Participating Provider Manual
TABLE OF CONTENTS
1. INTRODUCTION Page 5
• Psychcare, LLC’s Management Team • Mission statement
• Company background • Accreditations
• Provider network
2. MEMBER SERVICES Page 7
• Intake Coordinators • Referrals by member • Referrals by providers • Benefits eligibility
3. UTILIZATION MANAGEMENT Page 8
• Utilization management program
• Appropriate treatment; no financial incentives • Psychcare clinical criteria
• 24-hour access to UM inquiries • Utilization management activities
4. NETWORK MANAGEMENT Page 15
• Provider recruitment
• Request to join the network process
• Notification of “Request to join” process outcome • Availability standards – GeoAccess
• Network composition • Provider training • Provider complaints • Accreditations
5. INITIAL CREDENTIALING & RECREDENTIALING Page 19
• Application submission
• Basic credentialing elements for participation, based on government, accrediting agencies, and client standards
• Federal, state, and accreditation standards
• Time frame for completion of credentialing process • Site visits prior to submission to Credentialing Committee • Notification of Credentialing Committee decision • Credentialing cycle/Recredentialing
• Maintenance of credentialing file between cycles • Ongoing monitoring
6. REVIEW OF KEY CONTRACT COMPONENTS Page 26
• Missed appointments • Breach of contract
• Billing members for covered services • Billing members for non-covered services • Termination
• Continuity of care for members following termination of member
• Provider Notification Responsibilities (i.e. Changes of address, TIN, holds, terminations, etc.)
7. CLAIMS Page 29
• Claims Processing • Timely submission • Electronic claims • Paper claim form types
• Paper claim forms submission address • Clean claims
• Remittances
• Authorization numbers on claims • Prompt payment
• Resubmission of clams
• Claim questions answered via Psychcare’s online portal • Claim questions not answered via Psychcare’s online portal • Address change notifications
8. QUALITY MANAGEMENT Page 33
• Annual Quality Improvement Program • Quality Improvement Program goals • Scope of Quality Improvement Program • Clinical management guidelines
• Outpatient treatment record documentation • Collaborative activities
• Continuity and coordination of care activities
• Health literacy, cultural and linguistic needs of membership • Member safety
• Potential quality of care and/or member safety instances
• Privacy Practices – HIPAA, and federal and state confidentiality laws • Members’ Rights and Responsibilities
• Access to care and availability standards • Fraud, waste, and abuse activities
• Psychcare website
10. LIFE’S SOLUTIONS EAP – EMPLOYEE ASSISTANCE PROGRAM Page 50 • Access to EAP Services
• Treatment Beyond EAP Services
11. CONTACT LIST Page 52
Appendix A: Link to provider resources Page 53
Appendix B: Psychcare Website Page 54
Appendix C: Medicaid Addendum Page 55
Appendix D: Network Practitioner Outpatient Documentation Requirements and Review Tool Page 74 Appendix E: Practitioner’s Statement of Receipt of Participating Practitioner Manual Page 76
1. INTRODUCTION
Psychcare, LLC’s Management Team
Rodolfo Hernandez, M.D., President & Chief Executive Officer, takes pleasure in announcing the management team of Psychcare, LLC (Psychcare) to you, and Dr. Hernandez joins with the management team in welcoming you to Psychcare’s provider network!
• Daniel Hernandez, Senior Executive Vice President • Rudy Hernandez, Executive Vice President
• Jordi Cuervo, Vice President, Operations
Mission Statement
Psychcare’s mission is to establish and continue long-term partnerships with our clients through our commitment of providing quality behavioral healthcare and Employee Assistance Program (EAP) services, both of which meet the needs of our clients, as well as their members. Client satisfaction occurs through the collaboration of Psychcare’s team of dedicated and ethical staff members, who work with skilled and professional practitioners, providers and community agencies (provider network) in Psychcare’s network model. Psychcare’s commitment to client retention and quality care increases the value our clients derive from services offered through both Psychcare’s behavioral healthcare products, as well as from our EAP product, delivered through Psychcare’s subsidiary, Life’s Solutions EAP.
Company Background
Psychcare has experienced tremendous growth in recent years, and because of our growth, we have expanded our products to include:
• Life’s Solutions EAP, a national EAP program • Disease Management Programs
• Wellness Programs
• A Dependent Care Program • PharmAssist Program ©
Psychcare’s President & Chief Executive Officer, Rodolfo Hernandez, MD, has served on various consulting boards in the area of psychopharmacological development and treatment. In addition, Dr. Hernandez previously served as the Medical Director for specialty hospitals, as well as for other Managed Behavioral Health Care Organizations (MBHO’s).
In the mid-80’s, Psychcare began as an EAP program, EmploAssist. Since that time, Psychcare has grown into an accredited MBHO, with a subsidiary called Life’s Solutions EAP. Psychcare, a family-owned company, is a comprehensive MBHO that specializes in managing mental health and substance abuse benefits for HMOs, PPOs, and large employer groups. Psychcare also is experienced in providing EAP services to a wide variety of companies and governmental entities.
Psychcare is proud of its strong history of client retention. Some of Psychcare’s clients have been with the company for 15+ years, and others have returned to Psychcare after experiencing the differences in working
with other Managed Behavioral Healthcare Organizations. Psychcare’s staff offers service that is consistently rated “excellent” in customer satisfaction surveys.
Psychcare hopes that you will find this manual to be a helpful resource in learning the processes to follow when treating members managed by Psychcare. Hard copies are available for most of the resources, if you do not have the ability to download the information from a website.
Accreditations
Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare’s commitment to quality is evident by its continuous “full” accreditation status with URAC since 1998, as well as its “full” accreditation status with the National Committee for Quality Assurance (NCQA) since 2000. These accreditations are evidence of Psychcare’s ongoing measures which promote and provide for quality care and service to members managed by Psychcare.
Provider Network
Psychcare’s provider network is very important to us! Psychcare’s management team fosters a united effort between Psychcare and its provider entwork. The mutually-cohesive and collaborative work relationship between Psychcare’s staff members and the contracted Psychcare provider network results in the provision of effective, efficient, timely, and appropriate treatment services, rendered to both the managed behavioral healthcare (MBHO) and the EAP members, all of whom are serviced by Psychcare.
2. MEMBER SERVICES Intake Coordinators
Intake Coordinators are bilingual (English/Spanish). Psychcare accommodates all other non-English speaking members through a telephonic translation service at the time of the member’s call, a service which is available Monday through Friday, from 8:30 AM to 5:30 PM, Eastern Standard Time (EST). Intake Coordinators provide direct access to callers on eligibility information, routine referrals, and authorizations. Intake Coordinators transfer calls, as appropriate, to licensed clinicians and/or other departments for assistance.
Member Referrals
Members can access referrals by calling Psychcare’s toll-free telephone number of (800-221-5487). Lists of providers are available electronically, by fax, or mail. In addition, referrals can be given telephonically at the member’s request. Once an appointment is obtained, the member or the provider will receive an authorization telephonically or online.
Provider Referrals
For the purposes of coordination of care, providers are encouraged to contact Psychcare for network referrals for therapy and/or medication management.
Benefits Eligibility
Psychcare has updated benefit eligibility information and manages benefits based on clinical criteria, benefit plan coverage and service requests.
3. UTILIZATION MANAGEMENT Philosophy
Psychcare’s philosophy is to monitor the quality, safety, and appropriateness of clinical care and services rendered by our provider network, to verify that accepted national and community standards are being provided within the scope of federal and state regulations and laws.
Psychcare’s Utilization Management (UM) program provides a mechanism for monitoring utilization of services, and ensuring delivery of quality and cost-effective behavioral healthcare. UM activities are an integral part of Psychcare’s Quality Improvement Program.
Psychcare makes decisions whether to approve or not approve payment for services based only on the appropriateness of the care or service, and on the coverage available in the member’s benefit plan.
Utilization Management (UM) Decision-Making
Psychcare affirms the following:
• UM decision-making is based only on appropriateness of care and service and the existence of coverage;
• Psychcare does not specifically reward practitioners or other individuals for issuing denials of coverage or service care;
• Psychcare does not provide financial incentives for UM decision-makers, and • Psychcare does not encourage decisions that result in underutilization.
UM decisions are based on both the members’ benefit coverage, and:
• Psychcare’s ‘Level of Care Clinical Criteria’ for all Florida Commercial and Medicare members, as well as Medicaid members outside the State of Florida, and
• Florida’s Medicaid ‘Level of Care Guidelines’ for Florida Medicaid members.
If you would like a hard copy of either UM decision-making criteria or guidelines, please contact Psychcare at our toll-free telephone number of (800-221-5487).
The Scope of the Annual Utilization Management (UM) Program
The scope of the annual UM Program includes the following the following core activities:
• Communication Services; • Triage Processes;
• Acuity Level and Appropriate Level of Care; • Referral and Clinical Review Processes; • Interrater Reliability;
• Clinical Trainings;
• Over- and Underutilization Monitoring; • Member Satisfaction with UM processes;
• Continuity and Coordination of Care.
Communication Services Regarding UM Processes and UM Inquiries
Members and the provider network have access to Psychcare’s clinical staff, 24 hours per day, 7 days per week, via our toll-free telephone number of (800-221-5487), to allow for questions regarding Psychcare’s UM processes or any UM issues to be addressed.
Psychcare’s clinical staff is available to answer inquiries regarding Psychcare’s UM processes or any UM issues,via telephone, fax, and/or email, from both members and the provider network, Monday through Friday (excluding holidays), between 8:30 AM to 5:30 PM, EST. Following usual business hours, and on weekends and holidays, members and the provider network can contact an on-call Case Manager (a licensed clinician), via our toll-free telephone number of (800-221-5487).
Psychcare’s clinical staff addresses inquiries regarding Psychcare’s UM processes or any UM issues received via telephone calls, faxes and/or within one (1) business day, Monday through Friday (excluding holidays), between 8:30 AM to 5:30 PM, unless otherwise agreed upon. Emergency telephone calls received afterusual business hours, on weekends or on holidays, are responded to within thirty (30) minutes from receipt of the call. Non-urgent telephone calls received Monday through Friday, between 5:30 PM to 8:30 AM, or on weekends and holidays, are responded to by a Case Manager, no later than one (1) business day from receipt of the call, unless otherwise agreed upon.
Psychcare staff members identify themselves by name, title, and their affiliation with Psychcare, during both inbound and outbound communications to members and the provider network regarding Psychcare’s UM processes, UM issues, and/or requests for services. Bilingual (English/Spanish) staff members are available to assist members and the provider network, both during and after usual business hours. Psychcare accommodates all other non-English speaking members through a telephonic translation service at the time of the member’s call.
Clinical Criteria
Case Managers use a member’s benefit coverage and one of the following:
• Psychcare’s ‘Mental Health Level of Care Clinical Criteria’ and/or Psychcare’s ‘Substance Abuse Level of Care Clinical Criteria’ for all Florida Commercial and Florida Medicare members, and for Medicaid members outside of the State of Florida;
• ‘Florida Medicaid Level of Care Guidelines’ for Florida Medicaid members, or • ‘Applied Behavioral Analysis Criteria’ for Florida Commercial members.
Psychcare believes that the determination of the level of care should be based upon presenting signs and symptoms, indicating that all lesser alternative levels of care would be detrimental to the safety and/or health of the member. It is the responsibility of the Psychcare clinical staff, which includes the Associate Medical Director, Psychcare Case Managers, and Clinical Peer Reviewers, to direct all members to the appropriate level of care, based on an acuity assessment.
Psychcare’s ‘Level of Care Clinical Criteria’ and the ‘Florida Medicaid Level of Care Guidelines’ are available to members and the provider network on the Psychcare website, or they may be obtained in hard copy, upon request, by calling Psychcare’s toll-free telephone number of (800-221-5487).
Referral and Clinical Review Processes Pre-Service Non-Urgent Outpatient Referrals
Members seeking initial non-urgent outpatient referrals can access services, Monday through Friday (excluding holidays) , 8:30 AM to 5:30 PM, EST, via the toll-free telephone number of (800-221-5487). The call connects the members to Psychcare’s state-of- the-art telephone system, whereby the members are provided with a menu selection, and from this menu, the members can select the menu option for non-urgent outpatient referrals. The referrals are then handled by a Psychcare Intake Coordinator.
The Intake Coordinator verifies members’ benefits, confirms their addresses and telephone numbers, explains their financial obligations, such as copays, and completes ‘Initial Intake Screening’ forms with the members. Referral considerations include the geographic, cultural, and/or linguistic preferences of the members. The Intake Coordinator provides the members with the names of network providers in their preferred area. Members are then advised that once they have made their selection, they should call Psychcare to have services authorized to the provider selected from the referral sources.
Pre-service non-urgent care authorizations, inclusive of notification, are completed within fourteen (14) calendar days from the date of the request.
Should the provider selected not be avilable within the non-urgent outpatient appointment standard, Intake Coordinators ask the provider to refer the members back to Psychcare, so that additional referral sources can be given to the members for selection.
Use of Licensed Consultants
Licensed specialty consultants are on Psychcare’s Clinical Peer Reviewer panel. The panel consists of licensed behavioral health practitioners in active practices, who have both current and unrestricted licenses, and who are either board-certified psychiatrists, licensed doctorate-degree level psychologists, or master’s’ level licensed clinicians with clinical expertise in all areas of behavioral health. The Medical Director and/or Associate Medical Director may consult with a Clinical Peer Reviewer in a like or similar specialty to the attending practitioner, whose case is being reviewed, to assist in making a determination of medical necessity or clinical appropriateness, and in other situations, as necessary.
Initial Clinical Review
Psychcare’s ‘ Mental Health Level of Care Clinical Criteria’, Psychcare’s ‘ Substance Abuse Level of Care Clinical Criteria’, the ‘Florida Medicaid Level of Care Guidelines’, and ‘Psychcare’s Clinical Management Guidelines’ are used by the Psychcare Case Managers during the initial clinical review.
With oversight by the Associate Medical Director and supervision by the Vice President, Clinical Operations, actively- licensed Case Managers conduct both pre-service urgent care, as well as concurrent urgent and non-urgent care reviews. The Medical Director and/or Associate Medical Director are accessible for any clinical questions concerning authorization of services, 24 hours per day, 7 days per week.
Medical necessity denial determinations are never issued during the initial clinical review. Medical necessity denial determinations are only issued during the peer clinical review, conducted by the Medical Director and/or Associate Medical Director, with the attending practitioner.
Emergency Services and Urgent Care Review .
Emergency mental health services are defined as those services that are required to meet the needs of an individual who is experiencing an acute crisis resulting from mental illness, which is at the level of severity that would meet the requirements for involuntary hospitalization, pursuant to Chapter 394.463, F.S., and who, in the absence of a suitable alternative or psychiatric medication, would require hospitalization.
Emergency psychiatric services, necessary to screen and stabilize a member are authorized without prior approval, when a prudent layperson, acting reasonably, believes that an emergency exists or an authorized representative acting for the organization has authorized the provision of emergency services. Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member’s benefit plan. Pre-service Care Review
Pre-service reviews are conducted before treatment is provided to the member. A determination to authorize a particular service is based on the member’s benefit coverage and the definition of medical necessity, based on Psychcare’s ‘Level of Care Clinical Criteria’ or Florida’s ‘Medicaid Level of Care Guidelines’.
• Pre-service urgent care reviews, including verbal and written notifications, are completed as soon as possible, but no later than seventy-two (72) hours from the date and time of receipt of the request. • Pre-service nonurgent review decisions, including verbal and written notifications, are completed within
fourteen (14) calendar days from the date of receipt of the request. Concurrent Review
Concurrent reviews are conducted during the course of treatment to ensure treatment continues to meet Psychcare’s definition of medical necessity, based on Psychcare’s ‘Level of Care Clinical Criteria’ or Florida’s ‘Medicaid Level of Care Guidelines’.
• Concurrent urgent care review decisions, including verbal and written notifications, are completed within twenty-four (24) hours of the date and time of the request.
• Concurrent non-urgent review decisions, including verbal and written notification, are completed within fourteen (14) calendar days from receipt of the request. Providers may request concurrent outpatient authorizations by completing the applicable form(s) available on the Psychcare website www.psychcare.com
Both urgent and non-urgent concurrent care certification decision notifications include (1) the number of days or units of service authorized, (2) the next anticipated review point, (3) the new total of days or services approved, and (4) the date of admission or onset of services.
The Medical Director and/or Associate Medical Director make all post-service review determinations. Post-service reviews are conducted after the completion of a course of treatment. A post-Post-service review occurs when services were neither authorized nor denied by Psychcare. The determination and written notification of the decision are provided within thirty (30) calendar days of the date of the receipt of the request and/or all clinical information necessary to make a medical necessity decision. When a request for a post-service review is received by Psychcare, and there is insufficient clinical information to determine the medical necessity of the case, Psychcare requests that the clinical information necessary to determine medical necessity is received within forty-five (45) calendar days from the date of the receipt of the notice requesting same. The requested clinical information includes, but is not limited to:
• The initial psychiatric evaluation; • The physician’s orders;
• The daily physician’s progress notes; • The daily nursing progress notes, and • The discharge summary.
Network Provider Utilization Management Processes for Post-Service Review of Emergency Services
• The post-service review process for emergency services is based on Federal and State regulatory standards; • The definition of emergency services is based on (1) the member’s certificate of coverage and (2) per
Federal and State regulatory requirements;
• The submission and processing of a network provider request for a post-service review is based on (1) the individual network provider’s executed ‘Psychcare Participating Practitioner Agreement’ or ’Psychcare Participating Provider Agreement’, and the section of the agreement pertaining to adherence to Psychcare’s utilization management processes, (2) the member’s certificate of coverage, (3) the emergency service definition as per the applicable line of business, and (4) national accrediting body standards;
• Psychcare will not process post-service review requests for routine outpatient services;
• Psychcare shall, at all times, provide reimbursement for an emergency psychiatric evaluation as per the member’s benefit plan;
• It is the network provider’s responsibility to contact Psychcare within twenty-four (24) hours of the member’s admission, or, if unable to do so for circumstances beyond the provider’s control, on the next business day. Although Psychcare cannot deny payment for emergency services based on the provider’s failure to comply with the notification requirements, nothing shall alter any contractual responsibility of the member or provider to make contact with Psychcare subsequent to receiving treatment for the emergency condition;
• When the member is unable to provide insurance information upon admission, the network provider, in all circumstances, will obtain the member’s insurance information prior to the member’s discharge and will notify Psychcare of the member’s hospitalization;
• When the network provider identifies the member’s insurance information but was unable to contact Psychcare for authorization prior to the member’s discharge, as evidenced by the provider’s submission of a post-service review request to Psychcare, it is the network provider’s responsibility to document in the member’s treatment record, the provider’s efforts to contact Psychcare and to obtain authorization upon receipt of the member’s insurance information, prior to the member’s discharge. The post-service review request will not be processed if there is a lack of this documentation, and the network provider will receive written notification within five (5) business days of Psychcare’s review of the request, via mail and/or electronically of the decision, not to process the provider’s request, with the specific reasons listed;
• Requests for payment of service reviews follow the Federal and State submission time periods for post-service review requests. All requests received after the prescribed submission period shall be considered past the date of submission;
• When the network provider’s utilization management process responsibilities are fulfilled, Psychcare’s Medical Director or Associate Medical Director determines the medical necessity of the services previously rendered, based on;
ü All clinical documentation submitted with the post-service review request,
ü Psychcare’s ‘ Level of Care Clinical Criteria’, and when applicable, Florida’s ‘Medicaid Level of Care Guidelines’,
ü The member’s benefit coverage, and
ü The applicable definition for emergency services.
• When the network provider’s utilization management processes are not fulfilled, the network provider shall be sent written notification via certified mail and/or email, advising the provider that the post-service review will not be processed due to a breach in the agreement requring adherence to Psychcare’s utilization management processes;
• The post-service review determination, including written notification via certified mail and/or email, is completed within thirty (30) calendar days of the date of the receipt of the post-service review request; • As per Chapter 641.513, F.S., ‘Requirements for Providing Emergency Services and Care’, the member is not
held financially liable for the emergency services provided, except for any copayment or coinsurance; • The timeliness of post-service medical necessity review determinations, are reported quarterly to the
Utilization Management Committee; Peer Clinical Review
The Medical Director or Associate Medical Director conducts all initial peer clinical reviews. Medical necessity denial decisions are based on the relevant clinical information provided by the attending practitioner or UM personnel, Psychcare’s ‘Level of Care Clinical Criteria’, Florida’s ‘Medicaid Level of Care Guidelines’, and the definition of medical necessity.
Every reasonable opportunity is afforded to the member, member’s legal representative, attending practitioner or provider to consult directly with the Medical Director or Associate Medical Director within one (1) business day of the decision, to discuss the determination via the toll-free telephone number of (800-221-5487). .When the Associate Medical Director is unavailable within the specified time period for the peer clinical review, then a Psychcare Clinical Peer Reviewer, who is an actively practicing network practitioner of the same or similar specialty, conducts the peer clinical review within one (1) business day of the decision.
Medical Necessity Appeals
Commercial, Medicare, and Michigan Medicaid client health plan expedited, pre-service, and post-service member medical necessity appeals and network provider medical necessity appeals are contractually delegated to Psychcare by each client. Unless contractually delegated, Psychcare does not process Florida Medicaid medical necessity expedited, pre-service, and post-service member and network provider appeals. Second level appeals and/or external reviews of appeals by an Independent Review Organization (IRO) are not delegated to Psychcare by any of our clients.
An expedited appeal is a request to change a denial determination for urgent care, as per the urgent care definition, while the member is still undergoing treatment.
A board-certified Clinical Peer Reviewer in the same or similar specialty as the attending practitioner, who was not involved in the initial denial determination, reviews the appeal. A determination is rendered, and the parties are given verbal and written notification of the decision as soon as possible, but no later than seventy-two (72) hours from receipt of the appeal request.
Post-service Appeals
A board-certified Clinical Peer Reviewer in the same or similar specialty as the attending practitioner, who was not involved in the initial denial determination, reviews the appeal.
A post-service appeal is a request to change a denial determination for treatment that the member has already received.
Post-service appeal determinations, inclusive of written notification, are completed within thirty (30) calendar days from receipt of the request.
Practitioner Satisfaction with Psychcare UM Processes
Annually, Psychcare conducts a Network Practitioner Satisfaction Survey with all of our network practitioners, and a Florida Medicaid Stakeholder Survey with our Florida Medicaid providers for each of our Florida Medicaid clients. The purpose of each survey is to find out our network’s satisfaction with our clinical and administrative UM processes, and to identify opportunities to improve those areas of least satisfaction.
UM Information Contained on the Psychcare Website
• Psychcare Mental Health Level of Care Clinical Criteria • Psychcare Substance Abuse Level of Care Clinical Criteria • Psychcare Applied Behavioral Analysis Criteria
• Psychcare Florida Medicaid Level of Care Guidelines • Psychcare Neuropsychological Testing Criteria
• Accessibility to Customer Service Staff and Clinical Staff to discuss utilization management issues • Ensuring appropriate utilization management
• Conflict of Interest Statement
• Pre-service, concurrent, and post-service review decision-making timeliness standards • Authorization processes
• Post-service review processes for Psychcare network practitioners and providers
• The opportunity to request a Peer Clinical Review to discuss an initial medical necessity denial determination
Psychcare’s website address is www.psychcare.com. Most of the information described herein can be downloaded from our website. If you would like a hard copy of the any of the documents and/or activities located on our website, please call Psychare’s Quality Management Department at Psychcare’s toll-free telephone number of (800-221-5487), Monday through Friday, 8:30 AM to 5:30 PM, EST.
4. NETWORK MANAGEMENT Provider Recruitment
If you or someone you know would like to be considered for inclusion in Psychcare, LLC’s network, please refer to the “Request to Join Network Process” below in this section.
Request to Join the Network Process
Providers (practitioners) who have an interest in joining the network should print the Participating Provider Application, which can be downloaded from the Psychcare website at “Recruitment Contracting”. If you do not have access to a website, please contact the Network Development Department at the toll-free telephone number of (800-221-5487, Ext. 3998).
Once you have printed the application, please legibly complete the form, in full, then sign and return with all requested, supporting documentation, in one of three ways:
• Mail: Psychcare, LLC, 10200 Sunset Drive, Miami, FL 33173 Attention: Network Development • Fax: Network Development @ 800-370-1116
• Email: [email protected]
Upon receipt of a completed application, the following elements will be reviewed to assist Psychcare in determining initial eligibility for processing by the Credentialing Department:
• Specialty/area of expertise is needed in network;
• Location of practice is within network development-approved area;
• License must be current, valid, unrestricted, and in most geographic locations, independent; • DEA/Controlled substance registration current, unrestricted;
• Board certification (ABMS or AOA ONLY) is current and verifiable (Physicians only); • Residency training is completed and verifiable, if not board-certified. (Physicians only); • Education is completed and verifiable. (Providers with Doctorate and Master’s degrees);
• Work history must include five (5) current, consecutive years of experience in the field of interest. Gaps greater than one (1) year require a written explanation and will be reviewed. Gaps between six (6) months to one (1) year can be offered verbally, but the explanation is processed more efficiently when explained in writing, and
• Cultural, ethnic and linguistic needs of the network are considered and reviewed in each application. Note: If initial eligibility is not met, providers (practitioners) will be notified (See ‘Notification of Request to Join
Process Outcome’).
If initial eligibility is met, providers (practitioners) will be sent application, or if already received, application will be processed by the Credentialing Department.
Providers (facilities) with an interest in joining the network should contact the Network Development Department at the toll-free telephone number of (800-221-5487, Ext. 3998). This department will handle all of your questions regarding the possibility of network inclusion.
Upon receipt of a completed application, along with the supporting documentation, the provider (practitioner) will be notified within fifteen (15) business days following the next Credentialing Committee meeting, as to whether or not the application will be processed. The Credentialing Committee meets at least quarterly, typically on the 3rd Thursday of the month the meeting will be held. Meetings are currently scheduled
for the months of March, June, September, and December.
Please note that completion and submission of a credentialing application, in and of itself, does not confirm that the Credentialing Committee allowed for the application to be sent to the applicant, nor does it constitute network acceptance by the Credentialing Committee.
Availability Standards – GeoAccess
Psychcare’s Credentialing Committee conducts network analyses, at least annually, but availability standards are analyzed on an ongoing basis throughout the year. Availability standards are reviewed annually and are determined, based on client needs, state and federal standards, accrediting standards, and network composition needs.
Further, a network analysis is conducted prior to the processing of any initial credentialing application, to determine if there is a need in the network, based on GeoAccess-calculated availability standards, for a provider of the applicant’s scope of practice, location, language(s) spoken, and cultural/ethnic background.
Network Composition
Psychcare’s network is composed of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups.
The size and the scope of the network is determined by the Credentialing Committee and is reviewed on an ongoing basis to assure the network is inclusive of the appropriate number and distribution of providers (practitioners) who work independently, as well as providers (facilities), such as hospitals, community mental health centers, partial hospitalization programs, intensive outpatient programs, and accredited outpatient groups.
Provider Training
A Provider Training Module is available on our website at www.psychcare.com. The Provider Relations Department is also available to conduct training with new providers at the time they are contracted.
The Provider Training Module will include, but will not be limited to:
• Introduction to the Participating Provider Manual • Provider Responsibilities
• Authorization process
• Claims submission, processing, and payment • Electronic billing
• HIPAA Information • Treatment plans • Clinical summaries
• Medication management forms • Maintaining current credentialing file • Change of address process
• Who to contact with general questions • Contact list for Psychcare
Provider Complaints
Psychcare’s Provider Partnerships Department maintains a Provider Complaint Log with the following components addressed for each Provider Complaint received:
• Date of complaint
• Date of response to complaint • Name of health plan
• Practitioner name
• Practitioner license & state of issue for license • Practice/Facility name • Complaint type • Access • Authorizations • Claims • Service • Other • Complaint narrative
• Complaint resolution (i.e. who resolved, date resolved)
The Provider Complaint Log is maintained on an internal shared location, so that any Psychcare staff member may access and input information, should a provider submit a complaint.
• If, however, the Provider Complaint is given directly to the Provider Partnerships Department via an internal staff member’s notification, and the complaint was not logged, the Provider Partnerships Department will log the event, and
• The performance goal is to have 100% of provider complaints that are received, logged for review and resolution.
Providers are encouraged to file provider complaints through the Provider Partnerships Department, incorporating one of the following delivery methods: (1) Email: [email protected], (2) Fax: 305-397-1738, (3) Telephone: (800) 221-5487 x 3904, or (4) Mail: Psychcare, LLC, 10200 Sunset Drive, Miami, FL 33173 Attn: Provider Partnerships.
The Provider Complaint Log is reviewed on a daily basis, Monday through Friday, by the Provider Partnerships Department, and the complaints are given to the Vice President, Provider Partnerships, who will initiate the handling of the case.
Each time a provider complaint is logged, the Vice President, Provider Partnerships, will assign a member of the Provider Partnerships Department to fully investigate the complaint received, with the assistance of other departments and key personnel, as needed.
• To prevent possible discrimination in any review of a provider complaint, no one staff member may determine the outcome or the resolution of same.
• All state, federal and contractual obligations are considered during review of the complaint.
Once the provider complaint investigation is conducted, the Vice President of Provider Partnerships will present the complaint to the Credentialing Committee, a subcommittee of the Quality Improvement Committee. The Credentialing Committee will review the nature of the provider complaint and the data from the investigation. The Credentialing Committee will discuss and determine recommendations based on the outcome of the complaint investigation.
The practitioner will be advised of the outcome, in writing, within ten (10) business days of the Credentialing Committee decision.
• If the practitioner wishes to dispute the outcome, a written letter of dispute with supporting
documentation should be sent to the attention of the Credentialing Committee within forty-five (45) calendar days of the date of the outcome letter.
• The Credentialing Committee will convene an ad hoc meeting, and the dispute will be reviewed. If necessary, a conference call with the practitioner will be arranged.
• Following final review, a decision will be sent, in writing, to the practitioner, within ten (10) business days of the date the dispute was reviewed, either (1) in the ad hoc meeting, or (2) following the conference call with the practitioner, whichever comes last.
Quarterly, the Vice President of Provider Partnerships will present a summary of provider complaints to the Quality Improvement Committee. The summary report will include the following:
• The total number of provider complaints received;
• A trending analysis to identify whether the provider complaints identify a particular area of dissatisfaction.
• When a trend is identified the quarterly report will contain the area(s) of dissatisfaction and, an analysis of the barriers, identification of opportunities for improvement, and recommended implemented interventions.
Accreditations
Psychcare is licensed by the State of Florida as a Private Review Agent and Third Party Administrator, and Psychcare is also a Third Party Administrator in the State of Michigan. Psychcare’s commitment to quality is evident by its continuous “full” accreditation status with URAC since 1998, as well as its “full” accreditation status with the National Committee for Quality Assurance (NCQA) since 2000. These accreditations are evidence of Psychcare’s ongoing measures which promote and provide for quality care and service to members managed by Psychcare.
5. INITIAL CREDENTIALING/RECREDENTIALING Application Submission
The creation of the initial credentialing process begins when an applicant submits the completed, dated, and signed ‘Participating Provider Application’ or the ‘Participating Facility Application’, along with copies of documents requested on the “Attestation Page” of the application, to Psychcare via mail to Psychcare, LLC, 10200 Sunset Drive, Miami, FL 33173 Attention: Network Development, or via fax to Network Development @ 800-370-1116.
Documents requested include, but may not be limited to the following, as applicable to the provider:
• Curriculum vitae;
• Current license(s) to practice;
• Malpractice face sheet indicating amounts of coverage and expiration dates, or “Financial Responsibility Statement”;
• DEA (if applicable), and controlled substance registration; • Board certification by ABMS or AOA, and
• W-9.
Basic credentialing elements for participation, based on government, accrediting agencies, and client standards
DATA ELEMENT FOR GENERAL CREDENTIALING
CRITERIA
REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA
1. Specialties/Areas of
Expertise Specialties/areas of expertise are listed in Psychcare’s credentialing applications. Providers complete this information and provide documentation to support the ability to provide such specialty or area of expertise.
2. Location(s) of Practice (See
Availability Standards)
Location(s) of practice sites are reviewed and approved by the Credentialing Committee during the initial credentialing process. If any practice sites change, are deleted, or are added, Psychcare’s Credentialing Committee will review same, and the committee will make a determination as to whether such modifications will be accepted, based on the network need for the location of the site(s), and on the cultural, ethnic, and linguistic needs of Psychcare’s members in that area. Site visits will be required in all high-volume locations, as determined by an ongoing review of utilization data and claims history.
3. License(s) Providers must submit a legible copy of a current, valid, unrestricted, independent license(s) upon initial credentialing and upon each subsequent renewal of the licensure. Psychcare credentials its providers at the highest level of both education and licensure held by the provider, not merely by the highest level of education held by the provider. Therefore, if a provider has a doctorate degree (Ph.D, Psy.D., or Ed.D, etc.), but is licensed at the master’s level, the provider will be credentialed at the master’s level.
DATA ELEMENT FOR GENERAL CREDENTIALING
CRITERIA
REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA
If a provider’s level of licensure changes between credentialing cycles, it is the responsibility of the provider to notify Psychcare of the change for review by the Credentialing Committee at the next credentialing cycle.
Psychcare verifies all state licenses from the state licensing agency, via the internet, in writing, or telephonically, whichever is applicable to the State. Disciplinary actions, if any, are indicated by the State during the verification. Psychcare requests further information from the State, when necessary. All providers complete an application at the time of initial credentialing and at the onset of each subsequent credentialing cycle, and providers answer questions as to whether or not their license(s) (current or any other in the past) are or have ever been disciplined.
If a discrepancy is noted between the information given by the practitioner and by the State, the practitioner will be notified and will be given the opportunity to respond. The Credentialing Committee reviews these findings when the credentialing file is completed and presented for approval.
4. DEA/Controlled substance registration (Physicians and applicable providers only)
Providers must submit a copy of a legible, current, valid DEA registration upon initial credentialing and upon each subsequent renewal of the DEA. Psychcare verifies all DEA registrations from the NTIS (National Technical Information Service) internet database.
Providers must also submit a copy of a legible, current, valid controlled substance registration, if applicable, upon initial credentialing, and upon each subsequent renewal of the controlled substance registration. Controlled substance registrations are verified from the primary source, whenever possible; however, the copy received from the provider is acceptable and is placed in the credentialing file.
5. Residency Training (Physicians) or
Education (Providers with Doctorate and Master’s degrees)
Physicians:
If not board-certified, physicians must have completed a verifiable residency program. Psychiatrists must have completed a psychiatric residency program, and Addictionologists must have completed an internal medicine or other approved residency program.
Psychcare verifies all residency programs (i.e. general, child and adolescent, addiction, forensic, and geriatric) completed by physicians, via the AMA Physician Profile Report or via a letter written to the residency program.
Confirmation of the dates in the program and successful completion of the program is requested. If verification by the residency program is not possible, confirmation from the state licensing agency will suffice, ONLY if the agency
DATA ELEMENT FOR GENERAL CREDENTIALING
CRITERIA
REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA
can provide recent evidence that it conducts primary source verification of residency training. Physicians should be five (5) years post-graduate; this may include residency years.
Doctorate and Master’s Level Providers:
These providers must submit proof of completion of their master’s or doctorate level programs. Psychcare verifies all educational programs by doctorate and master’s level providers, online via the NSCH (National Student Clearinghouse), or in writing, via a letter to the educational institutions from which they received their degrees. If verification by the educational program is not possible, confirmation from the state licensing agency will suffice, ONLY if the agency can provide recent evidence that it conducts primary source verification of education.
6. Board Certification - (ABMS or AOA)
(Physicians only)
Physicians who are board-certified by the ABMS or AOA must submit copies of any board-certifications in psychiatry upon initial credentialing, and they must submit any renewals or additional board-certifications, as they are granted. Verification of a provider’s residency program(s) is not required if the provider is board-certified. Psychcare verifies all ABMS certifications via ABMS’s CertiFacts service, an NCQA-approved source for verification of board-certifications. Psychcare verifies AOA certifications online, via the AOA Official Osteopathic Physician Profile Report. Verifications from these NCQA-approved sources are valid for up to one (1) year, but the verification must be obtained from the most current edition of the document source.
7. Work History Work history is collected at the time of initial credentialing via the application and/or the curriculum vitae. A current, continuous, five (5) year work history in the field is reviewed. Gaps of more than six (6) months must be explained by the provider, either telephonically, with a note in the credentialing file, or in writing. Gaps of one (1) year or more must be explained in writing by the provider. Psychcare is not required to verify work history, but at the discretion of the Credentialing Committee, may choose to do so, prior to rendering a decision on the status of the applicant.
8. Malpractice History All providers will attest to the absence or presence of malpractice history in their credentialing applications. Providers must submit a copy of a current, valid malpractice face sheet upon initial credentialing and upon subsequent renewals of the malpractice insurance; coverage must be in the amounts required as a minimum by state law, and/or as noted in the Provider Agreements.
DATA ELEMENT FOR GENERAL CREDENTIALING
CRITERIA
REQUIREMENT OF DATA ELEMENT FOR GENERAL CREDENTIALING CRITERIA
malpractice coverage; these will be reviewed, on a case-by-base basis by the Credentialing Committee.
Psychcare verifies the malpractice history of all providers via the NPDB (National Practitioner Data Bank).
Additionally, Psychcare verifies the malpractice history for all doctorate and master’s level providers, in writing, from their malpractice carriers, because the NPDB (National Practitioner Data Bank) does not necessarily contain information on providers at this level. However, if a response is not received prior to the required credentialing date, the file will be presented to the Credentialing Committee, using only the NPDB (National Practitioner Data Bank) information. If the claims history from the carrier reveals negative findings upon receipt, the provider will be asked to file an explanation. The contract will be held until the carrier’s and the provider’s responses are received. The Credentialing Committee will be given the findings for review.
9. Clinical Privileges
(Physicians only) Physicians will attest to the absence or presence of a history of loss or limitation of privileges or disciplinary activity in their credentialing applications. Current clinical privileges will be listed and will be primary source verified.
10. Lack of present illegal drug use and/or felony convictions
All providers will attest either to (1) the absence or presence of present illegal drug use and/or (2) felony convictions, in their credentialing applications.
11. Cultural, ethnic, and linguistic needs
Cultural, ethnic, and linguistic needs are considered for each application presented, to assist in meeting the needs of all members.
Federal, State, and Accreditation Standards
Credentialing is conducted according to federal, state, and NCQA accreditation standards. Policies and procedures in credentialing are updated at least annually, or more often, if modifications become necessary during the year.
Time Frame for Completion of Credentialing Process
All credentialing files (initial and recredentialing), will be completed at least one hundred eighty (180) days prior to the presentation of the provider’s file to the Credentialing Committee. The timeframe for completion is typically 30-45 days from receipt of the application.
The Credentialing Committee meets at least quarterly, typically on the 3rd Thursday of the month the meeting
will be held. Meetings are currently scheduled for the months of March, June, September, and December.
Site Visits Prior to Submission to Credentialing Committee
Psychcare will conduct initial site visits to all potential high-volume behavioral health care practitioners, prior to their inclusion in the network, to ensure that these sites meet Psychcare’s practice site standards.
Psychcare is required to conduct site visits for behavioral health practitioners who meet the definition of “high-volume” at the time of initial credentialing. Psychcare has a method for identifying potential high-volume behavioral health practitioners, which is as follows: Potential high-volume psychiatrists are defined as network psychiatrists who will potentially have fifty (50) or more new referrals in a year. Potential high-volume clinicians are defined as network clinicians who will potentially have one hundred (100) or more new referrals in a year. This definition was developed, based on Psychcare’s client base and previous referral and claims data.
Initial Site Visits
A site visit must occur prior to the initial credentialing decision. For high-volume behavioral health practitioners who practice at more than one site, there must be documentation in the practitioner’s file demonstrating that Psychcare reviewed each site against the required criteria. For a multiple-site practice, Psychcare only needs to review treatment record-keeping practices at one site.
New Practitioner Joins Existing Site
An additional site visit is not necessary when a new practitioner joins an office site that has already had a site visit and is part of the network. If Psychcare credentials a new practitioner who joins an existing office site, Psychcare only needs to include documentation of the site visit for that office in the new practitioner’s initial credentialing file prior to the Credentialing Committee review.
NCQA does not require Psychcare to conduct a site visit if the practitioner relocates to an office that has already been reviewed and which meets Psychcare’s standards.
Existing Practitioner Relocates to an Existing Site
When a high-volume behavioral health practitioner relocates or opens an additional office, Psychcare must evaluate the new site.
Relocations and Additional Sites
Instances when Psychcare must visit new sites include, but are not limited to, when a practitioner:
• Leaves a group practice to open a solo practice;
• Moves an office site from one location to another, and/or • Opens an additional office.
Documentation of the new site visit should be included in the recredentialing file. Staff and Group Model Practices
Psychcare must conduct a single site visit of staff or group model practice sites. In behavioral health only, potentially high-volume groups require a site visit. Psychcare does not need to review the group at the time of each practitioner’s initial credentialing. Each practitioner’s credentialing file does not need to contain a copy of the site assessment; the organization must provide documentation of the site assessment at the time of an NCQA survey; however, the site visit information does not need to be considered by the Credentialing Committee.
Site Visits for Accredited Facilities
If a practitioner’s office is located in an accredited facility, Psychcare may accept a survey report or a letter from the accrediting body rather than conduct a site visit. Psychcare must document that the accrediting body’s survey criteria meets Psychcare’s quality assessment criteria and includes the high-volume practitioner’s office. Using a survey report in lieu of a site visit for an accredited facility is not delegation and NCQA does not require oversight.
Notification of Credentialing Committee Decision
All providers are sent letters advising them of the Credentialing Committee’s decision within fifteen (15) business days of the meeting in which the decision was rendered.
Credentialing Cycle/Recredentialing
At least once every three (3) years, and more often as required for specific requests, Provider Partnerships verifies that each provider continues to meet the established credentialing criteria, according to recredentialing standards set forth by Psychcare & NCQA. Providers will be sent recredentialing applications between 60-90 days in advance of their recredentialing due date, and they will be requested to complete and return these applications in a timely manner. Please be advised that it is the provider’s responsibility to be sure that the credentialing status remains current. Providers not responding to the recredentialing requests within the specified time frame must be terminated, in order for Psychcare to maintain its credentialing standards. Psychcare, LLC.
Maintenance of Credentialing File between Cycles
It is the responsibility of each provider to submit to Provider Partnerships, at the time of renewal, updated and current information regarding any of the following data elements which are time and date-sensitive, including but not limited to license(s) to practice, malpractice insurance face sheets, DEA/controlled substance registrations, and ABMS or AOA board certifications. These data elements must also be submitted at the time of recredentialing, and at any other time that such data elements are changed, are updated, or are requested by Psychcare, LLC:
Ongoing Monitoring
Review of information required to evaluate the continuing participation of providers in the Psychcare network is ongoing and periodic.
• Review information submitted to support their credentialing application • Correct erroneous information
• Receive the status of their credentialing or recredentialing application, upon request • Receive notification of these rights
6. REVIEW OF KEY CONTRACT COMPONENTS Provider Notification Responsibilities
It is the responsibility of each contracted provider to notify Psychcare in the event of the following, and you may do so by contacting the Provider Relations Department either via email at [email protected] or via the toll-free telephone number of (800-221-5487, Ext. 3904).
• Change of address, name change, merger, or other demographic change; • Change of tax identification number;
• Short-term hold on referrals; • Leaves of absence;
• Any condition that results in temporary closure of a facility or office;
• Revocation, suspension, restriction, termination, or voluntary relinquishment of any of the licenses, authorizations, or accreditations required by Psychcare;
• Any lapse or material change in professional liability insurance coverage;
• Any legal action pending for professional negligence which may reasonably be considered to be a material loss contingency, and the final disposition of the action;
• Restriction, suspension, revocation or voluntary relinquishment of medical staff membership or clinical privileges at any healthcare facility;
• Any indictment, arrest, or conviction for a felony or for any criminal charge related to an individual’s or a facility’s professional practice;
• Termination, or
• Continuity of care for members following termination of provider.
Licensing, Medicare, Medicaid Certification, and Federal Program Requirements.
Providers and Practitioners providing services via the Participating Agreement are not now, nor have they ever been excluded from Medicare, Medicaid, or any federal health program. Psychcare may request documentation to verify provider's participation with these agencies.
Missed Appointments
If you have a question about billing for a missed appointment, please contact the Provider Relations Department toll-free telephone number of (800-221-5487, Ext. 3904) for assistance.
Breach of Contract
Either party may terminate the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ with cause, upon fifteen (15) days notice for Commercial and Medicare contracts and sixty (60) day notice for Medicaid contracts with prior written notice, via certified mail, if the other party breaches any material provision of this Agreement, and such breach is not cured to the satisfaction of the non-breaching party within such fifteen (15) or sixty (60) day period, as applicable. Such termination shall be effective as of midnight, beginning the sixteenth (16th) or sixty first (61st) day, as applicable, following the date of the letter sent via
certified mail advising of the termination. Please review the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ to confirm
Florida
For all mental health services for covered services provided by provider under the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’, all factors related to electronic or hard copy claims, including the timeliness of claim submission, the establishment of the date a claim is considered received, the data required on a UB-04 or CMS-1500 form, the timeliness of payment of claims, the procedures and timeframes for notification of denial of claims, the procedures and timeframes for contesting claims, the procedures and timeframes for overpayment of claims, and the permissible error ratios for violation of terms related to payment of claims, shall be in accordance with Chapter 641.3155, F.S. on ‘Prompt Payment of Claims’, as well as Chapter 627.6131, F.S., on ‘Payment of Claims’. Provider shall not, under any circumstances, surcharge or otherwise bill a Member for any Mental Health Services, provided, however, that Provider may collect any applicable copayments and/or deductibles. Provider shall not balance-bill Members. Please review your contract to confirm.
Michigan
For covered Services provided to any member, Provider may bill such member directly for such non-covered services, provided that prior to providing such non-non-covered services, Provider advised member (1) that the services being provided by provider were non-covered Service.; (2) the applicable fees associated with any such service, and (3) that the Member was solely financially responsible to pay for such services. Please review your contract to confirm.
Termination
Either party may terminate the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ upon sixty (60) days prior written notice to the other party, for any issue that is not related to a quality care or service reason. Such termination shall be effective as of the first (1st) day of the month following the sixty (60) day notice.
Either party may terminate the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement with cause for Commercial or Medicare contracts upon fifteen (15) days prior written notice; and for Medicaid contracts upon sixty (60) days prior notice with or without cause via certified mail, if the other party breaches any material provision of the Agreement, and such breach is not cured to the satisfaction of the non-breaching party within such fifteen (15) or sixty (60) day period, as applicable. Such termination shall be effective as of midnight, beginning the sixteenth (16th) or sixty first (61st) day, as applicable, following the date of the letter sent
via certified mail advising of the termination.
Psychcare may terminate the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ immediately upon notice to Provider if (1) Provider becomes insolvent, files a petition for protection from its creditors, enters into any general arrangement or assignment for the benefit of its creditors, or suffers or consents to the appointment of a trustee or a receiver to take possession of substantially all of Provider’s assets, or in the event of the attachment, execution or other judicial seizure of substantially all of Provider’s asset, or (2) Psychcare determines, in good faith, that (a) the actions or inactions of Provider are causing or will cause imminent danger to the health, safety or welfare of any Member, and/or (b) Provider no longer meets the requirements for licensing, malpractice, or has exclusions from Medicare/Medicaid, or any federal program.
Psychcare should be notified, in writing, based on the terms of the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’.
Continuity of Care for Members following Termination of Provider
Psychcare will notify members and payors of the termination of the the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ prior to the effective date of termination, meeting timeliness standards for notification to members, as required for regulatory and accrediting agencies. Upon termination the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ , the rights of each party to the applicable Agreement shall terminate, except as otherwise provided herein, and as mandated by federal or state agencies. Commercial and Medicare members, who were receiving outpatient services prior to termination, will have access to their discontinued provider in accordance with applicable state and/or federal law. Please refer to the ‘Participating Provider Agreement’ or the ‘Participating Facility Agreement’ for specific time frames. Provider shall cooperate with Psychcare in the coordination and continuity of care for members affected by such termination. Notwithstanding anything herein to the contrary, if Psychcare or Payor becomes insolvent, provider shall continue to provide mental health services to members as mandated by CMS or state regulations or the applicable Psychcare/payor agreement.
7. CLAIMS
Claims Processing
Psychcare is committed to processing all claims accurately and in a timely manner by following all rules and regulations set forth by federal, state, and NCQA reporting requirements, as well as those mandated by our clients.
In order to avoid delay in payment or denial of a claim you submit to Psychcare, it is important for you to know the guidelines we follow, prior to your submission of a claim. To assist you, we have compiled some of the most frequently-asked questions, and we have listed them below in an easy-to-follow Q&A format.
FAQ’s
Timely Submission
Q: How long do I have to submit a claim?
A: Florida: According to Florida law, all claims must be submitted to Psychcare within six (6) months, or one hundred and eighty (180) days from the date of service.
A: Michigan: According to Michigan law, all claims must be submitted to Psychcare within one (1) year, or three hundred and sixty-five (365) days from the date of service.
Electronic Claims
Q: Can I submit my claim electronically?
A: Yes. If you would like to submit electronic claims to Psychcare through a clearinghouse, be advised of the following:
• The Psychcare Payor ID is: 51052
• All claims must have an authorization number (loop 2300)
• The member ID on the electronic claim must be the applicable health plan’s member ID, not the Medicaid ID or the provider’s internal ID (Loop 2010BA Segment: NM 109)
Psychcare uses Emdeon (www.Emdeon.com) exclusively for clearinghouse purposes. If you use a different clearinghouse, verify with them that they have an agreement with Emdeon to exchange claims.
The Emdeon Submitter Helpdesk Number is: 800-845-6592. Emdeon will help you set up your software. If you need software to submit claims, Emdeon also provides software for claims submission.
If you would like to contact Psychcare about claims submission please send an email to: [email protected] with “Electronic Claims” in the subject line.
Paper Claim Form Types
Q: What paper claim form should I use?
