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OptumHealth NYC BHO Provider Training. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2 Agenda.

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Presentation on theme: "OptumHealth NYC BHO Provider Training. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2 Agenda."— Presentation transcript:

1 OptumHealth NYC BHO Provider Training

2 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2 Agenda Introductions Overview of Optum Review of Contract between Optum and the Offices Admission & Discharge Review Provider Tools –Tool Review –Forms & Submission Process –Optum/New York Web site –ProviderConnect Question and Answer Session Wrap Up and Closing

3 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3 Optum New York Staff William Fishbein, Executive Director Optum New York –Michael Silver, Psychiatrist –Marc Minick, Community Liaison –Mark Simmons, Community Liaison –Amy Freeman, Behavioral Health Clinical Manager –Margaret Peggy Elmer, Behavioral Health Clinical Manager –Joni Richter, Behavioral Health Intake Manager –Erik Geizer, QI/Training Manager –Linda West, Reporting & Technology Manager

4 Optum Overview

5 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5 Optum Organizational Overview Optum is a health services business dedicated to making the health system work better for everyone We are comprised of three market-leading business segments: –OptumHealth –OptumInsight –OptumRx Optum serves the entire health ecosystem –250,000 health professionals and physician practices –6,200 hospitals and facilities – more than 270 state and federal government agencies –over 2,000 health plans; two of every five FORTUNE 500 employers; and one in every five U.S. consumers.

6 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6 Our Business Context Health care coverage and benefits businesses, unified under a master brand –Employer and Individual –Community and State –Medicare and Retirement UnitedHealthcare-Health Benefits Information and technology-enabled health services platform, encompassing: –Technology solutions –Intelligence and decision support tools –Health management and interventions –Administrative and financial services –Pharmacy solutions OptumHealth Services Helping people live healthier lives Helping to make the health care system work better for everyone UHG UNH=Publicly Traded Registrant (NYSE)

7 Contract Review

8 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8 NYC BHO – Contracted Region

9 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 childrens psychiatric centers or childrens 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10 Functions of the BHO include: Optum 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. Concurrent Review Discharge Planning & Tracking Each new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the State Tracking of Children with SED Provider Profiling /Analytics Community Liaisons Historical Clinical data will be provided by the Offices to the BHOs Data 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 Offices Optum will engage with the inpatient provider with respect to discharge planning for applicable admissions Enhanced efforts will be employed for inpatients identified as High Need Individuals Optum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disorders Facilitation of Cross System Linkages Quality Initiative Optum will devise a quality assurance program to monitor the quality of work performed within the contract

11 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11 Review of Contract The OfficesOptumProvider Community Supplies Optum with guidance to perform tasks Supplies historical clinical data Supports access to cross systems Performs initial/ concurrent reviews Monitoring discharge planning & post- discharge services Tracking of children with SED Provider profiling Facilitation of cross system linkage Quality Initiative Treatment History Form Follows concurrent review & discharge monitoring processes Provider Community Notify Optum of admission (Portal, Fax or Telephonic) Notify Optum regarding Children with SED

12 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12 What we need from you: Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitation Use your dedicated Care Advocate and Community Liaison as a part of your team Partner with Us Follow the concurrent review & discharge planning/tracking processes Identify Cross System Linkages Provide data as requested Use the tools provided Engage in the Process Dont hesitate to ask us questions Clinical questions can be directed to the Care Advocate or to: General questions can be directed to the Executive Director & Community Liaisons or to ProviderConnect technical questions/issues can be directed to: Ask Questions Other Let us help you! We want your feedback.

13 Provider Tools & Submission Processes

14 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14 Provider Tool Review- Methods for submission New provider portal: ProviderConnect software Portal Toll-free: (866) Dedicated Care Advocate assigned by Facility Telephonic Clinical Fax: (877) Fax # Fax Individual 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.

15 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15 Fax Submission Option Individual Information Matrix Form –3 components of the form: Admission –Providers 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 Review –Optum 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 –Provider 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16 Admission Information Is there OASAS consent on File? YES / NO Date: 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 Detox Diagnosis(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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 Form Facility/ ProviderDates of ServiceType of Service

19 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19 Concurrent Review Dedicated Care Advocate to be assigned by Facility. Check - Notice of Preliminary Finding- Verbal - Notice of Clinical Determination - Letter See next slide

20 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 didnt meet the members needs? Anticipated discharge date: Expected Length of Stay: Days Barriers to Discharge (biopsychosocial): Referral to local peer/family services programs/supports?

22 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 22 Concurrent Review Information Individual involved in discharge planning? Individuals 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? Medications NameDosageFrequency If more rows are needed to list medications, please list them here: Discontinued?

23 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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: NameDosageFrequency Does 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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? If the individual is assigned to a MCO, have they been contacted for post discharge physical health care needs? 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? 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: Contact Information: Contact Information: Date/Time of Appointment: Service Type: Provider #2 Name: Provider #4 Name: Provider ID: Contact Information: Contact Information: Date/Time of Appointment: Date/Time of Appointment: Service Type: Service Type:

25 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 25 Review of Process- MH Inpatient ActionTime Frame Report in Provider Profile Medicaid FFS beneficiary admitted for inpatient mental health treatment Admitting facility submits Individual Information Matrix via provider portal, fax or telephone to NYC BHO Within 24 hrs of admission or by 5 p.m. the next business day following weekend and holiday admissions BHO sends Treatment History Form to facility via fax, encrypted or provider portal BHO CA contacts designated facility clinician and conducts concurrent review; sets time for next concurrent review Within 72 hrs of admission or by 5 p.m. the next business day following notification of the admission by the provider, whichever is later BHO CA and designated facility clinician conduct concurrent reviews BHO CA documents facility compliance with required elements of treatment planning, treatment and discharge planning At least every 5 days* Consumers clinical condition no longer justifies continuing inpatient stay During 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 determination If the BHO psychiatrist concurs that continuing inpatient stay is no longer justified, BHO CA. CA gives verbal Notice of Preliminary Finding to the facility liaison Within 24 hours of concurrent review

26 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 26 Review of Process- MH Inpatient - continued ActionTime Frame Report in Provider Profile Potential Provider Responses Provider 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 Finding BHO psychiatrist completes review of additional clinical information and/ or doc-to-doc consultation to facility physician; communicates reconsideration determination to the facility and if ongoing care is determined to be required, BHO CA continues concurrent reviews. Within 24 hours of receipt of Reconsideration Request BHO issues Notice of Clinical Determination if the reconsideration review determines that the individual does not require treatment in an inpatient setting and the individual is not discharged by the facility. BHO CA communicates the Notice of Clinical Determination to the facility liaison verbally and in writing by portal, fax, or secure . Within 72 hours of Notice of Preliminary Finding OR Provider discharges consumer and submits required discharge information via portal, fax or secure ; BHO closes case 2) Within 48 hrs of receipt of Notice of Preliminary Finding OR BHO has received no discharge information and no request for reconsideration… BHO issues Notice of Clinical Determination to facility-designated representative via fax or secure and sends copy to the Offices (3) Within 48 hours of receipt of Notice of Preliminary Finding

27 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 care The 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 care The BHO care manager and provider concur that the current treatment and discharge plans best meet the individuals needs The individuals 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 28 Review of Process SA Inpatient Detox –Same process as MH Inpatient, however concurrent reviews conducted at least every 2 days SA Inpatient Rehab –Same process as MH Inpatient, however concurrent reviews conducted within 21 days of admission

29 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 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 Intake –Use 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 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 30 Provider Portal Submission Optum Provider Portal: –Use ProviderConnect via for online entry of data from Information Matrix form:www.optumhealthnyc.com Initial Admission Concurrent Review Discharge Planning

31 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 31 OptumHealth NYC BHO Provider Portal

32 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 32 OptumHealth NYC BHO Provider Portal Page.

33 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 33 ProviderConnect Login.

34 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 34 ProviderConnect Login (cont.).

35 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 35 ProviderConnect News.

36 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 36 ProviderConnect Main Menu.

37 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 37 Individual Search.

38 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 38 Individual Search

39 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 39 Admission Notification.

40 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 40 Admission Notification

41 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 41 Saving updates- Admission

42 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 42 Concurrent Review- Logging into Provider Connect

43 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 43 Individual Search - Concurrent Review

44 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 44 Concurrent Review

45 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 45 Concurrent Review

46 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 46 Concurrent Review

47 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 47 Concurrent Review

48 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 48 Concurrent Review

49 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 49 Concurrent Review

50 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 50 Concurrent Review

51 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 51 Concurrent Review

52 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 52 Concurrent Review

53 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 53 Concurrent Review

54 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 54 Current Medications

55 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 55 Adding Medications

56 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 56 Saving updates- Concurrent Review

57 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 57 Discharge- Logging into Provider Connect

58 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 58 Individual Search- Discharge

59 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 59 Discharge

60 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 60 Discharge

61 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 61 Discharge

62 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 62 Discharge

63 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 63 Saving updates- Discharge

64 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 64 Children with Serious Emotional Disturbance (SED) - Logging into Provider Connect

65 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 65 Individual Search- SED

66 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 66 Children with Serious Emotional Disturbance (SED)

67 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 67 Children with Serious Emotional Disturbance (SED)

68 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 68 Children with Serious Emotional Disturbance (SED)

69 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 69 Saving updates- SED

70 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 70 Next Steps Complete and submit Facility Information Form, if not yet submitted, to Suzanne Feeney via: –Fax at: (518) – at –Mail at: 900 Watervilet-Shaker Road, Suite 103, Albany, NY Providers who select ProviderConnect as their submission option should contact the Optum Help Desk to request a User ID/Password at (866) /prompt 4 Optum will post Care Advocate/Facility assignments and contact information on our Provider Portal at: –www.optumhealthnyc.comwww.optumhealthnyc.com 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

71 Questions?


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