residential rehabilitation, recovery coach, and recovery ...recovery coach and recovery support...
TRANSCRIPT
Residential Rehabilitation, Recovery Coach, and Recovery Support Navigator
Services Webinar
Tufts Health TogetherTufts Health Unify
Tufts Health Plan Senior Care Options (SCO)
December 2018
Agenda
HCPCS/CPT Codes Residential Rehabilitation Services Recovery Coach and Recovery Support Navigator
Notification & Clinical Review Process Notification & Clinical Review Submission Forms Performance Specifications Medical Necessity Guidelines Payment Policies Tufts Health Plan Contracting Contacts Provider Resources
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New Services Effective January 1, 2019Tufts Health Plan will cover three new services beginning January 1, 2019 for certain products.
Residential Rehabilitation Services (RRS)* Tufts Health Together Tufts Health Unify
Recovery Coach Tufts Health Together Tufts Health Unify Tufts Health Plan SCO
Recovery Support Navigator Tufts Health Together Tufts Health Unify Tufts Health Plan SCO
2 * Please note: SCO contract doesn’t cover RRS
HCPCS/CPT Codes for RRS Services
Service Billing Code
Residential Rehabilitation Services (RRS) H0019
RRS for Transitional Age Youth and Young Adults H0019-HF
RRS for Youth H0019-HA
RRS for Families H0019-HR
RRS for Pregnant and Post-Partum Women H0019-TH
Co-occurring Enhanced RRS H0019-HH
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Recovery Coach and Recovery Support Navigator Billing Codes
Service Code Modifier Notes
Recovery Coach H2016 HM Per diem
Recovery Support Navigator
H2015 HF Paid per 15 minute unit
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Notification & Clinical Review Process
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Notification ProcessUse Notification Form to notify Tufts Health Plan (THP) by fax within 7 days when a member begins services.
• Each service/level of care has its own form, to be used for Tufts Health Together, Tufts Health Unify and SCO
• The top of the form outlines the notification process• For members already in treatment on 1/1/19, notify THP
within 14 days• No clinical review will be completed by THP• Upon timely notification, an authorization will be entered
into the system by THP, allowing you to bill for services. An authorization letter will be sent to the provider
• Residential Rehabilitation Services: 90 days• Recovery Coach: 60 days• Recovery Support Navigator: 60 days
• Forms are posted on the THP website. Fillable forms will be posted at a later date.
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Clinical Review & Continued Authorization Process
A clinical review is NOT needed for the initial authorization.
Within 7 days prior to or after the latest authorization end date, complete a clinical review with Tufts Health Plan (THP) and outline how the member’s clinical symptoms indicate the need for continued stay for the specific level of care requested.
As long as a continued stay is clinically indicated, authorization approval will be issued, regardless of how long the member has been receiving the service.
Residential Rehabilitation Services & Recovery Coach• Each service/level of care has its own form, which is to be used for Tufts Health
Together, Tufts Health Unify or Tufts Health SCO• The top of each form outlines the review process• Call THP for subsequent reviews• Upon authorization approval, an authorization letter will be sent to the provider
Recovery Support Navigator• Call THP for all clinical reviews• Upon authorization approval, an authorization letter will be sent to the provider
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Notification & Clinical Review Forms
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INFORMATION ABOUT THE FORMS
Screen shots of Notification and Clinical Review forms are on subsequent slides.
While each form is shown on multiple slides, this ensures clarity. Most forms are about one page long.
Each form outlines the Notification or Clinical Review process.
Forms are based on clinical criteria and performance specifications.
All forms are posted on the Tufts Health Plan website. Fillable forms will be posted at a later date.
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Common Elements Across All Forms
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Please note: Use correct fax number, as they are different for Tufts Health Together, Tufts Health Unify , and Tufts Health SCO. This ensures the request gets to correct staff & avoids delay in authorization process
The SCO contract does not include Residential Rehabilitation Svcs
Residential Rehabilitation Services (RRS) Admission Notification Form for In-network Providers Only
Residential Rehabilitation Services (RRS) First Clinical Review Form for In-network Providers Only
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Residential Rehabilitation Services (RRS) First ClinicalReview Form for In-network Providers Only (continued)
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Residential Rehabilitation Services (RRS) First Clinical Review Form for In-network Providers Only (continued)
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Residential Rehabilitation Services (RRS) First Clinical Review Form for In-network Providers Only (continued)
Recovery Coach Services Notification Form for In-network Providers Only
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Recovery Coach Clinical Review Form
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Recovery Support Navigator Services Notification Form for In-network Providers Only
Calling Tufts Health Plan to Complete a Clinical Review
First Clinical review with Tufts Health Plan Call Tufts Health Public Plans Provider Services:
888.257.1985 for clinical review.
Call Tufts Health Plan SCO Provider Relations: 800.279.9022 for clinical review.
Requesting additional daysYou will be assigned to a clinician within Tufts Health Plan Behavioral Health Departments (Tufts Health Public Plans and Senior Products) and will work with that clinician moving forward.
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Residential Rehabilitation Forms - Forms on tuftshealthplan.com/provider
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Performance Specifications Performance specifications are available on the Tufts Health
Plan website: tuftshealthplan.com/providers
Performance specifications are the same across all insurance companies
The format and content include• Description of Services• Components of Service• Staffing Requirements• Service, Community and Collateral Linkages • Quality Management • Process Specifications
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Performance Specifications-Recovery Coach and Recovery Support Navigator
Medical Necessity Guidelines- Residential Rehabilitation Services (RRS)
RRS is reviewed using ASAM criteria. It is the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. The ASAM criteria can be purchased at: https://www.asam.org/resources/publications23
Medical Necessity Guidelines- Recovery Coach
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Medical Necessity Guidelines- Recovery Support Navigator
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Contracting Contact Information
RRS for Tufts Health Together and Tufts Health Unify: [email protected]
Recovery Support Navigators and Recovery Coaches for Tufts Health Unify:[email protected]
Recovery Support Navigators and Recovery Coaches for Tufts Health Plan SCO:[email protected]
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Provider Resources
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Navigating Tufts Health Plan’s Website- tuftshealthplan.com/provider
Tufts Health Plan’s Provider website has two distinct sections:
Public Provider website• Medical necessity guidelines• Payment policies• Pharmacy programs• Provider manuals• Training and education
Secure Provider website (registration required)Tufts Health Provider Connect (Tufts Health Public Plans only)
Tufts Health Plan Provider Portal (Commercial and Senior Products)• Claims status inquiry• Eligibility and benefits• Referral inquiry and submission• Inpatient notification request submission• Online claim adjustments
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Secure Provider Website Login- Select a Division
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Payment Policies
Claim Submission Information- Tufts Health Plan SCO
Tufts Health Plan encourages direct electronic claim submission Submit questions regarding electronic claim submission to EDI Operations by email at
[email protected] or by calling 888.880.8699, ext. 54042
Paper claims should be mailed to the following address:Tufts Medicare Preferred HMO and Tufts Health Plan SCOP.O. Box 9183Watertown, MA 02471-9183
Filing limit deadlines: For professional or outpatient services, claims must be received within
60 days from the date of service For inpatient/institutional services claims must be received within
60 days from the date of hospital discharge
For additional information about the submission of new/original claims, refer to the Claims Submission Policy available in the Resource Center of the public Provider website. tuftshealthplan.com/provider
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Claim Submission Policy- Tufts Health Plan Senior Care Options
Claim Submission Information- Tufts Health Public Plans
Tufts Health Plan encourages direct electronic claim submission
• Submit any questions regarding electronic claim submission to EDI Operations by email at [email protected] or by calling 888.880.8699, ext. 54042
Paper claims should be mailed to the following address:Tufts Health PlanP.O. Box 8115Park Ridge, IL 60068-8115
Filing limit deadlines: For professional or outpatient services, claims must be received within
90 days from the date of service For inpatient/institutional services claims must be received within
90 days from the date of hospital discharge
For additional information, refer to Chapter 5: Claims Procedures of the Tufts Health Public Plan Provider Manual available in the Resource Center of the public Provider website. tuftshealthplan.com/provider
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Tufts Health Public Plans- Tufts Health Public Plans Provider Manuals
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Provider Payment Dispute Overview-Tufts Health Plan Senior Care OptionsProviders have the right to file a payment dispute if they disagree with a decision regarding the denial or compensation of a claim.
The Online Claim Adjustment Tool on the secure Provider website is the primary means of submitting Commercial and Senior Products claim adjustment request and payment disputes.
When submitting a payment dispute by mail, the Request for Claim Review Form, along with any supporting documentation, is required. The form can be found in the Forms section of the Resource Center at tuftshealthplan.com/provider.
A separate dispute form must be submitted for each claim adjustment. All incomplete submissions will be returned.
For complete information, refer to the Provider Payment Dispute Policy found in the Payment Policy section of the Resource Center on the public Provider website.
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Submitting Payment Disputes By Mail A separate Request for Claim Review Form, along with any supporting
documentation, is required for each claim adjustment.
Make sure to list a valid claim number, Tufts Health Plan message code andindicate the appropriate review type on the form.
Provider Payment Dispute Overview-Tufts Health Public Plans
Click on the Request for Claim Review Mailing Information link to view the addresses to use when mailing the Request for Claim Review Form.
Provider Resource Guidestuftshealthplan.com/provider/training
Register to Receive Provider Update by Email The registration form can be accessed on the public Provider website
at tuftshealthplan.com/provider. Click "Register Your Email" below to complete and submit the short registration form.
Note: This email address will be used only for required notifications and other pertinent business communications. It will not change or grant login credentials to the secure Provider website.
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Contact Information
Provider Call Centers: Tufts Health Public Plans Provider Services (MA): 888.257.1985 Tufts Health Plan SCO Provider Relations: 800.279.9022
EDI Operations: 888.880.8699 ext. 54042 or [email protected]
Technical Inquiries: 888.884.2404, option 6 or [email protected]
Provider Education: [email protected]
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Questions?
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