellan Health Services, Inc. 30

31 Claim Submission Options (continued) #2 Direct Submit Primarily for high-volume claim submitters, but there is no minimum number necessary for submission HIPAA-compliant 837 files can be sent directly to the appropriate California company HIPAA-compliant 277 files can be sent directly to provider to review for accepted or rejected claims Magellan offers providers the EDI Direct Submit testing application, which is an electronic claims tool available on an EDI-dedicated website at Direct Submit streamlines the process by eliminating the middleman No charge to the provider Magellan Health Services, Inc. 31

32 Claim Submission Options (continued) #3 Claims Clearinghouses Act as a middleman between the provider and Magellan companies, and can transform non-hipaa compliant format to compliant 837 Magellan companies accept 837 transactions from the following clearinghouses: PayerPath (formerly Mysis and also known as Allscripts) Capario (formerly MedAvant Healthcare Solutions and ProxyMed) Availity (formerly THIN) Emdeon Business Services (formerly WebMD) RelayHealth (also known as McKesson) Gateway EDI Office Ally HIPAA-compliant 277 files enable providers to review for accepted or rejected claims Note that there may be charges from the clearinghouses Magellan Health Services, Inc. 32

33 Checking Claims Status Sign in on the Magellan provider website Select Check Claims Status from menu Search for claim by member or subscriber name, date of service, etc. Can view claim details such as check number, date and payment method If claim is denied, reason code and description provided Contact instructions available if provider has questions Can view EOB online Magellan Health Services, Inc. 33

34 Magellan Provider Website

35 A secure location for your provider transactions. Sign in and get started! Magellan Health Services, Inc. 35

36 Magellan Secure Provider Website Access Initial sign-in for individual providers: User Name = MIS number (Magellan system identifier) Password = year of birth & last four digits of TIN/SSN (whichever number you bill under) Group users: User Name = Group MIS number Password = 2003 & last four of the group TIN Administrator grants access to other group personnel Facility users: Same process as Group users Magellan Health Services, Inc. 36

37 Magellan Secure Provider Website Features Check member eligibility (for most customer plans) Obtain an initial authorization for routine outpatient services (for specific customer plans) Check on authorization requests and download authorization reports Print authorization letters and EOBs online Submit a claim for professional services (CMS-1500) and check on claim payment status View your outcomes reports Complete your recredentialing application online Register for Electronic Funds Transfer Check your credentialing status and contracting status Magellan Health Services, Inc. 37

38 Magellan Provider Website Features Website demonstration on homepage Online provider orientation program provider Provider Focus behavioral health newsletter Electronic claims submission information HIPAA billing code set guides Medical necessity criteria and CPGs Clinical and administrative forms Cultural competency resources Demos of all our online tools/applications: go to Education/Online Training Behavioral health information for members Plus providers can direct members to the Autism Resource Center on the website for members of Magellan companies at Magellan Health Services, Inc. 38

39 Online Provider Data Changes On the provider site, edit your practice information whenever updates are needed Accurate provider data is key to effective provider transactions and communication Groups must notify Magellan when a practitioner leaves or joins their group Group association form must be completed to add a new group member Only a practitioner may request a change to his or her mailing address Requests to change financial addresses must be submitted in writing Magellan Health Services, Inc. 39

40 Wrapping Up: Supporting the Provider with First-Class Service

41 Our Commitment to You, the Provider In providing first-class provider service to you, we focus on: Prompt, accurate claims payment Ease of credentialing and recredentialing Healthy referral volume Easily accessible provider resources (clinical, training, consultation, outcomes tools, etc.) Secure transactions on our provider website to ensure privacy Personalized service when you need assistance Magellan Health Services, Inc. 41

42 Free Continuing Education Opportunities Continuing education (CE) credits available at no charge to our contracted providers through our online education partner, Essential Learning Sign in on the website to begin; navigate to Education/CEUs and CMEs Literally hundreds of specialized courses available to providers via Essential Learning At least four courses on treating ASDs are available through our site Magellan Health Services, Inc. 42

43 Provider Contacts and Help Your care management center phone number for eligibility, authorization and claims questions is available in the quick reference guides or on the back of the member s benefit card. Magellan California Provider Services Line: , option 4 [email protected] Magellan Health Services, Inc. 43

44 Thanks for Your Time! Questions?