Applied Behavior Analysts (ABA) Provider Orientation...Microsoft PowerPoint - ABA Provider...

Applied Behavior Analysts (ABA) Provider Orientation

ValueOptions® Presents:

October/November2012

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Discussion Topics

• Overview of ValueOptions

• Overview of Operational Areas

• ABA Service Implementation

• Clinical Interface & Workflow

• Administrative Interface & Workflow

• ProviderConnect

• Questions and Answers

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Overview of ValueOptions

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ValueOptions

• Founded in 1983

• Committed to principles of recovery and resiliency

• Diverse client base – covering 32 million lives

– Commercial Division• Employer Groups• Health Plans

– Federal Division – Public Sector Division

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Our Mission, Vision and ValuesOur Mission

• We help people live their lives to the fullest potential.Our Business Focus

• We are a health improvement company specializing in mental and emotional wellbeing and recovery

Our Values• Consumer Engagement• Integrity• Innovation• Listen and Respect• People Development• Joint Accountability

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Shared Commercial and Public Program/Medicaid Membership

Commercial Membership Only

Regional support, EAP staff and corporate support offices

Major service centers

ValueOptions’ National Presence

Overview of Operational Areas

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ValueOptions National Network Services

• Provider Relations– Meeting members’ behavioral health care needs through a

geographically and clinically robust network of providers– Engaging in timely and appropriate recruitment to meet member and

client needs– Collaborative provider partnerships

– Education and Communication – Provider Connect

– Quality of Service and Access & Availability monitoring

• Provider Credentialing– Must meet ValueOptions minimum criteria for ABA network

consideration– Completion of the ValueOptions Credentialing Application required for

ABA network participation– Credentialing Department is NCQA accredited – Oversight by the National Credentialing Committees

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Customer ServiceClinical Customer Service

Provides the following services to Members and Providers as the front end to

the Clinical Department:

Claims Customer ServiceProvides the following services to both

Members and Providers:

–Responds to routine eligibility questions

–Responds to requests for authorizations

–Responds to referral requests

–Education assistance

–Responds to routine claims, benefits and eligibility questions via telephone, correspondence and web inquiries–Facilitates the resolution of complex claims issues via telephone, correspondence and web inquiries–Responds to all Administrative Complaints and Appeals via a dedicated Appeal and Complaint Unit–Provides dedicated Liaisons to investigate and resolve complex client and provider issues

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ValueOptions Quality Management

• The Quality Management Program Oversight is provided by a Medical Director.

• Key Quality Indicators include but are not limited to: – Satisfaction Survey measures– Access and Availability of Services – geographic access; phone

statistics; appointment availability; etc.– Complaints and Grievances tracking and reporting– Patient Safety – (adverse incidents and quality of care)– Coordination of Care– Quality Improvement Activities/Projects– Compliance with URAC Standards– Compliance with NCQA Standards

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• Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management

– Member referral process:• Emergencies are followed until disposition• Urgent referrals are offered appointments within 48 hours and are

called to ensure appointment is kept• Providers can contact ValueOptions for referral assistance if

needed• Providers should contact ValueOptions 24 hours a day/seven (7)

days a week if members require higher level of care or increased visit frequency

• Care Management staff will assist with referral to inpatient or specialty programs

Clinical Referral Assistance

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ABA Service Implementation

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Qualified Autism Service Professionals• Professionals certified by the National Behavior Analyst

Certification Board including BCBA-D, BCBA, BCaBA

DUTIES: Designs, Supervises, or Provides Treatment

• QAS Professional: BCBA-D, BCBA, BCaBA

DUTIES: Provides Treatment, Assessment, Supervision

• QAS Paraprofessional: May render services as clinically appropriate under the supervision of a certified ABA provider or Licensed Master’s Mental Healthcare Level provider

DUTIES: Direct Intervention

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Qualified Autism Services• Effective, November 1, 2012, ValueOptions will begin

covering applied behavior analysis (ABA) in New York State requiring private health insurance companies to provide coverage for the screening, diagnosis, and treatment of autism spectrum disorders.

• Covered diagnoses include Autism, developmental brain disorders known as Pervasive Developmental Disorders (PDD)

• Other covered pervasive developmental disorders not otherwise specified include:

– Asperger Syndrome– Rett Syndrome – Childhood Disintegrative Disorder

*These diagnoses along with a diagnosis of being “at risk” of Autism or PDD will be covered

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Benefit and Age Limits

• $45,000 yearly limit • Annual increase based on the increases to

the medical consumer price index• No age caps

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Covered Diagnoses

• Autistic Disorder 299.00• Atypical Autism 299.10• Childhood Disintegrative Disorder 299.10• Asperger's Disorder 299.80• Rett's Disorder 299.80• Pervasive Development Disorder not

otherwise specified (PPD- NOS) 299.80• Pervasive Development Disorder 299.80• “At Risk” of Autism or PDD

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Covered ABA Codes

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Clinical Operations & Referral

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Assessment and Referral • A Customer Services Representative will review benefits,

eligibility and forward information to the Care Manager

• The Care Manager will request the provider to submit their credentials via fax or email

• The Care Manager conducts a clinical assessment, including assessing for any high risk and provides a referral for ABA services

• The Care Manager continues to work with the family/member to confirm the referral was successful and that member has an appointment for an assessment

• Once the member is assessed the care manager coordinates with the ABA program to obtain the treatment plan request and clinical information.

• The request is then reviewed for medical necessity

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Administrative Operations & Workflows

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Billing & Claims Submission• Claims should be submitted using a standard CMS

1500 claim form

• ABA covered services should be billed directly to ValueOptions

• For general information regarding eligibility and benefit verifications, pre-certification requests, and claim inquiries please call the member’s dedicated toll-free number

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ValueOptions’ Website (www.ValueOptions.com)• ValueOptions’ website contains information about

ValueOptions and its business

• Offers links to information and documents important to providers are located here at the ‘Provider’ section

• Access to ProviderConnect

• ProviderConnect is a secure, password protected site where participating providers may conduct certain on-line activities with ValueOptions directly twenty four (24) hours a day, seven (7) days a week (excluding scheduled maintenance and unforeseen systems issues)

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ABA Network Specific Site

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http://www.valueoptions.com/providers/Network/Applied_Behavior_Analysts.htm

ProviderConnect

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NETWORKCONNECTSM

Robust network management and provider relations

CARECONNECTSM

Superior clinical case management and data collection

SERVICECONNECTSM

Industry-best customer service and issue resolution

MEMBERCONNECTSM

Online self-service and award-winning content for members

TELECONNECTSM

Easy-to-access telephonic self-service for providers and members

PROVIDERCONNECTSM

Secure, online administrative self-service for providers

ValueOptions Connect System

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ProviderConnect (Provider Online Services)• What is ProviderConnect?

• An online tool where providers can:– Verify member eligibility– Access ProviderConnect message center– Access and print forms– View authorizations– Download and print authorization letters– Submit claims and view status– Access Provider Summary Voucher– Submit customer service inquiries– Submit updates to provider demographic information– Submit re-credentialing applications

• Increased convenience, decreased administrative processesDisclaimer: Please note that ProviderConnect SM may look different and have different functionalities based on individual contract needs, therefore some functions may not be available or may look different for your specific contract.

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ProviderConnect Benefits• What are the benefits of ProviderConnect?

– Free and secure online application

– Access routine information 24 hours a day, 7 days a week

– Complete multiple transactions in single sitting

– View and print information

– Reduce calls for routine information

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How to Access ProviderConnect?• Go to www.ValueOptions.com, choose “Providers”.• All in-network providers can self register for ProviderConnect using

their provider ID number. Self-registration is only available toproviders that do not have an existing ProviderConnect electronicaccount

• If additional ProviderConnect log ons for that same provider ID number are desired, please do the following:― Fill out the Online Provider Services Account Request Form and fax the

completed form to 1-866-698-6032• Additional log on turnaround time is 2 business days

• ProviderConnect registration questions or questions about the form referenced above please contact the ValueOptions EDI Helpdesk at 1-888-247-9311 (Monday - Friday, 8 am - 6 pm ET)

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ProviderConnectSM Login Screen

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User Agreement Page

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Search/View Member Eligibility

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Member Eligibility Search

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Member Eligibility Results

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Review an Authorization

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Search Authorizations

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Authorization Search Results

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Authorization Summary

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Recent Authorization Letters

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New Authorization Letters

Authorization Letter Sample

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Direct Claim Submission

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Direct Claim Submission

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Direct Claim Submission

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Direct Claim Submission

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Direct Claim Submission

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Direct Claim Submission

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View Provider Summary Voucher

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View Provider Summary Voucher

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Provider Summary Voucher Results

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Provider Summary Voucher Sample

PaySpan Health• PaySpan® Health is a tool that will enable you to do the following:

– Receive payments automatically in the bank account of your choice – Receive email notifications immediately upon payment– View your remittance advice online– Download an 835 file to use for auto-posting purposes

• For PaySpan Registration Instructions please visit: http://www.valueoptions.com/providers/Files/pdfs/PaySpan_General_Training_Information.pdf

• Provider Support contact information: – 1-877-331-7154. – providersupport@payspanhealth.com

• Provider Support is available from 8am to 8pm Eastern time, Monday through Friday.

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• New York Service Center– newyorkservicecenter@valueoptions.com

• ABA Provider Network Specific Websitehttp://www.valueoptions.com/providers/Network/Applied_Behavior_Analysts.htm

• Provider Relations, Credentialing and Contracting Questions– 1-800-397-1630 (8 am - 5 pm ET Monday - Friday)

• Electronic Claims & ProviderConnect Technical Questions (EDI Help Desk)– 1-888-247-9311 (8 am - 6 pm ET Monday - Friday)

Provider Contacts

Questions & Answers

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Thank You

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