Objectives
Overview of Horizon Behavioral Health and
ValueOptions
Qualified ABA Services and
Covered Treatment Providers
Covered ABA Codes/AMA
CPT Codes
Claim Submission
Procedures
Transition of Care and Authorizations
Quality Management
Credentialing, Recredentialing and
Contracting
Contact Information
Questions and Answers
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Overview of Horizon Behavioral Health
and ValueOptions
• Effective July 1, 2014, Horizon Behavioral Health transitioned the
management of its behavioral health services to ValueOptions®
Inc., from Magellan Behavioral Health, Inc.
• Transition allows you to better serve your patients, by offering a
greater integration of all behavioral and medical health services,
including benefits for Applied Behavior Analysis (ABA).
• Horizon Behavioral Health will:
• Provide utilization management for ABA services for Horizon
BCBSNJ membership
• Have a specialized ABA team working with ABA providers to
handle all requests for ABA services
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Horizon Behavioral Health Operations
4
250 Century Parkway Mount Laurel, NJ
08054
Three Penn Plaza East Third Floor
Newark, NJ 07105
Co-located Staff
Loc
atio
n
103 Eisenhower Pkwy First Floor
Roseland, NJ 07068
10 British American Blvd
Latham, NY 12110
3800 Paramount Pkwy
Morrisville, NC 27560
Customer Engagement
Center
National Operations Center
Claims Processing Center
Claims Support Customer Service
Grievance/Appeals
Claims Clinical
Quality Management Clinical
Account Management Medical Director
Clinical Customer Service Provider Relations
Se
rvic
es
ValueOptions’ National Footprint
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34 Million Members 130,000 Provider locations
Under 100,000 Members
100,000 – 500,000 Members
500,000 – 1,000,000 Members
1,000,000 –2,500,000 Members
Over 2,500,000 Members
Engagement Centers
Corporate Headquarters
National Technology Center
National Operations Center
299.0 Autism Spectrum Disorder (DSM-5) determined by a
qualified provider, which is:
• MD;
• Licensed and credentialed psychologist;
• Nurse Practitioner;
• Physician Assistant, or
• as permitted by state and/or federal law
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Autism Spectrum (ASD) Diagnosis Determinations
Covered Treatment Providers
Qualified Autism Spectrum (QAS) Provider designs, supervises, or
provides treatment
• Board Certified Behavior Analyst (BCBA)
• Board Certified Behavior Analyst – Doctorate (BCBA-D)
• Licensed Mental Health Professional with specialization
QAS Professional provides treatment, assessment, and supervision
• Board Certified Behavior Analyst (BCBA)
• Board Certified Assistant Behavior Analyst (BCaBA)
QAS Technician provides care under the supervision of a BCBA
• Typically has a Bachelor degree in Social Work, Psychology,
Counseling, teaching or closely related field with experience in
applied behavior analysis
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Covered ABA Codes
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If authorization dates of service extend past July 1, claims will be paid if older codes are used.
New AMA CPT Codes
American Medical Association (AMA) recently published
CPT Category III temporary codes for Adaptive Behavior
Assessments & Treatments
• Published as temporary to allow for data collection for
emerging technology, services and procedures
• Becomes effective beginning on July 1, 2014
• Features greater detail on services provided to patients
• Identifies provider type delivering services
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New AMA CPT Codes
New codes distinguish by provider type:
• Physician
• Qualified healthcare professional [Board Certified
Behavior Analyst (BCBA)]
• Qualified technician under the direction of a physician
or BCBA or protocol established within a treatment plan
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New AMA CPT Codes
Old Codes and [policy] Process:
Using the prior HCPCS coding and consistent with the NJ
Department of Banking and Insurance Bulletin, Horizon BCBSNJ
provided coverage under the Autism Mandate for ABA
services when provided by a BCBA.
New [policy] Codes and Process Effective July 1, 2014:
Given the new detailed AMA codes now available, Horizon
Behavioral Health will begin honoring claims submitted for ABA services provided by qualified technicians for new treatment
plans if they meet specific criteria.
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Coverage Criteria for Qualified Technicians
Services provided by a technician must be provided under
the direction of a physician or qualified healthcare
professional and consistent with the protocol established in
the treatment plan.
• Claims must be submitted under Tax Identification
Number (TIN) of supervising physician or BCBA.
Six month treatment plan submitted by supervising provider
indicates a qualified technician will be administering the
services.
ABA services provided by qualified technicians will be paid
at a differential rate, reflecting the difference in expertise of
the provider delivering the services.
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Autism Code Resources
Additional information on the Autism codes on NaviNet.net:
• Horizon BCBSNJ’s Plan Central page
• Provider Reference Material page
Future updates in Blue Review
ValueOptions’ Network-specific Website:
• http://valueoptions.com/horizon/aba
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Claim Submission Timelines
You may continue to submit ABA claims for treatment plans
that were authorized by Magellan Behavioral Health prior to
July 1, 2014 until those approved treatment plans expire
using the following codes:
• Autism diagnoses codes (299.00, 299.01, 299.10, 299.11, 299.80,
299.81, 299.90, 299.91)
• Healthcare Common Procedure Coding System Codes
(H0031, H0032, H0046, H2019)
• Treatment plans that begin or are approved as of July 1, 2104 must use the new CPT Category III temporary
codes.
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Claim Submission Guidelines
Submit claims with dates of services on or after July 1, 2014 to be
electronically to Horizon.
• After logging into NaviNet.net, mouse over Claim
Management and select CMS 1500 Claim Submission
If you are not able to submit electronically, you can send paper
claims to our new address:
Horizon BCBSNJ
Horizon Behavioral Health
PO Box 10191
Newark, NJ 07101-3189
(Current claims addresses should be used
for services through June 30, 2014)
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Transition of Care
All services currently approved by Magellan will be honored
through expiration date of approval, even if extends
beyond July 1, 2014.
• ValueOptions has received from Magellan a copy of
your last submitted treatment plan.
Contact Horizon Behavioral Health at least two weeks prior
to the current approved treatment plan’s expiration date.
• 1-800-626-2212 or
1-800-991-5579 (for NJ State Health Benefits Program)
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ABA Assessment Authorization Process
• Providers should contact Horizon Behavioral Health to:
• Check member eligibility and benefit coverage relating to Autism
Spectrum Disorder and ABA services
Verification of Horizon BCBSNJ member benefits and eligibility available at
NaviNet.net
• Make sure all services receive review for medical necessity before
beginning services (e.g., assessment, initial and concurrent
authorization requests)
Confirmation of an Autism Spectrum Disorder diagnosis is required
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ABA Treatment Requests
Providers requesting continued treatment should complete and
submit an ABA Treatment Request and Treatment Plan Report via
fax at 855-241-8895 at least 1 week prior to the end of the
authorization period.
ABA Treatment Request forms (initial and concurrent) and ABA
Provider Progress Report Guidelines are accessible on the
ValueOptions.com provider website.
• http://valueoptions.com/horizon/aba
Medically necessary ABA treatment is authorized for a six month
period.
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Autism Case Management Program
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We are offering telephonic case management to members
with ASD:
Licensed clinicians who are trained in autism answer calls
Ability to make referrals to other levels of care and
community resources
Members or providers can call with questions about a wide
array of topics related to autism
Successful program model
• Existing enterprise-wide linkages and relationships
Complaint and grievance investigation and resolution
NCQA and URAC Case Management compliant
NCQA delegated entity
• Experience serving as the MBHO or as a delegated entity
Work across systems
• Support integrated medical and behavioral health services for
members
• Develop linkages for primary care physicians to access
behavioral resources
• Cross reference with pharmacy data
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Quality Management
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Quality Management and Improvement
National Quality Committee chaired by CEO
Shared client committee responsibilities
Chief Medical Officer nominated for and sits
on the NCQA Standards Committee
HEDIS monitoring, interventions and reporting
STAR rating Monitoring and interventions for
Medicare
Recredentialing and Credentialing
ValueOptions will administer Recredentialing and Credentialing
processes for Horizon Behavioral Health
Credentialing standards comply with NCQA requirements
Credentials Verification Organization certified for ten out of ten
verification services
Detailed credentialing process:
• Practitioners – 30 days after a completed application is received
• Facilities – 90 days after a completed application is received
Primary source verification for all providers
Recredentialing cycle on three-year intervals
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Recredentialing
Horizon Behavioral Health providers with recredentialing due dates
on or after July 1, 2014 are receiving recredentialing notices from
ValueOptions.
Notices sent approximately 4-5 months prior to the
renewal due date.
All providers with recredentialing due dates between
January 1, 2014 and June 30, 2014 will or have received
recredentialing information from Magellan.
Magellan will be completing recredentialing for these
providers
If providers are credentialed by both Horizon and ValueOptions,
the earliest recredentialing date will apply.
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Recredentialing
Notification every three years through:
CAQH-Universal Provider Datasource (UPD) (for CAQH members)
• Uses system reminders to prompt providers to update and
attest to their information every 120 days
• Telephonic message via Provider Pulse 4 months prior to due
date that application is available
• Telephone, fax, e-mail (for paper submitters)
• Telephonic message via Provider Pulse 4 months prior to due
date that application is available
• Follow up email or fax approximately 1 week later with
instructions for accessing application in ProviderConnect (to access application, click on link titled “Provider Data Sheet”)
• 60 and 90 day reminder notices
Failure to respond to requests from CAQH or ValueOptions will
result in disenrollment from the network
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Credentialing
Practitioners required to complete ValueOptions Credentialing
Application Process, using one of following methods:
Complete online universal credentialing application offered by
Council for Affordable Quality Healthcare (CAQH) and give
ValueOptions your identification number to access information
Contact CAQH Help Desk with questions at 1-888-599-1771
Complete a ValueOptions paper application
Application available by calling Provider Services Line at
1-800-397-1630
Complete a New Jersey Universal Application
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Contracting
New Providers joining Horizon network will sign Horizon
contracts
ValueOptions administers contracting process
Providers interested in joining the Horizon BCBSNJ networks
or with questions on contracting process can call
1-800-397-1630, 8 a.m. to 8 p.m., Monday-Friday
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ProviderConnect® Functionality
ValueOptions’ secure and HIPAA-compliant provider portal:
• Verify Member Eligibility
• Download and Print Authorization Letters
• View Authorizations
Note: Providers cannot use ProviderConnect to submit authorizations
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ProviderConnect® Registration Process
• New and Current ProviderConnect Users need to fax a completed
Account Request form to 1-866-698-6032 • Providers who already have a ProviderConnect account need to
submit a new form to request an additional login id to access Horizon
BCBSNJ member information
• Horizon BCBSNJ providers need to mark the box for Horizon Behavioral
Health Authorizations
• Providers who do not know their Provider ID can contact the Provider
Services Line at 1-800-397-1630, 8 a.m. to 8 p.m., Monday through Friday
• Account Request form located at
http://www.valueoptions.com/providers/Forms/Administrative/Online_
Services_Account_Request_Form-Editable.pdf
• If there are any questions on the form, providers can contact the EDI
Helpdesk at 1-888-247-9311, 8 a.m. to 6 p.m., Monday through Friday
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ProviderConnect ® Resources
ValueOptions.com > Providers>ProviderConnect
• Free demonstration:
http://www.valueoptions.com/PMC_prototype/ProviderConne
ct/pvd.html
• Quick Start Guide and Comprehensive User Guide
• Short Video Tutorials:
Viewing Member’s Eligibility, Submitting Authorizations, Submitting
an Inpatient or Higher Level of Care Request, Responding to
Requests for Additional Clinical Information, Recredentialing
Upcoming webinars:
• July 16, 2014 / 10-11 am Overview of ProviderConnect
• Customized training - Scheduled at your convenience
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Communication Channels
Email Alerts
Webinars
Video Tutorials
Monthly Valued Provider eNewsletter
Provider PulseSM Messages
Fax Communications
Onsite Presentations
Provider Mailings
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Provider Contacts
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Authorizations and Care Management
1-800-626-2212 or 1-800-991-5579 (for NJ State Health
Benefits Program)
ABA Treatment Request and Treatment Plan Report
Submission:
Fax: 1-855-241-8895
NaviNet
1-888-482-8057 or Navinet.net
Provider Contacts, cont’d.
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Provider Relations, Credentialing and Contracting
Questions:
1-800-397-1630 (8 am - 8 pm ET Monday – Friday)
horizonbehavioralhealthproviderrelations@valueoptions.
com
Complaints, appeals and/or general inquiries
1-800-626-2212 or
1-800-991-5579 (for NJ State Health Benefits Program)
Helpful Links
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Network-specific Website:
• www.valueoptions.com/horizon
• www.valueoptions.com/horizon/aba
NaviNet
• NaviNet.net
ABA Website for Members:
• https://www.achievesolutions.net/achievesolutions/en/h
orizonbehavioralhealth/Topic.do?centerId=370&topicId
=532