ae_nw3 bhrs consumer_family forum_060707 1 value behavioral health of pennsylvania bhrs...

AE_NW3 BHRS Consumer_Family Forum_060707

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Value Behavioral Health of Pennsylvania

BHRS Consumer/Family ForumCrawford, Mercer & Venango Counties

June 2007


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Pennsylvania HealthChoices Program

• State Medical Assistance (MA) Managed Care Program

• The HealthChoices Program has three main goals

• To improve access to healthcare services for MA consumers

• To improve the quality of care available to MA consumers

• To stabilize Pennsylvania’s MA spending


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Who is Value Behavioral Health-PA (VBH-PA)??

• Value Behavioral Health-PA (VBH-PA) is a managed care company

• VBH-PA is working with your county to ensure the success of the HealthChoices Program

• VBH-PA staff will be available to answer your questions when you call the toll-free member services number established for your county


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The Benefits of HealthChoices

• Supports the enhancement, expansion & improvement of county-specific delivery of services

• Provides a continuum of in-plan and supplemental services that promote recovery and resiliency

• Mental Health• Substance Abuse

• Provides consumers with a choice of in- network providers


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Behavioral Health Services Mental Health (MH)

• Inpatient Psychiatric• Residential Treatment

Facilities (RTF) for Children & Adolescents

• MH Partial Hospitalization

• MH Outpatient • Behavioral Health

Rehabilitation Services for Children/Adolescents (BHRS)

•Family-Based MH •Intensive Case Management (ICM)•Resource Coordination (RC)•Blended Case Management (BCM)•Certified Peer Specialist•Crisis Intervention•Clozapine Support Services•Laboratory Services


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Behavioral Health Services Substance Abuse

Substance Abuse

• Inpatient Drug & Alcohol (D&A) Detoxification/Rehabilitation

• Non-hospital Residential Detoxification/Rehabilitation

• Halfway House

• D&A Outpatient, including Intensive Outpatient (IOP)

• Outpatient Narcotic Addiction Treatment (Methadone Maintenance)


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Service Access

• HealthChoices means you have a CHOICE of providers

• When members call VBH-PA for a referral, they will be given at least two names of providers to choose from

• VBH-PA does not give recommendations, but will offer members a choice of providers

• VBH-PA clinicians will ask for information to assess the need for services (emergency, urgent, or routine)


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Service Access

There is no charge to you for in-plan services that you receive.

• HealthChoices members DO NOT pay for any covered services they need. There is no co-pay. (This does not include your prescriptions. Your prescriptions are paid by your physical health plan.)

• If members receive a bill, they should report this to the VBH-PA Member Service Representative.


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Toll-Free Contact NumbersVBH-PA Member Services

Erie 1-866-404-4560

NWBHP 1-866-404-4561(Northwest Behavioral Health Partnership: Crawford, Mercer & Venango Counties)

Cambria 1-866-404-4562

Toll-Free Provider Line: 1-877-615-8503

TTY Telephone Number: 1-877-615-8502


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Member Benefits

• All VBH-PA members are provided with a Member Handbook that includes important information on member benefits

• Handbooks are mailed to all eligible HealthChoices members in a bright pink envelope

• It is important to read and keep the handbook


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Member Benefits

The Member Handbook includes:

• A county-specific toll-free number to call with any questions about behavioral health care services and/or the HealthChoices program

• Information on filing a complaint or grievance

• Information on getting help in an emergency

• Ways to share your opinions about your services by taking a satisfaction survey

• Member rights and responsibilities


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Learn about Your Rights

• As part of the HealthChoices Program, you have the RIGHT to:

- Be treated with dignity and respect.- Have your medical records and conversations with people who

give you care kept private.- Take part in decisions about your care.- Have your treatment plan explained to you.- Help set up your treatment plan and ask for a change

to your treatment plan.- Choose your provider from a list of HealthChoices

Program Providers.- See your medical records and talk about them with

your provider.


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Learn about Your Rights (continued)

- Change your provider.- Ask your provider about his or her qualifications or any

person who is helping you.- Receive services without regard to race, color, religion,

sex, sexual orientation, age or ethnic background.

- Make a Complaint or file a Grievance about your care or the

services you receive.- Talk with a Consumer Family Satisfaction Team (C/FST) member about the quality of your services.- Receive information on available treatment services.- You have the right to be free from any form of restraint or

seclusion during your treatment that is used as a means of coercion, discipline, convenience or retaliation. - You have the right to create an Advanced Directive and share it with your treatment provider.


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Learn about Your Rights (continued)

- Have the side effects and risks of your medications explained to

you.- You may also request a copy of information maintained

by VBH-PA. The information may include claims information, complaints, referrals, disclosures and other documented contact you and your provider have had with us.

- You may request to amend (change) the VBH-PA information listed above in order to correct any errors. The decision to make a change is made by the VBH-PA Medical Director.

- You are free to exercise your rights. Exercising your rights will not affect how you are treated by your provider or by VBH-PA.

- You have the right to request a second opinion about your treatment.


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Learn about Your Responsibilities• As part of the HealthChoices program, you

have the RESPONSIBILITY to:

- Respect the dignity and privacy of others.- Give your provider the information that he or she

needs to better serve you.

- Work with your provider to help develop a treatment plan and ask questions when you do not understand your treatment.

- Try to follow the treatment plans you developed with your

provider.- Keep your appointment with your provider.


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Learn about Your Responsibilities (continued)

- Contact your provider if you need to cancel or re-schedule your appointment.

- Call the VBH-PA toll-free telephone number if you move

and/or change your address or phone number. If you are hearing impaired, call the TTY number at 1-866-615-8502.

• Become familiar with your Rights and Responsibilities. They are in your Member Handbook.


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CASSP Principles Mental health services in Pennsylvania are

guided by the principles of the Child and Adolescent Service System Program.

Central to CASSP Principles is the recognition that a child must be understood in his or her natural context—the family, the community and the child-serving systems—not just individually.

CASSP Principles are strengths-based and treatment-focused.


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CASSP Principles

Child-centered Family-focused Community-based Multi-system Culturally competent Least restrictive/least intrusive


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Evaluation Comprehensive Child and Adolescent

Strengths-Based Evaluation—Life Domain Best Practice format for initial evaluations

and re-evaluations Evaluation of the child’s strengths and

needs Review of past treatment trials and/or

review of treatment goals Consideration of the full continuum of care Documentation to support the medical

necessity of recommended level of care


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Independent Prescriber Model Prescribers who are credentialed by VBH-PA to

evaluate children/adolescents and make treatment recommendations

Criteria: Pennsylvania licensed psychiatrist, Pennsylvania

licensed psychologist or developmental pediatrician

Documented experience in evaluating children and adolescents with special needs

Satisfactory (85% or better) ratings on CCASBE-LD monitoring

No affiliation with a BHRS/FBMH provider Panel of providers will be recruited for each county


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Interagency Service Planning Team (ISPT)

Functions of the ISPT Meeting:

Mechanism for child-driven, family-focused treatment

Mechanism for individualization and positive envisioning

Mechanism to integrate prescriber expertise with multi-system participation


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Interagency Service Planning Team (ISPT)

Desired outcomes of the ISPT Meeting: Achieving consensus, based on common

understanding and common goals Initiating and maintaining an ongoing process of

collaboration and change Implementing practical, workable solutions for

the child, including integrated treatment and feasible sources of funding

Only possible with parent/guardian participation!


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Initial ISPT VBH-PA will schedule meeting within seven

(7) days of receipt of evaluation Parent/legal guardian, CYS/JPO, child if 14

years or older, and if appropriate, county representative, case manager, education (home school district), VBH-PA reviewer and other appropriate child-serving agencies

Evaluators are expected to participate (by phone or in person)

Provider is not a participant VBH-PA/County facilitates initial ISPT


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Ongoing & Discharge ISPT Provider is a participant and is responsible

to contact county to schedule the ISPT Provider takes the lead in discussing

progress of treatment goals, interventions utilized, skill transfer, barriers to treatment and discharge planning

Discharge planning meeting within 45 days of a projected discharge date

Provider facilitates ongoing/discharge ISPT’s


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Definition of Medically Necessary A service, item, procedure or level or care that is

necessary for the proper treatment or management of an illness, injury or disability is one that:

Will, or is reasonably expected to, prevent the onset of an illness, condition, or injury or disability.

Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.

Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.


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Medical Necessity Criteria

Licensed as an utilization review entity

Mandated to use Appendix T, Program Standards and Requirements

SI – Severity of Illness IS – Intensity of Service


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Peer Review Care Managers and CAFS Coordinators can only

authorize care Medical Necessity is questioned Peer Advisors render decisions

Certified Non-certified (denial)

Peer Advisors are board certified psychiatrists, licensed psychologists and addictionologists supervised by the MCO Medical Director

Peer Advisors are also available 24/7 and a monthly on-call schedule is maintained


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What is a denial of service? A VBH-PA Peer Advisor’s decision to deny a

service, to decrease a service or to approve a service different than the service requested because the care requested is not medically necessary or another level of care is more appropriate.

The member will be sent a denial letter on the same date the denial is given for all acute levels of care. For non-acute levels of care, the denial letter is sent to the member within two business days of the denial decision.


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What is a Grievance?

A grievance is when you are unhappy about a decision made about your treatment:• You may be denied a service.

• A decision was made to decrease the amount of service.

• You want a different service than what has been approved.


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How do I file a Grievance?• You will receive a letter when VBH-PA denies a

service, decreases your service, or approves something different than the service requested.

• There can be several steps to the Grievance Process including:• First Level Grievance• Second Level Grievance• External Grievance• Fair Hearing


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First and Second Level Grievances• You may send your Grievance in letter

form or you may call VBH-PA.

• Use the toll-free number on your card or have someone call for you.

• Your provider may also file a Grievance for you, if you give them written permission to do so.


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How Soon Must I File?• You have 45 days to file a Grievance

after you receive written notice of the change in your service.

• You may continue services through the Grievance process if you file within 10 days of your service being denied.


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If you are not satisfied

File a complaint if you are unhappy with the HealthChoices program.

• you do not like the care your provider is giving you

• you are unhappy with the services you are receiving


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Examples of Complaints

• I waited too long in the office.• The staff is rude.• The doctor will not let me take part in

deciding my care.• I was late because I could not get a

ride or the bus was late and my appointment was cancelled.

• I received a bill from my provider.


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How to File a Complaint• Call the toll-free number on your card or

have someone call for you.

• All calls are free.

• Write a letter to: VBH-PA520 Pleasant Valley RoadTrafford, PA 15085 Attention: Quality Department


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Need Help Filing...• A VBH-PA Member Services

Representative can help you file a complaint.

• Your complaint will be investigated within 30 days.

• You will be sent a letter from VBH-PA informing you of the

resolution.


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What if I still don’t like the resolution?

• You may file a Second Level Complaint by calling or writing VBH-PA.

• You have the right to meet with the Second Level Complaint Committee to resolve your complaint.

• This committee will meet within 30 days of your request and you will be notified of the results by a letter from VBH-PA.


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Still not happy?• You have 15 days to file an External

Complaint Review.

• This complaint is handled by either the Pennsylvania Department of Health (DOH) or the Pennsylvania Department of Insurance (DOI).


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Questions???

• VBH-PA is committed to providing quality behavioral health services to all our Members.

• VBH-PA wants its’ Members to strive for recovery and enjoy a good quality of life.

ae_nw3 bhrs consumer_family forum_060707 1 value behavioral health of pennsylvania bhrs...

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