State of Maryland MHA & VALUEOPTIONS Maryland

Transcription

1 State of Maryland MHA & VALUEOPTIONS Maryland Case Management Update April 2010

2 Presenters Nancy Calvert, Director, Provider Relations Donna Shipp, Provider Training Manager

3 Agenda Overview Requesting Authorizations Staying Connected Provider Connect Demonstration Questions?

4 Case Management Effective 9/1/09 Case Management transitioned from grant-funded to fee for service.

5 Case Management Assessments Case Management Assessments do not require authorization Initial Assessments: Fiscal Year 2010 Providers will be reimbursed for only one assessment Fiscal Year 2010 and forward Providers will be reimbursed for no more than two assessments per year. (Exception: If a consumer changes Case Management providers, a new assessment may be authorized within the existing six month period. Contact Clinical Management ( ) for authorization.) Reminder: Assessments are required every six months

6 Case Management Facts Case Management Codes: H0031 = Assessment - $105/assessment T1016 = Daily CM visit - $105/visit T1016-HW = Transitional CM visit - $158.16/visit Duration: Assessment not time defined Daily Session 60 minutes Authorization Span: Medicaid Eligible Consumers 6 months Uninsured Eligible Consumers 3 months Levels of Service: Medicaid General Maximum of 2 visits/month Intensive Maximum of 5 visits/month Uninsured General Only maximum of 2 visits/month

7 Service Provision Case Management services are not reimbursable in a nursing home or detention center. MHA has approved reimbursement for a service provided to a consumer with an pending discharge from a psychiatric unit. MHA does not specify the required number of cases on a Case Manager s case load The required length of a reimbursable 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.

8 Transitional Case Management Service Provided to consumers: Currently hospitalized and being referred to Case Management Have high inpatient recidivism, and are not connected with the service necessary for maintaining community tenure Services: Will not be duplicative of the discharge services the discharging hospital is required to provide Used to develop relationships between the consumer and the Case Manager to establish linkages to community services and treatment Require pre-authorization Preauthorization: call ValueOptions Maryland, Billing and Reimbursement: - Only one unit of service may be billed - Submit claim when the consumer has been discharged from the inpatient facility.

9 Requests for Case Management Services Consumers may self-refer by contacting the CSA, The Case Management Provider or ValueOptions Maryland. Shelter+Care Consumers: Medicaid Eligible must meet the diagnostic and Medical Necessity criteria Uninsured Presumed eligible for Case Management Do not need to meet the diagnostic or Uninsured Eligibility Criteria Do not need to follow the CSA/MHA approval process Shelter+Care must be documented in the request for uninsured eligibility request. Case Management Services for TAY consumers who do not meet the Medical Necessity Criteria will be considered on a case-by-case basis

10 Authorization Requests Authorizations will be issued from the date of the request for authorization, not from the first day of the month of request. Authorizations may not be back dated A diagnosis is not required for the initial authorization request. Diagnosis deferred (ICD-9 Code 799.9) may be used for the initial authorization request. A PMHS Specialty diagnosis is required on the claim for services. All 5 Axes are required on subsequent requests. Courtesy reviews are accepted for Case Management,if there is a reasonable expectation that the consumer may become eligible for Medicaid. The provider is expected to assist the consumer with the Medicaid Application.

11 Authorization Requests Requesting an initial or concurrent review for a consumer who: *has an open Uninsured Eligibility span, *is a Primary Adult Care (PAC) *a dually eligible QMB, SLMB/ Medicaid *is a Medicare/Uninsured Eligible consumer

12 Step 1: Request CSA Approval The Provider must use the Maryland: Provider Request to CSA for Urgent Care for Uninsured form to request Case Management services. Request for Case Management Services must be documented on the form. The provider may call, or fax, the request, using the designated form, to the CSA of the consumer s county of residence.

13 Step 2: CSA Determination The CSA will determine Uninsured Eligibility and establish urgency for case management, such as discharge from a state hospital or diversion from inpatient psychiatric care. If the CSA denies the request, the CSA notifies the provider. If the CSA approves the request, the CSA will obtain funding approval from MHA telephonically, or via fax, using the Form for Review of Uninsured for Case Management (Phone: , Fax: ).

14 Step 3: MHA Determination of Funding Availability If MHA denies: The CSA will be notified, telephonically, or via fax using the Form for Review of Uninsured for Case Management. The CSA notifies the provider. If MHA approves: The CSA will be notified, telephonically, or via fax using the Form for Review of Uninsured for Case Management. The CSA forwards the decision to ValueOptions Maryland, using the Request for Reimbursement for Non- Medicaid Outpatient Services form. Case Management Services approved must be documented on the form.

15 Step 4: ValueOptions Maryland ValueOptions Maryland will flag the consumer in Provider Connect, indicating that the consumer has been approved for Case Management Services ValueOptions Maryland will notify the provider that Uninsured Eligibility for Case Management has been approved.* The notice will be sent in a secure to the provider s address that was entered on the Request for Reimbursement for Non-Medicaid Outpatient Services form Please include the address on the form to ensure notification *This consumer has met the eligibility requirements for Case Management. You may now request an authorization for Case Management services via ProviderConnect Consumer ID: DOB: Effective Date:

16 Step 5: Provider Requests Authorization When notified of approval of Uninsured Eligibility for Case Management, the Provider submits a request for Case Management Services to ValueOptions Maryland in ProviderConnect. A ValueOptions Maryland Clinical Care Manager (CCM) reviews the request for medical necessity: If the consumer meets the medical necessity criteria, the CCM approves the authorization. If medical necessity criteria are not met, the case is forwarded for Physician Advisor review. Note: authorization may only be issued for the general level. I.e. A maximum of 6 units (2 per month) for a 3 months span.

17 Authorization Requests Process for uninsured consumers without an open Uninsured Eligibility span or Medicaid benefits: This is the process that must be followed for a consumer who does not have PAC, Medicaid or a current, open Uninsured Eligibility span

18 Step 1: Request an Uninsured Eligibility Span Consumers must meet the Uninsured Eligibility criteria. If the consumer does not have PAC, Medicaid or a current, open Uninsured eligibility span, the provider must first request an Uninsured Eligibility span online via ProviderConnect, prior to requesting CM services from the CSA and MHA.

19 Step 2: Uninsured Eligibility Determination If the consumer meets the uninsured eligibility criteria, an uninsured eligibility span will be opened in ProviderConnect. The provider may then initiate the request for Case Management services as described in the previous slides.

20 Step 2, cont d Uninsured Eligibility Determination If the consumer does not meet the uninsured eligibility criteria when requested on-line via ProviderConnect, the provider should indicate failure to meet uninsured criteria on the Maryland: Provider Request to CSA for Urgent Care for Uninsured form prior to submitting the form to the CSA Request for Case Management Services must also be documented on the form. The provider may call, or fax the request using the designated form, to the CSA of the consumer s county of residence.

21 Step 3: CSA Determination The CSA will determine Uninsured Eligibility and establish urgency for case management, such as discharge from a state hospital or diversion from inpatient psychiatric care.

22 This CSA/MHA approval process must be repeated every 3 months for non-medicaid consumers.

23 Staying Connected Automatic notification of all postings: Case Management Postings: WARNING! Please do not send Protected Health Information (PHI) via unencrypted . Submit inquires via ProviderConnect Fax to

24 ProviderConnect Demonstration

25 25 Questions

26 26 Thank You!