Download
1 / 33
340 likes | 544 Vues
CBH State of Georgia Provider Orientation. Cenpatico Behavioral Health. Today’s Presenters: Clinton Shedd CBH Network Development Manager Central & SW Region. Agenda. Overview of CBH CBH Provider Network CBH Georgia Provider Directory The Provider Role The Referral Process
E N D
CBH State of Georgia Provider Orientation
Cenpatico Behavioral Health Today’s Presenters: Clinton Shedd CBH Network Development Manager Central & SW Region
Agenda • Overview of CBH • CBH Provider Network • CBH Georgia Provider Directory • The Provider Role • The Referral Process • CBH Provider Specialty & Cultural Competency • Geo-Access Requirements and Wait Times • Member Benefits • Case Management • Authorization Process • Outpatient Treatment Report (OTR) • Claims Submission • EDI • Credentialing & Re-Credentialing • Network Management & Provider Relations • Provider Manual and Online Resources • Future Provider Training & Forums • Open Q&A
Cenpatico History • CBH began as a staff model behavioral health delivery system in 1994 in Texas. • The Centene Corporation, a St. Louis-based healthcare organization (CNC on the NYSE), acquired CBH in 2003. • CBH service offerings include UM, including assessment and triage, crisis intervention, intensive case management, QI, network development, credentialing, customer service and claims processing and payment. • We currently serve over 900,000 Medicaid consumers in the following markets; Arizona, Indiana, Kansas, Missouri, Ohio, Texas, and Wisconsin. • Offer special education school-based services in Arizona. • Received URAC health plan accreditation in January 2005. • CBH Corporate office is located in downtown Austin, TX.
The CBH Executive Team • Sam Donaldson, PhD- President & CEO • Alan Adkins, MD, MMM- VP Medical Affairs • Cindy Peterson, ACSW- VP Operations • Greg Shulman, LPC- Executive Account Manager • Sara Neale, RN- Director, Compliance & Government Affairs • Suzanne Feay, RN- Director, Corporate QI & Credentialing • Francis Terway- Finance Manager
CBH NSC Leadership Team • W. Mark Konyecsni, MD- NSC Medical Director • Claudia Sumrall, ACSW- Clinical Director • Lilli Olive, MA,LPC-Georgia Clinical manager • Agnes Ponce - Customer Service Manager • Melanie Howard, RN - Quality Improvement Manager
CBH Georgia Operations • CBH is headquartered in Austin, Texas and the National Service Center is also located in Austin. • CBH will has Licensed Master Level Personnel as Case managers and Care coordinators in Austin and Atlanta. • CBH will have dedicated network management staff in Georgia to provide local provider assistance and training.
CBH Provider Network • CBH Network Development contracts with clinically-licensed behavioral health clinicians, hospitals, community mental health centers, community service boards (CSB’s), free-standing psychiatric facilities, & significant traditional providers (STP’s). • CBH clinicians include, but are not limited to; MD, DO, ARNP, PhD, EdD, PsyD, LPC, LCSW, and LMFT.
The Provider Role • Provide quality covered behavioral health services within all accepted clinical, legal and ethical standards to CBH members. • Follow CBH Clinical Practice Guidelines and Medical Necessity Criteria. • Ensure members are able to avail themselves of their rights to execute Behavioral Health Advance Directives. • Abide by CBH Authorization, Claims, QI, UM and Credentialing/Re-Credentialing policies and procedures. • Abide by CBH contractual obligations. • Treat CBH clients as fairly and equally as any other clients. • Ensure HIPAA compliance.
Provider Directory • CBH providers and facilities will be listed in the Peach State Health Plan, Inc. (PSHP) online provider directory. The online directory will be updated to reflect the most current information. • CBH clinicians, agencies, CSB’s, and hospitals are listed in the Provider Directory. Information includes, but is not limited to: provider name, address, phone, and office hours. • The Directory is intended to reflect our current network and to provide another avenue for our providers and members to make informed referral decisions.
Referral Process • CBH employs a team of customer service representatives to provide referrals and eligibility verification to our members and our providers. • Providers and members are encouraged to visit the PSHP online directory at www.pshpgeorgia.com or visit the CBH directory at www.cenpaticoga.com (which is currently in its final stages of development). • CBH refers to in-network, or actively participating, providers and facilities.
Provider Specialty & Cultural Competency • CBH recognizes the uniqueness of each member, their needs, and treatment requests. • Consideration of a member’s race, country of origin, native language, social class, religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation and other characteristics should be included when developing their treatment plan. • CBH requests that providers share their languages spoken other than English, handicap accessibility, and treatment specialties with us so that we can tailor each referral to best meet our member’s needs. • Office sites should have posted and printed materials in English, Spanish, or other prevailing languages within the region.
Provider Accessibility, Availability, & Wait Times Current CBH access standards are as follows: • Routine appointments-within 14 business days • Urgent appointments-within 24 hours • Emergent-non-life threatening appointments - within six (6) hours • Discharge (from hospital) follow-up appointments - within seven (7) days of discharge
Covered Behavioral Health Services • Traditional Outpatient Services • Medication Management • Group and Family Therapy • Inpatient Hospitalization • Detoxification • 23-Hour Observation • Electroconvulsive Therapy (ECT) • Partial Hospitalization Program (PHP) • Intensive Outpatient Program (IOP) • Specific Community-Based Services
Case Management CBH has developed an Intensive Case Management program to: • Identify members with complex or chronic behavioral health conditions that require coordination of services and periodic monitoring in order to achieve desired outcomes. • Work collaboratively with the member, physician, family/significant others and providers of healthcare and support services to implement an individualized plan of care. • Maximize efficiency in utilization of available resources and plan benefits.
Components of Case Management • Early identification of cases • Assessment of cases to identify the needs of those at high risk • Referral to the appropriate providers and services • Provision of effective interventions in conjunction with providers to improve clinical outcomes • Coordination of support services • Member/Family education • Measurement of the intervention outcomes and use of those measures to improve the program’s effectiveness
Service Codes Not Requiring Pre-Authorization Medication Management services billed with the following codes do not require pre-authorization; • 90801/90802- Diagnostic Interview Examination • 90862- Pharmacologic Management • 90805- Individual Therapy (20-30 minutes) with med eval/mgmt services • 90811- Individual Therapy, interactive (20-30 minutes) with med eval/mgmt services • 90813- Individual Therapy, interactive (45-50 minutes) with med eval/mgmt services
Services Requiring Pre-Authorization • Inpatient Hospitalization • 23-Hour Observation • Detoxification • PHP & IOP • Psychological Testing • In-Home Therapy • Community-Based Services (Rehabilitative Services) • IFI Services • All covered outpatient therapy services greater than six (6) visits
Pre-Authorizing Care • Prior Authorization is required for inpatient (non-emergent) and higher levels of care such as ECT, PHP, IOP, Day Treatment programs, Psychological Testing, and in-home or community-based treatment. • Prior Authorization is NOT required for emergency services, post-stabilization and urgent care services. PLEASE NOTE: You must contact CBH Care Management within 24 hours of rendering these types of services for authorization and review.
Outpatient Treatment Report (OTR) • The initial six (6) visits of outpatient psychotherapy (CPT CODES 90804) do not require pre-authorization but do count against the member’s benefit limitations. Billing codes must be Covered Behavioral Health Services. • To approve all sessions beyond the initial six (6) will require that the provider submit an Outpatient Treatment Report (OTR). The form is in the back of the provider manual. • The OTR MUST be completed in its entirety for consideration. This includes the five (5) axis diagnoses as well as all other clinical information. • The OTR’s can be faxed to CBH or completed online for clinical review and additional sessions will be approved based upon medical necessity. • CBH WILL NOT retroactively approve sessions. Treatment must occur within the dates on the authorization. Any changes must be sent to CBH prior to the sessions occurring. • Failure to submit a timely OTR can result in delays in authorization and may result in payment denials.
Claims Submission • What is a Clean Claim? It’s a claim received by CBH for adjudication in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the provider. • It is critical that we have current and correct information to assure claims payment. This includes; W-9, Medicaid Number, Service Address, Tax ID #, & Billing name and address. • Ensure the member is effective on date of service, the service is a covered behavioral health service under the member’s benefit, and all CBH referral & authorization processes were followed and approved. • Claims Address; CBH Attn: Claims Department PO BOX 6700 Farmington, MO 63640-3816
Claim Submission Do’s • Do use the correct mailing address and PO Box number • Do submit all claims in 9”x12” envelope (or larger). • Do type all fields completely and correctly. • Do use black or blue ink only. • Do submit on proper form (CMS 1500 or CMS 1450).
Common Billing Errors • Remember to use SPECIFIC CPT-4 or HCPCS codes. • Avoid the use of non-specific or “catch-all” codes such as 99070. • Use the most current CPT-4 and HCPCS codes which can be found on your contracted Exhibit 2 (Compensation Schedule) • Use the 4th or 5th digit when required for ALL ICD-9 codes. • Submit all claims/encounters with your Medicaid Number and Tax Id Number. • Submit all Claims/encounters with the Member’s complete Medicaid Number or the Members PSHP ID Number.
Electronic Claims Submission • CBH has two national clearinghouses that are approved for EDI electronic claims submission. Payer Path and Emdeon (formally Web MD) Please contact the Centene EDI Department at the following to inquire or discuss EDI and your options; By phone: 1-800-225-2573, ext. 25525 By e-mail: EDIBA@centene.com
Credentialing & Re-Credentialing • As CBH is URAC accredited, CBH is obligated to follow URAC credentialing and re-credentialing guidelines. • A list of required credentialing materials can be found on pages 65 and 66 of the CBH Provider Manual. • Facilities and Health Delivery Organizations must be CARF, JCAHO, or COA accredited. If not, CBH must conduct an onsite facility site review. • CBH requires that you provide our Credentialing Department with updates to your license, insurance, and DEA (if applicable), as you receive them. • Each provider must be re-credentialed at least once every three years from the date of the initial approval. • Failure to complete the re-credentialing process may result in termination from the CBH network.
Network Manager & Provider Relations • CBH has employed a dedicated regional Network Manager in each of our service delivery regions; Atlanta-Carla Menchion- cmenchion@centene.com Central- Clinton Shedd- cshedd@centene.com Southwest- Clinton Shedd- cshedd@centene.com • Provider Specialist-Latisa Kidd- lkidd@centene.com • Network Development can assist with any questions regarding CBH or your Agreement, schedule trainings and forums, conduct site visits, and assist in conflict resolution. • CBH Georgia Provider Relations staff at our Corporate Office are an extension of the Network Development Manager and are available to assist at any time.
Provider Manual & Online Resources • CBH’s Provider Manual contains specific policies and procedures regarding credentialing, authorization, appeals, and claims. • Our Medical Necessity Criteria and Clinical Practice Guidelines can be found in the Provider Manual. • CBH Corporate Information can be found on our website at www.cenpatico.com. • CBH will have a direct CBH Georgia provider website; www.cenpaticoga.com, which is in final development stages.
Future CBH Training & Forums • CBH will conduct provider/facility trainings and forums in our service regions. • CBH will conduct at least one large event in your area per year, though we are open to schedule one- on-one trainings with your group or facility on an as needed basis. • CBH will notify all providers of upcoming events via mail, by phone, or in our Provider Newsletter. • Your suggestions for training and forum topics are always welcome!
