Targeted Case Management and Mental Health Rehabilitative Service through UnitedHealthcare Community Plan. Doc#

Transcription

1 Targeted Case Management and Mental Health Rehabilitative Service through UnitedHealthcare Community Plan Doc#

2 Eligible Population Mental health rehabilitative services and mental health targeted case management are available to Medicaid recipients who are assessed and determined to have: A severe and persistent mental illness such as schizophrenia, major depression, bipolar disorder or an other severely disabling mental disorder Children and adolescents ages 3 through 17 years with a diagnosis of a mental illness or who exhibit a serious emotional disturbance Optum is a leading health service business dedicated to making the health system work better for everyone. United Behavioral Health operating under the brand Optum Propriety and Confidential. Do not distribute. 2

3 Covered Services Targeted Case Management Must be face to face Include regular, but at least annual, monitoring of service effectiveness Proactive crisis planning and management for individuals Targeted Case Management is a Medicaid billable service provided separate from MCO service coordination Mental Health Rehabilitative Services include Crisis Intervention Services (H2011), (H2011, HA) Medication Training and Support Services Psychosocial Rehabilitative Services Skills Training and Development Services Day Programs for Acute Needs Propriety and Confidential. Do not distribute. 3

4 Managed Care Organization Responsibilities Must cover mental health rehabilitative and mental health targeted case management services effective September 1, 2014 Required to utilize the current Department of State Health Services (DSHS) utilization management guidelines Texas Resilience and Recovery (RRUMG) until September 2015es 2equired to utilize the current DSHS utilization management guidelines Texas n RRUMG for Adult Mental Health Services can be found at Texas Resilience and Recovery Utilization Management Guidelines - Adult Services RRUMG Child and Adolescent Services can be found at Texas Resilience and Recovery Utilization Management Guidelines- Child and Adolescent Services RRUMG will be redesigned to better integrate physical Benefits health and / behavioral health care services for contract year 2015 Authorization Provided (RRUMG) until September 2015 RRUMG for Adult M Health Services can be found h care services for contract year 2015 Propriety and Confidential. Do not distribute. 4

5 Managed Care Organization Responsibilities RRUMG service packages may include counseling, pharmacological management and other Medicaid covered mental health services The MCO must maintain a qualified Network of public and private entities, such as Local Mental Health Authorities (LMHAs) and multi-specialty groups, that employ providers of MH Rehab Services and Targeted Case Management Provider entities must attest to the MCO that the organization has the ability to provide, either directly or through sub-contract, Members with the full array of RRUMG services The MCO is not responsible for providing any services listed in the RRUMG that are not covered Propriety and Confidential. Do not distribute. 5

6 Community Mental Health Center s Responsibility All Qualified Mental Health Professionals must be certified yearly to administer the Adult Needs and Strengths Assessment and the Child and Adolescent Needs and Strengths Assessment ANSA/CANS The certificate must be kept on file and readily available An Attestation will be required from each LMHA and specialty group to ensure compliance Propriety and Confidential. Do not distribute. 6

7 Mental Health Rehab Services Crisis Intervention services are considered emergency behavioral health services and do not require prior authorization, but providers must follow current Texas Resilience and Recovery Utilization Management Guidelines (RRUMG). Services meeting the following criteria may be provided under Skills Training and Development: That provide training and support That are not job specific That focus on development of skills to reduce or overcome the symptoms of mental illness that interfere with individual s ability to retain employment These services should not be confused with Employment Assistance or Supported Employment allowed under the HCBS STAR+PLUS Waiver... Propriety and Confidential. Do not distribute. 7

8 Authorizations Optum is required to follow the current Department of State Health Services (DSHS) Resiliency and Recovery Utilization Management (RRUMG). The individual s Level of Care will be determined by the ANSA/CANS. The MCO will be required to pay for all services allowed in the level of care service package. Services packages may include counseling, pharmacological management and other Medicaid covered mental health services. Optum will require an authorization for TCM/PSR services via completion of MH Rehab and TCM Services Request Form TCM/PSR authorizations should be requested as soon as the CANS/ANSA is completed and sent to Optum Propriety and Confidential. Do not distribute. 8

9 Authorization Request and Provider Express Must complete State designed one page Authorization Request Form Completed Authorization Forms will be submitted to Optum via the Provider Express-Message Center If you aren t a registered user, please go to and click on Choose your provider type Populate the required fields Create your own user name and password Propriety and Confidential. Do not distribute. 9

10 Authorization Process Optum will review your authorization request and will utilize RRUMG for determination. Optum will follow HHSC guidelines for authorization requests. Optum will fax the authorization letter for the TCM/MHR core services located within the service package. The open authorization for therapy services can be found on Provider Express. Any services outside of the TCM/MHR service package will be subject to Optum s current policy and procedures. Propriety and Confidential. Do not distribute. 10

11 Appeals Non Urgent (Standard) Urgent (Expedited) Must be requested within 30 days from receipt of the notice of the complaint decision Pre-Service An Appeal of a service that has not yet been received by a Member. When a pre-service Appeal is requested, OPTUM will make an Appeal determination and notify the provider, facility, Member or authorized Member representative in writing within 15 calendar days of the request. Post-Service- An Appeal of a service after it has been received by a Member. When a post service Appeal is requested, OPTUM will make the Appeal determination and notify the provider, facility, Member or authorized Member representative in writing within 30 calendar days of the request. Must be requested within 10 days of the mailing of complaint decision notice or the intended effective date of the complaint decision, which ever is later. In Writing Unless the Appeal is urgent (expedited), an Appeal request must be in writing by the Member or Member Representative Propriety and Confidential. Do not distribute. 11

12 Services while in Appeal You may continue to provide service following an adverse determination, but the Member, or representative should be informed of the adverse determination by you in writing. The Member should be informed that the care will become the financial responsibility of the Member from the date of the adverse determination forward. The Member must agree in writing to these continued terms of care and acceptance of financial responsibility. You may charge no more than the Optum contracted fee for such services, although a lower fee may be charged. The consent of the Member to such care and responsibility will not impact the appeals determination, but will impact your ability to collect reimbursement from the Member for these services. If the Member does not consent in writing to continue to receive such care and Optum upholds the determination regarding the cessation of coverage for such care, you cannot collect reimbursement from the Member pursuant the terms of your Agreement. Propriety and Confidential. Do not distribute. 12

13 Claims TCM/MHR claims will be billed with the Group name Claims for all other services will be billed with rendering provider name Submit claims online via Provider Express or billed electronically through clearinghouse Please keep roster updated at all time Place of Service should be indicated on claim as applicable Submit claims with the group TPI Submit claims with the appropriate codes and modifiers Title of presentation goes here Propriety and Confidential. Do not distribute. 13

14 Applicable Modifiers For Mental Health Rehab Services Modifier ET HA HQ TD Description Emergency treatment Child/adolescent program Group setting RN Modifier not covered HZ Title of presentation goes here Propriety and Confidential. Do not distribute. 14

15 Mental Health Rehab Service Codes Day Program Service Adult Day Program for Acute Needs Procedure Code G1077 Modifier 1 Modifier 2 Unit min Medication Training and Support Service Procedure Code Modifier 1 Modifier 2 Unit Individual services for adult H min Group services for adult H0034 HQ 15 min Individual services for child and adolescent (with or without other individual) H0034 HA 15 min Group services for the child and adolescent H0034 HA HQ 15 min Title of presentation goes here Propriety and Confidential. Do not distribute. 15

16 Mental Health Rehab Service Codes Crisis Intervention Service Procedure Code Modifier Modifier 2 Unit Adult services H min Child and Adolescent services H2011 HA 15 min Skills Training and Development Service Individual services for adults Procedure Code H2014 Modifier Modifier 2 Unit 15 min Group Services for adults Individual services for child and adolescent (with or without other individual) Group services for the child and adolescent H2014 HQ 15 min H2014 HA 15 min H2014 HA HQ 15 min Title of presentation goes here Propriety and Confidential. Do not distribute. 16

17 Mental Health Rehab Service Codes Psychosocial Rehabilitative Services Service Individual services Individual services rendered by an RN Procedure Code H2017 Modifier Modifier 2 Unit 15 min H2017 TD 15 min Group services H2017 HD 15 min Group services rendered by an RN Individual crisis services H2017 HQ TD 15 min H2017 ET 15 min Title of presentation goes here Propriety and Confidential. Do not distribute. 17

18 Targeted Case Management Codes Title of presentation goes here Propriety and Confidential. Do not distribute. 18

19 Claim Tips Always file clean claims Ensure appropriate diagnosis is listed Code to the highest specificity Claims filing deadline 95 days from date of service Clean Claims Paid within 30 days of receipt Appeal Deadline 120 days from date of explanation of benefits Online Appeals Submitted via providerexpress.com Title of presentation goes here Propriety and Confidential. Do not distribute. 19

20 Important Reminders Verify benefits prior to rendering any services and receive authorization as appropriate through Provider Express All services must be performed by a Qualified Mental Health Professional for Community Services (QMHP-CS) or a Mental Health Targeted Case Management Qualified Members may not be balanced billed No co-pay, no out of pocket maximum, no deductible Out-of-network benefits are not available for STAR+PLUS Notify Optum within 10 calendar days whenever you make changes to your office location, billing address, phone number, Tax ID number, your entity name, close your business or retire via Provider Express Service Request Form should contain correct provider mailing address Propriety and Confidential. Do not distribute. 20

21 Questions Propriety and Confidential. Do not distribute. 21

22 Appendix QMHP-CS Mental Health Rehabilitative Services Qualified Providers-Qualified Mental Health Professionals for Community Services (QMHP-CS) the minimum requirement for a QMHP-CS are as follow: Demonstrated competency in the work to be performed; and Bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; or RN An LPHA, as defined in Attachment A of the Contract, is automatically certified as a QMHP-CS. A CSSP, a Peer Provider, and a Family Partner, as those terms are defined in Attachment A of the Contract, can be a QMHP-CS if acting under the supervision of an LPHA. If a QMHP-CS is clinically supervised by another QMHP-CS, the supervising QMHP-CS must be clinically supervised by an LPHA Additionally, a Peer Provider must be a certified peer specialist, and an Family Partner must be a certified family partner Propriety and Confidential. Do not distribute. 22

23 Appendix-Mental Health Targeted Case Management A qualified provider of mental health targeted case management must: Demonstrate competency in the work performed; and Possess a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; or Be a Registered Nurse (RN) Propriety and Confidential. Do not distribute. 23

24 Thank you. Texas Network Management 2000 West Loop South, Ste 900 Houston, TX Main Number: Fax Number: