Participating Provider Manual

Transcription

1 Participating Provider Manual Revised November 2011

2 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER SERVICES Page 7 Intake Coordinators Referrals by member Referrals by providers Benefits eligibility 3. UTILIZATION MANAGEMENT Page 8 Utilization management program Appropriate treatment; no financial incentives Psychcare clinical criteria 24-hour access to UM inquiries Utilization management activities 4. NETWORK MANAGEMENT Page 15 Provider recruitment Request to join the network process Notification of Request to join process outcome Availability standards GeoAccess Network composition Provider training Provider complaints Accreditations 5. INITIAL CREDENTIALING & RECREDENTIALING Page 19 Application submission Basic credentialing elements for participation, based on government, accrediting agencies, and client standards Federal, state, and accreditation standards Time frame for completion of credentialing process Site visits prior to submission to Credentialing Committee Notification of Credentialing Committee decision Credentialing cycle/recredentialing Maintenance of credentialing file between cycles Ongoing monitoring PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 2

3 6. REVIEW OF KEY CONTRACT COMPONENTS Page 26 Missed appointments Breach of contract Billing members for covered services Billing members for non-covered services Termination Continuity of care for members following termination of member Provider Notification Responsibilities (i.e. Changes of address, TIN, holds, terminations, etc.) 7. CLAIMS Page 29 Claims Processing Timely submission Electronic claims Paper claim form types Paper claim forms submission address Clean claims Remittances Authorization numbers on claims Prompt payment Resubmission of clams Claim questions answered via Psychcare s online portal Claim questions not answered via Psychcare s online portal Address change notifications 8. QUALITY MANAGEMENT Page 33 Annual Quality Improvement Program Quality Improvement Program goals Scope of Quality Improvement Program Clinical management guidelines Outpatient treatment record documentation Collaborative activities Continuity and coordination of care activities Health literacy, cultural and linguistic needs of membership Member safety Potential quality of care and/or member safety instances Privacy Practices HIPAA, and federal and state confidentiality laws Members Rights and Responsibilities Access to care and availability standards Fraud, waste, and abuse activities Psychcare website 9. PREVENTIVE HEALTH Page 49 PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 3

4 10. LIFE S SOLUTIONS EAP EMPLOYEE ASSISTANCE PROGRAM Page 50 Access to EAP Services Treatment Beyond EAP Services 11. CONTACT LIST Page 52 Appendix A: Link to provider resources Page 53 Appendix B: Psychcare Website Page 54 Appendix C: Medicaid Addendum Page 55 Appendix D: Network Practitioner Outpatient Documentation Requirements and Review Tool Page 74 Appendix E: Practitioner s Statement of Receipt of Participating Practitioner Manual Page 76 PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 4

5 1. INTRODUCTION Psychcare, LLC s Management Team Rodolfo Hernandez, M.D., President & Chief Executive Officer, takes pleasure in announcing the management team of Psychcare, LLC (Psychcare) to you, and Dr. Hernandez joins with the management team in welcoming you to Psychcare s provider network! Daniel Hernandez, Senior Executive Vice President Rudy Hernandez, Executive Vice President Jordi Cuervo, Vice President, Operations Mission Statement Psychcare s mission is to establish and continue long-term partnerships with our clients through our commitment of providing quality behavioral healthcare and Employee Assistance Program (EAP) services, both of which meet the needs of our clients, as well as their members. Client satisfaction occurs through the collaboration of Psychcare s team of dedicated and ethical staff members, who work with skilled and professional practitioners, providers and community agencies (provider network) in Psychcare s network model. Psychcare s commitment to client retention and quality care increases the value our clients derive from services offered through both Psychcare s behavioral healthcare products, as well as from our EAP product, delivered through Psychcare s subsidiary, Life s Solutions EAP. Company Background Psychcare has experienced tremendous growth in recent years, and because of our growth, we have expanded our products to include: Life s Solutions EAP, a national EAP program Disease Management Programs Wellness Programs A Dependent Care Program PharmAssist Program Psychcare s President & Chief Executive Officer, Rodolfo Hernandez, MD, has served on various consulting boards in the area of psychopharmacological development and treatment. In addition, Dr. Hernandez previously served as the Medical Director for specialty hospitals, as well as for other Managed Behavioral Health Care Organizations (MBHO s). In the mid-80 s, Psychcare began as an EAP program, EmploAssist. Since that time, Psychcare has grown into an accredited MBHO, with a subsidiary called Life s Solutions EAP. Psychcare, a family-owned company, is a comprehensive MBHO that specializes in managing mental health and substance abuse benefits for HMOs, PPOs, and large employer groups. Psychcare also is experienced in providing EAP services to a wide variety of companies and governmental entities. Psychcare is proud of its strong history of client retention. Some of Psychcare s clients have been with the company for 15+ years, and others have returned to Psychcare after experiencing the differences in working PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 5

6 with other Managed Behavioral Healthcare Organizations. Psychcare s staff offers service that is consistently rated excellent in customer satisfaction surveys. Psychcare hopes that you will find this manual to be a helpful resource in learning the processes to follow when treating members managed by Psychcare. Hard copies are available for most of the resources, if you do not have the ability to download the information from a website. Accreditations Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare s commitment to quality is evident by its continuous full accreditation status with URAC since 1998, as well as its full accreditation status with the National Committee for Quality Assurance (NCQA) since These accreditations are evidence of Psychcare s ongoing measures which promote and provide for quality care and service to members managed by Psychcare. Provider Network Psychcare s provider network is very important to us! Psychcare s management team fosters a united effort between Psychcare and its provider entwork. The mutually-cohesive and collaborative work relationship between Psychcare s staff members and the contracted Psychcare provider network results in the provision of effective, efficient, timely, and appropriate treatment services, rendered to both the managed behavioral healthcare (MBHO) and the EAP members, all of whom are serviced by Psychcare. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 6

7 2. MEMBER SERVICES Intake Coordinators Intake Coordinators are bilingual (English/Spanish). Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call, a service which is available Monday through Friday, from 8:30 AM to 5:30 PM, Eastern Standard Time (EST). Intake Coordinators provide direct access to callers on eligibility information, routine referrals, and authorizations. Intake Coordinators transfer calls, as appropriate, to licensed clinicians and/or other departments for assistance. Member Referrals Members can access referrals by calling Psychcare s toll-free telephone number of ( ). Lists of providers are available electronically, by fax, or mail. In addition, referrals can be given telephonically at the member s request. Once an appointment is obtained, the member or the provider will receive an authorization telephonically or online. Provider Referrals For the purposes of coordination of care, providers are encouraged to contact Psychcare for network referrals for therapy and/or medication management. Benefits Eligibility Psychcare has updated benefit eligibility information and manages benefits based on clinical criteria, benefit plan coverage and service requests. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 7

8 3. UTILIZATION MANAGEMENT Philosophy Psychcare s philosophy is to monitor the quality, safety, and appropriateness of clinical care and services rendered by our provider network, to verify that accepted national and community standards are being provided within the scope of federal and state regulations and laws. Psychcare s Utilization Management (UM) program provides a mechanism for monitoring utilization of services, and ensuring delivery of quality and cost-effective behavioral healthcare. UM activities are an integral part of Psychcare s Quality Improvement Program. Psychcare makes decisions whether to approve or not approve payment for services based only on the appropriateness of the care or service, and on the coverage available in the member s benefit plan. Utilization Management (UM) Decision-Making Psychcare affirms the following: UM decision-making is based only on appropriateness of care and service and the existence of coverage; Psychcare does not specifically reward practitioners or other individuals for issuing denials of coverage or service care; Psychcare does not provide financial incentives for UM decision-makers, and Psychcare does not encourage decisions that result in underutilization. UM decisions are based on both the members benefit coverage, and: Psychcare s Level of Care Clinical Criteria for all Florida Commercial and Medicare members, as well as Medicaid members outside the State of Florida, and Florida s Medicaid Level of Care Guidelines for Florida Medicaid members. If you would like a hard copy of either UM decision-making criteria or guidelines, please contact Psychcare at our toll-free telephone number of ( ). The Scope of the Annual Utilization Management (UM) Program The scope of the annual UM Program includes the following the following core activities: Communication Services; Triage Processes; Acuity Level and Appropriate Level of Care; Referral and Clinical Review Processes; Interrater Reliability; Clinical Trainings; Over- and Underutilization Monitoring; Member Satisfaction with UM processes; Practitioner Satisfaction with UM processes, and PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 8

9 Continuity and Coordination of Care. Communication Services Regarding UM Processes and UM Inquiries Members and the provider network have access to Psychcare s clinical staff, 24 hours per day, 7 days per week, via our toll-free telephone number of ( ), to allow for questions regarding Psychcare s UM processes or any UM issues to be addressed. Psychcare s clinical staff is available to answer inquiries regarding Psychcare s UM processes or any UM issues,via telephone, fax, and/or , from both members and the provider network, Monday through Friday (excluding holidays), between 8:30 AM to 5:30 PM, EST. Following usual business hours, and on weekends and holidays, members and the provider network can contact an on-call Case Manager (a licensed clinician), via our toll-free telephone number of ( ). Psychcare s clinical staff addresses inquiries regarding Psychcare s UM processes or any UM issues received via telephone calls, faxes and/or within one (1) business day, Monday through Friday (excluding holidays), between 8:30 AM to 5:30 PM, unless otherwise agreed upon. Emergency telephone calls received afterusual business hours, on weekends or on holidays, are responded to within thirty (30) minutes from receipt of the call. Non-urgent telephone calls received Monday through Friday, between 5:30 PM to 8:30 AM, or on weekends and holidays, are responded to by a Case Manager, no later than one (1) business day from receipt of the call, unless otherwise agreed upon. Psychcare staff members identify themselves by name, title, and their affiliation with Psychcare, during both inbound and outbound communications to members and the provider network regarding Psychcare s UM processes, UM issues, and/or requests for services. Bilingual (English/Spanish) staff members are available to assist members and the provider network, both during and after usual business hours. Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the member s call. Clinical Criteria Case Managers use a member s benefit coverage and one of the following: Psychcare s Mental Health Level of Care Clinical Criteria and/or Psychcare s Substance Abuse Level of Care Clinical Criteria for all Florida Commercial and Florida Medicare members, and for Medicaid members outside of the State of Florida; Florida Medicaid Level of Care Guidelines for Florida Medicaid members, or Applied Behavioral Analysis Criteria for Florida Commercial members. Psychcare believes that the determination of the level of care should be based upon presenting signs and symptoms, indicating that all lesser alternative levels of care would be detrimental to the safety and/or health of the member. It is the responsibility of the Psychcare clinical staff, which includes the Associate Medical Director, Psychcare Case Managers, and Clinical Peer Reviewers, to direct all members to the appropriate level of care, based on an acuity assessment. Psychcare s Level of Care Clinical Criteria and the Florida Medicaid Level of Care Guidelines are available to members and the provider network on the Psychcare website, or they may be obtained in hard copy, upon request, by calling Psychcare s toll-free telephone number of ( ). PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 9

10 Referral and Clinical Review Processes Pre-Service Non-Urgent Outpatient Referrals Members seeking initial non-urgent outpatient referrals can access services, Monday through Friday (excluding holidays), 8:30 AM to 5:30 PM, EST, via the toll-free telephone number of ( ). The call connects the members to Psychcare s state-of- the-art telephone system, whereby the members are provided with a menu selection, and from this menu, the members can select the menu option for nonurgent outpatient referrals. The referrals are then handled by a Psychcare Intake Coordinator. The Intake Coordinator verifies members benefits, confirms their addresses and telephone numbers, explains their financial obligations, such as copays, and completes Initial Intake Screening forms with the members. Referral considerations include the geographic, cultural, and/or linguistic preferences of the members. The Intake Coordinator provides the members with the names of network providers in their preferred area. Members are then advised that once they have made their selection, they should call Psychcare to have services authorized to the provider selected from the referral sources. Pre-service non-urgent care authorizations, inclusive of notification, are completed within fourteen (14) calendar days from the date of the request. Should the provider selected not be avilable within the non-urgent outpatient appointment standard, Intake Coordinators ask the provider to refer the members back to Psychcare, so that additional referral sources can be given to the members for selection. Use of Licensed Consultants Licensed specialty consultants are on Psychcare s Clinical Peer Reviewer panel. The panel consists of licensed behavioral health practitioners in active practices, who have both current and unrestricted licenses, and who are either board-certified psychiatrists, licensed doctorate-degree level psychologists, or master s level licensed clinicians with clinical expertise in all areas of behavioral health. The Medical Director and/or Associate Medical Director may consult with a Clinical Peer Reviewer in a like or similar specialty to the attending practitioner, whose case is being reviewed, to assist in making a determination of medical necessity or clinical appropriateness, and in other situations, as necessary. Initial Clinical Review Psychcare s Mental Health Level of Care Clinical Criteria, Psychcare s Substance Abuse Level of Care Clinical Criteria, the Florida Medicaid Level of Care Guidelines, and Psychcare s Clinical Management Guidelines are used by the Psychcare Case Managers during the initial clinical review. With oversight by the Associate Medical Director and supervision by the Vice President, Clinical Operations, actively- licensed Case Managers conduct both pre-service urgent care, as well as concurrent urgent and non-urgent care reviews. The Medical Director and/or Associate Medical Director are accessible for any clinical questions concerning authorization of services, 24 hours per day, 7 days per week. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 10

11 Medical necessity denial determinations are never issued during the initial clinical review. Medical necessity denial determinations are only issued during the peer clinical review, conducted by the Medical Director and/or Associate Medical Director, with the attending practitioner. Emergency Services and Urgent Care Review. Emergency mental health services are defined as those services that are required to meet the needs of an individual who is experiencing an acute crisis resulting from mental illness, which is at the level of severity that would meet the requirements for involuntary hospitalization, pursuant to Chapter , F.S., and who, in the absence of a suitable alternative or psychiatric medication, would require hospitalization. Emergency psychiatric services, necessary to screen and stabilize a member are authorized without prior approval, when a prudent layperson, acting reasonably, believes that an emergency exists or an authorized representative acting for the organization has authorized the provision of emergency services. Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member s benefit plan. Pre-service Care Review Pre-service reviews are conducted before treatment is provided to the member. A determination to authorize a particular service is based on the member s benefit coverage and the definition of medical necessity, based on Psychcare s Level of Care Clinical Criteria or Florida s Medicaid Level of Care Guidelines. Pre-service urgent care reviews, including verbal and written notifications, are completed as soon as possible, but no later than seventy-two (72) hours from the date and time of receipt of the request. Pre-service nonurgent review decisions, including verbal and written notifications, are completed within fourteen (14) calendar days from the date of receipt of the request. Concurrent Review Concurrent reviews are conducted during the course of treatment to ensure treatment continues to meet Psychcare s definition of medical necessity, based on Psychcare s Level of Care Clinical Criteria or Florida s Medicaid Level of Care Guidelines. Concurrent urgent care review decisions, including verbal and written notifications, are completed within twenty-four (24) hours of the date and time of the request. Concurrent non-urgent review decisions, including verbal and written notification, are completed within fourteen (14) calendar days from receipt of the request. Providers may request concurrent outpatient authorizations by completing the applicable form(s) available on the Psychcare website Both urgent and non-urgent concurrent care certification decision notifications include (1) the number of days or units of service authorized, (2) the next anticipated review point, (3) the new total of days or services approved, and (4) the date of admission or onset of services. Post-service Review PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 11

12 The Medical Director and/or Associate Medical Director make all post-service review determinations. Postservice reviews are conducted after the completion of a course of treatment. A post-service review occurs when services were neither authorized nor denied by Psychcare. The determination and written notification of the decision are provided within thirty (30) calendar days of the date of the receipt of the request and/or all clinical information necessary to make a medical necessity decision. When a request for a post-service review is received by Psychcare, and there is insufficient clinical information to determine the medical necessity of the case, Psychcare requests that the clinical information necessary to determine medical necessity is received within forty-five (45) calendar days from the date of the receipt of the notice requesting same. The requested clinical information includes, but is not limited to: The initial psychiatric evaluation; The physician s orders; The daily physician s progress notes; The daily nursing progress notes, and The discharge summary. Network Provider Utilization Management Processes for Post-Service Review of Emergency Services The post-service review process for emergency services is based on Federal and State regulatory standards; The definition of emergency services is based on (1) the member s certificate of coverage and (2) per Federal and State regulatory requirements; The submission and processing of a network provider request for a post-service review is based on (1) the individual network provider s executed Psychcare Participating Practitioner Agreement or Psychcare Participating Provider Agreement, and the section of the agreement pertaining to adherence to Psychcare s utilization management processes, (2) the member s certificate of coverage, (3) the emergency service definition as per the applicable line of business, and (4) national accrediting body standards; Psychcare will not process post-service review requests for routine outpatient services; Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member s benefit plan; It is the network provider s responsibility to contact Psychcare within twenty-four (24) hours of the member s admission, or, if unable to do so for circumstances beyond the provider s control, on the next business day. Although Psychcare cannot deny payment for emergency services based on the provider s failure to comply with the notification requirements, nothing shall alter any contractual responsibility of the member or provider to make contact with Psychcare subsequent to receiving treatment for the emergency condition; When the member is unable to provide insurance information upon admission, the network provider, in all circumstances, will obtain the member s insurance information prior to the member s discharge and will notify Psychcare of the member s hospitalization; When the network provider identifies the member s insurance information but was unable to contact Psychcare for authorization prior to the member s discharge, as evidenced by the provider s submission of a post-service review request to Psychcare, it is the network provider s responsibility to document in the member s treatment record, the provider s efforts to contact Psychcare and to obtain authorization upon receipt of the member s insurance information, prior to the member s discharge. The post-service review request will not be processed if there is a lack of this documentation, and the network provider will receive written notification within five (5) business days of Psychcare s review of the request, via mail and/or electronically of the decision, not to process the provider s request, with the specific reasons listed; PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 12

13 Requests for payment of post-service reviews follow the Federal and State submission time periods for postservice review requests. All requests received after the prescribed submission period shall be considered past the date of submission; When the network provider s utilization management process responsibilities are fulfilled, Psychcare s Medical Director or Associate Medical Director determines the medical necessity of the services previously rendered, based on; ü All clinical documentation submitted with the post-service review request, ü Psychcare s Level of Care Clinical Criteria, and when applicable, Florida s Medicaid Level of Care Guidelines, ü The member s benefit coverage, and ü The applicable definition for emergency services. When the network provider s utilization management processes are not fulfilled, the network provider shall be sent written notification via certified mail and/or , advising the provider that the post-service review will not be processed due to a breach in the agreement requring adherence to Psychcare s utilization management processes; The post-service review determination, including written notification via certified mail and/or , is completed within thirty (30) calendar days of the date of the receipt of the post-service review request; As per Chapter , F.S., Requirements for Providing Emergency Services and Care, the member is not held financially liable for the emergency services provided, except for any copayment or coinsurance; The timeliness of post-service medical necessity review determinations, are reported quarterly to the Utilization Management Committee; Peer Clinical Review The Medical Director or Associate Medical Director conducts all initial peer clinical reviews. Medical necessity denial decisions are based on the relevant clinical information provided by the attending practitioner or UM personnel, Psychcare s Level of Care Clinical Criteria, Florida s Medicaid Level of Care Guidelines, and the definition of medical necessity. Every reasonable opportunity is afforded to the member, member s legal representative, attending practitioner or provider to consult directly with the Medical Director or Associate Medical Director within one (1) business day of the decision, to discuss the determination via the toll-free telephone number of ( )..When the Associate Medical Director is unavailable within the specified time period for the peer clinical review, then a Psychcare Clinical Peer Reviewer, who is an actively practicing network practitioner of the same or similar specialty, conducts the peer clinical review within one (1) business day of the decision. Medical Necessity Appeals Commercial, Medicare, and Michigan Medicaid client health plan expedited, pre-service, and post-service member medical necessity appeals and network provider medical necessity appeals are contractually delegated to Psychcare by each client. Unless contractually delegated, Psychcare does not process Florida Medicaid medical necessity expedited, pre-service, and post-service member and network provider appeals. Second level appeals and/or external reviews of appeals by an Independent Review Organization (IRO) are not delegated to Psychcare by any of our clients. Expedited Appeals PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 13

14 An expedited appeal is a request to change a denial determination for urgent care, as per the urgent care definition, while the member is still undergoing treatment. A board-certified Clinical Peer Reviewer in the same or similar specialty as the attending practitioner, who was not involved in the initial denial determination, reviews the appeal. A determination is rendered, and the parties are given verbal and written notification of the decision as soon as possible, but no later than seventy-two (72) hours from receipt of the appeal request. Post-service Appeals A board-certified Clinical Peer Reviewer in the same or similar specialty as the attending practitioner, who was not involved in the initial denial determination, reviews the appeal. A post-service appeal is a request to change a denial determination for treatment that the member has already received. Post-service appeal determinations, inclusive of written notification, are completed within thirty (30) calendar days from receipt of the request. Practitioner Satisfaction with Psychcare UM Processes Annually, Psychcare conducts a Network Practitioner Satisfaction Survey with all of our network practitioners, and a Florida Medicaid Stakeholder Survey with our Florida Medicaid providers for each of our Florida Medicaid clients. The purpose of each survey is to find out our network s satisfaction with our clinical and administrative UM processes, and to identify opportunities to improve those areas of least satisfaction. UM Information Contained on the Psychcare Website Psychcare Mental Health Level of Care Clinical Criteria Psychcare Substance Abuse Level of Care Clinical Criteria Psychcare Applied Behavioral Analysis Criteria Psychcare Florida Medicaid Level of Care Guidelines Psychcare Neuropsychological Testing Criteria Accessibility to Customer Service Staff and Clinical Staff to discuss utilization management issues Ensuring appropriate utilization management Conflict of Interest Statement Pre-service, concurrent, and post-service review decision-making timeliness standards Authorization processes Post-service review processes for Psychcare network practitioners and providers The opportunity to request a Peer Clinical Review to discuss an initial medical necessity denial determination Psychcare s website address is Most of the information described herein can be downloaded from our website. If you would like a hard copy of the any of the documents and/or activities located on our website, please call Psychare s Quality Management Department at Psychcare s toll-free telephone number of ( ), Monday through Friday, 8:30 AM to 5:30 PM, EST. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 14

15 4. NETWORK MANAGEMENT Provider Recruitment If you or someone you know would like to be considered for inclusion in Psychcare, LLC s network, please refer to the Request to Join Network Process below in this section. Request to Join the Network Process Providers (practitioners) who have an interest in joining the network should print the Participating Provider Application, which can be downloaded from the Psychcare website at Recruitment Contracting. If you do not have access to a website, please contact the Network Development Department at the toll-free telephone number of ( , Ext. 3998). Once you have printed the application, please legibly complete the form, in full, then sign and return with all requested, supporting documentation, in one of three ways: Mail: Psychcare, LLC, Sunset Drive, Miami, FL Attention: Network Development Fax: Network [email protected] Upon receipt of a completed application, the following elements will be reviewed to assist Psychcare in determining initial eligibility for processing by the Credentialing Department: Specialty/area of expertise is needed in network; Location of practice is within network development-approved area; License must be current, valid, unrestricted, and in most geographic locations, independent; DEA/Controlled substance registration current, unrestricted; Board certification (ABMS or AOA ONLY) is current and verifiable (Physicians only); Residency training is completed and verifiable, if not board-certified. (Physicians only); Education is completed and verifiable. (Providers with Doctorate and Master s degrees); Work history must include five (5) current, consecutive years of experience in the field of interest. Gaps greater than one (1) year require a written explanation and will be reviewed. Gaps between six (6) months to one (1) year can be offered verbally, but the explanation is processed more efficiently when explained in writing, and Cultural, ethnic and linguistic needs of the network are considered and reviewed in each application. Note: If initial eligibility is not met, providers (practitioners) will be notified (See Notification of Request to Join Process Outcome ). If initial eligibility is met, providers (practitioners) will be sent application, or if already received, application will be processed by the Credentialing Department. Providers (facilities) with an interest in joining the network should contact the Network Development Department at the toll-free telephone number of ( , Ext. 3998). This department will handle all of your questions regarding the possibility of network inclusion. Notification of Request to Join Process Outcome PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 15

16 Upon receipt of a completed application, along with the supporting documentation, the provider (practitioner) will be notified within fifteen (15) business days following the next Credentialing Committee meeting, as to whether or not the application will be processed. The Credentialing Committee meets at least quarterly, typically on the 3 rd Thursday of the month the meeting will be held. Meetings are currently scheduled for the months of March, June, September, and December. Please note that completion and submission of a credentialing application, in and of itself, does not confirm that the Credentialing Committee allowed for the application to be sent to the applicant, nor does it constitute network acceptance by the Credentialing Committee. Availability Standards GeoAccess Psychcare s Credentialing Committee conducts network analyses, at least annually, but availability standards are analyzed on an ongoing basis throughout the year. Availability standards are reviewed annually and are determined, based on client needs, state and federal standards, accrediting standards, and network composition needs. Further, a network analysis is conducted prior to the processing of any initial credentialing application, to determine if there is a need in the network, based on GeoAccess-calculated availability standards, for a provider of the applicant s scope of practice, location, language(s) spoken, and cultural/ethnic background. Network Composition Psychcare s network is composed of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups. The size and the scope of the network is determined by the Credentialing Committee and is reviewed on an ongoing basis to assure the network is inclusive of the appropriate number and distribution of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups. Provider Training A Provider Training Module is available on our website at The Provider Relations Department is also available to conduct training with new providers at the time they are contracted. The Provider Training Module will include, but will not be limited to: Introduction to the Participating Provider Manual Provider Responsibilities Authorization process Claims submission, processing, and payment Electronic billing HIPAA Information Treatment plans Clinical summaries PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 16

17 Medication management forms Maintaining current credentialing file Change of address process Who to contact with general questions Contact list for Psychcare Provider Complaints Psychcare s Provider Partnerships Department maintains a Provider Complaint Log with the following components addressed for each Provider Complaint received: Date of complaint Date of response to complaint Name of health plan Practitioner name Practitioner license & state of issue for license Practice/Facility name Complaint type Access Authorizations Claims Service Other Complaint narrative Complaint resolution (i.e. who resolved, date resolved) The Provider Complaint Log is maintained on an internal shared location, so that any Psychcare staff member may access and input information, should a provider submit a complaint. If, however, the Provider Complaint is given directly to the Provider Partnerships Department via an internal staff member s notification, and the complaint was not logged, the Provider Partnerships Department will log the event, and The performance goal is to have 100% of provider complaints that are received, logged for review and resolution. Providers are encouraged to file provider complaints through the Provider Partnerships Department, incorporating one of the following delivery methods: (1) [email protected], (2) Fax: , (3) Telephone: (800) x 3904, or (4) Mail: Psychcare, LLC, Sunset Drive, Miami, FL Attn: Provider Partnerships. The Provider Complaint Log is reviewed on a daily basis, Monday through Friday, by the Provider Partnerships Department, and the complaints are given to the Vice President, Provider Partnerships, who will initiate the handling of the case. Each time a provider complaint is logged, the Vice President, Provider Partnerships, will assign a member of the Provider Partnerships Department to fully investigate the complaint received, with the assistance of other departments and key personnel, as needed. To prevent possible discrimination in any review of a provider complaint, no one staff member may determine the outcome or the resolution of same. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 17

18 All state, federal and contractual obligations are considered during review of the complaint. Once the provider complaint investigation is conducted, the Vice President of Provider Partnerships will present the complaint to the Credentialing Committee, a subcommittee of the Quality Improvement Committee. The Credentialing Committee will review the nature of the provider complaint and the data from the investigation. The Credentialing Committee will discuss and determine recommendations based on the outcome of the complaint investigation. The practitioner will be advised of the outcome, in writing, within ten (10) business days of the Credentialing Committee decision. If the practitioner wishes to dispute the outcome, a written letter of dispute with supporting documentation should be sent to the attention of the Credentialing Committee within forty-five (45) calendar days of the date of the outcome letter. The Credentialing Committee will convene an ad hoc meeting, and the dispute will be reviewed. If necessary, a conference call with the practitioner will be arranged. Following final review, a decision will be sent, in writing, to the practitioner, within ten (10) business days of the date the dispute was reviewed, either (1) in the ad hoc meeting, or (2) following the conference call with the practitioner, whichever comes last. Quarterly, the Vice President of Provider Partnerships will present a summary of provider complaints to the Quality Improvement Committee. The summary report will include the following: The total number of provider complaints received; A trending analysis to identify whether the provider complaints identify a particular area of dissatisfaction. When a trend is identified the quarterly report will contain the area(s) of dissatisfaction and, an analysis of the barriers, identification of opportunities for improvement, and recommended implemented interventions. Accreditations Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare s commitment to quality is evident by its continuous full accreditation status with URAC since 1998, as well as its full accreditation status with the National Committee for Quality Assurance (NCQA) since These accreditations are evidence of Psychcare s ongoing measures which promote and provide for quality care and service to members managed by Psychcare. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 18

19 5. INITIAL CREDENTIALING/RECREDENTIALING Application Submission The creation of the initial credentialing process begins when an applicant submits the completed, dated, and signed Participating Provider Application or the Participating Facility Application, along with copies of documents requested on the Attestation Page of the application, to Psychcare via mail to Psychcare, LLC, Sunset Drive, Miami, FL Attention: Network Development, or via fax to Network Documents requested include, but may not be limited to the following, as applicable to the provider: Curriculum vitae; Current license(s) to practice; Malpractice face sheet indicating amounts of coverage and expiration dates, or Financial Responsibility Statement ; DEA (if applicable), and controlled substance registration; Board certification by ABMS or AOA, and W-9. Basic credentialing elements for participation, based on government, accrediting agencies, and client standards DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA 1. Specialties/Areas of Expertise 2. Location(s) of Practice (See Availability Standards) REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA Specialties/areas of expertise are listed in Psychcare s credentialing applications. Providers complete this information and provide documentation to support the ability to provide such specialty or area of expertise. Location(s) of practice sites are reviewed and approved by the Credentialing Committee during the initial credentialing process. If any practice sites change, are deleted, or are added, Psychcare s Credentialing Committee will review same, and the committee will make a determination as to whether such modifications will be accepted, based on the network need for the location of the site(s), and on the cultural, ethnic, and linguistic needs of Psychcare s members in that area. Site visits will be required in all high-volume locations, as determined by an ongoing review of utilization data and claims history. 3. License(s) Providers must submit a legible copy of a current, valid, unrestricted, independent license(s) upon initial credentialing and upon each subsequent renewal of the licensure. Psychcare credentials its providers at the highest level of both education and licensure held by the provider, not merely by the highest level of education held by the provider. Therefore, if a provider has a doctorate degree (Ph.D, Psy.D., or Ed.D, etc.), but is licensed at the master s level, the provider will be credentialed at the master s level. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 19

20 DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA If a provider s level of licensure changes between credentialing cycles, it is the responsibility of the provider to notify Psychcare of the change for review by the Credentialing Committee at the next credentialing cycle. Psychcare verifies all state licenses from the state licensing agency, via the internet, in writing, or telephonically, whichever is applicable to the State. Disciplinary actions, if any, are indicated by the State during the verification. Psychcare requests further information from the State, when necessary. All providers complete an application at the time of initial credentialing and at the onset of each subsequent credentialing cycle, and providers answer questions as to whether or not their license(s) (current or any other in the past) are or have ever been disciplined. If a discrepancy is noted between the information given by the practitioner and by the State, the practitioner will be notified and will be given the opportunity to respond. The Credentialing Committee reviews these findings when the credentialing file is completed and presented for approval. 4. DEA/Controlled substance registration (Physicians and applicable providers only) 5. Residency Training (Physicians) or Education (Providers with Doctorate and Master s degrees) Providers must submit a copy of a legible, current, valid DEA registration upon initial credentialing and upon each subsequent renewal of the DEA. Psychcare verifies all DEA registrations from the NTIS (National Technical Information Service) internet database. Providers must also submit a copy of a legible, current, valid controlled substance registration, if applicable, upon initial credentialing, and upon each subsequent renewal of the controlled substance registration. Controlled substance registrations are verified from the primary source, whenever possible; however, the copy received from the provider is acceptable and is placed in the credentialing file. Physicians: If not board-certified, physicians must have completed a verifiable residency program. Psychiatrists must have completed a psychiatric residency program, and Addictionologists must have completed an internal medicine or other approved residency program. Psychcare verifies all residency programs (i.e. general, child and adolescent, addiction, forensic, and geriatric) completed by physicians, via the AMA Physician Profile Report or via a letter written to the residency program. Confirmation of the dates in the program and successful completion of the program is requested. If verification by the residency program is not possible, confirmation from the state licensing agency will suffice, ONLY if the agency PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 20

21 DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA can provide recent evidence that it conducts primary source verification of residency training. Physicians should be five (5) years post-graduate; this may include residency years. Doctorate and Master s Level Providers: These providers must submit proof of completion of their master s or doctorate level programs. Psychcare verifies all educational programs by doctorate and master s level providers, online via the NSCH (National Student Clearinghouse), or in writing, via a letter to the educational institutions from which they received their degrees. If verification by the educational program is not possible, confirmation from the state licensing agency will suffice, ONLY if the agency can provide recent evidence that it conducts primary source verification of education. 6. Board Certification - (ABMS or AOA) (Physicians only) Physicians who are board-certified by the ABMS or AOA must submit copies of any board-certifications in psychiatry upon initial credentialing, and they must submit any renewals or additional board-certifications, as they are granted. Verification of a provider s residency program(s) is not required if the provider is board-certified. Psychcare verifies all ABMS certifications via ABMS s CertiFacts service, an NCQA-approved source for verification of board-certifications. Psychcare verifies AOA certifications online, via the AOA Official Osteopathic Physician Profile Report. Verifications from these NCQA-approved sources are valid for up to one (1) year, but the verification must be obtained from the most current edition of the document source. 7. Work History Work history is collected at the time of initial credentialing via the application and/or the curriculum vitae. A current, continuous, five (5) year work history in the field is reviewed. Gaps of more than six (6) months must be explained by the provider, either telephonically, with a note in the credentialing file, or in writing. Gaps of one (1) year or more must be explained in writing by the provider. Psychcare is not required to verify work history, but at the discretion of the Credentialing Committee, may choose to do so, prior to rendering a decision on the status of the applicant. 8. Malpractice History All providers will attest to the absence or presence of malpractice history in their credentialing applications. Providers must submit a copy of a current, valid malpractice face sheet upon initial credentialing and upon subsequent renewals of the malpractice insurance; coverage must be in the amounts required as a minimum by state law, and/or as noted in the Provider Agreements. Physicians may issue a Financial Responsibility Statement in lieu of the PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 21

22 DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA malpractice coverage; these will be reviewed, on a case-by-base basis by the Credentialing Committee. Psychcare verifies the malpractice history of all providers via the NPDB (National Practitioner Data Bank). Additionally, Psychcare verifies the malpractice history for all doctorate and master s level providers, in writing, from their malpractice carriers, because the NPDB (National Practitioner Data Bank) does not necessarily contain information on providers at this level. However, if a response is not received prior to the required credentialing date, the file will be presented to the Credentialing Committee, using only the NPDB (National Practitioner Data Bank) information. If the claims history from the carrier reveals negative findings upon receipt, the provider will be asked to file an explanation. The contract will be held until the carrier s and the provider s responses are received. The Credentialing Committee will be given the findings for review. 9. Clinical Privileges (Physicians only) 10. Lack of present illegal drug use and/or felony convictions 11. Cultural, ethnic, and linguistic needs Physicians will attest to the absence or presence of a history of loss or limitation of privileges or disciplinary activity in their credentialing applications. Current clinical privileges will be listed and will be primary source verified. All providers will attest either to (1) the absence or presence of present illegal drug use and/or (2) felony convictions, in their credentialing applications. Cultural, ethnic, and linguistic needs are considered for each application presented, to assist in meeting the needs of all members. Federal, State, and Accreditation Standards Credentialing is conducted according to federal, state, and NCQA accreditation standards. Policies and procedures in credentialing are updated at least annually, or more often, if modifications become necessary during the year. Time Frame for Completion of Credentialing Process All credentialing files (initial and recredentialing), will be completed at least one hundred eighty (180) days prior to the presentation of the provider s file to the Credentialing Committee. The timeframe for completion is typically days from receipt of the application. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 22

23 The Credentialing Committee meets at least quarterly, typically on the 3 rd Thursday of the month the meeting will be held. Meetings are currently scheduled for the months of March, June, September, and December. Site Visits Prior to Submission to Credentialing Committee Psychcare will conduct initial site visits to all potential high-volume behavioral health care practitioners, prior to their inclusion in the network, to ensure that these sites meet Psychcare s practice site standards. Psychcare is required to conduct site visits for behavioral health practitioners who meet the definition of highvolume at the time of initial credentialing. Psychcare has a method for identifying potential high-volume behavioral health practitioners, which is as follows: Potential high-volume psychiatrists are defined as network psychiatrists who will potentially have fifty (50) or more new referrals in a year. Potential high-volume clinicians are defined as network clinicians who will potentially have one hundred (100) or more new referrals in a year. This definition was developed, based on Psychcare s client base and previous referral and claims data. Initial Site Visits A site visit must occur prior to the initial credentialing decision. For high-volume behavioral health practitioners who practice at more than one site, there must be documentation in the practitioner s file demonstrating that Psychcare reviewed each site against the required criteria. For a multiple-site practice, Psychcare only needs to review treatment record-keeping practices at one site. New Practitioner Joins Existing Site An additional site visit is not necessary when a new practitioner joins an office site that has already had a site visit and is part of the network. If Psychcare credentials a new practitioner who joins an existing office site, Psychcare only needs to include documentation of the site visit for that office in the new practitioner s initial credentialing file prior to the Credentialing Committee review. NCQA does not require Psychcare to conduct a site visit if the practitioner relocates to an office that has already been reviewed and which meets Psychcare s standards. Existing Practitioner Relocates to an Existing Site When a high-volume behavioral health practitioner relocates or opens an additional office, Psychcare must evaluate the new site. Relocations and Additional Sites Instances when Psychcare must visit new sites include, but are not limited to, when a practitioner: Leaves a group practice to open a solo practice; Moves an office site from one location to another, and/or Opens an additional office. Documentation of the new site visit should be included in the recredentialing file. Staff and Group Model Practices PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 23

24 Psychcare must conduct a single site visit of staff or group model practice sites. In behavioral health only, potentially high-volume groups require a site visit. Psychcare does not need to review the group at the time of each practitioner s initial credentialing. Each practitioner s credentialing file does not need to contain a copy of the site assessment; the organization must provide documentation of the site assessment at the time of an NCQA survey; however, the site visit information does not need to be considered by the Credentialing Committee. Site Visits for Accredited Facilities If a practitioner s office is located in an accredited facility, Psychcare may accept a survey report or a letter from the accrediting body rather than conduct a site visit. Psychcare must document that the accrediting body s survey criteria meets Psychcare s quality assessment criteria and includes the high-volume practitioner s office. Using a survey report in lieu of a site visit for an accredited facility is not delegation and NCQA does not require oversight. Notification of Credentialing Committee Decision All providers are sent letters advising them of the Credentialing Committee s decision within fifteen (15) business days of the meeting in which the decision was rendered. Credentialing Cycle/Recredentialing At least once every three (3) years, and more often as required for specific requests, Provider Partnerships verifies that each provider continues to meet the established credentialing criteria, according to recredentialing standards set forth by Psychcare & NCQA. Providers will be sent recredentialing applications between days in advance of their recredentialing due date, and they will be requested to complete and return these applications in a timely manner. Please be advised that it is the provider s responsibility to be sure that the credentialing status remains current. Providers not responding to the recredentialing requests within the specified time frame must be terminated, in order for Psychcare to maintain its credentialing standards. Psychcare, LLC. Maintenance of Credentialing File between Cycles It is the responsibility of each provider to submit to Provider Partnerships, at the time of renewal, updated and current information regarding any of the following data elements which are time and date-sensitive, including but not limited to license(s) to practice, malpractice insurance face sheets, DEA/controlled substance registrations, and ABMS or AOA board certifications. These data elements must also be submitted at the time of recredentialing, and at any other time that such data elements are changed, are updated, or are requested by Psychcare, LLC: Ongoing Monitoring Review of information required to evaluate the continuing participation of providers in the Psychcare network is ongoing and periodic. Practitioner Rights in Credentialing Process PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 24

25 Review information submitted to support their credentialing application Correct erroneous information Receive the status of their credentialing or recredentialing application, upon request Receive notification of these rights PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 25

26 6. REVIEW OF KEY CONTRACT COMPONENTS Provider Notification Responsibilities It is the responsibility of each contracted provider to notify Psychcare in the event of the following, and you may do so by contacting the Provider Relations Department either via at or via the toll-free telephone number of ( , Ext. 3904). Change of address, name change, merger, or other demographic change; Change of tax identification number; Short-term hold on referrals; Leaves of absence; Any condition that results in temporary closure of a facility or office; Revocation, suspension, restriction, termination, or voluntary relinquishment of any of the licenses, authorizations, or accreditations required by Psychcare; Any lapse or material change in professional liability insurance coverage; Any legal action pending for professional negligence which may reasonably be considered to be a material loss contingency, and the final disposition of the action; Restriction, suspension, revocation or voluntary relinquishment of medical staff membership or clinical privileges at any healthcare facility; Any indictment, arrest, or conviction for a felony or for any criminal charge related to an individual s or a facility s professional practice; Termination, or Continuity of care for members following termination of provider. Licensing, Medicare, Medicaid Certification, and Federal Program Requirements. Providers and Practitioners providing services via the Participating Agreement are not now, nor have they ever been excluded from Medicare, Medicaid, or any federal health program. Psychcare may request documentation to verify provider's participation with these agencies. Missed Appointments If you have a question about billing for a missed appointment, please contact the Provider Relations Department toll-free telephone number of ( , Ext. 3904) for assistance. Breach of Contract Either party may terminate the Participating Provider Agreement or the Participating Facility Agreement with cause, upon fifteen (15) days notice for Commercial and Medicare contracts and sixty (60) day notice for Medicaid contracts with prior written notice, via certified mail, if the other party breaches any material provision of this Agreement, and such breach is not cured to the satisfaction of the non-breaching party within such fifteen (15) or sixty (60) day period, as applicable. Such termination shall be effective as of midnight, beginning the sixteenth (16 th ) or sixty first (61 st ) day, as applicable, following the date of the letter sent via certified mail advising of the termination. Please review the Participating Provider Agreement or the Participating Facility Agreement to confirm Billing Members for Covered Services PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 26

27 Florida For all mental health services for covered services provided by provider under the Participating Provider Agreement or the Participating Facility Agreement, all factors related to electronic or hard copy claims, including the timeliness of claim submission, the establishment of the date a claim is considered received, the data required on a UB-04 or CMS-1500 form, the timeliness of payment of claims, the procedures and timeframes for notification of denial of claims, the procedures and timeframes for contesting claims, the procedures and timeframes for overpayment of claims, and the permissible error ratios for violation of terms related to payment of claims, shall be in accordance with Chapter , F.S. on Prompt Payment of Claims, as well as Chapter , F.S., on Payment of Claims. Provider shall not, under any circumstances, surcharge or otherwise bill a Member for any Mental Health Services, provided, however, that Provider may collect any applicable copayments and/or deductibles. Provider shall not balance-bill Members. Please review your contract to confirm. Michigan For non-covered Services provided to any member, Provider may bill such member directly for such noncovered services, provided that prior to providing such non-covered services, Provider advised member (1) that the services being provided by provider were non-covered Service.; (2) the applicable fees associated with any such service, and (3) that the Member was solely financially responsible to pay for such services. Please review your contract to confirm. Termination Either party may terminate the Participating Provider Agreement or the Participating Facility Agreement upon sixty (60) days prior written notice to the other party, for any issue that is not related to a quality care or service reason. Such termination shall be effective as of the first (1st) day of the month following the sixty (60) day notice. Either party may terminate the Participating Provider Agreement or the Participating Facility Agreement with cause for Commercial or Medicare contracts upon fifteen (15) days prior written notice; and for Medicaid contracts upon sixty (60) days prior notice with or without cause via certified mail, if the other party breaches any material provision of the Agreement, and such breach is not cured to the satisfaction of the non-breaching party within such fifteen (15) or sixty (60) day period, as applicable. Such termination shall be effective as of midnight, beginning the sixteenth (16 th ) or sixty first (61 st ) day, as applicable, following the date of the letter sent via certified mail advising of the termination. Psychcare may terminate the Participating Provider Agreement or the Participating Facility Agreement immediately upon notice to Provider if (1) Provider becomes insolvent, files a petition for protection from its creditors, enters into any general arrangement or assignment for the benefit of its creditors, or suffers or consents to the appointment of a trustee or a receiver to take possession of substantially all of Provider s assets, or in the event of the attachment, execution or other judicial seizure of substantially all of Provider s asset, or (2) Psychcare determines, in good faith, that (a) the actions or inactions of Provider are causing or will cause imminent danger to the health, safety or welfare of any Member, and/or (b) Provider no longer meets the requirements for licensing, malpractice, or has exclusions from Medicare/Medicaid, or any federal program. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 27

28 Psychcare should be notified, in writing, based on the terms of the Participating Provider Agreement or the Participating Facility Agreement. Continuity of Care for Members following Termination of Provider Psychcare will notify members and payors of the termination of the the Participating Provider Agreement or the Participating Facility Agreement prior to the effective date of termination, meeting timeliness standards for notification to members, as required for regulatory and accrediting agencies. Upon termination the Participating Provider Agreement or the Participating Facility Agreement, the rights of each party to the applicable Agreement shall terminate, except as otherwise provided herein, and as mandated by federal or state agencies. Commercial and Medicare members, who were receiving outpatient services prior to termination, will have access to their discontinued provider in accordance with applicable state and/or federal law. Please refer to the Participating Provider Agreement or the Participating Facility Agreement for specific time frames. Provider shall cooperate with Psychcare in the coordination and continuity of care for members affected by such termination. Notwithstanding anything herein to the contrary, if Psychcare or Payor becomes insolvent, provider shall continue to provide mental health services to members as mandated by CMS or state regulations or the applicable Psychcare/payor agreement. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 28

29 7. CLAIMS Claims Processing Psychcare is committed to processing all claims accurately and in a timely manner by following all rules and regulations set forth by federal, state, and NCQA reporting requirements, as well as those mandated by our clients. In order to avoid delay in payment or denial of a claim you submit to Psychcare, it is important for you to know the guidelines we follow, prior to your submission of a claim. To assist you, we have compiled some of the most frequently-asked questions, and we have listed them below in an easy-to-follow Q&A format. FAQ s Timely Submission Q: How long do I have to submit a claim? A: Florida: According to Florida law, all claims must be submitted to Psychcare within six (6) months, or one hundred and eighty (180) days from the date of service. A: Michigan: According to Michigan law, all claims must be submitted to Psychcare within one (1) year, or three hundred and sixty-five (365) days from the date of service. Electronic Claims Q: Can I submit my claim electronically? A: Yes. If you would like to submit electronic claims to Psychcare through a clearinghouse, be advised of the following: The Psychcare Payor ID is: All claims must have an authorization number (loop 2300) The member ID on the electronic claim must be the applicable health plan s member ID, not the Medicaid ID or the provider s internal ID (Loop 2010BA Segment: NM 109) Psychcare uses Emdeon ( exclusively for clearinghouse purposes. If you use a different clearinghouse, verify with them that they have an agreement with Emdeon to exchange claims. The Emdeon Submitter Helpdesk Number is: Emdeon will help you set up your software. If you need software to submit claims, Emdeon also provides software for claims submission. If you would like to contact Psychcare about claims submission please send an to: [email protected] with Electronic Claims in the subject line. Paper Claim Form Types Q: What paper claim form should I use? A: Outpatient services must be billed on a CMS-1500 (08/05). Inpatient services are billed on a UB-04. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 29

30 Paper Claim Forms Submission Address Q: Where should I submit my paper claim? A: All paper claims must be submitted to: Clean Claims Psychcare, LLC ATTN: Claims Department Sunset Drive Miami, FL Q: How do I know what to include on a claim? A: The authorization form mailed or faxed to you has most of the information you need in order to complete the claim form; however, you must include: Authorization number DOS Services rendered (by code authorized) Number of units A clean claim must contain no defect or impropriety, including a lack of any required substantiating documentation, HIPAA compliant coding or other particular circumstance requiring special treatment that prevents timely payments from being made. If, at any time, Psychcare, LLC requires additional information from any party external to Psychcare, LLC, the claim is no longer considered a clean claim and may be referred to as an unclean or contested claim. Authorization Numbers on Claims Q: Do I have to include an authorization number on the claim form? A: Yes. All services, except emergency services, must be pre-authorized by Psychcare unless the member has out-of-network benefits The authorization form is either mailed or faxed to the provider the day following the processing of same. The authorization form has most of the information needed in order to complete the claim form such as, services authorized (CPT code), number of units, and the time frame for which DOS from this authorization are valid. If you find a discrepancy in the authorization form, please contact Psychcare immediately for assistance, and to make any necessary corrections. Not doing so can delay the processing of your claims. Remittance Florida: Chapter (4)(a), F.S., requires a written acknowledgement of receipt of a paper claim within fifteen (15) days after receipt of such claim. In order to comply with the law, Psychcare is sending a remittance advice as acknowledgement; however, the check corresponding to the remittance will be sent under a separate correspondence in approximately 7 business days following the remittance advice. Please retain the remittance for your records. Once the check is received, it should be PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 30

31 Michigan: matched to the corresponding remittance advice. It is important that you understand that although you might receive a remittance advice with a check, these two documents are not related. Psychcare sends remittance advice within fifteen (15) days; however, the check corresponding to the remittance will be sent under a separate correspondence in approximately 7 business days following the remittance advice. Please retain the remittance for your records. Once the check is received, it should be matched to the corresponding remittance advice. It is important that you understand that although you might receive a remittance advice with a check, these two documents are not related. Prompt Payment Q: How long will it take Psychcare to process a claim? A: Florida: Commercial and Medicaid claims are paid, based on Chapter , F.S.. Please refer to same for any related questions. To summarize, claims for members with Commercial or Medicaid benefit plans will be processed within 20 days for electronic claims and 40 for paper claims All claims for members with a Medicare plan will be processed within thirty (30) days of receipt of the claim. A: Michigan: Commercial members in Michigan will be paid within forty five (45) days or if the claim has any defects, the claim shall be returned to the provider within thirty (30) days. All claims for members with a Medicare plan will be processed within thirty (30) days of receipt of the claim. Resubmission of Claims Q: How long do I have to return a corrected claim? A: Florida: The provider has thirty-five (35) days to resubmit a corrected claim. A: Michigan: The provider has twelve (12) months from the date of service to resubmit a corrected claim. Claim Questions Answered via Psychcare s Online Portal Q: I have a question about a claim I submitted recently. What can I do? A: Psychcare has exciting, new online tools that are available to providers which can be accessed through our online portal at Submitting Claims Authorization Lookup Claim Lookup Commercial and You have the ability to submit claims directly to Psychcare, or you may submit claims through our clearinghouse, Emdeon. This is a secure web application that allows you to review your authorizations from the last one hundred and eighty (180) days. You must sign-up online, and your account must be approved, before you can access this application. You can sort the output by authorization number, by DOS or by the member s last name. A print option is also available. This is a secure web application that allows you to review claims from the last thirty (30) days. You must sign-up online, and your account must be approved before you can access this application. You can sort the output by authorization number, by DOS or by the member s last name. A print option is also available. This application allows you to request initial outpatient authorizations online. The PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 31

32 Medicare Authorization Request Medicaid Authorization Request authorization will be faxed on the morning of the next business day following your request. These authorizations will then be available online as an Authorization Lookup. If the authorization cannot be processed, an error report will be sent, via , to the provider-supplied address. This application functions similar to the current online Authorization Request, but it will generate an authorization for Medicaid claims. Claim Questions NOT Answered via Psychcare s Online Portal Q: Who do I contact if I have a claim inquiry that cannot be answered on Psychcare s online portal? A: You can reach the Claims Department via one (1) of three (3) methods, and if payment or denial is not received by your office within the time allotted per applicable state and or federal law of submission of your claim, we strongly encourage you to contact us immediately, so we may assist you: Telephone: (800) , Ext Fax: (800) [email protected] Address Change Notifications Q: How do I notify Psychcare of an address change? A: It is the responsibility of each provider to notify Psychcare in the event of the following: Change of address, name change, merger, or other demographic change, by contacting the Provider Partnerships Department, either via at [email protected], or via our toll-free telephone number of ( , Ext. 3904). PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 32

33 8. QUALITY MANAGEMENT Philosophy Our mission is to promote quality and safety of clinical care, and quality of service to our members rendered by our provider (practitioner and facility) networks. Practitioners and facilities are carefully selected to join our network. We attempt to balance access and member preference, with quality, economic, and volume issues. Through a comprehensive credentialing process and approval by the Psychcare Credentialing Committee, highly competent and qualified practitioners are identified, who share our goal of providing quality services and effective treatment. Annually, Psychcare reports information to network practitioners, faclities, and members, about our QI program, including the program description and a report on our progress in meeting our goals, processes, and outcomes as they relate to member care and service. The information is maintained on the Psychcare website. Quarterly, as part of the Network Practitioner/Provider Website Notification and the Member Website Notification, network practitioners, providers and members are notified as to where to find the information and obtain a hard copy upon request. Quality Improvement Program Goals The annual QI Program s goals and objectives provide a comprehensive system that measures, and objectively evaluates the quality and safety of clinical care, and quality of the service. The QI Program provides ongoing monitoring to ensure that the following occur: Design clinical studies and quality improvement activities to identify opportunities to improve care, member safety, and service; Ensure that all Psychcare members receive equitable and effective care and services; Ensure that Psychcare staff and network practitioners/providers are respectful of, and responsive to the cultural and linguistic needs of our member populations; Provide timely access to behavioral healthcare services; Respond to emergency situations that can pose an immediate threat to the health and safety of members; Credentialing/recredentialing standards are maintained so that qualified practitioners receive referrals; Coordination of services is maintained among various levels of care, network practitioners, medical care, and community resources for continuity of care purposes; Utilization Management assures that care rendered is based on established clinical criteria, clinical guidelines, federal and state regulations and law, and accrediting body (ies) standards;. Appropriate use and disclosure of member protected health information ( PHI ) ensures that member privacy is properly maintained according to federal and state regulations, Ensure compliance with functions and activities governing program integrity in order to reduce the incidence of fraud, waste, and abuse; and comply with federal and state requirements. Scope of the QI Program The scope of the Annual QI Program includes the following activities: Annual Evaluation of the QI Program; PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 33

34 Review of the Annual QI Program Description and Work Plan; Member Satisfaction; Accessibility and Availability to Care; Serving a Culturally and Linguistically Diverse Membership; Clinical Quality; Continuity and Coordination of Care Activities; Member Safety; Clinical Studies; Privacy Practices; Staff Trainings; Preventive Health Programs; Utilization Management; Annual Review of Policies and Procedures; Credentialing/Recredentialing Activities, and Fraud, Waste, and Abuse. The following quality improvement activities are located on the Psychcare website. Quarterly, you will receive a Psychcare Network Practitioner/Provider Website Notification regarding current information, revisions and updates. Quality and Services Activities: How to obtain information about our Annual Quality Improvement Program, and a report on the progress in meeting our goals; Annual Publication of Safe Clinical Practices; Health Literacy, Cultural Competency, and Limited English Proficiency Activities; Psychcare Privacy Practices; Fraud, Waste and Abuse Prevention; Practice-site treatment record confidentiality standards; Provider treatment record confidentiality standards; Outpatient Treatment Record Confidentiality and Documentation Standards; AHCA Requirements for Florida Medicaid Outpatient Treatment Record Documentation, and Links to national and community resources, such as 12-step Programs, community support groups, HIPAA, and the FDA. Clinical Quality Activities: Psychcare Clinical Management Guideline Compendium, and Healthy Solutions Programs Related to High Risk, High Volume Behavioral Diagnoses. Continuity and Coordination of Care Activities: Continuity and coordination of care activities among behavioral healthcare specialists and between behavioral healthcare specialists PCPs. Most of the information on the website can be downloaded. If you would like a hard copy of the any of the documents and/or activities we have on our website, please call our Quality Management Department at the toll-free telephone number of ( ), Monday through Friday, 8:30 AM to 5:30 PM, EST. Psychcare Clinical Management Guidelines PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 34

35 The Psychcare Clinical Management Guidelines are a compendium of treatment recommendations for acute and chronic behavioral health and substance abuse conditions adapted from evidence based guidelines by nationally recognized sources. Development and Implementation The Clinical Standards Committee is responsible for developing, reviewing, and revising the Psychcare Clinical Management Guidelines. The Clinical Standards Committee s Clinical Management Guidelinse selection process includes the identification of annual high-risk/, high-volume member demographic data obtained from claims. The guidelines are adopted or adapted evidence based treatment guidelines from nationally recognized sources into the Psychcare Clinical Management Guidelines compendium, and includes a reference list. As part of the guideline development, Psychcare forwards the draft guideline to Psychcare network boardcertified psychiatrist specialists who may be affected by the identified guideline. The psychiatrists are asked to review the guideline and to provide their comments prior to the implementation of the guideline. Guideline Review and Revision The Clinical Standards Committee, a subcommittee of the Quality Improvement Committee, reviews the Psychcare Clinical Management Guidelines and when applicable, the guidelines are updated by the Clinical Standards Committee at least every two (2) years from the date of the last review. When new scientific evidence or nationally recognized standards are published before the two (2) year review date, the Clinical Standards Committee reviews the guidelines at the time the new scientific evidence and/or nationally recognized resource is published and revises the Psychcare Clinical Management Guidelines, when indicated. Performance Measurement Annually, Psychcare measures at least two (2) important aspects of each of the two (2) Psychcare Clinical Management Guidelines to determine practitioners adherence to the guidelines. The measurements must relate to clinical processes of care found within the guideline that are most likely to affect care. Quantitative and qualitative analyses are conducted based on the results of the annual evaluation of practitioner adherence to the guideline, opportunities for improvement are identified, and interventions are implemented, to improve practitioner performance with the guideline, and continually improve the quality of care provided to our members. Guideline Distribution The complete compendium of Psychcare s Clinical Management Guidelines are available on our website, and they can be downloaded. If you would like a hard copy of the guidelines, please call us at our toll-free telephone number of ( ). Outpatient Treatment Record Documentation PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 35

36 Psychcare measures practice site compliance with our standards for outpatient treatment record documentation. We assess whether improvement actions are indicated, and we monitor whether the actions taken have effectively improved treatment record documentation. Treatment record criteria are currently based on the 2010 NCQA MBHO Standards, QI 12: Standards for Treatment Record Documentation, and Medicaid Handbook; on opportunities for improvement identified from the previous year s annual review, on the annual Member Satisfaction Survey, and on the annual Member Complaint Analysis In accordance with federal program requirements as per 42 CFR ; Florida Statute, Title XXX, Chapters , , and ; Florida Medicaid program requirements, including the applicable provisions of; Attachment II, Medicaid Reform Heath Plan Model Contract, Section X.I Fraud Prevention ; and the Compilation of Social Security Laws, Social Security Act, Title XI, Sections 1128 B C, Psychcare monitors compliance with functions and activities governing program integrity in order to reduce the incidence of fraud and abuse. While onsite, a Psychcare clinical reviewer confirms that protected health information (PHI) is maintained as per the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information (Privacy Rule), Federal Regulations Confidentiality of Alcohol and Drug Abuse Records, Code 42, Chapter 1, Subchapter A, Part 2, and the Florida Mental Health Act, Chapter , Clinical Records; Confidentiality. When an onsite review is conducted, the Psychcare s clinical reviewer shall present a picture ID, identifying his/her affiliation with Psychcare, and the reviewer s full name shall be provided upon entrance to the office. Performance Standards: 100% of the member treatment records selected based on claims data will be available for review; 0% of the member treatment records will contain identified fraud, waste, and/or abuse; 85% overall plan wide compliance with treatment record retrievability, organization, and confidentiality requirements; Each practice site will meet a composite score of 80% compliance with all treatment record retrievability, organization, and confidentiality requirements; 85% overall plan wide compliance with treatment record documentation requirements, anad Each practice site will meet a composite score of 80% compliance with all treatment record documentation requirements. The documentation review will include the following elements: Treatment record content; Treatment record organization; Ease of retrieving treatment records, and Confidential patient information. Treatment records must be organized and stored in a manner that allows easy retrieval; and in a secure manner that allows access by authorized personnel only. Confidentiality of treatment records by the practice site must reflect the following: Records are stored securely; PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 36

37 Only authorized personnel have access to records, and Office staff receive periodic training in confidentiality of member information. Any practice site identified with a potential fraud, waste and/or abuse issue will be brought to the attention of either the Vice President of Clinical Operations or the Vice President, Quality Management, within one (1) business day of the review. A network practice site that failed to meet composite scores of 80% in the areas of treatment record retrievability, organization, and confidentiality requirements,; and/or 80% in the treatment record documentation requirements, will submit a written corrective action plan to the Quality Management Department within 30 calendar days of receipt of the letter, concerning opportunities for improvement. The Credentialing Committee will review each corrective action plan to determine whether further actions are indicated; and the practice site will be included the next year s review activity. The treatment record documentation standards are located in Appendix D of this manual and can be downloaded from on our website, If you would like a hard copy of the documentation standards please call us at our toll-free telephone number of ( ). Collaborative Activities The assessment, treatment, and follow-up of a member s care are essential in the provision of continuous and appropriate healthcare services for members who access multiple practitioners for medical and/or behavioral purposes. The Clinical Standards Committee, a committee that includes participation of network practitioners, developed high-risk communication criteria, noted below, to identify particular circumstances in which communication among behavioral healthcare practitioners/ providers, and between behavioral health practitioners/providers and medical specialists should occur to promote optimal behavioral health care: Members who are prescribed medications by their PCP and psychiatrist; PCPs who prescribe psychotropic medications; R/O thyroid disorders in members with symptoms of depression; Members who have an underlying medical condition and are being prescribed psychotropic medication by their psychiatrist; Failure to improve, and/or Sudden change(s) in mental status. Continuity and Coordination of Care among Psychcare Practitioners Annually, Psychcare identifies and acts on opportunities to improve coordination of behavioral health care by: Collecting data; Conducting quantitative and qualitative analyses of data to identify opportunities for improvement; Identifying and selecting an opportunity for improving the exchange of information across the continuum of behavioral health services; Identifying and selecting an opportunity for improving access and follow-up to appropriate behavioral health care practitioners in the network; PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 37

38 Taking action on the opportunity for the exchange of information across the continuum of behavioral health services, and Taking action on the opportunity for improving access and follow-up to appropriate behavioral health care practitioners in the network. Continuity and Coordination of Care between Behavioral Health and Medical Care Annually, Psychcare collects data about the following opportunities for collaboration between medical and behavioral care: Exchange of information; Appropriate diagnosis, treatment and referral of behavioral health disorders commonly seen in primary care; Appropriate uses of psychopharmacological medications; Management of treatment access and follow-up for members with coexisting medical and behavioral disorders, and Primary or secondary preventive behavioral health program implementation. Psychcare collaborates with our client health plans to improve the coordination of behavioral health care and general medical care including: Collaboration between Psychcare and our clients medical delivery systems or PCPs; Quantitative and qualitative analyses of data to identify improvement opportunities; Identification and selection of at least one opportunity for improvement, and Taking collaborative action to address at least one identified opportunity for improvement. The current continuity and coordination of care activities can be found on our website, The website also contains recommended communication tools to improve continuity and coordination of care among Psychcare network practitioners and between practitioners and your patients Primary Care Physicians and Medical Specialists. If you would like hard copy information on any of the activities, please call us at our toll-free telephone number of ( ). Health Literacy, Cultural and Linguistic Needs of Membership Psychcare is respectful of and responsive to our members literacy, cultural and linguistic needs. Based on references from the National Standards for Culturally and Linguistically Appropriate Services in Health Care, as published by the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH); the Federal Plain Language Guidelines, published by PlainLanguage.gov; and Measuring Knowledge and Health Literacy Among Medicare Beneficiaries, published by the Centers for Medicare and Medicaid Services Office of Research, we ensure that all Psychcare members receive equitable and effective care and services based on health literacy factors, and in a culturally and linguistically appropriate manner. Health Literacy All written and electronic behavioral health clinical, utilization management, and preventive health materials distributed to members are developed based on federal and state health literacy standards to increase members awareness and understanding of the information being provided. The reading ease of all written materials distributed to members is tested using the Flesch-Kincaid Grade Level Readability Statistics Test. Cultural Needs PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 38

39 Based on the 2000 U.S. Census Bureau data, or its subsequent data updates, prior to the 2010 U.S. Census, the Psychcare Commercial, Medicare and Michigan Medicaid practitioner and provider networks shall meet the cultural needs of member populations that comprise greater than 10% of the demographic population in each county that Psychcare members reside. Based on the 2000 U.S. Census Bureau data, or its subsequent data updates, prior to the 2010 U.S. Census, the Psychcare Florida Medicaid provider network shall meet the cultural needs of member populations that comprise greater than 5% of the demographic population in each county that Psychcare Florida Medicaid members reside. Linguistic (Limited English Proficiency) Based on the 2000 U.S. Census Bureau data, or its subsequent data updates, prior to the 2010 U.S. Census, the Psychcare Commercial, Medicare and Michigan Medicaid practitioner and provider networks shall meet the linguistic needs of member populations that comprise greater than 10% of the demographic population in each county that Psychcare members reside. Based on the 2000 U.S. Census Bureau data, or its subsequent data updates, prior to the 2010 U.S. Census, the Psychcare Florida Medicaid networks shall meet the linguistic needs of member populations that comprise greater than 5% of the demographic population in each county that Psychcare Florida Medicaid members reside. Psychcare written and electronic clinical, utilization management and preventive health educational materials distributed to members are translated from English to languages based on the 2000 U.S. Census Bureau data, or its subsequent data updates, prior to the 2010 U.S. Census, that comprise greater than 10% of the statewide demographic population in each state that Psychcare Commercial, Medicare and Michigan Medicaid members reside; and greater than 5% of the demographic population in each county that Psychcare Florida Medicaid members reside. Upon request, and on behalf of the member, written and electronic clinical, utilization management and preventive health educational materials will be translated into a language other than those identified by cultural and linguistic assessment data as indicated. Health Literacy, Cultural and Linguistic (Limited English Proficiency) Resources NCQA offers a free on-line CME and CEU course, Health Literacy, Cultural Competency, and Limited English Proficiency at The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care are available at American Medical Association. (1999). Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, Health literacy: Report of the Council on Scientific Affairs. Journal of the American Medical Association 281(6), Bann, C., & Berkman, N. (2002). Development and psychometric evaluation of beneficiary knowledge indices from the Medicare Current Beneficiary Survey. Report prepared for the Centers for Medicare and Medicaid Services under Contract No /003. Research Triangle Park, NC: Research Triangle Institute. Bann, Carla M., Nancy Berkman, and May Kuo. (2004). Insurance Knowledge and Decision-Making Practices among Medicare Beneficiaries. Medical Care, 42(11), To access the free program, A Family Physician s Practical Guide to Culturally Competent Care, please visit PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 39

40 Health Literacy Fact Sheets are available at Health Literacy Introductory Kit. American Medical Association. Chicago. AMA Foundation, This kit includes the video You Can t Tell by Looking, CHCS Health Literacy Fact Sheets, Health Literacy: Report of the AMA Council on Scientific Affairs, and materials for community presentations. The site provides information on how to obtain continuing medical education credits for using the kit. Diversity Rx. This website provides information about meeting the health care needs of multicultural populations. FirstGov. This website offers links to government agencies and departments, by keyword or agency name, e.g., Agency for Healthcare Research and Quality, Health Resources and Services Administration, National Institutes of Health, and Office of Minority Health. The following activities are monitored to assess whether the health literacy needs of our member populations are being met: Member Complaint Monitoring, and Annual Member Satisfaction Survey Analyses. The following activities are monitored to assess whether the cultural and linguistic needs of our member populations are being met: Member Complaint Monitoring; Annual Member Satisfaction Survey Analyses, and GeoAccess Assessment to determine the adequacy of the Psychcare network to meet the cultural and linguistic needs of our member populations. Member Safety Psychcare maintains a Clinical Risk Management Program, which is reviewed annually, to demonstrate our commitment to continually improving member safety. Psychcare collaborates with our practitioners and providers to foster supportive environments for members. We monitor and promote safe clinical practices, through the following activities: Member complaint reporting to monitor and investigate all potential member safety concerns; Distribution of information and tools to our network practitioners, providers, and clients Primary Care Physicians to enhance and encourage continuity and coordination of care across the medical and behavioral healthcare continuum; Distribution of educational materials, based on nationally recognized resources, to members, practitioners, and providers to facilitate decision-making, and improve knowledge about clinical safety in the care and treatment of specific high volume disorders; Evaluation of practitioner adherence to clinical guidelines to improve safe clinical practices; Inpatient underutilization monitoring to detect premature discharge/ termination from treatment;. Outpatient treatment record documentation review to ensure safe clinical practices, and Credentialing and recredentialing activities to validate that our network practitioners and providers are qualified to provide safe and effective treatment. Psychcare annually collects information from network providers and practitioners to improve member safety. The aggregate results of the network practitioner outpatient treatment record documentation reviews are PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 40

41 published on the member and provider sections of the Psychcare website. If you would like to review the information, please visit us at or if you would like a hard copy, call us at our toll-free telephone number of ( ). Psychcare alsos conduct an annual Psychcare Network Provider Patient Safety Survey, based on The Joint Commission s annual Behavioral Health Patient Safety Goals. Potential Quality of Care and/or Member Safety Instances Psychcare adheres to Social Security Act Section 1128C(a) as established by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the State of Florida Medicaid Contract, Section , Fraud Prevention Policies and Procedures, and the Health Care Quality Improvement Act of Investigation of a Potential Quality of Care and/or Member Safety Instance All potential quality of care and/or member safety concerns are reported verbally and/or electronically to the Quality Management Department. The investigation is initiated the same day the concern is received. The same day the concern is received, The Medical Director, or designee, is notified by the Quality Management Department, via a Potential Quality of Care/ Member Safety Notification and Tracking Form. The investigation includes adherence to HIPAA regulations, with the confirmation of the appropriate signed member consent for release of information to Psychcare, prior to the request for clinical information from the practitioner and/or provider. Suspension or restriction of clinical privileges in the network for a period of no longer than fourteen (14) business days may occur when a potential quality of care or member safety instance has a direct and imminent impact on the health of a Psychcare member. The same day of the decision, the practitioner is notified via fax and mail of the investigation, and the suspension or restriction of clinical privileges. The notification will contain a request to the practitioner and/or provider to submit a response to the concern, along with all pertinent information involving the issue within five (5) business days from receipt of the notification. The same day of the decision, Psychcare members in treatment with the practitioner and/or provider are notified of the suspension or restriction of clinical privileges, and offered a referral to another practitioner and/or provider. At no time shall Psychcare reveal the content of the investigation to the member, the member s legal representative, or any party who is not directly involved the investigation as per the 1986 Health Care Quality Improvement Act. The Quality Management Department is responsible for gathering all pertinent information pertaining to the particular incident, keeping in mind Psychcar s Policies & Procedures, member and provider confidentiality, and regulatory compliance. When a potential concern involves questionable clinical efficacy, possible noncompliance with community standards, and/or debatable ethical and/or legal misconduct, the Medical Director, or designee, will convene a Peer Review Committee. When indicated, the Peer Review Committee convenes within two (2) business days of receipt of the response and all pertinent information, which directly affects the investigation. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 41

42 Psychcare Peer Review Committee members who determine professional review actions shall not be liable in damages under Federal or State law. All individuals providing information to the Peer Review Committee regarding the competence or professional conduct of a practitioner shall not be held liable, unless such information is false. The practitioner is notified the same day of the decision and all clinical privileges are reinstated when the findings do not confirm a quality of care or member safety instance. When applicable, a Credentialing Committee will convene to review the Peer Review Committee s recommendation within one (1) business day of the Peer Review Committee. Confirmed Quality of Care or Member Safety Instances The Medical Director, the Peer Review Committee, and/or the Credentialing Committee may implement several types of actions because of a confirmed quality of care or member safety instance. Recommendations include, but are not limited to, the implementation of an improvement action plan, continued monitoring, or termination from the Psychcare networ,k with or without cause. Recommended actions are monitored and evaluated by the Medical Director within specific time frames. Follow-Up The Quality Management Department is responsible for ensuring that follow-up occurs at pre-determined time intervals, so that the effectiveness of the intervention(s) can be monitored. Ineffective interventions are reviewed with the Medical Director for recommendations. The case is closed when there is demonstrated improvement based on the recommendations. Risk Reporting Psychcare must report professional review actions to the applicable licensing board and the NPDB-HIPDB (National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank, when the professional review action (1) adversely affects the clinical privileges of a practitioner for a period longer than 30 days, (2) accepts the surrender of clinical privileges of a practitioner while the practitioner is under an investigation by Psychcare relating to possible incompetence or improper professional conduct, or in return for not conducting such an investigation or proceeding, or (3) in the case that a professional society takes a professional review action which adversely affects the membership of a practitioner in the society. The Quality Management Department coordinates communication of adverse occurrences between Psychcare and the health plan. The coordination of communication is essential in maintaining Psychcare's quality improvement philosophy. Privacy Practices Psychcare adheres to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Privacy Rule); CFR Title 45, Part 164, Subpart C; the Health Information Technology for Economic and Clinical Health Act (HITECH), Title XIII, Section of the American Recovery and Reinvestment Act of 2009; 16 C.F.R. Part 318: Health Breach Notification Rule: Final Rule -- Issued Pursuant to the American Recovery and Reinvestment Act of Requiring Vendors of Personal Health Records and Related Entities To Notify Consumers When the Security of Their Individually Identifiable Health Information Has Been Breached; Federal Regulations PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 42

43 Confidentiality of Alcohol and Drug Abuse Records, Code 42, Chapter 1, Subchapter A, Part 2; the Florida Mental Health Act, Chapter , Clinical Records; Confidentiality ; Medicare Advantage Program, 42 CFR, Part , Confidentiality and Accuracy of Enrollee Records; and Michigan Public Health Code, Act 368 of 1978, section Retention of Records. As noted in the Office of Civil Rights Privacy Brief, Summary of HIPAA Privacy Rule, adherence to privacy practices assures that individuals behavioral health information is properly protected while allowing the flow of information needed to provide and promote high quality care and protect our members health and wellbeing. Psychcare s Privacy Committee is responsible for overseeing and maintaining our privacy practices. Protected health information ( PHI ) includes individually identifiable health information, including demographic data such as name, address, birth date, Social Security number, as it relates to: The members past, present, or future physical or mental health, or condition; The provision of behavioral healthcare to the member, and The past, present, or future payment for the provision of behavioral healthcare to the member and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual. Detailed information about the following Psychcare privacy practices can be located on the Psychcare website, Routine Uses and Disclosures of PHI; Use of Authorizations and Access to PHI; Internal Protection of Oral, Written and Electronic PHI; Protection of Information Disclosed to Plan Sponsors or Employers, and Communication of PHI Use and Disclosure by Psychcare Network Practitioners and Providers. Psychcare is not the custodian of the members treatment record. Our network practitioners and providers are responsible for their patients PHI, in accordance with HIPAA Privacy Rules and the Health Information Technology for Economic and Clinical Health Act (HITECH), Title XIII, Section of the American Recovery and Reinvestment Act of 2009, and the implementation of processes such as member approval or denial of release of medical or other identifiable information, access and amendment of the treatment record, consent for treatment, consent for release of information, and all special consents in relation to the member s clinical treatment. Psychcare provides our Privacy Practices, and the website address for the Department of Health and Human Services, Office for Civil Rights, to all network practitioners and providers on the provider section of website, and upon request. Psychcare recommends that each network practitioner and/or provider consult with their legal counsel to implement and maintain the HIPAA Privacy Rule in their practice and/or facility. All information can be downloaded. If you would like a hard copy of the information, please call us at our toll-free telephone number of ( ). Members Rights and Responsibilities Psychcare is committed to maintaining quality care and service of your behavioral healthcare needs. The following are the members rights as well as our expectations of members responsibilities: PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 43

44 Members have the right to receive information about Psychcare, our services, practitioners and providers, and members rights and responsibilities; Members have a right to be treated with respect and recognition of their dignity and right to privacy; Members have a right to participate with practitioners in making decisions about their health care; Members have a right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage; Members have a right to voice complaints or appeals about Psychcare, or the care it provides; Members have a right to make recommendations regarding Psychcare s members rights and responsibilities policies; Members have a responsibility to supply information (to the extent possible) that Psychcare, and our network practitioners and providers in order to provide care; Members have a responsibility to follow plans and instructions for care that they have agreed on with their practitioners, and Members have a responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. The information is also available on our website in Spanish. We ask that you review the Members Rights and Responsibilities with your Psychcare patients. You can download a copy of the information at or if you would like a hard copy, please call us at our toll-free telephone number of ( ). Member Satisfaction Member Complaint Reporting Psychcare appreciates comments about our services and encourages our members to let us know what we can improve upon. If you have a patient who is dissatisfied with the care and/or services they received, we would like to hear about it. The complainant may call Psychcare s toll-free telephone number of ( ), Monday through Friday, between 8:30 AM to 5:30 PM, to speak with a staff member regarding their complaint. Bilingual (English/Spanish) staff members are available to assist all complainants. Psychcare accommodates all other non-english speaking members through a telephonic translation service at the time of the call. All written complaints are forwarded to Psychcare, Mail Stop QI, Sunset Drive, Miami, FL Whenever consent is indicated, the executed copy of the Consent for the Release of Confidential Information must be received from the member prior beginning the complaint investigation. The thirty (30) calendar day timeliness standard for complaint resolution is started once the executed copy of the consent is received by Psychcare. Letters and/or documentation are forwarded to the practitioner/provider, including a copy of the executed consent. The investigation is completed and the complaint is resolved, with communication to the complainant within thirty (30) calendar days from receipt of the member first level grievance, or when applicable the signed and dated release of information forms from the member or member s legal representative. Included in the resolution letter to the complainant is the grievance process, if the member is dissatisfied with the resolution of the first level grievance. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 44

45 All practitioner/provider investigative letters will be sent via fax. A network practitioner/provider is given five (5) days from receipt of the investigative letter to forward a response. If a response is not received within this timeframe, Psychcare reserves the right to hold all future initial referrals until a response is received and reviewed by Psychcare s Medical Director. At that time, a determination will be made as to the whether the response is acceptable to place closure on the complaint, or if further clarification is needed. Member complaints are placed into the following categories: Quality of Care and/or Member Safety; Quality of Practitioner Office Site; Acceptability; Availability; Accessibility; Psychcare Internal Processes, and Benefit Plan. Subcategories within the above categories provide further detail on the substance of the complaint. Semi-annually, Psychcare conducts an analysis of overall member complaints by the above categories to identify opportunities for improvement. Annual Florida and Michigan Commercial, Florida Medicare, and Michigan Medicaid Member Satisfaction Survey Psychcare conducts an annual Member Satisfaction Survey for all members who have accessed Psychcare services. The survey assesses members satisfaction with quality of care and services they received from Psychcare and our network practitioners and providers. The key areas assessed are: Getting Treatment Quickly; How Well Clinicians Communicated; Treatment Information Received from Clinicians; Rating of Counseling and Treatment; Access to Treatment and Information Received from Psychcare, and Satisfaction with Psychcare services and Network Practitioners in meeting members Cultural, Linguistic and Ethnic Needs. Annual Florida Medicaid Consumer Satisfaction Survey Annually Psychcare conducts a Florida Medicaid Consumer Satisfaction Survey for each of our Florida Medicaid clients, to assess consumer satisfaction with the services provided by Psychcare and our Florida Medicaid network practitioners/providers. Accessibility and Availability and Acceptability of Care and Services Access to Care PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 45

46 As per the definitions of emergency services and urgent care, Psychcare ensures that Medicare, Medicaid, and Commercial members have clinically-appropriate and timely access to outpatient emergent, urgent, and nonurgent (routine) care within the access standards as specified by CMS, state regulatory agencies, and accrediting bodies as noted below: Medicare Performance Goals: Members receive care for emergencies immediately; Members receive urgent care within 24 hours, and Members receive nonurgent care within one week. Florida Medicaid Performance Goals: Medicaid members with emergencies have access to behavioral healthcare immediately and/or 24 hours per day, 7 days per week; Urgent Care within one (1) day; Routine Sick Patient Care within one (1) week, and Well Care Visit within one (1) month. Commercial Performance Goals: Members receive care for non-life threatening emergencies within 6 hours; Members receive urgent care within 48 hours, and Members receive an appointment for a routine office visit within 10 business days. Annually, a survey is distributed to Psychcare s entire practitioner network. The survey asks for the practitioners outpatient appointment accessibility based on the urgency of care, depending on whether the member is a Medicare, Medicaid, or Commercial member. The aggregate survey information and member complaints reported in relation to the inability to access a timely outpatient appointment are incorporated into a report that is presented to the Utilization Management Committee, Credentialing Committee and Quality Improvement Committee annually. The committees identify and prioritize opportunities for improvement, based on the urgency of the issue and the ability to implement the intervention(s) that are likely to have a positive impact and can be implemented in a timely manner. When an individual practitioner is out of compliance with any of the access standards based on the results of the annual survey, and/or when a member complaint is reported, an improvement action plan shall be requested. The practitioner shall forward the improvement action plan within thirty (30) days of the request. The corrective actions are reviewed and approved by both the Utilization Management and Credentialing Committees. Availability and Acceptability of Services Annually, Psychcare assesses the geographic needs, and cultural and linguistic preferences of our Commercial, Medicare, and Medicaid member populations. We determine whether the network includes (1) a sufficient number of behavioral health care practitioners and providers, (2) adequate geographic distribution of its behavioral health care practitioners and providers, and (3) defined types of behavioral health care practitioners and providers, conveniently located to meet the needs of the members within its delivery system. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 46

47 We also assess our networks to identify the expressed cultural, ethnic, racial and linguistic needs of our member populations to determine the adequacy of its network in meeting these needs. Fraud, Waste and Abuse Prevention Psychcare is committed to ongoing monitoring to prevent fraud, waste, and/or abuse among contracted practitioners and providers; members; vendors; and/or other business entities. Psychcare shall monitor compliance with functions and activities governing program integrity in order to reduce the incidence of fraud and abuse and shall comply with federal program requirements as per 42 CFR ; Florida Statute, Title XXX, Chapters , , and ; Florida Medicaid program requirements, including the applicable provisions of; Attachment II, Medicaid Reform Heath Plan Model Contract, Section X.I Fraud Prevention ; and the Compilation of Social Security Laws, Social Security Act, Title XI, Sections 1128 B C. Psychcare provides annual fraud, waste and abuse prevention training to its employees, providers, and business entities as a general overview of fraud, waste and abuse regulations, potential fraud indicators, procedures for reporting fraud, waste, and abuse and the investigative process. The Psychcare Board of Directors has designated the Vice President, Quality Management to oversee compliance. The responsibilities include, but are not limited to, oversight of and adherence to federal and state regulations governing the detection and prevention of fraud, waste, and abuse. Annually Psychcare conducts training with all Psychcare employees. The Annual Fraud, Waste and Abuse Training Program, inclusive of definitions, federal and state regulations, monitoring activities, and reporting processes is located on the Psychcare website, If you would like a hard copy of the annual program, please contact the Quality Management Department at the toll-free telephone number of ( ). Psychcare Website Information Collected on the Website Information collected o n the Psychcare website, such as information concerning practitioner and provider credentialing/ recredentialing, and Preventive Health Stakeholder Comment Forms are for quality improvement, utilization management, and network management purposes. The confidentiality of such information is maintained as per HIPAA requirements. Psychcare does not collect member information on the website. Website Links Psychcare is committed to offering our members, practitioners, and providers, access to current educational information related to disease management and preventive health. We have provided links to other websites that include national organizations, along with educational information and tools from national companies that promote patient self-management of their behavioral health. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 47

48 Psychcare would like to emphasize that these links are not intended to provide medical advice, nor are they intended to endorse the use of any particular product from a national company. The links are for informational purposes only. We urge all members to consult with their healthcare practitioner regarding their specific personal questions. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 48

49 9. PREVENTIVE HEALTH Psychcare designs preventive health programs to prevent or detect the incidence, emergence or worsening of behavioral health disorders for at-risk member populations. The information for each prevention program, including educational brochures, 12-step programs, and links to community and national resources, can be viewed and downloaded on the Psychcare website, or is available in hard copy upon request via our toll-free telephone number of ( ). Psychcare conducts an annual assessment of our prevention programs to determine whether each program has effectively improved the quality of care to our members, or whether opportunities are indicated to improve a particular program. Quarterly, we notify you of each prevention program in our Network Practitioner/Provider Website Notification, which provides you with information about each of our prevention programs found on our website, or in hard copy upon request; and we request that you review and distribute the programs with your Psychcare patients, as indicated based on their clinical status. A Stakeholder Comment Form is included with each program to obtain your comments on the design and implementation of the program. Please assist us in our continuing efforts to improve the quality of care to our members. We ask that you distribute and review the preventive health programs educational resources with your Psychcare patients at your discretion. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 49

50 10. LIFE S SOLUTIONS EAP EMPLOYEE ASSISTANCE PROGRAM Access to EAP Services Eligible employees/associates, dependents and/or supervisors can access the EAP service through a twentyfour (24)-hour toll-free telephone line ( ). At the point of intake, Psychcare s case management staff will: Conduct a phone interview to assess the nature of the problem and the need for services; Obtain all necessary demographic information; Determine eligibility status; Select a network practitioner based on geographic location specialty/expertise, cultural competence, office hours, etc.; Give the member a choice of approved practitioners in the area, whenever possible; Instruct the member to call the practitioner of choice for an appointment; Contact the practitioner of choice with an initial authorization for evaluation one to three (1-3) visits, or based on specific EAP contracts, and Communicate with the Employer/Supervisor, in a confidential manner, when the EAP referral is made on a mandatory basis (compliance only). At the point of intake, the practitioner will: Schedule an appointment for the member in a timely manner; Have the member sign a release of information for communication with Psychcare s case management staff (See Attachment A EAP Authorization for Discussion of Treatment Form); Conduct an indepth assessment of the member s presenting problem; Attempt to stabilize the member s condition, if indicated; Attempt to resolve the member s presenting symptoms, using brief treatment interventions, whenever possible; Evaluate the member s benefit resources, including available community support systems, for making ongoing treatment recommendations, and Contact Psychcare s case management staff regarding the outcome of the evaluation process, including any recommendations or referrals, prior to the final session (referrals may include non-clinical services, such as a financial advisor or community agency). Treatment Beyond EAP Services EAP services are not necessarily designed to complete a course of therapeutic treatment. Upon completion of authorized EAP services, if additional treatment for the member is required, advise the member of your findings and recommendations, including available options, to include: Continuing in treatment on a fee-for-service; Referral to another clinician in the employee/associate s insurance plan, or Referral to a community-based agency. For many EAP members, Psychcare represents both the EAP and the managed behavioral healthcare vendor. In these cases, should the member require additional treatment, submission of a Psychcare Outpatient Case PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 50

51 Management Plan of Care or a Psychcare Substance Abuse Care Pla n will be necessary prior to the member s final EAP visit. The member is financially responsible for follow-up services not covered by Psychcare. Therefore, financial implications should be discussed completely with the member. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 51

52 11. CONTACT LIST Please know that although this manual will provide you with comprehensive information, Psychcare s staff members are always happy to help you, so please refer to the Contact List below, if you require assistance! Utilization Management (800) Authorizations for Managed Behavioral Healthcare Miami Dade County (305) Authorizations for Managed Behavioral Healthcare, Non-Miami-Dade (800) Authorizations for EAP Services (800) Claims (800) , Ext Quality Management (800) Medicaid (866) Provider Relations (800) , Ext Network Development (800) , Ext Credentialing (800) , Ext IT (800) , Ext Business Development (800) Fax (800) PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 52

53 APPENDIX A Link to Provider Resources Forms/Literature Claims: CMS 1500 (08/05) Claims: E-Claims log-in Claims: Information regarding Florida Prompt Payment Law Claims: Information regarding Michigan Prompt Payment Law Claims: Setting up electronic claims Claims: UB-04 Clinical form: Behavioral Health Practitioner Notification Form Clinical form: Clinical summary Clinical form: Medication management Clinical form: Behavioral Health Practitioner/Provider and Behavioral Practitioner/PCP Communication Forms Clinical form: Treatment plan Clinical information: Level of care guidelines Clinical information: Outpatient Treatment Record Documentation Requirements Clinical quality activities: Clinical Management Guideline Compendium Clinical quality activities: Healthy Solutions Programs Member information: Member Literature Member information: Member Rights and Responsibilities Preventive health Programs: Provider services: Join the network Provider services: Psychcare privacy practices Provider services: Report suspected fraud and abuse PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 53

54 APPENDIX B Website In order to improve services for our members, Psychcare has created new ways to navigate through the different resources available on our website. We are adding different programs, member newsletters and educational resources that have been developed over time for our members. The information found on the Psychcare website is strictly provided for educational and informational purposes only. Our website content should not be considered a substitute for medical treatment or a face-to-face consultation with a duly-licensed health care professional. Links on our website do not imply endorsement, approval, or warranty of any product, service, or web link by Psychcare, LLC, our affiliated companies or client companies. Website: These services are currently available to our contracted providers: Enter a Claim Enter a claim online with Psychcare claims entry system. Edit Your Information Edit/change your practice information (assists with online claims). Eligibility Lookup Find eligibility. View Claims View claims online. View Authorizations View authorizations online. Request Authorization Create an authorization request (non-medicaid). Medicaid Authorization Create a Medicaid authorization request. Problems/Suggestions Make suggestions or report problems. FARS/CFARS Reporting Enter FARS/CFARS data. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 54

55 APPENDIX C Medicaid Addendum NOTE: For the complete documentation regarding the Medicaid program, please refer to the Florida Medicaid s Community Behavioral Health Services Coverage and Limitations Handbook from AHCA. Medicaid services reimbursed directly by AHCA will pay at 100% of the prevailing Medicaid fee schedule minus applicable co-payments Quality Improvement Activities 1. Annual Medicaid Consumer Satisfaction Survey To assess consumer satisfaction with the services provided by Psychcare and our network practitioners/providers quarterly. 2. Medicaid Access to Care as per the State of Florida Medicaid Contract To monitor the ease with which Medicaid members can gain access to outpatient services with Psychcare s network practitioners. The definitions of life-threatening emergencies vs. non-life threatening emergencies are not applicable for Medicaid members, as per the State of Florida Medicaid Contract. Emergency mental health services are defined as those services that are required to meet the needs of an individual who is experiencing an acute crisis, resulting from mental illness, which is at the level of severity that would meet the requirements for involuntary hospitalization pursuant to Chapter , F.S., and who, in the absence of a suitable alternative or psychiatric medication, would require hospitalization. Urgent behavioral healthcare are those situations that require immediate attention and assessment, though the individual is not in immediate danger to self and others, and is able to cooperate in treatment. Medicaid members are seen within twenty-four (24) hours. Routine Sick Care Non-urgent problems that do not substantially restrict normal activity, but could develop complications if left untreated. Members have access to routine sick care services, within seven (7) calendar days. Routine Well Care Non-urgent problems that do not substantially restrict normal activity, but could develop complications if left untreated. Members have access to routine well care services, within one (1) month. 3. Practitioner Availability Based on the Assessed Needs and Preferences of the Medicaid Member Population Evaluate whether Psychcare maintains an adequate network of practitioners; and monitor how effectively the network meets the needs and preferences of our members as per AHCA requirements. Cultural and Linguistic Needs PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 55

56 The practitioner and provider networks will meet the cultural, ethnic, racial and linguistic needs of Psychcare covered member Medicaid populations that comprise greater than 5% of the demographic population in each county in which Psychcare manages an identified, covered membership, based on the demographic data obtained from the most recent full U.S. Census Bureau data. Practitioner Geographic Distribution The practitioner network in each county in which Psychcare has an identified membership will have 1 practitioner within a 30-minute/30 mile radius. The practitioner network in each county in which Psychcare has an identified membership will meet the 10,000 members: 1 practitioner ratio performance standard. Specialty practitioner networks (i.e. child psychiatrists and psychiatrists who treat substance abuse) in each county in which Psychcare has an identified membership will meet the 25,000 members: 1 practitioner ratio performance standard. Provider Geographic Distribution The provider network in each county, in which Psychcare has an identified membership, will have 1 provider within a 60 minute/60 mile radius performance standard. The provider network in each county in which Psychcare has an identified membership, will meet the 50,000 members: 1 provider ratio performance standard. 4. Medicaid Client-Specific Outpatient Treatment Record Documentation Activity On a quarterly basis, Psychcare shall ensure medical records are maintained for each member enrolled under the State of Florida Medicaid Contract in accordance with Sections , and a - d. 100% of the records audited shall include the quality, quantity, appropriateness and timeliness of services performed under the State of Florida Medicaid contract. 100% of members record must be legible and maintained in detail consistent with good clinical and professional practice, which facilitates effective internal and external peer review, medical audit, and adequate follow-up treatment. 100% of the records must contain identification of the physician or other service provider, date of service, the units of service and type of service must be clearly evident for each service provided. Psychcare shall monitor that 100% of network providers conduct a quarterly review of a random selection of ten percent (10%) or fifty (50) enrollee records, whichever is fewer, of enrollees who have received behavioral health care services during the previous quarter. Psychcare s policy and procedure, inclusive of treatment record retrievability, organization, confidentiality requirements, and treatment record documentation requirements are distributed to 100% of Medicaid network practitioners PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 56

57 The following medical record standards must be included/followed 100% appropriate: in each member's records as 1. Identifying information on the member, including name, member identification number, date of birth and sex, and legal guardianship. 2. Each record must be legible and maintained in detail. 3. A summary of significant surgical procedures, past and current diagnosis or problems, allergies, untoward reactions to drugs and current medications. 4. All entries must be dated and signed. 5. All entries must indicate the chief complaint or purpose of the visit; the objective findings of practitioner; diagnosis or medical impression. 6. All entries must indicate studies ordered, for example: lab, x-ray, EKG, and referral reports. 7. All entries must indicate therapies administered and prescribed. 8. All entries must include the name and profession of practitioner rendering services, for example: M.D., D.O., O.D., including signature or initials of practitioner. 9. All entries must include the disposition, recommendations, instructions to the patient, evidence of whether there was follow-up, and outcome of services. 10. All records must contain an immunization history. 11. All records must contain information on smoking/etoh (ethyl alcohol)/substance abuse. 12. All records must contain record of emergency care and hospital discharge summaries. 13. All records must reflect the primary language spoken by the member and translation needs of the member. 14. All records must identify members needing communication assistance in the delivery of health care services. 15. All records must contain documentation that the member was provided written information concerning the member s rights regarding advanced directives (written instructions for living will or power of attorney), and whether or not the member has executed an advance directive. The provider shall not, as a condition of treatment, require the member to execute or waive an advance directive in accordance with Chapter , F.S. The plan must comply with the requirements of 42 CFR , F.S. for maintaining written policies and procedures for advance directives. 100% of the records must contain documentation that the member was provided written information concerning the member s rights regarding advanced directives (written instructions for living will or power of attorney), and whether or not the member has executed an advance directive. The provider shall not, as a condition of treatment, require the member to execute or waive an advance directive in accordance with Chapter , F.S. The plan must comply with the requirements of 42 CFR for maintaining written policies and procedures for advance directives. Psychcare shall monitor that network providers maintain a behavioral clinical record for each Medicaid member in accordance with Privacy and Security provisions of the Health Insurance Portability and Accountability Act (HIPAA); and 42 CFR, Part 431, Subpart F. 100% of the medical record shall include confidentiality of a minor s consultation, examination, and treatment for a sexually transmissible disease in accordance with Chapter , F.S. Psychcare shall monitor a random selection of ten percent (10%) or fifty (50) enrollee records, to ensure that network practitioners have a procedure to capture services provided to its members by non-plan providers. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 57

58 Such services must include, but not necessarily be limited to, family planning services, preventive services, and services for the treatment of sexually transmitted diseases. 5. AHCA Approved Medicaid Client-Specific Major Depressive Disorders Study The overall percentage of members 18 years and olde, newly-diagnosed with Major Depressive Disorder (MDD) by a psychiatrist in an outpatient setting that had 1 initial and 2 follow-up antidepressant medication management visits during an eighty-four (84) day period (acute treatment phase). The overall percentage of members 18 years and older, newly diagnosed with MDD, in an outpatient setting who received 1 initial evaluation with a therapist, followed by an initial evaluation psychiatric evaluation. 6. AHCA Approved Medicaid Client-Specific Schizophrenia Study 1. The overall percent of Medicaid members ages diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Haloperidol; 2. The overall percent of Medicaid members ages 18 50, diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Risperidone; 3. The overall percent of Medicaid members ages diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Olanzapine; 4. The overall percent of Medicaid members ages diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Quetiapine; 5. The overall percent of Medicaid members ages diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Ziprasidone; 6. The overall percent of Medicaid members ages diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Aripiprazole, and 7. The overall percent of Medicaid members ages diagnosed with Schizophrenia in an outpatient setting who were treated with a normative dose range of Clozapine. The normative doses are as follows: 1. Haloperidol PO, 6 20 mg/ day; 2. Risperidone PO, 2 8 mg/ day; 3. Olanzapine PO, mg/ day; 4. Quetiapine PO, mg/ day; 5. Ziprasidone PO, mg/ day; 6. Aripiprazole PO, mg/ day, and 7. Clozapine PO, mg/ day Medicaid Services Level of Care Guidelines To identify whether the clinical criteria are within community standards for Medicaid members. Medicaid Services Level of Care Guidelines are reviewed annually. The following are Medicaid level of care services, by descriptions, criteria, exclusions and service code descriptors: 1. Assessment Services; PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 58

59 2. Limited Functional Assessment; 3. Brief Behavioral Health Status Examination; 4. In-Depth Assessment; 5. Bio-Psychosocial Evaluation; 6. Review of Records; 7. Psychological Testing; 8. Brief Individual Medical Psychotherapy; 9. Group Medical Therapy; 10. Behavioral Health Screening; 11. Behavioral Health Services; 12. Case Management Services; 13. Clubhouse Services; 14. Psychosocial Rehabilitation; 15. Adult Day Treatment Services; 16. Crisis Stabilization; 17. Intensive Case Management; 18. Medication Management; 19. Outpatient Services; 20. Specialized Case Management; 21. Therapeutic Behavioral Onsite Services; 22. Treatment Plan Development and Modification. 1. Assessment Services Description: a comprehensive evaluation that investigates the participant s clinical status including the presenting problem, history of the present illness, previous psychiatric history, physical history, relevant personal, and family history, personal strengths and a brief metal status exam. This examination concludes with a summary of findings, diagnostic formulation and treatment recommendations. Criteria: The evaluation should be conducted at the onset of illness or when the participant first presents for treatment It may be utilized again if an extended treatment hiatus occurs, marked change in mental status occurs or admission or readmission to an inpatient setting Exclusions: A psychiatric evaluation is not considered necessary when the participant has a previously established diagnosis of organic brain disorder unless there has been a change in mental status requiring an evaluation to rule out additional psychiatric processes that may respond favorably to treatment A maximum of two psychiatric evaluations per participant per fiscal year Services: H2000 HP comprehensive multidisciplinary evaluation/psychiatric evaluation by H2000 HO comprehensive multidisciplinary evaluation/ psychiatric evaluation by non physician 2. Limited Functional Assessment PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 59

60 Description: This assessment is restricted to the administration of the Multnomah Community Ability Scale (MCAS), Functional Assessment Rating Scale (FARS), and the Children s Functional Assessment Rating Scale (C- FARS) or any other functional assessment required by the Department of Children and Families (DCF). Criteria: The assessment must be provided by an individual who has been authorized by DCF to administer the assessment. A copy of the assessment must be placed in the participant s clinical record. This service does not require authorization in the treatment plan Exclusions: Medicaid reimburses a maximum of 3 limited functional assessments per participant per fiscal year Services: H0031 mental health assessment by non physician/limited functional assessment, mental health 3. Brief Behavioral Health Status Examination Description: A brief clinical, psychiatric, diagnostic, or evaluative interview to assess behavioral stability or treatment status. Criteria: Examination documentation must include the purpose of the exam, setting, mental status of the participant, findings, and plan. Must be provided, at a minimum, by a licensed practitioner of the healing arts or master s Exclusions: Medicaid reimburses a maximum of 10 quarter hour units annually, per participant, per fiscal year. Service: H2010 HO comprehensive multidisciplinary evaluation/brief behavioral health status exam 4. In-depth Assessment Description: A diagnostic tool for gathering information to establish or support a diagnosis, to provide the basis for the development of or modification to the treatment plan and the development of discharge criteria. The assessment must include an integrated summary. The summary is written to evaluate, integrate, and interpret from a broad perspective, history and assessment information collected. The summary identifies and prioritizes the participant s service needs, establishes a diagnosis, provided and evaluation of the efficacy of past interventions, and helps to establish discharge criteria. Criteria: PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 60

61 The participant must meet one of the following criteria to receive the assessment The participant has a documented history of being in need of a level of treatment beyond outpatient individual or group therapy or medication management The participant has been identified as high risk ( step down from inpatient treatment) The participant has been receiving intensive services for 6 months or longer and for whom the documentation supports a lack of significant progress The participant has been identified through the utilization management process as being a high risk / high utilizer. Exclusions: The assessment and integrated summary must be provided by a master s level practitioner Medicaid reimburses one in depth assessment, per participant, per fiscal year Services: H0031 HO mental health assessment by non physician, masters degree/in depth assessment, new patient, mental health H0031 TS mental health assessment by non physician, follow up services/in depth assessment established patient, mental health 5. Bio-psychosocial Evaluation Description: The evaluation describes the biological, psychological and social factors that may have contributed to the participant s need for services. The evaluation includes a brief mental status exam and preliminary service recommendations. Criteria: The evaluation must be reviewed, signed and dated by a master s level practitioner. The review must include clinical impressions, a provisional diagnosis and a statement by the reviewer that indicates concurrence or alternative recommendations regarding treatment. Exclusions: Medicaid reimburses 1 bio-psychosocial evaluation, per participant, per fiscal year Service: H0031 HN mental health assessment bachelor degree/ bio psychosocial evaluation, mental health 6. Review of Records Description: Includes the review of participant records, psychiatric reports, psychometric / projective tests, clinical and psychological evaluation date for diagnostic use in evaluating and planning for the participant. A written report must be done by the individual rendering services and must be included in the participant s medical record. Criteria: PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 61

62 A psychiatrist or other physician, or psychiatric arnp, at a minimum, must render psychiatric review of records. Exclusions: The review does not include a review of the provider agency s own records except for psychological testing and other evaluations or evaluative data used to explicitly to address documented diagnostic questions. Medicaid reimburses a maximum of 2 psychiatric reviews of records, per participant, per fiscal year. Service: H2000: comprehensive multidisciplinary evaluation/psychiatric review of records 7. Psychological Testing Description: Assessment, evaluation, and diagnosis of the participant s mental status or psychological condition through use of standardized testing materials Criteria: A participant is eligible to receive psychological testing only under the following circumstances: At the onset of illness or suspected illness or when the participant first presents for treatment. Testing may be repeated if an extended hiatus in treatment or a marked change in status occurs. The participant is being considered for admission or readmission to an inpatient treatment program. There is documented difficulty determining a diagnosis or where there are divergent diagnostic impressions. To gather additional information to evaluate or redirect treatment efforts. A written report based upon test results must be done by the individual rendering services and must be included the participant s medical record for all evaluation and testing services listed in the evaluation and testing section. Exclusions: Testing must be provided by an individual practitioner within the scope of professional licensure, training, protocols, and competence and in accordance with applicable statutes. Medicaid reimburses a maximum of 40 quarter hour units of psychological testing, per participant, per fiscal year. Service: H2019 therapeutic behavioral services, per 15 minutes/psychological testing 8. Brief Individual Medical Psychotherapy Description: A treatment activity designed to reduce maladaptive behaviors related to the participant s behavioral health disorder, to maximize behavioral self control, or to restore normalized functioning and more appropriate interpersonal relationships. Includes insight oriented, cognitive behavioral or supportive therapy. Criteria: PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 62

63 Therapy must be provided, at a minimum, by a psychiatrist, physician, physician assistant, or psychiatric arnp Exclusions: Medicaid reimburses a maximum of 16 quarter hour units, per participant, per fiscal year Services: H2010 HE comprehensive medication services/brief individual medical psychotherapy, mental health H2010 HF comprehensive medication services/brief individual medical psychotherapy, substance abuse 9. Group Medical Therapy Description: A treatment activity designed to reduce maladaptive behaviors, maximize behavioral self control, or to restore normalized functioning, reality orientation, and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships. This service includes continuing medical diagnostic evaluation and drug management, when indicated, and may include insight oriented, cognitive behavioral, or supportive therapy. Criteria: Therapy must be personally rendered by a psychiatrist or psychiatric arnp. Group therapy documentation must include the group topic, assessment of the group. level of participation, findings and plan. Exclusions: The size of the group can not exceed 10 participants Medicaid reimburses a maximum of 18 quarter hour units of group medical therapy, per participant, per fiscal year. Service: H2010 HQ comprehensive medication services, group setting/group medical therapy 10. Behavioral Health Screening Description: a face-to-face assessment of physical status, a brief history, and decision-making of low complexity. Criteria: The assessment must include at a minimum: o o o o Vital signs Medication concerns and possible side effects Brief mental status assessment Plan for follow up PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 63

64 o o The results of the examination must be included in the participant s medical record The service must be provided, at a minimum by a psychiatrist, physician, physician assistant, arnp or registered nurse Exclusion: Medicaid reimburses 2 behavioral health screening services, per participant, per fiscal year. Service: T1023 HE screening to determine appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol per encounter, mental health. Behavioral health screening. 11. Behavioral Health Services Description: A verbal interaction (15 minute minimum between the provider and the participant. This service must be directly related to the participant s behavioral health disorder or to monitoring side effects associated with medication (specimen collection, taking vitals, and administering injections) Criteria: Documentation for each service must describe the need and the participant s interaction. Verbal interaction must be provided by a minimum, by a physician s assistant, arnp or r.n. The monitoring of possible medication side effects must be provided by an individual qualified by licensure, training, protocols and competence and within purview of statutes applicable to his/her profession. Exclusion: A behavioral health service is not reimbursable on the same day for the participant as behavioral health screening services. Service: H0046 mental health services not otherwise specified/behavioral health services, verbal interaction, mental health. 12. Case Management Services Description: Case management entails the accessing, linking, coordinating and monitoring of psychosocial stressors from multiple providers in order to permit the individual to participate fully in family and community activities. Instrumental to this coordination is the creation of an individualized care plan which reflects the participant s strengths, personal goals, obtaining individualized services, facilitating linkages to community based resources, and reviewing the progress made over the course of care. Admission Criteria: The participant presents with an axis I diagnosis or a behavioral condition associated with an axis II condition PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 64

65 Family/individual requires assistance with obtaining, coordination necessary treatment, rehabilitation and social services without which they would likely require a more restrictive level of care. The participant has a history of multiple hospitalizations or a recent inpatient stay. Continued Care: An ongoing inability to obtain or coordinate services without program support Exclusions: When dealing with a child the family refuses services and the child continues to live within the family home. The participant chooses to no longer participate in the program. Severity of symptoms requires a more intensive level of care/treatment intervention. Discharge Criteria: The participant no longer requires program services. The individual/family are non participatory with the program. The participant requires a more restrictive level of care. Services: T1017 targeted case management for adults T1017 HA targeted case management for children birth to 17 T1017 HK intensive team targeted case management adults 13. Clubhouse Services Description: A place where people who have a mental illness come to rebuild their lives. Clubhouse services are structured, community-based group services provided in a group rehabilitation service setting. These services include a range of social, educational, pre-vocational and transitional employment. Every opportunity provided is the result of the efforts of the participant and staff who work together to achieve shared goals. These services are designed to assist the participant to eliminate the functional, interpersonal and environmental barriers created by their disabilities and to restore social skills for independent living and effective life management. Criteria: The participant must have a psychiatric diagnosis and be at least 16 years old. A referral from a psychiatrist, psychiatric arnp, or licensed practitioner of the healing arts. A weekly progress note that describes what activities were performed to enhance/support the participant s functioning. A monthly progress note at the end of each month that reflects how the services are linked to the goals and objectives of the participant s treatment plan. Documentation describes the participant progress relative to the treatment plan. Exclusions: PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 65

66 Medicaid reimburses services for a maximum of 1920 quarter hour units annually, per participant, per fiscal year. These units count against psychosocial rehabilitation units of service Service: H2030 mental health clubhouse, per 15 minutes 14. Psychosocial Rehabilitation Description: Services combine daily medication use, independent living and social skills training, support to clients and their families, housing, pre-vocational and transitional employment rehabilitation training, social support and network enhancement, structured activities to diminish tendencies towards isolation and withdrawal. Services are intended to restore a participant s skills and abilities essential for independent living. This differs from counseling/therapy in that it concentrates less upon the amelioration of symptoms and more upon restoring functional capabilities. Criteria: Services are appropriate for participants exhibiting psychiatric, behavioral or cognitive symptoms or clinical conditions of sufficient severity to bring about a significant impairment in day to day personal, social, pre-vocational and educational functioning. Daily documentation describes what activities the rehabilitation counselor did to enhance/support the participant s skills of daily life management. Monthly documentation reflects how the services are linked to the goals and objectives of the participant s treatment plan, and describes the participant s progress relative to the treatment plan. Exclusion: Medicaid reimburses a maximum of 1920 units of psychosocial rehabilitation services, per participant, per fiscal year. These units count against clubhouse service units. Service: H2017 psychosocial rehab services, per 15 minutes 15. Adult Day Treatment Description: Provides a coordinated set of individualized therapeutic services to participants with psychiatric disorders who may be able to function only partially in a school, work, and or home environment and need the additional structured activities of this level of care. Active family involvement is important unless contraindicated. Frequency should be based upon individual needs. Day treatment is for participants who need more active or inclusive services than is typically available through traditional outpatient mental health services. Day treatment leads to the attainment of specific goals through detailed therapeutic interventions within a designated timeframe and allows for transitioning of the participant to an outpatient level of care and to other necessary supports, or other structured activities. Admission Criteria: PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 66

67 The participant presents with symptoms associated with a diagnosis which requires and can be reasonably expected to respond to a therapeutic intervention. Exacerbation or persistence of a longstanding psychiatric disorder results in symptoms of thought, mood, behavior or perception that significantly limit functioning. Treatment planning should be individualized and specifically state what benefits the participant can reasonable expect to obtain. The participant requires structure for activities of daily living. The participant is seen as able to master more intricate personal and interpersonal life skills. Continued Care: The participant s condition continues to meet admission criteria at this level of care and participant is actively involved in the plan of care and treatment activities. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are apparent. Care is rendered in a clinically appropriate manner and focused on the participant s behavioral and functional outcomes as indicated in the treatment plan. All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practices. Exclusions: The participant s condition requires placement in a more restrictive level of care due to an increase in symptoms or can be managed in a less restrictive level of care due to a decrease in the severity of symptoms. The primary focus is social, economic, or one of physical health without a concurrent psychiatric episode meeting criteria for this level of care. Discharge Criteria: The participant has been able to achieve stated treatment goals and thus no longer meets the admission criteria. Treatment can now be provided in a less intensive level of care. The participant has shown an increase in symptom severity and thus requires services which are beyond the scope of the current treatment option. Non participation in treatment is of such a degree that treatment has been rendered ineffective or unsafe even with documented attempts to address this issue. The participant is not making progress towards obtaining treatment goals and there is no reasonable expectation of improvement at this level of care. Services: H2012 behavioral health day treatment, per hour/day services mental health H2012 HF behavioral health day treatment, per hour/day services substance abuse 16. Crisis Stabilization PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 67

68 Description: The most intensive level of psychiatric care. Twenty four hour skilled psychiatric nursing care, daily medical care, and a structure treatment milieu are required due to the participant s clinical presentation. Typically, the individual poses a significant risk to self or others or shows severe psychosocial dysfunction. Admission Criteria: The participant has been assessed by a licensed clinician and found to have symptoms associated with a psychiatric diagnosis which requires and can reasonably be expected to respond to therapeutic intentions/treatment. The participant has attempted suicide or displays severe suicidal ideation with a specific plan of self harm. Assaultive threats or behaviors, resulting from an axis I diagnosis, with clear risk of escalation. A recent history of violence resulting from an axis I or II diagnosis. Significant risk taking or poor impulse control resulting in danger to self or others. Command /bizarre behavior or psychomotor agitation or retardation that interferes with activities of daily living. These symptoms are of such a degree that the participant would not be able to function at a less intensive level of care. Disorientation or memory impairment which is due to an axis I diagnosis and endangers the wellbeing of the participant or others in the community. Exclusion Criteria: The participant can be safely maintained and treated in a less restrictive level of care. The participant exhibits serious and persistent mental illness and is not in an acute exacerbation of the illness. The primary problem is social, economic, or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care. Admission is being used as an alternative to imprisonment. Continued Care: The participant s condition continues to meet admission criteria for inpatient care, acute treatment interventions have not been exhausted and no less restrictive level of care would be adequate. All services and treatment are carefully structured to achieve optimal results in the most time proficient manner possible consistent with sound clinical practices. The participant is active in the plan of care and treatment to the extent possible given the current psychiatric symptoms. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress and or psychiatric/medical complications are evident Discharge Criteria: Treatment goals and objectives have been substantially met or continuing care can be implemented in a less restrictive level of care. The participant, family of guardian is competent but non-participatory in treatment or in following program rules/regulations. The non participant is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple attempts to address this issue. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 68

69 The participant is not making progress towards treatment goals and there is no reasonable expectation of progress at this level of care due to chronicity 17. Intensive Case Management Description: Intensive case management provides for the assignment of a single fixed point of accountability for the participant that ensures the coordination of services that will enable the participant to live in the least restrictive environment possible while increasing adaptive capabilities of the participants. Services include the development of a highly individualized and integrated care plan. Admission Criteria: The participant cannot be maintained in a less restrictive treatment setting without case management services. Individual/family requires assistance in obtaining and coordinating treatment, rehabilitation and social services, without which the participant would likely require a more restrictive level of care. The participant has been readmitted to an inpatient treatment setting within the past 30 days. Continued Care: Behaviors demonstrate the continued need for the service. Individual/family actively participates in the development and implementation of the treatment plan. Continued inability to obtain or coordinate services without program supports. Discharge Criteria: The participant has demonstrated the ability to remain out of the hospital for 3 months and/or the ability to maintain adherence with treatment plan and consent of referring agency. The goals have been substantially met and the participant shows the ability to be able to access needed services/supports and sustain activities of daily living. 18. Medication Management Description: The provision of a prescription, and ongoing medical monitoring. The sole service rendered by a qualified provider, is the evaluation of the need for psychotropic medication. Admission Criteria: There is a need for prescribing and monitoring of psychotropic medications Continued Care: Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress are evident All services and treatment are carefully structured to achieve optimal results in the most time efficient manner possible, consistent with sound clinical practices. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 69

70 Discharge Criteria: The participant no longer requires psychotropic medication. Consent for treatment has been withdrawn. Non participation is of such degree that treatment at this level of care is rendered ineffective or unsafe, in spite of multiple attempts to address the non compliance issues. Service: T1015 clinic visit, all inclusive, medication management. 19. Outpatient Services Description: Therapeutic services which are provided in an office, clinic setting, home or other location appropriate to the provision of psychotherapy or counseling. Services focus on the restoration, enhancement and /or maintenance of the participant s level of functioning and the lessening of symptoms which significantly interfere with functioning in at least one are of the participant s daily functioning. The goals, frequency and length of treatment will vary according to the needs of the participant and the response to treatment. Treatment can be seen as falling into 1 of 3 possible categories based upon the clinical information. 1. Situational: This is usually a brief clinical intervention (1-10 sessions) which has as a focus the resolution of a current life crisis, or adjustment to an external stressor. 2. Symptom Based: This type of intervention can be of an intermediate duration (1-20 sessions) and is focused on the reduction of symptoms associated with an axis I or II diagnosis and may include psychopharmacological measures. 3. Intricate: This intervention is to be considered for participants who have tried less restrictive clinical interventions which has been unsuccessful in controlling symptom severity. This approach may require the use of longer term therapy and medication management. Schedules or intermittent contact with a treatment provider is necessary to maintain the participant s current level of functioning and to prevent the possible need for more restrictive treatment interventions. Admission Criteria: The participant has a chronic mental illness (schizophrenia) or a refractory condition (personality disorder) which by history has required inpatient treatment. The participant shows symptoms which are consistent with an axis I diagnosis and can be reasonably expected to respond to therapeutic interventions. These symptoms are significant and interfere with the participant s ability to function on a daily basis. The belief exists that the participant has the ability to make significant progress towards treatment goals or treatment is necessary to maintain the current level of functioning. Continued Care: Improvement in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress are evident. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 70

71 All services and treatment are carefully structured to achieve optimal results in the most time efficient manner possible consistent with established clinical practices. Exclusions: Treatment is designed to address goals other that relief of symptoms associated with an axis I or II diagnosis. The primary problem is social, educational, economic, one of physical health without concurrent major psychiatric episode meeting criteria for this level of care. Admission is being used as an alternative to imprisonment. The participant requires a level of care beyond the scope of current services. Discharge Criteria: The treatment goals/objective have been substantially met. Non participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple attempts to address this issue. The participant is not making progress towards treatment goals and there is no reasonable expectation of improvement at this level of care. Services: H2019 HQ therapeutic behavioral services, per 15 minutes, group setting/group therapy H2019 HQ therapeutic behavioral services, per 15 minutes, family/couple with client present/individual and family therapy. 20. Specialized Case Management Description: Specialized case management is intended to be used in a wide variety of circumstances. A frequent use of this type of case management is to transition a participant from one level of care to another. This form of case managed may also be used with participants with non severe disorders, and their families, who need temporary assistance obtaining services. Admission Criteria: Participant has an axis I diagnosis or a behavioral condition associated with an axis II condition. Participant requires assistance in obtaining and coordinating treatment and social services to achieve treatment objectives. Continued Care: The participant shows a continued need for case management assistance to obtain and coordinate services to accomplish treatment plan objectives. The treatment plan clearly defines the expected treatment goals and the time frame for achieving these specific activities. Discharge Criteria: The goals of the care coordination have been successfully achieved. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 71

72 Exclusion Criteria: The participant has an axis I diagnosis which is not reasonably expected to improve or successfully respond to therapeutic interventions. 21. Therapeutic Behavioral Onsite Services Description: An intensive family based treatment intervention that is delivered in the home and designed to stabilize family functioning and preserve the safety of the child, family, community and maintaining the child within the home setting. Service components include comprehensive assessment of family structure, roles, and dynamics, crisis intervention, service coordination, and the teaching, accessing tangible resources and modeling of family skills. Intensity of treatment depends upon the clinical needs of the family unit. Admission Criteria: A family member demonstrates psychological symptoms which are consistent with and axis I diagnosis and which requires, and is likely to respond to, therapeutic interventions. Family functioning is seriously disrupted and threatens the wellbeing of the individual, family, community, or continued in home placement. The family has the ability and willingness to actively take part in this intervention. There are multiple systemic problems that require in-home intervention several hours a week and/or traditional, office based interventions have been ineffective in the stabilization of family functioning. Continued Care: Progress in relation to specific symptoms/impairments/dysfunction is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address the lack of progress is evident. The participant continues to meet admission criteria and there is active planning for transition to a less restrictive level of care. Exclusions: Consent is not obtained for this intervention. The home environment is not safe/stable enough to allow staff to appropriately intervene. The family based modification can be accomplished using a less restrictive intervention. Discharge Criteria: The family is not making progress towards goals and there is no reasonable expectation of improvement at this level. The family no longer has the ability/willingness to participate in this intervention. Treatment goals have been substantially met. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 72

73 Services: H2019 HM therapeutic behavioral services, per 15 minutes/less than bachelor degree level/onsite services, behavior management. H2019 HN therapeutic behavioral services, per 15 minutes onsite services, behavior management. H2019 HO therapeutic behavioral services, per 15 minutes/masters level/onsite services, behavior management, per 15 minutes 22. Treatment Plan Development and Modification Description: A structured, goal directed schedule of services developed jointly by the participant and the treatment team. If the participants age or clinical condition preclude participant in the development of the plan an explanation must be provided. The plan must contain written treatment-related goals and measurable objectives. Criteria: The treatment plan must contain the following elements: Specific diagnosis codes Goals which are focused on the participant s strengths and abilities Measurable objectives and target dates Services to be provided Frequency of treatment interventions An addendum may be used to make changes to the treatment plan in lieu of rewriting the entire plan. The addendum must be signed and dated by the treating practitioner and the participant Exclusion: Medicaid reimburses 1 treatment plan development, per provider, per fiscal year with a maximum total of 2 per participant per fiscal year. Service: H0032 mental health service plan development by non physician/treatment plan development, new and established patient mental health. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 73

74 APPENDIX D Network Practitioner Outpatient Documentation Requirements and Review Tool: TREATMENT RECORD DOCUMENTATION REVIEW TOOL Health Plan ID# Practice Site Name: Review Date: Treatment Record Retrievability, Organization, and Confidentiality Yes No 1. Are the treatment records securely stored? 2. Was the treatment record available for the review? 3. Was the treatment record organized? 4. The office has a process for access to treatment records by authorized personnel only. 5. Do the practitioners privacy practices incorporate the HIPAA Privacy Rules and the HITECH Act Requirements for Breach Notification of Disclosures? 6. Demonstration of periodic training for the practitioner office staff in the confidentiality of member information. 7. Is the practitioners privacy practices notice displayed in the either their office and/or included in the members treatment record? 8. Does the treatment record contain the members, or the member s legal representative (when the member is deemed incompetent or a minor), signed acknowledgment they have received the practitioners privacy practices notice? 9. If there was a lack of the members signed acknowledgment of receipt of the practitioners privacy practices notice, has the practitioner documented in the members treatment record the reason why there was a failure of obtaining the members written acknowledgment of their privacy practices? 10. Does the treatment record or the Psychcare Initial Treatment Plan contain a signed and dated member consent for the release of confidential information form to the members PCP for the promotion of continuity and coordination of care? 11. Is there a consent for treatment form that is dated and signed by either the member, or the member s legal representative (when the member is deemed incompetent, or under the age of 18)? 12. Are the Members Rights and Responsibilities prominently displayed in the office for patients to review? PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 74

75 Treatment Record Documentation Yes No N/A 1. The treatment record contains the following identifying information: patient s name; health plan ID number; date and birth; gender, and legal guardianship, when applicable. 2. The record is legible (if illegible to the primary reviewer, a second review of the legibility of the record is required). 3. All entries are dated and signed by the practitioner. 4. FOR PSYCHIATRIC PRACTICES ONLY Medication allergies and adverse reactions are clearly documented and dated. If the patient has NKA, this is prominently documented. 5. A medical history is documented. 6. A psychiatric history is documented. 7. For patients 18 and younger, a developmental history is documented. 8. Presenting problems are documented. 9. A mental status exam is documented. 10. The record indicates what medications have been prescribed. FOR PSYCHIATRIC PRACTICES ONLY When applicable, the dosage(s) and the date(s) of initial prescriptions or refills. 11. Special status situations, such as suicide risk, and emergency care rendered are documented. 12. The clinical findings and evaluation for each visit is documented. 13. Preventive services/ risk screening are documented, when applicable. 14. Documentation included ancillary services, and diagnostic tests ordered by the practitioner; and/or diagnostic and therapeutic services the practitioner referred their patient for, when applicable. 15. For patients 12 and older, documentation includes past and present use of cigarettes and alcohol, as well as illicit, prescribed, and over-the-counter drugs, or the lack thereof. 16. Is there documentation in the treatment record to the patients primary care physician and/or medical consultants? 17. Is there documentation in the treatment record from the patient s primary care physician and/or medical consultants? 18. If the patient is also receiving treatment from another behavioral health provider is there documentation in the treatment record to the other treating behavioral health practitioner? 19. If the patient is also receiving treatment from another behavioral health provider is there documentation in the treatment record from the other treating behavioral health practitioner? 20. Continuity and coordination of care activities between consultants, ancillary providers, community resources, and health care institutions are included, when indicated. PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 75

76 APPENDIX E Practitioner s Statement of Receipt of Participating Practitioner Manual PLEASE SIGN AND RETURN THIS PAGE WITHIN TEN (10) DAYS OF RECEIPT OF THIS MANUAL, TO: Psychcare, LLC Network Development Department Sunset Drive Miami, FL I have received and have had an opportunity to read a copy of Psychcare s Participating Practitioner Manual, including, but not limited to, all of the Practitioner Responsibilities, the Members Rights and Responsibilities, and the enclosed Attachments. A failure to comply with the terms, as noted throughout this manual, may result in one or more of the following: On-site practitioner and staff training; Official non-compliance warning, which may result in additional action(s); Denial of payment for services rendered, and/or Termination of Participating Provider Agreement. Upon receipt of this attestation, Psychcare will place this page in my contract file, as proof of receipt of the Participating Practitioner Manual. Please make copies of this page for each credentialed practitioner within your practice group. Each practitioner should sign and return this page. Practitioner name/licensure, as noted on contract - Please print Date Practitioner name/licensure, as noted on contract - Signature Name of contracted group practice, f applicable, as noted on contract Tax ID# used for claims, as noted on contract PARTICIPATING PROVIDER MANUAL 2011 psychcare.com Page 76