Kathy Nichols, LCSW DMA

1. Kathy Nichols, LCSW DMA 1915 (b)(c) Waiver Training Provider Network Operations January 2012

2. Network Analysis & Development

3. Closed Provider Network • The 1915 (b) Waiver permits you to operate a closed network where providers offer services in a balanced marketplace • When additional capacity is needed in a particular service area the LME-MCO can look within the Network to meet that need first

4. Provider Network Operations 6.4 - Accessibility of Services: • _________ shall establish and maintain a Provider Network with a sufficient number, mix, and geographic distribution of Providers to ensure that medically necessary Covered Services are delivered in a timely and appropriate manner, according to the Access Standards specified in Attachment T and elsewhere in this Contract.

5. Provider Network Analysis SOW 6.4 • Numbers and types of Providers required to provide the contracted services, including training, experience, and specialization • The # of providers who are not accepting new referrals • The geographic locations of Providers and recipients, considering travel distances, travel times, means of transportation, and physical access for Recipients with disabilities • Submit to DMA written reports of findings of the Provider Network analyses. • Submit to DMA a network development plan (when gaps are identified)

6. Development of your Community Needs Assessment The Community Needs Assessment should: • Include a representative sample from your entire community; • Include a clear explanation about the purpose of the assessment; • Include individuals and families receiving care, local provider agencies, public agencies, consumers who are not receiving care; • Also include a Gap Analysis or Gap In Services section.

7. Rural Area Definition • The Census Bureau’s urban-rural classification is fundamentally a delineation of geographical areas, identifying both individual urban areas and the rural areas of the nation.  The Census Bureau’s urban areas represent densely developed territory, and encompass residential, commercial, and other non-residential urban land uses.  The Census Bureau delineates urban areas after each decennial census by applying specified criteria to decennial census and other data. • The Census Bureau identifies two types of urban areas: • Urbanized Areas (UAs) of 50,000 or more people; • Urban Clusters (UCs) of at least 2,500 and less than 50,000 people. • “Rural” encompasses all population, housing, and territory not included within an urban area.

8. Provider Choice • 6.8 - Choice of Health Professional: • To the extent reasonably possible, the LME MCO shall offer freedom of choice to Enrollees in selecting a Provider from within the qualified Provider Network • Choice of 2 • Can get written waiver for DMA for specialties

9. Out-of-Network Providers SOW 6.4 • If specialty services are Medically Necessary but are not available in-network, arrange for these services to be provided out-of-network SOW 6.3 & 6.18 • Pay for ED and out-of-network emergencies without prior authorization. Should meet the definition of “Emergency Behavioral Health Services” (Attachment I)

10. Types of Providers Attachment P • Agency based providers • Specialty Providers • CABHAS • Licensed Practitioners and Professional Practice Groups

11. Provider Selection SOW 7.7, 42 C.F.R. 438.214 • Written policies and procedures for the selection and retention of Network Providers. • During the initial year (initial enrollment period) of the DMA contract, WHN is required to extend a Provider contract to all Medicaid providers in good-standing with NC Medicaid. • Shall not employ or contract with Providers excluded from participation in Federal health care programs

12. Provider Selection SOW 7.7 • Can use different reimbursement amounts for different specialties or for different practitioners in the same specialty; • First three years of operations, maintain state-established rates for ICF-MRs • First year of operations, must use DMA rates for State facilities (hospital, ICFs-MR, PRTF)

13. Network Provider Enrollment • Contract Attachment P outlines provider enrollment requirements. • Agency-based providers • Valid NC license • Application completion • Disclosure of sanctions and pending actions with Medicare/aid • Disclosure of previous business • Ownership • Identification of Board members • Affiliations with other providers • 2 references • “No-reject” policy

14. Network Provider Enrollment • Agency-based provider enrollment requirements (cont.) • Demonstration of competency • Participation in web-based billing • Consumer-friendly • Clinical infrastructure • Capacity for emergency response • Fiscal responsibility • Appropriate insurance • Ability to provide services as outlined in Medicaid Clinical Coverage Policy, Section 8 and Innovations waiver • Qualifying review

15. Network Provider Enrollment • Licensed practitioners • Valid NC license • Original source verification • Insurance coverage • Participation in web-based billing • Appropriate back-up clinician • Provide requested specific clinical and background information • Disclosure of sanctions and pending actions with Medicare/aid

16. Applications Application Types: Provider enrollment application Practitioner application (LIP app) Additional service application Additional site application Hospital Inpatient Billing Application

17. Provider Enrollment Application Packet Provider Corporate Endorsement and Service Application • Self Assessment for Application • Network Enrollment Policy and Procedure Review Form • Cultural, Racial, Ethnic, Gender and Linguistic Data Form • Practice Preference Data Form

18. Practitioner Application (LIP App) • Uniform Application to Participate as a Health Care Practitioner with Attestation Statement • LIP Cultural, Racial, Ethnic, Gender, and Linguistic Data Form • Two (2) Practitioner Evaluation Forms • Practitioner has a maximum of 60 days to submit the completed application packet • Upon receipt, application is reviewed for completeness by the Credentialing Specialist • If complete, the application is submitted to the credentialing process. • Practitioner must be Credentialed to move forward in the Contract Process

19. Application/Policy & Procedure Review Process • Provider Agency has a maximum of 60 days to submit the completed application packet • Background checks. • Reviewed for completeness of the applications • Any application that is missing information will be returned to the provider to complete all missing section(s) identified. • Application(s) that pass application completeness check will be scheduled for official review.

20. Application/Policy & Procedure Review Process • Review the Policy & Procedure Section(s) of the packet. • Complete a Health & Safety inspection of the provider’s sites • Packet is complete and can be approval/denial. • Once the request is approved the Provider will be notified that their request has been approved.

21. Corporate Endorsement • For Providers with Corporate HQTRS within LME MCO catchment: • Verification of Info registered with local municipality and/or NC Secretary • Verify that criteria for conducting business has been met • Verify Corporate endorsement issued by other LMEs – Notice of Endorsement Action (NEA Letters)

22. Credentialing • 7.6 - Credentialing: • Subject to DMA’s prior review and written approval, the LME MCO shall adopt and implement written policies and procedures governing the qualification, credentialing, re-credentialing, accreditation, and re-accreditation of its Network Providers. • Maintain records of credentialing activities • Routinely monitor the licensure, certification, registration, and accreditation status of its Network Providers.

23. Credentialing Practitioners and Groups • All Licensed Independent Practitioners must be credentialed to participate in the Network • Provisionally Licensed Practitioners are only credentialed if they are a part of a contracted Agency or LIP Group Practice • Exceptions • Psychiatrist who provide services exclusively in the inpatient setting are not required to be credentialed. • These psychiatrists must still submit an LIP application to be eligible for reimbursement.

24. Credentialing Practitioners • Primary Source Verifications • Licenses • DEA and CDS Certificates • Education and Training • Board Certifications • Malpractice Insurance • Liability Claims History • Criminal Background Check • State Sanctions, Restriction on license - limitations on scope of practice • Medicaid/Medicare Sanctions (NPDB & HIPDB) • Clean File • Credentialing Committee

25. Contract Process • After provider has receive Endorsement/LIP has been Credentialed: • Trading Partner Agreement (Online) • Contract Development Flow sheet • Contract formulated from template • Specific Contract Language: Reimbursement, rates, caps, Designated Funding Agreements, and Program Specific Authorizations – Finance

26. Contract Process • After provider has receive Endorsement/LIP has been Approved services, approved sites, specific programs and grants must be listed on a separate contract attachment • The Finance Department reviews and certifies the contract has been pre-audited • Two copies of the final contract are sent to the Provider/Practitioner • Contract is not considered executed until provider signs and returns both copies and is then signed by the LME CEO

27. Contract • Contract • Approved by Secretary of Health and Human Services • Evergreen (reviewed by the AG’s Office) • Consists of: • Main Contract with signature page • General Conditions of the Contract • Attachments • Operations Manuals • Provider Manual • Communication Bulletins • Amendments

28. Contracts • Types of Contracts: • Agency • LIP • Individual Practice • Group Practice • Hospital • Inpatient • Outpatient and/or Professional Services • Client Specific Contracts • Consumers served out of catchment area • Specialized consumer needs

29. Provider Monitoring • A provider’s performance shall be routinely measured through _________ Monitoring and through the Continuous Quality Improvement Process. _________ must utilize the state provider rating (report card) system in coordination with DMA and other state _________s.

30. Provider Monitoring • New providers placed on provisional status for 90 days • Routine status after 90 days Implementation Review and billing audit with minimum score of 75% • Routine – meeting compliance based standards only • Advanced placement potential after one year of service provision

31. Gold Star Process (continued) • Provider submits self assessment review for advanced placement

32. Gold Star Process (continued) • Providers scoring below 100% are required to submit a plan of correction • Providers scoring below 75% are evaluated 6 months after the review to ensure compliance with the plan of correction

33. Provider Manual • 7.8 - LME MCO shall develop, maintain, and distribute a Provider manual that provides information and education to Providers. This distribution may occur by making the manual available electronically on its website. DMA shall have the right to review and approve the Provider manual prior to its release. The manual shall be updated at least annually.

34. Provider Manual • At a minimum, the Provider manual shall cover the areas listed below. • Purpose and mission; • Treatment Philosophy and Community Standards of Practice; • Behavioral health Provider Network requirements, including: nondiscrimination, on-call coverage, credentialing, re-credentialing, access requirements, no-reject requirements, notification of changes in address, licensure requirements, insurance requirements, and required availability; • Appointment access standards; • Authorization, utilization review, and care management requirements;

35. Provider Manual • Care Coordination and discharge planning requirements; • Documentation requirements, as specified in APSM 45-2 or as required by the Physician’s Services Manual; • Provider appeals process; • Complaint investigation and resolution procedures; • Performance improvement procedures, including at a minimum: Recipient satisfaction surveys; Provider satisfaction surveys; clinical studies; incident reporting; and outcomes requirements; • Compensation and claims processing requirements, including required electronic formats, mandated timelines, and coordination of benefits requirements; and • Patient rights and responsibilities.

36. Questions?