Optum Health NYC BHO Provider Training Agenda Introductions

Optum. Health NYC BHO Provider Training

Agenda • Introductions • Overview of Optum • Review of Contract between Optum and the Offices • Admission & Discharge Review • Provider Tools – Tool Review – Forms & Submission Process – Optum/New York Web site – Provider. Connect • Question and Answer Session • Wrap Up and Closing Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2

Optum. Health New York City BHO Staff • William Fishbein Ph. D, MBA, Executive Director, Optum. Health NYC BHO – Amy Freeman, LMSW, Clinical Program Manager – Margaret “Peggy” Elmer, LMSW, Clinical Program Manager – Erik Geizer, MS, LMHC, CGAP, Quality Assurance/Training Manager – Linda West, BS, Reporting & Technology Manager – Michael Silver, MD, Psychiatrist – Marc Alan Minick, Ph. D, Community Liaison – Mark Simmons, LCSW-R, Community Liaison – Sybil Nurse-Reeves, LCSW-R, Community Liaison – Approximately 60 employees – highly educated and experienced – Master’s level clinical employees, “Clinical Care Managers” (MSW, LMHC, CASAC, etc. ) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3

Optum Overview

Optum Organizational Overview • Optum is a health services business dedicated to making the health system work better for everyone • We are comprised of three market-leading business segments: – Optum. Health – Optum. Insight – Optum. Rx • Optum serves the entire health ecosystem – 250, 000 health professionals and physician practices – 6, 200 hospitals and facilities – more than 270 state and federal government agencies – over 2, 000 health plans; two of every five FORTUNE 500 employers; and one in every five U. S. consumers. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5

Our Business Context UHG United. Healthcare-Health Benefits • Health care coverage and benefits businesses, unified under a master brand UNH=Publicly Traded Registrant (NYSE) Optum—Health Services • Information and technology-enabled health services platform, encompassing: – Employer and Individual – Technology solutions – Community and State – Intelligence and decision support tools – Medicare and Retirement – Health management and interventions – Administrative and financial services – Pharmacy solutions Helping people live healthier lives Helping to make the health care system work better for everyone Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6

Contract Review

NYC BHO – Contracted Region Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8

Populations covered under the program • All fee-for-service admissions to OMH-licensed psychiatric units (all ages) in general hospitals (Article 28 hospitals). • Fee-for-service children and youth admitted to OMH licensed private psychiatric hospitals (Article 31 hospitals). • Fee-for-service direct admissions to OMH State-operated children’s psychiatric centers or children’s units of psychiatric centers. • Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services (Article 28/32). • Fee-for-service OASAS certified hospital (Art 28/32) or freestanding (Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation Services. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9

Functions of the BHO include: Concurrent Review • Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5 pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals. Discharge Planning & Tracking • Optum will engage with the inpatient provider with respect to discharge planning for applicable admissions • Enhanced efforts will be employed for inpatients identified as “High Need Individuals” Tracking of Children with SED • Each new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the State Provider Profiling • Historical Clinical data will be provided by the Offices to the BHOs /Analytics • Data elements specific to each inpatient admission and provider will be collected by the BHO and shared with the Provider and the Offices. Community • Metric Reporting will be provided back to the Offices Liaisons Facilitation of Cross System Linkages Quality Initiative • Optum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disorders • Optum will devise a quality assurance program to monitor the quality of work performed within the contract Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10

Review of Contract The Offices • Supplies Optum with guidance to perform tasks • Supplies historical clinical data • Supports access to cross systems Optum Provider Community • Notify Optum of admission (Portal, Fax or Telephonic) • Notify Optum regarding Children with SED • Performs initial/ concurrent reviews • Monitoring discharge planning & postdischarge services • Tracking of children with SED • Provider profiling • Facilitation of cross system linkage • Quality Initiative • Treatment History Form Provider Community • Follows concurrent review & discharge monitoring processes Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11

What we need from you: Partner with Us • Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitation • Use your dedicated Clinical Care Manager and Community Liaison as a part of your team • Follow the concurrent review & discharge planning/tracking processes Engage in the Process Ask Questions Other • Identify Cross System Linkages • Provide data as requested • Use the tools provided • Don’t hesitate to ask us questions • Clinical questions can be directed to the Clinical Care Manager or to: NYCBHO. Clinical@optum. com • General questions can be directed to the Executive Director & Community Liaisons or to NYCBHO. General@optum. com • Provider. Connect technical questions/issues can be directed to: NYCBHO. tech@optum. com. • Let us help you! • We want your feedback. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12

Provider Tools & Submission Processes

Provider Tool Review- Methods for submission Fax # Telephonic Portal • Individual Information Matrix - Within 24 hours of admission - Concurrent Review at established intervals - Discharge by the date of discharge but no later than within 24 hours post discharge. • Clinical Fax: (877) 283 -0555 • Toll-free: (866) 505 -3398 • Dedicated Clinical Care Manager assigned by Facility • New provider portal: www. optumhealthnyc. com • Provider. Connect software Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14

Fax Submission Option • Individual Information Matrix Form – 3 components of the form: • Admission – Providers to notify their assigned BHO within 24 hours of admission, (except that for admissions which occur on a weekend or holiday such notification would be required by 5 P. M. of the next business day following such week-end or holiday) • Concurrent Review – Optum will complete concurrent reviews for applicable services of Fee-For-Service Medicaid members at regular intervals. • Discharge Planning – Provider to complete and submit by the date of discharge but no later than within 24 hours post discharge. • Form located on the Optum NYC BHO Provider Portal : www. optumhealthnyc. com • Submit forms to the Optum NYC BHO clinical fax number: (877) 283 -0555 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15

Admission Information • • • Is there OASAS consent on File? YES / NO Date: Facility Name: BHO Clinical Care Manager Assigned: Facility Contact Name: Facility Contact Phone: Facility Contact Fax: Individual Name: Medicaid ID: Date of Birth: Gender: County of Residence: Date of Admit: Time of Admit: Age Group of the Individual: Admission Type: Inpatient Psychiatric, Substance Abuse Rehab, Inpatient Detox Diagnosis(es) at Admission: – Axis I: – Axis II: – Axis IV: – Axis V: • Reason(s) for Admission (Why now? ): • Readmission to Facility within 30 days for Inpatient Psychiatric/45 days for SA Rehab or Detox? • Readmission to same facility: • *Please complete & submit within 24 hours following admission or by 5 p. m. the next business day following weekend and holiday admissions. • **If this is a readmission within 30 days for inpatient/detox or within 45 days for rehabilitation, send prior discharge plan with Matrix submission. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16

Feedback from Optum after Admission Notification • Optum will generate a Treatment History Form regarding the Individual admitted by the Facility within 72 hours after admission or by 5 pm of the next business day following notification of the admission by the provider. • See next slide Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17

Treatment History Form Information • • Facility Name: Phone: Individual Name: High Need Individual: Date of Admit: Date of History Transmission: Facility Contact: Fax: Medicaid ID: MH readmission w/in 30 days: Time of Admit: Time of History Transmission: Last six (6) months of behavioral health services utilized by individual: Facility/ Provider • • • Most recent diagnosis(es): – Axis I: – Axis III: – Axis IV: – Axis V: Dates of Service Type of Service There is/ is not additional treatment history information available on the individual. (circle one) *Facility is responsible for gaining executed release of information and sending to Optum. Health for the release of substance abuse treatment services. • OASAS Consent Form http: //www. oasas. ny. gov/mis/forms/trs-51. pdf Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18

Concurrent Review • Dedicated Clinical Care Manager to be assigned by Facility. • Check www. optumhealthnyc. com - Notice of Preliminary Finding- Verbal - Notice of Clinical Determination - Letter • See next slide Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19

Concurrent Review Information • What has worked in the past for treatment of individual? • What strengths do the individual and/or family system have that we can build on? • What is being done differently this time? • Current status of individual, including mental status examination results: • Status/Progress with Treatment Plan: • Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual? • If no, why? • Current Diagnosis(es): -Axis I: -Axis II: -Axis IV: -Axis V: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 20

Concurrent Review Information • • • • • • Physical & behavioral assessment findings: Current Status of Individual, including mental status examination results? Current Diagnosis: Axis II: Axis III: Axis IV: Axis V: For an admission from the community, what type of housing did the individual reside in? If individual was admitted from an institutional setting, what type of setting was the sending facility? What has worked in the past for treatment of individual? What strengths do the individual and/or family system have that we can build on? What is being done differently this time? Status/Progress with Treatment Plan: Assessment for case management completed? If case management is needed and individual is not currently enrolled, referral made? Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual? If no, why? Preliminary Discharge Plan: If this is a readmission, key factors in why the prior discharge plan didn’t meet the member’s needs? Anticipated discharge date: Expected Length of Stay: Days Barriers to Discharge (biopsychosocial): Referral to local peer/family services programs/supports? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 21

Concurrent Review Information • • • • Individual involved in discharge planning? Individual’s family involved in discharge planning? Contact with medical provider(s): Detail? Contact with behavioral provider(s): Detail? Is the individual enrolled in Managed Care? Is the individual enrolled in a Health Home? Did the individual have a care coordinator prior to admission? Case manager/ Care coordinator engaged in hospitalization? Name of case manager/care coordinator: If child/adolescent, other systems engaged? Other Issues / Notes? Medications Name Dosage Frequency • If more rows are needed to list medications, please list them here: • Discontinued? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 22

Discharge Planning Information • • Date of Discharge: Time of Discharge: CM/Care Coordinator? Individual Leave Against Medical Advice? Diagnosis(es) at Discharge: – Axis I: – Axis II: – Axis IV: – Axis V: • Medications: Name Dosage Frequency • Does the individual have a sufficient amount of medication until his/her follow up appointment? • If no, why? • Was case summary and discharge plan sent to the outpatient provider? – If yes, what date? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 23

Discharge Planning Information • If the individual has a care coordinator (i. e. ACT, OMH TCM, Children's HCBS Waiver, MATS, and Health Home), was he/she informed of the discharge? <drop down> • If the individual is assigned to a MCO, have they been contacted for post discharge physical health care needs? <drop down> • Peer/Family Support Service/Program Referral: – If yes, name & contact information: • For a discharge to the community, what type of residence is he/she being discharged to: • If the individual is being discharged to an institutional setting, what type? <drop down> • Has the individual been provided with written instructions for what to do in the event of a crisis prior to his/her first post-discharge appointment? – If no, why? • If individual is under 18 years, linkage of children with other service systems (e. g. juvenile justice, educational system, child welfare)? • Follow up appointments, inclusive of case management: Provider #1 Name: Provider #3 Name: Provider ID: Contact Information: Date/Time of Appointment: Service Type: Provider #2 Name: Provider #4 Name: Provider ID: Contact Information: Date/Time of Appointment: Service Type: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 24

Review of Process - MH Inpatient Action Time Frame Report in Provider Profile Medicaid FFS beneficiary admitted for inpatient mental health treatment Admitting facility submits Individual Information Matrix via provider portal, fax or telephone to NYC BHO Within 24 hrs of admission or by 5 p. m. the next business day following weekend and holiday admissions • BHO sends Treatment History Form to facility via fax, encrypted e-mail or provider portal • BHO CCM contacts designated facility clinician, reviews admission information, and schedules first concurrent review Within 72 hrs of admission or by 5 p. m. the next business day following notification of the admission by the provider, whichever is later • BHO CCM and designated facility clinician conduct concurrent reviews • BHO CCM documents facility compliance with required elements of treatment planning, treatment and discharge planning At least every 5 days* Consumer’s clinical condition no longer justifies continuing inpatient stay §During concurrent review, BHO CCM tells facility liaison that continuing inpatient stay may no longer be justified and that BHO CCM is sending the case for review by a BHO psychiatrist to make the determination §If the BHO psychiatrist concurs that continuing inpatient stay is no longer justified, BHO CCM gives verbal Notice of Preliminary Finding to the facility liaison Within 24 hours of concurrent review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 25

Review of Process - MH Inpatient - continued Action Time Frame Report in Provider Profile Potential Provider Responses Provider submits request for reconsideration and additional clinical information to support the need for continuing inpatient stay; (1) Within 24 hrs of receipt of Notice of Preliminary Finding BHO psychiatrist completes review of additional clinical information and/ or doc-to-doc consultation to facility physician; communicates reconsideration determination to the facility and if ongoing care is determined to be required, BHO CCM continues concurrent reviews. Within 24 hours of receipt of Reconsideration Request BHO issues Notice of Clinical Determination if the reconsideration review determines that the individual does not require treatment in an inpatient setting and the individual is not discharged by the facility. BHO CCM communicates the Notice of Clinical Determination to the facility liaison verbally and in writing by portal, fax, or secure email. Within 72 hours of Notice of Preliminary Finding OR Provider discharges consumer and submits required discharge information via portal, fax or secure e-mail; BHO closes case 2) Within 48 hrs of receipt of Notice of Preliminary Finding OR BHO has received no discharge information and no request for reconsideration… BHO issues Notice of Clinical Determination to facility-designated representative via fax or secure e-mail and sends copy to the Offices (3) Within 48 hours of receipt of Notice of Preliminary Finding Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 26

Review of Process - MH Inpatient - continued • NOTE: The Offices will waive the review requirement for maximum concurrent review intervals for individuals the BHO designates as “Long Stay” when all of the following criteria are met: • The individual meets the criteria for inpatient care • The individual presents with symptoms and/or history that demonstrates a significant likelihood of deterioration in functions/relapse if transitioned to a less intensive level of care • The BHO Clinical Care Manager and provider concur that the current treatment and discharge plans best meet the individual’s needs • The individual’s discharge is delayed pending availability of resources that both the provider and BHO believe are necessary to maintain the individual outside of the current hospital setting (e. g. intermediate care inpatient, residential treatment, or foster care beds) • For Long Stay individuals, the BHO Clinical Care Manager should schedule follow up reviews at intervals deemed appropriate based upon clinical judgment. • Notices of Preliminary Finding and Clinical Determination will not apply to individuals designated as Long Stay. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 27

Review of Process • SA Inpatient Detox – Same process as MH Inpatient, however concurrent reviews conducted at least every 2 days • SA Inpatient Rehab – Same process as MH Inpatient, however concurrent reviews conducted within 21 days of admission and every 7 days thereafter Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 28

Telephonic Submission Option • Call Optum Intake at (866) 505 -3398 for initial admission within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P. M. of the next business day following such week-end or holiday. • Make sure all of your information is ready when calling Optum Intake – Use Individual Information Matrix form as a guideline. Form located on the Optum NYC BHO Provider Portal : www. optumhealthnyc. com • Ongoing concurrent reviews will be conducted in partnership with assigned Optum Clinical Care Manager. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 29

Provider Portal Submission Optum • Provider Portal: – Use Provider. Connect via www. optumhealthnyc. com for online entry of data from Information Matrix form: • Initial Admission • Concurrent Review • Discharge Planning Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 30

Optum. Health NYC BHO Provider Portal Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 31

Optum. Health NYC BHO Provider Portal Page. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 32

Provider. Connect Login. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 33

Provider. Connect Login (cont. ) . Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 34

Provider. Connect News. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 35

Provider. Connect Main Menu . Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 36

Individual Search . Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 37

Individual Search Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 38

Admission Notification. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 39

Admission Notification Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 40

Saving updates- Admission Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 41

Concurrent Review- Logging into Provider Connect Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 42

Individual Search - Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 43

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 44

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 45

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 46

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 47

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 48

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 49

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 50

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 51

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 52

Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 53

Current Medications Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 54

Adding Medications Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 55

Saving updates- Concurrent Review Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 56

Discharge- Logging into Provider Connect Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 57

Individual Search- Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 58

Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 59

Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 60

Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 61

Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 62

Saving updates- Discharge Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 63

Children with Serious Emotional Disturbance (SED) - Logging into Provider Connect Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 64

Individual Search- SED Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 65

Children with Serious Emotional Disturbance (SED) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 66

Children with Serious Emotional Disturbance (SED) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 67

Children with Serious Emotional Disturbance (SED) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 68

Saving updates- SED Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 69

Next Steps • Complete and submit Facility Information Form, if not yet submitted, to Suzanne Feeney via: – Fax at: (518) 951 -2481 – email at suzanne. feeney@optum. com – Mail at: 900 Watervilet-Shaker Road, Suite 103, Albany, NY 12205. • Providers who select Provider. Connect as their submission option should contact the Optum Help Desk to request a User ID/Password at (866) 505 -3398/prompt 4 • Optum will post Clinical Care Manager/Facility assignments and contact information on our Provider Portal at: – www. optumhealthnyc. com • Start to notify Optum of admissions as of 1/3/2012. – Fax - Clinical Fax: (877) 283 -0555 – Telephonic - (866) 505 -3398 – Provider Portal (Provider. Connect) - www. optumhealthnyc. com • If you are using the Optum Provider Portal ‘Provider. Connect’ and have technical questions or encounter a problem, contact Optum (866) 505 -3398/prompt 4 or email us at NYCBHO. tech@optum. com. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 70

Questions?