Cenpatico Providers

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WELCOME
Cenpatico Providers
234 7/2007
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Cindy Smith Provider Relations Specialist
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What topics will we cover today?

• Cenpatico Quick Reference Guide
• Appeals Complaints
• OTRs
• Healthcare Integration
• Whats New
• Q A

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Quick Reference Guide

• Does not replace the Cenpatico Provider Manual
• Intended as a quick guide
• Applies to participating Cenpatico providers

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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)
• Formal Appeal (Level 2)

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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
• Cenpatico 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 Cenpatico Customer Service at
  1-877-MHS-4U4U (follow prompts for
  auth/Cenpatico)
• Via Letter Cenpatico Complaint, 504 Lavaca,
  Ste 850, Austin, TX 78701
• Your complaint will be researched and Cenpatico
  will respond within 30 days

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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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Total Healthcare Integration

• Collaboration of physical and mental healthcare

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Why?

• Initiative of the state
• Increase accessibility for mental health services
• Decrease no-show rate
• Better coordination of total health
• related services

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Who?

• Primarily Mental Health chooses to
• integrate into Physical Health
• Most interest has been shown by FQHCs
• There are several ways that integration can occur

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How?

• When a PHP contracts with a CMHC to provide the
  services
• Agreement between the PHP and an already
  contracted MHP
• The MHP can treat members
• The MHP does not have to be credentialed
  separately to provide services for the PHP
• The CMHC must bill Cenpatico for all services
  rendered not MHS

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How? (cont)

• When a PHP brings MHP in house to provide
• the services
• PHP can bring MHPs on staff
• The MHP can treat the member
• If HCP is a mid-level BHP, then must be
  supervised by Psychiatrist or HSPP in accordance
  with Indiana state law
• The supervising Psychiatrist or HSPP must be
  credentialed separately
• The PHP can bill for all appropriate BH services
  provided
• All MH services performed by a MHP must be
• billed to Cenpatico and not MHS

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Whats New!

• Expanded online claim submission
• e-ssential learning available

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QUESTIONS?
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