provider handbook supplement for blue shield of … · blue shield of california provider handbook...

© 2016 - 2017 Magellan Health, Inc. 11/17

Magellan Healthcare, Inc.*

Provider Handbook Supplement for Blue Shield of California (BSC)

*In California, Magellan does business as Human Affairs International of California, Inc. and/or Magellan Health Services of

California, Inc. – Employer Services.

Blue Shield of California Provider Handbook Supplement

2—©2016 - 2017 Magellan Health, Inc. 11/17

This document is the proprietary information of Magellan.

Table of Contents SECTION 1: INTRODUCTION ............................................................................................ 3

Welcome .......................................................................................................................... 3

SECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORK ..................................... 5

See the California Provider Handbook Supplement, section 2 ........................................ 5

SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN ...................................... 6

Before Services Begin...................................................................................................... 6

Concurrent Review ......................................................................................................... 8

Member Access to Care ................................................................................................. 10

Advance Directives - Medicare ...................................................................................... 12

SECTION 4: THE QUALITY PARTNERSHIP ................................................................... 13

A Commitment to Quality ............................................................................................. 13

Provider Input .............................................................................................................. 14

Cultural Competency .................................................................................................... 15

Language Assistance Services....................................................................................... 15

Appeals ......................................................................................................................... 17

Appeals - Medicare ........................................................................................................ 19

SECTION 5: PROVIDER REIMBURSEMENT .................................................................. 20

Claims Filing Procedures .............................................................................................. 20

Appendix H to the California Provider Handbook Supplement

https://www.magellanprovider.com/news-publications/state-plan-eap-specific-information/california.aspx




SECTION 1: INTRODUCTION

Welcome Welcome to the Human Affairs International of California (HAI-CA) Provider Handbook Supplement for

Blue Shield of California (BSC). This document supplements the Magellan Provider Handbook for the

National Provider Network and the California provider handbook supplement, addressing policies and

procedures specific for the BSC plan. This provider handbook supplement for BSC is to be used in

conjunction with the Magellan national provider handbook and with the California provider handbook

supplement. When information in the BSC supplement conflicts with the national handbook, or when

specific information does not appear in the national handbook, policies and procedures in the BSC

supplement prevail.

Covered Services

HAI-CA will manage the provision of medically necessary services pursuant to BSC plans. Providers should furnish medically necessary services in an amount, duration and scope that meet members’ needs. HAI-CA will not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or condition. Covered services may vary based on the member’s benefit plan. Covered services, when medically necessary, include:

Emergency room consultations

Outpatient psychotherapy (individual, family and group)

Outpatient psychiatric evaluations

Outpatient hospital services

Inpatient treatment for mental health and substance abuse (if patient’s benefit plan has a substance abuse rider)*

Office emergency visits

Partial hospitalization for mental health and substance abuse*

Intensive outpatient program for mental health and substance abuse*

Electroconvulsive therapy (ECT)

Psychological testing

Therapeutic or diagnostic injections

Home services

Consultations

Telehealth services

ABA - Applied Behavior Analysis for Autism

TMS – Transcranial Magnetic Stimulation Treatment

OBOT – Office Based Opioid Treatment

*Substance abuse services are covered only when the member’s benefit plan has a substance abuse rider.

https://www.magellanprovider.com/MHS/MGL/about/handbooks/index.asp

https://www.magellanprovider.com/MHS/MGL/about/handbooks/index.asp

https://www.magellanprovider.com/MHS/MGL/about/handbooks/supplements/cali/index.asp




Contact Information

If you have questions about covered services, you may contact HAI-CA at the following numbers:

DMHC plan members: 1-877-263-9952

HMO, HMO Inpatient Substance Abuse Rider

HMO/POS

PPO, PPO Inpatient Substance Abuse Rider

IFP HMO & PPO DOI plan members: 1-877-263-9952

PPO, PPO Inpatient Substance Abuse Rider

IFP ASO BSC Buy-Up Product plan members: 1-800-378-1109

CalPERS plan members: 1-866-505-3409

City and County of San Francisco plan members: 1-866-830-0328

Medicare plan members: 1-800-985-2398




SECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORK

See the California Provider Handbook

Supplement, section 2

https://www.magellanprovider.com/media/1704/casupp.pdf

https://www.magellanprovider.com/media/1704/casupp.pdf




SECTION 3: THE ROLE OF THE PROVIDER AND MAGELLAN

Before Services Begin

Our Philosophy HAI-CA joins with our members, providers and customers to make sure

members receive the most appropriate services and experience the most

desirable treatment outcomes for their benefit dollar.

Our Policy Our policy is to refer members to providers who best fit their needs and

preferences based on member information shared with HAI-CA at the time of

the call. We also confirm member eligibility and conduct reviews for initial

requests for clinical services upon request.

What You Need

to Do

Your responsibility is to: (Facility-Based Care)

Understand federal and state standards applicable to providers.

Comply with federal and state standards.

Contact HAI-CA for prior authorization of all facility-based care services:


DOI plan members: 1-877-263-9952

ASO BSC Buy-Up Product plan members: 1-800-378-1109




Contact HAI-CA to confirm member eligibility, member benefits, applicable member copayments/coinsurance/deductibles, and timely filing timeline prior to the member’s visit.

Not require a primary care physician (PCP) referral from members.

Not require prior authorization of emergency services or urgent care services.

Your responsibility is to: (Outpatient Care)

Not require a primary care physician (PCP) referral from members.

Not require prior authorization of emergency services or urgent care services.

Contact HAI-CA for prior authorization for outpatient ECT; TMS; OBOT; ABA; biofeedback and psychological testing (all provider types).

Contact HAI-CA to confirm member eligibility, member benefits, applicable member copayments/coinsurance/deductibles, and timely filing timeline prior to the member’s visit.

For routine outpatient codes, initiate services to the member. Prior authorization is not required. Psychiatrists do not need authorization for routine outpatient codes at any time.




Acquire the applicable copayment/coinsurance/deductible from the

member at the time of the each visit.

Submit all claims to HAI-CA on behalf of the member and follow billing

procedures detailed in Appendix H to the California Provider Handbook

Supplement.

What Magellan

Will Do

HAI-CA’s responsibility to you is to: (Facility-Based Care)

Operate a toll-free telephone number to respond to provider questions, comments and inquiries. Those numbers are listed above.

Establish a multi-disciplinary Utilization Management Oversight Committee to oversee all utilization functions and activities.

Make decisions about expedited prior authorizations and give verbal notification within 24 hours of receipt of the request. Written notification will be sent within the shorter of two business days from when the determination is made or 72 hours of receipt of the request.



Contact HAI-CA for eligibility and benefits prior to outpatient services beginning, as applicable:







HAI-CA’s responsibility to you is to:

(Outpatient Care)

Operate toll-free telephone numbers to respond to provider questions, comments and inquiries. Those numbers are listed above.


Conduct an expedited coverage review when the member’s condition is such that he/she faces an imminent and serious threat to his or her health, including, but not limited to the potential loss of life, limb, or other major bodily function, or the standard time frame for the decision-making process would be detrimental to the member’s life or health or could jeopardize the member’s ability to regain maximum function. Upon receipt of a request that is complete, a medical necessity review of requested services is initiated and verbal notification of the determination is given to the provider in a timely fashion appropriate for the member’s condition not to exceed 72 hours after receipt of the request.







Concurrent Review Our Philosophy HAI-CA believes in supporting the most appropriate services to improve health

care outcomes for members. We look to our providers to notify us if additional

services beyond those initially authorized are needed, including a second

opinion for complex cases.

Our Policy Concurrent utilization management review is required for all services, including but not limited to:

Inpatient

Intermediate ambulatory services such as residential treatment, partial hospital programs (PHP) or intensive outpatient (IOP) programs

What You Need

to Do

If, after evaluating and treating the member, you determine that additional services are necessary: (Facility-based Care)

Call the designated HAI-CA care management team member at least one day before the end of the authorization period for inpatient and intermediate ambulatory services, at the following numbers:







Be prepared to provide the HAI-CA care manager or physician advisor with an assessment of the member’s clinical condition, including any changes since the previous clinical review and discharge plan.

Request a second opinion if you feel it would be clinically beneficial.



Respond promptly to requests for additional clinical information. If, after evaluating and treating the member, you determine that additional non-routine outpatient services are necessary: (Outpatient Care)

Request a second opinion if you believe it would be clinically beneficial.



Contact HAI-CA for authorization of all non-emergent out-of-network services at the applicable number listed above.

Respond promptly to requests for additional clinical information.




What Magellan

Will Do

HAI-CA’s responsibility to you is to: (Facility-based Care)

Be available 24 hours a day, seven days a week, 365 days a year to respond to requests for authorization of care.

Promptly review your request for additional days or visits in accordance with the applicable medical necessity criteria.

Have a physician advisor available to conduct a clinical review in a timely manner if the care manager is unable to authorize the requested services.

Respond in a timely manner to your request, verbally and in writing, for additional days.

Make a decision and give verbal notification within 24 hours of receipt of the request. Written notification is sent within the shorter of two business days from when the determination is made or 72 hours of receipt of the request.

Operate toll-free telephone numbers to respond to provider questions, comments and inquiries. Those numbers are:








HAI-CA’s responsibility to you is to: (Outpatient Care)

Make a physician advisor or clinician advisor available to conduct a clinical review in a timely manner if the care manager is unable to authorize the requested services.

Make a decision within five business days of receipt of the request. The determination will be communicated via phone or fax to the requesting provider within 24 hours of making the determination and written notification will be sent within two business days of making the determination.

Operate toll-free telephone numbers to respond to provider questions, comments and inquiries. Those numbers are:








https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/MNC.asp





Member Access to Care

Our Philosophy Members are to have timely access to appropriate mental health, substance

abuse, and/or Employee Assistance Program (EAP) services from an in-

network provider 24 hours a day, seven days a week.

Our Policy Our access-to-care standards allow members to obtain behavioral health

services from an in-network provider within a time frame that reflects the

clinical urgency of the situation.

What You Need

to Do

In support of that commitment, we have established appointment and telephone access standards. We strongly encourage you to follow these standards. Appointment Access Standards

Life-Threatening Emergency Access – If you are unable to see a member who has a life-threatening emergency immediately, we ask that you immediately refer the member to the nearest emergency room or advise the member to call 911.

Non-Life-Threatening Emergency Access – We expect you to see members with non-life-threatening emergencies within six hours of contact.

Urgent Access – We expect you to see health plan and other managed care members with urgent situations within 48 hours of contact and EAP members with urgent situations within 24 hours of contact.

Routine Access – We expect you to see health plan and other managed care members for routine care within 14 calendar days of contact, Medicare members within 10 business days of contact, and EAP members within three business days of contact.

Unavailability - Notify us immediately when you become unavailable for new referrals by updating your appointment availability and/or requesting a hold of referrals for any date span via the provider website. Any hold request beyond 90 days will need to be received in writing and reviewed for approval by the Network and CNCC committee.

Telephone Access Standards If you are unavailable when a member calls, we expect you to return the member’s call within one business day and to communicate your telephone response time to members via your phone message and/or answering service. Of course, if a member message indicates urgency, please respond immediately or in accordance with good professional practice guidelines. We also ask that your phone message or answering service informs members that if they believe their situation requires immediate intervention, they should:

Go to the nearest emergency room

Hang up and call 911

Hang up and call 911 or go to the nearest emergency room.




In-Office Wait Times Members should not have to wait more than 15 minutes after the scheduled appointment time except when an emergency interrupts your schedule.

Referral Supplement – California Provider Specialty Information

Providers can update and maintain their specialties and appointment availability

via the www.MagellanProvider.com site using the online Provider Data Change

Form as explained in the National Provider Handbook. This information is

requested to meet regulatory requirements of the California Department of

Managed Health Care.

What Magellan

Will Do

In support of our commitment to these standards and to meet our regulatory

obligations, we may contact you through random audits to gauge your ability to

meet these standards. Failure to meet these standards may result in sanctions,

up to and including termination of your provider participation agreement. If

you have any concerns or comments, please contact us toll-free at 1-800-430-

0535.

http://www.magellanprovider.com/





Advance Directives - Medicare

Our Philosophy HAI-CA believes in a member’s right to self-determination in making health

care decisions.

Our Policy As appropriate, HAI-CA will inform adult members 18 years of age or older

about their rights to refuse, withhold or withdraw mental health and/or

substance abuse treatment through advance directives. HAI-CA supports the

state and federal regulations that provide for adherence to a member’s

psychiatric advance directive.

What You Need

to Do

Your responsibility is to:

Understand and comply with federal Medicare standards regarding psychiatric advance directives.

Maintain a copy of the psychiatric advance directive in the member’s file, if applicable.

Understand and follow a member’s declaration of preferences or instructions regarding behavioral health treatment.

Use professional judgment to provide care believed to be in the best interest of the member.

What Magellan

Will Do


Comply with federal advance directive laws.

Document the execution of a member’s psychiatric advance directive.

Not discriminate against a member based on whether the member has executed an advance directive.

Provide information to the member’s family or surrogate if the member is incapacitated and unable to articulate whether or not an advance directive has been executed.




SECTION 4: THE QUALITY PARTNERSHIP

A Commitment to Quality

Our Philosophy HAI-CA supports the delivery of quality care, with the primary goal of

improving the health status of members and, where the member’s condition is

not amenable to improvement, maintaining the member’s current health status

by implementing measures to prevent any further decline in condition or

deterioration of health status. This includes identifying members at risk of

developing conditions, implementing appropriate interventions, and designating

adequate resources to support the intervention(s).

Our Policy In support of our Quality Improvement Program, our providers are required to

be familiar with HAI-CA guidelines and standards and apply them in clinical

work with members.

What You Need

to Do

To comply with this policy, your responsibility is to:

Understand and comply with regulatory standards applicable to providers.

Provide input and feedback to HAI-CA to actively improve the quality of care provided to members.

Participate in quality improvement activities if requested by HAI-CA.

What Magellan

Will Do


Actively request input and feedback regarding member care.

Work with members, providers, community resources and agencies to improve the quality of care provided to members.

Operate a toll-free telephone hotline to respond to provider questions, comments and inquiries.

Establish a multi-disciplinary Quality Oversight Committee to oversee all quality functions and activities.

Maintain a health information system sufficient to support the collection, integration, tracking, analysis and reporting of data.

Provide designated staff with expertise in quality assessment, utilization management and continuous quality improvement.





Provider Input

Our Philosophy HAI-CA believes that provider input concerning our programs and services is a

vital component of our quality programs.

Our Policy HAI-CA obtains provider input through provider participation in various

workgroups and committees of the San Diego Care Management Center. We

offer providers opportunities to give feedback through participation in our

quality programs, or via requests for feedback in provider publications.

What You Need

to Do


Understand and comply with regulatory requirements and standards applicable to providers.

Provide input and feedback to HAI-CA to actively improve the quality of care provided to members.

Participate in quality improvement and utilization oversight activities if requested by HAI-CA.

What Magellan

Will Do


Actively request input and feedback regarding member care.

Operate a toll-free telephone number to respond to provider questions, comments and inquiries.

Establish a multi-disciplinary Quality Improvement Committee to oversee all quality functions and activities.

Maintain a health information system sufficient to support the collection, integration, tracking, analysis and reporting of data.

Provide designated staff with expertise in quality assessment, utilization management and continuous quality improvement.

Develop and evaluate reports, indicate recommendations to be implemented, and facilitate feedback to providers and members.

Participate in annual performance improvement projects (PIPs) that focus on clinical and non-clinical areas, and provide annual reports on performance improvement project results using a valid process for evaluation of the impact and assessment of the quality improvement activities.





Cultural Competency

Language Assistance Services

Our Philosophy We support the right of members with limited English Proficiency (LEP) to assistance that enhances their ability to understand and obtain needed services.

Our Policy We maintain a formal language assistance program (LAP) to identify and assist

members with LEP.

What You Need

to Do

Cultural sensitivity: Be sensitive to language needs and cultural backgrounds of our members; treat all members in a manner compatible with their cultural health beliefs and practices and preferred language. See the “Cultural Sensitivity Tips” section in Appendix I, Language Assistance Services.

Notice to members: Inform LEP members of the availability of our free language assistance services in connection with their behavioral health benefits or EAP services.

Selection of interpreters and translators: Use only qualified interpreters or translators when needed for an LEP member. Minimum qualifications include (i) being a native speaker and/or having at least 2 years experience of using English and each non-English language in health care settings and (ii) understanding of behavioral health terms and concepts in the non-English language(s). (You cannot be considered a bi-lingual provider unless you meet these standards.) If you are not a bi-lingual provider and do not have access to a qualified interpreter, we will arrange for a qualified interpreter.

Language assistance costs: Do not charge any member or his/her family or personal representative for interpretation or alternative-language translation services or represent to any member or his/her family or personal representative that there is a cost for such services.

Access to language assistance services: Call us 24/7/365 for assistance in providing timely interpretation and translation assistance.

Please see the “What We Expect from You, Our Provider” section of Appendix I,

Language Assistance Services for more information.

What Magellan

Will Do

We will make appropriate interpreter services available at our cost for LEP

members who request interpreter services for all telephonic contacts and for

your face-to-face communications with those members. We use a professional,

credentialed interpretation company with interpreters in various languages. If a

member’s language is not one of the languages provided by the interpretation

company, there may be a slight delay in identifying an appropriate interpreter,

but we will make efforts to locate an appropriate interpreter.

https://www.magellanprovider.com/media/1709/appilangassistanceservices.pdf





Please see Appendix I, Language Assistance Services for more information.






Appeals Our Philosophy HAI-CA supports the right of members and providers acting on the behalf of

members to appeal adverse determinations.

Our Policy Our customer organizations and applicable federal and state laws impact the clinical appeals process. The applicable procedure for appealing a clinical determination is outlined fully in the adverse determination notification letter. An appeal is a formal request by a member for reconsideration of a non-authorization decision or adverse claim determination with the goal of finding a mutually acceptable solution. For an appeal prior to the provision of the services, the member may submit the appeal or the provider, acting on the member’s behalf, may submit an appeal. Examples of actions that can be appealed include, but are not limited to, the following:

Denial or limited authorization of a requested service, including the type or level of service

Reduction, suspension or termination of a previously authorized service

Denial, in whole or in part, of payment for a service. An expedited appeal is a request that is made when the routine decision-making

process might seriously jeopardize the life or health of a member, or when the

member is experiencing severe pain. An expedited decision may involve an

admission, continued stay, or other health care services.

What You Need

to Do


Follow the instructions listed in the notification of an adverse determination to submit an appeal for services that have not been provided, by:

Submitting the appeal verbally by contacting the customer service number on the back of the member’s benefit card for appeals, or

Faxing the appeal to 1-888-656-1060, or

Mailing the appeal and supporting documentation to:

Blue Shield of California Mental Health Service Administrator P.O. Box 719002 San Diego, CA 92171-9002

Members must follow the instructions for submitting an appeal described on the notification of the adverse decision and contact HAI-CA directly.

Providers and other individuals filing on the member’s behalf should refer to the adverse determination notification letter for the specific procedures for appealing a clinical determination.




What Magellan

Will Do


Notify you verbally within 24 hours of our determination when we decide to reverse our non-authorization decision

Notify you in writing of our determination to reverse our non-authorization decision.

Forward appeals to BSC for further review and a determination when we decide to uphold our non-authorization decision.

Not take any punitive action against any provider who requests or supports an appeal.





Appeals - Medicare

Our Philosophy HAI-CA supports the right of members and their providers acting on the

member’s behalf to appeal adverse determinations.

Our Policy In the event of a dispute regarding coverage of mental health/substance abuse

services under a Medicare Advantage Full-Risk Benefit Plan, HAI-CA will refer

members to BSC for response and resolution. Should medical necessity be an

issue during the review, BSC will consider HAI-CA’s medical necessity criteria

when reviewing and rendering a decision. If HAI-CA’s criteria conflicts with

BSC medical policy, BSC medical policy will govern. All final decisions

regarding coverage are reserved to BSC.

What You Need

to Do


Contact the BSC Appeals and Grievance department to request an appeal for a Medicare Advantage member.

Members must follow the instructions for filing an appeal listed on the notification of an adverse decision and contact BSC directly.

Providers and other individuals filing on the member’s behalf should refer to the adverse determination (non-authorization) notification letter for the specific procedures for appealing a clinical determination, and contact BSC directly.

What Magellan

Will Do

HAI-CA’s responsibility is to: Refer you to BSC for handling of your Medicare Advantage appeal

determinations.




SECTION 5: PROVIDER REIMBURSEMENT

Claims Filing Procedures

Our Philosophy HAI-CA is committed to reimbursing our providers promptly and accurately in

accordance with our provider contracts.

Our Policy HAI-CA reimburses mental health and substance abuse treatment providers in

accordance with reimbursement schedules for professional services. The

reimbursement schedules contain current procedural terminology (CPT) codes

for traditional outpatient providers, and a combination of CPT and Healthcare

Common Procedure Coding System (HCPCS) codes. The reimbursement

schedule(s) is attached to your provider participation agreement.

What You Need

to Do

Your responsibility is to:

Collect the applicable copayment/coinsurance/deductible from the member at the time of the each visit. Contact the San Diego Care Management Center at the applicable number to verify eligibility, obtain information on co-payment amounts, and prior authorization for all higher levels of care and, except for routine outpatient care.

Sign up for online claims submission and electronic funds transfer (EFT) through www.MagellanProvider.com

Submit a clean claim form for the services that you have provided through www.MagellanProvider.com, an accepted clearinghouse, or via paper claim. Include Magellan submitter ID # 01260 on EDI claims.

Claim address: Human Affairs International of California, Inc. (A Magellan Health Services Company) P.O. Box 710400 San Diego, CA 92171-0400

In accordance with Centers for Medicare and Medicaid Services (CMS) requirements, HAI-CA requires Medicare claims to be submitted by the 90th calendar day.

HAI-CA encourages providers to submit claims within 60 calendar days of date of service or discharge; however, claims will be accepted until the 90th calendar day from date of service or discharge.

Bill using the Taxpayer Identification Number under which you are contracted.

Refrain from billing the member for any amount, including the difference between HAI-CA’s reimbursement amount and your standard rate, other than applicable deductibles and copayment. This practice is called balance billing and is prohibited.

Contact the San Diego Care Management Center if you are not certain which services require pre-authorization, what your reimbursement rate is, or for any questions that you have concerning the member in care.

See Appendix H to the California Provider Handbook Supplement for our Claims Settlement Practices.





What Magellan

Will Do


Provide verbal notice, send an authorization letter and/or provide

electronic authorization when we authorize services.

♦ Process your claim promptly upon receipt, and complete all transactions

within regulatory and contractual standards.

♦ Inform you of any reasons for administrative denials and action steps

required to resolve the administrative denial.

♦ Send you or make available online an Explanation of Payment (EOP) or

other notification for each claim submitted, including procedures for

appealing.

♦ Provide appropriate notice regarding corrective action or information

required if a claim is denied.

♦ Re-open your claim and process to final payment upon receipt of requested

information.

♦ Regularly update the Universal Services List and HIPAA-compliant billing

codes on our provider website.

♦ Review our reimbursement schedules periodically in consideration of

industry-standard reimbursement rates and revise them when indicated.

♦ Include all applicable reimbursement schedules as exhibits to your contract.

♦ Communicate changes to reimbursement rates in writing prior to their

effective date.

♦ Comply with applicable state and federal regulatory requirements regarding

claims payment.

Communicate changes to claims filing requirements and reimbursement

rates in writing prior to the effective date.

provider handbook supplement for blue shield of … · blue shield of california provider handbook...

Documents