Magellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP)

Transcription

1 Magellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP) 2014 Magellan Health Services

2 Table of Contents SECTION 1: INTRODUCTION... 3 Welcome... 3 Covered Services... 3 Contact Information... 3 SECTION 2: MAGELLAN S BEHAVIORAL HEALTH NETWORK... 4 Types of Providers... 4 Credentialing... 5 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN... 8 Care Management Overview... 9 Before Services Begin Functional Assessment Concurrent Review Appealing Care Management Decisions Member Access to Care Continuity, Coordination and Collaboration Medical Necessity Criteria SECTION 4: THE QUALITY PARTNERSHIP Complaint and Grievance Process Appeals SECTION 5: PROVIDER REIMBURSEMENT Claims Filing Procedures Magellan Health Services, 4/14

3 SECTION 1: INTRODUCTION Welcome Welcome to the Autism Support Program (ASP) Provider Handbook Supplement. This document supplements the Magellan National Provider Handbook, addressing policies and procedures specific for the ASP plan. This provider handbook supplement is to be used in conjunction with the Magellan National Provider Handbook (and Magellan organizational provider supplement, as applicable). When information in this supplement conflicts with the national handbook, or when specific information does not appear in the national handbook, the policies and procedures in the ASP supplement prevail. The Autism Support Program is administered by Magellan through a contract with the Iowa Department of Human Services. The program is primarily designed to cover applied behavior analysis (ABA) services for children with Autism who would clinically benefit for such treatment. The Autism Support Program will assist non-medicaid covered families with incomes at or below 400 percent of the federal poverty level by providing coverage from the State for ABA services (with cost sharing from the family). Families on Medicaid can access ABA services through the Iowa Plan, which is also administered by Magellan. Applied behavior analysis is the use of techniques and principles that bring about meaningful and positive change in behavior. It is an approach that has been successfully used by Iowa providers with children who have an autism spectrum disorder diagnosis and their families who also benefit from the behavior adaptation of the child. It has demonstrated outcomes that improve how a child functions within the home and in the community. The Autism Support Program is for children who have a diagnosis within the autism spectrum, do not qualify for Medicaid coverage and do not have coverage through their own commercial insurance plan. Specific criteria include; a child less than nine years of age who has been diagnosed with autism based on a diagnostic assessment of autism, is not otherwise eligible for coverage for applied behavioral analysis treatment under the medical assistance program, Iowa Code section 514C.28 or private insurance coverage, and whose household income does not exceed 400 percent of federal poverty level. Covered Services The following information is in regards to Applied Behavior Analysis services, the process for which the services are managed through Magellan Health Services. Contact Information PO Box Des Moines, IA Phone: Fax: Magellan Health Services, 4/14

4 SECTION 2: MAGELLAN S BEHAVIORAL HEALTH NETWORK Types of Providers Magellan is dedicated to recruiting and retaining individual practitioners and group practitioners with the behavioral health care credentials Board Certified Behavior Analysts (BCBA) to provide member care and treatment across a range of settings. Magellan refers members to credentialed and contracted practitioners in private practice, practitioners in a group practice, and provider organizations including facilities and agencies. Magellan refers members to credentialed and contracted providers in the following categories: Individual Practitioner a behavior analyst who provides applied behavior analysis and bills under his or her own Taxpayer Identification Number. Individual practitioners must meet Magellan and/or other applicable credentialing criteria (See Appendix B) and have a fully executed provider agreement with Magellan. Group Practice a practice contracted with Magellan as a group entity and as such bills as a group entity for the services performed by its Magellan-credentialed practitioners. Behavior analysts affiliated with the group must complete the individual credentialing process, and the group must have at least one active/credentialed group member in order to be eligible to receive referrals from Magellan. Agencies- an organization governed by a board of directors with policies and procedures to monitor all activities including clinical treatment, quality measures, safety of the structure, member engagement, etc.. A behavior analyst may be a staff member of an agency and provide services as long as the agency has met the credentialing and contracting requirements. Your responsibility is to: Provide Magellan with a complete Form W-9 for the contracting entity to facilitate referrals and claims processing; Notify Magellan and complete a new Form W-9 if your contracted entity changes, e.g., if you leave a group practice or new provider join a contracted group practice; Notify Magellan of any changes to the list of practitioners in your group or agency within 10 business days; Notify Magellan of changes in your service location, mailing and/or financial address information; and Adhere to the credentialing policies outlined in this handbook. Magellan s responsibility is to Review providers and prospective providers for credentialing or re Magellan Health Services, 4/14

5 credentialing without regard for race, color, creed, religion, gender, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical disability, or any other status protected by law; Develop and implement recruitment activities to solicit providers reflective of the membership we serve, subject to applicable state laws; and Make website-based tools available to providers so they can update their practice information, including Form W-9 data, in a convenient online fashion Magellan Health Services, 4/14

6 SECTION 2: MAGELLAN S BEHAVIORAL HEALTH NETWORK Credentialing To Do Magellan is committed to the provision of quality care to our members. In support of this commitment, practitioners and organizations must meet or exceed a set of credentialing criteria to be eligible to provide services to our members. Participating practitioners, groups and organizations must have an executed agreement with Magellan. The agreement sets out expectations on Magellan s policies and procedures, provider reimbursement, and terms and conditions of participation as a network provider. Magellan standards for provision of applied behavior analysis (ABA) require that behavior analysts that provide ABA services independently or with a group or agency, meet specific criteria. Provide a Magellan Participation Agreement to individual practitioners, groups or organizations identified for participation in the Magellan provider network; Execute the agreement after you or the group members has successfully completed the credentialing process and you have completed, signed and returned the agreement to Magellan; Execute the agreement after your organization has successfully completed the credentialing process (for all locations listed on the agreement) and you have completed, signed and returned the agreement to Magellan; Provide the fully executed agreement, signed by both parties, for your records; and Comply with the terms of the agreement, including reimbursement for covered services rendered. Practitioners and organizations must meet the credentialing criteria and agencies must provide the documentation that supports the following for their staff to be credentialed for ABA services. A behavior analyst masters/doctorial practitioner must meet criteria Certification and/or state licensure: Must meet at least one of the following: a. Be a Board Certified Behavior Analyst (BCBA) through the Behavior Analyst Certification Board (BACB); or b. Hold a state-issued license, certificate, registration, credential or other designation as a behavior analyst; or Magellan Health Services, 4/14

7 c. Meet Magellan s current individual practitioner credentialing criteria as a licensed behavioral health provider as the coursework and supervision indicated in the following criteria: Coursework: Masters degree or Doctorial degree in psychology, social work, professional counseling, or other human services related field, with coursework that includes, at a minimum, 40 coursework hours in behavior analysis, behavior management theory, techniques, interventions and ethics; and autism spectrum disorders; and Supervised experience: At a minimum, one year (1500 hours) supervised clinical experience inclusive of: i. Minimum one year direct care services to children; and ii. Minimum one year direct care utilizing applied behavior analysis, behavior techniques, interventions and monitoring of behavior plan implementation; and iii. Experience must have included work with individuals with Autism Spectrum Disorders 2. Covered by professional Liability insurance limits of $1,000,000 per occurrence, and $1,000,000 aggregate; 3. No sanctions or disciplinary actions on BCBA or BCBA-D certification and/or state licensure; 4. May not have Medicare/Medicaid sanctions or be excluded from participation in Federally funded programs (OIG-LEIE listing, System for Award Management (SAM) listing and state Medicaid sanctions listings); and 5. Must have a completed criminal background check to include Federal Criminal, State Criminal, County Criminal, and Sex Offender reports for the state and county in which the behavior analyst master sdoctorial is currently working and residing. a. Evidence of this background check is provided by the behavior analyst master s-doctoral or by the employer; b. Criminal background checks must be performed at the time of hire and at least every five years thereafter; and c. Behavior analysts Masters/Doctoral that Magellan will be contracting as solo practitioners must have background checks current within a year prior to initial application for network participation. Background checks must be performed at least every five years thereafter Magellan Health Services, 4/14

8 Criteria for Paraprofessionals Applicants must meet A, B, C and D and to be considered as behavior analyst support staff: A. Education: Minimum of bachelor s degree in human services or education field. B. Training: 40 hours minimum in applied behavior analysis by recognized organization such as: 1. A United States or Canadian institution of higher education fully or provisionally accredited by a regional, state, provincial or national accrediting body; or 2. A Joint Commission or a Commission on Accreditation of Rehabilitation Facilities accredited health care health facility; or 3. A private agency whose primary business activity is the delivery of services to children with developmental disabilities and whose governing board includes one or more BCBAs; or 4. Web-based instruction provided by an accredited institution of higher education. C. Supervision: 1. No fewer than two hours every two weeks of formal, documented supervision with the behavior analystmaster s/doctoral level or behavior analyst- bachelor s level who is supervised by a behavior analyst-master s/doctoral level. The supervisory relationship must be described in a formal written document. D. Applicants also must meet the following: 1. Covered by professional liability insurance to limits of $1,000,000 per occurrence, $1,000,000 aggregate through their employer or group; (if not professional liability insurance, then covered under general liability insurance through employer or group); 2. May not have a Medicaid/Medicare sanctions or be excluded from participation in Federally funded programs (OIG-LEIE listing, System for Award Management (SAM) listing and state Medicaid sanctions listings); 3. Must have a completed criminal background check to include federal criminal, state criminal, county criminal and sex offender reports for the state and county in which the support staff is currently working and residing. Evidence of this background check is provided by the employer(s). Criminal background checks must be performed at the time of hire and updates performed at least every five years thereafter Magellan Health Services, 4/14

9 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Care Management Overview Through our care management process, Magellan joins with our members, providers and customers to make sure members receive appropriate services and experience desirable treatment outcomes. Through the care management process, we assist members in optimizing their benefits by reviewing and authorizing appropriate services to meet their behavioral health care needs. We do not pay incentives to employees, peer reviewers (e.g., physician advisors), or providers to reduce or forego the provision of clinically necessary care. We do not reward or offer incentives to encourage non-authorization or under-utilization of behavioral health care services. Your responsibility is to: Participate in the care management processes, before beginning care, and at intervals during treatment, as required by the member s benefit plan; and Contact Magellan at the number on the member s benefit card or online at to request an initial authorization, when necessary, or concurrent review authorization of care, as required by the member s benefit plan. Magellan s responsibility is to: Provide timely access to appropriate staff to conduct care management reviews; Manage care with the least amount of intrusion into the care experience; Process referrals and complete the care management process in a timely manner; Care Managers authorize assessment hours prior to ongoing services beginning; Care Managers authorize services for up to 6 months for direct 1:1 services, case supervision, and parent training; Manage care in accordance with the requirements, allowances and limitations of the member s benefit plan; Conduct care management reviews and make determinations in accordance with Magellan s Medical Necessity Criteria (MNC) (See Appendix C) or other state or customer-required clinical criteria based on the assessment information provided; and Require Magellan employees to attend company compliance training regarding Magellan s policy to not provide incentives for nonauthorization or under-utilization of care Magellan Health Services, 4/14

10 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Before Services Begin When members contact Magellan for a referral, our philosophy is to refer them to practitioners who best fit their needs and preferences including provider location, service hours, specialties, spoken language(s), gender and cultural aspects. Our policy is to refer members to providers who best fit their needs and preferences based on member information shared with Magellan at the time of the call. We also confirm member eligibility and conduct reviews for initial requests for clinical services upon request. Your responsibility is to: Contact Magellan by phone via Customer Service to determine member eligibility for requested services before rendering care to a referred member; Contact Magellan by phone via Triage to request an initial services form for an initial authorization when required by the member s benefit plan; View your authorizations on the Magellan website: Securely sign in to your password-protected account at under My Practice on the left-hand side, go to View Authorizations and follow the steps outlined on the screen. Magellan s responsibility is to: Contact you directly to arrange an appointment for members needing emergent or urgent care; Note: those needing emergent care are referred to network facility providers as appropriate; Identify appropriate referrals based on information submitted by our providers through the credentialing process; Make an authorization determination based upon the information provided by the member and/or the provider; Include the type of service(s), number of sessions or days authorized, and a start- and end-date for authorized services in the authorization determination; Communicate the authorization determination (when necessary) by telephone, online and/or in writing to you as required by regulation and/or contract; and Note: while most authorization approval notices will only be communicated online, denial notices and other legally mandated correspondence is sent via U.S. Mail and/or fax (where applicable); Offer you the opportunity and contact information to discuss the determination with a Magellan physician reviewer if we are unable to authorize the requested services based on the medical necessity criteria review Magellan Health Services, 4/14

11 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Functional Assessment Magellan s philosophy is that treatment should be rendered at the most appropriate, least intensive level of care necessary to provide safe and effective treatment that meets the individual member s biopsychosocial needs. Psychological testing is authorized when it meets the Magellan medical necessity criteria for this service. Our policy is to authorize testing when the clinical interview alone is not sufficient to determine an appropriate diagnosis and treatment plan. A functional assessment must be completed in order to establish a treatment plan for ABA services Magellan Health Services, 4/14

12 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Concurrent Review Our philosophy is to support the most appropriate services to improve health care outcomes for individuals and families whose care we manage. We look to our providers to notify us if additional services beyond those initially authorized are needed to help improve the member s behavioral health. Our policy is to manage the concurrent review process as entrusted to us by our customers. The concurrent care management review process is required for all ABA services. If after evaluating and treating the member, you determine that additional treatment is necessary, your responsibility is to: Visiting and submit treatment update via your secure link on the Skills tool being sure to fill out all required fields including the amount or hours your are requesting for each billing code and the purposed length of service Magellan s responsibility is to: Review submitted information and corresponding data and make a determination of if the client continues to meet Medical Necessity criteria (MNC) and if request of service level is appropriate. If the request is determined appropriate requested level of service is authorized and communicated to the provider via telephone. If it is considered that the client has not met the MNC or if a question about the requested level of service occurs, the case will be sent to a physician for review and consultation with the provider to either be denied or approved Magellan Health Services, 4/14

13 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Appealing Care Management Decisions Providers have a right to appeal Magellan quality review actions that are based on issues of quality of care or service that impact the conditions of the provider s participation in the network. Client requirements and applicable federal and state laws may impact the appeals process; therefore, the process for appealing is outlined in the letter notifying a provider of changes in the conditions of their participation due to issues of quality of care or services. Follow the instructions outlined in the notification letter if you wish to appeal a change in the conditions of your participation based on a quality review determination. You can talk with your care manager about the process and the reasoning behind the denial. Notify you in a timely manner of the determination that the condition of your participation is changed due to issues of quality of care or service; and Consider any appeals submitted in accordance with the instructions outlined in the notification letter, subject to applicable accreditation and/or federal or state law Magellan Health Services, 4/14

14 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Member Access to Care Members are to have timely access to appropriate mental health, substance abuse, and/or Employee Assistance Program services from an in-network provider 24 hours a day, seven days a week. Our Access to Care standards enables members to obtain behavioral health services by an in-network provider within a time frame that reflects the clinical urgency of their situation. Given the nature of ABA services it is not expected that 24 hour service will be provided. Your responsibility is to: Provide access to services during established business hours, allowing for evening services and optional weekends; Provide coverage for your clients when staff is not available; Respond to telephone messages in a timely manner; Contact Families within 3 business days of an authorization to schedule the beginning of services; and Provide accurate and current level of availability in each area you service and provide language capabilities. Magellan s responsibility is to: Communicate the clinical urgency of the member s situation when making referrals; and Provide timely access to authorizations for services Magellan Health Services, 4/14

15 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Continuity, Coordination and Collaboration We appreciate the importance of the therapeutic relationship and strongly encourage continuity, collaboration, and continuation of care. Whenever a transition of care plan is required, whether the transition is to another outpatient provider or to a less intensive level of care, the transition is designed to allow the member s treatment to continue without disruption whenever possible. We also believe that collaboration and communication among providers participating in a member s health care is essential for the delivery of integrated quality care. Our commitment to continuity, collaboration and continuation of care is reflected in a number of our policies including but not limited to: Timely and confidential exchange of information - Through this policy, it is our expectation that, with written authorization from the member, you will communicate key clinical information in a timely manner to all other health care providers participating in a member s care, including the member s primary care physician (PCP). Timely access and follow-up for medication evaluation and management - Through this policy, our expectation is that members receive timely access and regular follow-up for medication management. We ask that you as the provider to keep the overall well being of the family in mind and please alert your care manager to any issues that may be related to mental and behavioral health so Magellan can reach out to the family. If alerted to any issues regarding family mental health issues, Magellan will follow appropriate steps to contact family or the direct them to appropriate services Magellan Health Services, 4/14

16 SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN Medical Necessity Criteria Magellan is committed to the philosophy of promoting treatment at the most appropriate, least intensive level of care necessary to provide safe and effective treatment to meet the individual member s biopsychosocial needs. Medical necessity criteria are applied based on the member s individual needs including, but not limited to, clinical features and available behavioral health care services. Magellan s Medical Necessity Criteria (MNC), which is based on current scientific evidence and clinical consensus, are used in making medical necessity determinations. We review the criteria annually, taking into consideration current scientific evidence and provider feedback, and revise them as needed. The revised criteria are made available to any interested party on the MagellanHealth.com/provider website or by hard copy upon request. Review and be familiar with Magellan s current MNC; If you have questions about which MNC apply to a specific benefit plan, contact the applicable Care Management Center medical director; and Submit suggestions for revisions to the MNC using the comment form located at or by submitting your feedback in writing to the applicable Magellan Care Management Center s medical director. Eligibility Magellan s responsibility is to: Make our MNC available to you free of charge; Invite and consider your comments and suggestions for revisions to the MNC; Conduct a comprehensive annual review of the MNC using scientific literature, expert advice from regional Provider Advisory Boards, other committees, and suggestions from the provider community; and Monitor the use of the MNC utilization to make sure they are applied consistently. A child less than nine years of age, who has been diagnosed with autism based on a diagnostic assessment of autism, is not otherwise eligible for coverage for applied behavioral analysis treatment under the medical assistance program, Iowa Code section 514C.28 or private insurance coverage, and whose household income does not exceed 400 percent of the federal poverty level Magellan Health Services, 4/14

17 SECTION 4: THE QUALITY PARTNERSHIP Complaint and Grievance Process We support the right of clients and their providers acting on the client s behalf to express dissatisfaction about any matter. A formal process is available for grievances and for complaints from ASP participants. The grievance or complaint decision is the final step in the grievance/complaint process and all grievance/complaint decisions are in writing. Your responsibility is to: Notify enrollees, participants, or their designees that they may file a grievance or complaint either orally or in writing. Others who are not enrollees or their designees are required to initiate the process with a written request. Magellan s responsibility is to: Resolve grievances and complaints and provide written notice of disposition within 14 calendar days of receipt of all required documentation Magellan Health Services, 4/14

18 SECTION 4: THE QUALITY PARTNERSHIP Appeals We support the right of enrollees and their providers acting on the enrollee s behalf to appeal any action. An appeal is used to request review of an action. At the time of the action, enrollees are informed of this right and how to proceed. Actions include the following: 1. Eligibility 2. Reduction, suspension, or termination of a previously authorized service 3. Denial, in whole or in part, of payment for a service Your responsibility is to: Refer to the Notice of Action for specific procedures for appealing an Action. An appeal must be filed either orally or in writing to Magellan within 30 days of Magellan s written Notice of Action. An oral request to appeal must be followed by a written, signed, appeal. If taking the time for a standard resolution could seriously jeopardize the enrollee s life or health or ability to attain, maintain, or regain maximum function, an expedited appeal may be requested. Within 30 days of the written notice of resolution, a provider, on behalf of an enrollee, may request a hearing, often referred to as an Administrative Law Judge (ALJ) hearing, if dissatisfied with Magellan s Appeal resolution. This falls under the provisions of the 441 Iowa Administrative Code Chapter 7. Magellan s responsibility is to: Notify you verbally of a non-authorization determination and the appeal process, to be followed up by a written Notice of Action within 10 business days. Acknowledge receipt of each appeal request. Ensure that oral inquiries seeking to appeal an Action are treated as appeals and confirm those inquiries in writing upon receipt of the written, signed appeal, unless the enrollee or the provider requests expedited resolution. Provide a reasonable opportunity to present evidence, and allegations Magellan Health Services, 4/14

19 of fact or law, in person as well as in writing. Complete all appeals by individuals with appropriate clinical experience who have not been previously involved in the decision. Complete standard appeals with written notification sent within 45 calendar days of the request. Extend the timeframe by up to 14 days if the enrollee requests the extension or with approval by DHS, when it is shown that there is need for additional information and when the delay is in the enrollee s interest. Honor the enrollee s right to request to continue to receive benefits pending an appeal or Hearing determination when all the following conditions are met: a) The appeal or Hearing is filed within 10 calendar days of the written notice from Magellan of an adverse appeal determination; b) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; c) The services were ordered by an authorized provider; d) The original authorization period has not expired; and e) The enrollee requests the extension of benefits. The enrollee s right to continue to receive benefits until one of the following occurs: a) The enrollee withdraws the appeal or request for the Hearing; b) Magellan s issues an adverse decision on the appeal and the enrollee does not request a Hearing within 10 calendar days from receipt of the decision; or c) The authorization expires or authorization service limits are met. The enrollee s responsibility to pay the cost of the services furnished to the enrollee while the appeal or Hearing was pending if the final resolution of the appeal or Hearing is adverse to the enrollee, but only to the extent that these services were furnished solely because the enrollee requested a continuation of benefits. Complete expedited appeals with written notification sent and reasonable efforts to provide oral notice within 72 hours of the request. When a Magellan action is modified or overturned by an appeal resolution or State Fair Hearing decision, Magellan reimburses providers in accordance with Iowa Plan policies and with the contract between Magellan and the provider in effect for those dates of service. New claims submission is required if an appropriate claim was not previously submitted for those dates of service. No reimbursement is made if the Appeal resolution or Hearing decision upholds Magellan s action Magellan Health Services, 4/14

20 SECTION 5: PROVIDER REIMBURSEMENT Claims Filing Procedures Your responsibility is to collect the cost sharing portion of the member s payment for services. For further information on this, reference IAC (225D) Magellan Health Services, 4/14