ICF-IID Provider Information Session

Presented by: Alliance Behavioral Healthcare & Rubicon Management, Inc.

January 29, 2013

Serving Durham, Wake, Cumberland and Johnston Counties Revised 2/11/13

Session Objectives

Providers will gain an understanding of:

• Procedure for initial ICF-IID eligibility determinations

• Procedure for ongoing determinations

• Use of Level of Care Eligibility Determination (LOC) Tool

• Process for vacancies and referrals

• Process for authorizations and claims (including Rubicon’s involvement)

Serving Durham, Wake, Cumberland and Johnston Counties Revised 2/11/13

ICF-IID Eligibility Determination

Alliance Behavioral Healthcare is responsible for determination decisions regarding ICF-IID level of care and follows a standardized process to determine an individual’s eligibility for ICF-IID level of care.

All reviews and decisions are tracked through the Alliance electronic consumer information system (AlphaMCS).

Revised 2/11/13

Initial Determinations

Eligibility for ICF-IID level of care is determined by psychologist/psychological associate (PA) or Primary Care Physician (PCP) Psychologist/PA- Intellectual Disability

PCP- Cerebral Palsy; Epilepsy; related condition

Documentation required Completed/updated IQ and adaptive skills evaluation

(Intellectual Disabilities) or completed/updated Medical Assessment (Medical Conditions)

How current does psych need to be? For an initial request, 3 years for child, 5 years for adult.

Completed MCO Level of Care Eligibility Determination Tool (LOC)

Revised 2/11/13

About the LOC

LOC is replacing the MR-2 form

This is a State form used for NC-Innovations and ICF-IID

It is not a triplicate form and may be submitted electronically

You may access the LOC on our website:

http://www.alliancebhc.org/providers/forms-applications

Revised 2/11/13

LOC Instructions

Instructions for Level of Care Determination This form is to be used for prior approval and utilization review of ICF-IID

level of care. Demographics Name-Print last name, first name, middle initial. If no middle name or

initial, use NMN. Address-Enter the complete address where the person lives. Date of Birth-Enter the month, day and year. Gender-Enter a capital F to indicate Female or a capital M to indicate Male. County of Medicaid Eligibility-List the county from which the person’s

Medicaid originates per the SIPPS system. Medicaid Number-Enter the Medicaid Number assigned to the person. Legally Responsible Person/Guardian-List the name of the person who is

the legal guardian or responsible person for the individual who is being reviewed.

Address of Legally Responsible Person/Guardian-Enter the complete address where the Legal Guardian/Responsible person lives.

Revised 2/11/13

LOC Instructions

Living in ICF-IID facility Place a check in the space indicating whether or not the

person lives in an ICF-IID residential facility. Diagnostic Information Check all of the disability areas that apply based on the

documented disability. Check if the person has Mental Retardation/Intellectual

Disability based on the documented assessment and document the IQ or the percentage of developmental delay.

Check if the person has a Medical Condition and list the condition based on the documented assessment. If no diagnosis, list NA.

Check if the person has a condition closely related to Mental Retardation based on the documented assessment and list the condition. If no diagnosis, list NA. Revised 2/11/13

LOC Instructions

Was the Disability manifested before the age of 22? Based on documented assessment, please check the correct

box. Is the disability likely to continue indefinitely? Based on documented assessment, please check the correct Current Substantial Functional Limitations Place a check in the Yes box for each functional deficit the

individual has based on documented assessment. If the individual does not have functional deficits in a specified area then check No.

Skill acquisition Check the appropriate box to address if the person could

benefit from Skill Acquisition.

Revised 2/11/13

LOC Instructions

Level of Care Certification Based on assessment check the appropriate box to designate if the person

meets the ICF-IID level of care. Get the Signature and Printed Name of a Licensed

Psychologist/Psychological Associate or Physician as appropriate based on who completed the assessment. Medical doctor can sign anytime for ICF-IID

Level of Care Recommendation (MCO Use Only) Based on review of information, check approved or denied for ICF-IID

Level of Care List the month/day/year that the Level of Care became effective Document the Prior Approval Number Get the signature of the UM Clinical Care Manager and date of signature Get the signature of Medical Director and date of signature if needed

Revised 2/11/13

Initial Determinations

If the psychologist or physician determines that the individual does not meet the ICF-IID eligibility criteria the decision is final and is not subject to appeal.

If the individual would like a second opinion, Alliance can arrange for a different assessor to complete the evaluation.

Revised 2/11/13

Initial Determination

The physician/psychologist forwards the LOC and a copy of the assessment/evaluation to the Alliance IDD Utilization Management (UM) Supervisor

The LOC and assessment/evaluation is forwarded to an IDD UM Care Manager for review The LOC is valid for 30 days and decision eligibility must be

made within 30 days of the signature date on the form

The IDD UM Care Manager reviews the information from the assessment/evaluation and verifies that the documentation supports the eligibility criteria that are documented on the LOC

Revised 2/11/13

Initial Determination

If eligibility is verified the IDD UM Care Manager builds a Service Authorization Request (SAR) in Alpha for the ICF-IID residential service

The consumer/legal guardian, receiving facility and the appropriate Department of Social Services (DSS) receive written notification of the approval

If the assessment/evaluations do not support that the person meets ICF-IID level of care, the Alliance Medical Director will review the information and make the final determination

If the Medical Director determines that the individual is not eligible, Alliance notifies the individual/legal guardian in writing and offers appeal rights.

Revised 2/11/13

Ongoing Determinations

Every 180 days, based on consumer’s initial date of eligibility, the ICF-IID facility/agency must complete an LOC that is signed by the facility physician/psychologist

Medical doctor can sign anytime for ICF-IID Will honor current MR2 until it expires We will be reviewing

the reauths based on providers current 180 cycle. The facility/Rubicon submits a SAR via the Alpha Provider Portal and uploads the LOC to the request Electronic submission of the LOC is fine, this is not a triplicate form and

originals are not required for submission

An Alliance IDD UM Care Manager reviews the SAR and LOC If the request is approved the consumer/legal guardian, IDD

Care Coordinator, facility and appropriate DSS office are notified

Revised 2/11/13

Ongoing Determinations

If eligibility cannot be determined, the case is forwarded to the Alliance Medical Director for review

If ongoing eligibility is not determined by the Alliance Medical Director, the consumer/legal guardian and facility receive notification including appeal rights

Revised 2/11/13

Vacancies and Referrals

If you have a vacancy:

Contact the Alliance IDD Care Coordination Manager

Local Care Coordination and IDD Access will determine appropriate referrals from the wait list for that county (individuals most urgently in need and residing in the county where the vacancy occurs)

Target will be to make referrals within 3 days of notification of an opening

If these referrals do not work out, contact the Alliance IDD Care Coordination Manager prior to considering referrals from Rubicon and/or other MCOs

Revised 2/11/13

ICF-IID Q&A’s

Q- What rates will be paid? A- Alliance has been directed by DMA as to what rates will be paid.

Rates cannot change for 3 years.

Q- What type of cost finds will be required? A- There will not be any cost finding.

Q- Will there be any type of cost settlement as there is under the current Plan? A- There will not be any cost settlement

Q- Who does a guardian contact if they have a complaint? A- Alliance 24-Hour Access and Information Line: (800) 510-9132

Q- Will Alliance be conducting on-site monitoring reviews? A- Yes, ICF-IID facilities are subject to monitoring and evaluation

from Alliance, but we will not duplicate the State Surveys. Revised 2/11/13

Alpha Provider Portal Training

http://www.alliancebhc.org/alpha-provider-portal-training

February 15, 2013 and February 21, 2013 10:30am-Noon – Claims Noon-1:00pm – Lunch 1:00-4:00pm – Clinical Available via webinar (Click on the “join the live webinar” link on the web address above) Pre-recorded webinars http://www.alliancebhc.org/providers/videoswebinars

Revised 2/11/13

Alpha Provider Portal Support

Alpha Provider Portal Handbook

http://www.alliancebhc.org/wp-content/uploads/Alpha-Provider-Portal-Handbook.pdf

Alpha Provider Helpdesk

919-651-8500

Talk with live staff about any Alpha related issue 8:30am- 5:15pm Monday-Friday

Alpha Support via E-mail

E-mail- alphasupport@alliancebhc.org

Revised 2/11/13

Alliance Weekly Claims Webinar

Alliance is hosting weekly webinars for providers (not contracted with Rubicon) every Tuesday from 2:00-3:00pm to address how to bill CMS 1500 and UB04 claims and to review resources available on the Alliance website. There will be a Q&A period after each training. The schedule is as follows:

February 5, February 12, February 19, February 26 March 5, March 12, March 19, March 26

To join a webinar follow this link: https://www1.gotomeeting.com/join/970442625/106813836

Revised 2/11/13

Example Alliance Checkwrite Schedule http://www.alliancebhc.org/providers/finance-and-claims-forms

Claim Received Date

ALPHA (Process To) Checkwrite Cycle Cutoff Date

Checkwrite Date

EFT's Effective

January 11-17, 2013

01/17/13 01/24/13 01/25/13

January 18-24, 2013

01/24/13 01/31/13 02/01/13

January 25-31, 2013

01/31/13 2/7/13 2/8/13

Revised 2/11/13

Rubicon Management

Doing ICF/MR business with Alliance through Rubicon Management ASO

Consolidated Billing and Collections Rubicon ICF Provider Members are able to bill and collect

from Rubicon on a weekly basis for all MCOs under contract with Rubicon.

Contracts to Date: • Alliance Behavioral Health • Cardinal (PBH) • Centerpoint • Coastal Care • East Carolina Behavioral Health • Eastpointe • Sandhills Center • Smoky Mountain Center

Revised 2/11/13

Joining Rubicon

• Provider membership in Rubicon is voluntary. Rubicon is a non-profit North Carolina corporation.

• Approximately 90% of non-state ICF consumers to be funded by Alliance are currently under contract with Rubicon

• Rubicon’s goal is 100% MCO and Provider membership

Revised 2/11/13

Consolidated billing via Rubicon

• Provider files claims weekly through Rubicon

• Via 837-5010 or Rubicon proprietary software (free of charge)

• Claims paid via direct deposit each Tuesday

• PDF Remittance Advices and 835-5010 returned regardless of filing method

• Consolidated billing, consolidated deposit, consolidated remittance advice

Revised 2/11/13

Rubicon- Provider Training in Billing Process

• If already under Rubicon contract, add Alliance consumers to your demographic upload file, and continue billing as usual

• If new to Rubicon, training in new processes will be held near future, via WebEx

Revised 2/11/13

Rubicon Advantages

• At 100%, providers handle cash flow matters through Rubicon, and Alliance/Other MCO’s only accept 837’s from Rubicon

• Transmissions from Rubicon to Alliance are bundled and submitted once a month to reduce claims processing burden for Alliance

• Rubicon clinical staff aid in maintaining state-wide waiting list, for use of MCOs and Providers after local MCO referrals from wait lists have been exhausted

• Rubicon will assist in SAR and LOC processing for Alliance’s consumers

• Alliance will have Rubicon complete 180-day reauthorizations

Revised 2/11/13

Contact Information

Johnston Provider Relations Lori Caviness 919-989-5557 lori.caviness@johnstonnc.com

Cumberland Provider Relations Rose-Ann Bryda 910 –222-6074 rbryda@mail.ccmentalhealth.org

Durham Provider Relations Sara Wilson 919-651-0089 swilson@alliancebhc.org

Wake Provider Relations Tanya Held 919-664-7933 theld@alliancebhc.org

Alliance UM Supervisor Andrea Kinnaugh 919-651-8422 akinnaugh@alliancebhc.org

Alliance Care Coordination Manager

Suzanne Goerger 919-651-8474 sgoerger@alliancebhc.org

Alliance Access & Information Line 800-510-9132

Rubicon Management Herb Whitesell H.Whitesell@RubiconNC.org Mike Harris M.Harris@RubiconNC.org 828-624-0001

Revised 2/11/13

Thank you for your time!

Questions?

Revised 2/11/13