OptumHealth NYC BHO Provider Training
Agenda Introductions Overview of Optum Review of Contract between Optum and the Offices Admission & Discharge Review Provider Tools Tool Review Forms & Submission Process Optum/New York Web site ProviderConnect Question and Answer Session Wrap Up and Closing Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2
OptumHealth New York City BHO Staff William Fishbein PhD, MBA, Executive Director, OptumHealth NYC BHO Amy Freeman, LMSW, Clinical Program Manager Margaret Peggy Elmer, LMSW, Clinical Program Manager Ray Carannante, LCSW, Clinical Program Manager Manita Bhat, BS, Behavioral Health Intake Supervisor Erik Geizer, MS, LMHC, CGAP, Quality Assurance/Training Manager Linda West, BS, Reporting & Technology Manager Michael Silver, MD, Psychiatrist Marc Alan Minick, PhD, Community Liaison Mark Simmons, LCSW-R, Community Liaison Approximately 60 employees highly educated and experienced Master s level clinical employees, Clinical Care Managers (LMSW, LMHC, RN, CASAC, etc.) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3
Optum Overview
Optum Organizational Overview Optum is a health services business dedicated to making the health system work better for everyone We are comprised of three market-leading business segments: OptumHealth OptumInsight OptumRx Optum serves the entire health ecosystem 250,000 health professionals and physician practices 6,200 hospitals and facilities More than 270 state and federal government agencies Over 2,000 health plans; two of every five FORTUNE 500 employers; and one in every five U.S. consumers. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5
Our Business Context UnitedHealthcare-Health Benefits UHG UNH=Publicly Traded Registrant (NYSE) Optum Health Services Health care coverage and benefits businesses, unified under a master brand Employer and Individual Community and State Medicare and Retirement Information and technology-enabled health services platform, encompassing: Technology solutions Intelligence and decision support tools Health management and interventions Administrative and financial services Pharmacy solutions Helping people live healthier lives Helping to make the health care system work better for everyone Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
Contract Review
NYC BHO Contracted Region Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8
Populations Covered Under the Program All fee-for-service admissions to OMH-licensed psychiatric units (all ages) in general hospitals (Article 28 hospitals) Fee-for-service children and youth admitted to OMH licensed private psychiatric hospitals (Article 31 hospitals) Fee-for-service direct admissions to OMH State-operated children s psychiatric centers or children s units of psychiatric centers Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services (Article 28/32) Fee-for-service OASAS certified hospital (Art 28/32) or freestanding (Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation Services Children and youth who are diagnosed SED Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9
Functions of the BHO include: Concurrent Review Discharge Planning & Tracking Optum will contact the facility to schedule initial concurrent review for applicable services of Fee-For-Service Medicaid members within 3 days or by 5pm of the next business day (for weekend and holiday admissions) following notification of the admission by the provider. Follow-up reviews will be conducted at regular intervals. Optum will engage with the inpatient provider with respect to discharge planning for applicable admissions Enhanced efforts will be employed for inpatients identified as High Need Individuals Tracking of Children with SED Each new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the State Provider Profiling /Analytics Community Liaisons Historical Clinical data will be provided by the Offices to the BHOs Data elements specific to each inpatient admission and provider will be collected by the BHO and shared with the Provider and the Offices. Metric Reporting will be provided back to the Offices Facilitation of Cross System Linkages Optum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disorders Quality Initiative Optum will devise a quality assurance program to monitor the quality of work performed within the contract Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10
Review of Contract The Offices Provider Community Optum Provider Community Supplies Optum with guidance to perform tasks Supplies historical clinical data Supports access to cross systems Notify Optum of admission (Portal, Fax or Telephonic) Notify Optum regarding Children with SED Performs initial/ concurrent reviews Monitoring discharge planning & postdischarge services Tracking of children with SED Provider profiling Follows concurrent review & discharge monitoring processes Facilitation of cross system linkage Quality Initiative Treatment History Form Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11
What we need from you: Partner with Us Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitation Use your dedicated Clinical Care Manager and Community Liaison as a part of your team Engage in the Process Follow the concurrent review & discharge planning/tracking process Identify Cross System Linkages Provide data as requested Use the tools provided Ask Questions Don t hesitate to ask us questions Clinical questions can be directed to the Clinical Care Manager or to: NYCBHO.Clinical@optum.com General questions can be directed to the Executive Director & Community Liaisons or to NYCBHO.General@optum.com ProviderConnect technical questions/issues can be directed to: NYCBHO.tech@optum.com. Other Let us be part of your clinical team. We want your feedback. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12
Provider Tools & Submission Processes
Provider Tool Review- Methods for submission Fax Individual Information Matrix - Within 1 day of admission to facility - Concurrent Review at established intervals - Report discharges within 24 hours of discharge. Fax # Clinical Fax: (877) 283-0555 Telephonic Toll-free: (866) 505-3398 Dedicated Clinical Care Manager assigned to Facility Portal New provider portal: www.optumhealthnyc.com ProviderConnect software Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14
Fax Submission Option Individual Information Matrix Form 3 components of the Matrix Form: Admission Form Providers to notify their assigned BHO within 1 day of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such weekend or holiday. Concurrent Review Form Optum will contact facility within 3 days after admission or by 5pm the next business day following a weekend or holiday, whichever is later. Follow-up concurrent reviews will be conducted at regular intervals. Discharge Form Provider to complete and submit no later than 1 day post discharge. Form located on the Optum NYC BHO Provider Portal: www.optumhealthnyc.com Submit forms to the Optum NYC BHO clinical fax number: (877) 283-0555 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15
Admission Information Is there an OASAS consent on file? [YES / NO] Date: Facility Name: BHO Care Advocate Assigned: Transaction Type [Admission, Concurrent, Discharge] Facility Contact Name: Facility Contact Phone: Facility Contact Fax: Individual Name: Medicaid ID: Date of Birth: Gender: County of Residence: Date of Admit: Time of Admit: Age Group of the Individual: [Child 0-12, Adolescent 13-17, Transitional 18-25, Adult 26-64, Elderly 65+] Admission Type:[ Inpatient Psychiatric, Substance abuse Rehab, Inpatient detox] Diagnosis(es) at Admission: Axis I: Axis II: Axis III: Axis IV: : [educational problems, financial difficulties, lack of adequate supports, legal problems, other psychosocial and environmental problems, problems with work, social issues] Axis V: Reason(s) for Admission (Why now?): Readmission to Facility within 30 days for Inpatient Psychiatric/45 days for SA Rehab or Detox? Readmission to same facility: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16
Feedback from Optum after Admission Notification Optum will generate a Treatment History Form regarding the Individual admitted by the Facility within 3 days of admission or by 5 p.m. the next business day following a weekend or holiday. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17
Treatment History Form Information Facility Name: Facility Contact: Phone: Fax: Individual Name: Medicaid ID: Date of Admit: Time of Admit: Date of History Transmission: Time of History Transmission: High Need Individual: Yes/No Last twelve (12) months of behavioral health services utilized by individual: Facility/ Provider Dates of Service Type of Service Most recent diagnosis(es): Axis I: Axis II: Axis III: Axis IV: Axis V: There is/ is not additional treatment history information available on the individual. (circle one) *Facility is responsible for gaining executed release of information and sending to OptumHealth for the release of substance abuse treatment services. OASAS Consent Form http://www.oasas.ny.gov/mis/forms/trs/trs-51.pdf Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18
Concurrent Reviews Dedicated Clinical Care Manager to be assigned to Facility. BHO will post assignments once finalized on www.optumhealthnyc.com Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 20
Concurrent Review Information Is there an OASAS consent on file? [YES / NO] Date: Facility Name: BHO Care Advocate Assigned: Facility Contact Name: Facility Contact Phone: Facility Contact Fax: Individual Name: Medicaid ID: Physical & behavioral assessment findings: Current status of individual, including mental status examination results: Current Diagnosis(es): Axis I: Axis II: Axis III: Axis IV: [educational problems, financial difficulties, lack of adequate supports, legal problems, other psychosocial and environmental problems, problems with work, social issues] Axis V: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 21
Concurrent Review Information Is there a co-occurring behavioral health disorder [Y/N] Detail: Is this being addressed in the treatment plan? [Y/N] Detail: Is this being addressed in discharge planning? [Y/N] Detail: Is there a co-morbid medical condition? [Y/N] Detail: Is this being address in the treatment plan? [Y/N] Detail: Is this being addressed in the discharge plan? [Y/N] Detail: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 22
Concurrent Review Information For an admission from the community, what type of housing did the individual reside in? [homeless street, homeless shelter, mental health community, OASA/SUD community, OCFS/ACS/DSS community, OPWDD community residence, other, private home or apartment] If individual was admitted from an institutional setting what type of setting was the sending facility? [article 28 hospital, children and youth RTF, correctional facility, nursing home or health related facility, OCFS institutional setting, OPWDD developmental canter, private psychiatric hospital, state psychiatric hospital] What has worked in the past for treatment of individual? What strengths do the individual and/or family system have that we can build on? What is being done differently this time? Status/Progress with Treatment Plan: Assessment for case management completed? [yes, no] If case management is needed and individual is not currently enrolled, referral made? [yes, no] Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual? [yes, no] If no, why? Preliminary Discharge Plan: If this is a readmission, key factors in why the prior discharge plan didn t meet the member s needs? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 23
Concurrent Review Information Anticipated discharge date: Expected Length of Stay: Days Barriers to Discharge (biopsychosocial): Referral to local peer/family services programs/supports? [declined, yes, no] Individual involved in discharge planning? [yes, no] Individual s family involved in discharge planning? [yes, no] Contact with medical provider(s): [yes, no] Detail? Contact with behavioral provider(s): [yes,no] Detail? Is the individual enrolled in Managed Care? [yes, no] Is the individual enrolled in a Health Home? [yes, no] Did the individual have a care coordinator prior to admission? [yes, no] Case manager/ Care coordinator engaged in hospitalization? [yes, no] Name of case manager/care coordinator: If child/adolescent, other systems engaged? [yes, no] If yes, specify: Other Issues/Notes: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 24
Concurrent Review Information CURRENT MEDICATIONS: Name Dosage Frequency Discontinued (Y/N) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 25
Discharge Information Must be submitted within 1 day of discharge Is there an OASAS consent on file? [YES / NO] Date: Facility Name: BHO Care Advocate Assigned: Facility Contact Name: Facility Contact Phone: Facility Contact Fax: Individual Name: Medicaid ID: Date of Discharge: Time of Discharge: CM/Care coordinator (ICM, Health Home etc.): Individual Leave Against Medical Advice?: [yes,no] CURRENT MEDICATIONS: Name Dosage Frequency Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 26
Discharge Information Diagnosis(es) at Discharge: Axis I: Axis II: Axis III: Axis IV: [educational problems, financial difficulties, lack of adequate supports, legal problems, other psychosocial and environmental problems, problems with work, social issues] Axis V: Does the individual have a sufficient amount of medication until his/her follow up appointment? [yes, no] If no, why? Was case summary and discharge plan sent to the outpatient provider? [yes,no] If yes, what date? If the individual has a care coordinator (i.e. ACT, OMH TCM, Children's CHBS Waiver, MATS, and Health Home), was he/she informed of the discharge?[yes, no] If the individual is assigned to a MCO, have they been contacted for post discharge physical health care needs? [yes,no] Peer/Family Support Service/Program Referral: [declined, yes, no] If yes, name & contact information: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 27
Discharge Information For a discharge to the community, what type of residence is he/she being discharged to: [DOH adult home, homeless shelter, homeless street, mental health community, OCFS/ACS/DSS community residence, OPWDD community residence, OASAS/SUD community residence, other, private home or apartment] If the individual is being discharged to an institutional setting, what type? [article 28 hospital, children or youth RTF, nursing home or health related facility, OCFS institutional setting, OPWDD developmental center, private psychiatric hospital, State psychiatric hospital, SUD inpatient rehabilitation] Has the individual been provided with written instructions for what to do in the event of a crisis prior to his/her first post-discharge appointment? [yes,no] If no, why? If individual is under 18 years, linkage of children with other service systems [e.g. juvenile justice, educational system, child welfare)? [yes, no] Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 28
Discharge Information APPOINTMENTS AT DISCHARGE Service Type examples: AA/NA, Case management, Health home, Intuitional transfer, IOP/partial, SA, other, OP methadone, OP SA adult, OP SA youth, PCP/medical, psychiatry, Residential MH, Residential SA, therapist MH Provider #1 Name: Provider ID: Contact Information: Date/Time of Appointment: Service Type: Provider #3 Name: Provider ID: Contact Information: Date/Time of Appointment: Service Type: Provider #2 Name: Provider ID: Contact Information: Date/Time of Appointment: Service Type: Provider #4 Name: Provider ID: Contact Information: Date/Time of Appointment: Service Type: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 29
Review of Process - MH Inpatient Action Time Frame Medicaid FFS beneficiary admitted for inpatient mental health treatment Admitting facility submits Individual Information Matrix via provider portal, fax or telephone to NYC BHO BHO sends Treatment History Form to facility via fax, encrypted e-mail or provider portal BHO CCM contacts designated facility clinician; sets time for concurrent review BHO CCM and designated facility clinician conduct concurrent reviews BHO CCM documents facility compliance with required elements of treatment planning, treatment and discharge planning Consumer s clinical condition no longer justifies continuing inpatient stay During concurrent review, BHO CCM tells facility liaison that continuing inpatient stay may no longer be justified and that BHO CCM is sending the case for review by a BHO psychiatrist to make the determination If the BHO psychiatrist concurs that continuing inpatient stay is no longer justified, BHO CCM gives verbal Notice of Preliminary Finding to the facility liaison. Within 1 day of admission or by 5 p.m. the next business day following weekend and holiday admissions Within 3 days of admission or by 5 p.m. the next business day following weekend and holiday admissions At least every 5 days* Within 1 day of concurrent review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 30
Review of Process - MH Inpatient - continued Action Time Frame Potential Provider Responses Provider submits request for reconsideration and additional clinical information to support the need for continuing inpatient stay; BHO psychiatrist completes review of additional clinical information and/ or doc-to-doc consultation to facility physician; communicates reconsideration determination to the facility and if ongoing care is determined to be required, BHO CCM continues concurrent reviews. BHO issues Notice of Clinical Determination if the reconsideration review determines that the individual does not require treatment in an inpatient setting and the individual is not discharged by the facility. BHO CCM communicates the Notice of Clinical Determination to the facility liaison verbally and in writing by portal, fax, or secure email. Within 1 day of receipt of Verbal Notice of Preliminary Finding Within 1 day of receipt of Reconsideration Request Within 3 days of Verbal Notice of Preliminary Finding OR Provider discharges consumer and submits required discharge information via portal, fax or secure e-mail; BHO closes case Within 2 days of receipt of Verbal Notice of Preliminary Finding OR BHO has received no discharge information and no request for reconsideration BHO issues Notice of Clinical Determination to facility-designated representative via fax or secure e-mail and sends copy to the Offices Within 2 days of receipt of Verbal Notice of Preliminary Finding Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 31
Long Stay Designation NOTE: The Offices will waive the review requirement for maximum concurrent review intervals for individuals the BHO designates as Long Stay when all of the following criteria are met: The individual meets the criteria for inpatient care The individual presents with symptoms and/or history that demonstrates a significant likelihood of deterioration in functions/relapse if transitioned to a less intensive level of care The BHO Clinical Care Manager and provider concur that the current treatment and discharge plans best meet the individual s needs The individual s discharge is delayed pending availability of resources that both the provider and BHO believe are necessary to maintain the individual outside of the current hospital setting (e.g. intermediate care inpatient, residential treatment, or foster care beds) For Long Stay individuals, the BHO Clinical Care Manager should schedule follow up reviews at intervals deemed appropriate based upon clinical judgment. Notices of Preliminary Finding and Clinical Determination will not apply to individuals designated as Long Stay. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 32
Concurrent Review Timeframes for Other Service Types SA Inpatient Detox Same process as MH Inpatient, however concurrent reviews conducted at least every 2 days SA Inpatient Rehab Same process as MH Inpatient, however concurrent reviews conducted within 21 days of admission and every 7 days thereafter Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 33
Telephonic Submission Option Call Optum Intake at (866) 505-3398 for initial admission within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday. Make sure all of your information is ready when calling Optum Intake Use Individual Information Matrix form as a guideline. Form located on the Optum NYC BHO Provider Portal : www.optumhealthnyc.com Ongoing concurrent reviews will be conducted in partnership with assigned Optum Clinical Care Manager. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 34
Provider Portal Submission Optum Provider Portal: Use ProviderConnect via www.optumhealthnyc.com for online entry of data from Information Matrix form: Initial Admission Concurrent Review Discharge Planning Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 35
OptumHealth NYC BHO Provider Portal Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 36
OptumHealth NYC BHO Provider Portal Page. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 37
ProviderConnect Login. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 38
ProviderConnect Login (cont.). Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 39
ProviderConnect News. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 40
ProviderConnect Main Menu. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 41
Individual Search. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 42
Individual Search Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 43
Admission Notification. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 44
Admission Notification Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 45
Saving updates- Admission Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 46
Concurrent Review- Logging into Provider Connect Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 47
Individual Search - Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 48
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 49
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 50
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 51
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 52
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 53
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 54
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 55
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 56
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 57
Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 58
Current Medications Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 59
Adding Medications Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 60
Saving updates- Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 61
Discharge- Logging into Provider Connect Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 62
Individual Search- Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 63
Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 64
Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 65
Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 66
Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 67
Saving updates- Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 68
Children with Serious Emotional Disturbance (SED) - Logging into Provider Connect Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 69
Individual Search- SED Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 70
Children with Serious Emotional Disturbance (SED) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 71
Children with Serious Emotional Disturbance (SED) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 72
Children with Serious Emotional Disturbance (SED) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 73
Saving updates- SED Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 74
Next Steps Complete and submit Facility Information Form, if not yet submitted, to NYC BHO via: Fax at: (877) 450-6020 email at NYCBHO.general@optum.com Mail at: 22 Corporate Woods Blvd., Albany, NY 12211 Providers who select ProviderConnect as their submission option should contact the Optum Help Desk to request a User ID/Password at (866) 505-3398/prompt 4 Optum will post Clinical Care Manager/Facility assignments and contact information on our Provider Portal at: www.optumhealthnyc.com Start to notify Optum of admissions as of 1/3/2012. Fax - Clinical Fax: (877) 283-0555 Telephonic - (866) 505-3398 Provider Portal (ProviderConnect) - www.optumhealthnyc.com If you are using the Optum Provider Portal ProviderConnect and have technical questions or encounter a problem, contact Optum (866) 505-3398/prompt 4 or email us at NYCBHO.tech@optum.com. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 75
Questions?