Transition to Managed Medicaid Blue Cross Blue Shield

Transition to Managed Medicaid Blue. Cross Blue. Shield of Western New York and Health Integrated May 11, 2016

Medicaid Managed Care: New benefits • Blue. Cross Blue. Shield not participating in HARP program • Coverage extended to SSI members • New benefits for Managed Care: – ACT, PROS, CDT – OMH outpatient mental health clinics – OASAS substance use disorder services • Services authorized per OMH guidelines by Health Integrated – Reimbursed by Blue. Cross Blue. Shield of Western New York • Effective date: 7/1/16

Determining benefits • Confirm Medicaid member benefit eligibility and provisions prior to authorization – Members may have changed insurances or may be ineligible • Providers verify eligibility and benefits – wnyhealthenet. com – Provider services (1 -800 -471 -4685) • Next steps – Contact Health Integrated for authorization requests – Contact Blue. Cross Blue. Shield for benefit or claims questions

Pros-ACT-CDT-IOP partial hospitalization • Authorization requirements vary by service – Check requirements with provider service (1 -800 -471 -4685) – Avoid payment issues by notifying Blue. Cross Blue. Shield of any member enrolled in your program on 7/1/2016 – Current patients have a 90 -day grace period • Preauthorization is required for new services – After benefits are confirmed, call Health Integrated to request preauthorization if required by NYS OMH (1 -877 -837 -0814)

Pros-ACT-CDT-IOP partial hospitalization Be prepared to provide: • • • Member demographics Provider information Start date of service Reason for services Clinical information that supports the need for the requested level of care – Current clinical presentation, history of CD/MH treatment, medications, lethality risk, living environment, support network, psychosocial stressors

Case management services • Case management (CM) is critical to complex care • Blue. Cross Blue. Shield provides CM to members with behavioral health issues • High-risk/high-need members will be assigned a telephonic CM • Community providers can request a CM for their patients (1 -887 878 -8785, option 2) • We encourage members to participate in their Health Home

Case management coordination Blue. Cross Blue. Shield case managers: – Oversee behavioral health and medical needs and services – Coordinate these services to improve all aspects of care – Contact providers with clinical and medical information to improve care – Work with facilities to improve diversion and service delivery – Work with Health Homes to engage and coordinate care

Family and peer involvement • Blue. Cross Blue. Shield believes peer and family support and involvement are critical to the success of a members recovery plan • We support community providers by promoting these services to our members • Blue. Cross Blue. Shield and Health Integrated will assist members and clinicians by making services available to members and helping them enroll

Denials/appeals processing • If an authorization is denied, members will be notified of their appeal rights in writing • Members will be instructed to follow the appeal processes outlined in the denial letter • When requesting an appeal, members should be prepared to submit medical records and any other information for consideration • Appeal determinations will be completed within regulatory guidelines

Billing guidelines • Claims for behavioral health carve-In services are billed on institutional format (837 i/UB-04) • Reference UB 04 Required Fields document to ensure all required information is included (this is a bad link) https: //securews. bcbswny. com/content/WNYprovider/tools-resources/UB-04 Guide. html • If not already, register with ASK Clearinghouse for electronic submissions http: //www. ask-edi. com/healthnow_ny/index. htm

Billing: important notes • Providers should adhere to NYS OMH/OASAS coding guidelines https: //www. omh. ny. gov/omhweb/bho/coding-taxonomy. xlsx • Include Medicaid rate code in the Value Code amount field • Clinic services should be billed with 091 X or 094 X revenue code series • For additional billing rules, see NYS OMH/OASAS Billing and Coding Manual https: //www. omh. ny. gov/omhweb/bho/harp-mainstream-billing-manual. pdf 11

Billing: test claims Beginning 6/1/16, we will accept up to 10 “practice” claims from providers interested in testing our processing/pricing capabilities – Paper submissions only – For providers with multiple new service types (e. g. , ACT/CDT/Clinic/PROS), up to 10 cases per service type will be accepted – Current Blue. Cross Blue. Shield patients should be used (both SSI and non-SSI). – Line level claim results will be provided on a test voucher – Providers should supply a testing contact (name, phone number, email, and address) – Mail test claim files to: Blue. Cross Blue. Shield of Western New York – Medicaid BH Testing Network Management 257 West Genesee Street Buffalo, NY 14202 -2657 12

Billing: network management contacts All Services Steve Nelson, Network Services Manager (716) 888 -1360 / nelson. stephen@bcbswny. com Mental Health John Godfrey, Senior Provider Relations Account Specialist (716) 887 -6881 / godfrey. john@bcbswny. com Substance Use Disorder Services Irina Bojanowski, Facility and Ancillary Provider Relationship Specialist II (716) 887 -8701 / bojanowski. irina@bcbswny. com Katie Ball, Facility and Ancillary Provider Relationship Specialist II (716) 887 -8513 / ball. katherine@bcbswny. com

Billing: Blue. Cross Blue. Shield websites Provider Portal https: //securews. bcbswny. com/content/WNYprovider/home. html EDI Details https: //securews. bcbswny. com/content/WNYprovider/Join. Our. Network/Ask. EDI. html UB-04 Guide (note: this is a bad link) https: //securews. bcbswny. com/content/WNYprovider/tools-resources/CMS-UB 04 Guide. html Provider and Facility Reference Manual (secure login required) https: //securews. bcbswny. com/content/dam/BCBSWNY/Provider/2016%20 BCBSWNY%20 Provid er%20 and%20 Facility%20 Reference%20 Manual_(Updated%20 Dec%202015). pdf 14

Billing: important websites WNYHEALTHe. NET http: //www. wnyhealthenet. com Payspan https: //www. payspanhealth. com/nps ASK Clearinghouse http: //www. ask-edi. com/healthnow_ny/index. htm The Managed Care Technical Assistance Center http: //mctac. org 15

Clinical training • Clinical training provided through CPI at Columbia University • Training and schedule available on Blue. Cross Blue. Shield behavioral health webpage bcbswny. com/behavioralhealth

Questions? Health Integrated, Behavioral Health Utilization Management – Paul Webb, LCSW-BH UM Manager, (813) 388 -2297 – Diane Farrell, RN-BH UM Supervisor, (813) 388 -4000 x 4589 Blue. Cross Blue. Shield Clinical Coordinator – Name, Title, (716) 887 -XXXX Q&As will be posted on bcbswny. com/behavioralhealth