Managed Long-Term Services and Supports (MLTSS)Phase 1: Sept – Dec 2018: Determine OBAT...
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This Document is Proprietary and Confidential – Do Not Print or Distribute Without Permission March 14, 2019 Carol Cianfrone Director, MLTSS Clinical Operations Managed Long-Term Services and Supports (MLTSS) Sharon Suk Manager, MLTSS Clinical Operations
Transcript of Managed Long-Term Services and Supports (MLTSS)Phase 1: Sept – Dec 2018: Determine OBAT...
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March 14, 2019
Carol CianfroneDirector, MLTSS Clinical Operations
Managed Long-Term Services and Supports (MLTSS)
Sharon SukManager, MLTSS Clinical Operations
Goals of MLTSS
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• Deliver Long Term Services and Supports
• Expand home and community based services
• Promote community inclusion
• Ensure quality and efficiency
• Provide comprehensive services and supports regardless of setting• Community• Community Alternative Residential Setting• Nursing Facility
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MLTSS Care Management
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• Horizon NJ Health members eligible for MLTSS are all assigned a dedicated Care Manager
• The Care Manager, Member/Member Representative and the clinical team create an agreed upon Plan of Care that is specific to the members physical, social, behavioral and long term care needs of the member
• Clinical team could include:• Primary Care Physician• Specialists• Therapists• Behavioral Health Providers
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MLTSS Care Management Requirements- HBSC Member
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• Outreach to member within 5 days of enrollment
• Complete a face to face visit within 45 days of enrollment to develop a Plan of Care
• Ongoing Face to Face visits with member in their residence• Annually• At least every 90 days• Change in Condition• Change in Level of Care• Post Facility Discharge (within 10 days of d/c)
• Acute Inpatient• Rehabilitation• Nursing Facility
• Services must be in place within 3 days of discharge
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Care Management Requirements- Facility Member
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• Outreach to member/facility within 5 days of enrollment into MLTSS
• Complete a face to face visit within 45 days of enrollment to develop a Plan of Care
• Ongoing Face to Face visits with member at the facility• Annually• At least every 180 days (Pediatric SCNF is every 90 days)• Change in Condition• Change in Level of Care
• Must participate in at least one facility Interdisciplinary Team meeting per year
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Care Management- MLTSS Service Authorizations
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All MLTSS Services are Authorized by the MLTSS Care Manager. These determinations are based on the members needs, agreed upon plan of care and other services that they receive.
MLTSS services:• Assisted Living Services (ALR, CPCH, ALP• Adult Family Care• Caregiver Participant Training• Chore Services• Community Residential Services• Community Transition Services• Home Based Supportive Care• Home Delivered Meals• Medication Dispensing System• Non- Medical Transportation• Nursing Facility and Special Care Facilities• Personal Emergency Response Services
• Private Duty Nursing- Over age 21• Residential Modifications• Respite- NF, AL and HCBS• Social Adult Day• Traumatic Brain Injury Services
• Behavior Management• Cognitive Therapy• Occupational Therapy• Physical Therapy• Speech, Language, Hearing• Structured Day• Supportive Day
• Vehicle Modification
Care Management Contacts
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• Carol Cianfrone- Director MTLSS 609-537-3125/c: [email protected]
• Sharon Suk- Manager MLTSS 973-803-6950Sharon_Suk@[email protected]
• Facility Alerts [email protected]
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This Document is Proprietary and Confidential – Do Not Print or Distribute Without Permission
March 14, 2019
Maria RavitzManager, Utilization Management
Utilization Management
Inpatient Utilization Management
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Authorization Process for Inpatient Services :
• Notification of Admission is required within 1 business day of admission
• Clinical information can be sent to Horizon in one of three ways• Faxed to the concurrent Review Department at (609)583-3011• Received electronically through Navinet (Care Affiliate) • Telephonically at (800) 682-9094
• Concurrent Reviews for acute inpatient hospitalization and post acute facilities are conducted on a daily basis or on a schedule that is clinically appropriate and according to the medical exigencies of the member.
• Determinations for continued services will rendered within 24 hours of receipt of the clinical information.
• Facilities have 72 hours to provide additional clinical information whenrequested by the Concurrent Review Nurse or Medical Director
• Retro review determinations are completed within 30 calendar days
• Determinations are communicated to the Facility Utilization Dept. by Fax
Inpatient Utilization Management
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Transitional Care for New Enrollees
• Any member/covered person enrolled under a Horizon plan may request continuation of coverage for ongoing treatment by a non-network healthcare professional, institutional provider or vendor at the in-network benefit level.
• To receive consideration for this transitional coverage, the request should be made no later than sixty (60) days following the effective date of enrollment, unless otherwise stipulated by the member's contract.
• Eligibility for continuation of coverage for a nonparticipating healthcare professional, institutional provider or vendor at the in-network benefit level must meet specific criteria and, if approved, will be granted for a limited time period.
Authorization Process for elective or scheduled Inpatient Services :
• Precertification must be obtained prior to elective or scheduled hospitalization a minimum of 5 days prior to the admission. Please note that Horizon NJ Health is allowed 14 calendars to process the authorization request.
• In addition prior authorization is required for some outpatient services are that are scheduled as a part of discharge planning.
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Outpatient Utilization Management
What is Clinical Staff’s Role?
• Our Utilization Management Clinical Team will review all request for medical necessity and will approve if medical criteria is met.
• If medical criteria is not met, the case is referred to our Medical Directors for review and determination
• Criteria tools utilized by hierarchy; HNJH Policies, HBSBSNJ Policies, MCG Guidelines.
• All Non-Par requests require Authorizations reviewed by Clinical staff.
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Outpatient Utilization Management
• Durable Medical Equipment is requested by DME Providers examples are: Wheelchair's,Beds, Oxygen, & Diabetic supplies. The DME department does not accept telephonicrequests for authorization, with the exception of requests for hospital discharge.
• All information must be completed in order to expedite the request. If pertinentinformation is missing, an letter will be generated that includes details on the missinginformation in order to complete the request. Additional information must besubmitted within 72 hours from the date of the letter.
• Horizon NJ Health will complete all routine requests within 14 calendar days fromreceipt of all information.
• Exception: Hospital Discharge DME is processed upon receipt of request by contactingthe DME auth request line (800) 682-9094 ext. 81017.
• Medline is Horizon NJ Health single vendor for incontinent supplies (Diapers and liners)- Authorization is required when requesting Medline products in quantities of 180 or greater per month.
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Durable Medical Equipment (DME) Process
NAVINET: By joining NaviNet, Horizon NJ Health providers get access to:Administrative Reports• Care Gap Reports• Claim Appeals Status• Claim Status Inquiries• Online Referral Submission• Referral InquiriesCARE AFFILIATE (CA): Providers who use NaviNet can access the CareAffiliate portal. This portal allows providers to communicate directly to Horizon NJ Health by checking status in real time. It is used to send and check the status of authorization requests. It also sends providers notifications wen authorization request are completed.
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Navinet.net
• Authorization Request Forms are located on our website/Provider Resources www.HorizonNJHealth.com
• MLTSS members, medical authorizations are processed by Horizon UM but MLTSS Benefits are processed by the MLTSS Case Managers.
• Horizon Government Programs has after hours clinical staff to meet UM needs.
• https://www.horizonnjhealth.com/securecms-documents/158/Quick_Reference_Guide.pdf
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General Authorization Information
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Delegated Utilization Management
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Provider Quick Contact Guide
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Provider Quick Contact Guide
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Provider Quick Contact Guide
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Provider Quick Contact Guide
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March 14, 2019
Medication-Assisted Treatment (MAT) AND Office-based Addiction Treatment (OBAT)
Vincent Visioli, LCSW Implementation Manager/ Behavioral Health Administrator
NJ Medication Assisted Treatment (MAT) and Office-based Addictions Treatment (OBAT) Model – NJ MATrx Model
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• NJ DHS/DMAHS looking to increase access to Substance Use Disorder (SUD) Medication-Assisted Treatment (MAT) by making Office-based Addictions Treatment (OBAT) a Medicaid reimbursable service within MATrx system
• OBAT introduces service navigation in a primary care setting
• Will allow for provision and coordination of multiple reimbursable services by PCPs and community-based BH specialists through MCO contracts
• Any contracted provider with Data 2000 waiver for prescribing Suboxonemay participate
Those not yet waivered can take advantage of DMHAS sponsored training opportunities
Seven (7) Buprenorphine Training courses coming up through Rutgers Medical School
CEUs and $750 financial reimbursement opportunity
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NJ Medication Assisted Treatment (MAT) and Office-based Addictions Treatment (OBAT) Model – NJ MATrx Model
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Goals of MATrx/ OBAT Program Goals
Increase statewide capacity of non-methadone Medication-assisted Therapy (MAT) providers for patients with substance use disorder
Increase provider capacity
Increase Quality through continuing education, training and consultation
Connect office-based opioid treatment providers with behavioral health supports (ie. peer support and care coordination (ie. Navigator) services
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NJ Medication Assisted Treatment (MAT) and Office-based Addictions Treatment (OBAT) Model – NJ MATrx Model
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• NJ DHS/DMAHS is looking to increase access to Substance Use Disorder (SUD) Medication-Assisted Treatment (MAT) by making Office-based Addictions Treatment (OBAT) a Medicaid reimbursable service within MATrx system
• Proposed MATrx Model would consist of 3 types of providers specializing in SUD and Opioid Use Disorder (OUD) tx:
Centers of Excellence – Comprehensive center that functions as ‘hub’ for integrated care & serves as resource for community, on-site training, mentorship & consultation for providers
Premier Providers – Independent clinics who provide integrated, coordinated care and qualify for ‘excellence’ through certification and best-practice guidelines
Office-based Addictions Treatment (OBAT)- Office-based addictions or primary care physicians with a ‘Data 2000 waiver’ who meet established standards for excellence. These practitioners would need to affiliate with Premier providers or Centers of Excellence to integrate care and meet best-practice guidelines
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NJ Medication Assisted Treatment (MAT) and Office-based Addictions Treatment (OBAT) Model – NJ MATrx Model
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NJ Medication Assisted Treatment (MAT) and Office-based Addictions Treatment (OBAT) Model – NJ MATrx Model
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NJ Medication Assisted Treatment (MAT) and Office-based Addictions Treatment (OBAT) Model – NJ MATrx Model
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Timeline:
Phase 1: Sept – Dec 2018: Determine OBAT requirements, establish OBAT reimbursement, identify OBAT providers, Determine Center of Excellence facilities and determine Criteria
Phase 2: Jan – March 2019: OBAT billing goes live, Determine requirements for Premier providers and reporting requirements
Phase 3: April – July 2019: Billing goes active for premier providers, Peer Support and Case Management Services covered by Medicaid by July 2019
Behavioral Health Prior Authorization – Services Requiring Prior Auth
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Requires Authorization No Authorization RequiredInpatient Psychiatric Treatment Outpatient psychotherapyPartial Hospitalization Outpatient psychiatric/ Medication Management
Partial Care Medication Assisted Treatment – not including actual medication
Adult Mental Health Rehabilitation (AMHR) Group Homes and Apartments
Outpatient treatment for substance use disorders
Psychological Testing Outpatient psychiatric/ Medication Management for substance use disorders
ECTTrans Magnetic StimulationShort Term Residential Treatment (ASAM 3.7)Ambulatory Withdrawal Management (ASAM 2-WM)Medically Monitored Detox (SUD ASAM 3.7D)IOP SUD (ASAM 2.1)
Partial SUD (ASAM 2.5)
Behavioral Health Prior Authorization
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Medicaid and DDD1-800-682-9091, option 2
MLTSS 1-855-777-0123, option 2
FIDE-SNP1-855-955-5590, option 2
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March 14, 2019
Edward RadwanskiDirector, Network Contracting
Provider Contracting and Strategy
Lori BembryManager, MLTSS Network Services
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Provider Contracting and Strategy
• Hospital, Physician, Ancillary and MLTSS Contracting Team
o Recruit Providers
o Negotiate Contracts (including Single Case Agreements)
o Oversight of Relationship
Provider Education (including HEDIS)
Provider Servicing
Coordinate with HNJH internal business partners, i.e. Credentialing, Claims Resolution, Contract Configuration, Provider File Operations, etc.
• Pricing and Reimbursement Team
o Create and maintain fee schedules
• Value Based Team
o Recruit, contract and educate providers on VB contracting methodologies
Ongoing education and reporting
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Provider Contracting and Strategy
Resources for Providers
Horizon NJ Health Website – HorizonNJ health.com
Navinet – www.Navinet.net
Provider Services – 1-800-682-9091, M-F 8am to 5pm
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