KanCare Training for Providers - Ubhonline.com

KanCare Training for Providers
Optum with UnitedHealthcare Community Plan Kansas

Our Mission
Helping people live their lives to the fullest

Introduction to Optum
• United Behavioral Health (UBH) was officially formed on February 2, 1997,
via the merger of U.S. Behavioral Health, Inc. (USBH) and United Behavioral
Systems, Inc. (UBS).
• Our company is a wholly owned subsidiary of UnitedHealth Group. Optum is
a health services business. You will see both UBH and Optum in our
communications to you.
• Optum will assume management of the behavioral health benefits for
KanCare members with coverage through UnitedHealthcare of the Midwest,
Inc.
• UnitedHealthcare Community Plan – Kansas has contracted with us to
administer behavioral health benefits to include mental health and substance
use disorders.
We are dedicated to making the health system better for everyone.
For the individuals we serve, you play a critical role in our commitment
to helping people live their lives to the fullest.
United Behavioral Health operating under the brand Optum
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3

Optum Philosophy of Care
A managed care plan that features:
• An integrated medical and behavioral health delivery system
• A focus on member involvement in identifying his or her needs
• Support for collaboration
Six key goals:
1. Improve screening and treatment of mental health and substance use
disorder diagnoses
2. Treat individuals at the point of care where they are comfortable
3. Treat individuals in a holistic manner, using a single treatment plan,
helping each individual access his/her natural community supports based
on personal strengths and preferences
4. Improve communication and collaboration between behavioral health and
medical clinicians
5. Operate with a collaborative team approach to deliver care using a
standardized protocol
6. Establish the necessary permissions from the individual to coordinate
care
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4

Behavioral Health Services

Providers in our Behavioral Health Network
• Psychiatrists
• Addictionologists
• Psychologists
• Master Level Clinicians
• Advanced Practice Registered Nurses (APRN)
• Network providers also include:
• Community Mental Health Centers
• Rural Health Clinics
• Federally Qualified Health Centers
• Substance Use Disorder Agencies
• Regional Alcohol Drug Assessment Center (RADAC)
• Inpatient Facilities
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
6

Behavioral Services
• Inpatient Hospitalization
• Residential Care
• Residential substance use
disorder treatment, including
detoxification
• Partial Hospitalization
Program/Extended Day
Treatment
• Intensive Outpatient
Treatment/Day Treatment
• Individual, group and/or family
therapy provided by a
psychologist or behavioral health
professional
• Outpatient substance use disorder
treatment services including:
– Assessment, Detoxification
Services, Counseling,
Medication Assisted Therapy
• Psychiatry Services
• Autism waiver program
• Serious Emotional Disturbance
(SED) waiver program
• Mental Health First Aid Program
• Peer Bridger Program
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7

Value Added Services
• Behavioral Health:
– Peer Bridger Program – Connects peers in recovery with another individual who is currently in
inpatient services to work on discharge planning and help prevent readmissions.
– Mental Health First Aid Program – Teaches others how to assist with managing mental health
services.
• Adult Wellness Rewards Program: Adults can earn between $5 and $15 in gift cards for
completing timely screenings and check-ups for themselves or their family members.
• Weight Management Programs: A free membership to a local Weight Watchers program for
qualified members to help them lose weight and eat more healthily. Members who complete 3 months
of the Weight Watchers program successfully can earn a $50 gift card for workout gear. Kids age 10
to 17 can be enrolled in an interactive program that engages parents and teens to learn about behavior
change, goal-setting, and healthy lifestyles. If they successfully complete the program, they can earn a
$50 debit card. Our UnitedHealth HEROES program provides micro-grants to schools to help them
begin a healthy lifestyles program.
• Programs for Youth: We will provide all children with the chance to join one youth organization
per year. Choices include 4-H, the YMCA, or the Boys and Girls Clubs. We offer one sports, school or
camp physical per year for children under 19.
• Empower Kansans: Designed to provide additional support to disabled individuals in their pursuit
of meaningful employment that aligns with their abilities.
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8

Value Added Services - continued
• Healthy Pregnancies: Baby Blocks - An interactive program using online and Smartphone tools
where members can earn gifts for themselves or their baby by attending their pre-natal, post-postpartum
and well-baby appointments. We will mail a copy of the book “Baby Basics” to all pregnant
members.
• Online Smart Tools for Health: Members can go to myuhc.com ® to help them manage their
health. The site will help them keep a health history and educate them on working with their doctor.
They can also track future visits. Members can get Smartphone applications. The applications will
help them track health goals and then find a doctor located close to where they are. Community
Services Connect – A program on the Internet that helps members find services close to where they
live. Certain high-risk members can get a cell phone to help them keep in touch with their doctors and
care coordinators.
• Additional Access to Providers: We will provide more vision services. The services will
include a better selection of eyeglass frames. It also includes loss or theft replacement. Some
members could get contact lenses. Members can get up to two additional podiatry visits per year.
They need to be over 21 and get approval from their Care Coordinator.
• Sesame Street and Dr. Health E. Hound: “A is for Asthma” - A program from Sesame Street
that teaches kids and parents about the best ways to live with asthma. “Sesame Street Food For
Thought Program” – A bilingual program to help families eat better. The program teaches families with
children between 2 and 8 years-old how to buy healthy food on a budget. “Sesame Street Healthy
Habits” – Learn from Sesame Street friends on going to the doctor for check-ups including the
importance of asthma screening and lead tests. Dr. Health E. Hound sends birthday cards to remind
kids and parents about how to be healthy with reminders on check-ups and preventive services they
can access.
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9

Prior Authorization Requirements
• Referrals Not Required
– Members shall be able to
access all behavioral
health outpatient services
(mental health and
substance use) without a
referral up to a prespecified
initial
authorization service limit.
• Prior Authorization Required
– For services above established limits,
prior authorization is required and may
be obtained by members or providers.
– Prior authorization is required for
services that are more intensive than
outpatient, such as Day Treatment,
Partial, Inpatient.
– Providers must ensure that the prior
authorizations are in place before
rendering non-emergent services.
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10

Pre-Specified Initial Authorization Limits
Mental Health
Covered Services
Individual Therapy
Group Therapy
Family Therapy (in office + home based)
Psychological Testing
Admission Evaluation
Early Childhood Assessment
Case Conference
Behavioral Assistant Care
Community Psychiatric Support & Treatment
Targeted Case Management
Psychosocial Rehabilitation - Individual
Psychosocial Rehabilitation – Adult Group
Psychosocial Rehabilitation – Child Group
Peer Support
Crisis
32 sessions
24 sessions
40 sessions
6 hours
5 sessions
2 per year
32 units
2000 units
No limits
No limits
750 hours
250 hours
Initial Authorization Limits
Re-evaluation is required by a QMHP
every 72 hours
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11

Pre-Specified Authorization Limits
Substance Use Disorders
Service Level
Level 1
Outpatient Services
Level 2
Intensive Outpatient
Level 3.1
Reintegration Services
Level 3.3/5
Residential Intermediate Services
Level 3.7D
Residential Acute Detox
Initial Authorization Limits
60 hours over 6 months
45 days over 15 weeks
30 days
14 days
Pending state guidelines
• The KanCare program relies on the American Society of Addiction Medicine
(ASAM) ) as the criteria used to make determinations for all Substance Use
Disorder requests.
• For services not included in this chart, you must obtain prior authorization by
phone at 855-802-7095.
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12

Authorization
Non-emergent situations
• Prior authorization can be
obtained by a member, family
member, or a provider. When
calling Optum be prepared to
provide demographic information
and a brief description of the
presenting problem. Optum will
explain the services available
under their benefit plan.
• Authorization phone
number: 855-802-7095
Emergent situations
• A medical professional, a member,
or a lay person in an emergency
situation can identify the need for
behavioral health services.
Conditions that warrant an
emergency admission are
situations in which there is a clear
and immediate risk to the safety of
the member or another person as
a direct result of mental illness or
substance abuse.
• Optum must be contacted for a
prior authorization of additional
care.
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13

KCPC
• KCPC – Kansas Client Placement Criteria
• A system of assessment and placement based on the ASAM Criteria (American Society of
Addiction Medicine)
• ASAM and the KCPC system recommend level of care based on 6 dimensions
• All Substance Use Disorder (SUD) treatment providers in the state of Kansas utilize KCPC
• The Providers submit requests for authorization of SUD Treatment to the client’s MCO
• The Providers use KCPC as an assessment tool while determining the client’s appropriate level of
care
Provider
performs
assessment
with Client
Provider completes
the KCPC
assessment tool and
documentation
Based on assessments
and ASAM criteria - Level of
Care decision is made
Provider submits a
Service Request
Voucher utilizing
KCPC to Client’s
MCO
MCO Care
Advocate reviews
clinical ASAM
criteria
Care Advocate determines
if level of care recommended
is appropriate based on the KCPC
Service Request Voucher
Submission
Care Advocate
communicates this
decision back to the
Provider (either
approval or denial)
through KCPC
Care Advocate
creates an
authorization or
denial in CareOne
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Eligibility and Benefit Review Process
• When a request for services is received, Optum will:
– review member benefit eligibility
– gather required clinical information
– reference the appropriate criteria set
– determine whether the requested care meets medical
necessity criteria
• Optum may certify levels of care and treatment services that are
specified as available under the specific benefit plan (e.g., acute
inpatient, residential, partial hospitalization, intensive outpatient, or
outpatient)
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
15

Utilization Management Statement
• Care Management decision-making is based only on the
appropriateness of care as defined by
– Optum Level of Care Guidelines
– Optum Psychological and Neuropsychological Testing Guidelines
– Optum Coverage Determination Guidelines
– American Society of Addiction Medicine Criteria
– Kansas Medical Necessity Criteria
Optum does not reward Medical Directors or licensed clinical staff
for issuing denials of coverage or service
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
16

Appeals and Grievances

Appeals
Non Urgent (Standard)
Urgent (Expedited)
• Must be requested within 180 days from
receipt of the notice of action letter
• Pre-Service: is an appeal of a service that
has not yet been received by a member.
When a pre-service appeal is requested,
we will make an appeal determination and
notify the provider, facility, member or
authorized member representative in
writing within fourteen (14) calendar days
of the request.
• Post-Service: is an appeal of a service
after it has been received by a member.
When a post service appeal is requested,
we will make the appeal determination and
notify the provider, facility, member or
authorized member representative in
writing within fourteen (14) calendar days
of the request.
• Must be requested as soon as possible
after the Adverse Determination.
• Optum will make a reasonable effort to
contact you prior to making a
determination on the appeal. If Optum is
unsuccessful in reaching you, an urgent
appeal determination will be made based
on the information available to Optum at
that time.
• Notification will occur as expeditiously as
the member’s health condition requires,
within three (3) business days, unless the
appeal is pertaining to an appeal relating to
an ongoing emergency or denial of
continued hospitalization, which we will
complete investigation and resolution of
not later than one (1) business day after
receiving the request.
Appeal requests can be made orally or in writing;
however, an oral request to appeal shall be followed up by a written, signed, appeal.
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18

Services While In Appeal
• You may continue to provide service following an adverse determination, but
the member should also be informed of the adverse determination.
• The member or the member representative should be informed that the care
will become the financial responsibility of the member from the date of the
adverse determination forward.
• The member must agree in writing to these continued terms of care and
acceptance of financial responsibility. You may charge no more than the Optum
contracted fee for such services, although a lower fee may be charged.
• If, subsequent to the adverse benefit determination and in advance of receiving
continued services, the member does not consent in writing to continue to
receive such care and we uphold the determination regarding the cessation of
coverage for such care, you cannot collect reimbursement from the member
pursuant the terms of your Agreement.
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19

Grievances
We strive for the best customer service, but if you have a grievance
please contact us:
• Call 855-802-7095 and a Customer Service representative will assist
with the grievance process
• Or send a written grievance to:
Optum
Attn. Appeals Department
10895 Grandview Dr, # 200
Overland Park, KS 66210-1562
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20

Treatment Record Documentation

General Documentation Standard
The following must be clearly documented in the members chart:
– Complete biopsychosocial assessment
– Substance abuse screening for consumers over the age of 11
– Full Axis I through V diagnosis
– Treatment plan with specific long term and short term goals
– Ongoing risk assessments
More information about documentation standards
can be found in the Optum KanCare Provider Manual.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
22

Discharge Planning
• Effective discharge planning addresses how a member’s needs will be met
during transition from one level of care to another or to a different treating
clinician.
• Planning begins with the onset of care and should be documented and
reviewed over the course of care.
• Discharge treatment planning will focus on achieving and maintaining a
desirable level of functioning after the completion of the current episode of care.
• Discharge instructions should be specific, clearly documented and provided to
the member prior to discharge. For discharge from an acute inpatient
program, the member’s follow-up appointment will be scheduled prior to
discharge and within seventy-two hours of the date of discharge.
• Throughout the treatment and discharge planning process, it is essential that
members be educated regarding the importance of enlisting community support
services, communicating treatment recommendations to all treating
professionals, and adhering to follow-up care.
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23

Release of Information
• We release information only to the individual, or to other parties
designated in writing by the individual, unless otherwise required or
allowed by law.
• Members must sign and date a Release of Information for each party
that the individual grants permission to access their PHI, specifying
what information may be disclosed, to whom, and during what period of
time.
• The member may decline to sign a Release of Information which must
be noted in the Treatment Record; the decline of the release of
information should be honored to the extent allowable by law.
• PHI may be exchanged with a network clinician, facility or other entity
designated by HIPAA for the purposes of Treatment, Payment, or
Health Care Operations.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
24

Billing and Claims

Claims Submission
Required Claim Forms
CMS-1500 form
Inpatient Hospital providers, use UB-04
Claims/Customer Service # : 855-802-7095
Electronic Claims Payer ID: 96385
Paper Claims:
When submitting behavioral Claims by paper, please mail claims to:
KMAP
P.O. Box 3571
Topeka, KS
66601-3571
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26

Claims Tips
To ensure clean claims remember:
• An NPI # is always required on all claims
• A complete diagnosis is also required on all claims
Claims filing deadline
• Example: 295 Schizophrenic disorders is an incomplete diagnosis
code as 5 digits are required
• Providers should refer to their contract with Optum to identify the
timely filing deadline that applies.
Claims Processing
Balance Billing
• Clean claims, including adjustments, will be adjudicated within 30
days of receipt.
• The member cannot be balance billed for behavioral services covered
under the contractual agreement.
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27

Claim Tips
• Member Eligibility
– Provider is responsible to verify member eligibility through KMAP
• Coding Issues
– Coding issues including incomplete or missing diagnosis
– Invalid or missing HCPC/CPT examples:
• Submitting claims with codes that are not covered services
• Required data elements missing, (i.e., number of units)
• Provider information missing/incorrect
– Example: provider information has not been completely entered on the claim
form or place of service
• Prior Authorization Required
– No authorization received for those services for which an authorization is
required
– Units exceeded, example: authorization was given for 10 days, facility has
billed for 11 inpatient days
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28

Member Information

Member ID Card
• Will be sent directly to the member
• The member’s ID number will be their Medicaid number
• All relevant contact information will be on the back of
the card for both medical and behavioral customer
service
Please note this image is for illustrative purposes only.
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30

Member Rights and Responsibilities
Members have the right to be treated with respect and recognition of his or her dignity, the
right to personal privacy, and the right to receive care that is considerate and respectful of
his or her personal values and belief system.
Members have the right to disability related access per the Americans with Disabilities Act.
You will find a complete copy of Member Rights and Responsibilities in the KanCare
Network Manual.
These can also be found on the website: providerexpress.com
These rights and responsibilities are in keeping with industry standards. All members
benefit from reviewing these standards in the treatment setting.
We request that you display the Rights and Responsibilities in your waiting room, or have
some other means of documenting that these standards have been communicated to the
members.
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31

Member Website
liveandworkwell.com, makes it simple for members to:
• Identify network clinicians and facilities
• Locate community resources
• Find articles on a variety of wellness and work topics
• Take self-assessments
The search engine allows members and providers to locate in-network
providers for behavioral health and substance use disorder services.
Providers can be located geographically, by specialty, license type and
expertise.
The website has an area designed to help members manage and take
control of life challenges.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
32

Provider and Member Resources
An extensive condition-based library covering key behavioral and
medical topics can be found on liveandworkwell.com under the
Health and Well-Being Center within BeWell.
• Abuse & Neglect: Child
• Abuse: Domestic Violence
• Abuse & Neglect: Elder
• ADHD (Adult)
• ADHD (Youth)
• Alzheimer’s & Dementia
• Anxiety
• Arthritis
• Asthma
• Autism
• Bipolar (Adult)
• Bipolar (Youth)
• Cancer
• Childhood Illness
• Chronic Pain
• Depression (Adult)
• Depression (Youth)
• Diabetes
• Eating Disorders (Adult)
• Eating Disorders (Youth)
• Heart Disease/Circulatory
• HIV
• Infertility
• Obesity
• Personality Disorders
• Obsessions & Compulsions
• Phobias
• Postpartum Depression
• Post-Traumatic Stress
Disorder
• Schizophrenia (Adult)
• Schizophrenia (Youth)
• Sexual Problems
• Stress
• Traumatic Brain Injury
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
33

Provider Responsibilities

Access to Care – Standards
Routine Outpatient –Mental Health
Routine Outpatient – Substance Use Disorders
Urgent
If not addressed in a timely way could escalate to an
emergency situation
Life threatening emergencies
Imminent risk of harm or death to self or others due to a
medical or psychiatric condition
Post Inpatient Discharge
If you are unable to see the member during this time –
refer to another in‐network provider to satisfy this
deadline
Special Health Care Needs: IV drug users identified as
having used drugs within the last 6 months, will need to be
seen for treatment
Missed an Appointment
The Optum Care Advocate for behavioral services will
contact members who have missed a post‐discharge
appointment to reschedule that appointment
Members will be offered an initial appointment
within 10 calendar days
Assessment within 14 days of initial contact.
Treatment services are delivered within 14 days
of assessment
Referral within 24 hours. Services delivered
within 48 hours of initial contact
Referral is Immediate
All members must be seen within 72 hours post
discharge
Within 14 calendar days of initial contact
Within 24 hours
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35

Provider Responsibilities
• Check member’s eligibility prior to performing services by phone or
online at uhccommunityplan.com
• Refer to in-network providers, directory available at liveandworkwell.com
• Adhere to the authorization policies as outlined in the provider manual
• Adhere to appointment and accessibility standards as outlined in the
provider manual
• Adhere to medical record keeping and chart review standards
• Provide services consistent with professional and ethical standards as
set forth by national certification and state licensing boards, and
applicable law or regulation regardless of a member’s Benefit Plan or
terms of coverage
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36

Provider Responsibilities
• Provide services to members in a non-discriminatory manner
• Determine if members have medical benefits through other insurance
coverage
• Advocate for members as needed
• Notify us at providerexpress.com within ten (10) calendar days
whenever you make changes to your office location, billing address,
phone number, Tax ID number, entity name, or active status (e.g., close
your business or retire)
This includes roster management.
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37

Behavioral Medical Integration
OUR GOAL is to increase medical and behavioral health care integration
for all members.
Clinicians are asked to refer members with known or suspected and
untreated physical health problems or disorders to their Primary Care
Physician for examination and treatment.
OUR GOAL is to increase integration of treatment for mental health and
substance use disorder conditions.
Our care management program to there to assist members with
complex medical and/or behavioral health needs in the coordination of
their care.
Members are expected to be treated from a holistic standpoint, this is especially
true for high-risk, high-service utilizers and other high-cost individuals with
complex needs.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
38

Optum Provider Website
• Providerexpress.com includes both public and secure pages
• Public Pages include general updates and other useful information
– Download standard forms (Ex. Agency Roster Update form)
– Find staff contacts
– Review clinical guidelines and the KanCare Network Manual
– Access current and archived issues of Network Notes, the provider
newsletter
• Secure pages are available only to network providers and require
registration
– KanCare providers will be able to update their practice information
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
39

Recovery and Resiliency
Definition
of Recovery
Definition
of Resilience
A process of change through which individuals improve
their health and wellness, live a self-directed life, and strive
to reach their full potential.
The ability to recover quickly from disruptive change,
illness, or misfortune without being overwhelmed or acting
in dysfunctional ways.
Principles of Recovery
Guiding Principles of Recovery
Recovery emerges from hope
Recovery is person-driven
Recovery occurs via many pathways
Recovery is holistic
Recovery is supported by peers and allies
Recovery is supported through relationship and
social networks
Recovery is culturally-based and influenced
Recovery is supported by addressing trauma
Recovery involves individual, family, and
community strengths and responsibility
Recovery is based on respect
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40

Network Participation

Contact Information
Prior Authorization
Claims Paper Submission
Electronic Claim
Submission
Optum at 855-802-7095
Mail paper claims to:
KMAP
PO Box 3571
Topeka, KS 66601-3571
Through UHCCommunityPlan.com or via EDI clearing house
Payor ID 96385
Claims Status
Claims Appeals
Eligibility Verification
Customer Service
Provider Assistance
Update Practice
Information
Customer Service Center at 855-802-7095
Web portal at UHCCommunityPlan.com
Optum
10895 Grandview Dr, #200
Overland Park, KS 66210-7095
855-802-7095
View eligibility online at UHCCommunityPlan.com
Monica Nicol-Meek, Network Manager (refer to handout)
Tamara Welty, Network Associate (refer to handout)
Optum National Provider Service Line at 1-877-614-0484
providerexpress.com or via 877-614-0484
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
42

Joining Our Network
If you have received a letter inviting you to the join the network, please complete
the materials that were attached and return them per the instructions in the letter.
If you did not receive a letter but want to join the network, please contact Optum:
by email at: (refer to handout)
or by fax at: 612-234-0220
Be sure to include the following information in your request:
Your full name
Your clinical license type
Your date of birth
Your CAQH Application ID Number
Your email address
Tax ID
Name of Group or Agency
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43

Thank You.