Welcome to UnitedHealthCare Provider Orientation...© 2019 Optum, Inc. All Rights Reserved...
Transcript of Welcome to UnitedHealthCare Provider Orientation...© 2019 Optum, Inc. All Rights Reserved...
© 2019 Optum, Inc. All Rights Reserved
BH2036_05/2019
United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
Children’s Behavioral Health
Transformation
Effective July 1, 2019
1
Welcome to UnitedHealthCare
Provider Orientation
© 2019 Optum, Inc. All Rights Reserved
BH2036_05/2019
United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
• Overview of Optum and UnitedHealthcare
• Clinical Vision
• Cultural Competency
• Children Behavioral Health
Services
• Health Home Care Management
• Credentialing
• Member Eligibility
• Utilization Management
• Quality Improvement
• Billing and Claims
• Provider Portal and Resources
Today’s Agenda
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
Our United Culture
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
• UnitedHealthcare plans and care
programs are uniquely designed to
address the complex needs of the
populations we serve, including the
chronically ill, those with disabilities
and people with higher risk
medical, behavioral and social
conditions
UnitedHealthcare Community Plan
• The largest health benefits company dedicated to providing diversified solutions to States that care for the economically disadvantaged, the medically underserved and those without benefit of employer-funded health care coverage
• Participate in programs in 24 states, plus Washington D.C.
• Serves more than 5 million beneficiaries of acute and long-term care Medicaid plans, the Children’s Health Insurance Program (CHIP), Special Needs Plans and other federal and state health care programs
5
Clinical Vision
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UnitedHealthcare: Our Goals
6
• Use recovery language and principles in every aspect of our work
• Promote Evidence Based and Emerging Best Practices
• Collaborate with providers and systems of care to ensure timely access to services
• Increase community-based services
• Right care at the right time
• Integrated person-centered care plans
• Broaden provider focus
• No wrong door access to care
• Engage community based care
• Reducing avoidable inpatient admissions
• Use natural community supports
Recovery
Focused
Improve
Access
to Care
Integrate
Physical &
Behavioral
Health Manage Cost
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Provider Network
Behavioral Health
Physical Health Quality
Outcomes
Utilization
Management Member
7
UnitedHealthcare: Our Organization
Cultural Competency
8
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Culture refers to integrated patterns of human behavior within various racial, ethnic, religious or social groups, including:
Cultural Competency
• Language
• Thoughts
• Communications
• Actions
• Customs
• Beliefs
• Values
• Institutions
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
Cultural and linguistic competence
is a set of congruent behaviors,
attitudes, and policies that come
together in a system, agency, or
among professionals, that enables
effective work in cross-cultural
situations.
Cultural Competency
Competence means having the capacity to function effectively as an
individual and an organization within the context of the cultural
beliefs, behaviors, and needs presented by members and their
communities.
omh.ny.gov/omhweb/cultural_competence
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• Given the diverse ethnic population in New York, providers must be prepared to provide culturally appropriate services
• Service settings and approaches should be culturally sensitive to engage individuals from diverse backgrounds to access services
Cultural Competency: Importance and Value
• Promoting open
discussions about mental
health or substance abuse
issues is an important step
to reduce the stigma many
individuals have
• Emphasizing individualized
goals and self-sufficiency
encourages members to
live their lives to the fullest
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Awareness of Diversity and Culture in Clinical Settings
• Differences found in diverse
populations • How individual differences affect
assessment and response to treatment
• Personality, culture, lifestyle and other
factors influencing client behavior
• Culturally sensitive counseling methods
• Dynamics of family systems in diverse
cultures and lifestyles
• Client advocacy needs specific to
diverse cultures
Children’s Behavioral Health Services
13
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Children and Family Treatment and Support Services (CFTSS)
Family Peer Support Services (FPSS)
NY State Office of Mental Health Licensed Services
Partial Hospitalization Inpatient Psychiatric Services and Outpatient Clinics1
Assertive Community Treatment (ACT) 2
Personalized Recovery Oriented Services (PROS) 2
Comprehensive Psychiatric Emergency Program (CPEP) 2
Continuing Day Treatment (CDT) 2
1 This includes OMH SED designated clinics and Children with SSI who were previously carved out of MMC 2 Minimum age 18 for these adult oriented services
Children and Family Treatment and Support Services (CFTSS)
Other Licensed Provider (OLP) Psychosocial Rehabilitation (PSR) Community Psychiatric Support and Treatment (CPST)
Children’s Behavioral Health Implementation Timeline
January 1, 2019
Completed
Carve In July 1, 2019
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Children and Family Treatment and Support Services (CFTSS)
Youth and Peer Support and Training Crisis Intervention
NY State Office of Alcohol and Substance Abuse Services1
Outpatient Clinic (Hospital Based) 2
Opioid Treatment Program (OTP) Services (Hospital Based) 2
Outpatient Rehabilitation Services (Hospital Based) 2
Inpatient Rehabilitative Services 3
1 Residential Rehabilitation Services for Youth (RRSY) is not currently included and implementation date is TBD 2 Under 21 SSI and Non-SSI population 3 Under 21 SSI population
Home and Community Based Services Consolidated Waiver
Voluntary Foster Care Agency (VCFA) per diem and Services
Mandatory enrollment for children in Waiver service or
residing in VCFA.
Children’s Behavioral Health Implementation Timeline (cont’d)
Carve In
July 1, 2019
October 1, 2019
January 1, 2020
HCBS Pending
CMS Approval
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Existing Waiver Services New Services
OMH HCBS OCFS B2H Waiver CFTSS
Skill Building Skill Building Psychosocial Rehabilitation (PSR)
Other Licensed Practitioner (OLP)
Crisis Response
Services
Immediate Crisis
Response Services
Community Psychiatric Supports and
Treatment (CPST) Crisis Intervention
OLP Crisis Component
Intensive In-Home
Services
Crisis Avoidance
Management and Training
Intensive In Home Services
CPST
Family Peer Support
Services (FPSS)
Family Peer Support Services
(FPSS)
Children and Family Treatment Services and Support (CFTSS)
Crosswalk
1/1/19
1/1/19
1/1/19
7/1/19
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New Mental Health Services Covered by Medicaid Managed Care
Early and Periodic Screening, Diagnostic, and Treatment Services for
Children (EPSDT)
• Children and Family Treatment and Supports:
Other Licensed Practitioner (OLP)
Community Psychiatric Supports and Treatment (CPST)
Psychosocial Rehabilitation (PSR)
Family Peer Support Services (FPSS)
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Four Core Service Components:
1.Psychotherapy
2.Crisis Intervention
3.Licensed Evaluation/Assessment
4.Treatment Planning
Key Features:
• Non-Physician Licensed Behavioral
Health Practitioners (NP-LBHP) provide services in the community or other
non-traditional settings such as the child/youth’s home or community
• The child/youth does NOT need to have a diagnosis and is intended to
enhance early identification and early health intervention
• OLP services can be provided in individual, family, or group settings
Other Licensed Practitioner (OLP)
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Community Psychiatric Support and Treatment (CPST)
Non Counseling Core Services:
1. Strengths Based Service Planning
2. Rehabilitative Supports
3. Rehabilitative Psychoeducation
CPST Has Six Core Service Components:
Counseling Core Services:
4. Intensive Interventions
5. Crisis Avoidance
6. Intermediate Term Crisis Management
Key Features:
• Goal Directed Supports and Solution Focused Interventions
• Provided in non-traditional settings
• Promotes recovery and resilience and is intended to support stabilization and
functional improvement
• Should improve social skills and interpersonal relationships
• Should emphasize the importance of family and caregivers in support and
treatment
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Psychosocial Rehabilitation (PSR)
PSR Has Four Core Service Components:
1. Social and Interpersonal Skills
2. Daily Living Skills
3. Community Integration
4. Personal and Community Competence
Key Features:
• Provided by a non-licensed practitioner
• Youth must have a diagnosis
• Aims to restore, rehabilitate, and re-establish the child/youth to the age
appropriate developmental functioning
• Meant to compensate for functional deficits, interpersonal and/or behavioral
health barriers
• Provided in community location or where child/youth lives
• “Hands on” task oriented services
• Allows child/youth to develop, practice and apply skills in natural situations
and settings
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Family Peer Support Services (FPSS)
Four Core Service Components:
1.Engagement, Bridging and Transition Support
2.Self-Advocacy, Self-efficacy and Empowerment
3.Parent Skill Development
4.Community Connections and Natural Support
Key Features:
• Provided face to face either individually or in a group
• Formal and informal activities and supports provided to families with a child who has been diagnosed with a behavioral health condition
• Offers a structured, strength-based relationships with a Family Peer Advocate (FPA)
• Goal is to offer supports to enable child to remain in the community
• Focuses on strengthening the family unit and natural supports, empowerment, skill building
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Mental Health Services Covered by Medicaid Managed Ca
Mental Health Services already covered by Medicaid Managed Care (MMC) for
adults 21 years of age and older will now be covered by MMC for eligible youth
under the age of 21, including SSI children. These services include:
• Assertive Community Treatment (ACT)
• Personalized Recovery Oriented Services (PROS)
• Inpatient Psychiatric Services
• Operation of Outpatient Programs
Continuing Day Treatment (CDT) Program
Partial Hospitalization
• Comprehensive Psychiatric Emergency Program (CPEP)
• Clinic Treatment Programs
Outpatient Clinic Services
Integrated Outpatient Clinic Services (IOP)
Licensed Behavioral Health Practitioner Services (LBHP)
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Substance Use Disorder (SUD) Services Covered by
Medicaid Managed Care
For eligible youth under the age of 21, including SSI children, the following
Substance Use Disorder (SUD) will now be covered by MMC including:
• Part 816 - Withdrawal and Stabilization Services
Hospital Based medically Managed Inpatient Detox
Medically supervised Inpatient Withdrawal and Stabilization
Medically Supervised Outpatient Withdrawal and Stabilization
• Part 818 - Chemical Dependence Inpatient Rehabilitation Services
• Part 820 - Residential Services Stabilization and Rehabilitation
• Part 822 - Outpatient Services
Chemical Dependence Outpatient (CD-OP) Clinic
Rehabilitation Services
Opioid Treatment Programs (OTP)
1 Delivered by hospitals only
Health Home
Care Management
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Health Home Definition:
A unified system of care to coordinate and integrate the physical and
behavioral health care, chemical dependence treatment and social
services provided to Members:
• Introduced by the Affordable Care Act (ACA) in Section 2703
• Individual states have the flexibility to determine eligible health home
care providers
What is a Health Home?
New York Health Home:
• Members must actively enroll
• If a Member opts out, it must be
documented
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UnitedHealthCare Community Plan contracts with Health Homes (HH) across NYS to provide care coordination and comprehensive care management to improve our Member’s health outcomes.
Health Homes: Overview
• January 2019 Children served
under 1915(c) waivers transition
to Health Homes Conflict-Free
Case Management Services
• Planned in collaboration with
child/youth, family members/
caregivers and systems involved
in the Member's life and care
• Define the goals for child/youth
• Develop a service plan
• Gather the necessary resources
• Provide appropriate support
• Evaluate progress
• Determine HCBS eligibility
• Follow HCBS workflow when
appropriate
Health Homes within Children’s
Implementation
Purpose
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.
Children must meet institutional and functional eligibility criteria for the
Level of Care (LOC) using either:
1. The Child and Adolescent Needs and Strengths New York (CANS-NY) tool
or
Behavioral Health Guidelines for Children
2. The Office for People with
Developmental Disabilities
(OPWDD) Level of
Care/Medical Care Screen
eligibility tool for children with
developmental disabilities who
may be medically frail or in
foster care
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• Medicaid beneficiary requires case
management services
and
• Two (2) or more chronic conditions
such as substance use disorder,
asthma, diabetes
or
• One (1) single qualifying condition:
HIV/AIDS
Serious Emotional Disturbance
(SED)
Complex Trauma
.
Health Home Enrollment
• UHC will send Member a letter
explaining eligibility and
assignment based on county of
residence
• Health Home enrollment is
encouraged but optional and
Member can opt out or disenroll at
will
• Encouraged for children who are
eligible for HCBS
• Health Home can connect
member with an appropriate Care
Manager to facilitate enrollment
Eligibility
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Children and Youth Evaluation Service (C-YES)
Children and Youth Evaluation Services (C-YES)
• Provides HCBS-Only Care Coordination
• Can complete:
Children’s HCBS eligibility determinations
HCBS Annual Assessments
HCBS Plans of Care outlining goals and services
• Assist with the Medicaid eligible application process
• Effective January 1, 2019, 1915(c) Waiver Care Managers became
Health Home Care Managers
• Members who do not want to participate in Health Home Care
Management can get care coordination from the Children and Youth
Evaluation Service (C-YES) without a disruption in service
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Members can be referred to Health
Home Care management by:
• You, the provider
• PCP or specialist
• Emergency room or inpatient discharge planner
• SPOA
• Other Service Providers
Health Home: Getting Connected
To make a referral for Health Home services:
• Reach out directly to the Health Home in the area where the member lives
• Each Health Home has a referral line or web portal for easy referral
For a list of the Health Home covering a member’s geographical area:
health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_map/index.htm
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Medicaid Helpline Toll-Free Line:
1-800-541-2831
New York State Department of Health’s
Health Home Line:
1-518-473-5569
Health Home Resource Center:
health.ny.gov/health_care/medicaid/program/medicaid_health_homes/lead_hhc.htm
.
Health Homes and Independent Entity Resources
Credentialing
32
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
Step 2: Submit Group or Facility Provider Application with Supporting
Documentation, such as:
• Signed Agreement
• Signed Disclosure of Ownership
Control Interest Statement
• W9 Form
Step 3: Application review and Approval by
Optum Credentialing Committee
UHC Community Plan NY General Information
33
Step 1: Must be a state designated provider
omh.ny.gov/omhweb/bho/provider-designation.html
matrix.ctacny.org/plan/7
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If your agency is already a participating provider,
you need to update your area of expertise
(AOE) as part of this implementation.
Email the Optum Network Mailbox with
questions via email:
or
Contact Your Network Manager
•
Participating Provider: Contract Amendments
A list of Network Managers for your region
is available at:
matrix.ctacny.org/
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• As established by NCQA, re-
credentialing occurs every 36-months
(3years)
• Providers should receive a re-
credentialing packet several months in
advance. (If you do not received it,
please proactively reach out to your
Network manager)
• Failure to complete re-credentialing
paperwork or participate in the re-
credentialing site audit (when
applicable) will impact the provider’s
status in the network
• All re-credentialing paperwork must be
completed
Participating Provider: Re-Credentialing
• Site audit may be required
• The re-credentialing process
takes time, so it is important to
complete and submit required
documentation as soon as
possible.
Member Eligibility
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Under 21 Membership Cards: Contact for Providers
For Providers: UHCprovider.com 866-362-3368
UnitedHealthcare Community Plan for Families
Administered by UnitedHealthcare of New York, Inc.
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Under Membership Cards: Contact for Members
For Members: 1-800-493-4647 TTY 711
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uhcprovider.com/eligibility
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Additional Resource: Member Eligibility
40
Medicaid Eligibility Verification (MEV) System:
• Telephone
• ePaces
• X12 270/271 Health Care Benefit Inquiry and
Response
• eMedNY Call Center 1-800-343-9000
Providers are required to check eligibility with UnitedHealthcare to ensure
services is eligible for payment:
uhcprovider.com
41
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Continuity of Care Requirements (Effective July 1, 2019)
• Continuity of Care (suspension of Utilization Management (UM) Activities)
for non-SSI children receiving OLP, CPST, and PSR ends on 6/30/19
Out of Network Providers should be communicating with UHC to
ensure authorizations are in place for services provided after
7/1/19
• Continuity of Care (suspension of UM activities) will be effective for 90
days for SSI children receiving OLP, CPST, and PSR effective 7/1/19
• Continuity of Care (suspension of UM activities) will be effective for 90
days for all children receiving FPSS services effective July 1, 2019
• For more information refer to:
New York State Children’s Health and Behavioral Health (BH) Services
– Children’s Medicaid System Transformation Guidance for
Transitional Period January 1, 2019 - January 1, 2020
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/nys_child_trans_bill_supp.pdf
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Other Licensed Practitioner (OLP) No No
Community Psychiatric Supports and Treatment (CPST) No No
Psychosocial Rehabilitation (PSR) No No
Family Peer Support Services (FPSS) No No
Prior & Concurrent Authorization for Network Providers:
Children and Family Treatment Support Services
For more information refer to:
omh.ny.gov/omhweb/bho/docs/prior-concurrent-auth-ambulatory-bh.pdf
Utilization management will apply for Out of Network Providers requesting CFTSS services.
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OMH Program Service Prior
Authorization
Concurrent
Authorization
Outpatient Clinic
• Initial Assessment • Psychosocial Assessment • Individual, Family/Collateral, or Group
Psychotherapy • Licensed Behavioral Health Practitioner
(LBHP)
No Yes
• Psychiatric Assessment or Medication Therapy
No No
• Psychological or Neuropsychological Testing
Yes N/A
Partial Hospitalization Yes Yes
Continuing Day Treatment (CDT) Yes Yes
Personalized Recovery Oriented Services (PROS)
• Pre-Admission Status No No
• Individualized Recovery Planning Yes No
• Active Rehabilitation Yes Yes
Assertive Community Treatment (ACT)
Yes Yes
July 2019 Update Prior Concurrent Authorization
Office of Mental Health Outpatient Programs
For more information refer to:
omh.ny.gov/omhweb/bho/docs/prior-concurrent-auth-ambulatory-bh.pdf
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Service Prior
Authorization
Concurrent
Authorization
Outpatient Rehabilitation Programs No No
Outpatient Addiction Services No No
Opioid Treatment Programs (OTP) No No
Residential Addiction Services No* Yes
Part 822 Clinic Services No No
Medically Supervised Outpatient Substance Withdrawal No No
July Update Prior Concurrent Authorization Network
Providers
Office of Alcoholism and Substance Abuse
For more information refer to:
omh.ny.gov/omhweb/bho/docs/prior-concurrent-auth-ambulatory-bh.pdf
*prior authorization is not required as long as notification by network provider meets NYS SUD Legislation 48H guidelines
Prior & concurrent authorization required for all Out of Network Providers.
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Services that require authorization and notification can be obtained by calling:
Toll-free line: 866-362-3368
Electronic Prior Authorization and Notifications and supporting documentation
including NYS SUD Notification Documents (Treatment plan/Appendix A and
LOCADTR) can be submitted for New York Medicaid (effective April 1, 2019):
uhcprovider.com/en/health-plans-by-state/new-york-health-plans/ny-
comm-plan-home/ny-cp-prior-auth.html
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Utilization Management Appeal
Request via Phone #: 800-493-4647
• Phone number can be used to check status of an appeal and verbally submit
an appeal. Note: Any appeal filed verbally must also be followed up with a
written, signed appeal
• Enrollees/Providers have 60 calendar days from the date of denial to request
an appeal
• Only one internal appeal allowed
• Clinical appeal turn around time is 72 hours
UM Appeals for ALL Behavioral Health Services:
UnitedHealthcare Community Plan
Attn: UM Appeals Coordinator
P.O. Box 31364
Salt Lake City, UT 84131
48
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FUH
Follow-up after
Hospitalization
AMM
Antidepressant
Medication
Management
Follow-up care for
Children prescribed
ADHD Medication
Quality Program HEDIS Measures
ncqa.org/hedis/
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• Contracted providers are required to cooperate with all aspects of the
investigation process, including providing requested charts, policies and other
documentation in a timely manner, and provide corrective action plans within
the required timeframe.
• Urgent complaints: resolved within 48 hours after receipt of all necessary
information and no more than 7 days from the receipt of report
• Non-Urgent complaints: resolved within 45 days after the receipt of all
necessary information and no more than 60 days from receipt of report
Complaints: Quality of Care (QOC) & Quality of Service (QOS)
Timeframes
• Member, a designee (with written consent), or plan representative
Who Can Report
Investigation
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Definition: Serious, unexpected occurrence involving a member that is believed to
represent a possible quality of care issue on the part of the
practitioner/facility providing services, which has, or may have,
deleterious effects on the Member, including death or serious disability,
that occurs during the course of a Member receiving behavioral health
treatment
List: A list of sentinel events/critical incidents that must be reported can be
found on providerexpress.com
Who Can Report: Provider
Timeframe(s): As soon as possible, no later than one (1) business day following the
event
Investigation: Contracted providers are required to cooperate with all aspects of our
investigation process, including providing requested charts, policies and
other documentation in a timely manner, as well as responding to
requests for corrective action plans within the required timeframe
How to report: Standardized reporting form located at providerexpress.com
Fax: 1-844-342-7704
Attn: Quality Department
Email: [email protected]
51
Sentinel Events/Critical Incidents
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Prompts
• At time of credentialing and re-
credentialing
• Part of ongoing monitoring efforts
• Part of a Quality of Care (QOC)
investigation or other complaint
Evaluated
• Physical Environment
• Policies and Procedures
• Member Records
• Personnel Files
Provider Performance Reviews
Audit tools and
documentation
guidelines are
located on
providerexpress.com
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Provider Performance Reviews Documentation
Documentation should include:
• Plan of Care with SMART Goals (reflective of progress/challenges)
• Start/Stop Time (length of time of service encounter)
• Medical Necessity
• Psychiatric and Medical History
• Presenting Problem
• Assessment and Risk Assessment (initial and ongoing)
• Medication Information
• Care Coordination with PCP (or other treating providers)
• Refusal of Care Coordination
• Substance Use Screening
• Legible (ideally EHR)
• Signed by Provider
• Discharge Plan
54
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
A claim with no defect or impropriety (including any lack of any required
substantiating documentation) or particular circumstance requiring special
treatment that prevents timely payments from being made on the claim is
considered a clean claim.
All required fields are: • Complete
• Legible
All claim submissions must include, but not limited to: • Member’s name, identification number and date of birth
• Provider’s Federal Tax I.D. number (TIN)
• National Provider Identifier (NPI)
• Taxonomy Code
• A complete diagnosis (ICD-10-CM)
Providers are responsible for billing in accordance with nationally recognized CMS
Correct Coding Initiative (CCI) standards. Additional information is available at cms.gov
55
Clean Claim
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On the correct claim form:
Agency
Facility (i.e. Hospital, Residential)
Basic information:
Member: Name, Medicaid ID, DOB
Provider: TIN, NPI, Taxonomy Code
ICD-10 codes
Correct code(s) corresponding to service provided:
Value, Rate Code, Revenue, CPT/HCPCS, Procedure Code, Modifiers, etc.
Date of Service
Revenue Codes
Clean Claim
BH1710_11/2018
All required fields
must be complete
and legible
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Submit batches of claims electronically, right out your practice management system software:
+ + + + +
• Ideal for high volume Providers
• Can be configured for multiple payers
• Clearinghouse may charge small fee
Optum can recommend a vendor that is right for you:
• Contact via phone 800-765-6705 or via email:
• Provide: Name, Tax ID, Claims Volume, Single or Multi-Payer Interest
Electronic Data Interchange (EDI)
© 2019 Optum, Inc. All Rights Reserved
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Benefits of Electronic Payments and Statements (EPS)
• Easy set-up, free to use
• Payments deposited into your bank
• Simplified claims reconciliation
• 24/7 access to your information
• Secure payment and remittance advice
Registering for EPS is easy!
• Login to Provider Express with your Optum ID
• Select “EPS” and provide the information necessary to enroll
• Contact Optum Financial Services for assistance: 1-877-620-6194
Receive Payment Faster
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Claims Submission
Electronic Claim Submission (837i): Payer ID 87726
Paper Claim Submission (UB-04): If you are unable to file electronically, follow
these tips to ensure smooth processing of your paper claim:
• Use an original UB-04 Claim Form (no photocopies)
• Type information to ensure legibility
• Complete all required fields (including ICD indicator and NPI number)
• Mail Paper Claims to:
+
Optum Behavioral Health
P.O. Box 30760
Salt Lake City, UT 84130-0760
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
• Billing Overview: An interactive UB-04 form that walks through the
components required to submit a clean claim
MCTAC Billing Tool
billing.ctacny.org/
• MCTAC PowerPoint presentation provides descriptions and
instructions for every field required for a successful claim submission
refer to:
North Country Managed Care and System Transformation Training
Electronic Claim Submission: MCTAC Resources
ctacny.org/sites/default/files/trainings-pdf/4.19.16-north-country.pdf
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MCTAC Billing Tool: Top section of UB-04 claim form
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MCTAC Billing Tool: Bottom section of UB-04 claim form
Unlicensed
practitioner ID
OMH-02249154
OASAS–02249145
OCFS -05448682
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Unlicensed Provider ID: Claim Submission
When submitting claims utilizing an unlicensed
practitioner ID as Attending, providers will submit
the NM1 Attending Provider Loop 2310A as follows:
NM108 and NM109 will be blank/not sent
REF Attending Provider Secondary Information will be added
REF01 G2
REF02 the OASAS, OMH, or OCFS (CFTSS and HCBS) Unlicensed
Practitioner ID (example: REF*G2*02249145~)
For Electronic/EDI Claims:
Unlicensed Providers
Unlicensed Practitioner ID as attending:
OASAS Unlicensed Practitioner ID: 02249145
OMH Unlicensed Practitioner ID: 02249154
OCFS Unlicensed Practitioner ID: 05448682
omh.ny.gov/omhweb/bho/claiming-guidance-for-clinics.pdf
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Unlicensed Provider NPI Claims Submission
MCTAC Billing Tool
billing.ctacny.org/
Field 76: Attending Provider
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Example: PROS Cross Walk
Claim 1: Community Rehabilitation Claim 2: Clinic Treatment
Description Field on UB-04
Description Field on UB-04
Rate Code 4521 (in header) 39 Rate Code 4525 (in header) 39
H2019 Px Code 44 T1015Px Code 44
U2 Modifier 44 HE Modifier 44
13-27 Units (at line level) 46 1 Unit (at line level) 46
Modifier Definitions Modifier Definitions
1.
2.
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Example: PROS Cross Walk - Claim 1: Community Rehabilitation
Value Code
Claim 1
• Value Code 24
• Rate Code 4521 in the header
(Field 39 on UB-04)
• HCPCS/CPT Code H2019 plus
U2 (Level of Care) Modifier
(Field 44)
• 13-27 Units at the line level
(Field 46)
HCPCS Units Rate Code
U2 Modifier
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Example: PROS Crosswalk - Claim 2: Clinic Treatment
Value Code
HCPCS
Rate Code
Service Units
Claim 2
• Value Code 24
• Rate Code 4525 in the header (Field 39 on UB-04)
• Px Code T1015 (Field 44)
• Modifier HE (Field 44)
• 1 Unit at the line level (Field 46)
HE Modifier
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Behavioral Health Revenue Codes
Program/Services Minimum Required
Assertive Community Treatment (ACT) 240, 900, 911
Opioid Treatment Programs (OTP) 513, 520, 900
Rehabilitative Program Services (SUD) 900, 911, 944, 945
Mental Health and Substance Use
Outpatient Clinic
General Services
Family Therapy
Group Therapy
Injections
Developmental, Neurobehavioral,
Neuropsychological and
Psychological Testing
513, 520, 900, 914
513, 520, 900, 914, 916
513, 520, 900, 914, 915
513, 520, 900, 914
513, 520, 900, 914, 918
Intensive Outpatient (SUD) 513, 520, 900, 906
Personalized Recovery Orientation Services
(PROS)
240, 900, 911
Continuing Day Treatment (CDT) 900,907, 911
Intensive psychiatric Rehabilitation Treatment 900, 911
Partial Hospitalization 912,913
Residential Treatment (SUD) 902
Home Community Based Services 900,911
ctacny.org/sites/default/files/trainings-pdf/revenu-codes-updated-12-21-15_1.pdf
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Service Rate
Code
CPT
Code Description Modifier Units Notes
Brief
Evaluation 4007 90791
Psychiatric Diagnosis
Evaluation HK,H5 1 Billed on a daily basis
Full Evaluation 4008 90791 Psychiatric Evaluation HK 1 Billed on a daily basis
Crisis
Outreach Visit 4009 S9485
Crisis Intervention,
Mental Health (Per Diem)
HK 1
Emergency Services provided outside
ER Setting. Code also pays in HCBS and APGs so use the HK Modifier to
differentiate the claim. Billed on a daily basis
Interim Crisis
Visit 4010 H0037
Community Psychiatric
Support and Treatment Program (Per Diem)
HK 1
Emergency Services provided outside
an emergency room setting to persons released from CPEP. Code also pays in
APGs. Billed Daily
Extended
Observation Bed (EOB)
4049 See Note
Use same coding rules as used with
rate code 2852 (inpatient psych per diem)
Comprehensive Psychiatric Emergency Program Billing
For more information about billing for CPEP services refer to:
omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf
omh.ny.gov/omhweb/bho/policy-guidance.html
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Service Rate
Code
CPT
Code Modifier Unit Measure
Unit Limit/
Day
Licensed Evaluation 7900 90791 EP 15 Minutes 10
Counseling
Individual 7901 H0004 EP 15 Minutes 4
Family w/ or w/o client 7901 H0004 HR Family with Client
HS Family without client 15 Minutes 4
Off Site Evaluation
(Individual or Family) 7920
90791
H0004
Evaluation EP, SC
Individual SC
Family w/client HR, SC
Family w/o client HS, SC
15 Minutes
Evaluation 10
Individual 4
Family 4
Group 7905 H0004 HQ, EP 15 Minutes 4
Offsite Group 7927 H0004 EP, HQ, SC 15 Minutes 4
Crisis
Offsite, In-person only 7902 H2011 EP, ET 15 Minutes 8
Triage (By Phone) 7903 H2011 EP, GT 15 minutes 2
Complex Care (Follow Up) 7904 90882 EP, TS 5 minutes 4
OLP Rate Code Descriptions
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Psychosocial Rehabilitation (PSR) Rate
Code CPT Code Modifier
Unit
Measures
Unit Limit/
Day
Professional (Individual) 7913 H2017 EP 15 Minutes 8
Professional (Group) 7914 H2017 EP, HQ 15 Minutes 4
Offsite (Individual) 7922 H2017 EP, SC 15 Minutes 8
Offsite (Group) 7929 H2017 EP, HQ, SC 15 Minutes 4
Family and Peer Support Services (FPSS) Rate
Code CPT Code Modifier
Unit
Measures
Unit Limit/
Day
Professional (Individual) 7915 H0038 EP 15 Minutes 8
Professional (Group) 7916 H0038 EP, HQ 15 Minutes 6
Offsite (Individual) 7923 H0038 EP, SC 15 Minutes 8
Offsite (Group) 7930 H0038 EP, HQ, SC 15 Minutes 6
Psychosocial Rehabilitation (PSR) and
Family Peer Support Services (FPSS)
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Service Rate
Code
CPT
Code Modifier
Unit
Measures
Unit Limit/
Day
Professional Individual and/or Family
(with or without the client) 7911 H0036 EP 15 Minutes 6
Professional (Group) 7912 H0036 EP, HQ 15 Minutes 4
Offsite Individual and /or Family
(with or without the client) 7921 H0036 EP, SC 15 Minutes 6
Offsite (Group) 7928 H0036 EP, HQ, SC 15 Minutes 4
Community Psychiatric Support and Treatment (CPST)
For more information about billing for all CFTSS programs refer to:
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/
docs/nys_child_trans_bill_supp.pdf
© 2019 Optum, Inc. All Rights Reserved
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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
Allowable Billing Combinations: Children’s Behavioral Health
Other Licensed
Practitioner
(OLP)
Community
Psychiatric Treatment
& Supports (CPST)
Psychosocial
Rehabilitation
(PSR)
Family & Peer
Support Services
(FPSS)
OMH Clinic Yes Yes Yes Yes
OASAS Clinic No Yes Yes Yes
Opioid Treatment Program No Yes Yes Yes
Assertive Community Treatment Yes No No Yes
Personalized Recovery Oriented Service No No No Yes
Continuing Day Treatment No No No Yes
OMH Partial Hospitalization Yes Yes Yes Yes
OASAS Outpatient Rehabilitation No Yes Yes Yes
Community Psychiatric Treatment &
Supports (CPST)
Yes - Yes Yes
Other Licensed Practitioner (OLP) - Yes Yes Yes
Psychosocial Rehabilitation (PSR) Yes Yes - Yes
Family & Peer Support Services (FPSS) Yes Yes Yes -
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Example: Off Site Billing
When submitting claims for Off-Site Services you will need to submit TWO
claims:
• One claim for the service provided, including the number of units
provided
• One claim with the offsite service code (1 Unit)
Other offsite
CFTSS services
are billed similarly
Claim 1 Claim 2
Counseling Session Off-site Visit
Rate Code 7905 Rate Code 7927
Px / CPT Code H0004 Px / CPt Code H0004
Modifiers HQ, EP Modifiers EP, HQ, SC
Units 4 Units 1
For Example:
If an OLP Counseling session lasts 60 minutes and occurs offsite:
© 2019 Optum, Inc. All Rights Reserved
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Licensed Behavioral Health Practitioners (LBHP)
• LBHP Services are priced based on the APG methodology
• Must be billed through a clinic. Clinic Rate Codes include:
Article 31 Clinics Rate Code 1507
Article 28 Hospital Based Rate Code 1519
• When on-site clinic services and a LBHP service are provided on the same
day, separate claims are required
• Possible Modifiers include: AF, AG, SA, U5
• The “After Hours” enhancement is billed using the CPT Code
• Developmental Testing is not covered under the LBHP benefit
© 2019 Optum, Inc. All Rights Reserved
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OASAS claims are reimbursed based on APG methodology:
• UB-04 claim form; 837i
• Value Code “24”
• Rate Code
• Revenue Codes
• CPT/HCPCS Codes
• Procedure Modifiers
• Date of Service
• Service Units
• OASAS Credentialed Alcoholism and Substance Abuse Counselor (CASAC) ID Number
OASAS Billing Requirements
OASAS: Important Modifier Reminders
• The HF modifier is requested for all OASAS
claim types
• The modifier does not impact pricing but will
support data collection
• OTP programs will continue to use the KP
modifier for the first medication administration
visit of the service week
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Part 820 Treatment Per Diem
• Residential Programs must bill with appropriate Rate Codes, HCPCS and
Modifier Code combination
• OASAS Residential Programs are also asked to use the HF Modifier The
modifier does not impact pricing but will support data collections.
• Room and board are reimbursed by the county
Program Rate Code CPT/HCPCS Code Modifiers
Stabilization 1144 (Treatment Services) H2036 TG , HF
E/M Codes for Ancillary Withdrawal Services HF
Rehabilitation 1144 (Treatment Services H2036 HF
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Community/Freestanding (Article 32 Only)
Rate Code
Hospital Based OASAS Certified Program Article 28/32
Rate Code
Outpatient Clinic program 1540 Outpatient Clinic Program 1528
Outpatient Rehabilitation Program 1573 Outpatient Rehabilitation Program 1561
Opiate Treatment Program 1564 Opiate Treatment Program 1567
Medical Services Medical Services
Outpatient Program 1468 Outpatient Program 1552
Outpatient Rehabilitation 1570 Outpatient Rehabilitation Program 1558
Opiate Treatment Program 1471 Opiate Treatment Program 1555
OASAS: Outpatient and Free Standing Facilities Rate Codes
Rate Codes are assigned based upon Certification/Program Type and Setting
(Hospital vs. Freestanding)
oasas.ny.gov/admin/hcf/ffschart.cfm
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Example: OASAS Claim
• Value Code 24
• Rate Code 1540 in the header
(Field 39 on UB-04)
• HCPCS/CPT Code H0001 plus
HF (OASAS Modifier) (Field 44)
• 10/01/2015 Date of Service
(Field 45)
• Rev Code 0914
• 1 Units at the line level (Field 46)
• Charges 1$50.00 (Field 47)
Units
Rate Code
HF
Modifier
HCPCS
Value Code
Service
Date Charges
Rev Code
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• Always verify member eligibility prior to rendering services
• Obtain prior authorization for those services that require it
• Use Value Code 24 and applicable Rate Code in the correct field
• One Rate Code per claim
• Include CPT Code (s), Modifier (s) and Service Units as applicable
• Do not use a hyphen in your Tax Identification Number (TIN)
• NPI numbers are required
• A complete Diagnostic Code is required (ICD-10)
• Review Provider Remittance Advice regularly to identify issues early
For more information about PRA’s go to:
Quick Reminders
uhcprovider.com/en/resource-library/edi/edi-835.html
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• Process by which member, or provider on behalf of member, requests a
review of adverse determination(s) on the health care services or any
amounts that the member must pay toward a covered service
• Appeal of claim payment (amount, partial) or denial: within 60-days of receipt of Provider Remittance Advice (PRA)
• Appeals should be submitted to:
Billing Appeals
United Healthcare Community Plan Appeals
P.O. Box 31364
Salt Lake City, Utah 84131-0364
© 2019 Optum, Inc. All Rights Reserved
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The Managed Care Technical Assistance Center (MCTAC) is a
training, consultation, and educational resource for all mental health
and substance use disorder providers in New York State.
What’s available:
Managed Care Technical Assistance Center (MCTAC
ctany.org
MCTAC Home Page
• Interactive Glossary of Terms
• Managed Care Language Guide
• Frequently Asked Questions
• MCO Plan Comparison Matrix
• Sample Instructional Claim Form
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OASAS Billing Guidance
oasas.ny.gov/admin/hcf/APG/documents/APGManual.pdf
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Claim Guidance: OMH and OASAS Outpatient Programs
Continuing Day Treatment Billing Regulations
govt.westlaw.com/nycrr/Document/I5037a9c7cd1711dda432a117e6e0f345?vie
wType=FullText&originationContext=documenttoc&transitionType=CategoryPa
geItem&contextData=(sc.Default)
Claiming Guidance for OMH and OASAS Clinics, OPT, PROS and
ACT
omh.ny.gov/omhweb/bho/claiming-guidance-for-clinics.pdf
+ +
85
86
UHC On-Line Resources
• providerexpress.com Demographic Updates Guidelines and Policies Best Practice Guidelines Network Manual Trainings & Resources Sentinel Events Reporting
Form
• uhcprovider.com Check member eligibility Check claim status and
payments Claims Reconsideration Electronic Data Interchange
(EDI) information Tools and Resources
• uhccommunityplan.com A website for Health Care
Professionals, Community Organizations and Members
For providers the links will direct you to important information in your state
Directs you to our secure provider site UnitedHealthcare Online®
• liveandworkwell.com Search for Providers in the Network Confidential Work/Life Resource
Center Offers Interactive Assessments Medication Database Self – Help Resources
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Provider Express: Public Pages
providerexpress.com
Clinical Resources
Training Other Information
Available:
• Clinical Guidelines
• Provider Manuals
• Required Forms
• Webinars
• Archived Trainings
© 2019 Optum, Inc. All Rights Reserved
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Provider Express: New York Page
providerexpress.com/content/ope-provexpr/us/en/our-network/welcomeNtwk/wNY.html
NY State Medicaid
Supplemental Provider
Manual
© 2019 Optum, Inc. All Rights Reserved
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Provider Express: Log Into Private Pages
To Set a UserID, select “First Time User” link
© 2019 Optum, Inc. All Rights Reserved
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Provider Express: Technical Assistance Support Center
Technical Support 866-209-9320 (toll-free)
Provider Express Support
© 2019 Optum, Inc. All Rights Reserved
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Liveandworkwell: Provider Directory
Select “Provider”
© 2019 Optum, Inc. All Rights Reserved
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Liveandworkwell: Provider Directory
Choose to search the
directory for Providers
for Adult Services
or Provider for Under
21
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Liveandworkwell: Provider Directory
Insert Search Key
Terms such as:
Name
Expertise
Condition
Phone
Number
Program
Location
© 2019 Optum, Inc. All Rights Reserved
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Liveandworkwell: Provider Directory
Enter Provider Name or Search
Term
Update Search Location
Search Filters
Search Filter Search Filter
© 2019 Optum, Inc. All Rights Reserved
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Liveandworkwell: Provider Directory
© 2019 Optum, Inc. All Rights Reserved
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UHC On Air on uhcprovider.com
© 2019 Optum, Inc. All Rights Reserved
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UHC On Air access
© 2019 Optum, Inc. All Rights Reserved
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UHC On Air on uhcprovider.com
NY Children's Medicaid 2019 Trainings
New York Children's Health Home Understanding the Program Requirements
Seven Challenges Program
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Multi-Dimensional Treatment Foster Care (MTFC)
Multi-Systemic Therapy (MST)
Functional Family Therapy (FFT)
Assertive Continuing Care & Adolescent Community Reinforcement Approach
Multi-Dimensional Family Therapy (MDFT)
Trauma-Informed Child-Parent Psychotherapy (CPP)
Dialectical Behavior Therapy (DBT)
99
External Behavioral Health Resources
© 2019 Optum, Inc. All Rights Reserved
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OASAS Free Learning and Development Opportunities
oasas.ny.gov/workforce/training/freeldo.cfm
State Approved Training Resources
OMH and OASAS Supported On-Line Trainings are available through the
Center for Practice Innovation (Children’s Trainings are coming live soon)
practiceinnovations.org
© 2019 Optum, Inc. All Rights Reserved
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Children’s Medicaid System Transformation Information
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/web-
info_child_mst.htm
• Transformation Webinars
• Children’s Medicaid and Behavioral Health System
Transformation Updates
• Children’s Health Home Webinars
• Training and Technical Assistance
• Children’s Transition Timeline and Family Treatment and
Support Services Rates
Additional information regarding the service transformation is available
on the New York State Department of Health Website. Examples
include:
© 2019 Optum, Inc. All Rights Reserved
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Additional Guides and Resources Department of Health
Children’s Behavioral Health Transition to Managed Care
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/index.htm
Children and Family Treatment and Support Services (CFTSS)
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.htm
Health Home Program Updated Billing Guidance
health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/update_bill_gui
dance.pdf
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Children’s CFTSS Provider Designation Information
Additional Guides and Resources Office of Mental Health
Children and Family Treatment and Support Services (CFTSS)
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.htm
health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/2018-04-
19_provider_designation_and_authorization.pdf
Approved Rates and Rate Codes
omh.ny.gov/omhweb/medicaid_reimbursement/
New York State Health and Recovery Plan (HARP) / Mainstream Behavioral
Health Billing and Coding Manual Billing and Coding Manual:
omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf
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OASAS Ambulatory Patient Groups (APG) Policy and Medicaid Billing Guidance
document. oasas.ny.gov/admin/hcf/APG/documents/APGManual.pdf
Office of Alcoholism and Substance Abuse Resources
Integrated Outpatient Services – Implementation oasas.ny.gov/LEGAL/CERTAPP/DOCUMENTS/IOSGUID.PDF
Medicaid APG Per Service Rate Chart OASAS oasas.ny.gov/mancare/APGService.cfm
OASAS Managed Care Webage oasas.ny.gov/mancare/index.cfm
Contact information
Thank you
105
Gayle Parker Wright, LCSW-R NY
Network Trainer
UnitedHealthcare Community Plan
Office: 1-612-642-7307
Questions?