Beacon Health Strategies will be responsible to perform the following functions. Beacon Responsibility. Member Services.

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1 General Why am I receiving this communication? You are receiving this communication because you serve or could serve Seton Health Plan CHIP and STAR members. Beacon Health Strategies has partnered with Seton Health Plan to administer the behavioral health benefits, as well as to develop and maintain the network of behavioral health providers. This change will become effective on March 1, Beacon Health Strategies will be responsible to perform the following functions. Function Credentialing and Contracting Beacon Responsibility (Beacon contracted providers only) Member Services Utilization Management Case Management Claims Adjudication / Payment What is the contact information for Beacon? Via the web: or For Seton Health Plan members: For provider referrals, authorization or clinical matters: For provider relations: For claims: For provider contracting: o Ed Vargas, Network Manager: March 6,

2 When will Beacon Health Strategies begin managing the behavioral health benefits on behalf of Seton Health Plan CHIP and STAR members? Beacon Health Strategies will begin to manage the behavioral health benefits for Seton Health Plan CHIP and STAR members on March 1, CLINICAL: What benefits will Beacon manage? The following list includes, but is not limited to, the benefits that Beacon will manage for Seton Health Plan CHP and STAR members beginning March 1, 2012: Traditional Outpatient Service Notification Protocol Benefit / Service Medicaid FFS Cap Limit Notification Requirement eservices notification Medication Management Individual / Family Therapy 30/CY PA required for additional visits beyond 30 Group Therapy 30/CY PA required for additional visits beyond 30 Prior authorization (PA) required Psychological Testing 8 hrs./cy PA required ECT PA required Telemedicine 30/CY PA required for additional visits beyond 30 Outpatient Diversionary Services Service Notification Protocol Benefit / Service Medicaid FFS Cap Limit Notification Requirement Prior Authorization required PHP Mental Health - Adult PA required PHP Mental Health - Child & Adol March 6,

3 PHP Substance Abuse - Adult PHP Substance Abuse - Child & Adol IOP Mental Health - Adult IOP Mental Health - Child & Adol IOP Substance Abuse - Adult IOP Substance Abuse - Child & Adol Inpatient Services Service Notification Protocol Benefit / Service Medicaid FFS Cap Limit Notification Requirement PA required IP Mental Health - Adult Telephonic PA required IP Mental Health - Child & Adolescent IP Mental Health - Geriatric IP Mental Health - Eating Disorder IP Substance Abuse- Adult Detox IP Substance Abuse - Child & Adolescent Detox IP Substance Abuse- Residential CSU 48 hrs. PA required after 48 hrs March 6,

4 AUTHORIZATION: What number should I call for authorizations for Seton Health Plan CHIP and STAR members? Beginning March 1, 2012, the phone number to call to obtain authorizations for behavioral health, community and diversionary services is What services need authorization? Some services may require prior authorization while other services will require no authorization up to the service cap limitations. Please refer to the Clinical section above for specific requirements or call How will I get authorizations? Inpatient authorizations: For dates of service beginning March 1, 2012, providers should work directly with Beacon Health Strategies to obtain any necessary authorizations for Seton Health Plan CHIP and STAR members. If a Seton Health Plan CHIP or STAR member is admitted through the hospital s Emergency Room, emergency service providers shall make a reasonable attempt to notify Beacon within twenty-four (24) hours of the member s presenting for emergency behavioral health services. *Please note: If a member was admitted prior to March 1, 2012, please contact Seton Health Plan or Tejas Behavioral Health. Tejas Behavioral Health will continue to be responsible for authorizations and claims payment for those CHIP members until they are discharged. However, please contact Beacon for assistance with discharge planning at Outpatient authorizations: Beginning March 1, 2012, members are eligible to receive up to 30 Initial Encounters without prior authorization. However, it is recommended that by the 25 th visit, prior authorization be obtained for visits beyond 30. To obtain authorization beyond 30 visits, providers may log on to Beacon Health Strategies eservices at or call March 6,

5 Once a request through eservices has been made, providers will receive an notification regarding the decision. Providers can access and print all information related to the authorization request at What if I have a member who is inpatient on the effective date of the new relationship? If you are treating a Seton Health Plan CHIP member on an inpatient basis at start-up, contact Beacon Health Strategies for a medical necessity review and discharge planning at What level-of-care criteria will Beacon Health Strategies use with Seton Health Plan CHIP and STAR members? For contracted providers, Beacon Health Strategies will use our proprietary Medical Necessity Criteria. Providers can view and download a copy of the level of care criteria at or by calling Beacon at Note: It is recommended that providers review and become familiar with Beacon Health Strategies level-of-care criteria prior to providing services to Seton Health Plan CHIP and STAR members. CLAIMS Where should I send my claims for behavioral health services beginning on March 1, 2012? Providers should submit claims for all Seton Health Plan CHIP and STAR members to Beacon Health Strategies either through electronic data interchange (EDI) connection to Beacon or via Beacon s eservices web application. EDI claims can be submitted directly by a provider, or through a billing intermediary. EDI: Providers or their billing intermediaries should edi.operations@beaconhs.com for detailed information and to begin testing. 835/837 and 270/271 transactions are available. eservices: Please visit for information on the quick and easy registration process. Through the TMHP portal at: March 6,

6 Beacon Health Strategies prefers to receive claims electronically. However, if you prefer to submit a paper claim, please send to: Beacon Health Strategies Seton Health Plan Claims Department 500 Unicorn Park Drive, Suite 401 Woburn, MA For more information on claims submission, please go to What is Beacon s timely filing rule? Beacon Health Strategies timely filing rule is consistent with that of the Texas Medicaid Program. The timely filing deadline for claims to be submitted to Beacon Health Strategies is 95 days from the date of service. What are Beacon s claims turnaround times? If a clean claim is submitted in a non-electronic format, the claim will be adjudicated no later than the 45th day after the date it is received. If a clean claim is submitted in an electronic format, Beacon Health Strategies will adjudicate the claim by the 30th day after the date it is received. Will Beacon pay claims that are submitted by a non-behavioral health provider? No. Beacon will only pay claims for covered services provided by a behavioral health provider as defined by HHSC. Will there be a new Billing Guide for Seton Health Plan members? Beacon will develop and post on the Beacon website a Provider Manual for providers who provide services to Seton Health Plan CHIP and STAR members before the start-up of behavioral health services. Contained within the manual will be a Claims/Billing section detailing our policies and procedures. What is Beacon s reimbursement model? Beacon uses various reimbursement methodologies. Beacon-contracted providers that provide services to Seton Health Plan CHIP and STAR members will be paid according to their Beacon contracted rate. March 6,

7 How does Beacon Health Strategies partnership with Seton Health Plan for the CHIP and STAR programs change my business? Beacon Health Strategies partnership with Seton Health Plan will require behavioral health providers to work directly with Beacon Health Strategies for Seton Health Plan CHIP and STAR members. CONTRACTING: Do I need to contract with Beacon? Providers do not have to be contracted with Beacon. However, without a contract in place, you will see a reduction in payment of 5%, as required in Chapter 353, Subchapter A, of the Texas Administrative Code. You will also be asked to sign a single case agreement that will provide you with useful and necessary information concerning the treatment of the member. The single case agreement will also provide you with the information Beacon will need to process your claim. In order to contract directly with Beacon, contact Ed Vargas, Beacon Health Strategies Network Manager, at or by at edward.vargas@beaconhs.com. Whom can I call at Beacon to talk about contracting and/or the materials I have received? Call Ed Vargas, Network Manager at MEMBER ELIGIBILITY: Will Seton Health Plan members retain their current ID numbers? Yes. Members will retain their Seton Health Plan ID number, which providers can use to identify members within the Beacon Health Strategies system. Where should I check member eligibility? March 6,

8 Beginning on March 1, 2012, providers can check eligibility for all Seton Health Plan members through Beacon Health Strategies eservices at or by calling Beacon s automated eligibility line (IVR) at (888) or via the 270/271 EDI transaction. To set up an EDI connection with Beacon, go to and review the 270/271 companion guide or edi.operations@beaconhs.com for more information on 270/271 EDI eligibility transactions. OTHER: Why is Beacon taking over the benefit management? Who is currently managing the benefit? Beacon Health Strategies was chosen by Seton Health Plans to arrange for the delivery of behavioral health services to their CHIP and STAR members beginning on March 1, Tejas Behavioral Health Services previously managed the behavioral health services. What should I expect from Beacon Health Strategies post transition? First and foremost, Beacon Health Strategies is focused on the continuity of the member s care during this transition. Beacon Health Strategies staff will work closely with you, Seton Health Plan and Tejas Behavioral Health Services, to ensure that members receive continuity of care for all levels of treatment. Seton Health Plan and Beacon Health Strategies will communicate frequently with members and providers to ensure transparency. Post transition, providers and members should expect their relationship with Beacon Health Strategies to be a highly collaborative partnership giving provider the tools necessary to manage the care of the member. Beacon Health Strategies will place an emphasis to focus on member outcomes, and case management. Beacon Health Strategies encounter data, claims and other clinical and administrative processes are designed to offer superior mental health and clinical management information to network providers. This information will give providers the required tools to provide a high level of effective and efficient services to Seton Health Plan CHIP and STAR members. March 6,