"Delivering Responsive and Compassionate
Behavioral Health Care"
TABLE OF CONTENTS
I. INTRODUCTION ……………………………[P 3-8]
IV. UM: CARE COORDINATION & ADVOCACY [P 30-44]

Medica Health Plans of Florida

Care Coordination & Care Advocacy

Who We Are: Our Mission and Goals

Access to Care

Contacting Concordia

Medically Necessary

Initial Authorizations

Authorization and Care Advocacy Processes

Provider Forms

Denials and Appeals
II. PROVIDER RELATIONS …………………… [P 10-19]

Using the Concordia Provider Manual

Our Network: Overview

What We Offer Our Providers

What We Expect From Providers

Critical Incident Reporting by Providers

Credentialing & Recredentialing

Concordia’s Provider Web Portal
III. CLAIMS PROCESSING & PAYMENTS………[P 19-29]
IV. QUALITY IMPROVEMENT…………………..[P 44-45]

Culture of Safety & Quality Care

Intensive Care Advocacy Program

Early Identification of At-Risk Enrollees

FARS and CFARS

Web Portal and Claims Processing

Person-Centered Care & Advocacy

Instructions for Eligibility and Submitting Claims

Advance Directives

What is a clean claim?

Improving Continuity & Coordination of Care:

Helpful Claims Filing Tips

Fraud Waste & Abuse
Communication between Health Providers
2
Concordia Behavioral Health is a Florida-based AAAHC
Accredited MBHO. We have partnered with Medica Health Plans
of Florida (MHP) to manage behavioral health benefits across
various lines of business delivering the priority care your patients
deserve. Both Concordia and MHP are committed to quality and
to sound utilization management practices that are data-driven
and support evidence-based practices. We value our provider
partners and promote the integration of medical and behavioral
care.
3
CONCORDIA’S MISSION
To provide a more responsive and
compassionate behavioral health care
experience to those we serve.
4
Goals of Concordia Provider Training
• Overview of Who We Are
• Components of Concordia and Provider
Partnership
• Instructions for Authorization requests, Forms,
Reporting and Medicaid Requirements
• Concordia Web Portal Log in and Claims
Submission
5
The Concordia Team:
Holds itself to the highest standards and strives to be a socially
conscious company that makes a positive difference in the lives
of those with whom we work.
Is dedicated to administering an integrated care delivery system
that ensures all behavioral healthcare services are clinically
responsive, safe, timely, cost-effective and delivered in a
compassionate manner.
Believes that enrollees should receive the most appropriate
behavioral healthcare services available in the least restrictive
environment possible.
Is committed to continually reviewing and improving every
process and system to ensure excellent behavioral care
outcomes for enrollees.
6
The Concordia Team:
Recognizes that, while our principal commitment is to the
health of enrollees, we are ultimately guided by a genuine
interest in the satisfaction of ALL who are involved in the
care delivery process. We’re committed to establishing
and maintaining a collegial and collaborative relationship
with our providers.
7
CONTACTING CONCORDIA
Business Hours:
Monday – Friday: 8:30 am to 5:30 pm
A Licensed MH/SA clinician
is always available: 24-hours a day,
Afterhours Access:
7-days/week, 365-days/year
Local (Miami-Dade): 305-514-5300
Main Office Numbers:
Toll Free:
855-541-5300
TYY:
305-514-5399
Local (Miami-Dade): 305-514-5301
Toll Free:
Our Fax:
855-698-5301
[email protected]
E-Mails:
Provider Relations
Coordination & Advocacy
[email protected]
[email protected]
Claims
Concordia Behavioral Health
Office Address:
7190 SW 87th Avenue, Suite 204
Miami, FL 33173
Website (and Provider Portal):
www.concordiabh.com
8
USING CONCORDIA BEHAVIORAL HEALTH’S
PROVIDER MANUAL
Our Provider Manual is divided into the following
sections:
•
Introduction to Concordia Behavioral Health
(Concordia)
•
The Behavioral Health Program for Florida
Medicaid Enrollees
Appendix:
•
Covered Services Requirements
•
Hospital Discharge Planning Guidelines
•
Service Vision and Core Treatment Values
•
Enrollee-Centered Care
•
Promoting Cultural and Linguistic
Competence – Self Assessment
•
Covered Services Limitations and
Exclusions
•
Emergency Care
•
Access to Care Standards
•
Web-Based Training Resources
•
Care Coordination: Authorizations and
Referrals
•
Medical Records Standards: Chart Review
Guidelines
•
•
•
•
Utilization Management (UM)
Quality Improvement (QI)
Claims
Provider Relations
The entire Manual will be available on our
Provider Portal. When there are updates to the
manual, a historical changes/updates record will
be posted on the portal.
9
OVERVIEW OF OUR NETWORK
•
Our network includes psychiatrists, psychologists, clinical social workers, mental health
counselors, addictions specialists and nurse practitioners.
•
All behavioral health professionals with whom we contract directly must be at the Master’s degree
level or above and licensed to practice their specialty.
•
We also contract with facilities, CMHCs and group or individual providers to provide the following
spectrum of services (as dictated by the enrollee’s health plan benefits):
Behavioral Health Evaluations
Outpt Individual Family Tx
Day Treament Program
Partial Hospitalization
TCM, T-BOS, PSR
Residential Treatment
Outpatient Group Therapy
Crisis Stabilization
Medication Managment
Inpatient MH/SA Treatment
Intensive Outpt Treatment
Psychological Testing
10
WHAT WE OFFER OUR PROVIDERS
• A Company that aims to be a steady source of referrals
for its network providers. We hope to minimize the time
our Providers spend on administrative tasks
• A Provider Relations Department responsive to your
needs that strives to foster respectful, mutually beneficial
partnerships
• A Utilization Management (UM) team and clinical staff
that sees our Network Providers as colleagues whose
clinical judgment is valuable and who have a shared,
vested interest in the care of our enrollees
11
WHAT WE OFFER OUR PROVIDERS
• Well-trained and courteous Care Coordinators ready to
verify eligibility and facilitate the referral and preauthorization process
• Care Advocates you can access 24-hours a day, 7-days a
week, 365-days of the year.
• A Claims Department dedicated to the timely and accurate
processing and payment of your claims
12
WHAT WE EXPECT FROM OUR PROVIDERS
•
Submission of updates to important credentials (i.e. current license,
malpractice, certifications, registrations, etc.)
•
Notification of any changes to Practice (name, address, phone, tax id,
mergers)
•
Cooperation with Site Visits and Records Review Audits
•
Timely submission of FARS and CFARS to Concordia
•
Adherence to all Local, State, Federal Laws & Regulations, and
Professional Standards
•
Providing enrollees with appointments according to Concordia’s
accessibility and timeliness standards
•
Protection of enrollee’s confidentiality, PHI and adhering to HIPAA standards
13
WHAT WE EXPECT FROM OUR PROVIDERS
•
Good record-keeping practices that meet standards
•
Coordination of care with the PCP and other behavioral health providers
•
Discussing Advanced Directives
•
Notifying Concordia immediately of Critical Incidents
•
Cooperation with UM processes and Quality Improvement activities
•
Collaboration with Concordia Care Advocates to manage high-risk enrollees
•
Emergency availability
•
The provision of culturally sensitive, resiliency oriented, strength-based,
family centered, trauma informed, cost-sensitive, compassionate care to our
enrollees
14
Critical Incident Reporting by Providers
•
Due immediately to the Agency, no later than 24 hours after occurrence or
knowledge of the incident. The health plan shall report events immediately
to the Agency’s Bureau of Managed Health Care behavioral health plan
analyst via encrypted email with the subject line: CRITICAL INCIDENT.
•
Critical Incidents include:
–
–
–
–
–
–
–
–
•
Enrollee Death- Suicide/Homicide; Abuse/Neglect; Other
Enrollee Injury or Illness
Sexual Battery
Medication Error – Acute Care; Children
Enrollee Suicide Attempt
Altercations Requiring Medical Intervention
Enrollee Escape or Elopement
Other Reportable Incident
Refer to the Medicaid Report Guide for specific descriptions of each
category
15
Reporting Critical Incidents
16
CREDENTIALING & RECREDENTIALING
•
Concordia evaluates its network on an ongoing basis to ensure enrollees’
have access to providers based on location, specialty, language and
cultural/ethnic background. Credentialing and re-credentialing are integral
components of quality care.
•
We adhere to access and availability standards as per state and federal
standards, accrediting standards and network composition needs.
•
To ensure that our Network is comprised of qualified behavioral health
clinicians and facilities, all potential and/or existing providers undergo a
thorough selection and review process to determine whether they are
qualified to competently practice within the scope of their experience and
expertise and meet our established credentialing criteria and nationally
recognized professional standards.
•
Re-credentialing of our Network Practitioners occurs every 3 years.
Providers are contacted in advance, informed of the documentation needed
and the deadline for their submissions.
17
CONCORDIA’S RECREDENTIALING PROCESS
ALSO CONSIDERS
• UM/QI provider performance reviews
• Site visit audits (adequateness of provider’s physical office,
clinical record keeping practices, access and availability and
other standards)
• Enrollee Satisfaction Surveys
• Enrollee complaints/grievances
• Any other quality of care indicators (i.e. responsiveness to a
CAP, peer reviews, etc.)
18
CONCORDIA’S
PROVIDER WEB PORTAL & CLAIMS PROCESSING
•
Concordia aspires to the accurate and timely processing and payment of your claims.
•
Through our secure Provider Portal you will be able to verify an Enrollees’ eligibility.
•
Providers who bill using the CMS-1500, will have option to file claims electronically
and receive an immediate EOB. Facilities must use paper claims.
•
According to a study conducted by Milliman Technology & Operations Solutions
electronic transactions can provide a 50-90% savings over manual transactions.
(“Electronic Transactions Savings Opportunities for Physicians”/2008).
Our
Provider
24-HOURS A DAY, 7-DAYS A WEEK
www.concordiabh.com
Web Portal
19
INSTRUCTIONS FOR
CHECKING ELIGIBILITY & SUBMITTING CLAIMS
PROVIDERS
USING A
CMS-1500 FORM TO FILE ELECTRONICALLY:
•
(We will provide electronic acknowledgement of receipt within twenty-four (24) hours of claim
submission, beginning the next business day. We will process and respond to a “clean” electronic
claim within twenty (20) days of receipt).
•
Go to www.Concordiabh.com and login Into the Provider Portal
•
If this is your first time using the Provider Portal, please follow the directions for registering as a
new user on our website
•
If you are already registered, go to the Provider Portal button and sign in with your user name
and password
•
Once you are in the Provider Portal you will be able to access all Concordia documents that are
available to you
•
To verify Eligibility – We recommend checking eligibility immediately prior to servicing the
enrollees. It is a very quick process!
– Go to Payor and click Concordia
– Go to Enter ID Number and type it in
– Go to Service Dates and verify
20
Once the service dates are verified…
• Click on Determine Eligibility. If the message is in green letters the message will say the
enrollees is eligible. Red letters indicate the enrollee is no longer eligible.
• To Submit a Claim click on Superbill (middle of page) and choose Behavioral Health
and Substance Abuse.
• Click on Create Patient Superbill.
Once the Superbill appears, follow the steps below:
• Enter Diagnosis Code(s) or search for Diagnosis Code(s). Please make sure you bill the
appropriate Diagnosis Codes as per Notice of Authorization.
• Enter CPT Code(s) or search for CPT Code(s). Please make sure to bill the appropriate
CPT Code(s).
21
INSTRUCTIONS FOR CHECKING ELIGIBILITY
& SUBMITTING CLAIMS CONTINUED
•
Enter the Claim date and verify the DOS, Dx Code, POS and Fee (billed
charges) are correct
•
Once the information is verified click OK
•
Click the Review bottom (right hand corner) to review the claim before
submission for auto-adjudication
•
Click on Preview claim to make sure claim is correct. If it is not, make changes
•
If claim is correct click on Submit Claim (bottom right hand). A message will
appear indicating that the claim will be submitted to “Concordia” for processing
•
Click OK (wait a few seconds and the actual benefit payment subject to
verification will show). You can review, reverse or print the EOB
•
To logout, click on Utilities and highlight the Log Out button, then hit Enter
22
Paper Claims and facilities
using the UB-04 Form
•
Paper claims for outpatient services should be submitted using a standard CMS-1500
form
•
Facilities filing inpatient paper claims are required to use a UB-04 form
•
We will provide acknowledgement of paper claim receipt within fifteen (15) days,
beginning the next business day.
•
We will process and respond to a “clean” claim within forty (40) days of receipt.
Please send claims to the following address:
Concordia Behavioral Health
P.O. BOX 431403
Miami, FL 33243
ATTN: Claims Department
23
WHAT IS A “CLEAN” CLAIM?
A claim that contains the required, correct information
to allow processing is a “clean claim”.
•
“Clean claims” lead to quick processing.
•
If our Claim’s Department requires additional information from any party external to
Concordia, the claim is no longer considered a “clean claim”.
•
The Concordia Notice of Authorization form mailed/faxed to you when services are
authorized, includes most of the information that you need to include on the claim
form. Your claims should include:
–
Enrollee’s Identifying Information: Name, DOB, Subscriber health plan ID#
–
The Authorization Number: Found on the Notice of Authorization
–
The Type of Service(s): Use Procedure Codes. Be sure the code corresponds to the one(s) issued
under the authorization number
24
“CLEAN” CLAIM CONTINUED:
–
The Date(s) of Service (and duration): Be sure that the date(s) of service is/are accurate and
correspond to those on the authorization; check that they fall within the valid timeframe
(between the effective and expiration dates of the authorization)
–
The Diagnosis: Provide a complete Mental Health/Substance Abuse primary diagnostic
code; use latest DSM-IV or ICD-9 related codes
–
Place of Service(s): Use the code corresponding to the service setting
–
The Patient’s Signature: Required in two (2) places / an indication that patient’s signature is
on file
–
Your (Provider) Identifying Information:
Practitioner/Facility name, “Group Practice” name
(if applicable); Provider’s credentials, Tax ID and NPI number (field #24 for each line billed
and #33a), Provider’s mailing/billing address and the address where the service was
rendered. Be sure to sign and date the claim (paper claims only)
25
HELPFUL CLAIMS FILING TIPS
Don’t delay! File promptly!
You have up to one hundred and eighty (180) days/six
(6) months from the date of service to submit your claims
to us.
• Use the correct claim form: For outpatient services
use a CMS-1500; for inpatient use a UB-04.
Be aware of & abide by our
billing practices & proscriptions
26
HELPFUL CLAIMS FILING TIPS
Never charge enrollees for missed appointments
•
You can bill the Enrollees for missed appointments only if you have advised them of
this billing practice at the start of treatment and they have signed a written
acknowledgement. Then, your charge must not exceed your contracted rate with
Concordia.
•
Be aware that some plans and government-funded programs prohibit billing for
missed appointment under any and all circumstances.
Never “balance bill” enrollees
•
You must never bill our Enrollees for the difference (‘balance’) between
Concordia’s contracted rate and your usual and customary rate. Concordia
considers “balance billing” grounds for terminating our contract.
Never bill enrollees for a service that was NOT pre-authorized
•
Under no circumstances is a Concordia Enrollee to be charged for failure to have
a service pre-authorized
27
FRAUD, WASTE & ABUSE
Concordia is committed to detecting and investigating alleged or
suspected fraud, waste or abuse. Such practices include (but are not
limited to):
– Filing fraudulent claims
– Fraudulent authorization of claims
– Misrepresentation of services provided
– Abuse of services in order to obtain a benefit (including
personal or commercial gain) to which an individual or entity
is not entitled
28
FRAUD, WASTE & ABUSE CONTINUED
•
We examine claims for potentially fraudulent activities such as:
– More than two (2) instances where a pattern of filing claims encounter
data that did not occur is evident
– Having on more than two (2) occasions demonstrated a pattern of
overstated claims reports or up-coded levels of service
– On more than one (1) occasion charging beneficiaries for covered
services
•
Concordia will conduct an investigation of the claims data, within one (1)
working day of identifying the pattern/issue. When the submission of a
potentially fraudulent claim has been confirmed, Concordia will coordinate
further actions within one (1) working day.
•
By contractual agreement our Network Providers are required to cooperate
with Concordia’s review process of any alleged/suspected fraud, waste
and/or abuse and cooperate with the review process, including any requests
for medical records.
29
CARE COORDINATION & CARE ADVOCACY
•
Concordia’s Coordination of Care and Care Advocacy staff is always accessible
during business hours for routine calls and after business hours for emergencies, all
year long.
•
Our Care Advocates are all licensed and have years of experience in mental
health/substance abuse. They regard you as a valuable colleague. We hope you will
find their care management assistance invaluable and their guidance useful when
providing care to our Enrollees.
Access to
Coordination
of Care
24-HOURS A DAY, 7-DAYS A WEEK, 365 DAYS OF YEAR
Local (Miami-Dade):
305-514-5300
Toll Free (Out-of-Area): 855-541-5300
30
ACCESSING CARE
There are 3 principles that guide the access to care process:
•
•
•
Care must be appropriate – medically necessary, evidence-based and at the least restrictive level
of care
Care must be responsive to enrollees’ needs
Care must be accessible and meet nationally accepted access to care standards
MEDICARE
FL MEDICAID
COMMERCIAL
Life-threatening:
Emergencies
CONCORDIA’S ACCESS TO CARE Immediate
TIMEFRAME
– PERFORMANCE GOALS
response
Immediate response
We askImmediate
that ourresponse
network providers assist us in meeting these
goals.
Non-life
threatening:
24-hrs/day, 7-days/wk
within 6 hours
Urgent Care
Within 24 hours
Within 24 hours
Within 48 hours
Post-Hospital F/U
Within 7 days
Within 7 days
Within 7 days
Routine Care
Within 7 business days
Routine Consults:
Within 7 business days
Routine Consults:
Within 10 business days
Routine Consults:
Psychiatric Inpatient
Consult
within 24 hours
within 24 hours
within 24 hours
Emergency Consults:
Emergency Consults:
Emergency Consults:
within 6 hours
within 6 hours
within 6 hours
31
MEDICALLY NECESSARY – MEDICAID DEFINITION
Medicaid reimburses for services that are determined medically necessary and do not
duplicate another provider’s service. In addition, the services must meet the following
criteria:
–
Be necessary to protect life, to prevent significant illness or significant disability, or to
alleviate severe pain;
–
Be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or
injury under treatment, and not in excess of the recipient’s needs;
–
Be consistent with generally accepted professional medical standards as determined by the
Medicaid program, and not experimental or investigational;
–
Reflect the level of services that can be safely furnished, and for which no equally effective
and more conservative or less costly treatment is available statewide; and
–
Be furnished in a manner not primarily intended for the convenience of the recipient, the
recipient’s caretaker, or the provider.
–
The fact that a provider has prescribed, recommended, or approved medical or allied care,
goods, or services does not, in itself, make such care, goods or services medically necessary
or a covered service.
32
INITIAL AUTHORIZATIONS
(NOT ALL SERVICES REQUIRE AN INITIAL AUTH)
• Who can contact Concordia to provide information related to a
enrollee?
• Anyone can provide us with information
• Concordia CAN release general information related to health plan
benefits, providers in network, etc. to any caller
• Concordia CANNOT release PHI to any caller
• Concordia strictly adheres to HIPAA regulations and takes the
necessary steps to safeguard protected health information (PHI).
33
Who can obtain an initial auth for a enrollee?
•
•
•
•
•
•
•
•
The enrollee
The enrollee’s legal guardian, representative, surrogate for mental
health issues or someone with a valid Power of Attorney
A network provider treating the enrollee
An OON Provider at the request of the enrollee
The health plan
The PCP
Any individual with written/verbal consent from the enrollee
An individual interceding on behalf of the enrollee in a moment of crisis can
call Concordia and a Care Coordinator will check benefits and eligibility.
For urgent/emergent calls, a Licensed Care Advocate will help coordinate
services and authorize the appropriate level of care. A Notice of
Authorization will be faxed or mailed to the provider.
34
AUTHORIZATION & CARE ADVOCACY PROCESSES
Continued Care / Extended Stay Authorizations (Concurrent Reviews):
•
Authorization requests for continued care/extended stay are initiated by the
treating practitioner/facility providing the service.
•
Outpatient services: Authorization requests for continued outpatient
services are processed by our Care Advocates and require that the treating
Provider complete and submit a Confidential Outpatient Care Advocacy
Treatment Plan - Medicaid. You can access our Care Plan Form on our
website’s Provider Portal. Care Plans can be faxed or mailed:
24-hours a day, 7-days a week, 360 days a year
SEND
Local Fax (Miami-Dade): 305-514-5301
OUTPATIENT
CARE PLANS TO:
Toll Free Fax (Out-of-Area): 855-698-5301
Mailing Address: Concordia Behavioral Health
7190 SW 87th Avenue, Suite 204, Miami, FL 33173
Attn: Care Advocacy Department
35
Continued Care / Extended Stay Authorizations
(Concurrent Reviews):
•
Inpatient hospitalization & Intensive services: Authorization requests for
continued/ extended stay at a MH/SA inpatient hospital or hospital alternatives –
intensive treatment settings such as: Residential treatment, Partial Hospitalization,
Day Treatment and Intensive Outpatient services are reviewed and processed at
regular intervals by our Care Advocates. Reviews are routinely conducted via a
phone conference but may also occur on-site. Our Medical Director will engage in
peer-to-peer phone consultation regularly.
•
Post-Service Authorizations (Retrospective Reviews): Post-service requests are
most commonly requested by the practitioner/facility that provided the service. Postservice authorizations are processed, reviewed and determinations made by the
Medical Director.
Concordia has developed the Florida Medicaid Medical Necessity and Level of Care
Guidelines to assist in the patient care decision-making process. For a description of
Mediciad services and limits, refer to the FL Medicaid Handbooks available at
http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_P
roviderHandbooks/tabId/42/Default.aspx
An enrollee’s eligibility can change at any time. An authorization is not a guarantee of
payment. We recommend providers check eligibility through our provider portal at
www.concordiabh.com prior to serving an enrollee It is a very quick process that protects
you.
36
FOUR Services Always Require
Pre- Authorization
PSR, TCM, T-BOS,
Psychological Testing
37
Provider Forms
•
Confidential Outpatient Treatment Plan –
Medicaid
•
Psychological Testing Request Form
•
Authorization Form
•
Coordination of Care Between Providers Form
38
39
40
PSYCHOLOGICAL TESTING
AUTHORIZ ATION REQUEST FORM
Date: ________________________
Patient Name: ___________________________________________
Patient’s DOB: ________________
Patient’s ID #: ___________________________________________
Provider Name: ______________________________________
Has a diagnostic interview (90801) been done?
 Yes
Is a psychiatrist involved in the patient's care?
 Yes  No
part of Concordia’s rates. Psychological Testing is
NOT covered under the behavioral health benefit for
Provider Ph: _______________________
Date: _____________
Note: Test time and report writing are included as
academic / career placement, research purposes, or
medical procedures s.
 No
Explain: ______________________________________________________________
Patient’s Presenting Problem and Symptoms: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Patient’s DX: Axis I: _____________________________________________________
Axis II: ___________________________________________________
Axis III: ____________________________________________________
Axis IV: __________________________________________________
Axis V: Current GAF: _______
GAF at beginning of treatment: _______
GAF last years: _______
Purpose of Testing: _______________________________________________________________________________________________________________________
Clinical Rationale: ________________________________________________________________________________________________________________________
Name of Tests and Number of Hours requested for each:
Test:
Psychological Testing:
96101 =
96102 =
96103 =
Hours:
Test:
Neuropsychological Testing:
96118=
96119 =
96120 =
Hours:
Test:
Hours:
Neuro-Behavioral Evaluation:
96116=
41
42
Coordination of Care Between
Health Care Providers
CONFIDENTI AL : PROTECTED HEALTH INFORM ATION
Dear _____________________________
(Health Provider)
_________________________________ has given written consent allowing me to communicate with
(Patient Name)
you and inform you of the care I am providing to them. I have been seeing the patient since
____________________________ for __________________________________________________.
(Date: Onset of care)
(DSM DX / condition)
The current care consists of:

Medication Management (Current Plan):
MEDICATION
DOSE
FREQUENCY

Individual Psychotherapy
(Frequency: _________)

Group Psychotherapy
(Frequency: _________)

Family Therapy
(Frequency: _________)

Other:
DATE STARTED
________________ (Frequency: _________)
Summary to Date:
_______________________________________________________________________________
_______________________________________________________________________________
We are currently estimating the length of care to be: ________
Please do not hesitate to contact me at: ___________________ if you have any questions or feedback.
(Provider Phone)
Respectfully,
______________________________
(Provider Printed Name)
______________________________
(Provider Signature)
________
(Date)
43
DENIAL & APPEALS PROCESS
• Concordia makes every reasonable effort to avoid
disagreement with Enrollees and Network Providers
regarding Utilization Management (UM) decisions
• If attempts to negotiate a mutually acceptable outcome
are
not
successful,
the
Enrollees,
treating
Provider/Practitioner acting on the Enrollee’s behalf or a
designated Enrollees representative (including a family
enrollees) has the right to initiate an appeal of an
adverse care decision (i.e., a denial) by contacting their
health plan
44
QI: CULTURE OF SAFETY & QUALITY CARE
In our effort to meet the goal of promoting safe, timely, appropriate and
effective level of care interventions and an integrated approach to quality,
behavioral care, Concordia has 3 central initiatives that rely on your
participation:
SAFETY
QUALITY
INTEGRITY
•
Early identification of at-risk enrollees: Of those in need of a more
intensive, targeted case management approach from our Care
Advocate.
•
Improving coordination & continuity of care: Communicating
pertinent clinical information with other care providers – behavioral
health and medical service providers, (especially, the enrollees Primary
Care Physician) and collaborating on care.
•
Promoting person-centered care & a strength-based perspective:
A care approach that uses our Enrollee’s personal strengths, existing
“natural” support system, expands on them, reaching beyond the
professional resources and environment.
45
CONCORDIA’S
INTENSIVE CARE ADVOCACY PROGRAM (ICA):
The main strategies of our Intensive Care Advocacy approach center on:
•
Setting early identification of “at-risk” Enrollees as a priority
•
Educating Concordia’s Care Coordinators, Care Advocates, UM staff and Network Providers
on recognition of at-risk factors
•
Designating Intensive Care Advocates to closely manage the care of “at-risk” Enrollees by
applying a more rigorous and intensive case management approach and a broader scope of
case management activities
•
Enlisting our Network Providers to help us detect at-risk Enrollees early in treatment and
engaging their collaboration in developing and implementing a risk-reduction plan with our
Intensive Care Advocates
•
When Concordia refers a Enrollees to you for care, we will inform you if they have been
identified as “at-risk”. Conversely, we ask you to alert us of any Concordia patient who may
exhibits signs of being “at-risk” and arrange a phone consult with one of our Care Advocates
on the enrollees care. We ask that you immediately report to our Director of Clinical
Operations any occurrence of an unintended adverse patient outcomes and a sentinel event.
The chart below summarizes factors that put enrollees at-risk.
(Note: This list of “At-risk” factors is not indented to be all-inclusive)
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CONCORDIA’S
INTENSIVE CARE ADVOCACY PROGRAM (ICA):
•
Enlisting our Network Providers to help us detect at-risk Enrollees early in
treatment and engaging their collaboration in developing and implementing
a risk-reduction plan with our Intensive Care Advocates
•
When Concordia refers a Enrollees to you for care, we will inform you if they
have been identified as “at-risk”. Conversely, we ask you to alert us of any
Concordia patient who may exhibits signs of being “at-risk” and arrange a
phone consult with one of our Care Advocates on the enrollees care.
•
We ask that you immediately report to our Director of Utilization
Management any occurrence of an unintended adverse patient outcome or
critical incident. The chart below summarizes factors that put enrollees atrisk.
(Note: This list of “At-risk” factors is not indented to be all-inclusive)
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‘AT-RISK’: SAFETY – HARM TO SELF
‘AT-RISK’: SAFETY – HARM TO OTHERS
Current/recent presence of thoughts/ideas of self-harm
Current/recent presence of thoughts/ideas to harm others
Current/recent suicide attempt, gesture, threat, plan
Current/recent assaults/violence, threats to hurt other
Prior history of self-harm; Family history of suicide
Prior history of violence
Co-occurring SA; pattern of intoxication
Co-occurring substance use/abuse; pattern of intoxication
Presence of active hallucinations suggesting self-harm
Presence of active hallucinations – particularly voices suggesting / urging harm
to others
Severe Anorexia
Severe impulsivity and poor judgment
Severe Impulsivity and poor judgment
Drug overdose with suspicion of suicidal intent
History of prior admissions:

AT-RISK:
POOR
CLINICAL
OUTCOMES

•
•
•
•
•
and/or
•
UNUSUALLY
•
•
•
EXCESSIVE
UTILIZATION
•





Within the past 12 months (1 year) has had more than 1 admission to an inpatient psychiatric unit, a residential treatment facility, a crisis
stabilization unit (CSU) or any combination of these facilities
Within the past 36 months (3 years) has had 2 or more admissions to an inpatient psychiatric unit, a residential treatment facility, a crisis
stabilization unit (CSU) or any combination of these facilities
History of poor/ unsuccessful response to past/current treatment interventions
Sustained/persistent acute symptoms preventing transition to lower level of care
Challenges with Discharge Planning (e.g., lack/limited support system, financial problems barriers to fulfilling aftercare plan,
no shelter)
History of recurring episodes of a serious psychiatric disorder and/or presently/recently exhibiting acute mood/behavioral symptoms that
requires advocacy and coordination of services to maintain or improve level of functioning or prevent more intensive LOC
Severe symptoms that can include: disorganized/bizarre behavior, role impairment, psychomotor retardation, significant weight change,
impaired thinking or ability for self-care
History of compliance issues: e.g., poor/inconsistent adherence to outpatient medications
Presence of a secondary, co-occurring Axis I/Axis II psychiatric disorder including an active SA
Presence of an Axis III medical illness seriously impacting functioning or Medical/Drug complications that can include life-threatening
complications due to alcohol withdrawal, being pregnant, eating disorder, or complications from psychotropic meds.
Significant Axis IV psychosocial stressors:
Recent loss(es) – death of loved one, marital separation/divorce, relationship ‘break-up’
Financial hardship – unemployment, business loss, no shelter
Diagnosis of serious medical illness / terminal diagnosis
Legal problems – criminal/civil
Lack of social support system/family/friendships to provide assistance with accessing or maintaining needed psychiatric, medical, social,
educational and other services
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WE STRIVE TO PROMOTE
ENROLLEE SATISFACTION,
POSITIVE CLINICAL OUTCOMES AND
QUALITY CARE!
49
FARS and CFARS and
the Member Satisfaction Survey
Plan
Plan Id#
CBH Auth #
Concordia Pre-Filled Data
Enrollee ID # Last Name First Name
Subcontactor/NPI #
Assessment Date
Assessment Type
Asssessment Purpose
Provider Filled Data
Disability
Emotionality
Relationship
Safety
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PERSON-CENTERED CARE & ADVOCACY
Family
Friends
School &
Neighbors
W o r k P e e rs
Community
Agencies
Church
Pr imary
Car e
Physician
Enrollee
Behavioral
Health
Provider
We ask that as part of a strength-based assessment and care planning
process, you identify and list our Enrollee’s existing “natural” support systems
and resources, and consider other available ones that may assist in their
recovery and wellness. When developing our Enrollees’ care plans we
encourage you to integrate their “natural” support systems/resources looking
towards support systems that will help sustain treatment gains and help prevent
future recurrences/relapse once treatment is terminated.
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Advance Directives
Behavioral Health Clinicians are in an excellent
position to initiate discussion on this very important
topic that can save millions in healthcare costs and
minimize having to make very difficult decisions on
behalf of a loved one at a critical time.
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IMPROVING CONTINUITY & COORDINATION OF CARE
Communication between Care Providers
As a Network Provider, we ask that you recognize, support and
cooperate with Concordia’s effort to improve communication with other
medical and behavioral health clinicians who are providing concurrent
care to our Enrollees.
We believe the exchange of pertinent clinical information between
behavioral health and medical service providers, especially the
enrollee’s Primary Care Physician (PCP) is instrumental to enhancing
the quality of care, providing safe treatment and promoting positive
treatment outcomes.
We ask our Network Providers to educate our Enrollees on the
importance of this communication and obtain their signed consent to
allow for this essential communication. You can access Concordia’s
Coordination of Care between Health Providers Form from our Provider
Web Portal.
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54
Date: __________________
Dear Dr. ______________________________,
We
would
like
to
advise
you
that
____________________,
DOB
________________ (“Member”):
______
is receiving psychiatric services with ________________________.
______
initiated psychotherapy services with _______________________.
______
is in our ICA Program (Intensive Care Advocacy for high risk).
______
is in our DUR Program
______
was discharged from the hospital on ________________________.
______
other:
________________________________________________________________.
Concordia encourages coordination of care between health care providers. If we
can be of further service, please contact our Care Advocacy Department at (305)
514-5320, [email protected].
Respectfully,
The Concordia Care Advocacy Department
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Thank you for joining our Network.
We look forward to building a
strong and effective partnership with you.
Your questions, comments and suggestions
are welcomed and appreciated.
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