Provider Manual Regional Behavioral Health System

Health Share of Oregon Broadway Plaza, Suite #200 Portland, OR 97201 Phone: 503-416-1460 Fax: 503-459-5749 www.healthshareoregon.org

Revised / Effective July 1, 2016

Contents Values & Principles ..................................................................................................................................................................................... 4 Values ...................................................................................................................................................................................................... 4 Principles .............................................................................................................................................................................................. 4-5 Plan Contact List .................................................................................................................................................................................... 6-10 Regional Contacts ............................................................................................................................................................................. 10-11 Glossary ............................................................................................................................................................................................... 12-13 Abuse Reporting .................................................................................................................................................................................. 14-15 Regional Practice Guidelines ................................................................................................................................................................... 15 Services Requiring Pre-Authorization...................................................................................................................................................... 16 Access................................................................................................................................................................................................... 17-18 Member Rights ......................................................................................................................................................................................... 18 Advance Directives ................................................................................................................................................................................... 18 Member Assignment and Termination .............................................................................................................................................. 18-19 Transfers ................................................................................................................................................................................................... 20 Care Integration and Coordination ..................................................................................................................................................... 20-21 Grievances ................................................................................................................................................................................................ 21 Crisis Response System ............................................................................................................................................................................ 22 Critical Incident Reporting ....................................................................................................................................................................... 22 Interpreter Services ............................................................................................................................................................................. 22-23 Second Opinions .................................................................................................................................................................................. 24-25

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Member Privacy ....................................................................................................................................................................................... 25 Flexible Services .................................................................................................................................................................................. 26-29 Code and Authorization Guides ............................................................................................................................................................... 30 Billing, Service Authorization and Claims Management.................................................................................................................... 31-33 Corrected Claims ................................................................................................................................................................................. 33-34 Credentialing and Re-credentialing Requirements ............................................................................................................................ 35-38 Fraud, Waste and Abuse ..................................................................................................................................................................... 38-42 Additional Requirements – Organizational Providers Only ..................................................................................................... 40-41 Additional Requirements – COA Providers Only .......................................................................................................................... 41 Additional Requirements – Providers receiving $5 million or more annually (total of all OHP contracts combined) Only ... 41-42 Overpayment Recoveries ......................................................................................................................................................................... 42 Audit Rights of Health Share & Health Plan Partners ............................................................................................................................. 43 Required Submissions .............................................................................................................................................................................. 43 Mental Health Outcomes: Outpatient Case Rate Providers & Contracted Outpatient FFS Providers (self-authorizing) ................... 44 Case Rate Providers............................................................................................................................................................................. 44-46 Provider Performance Expectations ........................................................................................................................................ 44-45 Risk Corridor Reconciliation Process............................................................................................................................................. 45 Day Treatment Clinical Services Providers ......................................................................................................................................... 46-48 Psychiatric Residential Treatment Services Providers ....................................................................................................................... 48-50

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Values & Principles Values Health Share of Oregon (Health Share) and Health Share’s Behavioral Health Plan Partners promote resilience in and recovery of our Members. We support a system of care that promotes and sustains a person’s recovery from a mental health condition by identifying and building upon their strengths and competencies in order to assist them in achieving a meaningful life within their community. Members are to be served in the most normative, least restrictive, least intrusive, and most cost-effective level of care appropriate to their diagnosis and current symptoms, degree of impairment, level of functioning, treatment history, individual voice and choice, and extent of family and community supports. Practice guidelines are intended to assure appropriate and consistent utilization of mental health services and to provide a frame of reference for clinicians in providing services to individuals enrolled in Health Share. The guidelines offer a best practice approach and are not intended to be definitive or exhaustive. When multiple Providers are involved in the care of our Members, it is our expectation that regular coordination and communication occurs between these Providers to ensure coordination of care. This could include sharing of service plans, joint session, phone calls or team meetings.

Principles 1. Treatment planning incorporates the principles of resilience and recovery, and: a. b. c. d. e. f.

Employs strengths-based assessment Is individualized and person-centered Promotes access and engagement Encourages family participation Supports continuity of care Empowers the Member

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g. Respects the rights of the individual h. Involves individual responsibility and hope in achieving and sustaining recovery i. Uses natural supports as the norm rather than the exception 2. Policies governing service delivery are age and gender appropriate, culturally competent, evidence-based and trauma-informed, attend to other factors known to impact individuals’ resilience and recovery, and align with the individual’s readiness for change. With the goal of the individual receiving all services that are clinically indicated. --- Ensuring that individuals have access to services that are clinically indicated. 3. Positive clinical outcomes are more likely when clinicians use evidence based practices or best clinical practices based on a body of research and as established by professional organizations. 4. Treatment interventions should promote resilience and recovery as evidenced by: a. b. c. d. e.

Maximized quality of life for individuals and families Success in work and/or school Improved mental health status and functioning Successful social relationships Meaningful participation in the community

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Plan Contact List Clackamas Contacts

Adult Mental Health Initiative (AMHI)

Hazel Barrett [email protected] 503-742-5960

Multnomah Contacts

Greg Watson (general inquiries): [email protected] General inquiries: [email protected]

Secure Email:

Appeals upon receipt of Notice of Action or claim denial

[email protected]

Phone: 503-742-5335 Fax: 503-742-5304 2501 Kaen Road, Suite 154 Oregon City, OR 97045

Washington Contacts

Appeals and Complaints Coordinator Fax: 503-988-4015

Sarah Wells (staffing & screening): [email protected] 503-846-4593 Washington County Behavioral Health Quality and Compliance Secure email: [email protected] Phone: 503-846-4515 155 N First Ave, Suite 250, MS 70 Hillsboro, OR 97124

Continued →

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Plan contact list continued… Clackamas Contacts

Multnomah Contacts

Washington Contacts

Mental Health Treatment Authorization Request (TAR)

Authorizations (services requiring pre-authorization and Treatment Authorization Request Form)

Adult: Jeff Cotta 503-742-5348 Child: Allyn LaTorre 503-742-5937 SUD: Casey Palmer 503-742-5968

Forms https://multco.us/mhas/mentalhealth-Provider-documents-resources Completed forms Email: [email protected] Fax: 503-988-3137 SUD: Andrea Quicksall [email protected] 503-988-8359

Adult: Sarah Wells 503-846-4593 Child: Kirsten Drashner 503-846-4576 Inpatient/Respite/Exceptional Needs: Heidi Watson 503-846-3168 SUD: Kathy Prenevost 503-846-4432

Trina Connolly- Fairchild [email protected] 503-201-5037

Changing your Provider Profile (e.g. Name, Address)

Secure Email: [email protected]

Phone: 503-742-5335

Submit by fax: 503-988-5870

Secure email: [email protected] Phone: 503-846-4515

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Plan contact list continued… Clackamas Contacts

Multnomah Contacts

Washington Contacts

Email: [email protected]

Email: [email protected]

Email:

Claims

[email protected]

Phone: 503.742.5365 Secure Email:

Secure email: [email protected]

[email protected]

Complaints and Grievances

Phone: 503-742-5335 Fax: 503-742-5304

Member Relations Specialist 503-988-8600

155 N First Ave, Suite 250, MS 70 Hillsboro, OR 97124

2501 Kaen Road, Suite 154 Oregon City, OR 97045

HIPAA Confidentiality (Privacy and Security incidents involving Member Information must be immediately reported)

Quality Management Manager, Joan Rice Quality Management Supervisor: [email protected]

Phone: 503-846-4515

Phone: 503-969-5133 [email protected]

Quality Assurance Program Coordinator Phone: 503-846-4554

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Plan contact list continued… Clackamas Contacts

Contract Inquiries

Angela Brink 503-742-5318 [email protected]

Multnomah Contacts

MMH Contract Specialist [email protected]

Washington Contacts Adults/ENP: Ava Mitchell [email protected] 503-846-4574 Child: Maureen Seferovich [email protected]

503-846-3161 Secure email:

Secure email: [email protected]

[email protected]

Critical Incidents

Phone: 503-742-5335 Fax: 503-742-5304

Quality Improvement Coordinator [email protected]

Phone: 503-846-4515 155 N First Ave, Suite 250, MS 70. Hillsboro, OR 97124

2501 Kaen Road, Suite 154, Oregon City, OR 97045

Secure email: [email protected]

Fraud and Abuse Reports

Quality Management Supervisor [email protected]

Compliance Coordinator [email protected]

Phone: 503-846-4515 155 N First Ave, Suite 250, MS 70. Hillsboro, OR 97124

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Plan contact list continued… Clackamas Contacts

Multnomah Contacts

Washington Contacts Adult: Sarah Wells 503-846-4593

Adult: Jeff Cotta 503-742-5348

Utilization Review

Child: Allyn LaTorre 503-742-5937

General inquiries email [email protected]

SUD: Casey Palmer 503-742-5968

Member Services

Phone: 503-742-5335

Child: Kirsten Drashner 503-846-4576 Inpatient/Respite: Heidi Watson 503-846-3168 SUD: Kathy Prenevost 503-846-4432

Phone: 503-988-5887 24/7 Availability

Phone: 503-291-1155

Regional Contacts PH Tech Provider Relations PH Tech Provider Instruction Manuals Health Share Contract & Credentialing Specialist

Phone: 1-800-478-2818 Web-based authorization and claims system manual: https://phtech.zendesk.com/home Phone: 1-800-478-2818 Phone: 503-416-3956 Email: [email protected]

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Plan contact list continued… Abuse Reporting Contacts

Phone: 1-855-503-SAFE (7233) Abuse Reporting

This toll-free number allows you to report abuse or neglect of any child or elderly person, or persons with developmental disabilities to the Oregon Department of Human Services.

Report suspected abuse, neglect or financial exploitation of an adult with mental illness to your county mental health program:

Adult Protective Services

Clackamas Contacts

Multnomah Contacts

Washington Contacts

Secure Email: [email protected] Phone: 503-650-3000

Email: [email protected] Phone: 503-988-8170

Phone: 503-846-3653 Fax: 503-846-4521

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Glossary General Terms Risk Accepting Entity (aka RAE) / Behavioral Health Plan Partner: Refers to Clackamas Mental Health; Washington County Mental Health, or Multnomah Mental Health.

Provider Category Terms Exceptional Needs Providers: Exceptional needs providers receive reimbursement on a fee for service basis. Services require preauthorization. Members are referred to these providers for exceptional needs services that are not available with other contracted providers. Exceptional needs providers are accessible when the need for their specialization arises. Non-Contracted Single Case Providers: Non-contracted single case providers hold a one-time, member-specific single-case agreement which enables them to receive reimbursement for services delivered to an individual member. Outpatient Small Group Providers: Outpatient small group providers receive reimbursement on a fee for service basis; selfauthorize services; and submit ‘Authorization Increase Requests’ to UR each respective RAE, if needed, on a per-member basis. Specialty Providers: Specialty providers receive reimbursement on a fee for service (FFS) basis, self-authorize services, and complete Level of Care assessments.

Authorization Terms Appeals: Appeals are defined in Regional Notice of Appeals (NOA) Policy. Authorization Amount: Describes the amount that is pre-approved for fee for service Providers that enter self-authorizations. Authorization Increase Request: Describes the request and clinical review process that Providers engage in with the RAEs for determination of whether or not funds will be added to and existing authorization (based on medical necessity).

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Denials: Are defined in the Regional Notice of Appeals (NOA) policy Did not meet medical necessity criteria: Refers to a scenario whereby the clinical information provided did not meet either the admission criteria or continued stay criteria in the Health Share of Oregon Regional Utilization Management Guidelines. Initial Authorization: Describes all ‘new’ authorizations and also authorizations for Levels of Care or specialty services that require pre-authorization. Notice of Action: Are defined in Regional Notice of Appeals (NOA) Policy Re-Authorization: Refers to outpatient re-authorizations, also known as ‘concurrent review’ or ‘continued stay’. UM Guidelines: Refers to the Health Share of Oregon Regional Utilization Management Guidelines, which outline Regional Medical Necessity Criteria. We request additional clinical information: For the purposes of clinical review, RAE Utilization Review staff request clinical information that is current, valid, and congruent with the member’s level of functioning at the time of the request. When a request for additional clinical information is made, the provider shall provide a brief description of the member’s current clinical presentation, response to interventions, prognosis, and description of need for continuation/extension of services.

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Abuse Reporting Providers will comply with all patient abuse reporting requirements and fully cooperate with the State for purposes of ORS 410.610 et seq., ORS 419B.010 et seq., ORS 430.735 et seq., ORS 433.705 et. seq., ORS 441.630 et. seq., and all applicable rules associated with those statutes. Furthermore, Providers will comply with all protective services, investigation and reporting requirements described in OAR 943-045-0250 through 943-045-0370 and ORS 430.735 through 430.765. As a Provider of behavioral health services, you are a Mandatory Reporter. You have the legal responsibility to report alleged abuse of the following individuals: children, adults aged 65 and over, adults with developmental disabilities, adults with mental illness and residents in nursing facilities. What constitutes a mandatory report, and when and to whom to make the report, varies depending on which of these individuals is the subject of the report. If you are uncertain regarding the proper reporting authority, request assistance from the Adult Protective Services contact listed in the Plan Contact List of this Provider Manual. At minimum, abuse reports for all individuals should include the following:     

The name, age and present location of the allegedly abused Member; The names and addresses of persons responsible for the Member’s care; The nature and extent of the alleged abuse, including any evidence of previous abuse; Any information that led the person making the report to suspect that abuse has occurred, plus any other information that the person believes might be helpful in establishing the cause of the abuse and the identity of the perpetrator; and The date of the incident.

Reporting Suspected Abuse of a Child Provider shall immediately report any suspected abuse of a child to the State of Oregon DHS Child Welfare Child Abuse Hotline at (503) 731-3100, or Oregon’s Statewide Abuse Reporting Hotline: 1-855-503-SAFE (7233). By law, mandatory reporters must report suspected abuse or neglect of a child regardless of whether or not the knowledge of the abuse was gained in the reporter’s official capacity. In other words, the mandatory reporting of abuse or neglect of children is a 24-hour obligation. For the purpose of this policy, the term “Child” means an unmarried person who is under 18 years of age.

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Reporting the Death of an Adult Member Receiving Services Upon becoming aware of the death of an adult Member who was receiving mental health services, the Provider shall report the death to the County Adult Protective Services contact listed in the Plan Contact List above. The Oregon Health Authority requires the County to investigate any death of an adult Member receiving mental health services. Additional Requirements for Providers Operating Under a Certificate of Approval Providers operating under a State issued certificate of approval shall develop policies and procedures and comply with all investigation and reporting requirements described in OAR 943-045-0250 through 943-045-0370 and ORS 430.735 through 430.765.

Regional Practice Guidelines Medicaid managed care organizations are required to adopt practice guidelines that are based on valid and reliable clinical evidence, consider the needs of our individuals, and are adopted in consultation with our participating Providers. Decisions for utilization management and coverage of services should be consistent with these guidelines. Health Share, along with the Behavioral Health Plans, has adopted a definition of medical necessity criteria and a set of practice guidelines as a resource for both Providers and our staff. It should be noted that these guidelines are administrative in nature; they are not clinical practice guidelines. Clinical practice guidelines reflect practice standards for the management and treatment of specific conditions. Administrative guidelines describe the criteria for authorization for specific types of service. The primary purpose of these guidelines is to assist Providers in selecting the appropriate level of care for Members and to inform Providers of the criteria used by Behavioral Health Plans in authorizing services. Please refer to Appendix A: 2016 Practice Guidelines.

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Services Requiring Pre-Authorization Many services require a pre-authorization by the Behavioral Health Plans. These services include but are not limited to:                  

Outpatient Mental Health Treatment with Exceptional Needs Provider Single Case Agreements with Non-Contract Providers Partial Hospitalization Dialectical Behavioral Therapy Acute Care Hospitalization Intensive Case Management Assertive Community Treatment Electro-Convulsive Therapy (ECT) Sub-Acute Eating Disorder Treatment Transcranial Magnetic Stimulation Gender Dysphoria Assessments for Hormone Therapies and Gender Reassignment Applied Behavioral Analysis (ABA) Services Child Respite Crisis Stabilization Day Treatment Psychological Testing Psychiatric Residential

To receive authorization from the Behavioral Health Plan in the County in which the Member resides for services that require preauthorization, please refer to Appendix B: Exceptional Needs Authorizations.

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Access When a Provider receives a request for community treatment services, the Provider determines the nature and urgency of the Member’s treatment needs and offers an initial service appointment within the appropriate time frame. Timely access is defined as the following: 

Routine: 14 calendar days from the time of the request o Routine requests for service include circumstances where there is not an identifiable risk of harm, the need for inpatient treatment or out of home care is not imminent, and the individual requesting services can reasonably be expected to wait for the initial service without foreseeable risk.



Urgent: 48 hours from the time of the request for individuals with urgent treatment needs.



Emergent: 24 hours from the time of the request for individuals with emergent treatment needs

For urgent/emergent situations, other appropriate services may include referral to the local county crisis service or to a hospital emergency department as necessary to prevent injury or serious harm. If a Provider is unable to schedule an appointment within 24 hours in an emergency situation, the Provider is to make a referral to the appropriate county crisis services or nearest emergency department. When a Provider is not able to offer timely access to services, the Provider will offer information that allows the Member seeking care to make an informed choice about waiting for a later appointment or seeking services elsewhere. If the Member prefers to seek services elsewhere due to the wait, the Provider must offer referral information to appropriate Providers within the Health Share contracted Provider system and will include information about each of the contracted Providers that provide the requested service, including the name of the Provider, the address or general location of the Provider, and phone number. The Provider will also educate the Member on how to contact the appropriate Behavioral Health Plan Member services for further assistance.

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In circumstances where the Member elects to wait for a later appointment with the same Provider, the next available appointment will be offered in addition to referral information for other Providers. Provider will inform program staff who receive service requests and who coordinate access to services that Members seeking services have freedom of choice among participating Providers but may elect to remain on the wait list with the initial Provider. The contracted Provider will also inform the program staff of the expectation to provide timely access to services and appropriate referral information when access cannot be offered within expected time frames. Provider shall attempt to engage Members and provide access for a second appointment within fourteen (14) days of the first visit and an additional two (2) visits after fourteen (14) days to total four (4) clinical visits within the first forty-five (45) days of care.

Member Rights Provider must notify Members of their rights at time of intake. Member rights are included in the Health Share Member Handbook, which is available on the Health Share website.

Advance Directives Advance directives information is available in the Health Share Member Handbook and in the Provider’s contract. Providers shall offer assistance with Advanced Directives to Members upon request.

Member Assignment & Termination Members may choose to receive care from any contracted Provider that has the capacity to meet the individual’s assessed behavioral health treatment needs. Once the Member has made a successful connection with the Provider, as evidenced by an authorization for routine services, the individual will be considered “enrolled.” For all enrolled Members, Provider will have the responsibility to assist Members to access services by providing outreach, office- and/or community-based appointments, engagement techniques and other methods likely to improve the chances that those in need will receive services.

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Provider may not refuse to provide services to any Member meeting Health Share Utilization Management criteria. If there are reasonable clinical reasons why the Provider is unable to provide services that otherwise are a good fit for the Member, arrangements for service to be received at an alternative agency is the mutual responsibility of the Member, the Provider and the Behavioral Health Plan. Providers will continue to maintain responsibility for any Member with an open authorization, including providing post-hospital follow up. The only circumstances that would terminate the Provider's responsibility for a Member with an open authorization are one or more of the following circumstances: 1. The Member has transferred services to another Provider, and the new Provider has confirmed that they have accepted the Member. 2. The Provider and Member have agreed that the Member no longer needs formal mental health services, and has an established natural system of support that is likely to meet their ongoing needs. The Provider will be available to reopen the Member’s treatment plan or provide aftercare services, as clinically appropriate. 3. The Provider has documented consistent efforts to engage the Member over a significant period of time which have not been successful, and the Member is not judged to be at risk for requiring a higher level of care. 4. The Member moves out of the area and referral has been made to a receiving agency. 5. The Member dies. 6. The Member requests termination of services with the Provider. Except for in these identified scenarios, case rate Providers are expected to continue to provide medically necessary services for the duration of the authorization period and may not terminate the individual from treatment while the Member has benefits through Health Share.

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Transfers If a Member with an open service authorization requests a transfer of services to another contracted behavioral health Provider, the Provider will cooperate with the Member and assist in making transfer arrangements with the new Provider and the Behavioral Health Plan. The current Provider is responsible for determining the best course of action.

Care Integration and Coordination Coordination with Physical Health Health Share expects coordination of care and exchange of protected health information between the physical health care Provider and the behavioral health Provider to address physical and behavioral health needs, when indicated. As a best practice, behavioral health Providers are responsible for informing the Primary Health Provider (PCP) of the Member’s entry into behavioral health treatment after an appropriate release has been signed (when required). However, exchange of protected health information may be done without a Release of Information, given that both Providers are operating under Health Share of Oregon agreements. Providers are also responsible for informing the PCP of any significant change in the Member’s mental status or medications. The Behavioral Health Plans support a model of care that emphasizes prevention and routine care. As a best practice, Providers determine if the Member has a PCP and assist Members to receive routine health exams with their PCP even when there is not an immediate health concern.

Members with no Identified PCP The amount of assistance given to a Member by a Provider in obtaining a PCP or identifying their assigned PCP will be based on the functioning level of the Member and the Member’s need for assistance. Either the Behavioral Health Plan or the Provider will encourage Members receiving outpatient level of care services who disclose that they have no PCP to call their Physical Health Plan’s Member Services to find out the process for obtaining a PCP. If the Member is a child or adolescent, their parent or guardian will be encouraged to obtain a PCP for their youth. Clinicians providing behavioral health services and supports to Health Share Members with severe and persistent mental illness (both adult and child/adolescent) are expected to take an active role in seeking PCP services for their Members.

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Members with no insurance coverage for physical health care will be provided with information about “safety net” clinic alternatives. Members with Chronic Disease Members or their guardians are asked to identify any current or chronic medical conditions as part of the mental health assessment. If such a medical disease or disorder is identified, the Provider will follow procedures outlined above to determine if the Member is receiving care for this condition from a PCP or a medical specialist. If a Member identifies a significant physical disease or disorder for which the Member is not receiving treatment, the Provider will encourage and/or assist the Member to obtain necessary treatment as appropriate. When a Member with a significant medical disease or disorder is receiving behavioral health treatment, the Provider is encouraged to monitor the Member’s compliance with their medical treatment plan.

Grievances Provider will assist the Member in accessing their physical health plan’s grievance process. A Provider who has a Certificate of Approval (COA) is required to maintain a grievance system in accordance with the following OARs specific to business lines, as applicable: • • •

Outpatient services provided by an agency required to maintain a Certificate of Approval: OAR 309-019-0105 (41) and 309019-0215; Intensive Treatment Services for Children and Adolescents: OAR 309-022-0105 (38) and 309-022-0190; and Residential A&D: 309-018-0210.

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Crisis Response System Case rate Provider agencies will have a crisis response system for Members enrolled in their program. At a minimum, the Provider agency will have a clinician available by phone for consultation at all times. This individual shall be familiar with the Member or shall have the ability to access relevant information about the Member to assist in crisis response. Enrolled Members who come to the attention of a crisis line shall be referred to their current Provider for crisis response during normal business hours. If a Member who is enrolled with one of the local Provider agencies comes to the attention of a crisis program, the team will contact the Provider directly and request assistance in responding to the situation. Individual and small practice non-case rate Providers will provide Members with the phone number to the crisis line and coordinate care with the crisis line as needed.

Critical Incident Reporting A ‘critical incident’ includes, but is not limited to, serious injury, act of physical aggression that results in injury or death, suspected abuse or neglect, involvement of law enforcement or emergency services, or any other serious incident that presents a risk to health and safety. Provider will immediately report to the Behavioral Health Plan Quality Assurance team or other appropriate Behavioral Health Plan employee any significant incidents that may become a matter of public record.

Interpreter Services Interpreter services are a covered benefit for Health Share Members at no cost to the Provider. Details for accessing these services are as follows, based on the County where the Member lives.

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CLACKAMAS MULTNOMAH WASHINGTON

Organization

Access Information for On-Demand /Telephone Interpreting

Access Information for On-Site/ In-Person Interpreting & Translation

IRCO - http://www.irco.org/ General information: 503-234-5185

PHONE: 503.505.5187 Access Code: 97015

PHONE: 503.234.0068 E-mail: [email protected]

Linguava Interpreters http://www.linguava.com

PHONE: 503.265.8515 Access Code: 14530

PHONE: 503.265-8515 E-mail: [email protected]

Passport to Languages http://www.passporttolanguages.com

PHONE: 1-866-533-4998 Access Code: 41416

PHONE: 503.297.2707 E-mail: [email protected]

IRCO - http://www.irco.org/ General information: 503-234-5185

PHONE: 503.505.5185 Access Code: 4721

PHONE: 503.234.0068 E-mail: [email protected]

Linguava Interpreters http://www.linguava.com

PHONE: 888.393.9606 Access Code: 19056

PHONE: 503.265-8515 E-mail: [email protected]

Passport to Languages http://www.passporttolanguages.com

PHONE: 1-866-533-4998 Access Code: 403295

PHONE: 503.297.2707 E-mail: [email protected]

Linguava http://www.linguava.com

PHONE: 503.265.8515 Access Code: 14557 (Medicaid) 14556 (General Fund)

PHONE: (503)265-8515 E-mail: [email protected] Access Code: 14557 (Medicaid) 14556 (General Fund)

Passport to Languages – http://www.passporttolanguages.com

PHONE: 1-800-297-2707 Access Code: 42216 (Medicaid) 42316 (General Fund)

PHONE: 1-800-297-2707 Access Code: 42216 (Medicaid) 42316 (General Fund)

PHONE: 503-535-2151 Access Code: 88631 (Medicaid) 88638 (General Fund)

PHONE: 503-535-2151 Access Code: 88631 (Medicaid) 88638 (General Fund)

Telelanguage – www.telelanguage.com

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Second Opinions In establishing an adequate network of Providers, the Behavioral Health Plans are required by federal rule to ensure that the network “Provides for a second opinion from a qualified (behavioral or physical) health care professional within the network, or arranges for the enrollee to obtain one outside the network, at no cost to the enrollee” [42 CFR 438.206(b)(3)]. Previously authorized Members have a right to a “second opinion” by a qualified health care professional within the organization where their service authorization originates, OR from any other contracted behavioral health Provider. If the Member’s current Provider is unable to provide a second opinion, or the Member wishes to obtain a second opinion from another Provider, the Member’s current Provider will arrange the second opinion. Requests for a second opinion from a behavioral health Provider outside of the Provider agency may be considered as an Exceptional Need request and will be handled in accordance with the Behavioral Health Plan’s Exceptional Needs Requests procedures outlined in the Provider Manual. Members may request a second opinion either orally or in writing to their current Provider or directly to the Behavioral Health Plan. Guidelines:      

Member has had at least one session with their assigned Provider at their current Provider agency; Member has been encouraged to talk about any concerns with their current Provider; The Member’s primary clinician will attempt to resolve the concern by exploring the basis of the concern with the Member. In situations where the concern is regarding the Provider, the primary clinician may act as an advocate for the Member and sit in with the Member to support them in discussing their concerns with their Provider; If the Member’s concerns are not resolved, the clinical team may support a request from the Member for a second opinion outside of the Provider agency; Member must agree to sign a release of information for the second opinion Provider and allow records to be released to that Provider prior to the scheduled appointment; and Authorization for a second opinion will be for a single assessment/evaluation with the expectation that the two professionals will communicate about recommendations for Member’s ongoing treatment with the primary Provider.

All requests for a second opinion outside of the assigned Provider agency should be submitted in writing to a Behavioral Health Plan Care Coordinator. The request should provide the following information:

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    

The Member’s current presentation; The Member’s mental health history; Member’s concern about recommended course of treatment by current Provider and documentation that Member has addressed concerns with the Provider; Documentation of attempts to resolve the Member’s concerns by referring the Member to another clinician within the agency; and Any additional information required by the relevant Behavioral Health Plan such as exceptional needs treatment authorization request forms and/or supporting documentation

A qualified Behavioral Health Plan representative will review the request using the exceptional needs authorization procedure and make a decision within 14 days. The Behavioral Health Plan representative will assist in identifying an appropriate Provider for the second opinion and authorize the service. The referring Provider is expected to send a signed release of information to the secondary Provider along with Member’s clinical records for review. The Behavioral Health Plan will attempt to honor the Member’s preferences about who will provide the second opinion where possible, but retains the right for a second opinion to be provided by a contracted Provider whenever available. The Behavioral Health Plan or the contracted Provider will inform the Member of the outcome of the second opinion request in writing. If the outcome is not what the Member requested, a Notice of Action may be issued to the Member in those instances where the outcome results in a denial, suspension, reduction or termination of a covered service. The Member will be informed of their right to appeal the decision through the established grievance and appeal process.

Member Privacy Provider policies and procedures must ensure that records are secured, safeguarded and stored in accordance with Provider contract and applicable ORS 413.171; ORS 414.679; SB 1580, Section 16; OAR 410-120-1360; OAR 943-014-0300 through 943-0140320; and OAR 943-120-0000 through 943-120-0200 and OAR 410-141-0180.

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Flexible Services Effective January 1, 2016, Health Share Flexible Services Policy CORP-17 requires the following criteria to be met for the use of Flexible Funding by contracted Providers. Requirements for Administering Flexible Services:       

Items and services purchased must not be otherwise Medicaid reimbursable. Funds are used when no other funding source is available to cover the cost of the service or item purchased (e.g. AMHI, ENCC). There are documented processes in place for authorizing funds, coordinating services and providing oversight. There is a defined mechanism for a Provider to request a flexible service at the individual Member level. Staff decision making authority is clearly outlined. All staff who administer flexible services are provided adequate education and training. All services and supports provided must be clarly related to achieve a treatment goal and document in the Member’s plan of care. All flexible services provided are tracked including number of Members served, services provided and associated costs.

The service plan must clearly identify the current clinical justification (i.e. behavioral issue, psychosocial stressor, and/or functional impairment including intervention to address goal) for the use of flex funds and explain how the specific service or item will address/ameliorate issues/stressor/impairment.

Clackamas County Procedures for Accessing Flex Funds 

Acceptable usage is as follows: o Rental Assistance:  

Move-in costs (first and last month’s rent, security deposits) not to exceed $1,500 Utilities (initial payments for startup or back bill pay) not to exceed $300 26

   

Payment for background/credit check not to exceed $100 Rent subsidy – 6 months maximum, not to exceed $700 per month. Basic furnishings not to exceed $500 Basic personal items not to exceed $150

o o o o

Guardianship for Adults in the AMHI Program Transportation assistance – bus tickets, bus passes, cab rides; Not to exceed $250 per year Home needs – lock boxes, door alarms, land-line or cell phone set-up; up to $100 one time only Alternative therapies not covered by Medicaid – Yoga classes, drumming, equine therapy, music/voice lessons, swimming, gym Memberships, sports fees and equipment, summer camps; not to exceed $250 per year o Activities through organizations such as Fuego and Ant Farm; not to exceed $250 per year o Stipends for respite by natural supports not to exceed $50 per day. Not to exceed $500 per year. 

Providers with a flex fund contract with Clackamas County: Providers submit an invoice by the 10th of the month following the month flexible services were provided. The invoice shall include the Member OHP ID number, date of service, the total amount for each service provided and the total amount due for all flexible services provided during the month. Invoices with back-up shall be submitted electronically to [email protected]. Designate the Providers name in the subject of the e-mail. Within thirty (30) days after the receipt of the bill, Clackamas County shall pay the amount requested to the Provider.



Providers without a flex fund contract with Clackamas County serving a Health Share/Clackamas County Member: Contact the following supervisors to access flexible funding for these Members: o Adults: Jeff Cotta: 50-742-5348 o Children: Allyn LaTorre: 503-742-5937 o Substance Use Providers: Casey Palmer: 503-742-5968

Multnomah County Procedures for Accessing Flex Funds 

Flex Funds Availability: Flex Funds may be available for Members in Level D ICM or ACT services, to assist with a mental health diagnosis where the use of those funds could divert from higher levels or care, prevent decompensation, assist

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environmental stability enhance consumer and family engagement, and/or increase independence from formalized services. Flex fund purchases must be tied to the consumer’s treatment plan. Flex funds should only be used when no other source of funding is available to cover the cost of the item purchased. 

Flex Fund Billing Process: Providers submit an invoice in the month following the month flexible services were provided. The invoice shall include the Member OHP ID number, date of service, and the total amount for each service provided and the total amount due for all flexible services provided during the month. All required back-up documentation shall be submitted with each invoice



Flex Fund Usage: Examples of Flex Fund uses are listed below, uses are not limited to the listed items. All purchases must fit the criteria in the Availability section. o o o o o o o o o

Rent Transportation Utilities Support Group/ Activity Participation Education and Training for the Consumer Critical Home Improvements Food, clothing ID Card Storage Fees

Washington County Procedures for Accessing Flex Funds 

Distribution of Funds: o Funds are allocated through the contract to specific Provider agencies. The Provider will seek reimbursement for these expenses through invoices to the County. o Funds will be allocated based on the number of Members in each service area, historical allocations and specific funding awards.

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o Providers without flex fund contracts who have authorization to treat Health Share Washington County Members should contact the following supervisors to access flexible funding for these Members:    

Adults: Ava Mitchell (503)846-4574 Children: Maureen Seferovich (503)846-3161 Substance Use Providers: Kathy Prenevost (503)846-4432

Monitoring of Approvals/Supervisory Oversight: o Contracts with Provider agencies include guidelines for the expenditure of these flexible funds. Provider agencies are expected to educate staff on the appropriate use of funds. At the time of submission, requests for reimbursement should include supervisor signature to ensure that oversight of expenditures is occurring. o Provider shall manage the utilization of funds in such a manner as to ensure funds are available for each service area described above and that funds remain available throughout the contract period.



Use of Funds: o Training and Education for Health Improvement and Management: Classes, curriculum, etc. o Self-Help or Support Group Activities o Care Coordination, Navigation, Case Management Activities in Support of the Individual, not covered by Medicaid: Flexible supports such as food, recreational activities, clothing, ID cards, storage fees, etc. These funds should only be utilized when all other resources have been ruled out as options and the Member is likely to deteriorate without the support. o Home/Living Environmental Items or Improvements: improvements to address a particular health condition o Transportation Not Covered under Medicaid o Programs to Improve General Community Health o Housing Supports Related to Social Determinants of Health: shelter, utilities, critical repairs, etc.

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Code & Authorization Guides The Behavioral Health Plans maintain a Regional Authorization and Code Guide, attached as Appendix C on the PH Tech CIM. The Behavioral Health Plans maintain a set of non-billable, or encounter only, codes that are allowable with many authorization types. These codes are offered as a way to capture the additional services provided or offered that are not billable using CPT or HCPCS codes. Providers should refer to their authorization structure to confirm if these codes are available for use. Please refer to Appendix D: Frequently Asked Questions about 90899 Codes.

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Billing, Service Authorization and Claims Management Health Share of Oregon and the Behavioral Health Plan Partners work with a Third Party Administrator, Performance Health Technology (PH Tech), for authorization and claims management. The Community Integration Manager (CIM), also referred to as the Portal, is the online tool offered by PH Tech for the submission and management of service authorizations; it can also be used to manage adjudicated claims. Detailed instructions for accessing CIM can be found on the Health Share of Oregon ‘For Providers’ web page.

General Process Overview for Claims and Billing Check Benefits/Eligibility Confirm Current Member Benefits & Eligibility

Note assigned RAE (if prior authorization for service is required)

Authorization Enter Self Authorization via CIM

OR

Call assigned RAE if service requires prior authorization

Submit Claims Submit Electronic Claims to PH Tech (preferred)

OR

Mail Paper Claims to PH Tech

Receive Payment and/or Voucher Recieve Payment via PaySpan EFT or Paper Check

AND/OR

Receive Voucher with Claim Line Adjudication Detail

Direct any questions to desingated RAE Bililng Support Multnomah Billing Support

Clackamas Billing Support

Washington Billing Support

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Service Authorizations For most general outpatient services, Providers may self-authorize directly in CIM. Please refer to Appendix E: CIM Provider Tools. For services that require prior authorization, Providers should work with the appropriate County Behavioral Health Plan Partner to request authorization. This process often requires the completion of a request form and the submission of clinical documentation. Please refer above to the section, “Services Requiring Pre-Authorization,” or contact the specific County Behavioral Health Plan Partner for additional information on requesting services that require prior authorization. Claims Submission and Adjudication Providers may submit claims by paper or electronically to PH Tech. The preferred method of claims submission is via electronic data interchange (EDI). For questions on electronic claims submission, please contact PH Tech’s EDI Team via email at [email protected] or by phone at 503-584-2169, option 1. Paper claims will be accepted on original copies of the current CMS (HCFA) 1500 claim form. Photocopies of this form will not be accepted. Paper claims may be mailed to: Health Share of Oregon PO Box 5490 Salem, OR 97304 Please limit claims to services provided by one provider per claim. If your agency provides services to Health Share members for both mental health and SUD, please limit each claim to services for only mental health or only SUD services. SUD claims will be required to have a program tag to identify that claim as an SUD claim. Paper claims: Box 24J on the CMS 1500, the top/shaded portion of that field, please enter “CD”. Electronic claims: Please enter “CD” in the 2310B loop (REF segment, Secondary ID). In addition, it is best practice to submit a test file to assure that the program tag is being sent correctly. Please contact the EDI Team (contact information above) to test your electronic file. You may also contact Performance Health Technology Account Representative, Rachel Ganzon, with questions. She may be reached at [email protected] or 503-584-2107.

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Timely Filing for Claims and Authorizations    

Claims must be received within 120 days from the date of service, when Health Share of Oregon is the primary payer. Claims received outside of this timeline will be denied. When Health Share of Oregon is the secondary payer, claims must be approved by the primary payer and submitted with the primary payer’s explanation of benefits (EOB) within 365 days from the date of service. Providers have up to 365 days to request the reprocessing of a claim that was denied in error. For self-authorized services, Providers must submit an initial authorization into CIM no more than 45 days from the first date of service.

National Correct Coding Initiative Health Share of Oregon adheres to the National Correct Coding Initiative (NCCI) edits for claims adjudication. Information about the National Correct Coding Initiative and the related edits can be found on the CMS National Correct Coding Initiative Edits website.

Corrected Claims Provider requests to change required data elements to a claim cannot be accepted via email that is submitted either directly to PH Tech staff or via CIM link. Instead, Providers are required to submit a corrected claim reflecting needed changes either by paper or electronically as applicable. Below is a list of example data elements that cannot be changed based on email submitted either directly to PH Tech staff or via CIM link (this list is not exhaustive):          

Provider name/Tax ID/NPI Billing Provider name/Tax ID/NPI Plan/Provider/billing Provider/location address From and To Dates Of Service Diagnosis Code CPT Code Modifier Diagnosis Pointer Units National Drug Code (NDC) 33

Provider is encouraged to continue to use the CIM link for the following types of communication (this list is not exhaustive):     

Providers requesting adjustment to Authorization information Providers relaying information about patient/Member eligibility (retro changes) Claim status questions Provider questions concerning how decisions are made to process and pay claims, including fee schedule, benefits, edits, etc. Provider request to VOID a claim

How to submit a corrected claim: 1. If submitting a corrected claim by paper, please do not over-write or handwrite changes to the original claim as these will not be accepted. 2. Create a new claim with applicable changes, noting on the top margin that the claim is a corrected claim. 3. Submit the paper claim as you would a new claim. 4. If submitting a corrected claim through electronic billing, the following loop information should be referred to: Loop 2300 Claim Information  Segment CLM05-03 Claim Frequency Type Code - inserting a value of ‘7’ indicates that the claim is are placement of the original 

Segment REF-Payer Claim Control Number (these two segments correspond to CMS 1500 form, box 22a and 22b) REF01 – Reference Identification Qualifier, inserting a value of ‘F8’ indicates Original Reference Number REF02 – Reference Identification or Payer Claim Control Number, the original claim number should be listed

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Credentialing & Re-Credentialing Requirements Organizational Providers Providers are expected to retain active policies and documentation listed below at all times while contracting with Health Share. Providers are encouraged to send renewal documentation to the OHA credentialing databank at [email protected]. Health Share may also ask Providers for this documentation upon expiration, as a part of ongoing monitoring or at time of recredentialing. Re-credentialing occurs between every 2-3 years at the discretion of Health Share. Provider will be notified upon contracting with Health Share of the date of next re-credentialing and will be sent the necessarily paper work prior to that date. Effective January 1, 2017, documentation that will be required to at time of re-credentialing: 

An Organizational Provider Credentialing Application and Attestation (Provided by Health Share)



As applicable, an active health care accreditation and/or site visit report (conducted by OHA or Health Share) for each facility covered in the Provider’s contract. Examples of accreditation includes: o Certificate of Approval o CARF accreditation o JCHAO accreditation



As applicable, active licensure for facilities covered in the Provider’s contract. Examples of licensure include: o DEA for any facilities that provides covered maintenance and detox services to Health Share Members. o Current OHA licensure(s) for any facility that provides covered adult residential treatment services to Health Share Members. o Current DHS licensure(s) for any facility that will be providing covered child residential treatment services to Health Share Members. o Any other current health care related licensure granted to any facility that will be providing covered services to Health Share Members. 35



Face sheet showing active liability insurance with: o General facility coverage with at least $1M per occurrence/ $3M aggregate coverage o Professional liability coverage with at least $1M per occurrence/$3M aggregate coverage o Worker’s Compensation coverage (no minimum required)



Policy that states that no Member shall be restrained or secluded in any manner.



Credentialing Policy that outlines the credentialing procedures for the internal employees of the organization.

Credentialing requirements for licensed Providers covers the following regulations:       

42 CFR 438.214 Provider Selection 42 CFR 455.412 Verification of Provider Licenses 42 CFR 455.422 Appeal rights 42 CFR 455.440 NPI 42 CFR 438.12 Non-discrimination 42 CFR 455.436 Federal database checks OAR 410-141-3120(4) Non-discrimination and re-credentialing

Credentialing requirements for unlicensed Providers align with the following requirements: 

“Qualified Mental Health Associate” or “QMHA:” o Is a person delivering services under the direct supervision of a QMHP. o Has a bachelor’s degree in a behavioral sciences field or combination of at least three years’ relevant work, education, training. o Understands Mental Health Assessment, treatment and service terminology and how to apply the concepts o Can provide Psychosocial Skills Development and implement interventions prescribed in a Treatment Plan within their scope of practice.

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

“Qualified Mental Health Professional” or “QMHP:” o Is a Licensed Medical Practitioner (LMP) or any other person meeting the following minimum qualifications:  Has earned a graduate degree in psychology, bachelor’s degree in nursing and licensed by the State of Oregon, graduate degree in social work, graduate degree in behavioral science field, graduate degree in recreational, art or music therapy, or a graduate degree in Occupational Therapy and is licensed by the State of Oregon. 



Has education and experience which demonstrates the competencies to identify precipitating events; gather histories of mental and physical disabilities, alcohol and drug use, past mental health services and criminal justice contacts; assess family, social and work relationships; conduct a mental status examination; document a DSM Five-Axis Diagnosis; write and supervise a treatment plan; conduct a Comprehensive Mental Health Assessment; and provide individual therapy, family therapy, and/or group therapy within the scope of their training.

Other unlicensed Providers include any person not meeting either the definition of a QMHP or QMHA. This type of Provider shall have documentation that shows that that person’s education, experience, competence, and supervision are adequate to permit the person to perform his or her specific assigned duties.

Individual Providers Providers are expected to retain active policies and documentation listed below at all times while contracted with Health Share. Health Share may ask the Provider for this documentation upon expiration, as a part of ongoing monitoring or at time of recredentialing. Re-credentialing occurs between every 2-3 years at the discretion of Health Share. Provider will be notified upon contracting with Health Share of their date of next re-credentialing and will be sent the necessarily paper work prior to that date. Effective January 1, 2017, documentation that will be required to at time of re-credentialing: 

An Oregon Practitioner Credentialing Application and Attestation (provided by Health Share)

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    

Face sheet showing active liability insurance with professional liability coverage with at least $1M per occurrence/$3M aggregate coverage If applicable, current DEA Current licensure(s) for services provided to Health Share Members If applicable, current board certification(s) for services provided to Health Share Members PCPs should contact Health Share for additional requirements

Fraud, Waste & Abuse Effective System for Routine Monitoring and Identification of Fraud, Waste and Abuse The best way for Providers to reduce risk of Fraud and Abuse is to maintain a robust process for monitoring claims. The Behavioral Health Plans can provide technical assistance regarding frequency and minimum content for internal agency billing accuracy audits. Reporting Providers will promptly (within 5 business days) refer all verified and/or suspected cases of fraud and abuse, including fraud by their employees and subcontractors, to the Medicaid Fraud Control Unit (MFCU) or to the DHS Provider Audit Unit and to the relevant Behavioral Health Plans of Health Share. Providers will cooperate with and permit the Behavioral Health Plans, Health Share, the MFCU and/or DHS to inspect, evaluate, or audit books, records, documents, files, accounts, and facilities, as required to investigate an incident of fraud and abuse. The Behavioral Health Plans and Health Share reserve the right to impose sanctions, up to and including termination of contact, with any individual or organization found to have committed fraud or abuse. Medicaid Fraud Control Unit of Oregon Office of the Attorney General 1515 SW 5th Avenue, Suite 410 Portland, OR 97201 PHONE: (971) 673-1880 FAX: (971) 673-1890

Oregon DHS Provider Audit Unit 2850 Broadway St. NE Salem, OR 97303 PHONE: (503) 378-3500 FAX: (503) 378-3437

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When making a report, Provider will include the following information:      

Provider Name, Oregon Medicaid Provider Number, Address and Phone Type of Provider Source and nature of complaint The approximate range of dollars involved The disposition of complaint when known Number of complaints for the time period

Examples of reportable incidents Reportable incidents may include, but are not limited to:        

Providers who consistently demonstrate a pattern of intentionally reporting encounters or services that did not occur as evidence by complaint or focused encounter data audits showing encounters billed without appropriate documentation. Providers who consistently demonstrate a pattern of intentionally reporting overstated or up-coded levels of service. Any verified case where the Provider intentionally billed Health Share more than the usual charge to non-Medicaid recipients or other insurance programs. Any verified case where the Provider purposefully altered, falsified, or destroyed clinical record documentation for the purpose of artificially inflating or obscuring his/her compliance rating and/or collecting Medicaid payments otherwise not due. Providers who intentionally make false statements about the credentials of persons rendering care to OHP Members. Providers who intentionally fail to render medically appropriate covered services that they are obligated to provide OHP recipients under their contracts with the Coordinated Care Organization Agreement and OHP regulations. Providers who knowingly charge OHP Members for services that are covered or intentionally bill an OHP Member the difference between the total fee-for-service charge and County’s payment to the Provider. Any case of theft, embezzlement or misappropriation of Title XIX program money.

Additional Requirements Organizational Providers ONLY Policies and Procedures Provider will have fraud and abuse policies and procedures in accordance with contract expectations. Provider will review its fraud and abuse policies annually. Participation of Suspended or Terminated Providers The following persons, or their affiliates as defined in the Federal Requisition Regulations, may not provide covered services to Health Share Members:  Persons who are currently suspended, debarred or otherwise excluded from participating in procurement activities under the Federal Requisition Regulation or from participating in non-procurement activities under regulations issues pursuant to Executive Order No. 12549 or under guidelines implement such order.  Persons or programs that are currently suspended or terminated from the Oregon Medical Assistance Program.  Persons or programs that are currently excluded from Medicaid participation and listed on the federal EPLS and/or Office of Inspector General Medicaid exclusion list (http://exclusions.oig.hhs.gov). Providers shall not refer Health Share Members to persons or organizations whose participation in Medicaid or Medicare programs has been suspended or terminated. Providers will not knowingly:  Allow a person whose participation in Medicaid or Medicare programs has been suspended or terminated to serve as a director, officer, partner; or  Enter into an employment, consulting, or other agreement with a person whose participation in Medicaid or Medicare programs has been suspended or terminated for the provision of items and services that are significant and material to Health Share’s service agreement Organizational Providers shall perform monthly exclusion list checks of all employees, contractors, volunteers, interns and any other persons providing, arranging, or paying for behavioral health services paid in whole or in part with Medicaid dollars, against the OIG List of Excluded Individuals/Entities (LEIE) and the SAM/EPLS database. Provider will maintain monthly verification of this check.

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Whistleblower Protection Retaliation for good faith reporting of perceived or suspected violations of law, regulation, or state policy or procedure, or for participation in an investigation of an alleged violation is strictly prohibited. Any employee, supervisor, manager or executive who commits or condones any form of retaliation, retribution or harassment against a reporting employee can be held accountable in a review. Agency policies should take appropriate measures to safeguard employees against retaliation.

Additional Requirements COA Providers ONLY Employee Code of Conduct Provider must maintain a written employee code of conduct that addresses conflicts of interest; safeguards protected health information (PHI); and maintains compliance with all applicable laws and regulations, Fraud, Waste and Abuse policies, internal investigations, and employee education and accountability. Mandatory Training Provider must provide and document appropriate orientation training for each program staff, or person providing services, within 30 days of the hire date on fraud, waste and abuse in Federal Medicaid and Medicare programs compliant with OAR 410-120-1380 and 410-120-1510.

Additional Requirements Providers Receiving $5 Million or More Annually (total of all OHP contracts combined) ONLY Policies and Procedures Provider will establish written policies for all employees of the Provider (including management), and of any contractor, subcontractor, or agent of the Provider, that provide detailed information about the False Claims Act established under sections 3729 through 3733 of title 31, United States Code, administrative remedies for false claims and statements established under chapter 38 of title 31, United States Code, any Oregon State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblowing protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs (as defined in section 1128B(f)).

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Employee Handbook Provider will include in any of its employee handbooks a specific discussion of the laws described in the policies and procedures section above, the rights of the employees to be protected as whistleblowers, and the Provider’s policies and procedures for detecting and preventing fraud, waste, and abuse.

Overpayment Recoveries Section 6402(a) of the Affordable Care Act (Social Security Act 1128 J (d)) requires agencies that have received an overpayment from Medicare or Medicaid to report and return the overpayment, including a written notice explaining the reason for the overpayment. Overpayments must be reported and returned by the later of 60 days from the identification of the overpayment or the date of the applicable cost report. Affiliated Health Plan Partner’s define the date of notice of overpayment as the following: (1) The date on which any Medicaid agency official or other State official first notifies a Provider in writing of an overpayment and specifies a dollar amount that is subject to recovery; (2) The date on which a Provider initially acknowledges a specific overpaid amount in writing to the Medicaid agency; or (3) The date on which any State official or fiscal agent of the State initiates a formal action to recoup a specific overpaid amount from a Provider without having first notified the Provider in writing A. Provider Agency Voluntary Self-Report of Overpayment i. Voluntary reports of overpayment can be made either to the Third Party Administrator or directly to Affiliated Health Plan Partners. B. Notification of Provider Agency i. When preliminary overpayment findings are identified through the third party administrator, encounter data audit, or data mining, an overpayment communication is sent to the Provider agency with a letter requesting the agency respond within 14 days from the date of the letter or an agreed upon individualized timeline. Provider agencies are given an opportunity to agree or disagree with preliminary findings. If the Provider agency is in disagreement with one or more finding, they must provide supporting documentation to refute the finding. C. The Provider agency will be communicated to the agency through a “final determination” letter along with repayment amounts, instructions, and a timeline of 30 days for repayment.

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Audit Rights of Health Share and Health Plan Partners Providers will be subject to periodic Compliance/Quality Management audits to assure compliance with all Federal, State and local laws. Providers shall cooperate by providing access to records and facilities for the purpose of Compliance/Quality Management reviews by Health Share and the Behavioral Health Plan Partners. Required documentation shall be made available upon request. Requested documentation may include, but is not limited to the following: Fraud, Waste and Abuse, Credentialing, Member Rights, Grievances and Appeals, and Critical Incidents.

Required Submissions Mental Health Access Report The regional mental health access report measures access to non-urgent, urgent and emergent outpatient mental health assessment and treatment services for Health Share Members. The report captures the number of requests for an assessment or a level A, B, or C covered mental health service, and the number of appointments that were offered over the preceding calendar month within the prescribed access timelines. Routine Outpatient Mental Health Provider agencies are required to provide a monthly report detailing access to outpatient mental health services that are not predicated upon participation in other services (residential, A & D treatment, etc). This report is due on the 15th of each month. The report can be made at: www.surveymonkey.com/s/ComprehensiveMentalHealthAccessReport. This information is required for all Health Share Providers. If you do not serve members in one of these counties, you will be required to enter 0. Please note that this report only captures members whose mental health services are not predicated upon participation in other specialty services (such as Residential, A & D treatment, etc.).

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Mental Health Outcomes: Outpatient Case Rate Providers & Contracted Outpatient Fee-for-Service Providers (self-authorizing) The following information on outcomes applies to all contracted Outpatient Case Rate Providers and Contracted Outpatient Fee for Service Providers (self-authorizing). Outcomes measurement and tracking requirements do not apply to Exceptional Needs Outpatient Providers and Non Contracted Single Case Agreement Providers. Mental Health Outcomes Measurement Performance and Standards Organizational Providers as outlined above are expected to utilize a Health Share-approved outcomes instrument to aid in treatment planning. Providers are able to self-select another outcomes assessment tool approved by a subcommittee of the outpatient Provider association. Agencies shall determine how the tool will be used most effectively, and how information will be reported to the Behavioral Health Plans. It is the expectation that organizational Providers use the identified outcomes tool with their Health Share Member population. A Collaborative Outcomes Resource Network (ACORN) is the current identified outcomes tool for many outpatient programs. The website for ACORN general information is: https://psychoutcomes.org/bin/view/COMMONS. The Behavioral Health Plans hold WebEx meetings with Center for Clinical Informatics twice each month. Providers using the ACORN are encouraged to attend to get questions answered and to help improve the tool. If you do not have current representation on the ACORN group please contact the Regional Behavioral Health Outcomes Coordinator to get added to the list for notifications and meeting information.

Case Rate Providers Performance Expectations A key element of health care transformation is moving away from paying for volume to paying for value. The fee-for-service payment model may create an incentive to provide as many services as possible, while case rates support a shift in focus to achieving outcomes. Case rates are meant to provide flexibility to the Provider and Member, in order to ensure that mutually established treatment outcomes are met. Ultimately, case rates will contribute to achieving the Triple Aim of better care, better 44

health and lower costs. Case rates are an AVERAGE payment for all of the Members served at a given level of care. By definition, some individuals will require MORE care and some will require LESS care in order to achieve the intended outcomes. Case rates are NOT a fixed budget for an individual Member. Performance expectations include, but are not limited to the following: 1. Provider shall maintain required access for routine, urgent and emergent appointments within timelines per the access requirements outlined in Regional Access Report. 2. Provider shall ensure follow-up care for Members after discharge from a hospital for mental illness within seven (7) days of hospital discharge. 3. Provider shall assign Levels of Care (LOC) accurately and with inter-rater reliability. 4. Provider shall ensure Members are receiving the frequency and intensity of service that is clinically indicated by the consumer's LOC. 5. Provider shall improve outcomes by the use of approved outcomes tools. 6. Provider shall provide 24-hour, seven day a week telephonic or face-to-face crisis support coverage as outlined in OAR Chapter 309. Details of the case rate levels of care and case rate payment structure are outlined in Appendix F: Global/Case Rate Changes for Providers of the Mental Health RAEs of Health Share of Oregon. For information on required Health Share reports regarding case rate management, refer to Appendix G: Case Rate Reports Technical Manual.

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Risk Corridor Reconciliation Process A regional risk corridor will be calculated to evaluate case rate payments in relation to the fee-for-service equivalent value of the encounterable services. There will be one regional risk corridor effective 7/1/16 with an 80% floor and a 125% ceiling. The regional risk corridor will be calculated annually and the first calculation will occur approximately November 1, 2017. Fee-for-Service equivalents are identified on the regional fee schedule. Please note that if a Provider’s usual and customary billed rate is lower than Health Share’s fee-for-service equivalent, then the Provider’s usual and customary billed rate will be used to calculate the risk corridor.

Day Treatment Clinical Services Providers Provider will ensure consistent coordination and communication with other agencies including Child Welfare, OYA and Juvenile Justice. Minimally, these communications should include monthly treatment progress reports and invitations to treatment reviews and other relevant meetings. Service planning and provision will be child and family-centered. The individualized needs of the child and family will determine the type, intensity, and frequency of services provided. Provider will demonstrate a philosophy of families as equal partners and family involvement and participation in all phases of orientation, assessment, treatment planning and the child's treatment by documentation in the clinical record. Provider will have a policy and procedure on family involvement that includes specific supports to family Members that address and prevent barriers to family involvement. Provider will ensure that a primary focus of treatment is assisting Members and their family Members in transferring newly developed skills to the home and community settings. Specific services may include comprehensive mental health assessment; individual, group and family therapy; multi-family treatment group; parent or child skills training; pre-vocational/vocational rehabilitation; behavior management; activity and recreational therapy; physical health care coordination; interpreter services; case management; clinical services coordination; and consultation. Provider will coordinate referrals to early intervention as appropriate and maintain coordination with early intervention services. Services shall be provided in the home, community or discharge school setting as clinically indicated. Provider shall maintain regular contact with the Behavioral Health Plan Care Coordinators and will ensure they are invited with sufficient advance notice to treatment reviews and IEP meetings, and that they consistently receive treatment updates. Provider shall provide at least four (4) hours of services each working day to consumers enrolled in preschool through fifth grade programs

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and at least five (5) hours of services each working day to consumers enrolled in sixth through twelfth grade programs. These services will be billed per diem using HCPC Code H0037. Provider shall ensure that Care Coordinators are routinely provided with written clinical documentation including mental health assessment and treatment plan, medication management notes and treatment plan updates. These should be provided minimally on a quarterly basis. In the event that an enrolled Member’s absence or transition precludes Contractor’s delivery of the minimum number of per diem hours, Provider may deliver services to the absent or transitioning consumer on an hourly basis. Provider shall document and submit claims for services provided on an hourly basis. These services will be billed on an hourly basis using HCPC Code H2012. Provider shall participate in Child and Family Team meetings to occur no less frequently than every 30 days. These meetings may be held at the facility, but may also occur in the family’s home or elsewhere in the community that is convenient for the family. Child and family teams will include family Members including involved biological family Members, or foster parents, the Behavioral Health Plan Care Coordinator, involved Provider and agencies such as Child Welfare, the child when appropriate, and any other natural, formal, and informal supports as identified by the family. Individualized Service Coordination Plans shall be developed by a child and family team and subsequent revisions to be done every 90 days. The child’s individual treatment plan shall be integrated into the Service Coordination Plan. Provider shall provide active, focused case management beginning at the date of admission which will link the child to appropriate community-based services delineated in the service coordination plan, coordinate care with pre-admission and post-admission agencies, and develop and implement discharge plans. Discharge planning shall include applicable education service district or school district to coordinate and provide needed educational services for the children after discharge, and these discussions should begin at intake. Final discharge planning meetings should occur at the child’s discharge placement to accommodate teachers and other staff from the new setting. The applicable school district or education service district representative shall be invited to the intake and all subsequent treatment reviews and IEP meetings. Provider shall include the parent and/or guardian in discharge planning and reflect their needs and desires to the extent clinically indicated. Provider shall ensure that admitted children shall have, or have been, screened for an Individual Education Plan, Personal Education Plan or Individual Family Service Plan.)

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Provider will coordinate with education staff to ensure that IEP’s are routinely updated. Provider will utilize a clinical model that is evidence-based and integrated into all aspects of milieu treatment, and will not rely on a point system for behavior management. If a point or level system is clinically indicated for a specific Member, it will be individualized and justified in the Member’s clinical record. Staff supervision will incorporate a focus on the ongoing implementation of evidence based practices. Provider shall, with involvement of parents, caregivers, and the child, develop Service Plan (SP) as defined in 309-022-1505(86). The SP shall include behavioral support services according to OAR 309-022-0140(3)(f) and 309-022-0165. Provider shall provide at least one face-to-face contact per month with a Licensed Medical Practitioner (LMP) to each child and adolescent served under this Contract. Additional medication management services may be provided by a psychiatric nurse practitioner based on medical necessity. Medication management is included in the per diem rate for services. To ensure a smooth and coordinated transition for the Member from one school setting to the next, Provider shall obtain the appropriate release and submit mental health information to the receiving school district using the appropriate. Provider shall cooperate with the Wraparound and/or Behavioral Health Plan-designated care coordinator(s) for children requiring admission to; and discharge from acute, sub-acute, and less restrictive levels of care as medically necessary.

Psychiatric Residential Treatment Services Providers Health Share members in Psychiatric Residential Treatment Services are a priority population for Wraparound Care Coordination, which is a team-based planning process for youth with complex needs. Provider shall participate in Wraparound care coordination and Wraparound team meetings for youth in their services. . Provider shall participate in Wraparound Team meetings to occur no less frequently than every 14 days, and may occur more frequently. Individualized Plans of Care shall be developed by the Wraparound team, and subsequent revisions will be done at least every 14 days and as needed. Wraparound teams will include: family Members including involved biological family Members, or foster parents, the Health Share Care Coordinator, representatives from the school district or appropriate Education Services District, involved Providers and agencies such as Child Welfare, the child when appropriate, and any other natural, formal, and informal supports as identified by the family.

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A comprehensive mental health assessment will be completed for each resident that includes all relevant domains and includes strengths and needs assessment within each domain. Services shall be based on the comprehensive mental health assessment, shall be culturally and linguistically appropriate and reflect an understanding of the unique cultural background of the child and family, and shall be individually tailored in type, level and intensity to meet the individual Member and family’s needs. Individual service plans shall be developed and integrated with the Wraparound Plan of Care provided by the Health Share Care Coordinator. Service plans shall reflect integration of Provider’s clinical model and incorporate skill development, treatment that addresses the family system, and family involvement and education. Provider will demonstrate a philosophy of families as equal partners and include families in all phases of assessment, treatment and discharge planning, which will be evidenced by documentation in the clinical record, feedback from families and system partners, and/or interviews with treatment team Members and agency staff. Families and Members will be educated on the Provider’s clinical model and be provided assistance in generalizing learned skills to the home and community setting. Provider will have policies and procedures in place that support family involvement and identify, address and prevent barriers to their participation in treatment. Active, focused discharge planning will be provided beginning at the date of admission which will link the child to appropriate community-based services delineated in the plan of care, coordinate care with pre-admission and post-admission Providers and agencies, and develop and implement discharge plans. Discharge and transition planning will be done in collaboration with the Health Share Care Coordinator. Discharge planning shall include applicable education service district or school district to coordinate and provide needed educational services for the children after discharge. School districts shall be notified in advance of all discharge planning meetings and have at least 14-day notice of a child enrolling in their district (or as soon as length of stay permits). In the event that a child is discharged unexpectedly, Provider will make every effort to coordinate with the receiving school district to facilitate a smooth transition. Discharge instructions shall be part of the information given to the parent or guardian upon or prior to discharge. Discharge instructions include diagnosis, current medication and medical information, community treatment appointments and Provider information. In addition, Provider will ensure that intervention strategies to manage the child are given to the parent or guardian at the time of discharge and in language the caretaker can understand, prior to receiving a discharge summary. Prior to discharge, Provider will ensure that family/guardian has a written safety plan developed by Provider or Member’s community treatment Provider. Services are to be evidence-based and include promising practices whenever evidence exists appropriate for children with severe mental, emotional, or behavioral disorders. Specific services to include: milieu treatment integrated with individual services and

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supports plan; psychiatric assessment; medication evaluation and management; individual, group and family therapy; multi-family treatment group; parent and child skills training; pre-vocational/vocational rehabilitation; speech, language and hearing rehabilitation services; behavior management; activity and recreational therapy; nutrition; physical health care services and coordination; interpreter services; case management; clinical services coordination; and consultation. Provider will ensure that admitted youth have at least weekly access to psychiatry and medication evaluation and management. Provider will develop written agreements with DHS Child Welfare, Oregon Youth Authority and the Juvenile Department to include expectations for coordination/communication. Minimally, these communications should include monthly treatment progress reports. If a child’s Service Coordination Plan indicates DHS or OYA placement is required at discharge, DHS or OYA shall be informed of the plan on admission or as soon as the placement need is identified (minimum of 30 days prior to the planned discharge date). Provider shall inform Health Share and the child’s legal guardian within one working day of reportable incidents as defined in OAR 309-022-0105(79).

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