Welcome to UnitedHealthCare Provider Orientation...© 2019 Optum, Inc. All Rights Reserved...

© 2019 Optum, Inc. All Rights Reserved

BH2036_05/2019

United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum

Children’s Behavioral Health

Transformation

Effective July 1, 2019

1

Welcome to UnitedHealthCare

Provider Orientation


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• Overview of Optum and UnitedHealthcare

• Clinical Vision

• Cultural Competency

• Children Behavioral Health

Services

• Health Home Care Management

• Credentialing

• Member Eligibility

• Utilization Management

• Quality Improvement

• Billing and Claims

• Provider Portal and Resources

Today’s Agenda


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Our United Culture


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• UnitedHealthcare plans and care

programs are uniquely designed to

address the complex needs of the

populations we serve, including the

chronically ill, those with disabilities

and people with higher risk

medical, behavioral and social

conditions

UnitedHealthcare Community Plan

• The largest health benefits company dedicated to providing diversified solutions to States that care for the economically disadvantaged, the medically underserved and those without benefit of employer-funded health care coverage

• Participate in programs in 24 states, plus Washington D.C.

• Serves more than 5 million beneficiaries of acute and long-term care Medicaid plans, the Children’s Health Insurance Program (CHIP), Special Needs Plans and other federal and state health care programs

5

Clinical Vision


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UnitedHealthcare: Our Goals

6

• Use recovery language and principles in every aspect of our work

• Promote Evidence Based and Emerging Best Practices

• Collaborate with providers and systems of care to ensure timely access to services

• Increase community-based services

• Right care at the right time

• Integrated person-centered care plans

• Broaden provider focus

• No wrong door access to care

• Engage community based care

• Reducing avoidable inpatient admissions

• Use natural community supports

Recovery

Focused

Improve

Access

to Care

Integrate

Physical &

Behavioral

Health Manage Cost


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Provider Network

Behavioral Health

Physical Health Quality

Outcomes

Utilization

Management Member

7

UnitedHealthcare: Our Organization

Cultural Competency

8


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Culture refers to integrated patterns of human behavior within various racial, ethnic, religious or social groups, including:

Cultural Competency

• Language

• Thoughts

• Communications

• Actions

• Customs

• Beliefs

• Values

• Institutions


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Cultural and linguistic competence

is a set of congruent behaviors,

attitudes, and policies that come

together in a system, agency, or

among professionals, that enables

effective work in cross-cultural

situations.

Cultural Competency

Competence means having the capacity to function effectively as an

individual and an organization within the context of the cultural

beliefs, behaviors, and needs presented by members and their

communities.

omh.ny.gov/omhweb/cultural_competence

https://omh.ny.gov/omhweb/cultural_competence/


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• Given the diverse ethnic population in New York, providers must be prepared to provide culturally appropriate services

• Service settings and approaches should be culturally sensitive to engage individuals from diverse backgrounds to access services

Cultural Competency: Importance and Value

• Promoting open

discussions about mental

health or substance abuse

issues is an important step

to reduce the stigma many

individuals have

• Emphasizing individualized

goals and self-sufficiency

encourages members to

live their lives to the fullest


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United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum 12

Awareness of Diversity and Culture in Clinical Settings

• Differences found in diverse

populations • How individual differences affect

assessment and response to treatment

• Personality, culture, lifestyle and other

factors influencing client behavior

• Culturally sensitive counseling methods

• Dynamics of family systems in diverse

cultures and lifestyles

• Client advocacy needs specific to

diverse cultures

Children’s Behavioral Health Services

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Children and Family Treatment and Support Services (CFTSS)

Family Peer Support Services (FPSS)

NY State Office of Mental Health Licensed Services

Partial Hospitalization Inpatient Psychiatric Services and Outpatient Clinics1

Assertive Community Treatment (ACT) 2

Personalized Recovery Oriented Services (PROS) 2

Comprehensive Psychiatric Emergency Program (CPEP) 2

Continuing Day Treatment (CDT) 2

1 This includes OMH SED designated clinics and Children with SSI who were previously carved out of MMC 2 Minimum age 18 for these adult oriented services


Other Licensed Provider (OLP) Psychosocial Rehabilitation (PSR) Community Psychiatric Support and Treatment (CPST)

Children’s Behavioral Health Implementation Timeline

January 1, 2019

Completed

Carve In July 1, 2019


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Youth and Peer Support and Training Crisis Intervention

NY State Office of Alcohol and Substance Abuse Services1

Outpatient Clinic (Hospital Based) 2

Opioid Treatment Program (OTP) Services (Hospital Based) 2

Outpatient Rehabilitation Services (Hospital Based) 2

Inpatient Rehabilitative Services 3

1 Residential Rehabilitation Services for Youth (RRSY) is not currently included and implementation date is TBD 2 Under 21 SSI and Non-SSI population 3 Under 21 SSI population

Home and Community Based Services Consolidated Waiver

Voluntary Foster Care Agency (VCFA) per diem and Services

Mandatory enrollment for children in Waiver service or

residing in VCFA.

Children’s Behavioral Health Implementation Timeline (cont’d)

Carve In

July 1, 2019

October 1, 2019

January 1, 2020

HCBS Pending

CMS Approval


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Existing Waiver Services New Services

OMH HCBS OCFS B2H Waiver CFTSS

Skill Building Skill Building Psychosocial Rehabilitation (PSR)

Other Licensed Practitioner (OLP)

Crisis Response

Services

Immediate Crisis

Response Services

Community Psychiatric Supports and

Treatment (CPST) Crisis Intervention

OLP Crisis Component

Intensive In-Home

Services

Crisis Avoidance

Management and Training

Intensive In Home Services

CPST

Family Peer Support

Services (FPSS)

Family Peer Support Services

(FPSS)

Children and Family Treatment Services and Support (CFTSS)

Crosswalk

1/1/19

1/1/19

1/1/19

7/1/19


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New Mental Health Services Covered by Medicaid Managed Care

Early and Periodic Screening, Diagnostic, and Treatment Services for

Children (EPSDT)

• Children and Family Treatment and Supports:


Community Psychiatric Supports and Treatment (CPST)

Psychosocial Rehabilitation (PSR)



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Four Core Service Components:

1.Psychotherapy

2.Crisis Intervention

3.Licensed Evaluation/Assessment

4.Treatment Planning

Key Features:

• Non-Physician Licensed Behavioral

Health Practitioners (NP-LBHP) provide services in the community or other

non-traditional settings such as the child/youth’s home or community

• The child/youth does NOT need to have a diagnosis and is intended to

enhance early identification and early health intervention

• OLP services can be provided in individual, family, or group settings



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Community Psychiatric Support and Treatment (CPST)

Non Counseling Core Services:

1. Strengths Based Service Planning

2. Rehabilitative Supports

3. Rehabilitative Psychoeducation

CPST Has Six Core Service Components:

Counseling Core Services:

4. Intensive Interventions

5. Crisis Avoidance

6. Intermediate Term Crisis Management

Key Features:

• Goal Directed Supports and Solution Focused Interventions

• Provided in non-traditional settings

• Promotes recovery and resilience and is intended to support stabilization and

functional improvement

• Should improve social skills and interpersonal relationships

• Should emphasize the importance of family and caregivers in support and

treatment


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Psychosocial Rehabilitation (PSR)

PSR Has Four Core Service Components:

1. Social and Interpersonal Skills

2. Daily Living Skills

3. Community Integration

4. Personal and Community Competence

Key Features:

• Provided by a non-licensed practitioner

• Youth must have a diagnosis

• Aims to restore, rehabilitate, and re-establish the child/youth to the age

appropriate developmental functioning

• Meant to compensate for functional deficits, interpersonal and/or behavioral

health barriers

• Provided in community location or where child/youth lives

• “Hands on” task oriented services

• Allows child/youth to develop, practice and apply skills in natural situations

and settings


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Four Core Service Components:

1.Engagement, Bridging and Transition Support

2.Self-Advocacy, Self-efficacy and Empowerment

3.Parent Skill Development

4.Community Connections and Natural Support

Key Features:

• Provided face to face either individually or in a group

• Formal and informal activities and supports provided to families with a child who has been diagnosed with a behavioral health condition

• Offers a structured, strength-based relationships with a Family Peer Advocate (FPA)

• Goal is to offer supports to enable child to remain in the community

• Focuses on strengthening the family unit and natural supports, empowerment, skill building


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Mental Health Services Covered by Medicaid Managed Ca

Mental Health Services already covered by Medicaid Managed Care (MMC) for

adults 21 years of age and older will now be covered by MMC for eligible youth

under the age of 21, including SSI children. These services include:

• Assertive Community Treatment (ACT)

• Personalized Recovery Oriented Services (PROS)

• Inpatient Psychiatric Services

• Operation of Outpatient Programs

Continuing Day Treatment (CDT) Program

Partial Hospitalization

• Comprehensive Psychiatric Emergency Program (CPEP)

• Clinic Treatment Programs

Outpatient Clinic Services

Integrated Outpatient Clinic Services (IOP)

Licensed Behavioral Health Practitioner Services (LBHP)


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Substance Use Disorder (SUD) Services Covered by

Medicaid Managed Care

For eligible youth under the age of 21, including SSI children, the following

Substance Use Disorder (SUD) will now be covered by MMC including:

• Part 816 - Withdrawal and Stabilization Services

Hospital Based medically Managed Inpatient Detox

Medically supervised Inpatient Withdrawal and Stabilization

Medically Supervised Outpatient Withdrawal and Stabilization

• Part 818 - Chemical Dependence Inpatient Rehabilitation Services

• Part 820 - Residential Services Stabilization and Rehabilitation

• Part 822 - Outpatient Services

Chemical Dependence Outpatient (CD-OP) Clinic

Rehabilitation Services

Opioid Treatment Programs (OTP)

1 Delivered by hospitals only

Health Home

Care Management

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Health Home Definition:

A unified system of care to coordinate and integrate the physical and

behavioral health care, chemical dependence treatment and social

services provided to Members:

• Introduced by the Affordable Care Act (ACA) in Section 2703

• Individual states have the flexibility to determine eligible health home

care providers

What is a Health Home?

New York Health Home:

• Members must actively enroll

• If a Member opts out, it must be

documented

https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_contacts.htm


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UnitedHealthCare Community Plan contracts with Health Homes (HH) across NYS to provide care coordination and comprehensive care management to improve our Member’s health outcomes.

Health Homes: Overview

• January 2019 Children served

under 1915(c) waivers transition

to Health Homes Conflict-Free

Case Management Services

• Planned in collaboration with

child/youth, family members/

caregivers and systems involved

in the Member's life and care

• Define the goals for child/youth

• Develop a service plan

• Gather the necessary resources

• Provide appropriate support

• Evaluate progress

• Determine HCBS eligibility

• Follow HCBS workflow when

appropriate

Health Homes within Children’s

Implementation

Purpose


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.

Children must meet institutional and functional eligibility criteria for the

Level of Care (LOC) using either:

1. The Child and Adolescent Needs and Strengths New York (CANS-NY) tool

or

Behavioral Health Guidelines for Children

2. The Office for People with

Developmental Disabilities

(OPWDD) Level of

Care/Medical Care Screen

eligibility tool for children with

developmental disabilities who

may be medically frail or in

foster care


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• Medicaid beneficiary requires case

management services

and

• Two (2) or more chronic conditions

such as substance use disorder,

asthma, diabetes

or

• One (1) single qualifying condition:

HIV/AIDS

Serious Emotional Disturbance

(SED)

Complex Trauma

.

Health Home Enrollment

• UHC will send Member a letter

explaining eligibility and

assignment based on county of

residence

• Health Home enrollment is

encouraged but optional and

Member can opt out or disenroll at

will

• Encouraged for children who are

eligible for HCBS

• Health Home can connect

member with an appropriate Care

Manager to facilitate enrollment

Eligibility


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Children and Youth Evaluation Service (C-YES)

Children and Youth Evaluation Services (C-YES)

• Provides HCBS-Only Care Coordination

• Can complete:

Children’s HCBS eligibility determinations

HCBS Annual Assessments

HCBS Plans of Care outlining goals and services

• Assist with the Medicaid eligible application process

• Effective January 1, 2019, 1915(c) Waiver Care Managers became

Health Home Care Managers

• Members who do not want to participate in Health Home Care

Management can get care coordination from the Children and Youth

Evaluation Service (C-YES) without a disruption in service


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Members can be referred to Health

Home Care management by:

• You, the provider

• PCP or specialist

• Emergency room or inpatient discharge planner

• SPOA

• Other Service Providers

Health Home: Getting Connected

To make a referral for Health Home services:

• Reach out directly to the Health Home in the area where the member lives

• Each Health Home has a referral line or web portal for easy referral

For a list of the Health Home covering a member’s geographical area:

health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_map/index.htm

https://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_map/index.htm


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Medicaid Helpline Toll-Free Line:

1-800-541-2831

New York State Department of Health’s

Health Home Line:

1-518-473-5569

Health Home Resource Center:

health.ny.gov/health_care/medicaid/program/medicaid_health_homes/lead_hhc.htm

.

Health Homes and Independent Entity Resources

Credentialing

32


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Step 2: Submit Group or Facility Provider Application with Supporting

Documentation, such as:

• Signed Agreement

• Signed Disclosure of Ownership

Control Interest Statement

• W9 Form

Step 3: Application review and Approval by

Optum Credentialing Committee

UHC Community Plan NY General Information

33

Step 1: Must be a state designated provider

omh.ny.gov/omhweb/bho/provider-designation.html

matrix.ctacny.org/plan/7

https://omh.ny.gov/omhweb/bho/provider-designation.html

https://matrix.ctacny.org/plan/7/


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If your agency is already a participating provider,

you need to update your area of expertise

(AOE) as part of this implementation.

Email the Optum Network Mailbox with

questions via email:

or

Contact Your Network Manager

•

Participating Provider: Contract Amendments

A list of Network Managers for your region

is available at:

[email protected]

matrix.ctacny.org/

matrix.ctacny.org/

mailto:[email protected]

https://matrix.ctacny.org/


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• As established by NCQA, re-

credentialing occurs every 36-months

(3years)

• Providers should receive a re-

credentialing packet several months in

advance. (If you do not received it,

please proactively reach out to your

Network manager)

• Failure to complete re-credentialing

paperwork or participate in the re-

credentialing site audit (when

applicable) will impact the provider’s

status in the network

• All re-credentialing paperwork must be

completed

Participating Provider: Re-Credentialing

• Site audit may be required

• The re-credentialing process

takes time, so it is important to

complete and submit required

documentation as soon as

possible.

Member Eligibility


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Under 21 Membership Cards: Contact for Providers

For Providers: UHCprovider.com 866-362-3368

UnitedHealthcare Community Plan for Families

Administered by UnitedHealthcare of New York, Inc.


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Under Membership Cards: Contact for Members

For Members: 1-800-493-4647 TTY 711


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uhcprovider.com/eligibility


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Additional Resource: Member Eligibility

40

Medicaid Eligibility Verification (MEV) System:

• Telephone

• ePaces

• X12 270/271 Health Care Benefit Inquiry and

Response

• eMedNY Call Center 1-800-343-9000

Providers are required to check eligibility with UnitedHealthcare to ensure

services is eligible for payment:

uhcprovider.com

https://www.uhcprovider.com/

41


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Continuity of Care Requirements (Effective July 1, 2019)

• Continuity of Care (suspension of Utilization Management (UM) Activities)

for non-SSI children receiving OLP, CPST, and PSR ends on 6/30/19

Out of Network Providers should be communicating with UHC to

ensure authorizations are in place for services provided after

7/1/19

• Continuity of Care (suspension of UM activities) will be effective for 90

days for SSI children receiving OLP, CPST, and PSR effective 7/1/19

• Continuity of Care (suspension of UM activities) will be effective for 90

days for all children receiving FPSS services effective July 1, 2019

• For more information refer to:

New York State Children’s Health and Behavioral Health (BH) Services

– Children’s Medicaid System Transformation Guidance for

Transitional Period January 1, 2019 - January 1, 2020

health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/nys_child_trans_bill_supp.pdf

https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/nys_child_trans_bill_supp.pdf


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Other Licensed Practitioner (OLP) No No

Community Psychiatric Supports and Treatment (CPST) No No

Psychosocial Rehabilitation (PSR) No No

Family Peer Support Services (FPSS) No No

Prior & Concurrent Authorization for Network Providers:

Children and Family Treatment Support Services

For more information refer to:

omh.ny.gov/omhweb/bho/docs/prior-concurrent-auth-ambulatory-bh.pdf

Utilization management will apply for Out of Network Providers requesting CFTSS services.

https://omh.ny.gov/omhweb/bho/docs/prior-concurrent-auth-ambulatory-bh.pdf


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OMH Program Service Prior

Authorization

Concurrent

Authorization

Outpatient Clinic

• Initial Assessment • Psychosocial Assessment • Individual, Family/Collateral, or Group

Psychotherapy • Licensed Behavioral Health Practitioner

(LBHP)

No Yes

• Psychiatric Assessment or Medication Therapy

No No

• Psychological or Neuropsychological Testing

Yes N/A

Partial Hospitalization Yes Yes

Continuing Day Treatment (CDT) Yes Yes

Personalized Recovery Oriented Services (PROS)

• Pre-Admission Status No No

• Individualized Recovery Planning Yes No

• Active Rehabilitation Yes Yes

Assertive Community Treatment (ACT)

Yes Yes

July 2019 Update Prior Concurrent Authorization

Office of Mental Health Outpatient Programs





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Service Prior

Authorization

Concurrent

Authorization

Outpatient Rehabilitation Programs No No

Outpatient Addiction Services No No

Opioid Treatment Programs (OTP) No No

Residential Addiction Services No* Yes

Part 822 Clinic Services No No

Medically Supervised Outpatient Substance Withdrawal No No

July Update Prior Concurrent Authorization Network

Providers

Office of Alcoholism and Substance Abuse



*prior authorization is not required as long as notification by network provider meets NYS SUD Legislation 48H guidelines

Prior & concurrent authorization required for all Out of Network Providers.



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Services that require authorization and notification can be obtained by calling:

Toll-free line: 866-362-3368

Electronic Prior Authorization and Notifications and supporting documentation

including NYS SUD Notification Documents (Treatment plan/Appendix A and

LOCADTR) can be submitted for New York Medicaid (effective April 1, 2019):

uhcprovider.com/en/health-plans-by-state/new-york-health-plans/ny-

comm-plan-home/ny-cp-prior-auth.html

https://www.uhcprovider.com/en/health-plans-by-state/new-york-health-plans/ny-comm-plan-home/ny-cp-prior-auth.html


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Utilization Management Appeal

Request via Phone #: 800-493-4647

• Phone number can be used to check status of an appeal and verbally submit

an appeal. Note: Any appeal filed verbally must also be followed up with a

written, signed appeal

• Enrollees/Providers have 60 calendar days from the date of denial to request

an appeal

• Only one internal appeal allowed

• Clinical appeal turn around time is 72 hours

UM Appeals for ALL Behavioral Health Services:


Attn: UM Appeals Coordinator

P.O. Box 31364

Salt Lake City, UT 84131

48


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FUH

Follow-up after

Hospitalization

AMM

Antidepressant

Medication

Management

Follow-up care for

Children prescribed

ADHD Medication

Quality Program HEDIS Measures

ncqa.org/hedis/

https://www.ncqa.org/hedis/


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• Contracted providers are required to cooperate with all aspects of the

investigation process, including providing requested charts, policies and other

documentation in a timely manner, and provide corrective action plans within

the required timeframe.

• Urgent complaints: resolved within 48 hours after receipt of all necessary

information and no more than 7 days from the receipt of report

• Non-Urgent complaints: resolved within 45 days after the receipt of all

necessary information and no more than 60 days from receipt of report

Complaints: Quality of Care (QOC) & Quality of Service (QOS)

Timeframes

• Member, a designee (with written consent), or plan representative

Who Can Report

Investigation


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Definition: Serious, unexpected occurrence involving a member that is believed to

represent a possible quality of care issue on the part of the

practitioner/facility providing services, which has, or may have,

deleterious effects on the Member, including death or serious disability,

that occurs during the course of a Member receiving behavioral health

treatment

List: A list of sentinel events/critical incidents that must be reported can be

found on providerexpress.com

Who Can Report: Provider

Timeframe(s): As soon as possible, no later than one (1) business day following the

event

Investigation: Contracted providers are required to cooperate with all aspects of our

investigation process, including providing requested charts, policies and

other documentation in a timely manner, as well as responding to

requests for corrective action plans within the required timeframe

How to report: Standardized reporting form located at providerexpress.com

Fax: 1-844-342-7704

Attn: Quality Department

Email: [email protected]

51

Sentinel Events/Critical Incidents


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Prompts

• At time of credentialing and re-

credentialing

• Part of ongoing monitoring efforts

• Part of a Quality of Care (QOC)

investigation or other complaint

Evaluated

• Physical Environment

• Policies and Procedures

• Member Records

• Personnel Files

Provider Performance Reviews

Audit tools and

documentation

guidelines are

located on

providerexpress.com

https://www.providerexpress.com/content/ope-provexpr/us/en.html


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Provider Performance Reviews Documentation

Documentation should include:

• Plan of Care with SMART Goals (reflective of progress/challenges)

• Start/Stop Time (length of time of service encounter)

• Medical Necessity

• Psychiatric and Medical History

• Presenting Problem

• Assessment and Risk Assessment (initial and ongoing)

• Medication Information

• Care Coordination with PCP (or other treating providers)

• Refusal of Care Coordination

• Substance Use Screening

• Legible (ideally EHR)

• Signed by Provider

• Discharge Plan

54


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A claim with no defect or impropriety (including any lack of any required

substantiating documentation) or particular circumstance requiring special

treatment that prevents timely payments from being made on the claim is

considered a clean claim.

All required fields are: • Complete

• Legible

All claim submissions must include, but not limited to: • Member’s name, identification number and date of birth

• Provider’s Federal Tax I.D. number (TIN)

• National Provider Identifier (NPI)

• Taxonomy Code

• A complete diagnosis (ICD-10-CM)

Providers are responsible for billing in accordance with nationally recognized CMS

Correct Coding Initiative (CCI) standards. Additional information is available at cms.gov

55

Clean Claim

https://www.cms.gov/


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On the correct claim form:

Agency

Facility (i.e. Hospital, Residential)

Basic information:

Member: Name, Medicaid ID, DOB

Provider: TIN, NPI, Taxonomy Code

ICD-10 codes

Correct code(s) corresponding to service provided:

Value, Rate Code, Revenue, CPT/HCPCS, Procedure Code, Modifiers, etc.

Date of Service

Revenue Codes

Clean Claim

BH1710_11/2018

All required fields

must be complete

and legible


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Submit batches of claims electronically, right out your practice management system software:

+ + + + +

• Ideal for high volume Providers

• Can be configured for multiple payers

• Clearinghouse may charge small fee

Optum can recommend a vendor that is right for you:

• Contact via phone 800-765-6705 or via email:

• Provide: Name, Tax ID, Claims Volume, Single or Multi-Payer Interest

Electronic Data Interchange (EDI)

[email protected]

mailto:[email protected]


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Benefits of Electronic Payments and Statements (EPS)

• Easy set-up, free to use

• Payments deposited into your bank

• Simplified claims reconciliation

• 24/7 access to your information

• Secure payment and remittance advice

Registering for EPS is easy!

• Login to Provider Express with your Optum ID

• Select “EPS” and provide the information necessary to enroll

• Contact Optum Financial Services for assistance: 1-877-620-6194

Receive Payment Faster


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Claims Submission

Electronic Claim Submission (837i): Payer ID 87726

Paper Claim Submission (UB-04): If you are unable to file electronically, follow

these tips to ensure smooth processing of your paper claim:

• Use an original UB-04 Claim Form (no photocopies)

• Type information to ensure legibility

• Complete all required fields (including ICD indicator and NPI number)

• Mail Paper Claims to:

+

Optum Behavioral Health

P.O. Box 30760

Salt Lake City, UT 84130-0760


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• Billing Overview: An interactive UB-04 form that walks through the

components required to submit a clean claim

MCTAC Billing Tool

billing.ctacny.org/

• MCTAC PowerPoint presentation provides descriptions and

instructions for every field required for a successful claim submission

refer to:

North Country Managed Care and System Transformation Training

Electronic Claim Submission: MCTAC Resources

ctacny.org/sites/default/files/trainings-pdf/4.19.16-north-country.pdf

https://billing.ctacny.org/

https://www.ctacny.org/sites/default/files/trainings-pdf/4.19.16-north-country.pdf


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MCTAC Billing Tool: Top section of UB-04 claim form


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MCTAC Billing Tool: Bottom section of UB-04 claim form

Unlicensed

practitioner ID

OMH-02249154

OASAS–02249145

OCFS -05448682


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Unlicensed Provider ID: Claim Submission

When submitting claims utilizing an unlicensed

practitioner ID as Attending, providers will submit

the NM1 Attending Provider Loop 2310A as follows:

NM108 and NM109 will be blank/not sent

REF Attending Provider Secondary Information will be added

REF01 G2

REF02 the OASAS, OMH, or OCFS (CFTSS and HCBS) Unlicensed

Practitioner ID (example: REF*G2*02249145~)

For Electronic/EDI Claims:

Unlicensed Providers

Unlicensed Practitioner ID as attending:

OASAS Unlicensed Practitioner ID: 02249145

OMH Unlicensed Practitioner ID: 02249154

OCFS Unlicensed Practitioner ID: 05448682

omh.ny.gov/omhweb/bho/claiming-guidance-for-clinics.pdf

https://www.omh.ny.gov/omhweb/bho/claiming-guidance-for-clinics.pdf


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Unlicensed Provider NPI Claims Submission

MCTAC Billing Tool

billing.ctacny.org/

Field 76: Attending Provider


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Example: PROS Cross Walk

Claim 1: Community Rehabilitation Claim 2: Clinic Treatment

Description Field on UB-04

Description Field on UB-04

Rate Code 4521 (in header) 39 Rate Code 4525 (in header) 39

H2019 Px Code 44 T1015Px Code 44

U2 Modifier 44 HE Modifier 44

13-27 Units (at line level) 46 1 Unit (at line level) 46

Modifier Definitions Modifier Definitions

1.

2.


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Example: PROS Cross Walk - Claim 1: Community Rehabilitation

Value Code

Claim 1

• Value Code 24

• Rate Code 4521 in the header

(Field 39 on UB-04)

• HCPCS/CPT Code H2019 plus

U2 (Level of Care) Modifier

(Field 44)

• 13-27 Units at the line level

(Field 46)

HCPCS Units Rate Code

U2 Modifier


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Example: PROS Crosswalk - Claim 2: Clinic Treatment

Value Code

HCPCS

Rate Code

Service Units

Claim 2

• Value Code 24

• Rate Code 4525 in the header (Field 39 on UB-04)

• Px Code T1015 (Field 44)

• Modifier HE (Field 44)

• 1 Unit at the line level (Field 46)

HE Modifier


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Behavioral Health Revenue Codes

Program/Services Minimum Required

Assertive Community Treatment (ACT) 240, 900, 911

Opioid Treatment Programs (OTP) 513, 520, 900

Rehabilitative Program Services (SUD) 900, 911, 944, 945

Mental Health and Substance Use

Outpatient Clinic

General Services

Family Therapy

Group Therapy

Injections

Developmental, Neurobehavioral,

Neuropsychological and

Psychological Testing

513, 520, 900, 914

513, 520, 900, 914, 916

513, 520, 900, 914, 915

513, 520, 900, 914

513, 520, 900, 914, 918

Intensive Outpatient (SUD) 513, 520, 900, 906

Personalized Recovery Orientation Services

(PROS)

240, 900, 911

Continuing Day Treatment (CDT) 900,907, 911

Intensive psychiatric Rehabilitation Treatment 900, 911

Partial Hospitalization 912,913

Residential Treatment (SUD) 902

Home Community Based Services 900,911

ctacny.org/sites/default/files/trainings-pdf/revenu-codes-updated-12-21-15_1.pdf

https://ctacny.org/sites/default/files/trainings-pdf/revenu-codes-updated-12-21-15_1.pdf


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Service Rate

Code

CPT

Code Description Modifier Units Notes

Brief

Evaluation 4007 90791

Psychiatric Diagnosis

Evaluation HK,H5 1 Billed on a daily basis

Full Evaluation 4008 90791 Psychiatric Evaluation HK 1 Billed on a daily basis

Crisis

Outreach Visit 4009 S9485

Crisis Intervention,

Mental Health (Per Diem)

HK 1

Emergency Services provided outside

ER Setting. Code also pays in HCBS and APGs so use the HK Modifier to

differentiate the claim. Billed on a daily basis

Interim Crisis

Visit 4010 H0037

Community Psychiatric

Support and Treatment Program (Per Diem)

HK 1

Emergency Services provided outside

an emergency room setting to persons released from CPEP. Code also pays in

APGs. Billed Daily

Extended

Observation Bed (EOB)

4049 See Note

Use same coding rules as used with

rate code 2852 (inpatient psych per diem)

Comprehensive Psychiatric Emergency Program Billing

For more information about billing for CPEP services refer to:

omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf

omh.ny.gov/omhweb/bho/policy-guidance.html

https://www.omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf

https://www.omh.ny.gov/omhweb/bho/policy-guidance.html


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Service Rate

Code

CPT

Code Modifier Unit Measure

Unit Limit/

Day

Licensed Evaluation 7900 90791 EP 15 Minutes 10

Counseling

Individual 7901 H0004 EP 15 Minutes 4

Family w/ or w/o client 7901 H0004 HR Family with Client

HS Family without client 15 Minutes 4

Off Site Evaluation

(Individual or Family) 7920

90791

H0004

Evaluation EP, SC

Individual SC

Family w/client HR, SC

Family w/o client HS, SC

15 Minutes

Evaluation 10

Individual 4

Family 4

Group 7905 H0004 HQ, EP 15 Minutes 4

Offsite Group 7927 H0004 EP, HQ, SC 15 Minutes 4

Crisis

Offsite, In-person only 7902 H2011 EP, ET 15 Minutes 8

Triage (By Phone) 7903 H2011 EP, GT 15 minutes 2

Complex Care (Follow Up) 7904 90882 EP, TS 5 minutes 4

OLP Rate Code Descriptions


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Psychosocial Rehabilitation (PSR) Rate

Code CPT Code Modifier

Unit

Measures

Unit Limit/

Day

Professional (Individual) 7913 H2017 EP 15 Minutes 8

Professional (Group) 7914 H2017 EP, HQ 15 Minutes 4

Offsite (Individual) 7922 H2017 EP, SC 15 Minutes 8

Offsite (Group) 7929 H2017 EP, HQ, SC 15 Minutes 4

Family and Peer Support Services (FPSS) Rate

Code CPT Code Modifier

Unit

Measures

Unit Limit/

Day

Professional (Individual) 7915 H0038 EP 15 Minutes 8


Offsite (Individual) 7923 H0038 EP, SC 15 Minutes 8


Psychosocial Rehabilitation (PSR) and



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Service Rate

Code

CPT

Code Modifier

Unit

Measures

Unit Limit/

Day

Professional Individual and/or Family

(with or without the client) 7911 H0036 EP 15 Minutes 6


Offsite Individual and /or Family

(with or without the client) 7921 H0036 EP, SC 15 Minutes 6


Community Psychiatric Support and Treatment (CPST)

For more information about billing for all CFTSS programs refer to:

health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/

docs/nys_child_trans_bill_supp.pdf





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Allowable Billing Combinations: Children’s Behavioral Health

Other Licensed

Practitioner

(OLP)

Community

Psychiatric Treatment

& Supports (CPST)

Psychosocial

Rehabilitation

(PSR)

Family & Peer

Support Services

(FPSS)

OMH Clinic Yes Yes Yes Yes

OASAS Clinic No Yes Yes Yes

Opioid Treatment Program No Yes Yes Yes

Assertive Community Treatment Yes No No Yes

Personalized Recovery Oriented Service No No No Yes

Continuing Day Treatment No No No Yes

OMH Partial Hospitalization Yes Yes Yes Yes

OASAS Outpatient Rehabilitation No Yes Yes Yes

Community Psychiatric Treatment &

Supports (CPST)

Yes - Yes Yes

Other Licensed Practitioner (OLP) - Yes Yes Yes

Psychosocial Rehabilitation (PSR) Yes Yes - Yes

Family & Peer Support Services (FPSS) Yes Yes Yes -


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Example: Off Site Billing

When submitting claims for Off-Site Services you will need to submit TWO

claims:

• One claim for the service provided, including the number of units

provided

• One claim with the offsite service code (1 Unit)

Other offsite

CFTSS services

are billed similarly

Claim 1 Claim 2

Counseling Session Off-site Visit

Rate Code 7905 Rate Code 7927

Px / CPT Code H0004 Px / CPt Code H0004

Modifiers HQ, EP Modifiers EP, HQ, SC

Units 4 Units 1

For Example:

If an OLP Counseling session lasts 60 minutes and occurs offsite:


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Licensed Behavioral Health Practitioners (LBHP)

• LBHP Services are priced based on the APG methodology

• Must be billed through a clinic. Clinic Rate Codes include:

Article 31 Clinics Rate Code 1507

Article 28 Hospital Based Rate Code 1519

• When on-site clinic services and a LBHP service are provided on the same

day, separate claims are required

• Possible Modifiers include: AF, AG, SA, U5

• The “After Hours” enhancement is billed using the CPT Code

• Developmental Testing is not covered under the LBHP benefit


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OASAS claims are reimbursed based on APG methodology:

• UB-04 claim form; 837i

• Value Code “24”

• Rate Code

• Revenue Codes

• CPT/HCPCS Codes

• Procedure Modifiers

• Date of Service

• Service Units

• OASAS Credentialed Alcoholism and Substance Abuse Counselor (CASAC) ID Number

OASAS Billing Requirements

OASAS: Important Modifier Reminders

• The HF modifier is requested for all OASAS

claim types

• The modifier does not impact pricing but will

support data collection

• OTP programs will continue to use the KP

modifier for the first medication administration

visit of the service week


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Part 820 Treatment Per Diem

• Residential Programs must bill with appropriate Rate Codes, HCPCS and

Modifier Code combination

• OASAS Residential Programs are also asked to use the HF Modifier The

modifier does not impact pricing but will support data collections.

• Room and board are reimbursed by the county

Program Rate Code CPT/HCPCS Code Modifiers

Stabilization 1144 (Treatment Services) H2036 TG , HF

E/M Codes for Ancillary Withdrawal Services HF

Rehabilitation 1144 (Treatment Services H2036 HF


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Community/Freestanding (Article 32 Only)

Rate Code

Hospital Based OASAS Certified Program Article 28/32

Rate Code

Outpatient Clinic program 1540 Outpatient Clinic Program 1528

Outpatient Rehabilitation Program 1573 Outpatient Rehabilitation Program 1561

Opiate Treatment Program 1564 Opiate Treatment Program 1567

Medical Services Medical Services

Outpatient Program 1468 Outpatient Program 1552

Outpatient Rehabilitation 1570 Outpatient Rehabilitation Program 1558

Opiate Treatment Program 1471 Opiate Treatment Program 1555

OASAS: Outpatient and Free Standing Facilities Rate Codes

Rate Codes are assigned based upon Certification/Program Type and Setting

(Hospital vs. Freestanding)

oasas.ny.gov/admin/hcf/ffschart.cfm

https://www.oasas.ny.gov/admin/hcf/ffschart.cfm


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Example: OASAS Claim

• Value Code 24

• Rate Code 1540 in the header

(Field 39 on UB-04)

• HCPCS/CPT Code H0001 plus

HF (OASAS Modifier) (Field 44)

• 10/01/2015 Date of Service

(Field 45)

• Rev Code 0914

• 1 Units at the line level (Field 46)

• Charges 1$50.00 (Field 47)

Units

Rate Code

HF

Modifier

HCPCS

Value Code

Service

Date Charges

Rev Code


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• Always verify member eligibility prior to rendering services

• Obtain prior authorization for those services that require it

• Use Value Code 24 and applicable Rate Code in the correct field

• One Rate Code per claim

• Include CPT Code (s), Modifier (s) and Service Units as applicable

• Do not use a hyphen in your Tax Identification Number (TIN)

• NPI numbers are required

• A complete Diagnostic Code is required (ICD-10)

• Review Provider Remittance Advice regularly to identify issues early

For more information about PRA’s go to:

Quick Reminders

uhcprovider.com/en/resource-library/edi/edi-835.html

https://www.uhcprovider.com/en/resource-library/edi/edi-835.html


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• Process by which member, or provider on behalf of member, requests a

review of adverse determination(s) on the health care services or any

amounts that the member must pay toward a covered service

• Appeal of claim payment (amount, partial) or denial: within 60-days of receipt of Provider Remittance Advice (PRA)

• Appeals should be submitted to:

Billing Appeals

United Healthcare Community Plan Appeals

P.O. Box 31364

Salt Lake City, Utah 84131-0364


BH2036_05/2019


The Managed Care Technical Assistance Center (MCTAC) is a

training, consultation, and educational resource for all mental health

and substance use disorder providers in New York State.

What’s available:

Managed Care Technical Assistance Center (MCTAC

ctany.org

MCTAC Home Page

• Interactive Glossary of Terms

• Managed Care Language Guide

• Frequently Asked Questions

• MCO Plan Comparison Matrix

• Sample Instructional Claim Form

https://www.ctacny.org/


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OASAS Billing Guidance

oasas.ny.gov/admin/hcf/APG/documents/APGManual.pdf

https://www.oasas.ny.gov/admin/hcf/APG/documents/APGManual.pdf


BH2036_05/2019


Claim Guidance: OMH and OASAS Outpatient Programs

Continuing Day Treatment Billing Regulations

govt.westlaw.com/nycrr/Document/I5037a9c7cd1711dda432a117e6e0f345?vie

wType=FullText&originationContext=documenttoc&transitionType=CategoryPa

geItem&contextData=(sc.Default)

Claiming Guidance for OMH and OASAS Clinics, OPT, PROS and

ACT

omh.ny.gov/omhweb/bho/claiming-guidance-for-clinics.pdf

+ +

https://govt.westlaw.com/nycrr/Document/I5037a9c7cd1711dda432a117e6e0f345?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

https://www.omh.ny.gov/omhweb/bho/claiming-guidance-for-clinics.pdf

85

86

UHC On-Line Resources

• providerexpress.com Demographic Updates Guidelines and Policies Best Practice Guidelines Network Manual Trainings & Resources Sentinel Events Reporting

Form

• uhcprovider.com Check member eligibility Check claim status and

payments Claims Reconsideration Electronic Data Interchange

(EDI) information Tools and Resources

• uhccommunityplan.com A website for Health Care

Professionals, Community Organizations and Members

For providers the links will direct you to important information in your state

Directs you to our secure provider site UnitedHealthcare Online®

• liveandworkwell.com Search for Providers in the Network Confidential Work/Life Resource

Center Offers Interactive Assessments Medication Database Self – Help Resources


BH2036_05/2019


Provider Express: Public Pages

providerexpress.com

Clinical Resources

Training Other Information

Available:

• Clinical Guidelines

• Provider Manuals

• Required Forms

• Webinars

• Archived Trainings


BH2036_05/2019


Provider Express: New York Page

providerexpress.com/content/ope-provexpr/us/en/our-network/welcomeNtwk/wNY.html

NY State Medicaid

Supplemental Provider

Manual

http://www.providerexpress.com/content/ope-provexpr/us/en/our-network/welcomeNtwk/wNY.html


BH2036_05/2019


Provider Express: Log Into Private Pages

To Set a UserID, select “First Time User” link


BH2036_05/2019


Provider Express: Technical Assistance Support Center

Technical Support 866-209-9320 (toll-free)

Provider Express Support


BH2036_05/2019


Liveandworkwell: Provider Directory

Select “Provider”


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Choose to search the

directory for Providers

for Adult Services

or Provider for Under

21


BH2036_05/2019



Insert Search Key

Terms such as:

Name

Expertise

Condition

Phone

Number

Program

Location


BH2036_05/2019



Enter Provider Name or Search

Term

Update Search Location

Search Filters

Search Filter Search Filter


BH2036_05/2019




BH2036_05/2019


UHC On Air on uhcprovider.com


BH2036_05/2019


UHC On Air access


BH2036_05/2019


UHC On Air on uhcprovider.com

NY Children's Medicaid 2019 Trainings

New York Children's Health Home Understanding the Program Requirements

Seven Challenges Program

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Multi-Dimensional Treatment Foster Care (MTFC)

Multi-Systemic Therapy (MST)

Functional Family Therapy (FFT)

Assertive Continuing Care & Adolescent Community Reinforcement Approach

Multi-Dimensional Family Therapy (MDFT)

Trauma-Informed Child-Parent Psychotherapy (CPP)

Dialectical Behavior Therapy (DBT)

99

External Behavioral Health Resources


BH2036_05/2019


OASAS Free Learning and Development Opportunities

oasas.ny.gov/workforce/training/freeldo.cfm

State Approved Training Resources

OMH and OASAS Supported On-Line Trainings are available through the

Center for Practice Innovation (Children’s Trainings are coming live soon)

practiceinnovations.org

https://oasas.ny.gov/workforce/training/freeldo.cfm

http://practiceinnovations.org/About/What-are-Evidence-Based-Practices


BH2036_05/2019


Children’s Medicaid System Transformation Information

health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/web-

info_child_mst.htm

• Transformation Webinars

• Children’s Medicaid and Behavioral Health System

Transformation Updates

• Children’s Health Home Webinars

• Training and Technical Assistance

• Children’s Transition Timeline and Family Treatment and

Support Services Rates

Additional information regarding the service transformation is available

on the New York State Department of Health Website. Examples

include:

https://health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/web-info_child_mst.htm


BH2036_05/2019


Additional Guides and Resources Department of Health

Children’s Behavioral Health Transition to Managed Care

health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/index.htm


health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.htm

Health Home Program Updated Billing Guidance

health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/update_bill_gui

dance.pdf

health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/index.htm

https://health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.htm

https://health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/update_bill_guidance.pdf


BH2036_05/2019


Children’s CFTSS Provider Designation Information

Additional Guides and Resources Office of Mental Health


health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.htm

health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/2018-04-

19_provider_designation_and_authorization.pdf

Approved Rates and Rate Codes

omh.ny.gov/omhweb/medicaid_reimbursement/

New York State Health and Recovery Plan (HARP) / Mainstream Behavioral

Health Billing and Coding Manual Billing and Coding Manual:

omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf

https://health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/proposed_spa.htm

https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/20180614_final_spa_slides_updated.pdf

https://omh.ny.gov/omhweb/medicaid_reimbursement/

https://www.omh.ny.gov/omhweb/bho/harp-mainstream-billing-manual.pdf


BH2036_05/2019


OASAS Ambulatory Patient Groups (APG) Policy and Medicaid Billing Guidance

document. oasas.ny.gov/admin/hcf/APG/documents/APGManual.pdf

Office of Alcoholism and Substance Abuse Resources

Integrated Outpatient Services – Implementation oasas.ny.gov/LEGAL/CERTAPP/DOCUMENTS/IOSGUID.PDF

Medicaid APG Per Service Rate Chart OASAS oasas.ny.gov/mancare/APGService.cfm

OASAS Managed Care Webage oasas.ny.gov/mancare/index.cfm

https://oasas.ny.gov/admin/hcf/APG/documents/APGManual.pdf

https://oasas.ny.gov/LEGAL/CERTAPP/DOCUMENTS/IOSGUID.PDF

https://www.oasas.ny.gov/mancare/APGService.cfm

https://www.oasas.ny.gov/mancare/index.cfm

Contact information

Thank you

105

Gayle Parker Wright, LCSW-R NY

Network Trainer


Office: 1-612-642-7307

[email protected]

Questions?

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