Manual for Community Care Network Providers
Transcription
Manual for Community Care Network Providers
Manual for Community Care Network Providers Community Care Behavioral Health Organization 339 Sixth Avenue Suite 1300 Pittsburgh, PA 15222 Provider Line: 1-888-251-CCBH (2224) Website: www.ccbh.com Welcome Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 1 Dear Network Provider, Welcome to Community Care Behavioral Health Organization (Community Care). This Provider Manual is designed to introduce you to Community Care and provide you with contact numbers; instructions regarding authorizations, billing, and quality of service; and access to our performance standards. As this Provider Manual is utilized for all of Community Care’s HealthChoices contracts, we publish a companion guide within the manual for any contract where there are changes related to specific counties (please see Appendix E and Appendix F). The companion guide will identify additions and deletions to specific sections of the manual related to specific counties. Please be sure to review the appropriate document(s) in conjunction with this manual. We hope that you find this manual to be clear and easy to follow. If you have any questions, please call your assigned provider representative. Provider representatives’ contact information can be found at http://www.ccbh.com/providers/networkdevelopment/providerreps or call our provider toll-free telephone line, 1-888-251-2224, for assistance. The Provider Line answers 24 hours a day/seven days a week. We look forward to working with you. Sincerely, Kristin Burns Senior Director, Network Management Community Care Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 2 Welcome to the Community Care HealthChoices Network Community Care is pleased to welcome you to our network. Since 1999, we have worked to serve HealthChoices* members and to create and support a strong network of providers and quality care. Our knowledge of managing care for highrisk populations combined with stakeholder input regarding program development has been the key to the successful management of our members’ care. Community Care’s mission is to improve the health and well-being of the community by delivering effective, high-quality, and accessible behavioral health services in a nonprofit partnership with public agencies, experienced local providers, and involved members and their families. Community Care values: • Excellence in customer service. • Collegial relationships with managed care partners. • Decision making based on criteria and data. • Effective individualized care and service. • Collaborative relationships with customers, stakeholders, and providers. • Continuous quality improvement. This manual contains information about Community Care’s commitment to acting responsibly and ethically and meeting the highest standards of care for members. It describes who we are, our HealthChoices members, what you need to know as a network provider, and our policies and procedures for providing care. This manual also contains instructions for claims submission (see the Billing section). Information is always changing; please tell us about any changes in your contact information or services. And watch for Provider Alerts from us; Provider Alerts amend the content of this manual and your contractual obligations. We welcome your suggestions about how Community Care can improve our service to you. Together we can present our members with a “seamless” system of high-quality behavioral health services and contribute to the communities and regions in which we work. *Community Care manages behavioral health services for Medicaid recipients (the program is known in Pennsylvania as HealthChoices) in counties throughout the Commonwealth of Pennsylvania. Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 3 HealthChoices Contact Information Corporate Office: Community Care Behavioral Health Organization 339 Sixth Avenue Suite 1300 Pittsburgh, PA 15222 Telephone: 412-454-2120; 1-866-415-1707; TTY: 1-877-877-3580 Fax: 1-412-454-2177 Provider Reference Materials: Appendix T for Mental Health Medical Necessity Criteria may be obtained from: http://www.ccbh.com/providers/phealthchoices/medicalnecessity Chemical Dependency Medical Necessity Criteria, Pennsylvania Client Placement Criteria (PCPC) may be obtained from: http://www.ccbh.com/providers/phealthchoices/medicalnecessity Department of Health, Bureau of Drug and Alcohol Programs, Room 929, Health and Welfare Building, Harrisburg, PA 17108 or from American Society for Addiction Medicine (ASAM) criteria may be obtained from: www.asam.org Patient Placement Criteria (PPC-2R) may be obtained from ASAM Publications Distribution Center, 1-800-844-8948, or P.O. Box 101, Annapolis Junction, MD 20701-0101. Provider Lines Provider Phone Line (Answers 24/7) Claims Questions Outpatient Registration (OPR) Authorization Forms Fraud and Abuse Hotline 1-888-251-2224 opt 1, opt 2, opt 1 1-877-371-0014 1-866-445-5190 Customer Service Lines for Members (24/7) by County: Adams Blair Carbon Clarion Columbia Forest Juniata Lycoming Monroe Pike Snyder Tioga Wayne 1-866-738-9849 1-855-520-9715 1-866-473-5862 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-855-520-9787 1-866-473-5862 1-866-473-5862 1-866-878-6046 1-866-878-6046 1-866-878-6046 Allegheny Bradford Centre Clearfield Elk Huntingdon Lackawanna McKean Montour Potter Sullivan Union Wyoming 1-800-553-7499 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-668-4696 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-668-4696 Berks Cameron Chester Clinton Erie Jefferson Luzerne Mifflin Northumberland Schuylkill Susquehanna Warren York 1-866-292-7886 1-866-878-6046 1-866-622-4228 1-855-520-9787 1-855-224-1777 1-866-878-6046 1-866-668-4696 1-866-878-6046 1-866-878-6046 1-866-878-6046 1-866-668-4696 1-866-878-6046 1-866-542-0299 Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 6 Clinical Fax by County: Adams Blair Carbon Clarion Columbia Forest Juniata Lycoming Monroe Pike Snyder Tioga Wayne 1-866-418-0366 1-855-473-2359 1-866-901-8367 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-855-473-2360 1-866-901-8367 1-866-901-8367 1-866-294-3935 1-866-294-3935 1-866-294-3935 Allegheny Bradford Centre Clearfield Elk Huntingdon Lackawanna McKean Montour Potter Sullivan Union Wyoming 1-888-251-0087 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-284-9184 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-284-9184 TTY for people who are Deaf/Hard-of-Hearing Spanish Line Autism Support Line PA Child Abuse Hotline Berks Cameron Chester Clinton Erie Jefferson Luzerne Mifflin Northumberland Schuylkill Susquehanna Warren York 1-877-877-3580 1-866-229-3187 1-866-415-1708 1-800-932-0313 Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 7 1-866-418-0366 1-866-294-3935 1-888-589-6559 1-855-473-2360 1-855-892-8495 1-866-294-3935 1-866-284-9184 1-866-294-3935 1-866-294-3935 1-866-294-3935 1-866-284-9184 1-866-294-3935 1-866-418-0366 Guidelines for Obtaining Approval for In-Plan and Supplemental Services Mental Health Service Emergency Evaluation Crisis Services: Mobile, Telephone, Walk-In Psychiatric Outpatient Evaluation or Initial Non-MD evaluation Best Practice / Life Domain Evaluation2 Authorization Type Authorization via Request Center submission None Notification; Approved BHRSCA Providers and BHRSCA prescribers submit via Facsimile Transmittal Request Form Limits/Exclusions/Definitions Hospital not reimbursed separately if patient is admitted within 24 hours to the evaluating facility. Requests may be made up to 30 days before and 60 days after the start of service. Child: State-approved Best Practices format is required for Behavioral Health Rehabilitation Services for Children and Adolescent (BHRSCA) services and RTF. In some parts of the Commonwealth there is very limited access to licensed psychologists and nonlicensed providers sometimes complete evaluations without any face-to-face evaluation by the licensed psychologist. Community Care will allow this practice to continue. However, we encourage licensed prescribers to continue to participate in all Best Practice evaluations and re-evaluations unless access issues make that option impossible. Please note that, if doctoral or master's level clinicians who are non-prescribers are conducting parts of or the entire BP evaluation, these individuals must be designated by and directly supervised by the licensed prescriber. Please refer to Chapter 41 of the PA Code for Psychologists by the State Board of Psychology. Community Care advocates that prescribers review the case w/the doctoral or master’s level clinicians who are conducting parts of or the entire evaluation. Request Form must be submitted following the initial evaluation; not to exceed the timely filing limits for Claims submission for the member’s product coverage. Concurrent: Request Form must be submitted following the updated evaluation Request; not to exceed the timely filing limits for Claims submission for the member’s product coverage. Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 8 Outpatient Therapy1 Annual Registration Only MD Outpatient Medication Check RN Outpatient Medication Check1 None Service Coordination: •Intensive Case Management •Resource Coordination •Blended Case Management Family-Based Mental Health Services Authorization via Request Center submission Annual Registration Only Precertification Initial: Registration must be submitted following the initial outpatient visit; not to exceed the timely filing limits for Claims submission for the Member’s product coverage. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period; not to exceed the timely filing limits for Claims submission for the member’s product coverage. REFER TO THE BILLING SECTION FOR TIMELY FILING LIMITS FOR EACH HEALTHCHOICES PRODUCT. — Initial: Registration must be submitted following the initial outpatient visit; not to exceed the timely filing limits for Claims submission for the member’s product coverage. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period; not to exceed the timely filing limits for Claims submission for the member’s product coverage. REFER TO THE BILLING SECTION FOR TIMELY FILING LIMITS FOR EACH HEALTHCHOICES PRODUCT Unit definition: 1 unit = 15 minutes. Requests may be made up to 30 days before and 60 days after the start of service. Unit definition: 1 unit = 15 minutes. Providers send/fax precert to their designated care manager who reviews and, if case meets medical necessity for the service, authorizes. The standard review schedule is to complete a Continued Stay Review at month 3 then again at month 6. The final review (Discharge Review) is completed within 5 business days of discharging the client from treatment. Of note, care managers always reserve the right to authorize and schedule reviews at their discretion based on such concerns as poor progress in treatment or high risk cases that require more care manager involvement and/or more frequent review. Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 9 Psychological Testing/ Neuropsychological Testing Electroconvulsive Therapy Non-Acute Partial Hospitalization Acute Partial Hospital Residential Treatment Facility Behavioral Health Rehabilitative Services (BHRS)2 Inpatient Admission Clozaril (Monitoring/Evaluati on and Support Services)1 Psychiatric Rehabilitation; SiteBased, Mobile, Clubhouse Peer Support Multi-systemic Therapy (MST) Precertification; Facsimile Transmittal Request Form Precertification for Outpatient only Notification; Facsimile Transmittal Request Form Telephonic Precertification Precertification Precertification Precertification exempt for Medicare Primary Annual Registration Only Precertification; Facsimile Transmittal Request Form Notification; Facsimile Transmittal Request Form Mail Child or Adolescent: Authorized by testing group, peer review. Adult: Authorized by test, peer review. Peer review. Limit of 3 hours minimum to 6 hours maximum per day. Limit of 3 hours minimum to 6 hours maximum per day. Based on clinical necessity. Re-evaluation required every 90 days. Authorized by specific procedure; Community Care care manager to be invited to all interagency service planning team meetings. Packet is due one week after the ISPT meeting Based on medical necessity criteria. Requires diagnoses on all 5 Axes; no V-codes Notification of admissions and within 30 days of discharge for Medicare Primary. Initial: Registration must be submitted following the initial outpatient visit; not to exceed the timely filing limits for claims submission for the member’s product coverage. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period; not to exceed the timely filing limits for claims submission for the member’s product coverage. REFER TO THE BILLING SECTION FOR TIMELY FILING LIMITS FOR EACH HEALTHCHOICES PRODUCT Based on clinical necessity. Initial: Two months authorized at pre-certification. Continued Stay: Three months authorized at continued stay. Unit definition: 1 unit = 15 minutes. Members must be age 18 or older or age 22 if in Special Education. Maximum six months authorized for each request. Packet is due one week after the ISPT meeting. Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 10 Functional Family therapy (FFT) Multidimensional Treatment Foster Care (MTFC ) Mobile Mental Health Treatment (MMHT) Tobacco/Smoking Cessation 1 2 Mail Packet is due one week after the ISPT meeting. Mail Packet is due one week after the ISPT meeting. Notification; Facsimile Transmittal Request Form Members must be age 21 or older. None Individual and group delivery. Maximum 30 units per 90 day authorization time frame. Based on clinical necessity and will be reviewed every 90 days. Maximum 70 units per year, per member/provider. The maximum unit is calculated by the total number of combined units (individual and/or group). Outpatient registration (OPR): Annual registration of Member required Includes mental health, mental retardation, and chemical dependency services Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 11 Guidelines for Obtaining Approval for In-Plan and Supplemental Services Chemical Dependency Service Emergency Evaluation Psychiatric Outpatient Evaluation or Initial Non-MD Evaluation Outpatient Therapy1 Methadone Maintenance (Outpatient)1 Authorization Type None Annual Registration Only Annual Registration Only Limits/Exclusions/Definitions For a hospital, not reimbursed separately if patient is admitted within 24 hours to the evaluating facility. Initial: Registration must be submitted following the initial outpatient visit; not to exceed timely filing limits for claims submission for the member’s product coverage. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period; not to exceed the timely filing limits for claims submission for the member’s product coverage. REFER TO THE BILLING SECTION FOR TIMELY FILING LIMITS FOR EACH HEALTHCHOICES PRODUCT Unit definition: Bundled = 1 week (methadone and treatment) Unbundled = 1 day (methadone only) Initial: Registration must be submitted following the initial outpatient visit; not to exceed the timely filing limits for claims submission for the member’s product coverage. Concurrent: Registration must be submitted prior to the expiration of the initial annual registration period; not to exceed the timely filing limits for claims submission for the member’s product coverage. Intensive Outpatient Therapy Authorization via Request Center submission REFER TO THE BILLING SECTION FOR TIMELY FILING LIMITS FOR EACH HEALTHCHOICES PRODUCT Must meet PCPC or ASAM for adolescents. Requests may be made up to 30 days before and 60 days after the start of service. Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 12 Non-Acute Partial Hospitalization Acute Partial Hospitalization Notification via Facsimile Transmittal Request Form Precertification Must meet PCPC or ASAM for adolescents; at least 3 visits per week with a minimum of 10 hours per week. Must meet PCPC or ASAM for adolescents; at least 3 visits per week with a minimum of 10 hours per week. Must meet PCPC or ASAM for adolescents for level 2B. Must meet PCPC or ASAM for adolescents for Level 4B. Requires diagnoses on all 5 Axes; no V-codes. Must meet PCPC or ASAM for adolescents for level requested. Halfway House Precertification Medically Managed Rehabilitation Non-Hospital Residential Rehabilitation (3B; short-term or 3C; long term) Medically Managed Detoxification Non-Hospital Detoxification Precertification Drug & Alcohol Case Management (ICM/RC) Authorization via Request Center submission Unit definition: 1 unit = 15 minutes. Drug & Alcohol Level of Care Assessment Authorization via Request Center submission Unit definition: 1 unit = 15 minutes. 1 Precertification Precertification Must meet PCPC for Level 4A. Requires diagnoses on all 5 Axes; no V-codes. Precertification Must meet PCPC for Level 3A. Requests may be made up to 30 days before and 60 days after the start of service. Requests may be made up to 30 days before and 60 days after the start of service. Outpatient registration (OPR): Annual registration of Member required Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 13