Children s Rehabilitative Services (CRS) Provider and Community Program Overview October 2014

Transcription

1 Children s Rehabilitative Services (CRS) Provider and Community Program Overview October 2014

2 Agenda Sections Arizona Programs At-A-Glance CRS Program Overview Optum Behavioral Health Provider Billing CRS Contract Requirements, Important Contacts and Community Events 2

3 Arizona Programs At-A-Glance 3

4 Section II UnitedHealthcare Community Plan CRS Integrated Program

5 CRS Program Overview - Membership GSA # Counties CRS Members July Yuma, La Paz Mohave, Navajo, Coconino, Apache 1, MOHAVE (4) 521 YAVAPAI (6) 457 COCONINO (4) Flagstaff 612 NAVAJO (4) 304 APACHE (4) 6 Yavapai Gila, Pinal 1, Pima, Santa Cruz 4,046 Yuma 34 LA PAZ (2) 927 YUMA (2) 246 Phoenix GILA 14,239 (8) MARICOPA (12) 908 PINAL (8) 101 GRAHAM (14) 17 GREENLEE (14) 12 Maricopa 14, Cochise, Graham, Greenlee 533 3,764 PIMA (10) Tucson 282 SANTA (10) CRUZ 415 COCHISE (14) TOTAL 23,428 =MSIC location 5

6 CRS Program Overview - History Beginnings dates back to 1929 as the Arizona Society of Crippled Children Past operated as a specialty carve-out program under the Arizona Department of Health Services Today program is integrated for CRS specialty care, primary care and behavioral health services, under the Arizona Health Care Cost Containment System (AHCCCS)/Medicaid Agency The mission of the CRS program is to improve the health and quality of life for individuals who have certain medical disabling or potentially disabling conditions by providing family centered care, rehabilitation and related support services. 6

7 CRS Program Overview: Medical Eligibility Examples of Common CRS Eligible Conditions 1. Cerebral palsy 2. Club feet 3. Dislocated hips 4. Cleft palate 5. Scoliosis 6. Spina bifida 7. Cystic fibrosis 8. Heart conditions due to congenital deformities 9. Metabolic disorders 10. Muscle and nerve disorders 11. Neurofibromatosis 12. Sickle cell anemia AZ State Code on CRS Medical Eligibility Criteria CRS enrolls Members who require treatment for medically disabling or potentially disabling conditions as defined in A.A.C. R *For a complete listing of covered conditions, clarifications and excluded conditions go to the AHCCCS AMPM Policy Chapter 300, Exhibit ds/medicalpolicymanual/chap300.pdf 7

8 CRS Program Overview: Eligibility and Application Process CRS Eligibility Requirements: Individuals under 21 years of age who are enrolled in AHCCCS U.S. citizens or qualified aliens Arizona resident Diagnosed with a CRS covered condition CRS Application: Anyone can complete a CRS application, available online at: Completed applications can be Faxed to: OR Mailed to: AHCCCS-CRS Attn: CRS Enrollment 801 E. Jefferson St, MD 3500 Phoenix, AZ Questions: Call AHCCCS CRS Enrollment at

9 CRS Program Overview: CRS Coverage Types Fully Integrated Members receive all of their AHCCCS covered benefits from UnitedHealthcare Community Plan: CRS specialty services Primary Care services Behavioral Health services This coverage type applies to the majority of CRS Members Partially Integrated BH Members enrolled in CMDP (foster care) or DDD receives these benefits from UnitedHealthcare Community Plan: CRS specialty services Behavioral Health services Members will receive primary care from their CMDP or DD health plan. Partially Integrated Acute American Indian (AI) Members receive these benefits from UnitedHealthcare Community Plan: CRS specialty services Primary Care services Members will receive their behavioral health services from a Tribal Regional Behavioral Health Authority (RBHA). CRS Only American Indian (AI) Members receive these benefits from UnitedHealthcare Community Plan: CRS specialty services Members will receive primary care from their primary program of enrollment and behavioral health services from: CMDP AI Members from a Tribal RBHA DDD AI Members from a Tribal RBHA AI Fee for Service Members from a Tribal RBHA 4 CRS coverage types All Members get CRSrelated/specialty services Acute care and behavioral health (BH) services available by coverage type One-time option at age 20 to remain enrolled past 21 st B- day American Indian (AI) Members can be in any one of the 4 coverage types 9

10 Multi-Specialty Interdisciplinary Clinic (MSIC) Assigned CRS Health Home Metro Phoenix DMG Children s Rehabilitative Services 3141 N 3 rd Avenue Phoenix, AZ Services available CRS Specialty New Primary Care Expanded Behavioral Health Services Southwestern Region Tuscany Medical Plaza Yuma CRS Clinic 2851 S Avenue B Suite 25 Yuma, AZ Services available CRS Specialty New Primary Care Southern Region Children s Clinics Rehabilitative Services 2600 N Wyatt Tucson, AZ Services available CRS Specialty New Primary Care Expanded Behavioral Health Services Northern Region Children s Rehabilitative Services at Flagstaff Regional Medical Center 1200 N Beaver Flagstaff, AZ Services available CRS Specialty 10

11 CRS Program Overview: MSIC Based Contacts CRS Program Administration Phone FAX Site Location Yuma Recruiting TBD TBD TBD Yuma MSIC Adriana Molina (602) (855) Phoenix MSIC Whitney Alli (602) (866) Phoenix MSIC Ana Lievanos (520) (855) Tucson MSIC Josie Vaughan (928) (855) Flagstaff MSIC CRS Clinical Liaisons Phone Fax Site Location Kari Hartwick (602) ext (866) Phoenix MSIC Marta Urbina (602) Ext (855) Phoenix MSIC Tobie Bardsley (602) (855) Flagstaff MSIC Irma Guzman (520) (888) Tucson MSIC Dina Hernandez (928) (866) Yuma MSIC 11 Note: CRS Clinical Liaisons and Admin Reps are located at the local MSICs and are available to help with Care Coordination, AHCCCS/CRS enrollment issues and provider questions

12 CRS Program Overview: Transportation and MTBA Coverage Type CRS Acute BH Notes Transportation by MTBA/United CRS Fully Integrated X X X Members receive all services from UnitedHealthcare including Acute health, behavioral health and CRSrelated services Acute Med Y CRS Med Y BH - Y CRS Partially Integrated-Acute X X American Indian (AI) Members receive all acute health and CRS-related services from UnitedHealthcare and have the option to receive behavioral health services from a Tribal RBHA Acute Med Y CRS Med Y BH 1 st Appt. Only, then becomes responsibility of T/RBHA CRS Partially Integrated-BH X X CMDP or DDD Members receive all behavioral health and CRS-related services from UnitedHealthcare tor and receive acute health services from the primary program of enrollment (CMDP or DDD) CRS Med Y BH Y Acute Med N, contact CMDP or DDD health plan CRS Only X For AI Members enrolled in either CMDP or a DDD health plan. Members receive all CRS-related services from the CRS Contractor and receive acute health services from either CMDP or their DDD health plan. Members have the option to receive behavioral health services from UnitedHealthcare a Tribal RBHA CRS Med Y BH N Acute Med N, contact CMDP or DDD health plan MTBA or For routine appointments, Members need to call at least 72 hours before their appointment For transportation to a medical urgent care center the Member can call any time, any day of the week For crisis, call the existing RBHA Crisis Lines 12

13 CRS Program Overview: CRISIS NETWORK Same crisis 24/7 numbers as used by the RHBAs Area Code Crisis Line Crisis Vendor Crisis Response Network Crisis Response Network Crisis Response Network Northern Arizona Crisis Response Network Protocol 928 Southern Arizona Nursewise 13

14 CRS Program Overview: CRS Prior Authorization The prior authorization list is available online in the Provider Forms section located at: Showing only BH Requirements. Full CRS PA list for medical available online. 14

15 CRS Program Overview: CRS Prior Authorization Pharmacy The list of CRS covered pharmacy drugs is available online under the Pharmacy Program section located at: A CRS covered drug is determined by the Member s CRS Coverage Type 15

16 CRS Program Overview: BH Guideline Level II Adult and Pediatric CRS Behavioral Health Level II Residential treatment Guideline is in DRAFT form and will be available via the Provider Portal under Clinical Guidelines located at: 16

17 CRS Program Overview: Inpatient Utilization Management All acute facility Inpatient Admissions require authorization Clinical review will be conducted initially to ensure clinical criteria is met for an acute admission. Continued utilization will be performed every 2 days until discharge All Residential Treatment Centers Level I require authorization Clinical review will be required prior to admission to ensure the member meets the criteria for this level of care All Residential Treatment Centers Level II require authorization Clinical review is conducted initially and monthly until discharge Facility Provide notification to UnitedHealthcare Community Plan by contacting the Prior-Authorization Intake Department (call) or (fax) Questions regarding psychiatric inpatient or RTC Level I / Level II, call CRS Placement Nurse: Tiffany Paprocki, RN (office) and (fax) Initiates and participates in discharge planning with CRS Care Team 17

18 CRS Program Overview: Notice of Action UnitedHealthcare Community Plan sends a Notice of Action (NOA) to the member when a prior authorization request is denied. UnitedHealthcare Community Plan has 14 days to make a determination Three days for Urgent requests The requesting provider receives a Notice of Non-Coverage (NONC). Only prior authorized services are noticed of action and member appeal rights given. CRS members should not be sent a RBHA NOA when there is a change in service plan. If a member is being closed to services due to non-compliance or unable to contact after three attempts, then CRS members should be sent your agency s closure letter. Please outreach to the Clinical Liaison if you are having trouble prior to closing to see if the Clinical Liaison can assist in locating the members, etc. Send copy of the closure letter to Clinical Liaison. 18

19 CRS Program Overview: Appeals & Grievances If a service request has been denied and the member disagrees, an Appeal may be filed. This can be done by the Member or Provider on behalf of the member. Members may file a Grievance (complaint) if they are not happy with their doctor or any part of their health care. An Appeal or Grievance may be filed verbally or in writing Appeals Grievance Member Services UnitedHealthcare Community Plan Attn: Appeals Department 1 East Washington Phoenix, AZ UnitedHealthcare Community Plan Attn: Grievance Coordinator 1 East Washington Phoenix, AZ

20 CRS Program Overview: CRS High Risk Case Management When a CRS High Risk Case manager may be needed: Member has court ordered treatment or court ordered evaluation Member is designated as SMI Member s CASII score is 4 or higher CRS High Risk Case Manager can assist with the following: Attend CFTs Assist with Prior-auth process Helping to resolve barriers to care Coordinate with Community partners for a member (DDD, CPS, school systems, etc.) Work collaboratively with high needs cases manager & care coordinators from CRS contracted BH providers Member is unstable in the community with the current service plan Member Transition 20

21 CRS Program Overview: CRS High Risk Case Managers High Risk Case Managers Phone FAX Site Location Judy Smith, LCSW Northern Arizona Mary Krawczyk, LCSW Southern Arizona and COE/COT/SMI Pamela Ray, RN Central Arizona Last Names beginning with A-L Shannon Lopez, RN Central Arizona Last Name beginning with M-Z 21

22 CRS Program Overview: SMI Determination CRS enrollment extends past a member s 21 st birthday, if member chooses to Opt In 60 days prior to their 21st birthday. CRS members who are determined to be SMI continue enrollment in CRS as long as the individual continues enrollment in AHCCCS and has a CRS eligible medical condition. CRS members who are SMI do not transition to Mercy Maricopa Integrated Care (MMIC). They remain with UnitedHealthcare Community Plan CRS. Each RBHA has contracted providers who CRS uses to process SMI referrals and make determinations on SMI eligibility. When a CRS member is determined to be SMI, the determination information must be sent to UnitedHealthcare Community Plan, specifically to Mary Krawczyk s fax (855) Mary will assign member to a contracted CRS SMI clinic or agency, and oversee their care plan along with our BH partners. 22

23 CRS Program Overview: CASII (Ages 6 18) Child and Adolescent Service Intensity Instrument (CASII) is a tool to determine the appropriate level of care placement for a child or adolescent. To properly integrate and coordinate care, the BH provider should send the CASII assessment/result/score to the Clinical Liaison located at the Member s assigned MSIC (medical home). The Clinical Liaison will review and add this information to the member s CRS Integrated Service Plan Minimally should be completed after opening to care and subsequent change in condition Under age 6, utilize existing agency assessment tool 23

24 Section III Optum Behavioral Health CRS Behavioral Health Services

25 CRS Program Overview: Optum/UHCCP Relationship Optum Behavioral Health is our partner, who has contracted a CRS statewide Behavioral Health Network, and is responsible for contracting, training and provider services UnitedHealthcare Community Plan administers CRS BH benefits for the program Benefits Services Dual Medicaid/Medicare Commercial Contracting Provider Training Provider Services Specialty Pharmacy Medicare Advantage Revenue Cycle Management Tricare 25

26 CRS Program Overview: Behavioral Health Services Counseling Services Individual, Family, Group Therapy Treatment Services Assessment, Evaluation and Screening Support Services Family, Peer, Home Care Training, Supported Housing, etc. Behavioral Health Day Programs Inpatient Services Hospital, Sub-Acute, and Residential Treatment Centers (RTC) Crisis Intervention Services Psychiatry Services Medication Management Outpatient Substance Abuse Services Assessment, Counseling, Medication Assisted Therapy 26 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

27 CRS Program Overview: CRS Behavioral Health Network Network providers include: Community Mental Health Centers Substance Use Disorder Agencies Inpatient Facilities Behavioral Health Outpatient Clinics Community Service Agencies Residential Care Facilities (Levels I, II, and III) Peer Support Providers Crisis Services HCTC Providers Multi-specialty Interdisciplinary Clinics (MSIC) Clinician Types: Psychiatrists Psychologists Master Level Clinicians Nurse Practitioners 27 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

28 CRS Program Overview: How to Find a Doc Medical Providers ldrens-rehabilitative-services/find-a-provider.html Behavioral Health Providers 9&lang=en&eapCert=false&trans= 28

29 CRS Program Overview: BH Provider Responsibilities Coordinate care with the Member s CRS MSIC (assigned CRS Health Home), UnitedHealthcare Community Plan staff, and within the CRS provider network Follow CRS Prior Auth requirements Provide services to Members in a non-discriminatory manner Provide BH service plans to Clinical Liaison at the MSIC Provide any incident report to Clinical Liaison at the MSIC; if applicable Send crisis plan to Clinical Liaison at the MSIC; if applicable Refer to CRS contracted providers Invite CRS to CFT's Follow AHCCCS Appointment Standards: Emergency Appointment: Same day or within 24 hours of referral Urgent Care Appointment for CMDP Member: 72 hours after notification Initial Services: Within 7 days of referral Ongoing Services: Within 23 days of initial appointment 29

30 Section IV Provider Billing

31 Provider Billing: UnitedHealthcareOnline.com 31 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

32 Provider Billing: Checking Member Eligibility UnitedHealthcareonline.com 32 View eligibility information and identify to which program(s) a Member belongs by searching using the Alpha Search option and entering the Member s Name and Date of Birth Doc#: UHC2595t_ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

33 Provider Billing: Checking Member Eligibility UnitedHealthcareonline.com Select Details for the program information and to view the Member s ID Card, which will show the Member s correct Member ID Card Number. 33 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

34 Provider Billing: Checking Member Eligibility UnitedHealthcareonline.com To view the Member s correct ID Number select View Patient s ID Card Another window will open showing you the correct Member ID Number 2xxxxxxxx x 34 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

35 Provider Billing: Claims and Payments UnitedHealthcareOnline.com 35 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

36 Provider Billing: Help Functions UnitedHealthcareOnline.com In the Help section, (link in upper right corner), you can find Quick Reference Guides, Frequently Asked Questions and other helpful information 36 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

37 Provider Billing: Quick Reference Guides UnitedHealthcareOnline.com Quick Reference Guides provide tips and information on a variety of topics. 37 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

38 Provider Billing: Placement of NPI Number for Behavioral Health Claim Box 24J In the non-shaded field, enter the AHCCCS-registered NPI number (individual provider or sitespecific NPI) Behavioral Health Providers NPI # for the site where the services are rendered or the clinician listed on the roster s NPI 38

39 Provider Billing: Placement of Billing Group/Agency for Behavioral Health Claim Provider / Group / BH Agency name, address and phone number XYZ Agency 1234 Data St Phoenix, AZ Box 33a Provider / Group / BH Agency AHCCCS-registered NPI number 39

40 Provider Billing: Diagnosis Codes for Behavioral Health Claim The CMS Form 1500 was revised effective April 1, 2014 and is the only claim form that is now accepted. The revised form includes an ICD indicator and an increase in the number of diagnosis codes that can be reported. In addition, several fields were removed. AHCCCS does not accept DSM-IV diagnosis codes. AHCCCS does accept ICD-9 codes. The implementation of ICD-10 has been extended to October 1, More updates to come. Enter at least one ICD-9 diagnosis code describing the patient s condition Behavioral Health providers must not use DSM-IV diagnosis codes Up to 12 diagnosis codes, in priority order, may be entered (i.e. primary condition, secondary condition, etc.) In support of industry standardization and a uniform provider experience, we will continue with the DMS-5 implementation effective October 1, 2014, as previously announced

41 Provider Billing: Reminder Providers need to bill all same services on one line item with the corresponding number of units. Incorrectly Billed: Correctly Billed: 41 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

42 Provider Billing: Duplicate Denials All services for one Member, one date of service, provided by same provider must be billed on one claim form. If you are billing for multiple dates of service, please ensure all billable services are listed for the dates of service. * Providers will receive duplicate denials if multiple claims are submitted for the same day, for the same Member, by the same provider. The exception to these denials are when one of the following apply: Different procedure codes Different modifiers Different NDC numbers are listed Different place of service (POS) listed Services billed by provider of different specialty All services billed on a UB-04 form need to be listed on one claim form. Multiple claim form submissions will be denied as duplicate. - System was updated on July 6 th and claims projects are underway - * If a correction is needed to submit additional services, please rebill a corrected claim for all services. For repeat services by the provider on the same day, the appropriate modifier should be applied. 42 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

43 Provider Billing: Submitting Corrected Claims How to submit corrected Behavioral Health claims: Corrected claims can be submitted electronically by placing a frequency type code of 7 (replacement of prior claim/correction) in the appropriate loop/segment of the 837p transaction to payor ID # Corrected claims can be submitted on paper, with Corrected on the top of the claim form and the previous claim number located in box 22 of the CMS Form-1500 (claim form). UnitedHealthcare Community Plan Optum P.O. Box Salt Lake City, UT Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

44 Provider Billing: April 1, 2014 Changes 44

45 Provider Billing: April 1, 2014 Changes (cont d) 45

46 Provider Billing: April 1, 2014 Changes (cont d) 46

47 Provider Billing: Resources Provider Services: Claims Information UHCOnline.com: Website Customer Support EFT/EDI: EFT/EDI Set-Up and Customer Support Optum Insight: option 2 ERA information Member Services: Eligibility Prior Authorization Clinical Services 47

48 Section V CRS Contract Requirements, Important Contacts and Community Events

49 Recredentialing & Notification Requirements Re-credentialing Providers are recredentialed every 3 years Optum sends notification nine months and again at six months prior to the credentialing expiration date Providers receive an urgent notification if no response to recredentialing notifications have been received 90 days prior to credentialing expiration Providers are required to resubmit: Proof of Accreditation Licensure Insurance Contractually-required Notifications Address Changes Roster Updates Temporary Hold for Referrals Mergers 49 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

50 CRS Program: Important Contacts Kristen Challacombe, MSW VP, CRS Program Management (602) Laurie Ganzermiller CRS Operations Manager (602) Leslie Paulus, MD, PhD, FACP Medical Director (602) F [email protected] Heidi Esposito CRS Program Administration Manager (enrollment) (602) [email protected] Judith A. Walker (Judie) Ombudsman/Member Advocate (602) [email protected] Braulio Gomez, MBA Director, Network Services, Western Region (602) [email protected] Erica Goble, MBA Network Manager, Behavioral Network Services (612) [email protected] Stephen Back Network Associate, Behavioral Network Services (602) [email protected] Or us at: [email protected] 50

51 51 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

52 Closing Comments Thank You! 52