Maternal and Maternal and Infant Health Infant Health Social Work Social Work

ServicesServices

OHCA Rules and PoliciesOHCA Rules and Policies

August 15, 2008August 15, 2008

Who is OHCA?Who is OHCA?Oklahoma Medicaid AgencyOklahoma Medicaid Agency

– SoonerCareSoonerCare (Name of Insurance Program) (Name of Insurance Program)– SoonerCare TraditionalSoonerCare Traditional – SoonerCare ChoiceSoonerCare Choice– Insure Oklahoma/OEPICInsure Oklahoma/OEPIC– Oklahoma Cares (BCC)Oklahoma Cares (BCC)– TEFRATEFRA– SoonerPlan (Family Planning)SoonerPlan (Family Planning)– Soon To Be SoonersSoon To Be Sooners

Member Eligibility Member Eligibility Two-prongs for eligibilityTwo-prongs for eligibility

– Low income individuals (based on federal Low income individuals (based on federal poverty level percentages)poverty level percentages)

– Categorical need (i.e., children, pregnant, Categorical need (i.e., children, pregnant, disabled)disabled)

Eligibility determined by Oklahoma Eligibility determined by Oklahoma Department of Human Services (OKDHS)Department of Human Services (OKDHS)

SoonerCare and Perinatal SoonerCare and Perinatal ServicesServices

Large percent of births are paid by Large percent of births are paid by SoonerCareSoonerCare

FY 2007—SoonerCare paid for FY 2007—SoonerCare paid for over 32,000 deliveries (57% of over 32,000 deliveries (57% of Oklahoma births)Oklahoma births)

Prenatal Care BenefitsPrenatal Care Benefits Routine OB care—prenatal visits, labs, Routine OB care—prenatal visits, labs,

prescriptions, deliveriesprescriptions, deliveries Smoking cessation counselingSmoking cessation counseling Prenatal assessmentPrenatal assessment Limited ultrasounds Limited ultrasounds High risk pregnancy services High risk pregnancy services Limited dental careLimited dental care Genetic counselingGenetic counseling Lactation consultant servicesLactation consultant services Maternal and infant health social work servicesMaternal and infant health social work services Soon To Be SoonersSoon To Be Sooners

MIH Social Work ServicesMIH Social Work Services Direct face to face service provided to Direct face to face service provided to

pregnant/postpartum SoonerCare members pregnant/postpartum SoonerCare members with psychosocial concerns that may impact with psychosocial concerns that may impact pregnancy outcomes and/or the health of the pregnancy outcomes and/or the health of the infant--include but not limited to:infant--include but not limited to:– Domestic violenceDomestic violence

– Substance abuseSubstance abuse

– Lack of basic resourcesLack of basic resources

– Mental IllnessMental Illness

MIH Social Workers:MIH Social Workers:

Connect women with necessary Connect women with necessary services which will promote optimal services which will promote optimal pregnancies and best outcomes for pregnancies and best outcomes for the infantthe infant– Help ascertain the best fit for the Help ascertain the best fit for the

individual woman individual woman

MIH Social Workers:MIH Social Workers:

Assist the woman in emotionally Assist the woman in emotionally understanding and accepting the understanding and accepting the need for services or treatmentneed for services or treatment– Ensure she follows through on all Ensure she follows through on all

needed careneeded care– Follows up to see if the care she Follows up to see if the care she

received met her needsreceived met her needs

MIH Social Workers:MIH Social Workers:

Provide short term problem Provide short term problem focused counselingfocused counseling

Assess maternal emotional well Assess maternal emotional well beingbeing

Maternal –infant bonding and Maternal –infant bonding and interactionsinteractions

Eligible ProvidersEligible Providers

Licensed Clinical Social Workers (Licensed Licensed Clinical Social Workers (Licensed in the state services are provided)in the state services are provided)

Must have a current OHCA contractMust have a current OHCA contract– Need to demonstrate current licenseNeed to demonstrate current license– Six hours of continuing education or technical Six hours of continuing education or technical

assistance in area of MIH assistance in area of MIH

CoverageCoverage

Pregnant and/or up to 60 days postpartum Pregnant and/or up to 60 days postpartum SoonerCare &/or Soon To Be Sooners SoonerCare &/or Soon To Be Sooners members members

Existing psychosocial condition that may Existing psychosocial condition that may negatively impact the pregnancy/well-being negatively impact the pregnancy/well-being of newbornof newborn

Condition identified by OB provider during Condition identified by OB provider during prenatal care assessment or during Social prenatal care assessment or during Social work assessmentwork assessment

Coverage Coverage

Self referred or referred by any provider (no Self referred or referred by any provider (no formal referral needed)formal referral needed)

Services must be provided in office, home or Services must be provided in office, home or other confidential clinic settingother confidential clinic setting

Face to face and individual serviceFace to face and individual service No separate reimbursement for inpatient No separate reimbursement for inpatient

servicesservices Separate facility fee not reimbursedSeparate facility fee not reimbursed

Billing Codes/Billing Codes/Reimbursement RatesReimbursement Rates

Use CPT codes:Use CPT codes: 9615096150-Health and Behavior Assessment -Health and Behavior Assessment

$16.79 per 15 minutes$16.79 per 15 minutes 9615296152-Health and Behavior Intervention, -Health and Behavior Intervention,

Individual Individual $15.41 per 15 minutes$15.41 per 15 minutes

9615496154-Health and Behavior Intervention, -Health and Behavior Intervention, Family with Patient Present Family with Patient Present $15.13 per 15 minutes$15.13 per 15 minutes

Maximum Units of ServiceMaximum Units of Service

32 total units per pregnancy/postpartum 32 total units per pregnancy/postpartum (unit=15 minutes)(unit=15 minutes)

Maximum of 6 units per day/session Maximum of 6 units per day/session Any combination of the three codes as Any combination of the three codes as

clinically appropriateclinically appropriate Billing time = time spent in face-to-face Billing time = time spent in face-to-face

contact with the clientcontact with the client

Contracting InformationContracting Information Go to Go to www.okhca.orgwww.okhca.org and choose: and choose:

– ProvidersProviders– EnrollmentEnrollment– New contractsNew contracts– MMaternal and Infant Health LCSWsaternal and Infant Health LCSWs

Download contract and follow instructionsDownload contract and follow instructions Mail in completed contract with required Mail in completed contract with required

professional documentationprofessional documentation Will take a couple of weeks to process/receive Will take a couple of weeks to process/receive

provider numberprovider number Call 800-522-0114 for helpCall 800-522-0114 for help

OHCA ContractOHCA Contract Requirements Requirements

Attach copy of certification Attach copy of certification Show 6 hours of CEUs or technical Show 6 hours of CEUs or technical

assistance in MIH social workassistance in MIH social work Complete 6 hours CEU/technical assistance Complete 6 hours CEU/technical assistance

each calendar yeareach calendar year Maintain confidential recordsMaintain confidential records Service records must be readily accessible Service records must be readily accessible

for OHCA audit/inspection for 6 years from for OHCA audit/inspection for 6 years from date of servicedate of service

Getting started—Getting started—Referral resourcesReferral resources

Members may self-refer, no formal referral neededMembers may self-refer, no formal referral needed Once contracted, obtain a list of contracted Once contracted, obtain a list of contracted

SoonerCare OB providers in your area SoonerCare OB providers in your area Outreach to OB providers, inform them you are a Outreach to OB providers, inform them you are a

SoonerCare contracted provider and of your SoonerCare contracted provider and of your servicesservices

You may wish to discuss how you will share You may wish to discuss how you will share information regarding the patientsinformation regarding the patients

You should discuss how the OB provider will make You should discuss how the OB provider will make referrals to youreferrals to you

Getting Started—BillingGetting Started—Billing

Welcome packet from EDS Welcome packet from EDS (OHCA’s fiscal agent)(OHCA’s fiscal agent)

Field rep contact info Field rep contact info Free, on-site training or register Free, on-site training or register

for bi-monthly training in OKC or for bi-monthly training in OKC or MuskogeeMuskogee– SoonerCare basicsSoonerCare basics– Secure websiteSecure website– Training registrationTraining registration

Secure websiteSecure website

No cost (need internet access)No cost (need internet access) Verify member eligibilityVerify member eligibility Immediate notification of claim statusImmediate notification of claim status

– Denied claims resolution resourcesDenied claims resolution resources Call centerCall center Provider repsProvider reps

Weekly payment cycleWeekly payment cycle– If you file weekly, you get paid weeklyIf you file weekly, you get paid weekly

Third Party LiabilityThird Party Liability

Third Party Liability (TPL) means Third Party Liability (TPL) means another party is responsible for another party is responsible for paying health care costs before (& paying health care costs before (& sometimes after) SoonerCare payssometimes after) SoonerCare pays

SoonerCare is the payer of last resortSoonerCare is the payer of last resort About 10% of Sooner Care members About 10% of Sooner Care members

have another insurer in addition to have another insurer in addition to SoonerCareSoonerCare

TPLTPL

Ask your clients if they have other Ask your clients if they have other insurance coverageinsurance coverage

If so, get insurance carrier info from themIf so, get insurance carrier info from them It is unlikely you will run into this situation, It is unlikely you will run into this situation,

BUT if you do, BUT if you do, help is availablehelp is available Call OHCA--we will happily walk you Call OHCA--we will happily walk you

through the process!through the process! 1-800-522-0114 option 7 (TPL)1-800-522-0114 option 7 (TPL)

DocumentationDocumentation

Services must be documented in medical Services must be documented in medical record to include:record to include:– Date of serviceDate of service– Start and stop time for each sessionStart and stop time for each session– Service provider signature and credentialsService provider signature and credentials– Documentation of referral sourceDocumentation of referral source

DocumentationDocumentation

Treatment plan including problems, goals Treatment plan including problems, goals and/or objectivesand/or objectives

Methods to be used to address problems, Methods to be used to address problems, goals and objectivesgoals and objectives

Progress madeProgress made Client response to the session/interventionClient response to the session/intervention Any new problems, goals or objectives Any new problems, goals or objectives

identifiedidentified

OHCA ContactsOHCA Contacts Child Health UnitChild Health Unit

– Terrie Fritz, LCSW, Director of Child HealthTerrie Fritz, LCSW, Director of Child Health 405-522-7377405-522-7377 Terrie.Fritz@okhca.orgTerrie.Fritz@okhca.org

– Shelly Patterson, CPH, Perinatal CoordinatorShelly Patterson, CPH, Perinatal Coordinator 405-522-7332405-522-7332 Shelly.Patterson@okhca.orgShelly.Patterson@okhca.org

OHCA Provider RepresentativeOHCA Provider Representative– 1-877-823-4529 option 21-877-823-4529 option 2

OHCA websiteOHCA website– www.okhca.orgwww.okhca.org

Helpful OHCA NumbersHelpful OHCA Numbers

OHCA Call TreeOHCA Call Tree (Provider)(Provider) 1-800-522-0114 1-800-522-0114 OHCA Call TreeOHCA Call Tree (Member)(Member) 1-800-522-71711-800-522-7171 SoonerCare Helpline SoonerCare Helpline (Member)(Member)1-800-987-77671-800-987-7767 Behavioral HealthBehavioral Health 1-800-652-20101-800-652-2010 SoonerRideSoonerRide 1-877-404-45001-877-404-4500 Patient Advice LinePatient Advice Line 1-800-530-30021-800-530-3002

Questions?Questions?