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Magellan Health in LouisianaNew Provider Orientation
Magellan Welcomes You To The Louisiana CSoC Provider Network
We value your participation in the Magellan Network, and all that you do to provide the very best
services to our children.
2 New Provider Orientation (Revised 12/27/2016)
Provider Relations
3 New Provider Orientation (Revised 12/27/2016)
Provider Relations Liaison (PRL)
Your PRL is here to assist you with issues related to, but not limited to:
•service delivery,
•access to services,
•claims resolution, and
•provider tools that will allow you to be more self-sufficient
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How To Reach A Provider Relations Liaison (PRL)
CALL MEMBER SERVICES
1-800-424-4489
And ask to speak to a PRL
5 New Provider Orientation (Revised 12/27/2016)
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RECEIVE A NEW CLIENT
TO YOUR PRACTICE/
AGENCY/ FACILITY
1. VERIFY MEDICAID ELIGIBILITY & CONFIRM
SPECIFIC BENEFIT PLAN.
2 2. OBTAIN PRIOR AUTHORIZATIONS
FOR SERVICES BEFORE RENDERING THEM.
3. PREPARE TREATMENT PLAN, CONDUCT
SERVICE DELIVERY AND DOCUMENT CLIENT
ENCOUNTERS AS REQUIRED BY YOUR AGENCY.
KEEP CONCURRENT REVIEW APPOINTMENTS
WITH CARE. MANAGERS, AS REQUIRED.
5. SUBMIT CLAIMS TO MAGELLAN AS PER
YOUR CHOSEN CLAIMS SUBMISSION OPTION
AND AS OFTEN AS YOU WOULD LIKE WITHIN
THE REQUIRED BILLING PERIOD.
4. CONTACT AND COLLABORATE WITH THE
WRAPAROUND AGENCY.
Process Flow For Inpatient and Crisis Services
New Provider Orientation (Revised 12/27/2016)
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RECEIVE A NEW CLIENT
TO YOUR PRACTICE/
AGENCY/ FACILITY
1. VERIFY MEDICAID ELIGIBILITY & CONFIRM
SPECIFIC BENEFIT PLAN.
2 2. OBTAIN PRIOR AUTHORIZATIONS
FOR SERVICES BEFORE RENDERING THEM.
3. PREPARE TREATMENT PLAN, CONDUCT
SERVICE DELIVERY AND DOCUMENT CLIENT
ENCOUNTERS AS REQUIRED BY YOUR AGENCY.
KEEP CONCURRENT REVIEW APPOINTMENTS
WITH CARE. MANAGERS, AS REQUIRED.
5. SUBMIT CLAIMS TO MAGELLAN AS PER
YOUR CHOSEN CLAIMS SUBMISSION OPTION
AND AS OFTEN AS YOU WOULD LIKE WITHIN
THE REQUIRED BILLING PERIOD.
4. CONTACT AND COLLABORATE WITH THE
WRAPAROUND AGENCY.
Process Flow For CSoCWaiver Service, Outpatient and HCBS Providers
New Provider Orientation (Revised 12/27/2016)
The BasicsOf Utilization Management
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The purpose of utilization management is to ensure that the member has:• the right treatment •in the right intensity •at the right time.
New Provider Orientation (Revised 12/27/2016)
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What is a prior authorization?An authorization for reimbursement for services rendered
What are the elements of an authorization?
•A member•A service•A provider•A date range•An intensity of service
Examples of Authorizations:
“Jane Doe is authorized for 25 units of PSR to be rendered by the Sunshine Counseling Agency from June 1 through July 31.”
“John Doe is authorized for 3 days of inpatient psychiatric treatment at the Healthy Hospital beginning of August 1, with a last covered day of August 3.”
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What Services Require An Authorization?
All 24-hour levels of care -HospitalizationCrisis Stabilization
Home & Community Based Services -CPST PSRCrisis Intervention FFTHomebuilders
All CSoC services – effective 9/1/2016 Crisis Stabilization is no longer a Waiver ServicePsychological Testing Substance Use Disorder IOPOutpatient services beyond the “pass-through” limits
New Provider Orientation (Revised 12/27/2016)
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How Do I Request An Authorization?
By telephone (1-800-424-4489) for…
•Hospitalization•Crisis Stabilization•Crisis Intervention
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How Do I Request An Authorization?
Through the Plan of Care.
Attend the Child & Family Team Meeting with the family, the Wraparound Agency, and others…
CPST
PSR
Crisis Intervention
FFT
Homebuilders
Psychological Testing
All CSoC services
Substance Use Disorder IOP
New Provider Orientation (Revised 12/27/2016)
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When Do I Request An Authorization?
Before the service is rendered
•For telephonic requests, Magellan will consider a request timely if the authorization is requested up to 1 business day after the date the authorization should begin.
•If the member continues to need services beyond those of the initial authorization period, then request should be made before the current authorization ends.
•This request for ongoing authorization is called a concurrent review. Concurrent reviews occur in the same format as the initial authorization (phone or written).
New Provider Orientation (Revised 12/27/2016)
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How are authorization decisions made?
The care manager will review the member’s clinical situation. Information typically reviewed includes:
Current symptomsCurrent social supportsMedicationsMedical informationDiagnosisTreatment planDischarge planCare coordination
New Provider Orientation (Revised 12/27/2016)
Provider Tips & Best Practices
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PROVIDER TIP NO. 1
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KNOW THE SPECIFIC SERVICES THAT YOU ARE CONTRACTED TO PROVIDE.
REFER TO YOUR FEE SCHEDULE (LAST PAGE OF CONTRACT), FOR THE NECESSARY CODES, ETC.
YOU ARE ONLY ABLE TO BILL FOR THOSE SERVICES FOR WHICH YOU ARE CONTRACTED TO PROVIDE.
New Provider Orientation (Revised 12/27/2016)
PROVIDER TIP NO. 2:
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Know the Details of The Services as Defined and Outlined in the DHH Services
Definition Manual Located at:
SERVICES DEFINITION MANUAL
New Provider Orientation (Revised 12/27/2016)
PROVIDER TIP NO. 3:
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Be Sure to Request and Secure Needed Authorizations Prior to Providing Your Contracted Services
Be Familiar With Authorization Procedures as Stated in The Service Authorization Criteria Guide Which is
Located at:
SERVICE AUTHORIZATION CRITERIA
New Provider Orientation (Revised 12/27/2016)
PROVIDER TIP NO. 4:
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• Verify Member Eligibility at The Magellan Provider Website:
WWW.LouisianaMedicaid.com
• Eligibility Changes Often – It is Best to Verify at Every Member’s Visit
New Provider Orientation (Revised 12/27/2016)
MAKING CHANGES TO YOUR PROVIDER AGREEMENT
Making Changes To Your Provider Agreement
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To make changes to your provider agreement, including but not limited to, adding and/or removing covered services under your current Medicaid Agreement, please refer to the Magellan of LA website at the Quick Tips & References Link:
• Making Changes to Your Provider Agreement *
Follow the step-by-step instructions listed at that site and take notice of all notices given there.
New Provider Orientation (Revised 12/27/2016)
Online Practice Changes –Easy, Convenient, Secure and Immediate
• Make real-time updates to practice data, such as:‒ Email address‒ Office locations‒ Telephone number‒ Business hours‒ Staff rosters
• Allows immediate upload of your practice information to Magellan’s systems
• Is efficient and secure
• Developed with provider input
Current practice data is vital to facilitating effective member referrals, claims processing and correspondence.
24 New Provider Orientation (Revised 12/27/2016)
More Benefits of Online Applications
• Free to use
• Environmentally friendly – no more paper!
• Available at your convenience – 24 hours a day/seven days a week
• Allows you/your staff to enter changes, ensuring that accurate information gets uploaded directly into our database.
25 New Provider Orientation (Revised 12/27/2016)
Online Practice Changes Options
•General Practice Information•Office Contacts•Access•Specialties•Mailing Address•Financial Address•Service Address
•Hours of Operation•Home Address•Electronic Funds
Transfer•W-9•Resign From Network•Roster Maintenance
26 New Provider Orientation (Revised 12/27/2016)
Key Contacts & Links:
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•MEMBER SERVICES: 1-800-424-4489
• PROVIDER WEBSITE (MP.COM) TECHNICAL ASSISTANCE: 1-800-788-4005 OR [email protected]
MAGELLAN WEBSITES:•www.MagellanofLouisiana.com•www.MagellanProvider.com
VITAL PROVIDER DOCUMENTS:•SERVICES DEFINITION MANUAL
•SERVICE AUTHORIZATION CRITERIANew Provider Orientation (Revised 12/27/2016)
Interpretive Services AvailableVia Magellan:
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Global Interpreting Network-
- This service is meant for on-site sign language interpretation or language interpretation for our Network Providers. These services are paid by Magellan if approved, authorized and arranged by a Magellan employee.
- To obtain authorizations and arrangements for these services, please contact Magellan Member Services at 800-424-4489.
New Provider Orientation (Revised 12/27/2016)
Quality Improvement
Magellan’s Quality Improvement Department Monitors Quality Through Different Mechanisms
• Treatment Record Reviews
‒ Monitor documentation and record keeping practices
• Member and Provider Satisfaction Surveys
‒ Annual surveys inform quality improvement activities
• Member and Provider Grievances
‒ Provides a mechanism to submit expressions of dissatisfaction
• Adverse Incident Reporting
‒ Monitor critical incidents
New Provider Orientation (Revised 12/27/2016)30
Treatment Record Reviews• Standard quality review of documentation and record keeping practices.
• These reviews can be onsite or desktop.
‒ Magellan typically gives 10 days to prepare records for review.
• Documentation requirements are outlined in the CSoC Provider Handbook Supplement.
• Audit tool is on the Magellan of Louisiana webpage under Quality Improvement and Outcomes: Quality Improvement
• The following resources are available for you at the above link:
o Member Rights and Responsibilities Acknowledgment Forms
o Advance Psychiatric Directive - tips and resources
o Tips for Writing Progress Notes
o Tips for Writing Treatment Plans
o Informed Consent for Medication Form
o Member Discharge Summary Form
o Crisis Plan Form
New Provider Orientation (Revised 12/27/2016)31
Member and Provider Grievances• A grievance is defined as an expression of dissatisfaction.
Possible subjects for grievances include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member's rights.
• Providers should assist members in submitting grievances when requested.
• Members or providers can submit grievances by phone, in writing or online:
‒ By Phone: Toll-free line at 1-800-424-4489
‒ Online: https://www.magellanassist.com/mem/memserv/messaging/default.aspx?CatID=20&SubcatID=110&CatName=Feedback&SubcatName=Complaints
‒ In writing: Magellan Health, Inc.P.O. Box 83680, Baton Rouge, LA 70884-3680 Attn: Appeals Department
New Provider Orientation (Revised 12/27/2016)32
Adverse Incident Reporting
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• Providers are required to submit the Adverse Incident Reporting form to Magellan within 24 hours of an adverse incident occurrence.
‒ This form serves to capture any reportable incidents involving a member of the Louisiana CSoC, currently in treatment or discharged from treatment within 180 days prior to the incident.
• Please access our Adverse Incident Reporting webpage on Magellan of Louisiana for additional information including:
‒ Adverse Incident Reporting Form
‒ Adverse Incident Reporting Form Instructions & Definitions
‒ Adverse Incident Training Module
New Provider Orientation (Revised 12/27/2016)
FRAUD, WASTE AND ABUSE
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Magellan takes provider fraud, waste and abuse very seriously. We engage in considerable efforts and dedicate substantial resources to prevent these activities and to identify those committing violations. We have made a commitment to actively pursue all suspected cases of fraud, waste and abuse and will work with law enforcement for full prosecution under the law. For definitions, corporate policies and more information, see the Fraud, Waste and Abuse section of our National Provider Handbook and can also be found in the Provider Handbook Supplement.
New Provider Orientation (Revised 12/27/2016)
FRAUD, WASTE AND ABUSE (CONT.)
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As per the Provider Handbook-
Providers Are Expected To:
• Develop, implement, and maintain a written Compliance Plan which adheres to applicable federal and Louisiana state law and any applicable guidance on such plans issued by the HHS-OIG or the Louisiana Department of Health and Hospitals-Office of Behavioral Health (DHH-OBH).
New Provider Orientation (Revised 12/27/2016)
FRAUD, WASTE AND ABUSE (CONT.)
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DHH-OBH defines “fraud” as follows:
As it relates to the Medicaid Program, an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable federal or state law. Fraud may include deliberate misrepresentation of need or eligibility, providing false information concerning costs or conditions to obtain reimbursement or certification, or claiming payment for services which were never delivered or received.
New Provider Orientation (Revised 12/27/2016)
Claim Submissions
37 New Provider Orientation (Revised 12/27/2016)
Claims SubmissionSubmitting Claims for Services Rendered
Electronic Claims Submission
• Claims Courier• Direct Submit• Clearinghouses
Sign in to the Magellan provider website www.MagellanofLouisiana.com
When submitting claims electronically, use submitter ID # 01260 for all except Emdeon 837I which is submitter ID# 12X27
Paper Claims - Mailing address (for paper claims): Magellan Health Services
Attention: Claims DepartmentP.O. Box 1286
Maryland Heights, MO 63043
38 New Provider Orientation (Revised 12/27/2016)
Claims Submission Formats
•Claims for inpatient services that require a revenue code must be submitted on 837I or UB-04
•Claims with CPT or HCPCS procedures are to be submitted on a 837P or CMS-1500
•Standard data elements are required for theUB-04 and CMS- 1500
Claims Tips•Find basic billing tips on the Magellan provider website, www.MagellanHealth.com/provider, (accessible via www.MagellanofLouisiana.com) and click the “Getting Paid” top- menu item.
•Preparing Claims – Claims Filing Procedures, Elements of a Clean Claim, Claims Tip Sheets, Coordination of Benefits
•HIPAA – Coding Information for Professional and Facility/Program Services, Code Sets, Resources
•Electronic Transactions – Options to submit transactions/claims electronically to Magellan, Companion Guides, Clearinghouse Information, Electronic Funds Transfer, National Provider Identifiers (NPI)
•Paper Claim Forms – We highly recommend electronic submission, but accept paper claims on CMS-1500 and UB-04 forms
1. Provider Handbook – Magellan National Provider Handbook andProvider Handbook Supplement on www.MagellanofLouisiana.com
40 New Provider Orientation (Revised 12/27/2016)
Claims Tips –Do-
Do Give Complete Information on the Member and Policy Holder
• Please provide complete information for items such as the name, birth date, sex, and relationship for both the member and the policy holder.
• Verify that this information matches the patient’s insurance card; also, membership can be verified through the Magellan provider website.
• Watch out for name variations and changes.
• Errors and omissions of these items can cause an unnecessary delay in processing the claim.
41 New Provider Orientation (Revised 12/27/2016)
Claims Tips –Do- (continued)
• Please provide complete information regarding the provider, including the names of both the rendering provider and the billing entity.
•Taxpayer Identification (TIN) and National Provider Identifier (NPI)
• Degree modifier
•Other Carrier Payment Information
•Complete Diagnosis
• Monitor Your EDI Transactions Reports
42 New Provider Orientation (Revised 12/27/2016)
Eligibility and Claims ProcessDuring the Month of Referral
To Be Discussed:
New Provider Orientation (Revised 12/27/2016)44
• Presumptive Eligibility Period
• Responsibility for Payment of Provider Claims
Presumptive Eligibility Period
• Child/youth meets clinical criteria for CSoC based on brief CANS screen
• Child/youth formally referred by Magellan to the WAA
• Presumptive Eligibility Period begins on the date of referral to WAA
• Date of referral is date referral was made to WAA
• WAA can validate this date on Medicaid’s Website
• Period of Presumptive Eligibility limited to no more than 30 consecutive calendar days
New Provider Orientation (Revised 12/27/2016)45
Presumptive Eligibility Period
During period of Presumptive Eligibility, child/youth is eligible to receive:
• Behavioral Health Services
• Wraparound Facilitation
• FSO Services
• Services of the other Specialized Behavioral Health providers (those offering one or more of the 4 CSoC waiver services)
New Provider Orientation (Revised 12/27/2016)46
Responsibility for Payment
New Provider Orientation (Revised 12/27/2016)47
Based on the child/youth’s enrollment status as of the first day of the service month.
New Provider Orientation (Revised 12/27/2016)48
Referral Date 1st of the Month
1. Wraparound 2. Youth Support
3. Parent Support 4. Independent Living Skills Building
5. Respite
6. Inpatient Psychiatric Treatment
7. Home and Community Based Services (CPST, PSR, FFT, Homebuilders,
Out-patient Counseling, Medication Management, Crisis Stabilization,Crisis Intervention)
• If referral is made by Magellan to the WAA on the 1st day of the month, for the referral Month, Magellan pays for the following7 service types:
New Provider Orientation (Revised 12/27/2016)49
Referral Date 2nd through the 31st of the Month
• If referred made by Magellan to the WAA on the 2nd through the 31st day of the month, for the referral Month, Magellan pays for the following 5 service types:
1. Wraparound 2. Youth Support
3. Parent Support 4. Independent Living Skills Building
5. Respite
• For the referral Month, the Bayou Health Plan pays for the other two service types:
1. Inpatient Psychiatric Treatment2. Home and Community Based Services (CPST, PSR, FFT, Homebuilders, Out- patient Counseling, Medication Management, Crisis Intervention, Crisis Stabilization)
To Be Noted:
• Payment of provider claims for CSoC Waiver Services is ALWAYS Magellan’s responsibility.
• Payment of provider claims for Residential Treatment is ALWAYS the Bayou Health Plan’s responsibility.
New Provider Orientation (Revised 12/27/2016)50
What Providers Need to DoFor a child/youth referred by Magellan to the WAA on the 2nd through the 31st day of the month, providers must contact the appropriate Bayou Health Plan for service authorizations/claims submission for the following services provided during the referral month:
• Home and Community Based Serviceso CPSTo PSRo FFTo Homebuilderso Out-patient Counselingo Medication Managemento Crisis Interventiono Crisis Stabilization
• Inpatient Psychiatric Treatment
New Provider Orientation (Revised 12/27/2016)51
Additional Training Resources Available On Magellan Provider Website
52 New Provider Orientation (Revised 12/27/2016)
Additional Training Resources Available On Magellan Provider Website
53 New Provider Orientation (Revised 12/27/2016)
We value your participation in the Magellan Network
Thank You!
CONFIDENTIALITY STATEMENT FOR PROVIDERS
The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.
