Transcript Maternal and Infant Health Social Work Services Presentation

Maternal and
Infant Health
Social Work
Services
OHCA Rules and Policies
August 15, 2008
Who is OHCA?
Oklahoma Medicaid Agency
–
SoonerCare (Name of Insurance Program)
SoonerCare Traditional
– SoonerCare Choice
– Insure Oklahoma/OEPIC
– Oklahoma Cares (BCC)
– TEFRA
– SoonerPlan (Family Planning)
– Soon To Be Sooners
–
Member Eligibility
 Two-prongs for eligibility
– Low income individuals (based on federal
poverty level percentages)
– Categorical need (i.e., children, pregnant,
disabled)
 Eligibility determined by Oklahoma
Department of Human Services (OKDHS)
SoonerCare and Perinatal
Services
 Large percent of births are paid by
SoonerCare
 FY 2007—SoonerCare paid for
over 32,000 deliveries (57% of
Oklahoma births)
Prenatal Care Benefits
 Routine OB care—prenatal visits, labs,
prescriptions, deliveries
 Smoking cessation counseling
 Prenatal assessment
 Limited ultrasounds
 High risk pregnancy services
 Limited dental care
 Genetic counseling
 Lactation consultant services
 Maternal and infant health social work
services
 Soon To Be Sooners
MIH Social Work Services
 Direct face to face service provided to
pregnant/postpartum SoonerCare members
with psychosocial concerns that may impact
pregnancy outcomes and/or the health of
the infant--include but not limited to:
– Domestic violence
– Substance abuse
– Lack of basic resources
– Mental Illness
MIH Social Workers:
 Connect women with necessary
services which will promote optimal
pregnancies and best outcomes for
the infant
– Help ascertain the best fit for the
individual woman
MIH Social Workers:
 Assist the woman in emotionally
understanding and accepting the
need for services or treatment
– Ensure she follows through on all
needed care
– Follows up to see if the care she
received met her needs
MIH Social Workers:
 Provide short term problem
focused counseling
 Assess maternal emotional well
being
 Maternal –infant bonding and
interactions
Eligible Providers
 Licensed Clinical Social Workers
(Licensed in the state services are
provided)
 Must have a current OHCA contract
– Need to demonstrate current license
– Six hours of continuing education or
technical assistance in area of MIH
Coverage
 Pregnant and/or up to 60 days postpartum
SoonerCare &/or Soon To Be Sooners
members
 Existing psychosocial condition that may
negatively impact the pregnancy/well-being
of newborn
 Condition identified by OB provider during
prenatal care assessment or during Social
work assessment
Coverage
 Self referred or referred by any provider (no
formal referral needed)
 Services must be provided in office, home or
other confidential clinic setting
 Face to face and individual service
 No separate reimbursement for inpatient
services
 Separate facility fee not reimbursed
Billing Codes/
Reimbursement Rates
Use CPT codes:
 96150-Health and Behavior Assessment
$16.79 per 15 minutes
 96152-Health and Behavior Intervention,
Individual
$15.41 per 15 minutes
 96154-Health and Behavior Intervention,
Family with Patient Present
$15.13 per 15 minutes
Maximum Units of Service
 32 total units per pregnancy/postpartum
(unit=15 minutes)
 Maximum of 6 units per day/session
 Any combination of the three codes as
clinically appropriate
 Billing time = time spent in face-to-face
contact with the client
Contracting Information
 Go to www.okhca.org and choose:
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–
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–
Providers
Enrollment
New contracts
Maternal and Infant Health LCSWs
 Download contract and follow instructions
 Mail in completed contract with required
professional documentation
 Will take a couple of weeks to process/receive
provider number
 Call 800-522-0114 for help
OHCA Contract
Requirements
 Attach copy of certification
 Show 6 hours of CEUs or technical
assistance in MIH social work
 Complete 6 hours CEU/technical assistance
each calendar year
 Maintain confidential records
 Service records must be readily accessible
for OHCA audit/inspection for 6 years from
date of service
Getting started—
Referral resources
 Members may self-refer, no formal referral needed
 Once contracted, obtain a list of contracted
SoonerCare OB providers in your area
 Outreach to OB providers, inform them you are a
SoonerCare contracted provider and of your
services
 You may wish to discuss how you will share
information regarding the patients
 You should discuss how the OB provider will make
referrals to you
Getting Started—Billing
 Welcome packet from EDS
(OHCA’s fiscal agent)
 Field rep contact info
 Free, on-site training or register
for bi-monthly training in OKC or
Muskogee
– SoonerCare basics
– Secure website
– Training registration
Secure website
 No cost (need internet access)
 Verify member eligibility
 Immediate notification of claim status
– Denied claims resolution resources
 Call center
 Provider reps
 Weekly payment cycle
– If you file weekly, you get paid weekly
Third Party Liability
 Third Party Liability (TPL) means
another party is responsible for
paying health care costs before (&
sometimes after) SoonerCare pays
 SoonerCare is the payer of last resort
 About 10% of Sooner Care members
have another insurer in addition to
SoonerCare
TPL
 Ask your clients if they have other
insurance coverage
 If so, get insurance carrier info from them
 It is unlikely you will run into this situation,
BUT if you do, help is available
 Call OHCA--we will happily walk you
through the process!
 1-800-522-0114 option 7 (TPL)
Documentation
 Services must be documented in medical
record to include:
– Date of service
– Start and stop time for each session
– Service provider signature and credentials
– Documentation of referral source
Documentation
 Treatment plan including problems, goals
and/or objectives
 Methods to be used to address problems,
goals and objectives
 Progress made
 Client response to the session/intervention
 Any new problems, goals or objectives
identified
OHCA Contacts
 Child Health Unit
– Terrie Fritz, LCSW, Director of Child Health
 405-522-7377
[email protected]
– Shelly Patterson, CPH, Perinatal Coordinator
 405-522-7332
[email protected]
 OHCA Provider Representative
– 1-877-823-4529 option 2
 OHCA website
– www.okhca.org
Helpful OHCA Numbers
 OHCA Call Tree
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(Provider)
1-800-522-0114
OHCA Call Tree (Member)
1-800-522-7171
SoonerCare Helpline (Member)1-800-987-7767
Behavioral Health
1-800-652-2010
SoonerRide
1-877-404-4500
Patient Advice Line
1-800-530-3002
Questions?