Challenges and lessons with enrollment and eligibility Transitory nature of population Picture Identification requirements Failure to disclose all income (i.e.: unemployment) Individuals with benefits in neighboring counties Delayed notification of coverage to providers No automated eligibility verification once billing is “back-end” submitted Medical Necessity Developed by team of BHRS, Providers, and clinical experts Informed by ASAM, medical necessity requirements of other health insurers Provider capacity expansion Diagnosis - staffing implications and recommend language change to diagnostic impression Staff Credentialing Requirements (AOD certified vs. licensed) BH integration, MAT, and Screening/Intervention services and medical necessity are still being determined Treatment Authorization Prior treatment service authorizations required ACCESS Call Center processes MCE Authorization and Requests, via Avatar Service Packages, initial authorization period Residential Detoxification Services– 5 calendar days maximum Residential Services 60 calendar day (2 months) maximum – Intensive Outpatient Services 120 day (4 months) maximum – Outpatient Services– 6 months maximum Narcotic Replacement Treatment 1 year maximum – Retroactive requests permitted when client MCE is “auth” “pending enrollment” up to 90 days from date of first service. Service Billing $2,894,627 FY 11/12 billing – Represents $1,447,313 in new federal funds for SUD treatment in San Mateo County Limited provider experience tracking and billing for services by the minute (OP only) Temporary was up for billing, until transition to Avatar was “scantron” completed Successes, Challenges, Lessons SUD Provider Readiness
Challenges and lessons with enrollment and eligibility Transitory nature of population Picture Identification requirements Failure to disclose all income (i.e.: unemployment) Individuals with benefits in neighboring counties Delayed notification of coverage to providers No automated “back-end” eligibility verification once billing is submitted Medical Necessity Developed by team of BHRS, Providers, and clinical experts Informed by ASAM, medical necessity requirements of other health insurers Provider capacity expansion Diagnosis - staffing implications and recommend language change to diagnostic impression Staff Credentialing Requirements (AOD certified vs. licensed) BH integration, MAT, and Screening/Intervention services and medical necessity are still being determined Treatment Authorization Prior treatment service authorizations required ACCESS Call Center processes MCE Authorization and Requests, via Avatar Service Packages, initial authorization period Residential Detoxification Services– 5 calendar days maximum Residential Services – 60 calendar day (2 months) maximum Intensive Outpatient Services – 120 day (4 months) maximum Outpatient Services– 6 months maximum Narcotic Replacement Treatment – 1 year maximum Retroactive “auth” requests permitted when client MCE is “pending enrollment” up to 90 days from date of first service. Service Billing $2,894,627 – FY 11/12 billing Represents $1,447,313 in new federal funds for SUD treatment in San Mateo County Limited provider experience tracking and billing for services by the minute (OP only) Temporary “scantron” was up for billing, until transition to Avatar was completed Successes, Challenges, Lessons SUD Provider Readiness