Presentation Title

Presentation Title

VA Medicaid EPSDT ABA Provider Orientation Optum with UnitedHealthcare Community Plan Virginia 1 Who is Optum? Optum is a collection of people, capabilities, competencies, technologies, perspectives and partners sharing the same simple goal: to make the health care system work better for everyone Optum works collaboratively across the health system to improve care delivery, quality and cost-effectiveness We focus on three key drivers of transformative change: engaging the consumer, aligning care delivery and modernizing the health system infrastructure

2 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum UnitedHealth Group Structure Helping make the health system work better for everyone Information and technologyenabled health services: Technology solutions Pharmacy solutions Intelligence and decision support tools Health management and interventions

Administrative and financial services Helping people live healthier lives Health care coverage and benefits: Employer & Individual Medicare & Retirement Community & State Military & Veterans Global

3 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Company Structure 4 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Our United Culture 5 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum is now Here at UnitedHealthcare, we help people live healthier lives and help make the health system work better for everyone! 6 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Optum and You Our relationship with you is foundational to the recovery and well-being of the individuals and families we serve. We are driven by a compassion that we know you share. Together, we can set the standard for industry innovation and performance. Achieving our Mission:

Starts with Providers Serves Members Applies global solutions to support sustainable local health care needs From From risk risk identification identification to to integrated integrated therapies, therapies, our our mental mental health health and and substance substance abuse abuse solutions solutions help

help to to ensure ensure that that people people receive receive the the right right care care at at the the right right time time from from the the right right providers. providers.

7 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Specialty Network Services Customers we serve: 50% of the Fortune 100 and 34% of the Fortune 500 Largest provider of global Employee Assistance Programs (EAP), covering more than 19 million lives in over 140 countries Local, state and federal government contracts (Public Sector) Serving almost 43 million members:

Simultaneous NCQA and URAC accreditation Staff expertise: Multi-disciplinary team of 50 staff Medical Directors (e.g., child and adolescent, medical/ psychiatric, Board Certified Behavior Analysts, and addiction specialists) just to name a few 1 in 6 insured Americans The largest network in the nation, delivering best in class density, discounts and quality segmentation More than 140,000 practitioners; 4,200 facilities with 9,000 facility locations

8 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Optum EPSDT ABA Program Member Information 9 Member ID Card Will be sent directly to the member The members ID number will be their Medicaid number All relevant contact information will be on the back of the card for both medical and behavioral customer service

Please note this image is for illustrative purposes only. 10 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Member Rights and Responsibilities Members have the right to be treated with respect and recognition of his or her dignity, the right to personal privacy, and the right to receive care that is considerate and respectful of his or her personal values and belief system Members have the right to disability related access per the Americans with Disabilities Act You will find a complete copy of Member Rights and Responsibilities in the Provider Network Manual These can also be found on the website: providerexpress.com These rights and responsibilities are in keeping with industry standards. All members benefit from reviewing these standards in the treatment setting

We request that you display the Rights and Responsibilities in your waiting room, or have some other means of documenting that these standards have been communicated to the members 11 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Member Website liveandworkwell.com makes it simple for members to: Identify network clinicians and facilities Locate community resources Find articles on a variety of wellness and work topics Take self-assessments The search engine allows members and providers to locate in-network providers for behavioral health and substance use disorder services. Providers can be located geographically, by specialty, license type and expertise.

The website has an area designed to help members manage and take control of life challenges. 12 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Who is eligible? To be eligible for VA Medicaid EPSDT ABA services, a client must meet both of the following criteria: Be 21 or younger Be covered under VA Medicaid EPSDT ABA Program AND meet the following criteria: Have a current DSM dx that is relevant to the need for behavioral therapy or has a provisional psychiatric diagnosis 13

BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum EPSDT ABA Program Services 14 VA Medicaid EPSDT ABA Provider Credentialing Criteria Individual Board Certified Behavior AnalystsSolo Practitioner Board Certified Behavior Analyst (BCBA) with active certification from the national Behavior Analyst Certification Board, and State licensure State Medicaid certification in good standing Compliance with all state/autism mandate requirements as applicable to behavior analysts

Minimum professional liability coverage of $1 million per occurrence/ $1 million aggregate 15 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum VA Medicaid EPSDT ABA Provider Credentialing Criteria ASD Groups BCBAs must meet standards above and hold supervisory certification from the national Behavior Analyst Certification Board if in supervisory role Compliance with all state/autism mandate requirements as applicable to behavior analysts BCaBAs must have active certification from the national Behavior Analyst Certification Board and appropriate state licensure Behavior Technicians must have RBT certification from the national Behavior Analyst

Certification Board, or alternative national board certification, and receive appropriate training and supervision by BCBAs BCBA on staff providing program oversight BCBA performs skills assessments and provides direct supervision of paraprofessionals in joint sessions with client and family $1 million/occurrence and $3 million/aggregate of professional liability and $1m/$1m of general liability if services are provided in a clinic setting $1 million/occurrence and $3 million/aggregate of professional liability and $1m/$1m of supplemental insurance if the agency provides ambulatory services only (in the patients home) 16 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Steps in Providing Treatment

17 Clinical Team: VA Medicaid EPSDT ABA Program Dedicated Autism Clinical Team There is a dedicated autism clinical team that will be supporting the VA Medicaid EPSDT ABA program Each team member is a licensed behavioral health clinician or BCBA with experience and training in Autism Supervised by a manager who is a licensed psychologist and BCBA-D 18 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Intake At Intake: Copy front and back of the members insurance card Record subscribers name and date of birth Suggested information: Provide subscriber with your HIPAA policies Provide subscriber with consent for billing using protected health information including signature on file Always get a consent for services Informed Consent: services, to leave voicemail, email, etc. Billing policies and procedures Release of Information to communicate with other providers 19 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Release of Information We release information only to the individual, or to other parties designated in writing by the individual, unless otherwise required or allowed by law Members must sign and date a Release of Information for each party that the individual grants permission to access their PHI, specifying what information may be disclosed, to whom, and during what period of time The member may decline to sign a Release of Information which must be noted in the Treatment Record; the decline of the release of information should be honored to the extent allowable by law PHI may be exchanged with a network clinician, facility or other entity designated by HIPAA for the purposes of Treatment, Payment, or Health Care Operations 20 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Eligibility and Prior Authorization Call the number on the back of the members insurance card to see if member is eligible for your services or verify on provider portal Check benefit coverage relating to both the service and the diagnosis on provider portal or by calling the number on the members insurance card. Make sure all services receive prior approval before beginning services When calling the Autism Care Advocate you must have the members name, ID#, date of birth and address 21 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Assessment/Treatment Plan Requirements

Prior authorization not required for initial assessment, code H0032 UA Prior Authorization obtained by faxing treatment plan to: 1-855-368-1542 Meet Medical Necessity this applies to initial and concurrent reviews Provider must submit the results of the ABA assessment and the treatment plan for any treatment requests. For more information, please see the Autism Treatment Plan Authorization Request Form on the Autism/Applied Behavior Analysis page of Provider Express. 22 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Treatment Plan Requirements (cont.) Meet Medical Necessity Goals are:

Includes: Related to the core deficits Baseline and mastery criteria Objective Measurable Individualized Transition Plan to lower level of care Discharge Criteria Behavior Reduction Plan/Crisis Plan Parent Goals Supervision and treatment planning hours Relevant psychological information Coordination of care with other

providers Not educational in nature For more information, please see the Treatment Plan Guidelines on the Autism/Applied Behavior Analysis page of Provider Express. 23 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Clinical Information Requirements for Each Review Confirmation member has an appropriate DSM-5 diagnosis that can benefit from ABA Any medical or other mental health diagnoses Any other mental health or medical services member is in

Any medications member is taking How many hours per week is member in school? How long has member been in services? Goals must not be educational or academic in nature; they must focus only on the core deficits such as imitation, social skills deficits and behavioral difficulties Discharge criteria Must meet medical necessity (see Provider Express for the Level of Care Guidelines and Coverage Determination Guidelines) Parent participation Why IBT now?

For more information, please see the Treatment Guidelines on the Autism/Applied Behavior Analysis page of Provider Express. 24 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Concurrent Reviews The same information will be needed for each review: Any medical or other mental health diagnoses Any other mental health or medical services member is in

Any medications member is taking How many hours per week is member in school? Parent participation Progress or lack thereof

Goals must not be educational or academic in nature focusing only on the core deficits such as imitation, social skills deficits and behavioral difficulties Discharge criteria Must meet medical necessity (see Provider Express for the Optum Autism/ABA Clinical Policy) 25

BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Initial Authorization Request and Continued Stay Forms Forms are available on the Autism ABA Corner on providerexpress.com Initial assessments do not require an authorization, but ongoing assessments do. Submit forms via fax within 14 business days: UnitedHealthcare Fax: 1-855-368-1542 26 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Initial Authorization Request Form (page 1) 27 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Initial Authorization Request Form (page 2) 28 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Initial Authorization Request Form (page 3)

29 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Continued Stayed Form (page 1) 30 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Continued Stayed Form (page 2) 31 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum ABA Continued Stayed Form (page 3) 32 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Prior Authorization - Online Portal Submission 33 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Prior Authorization - Online Portal Submission

34 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Prior Authorization - Online Portal Submission 35 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Coding, Billing and Reimbursement 36

VA Medicaid EPSDT ABA Program Provider Fee Schedule 37 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claims Submission Required Claim Forms: Form1500 claim form Claims/Customer Service #: Phone: 1-877-843-4366 Fax: 1-855-368-1542 Electronic Claims Payer ID: 87726 Paper Claims: When submitting behavioral Claims by paper,

please mail claims to: United Healthcare P.O. Box 5270 Kingston, NY 12402 38 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claims Submission (Cont.) If not submitting claims online, providers must submit claims using the current Form 1500 claim form with appropriate coding UnitedHealthcare Community Plan requires that you initially submit your claim within 365 days of the date of service When a provider is contracted as a group, the payment is made to the group, not to an individual

All claim submissions must include: Member name, Medicaid identification number and date of birth Providers Federal Tax I.D. number National Provider Identifier (NPI) Providers are responsible for billing in accordance with nationally recognized CMS Correct Coding Initiative (CCI) standards. Additional information is available at www.cms.gov 39 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claims Submission Option 1- Online Log on to UHCprovidercom: Secure HIPAA-compliant transaction features streamline the claim submission process

Performs well on all connection speeds Submitting claims closely mirrors the process of manually completing a Form1500 claim form Allows claims to be paid quickly and accurately You must have a registered user ID and password to gain access to the online claim submission function: To obtain a user ID, call toll-free 1-866-842-3278 40 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claims Submission Option 2 - EDI/Electronically Electronic Data Interchange (EDI) is an exchange of information Performing claim submission electronically offers distinct benefits:

Fast: eliminates mail and paper processing delays Convenient: easy set-up and intuitive process, even for those new to computers Secure: higher data security than with paper-based claims Efficient: reduces pre- submission errors so more claims autoadjudicate Notification: gives providers feedback that payer received claims; distributes error reports for claims that fail submission Cost-efficient: eliminates mailing costs, the solutions are free or low-cost 41 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claims Submission Option 2 EDI/Electronically Providers may use any clearinghouse vendor to submit claims Payer ID for submitting claims is 87726

Additional information regarding EDI is available on: uhccommunityplan.com/healthprofessionals/la/electronic-data-interchange.html and UHCprovider.com 42 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Online Claims Submission Electronic Data Interchange (EDI) Support Services Provides support for all electronic transactions involving claims and electronic remittances EDI Issue Reporting Form

This form should be used to report EDI related issues Providers can also call us at 800-210-8315 or e-mail us at [email protected] UHCprovider.com Help Desk - 866-842-3278 If a provider experiences technical problems, needs assistance in using UHCprovider.com or has login or User ID/Password issues, they can call the UHCprovider.com Help Desk for support 43 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Electronic Payment & Statements (EPS)

With EPS, providers will receive electronic funds transfer (EFT) for claim payments, plus their EOBs are delivered online: Lessens administrative costs and simplifies bookkeeping Reduces reimbursement turnaround time Funds are available as soon as they are posted to your account To receive direct deposit and electronic statements through EPS providers will need to enroll at myservices.optumhealthpaymentservices.com. The following information is needed: Bank account information for direct deposit Voided check or bank letter to verify bank account information Copy of the provider practices W-9 form If a provider is already signed up for EPS with UnitedHealthcare, they will automatically receive direct deposit and electronic statements through EPS for UnitedHealthcare Community Plan of Louisiana when the program is deployed Note: For more information, providers can call 1-866-842-3278, option 5, or go to UHCprovider.com > Quick Links > Electronic Payments and Statements

44 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claims Tips To Ensure Clean Claims: NPI number is always required on all claims Complete diagnosis also required on all claims Claims Filing Deadline: Providers have 365 days from the date of service to file Medicaid claims Claims Processing: Clean claims, including adjustments, will be adjudicated within 30 days of receipt

Balance Billing: The member cannot be balance billed for behavioral services covered under the contractual agreement 45 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Claim Tips, (continued) Member Eligibility: Provider is responsible to verify member eligibility through UHCprovider.com Examples of coding Issues related to claims denials:

Incomplete or missing diagnosis Invalid or missing HCPCS/CPT codes and modifiers Use of codes that are not covered services Required data elements missing, (e.g., number of units) Provider information is missing/incorrect Required authorization missing Units exceed authorization (e.g., 10 inpatient days were authorized, facility billed for 11 days) BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum

Claims Submission Option 3 Hardcopy All billable services must be coded. Form 1500: formerly called CMS-1500 or HCFA Coding can be dependent on several factors: Type of service (assessment, treatment, etc.) Rate per unit (BCBA vs. Paraprofessional) Place of service (home or clinic) Duration of therapy (1 hr vs. 15 min) One DOS per line You must select the code that most closely describes the service(s) provided.

Please note: Field 31 must have a rendering provider name. Rendering supervisor (BCBA/Licensed Clinician) will bill for all services by them or the Behavior Technician under the supervisory protocol. 47 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Diagnostic Coding Guides for Coding: DSM-5 defined conditions Current DSM dx that is relevant to the need for behavioral therapy or has a provisional psychiatric diagnosis A complete diagnosis with all 4 digits is required on all

claims utilizing the ICD-10 coding. 48 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Appeals and Grievances 49 Appeals UnitedHealthcare Community Plan (UHCCCP) is responsible for member appeals and Optum is responsible for PAR Provider post-service appeals. For Urgent Appeals providers can submit their request to C&S: UHCCCP Appeals Phone # 1-888-650-3462

Urgent Appeal Fax # 1-801-994-1082 Fax # for misdirected appeals 1-801-994-1082 For Non-Urgent Post Service Appeals Par Providers can submit to: Optum Appeals & Grievances P.O. Box 30512 Salt Lake City, UT 84130-0512 Fax: 1-855-312-1470 Phone 1-866-556-8166 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Appeals Non-Urgent (Standard) Urgent (Expedited)

Must be requested within 60 days from receipt of the Notice of Action letter Must be requested as soon as possible after the Adverse Determination When an appeal is requested, UHCCP will make an appeal determination and notify the provider, facility, Member or authorized Member representative in writing within 30 calendar days of receipt of request.

Optum will make a reasonable effort to contact you prior to making a determination on the appeal. If Optum is unsuccessful in reaching you, an urgent appeal determination will be made based on the information available to Optum at that time Notification will occur as expeditiously as the members health condition requires, within two (2) business days, unless the appeal is pertaining to an appeal relating to an ongoing emergency or denial of continued hospitalization, which we will complete investigation and resolution of no later than one (1) business day after receiving the request

Appeal requests can be made verbally or in writing. Verbal requests must be followed with a written and signed appeal. BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Services While in Appeal You may continue to provide service following an adverse determination if the following are met: o The Member is informed of the adverse determination o The Member is informed that the care will become the financial responsibility of the Member from the date of the adverse determination forward o The Member agrees in writing to these continued terms of care and acceptance of financial responsibility o You charge no more than the United contracted fee for such

services, although a lower fee may be charged If, subsequent to the adverse benefit determination and in advance of receiving continued services, the Member does not consent in writing to continue to receive such care and we uphold the determination regarding the cessation of coverage for such care, you cannot collect reimbursement from the Member pursuant to the terms of your Agreement BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Resources 53 UHCprovider.com Provider Website

54 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum New User Registration uhcprovider.com Provides clinicians with access to the latest news, policy information and to Link self-service tools for care providers. Create an Optum ID In order to access secure content on UHCprovider.com or to access Link self-service tools to submit claims, verify eligibility or to check for prior authorization requirements, you first need to have an Optum ID that has been connected to the Tax ID of your practice, facility or organization.

Video: Accessing Link via UHCprovider.com Need an Optum ID? Please register to create your Optum ID. Have an Optum ID, but need to connect a Tax ID? To start the process, sign in with your Optum ID on UHCprovider.com and click "No" when asked if you received a registration letter that included a security code. From that point, complete the required fields for the form as prompted. For help see the Accessing Link - Quick Reference Guide. Need help accessing certain applications on Link? If you are unable to access specific Link Self-Service application using your Tax ID connected Optum ID login, please contact your organizations practice administrator they are the only ones able to manage and make changes to account access.

55 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum VA Medicaid EPSDT ABA Program Page 56 BH1317_3.13.18 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Quick Reference Guide 57 BH1317_3.13.18

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum Provider and Member Resources An extensive condition-based library covering key behavioral and medical topics can be found on liveandworkwell.com under the Health and Well-Being Center within BeWell. Abuse & Neglect: Child Abuse: Domestic Violence Abuse & Neglect: Elder ADHD (Adult) ADHD (Youth) Alzheimers & Dementia Anxiety Arthritis Asthma Autism

Bipolar (Adult) Bipolar (Youth) BH1317_3.13.18 Cancer Childhood Illness Chronic Pain Depression (Adult) Depression (Youth) Diabetes Eating Disorders (Adult) Eating Disorders (Youth) Heart Disease/Circulatory HIV Infertility

Obesity Personality Disorders Obsessions & Compulsions Phobias Postpartum Depression Post-Traumatic Stress Disorder Schizophrenia (Adult) Schizophrenia (Youth) Sexual Problems Stress Traumatic Brain Injury

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 58 Thank you. Helping People Live Their Lives To The Fullest 59

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