CBH Providers

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WELCOME
CBH Providers
234 7/2007
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Todays Presenters

Terry Buford - Network Manager 10 years of
experience in Community Mental Health
Centers Cindy Smith Provider Relations
Specialist 26 years experience in all aspects of
the health insurance industry 11 years experience
in provider relations Bart Marshall, LCSW
Clinical Provider Trainer Previously with Midtown
MHC Extensive experience with school based
services
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What topics will we cover today?

• NPI / Taxonomy
• Revenue Code 510
• CBH Quick Reference Guide
• NPI Numbers
• Appeals Complaints
• OTRs
• E M Codes
• Web Portal
• ELearning

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Quick Reference Guide

• Does not replace the CBH Provider Manual
• Intended as a quick guide
• Applies to participating CBH providers
• If Provider is non-par all services require
  authorization and should see existing patients
  only

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Appeals 2 Types

• Medical Management
• Claims

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Claim Appeals

• Status Inquiries Claims Support 1-866-324-3642
  M-F 800 am to 500 pm CST
• Informal Claims Dispute (level 1) to seek a
  reconsideration or exception 60 days from the
  date you received the EOP
• Formal Appeal (level 2) only after exhausting
  the Informal Claims Dispute. - 60 days from
  completion of the informal dispute.

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Medical Management Appeals

• Appeal of adverse decision notice
• Level 1 (grievance) Must be received with in 60
  days of the date the member/provider were
  notified of determination
• CBH will resolve within 20 business days
• Resolution letter sent within 5 business days
  from date of decision

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Medical Management Appeals

• Level 2 (appeal) Must be received within 30
  days of the date the member or provider were
  notified of determination of level 1 denial
• MHS will resolve within 25 business days
• Resolution letter sent within 5 business days
  from date of decision

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Medical Management Expedited Appeals

• Completed within 24 hours of receipt
• ONLY for inpatient denials
• Patient must still be inpatient at the time of
  request

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Provider Complaints

• An expression of dissatisfaction about a given
  matter
• Via Phone CBH Customer Service at
  1-877-MHS-4U4U (follow prompts for auth/CBH)
• Via Letter CBH Complaint, 504 Lavaca, Ste 850,
  Austin, TX 78701
• Your complaint will be researched and CBH will
  respond within 30 days

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NPI and Taxonomy
What To Watch For

• Verify that all rendering providers are linked to
  their respective billing provider
• Verify that your NPI is correctly recorded in the
  EDS data base
• Use taxonomy

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NPI and Taxonomy

• Once a claim is received the following
  reconciliation occurs
• NPI
• NPI Zip Code
• NPI Zip Code (plus four)
• NPI Zip Code (plus four) Taxonomy

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Outpatient Treatment Request (OTR)

• Outpatient sessions beyond the initial
  assessment (1) and (5) therapy visits require
  authorization

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Services Requiring Pre-Authorization

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Services Not Requiring Authorization

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OTR

• For better treatment outcomes, ensure that
  discharge begins at intake.
• Inquire about what will it look like when you do
  not have to have therapy anymore?
• Inquire as to how long do you think it will take
  to reach your goals?
• Ensure that your OTR shows clients progress
  towards his/her goals and treatment changes if
  the client is not making progress.

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Evaluation Management CPT Codes

• Review the fee schedule included with your CBH
  contract
• NOT all EM codes are billable under the CBH
  agreement
• EM codes do require
  authorization

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• Intensive Case
• Management

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Intensive Case Management

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Intensive Case Management

• WHAT?
• Consult with both the members physical and
  behavioral health providers
• Facilitate the sharing of clinical information
• Development and maintenance of a coordinated
  physical health and BH treatment plan for the
  member.

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Intensive Case Management

• Conduct in-depth assessment for use in developing
  the plan of care
• Documentation of members demographics
• Reason for referral to ICM
• Diagnosis (medical and psych)
• Medications
• Treatment history
• Compliance with treatment
• Living situation
• Understanding of Illness
• Psychosocial and socioeconomic factors
• Education level
• Current level of functioning
• Willingness to participate in ICM

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Objective of ICM

• Design interventions to support enrollee
  improvements in functional status
• Maintaining members in appropriate, least
  restrictive level of care
• Improve treatment compliance
• Decrease suicidal/homicidal gestures
• Decrease psychotic episodes
• Relapse reduction
• Improve coordination of care among multiple
  providers
• Facilitate progress in treatment

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Care Coordination . . .

• help patients overcome barriers to obtaining
  behavioral services
• Contact patients discharged from hospitals to
  ensure they have outpatient appointments and are
  compliant with treatment
• Referrals from the health plan member advocates
  for members having difficulty accessing services
• Resource for information on providers and
  services in their assigned area

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Intensive Case Managers and Care Coordinators

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Web Portal
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e-ssential Learning Now available!
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How can we help you?
QUESTIONS?