wa apple health aba provider orientation

Washington Apple Health Medicaid ABA Provider OrientationOptum with UnitedHealthcare Community Plan of Washington

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 1

Today’s Topics• Agenda

– Optum Overview– Member Information– Provider Credentialing Criteria– Provider Responsibilities– Authorizations, Treatment Plans, Concurrent Reviews– Coding, Billing and Reimbursement– Resources– Q & A

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2Revised 1/12/2017

Optum -Helping People Live Their Lives To The Fullest


Who is Optum?

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

• Optum is a collection of people, capabilities, competencies, technologies, perspectives and partners sharing the same simple goal: to make the health care system work better for everyone

• Optum works collaboratively across the health system to improve care delivery, quality and cost-effectiveness

• We focus on three key drivers of transformative change: engaging the consumer, aligning care delivery and modernizing the health system infrastructure

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Company Structure

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.Revised 1/12/2017 5

Optum and You

Our relationship with you is foundational to the recovery and well-being of the individuals and families we serve. We are driven by a compassion that we know you share. Together, we can set the standard for industry innovation and performance.

~ Deb Adler, SVP Network Services

• Achieving our Mission:– Starts with Providers

– Serves Members

– Applies global solutions to support sustainable local health care needs

From risk identification to integrated therapies, our mental health and substance abuse solutions help to ensure that people receive the right

care at the right time from the right providers.


Specialty Network Services• Customers we serve

– 50% of the Fortune 100 and 34% ofthe Fortune 500

– Largest provider of global Employee Assistance Programs (EAP), covering more than 19 million lives in over 140 countries

– Local, state and federal government contracts (Public Sector)

• Serving almost 43 million members– 1 in 6 insured Americans– The largest network in the nation,

delivering best in class density, discounts and quality segmentation

– More than 140,000 practitioners; 4,200 facilities with 9,000 facility locations

• Simultaneous NCQA and URAC accreditation

• Staff expertise:– Multi-disciplinary team of 50 staff

Medical Directors(e.g., child and adolescent, medical/psychiatric,Board Certified Behavior Analysts, and addiction specialists) just to name a few.

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7Revised 1/12/2017 7

Optum Autism/ABA Program

Specialty Network

Dedicated department responsible for building a network of autism specialty providers made up of Board Certified Behavior Analysts (BCBA) and licensed behavior clinicians with experience in intensive behavior therapies

Extensive credentialing process/review ofautism specialty providers that includes asite and medical record review

In-depth provider orientations held monthly for all new and existing autism specialty providers

Autism Corner on provider portal, ProviderExpress, offers network and clinical resource information for autism specialty providers.

National network of over 1800 autism specialty provider locations

Clinical Oversight

DedicatedAutism Clinical Team consisting of masters and doctoral level, specialty-trained care advocates, led by two licensed Psychologists, one a BCBA

Autism Clinical Team assists families with resources, education, care coordination and claims

Autism Clinical Team provides a monthly Treatment Plan Orientation to new and existing providers

Clinical Technology Committee currently reviewing components ofABAto see which interventions are most successful

National Institute of Mental Health Grant—longitudinal study ofAutism patient health data, including costs


Kudos From Customers

“I wanted to send a letter out to all of our otherclients encouraging them to switch to Optumwhen the open enrollments occur this fall as it has been such as great experience for us andthe children are getting the services they sodesperately need without a hassle.” - Pat,Children Making Strides

“I wanted to let you know I attended theAPBA’s convention in Boston yesterday andpeople from all over the country attended.Everyone in the room had wonderful things tosay about UBH! And I want to personallythank you, Debbie, for all the hard work and assistance. I could not have done it withoutyou!” – Anne, Beacon

Operational Initiatives

Autism coverage protocols and medical necessity guidelines in place

Specialized team to assist members and facilitate authorizations and claims payment

Optum Autism/ABA Program (cont.)


Washington Apple Health Medicaid ABA Program Member Information


To be eligible forABAservices, a client must meet both of the following criteria:

• Be younger than age 21

• Be covered under WashingtonApple Health

AND meet at least one of the following criteria:

• Have a diagnosis of an autism spectrum disorder, as defined by the most current version of the Diagnostic and Statistical Manual (DSM-5)

• Have a developmental disability for which there is evidenceABAtherapy is effective

Who is eligible?


Member ID Card• ID card is sent directly to the member• The member ’s ID number is their Medicaid number• All relevant contact information is on the back of the card for both

medical and behavioral customer service

Please note this image

is for illustrative purposes only.


Member Rights and Responsibilities


• Members have the right to be treated with respect and recognition of his or her dignity, the right to personal privacy, and the right to receive care that is considerate and respectful of his or her personal values and belief system

• Members have the right to disability related access per the Americans with Disabilities Act

• A complete copy of Member Rights and Responsibilities is available in the Community Plan of Washington Administrative Guide

• These can also be found on the website: providerexpress.com

• These rights and responsibilities are in keeping with industry standards. All members benefit from reviewing these standards in the treatment setting

• We request that you display the Rights and Responsibilities in your waiting room, or have some other means of documenting that these standards have been communicated to the members

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Credentialing Criteria for Inclusion in the Washington Apple Health Medicaid ABA Network


Apple Health Autism Provider Credentialing Criteria


Washington Apple Health Medicaid ABA Providers must meet the following criteria:• Be an approved, certified ABAProvider under the state’s Medicaid program,

either as a Lead BehavioralAnalyst Therapist (L-BAT) or a TherapyAssistant

• Be enrolled as a Washington Medicaid (ProviderOne) provider

• Have a National Provider Identifier (NPI) number

• Meet professional liability insurance requirements:

– $1 million/$1 million for individual

– $1 million/$3 million for groups

• Complete and submit specific WAApple HealthABAProvider Enrollment and contract packet

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Provider Responsibilities


Intake• At Intake

– Copy front and back of the member’s insurance card– Record subscriber’s name and date of birth

• Additional information to obtain from the member– Consent for services– Informed Consent: services, to leave voicemail, email, etc.– Release of Information to communicate with other providers– Consent for billing using protected health information, including signature on

file• Information to provide to the member or subscriber

– Your HIPAA policies– Your billing policies and procedures


Eligibility and Prior Approval• Call the number on the back of the ID card

to see if member is eligible for your services

• Check benefit coverage relating to both the service (e.g., Is ABA-based therapy covered?) and the diagnosis (e.g., Is autism covered?)

• Make sure services receive prior approval before beginning services, not all ABA services require prior approval for WA Apple Health Medicaid ABA program


Optum Authorizations, Treatment Plans, Concurrent Reviews


Clinical Team: Washington Apple Health ABA

Enhanced Autism/ABA Clinical Team

There is a dedicated, enhanced autism/ABAclinical team that will besupporting the WAApple HealthABAprogram

• Each team member is a licensed behavioral health clinician with experience inAutism and training inABA

• Supervised by managers that are licensed psychologists and BCBA-Ds


Assessment Process

Assessments• Up to 3Assessments allowed per year

• No approval required

• Conducted by BCBA


Billing Code

Modifier Service Description Unit: Reimbursement Rate:

0359T NONE MH Assessment by Non-PhysicianDirect Services for Assessment/Treatment Planning by BCBA only; limit 3 per year, per provider

Per session $400.00

0362T NONE MH Expose Behavioral Assessment by Non-Physician Direct Services for Expose BH Assessment/Treatment Planning by BCBA only; first 30 minutes, limit 3 per year; 1 unit = 30 minutes

Unit $100.00

0363T NONE MH Expose Behavioral Assessment by Non-Physician, additional Direct Services for additional Expose BH Assessment/Treatment Planning by BCBA only; limit 1 additional segment, per assessment, limit 3 per year, per provider1 unit = 30 minutes

Unit $100.00

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Treatment Plan Requirements• Meet Medical Necessity – this applies to initial and concurrent reviews

• Concurrent reviews - Due at least 10 days prior to the end of the authorization period but no more than 30 days in advance

• See attached treatment plan


Coding, Billing and Reimbursement


Diagnostic Coding


• Two Guides for Coding

– DSM-5 (Diagnostic and Statistical Manual, 5th edition)

– ICD-9 (for dates of service prior to 10/1/2015) or ICD-10 (for dates of service beginning 10/1/2015)

• ASD Coverage

– ICD-9, Autism Spectrum Disorder, 299.00

– ICD-10, F84.0 (effective 10/2015)

A complete diagnosis code is required on all claims

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Claims Submission


• Electronic Submission at www.providerexpress.com

– Electronic Claims Payer ID: 87726

• Paper Claims

– Requires CMS-1500 (v02.12) claim form (sometimes referenced asHealth Care Financing Administration or HCFA form)

– Mail to: UBHPO Box 30757Salt Lake City, UT 84130

• Claims Customer Service # : 855-802-7089

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Claim Tips

• To facilitate timely claims processing, please remember:– The provider’s NPI is required on all claims– A complete diagnosis code is required on all claims (example, using ICD-9

coding, 299.00 Autism Spectrum Disorder, current or active state disordersis an accurate diagnosis code, including all 5 required digits)

– Fully complete the online claim or claim form, including member ID or SSN– Billing address on claim must match the address in our system– Rendering provider must be on all claims

• Claims filing deadlines– Claims must be submitted no more than 90 days from the date(s) of service– Any correction requests must be submitted within 120 days on

providerexpress.com (if claim was originally submitted on Provider Express) or on a paper claim via mail with “CORRECTED CLAIM” noted

• Claims and claim adjustments are generally adjudicated within 30 days of receipt of all required information

• Member cannot be balance-billed for behavioral services covered under the terms of the contractual agreement

• Revised 1/12/2017 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 26

CMS-1500 Claim Form

All billable services must be coded• Coding can be dependent on several factors:

– Type of service (assessment, treatment, etc.)

– Rate per unit (BCBA vs.Paraprofessional)

– Place of service (home or clinic)– Duration of therapy (1 hr vs. 15 min)– One DOS per lineYou must select the code that most closely

describes the service(s) providedPlease note: Fields 24J and 31 must have

rendering provider information.

CMS-1500 Claim Form formerlycalled HCFA


WA Medicaid Fee Schedule


UNITED BEHAVIORAL HEALTH (OHBS)2014 cpt code version

Effective Date: 7/1/2015Autism/ABA Agency Fee Schedule: FS 1993 Washington State Medicaid ABA Fee Schedule

Billing Code Modifier Service Description Unit: Reimbursement Rate:

Prior Auth Required (PA)

0359T NONE MH Assessment by Non-PhysicianDirect Services for Assessment/Treatment Planning by BCBA only; limit 3 per year, per provider

Per session

$400.00 No Auth

0362T NONE MH Expose Behavioral Assessment by Non-PhysicianDirect Services for Expose BH Assessment/Treatment Planning by BCBA only; first 30 minutes, limit 3 per year;

Unit $100.00 No Auth

1 unit = 30 minutes0363T NONE MH Expose Behavioral Assessment by Non-Physician, additional

Direct Services for additional Expose BH Assessment/Treatment Planning by BCBA only; limit 1 additional segment, per assessment, limit 3 per year, per provider1 unit = 30 minutes

Unit $100.00 No Auth

0364T NONE Adaptive Behavior TreatmentFirst 30 minutes

Unit $22.00 Prior Auth Required (PA)

0365T NONE Adaptive Behavior TreatmentAdditional 30 minutes


0368T NONE MH Behavior treatment modifiedDirect ABA Services by BCBA or BCaBA only; first 30 minutes

Unit $25.00 No Auth

0369T NONE MH Behavior treatment modified, additionalDirect ABA Services by BCBA or BCaBA only; additional 30 minutes

Unit $25.00 No Auth

0370T NONE Family Behavioral Treatment GuidanceDirect ABA Services by BCBA or BCaBA only; 60-75 minute session; per diem

Per Diem $65.00 No Auth

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WA Medicaid Fee Schedule (cont.)






0371T UN Parent Training – 2 families Per Visit $55.00 No Auth0371T UP Parent Training – 3 families Per Visit $50.60 No Auth0371T UQ Parent Training – 4 families Per Visit $46.55 No Auth0371T UR Parent Training – 5 families Per Visit $42.83 No Auth0371T US Parent Training – 6 + families Per Visit $39.40 No Auth0366T UN Skills Training and Development – 2 clients

First 30 minutes, per day 1 unit = 30 minutes


0367T UN Skills Training and Development – 2 clientsAdditional 30 minutes, per day 1 unit = 30 minutes


0366T UP Skills Training and Development – 3 clientsFirst 30 minutes, per day 1 unit = 30 minutes


0367T UP Skills Training and Development – 3 clientsAdditional 30 minutes, per day 1 unit = 30 minutes


0366T UQ Skills Training and Development – 4 clientsFirst 30 minutes, per day 1 unit = 30 minutes


0367T UQ Skills Training and Development – 4 clientsAdditional 30 minutes, per day 1 unit = 30 minutes


0366T UR Skills Training and Development – 5 clientsFirst 30 minutes, per day 1 unit = 30 minutes


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WA Medicaid Fee Schedule (cont.)






0367T UR Skills Training and Development – 5 clientsAdditional 30 minutes, per day 1 unit = 30 minutes


0366T US Skills Training and Development – 6+ clientsFirst 30 minutes, per day 1 unit = 30 minutes


0367T US Skills Training and Development – 6+ clientsAdditional 30 minutes, per day 1 unit = 30 minutes


H2020 NONE Therapeutic Behavioral Services, per diem Per Diem $506.92 Prior Auth Required (PA)

Q3014 NONE Telehealth originating site facility feePer completed transmission

Per session

$24.63 No Auth

99366 NONE Team conference with interdisciplinary team of healthcare professionals, face-to-face with patient and/or family, 30 minutes or more

Unit $25.66 No Auth

99368 NONE Team conference with interdisciplinary team of healthcare professionals, patient and/or family not present, participation by nonphysician qualified healthcare professional, 30 minutes or more

Unit $22.08 No Auth

1) Units: The Reimbursement Rate made to Provider for each unit of service provided to a Member as defined by the definition of the Billing Code. Such payment shall be considered payment in full for all MH Services provided to the Member, included but not limited to nursing care, diagnostic and therapeutic services, and supplies. Such payment is exclusive of physician fees. If physician services are rendered, such services are included in the rate of reimbursement.2) The MH Services authorized by UBH and provided to a Member on an outpatient basis of the diagnosis, testing, and/or treatment of a mental health condition, other than Emergency MH Services or as part of a partial hospitalization or day treatment program, Provider shall be paid by Payor the lesser of (a) Provider's Customary Charge for such MH Services, less any applicable Member Expenses; or (b) the Method of Payment set forth above, less any applicable Member Expense(s).3) Proper billing form: CMS 1500

Revised 1/12/2017

Resources



Autism Network Managers – State Assignments (updated 1/10/17)

HI

IN

AL

MDDE

WV

AK

D.C.

MT

WY

IDOR

WA

CA

NV UTCO

NMAZ

ND

SD

MN

WI

NE IA

IL

MOKS

OK AR

TX

TN

LAMS GA

SC

NC

KY

MI

PR FL

ME

NH

PA

NJCT

RI

VT

MAOH

VA

NY

VI

Betty Rubin [email protected]

Debbie [email protected]

Darlene Fitzpatrick [email protected]

Justin Anderson [email protected]

Carol [email protected]

Jeanna Gonzales [email protected]

Joslyn [email protected]

Chris Reinsberg [email protected]

Providerexpress.com


providerexpress.comYou can find…

• Level of Care Guidelines• Best Practices• Optum Network Manual• Contact Information• Common Forms• Eligibility and Benefits• Claims Status• Claim Submission

Proprietary and Confidential. Do not distribute. 34Revised 1/12/2017 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

providerexpress.com


providerexpress.com - First-time Users• Register online for immediate access to secure Transactions• No fees apply

• Provider Express Support Center available from 7 am to 9 pm Central time – toll free at 1-866-209-9320

• Live chat feature also available


Helpful Websites


• To get an NPI number– https://nppes.cms.hss.gov/NPPES/Welcome.do

• To learn more about HIPAA– http://www.hhs.gov/ocr/privacy/

• To learn more about Tax IDs or Employee IDs– www.irs.gov

• Optum provider website– providerexpress.com

• Claim Tips: Provider Express > Quick Links > Claim Tips• Claim Forms: Provider Express > Quick Links > Forms > Optum Forms

– Autism Votes website• https://www.autismvotes.org/site

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Q&AConfidential property of Optum. Do not distribute or reproduce without express permission from Optum. 38Revised 1/12/2017

Thank You.


wa apple health aba provider orientation

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