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1 Please stand by There is no audio being streamed right now. We are doing a audio/sound check before we begin the presentation 2/9/2016 1

2 Webinar Tips Today s webinar is a one-way audio broadcast through the participants computer speakers or phone devices. For best results, please dial in from a land line. The toll free number and access code were provided in the notice. You may send your questions using the Chat tool. At the top of your screen, use the drop down and select Chat. The chat box will appear on the right side of your screen. Questions will be addressed at the end of the webinar. Please let us know if you are viewing this presentation with other people from your office. Just type in the chat box the number of attendees; names are not necessary. The information we gather will be used for attendance and education reporting purposes. 2/9/2016 2

3 To ask a question or make a comment: 1. Click on the Chat icon at the top 2. Send to: HOST 3. Type your message in the Chat space here. 2/9/2016 3

4 Upcoming HMSA Provider Trainings Applied Behavioral Analysis Provider Training 12/30/15 New Provider Orientation Webinar 1/20/16, 2/17/16, 3/16/16, 4/20/16, 5/18/16, 6/15/16, 7/20/16, 8/17/16, 9/21/16, 10/19/16, 11/16/16 & 12/21/16 Cozeva Provider Training 1/13/16 Pay For Quality for Primary Care Providers 1/28/16 2/9/2016 4

5 Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder (ASD) December

6 Agenda HRS Chapter 431, Article 10A Eligibility - Providers Eligibility HMSA Members Mandated Benefits Prior Authorization Process Forms Criteria Claims Filing Requirements Deadlines HMSA Provider Resources 2/9/2016 6

7 Applied Behavior Analysis Therapy HRS Chapter 431, Article 10A Effective January 1, 2016 Applied Behavior Analysis Necessary to develop, maintain, or restore to the maximum extent practicable, the functioning of an individual; and Provided or supervised by an autism service provider Diagnosis and Treatment of Autism Medically necessary assessments, evaluations or tests conducted to diagnose whether an individual has autism determined by evidence based studies Treatment for autism must be prescribed/ordered by a licensed physician, psychiatrist, psychologist, clinical social worker or registered nurse practitioner Does not apply to Disability, Medicare, Medicare Supplement, Student accident and health or sickness insurance, Dental only, Vision only plans. 2/9/2016 7

8 Applied Behavior Analysis Therapy HRS Chapter 431, Article 10A Eligible Members: Commercial Plans Children with autism under 14 years of age Note: Currently a benefit for QUEST Integration Children under age 21 years of age. Eligible Providers Board Certified Behavioral Doctorate (BCBA-D) Board Certified Behavioral Analyst (BCBA) Board Certified Assistant Behavioral Analyst (BCaBA)* Registered Behavior Technician (RBT)* performing under supervision of a BCBA, BCaBA, or BCBA-D *Formal agreements must be in place with a Supervising BCBA/ or BCBA-D. 2/9/2016 8

9 HMSA Provider Credentialing Who May Apply for Credentialing? Currently accepting Autism Program applications from select Clinics/Organizations that meet credentialing requirements (Accreditation will eventually be required) Accepting Individual Applications for Licensed BCBA or BCBA-D only starting January 1, The Following are Ineligible to Apply for Credentialing: *BCaBA *RBT Any Unlicensed Individual *Formal agreements must be in place with a Supervising BCBA/ or BCBA-D. 2/9/2016 9

10 HMSA Provider Credentialing What Other Provider Types are Qualified to Directly Render ABA Services? Psychiatrists: General Psychiatrists: Child/Adolescent Psychologists Other Licensed Professional Demonstrating Adequate Training and Competence How Long Will the Credentialing Processes Take? Approximately 60 Days (Contracting will require additional time) 2/9/

11 Applied Behavior Analysis Therapy HRS Chapter 431, Article 10A Mandated Benefits Autism diagnosis and treatment; must include treatment plan Applied Behavior Analysis evaluation of environmental modifications using behavioral stimuli and consequences to improve human behavior Commercial Plans - Maximum benefit of $25,000 per year (ABA only); Note: QUEST Integration no max benefit. Copayment, deductible and coinsurance provisions apply Excludes coverage for: Care that is custodial in nature; Services and supplies that are not clinically appropriate; Services provided by family or household members; Treatments considered experimental; and Services provided outside of the State of Hawaii* *Note Subject to review; HMSA plans may recognize services outside of Hawaii 2/9/

12 Applied Behavior Analysis Therapy HRS Chapter 431, Article 10A Prior Authorization Not required for screening or diagnostic evaluation Required for trial period of ABA treatment Required for initial assessment and treatment plan development, provision of ABA services and re-evaluation continuing ABA treatment. Will be approved for ongoing services (up to benefit maximum of $25,000) when patient is demonstrating documented improvement Refer to HMSA Medical Policy for policy description and codes at: vior_analysis_therapy_for_treatment_of_autism_spectrum_disorder_ pdf 2/9/

13 Applied Behavior Analysis Therapy HRS Chapter 431, Article 10A Prior Authorization Process Prior authorization requests must be submitted via Fax # using the HMSA Precertification Request form located in the HMSA Provider Resource Center Form.pdf Must include clinical notes that document the patient s developmental delays, initial assessment and treatment plan Must be submitted two (2) weeks prior to services being rendered 2/9/

14 Prior Authorization Review Process A qualified provider diagnosed ASD. Diagnosis does not require Prior Authorization Treating provider submits a PA request for Initial Assessment and Treatment Plan development. HMSA Utilization Review clinician reviews PA request and notifies the requester. Provider conducts Functional Assessment and creates Treatment Plan. Once the initial assessment is completed, the treating provider submits a PA request for ABA treatment. HMSA UR Clinician reviews PA for ABA Treatment and notifies Provider. 2/9/

15 HMSA ABA Prior Authorization Form APPLIED BEHAVIOR ANALYSIS PRECERTIFICATION REQUEST Please fax completed form to: (808) PROVIDER CONTACT INFORMATION Any questions or concerns regarding this request may be directed to: Or Mail to: HMSA Medical Management Department P. O. Box 2001 Honolulu, Hawaii Phone Nos: (808) Oahu (808) Neighbor Island Contact Name (First, Last) Phone Number Fax Number A. MEMBER INFORMATION Membership Number Patient s Name (Last, First, MI) Date of Birth Subscriber s Name (Last, First, MI) Phone number B. ICD-10-CM DIAGNOSIS CODE(S) Diagnosis Code(s): C. TREATMENT INFORMATION Place of Service: Home Clinic Other CPT Code Modifier Units Per Week CPT Code Modifier Units Per Week Requested treatment type (check only one): Assessment/Re-assessment ABA Trial ABA Treatment Estimated Start Date: Estimated End Date: Duration in Weeks: D. PROVIDER INFORMATION Supervising Provider Name Provider ID Provider Credentials Rendering Provider Name Provider ID Provider Credentials E. BCBA/BCBA-D ATTESTATION My signature below confirms that any paraprofessional under my supervision is certified as a BCaBA or RBT and will be supervised according to the Behavior Analyst Certification Board requirements. Requesting Provider Signature Requesting Provider Name Date Provider Credentials F. NOTES Requests for assessment must include comprehensive diagnostic evaluation completed by diagnosing provider. Requests for ABA treatment must include functional assessment and treatment plan. CPT codes 0359T, 0360T, 0362T, 0364T, 0366T, 0368T, 0370T, 0371T, 0372T and 0373T can be submitted only once per day. 2/9/

16 Applied Behavior Analysis Therapy HRS Chapter 431, Article 10A Claims Filing HMSA claims filing instructions can be found in the HMSA Provider Resource Center at Submission deadline: 1 year from date of service; claims filed after one year from date of service are not payable Must be legible; do not use red ink, highlighter; must use Arial or Times New Roman font with font size of 8-10 that is bolded using black or dark blue ink Computer printed or typed claims are preferred (note: handwritten claims may result in delayed processing) When patient is referred to you for service, please be sure to complete block 17 of the CMS 1500 claim form 2/9/

17 HMSA Provider Resources HMSA supports providers through excellent and friendly provider phone servicing staff: Customer Relations for routine questions, claims status and benefits. Call on Oahu; 1 (800) from the Neighbor Islands QUEST Integration Provider Service. Call on Oahu; 1 (800) from the Neighbor Islands BlueCard Tele-Service. Call on Oahu; 1 (800) from the Neighbor Islands Provider Data Administration Call on Oahu; 1 (800) ext toll-free on the Neighbor Islands Medical Management for preauthorization request questions, medical policy. Call on Oahu; 1 (800) from the Neighbor Islands

18 Click Learn More 2/9/

19 HMSA Provider Resource Center 2/9/

20 HMSA Provider Resource Center Applied Behavior Analysis Medical Policy or_analysis_therapy_for_treatment_of_autism_spectrum_disorder_ pdf Applied Behavior Analysis Pre-Certification Form Form.pdf 2/9/

21 Questions? Webinar participants: Please use the drop down menu at the top of your screen and select CHAT. Use the Chat box to type your questions. Please complete the Evaluation form and fax it to Mahalo! 21

22 Mahalo! Living healthy and enjoying life to the fullest. That s what we re striving for. 2/9/