Transcript Document

Medi-Cal Expansion Recruitment Project
A presentation for the California Council of Community Mental Health Agencies
December, 2013
Agenda
• Welcome and Introductions
• Overview:
– Who is Optum?
– Recruitment Effort
• Joining the Network:
– Network Requirements
– Application
– Credentialing & Recredentialing Process
– Telepsychiatry Service Requirements
• Provider Express:
– Navigating the website
– Roster Management
– Registering for the website
•Q&A
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2
Welcome and Introductions
Your presenters are:
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3
Overview
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4
Who Is Optum?
• OptumHealth Behavioral Solutions of California (Optum)* — a
UnitedHealth Group company — is a health services business
dedicated to making the health system work better for everyone
• Our Mission is to help people live their lives to the fullest
• Our Vision is to be a constructive and transformational force in the
health care system
• Our industry-leading website, Provider Express, includes both public
and secure pages:
– Public pages include general updates and useful information
– Secure pages are available only to Network Providers and require
registration
* U. S. Behavioral Health Plan, California, doing business as OptumHealth Behavioral Solutions of California
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Optum in California
• Optum has a strong presence in
California, with offices in San
Francisco and San Diego
San Francisco
Region
North
Central
South
Total
Members
58,532
934,786
1,333,386
2,326,754
San Diego
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6
Overview of Recruitment
To better serve the diverse membership needs in the state of California,
Optum is currently contracting with Community Clinics and Health
Centers and Community-based Agencies for the following behavioral
health services:
• Individual and group mental health evaluation and treatment (therapy)
• Psychological testing
• Outpatient services for monitoring drug therapy/medication
management
• Psychiatric consultation
• Telepsychiatry
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Overview of Recruitment (cont.)
• Recruitment for Medi-Cal
expansion focused primarily on the
following counties:
– Kern
– San Diego
• Additional recruitment in:
– Merced
– Monterey
– Santa Cruz
– Napa
– Solano
– Yolo
Yolo
Napa
Solano
Merced
Santa Cruz
Kern
Monterey
• Main provider types:
– Community Clinics and Health
Centers / Community-based
Agencies
– Telepsychiatry Providers
San Diego
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8
Joining the Optum Network
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9
Network Requirements - Agencies
• Must complete an application documenting business/clinical structure
• Must be in good standing with state and federal regulatory bodies
• Must be accredited by an Optum-recognized accrediting body (e.g.,
Joint Commission, COA, CARF, AOA):
– If not accredited by an Optum-recognized body, a site audit is
conducted prior to credentialing
– In lieu of site visit, Optum may accept certification from CMS or
State Agency if reviewed within last 3 years
• Must have insurance with following minimums per occurrence /
aggregate:
– Professional liability insurance - $1 million/$3 million minimum
– General liability insurance - $1 million/$1 million minimum
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10
Agency Application and Credentialing Process
• Agency submits a completed Agency Application to the Network
Manager
• In addition to the completed application, the following documents
should be submitted:
– Copies of current state license(s)/certificates for all services the
Agency provides
– Accreditation status
– Professional and general liability insurance certificates
– Form W-9 (one for each Tax ID under which Agency bills)
– Policies and procedures on:
• Intake/Access Process to Behavioral Medicine
• Quality Improvement Plan
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Agency Application and Credentialing Process
• Upon receipt of completed application and required documents, Optum
reviews materials to assess network need and Agency eligibility
• If an unaccredited Agency, a site audit is scheduled to assess:
– Type and quality of programming
– Types of staff providing services
– Staff competencies
– Treatment documentation standards
– Physical environment
• Eligible Agencies’ applications are
forwarded to the Credentialing Department
• Credentialing is generally completed within
180 days of receipt of completed application
and required documents
• The Agency is notified within 10 days of the
Credentialing Committee’s decision
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Recredentialing
• Optum recredentials agencies at least once
every 36 months:
– State law or client requirements may
require a different recredentialing cycle
• Very similar to initial credentialing, including
Primary Source Verifications and notification
to you of any discrepancies found during the
process
• It is important that you maintain current
demographic information with Optum
• To update the Agency’s information, use the
Provider Express secure “Transactions”
feature or contact your Network Manager
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Important Reminders
• Between credentialing cycles, please remember to:
– Update Optum with any changes to the Agency’s demographic
information such as:
•
Tax ID number
•
Changes or renewals of licenses
•
Renewal of insurance
– Notify Optum if the Agency is unable to take new referrals (for
example, due to full practice)
– Notify Optum of any action that could potentially result in the
suspension, sanction, revocation or restriction of your license
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Telepsychiatry Service Requirements
• Qualifications:
– Originating site must offer a secure, private area for members to
receive telepsychiatry services in accordance with HIPAA
guidelines:
• If behavioral health provider offices, provider must be credentialed
and contracted with Optum unless specially approved
– Distant Site Providers must:
• Be licensed in the state of California and meet Optum’s
credentialing criteria
• Attest to adherence to the Telehealth Coverage Determination
Guidelines, including delivering services in a manner consistent
with HIPAA regulations
• Offer telepsychiatry services that are two-way, real-time
interactive telecommunication
• Submit claims for services via CMS-1500 forms
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Telepsychiatry Services (cont.)
• Recruitment:
– Network Managers identify need for telepsychiatry services based
on evaluation of network in specific area
– Network Managers identify potential telepsychiatry providers and
initiate contracting discussion with the provider
– Interested providers submit the Telepsychiatry Questionaire, follow
the application process, and are credentialed into the Optum
network
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Provider Express
providerexpress.com
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Navigating Provider Express
• Our provider website,
providerexpress.com, is a great
resource
• Available 24/7
• In the public area, you can find:
̶
Provider Newsletters
̶
Level of Care, Best Practice
& Coverage Determination
Guidelines
̶
Claim Tips
̶
Forms
̶
Important updates
̶
Training on the site’s features
and functions
̶
Much more!
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Provider Express – Secure Transactions
Through secure “Transactions”, participating providers can:
• Check member eligibility and benefits
• Request authorizations or check
authorization status
• Submit claims and check their status
• Request claim adjustment
• Use Provider Message Center to
securely communicate with us
•
Manage your roster
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Roster Management
• It is important to keep your Agency’s roster up-to-date whenever there
are personnel changes
• The roster should include the following data elements for all
independently licensed staff:
– Last name
– First name
– License level
– License/certification number
– Individual NPI #
– Taxonomy Code
– Medicaid ID #
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Roster Management (cont.)
• The easiest way to keep the Agency’s roster up-to-date is by using
Optum’s website, Provider Express, secure “Transactions” > “My
Practice Info”
Use the link provided to manage the roster
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Roster Management (cont.)
• This screen allows users to manage their roster, providing the option to
delete existing names or add new Clinicians
My Practice Info - Manage Roster
John Doe
123456789
Displays a list of currently
rostered clinicians
Gives options to delete
clinician or add new clinician
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Roster Management (cont.)
• There is also the option of a
roster management form:
– Available on Provider
Express under: Forms >
Optum Forms > Clinician
Application and Update
Forms
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How to Register for Provider Express
• For participating providers: from the home page of Provider Express,
select “First-time User”
• Then select
“Register”
• If you need
assistance, you
can use the live
chat feature or
call:
1-866-209-9320
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Provider Express Training
By selecting “Training”, you can
access a variety of
presentations that provide
instruction on Provider Express
functionality
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Q&A
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Thank You!