Microsoft word - ad 12 101 transition to unmatched 2012.docx

CBHNP Network TCM, Crisis Intervention, MH OP, SA OP, Lab, and
MMHT, Providers
Don Stiffler, Provider Relations Manager
April 9, 2012, 2012
AD 12 101 Transition to Registration Free Process for Most Ambulatory /
Outpatient Services (Capital Counties, Lycoming/Clinton, Franklin/Fulton)

This memo is a follow up to AD 09 103 (August 2009) and AD 09 108 (October 2009) memos related to code changes in preparation for transition to a registration free process for certain outpatient services. CBHNP recognizes that there are certain services that require less management and, in fact, utilization of such services may ultimately reduce overall cost to the system by reducing or eliminating the need for higher levels of care. Throughout 2011, providers in designated areas of the network have participated in a pilot to test the transition to a “registration free” process for certain outpatient services. CBHNP is pleased to announce that effective immediately, Providers will no longer need to obtain an authorization number in order to submit claims and receive payment for most outpatient services. Claims submission will no longer require an authorization number for the services noted below. It is, however, very important that providers submit accurate and timely claims which include proper procedure codes, modifiers, and place of service codes for the services delivered. Beginning immediately, an Authorization request will not be required for the following services (full list of Authorization Requirements is available on the provider portal document named AD12 101A Authorization Requirements By Service for reference): Targeted Case Management* for MH and SA services (ICM, RC and Blended)
*Initial TCM services will continue to require registration for completion of the eligibility matrix,
however, no authorization or re-authorization of services will occur.
Mental Health Outpatient Services (Includes Clozaril, Mobile Mental Health Outpatient Treatment and Telepsychiatry) Substance Abuse Outpatient Services (Includes Suboxone)
Please note the following exceptions which still require form submission:
90801 performed by an MD/DO which recommends RTF, CRR HH, BHRS and any BHRS funded service. Examples of these services are listed on the Child Adolescent Services Submission Sheet. An Initial registration is still required so that the referral / ISPT process can be initiated. 90801 diagnostic interview by a psychologist which recommends BHRS and any BHRS funded services. An Initial registration is still required so that the referral / ISPT process can be initiated. AD 12 101Transition to Registration Free Process for Certain Ambulatory / Outpatient Services (Capital Counties, Lycoming/Clinton,
Franklin/Fulton)
Psychological/Neuropsychological Testing Psychiatric Rehabilitation including Clubhouses and Peer Support Any MH OP request when there is a current Level of Care approved that includes therapy since this could be considered a duplication of service (see section below regarding duplication of service for a full list of applicable services). When one of the services listed is approved for a Member, the outpatient provider must request prior authorization by submitting the CBHNP Adjunct MH OP Therapy Request form. Other important points for Providers to note: The effective date of this change is based on the claims received date and not the date of service therefore, claims for services identified above can be submitted without an authorization from this day forward and be paid. If you require additional codes to be added to your profile, contact your Provider Relations Representative prior to sending the claims (example services with an interpreter). Claims must be submitted within timeframe indicated in the Provider Agreement and Provider Manual Claims may not be submitted for mixed levels of care o For example, if one psychiatric evaluation (90801) and one group therapy (90853) service has been provided, this will be submitted as two (2) separate claims. One claim will reflect 90801 and a separate claim will be submitted for 90853. Multiple dates for the same service can be included on a claim. o This is not a change from current CBHNP requirements.
While we are pleased with the reduced administrative burden to providers we are aware that there will be some
challenges as well. Right now, when a request for a service comes in, CBHNP staff can identify immediately if the
service represents duplication and can notify the Provider. Going forward, it is more important than ever that all
Providers have a process in place to address coordination of services.
Please understand that CBHNP still expects service delivery to be in accordance with Medical Assistance rules and
guidelines. In short, services must be delivered based on medical necessity, with expedience so as to prevent waste
and documented clearly. Regular treatment record reviews by CBHNP will assure proper service delivery. If you
have any questions regarding specific code-modifier combinations, please contact your Provider Relations
Representative for clarification. You must also be Medical Assistance enrolled and credentialed by CBHNP for the
services you are billing in order for the claims to be paid.
Duplication of Service
As previously mentioned, Individual, Family and/or Group Mental Health Outpatient therapy may be considered a
duplication of service if there is concurrent authorization of any service indicated in the table below. If a request for
Individual and/or Family MH OP is submitted to CBHNP and one of these services is currently authorized, then prior
authorization of the MH Outpatient Service Request is required to avoid duplication of therapy. If one of the services
below is currently authorized and there is interest in additional adjunct / outpatient services, the Provider will submit
the CBHNP Adjunct MH OP Therapy Request form for approval prior to rendering the outpatient service. Please
contact CBHNP Provider Relations Representative for your agency if you are unsure if prior approval is necessary.
CBHNP will audit for services delivered without prior authorization and are a duplication of the services listed below;
if found, providers will be liable for financial recoveries.
Abuse Resolution & Recovery Treatment Services AD 12 101Transition to Registration Free Process for Certain Ambulatory / Outpatient Services (Capital Counties, Lycoming/Clinton,
Franklin/Fulton)
Community Residential Rehabilitation- Host Home Juvenile Firesetter Assessment Consultation Treatment Service Multisystemic Therapy-Problem Sexual Behaviors Structured Therapeutic Enhanced Programming for Success Trans-Disciplinary Treatment Team Services While there are some minor challenges, we believe this will be a very positive change for Providers as well as CBHNP. Your thoughts and comments are welcome. Please feel free to contact your Provider Relations Representative with questions or concerns or if you need additional time to adjust to this change. cc: Pam Marple, Behavioral Health Services of Somerset & Bedford Counties Deborah Duffy, Lycoming/Clinton Joinder Board Amy Shanafelt, Blair HealthChoices Missy Reisinger, Tuscarora Managed Care Alliance Scott Suhring, Capital Area Behavioral Health Collaborative CBHNP Management Team CBHNP Provider Relations AD 12 101Transition to Registration Free Process for Certain Ambulatory / Outpatient Services (Capital Counties, Lycoming/Clinton,
Franklin/Fulton)

Source: http://providers.cbhnp.org/files/forms/AD%2012%20101%20Transition%20to%20Unmatched%202012.pdf