State of Maryland

Department of Health and Mental Hygiene & VALUEOPTIONS®

October 2009

Clinical Training For

Case Management Providers

Presenters

• Nancy Calvert, Director, ValueOptions® Maryland Provider Relations

• Mara Rapant, ValueOptions® National Director of Clinical Services

Agenda

• Update

• Case Management Overview

• Overview of ProviderConnect

• Requesting Authorizations

• Questions

Updates

• ValueOptions® Maryland Website• http://maryland.valueoptions.com

– Provider Alerts• MHA Policy Clarification Memos and Announcements• ValueOptions® Maryland Updates and

Announcements– Training Schedule– ProviderConnect “tips”– Maryland Specific ProviderConnect “demo”– Provider Forms – including a hard copy concurrent review

form– Coming Soon:

• Provider Manual• Diagnostic Crosswalk• Fee Schedule• Service Grid

– Consumer Information

Important Information

• MHA Memo dated August 12, 2009:• Download at:• http://maryland.valueoptions.com/provider/alerts/081209_Case_Management_Transiti

on_Update.pdf

• Effective Sept. 1, 2009, CM transitioned to fee-for-service• Consumers receiving CM services prior to 9/1/2009 may receive:

– A maximum of 2 visits/month for Uninsured Eligible consumers, without authorization

– A maximum of 5 visits/month for Medicaid Eligible consumers, without authorization

• New Uninsured consumers:– Must be approved for Uninsured Eligibility by the CSA and MHA. – Courtesy review must be submitted for all new uninsured consumers:

• If MA is approved, payment will be made back to the eligibility start date.

• If MA is not approved, an uninsured eligibility span will not be opened.

Assessments:

• Fiscal Year 2010– Providers will be reimbursed for only one

assessment

• Fiscal Year 2011 and forward– Providers will be reimbursed for no more than

two assessments

• Reminder: Assessments are required every six months.

Uninsured Eligibility Requests• Provider must submit the request for Case Management

services for new, uninsured consumers to ValueOptions® Maryland.

• The case management request must meet the both the uninsured eligibility and case management criteria for case management services to be considered for an exception by MHA and the CSA.

• The ValueOptions® Maryland Care Manager will review the request, pend the decision in ProviderConnect and forward the request to the CSA for review and approval.

• If approval is recommended by the CSA, the CSA will request final confirmation by phone or email to MHA – Penny Scrivens, LCSW-C, Case Management Coordinator, at 410-402-8482, or pscrivens@dhmh.state.md.us, or James Chambers, Director, Adult Services at 410-402-8476 or jchambers@dhmh.state.md.us.

• MHA will review the request, determine if funds are available and forward the decision to the CSA within 2-3 working days.

• If MHA approves, the CSA will enter the approval in ProviderConnect.

Uninsured Eligibility Requests

• Exceptions granted will be very limited and contingent upon the urgency of the request, such as a discharge from a state hospital, or diversion from inpatient psychiatric care, and the expectation that the provider will link the individual to the necessary benefits in order to obtain Medicaid coverage for future services.

Case Management – Quick Tips• Case Management Codes:

– H0031: Assessment- $105/assesssment – T1016: Daily Session - $105/session

• Duration:– Assessment: not time defined– Daily Session: minimum 60 minutes

• Authorization Span:– Medicaid: 6 months– Uninsured Eligible: 3 months

• Levels of Service:– Medicaid:

• General – maximum of 2 visits/month• Intensive – maximum of 5 visits/month

– Uninsured Eligible:• General only – maximum of 2 visits/month

Levels of Service

• General is based on the severity of the consumer’s mental illness, and the consumer must meet at least one of the following conditions.

• Not linked to mental heath and medical services;• Lacks basic supports for shelter, food, and income;• Transitioning from one level of care; or• Need to maintain community-based treatment and

services.• Intensive is based on the severity of the

consumer’s mental illness, and the consumer meets more than one of the following conditions.

• Not linked to mental heath and medical services;• Lacks basic supports for shelter, food , and income;• Transitioning from one level of care; or• Need to maintain community-based treatment and

Service Provision

• Case Management services are not reimbursable in an inpatient facility, e.g. hospitals or nursing homes or detention centers:– The consumer must be discharged from CM and a new

authorization requested upon discharge from the inpatient.

• The MHA does not specify the required number of cases on a Case Manager’s case load.

• The required length of a visit is 60 minutes– Visits must be face-to-face, or combined with same day

telephonic or collateral contacts.– Only an encounter with the minor’s guardian or parent

can be counted as a visit (excludes a face-to-face encounter with a school counselor.)

– Travel time is not reimbursable unless an intervention occurs and is documented in the consumer’s record.

– Start and end times of the encounter must be documented.

• Only one visit may be billed per day.

Requests for Case Management Services

• Clients may self-refer by contacting the CSA, the Case Management Provider or ValueOptions® Maryland.

• An Uninsured Eligibility request may be submitted for Shelter+Care consumers who are not Medicaid recipients.

• Case Management Services for Transitional Age Youth (TAY) who do not meet the Medical Necessity Criteria may be considered for CM services on a case-by-case basis.

• The diagnostic criteria for admission to Case Management is under review and will be released in the near future.

Authorization Requests

• Authorizations will be issued from the date of the request for authorization, not from the first day of the month of the request.

• Authorizations may not be backdated.• A diagnosis is not required for the initial

authorization request. “Diagnosis Deferred” (ICD-9 Code 799.9) may be used for the initial request. Please note: All 5 Axes are required on the subsequent requests.

• Courtesy reviews are accepted for Case Management, if there is a reasonable expectation that the consumer is eligible for Medicaid. The provider is expected to assist the consumer with the Medicaid Application.

Authorization Requests, Continued• The preferred method for requesting an

authorization is on-line, via ProviderConnect.• Currently, providers must complete the

request via ProviderConnect in one sitting. A future ProviderConnect enhancement will include a “save” function.

• Providers should enter only the information pertinent to the consumer on the problem list screen in ProviderConnect. It is not necessary to complete all of the 10 fields available.

• Providers may attach the COMAR compliant Care Plan in lieu of completing the Plan in ProviderConnect.

ProviderConnect

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ValueOptions® ProviderConnect

• Free, secure, online application

• Easy access 24 hours a day, 7 days a week

• Complete multiple transactions in a single sitting

ProviderConnect is an online tool that increases convenience & decreases

administrative burden.

ValueOptions® ProviderConnect Features

• Verify Consumer eligibility

• Register Uninsured Consumers

• Request Authorizations

• View Authorizations

• Submit Claims (Batch and Direct/On-line claim)

• View Claim Status

• View and Print Provider Summary Voucher

• Submit inquiries to Customer Service

• Access and print forms

With ProviderConnect providers can:

Accessing ProviderConnect• Each provider has a secure login and

online registration, including a provider ID number via the ProviderConnect Web site.

• Additional logins for other providers in the same practice are available through ProviderConnect. Contact:

ValueOptions® EDI Helpdesk (888) 247-9311, Option 3 Monday through Friday

8 a.m. – 6 p.m. EST

Turn around time for additional logins is 48 hours.

September 25th Upgrade

• Online Uninsured Eligibility Registration (request function) is now available to providers.

• Axis 1-V diagnoses are now required on concurrent reviews

• The “Individual Care Plan” – The Plan tab has been added to the Mobile Treatment

authorization request screen.– The Service Code Field has been removed– Providers now have the option to print the Plan separately.

• “MCO” is no longer a required field.• “Education Level” has been deleted from the

federally required questions.• “N/A” is no longer an option to the “Race”

question.

Requesting an Authorization for

Case Management

Live Demonstration

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Questions

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