2 Agenda Introductions Overview of Optum Review of Contract between Optum and the OfficesAdmission & Discharge ReviewProvider ToolsTool ReviewForms & Submission ProcessOptum/New York Web siteProviderConnectQuestion and Answer SessionWrap Up and Closing
3 Optum New York StaffWilliam Fishbein, Executive Director Optum New YorkMichael Silver, PsychiatristMarc Minick, Community LiaisonMark Simmons, Community LiaisonAmy Freeman, Behavioral Health Clinical ManagerMargaret “Peggy” Elmer, Behavioral Health Clinical ManagerJoni Richter, Behavioral Health Intake ManagerErik Geizer, QI/Training ManagerLinda West, Reporting & Technology Manager
5 Optum Organizational Overview Optum is a health services business dedicated to making the health system work better for everyoneWe are comprised of three market-leading business segments:OptumHealthOptumInsightOptumRxOptum serves the entire health ecosystem250,000 health professionals and physician practices6,200 hospitals and facilitiesmore than 270 state and federal government agenciesover 2,000 health plans; two of every five FORTUNE 500 employers; and one in every five U.S. consumers.
6 UnitedHealthcare-Health Benefits Optum—Health Services Our Business ContextUHGUNH=Publicly Traded Registrant (NYSE)UnitedHealthcare-Health BenefitsOptum—Health ServicesHealth care coverage and benefits businesses, unified under a master brandEmployer and IndividualCommunity and StateMedicare and RetirementInformation and technology-enabled health services platform, encompassing:Technology solutionsIntelligence and decision support toolsHealth management and interventionsAdministrative and financial servicesPharmacy solutionsUNITEDHEALTHCARE: Employer and Individual --Health benefit plans for individuals, small- and mid-sized businesses, and large multi-site employers.Working with individuals, small- and medium-sized businesses, and large multi-site employers to find health care benefits that work well for everyone.UnitedHealthcare coordinates network-based health and well-being products and services that are innovative, affordable, and keep individuals involved in their own health and wellness. After all, informed consumers make better decisions, and that leads to lower medical costs.In addition to health benefit plans, UnitedHealthcare offers specialty care programs such as vision and dental care, as well as HSAs (health savings accounts) and HRAs (health reimbursement accounts).UnitedHealthcare National Accounts creates customized health benefits solutions to meet the often complex needs of large sophisticated multi-location employers and also provides health care services for employees located overseas.In a complex and ever-evolving health care environment, UnitedHealthcare works to make the health care experience simpler and better for individuals, physicians and employers.UnitedHealthcare Community and State--High-quality, personalized, public sector health care programs.Health care benefits and services for beneficiaries of Medicaid and other government-sponsored health care programs.Public sector health care operates under a unique set of business imperatives. By investing in the systems and personnel required to successfully provide quality service to these customers, UnitedHealthcare Community & State can offer health plans that meet the unique needs of the beneficiaries of Medicaid and other government-sponsored health care programs.UnitedHealthcare Medicare and Retirement—Serving the health care needs of seniors.Providing health care choices and peace of mind to a growing market.UnitedHealthcare Medicare & Retirement is dedicated to providing innovative health and well-being solutions that help senior Americans achieve healthier and more secure lives.Serving 9 million seniors and one-in-five Medicare beneficiaries, UnitedHealthcare Medicare & Retirement is the largest business dedicated to the health and well-being needs of seniors. UnitedHealthcare Medicare & Retirement manages a full array of products and services, which include Medicare Advantage plans, Medicare Supplement plans, Part D prescription drug plans, employer retiree health services, chronic disease management and care coordination programs.UnitedHealthcare Medicare & Retirement products, services and programs are designed to meet the individual needs of its customers, their families, physicians and communities.SecureHorizons by UnitedHealthcare – A leading provider of quality health care plans serving more than 1.6 million Medicare beneficiaries through a variety of Medicare Advantage plans and other value-added services. Learn more at SecureHorizons.com.Medicare Part D plans – The nation’s largest provider of Medicare prescription drug benefits (Part D) on a stand-alone basis to 4.2 million beneficiaries throughout the United States and its territories. Learn more at AARPMedicareRx.com and UnitedHealthRx.com.Insurance Solutions – Operates the nation’s largest Medicare Supplement business in association with AARP. Learn more at AARPHealthcare.com.Evercare by UnitedHealthcare – Provides one of the largest care coordination programs for individuals living with disabilities, long-term or advanced illness. Evercare serves individuals and families nationwide through its Medicare Special Needs Plans, hospice and caregiver programs and services. Learn more at EvercareHealthPlans.com.UnitedHealthcare Retiree Services – Providing employers with high-quality, affordable health care solutions for retirees such as Medicare Advantage, Medicare Supplement and Medicare Part D plans.Helping people live healthier livesHelping to make the health care system work better for everyone
9 Populations covered under the program All fee-for-service admissions to OMH-licensed psychiatric units (all ages) in general hospitals (Article 28 hospitals).Fee-for-service children and youth admitted to OMH licensed private psychiatric hospitals (Article 31 hospitals).Fee-for-service direct admissions to OMH State-operated children’s psychiatric centers or children’s units of psychiatric centers.Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services (Article 28/32).Fee-for-service OASAS certified hospital (Art 28/32) or freestanding (Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation Services.
10 Functions of the BHO include: ConcurrentReviewOptum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals.Discharge Planning & TrackingOptum will engage with the inpatient provider with respect to discharge planning for applicable admissionsEnhanced efforts will be employed for inpatients identified as “High Need Individuals”Tracking of Children with SEDEach new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the StateProvider Profiling /AnalyticsCommunity LiaisonsHistorical Clinical data will be provided by the Offices to the BHOsData elements specific to each inpatient admission and provider will be collected by the BHO and shared with the Provider and the Offices.Metric Reporting will be provided back to the OfficesFacilitation of Cross System LinkagesOptum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disordersQuality InitiativeOptum will devise a quality assurance program to monitor the quality of work performed within the contract
11 (Portal, Fax or Telephonic) Notify Optum regarding Children with SED Review of ContractProvider CommunityThe OfficesOptumProvider CommunityNotify Optum of admission(Portal, Fax or Telephonic)Notify Optum regarding Children with SEDSupplies Optum with guidance to perform tasksSupplies historical clinical dataSupports access to cross systemsPerforms initial/ concurrent reviewsMonitoring discharge planning & post-discharge servicesTracking of children with SEDProvider profilingFacilitation of cross system linkageQuality InitiativeTreatment History FormFollows concurrent review & discharge monitoring processes11
12 What we need from you: Partner with Us Engage in the Process Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitationUse your dedicated Care Advocate and Community Liaison as a part of your teamEngage in the ProcessFollow the concurrent review & discharge planning/tracking processesIdentify Cross System LinkagesProvide data as requestedUse the tools providedAsk QuestionsDon’t hesitate to ask us questionsClinical questions can be directed to the Care Advocate or to:General questions can be directed to the Executive Director & Community Liaisons or toProviderConnect technical questions/issues can be directed to:OtherLet us help you!We want your feedback.
14 Provider Tool Review- Methods for submission FaxIndividual Information Matrix- Within 24 hours of admission- Concurrent Review at established intervals- Discharge by the date of discharge but no later than within 24 hours post discharge.Fax #Clinical Fax: (877)TelephonicToll-free: (866)Dedicated Care Advocate assigned by FacilityPortalNew provider portal:ProviderConnect software
15 Fax Submission Option Individual Information Matrix Form 3 components of the form:AdmissionProviders to notify their assigned BHO within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday.Concurrent ReviewOptum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals.Discharge PlanningProvider to complete and submit by the date of discharge but no later than within 24 hours post discharge.Form located on the Optum NYC BHO Provider Portal :Submit forms to the Optum NYC BHO clinical fax number: (877)
16 Admission Information Is there OASAS consent on File? YES / NODate: Facility Name:BHO Care Advocate Assigned: Facility Contact Name:Facility Contact Phone: Facility Contact Fax: Individual Name: Medicaid ID: Date of Birth: Gender:County of Residence:Date of Admit: Time of Admit: Age Group of the Individual:Admission Type: Inpatient Psychiatric, Substance Abuse Rehab, Inpatient DetoxDiagnosis(es) at Admission:Axis I: Axis II: Axis III: Axis IV: Axis V: Reason(s) for Admission (Why now?): Readmission to Facility within 30 days for Inpatient Psychiatric/45 days for SA Rehab or Detox? Readmission to same facility:*Please complete & submit within 24 hours following admission or by 5 p.m. the next business day following weekend and holiday admissions.**If this is a readmission within 30 days for inpatient/detox or within 45 days for rehabilitation, send prior discharge plan with Matrix submission.
17 Feedback from Optum after Admission Notification Optum will generate a Treatment History Form regarding the Individual admitted by the Facility within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider.See next slide
18 Treatment History Form Information Facility Name: Facility Contact: Phone: Fax: Individual Name: Medicaid ID: High Need Individual: MH readmission w/in 30 days: Date of Admit: Time of Admit: Date of History Transmission: Time of History Transmission: Last three (3) months of behavioral health services utilized by individual: Most recent diagnosis(es):Axis I: Axis II: Axis III: Axis IV: Axis V: There is/ is not additional treatment history information available on the individual. (circle one)*Facility is responsible for gaining executed release of information and sending to OptumHealth for the release of substance abuse treatment services.OASAS Consent FormFacility/ ProviderDates of ServiceType of Service
19 Concurrent ReviewDedicated Care Advocate to be assigned by Facility.Check- Notice of Preliminary Finding- Verbal- Notice of Clinical Determination - LetterSee next slide
20 Concurrent Review Information What has worked in the past for treatment of individual? What strengths do the individual and/or family system have that we can build on? What is being done differently this time? Current status of individual, including mental status examination results: Status/Progress with Treatment Plan: Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual?If no, why? Current Diagnosis(es):-Axis I: -Axis II: -Axis III: -Axis IV: -Axis V:
21 Concurrent Review Information Physical & behavioral assessment findings: Current Status of Individual, including mental status examination results?Current Diagnosis:Axis I:Axis II:Axis III:Axis IV:Axis V:For an admission from the community, what type of housing did the individual reside in?If individual was admitted from an institutional setting, what type of setting was the sending facility?What has worked in the past for treatment of individual?What strengths do the individual and/or family system have that we can build on?What is being done differently this time? Status/Progress with Treatment Plan: Assessment for case management completed?If case management is needed and individual is not currently enrolled, referral made? Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual? If no, why? Preliminary Discharge Plan: If this is a readmission, key factors in why the prior discharge plan didn’t meet the member’s needs? Anticipated discharge date: Expected Length of Stay: DaysBarriers to Discharge (biopsychosocial): Referral to local peer/family services programs/supports?
22 Concurrent Review Information Individual involved in discharge planning?Individual’s family involved in discharge planning?Contact with medical provider(s):Detail? Contact with behavioral provider(s):Detail? Is the individual enrolled in Managed Care?Is the individual enrolled in a Health Home? Did the individual have a care coordinator prior to admission?Case manager/ Care coordinator engaged in hospitalization?Name of case manager/care coordinator: If child/adolescent, other systems engaged?Other Issues / Notes?MedicationsNameDosageFrequencyIf more rows are needed to list medications, please list them here: Discontinued?
23 Discharge Planning Information Date of Discharge: Time of Discharge: CM/Care Coordinator? Individual Leave Against Medical Advice?Diagnosis(es) at Discharge:Axis I: Axis II: Axis III: Axis IV: Axis V: Medications: NameDosageFrequencyDoes the individual have a sufficient amount of medication until his/her follow up appointment?If no, why? Was case summary and discharge plan sent to the outpatient provider?If yes, what date?
24 Discharge Planning Information If the individual has a care coordinator (i.e. ACT, OMH TCM, Children's HCBS Waiver, MATS, and Health Home), was he/she informed of the discharge? <drop down>If the individual is assigned to a MCO, have they been contacted for post discharge physical health care needs? <drop down>Peer/Family Support Service/Program Referral:If yes, name & contact information: For a discharge to the community, what type of residence is he/she being discharged to:If the individual is being discharged to an institutional setting, what type? <drop down>Has the individual been provided with written instructions for what to do in the event of a crisis prior to his/her first post-discharge appointment?If no, why? If individual is under 18 years, linkage of children with other service systems (e.g. juvenile justice, educational system, child welfare)?Follow up appointments, inclusive of case management:Provider #1 Name: Provider #3 Name: Provider ID: Provider ID: Contact Information: Contact Information: Date/Time of Appointment: Date/Time of Appointment: Service Type: Service Type:Provider #2 Name: Provider #4 Name: Date/Time of Appointment: Date/Time of Appointment: Service Type: Service Type:
25 Review of Process - MH Inpatient ActionTime FrameReport inProviderProfileMedicaid FFS beneficiary admitted for inpatient mental health treatmentAdmitting facility submits Individual Information Matrix via provider portal, fax or telephone to NYC BHOWithin 24 hrs of admission or by 5 p.m. the next business day following weekend and holiday admissionsBHO sends Treatment History Form to facility via fax, encrypted or provider portalBHO CA contacts designated facility clinician and conducts concurrent review; sets time for next concurrent reviewWithin 72 hrs of admission or by 5 p.m. the next business day following notification of the admission by the provider, whichever is laterBHO CA and designated facility clinician conduct concurrent reviewsBHO CA documents facility compliance with required elements of treatment planning, treatment and discharge planningAt least every 5 days*Consumer’s clinical condition no longer justifies continuinginpatient stayDuring concurrent review, BHO CA tells facility liaison that continuing inpatient stay may no longer be justified and that BHO CA is sending the case for review by a BHO psychiatrist to make the determinationIf the BHO psychiatrist concurs that continuing inpatient stay is no longer justified, BHO CA. CA gives verbal Notice of Preliminary Finding to the facility liaisonWithin 24 hours of concurrent review
26 Review of Process - MH Inpatient - continued ActionTime FrameReport inProviderProfilePotential Provider ResponsesProvider submits request for reconsideration and additional clinical information to support the need for continuing inpatient stay;(1) Within 24 hrs of receipt of Notice of Preliminary FindingBHO psychiatrist completes review of additional clinical information and/or doc-to-doc consultation to facility physician; communicatesreconsideration determination to the facility and if ongoing care isdetermined to be required, BHO CA continues concurrent reviews.Within 24 hours of receipt of Reconsideration RequestBHO issues Notice of Clinical Determination if the reconsiderationreview determines that the individual does not require treatment in aninpatient setting and the individual is not discharged by the facility. BHOCA communicates the Notice of Clinical Determination to the facilityliaison verbally and in writing by portal, fax, or secure .Within 72 hours of Notice of Preliminary FindingORProvider discharges consumer and submits required discharge information via portal, fax or secure ; BHO closes case2) Within 48 hrs of receipt of Notice of Preliminary FindingBHO has received no discharge information and no request forreconsideration…BHO issues Notice of Clinical Determination to facility-designatedrepresentative via fax or secure and sends copy to the Offices(3) Within 48 hours of receipt of Notice of Preliminary Finding
27 Review of Process - MH Inpatient - continued NOTE: The Offices will waive the review requirement for maximum concurrent review intervals for individuals the BHO designates as “Long Stay” when all of the following criteria are met:The individual meets the criteria for inpatient careThe individual presents with symptoms and/or history that demonstrates a significant likelihood of deterioration in functions/relapse if transitioned to a less intensive level of careThe BHO care manager and provider concur that the current treatment and discharge plans best meet the individual’s needsThe individual’s discharge is delayed pending availability of resources that both the provider and BHO believe are necessary to maintain the individual outside of the current hospital setting (e.g. intermediate care inpatient, residential treatment, or foster care beds)For Long Stay individuals, the BHO care manager should schedule follow up reviews at intervals deemed appropriate based upon clinical judgment.Notices of Preliminary Finding and Clinical Determination will not apply to individuals designated as Long Stay.
28 Review of Process SA Inpatient Detox Same process as MH Inpatient, however concurrent reviews conducted at least every 2 daysSA Inpatient RehabSame process as MH Inpatient, however concurrent reviews conducted within 21 days of admission
29 Telephonic Submission Option Call Optum Intake at (866) for initial admission within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday.Make sure all of your information is ready when calling Optum IntakeUse Individual Information Matrix form as a guideline. Form located on the Optum NYC BHO Provider Portal :Ongoing concurrent reviews will be conducted in partnership with assigned Optum Care Advocate.
30 Provider Portal Submission Optum Use ProviderConnect via for online entry of data from Information Matrix form:Initial AdmissionConcurrent ReviewDischarge Planning
70 Next StepsComplete and submit Facility Information Form, if not yet submitted, to Suzanne Feeney via:Fax at: (518)atMail at: 900 Watervilet-Shaker Road, Suite 103, Albany, NYProviders who select ProviderConnect as their submission option should contact the Optum Help Desk to request a User ID/Password at (866) /prompt 4Optum will post Care Advocate/Facility assignments and contact information on our Provider Portal at:Start to notify Optum of admissions as of 1/3/2012.Fax - Clinical Fax: (877)Telephonic - (866)Provider Portal (ProviderConnect) -If you are using the Optum Provider Portal ‘ProviderConnect’ and have technical questions or encounter a problem, contact Optum (866) /prompt 4 or us at
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