Behavioral Health

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Behavioral Health

• Indiana Health Coverage Programs
• 2008 Provider Seminar

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Indiana Health Coverage Programs
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Behavioral Health Integration

• Beginning January 1, 2009, MDwise will manage
  Behavioral Health service administration.
  CompCare will not administer the MDwise
  Behavioral Health after December 31, 2008.
• MDwise has a goal to more fully integrate
  physical and behavioral health.

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Network Development

• MDwise has selected Behavioral Health Management,
  Inc. (BHMI), an Indiana based provider
  organization to develop the MDwise Behavioral
  Health Provider Network.
• Provider contracting
• Provider credentialing
• Provider education

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MDwise Delivery Systems

• MDwise utilizes a delivery system of care.
  MDwise members choose or are assigned to a PMP in
  one of the MDwise networks or delivery systems.
  For Behavioral Health, the MDwise delivery
  systems will be responsible for
• Claims payment
• Prior authorization of services

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MDwise Delivery Systems
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How to check eligibility

• The most accurate way to confirm eligibility is
  to use one of the EDS systems (e.g. Web
  interChange, Omni, AVR)
• Before providing services, it is necessary to
  confirm
• Is the member eligible for services today?
• In what IHCP Plan are they enrolled? (Hoosier
  Healthwise, Medicaid Select, Traditional
  Medicaid, or HIP)
• If the member is in Hoosier Healthwise, what MCO
  are they assigned? (MDwise, Anthem, MHS)
• If the member is enrolled in Hoosier Healthwise,
  what services are they eligible to receive?
  (Package A, B, or C)
• If the member is with MDwise, what delivery
  system are they assigned to?
• Does the member have primary health insurance
  other than Medicaid (frequently seen with package
  B moms)?

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Prior Authorizations and Claims

• Once you have determined what program the member
  is in and what MDwise delivery system, use the
  Quick Reference Sheet find
• Phone number Fax number for prior authorization
• Claims address or EDI number
• Phone number Fax number for Pharmacy prior
  authorization (PerformRx)
• (See Quick Reference Sheet)

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Customer Service

• MDwise maintains a 24-hour customer service line
  that is available to both members and providers.
  
• Assist members in finding a provider
• Schedule transportation to appointments
• Register a complaint
• Get information about program
• Get assistance from a Member Advocate
• 24-Hour Crisis/Triage service

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Covered Behavioral Health Services

• MDwise covers the following general categories of
  behavioral health services
• Inpatient psychiatric and substance abuse
  services
• Emergency/crisis services
• Alcohol and drug abuse services
• Screening, evaluation and diagnostic evaluations
• Therapy and counseling, individual, group or
  family
• Pharmacological management
• Electroconvulsive therapy (ECT)
• Neuropsychology and psychological testing
• Psychiatric drugs included on the MDwise PDL
• Laboratory and radiology services for diagnosis
  medication regulation

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Behavioral Health Providers

• Reimbursement for behavioral health services is
  available for the following behavioral health
  provider types
• Psychiatric hospital, distinct part of or unit of
  acute care hospital. (011)
• Psychiatric facility-Institutions for Mental
  Disease that are freestanding or have independent
  organizational structure. (011)
• Community Mental Health Centers. (111)
• Outpatient Mental Health Clinics. (110)
• Physicians, including Psychiatrists. (339)
• Health Service Providers in Psychology (HSPP).
  (114)
• (Contiued next page)

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Behavioral Health Providers

• Reimbursement is also available for medically
  necessary Physician or Health Service Provider in
  Psychology (HSPP) directed and supervised
  outpatient mental health services for group,
  family, and individual psychotherapy when
  services are provided by one of the following
  mid-level practitioners
• Licensed Psychologist (112 or 113)
• Licensed Independent Practice School Psychologist
• Licensed Social Worker (116, 115, LCSW)
• Licensded Marital and Family Therapist
• Licensed Mental Health Counselor
• Person holding a Masters degree in social work,
  marital and family therapy, or mental health
  counseling
• Avanced Practice Nurse who is a licensed,
  registered nurse with a masters degree in
  nursing with a major in psychiatric or mental
  health nursing from an accredited school (117)

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Behavioral Health Providers

• Mid-Level Practitioners may not be enrolled
  separately as individual providers to receive
  direct reimbursement. Services rendered by
  mid-level practitioners must be billed using the
  rendering NPI numbers of the supervising
  practitioner and the billing provider NPI number
  of the outpatient mental health clinic or
  facility. Claims are paid at 80 of Medicaid fee
  schedule.
• Midlevel practitioners are to use the correct
  modifier with the appropriate procedure code when
  submitting a claim for reimbursement
• AH Clinical Psychologist
• AJ Clinical Social Worker
• SA Nurse Practitioner or Clinical Nurse
  Specialist
• HE Any other midlevel practitioner (404 IAC
  5-25)
• For medical managements visits, an HE/SA modifier
  is required.

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Inpatient Psychiatric Care

• With the exception of emergency admissions, prior
  authorization is required for any psychiatric
  admission, including admissions for substance
  abuse.
• Emergency admissions that require authorization
  must be reported to the MDwise delivery system
  medical management department within 48 hours of
  admission. If the end of the 48-hour period
  falls on a weekend or legal holiday, emergency
  admissions must be reported on the next business
  day after the weekend or holiday.
• Freestanding Psychiatric Hospital Coverage is
  available for medically necessary inpatient
  services provided to individuals under 22 years
  of age, if the facility has more than 16 beds.
  If the facility is licensed as a psychiatric
  hospital and has less than 17 beds, MDwise will
  reimburse for medically necessary inpatient
  services provided to eligible individuals of any
  age.

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Inpatient Psychiatric Care

• Reimbursement Inpatient psychiatric services
  are reimbursed at an all-inclusive, statewide per
  diem rate that includes all inpatient costs
  (including services of health service providers
  in psychology (HSPP), clinical psychologist, and
  clinical social worker), costs of routine
  inpatient care, and ancillary services.
  Additional payments are provided for Capital cost
  and Med Ed costs (residency program).
• Direct care services of Physicians, including
  psychiatric evaluations, are excluded from the
  per diem rate and are billable separately by the
  rendering provider on the CMS-0805 claim form or
  electronically.

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Inpatient Psychiatric Care

• Reimbursement Inpatient services for substance
  abuse and chemical dependency are based on DRG
  payment methodology (DRGs 743 through 751) that
  reimburse at a case rate according to diagnoses
  procedures, age, gender, and discharge status.
  The DRG reimbursement rates are intended to cover
  all inpatient hospital costs, including costs of
  inpatient routine care and ancillary services.
  Additional payments to hospitals are provided for
  Capital cost, Med Ed costs (if applicable0 and
  Outlier payment (if applicable).
• Direct care services of physicians, including
  psychiatric evaluations, are excluded from the
  per diem rate and are billable separately by the
  rendering provider on the CMS-0805 claim form
  electronically.
• The following DRGs for psychiatric care are
  excluded fromDRG reimbursement, and are instead
  reimbursed on a per diem basis
• 424 through 432
• DRG 429 excludes diagnoses 317XX through 319XX

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Inpatient Psychiatric Care

• Electroconvulsive therapy (ECT).
  Electroconvulsive therapy (CPT code 90870) may be
  performed while a member is hospitalized or as an
  outpatient procedure. In either case, it's done
  under brief general anesthesia (CPT 00104).
  Outpatient ECT services require prior
  authorization. Inpatient ECT services are
  authorized as part of the inpatient stay.

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Outpatient Services

• Providers must include a primary behavioral
  health diagnosis code and revenue code and/or
  procedure code to be reimbursed for behavioral
  services.
• Diagnostic Interview (90801) Ongoing Therapy
• According to 405 IAC 5-20-8 (10), reimbursement
  is available for one unit of diagnostic interview
  (90801) per recipient, per billing provider, per
  rolling 12-month period without prior
  authorization.
• A maximum of 2 units of diagnostic interview per
  member per rolling 12 month period is allowed
  without prior authorization when a member is
  separately evaluated both by a physician or HSPP
  and a mid-level practitioner. Of the 2 units
  allowed without PA, one unit must be provided by
  a Physician or HSPP, and, one by the mid-level
  practitioner. All additional units require prior
  authorization.

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Outpatient Services

• Members may self-refer to any IHCP enrolled
  Psychiatrist or a MDwise contracted behavioral
  health provider for behavioral health care
  services without authorization.
• For contracted MDwise Providers, after the
  initial 90801, members can receive up to five (5)
  therapy sessions without prior authorization.
  This includes codes 90804, 90806, 90846 and
  90847. All services for out-of-network providers
  (excluding Psychiatrists) require prior
  authorization.
• Members may see any IHCP enrolled Psychiatrist
  for the first 20 visits, per rolling 12 month
  period. All services after 20 visits require
  prior authorization. The following HCPCS codes,
  in combination, are subject to 20 units per
  member, per provider, per rolling 12 months
• 90801 90802
• 90804 90815
• 90845 90862
• 96151 - 96153

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Outpatient Services

• Neuropsychological Psychological Testing.
  Medically necessary psychological testing and
  neuropsychological testing are covered services,
  however require prior authorization. According to
  the IHCP Provider Manual and fee schedule, this
  applies to CPT codes 96101, 96110, 96111, 96116,
  96118, and 96150-96155. According to 405 IAC
  5-20-8(5), a physician or HSPP must provide this
  service.

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Outpatient Services

• Pharmacological management. CPT codes 90805,
  90807, 90809, 90811, 90813, and 90815, 90824,
  90827 and 90829 for psychotherapy with medical
  evaluation and management, and CPT code 90862 for
  pharmacological management are medical services.
  Therefore, MDwise does not reimburse clinical
  social workers, clinical psychologists, or any
  midlevel practitioners (excluding nurse
  practitioners and clinical nurse specialists who
  have prescription authority) for these codes.
• Per direction from OMPP, Prior Authorization is
  not required for members seen for a medication
  management assessment (90801 or 90802) and 19
  medication management appointments (90862, 90805,
  90807, 90811, 90813), per billing provider, per
  rolling 12 months. After the 20 (total)
  appointments, prior authorization is required.

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Outpatient Services

• Facility Fees In accordance with IHCP Provider
  Bulletin BT200820, certain facilities can bill
  for the facility use associated with the
  provision of outpatient behavioral health
  services, using the appropriate revenue code (500
  or 510).
• Facility fees may be billed for inpatient and
  outpatient, non-medical rehabilitation option
  (non-MRO), behavioral health services that are
  provided to MDwise members by facilities that
  are
• Licensed as hospitals by the Indiana State
  Department of Health under IC 16-21 and
  enrolled in Medicaid as a hospital.
• Licensed as psychiatric hospitals by the Division
  of Mental Health and Addiction under IC 12-25 and
  enrolled in Medicaid as a psychiatric hospital.
• Community Mental Health Centers (CMHC) that are
  enrolled in Medicaid as psychiatric hospitals, or
  that are part of a larger hospital system are
  covered.
• Must be billed under the hospital provider
  number.

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Outpatient Services

• Observation Stays. Psychiatric and
  substance/chemical abuse observation stays in
  acute care hospitals and freestanding psychiatric
  hospitals are reimbursable. The observation
  period must last no more than three days (72
  hours).
• Providers can retain members for more than one
  23-hour observation period when the member has
  not met criteria for admission but the treating
  physician believes that allowing the member to
  leave the facility would likely put the member at
  serious risk. This observation period can last
  not more than three days or 72 hours and is
  billed as an outpatient claim.

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Outpatient Services

• Emergency behavioral health services are covered
  subject to the prudent layperson standard of an
  emergency medical condition. All medically
  necessary screening services provided to an
  individual who presents to an emergency
  department with an emergency medical condition
  are covered.
• MDwise does not require prior authorization for
  emergency services in accordance with the federal
  Balanced Budget Act of 1997 (BBA) and House
  Enrolled Act 1872 (IC 12-15-12). However, a
  retrospective or post-service review may be made
  for determination of payment.

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Non-Covered Services

• Long-Term Institutional Custodial Care. MDwise
  does not cover State psychiatric hospital
  treatment or long term care or custodial care
  provided in skilled nursing facilities, nursing
  homes, group homes, halfway homes, or other
  residential facilities. If a MDwise member
  becomes eligible for any of these services the
  member is disenrolled from managed care. The
  same applies to members that are receiving home
  and community-based waiver services or hospice
  services.
• Note MDwise members who qualify for long-term
  institutional care, hospice care, or waiver
  services are disenrolled from MDwise according to
  OMPP policies and procedures. However, it is
  possible for a members Indiana Pre-Admission
  Screening/Pre-Admission Screening and Resident
  Review (IPAS/PASRR) process to be underway (but
  not yet complete) when the member is linked to an
  MCO. In this situation, the financial
  responsibility lies with the MCO for no more than
  60 days.

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Non-Covered Services

• MRO Services MRO Services are carved out of
  MDwise payment responsibility. These include
  codes H0002 H0004-HW, -HS, -HR or HQ
  H0031-HW H0033-HW H0035-HW H0040 HW
  H2011-HW H2014-HW T01016-HW or TG 97535-HW or
  HQ 97537-HW or HQ (all services for SPMI and
  DD members). Services are rendered through
  Community Mental Health Centers (CMHC), however
  care coordination may be required by MDwise for
  members receiving MRO services. MDwise is also
  responsible for associated services related to
  MRO services including, but not limited to
  transportation and pharmacy services.

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Non-Covered Services

• Psychiatric Residential Treatment Facilities
  (PRTF) provider specialty code 034. The IHCP
  reimburses for medically necessary services
  provided to children younger than 21 years old in
  a PRTF, however these services are carved out
  of MDwise payment responsibility. MDwise is not
  responsible for the PRTF per diem payment or any
  IHCP covered psychiatric/HSPP services during the
  stay.
• MDwise is however, responsible for care
  coordination with physical and other behavioral
  health services, which are not included in the
  PRTF per diem for individuals receiving PRTF
  services. MDwise is also responsible for
  associated services related to PRTF services that
  are unrelated to the patient's psychiatric
  condition and are performed outside the PRTF
  because the service is not available at the PRTF.
  This includes medical services provided outside
  of the PRTF, transportation and pharmacy
  services.

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Behavioral Health

• Thank You!