Microsoft 2012 CM Presentation [Compatibility Mode] HV 18
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SoonerCare Case Management Policy Who is the contact? Prior Authorization* OHCA Provider Helpline for Cl i Claims and d Billing Billi (800)522-0114 Option 2,3 Call or email if you have a question: JJavey D Dallas ll (405) 522-7543 J Javey.Dallas@okhca.org D ll @ kh What are the rules of the road? How to find the rules: www.okhca.org kh Go to the Providers’ Providers section Policies & Rules, and then, OHCA Medicaid Rules Chapter 30 – Medical Providers SubChapter 5 – Individual Providers Part 67 – CM Part 21 – OPBH Agencies SoonerCare Requirement: For behavioral health case management g services to be compensable by SoonerCare, the case manager g performing the service must have and maintain a current behavioral health case manager certification from the ODMHSAS. ◦ A provisional certification is not allowable. p certification is not allowable. ◦ Suspended Change 7/1/2010 For Certified Case Manager g II, after July J y 1, 2010: Any bachelors or masters degree earned from a regionally g y accredited college or university recognized by the USDE is allowable. Case Management Professional Levels Level of CM Code Modifier Rate CM III,, LBHP T1017 HO 13.53 CM II, MA/BA level T1017 HN 10.48 CM I, less than BA T1017 HM 7.43 SOC, CM III, LBHP (ODMHSAS only) T1016 TF 21.61 SOC, CM II, BA (ODMHSAS only) T1017 TF 16.21 18 and up Intensive - CMHC, CM III, LBHP (ODMHSAS only) T1016 TG 19.55 Intensive - CMHC, CM II, BA (ODMHSAS only) T1017 TG 14.74 Age Targeted Case Management, CM III, SOC, LBHP level Targeted Case Management, CM II, SOC, MA/BA level Targeted Case Management, CM III, Intensive, CMHC, MA level Targeted Case Management, CM II, Intensive, CMHC, BA level Targeted Case Management, CM III, LBHP/MA level l l Targeted Case Management, CM II, MA/BA level Targeted Case Management, CM I, less than BA Targeted Case Management, PACT T1016 T1017 T1016 T1017 T1017 T1017 T1017 T1017 HE/HF/HV HE/HF/HV HE/HF/HV HE/HF/HV HE/HF/HV HE/HF/HV HE/HF/HV HE/HF/HV TF TF TG TG HO HN HM Daily Limits Monthly Limit Contract Type 16 56 ODMHSAS 16 56 ODMHSAS 16 25 ODMHSAS 16 25 ODMHSAS 16 25 110 - OPBH 16 25 110 - OPBH 16 25 110 - OPBH 16 56 ODMHSAS 0-20 0-20 18 - 999 18 - 999 0 - 999 0 - 999 0 - 999 18 - 999 Always use the rates and code sheet Modifiers 1st Position Modifiers HE Mental Health HF Substance Abuse HH Integrated MH & SA HV Gambling 2nd Position Modifiers TF Low Complexity TG This modifier is multipurpose: Complex/high level of care for CALOCUS Targeted CM HN This modifier is multipurpose: Bachelor Level designation for CM Psychotherapy codes only: CADC (HN to signify CADC is sometimes required in 2nd and in other situations 3rd.) HS F il th Family therapy without ith t patient ti t presentt HR Family therapy with patient present HQ Group HL Intern Program HP Doctoral Level HO LBHP 3rd Position Modifier HN CADC TF ODMHSAS HK Specialized Program (PACT) Modifiers are required to be listed in the correct position in order for claims to be paid in a correct manner. Incorrect positioning of a modifier may lead to an incorrect payment and result in a recoupment. This next part is . . . . Who is Case Management for? “persons p under age g 21 who are in imminent risk of out-of-home placement for p psychiatric y or substance abuse reasons or are in out-of-home placement due to p psychiatric y or substance abuse reasons and chronically and/or severely mentallyy ill adults who are institutionalized or are at risk of institutionalization” Strengths based model of case management Policy says: “In order to be compensable, the service must be performed utilizing the ODMHSAS Strengths Based model of case management. management.” United States Department of Health and Human Services,, Substance Abuse and Mental Health Services Administration A Life in the Community for Everyone: Behavioral Health is Essential to Health, Prevention Works, Treatment is Effective, People Recover. SAMHSA Defines Recovery Recovery From Mental and Substance Use Disorders: A process of change through which individuals improve p their health and wellness, live a self-directed life, and strive to reach their full potential. Guidingg Principles p of Recovery: y * * * * * * * * * * Recovery is person-driven. Recovery occurs via many pathways. pathways Recovery is holistic. Recovery is supported by peers and allies. Recovery is supported through relationships and social networks. Recovery is culturally based and influenced. influenced Recovery is supported by addressing trauma. Recoveryy involves individual,, family, y, and community strengths and responsibility. Recovery is based on respect. R Recovery emerges from f hope. h More in policy: “Behavioral case management: ◦ Promotes recovery; ◦ Maintains community tenure; and ◦ Assists individuals in accessing services for th themselves.” l ” Love this statement in the policy Per p policy: y “This model assists individuals in identifying and securing the range of resources, environmental and personal, p needed to live in a normally p wayy in the community.” y interdependent CM service plan development is billable. b ll bl The policy Th li states: “The “Th individual i di id l plan l off care must be developed with participation by, as well as, reviewed i d and d signed i d by b the h member, b the h parent or guardian (if the member is under 18), the h behavioral b h i l hhealth l h CM, CM and d a LBHP as defined at OAC 317:30-5-240” for it to be compensable bl Licensed Behavioral Health Practitioner’s Role in CM In order to obtain an authorization for case management, the LBHP needs to complete a BH assessment. This is a requirement for anyone to receive Medicaid compensable services. As a case manager you may not be able to change the world, but you can change the world for one person. Service Plans “The The service plan must include general goals and objectives pertinent to the overall recovery needs of the member. member” It is OK for the service plan to be written in the member’s member s words. words It needs to be a therapeutically meaningful process ffor the h member. b It I is i the h member’s b ’ plan l and it is being developed for them. “If you give a man a fish he eats for a day, teach them how to fish and they eat forever” SoonerCare reimbursable behavioral health case management services include the following: ( ) Gatheringg necessaryy psychological, (I) py g educational, medical, and social information for the purpose of service plan development. (II) Face-to-face meetings with the member and/or the pparent/guardian/family g y member for the implementation p of activities delineated in the service plan. (III) Face-to-face meetings with treatment or service providers, necessaryy for the implementation p of activities delineated in the service plan. (IV) Supportive activities such as non face-to-face communication with the child and/or pparent/guardian/family g y member. (V) Non face-to-face communication with treatment or service providers necessary for the implementation of activities delineated in the service plan. p Specific Case Management Activities ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Needs Assessment Service Plan Development Referral Linkage Advocacy Follow-up Monitoring Outreach Crisis Diversion New as of 3/3/2010 Crisis diversion (unanticipated, (unanticipated unscheduled situation requiring supportive assistance, faceto-face or telephone telephone, to resolve immediate problems before they become overwhelming and severely impair the individual individual'ss ability to function or maintain in the community) to assist member(s) from progression to a higher level of care. Case management crisis diversion is different than crisis intervention. 317:241.4-241.4 Crisis 317:241.4Intervention I i [Issued [I d 04 04--01 01--09] (1) Definition. Crisis Intervention Services are for the purpose of responding to ac te beha acute behavioral i ral orr em emotional ti nal dysfunction d sf ncti n as evidenced e idenced bby psychotic, s ch tic suicidal, s icidal homicidal severe psychiatric distress, and/or danger of AOD relapse.The crisis situation including the symptoms exhibited and the resulting intervention or recommendations must be clearly documented. (2) Limitations. Crisis Intervention Services are not compensable for SoonerCare members who reside in ICF/MR facilities, or who receive RBMS in a group home or Therapeutic Foster Home. CIS is also not compensable for members who experience acute behavioral or emotional dysfunction while in attendance for other behavioral health services, unless there is a documented attempt of placement in a higher level of care.The maximum is eight units per month; established mobile crisis response teams can bill a maximum of sixteen units per month, and 40 units each 12 months per member. New as of 3/3/2010 (VIII) Transitioning from institutions to the community. Individuals ( (except individuals d d l ages 22 to 64 who h reside d in an institution ffor mental diseases (IMD) or individuals who are inmates of public institutions) may be considered to be transitioning to the community during the last 60 consecutive days of a covered, covered long-term, institutional stay that is 180 consecutive days or longer in duration. For a covered, short term, institutional stay of less ess than t a 180 80 consecutive co secut ve days, ays, individuals v ua s may ay be co considered s e e to be transitioning to the community during the last 14 days before discharge. These time requirements are to distinguish case management services that are not within the scope of the i i i ' di institution's discharge h planning l i activities i i i ffrom case management required for transitioning individuals with complex, chronic, medical needs to the community. Transition Case Management Excludes individuals ages 22 to 64 who are on a psychiatric inpatient unit (IMD) or inmates of public institutions. Individuals may be considered transitioning the last 14 days before discharge of a stay that is less than 180 consecutive days. days Individuals may be considered transitioning the last 60 days of a covered covered, long-term institutional stay that is 180 days or longer in duration. Exclusions SoonerCare members who reside in nursing facilities, residential behavior management g services, group g p or foster homes, or ICF/MR's may not receive SoonerCare compensable p case management services. This includes DHS and OJA children who are in their custody. custody Case Management Indirect S Services: i With regard to the TCM rates, CMS has shown a trend across g in the states of not reimbursingg for “indirect case management” situations where the case manager spends time preparing the actual assessment document and the service plan paperwork. Our state plan does refer to “indirect case management” but those services are intended for the time that the case manager is not face to face with the actual client, but is spending time speaking with family members, other health care providers, etc. that can provide information about the client. These research activities are considered reimbursable. reimbursable The model assumptions upon which the rate is based include 10% for administrative and/or management costs. This accounts for overhead and the other administrative duties such as the time it takes to prepare the assessment and/or service plan documents. documents Case Management Travel Time: With regard to the question on travel time, when the rate was re-calculated, re calculated travel time was built into the average length of face to face time spent with a member (i.e. the rate assumes that the case manager will ill spend d some amountt off time ti traveling to the member for the face to face service). The case manager should only bill for the h actuall face f to face f time i that h they h spend d with ih the client providing actual CM services & not bill for “windshield time”. This would be considered duplicative billing since the rate assumes the travel component already. Reimbursable case management does not i l d include: ( ) pphysically (I) y y escortingg or transporting p g a member to scheduled appointments or staying with the member during an appointment; or ((II)) monitoringg financial goals; g or (III) providing specific services such as shopping or paying bills; or ((IV)) deliveringg bus tickets, food stamps, p money, y etc.; or (V) services to nursing home residents; or (VI) counseling or rehabilitative services, psychiatric assessment, or discharge; g ; or (VII) filling out forms, applications, etc., on behalf of the member when the member is not present; or ((VIII)) fillingg out SoonerCare forms,, applications, pp , etc.,, or;; (IX) services to members residing in ICF/MR facilities. From p policy: y The relationshipp between the member and the behavioral health case manager is y collaboration, and characterized byy mutuality, partnership. Remember: It is your job to empower them not to enable them! Documentation of records All behavioral health case management services rendered must be reflected by documentation in the records. In addition to a complete behavioral health case management service plan documentation of each session must include, but is not limited to: (1) date; (2) person to whom services are rendered; (3) start and d stop times i for f eachh service; i (4) original signature of the service provider (5) credentials of the service provider; ((6)) specific p service plan p needs,, ggoals and/or objectives j addressed;; (7) specific activities performed by the behavioral health case manager on behalf of the member related to advocacy, linkage, referral, or monitoring used to address needs, goals and/or objectives; ((8)) pprogress g or barriers made towards goals g and/or objectives; j (9) member (family when applicable) response to the service; (10) any new service plan needs, goals, and/or objectives identified during the service; and ((11)) member satisfaction with staff intervention. Primary Care Physicians Network with p physician’s y offices. Let them know that you are available to assist them with anyone y who needs BH services. We are encouraging physicians to routinelyy screen for psychiatric py problems: substance misuse, abuse, dependency, p y emotional and other behavioral health problems. What Irks Primary Care Physician No responses back when they refer a patient. Long responses that use mental health jargon. Lack of explicit p recommendations theyy can act on. No response p to a medical record/release of information request. Long delays in getting the patient seen for an initial consult. Medicare's 8 Minute Rule Actual Time 8 Minute Rule Minimum and Maximum Times 1 unit it = 15 8 minutes i t tto 22 minutes i t 2 units = 30 23 minutes to 37 minutes 3 units = 45 38 minutes to 52 minutes 4 units = 60 53 minutes to 67 minutes 5 units = 75 68 minutes to 82 minutes 6 units = 90 83 minutes to 97 minutes 7 units = 105 98 minutes to 112 minutes 8 units = 120 113 minutes to 127 minutes 9 units it = 135 128 minutes i t tto 142 minutes i t 10 units = 150 143 minutes to 157 minutes 11 units = 165 158 minutes to 172 minutes 12 units = 180 173 minutes to 187 minutes Units Questions, Q i comments??
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