1. Value Behavioral Health of Pennsylvania
BHRS Consumer/Family Forum
Crawford, Mercer & Venango Counties
June 2007
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2. Pennsylvania HealthChoices Program
State Medical Assistance (MA) Managed Care Program
The HealthChoices Program has three main goals
To improve access to healthcare services for MA consumers
To improve the quality of care available to MA consumers
To stabilize Pennsylvania’s MA spending
Shar
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3. Who is Value Behavioral Health-PA (VBH-PA)??
Value Behavioral Health-PA (VBH-PA) is a managed care company
VBH-PA is working with your county to ensure the success of the HealthChoices Program
VBH-PA staff will be available to answer your questions when you call the toll-free member services number established for your county
Shar
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4. AE_NW3 BHRS Consumer_Family Forum_060707
Shar
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5. The Benefits of HealthChoices
Supports the enhancement, expansion & improvement of county-specific delivery of services
Provides a continuum of in-plan and supplemental services that promote recovery and resiliency
Mental Health
Substance Abuse
Provides consumers with a choice of in- network providers
Shar
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6. Behavioral Health Services Mental Health (MH)
Inpatient Psychiatric
Residential Treatment Facilities (RTF) for Children & Adolescents
MH Partial Hospitalization
MH Outpatient
Behavioral Health Rehabilitation Services for Children/Adolescents (BHRS)
Family-Based MH
Intensive Case
Management (ICM)
Resource Coordination
(RC)
Blended Case Management
(BCM)
Certified Peer Specialist
Crisis Intervention
Clozapine Support Services
Laboratory Services
Shar
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7. Behavioral Health Services Substance Abuse
Inpatient Drug & Alcohol (D&A) Detoxification/Rehabilitation
Non-hospital Residential Detoxification/Rehabilitation
Halfway House
D&A Outpatient, including Intensive Outpatient (IOP)
Outpatient Narcotic Addiction Treatment
(Methadone Maintenance)
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8. AE_NW3 BHRS Consumer_Family Forum_060707
Service Access
HealthChoices means you have a CHOICE of providers
When members call VBH-PA for a referral, they will be given at least two names of providers to choose from
VBH-PA does not give recommendations, but will offer members a choice of providers
VBH-PA clinicians will ask for information to assess the need for services (emergency, urgent, or routine)
Shar
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9. There is no charge to you for in-plan services that you receive.
Service Access
There is no charge to you for
in-plan services that you receive.
HealthChoices members DO NOT pay for any covered services they need. There is no co-pay. (This does not include your prescriptions. Your prescriptions are paid by your physical health plan.)
If members receive a bill, they should report this to the VBH-PA Member Service Representative.
Shar
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10. Toll-Free Contact Numbers
VBH-PA Member Services
Erie
NWBHP
(Northwest Behavioral Health Partnership: Crawford, Mercer & Venango Counties)
Cambria
Toll-Free Provider Line:
TTY Telephone Number:
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11. AE_NW3 BHRS Consumer_Family Forum_060707
Member Benefits
All VBH-PA members are provided with a Member Handbook that includes important information on member benefits
Handbooks are mailed to all eligible HealthChoices members in a bright pink envelope
It is important to read and keep the handbook
Frank
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Member Benefits
The Member Handbook includes:
A county-specific toll-free number to call with any questions about behavioral health care services and/or the HealthChoices program
Information on filing a complaint or grievance
Information on getting help in an emergency
Ways to share your opinions about your services by taking a satisfaction survey
Member rights and responsibilities
Frank
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13. Learn about Your Rights
As part of the HealthChoices Program, you have the RIGHT to:
- Be treated with dignity and respect.
- Have your medical records and conversations with people who give you care kept private.
- Take part in decisions about your care.
- Have your treatment plan explained to you.
- Help set up your treatment plan and ask for a change
to your treatment plan.
- Choose your provider from a list of HealthChoices
Program Providers.
- See your medical records and talk about them with
your provider.
Frank
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14. Learn about Your Rights (continued)
- Change your provider.
- Ask your provider about his or her qualifications or any
person who is helping you.
- Receive services without regard to race, color, religion, sex,
sexual orientation, age or ethnic background.
- Make a Complaint or file a Grievance about your care or the
services you receive.
- Talk with a Consumer Family Satisfaction Team (C/FST)
member about the quality of your services.
- Receive information on available treatment services.
- You have the right to be free from any form of restraint or
seclusion during your treatment that is used as a means of
coercion, discipline, convenience or retaliation.
- You have the right to create an Advanced Directive and share
it with your treatment provider.
Frank
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15. Learn about Your Rights (continued)
- Have the side effects and risks of your medications explained to
you.
- You may also request a copy of information maintained
by VBH-PA. The information may include claims
information, complaints, referrals, disclosures and other
documented contact you and your provider have had with
us.
- You may request to amend (change) the VBH-PA
information listed above in order to correct any errors.
The decision to make a change is made by the VBH-PA
Medical Director.
- You are free to exercise your rights. Exercising your
rights will not affect how you are treated by your
provider or by VBH-PA.
- You have the right to request a second opinion about your
treatment.
Frank
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16. Learn about Your Responsibilities
As part of the HealthChoices program, you have the RESPONSIBILITY to:
- Respect the dignity and privacy of others.
- Give your provider the information that he or she needs
to better serve you.
- Work with your provider to help develop a treatment
plan and ask questions when you do not understand
your treatment.
- Try to follow the treatment plans you developed with your
provider.
- Keep your appointment with your provider.
Frank
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17. Learn about Your Responsibilities (continued)
- Contact your provider if you need to cancel or
re-schedule your appointment.
- Call the VBH-PA toll-free telephone number if you move
and/or change your address or phone number. If
you are hearing impaired, call the TTY number at
Become familiar with your Rights and Responsibilities. They are in your Member Handbook.
Frank
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18. AE_NW3 BHRS Consumer_Family Forum_060707
CASSP Principles
Mental health services in Pennsylvania are guided by the principles of the Child and Adolescent Service System Program.
Central to CASSP Principles is the recognition that a child must be understood in his or her natural context—the family, the community and the child-serving systems—not just individually.
CASSP Principles are strengths-based and treatment-focused.
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CASSP Principles
Child-centered
Family-focused
Community-based
Multi-system
Culturally competent
Least restrictive/least intrusive
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Evaluation
Comprehensive Child and Adolescent Strengths-Based Evaluation—Life Domain
Best Practice format for initial evaluations and re-evaluations
Evaluation of the child’s strengths and needs
Review of past treatment trials and/or review of treatment goals
Consideration of the full continuum of care
Documentation to support the medical necessity of recommended level of care
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21. Independent Prescriber Model
Prescribers who are credentialed by VBH-PA to evaluate children/adolescents and make treatment recommendations
Criteria:
Pennsylvania licensed psychiatrist, Pennsylvania licensed psychologist or developmental pediatrician
Documented experience in evaluating children and adolescents with special needs
Satisfactory (85% or better) ratings on CCASBE-LD monitoring
No affiliation with a BHRS/FBMH provider
Panel of providers will be recruited for each county
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22. Interagency Service Planning Team (ISPT)
Functions of the ISPT Meeting:
Mechanism for child-driven, family-focused treatment
Mechanism for individualization and positive envisioning
Mechanism to integrate prescriber expertise with multi-system participation
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23. Interagency Service Planning Team (ISPT)
Desired outcomes of the ISPT Meeting:
Achieving consensus, based on common understanding and common goals
Initiating and maintaining an ongoing process of collaboration and change
Implementing practical, workable solutions for the child, including integrated treatment and feasible sources of funding
Only possible with parent/guardian participation!
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24. AE_NW3 BHRS Consumer_Family Forum_060707
Initial ISPT
VBH-PA will schedule meeting within seven (7) days of receipt of evaluation
Parent/legal guardian, CYS/JPO, child if 14 years or older, and if appropriate, county representative, case manager, education (home school district), VBH-PA reviewer and other appropriate child-serving agencies
Evaluators are expected to participate (by phone or in person)
Provider is not a participant
VBH-PA/County facilitates initial ISPT
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25. Ongoing & Discharge ISPT
Provider is a participant and is responsible to contact county to schedule the ISPT
Provider takes the lead in discussing progress of treatment goals, interventions utilized, skill transfer, barriers to treatment and discharge planning
Discharge planning meeting within 45 days of a projected discharge date
Provider facilitates ongoing/discharge ISPT’s
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26. Definition of Medically Necessary
A service, item, procedure or level or care that is necessary for the proper treatment or management of an illness, injury or disability is one that:
Will, or is reasonably expected to, prevent the onset of an illness, condition, or injury or disability.
Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.
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27. Medical Necessity Criteria
Licensed as an utilization review entity
Mandated to use Appendix T, Program Standards and Requirements
SI – Severity of Illness
IS – Intensity of Service
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Peer Review
Care Managers and CAFS Coordinators can only authorize care
Medical Necessity is questioned
Peer Advisors render decisions
Certified
Non-certified (denial)
Peer Advisors are board certified psychiatrists, licensed psychologists and addictionologists supervised by the MCO Medical Director
Peer Advisors are also available 24/7 and a monthly on-call schedule is maintained
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29. What is a denial of service?
A VBH-PA Peer Advisor’s decision to deny a service, to decrease a service or to approve a service different than the service requested because the care requested is not medically necessary or another level of care is more appropriate.
The member will be sent a denial letter on the same date the denial is given for all acute levels of care. For non-acute levels of care, the denial letter is sent to the member within two business days of the denial decision.
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What is a Grievance?
A grievance is when you are unhappy about a decision made about your treatment:
You may be denied a service.
A decision was made to decrease the amount of service.
You want a different service than what has been approved.
Mary
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31. How do I file a Grievance?
You will receive a letter when VBH-PA denies a service, decreases your service, or approves something different than the service requested.
There can be several steps to the Grievance Process including:
First Level Grievance
Second Level Grievance
External Grievance
Fair Hearing
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32. First and Second Level Grievances
You may send your Grievance in letter form or you may call VBH-PA.
Use the toll-free number on your card or have someone call for you.
Your provider may also file a Grievance for you, if you give them written permission to do so.
Mary
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How Soon Must I File?
You have 45 days to file a Grievance after you receive written notice of the change in your service.
You may continue services through the Grievance process if you file within 10 days of your service being denied.
Mary
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34. If you are not satisfied
File a complaint if you are unhappy with the HealthChoices program.
you do not like the care your provider is giving you
you are unhappy with the services you are receiving
Mary
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35. Examples of Complaints
I waited too long in the office.
The staff is rude.
The doctor will not let me take part in deciding my care.
I was late because I could not get a ride or the bus was late and my appointment was cancelled.
I received a bill from my provider.
Mary
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How to File a Complaint
Call the toll-free number on your card or have someone call for you.
All calls are free.
Write a letter to:
VBH-PA
520 Pleasant Valley Road
Trafford, PA 15085
Attention: Quality Department
Mary
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37. AE_NW3 BHRS Consumer_Family Forum_060707
Need Help Filing...
A VBH-PA Member Services Representative can help you file a complaint.
Your complaint will be investigated within 30 days.
You will be sent a letter from
VBH-PA informing you of the resolution.
Mary
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38. What if I still don’t like the resolution?
You may file a Second Level Complaint by calling or writing VBH-PA.
You have the right to meet with the Second Level Complaint Committee to resolve your complaint.
This committee will meet within 30 days of your request and you will be notified of the results by a letter from VBH-PA.
Mary
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Still not happy?
You have 15 days to file an External Complaint Review.
This complaint is handled by either the Pennsylvania Department of Health (DOH) or the Pennsylvania Department of Insurance (DOI).
Mary
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Questions???
VBH-PA is committed to providing quality behavioral health services to all our Members.
VBH-PA wants its’ Members to strive for recovery and enjoy a good quality of life.
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