Provider Orientation- Behavioral Health Services for Healthcare Providers

(1)

Provider Orientation- Behavioral Health Services

for Healthcare Providers

(2)

Orientation Topics

• Metroplus Overview (3)

• Metroplus Product Lines (4)

• Behavioral Health (5-6)

• Health and Recovery Plans (HARP) (7-13)

• Home and community based services (HCBS) (14-16)

• Plan of Care (POC) (17)

• Evidence based practice (18-19)

• Assertive Community Treatment (ACT) (20)

• Assisted Outpatient Treatment (AOT) (21)

• Children’s Special Services Program (CSS) (22-27)

• Developmental Disabilities (28)

• Additional Supports/ Initiatives (29-30)

• Vaccines for Children (31)

• Children’s services link (32)

• Laboratory Service (33)

• Pharmacy Benefits (34-35)

• Restricted Recipents (36)

• Virtual Visits (37)

• Transportation Services (38)

• Language Interpreter Services (39)

• Care Management (40-44)

• Claims (45-48)

• Utilization Management (49-61)

• Clinical Practice Guidelines (62)

• Quality Management (63-64)

• Provider Responsibilities (65-66)

• Access to care (67-68)

• Handling Crisis Calls (69)

• Advanced Directives (70)

• Communicable diseases (71)

• Smoking Cessation (72)

• Compliance Policy (73)

• MetroPlus Fraud and Abuse Prevention Program (74-75)

• Cultural Competency (76)

• Notification of Changes in your Practice (77)

• Provider Service Representatives (78- 79)

• MetroPlus Website and Provider Portal (80)

• Helpful Resources (81)

• Key Points to Remember (82)

• Glossary of Terms (83-91)

(3)

MetroPlus Overview

• MetroPlus is a Prepaid Health Services Plan (PHSP) licensed to operate in all 5 NYC borough (Manhattan, Brooklyn, Queens, Bronx, Staten Island)

• We have over 600,000 members across all our lines of business

• MetroPlus, which began operations in 1985, is a wholly owned subsidiary of NYC Health + Hospitals.

• Ranked #1 in overall quality in the 2020 Medicaid Quality Incentive Program, according to the NYS Department of Health’s 2020 Quality Incentive results

• Our headquarters are located at 50 Water Street, in lower Manhattan

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METROPLUS HEALTH INSURANCE PRODUCTS

Medicaid Managed Care

(MMC)

Child Health Plus (CHP)

Qualified Health Plan

(MarketPlace Plans)

Partnership in Care (SNP)

Essential Plan (EP)

MetroPlusHealth Medicare Advantage Plan

(HMO SNP)

MetroPlus Medicare Platinum Plan

(HMO)

MetroPlusHealth Gold

MetroPlusHealth Enhanced

(HARP)

MetroPluHealth GoldCare

Medicaid Advantage Plus (MAP) Ultracare

Effective 11/1/21

(5)

• As of 10/1/21, MetroPlusHealth will be providing the Behavioral Health services previously delegated to Beacon Health Options.

Services include:

• Provider network development and contracting

• Care management & coordination

• Utilization management

• Customer services & grievance management

• Claims processing & payment

• Quality management

Behavioral Health Program

MetroPlusHealth BH includes:

1.Health and Recovery Plan (HARP)

2.Children’s services, including Voluntary Foster Care Agencies

3.Behavioral Health services for other MetroPlusHealth

Plan lines of business.

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BH Populations

Adults with behavioral health needs such as mental health needs and/or substance use disorders

Transition age youth with behavioral health needs

Children with behavioral health needs such as mental health needs, substance use disorders and/or Voluntary Foster Care Agency services

High risk groups such as individuals with co-occurring disorders, co-morbid medical needs or those

involved in multiple services systems (e.g. education, justice, medical, welfare, and child welfare)

Individuals with Intellectual/Developmental Disorders in need of behavioral health services

(7)

HARP Vision & Values

• To create an environment where managed care plans, service

providers, peers, families, and government partner to help members prevent chronic health conditions and recover from serious mental illness and substance use disorders.

• HARP Values

• Person-Centered Care

• Recovery-Oriented Care

• Data-driven

• Integrated Care

• Evidence-Based Practices

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The Goals of HARP

• Improve physical health and behavioral health life outcomes.

• Improve social/recovery outcomes including employment.

• Improve member‘s experience of care.

• Reduce rates of unnecessary/inappropriate ER use.

• Reduce need for repeated hospitalization and re- hospitalization.

• Reduction or elimination of duplicative health care services and associated costs.

• Transformation to a more culturally competent

community-based, recovery-oriented, person-

centered service system.

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HARP Team Coordinates the Care of MH & PH services

• Making PCP (Personal Care Physician) appointments

• Looking up Providers

• DME (Durable Medical Equipment)

• PCS (Personal Care Services)

• Transportation to appointments

• Dental Care

• Vision

• Hospital stays

• Promote Medication Adherence

• Collaborate with providers/vendors

• Assisting with integrated care

• Home and Community Based Services (HCBS) that can be delivered in members home or social setting

• Inpatient and outpatient psychiatric care

• Partial Hospitalization Program (PHP)

• Substance Use Disorder Inpatient Detoxification

• Substance Use Disorder Inpatient Rehabilitation

• Crisis Residence and/or Crisis Respite

• Assertive Community Treatment (ACT)

• Personalized Recovery Oriented Services(PROS)

Mental Health Benefits Physical Health Benefits

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How to Identify HARP Eligibility Status?

• HARP eligibility is based on certain factors, such as past use of behavioral health services in Medicaid.

• HARP eligibility status appears in e-PACES on an individual’s file in the restriction/exception code part of the report. Individuals can ask their treating providers to look up their eligibility status or they can call New York Medicaid Choice at 1-855-789-4277; TTY users: 1-888-329-1541.

• HARP eligibility and enrollment status is indicated by the use of restriction/exception codes that begin with the letter “H”.

• If the individual’s e-PACES report has an “H9” code, then the person is

HARP eligible but has not yet enrolled in a HARP.

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Enrolling HARP Eligible Members into a HARP

• “H9” refers to member that are eligible for HARP based on a number of elements, including their treatment needs and utilization patterns for physical and behavioral health services.

• NYS determines who is eligible for HARP and generates an updated list of H9s every other month. The H9 code can be found

• In ePaces: in individual’s file in the restriction/exception code part of the report

• In MAPP, Psyckes, and EMEDNY

• By calling NY Medicaid Choice @ 1-855-789-4277 (TTY users: 1-888-329-1541)

• As HARP enrollment is voluntary, these eligible members can choose to enroll in a HARP at any time. The individual will need to have the following information when contacting NY Medicaid Choice

• Medicaid CIN or SNN, full name, DOB, home address & phone number

• H9 members must be 21 or older and be insured by Medicaid only (just like HARP)

• Insurance companies, including MetroPlus, are not allowed to directly enroll

patient into HARP plans. The process must be initiated by the patient (either alone

or with their provider).

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What is HARP Collaboration and Integration?

• The Integrated Care approach blends the expertise of mental health, substance use, and primary care clinicians along with Health Home providers. We use a model of collaboration which is a team-

based intervention designed to improve member care through support, provider decision, and shared clinical care plans that incorporate specific member goals.

• HARP Care Managers identify members with high-risk physical and behavioral health conditions in need of Case Management through multiple means:

• MHP Risk algorithm

• Inpatient hospitalization

• Health Risk Assessments

• Referrals from Health Home referrals, Medical and Behavioral Health Provider, Member or Care Giver self-referral, Personal Care Services (PCS), Partnership in Care (PIC)-HIV/SNP, Customer Services & Network Relations.

• MetroPlus Behavioral CMs support external providers & Health Homes on a routine basis; offering

guidance with appropriate in-network referrals for both physical and behavioral health needs.

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• Health Homes provide the opportunity to receive enhanced integration and coordination of primary, acute, behavioral health, and long-term services for persons with chronic illness.

• Health Homes Goals:

• Reduce utilization associated with avoidable inpatient stays

• Reduce utilization associated with avoidable emergency visits

• Improve outcomes for persons with mental illness or substance abuse disorders

• Improve disease-related care for chronic conditions

• Improve preventive care outcomes

• There are 33 health homes in NYS (16 serve children, 17 serve adults only)

• To refer members to a health home:

• Contact the Medicaid Helpline (1-800-541-2831) or the NYS DOH Health Home line (518)-473-5569

• Contact a lead health home (either directly or via the MHP Health Home coordinator)

HARP members should be enrolled in Health Homes

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Coordinating with Health Homes to promote HCBS Services

• MetroPlus Health Plan is notified by New York State of a member’s eligibility for HARP and eligibility for a Community Assessment.

• The assigned Health Home or CMA (Care Management Agency) worker completes the assessment to determine the level of appropriate need, or eligibility, to have additional services (HCBS) available to them.

• Therefore, all members enrolled in the HARP program will be offered Health Home care management services which will serve as a primary goal of successful HARP participation.

• Members who are hesitant about joining a Health Home will be given the option to enroll within

an RCA (Recovery Coordination Agency) and still be given the opportunity to access adult

behavioral health HCBS.

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• Health Home Care Managers (HHCMs) use the NYS Eligibility Assessment to determine if HARP

eligible/HIV SNP enrollees are eligible for Adult BH HCBS and, if so, which tier of service they qualify for.

• Prior to the assessment, the HHCM must verify current HARP or HIV SNP enrollment through EPACES/EMEDNY.

• Tier 1 Services

• Education

• Employment

• Peer Support

• Tier 2 Services includes all items from Tier 1, plus

• Habilitation/Residential Supports

• Psychosocial Rehabilitation

• Community Psychiatric Support and Treatment

• Family Support and Training

• Note: NYS is in the process of changing the HCBS assessment process and the are rebranding

HCBS services as CORE (Community Oriented Recovery & Empowerment) services. The goal is to

eliminate the barriers to access and broaden the referral network to promote increased use of the services.

HCBS Eligibility and Tiers

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• HCBS can help MetroPlus HARP members achieve their life goals and be more involved in the community.

• These services can help with:

• Independence: Daily Living and Social Skills

• Education and Employment

• Peer and Family Supports

• Managing Crises - Crisis Respite Services help manage mental health and substance use crises in a safe environment.

Home & Community Based Services (HCBS)

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What Is A Plan of Care (POC) and What Does It Do?

The POC will address all identified care and service needs of members including the following as needed:

• All active chronic problems, current non-chronic problems, and problems that were

previously controlled and or classified as maintenance care but have been exacerbated by disease progression and/or other intervening conditions.

• All current medications taken by the member.

• For each need identified, the POC will state the problem, interventions to resolve or mitigate the problem, the measurable outcomes to be achieved by the interventions, the anticipated timelines in which to achieve the desired outcomes, and the individual

responsible for conducting the interventions and monitoring the outcomes.

• All services authorized and the frequency and duration of the services authorized including any services that were authorized by the Plan since the last POC review was finalized and that needs to be authorized moving forward.

• Member's long and short-term goals; preferences and how they will be addressed, taking into consideration the member's expectations, characteristics, and previous daily routines

• Member requests are taken into consideration during the POC review with the member.

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Evidence Based Practice- Children

Patients are offered treatments with credible research evidence to support their efficacy in treating the target condition. These will include:

Trauma-focused cognitive behavioral therapy Multidimensional family therapy Seven challenges Trauma informed care

Adolescent community reinforcement Multisystemic therapy Assertive continuing care Functional family therapy Trauma informed child-parent psychotherapy Dialectical behavior therapy

Multi-dimensional treatment foster care

(19)

Evidence Based Practices For Adults

• The Plan shall adopt, disseminate, and implement the State selected clinical practice guidelines listed below as well as nationally recognized clinical practice guidelines, including other evidence-based and promising practices.

• a. SAMHSA’s ACT Assertive Community Treatment (ACT) Evidence-Based Practices (EBP) KIT | SAMHSA Publications and Digital Products

• b. SAMHSA’s Illness Management and Recovery Illness Management and Recovery - Practitioners Guides and Handouts (samhsa.gov)

• c. SAMHSA’s Integrated Dual Disorder Treatment for co-occurring disorders Clinical Guide for Integrated Dual Disorder Treatment (IDDT) (easacommunity.org)

• d. SAMHSA’s Supported Employment (Individual Placement and Support) Transforming Lives Through Supported Employment | SAMHSA; Supported Employment Evidence-Based Practices (EBP) KIT | SAMHSA

• e. SAMHSA’s Family Psychoeducation Family Psychoeducation Evidence-Based Practices (EBP) KIT | SAMHSA Publications and Digital Products

• f. Tobacco cessation

• g. OMH FEP practice guidelines nimh-white-paper-csc-for-fep_147096.pdf (nih.gov)

• h. Seeking Safety Seeking Safety - Treatment Innovations (treatment-innovations.org)

• i. Motivational Enhancement Therapy Motivational Enhancement Therapy for AUD508.pdf Project MATCH Volume 2:

Motivational Enhancement Therapy Manual (nih.gov)

• j. Twelve- Step Facilitation Project Match Volume 1: Twelve Step Facilitation Therapy Manual (nih.gov)

• k. Cognitive Behavioral Therapy for SUD Cognitive-Behavioral Therapy for Substance Use Disorders (nih.gov)

• l. Medication Assisted Recovery for SUD Medication-Assisted Treatment (MAT) | SAMHSA TIP 63: Medications for Opioid Use

Disorder - Full Document | SAMHSA Publications and Digital Products

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• Evidence-based practice offering treatment, rehabilitation, and support services

• Assertive outreach

• Mental health treatment

• Vocational support

• Integrated dual disorder treatment

• Serves people with SMI (serious mental illness) impairing their functioning in the community

• Priority given to people with schizophrenia, and other psychotic disorders (e.g., schizo-affective disorder), bipolar disorder and/or major or chronic depression.

• Priority is also given to individuals with continuous high service needs that are not being met in more traditional service settings.

• Individuals with a primary diagnosis of a personality disorder(s), substance abuse disorder or mental retardation are not appropriate for ACT.

• To refer members to ACT in NYC click on the link for the Single Point of Access (SPOA) Care Coordination/ACT Programs OR you can call or email to the following contact

info: spoa@health.nyc.gov or 347-396-7258.

Assertive Community Treatment (ACT)

Source: https://omh.ny.gov/omhweb/act/

• Family education

• Wellness skills

• Community linkages

• Peer support

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• Assisted Outpatient Treatment (AOT) is also referred to as "Kendra's Law“- (Kendra died after being pushed in front of a subway train by a mentally ill person who was living in the community at the time, but was not receiving any type of treatment for his sickness)

• Kendra’s Law establishes a procedure for obtaining court orders for certain individuals with mental illness to receive and accept outpatient treatment.

• AOT is for certain people with mental illness who, in view of their treatment history and present circumstances, are unlikely to survive safely in the community without supervision.

• 18 yrs or older, with SMI, has a lack of compliance with MH treatment that results in either MH hospitalization, incarceration or acts of self-harm or harm to others

• When court ordered, ACT services are called AOT

• To refer someone to AOT, you must contact your county mental health coordinators (AOT contacts are listed on the OMH website provided below)

What Is Assisted Outpatient Treatment (AOT)?

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• The CSS team that serves medically fragile children under 21 years old that ^:

• Coordinates care -oversight of utilization and case management to support the complex physical, behavioral, and developmental health needs of members

• Monitors plans of care for children eligible for Home and Community Based Services to anticipate complex needs by collaborating with Health Homes and assessing if services in place

are meeting member needs

• Follow-up on issues raised by members/families, Care Management Agencies (CMA), Voluntary Foster Care Agencies (VFCAs), PCPs, specialty providers, homecare agencies, DME providers, pharmacy, and any other collateral contacts to support the complex member’s needs

• The CSS team takes a multi-generational approach to care management. Supporting the caregivers’ needs helps to ensure that the child/youth will continue to receive support to remain in the community and engage in their care. Many of the new services in this program

are designed to support the member and family to promote better outcomes.

CSS Department can be reached by calling MetroPlusHealth at 1-800-303-9626

MetroPlusHealth Children’s Special Services Program (CSS)

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NYS focus on improving health outcomes, managing costs, and providing care

management services for Medicaid children and youth under 21 years with complex medical, behavioral, and/or developmental issues makes these services available to MetroPlusHealth members:

• Child and Family Treatment Supports and Services (CFTSS)

• Medicaid or SNP members 0-21 have access to 6 CFTSS behavioral health services that members can receive in clinics, home, or in the community

• Home and Community Based Services (HCBS)

• For children with complex medical, behavioral, and/or developmental health issues who are at risk for institutional placement and have been determined eligible for waiver services

Crisis Residence

Support for Children placed in the care of Voluntary Foster Care Agencies

• Members will have access to new benefits and care

Improving Care for Children

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• Members 0-21 who have Medicaid or SNP can be referred for CFTSS services.

Members can self-refer, be referred by their PCP or BH provider, or by their case managers

• The CSS team can coordinate referrals to designated CFTSS providers

• No authorization is required for CFTSS services

• Children 0-21 with Medicaid or SNP with complex issues:

• To be eligible for Children’s HCBS (waiver) services, children must have a physical health, developmental disability, or mental health diagnosis with related needs that place them at risk of hospitalization, institutionalization*, or need to return safely home from a higher level of care

• Members who do not have Medicaid or SNP but may be eligible for HCBS can be referred to C-YES (Child and Youth Evaluation Services) through Maximus to be evaluated for level of care (LOC) eligibility and Medicaid Family of One coverage. Providers and organizations can download the referral form: https://nymedicaidchoice.com/connecting-children-home-and- community-based-services

* Institutionalization refers to children at risk of being admitted to a higher level of care such as out-of-home residential settings, hospitalization, ICF-I/ID, or nursing facility

Identifying and Referring Members for Children’s Specialty Services

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• Refer child/family to a Children’s HH to have CANS Assessment (Child and Adolescent Needs and Strengths Assessment) to establish LOC. When score meets criteria for LOC for HCBS (waiver) services an eligibility code is added to the Medicaid card

• Providers can refer directly to one of 5 NYC Children’s HH:

a. Collaborative for Children and Families (CCF) https://ccfhh.org/ 212-444-5437

b. Coordinated Behavioral Care (CBC) http://www.cbcare.org 646-930-8851 or 866-899- c. Bronx Accountable Health Network (BAHN) https://www.montefiore.org/bahn-contact- 0152

us 1-855-680-2273

d. Northwell Health Home https://www.northwell.edu/about/our-organization/northwell- health-solutions/health-home (888) 680-6501

e. Community Care Management Partners (CCMP) http://ccmphealthhome.org/ (888) 682-1377

Refer member to CSS team for support with the process

• Process take time depending on appointment and family availability. Support the family by exploring other services/ resources

• Offer linkage to CFTSS services to provide in home or community support

Establishing Level of Care (LOC) Eligibility for Children’s HCBS

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For eligible children with:

• Serious Emotional Disturbance (SED)

• Medically Fragile Children (MFC)

• Developmental Disability (DD) and Medically Fragile

• Developmental Disability (DD) and in Foster Care

HCBS services:

• Enable children to remain at home, and/or in the community, therefore avoiding institutional placement

• Safely return a child from a higher level of care back to the community with support services provided where they are most comfortable

• Support children and adolescents as they grow and work toward their goals

• Offer person-centered flexible services to meet the medical, mental health, substance use treatment and/or developmental needs of children/youth

Home and Community Based Services (HCBS)

(27)

When a child meets criteria for HCBS, they are eligible for the full range of services that include:

Children’s Home and Community Based Services (HCBS)

• Caregiver/Family Supports and Services

• Community Self-Advocacy Training and Support

• Community Habilitation

• Day Habilitation

• Prevocational Services

• Supported Employment

• Planned Respite Crisis Respite

• Accessibility Modifications

• Environmental Modifications

• Vehicle Modifications

• Adaptive and Assistive Equipment

• Palliative Care

• Non-Medical transportation

(FFS)

(28)

Members with Developmental Disabilities (DD)

• The NYS Office for People With Developmental Disabilities (OPWDD) coordinates services for New Yorkers with developmental disabilities

• To qualify for OPWDD services, a member must have had developmental disability prior to turning 21

• Members requesting OPWDD services, need the following documentation:

• Psychological evaluation (within the last 3 years)

• Psychosocial evaluation (within the last year)

• Medical evaluation (anything signed by a doctor that indicates a DD diagnosis)

• School records (the member must contact the DOE to have records mailed)

• Care Coordination Organizations that provide care management to people with DD:

• Care Design - Enroll for Services - Care Design NY

• Advance Care Alliance - Enroll | ACA NY

• Tri-County Care - Contact - Tri-County Care (tricountycare.org)

Borough OPWDD office (DDSO) info can be found here

• Manhattan - Home - Manhattan DD Council

• Queens - Queens Council on

Developmental Disabilities (qcddny.org)

• Brooklyn - Brooklyn Developmental Disabilities Council

(brooklynddcouncil.org)

• Bronx - A description of the Bronx DD Council .

• Staten Island - SIDDC

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• Children/youth in HCBS services are usually enrolled with Children’s Health Homes to coordinate care and promote health outcomes

• Health Homes provide care management to help members/families connect to the services that meet their needs

• Foster care children receive care coordination from MetroPlusHealth, Voluntary Foster Care Agencies, and community providers

• If eligible, children in foster care will also receive HCBS services and care coordination from Children’s Health Homes

• The additional services that have been transitioned to managed care, allow Metro Plus and providers to work together to support children’s goals and development as they transition to adulthood

Additional Supports

(30)

• Psychotropic Pharmacy Initiative

• Medicaid children on multiple psychotropic medications receive telephonic

MetroPlus CSS team support to assess needs, review gaps in care, and assist with community linkages including treatment, housing, food insecurity, health coverage for caregivers, and technology/educational issues

• Children/youth on Blood Clotting Factor Medications

• CSS provides care management for members on Blood Clotting Factor

• Khalilah McCrimon, Manager of CSS and Medically Fragile Liaison oversees the care of these complex member s

• Children/youth with Sickle-Cell Anemia

• CSS provides care management for these members

• Khalilah McCrimon, Manager of CSS and Medically Fragile Liaison oversees the care of these complex members

Additional Initiatives

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The NYS Vaccines for Children Program (VFC) supplies selected vaccinations to providers caring for Health Medicaid and CHP members at no cost

Eligible members must be 19 years of age or younger and enrolled in Medicaid and CHP LOB plans.

Providers may order vaccines for Medicaid and CHP members at no cost through the VFC program.

For additional information on the VFC immunization Program or order vaccines for MetroPlus Medicaid CHP members, call:

• New York State Department of Health Bureau of Immunization 518-473-4437

• New York City Department of Health and Mental Hygiene Immunization Hotline 347-396-2400

• New York State Vaccines for Children Program 800- KIDSHOT (800-543-7468)

VACCINES FOR CHILDREN PROGRAM

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CSS Program Contacts:

• CSS Director: Rosemary Salopek, LMSW 212-908-3744

• CSS Manager: Khalilah McCrimon, RN 212-908-3104

• CSS Foster Care Liaison: Olanike (Nikki) Oyeyemi 212-908- 4000

To submit clinical information, Plans of Care, authorization requests, or Transmittal Forms:

• CSS email: childrensspecialservice@metroplus.or ^g

Health Home Liaison:

• Lisa Molinari MOLINL@metroplus.org 212-908-8494

Links to Access Children’s Services

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• Participating labs can be found on www.metroplus.org

• To perform in-office lab testing, a location must have a CLIA (Clinical Laboratory Improvement Act) certificate.

• Providers may bill one draw fee per patient (CPT Code 36415 or 36416) per day; providers paid under a capitated arrangement will be reimbursed for in-office lab services in their monthly capitation payment

• All other lab tests must be referred to a MetroPlusHealth participating reference laboratory

• Any lab test not available at an in-network laboratory, call Utilization Management at 800-303-9626 to obtain an out-of-network prior authorization

• Any claims from a provider for tests other than the list of approved tests will be denied;

please remember that MetroPlusHealth members cannot be billed for these services.

LABORATORY SERVICES &

APPROVED IN-OFFICE LAB TESTS

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• PHARMACY

• Member formularies available at www.metroplus.org

• Long-acting antipsychotic injections covered without prior authorization

• Some drugs may have additional requirements or limits on coverage, including prior authorization, quantity limits and step therapy. Please see below for contact info to initiate a request.

PHARMACY BENEFITS THROUGH THE PHARMACY BENEFIT

MANAGER CVS CAREMARK

(35)

• PHARMACY (Con’t)

PHARMACY BENEFITS THROUGH THE PHARMACY BENEFIT MANAGER CVS CAREMARK

• Child Health Plus (CHP)

• Partnership in Care (SNP)

• MetroPlus Enhanced (HARP) Phone: 877-433-7643

Fax: 866-255-7569

• MetroPlusHealth Medicare Advantage Plan (HMO SNP

• MetroPlusHealth Medicare Platinum Plan (HMO)

Phone: 866-693-4615 Fax: 855-633-7673

For All Other Plan Products :

Phone: 855-582- 2022 Fax: 855-245-8333

• Medicaid, CHP, HIV SNP, or HARP members can receive a 90-day supply for maintenance medication

• No authorization is needed for Sublocade injection received in the provider’s office.

• Effective 10/1/2021, Sublocade will also be covered under the pharmacy benefit without prior authorization for Medicaid, CHP, HIV SNP and HARP members

For members who require specialty drugs, call MetroPlus Pharmacy department at:

Phone: 800-303-9626

Fax: 844-807-8455

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• Medicaid consumers with a pattern of misusing benefit services

• Required to enroll in a Medicaid Managed Care Plan

• Services from medical providers, dentists, podiatrists, hospitals, pharmacies, and durable medical equipment (DME) vendors can be restricted

• Health Plans identify the need for member restrictions, enforce restrictions, and assess if restrictions should remain in place

• MetroPlus care manages restricted members to ensure that their medical and behavioral health needs are being met

• Providers must verify member eligibility before every encounter and identify restrictions:

• Members restricted to a particular doctor, cannot be seen by another doctor without a prior authorization; claims without an authorization will be denied

• Members restricted to a NYC Health + Hospitals facilities require a prior authorization to visit another NYC Health + Hospitals facility

RESTRICTED RECIPIENTS PROGRAM

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• Virtual Visits are a plan benefit through American Well (AmWell) for medical and initial online behavioral health visits

• Members use online technology to connect to board certified medical providers by using a smart phone, tablet or computer

• Doctors are available 24/7 for the treatment of non-emergencies.BH televisits must be scheduled.

• Urgent Care: migraines, sinus infections, bronchial problems, cold, flu, sore throat, strep throat, pink eye, diarrhea, urinary infections

• Mental Health Therapy: depression, anxiety, bereavement, trauma, couples therapy, stress

• Psychiatry: insomnia, mild substance abuse, panic attacks, PTSD, OCD

• MetroPlusHealth members can access virtual visits at

www.metroplusvirtualvisits.com

VIRTUAL VISITS

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Providers are responsible to prepurchase MetroCards from the MTA and distribute to members of the following plans for public transportation:

• Medicaid Managed Care

• Medicaid HIV Special Needs Plan

Providers must register to participate for reimbursement in the Public Transportation Automated System (PTAR) available on:

http://www.nyc.gov/html/hra/html/services/ptar_system.shtml

TRANSPORTATION SERVICES

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CyraCom, the leading provider of language interpreter services in healthcare is available to

reduce language barriers for MetroPlusHealth members. CyraCom offers a variety of services to

assist with language needs, including qualified interpreters. More information can be found at

www.cyracominternational.com

CYRACOM

LANGUAGE INTERPRETER SERVICES

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MetroPlusHealth Care Management

• Case managers coordinate services to meet the medical, behavioral, psychosocial and

functional goals of members helping them attain wellness and autonomy through advocacy, assessment, planning, communication, and education.

• Case Managers collaborate with providers, health homes and other case managers around inpatient admissions, discharge planning and gaps of care. Case Managers coordinate the services of physical, substance use disorder and mental health providers to help members attain optimal health outcomes.

• MetroPlusHealth Case Managers are Social Workers, LMHC’s, Nurses (RN) and CASACs working with members’ assigned Health Home and/or Care Management Agency workers, medical professionals, service providers and other community resources.

• Care managers

• Link members to providers and resources

• Identifying and reduce the impact of clinical and social determinants of health issues

• Ensure members receive medical, behavioral, and social services consistent with their

plan of care

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Components of Care Planning

• HRA (Health Risk Assessment): assessment of medical health, behavioral health, long-term services and supports (LTSS), and social needs. Responses help create the

individualized care plan (ICP). Includes, functional status, sensory impairment, nutrition, living situation, and major medical diagnoses

• ICT Meeting: The interdisciplinary care team (ICT) supports the member to improve health outcomes

• Individualized Care Plan (ICP): The ICP is developed with the member and/or the member’s caregiver. ICPs include

member-specific health care goals, planning for care, and addressing member’s needs

• Care Coordination: ensures access to plan benefits and

continuity of care

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CARE PLANNING (con’t)

Care Plans Include:

• Active concerns, conditions, and current medications

• Needs, long and short-term goals and interventions with measurable outcomes, the anticipated timelines, & the person responsible for monitoring outcomes

• Authorized services including frequency and duration of authorization

• Member’s preferences and how they will be addressed, taking into consideration the member expectations, characteristics, and daily routines

Care plans may be referred to as Plans of Care (POC), ICP (Individualize Care Plans) or PCSP (person-centered service plans) depending on the member’s line of business

Care plans are living, evolving documents and are shared with members and providers

(43)

Care Plan Review

• Care plans are regularly reviewed by the MetroPlusHealth Care Manager.

• Care Managers monitor utilization to identify changes in health status and member needs.

• To avoid duplicate referrals for services, AOT member Plans are

updated by the AOT and CMA worker in conjunction with the assigned BH Care Manager

• The Care Manager will closely monitor inpatient utilization, alerting providers and others (e.g., community CMA or AOT workers) of

admissions so POCs can be updated post hospitalization.

(44)

Enrolling a Member in Behavioral Health Care Management

• To enroll a member in BH care management services:

Call the member services phone

number, (800) 303-9626, and request a

transfer to BH or HARP Care Manager to assist with enrollment and connection to services

• To refer a member to a Health Home:

• Call (844)-225-4277 to facilitate

coordination with a Health Home

(45)

Claims must be submitted detailing services rendered for every encounter within 90 days of the date of service or discharge

• This applies regardless of whether the provider is paid on a capitated or fee-for-service methodology

Please allow 30 days for electronic and 45 days for paper claim submission date to receive payment.

Claims for all members can be submitted electronically using MetroPlus Emdeon Payer ID# 13265.

Paper claims must be submitted on CMS 1500 or UB-04 forms

• Send paper claims for Medicaid, CHP, EP, SNP, MetroPlus Gold, Managed Long- Term Care (MLTC), MetroPlus Enhanced (HARP) and QHP (Exchange) to:

MetroPlus Health Plan P.O. Box 830480

Birmingham, AL 35283-0480

• Send paper claims for MetroPlus Medicare to:

MetroPlus Health Plan P.O. Box 381508

Birmingham, AL 35238-1508

CLAIMS SUBMISSION

(46)

Claims can be submitted through:

• The MetroPlusHealth provider portal at http://providers.metroplus.org

-Providers can register for access to the provider portal at www.metroplus.org

• The Change HealthCare or Relay clearinghouse

Claims status can be checked at:

• http://providers.metroplus.org

• MetroPlusHealth Customer Services 800.202.9626

PORTAL & CLEARINGHOUSE

CLAIMS SUBMISSION

(47)

You have the right to appeal claim determinations. Explanation for the appeal, all pertinent information, as well as a copy of the original claim must be provided. Claims must be submitted in writing within 45 calendar days of the date of the original check or denial notification.

• Regular Mail:

MetroPlus Health Plan P.O. Box 830480

Birmingham, AL 35283-0480

• Certified Mail:

50 Water Street, 7 ^th Floor New York, NY 10004

• By phone: 800-303-9626

• By fax: 212-908-8789

CLAIM RECONSIDERATION/ APPEALS

(48)

• Balance billing is prohibited. Providers may not balance bill

members above allowed co-pays, deductibles, or co-insurance for any covered services.

• Providers who seek payment from a member for any covered service, may be subject to termination as a participating provider.

• Providers are required to educate staff and affiliated providers concerning this requirement.

• Check Claim Status

• MetroPlusHealth Provider Portal: http://providers.metroplus.org

• MetroPlusHealth Customer Services: 800-303-9626

BALANCE BILLING & CLAIM STATUS

(49)

Behavioral Health Utilization Management

A team of Licensed Clinicians (LMHC, LMSW, LCSW) and physicians

specializing in BH of children, BH of adults, and substance use disorders. The

BH utilization management team monitors and evaluates medical necessity and

appropriateness of behavioral health services or procedures.

(50)

Provider

communication of clinical

information

Providers can provide clinical information for

review via the web portal at providers.metroplus.org.

Telephonically at 1-800-303- 9626.

The phone IVR will direct providers to the appropriate behavioral health queue.

By Fax:

BH UM Fax: 212-908-5208

BH UM Appeals Fax: 212-908-

5209

(51)

Services Reviewed

in addition to BH Clinical Denials & Appeals for these Services Inpatient Behavioral Health Services:

• Inpatient psychiatric

• Partial Hospitalization Program (PHP)

• Substance Use Disorder Inpatient Detoxification

• Substance Use Disorder Inpatient Rehabilitation

• Intermediate Stay Unit

• Crisis Residence and/or Crisis Respite

• Out of network inpatient behavioral health care

Outpatient Behavioral Health Services:

• Assertive Community Treatment (ACT)

• Continuing Day Treatment Program

• Personalized Recovery Oriented Services (PROS)

• Substance Use Disorder Outpatient Detoxification

• Substance Use Disorder Residential Treatment Program

• Opioid Treatment Program

• ECT(Electroconvulsive Therapy)

• Out of network outpatient behavioral health care

• Applied Behavioral Analysis (ABA)

• Children’s Special Services (CSS)

• Home and Community Based Services

(HCBS/CORE)

(52)

Behavioral Health UM Process

Provider Notification to

MetroPlus &

Event Set Up

Providers notify MetroPlusHealth of authorization

need via phone, fax or portal. The

BH UM

Coordinators will set up the event

information in our information

system

Review &

Authorization BH UM Clinicians

conduct a preauthorization,

concurrent or retrospective review

upon receipt of clinical information

to assess for medical necessity.

Treatment and Discharge

Planning

BH UM Clinicians assist with treatment

and discharge planning by providing treatment

history, family and related provider contact information

and resources to enhance member’s

connectivity to supportive services.

BH UM Clinicians will collaborate with

BH CM to initiate

Care Management

(53)

Behavioral Health Denials/Appeals

Authorization request from

Provider is denied by MetroPlus via

∗IAD

Provider appeals the

denial of services

UM Denials &

Appeals Clinician processes the

appeal

Denial is upheld or overturned or

sent for an external appeal

review

*FAD

∗ IAD (Initial Appeal Determination)

∗ FAD (Final Appeal Determination)

(54)

Behavioral Health UM Terms

Level of Care for Alcohol and Treatment Drug Referral (LOCATDR): web-

based tool that aids in determining the best level of

care for a member with a substance use disorder.

Interqual Criteria: a screening tool used to

determine the appropriateness of care for members in need of

psychiatric treatment.

PSYCKES: Psychiatric Services and Clinical Knowledge Enhancement System (Psyckes). is a web- based platform developed by New York State Office of Mental

Health.

NOA: Notice of admission Pre-determined set of authorized dates per line of business upon submission of

NOA documents.

(55)

REQUIRED MENTAL HEALTH AUTHORIZATIONS (1 of 7)

Medicaid & NY Children (MCD TANF / MDC SSI / QMP SNP / QMP

TANF / QMP SSI)

MetroPlus Enhanced (HARP) SNP

Enhanced / QMP Enhanced HIV Special Needs (Medicaid SNP)

Medicare Advantage [Dual]

/ Medicare Premium

(Medicare) CHP (Child Health Plus) Essential Plan 1&2 Non- Aliessa / Essential Plan 3&4

Aliessa (Essential Plan)

MetroPlusGold / GoldPlus / GoldPrime / Silver Plus / Platinum

Plus / MedPlus Catastrophic / MetroPlusGold // BronzePlus / BronzePlus HAS / Silver Prime / SHOP (Exchange HBE // QHP

Prime) H+H Auths Required

MetroPlus GoldCare 1, 1A, 1B, II, IIA, IIB (GoldCare - H+H Employees -

Commerical) OON/Out of State

CPEP (Comprehensive Psychiatric Emergency Program)

/ Obs Beds No Auth Req'd No Auth Req'd No Auth Req'd No Auth Req'd No Auth Req'd No Auth Req'd No Auth Req'd Not covered Benefit No Auth Req'd

IP MH (Mental Health) NOA NOA NOA Pre Cert NOA NOA NOA NOA Pre Cert only if a Covered

benefit

IP SUD (Substance Use) NOA NOA NOA Pre Cert NOA NOA NOA NOA Pre Cert only if a Covered

benefit RTC (Residential Treatment

Centers) Stabilization ^NOA ^NOA ^NOA Not covered Benefit Rehab 28 Stabilizaton = not a

covered benefit NOA Rehab 28 Stabilizaton = not a covered

benefit Rehab 28 Stabilizaton = not a covered

benefit Pre Cert only if a Covered benefit RTC (Residential Treatment

Centers) Rehabilitation ^NOA ^NOA ^NOA Not covered Benefit Rehab 28 Stabilizaton = not a

covered benefit NOA Rehab 28 Stabilizaton = not a covered

benefit Rehab 28 Stabilizaton = not a covered

benefit Pre Cert only if a Covered benefit

Intermedicate Stay Unit Pre Cert Pre Cert Pre Cert Not covered Benefit Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert only if a Covered

benefit

Crisis Residence NOA NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered

benefit

PHP (Partial Hospital Program) NOA NOA NOA Pre Cert NOA NOA NOA NOA Pre Cert only if a Covered

benefit

IOP MH/SUD NOA NOA NOA Pre Cert NOA NOA NOA NOA Pre Cert only if a Covered

benefit

CDT (Continung Day Tx) Pre Cert 18 + only - Auth Required Pre Cert Not covered Benefit Pre Cert Pre Cert Not covered Benefit Not covered Benefit Pre Cert only if a Covered

benefit ACT (Assertive Community

Treatment) ^{Pre Cert} 18 + only - Auth Required (except for

pre-admission) Pre Cert Not covered Benefit Only Covered 18+ No Auth Req'd Not covered Benefit Only Covered 18+ No Auth Req'd Gold Care Not covered Benefit Commercial Only Covered 18+ No Auth

Req'd

Pre Cert only if a Covered benefit

PROS Preadmission no auth req (up to 60

days). Prior auth after ISR Submitted Preadmission no auth req (up to 60

days). Prior auth after ISR Submitted Not covered Benefit Only Covered 18+ Preadmission no auth req (up to 60 days).

Prior auth after ISR Submitted Not covered Benefit Only Covered 18+ No Auth Req'd Only Covered 18+ No Auth Req'd Pre Cert only if a Covered benefit

OP Psychotherpay No Auth Required No Auth Required No Auth Required No Auth Required No Auth Required No Auth Required No Auth Required No Auth Required Pre Cert only if a Covered

benefit

(56)

REQUIRED MENTAL HEALTH AUTHORIZATIONS (2 of 7)

Medicaid & NY Children (MCD TANF / MDC SSI / QMP SNP /

QMP TANF / QMP SSI)

MetroPlusGold / GoldPlus / GoldPrime / Silver Plus / Platinum Plus / MedPlus Catastrophic / MetroPlusGold //

BronzePlus / BronzePlus HAS / Silver Prime / SHOP (Exchange

HBE // QHP Prime) H+H Auths Required

TMS Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert only if a Covered benefit

ECT Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert only if a Covered benefit

Psych Testing Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert only if a Covered benefit

Neuro Psych Testing Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Psychosocial

Rehab (PSR) Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Community Psychiatric Support &

Treatment (CPST)

Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community

Based Services) - Peer Supports Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Substance

Abuse Peer Supports Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Habiltative

Residential Support Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Family

Support & Training Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Habiltative Residential Support (Habilitation)

(57)

REQUIRED MENTAL HEALTH AUTHORIZATIONS (3 of 7)

Medicaid & NY Children (MCD TANF / MDC SSI / QMP SNP /

QMP TANF / QMP SSI)

MetroPlusGold / GoldPlus / GoldPrime / Silver Plus / Platinum Plus / MedPlus Catastrophic / MetroPlusGold //

BronzePlus / BronzePlus HAS / Silver Prime / SHOP (Exchange

HBE // QHP Prime) H+H Auths Required

HCBS (Home & Community Based Services) - Vocational/Employment Supports

HCBS (Home & Community Based Services) - Education

Support Services Not covered Benefit NOA NOA Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Intensive

Crisis Respite Not covered Benefit No Auth Req'd No Auth Req'd Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) - Short Term

Crisis Respite Not covered Benefit No Auth Req'd No Auth Req'd Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

HCBS (Home & Community Based Services) -

Transportation Add-on Not covered Benefit No Auth Req'd No Auth Req'd

If H4 / H6 Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert only if a Covered benefit

Child and Family Treatment Supports and Services (CFTSS) - Other Licensed Practitioner (OLP)

No Auth Req'd Not covered Benefit No Auth Req'd Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert OON/ No Out of State

Child and Family Treatment Supports and Services (CFTSS) - Psychosocial Rehabilitation (PSR)

Child and Family Treatment Supports and Services (CFTSS) - Community Psychiatric Support and Treatment (CPST)

Child and Family Treatment Supports and Services (CFTSS) - Family Peer Supports and Services (FPSS)

Child and Family Treatment Supports and Services (CFTSS) -

Youth Peer Supports and No Auth Req'd Not covered Benefit No Auth Req'd Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Not covered Benefit Pre Cert OON/ No Out of State