A1261984507Bpbyk

1


CBH State of Georgia Provider Orientation
2
Cenpatico Behavioral Health

• Todays Presenters
• Clinton Shedd
• CBH Network Development Manager
• Central SW Region

3

Agenda

• Overview of CBH
• CBH Provider Network
• CBH Georgia Provider Directory
• The Provider Role
• The Referral Process
• CBH Provider Specialty Cultural Competency
• Geo-Access Requirements and Wait Times
• Member Benefits
• Case Management
• Authorization Process
• Outpatient Treatment Report (OTR)
• Claims Submission
• EDI
• Credentialing Re-Credentialing
• Network Management Provider Relations
• Provider Manual and Online Resources
• Future Provider Training Forums
• Open QA

4
Centene Organizational Chart
5
Cenpatico Behavioral Health, LLC
6
Cenpatico History

• CBH began as a staff model behavioral health
  delivery system in 1994 in Texas.
• The Centene Corporation, a St. Louis-based
  healthcare organization (CNC on the NYSE),
  acquired CBH in 2003.
• CBH service offerings include UM, including
  assessment and triage, crisis intervention,
  intensive case management, QI, network
  development, credentialing, customer service and
  claims processing and payment.
• We currently serve over 900,000 Medicaid
  consumers in the following markets Arizona,
  Indiana, Kansas, Missouri, Ohio, Texas, and
  Wisconsin.
• Offer special education school-based services in
  Arizona.
• Received URAC health plan accreditation in
  January 2005.
• CBH Corporate office is located in downtown
  Austin, TX.

7
The CBH Executive Team

• Sam Donaldson, PhD- President CEO
• Alan Adkins, MD, MMM- VP Medical Affairs
• Cindy Peterson, ACSW- VP Operations
• Greg Shulman, LPC- Executive Account Manager
• Sara Neale, RN- Director, Compliance Government
  Affairs
• Suzanne Feay, RN- Director, Corporate QI
  Credentialing
• Francis Terway- Finance Manager

8
CBH NSC Leadership Team

• W. Mark Konyecsni, MD- NSC Medical Director
• Claudia Sumrall, ACSW- Clinical Director
• Lilli Olive, MA,LPC-Georgia Clinical manager
• Agnes Ponce - Customer Service Manager
• Melanie Howard, RN - Quality Improvement Manager

9
CBH Georgia Operations

• CBH is headquartered in Austin, Texas and the
  National Service Center is also located in
  Austin.
• CBH will has Licensed Master Level Personnel as
  Case managers and Care coordinators in Austin and
  Atlanta.
• CBH will have dedicated network management staff
  in Georgia to provide local provider assistance
  and training.

10
CBH Provider Network

• CBH Network Development contracts with
  clinically-licensed behavioral health clinicians,
  hospitals, community mental health centers,
  community service boards (CSBs), free-standing
  psychiatric facilities, significant traditional
  providers (STPs).
• CBH clinicians include, but are not limited to
  MD, DO, ARNP, PhD, EdD, PsyD, LPC, LCSW, and
  LMFT.

11
The Provider Role

• Provide quality covered behavioral health
  services within all accepted clinical, legal and
  ethical standards to CBH members.
• Follow CBH Clinical Practice Guidelines and
  Medical Necessity Criteria.
• Ensure members are able to avail themselves of
  their rights to execute Behavioral Health Advance
  Directives.
• Abide by CBH Authorization, Claims, QI, UM and
  Credentialing/Re-Credentialing policies and
  procedures.
• Abide by CBH contractual obligations.
• Treat CBH clients as fairly and equally as any
  other clients.
• Ensure HIPAA compliance.

12
Provider Directory

• CBH providers and facilities will be listed in
  the Peach State Health Plan, Inc. (PSHP) online
  provider directory. The online directory will be
  updated to reflect the most current information.
• CBH clinicians, agencies, CSBs, and hospitals
  are listed in the Provider Directory.
  Information includes, but is not limited to
  provider name, address, phone, and office hours.
• The Directory is intended to reflect our current
  network and to provide another avenue for our
  providers and members to make informed referral
  decisions.

13
Referral Process

• CBH employs a team of customer service
  representatives to provide referrals and
  eligibility verification to our members and our
  providers.
• Providers and members are encouraged to visit the
  PSHP online directory at www.pshpgeorgia.com or
  visit the CBH directory at www.cenpaticoga.com
  (which is currently in its final stages of
  development).
• CBH refers to in-network, or actively
  participating, providers and facilities.

14
Provider Specialty Cultural Competency

• CBH recognizes the uniqueness of each member,
  their needs, and treatment requests.
• Consideration of a members race, country of
  origin, native language, social class, religion,
  mental or physical abilities, heritage,
  acculturation, age, gender, sexual orientation
  and other characteristics should be included when
  developing their treatment plan.
• CBH requests that providers share their languages
  spoken other than English, handicap
  accessibility, and treatment specialties with us
  so that we can tailor each referral to best meet
  our members needs.
• Office sites should have posted and printed
  materials in English, Spanish, or other
  prevailing languages within the region.

15
Provider Accessibility, Availability, Wait Times

• Current CBH access standards are as follows
• Routine appointments-within 14 business days
• Urgent appointments-within 24 hours
• Emergent-non-life threatening appointments -
  within six (6) hours
• Discharge (from hospital) follow-up appointments
  - within seven (7) days of discharge

16
Covered Behavioral Health Services

• Traditional Outpatient Services
• Medication Management
• Group and Family Therapy
• Inpatient Hospitalization
• Detoxification
• 23-Hour Observation
• Electroconvulsive Therapy (ECT)
• Partial Hospitalization Program (PHP)
• Intensive Outpatient Program (IOP)
• Specific Community-Based Services

17
Case Management

• CBH has developed an Intensive Case
  Management
• program to
• Identify members with complex or chronic
  behavioral health conditions that require
  coordination of services and periodic monitoring
  in order to achieve desired outcomes.
• Work collaboratively with the member, physician,
  family/significant others and providers of
  healthcare and support services to implement an
  individualized plan of care.
• Maximize efficiency in utilization of available
  resources and plan benefits.

18
Components of Case Management

• Early identification of cases
• Assessment of cases to identify the needs of
  those at high risk
• Referral to the appropriate providers and
  services
• Provision of effective interventions in
  conjunction with providers to improve clinical
  outcomes
• Coordination of support services
• Member/Family education
• Measurement of the intervention outcomes and use
  of those measures to improve the programs
  effectiveness

19
Service Codes Not Requiring Pre-Authorization

• Medication Management services billed with the
  following codes do not require pre-authorization
  
• 90801/90802- Diagnostic Interview Examination
• 90862- Pharmacologic Management
• 90805- Individual Therapy (20-30 minutes) with
  med eval/mgmt services
• 90811- Individual Therapy, interactive (20-30
  minutes) with med eval/mgmt services
• 90813- Individual Therapy, interactive (45-50
  minutes) with med eval/mgmt services

20
Services Requiring Pre-Authorization

• Inpatient Hospitalization
• 23-Hour Observation
• Detoxification
• PHP IOP
• Psychological Testing
• In-Home Therapy
• Community-Based Services (Rehabilitative
  Services)
• IFI Services
• All covered outpatient therapy services greater
  than six (6) visits

21
Pre-Authorizing Care

• Prior Authorization is required for inpatient
  (non-emergent) and higher levels of care such as
  ECT, PHP, IOP, Day Treatment programs,
  Psychological Testing, and in-home or
  community-based treatment.
• Prior Authorization is NOT required for emergency
  services, post-stabilization and urgent care
  services. PLEASE NOTE You must contact CBH Care
  Management within 24 hours of rendering these
  types of services for authorization and review.

22
Outpatient Treatment Report (OTR)

• The initial six (6) visits of outpatient
  psychotherapy (CPT CODES 90804) do not require
  pre-authorization but do count against the
  members benefit limitations. Billing codes must
  be Covered Behavioral Health Services.
• To approve all sessions beyond the initial six
  (6) will require that the provider submit an
  Outpatient Treatment Report (OTR). The form is
  in the back of the provider manual.
• The OTR MUST be completed in its entirety for
  consideration. This includes the five (5) axis
  diagnoses as well as all other clinical
  information.
• The OTRs can be faxed to CBH or completed online
  for clinical review and additional sessions will
  be approved based upon medical necessity.
• CBH WILL NOT retroactively approve sessions.
  Treatment must occur within the dates on the
  authorization. Any changes must be sent to CBH
  prior to the sessions occurring.
• Failure to submit a timely OTR can result in
  delays in authorization and may result in payment
  denials.

23
Claims Submission

• What is a Clean Claim? Its a claim received by
  CBH for adjudication in a nationally accepted
  format in compliance with standard coding
  guidelines and which requires no further
  information, adjustment, or alteration by the
  provider.
• It is critical that we have current and correct
  information to assure claims payment. This
  includes W-9, Medicaid Number, Service Address,
  Tax ID , Billing name and address.
• Ensure the member is effective on date of
  service, the service is a covered behavioral
  health service under the members benefit, and
  all CBH referral authorization processes were
  followed and approved.
• Claims Address CBH
• Attn Claims Department
• PO BOX 6700
• Farmington, MO 63640-3816

24
Claim Submission Dos

• Do use the correct mailing address and PO Box
  number
• Do submit all claims in 9x12 envelope (or
  larger).
• Do type all fields completely and correctly.
• Do use black or blue ink only.
• Do submit on proper form (CMS 1500 or CMS 1450).

25
Common Billing Errors

• Remember to use SPECIFIC CPT-4 or HCPCS codes.
• Avoid the use of non-specific or catch-all
  codes such as 99070.
• Use the most current CPT-4 and HCPCS codes which
  can be found on your contracted Exhibit 2
  (Compensation Schedule)
• Use the 4th or 5th digit when required for ALL
  ICD-9 codes.
• Submit all claims/encounters with your Medicaid
  Number and Tax Id Number.
• Submit all Claims/encounters with the Members
  complete Medicaid Number or the Members PSHP ID
  Number.

26
Electronic Claims Submission

• CBH has two national clearinghouses that are
  approved for EDI electronic claims submission.
  Payer Path and Emdeon (formally Web MD)
• Please contact the Centene EDI Department at the
  following to inquire or discuss EDI and your
  options
• By phone [phone], ext. 25525
• By e-mail EDIBA_at_centene.com

27
Credentialing Re-Credentialing

• As CBH is URAC accredited, CBH is obligated to
  follow URAC credentialing and re-credentialing
  guidelines.
• A list of required credentialing materials can be
  found on pages 65 and 66 of the CBH Provider
  Manual.
• Facilities and Health Delivery Organizations must
  be CARF, JCAHO, or COA accredited. If not, CBH
  must conduct an onsite facility site review.
• CBH requires that you provide our Credentialing
  Department with updates to your license,
  insurance, and DEA (if applicable), as you
  receive them.
• Each provider must be re-credentialed at least
  once every three years from the date of the
  initial approval.
• Failure to complete the re-credentialing process
  may result in termination from the CBH network.

28
Network Manager Provider Relations

• CBH has employed a dedicated regional Network
  
• Manager in each of our service delivery
  regions
• Atlanta-Carla Menchion- cmenchion_at_centene.com
• Central- Clinton Shedd- cshedd_at_centene.com
• Southwest- Clinton Shedd- cshedd_at_centene.com
• Provider Specialist-Latisa Kidd-
  lkidd_at_centene.com
• Network Development can assist with any questions
  
• regarding CBH or your Agreement, schedule
  trainings and
• forums, conduct site visits, and assist in
  conflict resolution.
• CBH Georgia Provider Relations staff at our
  Corporate
• Office are an extension of the Network
  Development
• Manager and are available to assist at any
  time.

29
Provider Manual Online Resources

• CBHs Provider Manual contains specific policies
  and procedures regarding credentialing,
  authorization, appeals, and claims.
• Our Medical Necessity Criteria and Clinical
  Practice Guidelines can be found in the Provider
  Manual.
• CBH Corporate Information can be found on our
  website at www.cenpatico.com.
• CBH will have a direct CBH Georgia provider
  website www.cenpaticoga.com, which is in final
  development stages.

30
Future CBH Training Forums

• CBH will conduct provider/facility trainings and
  forums in our service regions.
• CBH will conduct at least one large event in your
  area per year, though we are open to schedule
  one- on-one trainings with your group or facility
  on an as needed basis.
• CBH will notify all providers of upcoming events
  via mail, by phone, or in our Provider
  Newsletter.
• Your suggestions for training and forum topics
  are always welcome! 
•  
•  
•  

31
Member Card- Front
32
Member Card-Back
33
Questions and Answers