Provider Update. December 2017 Health Share Pathways Provider Update. Regional Provider Manual Updates. December 2017

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1 Provider Update December 2017 In this Edi on Provider Manual Updates Fee Schedule Updates Important Things to Know Organiza onal Provider Roster Requirement Checking Member Eligibility No PA required for Vivitrol December 2017 Health Share Pathways Provider Update Health Share Pathways Providers are contracted directly with Health Share to provide specialty mental health and substance use disorder (SUD) treatment services. This quarterly Pathways Provider Update is the place where contracted providers will be provided official no fica on of upcoming updates to the Pathways program, including updates to the Pathways Provider Manual, and learn about other important informa on and resources that will support providers when delivering services to Health Share members. Regional Provider Manual Updates The Pathways Provider Manual includes cri cal contacts, claims management informa on, compliance and quality assurance guidance, and the most current rate and fee schedules. Providers are contractually obligated to comply with all policies and procedures set forth in the Provider Manual. Providers can find the Pathways Provider Manual on the Health Share website. The following updates will be made to the Provider Manual, effec ve January 1, 2018: Changes within Specific Sec ons of the Pathways Provider Manual Updates to En re Document and All Appendices Replaced all instances of Risk Accep ng En ty (RAE) with Behavioral Health Plan Partner (BH Plan). Replaced all instances of Provider Managed Self Authoriza on with Provider Submi ed Authoriza on. Appendix Updates Updated Appendix A: 2017 Regional Prac ce Guidelines to reflect the New Year. New Guidelines added and exis ng Guidelines updated. Updated format of Appendix C: Day Treatment Clinic Services (Mental Health) Guidelines for document consistency and changed the name to Appendix C: Mental Health Day Treatment Clinic Services Guidelines. Updated format of Appendix F1: SUD Day Treatment Authoriza on Form, Appendix F3: SUD Residen al Treatment Programs Authoriza on Form, and Appendix F4: SUD Residen al Dual Diagnosis Authoriza- on Form for document consistency and changed the Multnomah County contact name. Pathways Provider Update December of 5

2 Changes within Specific Sec ons of the Pathways Provider Manual (con nued) Appendix Updates (con nued) Replaced Appendix F2: SUD Medically Monitored Residen al Withdrawal Management Authoriza on/ Reauthoriza on Requests with NEW Appendix F2: SUD 3.7 Medically Monitored Residen al Treatment Authoriza on/reauthoriza on Request Form Made minor changes to the format of the following appendices to maintain document consistency: Appendix B: Inpa ent Mental Health/Acute Care Guidelines Appendix D: Psychiatric Residen al Treatment Services Guidelines Updated Appendix E: Excep onal Needs Authoriza ons by Member s County of Residence Appendix I: Frequently Asked Ques ons about Codes Appendix J2: CIM Message Func ons Appendix O: PH Tech Paper Claim Submission Guidelines Removed the following outdated Appendices: Appendix K: Global Case Rate Changes Appendix L: Case Rate Repor ng Technical Manual Added the following NEW Appendices: Appendix E1: Clackamas County Authoriza on Renewal Request Form Appendix K: Behavioral Health Timely Filing Waiver Request Form Appendix L: Organiza onal Roster Informa on Template Appendix P1: LOC Adult Ini al Treatment Registra on Form Appendix P2: LOC Adult Con nued Stay Treatment Registra on Form Appendix P3: LOC Child & Family Ini al Treatment Registra on Form Appendix P4: LOC Child & Family Con nued Stay Treatment Registra on Form Plan Contact List Updates Updated the contact for Multnomah County SUD Authoriza ons. Removed contacts for the Changing your Provider Profile sec on. All provider data changes should send directly to Ph Tech and to Health Share. Updated the contacts for Multnomah County U liza on Review. Updated the address for the Health Share Creden aling Specialist. Services Requiring Pre Authoriza on / Substance Use Disorder (SUD) SUD Clinically-Managed Withdrawal Management Residen al, and SUD Medically-Monitored Withdrawal Management Residen al were replaced with SUD Withdrawal Management Residen al and Outpa ent Access / Substance Use Disorders Added policy requirements based on OAR Member Rights Added content regarding members rights to be free from discrimina on. Pathways Provider Update December of 5

3 Changes within Specific Sec ons of the Pathways Provider Manual (con nued) Flex Funds for Mental Health Providers Updated Acceptable Usage for Flexible Funds in Clackamas and Multnomah Coun es. Billing, Service Authoriza on and Claims Management / Confirming Member Eligibility Added clarifica on regarding Provider s responsibility to confirm member s eligibility and coverage by other payors. Corrected Claims Added clarifica on regarding the meliness of corrected claims. Provider Data Management / Roster Submissions (NEW SECTION) New requirement for contracted organiza onal providers to regularly submit provider rosters to Health Share. Provider Data Management / Upda ng/terming a Current Praconer with an Organiza onal Provider Updated contact informa on for sending updates to praconer data. Alterna ve Payment Confiden ality Requirements (New Sec on) Sec on added to outline confiden ality requirements regarding Health Share s alterna ve payment structures. Level of Care (LOC) Mental Health Providers (NEW SECTION) Sec on added outline requirements regarding Level of Care Assignment based on the UM Prac ce Guidelines. Pathways Provider Fee Schedule Updates The Newly Updated Regional Mental Health and SUD Fee Schedules can be located in the Behavioral Health Resources section on our website. The updated fee schedules will be effec ve January 1, Updates to the Mental Health and SUD fee Schedules are outlined on the following page. Pathways Provider Update December of 5

4 Edits to Fee Schedules Mental Health Fee Schedule Updates H0019: In Facility Rate per Unit Increase H2013: In Facility Rate per Unit Increase H2000: Updated to Service Criteria Substance Use Disorder Fee Schedule Updates HF/HG: Update to Permissible Staff HF/HG: Update to Permissible Staff H0001 HF/HG: Update to Permissible Staff H0002 HF/HG: Update to Permissible Staff H0004 HF/HG: Update to Permissible Staff H0005 HF/HG: Update to Permissible Staff H0006 HF/HG: Update to Permissible Staff H0010 HF/HG: Update to Permissible Staff H0011 HF/HG: Update to Permissible Staff H0012 HF/HG: Update to Permissible Staff H0013 HF/HG: Update to Permissible Staff H0016 HF/HG: Update to Permissible Staff H0018 UA: Update to Permissible Staff H0018 HB: Update to Permissible Staff H0018 HB & HH: Update to Permissible Staff H0018 UA & HH: Update to Permissible Staff H0018 HB & HT: Update to Permissible Staff H0019 UA: Update to Permissible Staff H0019 HB: Update to Permissible Staff H0019 HB & HH: Update to Permissible Staff H0019 UA & HH: Update to Permissible Staff H0019 HB & HT: Update to Permissible Staff H0020 HG: Update to Permissible Staff H0033 HG: Update to Permissible Staff H0038 HB/HG/HF/UA: Update to Permissible Staff H0038 HB/HB/HF/UA + HQ: Update to Permissible Staff H0048 HF/HG: Update to Permissible Staff H2010 HF/HG: Update to Permissible Staff T1006 HF/HG: Update to Permissible Staff T1007 HF/HG: Update to Permissible Staff T1502 HG: Update to Permissible Staff Pathways Provider Update December of 5

5 Important Things to Know Organiza onal Praconer Rosters Required Star ng in 2018 In order to ensure network accuracy, organiza onally contracted Providers must submit a full praconer roster to Health Share on a quarterly basis beginning March Roster must include the following data elements: Praconer Full Name Praconer License/Cer fica on Praconer NPI Praconer Oregon Medicaid ID Praconer Specialty Foreign Languages Spoken (including ASL) Culturally Specific Focus (if applicable) Effec ve Date (if new) Office Loca on (s) If desired, Provider may supply the following data elements in order to help Health Share more accurately direct members for appropriate care: Praconer Race Praconer Ethnicity Praconer Gender Praconer rosters should be sent to providers@healthshareoregon.org no later than the 2 nd Friday of the 3rd Month of each quarter (March, June, September, and December). Providers shall use Appendix L: Organiza onal Roster Informa on Template in the Provider Manual to submit praconer informa on to Health Share. Confirming Member Eligibility and Other Insurance Coverage Providers are contractually required to confirm new and current Member benefits and eligibility prior to providing all services. Failure to confirm Member eligibility may result in the Provider not being reimbursed, should the Member be ineligible for services. Addi onally, as Medicaid is the payor of last resort, Providers must check Member benefits and eligibility to confirm if member has other coverage prior to billing Health Share of Oregon. If it is determine that the Member has other coverage, Provider must bill the primary payor prior to billing Health Share. Provider must also no fy PH Tech at tprgroup@phtech.com, as well as the appropriate Behavioral Health Plan Partner, if a member has other insurance coverage (excluding Medicare coverage). No Prior Authoriza on Required for Vivitrol Currently, Health Share does not require Prior Authoriza on for medica on-assisted treatment with Methadone or Suboxone in the treatment of Opioid Use Disorder. Effec ve , Health Share will no longer require that behavioral health providers request Prior Authoriza on for Vivitrol in the treatment of Opioid Use Disorder. This will increase treatment choice for our members seeking medica on-supported recovery, as well as remove administra ve barriers for behavioral health providers. Pathways Provider Update December of 5