Mental Rehabilitation & Targeted Case Management (SB58)
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Mental Rehabilitation & Targeted Case Management (SB58) Effective 9/1/2014
Transcript of Mental Rehabilitation & Targeted Case Management (SB58)
Mental Rehabilitation & Targeted Case
Management (SB58)
Effective 9/1/2014
What is Senate Bill 58?
• Texas Legislation which integrates into the Medicaid Managed Care program, the following services for
Medicaid-eligible persons:
a) Behavioral health services, including targeted case
management and psychiatric rehabilitation services; and
b) Physical health services
c) Managed care organizations that contract with the
commission under this chapter shall develop a network of
public and private providers of behavioral health services and
ensure that adults with serious mental illness and children with
serious emotional disturbance have access to a
comprehensive array of services.
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Behavioral Health Carve-In
Effective September 1, 2014
• Targeted Case Management and Mental Health
Rehabilitative services for STAR, STAR Health and
STAR+PLUS enrollees will be included in the managed
care benefit package.
• The NorthSTAR service area will continue to receive
Targeted Case Management and Mental Health
Rehabilitative services through the NorthSTAR delivery
model
Dallas, Ellis, Collin, Hunt, Navarro, Rockwall and
Kaufman counties
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Assessment of Services
• Rehabilitative and Targeted Case Management services may be provided to individuals with a severe and persistent mental illness or a severe and emotional disturbance and who require services as determined by the:
Adults Needs and Strengths Assessment (ANSA)
or
Child and Adolescent Needs and Strengths
Assessment (CANS)
• For State Fiscal Year 2015, Cenpatico is required to utilize the DSHS utilization management guidelines Texas Resilience and Recovery (RRUMG).
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Provider Network
• Prospective providers can access Cenpatico website at www.cenpatico.com to submit a Join our Network application.
o Select Provider, Texas and Join Our Network.
• Participating Facilities should submit a rendering provider roster to Cenpatico to add a licensed provider to their current contract.
• Cenpatico is required to perform DFPS Background Checks on all Foster Care providers. Providers must submit a DFPS 1600 Form for all licensed Foster Care providers.
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Contract Requirements
Providers are required to attest to the following:
• Participating Provider(s) is currently trained and certified to administer the ANSA and CANS assessment tools to recommend a level of care to Cenpatico covered persons.
• Participating Provider(s) will complete the Mental Rehabilitation and Targeted Case Management Services Request Form and submit to Cenpatico.
• Participation Provider(s) will utilize the current DSHS Texas Resilience and Recovery Utilization Management Guidelines (RRUMG).
• Provider entities have the ability to provide covered persons with the full array of RRUMG services.
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AUTHORIZATIONS
Authorizations
Authorization Process:
• Providers must submit the Service Request Form to Cenpatico via fax (866-469-0725) or via email [email protected] to obtain prior authorization for Mental Rehabilitation and Targeted Case Management services.
• Cenpatico will send authorization determination to provider via fax, within two business days.
• Level of care deviations must be submitted to Cenpatico with medical documentation supporting the need for the alternative level of care.
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Authorizations
• Crisis Services do not require prior authorization, however provider must submit Service Request Form
within two business days of crisis event.
• Provider must submit justification documents if not able to submit Service Request Form within timeframe.
• Cenpatico will honor all state provided authorizations
for a minimum of 90 days.
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Service Coordinators
Cenpatico has Service Coordinators who provide:
• Case management services and assistance with
scheduling outpatient appointments.
• Face-to-Face visits with enrollees in inpatient settings
• Assistance to inpatient facilities with discharge
planning
• Assistance with 7 day follow-up
• Licensed clinicians that are available for enrollees with
greater needs.
• Assistance to enrollees with obtaining resources in their
area.
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Mental Health Rehabilitation
Mental Health Rehabilitative Services include:
• Crisis Intervention Services (H2011)
• Medication Training and Support Services (H0034)
• Psychosocial Rehabilitative Services (H2017)
• Skills Training and Development Services (H2014)
• Adult Day Program (G0177)
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Mental Health Rehabilitation
Modifiers:
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Modifier Description
ET Emergency Treatment
HA Child/Adolescent Program
HQ Group Setting
TD Services rendered by RN
Service Codes & Modifiers
Crisis Intervention
Diagnosis code 799.9 should only be submitted when a
diagnosis has not been determined.
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Service Procedure
Code
Modifier
1
Modifier
2
Rate Unit
Adult
Services
H2011 $36.89 15 min
Child and
Adolesce
nt Services
H2011 HA $36.89 15 min
Service Codes & Modifiers
Medication Training and Support Services:
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Service Procedure
Code
Modifier
1
Modifier
2
Rate Unit
Individual Services for
Adult
H0034 $13.53 15 min
Group Services for
Adult
H0034 HQ $2.71 15 min
Individual Services for
Child and Adolescent
(with or without other
individual)
H0034 HA $13.53 15 min
Group Services for Child
and Adolescent (with
or without other group)
H0034 HA HQ $3.38 15 min
Service Codes & Modifiers
Psychosocial Rehabilitative Services:
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Service Procedure
Code
Modifier
1
Modifier
2
Rate Unit
Individual Services H2017 $26.93 15
min
Individual Services
rendered by RN
H2017
TD $26.93 15
min
Group Services rendered
by RN
H2017
H2017
HQ
HQ
TD
$5.39
$5.39
15
min
Individual Crisis Services H2017
ET $26.93 15
min
Service Codes & Modifiers
Skills Training and Development Services:
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Service Procedure
Code
Modifier
1
Modifier
2
Rate Unit
Individual Services
for Adult
H2014 $25.02 15 min
Group Services for
Adult
H2014 HQ $5.00 15 min
Individual Services
for Child and
Adolescent (with or
without other
individual)
H2014 HA $25.02 15 min
Group Services for
Child and
Adolescent
H2014 HA HQ $6.26 15 min
Service Codes & Modifiers
Day Programs:
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Service Procedure
Code
Modifier
1
Modifier 2 Rate Unit
Adult Day
Program for Acute
Needs
G0177 $24.32 45-60 min
Target Case Management
Targeted Case Management (T1017):
• Must be face-to-face
• Include regular, at least annual, monitoring of service
effectiveness
• Proactive crisis planning and management for individuals
• Targeted Case Management is a Medicaid billable
service provided separate from Cenpatico service
coordination o Service Coordinators coordinate with providers to ensure
integration of behavioral and physical health needs of
enrollees.
o Service Coordinators refer non-eligible enrollees to Local
Mental Health Authorities that can provide indigent mental
healthcare.
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Target Case Management
Modifiers:
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Modifier Description
TF Intermediate Level of Care
HA Child/Adolescent Program
TG Complex/High Tech Level of
Care
Service Codes & Modifiers
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Claims Filing
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Claims Filing
• Cenpatico offers several methods for providers to submit claims to receive reimbursement for services provided. o Cenpatico Web Portal Claim Submission
o Electronic Claim Submission
o Paper Claim Submission
• Claims are submitted on CMS 1500 or UB04 forms within 95 days from date of service or primary insurance disposition date.
• All requests for reconsideration or adjustment must be received within 120 days from the date of adjudication.
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Web Portal Claims Submission
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Electronic Claims Submission
• Centene EDI o Phone: 1-800-225-2573 extension 25525
• EDI Clearinghouse o Emdeon (Payor ID 68068)
(866) 369-8805
www.transact.emdeon.com
o Availity (Payor ID 68068)
(800) 282-4548
www.availity.com
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Paper Claim Submission
• CMS 1500 or UB04 red claim form
• Claims must be typed or computer generated
o Handwritten claims will be rejected
• Paper claims must be mailed to the following address:
Cenpatico Claims
PO BOX 6300
Farmington, MO 63640-3806
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Corrected Claims vs. Appeals
Corrected claim
• Adjustment requiring no supporting documentation
from the provider, could be prompted by the provider
or by the Plan (i.e. wrong date of birth, incorrect
modifier).
Appeal
• Request from a provider for adjustment to a claim that
requires supporting documentation from the provider
to consider the request (i.e. medical records, proof of
timely filing, etc.).
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Claim Appeals
• Must be submitted within 120 days from the date of notification or claim adjudication
• Include copy of UB04 or CMS1500 and EOP with claim
# identified
• Include all supporting documentation
• Claims appeals must be submitted to:
Cenpatico Claims Appeals
P.O. Box 6000
Farmington, MO 63640-3809
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SB58 Claim Filing Tips
• Services rendered by licensed providers must be submitted with the rendering provider NPI/Taxonomy in box 24J of 1500 Claim Form.
• Services rendered by a non-licensed provider should be submitted with the facility NPI/Taxonomy in box 24J and box 33 of the 1500 Claim form.
• Modifiers must be submitted in appropriate modifier position as indicated.
• A diagnosis code 799.9 is only payable for Crisis Services when a diagnosis has not been determined.
• Services billed with modifier HZ (Criminal Justice) will be denied as bill to state.
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Provider Resources
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PaySpan Health
• Cenpatico has partnered with PaySpan Health to offer expanded claim payment services to include: o Electronic Claim Payments (EFT)
o Online remittance advices (ERA’s/EOPs)
o HIPAA 835 electronic remittance files for download directly to
HIPAA-compliant Practice Management or Patient Accounting
System
• Register at: www.PaySpanHealth.com
• For Further information contact 1-877-331-7154, email
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Pharmacy Benefits
Superior Health Plan has contracted with US Script as the
Pharmacy Benefit Manager (PBM).
Pharmacy Benefits:
• US Script is responsible for payment of pharmacy claims
• US Script provides pharmacy network for enrollees o (more than 95% of Vendor Drug pharmacies are contracted)
• US Script is responsible for prior authorization of
prescriptions, as applicable
• State formulary will be adopted for Medicaid and CHIP
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Pharmacy Benefits
US Script Contact Information
Outpatient Rx (PBM: US Script)
• Pharmacy Help Desk: o 800-460-8988
• Prescriber Prior Authorization Requests o Phone: 866-399-0928
o Fax: 866-399- 0929
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Medical Transportation Program
• Transportation is available for STAR Medicaid enrollees under the Medical Transportation Program (MTP).
• Enrollees under 18 years of age may be required to
travel with an adult.
• MTP can provide gas money to someone who drives the enrollee to an appointment, to include family
members, neighbors or other volunteers.
• An enrollee that: o •Live in the Houston / Beaumont area call 1-855-687-4786.
o •Live in the Dallas area call 1-855-687-3255.
o •Everyone else can call 1-877-633-8747 (1-877-MED-TRIP).
• Transportation specialists are available to take
requests weekdays 8:00 a.m. to 5:00 p.m.
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Contact Information
Customer Service • For assistance with non-clinical questions, enrollee
eligibility verification, enrollee benefits, or authorizations please call:
• CHIP (888) 471-4357
• STAR (800) 716-5650
• STAR+PLUS (800) 466-4089
• RSA / EPO (800) 213-9927
• Medicaid RSA (877) 644-4517
• STAR Health (866) 218-8263
• Medicare Advantage (877) 391-5921
• For assistance with claims related questions or issues please call Claim Support Services at (877) 730-2117.
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• Lubbock/ Amarillo/EL Paso & Panhandle Service Area o Shelly Scott
• Houston, S.E. TX Service Area o Eraca Wilson
• Valley & Corpus Christi o Nina Worley
• San Antonio & Surrounding
RSA o Joann Gonzales
• North – North East TXDFW –
Tyler o Carl Wilson
• Austin & Central RSA o May Togo
Provider Relations Representatives
Clinical Staff Representatives
• Lubbock/ Amarillo/EL Paso & Panhandle Service Area o Leanne Fenter o [email protected]
• Houston, College Station S.E. TX Service Area, North – North East TXDFW – Tyler o Shivangi Patel o [email protected]
• Valley & Corpus Christi o Dalia Dimerson o [email protected]
• San Antonio & Surrounding RSA o Stacy McGee o [email protected]
• Austin & Central RSA o Victoria Malott o [email protected]
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Questions?
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