Download Title goes here - Magellan Provider`s

Provider Orientation
Magellan Providers of Applied Behavior Analysis (ABA)
Services for Autism Spectrum Disorders (ASD) Members
CalOptima
December 2016
Agenda
• Welcome to the Magellan Network!
• Who is CalOptima?
• Assessment and Treatment Planning, the Authorization Process
• Credentialing, Contracting and Recredentialing
• Claim Submission and Tracking
• Magellan Provider Service Center Website
• Wrapping Up: Supporting the Provider with First-Class Service
2
Welcome to the Magellan Network!
You play an important role in serving CalOptima members.
Magellan Healthcare, Inc.* is the leading behavioral health care management
organization in the industry.
With identification of children with autism spectrum disorders (ASD) increasing
dramatically nationwide, coverage and services are expanding:
• A majority of states have passed or proposed legislation requiring health insurers to
provide coverage for autism treatment.
• A smaller number of states have adopted more comprehensive legislation requiring
coverage of specialized services including applied behavior analysis (ABA) services
for the treatment of autism.
• Magellan’s customers are looking to Magellan to provide full-service support for
this disorder.
*In California, Magellan does business as Human Affairs International of California, Inc. and/or Magellan Health
Services of California, Inc. – Employer Services
3
Who is CalOptima?
CalOptima is one of six County Organized Health systems (COHS) in the state of
California created as a public agency by County, State and Federal action.
CalOptima started operations on Oct. 1, 1995 as the sole managed Medi-Cal health plan
for individuals residing in Orange County.
Today, CalOptima administers health benefits to approximately 800,000 members (about
775,000 Medi-Cal only and about 17,000 dual eligible) for the following programs:
• Medi-Cal (California’s Medicaid program) for most members residing in Orange
County
• In 2014, with the Affordable Care Act (ACA) Essential Health Benefits, a limited
outpatient only Behavioral Health benefit was added for the Medi-Cal members.
This was further expanded in September 2014 to include Applied Behavior Analysis
that is medically necessary to treat Autism Spectrum Disorder (ASD).
4
Who is CalOptima?
• OneCare [Medicare Advantage Duals Special Needs Plan (D-SNP) available to
members who are dually eligible for Medicare and Medi-Cal, “Duals”] – In
2005, CalOptima added OneCare, which has a more comprehensive behavioral
health benefit (full outpatient and inpatient) than Medi-Cal managed care
plans are responsible for.
• OneCare Connect (California’s Coordinated Care Initiative, also known as the
“Duals” Demonstration Program or Cal MediConnect) – This program has the
same behavioral health benefit as OneCare.
5
CalOptima’s Mission
To provide members with access to quality health
care services delivered in a cost-effective and
compassionate manner
6
CalOptima Applied Behavior Analysis Benefit
Who is covered?
• Individuals ages 0-20 years old (up to the member’s 21st birthday)
What is covered?
• Diagnosis and treatment of ASDs including:
 Applied behavioral analysis
 Psychiatric and psychological services
7
CalOptima Applied Behavior Analysis Benefit-Contd.
What are the coverage limits?
• There is no coverage limit
• Services must not be duplicative to what is currently being offered at
school. The member’s most recent IEP may be requested for verification.
• Must be medically necessary
8
The Provider Role: Assessment and
Treatment Planning, the Authorization
Process
Expectations for ABA and Other Qualified
ASD Providers: Assessment and Treatment Planning
• Magellan dedicated autism care
managers refer members to you
• You conduct initial functional
assessment, confirm diagnostic
evaluation and develop treatment
plan
• You conduct follow-up and
reassessment
• Obtain authorizations for additional
services as needed
• Follow Magellan medical necessity
criteria and clinical practice
guidelines
• In some regions, review of treatment
plans for pre-existing cases is
necessary
10
The Authorization and Review Process
Purpose: To authorize care based on a thorough assessment of the member’s
unique needs, with services delivered at the least intensive, appropriate level
of care
• Authorization is the responsibility of the provider/program/facility
by calling 1-855-877-3885.
 All existing cases currently covered by CalOptima will have their current
authorization honored. At the end of your current authorization we will provide
you with a new auth contingent that the member continues to meet medical
necessity.
• For newly diagnosed cases in need of an initial evaluation, Magellan will
authorize an initial assessment and provide hours to complete a Functional
Behavioral Assessment (FBA).
• The provider will need to complete the Magellan treatment planning
template (available on the provider website www.MagellanProvider.com) in
addition to the submission of the results of an ABAS, Vineland or other
developmental assessment that has been accepted by Magellan.
11
Authorization Determinations
Magellan will:
• Make an authorization decision based upon the completed care planning
and assessment template, Vineland/ABAS and any telephonic review we do
with you.
• Advise you of the ABA service type and units authorized, number of sessions
or days authorized, and a start and end date for authorized services.
• Communicate authorization decisions by telephone and/or in writing.
• Offer the opportunity to discuss the determination with a physician advisor
if we are unable to authorize the requested service(s) for clinical reasons.
12
Treatment Planning
• The provider develops the Autism Treatment Plan based on the findings of
an assessment and evaluation; the plan will be reviewed by a Magellan care
manager.
• The provider must submit a new treatment plan each time additional
sessions are requested along with a new Vineland or ABAS evaluation.
• Autism Treatment Plan includes the following domains of focus
(Speech/Language/Communication, Sociability, Sensory/Cognitive
Awareness and Health/Physical Behavior), specific interventions, and
measurable goals that have been developed based on the concerns
identified through the assessment and evaluation process and family
priorities.
• The treatment plan will be accessible on the Magellan provider website.
13
Sample Authorization for ABA Services*
Treatment/Billing
Code Description
Number of
Units
Duration
Total Hours
Authorized
H0031 – Functional
behavioral assessment
by BCBA
16
15-minute unit/duration
4
H2019 – Direct ABA
services by a BCBA or
paraprofessional
8
15-minute unit/duration
2
H2014 – Skills training
and development
12
15-minute unit/duration
3
S5110 – Home care
training, family
4
15-minute unit/duration
1
* Covered services may differ by region and/or customer.
14
Magellan Clinical Policy Resources—MNC
Magellan medical necessity criteria for outpatient ABA:*
• Established DSM diagnosis of pervasive developmental disorder
• A severe challenging behavior that presents a health or safety risk or
significantly interferes with home or community activities
• Less intensive behavior treatment or other therapy has been considered or has
been insufficient
• Patient is medically stable and does not require 24-hour medical/nursing
monitoring
• Treatment plan should be established upon individualized goals, with
measurable objectives
• Treatment plan should include parent/caregiver training and support
* Covered services may differ by region and/or customer.
15
Magellan Clinical Policy Resources—MNC
(continued)
• Magellan’s medical necessity criteria are based on scientific evidence
• Magellan clinical leaders review the criteria annually, taking into
consideration:
 Current scientific evidence
 Provider feedback
• MNC available at www.MagellanProvider.com under Providing Care/Clinical
Guidelines
16
Credentialing, Contracting and
Recredentialing
Credentialing and Contracting
•
To be a Magellan network provider, you must be both credentialed and contracted
•
Magellan encourages the use of the Council for Affordable Healthcare (CAQH)
credentialing application. If you do not have a CAQH profile, we can help you to create
one
•
Magellan’s credentialing process reflects industry standard and is compliant with
regulatory, state and customer requirements. The process includes, though is not limited
to, the collection and/or verification of credentials including licensure, board
certification, education and training, work history and malpractice insurance coverage
•
The Regional Network and Credentialing Committee reviews completed credentialing
applications and renders credentialing decisions
•
Once credentialing and contracting are complete, notification will be sent to inform you
that you may treat and bill for patient services.
18
Group Contracting
•
To be an in-network group provider, the group must be contracted with Magellan AND
certain practitioners within the group must be individually credentialed by Magellan
•
A master’s or doctoral-level practitioner who is a member of a contracted group must be
individually credentialed by Magellan to be eligible to receive ABA referrals as an innetwork provider
•
Paraprofessional who is a member of a contracted group, the group must attest that they
hold a state-issued license, certificate, registration, credential or other designation as a
behavior technician; or hold a certification as a Registered Behavior Technician (RBTTM)
through the Behavior Analyst Certification Board (BACB®)
•
A group member who leaves the group practice is no longer considered a Magellan innetwork provider unless the practitioner is also contracted under an individual provider
participation agreement with Magellan AND has an active Taxpayer Identification Number
(TIN)
•
Groups must notify Magellan when staff join or leave their practice
•
Groups must attest that all Applied Behavioral Analysis providers have successfully
completed a background screening at least every 5 years
19
Organizational Contracting
• To be an in-network provider, the agency/organization must be contracted
with Magellan AND must be organizationally credentialed
• Agencies must be accredited and/or hold acceptable program/agency
licensure to meet organizational credentialing standards. If an agency is not
accredited, a site visit is required. A state or CMS survey may be accepted in
lieu of a site visit conducted by Magellan staff.
• Organizations must provide roster information for all ABA service providers
at the time of contracting and update Magellan when staffing changes
• Organizations must attest to staffing qualifications on the Network
Organizational Credentialing Standards Attestation
20
Recredentialing
• Must be completed once every three years
• Magellan accepts CAQH for recredentialing of practitioners; please maintain
your CAQH updates quarterly; you will NOT receive notification of the need
to recredential when a CAQH application is utilized
• However, you will receive written notice prior to your credentialing
anniversary date when no CAQH application is available or you have not
completed a Magellan online recredentialing form
• Applications and recredentialing notifications are mailed to all
agencies/organizations prior to the credentialing anniversary
• Return/complete recredentialing applications within 30 days of receipt
21
Paraprofessional Requirements
Magellan will ask its CalOptima providers to meet the minimum requirement
for paraprofessional certification in 2017.
• Date has not been established; will not be within the first few months of
transition to Magellan
• Currently accepting either RBT or BCAT as the certification
• A minimum of 90 days notice will be provided to have your staff come
under the minimum requirement of certification for direct level staff
• Your group will be required to provide self-attestation that the
requirements are being met
• Groups are subject to audit/SIU should there be suspicion that direct level
staff are not certified at time of implementation
22
Helpful Hints for Credentialing and Contracting
(Practitioners)
• If possible, use CAQH (Universal
Provider DataSource®)
• Make sure you indicate the
one TIN number with which
you will complete your W-9—
either your Social Security Number (SSN) OR Employer Identification
Number (EIN)—NOT BOTH
• Please note and explain in the comments section of the application any
periods of unemployment of more than six months
• Keep copies of your completed contract and application
23
The Quality Partnership
A commitment to quality:
• Magellan maintains a Continuous Quality Improvement (CQI) program
• Magellan’s providers are an integral component of the quality program
Magellan obtains meaningful input from providers through:
• Regional Network and Credentialing Committees
• Annual provider satisfaction surveys
• Provider Advisory Groups
We provide information to providers through:
• Provider Focus newsletter
• Provider forums and webinars
• Magellan provider website
24
Claim Submission
and Tracking
Magellan Claim Tips
Claims with CPT or HCPCS procedures should be submitted on a 837P or CMS1500.
Timely filing requirements are 90 days from Date of Service.
Hints for claim completion:
• Give complete information on the member (name, address, DOB)
• Give complete provider information





TIN
Individual provider name and degree
Rendering provider name
Billing “pay to” provider name and address
National Provider Identification [NPI] number for both the rendering and billing
provider
• Attach primary carrier’s Explanation of Benefits when billing secondary insurer
• Include all HIPAA-compliant diagnosis codes (ICD-10 required)
• Include the appropriate billing modifier in conjunction with the HCPCS
26
Claim Submission Example
Sample autism-related services fee schedule*
Description
CPT/HCP
CS Codes
Behavior Analyst
(Modifier HO or
HP)
Assistant Behavior Analyst or
Non-Certified Support Staff
(Modifier HM or HN)
Functional Behavioral Assessment per
15 min up to 4 hours
H0031
$31.25
Not billed for HN or HM
Direct Applied Behavior Analysis (ABA)
services by a BCBA or paraprofessional
per 15 min
H2019
$18.00
$12.50
Case oversight and management by
treatment team by BCBA per 15 min
H0032
$18.00
$15.50, Not billed for HM
Modifier
*Schedules vary by region
27
Description
HO
Board Certified Behavior Analyst (BCBA or BCBA-D), Licensed Master’s
Level Behavioral Health Professional, or Doctoral Level Clinician
HN
Board Certified Assistant Behavior Analyst or Tier 2 Program Manager
(non-licensed Master’s level)
HM
Non-Certified Support Staff or Registered Behavior Technician
HQ
Group Setting
Claim Submission Example (continued)
Sample CMS-1500 claim form information to input
Dates of Service
(Field 24A)
Place of
Service
Procedures, Services or Supplies
CPT/HCPCS
Modifier
(Field 24B)
(Field 24D)
Charges
Units
(Field 24F)
(Field 24G)
7/1/2015
12
H0031
HO
$250.00*
8
7/28/2015
12
H2014
HN
$50.00*
4
7/15/2015
12
H2019
HM
$50.00*
4
Note: The above samples are not inclusive of all possible billing codes and/or unit durations
utilized by Magellan for autism services, which are subject to the provisions and limitations of
the member’s benefit plan. Billing codes and unit durations may vary by region. For the
applicable rates, refer to the fee schedule attached to your provider agreement.
*Total charge should reflect the number of units in field 24G x the rate per unit for the billed
procedure code (e.g., 4 units @$21/unit = $72.00 total charge)
28
Claim Submission Options
Magellan’s Three Electronic Submission Options…
#1 Claims Courier
Claims Courier (Submit a Claim Online) is
a web-based data entry application for
providers submitting professional claims
on a claim-at-a-time basis
• Accessible after sign-in on Magellan’s
provider website
• Claims Courier streamlines the claims
process by eliminating the
middleman
• Claims Courier provides information
on accepted or rejected claims
• No charge to the provider
29
Claim Submission Options (continued)
#2 Direct Submit
Primarily for high-volume claim
submitters, but there is no minimum
number necessary for submission
•
•
•
•
•
Magellan offers our providers the
EDI Direct Submit testing application, which is
an electronic claims tool available on an EDIdedicated website at
www.edi.MagellanProvider.com
HIPAA-compliant 837 files can be
sent directly to Magellan
HIPAA-compliant 277 files can be sent directly
to provider to review for accepted or rejected
claims
Direct Submit streamlines the process by
eliminating the middleman
No charge to the provider
30
Claim Submission Options (continued)
#3 Claims Clearinghouses
Act as a middleman between the provider and Magellan, and can transform non-HIPAA
compliant format to compliant 837
Magellan accepts 837 transactions from the following clearinghouses:
• PayerPath (formerly Mysis and also known as Allscripts)
• Capario (formerly MedAvant Healthcare Solutions and ProxyMed)
• Availity (formerly THIN)
• Emdeon Business Services (formerly WebMD)
• NaviNet Claims (also known as AmpMed Corporation)
• RelayHealth (also known as McKesson)
• Gateway EDI
HIPAA-compliant 277 files enable providers to review for accepted or rejected claims
Note that there may be charges from the clearinghouses.
When submitting claims electronically, Magellan’s submitter ID is 01260.
31
Electronic Funds Transfer (EFT)
It is expected that providers/groups sign up for Electronic Funds Transfer for
Magellan-paid claims
The benefits of EFT are
• Claims payments get to your bank account more quickly than the standard process
of mailing and cashing or depositing a check
• No risk of lost or misplaced checks
• More time to devote to your practice
Explanation of Benefits (EOB) are available on www.MagellanProvider.com
• Sign into the secure network
• Click on Check Claims Status from the left-hand menu
• Click on the EOB Search on the top tab
32
Contact Info & Assistance Offered for
Electronic Claims Submitted
EDI/EFT Support Telephonic Line:
• 1-800-450-7281 ext 75890
EDI/EFT Support via email:
• [email protected]
33
Magellan Health, Inc.
Magellan
Provider Service Center Website
MagellanProvider.com
A secure location for your provider transactions –
sign in and get started!
35
Magellan Provider Service Center Access
Initial sign-in for individual providers:
• User Name = MIS number (Magellan system identifier)
• Password = year of birth and last four digits of TIN/SSN (whichever number
you bill under)
Group users:
• User Name = Group MIS number
• Password = 2003 and last four digits of the group TIN
• Administrator grants access to other group personnel
Facility users:
• Same process as Group users
36
Magellan Provider Service Center Features
• Check member eligibility (for most customer plans)
• Obtain an initial authorization for routine outpatient services (for specific
customer plans)
• Check on authorization requests and download authorization reports
• Print authorization letters and EOBs online
• Submit a claim for professional services (CMS-1500) and check on claim
payment status
• View your outcomes reports
• Complete your recredentialing application online
• Register for Electronic Funds Transfer
• Access MyMessages for secure communication with Magellan staff
• Check your credentialing status and contracting status
37
Magellan Provider Service Center Features
(continued)
Website demonstration on home page
www.MagellanProvider.com
Online provider orientation program
Provider Focus behavioral health newsletter
Electronic claims submission information
HIPAA billing code set guides
MNC and CPGs
Clinical and administrative forms
Cultural competency resources
Demos of all our online tools/applications: go to Education/Online Training
Behavioral health information for members
Plus…Autism Resource Center on member site at
https://www.magellanassist.com/mem/library/autism.asp
•
•
•
•
•
•
•
•
•
•
•
38
Updating Practice Information
Updating your practice data is critical to all transactions with Magellan.
Practice data impacts:
• Authorization notifications
• Recredentialing notifications
• Network/contractual-related communications
• Provider directories
• Claims payment
Office managers/group administrators must be cautious when updating
practitioner information, particularly when the provider maintains a solo
practice and/or works for other group practices.
39
Updating Practice Information (continued)
What You Need to Do – Solo Clinicians
Notify Magellan within ten business days of any changes in your individual
practice information:
• General information
• Contact information
• Access
Promptly notify us if you are unable to accept referrals for any reason
including:
o Illness
o Practice not accepting new patients
o Professional travel, sabbatical, vacation, leave of absence, etc.
• Specialties
• Service, mailing or financial address

40
Updating Practice Information (continued)
What You Need to Do – Group Practices
• Notify Magellan within ten business days of any changes in your practice
information:
 General information
 Contact information
 Specialties
 Service, mailing or financial address
 Practitioners departing the group practice
 New practitioners joining the group practice
 Access
o
41
Promptly notify us if you are unable to accept referrals for any reason
including:
• Illness
• Practice not accepting new patients
• Professional travel, sabbatical, vacation, leave of absence, etc.
Updating Practice Information (continued)
What You Need to Do
• Magellan’s mandatory online Provider Data Change Form (PDCF) allows
you to update your information in real time
 Go to www.MagellanProvider.com
 Sign in to the secure network
 Click Display/Edit Practice Information from left-hand menu
• Training is available online under the Education heading on the provider
website
• Network staff members are also available to assist with provider training
42
Provider Data Change Form
43
Wrapping Up: Supporting the
Provider with First-Class Service
Our Commitment to You, the Provider
In providing first-class provider service to you, Magellan focuses on:
Prompt, accurate claims payment
Ease of credentialing and recredentialing
Healthy referral volume
Easily accessible provider resources (clinical, training, consultation,
outcomes tools, etc.)
• Secure transactions on our provider website to ensure privacy
• Personalized service when you need assistance
•
•
•
•
45
The Quality Partnership
A commitment to quality:
• Magellan maintains a Continuous Quality Improvement (CQI) program
• Magellan’s providers are an integral component of the quality program
Magellan obtains meaningful input from providers through:
• Regional Network and Credentialing Committees
• Annual provider satisfaction surveys
• Provider Advisory Groups
We provide information to providers through:
• Provider Focus newsletter
• Provider forums and webinars
• Magellan provider website
46
Free Continuing Education Opportunities
• Continuing education (CE) credits available at no charge to our contracted
providers through our online education partner, Essential Learning
• Sign in on the website to begin; navigate to Education/CEUs and CMEs
• Literally hundreds of specialized courses available to providers via Essential
Learning
• No less than four courses on treating ASDs are available through our site
47
Provider Contacts and Help
• Magellan Provider Services Line:
1-800-788-4005
• West Field Network Support:
1-800-430-0535
• For ABA eligibility, authorization and claims
questions, use the customer service # on the
back of the member’s card to reach the
Magellan Care Management Center.
48
Magellan Health, Inc.
Thank You