Transcript State of Maryland Department of Health and Mental Hygiene

State of Maryland
Department of Health and
Mental Hygiene &
VALUEOPTIONS®
Clinical Training
For
Case Management Providers
October 2009
Presenters
• Nancy Calvert, Director, ValueOptions®
Maryland Provider Relations
• Mara Rapant, ValueOptions® National
Director of Clinical Services
Agenda
• Update
• Case Management Overview
• Overview of ProviderConnect
• Requesting Authorizations
• Questions
Updates
• ValueOptions® Maryland Website
•
http://maryland.valueoptions.com
– Provider Alerts
• MHA Policy Clarification Memos and Announcements
• ValueOptions® Maryland Updates and Announcements
– Training Schedule
– ProviderConnect “tips”
– Maryland Specific ProviderConnect “demo”
– Provider Forms – including a hard copy concurrent review form
– Coming Soon:
• Provider Manual
• Diagnostic Crosswalk
• Fee Schedule
• Service Grid
– Consumer Information
Important Information
• MHA Memo dated August 12, 2009:
• Download at:
•
http://maryland.valueoptions.com/provider/alerts/081209_Case_Management_Transition_Update.
pdf
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Effective Sept. 1, 2009, CM transitioned to fee-for-service
Consumers receiving CM services prior to 9/1/2009 may receive:
– A maximum of 2 visits/month for Uninsured Eligible consumers, without
authorization
– A maximum of 5 visits/month for Medicaid Eligible consumers, without
authorization
•
New Uninsured consumers:
– Must be approved for Uninsured Eligibility by the CSA and MHA.
– Courtesy review must be submitted for all new uninsured consumers:
• If MA is approved, payment will be made back to the eligibility start date.
• If MA is not approved, an uninsured eligibility span will not be opened.
Assessments:
• Fiscal Year 2010
– Providers will be reimbursed for only one assessment
• Fiscal Year 2011 and forward
– Providers will be reimbursed for no more than two
assessments
• Reminder: Assessments are required every six months.
Uninsured Eligibility Requests
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Provider must submit the request for Case Management services for
new, uninsured consumers to ValueOptions® Maryland.
The case management request must meet the both the uninsured
eligibility and case management criteria for case management services
to be considered for an exception by MHA and the CSA.
The ValueOptions® Maryland Care Manager will review the request,
pend the decision in ProviderConnect and forward the request to the
CSA for review and approval.
If approval is recommended by the CSA, the CSA will request final
confirmation by phone or email to MHA – Penny Scrivens, LCSW-C,
Case Management Coordinator, at 410-402-8482, or
[email protected], or James Chambers, Director, Adult
Services at 410-402-8476 or [email protected].
MHA will review the request, determine if funds are available and
forward the decision to the CSA within 2-3 working days.
If MHA approves, the CSA will enter the approval in ProviderConnect.
Uninsured Eligibility Requests
•
Exceptions granted will be very limited and
contingent upon the urgency of the request, such as a
discharge from a state hospital, or diversion from
inpatient psychiatric care, and the expectation that the
provider will link the individual to the necessary benefits
in order to obtain Medicaid coverage for future services.
Case Management – Quick Tips
• Case Management Codes:
– H0031: Assessment- $105/assesssment
– T1016: Daily Session - $105/session
• Duration:
– Assessment: not time defined
– Daily Session: minimum 60 minutes
• Authorization Span:
– Medicaid: 6 months
– Uninsured Eligible: 3 months
• Levels of Service:
– Medicaid:
• General – maximum of 2 visits/month
• Intensive – maximum of 5 visits/month
– Uninsured Eligible:
• General only – maximum of 2 visits/month
Levels of Service
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General is based on the severity of the consumer’s mental
illness, and the consumer must meet at least one of the
following conditions.
Not linked to mental heath and medical services;
Lacks basic supports for shelter, food, and income;
Transitioning from one level of care; or
Need to maintain community-based treatment and services.
Intensive is based on the severity of the consumer’s mental
illness, and the consumer meets more than one of the
following conditions.
Not linked to mental heath and medical services;
Lacks basic supports for shelter, food , and income;
Transitioning from one level of care; or
Need to maintain community-based treatment and
Service Provision
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Case Management services are not reimbursable in an
inpatient facility, e.g. hospitals or nursing homes or
detention centers:
– The consumer must be discharged from CM and a new
authorization requested upon discharge from the inpatient.
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The MHA does not specify the required number of
cases on a Case Manager’s case load.
The required length of a visit is 60 minutes
– Visits must be face-to-face, or combined with same day telephonic
or collateral contacts.
– Only an encounter with the minor’s guardian or parent can be
counted as a visit (excludes a face-to-face encounter with a school
counselor.)
– Travel time is not reimbursable unless an intervention occurs and
is documented in the consumer’s record.
– Start and end times of the encounter must be documented.
•
Only one visit may be billed per day.
Requests for Case Management Services
• Clients may self-refer by contacting the CSA, the Case
Management Provider or ValueOptions® Maryland.
• An Uninsured Eligibility request may be submitted for
Shelter+Care consumers who are not Medicaid
recipients.
• Case Management Services for Transitional Age Youth
(TAY) who do not meet the Medical Necessity Criteria
may be considered for CM services on a case-by-case
basis.
• The diagnostic criteria for admission to Case
Management is under review and will be released in the
near future.
Authorization Requests
• Authorizations will be issued from the date of the
request for authorization, not from the first day of the
month of the request.
• Authorizations may not be backdated.
• A diagnosis is not required for the initial authorization
request. “Diagnosis Deferred” (ICD-9 Code 799.9) may
be used for the initial request. Please note: All 5 Axes
are required on the subsequent requests.
• Courtesy reviews are accepted for Case Management, if
there is a reasonable expectation that the consumer is
eligible for Medicaid. The provider is expected to assist
the consumer with the Medicaid Application.
Authorization Requests, Continued
• The preferred method for requesting an authorization is
on-line, via ProviderConnect.
• Currently, providers must complete the request via
ProviderConnect in one sitting. A future
ProviderConnect enhancement will include a “save”
function.
• Providers should enter only the information pertinent to
the consumer on the problem list screen in
ProviderConnect. It is not necessary to complete all of
the 10 fields available.
• Providers may attach the COMAR compliant Care Plan in
lieu of completing the Plan in ProviderConnect.
ProviderConnect
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ValueOptions® ProviderConnect
ProviderConnect is an online tool that increases
convenience & decreases administrative burden.
• Free, secure, online application
• Easy access 24 hours a day, 7 days a week
• Complete multiple transactions in a single sitting
ValueOptions® ProviderConnect Features
With ProviderConnect providers can:
• Verify Consumer eligibility
• Register Uninsured Consumers
• Request Authorizations
• View Authorizations
• Submit Claims (Batch and Direct/On-line claim)
• View Claim Status
• View and Print Provider Summary Voucher
• Submit inquiries to Customer Service
• Access and print forms
Accessing ProviderConnect
• Each provider has a secure login and online
registration, including a provider ID number via
the ProviderConnect Web site.
• Additional logins for other providers in the
same practice are available through
ProviderConnect. Contact:
ValueOptions® EDI Helpdesk
(888) 247-9311, Option 3
Monday through Friday
8 a.m. – 6 p.m. EST
Turn around time for additional logins is 48 hours.
September 25th Upgrade
• Online Uninsured Eligibility Registration (request
function) is now available to providers.
• Axis 1-V diagnoses are now required on concurrent
reviews
• The “Individual Care Plan”
– The Plan tab has been added to the Mobile Treatment
authorization request screen.
– The Service Code Field has been removed
– Providers now have the option to print the Plan separately.
• “MCO” is no longer a required field.
• “Education Level” has been deleted from the federally
required questions.
• “N/A” is no longer an option to the “Race” question.
Requesting an Authorization
for
Case Management
Live Demonstration
Questions
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Thank You!
Please complete the survey which will appear
shortly.
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