Wake LME Provider Training

1. September 21, 2009 1 Wake LMEProvider Training

2. Agenda 2 FY10 Outlook Goals for FY10 Service Provision How Can Providers Help New Access/STR Center (moved earlier on agenda) CMHSA Consumer Groups & Benefit Plan DD Consumer Groups & Benefit Plan ASA Consumer Groups & Benefit Plan AMH Consumer Groups & Benefit Plan

3. Agenda, Cont. 3 Appeals Process Community Support Avatar Implementation Impact on Providers Direct Enrolled Clinician Input?

4. 4 FY10 Outlook

5. FY10 Outlook 5 Wake LME has had their State/Federal allocation reduced by $3.8 million. The impact of changes and reductions in Medicaid services is expected to be significant, but is unclear: Child Residential Community Support Case Management consolidation, rates, and definition Potential changes in other service definitions Increase in demand experienced in FY09 is expected to continue

6. 6

7. 7 Goals for FY10 Service Provision

8. Goals for FY10 Service Provision 8 The LME is committed to providing services to populations and consumer groups most in need Persons with major, chronic disorders, and those where there is a risk of harm, are the top priorities Clinically effective services and continuity of care for priority consumer groups are essential objectives

9. Goals for FY10 Service Provision 9 To manage the allocation reduction, consumers in the lower priority groups will be referred to community resources that are not reimbursed by the LME Where there are not adequate alternative services, lower priority consumers will be put on waiting lists Cost effective services will be emphasized

10. Goals for FY10 Service Provision 10 Consumer Groups and Benefit Plans are key to this plan It is important for Providers to train their clinical staff on the Benefit Plans, and to implement new models of care where necessary LME UR staff will assess clients to determine what Consumer Group they fall in

11. Goals for FY10 Service Provision 11 The LME will be gathering and analyzing data to make decisions regarding authorization of services for the lower priority groups: Numbers of consumers in each Consumer Group The array and frequency of services being provided to each Consumer Group The cost of services for each Consumer Group and average cost per client Number persons waiting for services by service type

12. 12 How Can Providers Help?

13. How Can Providers Help? 13 Understand that initial assessments may result in consumers who are not eligible for authorization and reimbursement from Wake LME. It is not possible to screen for clinical eligibility based on a short STR contact. If you received an authorization with the referral, you will be reimbursed for the assessment.

14. How Can Providers Help? 14 If the consumer does not meet criteria for IPRS funding, continued services will need to be supported from self pay or other sources, or you may transfer them to other appropriate community services. If providers will not accept self-pay consumers (who have the ability to pay), the LME may be forced to discontinue IPRS contracts. State funds are the payer of last resort.

15. How Can Providers Help? Cont. 15 Provide feedback to the LME on ways to make services more effective and efficient. Train your staff in brief therapy models; the Behavioral Health Collaborative will be developing training When beginning therapy, communicate a plan to the consumer for service reduction or discharge, in order to prevent an expectation of ongoing, long-term services. If there is time at the end, we’ll want to hear your ideas to cut costs and increase efficiency.

16. 16 Wake LME’sNew Access Center (STR)

17. What is Screening, Triage, and Referral? 17 Screening, Triage, and Referral (STR) is a required function of all LME’s.  STR is the LME’s doorway to mental health, developmental disability, and substance abuse services.  STR is a brief process, usually telephonic, to determine severity and where best to refer someone on for further clinical assessment , eligibility determination, and engagement in treatment.

18. What is Screening, Triage, and Referral? 18 STR determines whether a person’s needs are emergent, urgent, or routine. People with: emergent needs must be seen within 2 hours, urgent needs within 2 days, and routine needs within 2 weeks.  STR is available 24 hours a day, 7 days a week, 365 days a year.

19. Who does STR for Wake Co. LME? 19 The Access Center of Wake Co. LME does screening, triage, and referral for all new or inactive consumers seeking mental health, substance abuse, or developmental disability services. The Access Center’s ‘Call Center’ will be located at 3010 Falstaff Road. The Access Center’s ‘Walk In Center’ will be co-located with Crisis Services at 3000 Falstaff Road.

20. Who does STR for Wake Co. LME? 20 Once fully staffed there will be one Program Manager, 3 Supervisors, and 20.5 Access Specialists working rotating shifts to cover all hours of operation. A licensed professional must be on site at all times for consultation.

21. How do I contact Wake Co. LME’s Access Center? 21 Wake Co.’s STR Access numbers are: Local: 919-250-3133 Toll Free: 1-866-518-6784 TTY: 919-250-1499

22. Effective October 1, 2009 The changes for each Age/Disability will be highlighted. 22 Consumer Groups and Benefit Plans

23. Consumer Group Criteria Benefit Plan (see handout) 23 Child Mental Health and Substance Abuse

24. Consumer Group Criteria Benefit Plan (see handout) 24 Developmental Disabilities

25. Consumer Group Criteria Benefit Plan (see handout) 25 Adult Substance Abuse

26. Consumer Group Criteria Benefit Plan (see handout) 26 Adult Mental Health

27. Overview and Clarifications 27  Non-Medicaid Appeals

28. Authorization Decisions that Result in Appeal Notification 28 Denial – On an Initial Request, the service is determined not clinically necessary or not the appropriate level of care Reduction – Units authorized are less than requested Termination – Denial of a Continuing Request Suspension – Termination or Denial due to incomplete information from the Provider for clinical decision-making

29. Non-Medicaid Appeals 29 An appeal request can only be filed by the consumer, a legal representative of the consumer, or any other individual who does not have a conflict of interest and has been selected by the consumer and/or their legal representative Due to conflict of interest, the provider cannot initiate an appeal

30. Non-Medicaid Appeals 30 Non-Medicaid funded services are not an entitlement; therefore, a request for an appeal in no way guarantees the consumer the specified service regardless of the outcome of the review. Payment can be denied for services based on allowable limits in the Benefit Plan, or by other budgetary limitations of Non-Medicaid funding.

31. Non-Medicaid Appeals 31 As of 10/1/09, certain “administrative” reasons for UR decisions will not be subject to consumer appeal Examples include(but not limited to): The person does not meet defined Target Population eligibility for the service requested The provider failed to provide sufficient information in a timely manner to complete the review The provider, however, can submit a new request with additional or previously requested information for review

32. How Providers Can Prevent Unneccessary Letters 32 Prior to submission of requests: -Proofread for simple errors (service/units not indicated; omission of GAF, meds, attendance, leaving sections blank, etc.) -Refer to guidelines listed in the Provider Manual (Section III, p. 17) for all documents needed with the request to ensure a complete packet -Refer to the IPRS Benefits Package for the service being requested to ensure that what is being requested is consistent with what is allowable

33. How Providers Can Prevent Unnecessary Letters 33 Ensure that the documentation submitted provides clinical information that supports service being requested Be mindful of authorization timeliness guidelines for all paperwork Consult your Care Manager if clarification is needed regarding the additional information requested Notify your Care Manager when a pending authorization is no longer needed

34. Brief update on status of changes 34 Community Support

35. Community Support Legislative mandate to end Community Support Official Communication in Implementation Update #60

36. Community Support Effective Oct 12 No New Admissions for CS The paraprofessional (PP) level of Community Support will be eliminated CS cannot be billed if consumer is receiving other enhanced services (except CMH Res Tx.) “Clinical Home” responsibilities transition to other enhanced service providers

37. Community Support Effective September 28, 2009, qualified professional level (licensed professional and qualified professional) Community Support may be provided to a child in Residential Level III and IV to assist in discharge planning. The qualified professional may provide up to a maximum of 96 units (24 hours) of case management functions over a 90-day authorization period as approved by Value Options or the LME.

38. Community Support Effective June 30, 2010, Community Support services will not be a covered service under the NC State Medicaid Plan. Requests for Community Support services for children must follow the established EPSDT process

39. Community Support Any Community Support provider that ceases to function as a provider shall provide written notification to DMA, the LocalManagement Entity, recipients, and the prior authorization vendor 30 days prior to closing of the business. Medical and financial record retention is the responsibility of the provider and shall be in compliance with the recordretention requirements of their Medicaid provider agreement or State funded services contract. Records shall also be available to state, federal, and local agencies.

40. Wake’s New Computer System Preview of Changes Effective Jan. 1, 2010 40 Avatar Implementation

41. Changes to Consumer Enrollment, Authorization and Claims Processing 41 Looking Ahead Wake LME is changing from the UniCare software system to NetSmart Avatar & CareLink effective Jan 1, 2010. Terms and Definitions NetSmart – the company behind Avatar and CareLink. Avatar – practice management and managed service organization software, which includes client data, authorizations, and claims processing.

42. Terms and Definitions 42 CareLink – web-based portal for providers affiliated with an LME using Avatar, which includes: access client demographic data and authorization request authorizations and monitor authorization status, transfer electronic documents to and from the LME regarding clients/authorizations, submit and bill treatment services against an authorization for payment

43. Terms and Definitions 43 Calcium – Web-based calendar, not associated with NetSmart, used by Providers to indicate available intake appointments, and used by Wake LME STR/Access Center to schedule appointments for new clients with their chosen provider, 24/7.

44. Changes in how and what consumer information is submitted for new enrollments: 44 Screening, Triage, and Referral (STR) will become the responsibility of Wake LME’s new Access Center (and no longer provided by CAS) starting January 1, 2010. Providers seeing new consumers can either: (1) contact the Access Center by phone (available 24/7) for an STR with the consumer present OR (2) complete an STR (using the State form) and submit to the Access Center. NOTE: STR is not a reimbursable service. The Access Center staff will obtain from the consumer or Provider the information required on the State’s STR form.

45. Changes in how and what consumer information is submitted for new enrollments: 45 The Access Center will issue a Referral Authorization to the Provider via CareLink. If the Access Center is initiating the referral, the appointment will be entered in the Calcium calendar. Around Jan 1, Providers are to discontinue using Wake Demographic and Consumer Enrollment forms, and begin using the State’s LME Consumer Admission Discharge form (LCAD) instead.

46. Changes in how authorizations are issued and requested: 46 Around Feb 1, instead of being submitted over fax machines, the LCAD form and Fee App will be submitted as electronic attachments to Authorization Requests over CareLink. All IPRS providers will be issued a User ID and password to access the CareLink system on the web.

47. Changes in how authorizations are issued and requested: 47 Providers will receive training on the use of CareLink in late January 2010. Providers will begin requesting authorizations via CareLink about Feb 1, 2010, instead of on the paper Service Authorization Request form. Providers will be able to submit clinical information by attaching Word documents or scanned PDF files to the authorization request.

48. Changes in how claims are submitted and processed: 48 Starting in Jan. 2010, Providers will have a choice of entering claims through CareLink or submitting claims electronically (837). Claims submitted via CareLink will be entered after selecting the appropriate authorization – CareLink will not allow entry of a service that falls outside of the limits of the authorization.

49. Changes in how claims are submitted and processed: 49 Receipt of an 837 will be acknowledged. Providers will receive payment the same as currently. Providers will receive an EOB in a different format than currently. Providers who submit claims via an 837 will receive an 835.

50. How the transition will be managed: 50 December and prior dates of service are to be submitted the old (current) way by Jan 8, 2010. ALL claims submissions after that date will be either through CareLink or 837. Hold January claims until after you receive your CareLink training, in the third or fourth week of January. During the month of January, the LME will be processing 2009 claims through UniCare and closing out that system. The LME will also be ensuring all clients and authorizations are set up in Avatar.

51. How the transition will be managed: 51 During January, Providers may still request and receive authorizations by fax or drop off/pick up, while this transition is taking place. Around Jan 1, Providers are to discontinue using Wake Demographic and Consumer Enrollment forms, and begin using the State’s LME Consumer Admission Discharge form (LCAD) instead. These authorizations will be generated by the new Avatar system. CareLink training will take place in the last half of January. Providers will be given a date on or around Feb 1, 2010, to begin accessing and requesting authorizations via CareLink, and submitting claims via CareLink or 837.

52. 52 Starting Now – Info Needed on Direct Enrolled Clinicians

53. New direct enrolled clinician information requirements 53 Providers will need to complete a web based survey to submit information on professional clinicians. A link will be emailed to the manager you designate today with the LME for this purpose. Entry may begin October 15, one survey per applicable staff member. Current staff must be entered by November 15, 2009

54. Which staff must be included? 54 Behavioral health outpatient clinicians who are licensed or provisionally licensed, who provide IPRS and/or Medicaid services (exclusive of Independent Practitioners, unless they have an IPRS contract). Do NOT include staff who provide enhanced services only.

55. How will this data be kept current? 55 After the initial web based survey to collect the information, the LME will send an email routinely to your designated manager with a list of all the information the LME currently has regarding your staff. Your designated manager will confirm the information is current, or that certain information needs revision (i.e., change in licensure status, new staff hired or terminations).

56. Why is this necessary? 56 Without NPI numbers and other information on this survey, the LME will be unable to process payments for services rendered by those professionals once on the Avatar software. Information about professional staff specialties will be available to Access Center staff when giving consumers choice of providers.

57. Ways to get ready for Avatar: 57 Complete the web survey on your directly enrolled clinicians (Oct 15 – Nov 15). Ensure you have the capacity to scan documents into PDF files, where a multi-page document is scanned into one PDF file (not one page per file). Word documents will also be accepted. Provide Wake LME the name and email/phone for your CareLink representative if not today, to Dorvetta.Wilson@Wakegov.com

58. 58 Advantages of transitioning to Avatar & CareLink

59. Advantages of Avatar 59 The goal is No More Faxes! Speed up the transmission of information between the Provider and LME. Increase the reliability of the transmission of information between the Provider and LME.

60. Advantages of Avatar 60 Documents are attached to authorizations (such as PCPs and assessments) and are available for both the LME and Provider to view. These changes implement State requirements regarding standardized forms and the STR process.

61. Ideas on managing the budget cuts from the audience. 61 Input?

62. The information from this training will be posted on WakeGov.com in the LME section 62 Thank you for your participation.