Eastpointe March Provider Meeting

1. Eastpointe March Provider Meeting Eastpointe March 16, 2016 10:00am until 1:00pm Webinar

2. Agenda Welcome and Overview Karen Salacki Eastpointe Provider Network Council Barry Dixon Slot Scheduler & Appointment Follow Jamie Lewis Up Form Henry Harris Utilization Management Updates Lynnette Gordon External Operations Updates Karen Salacki

3. Agenda (cont.) Update on Innovations Slots Becky Cale And Registry of Unmet Needs IPRS Contracts Dennis Murphy Quarterly Alpha Portal Anita Testino User Security Audit Claims and Funding Services Tammy Powers

4. Agenda (cont.) Disaster Behavioral Health Tiffany Purdy Response Plan First Commitment Waiver Lynn Winstead Network Operations Updates Linda Hawley Isbell Provider Meeting Topics Listserve Next Provider Meeting Karen Salacki

5. Welcome and Overview

6. Eastpointe Provider Network Council Barry Dixon Eastpointe Provider Network Council

7. Eastpointe Provider Network Council • For Council Information: Go to www.eastpointe.net, then For Provider Community, the Eastpointe Provider Network Council Information • Contact Information: providercouncil@eastpointe.net

8. Slot Scheduler and Member Appointment Follow Up Form Training (Recording) Jamie Lewis and Henry Harris

9. Utilization Management (UM) UpdatesLynnette Gordon, LPC, LCASDirector of UM lgordon@eastpointe.net

10. IPRS Guideline Reminders for July 2015- June 2016 • SAIOP • One time episode per fiscal year • Max three months per fiscal year • CASP funded programs may request more time up to length of their program. • SACOT • One time episode per fiscal year • Max four months per fiscal year • CASP funded programs may request more time up to length of their program. • If SAR Auth guidelines indicate financial eligibility please attach the document utilized to determine IPRS eligibility during intake

11. IPRS Guideline Reminders for July 2015- June 2016 • CST • Decreased amount of time per fiscal year- 6 months • Max 6 months per fiscal year with no additional time • Provider needs to submit documentation of working with the member for Medicaid eligibility • ACTT • Add to benefit plan that there needs to be documented evidence of applying for Medicaid • No new ACTT members except if involved with the transition to community living program.

12. IPRS Guideline Reminders for July 2015- June 2016 • PSR • Max 30 hours a week. This is a decrease from 40 hours a week • Auth periods up to 90 days • Residential Services • All requests need to include a detailed discharge/transition plan • Developmental Therapy • Provider will be able to request a 4 month auth instead of a 3 month initial. The max will remain the same of 4 months per fiscal year.

13. IPRS Guideline Reminders for July 2015- June 2016- IDD IPRS Requests • For all requests please include the following: • Specific detailed progress on how the member has been doing with the goals since the last review • Transition/Discharge plan for all residential services • Updated SNAP score if appropriate and if changes to SNAP from the previous SNAP please include summary regarding need for update

14. Medicaid Denial Letters • Effective March 1, 2016, the Alpha system generates the Medicaid Adverse Decision and Appeal Letters. • The following letters are viewable in the Service Tile under the Denial Letter button: • Full Denial Letter for Adult and Child • Partial Denial Letter for Adult and Child • Administrative Denial Letter • Please note that the peer to peer memo and all IPRS letters will continue to be posted in the Provider Communication Tile.

15. Important Reminders for SAR submission • A SAR should be submitted on or before the start date for the requested service. UM does not back date requests unless it is related to retroactive Medicaid eligibility and initial Medicaid inpatient services. See the appropriate service definition for information regarding prior approval. • Level of Care needs to be completed • LOCUS/CALOCUS/ASAM/SNAP • If Substance use indicated, please include • last reported use and drug screen (if applicable, for example it may be a part of programming such as SAIOP) • How each dimension of the ASAM criteria is met Contact phone number and email for person submitting SAR to be included in SAR Justification section

16. Reminders • A request in saved status will not be processed by UM, request needs to be in submitted status • List current medications and medication adherence • Complete the correct Level of care with enough detail to support medical necessity • Please check the Provider Communication section for any notes back from UM • Discharge SARs do not need to be submitted • If discharging a member from service, please complete a client update enrollment

17. Administrative Denials • Please submit all required documents with request, requests may be UTP or Administratively denied based on the appropriate service definition and/or record manual requirements. • For example if Clinical Coverage policy indicates that PCP updates are needed for continued stay then make sure to submit the PCP with the updates. • If the request is submitted without the PCP for the example above then the request may be administratively denied. • If an administrative denial is issued, the member will be sent a letter with appeal rights • The member/guardian will need to complete and submit a signed reconsideration appeal form per the instructions included with the letter and additional information to be considered during the appeal process. • The member/guardian may designate in writing a provider or someone else to help with the appeal.

18. UM Resources • Medicaid Clinical Decision Support Tools for Behavioral Health • http://www.ncdhhs.gov/dma/mp/index.htm • EPSDT Information • http://www.ncdhhs.gov/dma/epsdt/index.htm • IPRS Clinical Decision Support Tools • http://www.ncdhhs.gov/mhddsas/providers/servicedefs/index.htm • Records and Documentation Manual • http://www.ncdhhs.gov/providers/provider-info/mental-health/records-management

19. Discharge Requests • If a member is no longer in service, please make sure to complete the service only discharge in alpha. Do not complete a discharge SAR. • Refer to Alpha University under Clinical/ Discharge Requests

20. Urgent/Expedited Requests • The following services are urgent levels of care: • Inpatient Hospitalization • Facility based crisis • Non-Hospital detox • Mobile Crisis • Partial Hospitalization • Health and safety of member is jeopardized • Documentation for health and safety needs to be documented in SAR or may verbally contact and provide information if SAR already submitted. Major life change examples could be recent hospitalization, incarceration, children in services being displaced from home environment or deterioration of functioning and members unable to maintain or regain functioning. Information regarding major life change needs to be clearly documented in the Service Authorization Request (SAR).

21. Urgent /Expedited Requests • The excessive number of requests slows down the UM processing timeframes due to having to touch each SAR to determine that there is or is not a health and safety concern. • Please utilize and document health and safety concerns on a expedited requests

22. Reminders for Submitting Documents • Clearing out the browser history first before starting a new SAR may assist with attaching documents • When scanning documents to attach, please scan to the lowest resolution and submit the lowest resolution • Multiple documents can be submitted

23. Adding additional documents after request submitted • If request submitted, additional documents requested for that SAR in review can be submitted through utilizing the Provider Communication tile. • Click create • Select Comment Type • Write a note for reason for attaching • Click upload and select your document • Please do not submit additional information in the provider communication tile if the request has already been approved, denied, unable to process or in peer review status.

24. Contact Information • Network Operations Call Center: • 1-888-977-2160Network Operations Call Center staff will forward question to the appropriate UM staff to assist if additional information needed • Lynnette Gordon, UM director • lgordon@eastpointe.net • 910-298-7036 • Requesting a peer to peer • 1-888-977-2160 • Requesting a copy of the clinical rationale • 1-800-513-4002 option 3

25. External Operations Updates

26. Eastpointe’s Provider Network • Our Provider Network is closed for Medicaid and IPRS. • We are only accepting applications for Medicaid services for Psychiatrists in private practice and Hospitals. Agencies may add an Outpatient Therapist. • For further clarification please contact Network Operations.

27. Eastpointe Provider Network • If you are requesting to add an Outpatient Site you must follow the Add a Site process. • Please remember that you cannot open a new Outpatient site until you receive an approval letter from Network Operations. • Please remember that an Licensed Independent Practitioner (LIP) cannot provide services to an Eastpointe member until they have been Credentialed.

28. Re-Credentialing

29. Who has to be Re-Credentialed? • Licensed Independent Practitioners (LIP’s) who only provide basic benefit outpatient therapy services covered under Clinical Policy 8C who have their own contract or work for an agency. • If an LIP provides bothbasic benefit outpatient services covered under Clinical Policy 8C and other services they will need to be Re-Credentialed.

30. Who has to be Re-Credentialed? (cont.) • If an LIP only provides services other than basic benefit outpatient services they do not have to be Re-Credentialed. For example if an LIP currently provides SAIOP or ACTT.

31. Re-Credentialing (cont.) • If an agency wants to request the Re-Credentialing status of an LIP who works for them they must submit a Release of Information that includes all of the following: • LIP’s Name • Date of Birth • Last four numbers of their social security number • Signature of the LIP

32. Re-Credentialing (cont.) • The only information that will be released to the agency is the following: • If the application has not been received • If Eastpointe has requested follow up information from the LIP once and it has not been received. • If Eastpointe has requested follow up information from the LIP multiple times and it has not been received. • If the LIP is not a credentialed provider in our network.

33. Nurse Practitioners providing Outpatient Therapy and Medication Management

34. Local and State Updates

35. Update on Innovations Slotsand Registry of Unmet Needs Becky Cale, I/DD Clinical Director

36. Eastpointe Innovations Slots • Total Number of Innovations Slots for Waiver Year 8/1/15 to 7/31/16= 1,306 • 1,290 “Regular” Innovations Slots • 9 Money Follows the Person (MFP) Slots • 2 allocated, 2 active • 7 available • 6 Emergency Slots • 4 allocated, 4 active • 2 available • 1 CAP-C Age-Out Slot • 1 available

37. Waiver Year To Date • As of 2/28/16, Active Slots= 1,225 • 18 Terminations 8/1/15 to 2/28/16 • Death= 9 • Change in Level of Care= 4 • Moved from state= 2 • Refused services= 2 • Medicaid Terminated= 1 • Transfers to other MCOs 8/1/15 to 2/28/16= 8 • Transfers from other MCOs 8/1/15 to 2/28/16= 1

38. Turnover Slots • Filling 101 Turnover Slots • Bladen= 3 • Columbus= 1 • Duplin= 9 • Edgecombe= 7 • Greene= 2 • Lenoir= 4 • Nash= 20 • Robeson= 13 • Sampson= 13 • Scotland= 3 • Wayne= 20 • Wilson= 6

39. Turnover Slots Status • Processed 143 individuals as of 3/10/16 from the Registry of Unmet Needs (RUN) • Number Currently Allocated= 101 • Number Active= 61 • Various stages of eligibility process= 40 • Number uninterested in waiver slot now, remain on RUN= 11

40. Turnover Slots Status- continued • Number removed from the RUN= 31 • 16 no response to written correspondence (14 day and 30 day letters) • 6 Guardian uninterested in the Waiver • 5 Level of Care denied, no appeal/reconsideration requested • 2 psychologist denied LOC and guardian declined second opinion • 1 deceased • 1 moved to another MCO area, Referral Date transferred to the other MCO’s RUN

41. Registry of Unmet Needs (RUN) • 751 on the Registry as of 2/28/16 • 64 or 9% receiving B3 services • 227 or 30% receiving State Funded services • 291 or 39% receiving State and/or B3 Services • 460 or 61% receiving no state or B3 Services • Of these 460 individuals, there are individuals receiving Medicaid reimbursable services

42. Registry of Unmet Needs- continued • 762 on the Registry as of 1/31/16 • 63 or 8% receiving B3 services • 230 or 30% receiving state funded services • 69 or 9% receiving Medicaid services • 362 or 48% receiving State, Medicaid and/or B3 services • 400 or 52% receiving no Medicaid, state, or B3 Services

43. IPRS Contracts Dennis Murphy

44. Quarterly Alpha Portal User Security Audit Sponsored by: Management Information Systems (MIS)of Eastpointe

45. Eastpointe MIS Department is conducting a Portal User audit as part of a HIPAA Security check to ensure that all our members data is secure and is accessible to the appropriate portal users.

46. Each Security Representative will be contacted by a MIS Department staff to validate Provider information. Please look for an email from us regarding this as this is a Time Sensitive matter.

47. TIME FRAME FOR AUDIT We will performing this audit during the month of March and will begin performing these on a quarterly basis. We THANK YOU for your help and cooperation in completing this as it will help us to help you.

48. Eastpointe Claims and Funding Services

49. March

50. Listserve Announcements February 25, 2016 Time limit override cut-off for FY15 Medicaid funded claims is March 31, 2016. After March 31, 2016 Eastpointe will no longer review claims with dates of service 7/1/14-6/30/15 for time limit overrides. March 1, 2016 Attention Hospital Providers Effective March 1, 2016, self administered drugs when administered during an outpatient hospital visit, are not payable by Eastpointe under Medicaid covered services.