ValueOptions® Florida/First Coast Advantage, LLC Provider Orientation 2013 1 Agenda and Objectives ValueOptions® Florida and First Coast Advantage, LLC Medicaid Program, benefits and services ProviderConnect® Authorization process Claims and Claims Status Other features Quality Management Questions 2 ValueOptions Overview Market leader in behavioral health care services Experienced and recognized leader in Medicaid program services Respected clinical programs and interventions Approximately 23 million lives under contract 4,600 employees nationwide National Presence with 20 service locations throughout the United States More than 50,000 providers, more than 5,000 facilities 3 First Coast Advantage LLC is a FFS Provider Service Network (PSN) for Medicaid Reform and Non-Reform counties in Regions 3 and 4. FCA’s membership is over 74,000 for Managed Care (Medical Care and/or Integrated Medical and Behavioral Health services) to coordinate benefits for the Medicaid population for (Temporary Assistance for Needy Families (TANF), Aged, Blind and Disabled (ABD) and Dual Eligible. 4 Non Reform Counties: Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter Suwanee and Union Region 4: Flagler, St. Johns and Volusia 5 Veronica S. Walton, BA Contract Manager 1-800-790-4734 Ext.4-9255 6 ValueOptions Credentialing & Contracting ValueOptions Florida Contracting & Credentialing Provider Credentialing Application Facility Program Specific Addendums ValueOptions Provider Agreement Florida Medicaid Addendum Fee Schedules Did you get your ValueOptions provider amendment for the First Coast Advantage network, or are you interested in joining the ValueOptions network? Questions about your contract? Call 1-800-808-0832 ext. 327223 (8am – 5pm EST) or email us at [email protected] 7 Provider Network Participation Requirements In order to participate in the First Coast Advantage, LLC network: Providers must either be participating in the Florida Medicaid program and have an existing Medicaid ID number; or Complete a Managed Care Treating Provider Registration Form to obtain a Medicaid Registration number If you have previously registered with another plan, there is no need to register again. 8 Utilization Management ValueOptions medical necessity criteria is available online at www.valueoptions.com Via that website, there is 24 hour access to ProviderConnect which includes a lot of functionality, including a authorization request tool Emergency mental health services will not be denied and do not require prior authorization. Facilities are asked to notice ValueOptions within 24 hours of the emergency admission. Complete discharge planning and outcome assessment is a vital component of the ValueOptions process Care Managers are available 24 hours/day, 7 days/week, 365 days/year We are here to assist you with access to care, referrals and other related clinical questions. Just call 1-855-627-0390 9 Behavioral Health Benefit Coverage Only certain diagnosis codes and procedure codes are covered under the behavioral health benefits for First Coast Advantage. All benefit coverage provisions follow the guidelines outlined within the Florida Medicaid Community Behavioral Health and Targeted Case Management Handbooks. Providers must bill in accordance with the above handbooks in order to obtain reimbursement for services. 10 Covered and Non-Covered Behavioral Health Services Covered Services Non-Covered Services • Inpatient hospital care for psychiatric • Residential Care conditions • Statewide Inpatient Psychiatric Program Services • Outpatient hospital care for psychiatric (SIPP) conditions • Long- Term Care Institutional Services including • Psychiatric physician services Nursing Home, Institution for the Developmentally • Community mental health services Disabled, State Mental Hospital. • Behavioral Health Targeted Case • Services to enrollees assigned to a FACT team by Management DCF (SAMH) office • Behavioral Health Intensive • Services for enrollees enrolled in the Child Welfare • Targeted Case Management Prepaid Mental Health Plan (CWPMHP) • Psychosocial Rehabilitation Services • Specialized Therapeutic Foster Care. • Therapeutic Behavioral On-Site Services • Therapeutic Group Services (TGCS) • Day Treatment Services • Behavioral Health Overlay Services (BHOS) • Self- Help/Peer Services • Comprehensive Assessments • Crisis Intervention Mental Health Services • Community Substance Abuse Services (excluding and Post-Stabilization Care Services members with Co-occurring medically complex diagnosis and pregnant members) • Inpatient Substance Abuse Detox Services (members pregnant members only) 11 Behavioral Health Claim Submission Participating providers are encouraged to submit claims electronically through ProviderConnect on the “Provider” section of the ValueOptions website. Or via mail to the following address: ValueOptions P.O. Box 12699, Department FL – Claims, Norfolk, VA 23541-0699 Providers who participate with a Clearinghouse should call the EDI Help Desk at 1-888-247-9311 12 ProviderConnect® 13 ProviderConnect® Benefits What are the benefits of ProviderConnect? Free and secure online application Access routine information 24 hours a day, 7 days a week Complete multiple transactions in single sitting View and print information Reduce calls for routine information 14 How to Access ProviderConnect? Go to www.ValueOptions.com, choose “Providers”. All in-network providers are required to use ProviderConnect to request authorization for services. After registering, if additional ProviderConnect log ons for that same provider ID number are desired, please do the following: Fill out the Online Provider Services Account Request Form and fax the completed form to 1-866-698-6032. Additional log on turnaround time is 2 business days If your facility requires separate log ons for Clinical vs. Business Claims staff, a Role-Based Security options is available. ProviderConnect registration questions or questions about the form referenced above please contact the ValueOptions® EDI Helpdesk at 1-888-247-9311 (Monday to Friday, 8:00 a.m. - 6:00 p.m. ET) 15 ProviderConnect (Provider Online Services) What is ProviderConnect? An online tool where providers can: Verify member eligibility Access ProviderConnect message center Access and print forms Request & view authorizations Download and print authorization letters Submit claims and view status Access Provider Summary Voucher Submit customer service inquiries Submit updates to provider demographic information Submit recredentialing applications 16 17 18 ProviderConnect Login Screen 19 User Agreement Page 20 Search/View Member Eligibility 21 Member Eligibility Search 22 Member Eligibility Results 23 Member Eligibility – Enrollment History 24 Member Eligibility - Benefits 25 Authorization Requests 26 Request for Authorization Outpatient Services 27 28 29 30 31 32 33 34 35 36 37 38 39 ProviderConnect Service Request Guidelines The primary method for all service requests will be via the web on www.valueoptions.com using ProviderConnect (with the exception of requests for ECT) beginning with an easy-to-use short web form that can be accessed 24/7/365. Providers can then: Log into ProviderConnect and track where the request is in the system, Store completed requests, or print them for paper files, Send messages back and forth to clinicians If a provider does not have online access, they can make telephonic or fax requests for services. Additional information on how to make a service request via ProviderConnect is included in this training as a separate attachment. 40 Service Requests Have Rules and Limitations Medicaid Community Mental Health and Targeted Case Management Handbook Rules Apply for Mental Health services only. Some services are deemed duplicative by ValueOptions if done by the same provider on the same day. ProviderConnect is set up to behave differently depending on the type of request made. 41 Service Request Protocols for FCA Some services pay without an authorization upon submission of a ‘clean’ claim as long as Medicaid Handbook(s) Rules and Limitations are met: e.g.: covered evaluations and assessments Some services pay without an authorization upon submission of a ‘clean’ claim e.g.: mental status exams done in the emergency rooms Some requests will not be denied but will require clinical data before claims come in so ValueOptions can register the event to facilitate claims payment e.g.: Emergency inpatient and post-stabilization services Some requests will pend for clinician review to assess medical necessity or manage high risk benefits e.g.: Non-Emergent hospital admissions, Day Treatment, Inpatient Detox for pregnant women, psych testing 42 Service Request Protocols for FCA (cont.) Some requests bounce up against auto-approval rules and the provider will get generous portions of the Medicaid annual limits without ever speaking to a clinician. (The remainder of the benefit will be given based on concurrent review of medical necessity) OP Services: including all therapy, medication management, TBOS, TCM, ICM, PSR These auto-approval rules renew every fiscal year (July 1st) Some requests can only be made by phone ECT 43 Authorization Requests from ProviderConnect – Communication for Additional Clinical Information Overview At times clinicians may require additional information from providers to make medical necessity decisions.