WELCOME! Wake County Local Managing Entity Provider Manual Training July 10, 2006 HOUSEKEEPING Cellular Phones Restrooms Registration Agenda/Forms Refreshments Questions HANDOUTS Agenda Changes CE Form MH/SA Clinical Services Request Form (2 pgs) Evaluation Form Introduction Section I: Provider Relations Section II: State & Federal Requirements Section III: Authorization Process Section IV: Claims & Reimbursement Section V: Provider Documentation Section VI: Quality Improvement & Monitoring Section VII: Service Provision Procedures Section VIII: Glossary FOCUS TODAY: Highlighting changes for FY’07 Questions are welcome, but may have to hold some due to time constraints Main Changes New Wake County LME website Authorization principles and procedures updated to reflect Medicaid moving to VO Medicaid Authorization overview Rate Table revisions – new CPT rates New Non-Medicaid Timely Filing dates New CE Form Major Changes, Cont. Revised Transfer procedure New Sanctions, Appeals, Withdrawal of Endorsement procedures Revised Person Centered Plan procedure New Supported Housing Expectations procedure TABLE Section 1. Name of Policy or Procedure Effective Date: specified Version Date: indicates latest here change date Informational Only Reference: to State/Fed Requirement regulations or statutes Defines content of the section Requirement Applies to Provider Type: CAP/MRDD Medicaid Basic Svc (Direct Enrolled) Cat. A Licensed Facilities Medicaid Basic Svc (Not Direct Cat. B Comm Based Providers Enrolled) Cat. C Institutions/Facilities Medicaid Enhanced Svc Cat. D Lic/Cert. Outpatient/Day Svcs Non-Medicaid Contracted Svcs ICF-MR Section I. Provider Relations 2. Notification of Change procedure - added notification for change in email address 3. List of Contacts - Data Support Specialists - EPSDT contacts Section II. State and Federal Requirements New Wake County LME Website: www.wakegov.com/humanservices/ localmanagemententity.htm Section III Authorization Process III.1. Referral and Acceptance Principles remain regarding: •Informed Choice of Providers •Prompt Acceptance/Admission •Adverse Selection •Waiting Lists III.1.Referral and Acceptance Timeframes for Acceptance & Initiation of Services: Acceptance/ Non- Initiation of Services* Acceptance (Maximum # of days (Maximum # of days Service from referral date) from referral date) Behavioral Health Outpatient, Diagnostic 3 7 Assessment, Community Support and all other enhanced services not listed below Vocational and Psychosocial 30 60 Rehabilitation Services Residential 30 90 III.1.Referrals Between Providers Providers must present the consumer who requests services that are reimbursed by Medicaid or other public funds with an informed choice of service providers. Consumers will sign an Acknowledgement of Consumer Choice form. List of registered and endorsed providers can be found on the web. III.2. Authorization Policy and Principles Authorization Requirement (service must be authorized) Clinical Authorization Principles (eligible for Target Pop, clinically necessary, least restrictive) Fiscal Management Principles (Consumer falls in public purview, there are funds available) III.3. DD Elig. & Authorization Eligibility for services must be determined by the DD Single Portal office prior to referral or acceptance into services. III.3. DD Elig. & Authorization Residential/Vocational/TCM • Single Portal remains the referral entity for the services above. • Acceptance/Non-Acceptance and Initiation of Services time lines have shortened. • Lead Agency is responsible for requesting authorization for all services. • Maximum authorization time period for Long Term Vocational Support has changed to 1 year. III.3. DD Elig. & Authorization Developmental Therapy and Non-Medicaid Personal Care • Referrals are made directly to the agency from the case manager • Case manager is always lead agency and therefore responsible for requesting authorization for all services. • Acceptance/Non-Acceptance and Initiation of Services time lines have shortened. III.3. DD Elig. & Authorization Re-authorizations • Request submitted 10 working days prior to current auth expiration • Step-down plan included if receiving Developmental Therapy • UPCP/PCP annually or if changes to the plan • Target Pop review completed (if due). III.3. DD Elig. & Authorization Referral and authorization procedures for services funded by DD/MI and CAP-MR/DD are different and can be obtained from the Service Director for each program. ValueOptions will assume authorizations for Medicaid funded DD Services per schedule published by DHHS. III.4. MH/SA Authorization Proc. Medicaid authorization transitioning to ValueOptions. Wake County LME UR Team has issued continuation Medicaid Authorizations through July 15th for Children, and Aug. 15th for Adults For new Medicaid services, and Medicaid services after these dates, authorizations will be issued by ValueOptions Wake County LME UR Team will continue to issue authorizations for non-Medicaid (IPRS) services III.4. MH/SA Authorization Two ways to get initial authorization for Non-Medicaid services: 1. WC LME does a face-to-face screening and refers the consumer to a Provider with an initial authorization. 2. Provider does the admission assessment and requests authorization for services. III.4. MH/SA Authorization If you receive the referral/authorization from WC LME, you: – Respond that you accept the consumer on the Referral Coversheet – Submit a Consumer Enrollment form within 10 days of admission, and prior to billing III.4. MH/SA Authorization If consumer is not referred/authorized by WC LME, you must complete and submit: – Clinical Assessment, inc. ASAM if SA – PCP/Svc Plan (optional if <30 days) – Demographic form – MH/SA Clinical Services Request – Target Pop Eligibility (Non-Medicaid service) – Application for Reduced Fee (in Non-Medicaid) III.4. MH/SA Authorization Level of care/entrance criteria can be found in the State Service Definitions Only Residential service requests require presentation in person with the WC LME UR Team Medical Record numbers are communicated on the Authorization Mailer III.4. MH/SA Authorization Continuing Authorizations Request 10 working days prior to current auth expiration MH/SA Clinical Services Request PCP/Svc Plan (if changed) Target Pop Elig form (if due) III.5. Referral To Direct Enrolled Behavioral Health Outpatient Providers Medicaid Direct Enrolled BHO Providers who do not have a contract with Wake County LME must register with the LME to receive referrals. Once the registration application is processed & approved, the provider must sign an MOA. Providers/Provider Agencies who have non- Medicaid contract with the LME do not need to register. III.6. Medicaid Authorization Requests See Value Options website at: http://www.valueoptions.com/provider/ contractspecific/ncmedicaid.htm to access forms. III.6. Medicaid Authorization Procedure Timeframes for Transition to ValueOptions: – New Services for a Child (under age 21): June 1 – Continuing Services for a Child: July 15 – New Services for an Adult (age 21 +: July 1 – Continuing Services for a Adult: August 15 – New Authorizations are required for Behavioral Health (ORF2 form attending provider/procedure specific): July 15 – Proposed CAP and Targeted Case Management: September 1 III.6. Medicaid Authorization Procedure Behavioral Health Outpatient Authorizations – New Form Required for Dates of Service after July 15 : ORF2 – BHO authorizations will be attending provider specific – BHO authorizations will be procedure code specific – Authorization letters will be sent to address in DMA’s provider file for direct enrolled attending provider III.6. Medicaid Authorization Procedure Authorizations for Enhanced Services – Requirements specified in Medicaid Special Bulletin “Enhanced Mental Health Services,” May 2006. – Authorization requested using ITR form • PCP required with initial auth request • Treatment Plan & Service Order OK during transition period – For Medicaid consumers under age 21, EPSDT rules allow authorization of medically necessary service. Special EPSDT request process applies. Section IV. Claims and Reimbursement IV.1. Fee Policy and Principles N.C.G.S. 122C-146 states that "The area authority and its contractual agencies shall prepare fee schedules for services and shall make every reasonable effort to collect appropriate reimbursement for costs in providing these services for individuals or entities able to pay." Accordingly, DMH/DD/SAS requires each LME to have a sliding fee scale that is applied uniformly throughout their respective catchment area. IV.2. MH/DD/SA Fee Procedures Application for Reduced Fee began in May for Non-Medicaid Authorizations, to determine if the consumer falls in the “public’s purview”. Consumer’s income, dependents and County of residence will be verified by WC LME. Consumers over 300% of poverty are not eligible for Non-Medicaid subsidy of BHO services, SAIOP or SACOT or Room & Board. Persons in Family or 300% of Household Poverty Poverty 1 $9,800 $ 29,400 2 13,200 $ 39,600 3 16,600 $ 49,800 4 20,000 $ 60,000 5 23,400 $ 70,200 6 26,800 $ 80,400 7 30,200 $ 90,600 8 33,600 $ 100,800 9 37,000 $ 111,000 10 40,400 $ 121,200 IV.2. MH/DD/SA Fee Procedures Provider can charge usual sliding fee scale until WC LME implements a standard fee/co-pay (planned for Oct). If services are being subsidized by WC LME, it is expected that the consumer’s fee is based on their ability to pay – NOT full cost. IV.2. MH/DD/SA Fee Procedures Transition Plan can be found on Section IV page 7. Currently, we are running a bit behind schedule on the plan. A new schedule for implementation of the uniform fee scale is being developed. Continue submitting the Application for Reduced Fee with new auth requests. IV.3. Reimbursement Rate Table Discontinued rates have been deleted. DMA just published new CPT code rates, which also changed the CPT IPRS rates. CPT codes for services over 75 minutes are not reimbursable with Non-Medicaid funds. Section IV Claims & Reimbursement 4. Child Residential Service Codes – Deleted R&B Therapeutic Leave, as this is no longer reimbursed 5. General Billing Requirements 6. Accounting for Time No other major changes to these procedures. IV.7. Non-Medicaid Claims Submission Continue using Excel forms in the WCHS Non-Medicaid Service and Adjustment Forms workbook. IV.8. Non-Medicaid Timely Filing Service Month Timely Due Date Final Deadline July 2006 August 7, 2006 September 29, 2006 August 2006 September 8, 2006 October 31, 2006 September 2006 October 6, 2006 November 30, 2006 October 2006 November 7, 2006 December 29, 2006 November 2006 December 7, 2006 January 31, 2007 December 2006 January 8, 2007 February 28, 2007 January 2007 February 7, 2007 March 30, 2007 February 2007 March 7, 2007 April 30, 2007 March 2007 April 6, 2007 May 31, 2007 *April 2007 May 5, 2007 June 29, 2007 *May 2007 June 7, 2007 July 31, 2007 *June 2007 July 9, 2007 August 31, 2007 Non-Medicaid Attn: Alice O. Wilkerson, Billing Unit Billing must be Wake County Human Services submitted to: 23 Sunnybrook Rd Suite 169, Raleigh, NC 27610 IV.9. Non-Medicaid Payment Processing Provider submits Excel form by 5th working day of following month WCHS Billing Unit processes or denies within 18 days – Denials mainly include consumer not open, service not authorized – WCHS Accounts Payable sends EOB and payment within 48 days – EOB may include denials for claims that exceed units IV.9. Non-Medicaid Processing- Re- Billing and Adjustments Non-Medicaid Claim is Provider can re-submit the denied by WCHS claim on a WCHS Re- Billing Dept. because Bill form once the error - the client was not open, is corrected (opening - the service was not paperwork has been authorized, or submitted, they have requested and received - units exceed authorized an authorization for the units. service). IV.9. Non-Medicaid Processing- Re- Billing and Adjustments Apparent Duplicate If NOT a duplicate, Service: then the Provider Same client/date/ can correct the units service/provider agency submitted by combination, with the same or a different completing a WCHS number of units, WCHS Adjustment Form Billing Dept will deny with the total the second one as number of units duplicate. indicated. IV.9. Non-Medicaid Processing- Re- Billing and Adjustments Provider discovers Provider to use the error-- Provider WCHS Adjustment billed the wrong Form to indicate service code, wrong original and number of units, or corrected billing. realizes they should If the change results in not have billed the payback, Provider service, AND they should include have not received a payment with the WCHS Denial letter. form. IV.9. Non-Medicaid Processing- Re-Billing and Adjustments Late Billing: If more than 60 days has elapsed since the Provider obtained month the service was retroactive Non- delivered, it’s late. Medicaid Submit WCHS Time Over- Ride Request, and Authorization due to WCHS Re-Bill Form OR Insurance denial or Non-Medicaid Service other legitimate Reporting form, PLUS special Retro authorization or circumstance. insurance denial. IV.9. Non-Medicaid Processing- Re-Billing and Adjustments WCHS EOB Denial 02 Provider may request that Authorization Staff or 03: authorize extra units. Denial on EOB - If granted, Authorization staff indicates no units will send the Authorization Mailer to the Provider. available or exceeds - Provider must contact WCHS authorized units. A/P rep and fax a request (919-250-3943) to the WCHS AP Unit to pay the service, include Authorization and the EOB. IV.10. Medicaid Payment Processing For July and later dates of service, Medicaid services must be billed using your directly enrolled provider number, EXCEPT: – Behavioral Health Outpatient services by providers who cannot direct enroll • Only interns and provisionally licensed QP’s can continue billing H0004 after 9/30/2006! – Child Residential Providers who cannot direct enroll • Therapeutic Foster Care • Level I and II Family Type, Level III<4 beds – Targeted Case Management Break Section V. Provider Documentation Submission Requirements V.1. Required Consumer Record Information Forms Required at Admission Medicaid Non-Medicaid Basic Enhance Referred Agency Svc, Not d Service with requests Direct Auth. Auth. WCHS Demographic Screening * Enrolled Y Y Y WCHS Consumer Enrollment * Y Y Y Y WCHS MH/SA Clinical Services Y Y Request (MH/SA only) WCHS Target Population Y Eligibility WCHS Application for Reduced If not Y Fee complete Release of Information for Y Y Y Y consumers with Substance Abuse diagnosis V.1. Required Consumer Record Information, Cont. Consent to Release Information – Federal confidentiality regulations (42 CFR Part 2) require that programs that provide substance abuse diagnosis, treatment, or referral for treatment strictly maintain the confidentiality of these consumer records. Disclosure of information is permissible if the consumer has signed a valid consent form that has not expired or been revoked. V. Provider Documentation V.2. Consumer Record Rules regarding Adoptions and Name Changes V.3. Other Required Medical Record Procedures – Teleworking – Record Retention – Countersignatures V.4. Consumer Enrollment Required whether consumer presents initially at Wake County or with the Provider See procedures for instructions Submit within 10 days of admission, and PRIOR to submitting claims Now must specify Lead Provider on CE form V.5. Target Population Eligibility • Target Pop changes: • No TNC Target Pops • New AMH Target Pop – AMSRE Stable Recovery • Form can only be completed by person who does the eligibility determination • MH & SA form MUST be updated annually • DD Target pop reviewed with annual PCP, new form not required annually • Target Pop is verified by WC LME V. 6. Transfers Initiate transfer with Referral Coversheet May involve a two step process: 1. Initiation of some services at intake (e.g., therapy) 2. Completion of array of services (e.g., psychiatry intake) Receiving provider notifies when all services transitioned satisfactorily V.7 Discharges Discharge/Transfer Summary must be submitted on all consumers of – Non-Medicaid Services – Medicaid Enhanced services – Basic Services -Not Direct Enrolled V.8 Child to Adult Transition Providers who request a waiver to serve children over 18 in Residential Treatment shall notify WC LME Child Residential Services Team Director (Greta Gill) VI. Quality Improvement And Performance Monitoring Quality Improvement and Performance Monitoring This section covers the three major functions performed by the Quality Management Team – monitoring, incident review and complaints, as well as certain performance standards. The contents of this section outline expectations and standards for providers to assist them in assuring quality service provision to Wake County consumers. OVERVIEW Clarification of existing procedures: 1. VI.2 Consumer Rights 2. VI.8 Provider Monitoring New procedures : 1. VI.9 Sanctions 2. VI.10 Appeal of Findings of Audits and Monitoring 3. VI.11 Withdrawal of Endorsement Clarification of Procedures VI.2 Consumer VI.8 Provider Rights Monitoring Information related to New Wake LME Medicaid Appeals website: moved to section III.7 - Medicaid www.wakegov.com/hu Appeals manservices/ localmanagementen tity.htm New Procedures VI.9 Sanctions – Types: fines, payback and suspension – Discovered through: monitoring, complaints, incidents, results of investigations by others (CPS, APS, DFS, other LME’s DMH etc.) – Processes: decisions to invoke sanctions, procedures for LME and Providers, appeal process New Procedures – cont’d VI.10 Appeal of Findings of Audits and Monitoring – Processes and timelines for appealing any fine, payback, sanction or corrective action levied as a results of a Provider audit or monitoring New Procedures – cont’d VI.11 Withdrawal of Endorsement – A gentle reminder to Providers of Enhanced Medicaid services that failure to meet all quality standards can led to withdrawal of endorsement which can lead to revocation of a provider’s ability to bill Medicaid. – Process is fully delineated at: http://www.dhhs.state.nc.us/mhddsas/announce/c ommbulletins/combullerin044/commbulletin044p olicies.pdf Section VII. Service Provision Policies and Procedures VII.1. Lead Provider Lead Provider is responsible for: – Person Centered Plan or Service Plan – Acknowledgement of Consumer Choice – PCP Preferences form VII.2. Person Centered Plan PCP required for consumers of Enhanced and intensive services Regular Service Plan may be used for basic services VII. 6. Crisis Intervention Services that require First Responders must have that capacity 24/365 Behavioral Health Outpatient providers must have crisis response capacity Crisis plans shall be submitted to WC LME UR with authorization requests VII.7 Housing Support Requirements Applies to providers of services for adult MH/SA consumers who – reside in government-funded housing and – require assistance to live independently in the community Providers will – assist the consumer with independent living skills – communicate with landlords on behalf of the consumer ANY QUESTIONS? THANK YOU FOR COMING TO THE TRAINING TODAY.