Transition to Managed Medicaid BlueCross BlueShield of Western New York and Health Integrated May 11, 2016

Medicaid Managed Care: New benefits BlueCross BlueShield not participating in HARP program Coverage extended to SSI members New benefits for Managed Care: – ACT, PROS, CDT – OMH outpatient mental health clinics – OASAS substance use disorder services Services authorized per OMH guidelines by Health Integrated – Reimbursed by BlueCross BlueShield of Western New York Effective date: 7/1/16

Determining benefits Confirm Medicaid member benefit eligibility and provisions prior to authorization – Members may have changed insurances or may be ineligible Providers verify eligibility and benefits – wnyhealthenet.com – Provider services ( ) Next steps – Contact Health Integrated for authorization requests – Contact BlueCross BlueShield for benefit or claims questions

Pros-ACT-CDT-IOP partial hospitalization Authorization requirements vary by service – Check requirements with provider service ( ) – Avoid payment issues by notifying BlueCross BlueShield of any member enrolled in your program on 7/1/2016 – Current patients have a 90-day grace period Preauthorization is required for new services – After benefits are confirmed, call Health Integrated to request preauthorization if required by NYS OMH ( )

Pros-ACT-CDT-IOP partial hospitalization Be prepared to provide: Member demographics Provider information Start date of service Reason for services Clinical information that supports the need for the requested level of care –Current clinical presentation, history of CD/MH treatment, medications, lethality risk, living environment, support network, psychosocial stressors

Case management services Case management (CM) is critical to complex care BlueCross BlueShield provides CM to members with behavioral health issues High-risk/high-need members will be assigned a telephonic CM Community providers can request a CM for their patients ( , option 2) We encourage members to participate in their Health Home

Case management coordination BlueCross BlueShield case managers: – Oversee behavioral health and medical needs and services – Coordinate these services to improve all aspects of care – Contact providers with clinical and medical information to improve care – Work with facilities to improve diversion and service delivery – Work with Health Homes to engage and coordinate care

Family and peer involvement BlueCross BlueShield believes peer and family support and involvement are critical to the success of a members recovery plan We support community providers by promoting these services to our members BlueCross BlueShield and Health Integrated will assist members and clinicians by making services available to members and helping them enroll

Denials/appeals processing If an authorization is denied, members will be notified of their appeal rights in writing Members will be instructed to follow the appeal processes outlined in the denial letter When requesting an appeal, members should be prepared to submit medical records and any other information for consideration Appeal determinations will be completed within regulatory guidelines

Billing guidelines Claims for behavioral health carve-In services are billed on institutional format (837i/UB-04) Reference UB04 Required Fields document to ensure all required information is included (this is a bad link) If not already, register with ASK Clearinghouse for electronic submissions

Billing: important notes Providers should adhere to NYS OMH/OASAS coding guidelines Include Medicaid rate code in the Value Code amount field Clinic services should be billed with 091X or 094X revenue code series For additional billing rules, see NYS OMH/OASAS Billing and Coding Manual

Billing: test claims Beginning 6/1/16, we will accept up to 10 “practice” claims from providers interested in testing our processing/pricing capabilities – Paper submissions only – For providers with multiple new service types (e.g., ACT/CDT/Clinic/PROS), up to 10 cases per service type will be accepted – Current BlueCross BlueShield patients should be used (both SSI and non-SSI). – Line level claim results will be provided on a test voucher – Providers should supply a testing contact (name, phone number, , and address) – Mail test claim files to: BlueCross BlueShield of Western New York – Medicaid BH Testing Network Management 257 West Genesee Street Buffalo, NY

Billing: network management contacts All Services Steve Nelson, Network Services Manager (716) / Mental Health John Godfrey, Senior Provider Relations Account Specialist (716) / Substance Use Disorder Services Irina Bojanowski, Facility and Ancillary Provider Relationship Specialist II (716) / Katie Ball, Facility and Ancillary Provider Relationship Specialist II (716) /

Billing: BlueCross BlueShield websites Provider Portal EDI Details UB-04 Guide (note: this is a bad link) Provider and Facility Reference Manual (secure login required) r%20and%20Facility%20Reference%20Manual_(Updated%20Dec%202015).pdf r%20and%20Facility%20Reference%20Manual_(Updated%20Dec%202015).pdf 14

Billing: important websites WNYHEALTHeNET Payspan ASK Clearinghouse The Managed Care Technical Assistance Center

Clinical training Clinical training provided through CPI at Columbia University Training and schedule available on BlueCross BlueShield behavioral health webpage bcbswny.com/behavioralhealth bcbswny.com/behavioralhealth

Questions? Health Integrated, Behavioral Health Utilization Management – Paul Webb, LCSW-BH UM Manager, (813) – Diane Farrell, RN-BH UM Supervisor, (813) x4589 BlueCross BlueShield Clinical Coordinator – Name, Title, (716) 887-XXXX Q&As will be posted on bcbswny.com/behavioralhealthbcbswny.com/behavioralhealth