Applied Behavior Analysts (ABA) Provider Orientation

Objectives

Overview of Horizon Behavioral Health and

ValueOptions

Qualified ABA Services and

Covered Treatment Providers

Covered ABA Codes/AMA

CPT Codes

Claim Submission

Procedures

Transition of Care and Authorizations

Quality Management

Credentialing, Recredentialing and

Contracting

Contact Information

Questions and Answers

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Overview of Horizon Behavioral Health

and ValueOptions

• Effective July 1, 2014, Horizon Behavioral Health transitioned the

management of its behavioral health services to ValueOptions®

Inc., from Magellan Behavioral Health, Inc.

• Transition allows you to better serve your patients, by offering a

greater integration of all behavioral and medical health services,

including benefits for Applied Behavior Analysis (ABA).

• Horizon Behavioral Health will:

• Provide utilization management for ABA services for Horizon

BCBSNJ membership

• Have a specialized ABA team working with ABA providers to

handle all requests for ABA services

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Horizon Behavioral Health Operations

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250 Century Parkway Mount Laurel, NJ

08054

Three Penn Plaza East Third Floor

Newark, NJ 07105

Co-located Staff

Loc

atio

n

103 Eisenhower Pkwy First Floor

Roseland, NJ 07068

10 British American Blvd

Latham, NY 12110

3800 Paramount Pkwy

Morrisville, NC 27560

Customer Engagement

Center

National Operations Center

Claims Processing Center

Claims Support Customer Service

Grievance/Appeals

Claims Clinical

Quality Management Clinical

Account Management Medical Director

Clinical Customer Service Provider Relations

Se

rvic

es

ValueOptions’ National Footprint

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34 Million Members 130,000 Provider locations

Under 100,000 Members

100,000 – 500,000 Members

500,000 – 1,000,000 Members

1,000,000 –2,500,000 Members

Over 2,500,000 Members

Engagement Centers

Corporate Headquarters

National Technology Center

National Operations Center

Qualified ABA Services

and Covered

Treatment Providers

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299.0 Autism Spectrum Disorder (DSM-5) determined by a

qualified provider, which is:

• MD;

• Licensed and credentialed psychologist;

• Nurse Practitioner;

• Physician Assistant, or

• as permitted by state and/or federal law

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Autism Spectrum (ASD) Diagnosis Determinations

Covered Treatment Providers

Qualified Autism Spectrum (QAS) Provider designs, supervises, or

provides treatment

• Board Certified Behavior Analyst (BCBA)

• Board Certified Behavior Analyst – Doctorate (BCBA-D)

• Licensed Mental Health Professional with specialization

QAS Professional provides treatment, assessment, and supervision

• Board Certified Behavior Analyst (BCBA)

• Board Certified Assistant Behavior Analyst (BCaBA)

QAS Technician provides care under the supervision of a BCBA

• Typically has a Bachelor degree in Social Work, Psychology,

Counseling, teaching or closely related field with experience in

applied behavior analysis

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Covered ABA Codes/

AMA CPT Codes

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Covered ABA Codes

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If authorization dates of service extend past July 1, claims will be paid if older codes are used.

Covered ABA Codes, cont’d.

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Covered ABA Codes, cont’d.

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New AMA CPT Codes

American Medical Association (AMA) recently published

CPT Category III temporary codes for Adaptive Behavior

Assessments & Treatments

• Published as temporary to allow for data collection for

emerging technology, services and procedures

• Becomes effective beginning on July 1, 2014

• Features greater detail on services provided to patients

• Identifies provider type delivering services

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New AMA CPT Codes

New codes distinguish by provider type:

• Physician

• Qualified healthcare professional [Board Certified

Behavior Analyst (BCBA)]

• Qualified technician under the direction of a physician

or BCBA or protocol established within a treatment plan

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New AMA CPT Codes

Old Codes and [policy] Process:

Using the prior HCPCS coding and consistent with the NJ

Department of Banking and Insurance Bulletin, Horizon BCBSNJ

provided coverage under the Autism Mandate for ABA

services when provided by a BCBA.

New [policy] Codes and Process Effective July 1, 2014:

Given the new detailed AMA codes now available, Horizon

Behavioral Health will begin honoring claims submitted for ABA services provided by qualified technicians for new treatment

plans if they meet specific criteria.

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Coverage Criteria for Qualified Technicians

Services provided by a technician must be provided under

the direction of a physician or qualified healthcare

professional and consistent with the protocol established in

the treatment plan.

• Claims must be submitted under Tax Identification

Number (TIN) of supervising physician or BCBA.

Six month treatment plan submitted by supervising provider

indicates a qualified technician will be administering the

services.

ABA services provided by qualified technicians will be paid

at a differential rate, reflecting the difference in expertise of

the provider delivering the services.

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Autism Code Resources

Additional information on the Autism codes on NaviNet.net:

• Horizon BCBSNJ’s Plan Central page

• Provider Reference Material page

Future updates in Blue Review

ValueOptions’ Network-specific Website:

• http://valueoptions.com/horizon/aba

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Claim Submission

Procedures

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Claim Submission Timelines

You may continue to submit ABA claims for treatment plans

that were authorized by Magellan Behavioral Health prior to

July 1, 2014 until those approved treatment plans expire

using the following codes:

• Autism diagnoses codes (299.00, 299.01, 299.10, 299.11, 299.80,

299.81, 299.90, 299.91)

• Healthcare Common Procedure Coding System Codes

(H0031, H0032, H0046, H2019)

• Treatment plans that begin or are approved as of July 1, 2104 must use the new CPT Category III temporary

codes.

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Claim Submission Guidelines

Submit claims with dates of services on or after July 1, 2014 to be

electronically to Horizon.

• After logging into NaviNet.net, mouse over Claim

Management and select CMS 1500 Claim Submission

If you are not able to submit electronically, you can send paper

claims to our new address:

Horizon BCBSNJ

Horizon Behavioral Health

PO Box 10191

Newark, NJ 07101-3189

(Current claims addresses should be used

for services through June 30, 2014)

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Transition of Care and

Authorizations

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Transition of Care

All services currently approved by Magellan will be honored

through expiration date of approval, even if extends

beyond July 1, 2014.

• ValueOptions has received from Magellan a copy of

your last submitted treatment plan.

Contact Horizon Behavioral Health at least two weeks prior

to the current approved treatment plan’s expiration date.

• 1-800-626-2212 or

1-800-991-5579 (for NJ State Health Benefits Program)

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ABA Assessment Authorization Process

• Providers should contact Horizon Behavioral Health to:

• Check member eligibility and benefit coverage relating to Autism

Spectrum Disorder and ABA services

Verification of Horizon BCBSNJ member benefits and eligibility available at

NaviNet.net

• Make sure all services receive review for medical necessity before

beginning services (e.g., assessment, initial and concurrent

authorization requests)

Confirmation of an Autism Spectrum Disorder diagnosis is required

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ABA Treatment Requests

Providers requesting continued treatment should complete and

submit an ABA Treatment Request and Treatment Plan Report via

fax at 855-241-8895 at least 1 week prior to the end of the

authorization period.

ABA Treatment Request forms (initial and concurrent) and ABA

Provider Progress Report Guidelines are accessible on the

ValueOptions.com provider website.

• http://valueoptions.com/horizon/aba

Medically necessary ABA treatment is authorized for a six month

period.

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ABA Treatment Request Form

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Autism Case Management Program

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We are offering telephonic case management to members

with ASD:

Licensed clinicians who are trained in autism answer calls

Ability to make referrals to other levels of care and

community resources

Members or providers can call with questions about a wide

array of topics related to autism

Quality Management

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Successful program model

• Existing enterprise-wide linkages and relationships

Complaint and grievance investigation and resolution

NCQA and URAC Case Management compliant

NCQA delegated entity

• Experience serving as the MBHO or as a delegated entity

Work across systems

• Support integrated medical and behavioral health services for

members

• Develop linkages for primary care physicians to access

behavioral resources

• Cross reference with pharmacy data

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Quality Management

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Quality Management and Improvement

National Quality Committee chaired by CEO

Shared client committee responsibilities

Chief Medical Officer nominated for and sits

on the NCQA Standards Committee

HEDIS monitoring, interventions and reporting

STAR rating Monitoring and interventions for

Medicare

Credentialing,

Recredentialing and

Contracting

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Recredentialing and Credentialing

ValueOptions will administer Recredentialing and Credentialing

processes for Horizon Behavioral Health

Credentialing standards comply with NCQA requirements

Credentials Verification Organization certified for ten out of ten

verification services

Detailed credentialing process:

• Practitioners – 30 days after a completed application is received

• Facilities – 90 days after a completed application is received

Primary source verification for all providers

Recredentialing cycle on three-year intervals

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Recredentialing

Horizon Behavioral Health providers with recredentialing due dates

on or after July 1, 2014 are receiving recredentialing notices from

ValueOptions.

Notices sent approximately 4-5 months prior to the

renewal due date.

All providers with recredentialing due dates between

January 1, 2014 and June 30, 2014 will or have received

recredentialing information from Magellan.

Magellan will be completing recredentialing for these

providers

If providers are credentialed by both Horizon and ValueOptions,

the earliest recredentialing date will apply.

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Recredentialing

Notification every three years through:

CAQH-Universal Provider Datasource (UPD) (for CAQH members)

• Uses system reminders to prompt providers to update and

attest to their information every 120 days

• Telephonic message via Provider Pulse 4 months prior to due

date that application is available

• Telephone, fax, e-mail (for paper submitters)

• Telephonic message via Provider Pulse 4 months prior to due

date that application is available

• Follow up email or fax approximately 1 week later with

instructions for accessing application in ProviderConnect (to access application, click on link titled “Provider Data Sheet”)

• 60 and 90 day reminder notices

Failure to respond to requests from CAQH or ValueOptions will

result in disenrollment from the network

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Credentialing

Practitioners required to complete ValueOptions Credentialing

Application Process, using one of following methods:

Complete online universal credentialing application offered by

Council for Affordable Quality Healthcare (CAQH) and give

ValueOptions your identification number to access information

Contact CAQH Help Desk with questions at 1-888-599-1771

Complete a ValueOptions paper application

Application available by calling Provider Services Line at

1-800-397-1630

Complete a New Jersey Universal Application

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Contracting

New Providers joining Horizon network will sign Horizon

contracts

ValueOptions administers contracting process

Providers interested in joining the Horizon BCBSNJ networks

or with questions on contracting process can call

1-800-397-1630, 8 a.m. to 8 p.m., Monday-Friday

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Overview of Operational Areas:

National Network Services (cont’d.)

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Overview of

ProviderConnect®

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ProviderConnect® Functionality

ValueOptions’ secure and HIPAA-compliant provider portal:

• Verify Member Eligibility

• Download and Print Authorization Letters

• View Authorizations

Note: Providers cannot use ProviderConnect to submit authorizations

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ProviderConnect® Registration Process

• New and Current ProviderConnect Users need to fax a completed

Account Request form to 1-866-698-6032 • Providers who already have a ProviderConnect account need to

submit a new form to request an additional login id to access Horizon

BCBSNJ member information

• Horizon BCBSNJ providers need to mark the box for Horizon Behavioral

Health Authorizations

• Providers who do not know their Provider ID can contact the Provider

Services Line at 1-800-397-1630, 8 a.m. to 8 p.m., Monday through Friday

• Account Request form located at

http://www.valueoptions.com/providers/Forms/Administrative/Online_

Services_Account_Request_Form-Editable.pdf

• If there are any questions on the form, providers can contact the EDI

Helpdesk at 1-888-247-9311, 8 a.m. to 6 p.m., Monday through Friday

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ProviderConnect ® Resources

ValueOptions.com > Providers>ProviderConnect

• Free demonstration:

http://www.valueoptions.com/PMC_prototype/ProviderConne

ct/pvd.html

• Quick Start Guide and Comprehensive User Guide

• Short Video Tutorials:

Viewing Member’s Eligibility, Submitting Authorizations, Submitting

an Inpatient or Higher Level of Care Request, Responding to

Requests for Additional Clinical Information, Recredentialing

Upcoming webinars:

• July 16, 2014 / 10-11 am Overview of ProviderConnect

• Customized training - Scheduled at your convenience

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Contact Information

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Communication Channels

Email Alerts

Webinars

Video Tutorials

Monthly Valued Provider eNewsletter

Provider PulseSM Messages

Fax Communications

Onsite Presentations

Provider Mailings

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Provider Contacts

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Authorizations and Care Management

1-800-626-2212 or 1-800-991-5579 (for NJ State Health

Benefits Program)

ABA Treatment Request and Treatment Plan Report

Submission:

Fax: 1-855-241-8895

NaviNet

1-888-482-8057 or Navinet.net

Provider Contacts, cont’d.

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Provider Relations, Credentialing and Contracting

Questions:

1-800-397-1630 (8 am - 8 pm ET Monday – Friday)

horizonbehavioralhealthproviderrelations@valueoptions.

com

Complaints, appeals and/or general inquiries

1-800-626-2212 or

1-800-991-5579 (for NJ State Health Benefits Program)

Helpful Links

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Network-specific Website:

• www.valueoptions.com/horizon

• www.valueoptions.com/horizon/aba

NaviNet

• NaviNet.net

ABA Website for Members:

• https://www.achievesolutions.net/achievesolutions/en/h

orizonbehavioralhealth/Topic.do?centerId=370&topicId

=532

Questions?

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