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Anthem Hoosier Healthwise /Healthy Indiana PlanBehavioral Health Provider Training
An Innovative Solution for Hoosier Healthwise andHealthy Indiana Plan Members Connecting everyone involved toh l IndianahelpI dimembersbimproveihealthh lthoutcomes Strive to develop strong collaborativerelationships with our provider/partnersCare Management / Disease Managementprograms tot promotet betterb tt healthh lthDevelop best practicesMembersProvidersAnthemHoosierHealthwise /HealthyIndiana Plan2
Program ObjectivesOur ObjectivesMaking a difference in the lives of our Indiana enrollees Create health care efficiencies for Hoosier Healthwise and Healthy Indiana PlanmembersImplement a fully integrated quality-based managed care programProvide timely access to high quality healthcare in both traditional and non-traditionalsettingsSignificantly improve quality of care and specific health care outcomesObtain innovative,innovative resultsresults-orientedoriented quality outcomesProvide care that promotes health and wellnessOur Goals Make fundamental differences in member health outcomesIntegrate provider partnershipsEnhance care coordinationProvide service excellence3
Integration of Care for MemberMember’ss Better HealthStrive to develop strongcollaborative relationships withour providers / partners Providers are one of the mostpowerful forces in influencing ourmember’smembers care and health Our providers are team members,not vendorsDevelop best practices Provide comprehensive care formembers Preventive Acute ChronicCase Management programs topromote better health Proactive Intervention Medical Management Increase health literacy Overcome social and otherbarriersDisease Management Programs Co-Existing Depression andAnxiety Program (CODA) Maternity Depression Program(MDP) Bipolar Disease Management Attention Deficit HyperactivityDisorder (ADHD) Program Autism Program4
Why Integration? Integration is a vital part of Hoosier Healthwise and theHealthy Indiana Program Integration and Coordination of Care: Insures member health needs are addressed throughout all levelsand types of care; Allows for the expeditious referral of members into one or more ofthe multiple disease management / condition care programsdesigned specifically for their needs; Prevents both under and over utilization of services; Mitigates multiple services / medications which arecontraindicated;t i di t d Assures the holistic treatment of each member5
Benefits Covered by Hoosier Healthwise andHealthy Indiana Plan Acute Inpatient / Outpatient Hospital ServicesEmergency ServicesPhysician ServicesPreventative ServicesAncillary ServicesFQHC / Rural Health Clinic ServicesEmergency Transportation ServicesFamily Planning ServicesComprehensivepDisease ManagementgServicesEarly Intervention Services (Early Periodic Screening, Diagnosis and Treatment) *Vision *Chiropractic Services *Non Emergency Transportation *Pre-natal Care *Services with an asterisk are Healthwise Benefits Only6
Benefits Covered or Excluded by The StateBenefits Covered by the State Pharmacy Services Medicaid Rehabilitation Option Services (HHW Only) Dental Services (HHW Only) Psychiatric Residential Treatment Facility Services (HHWOnly) PsychiatricyTreatment in a State facilityy ((HHW))Excluded Services Long-term Institutional Care HomeHandd community-basedit bd waiveriservicesi7
Hoosier Healthwise and Healthy Indiana PlanSelf-ReferralSelfReferral Services Chiropractic ServicesEye Care ServicesPodiatric ServicesPsychiatric ServicesBehavioral Health ServicesFamily Planning ServicesSelf-Referral Services may require prior-authorization8
Key Contactsfor Behavioral HealthJoe Garten, Ph.D.Director of Behavioral Health State Sponsored Business Operations317 287 2920317-287-2920Keith Isenberg, MDBehavioral Health Medical Director314 923 8647314-923-8647Letitia Jackson, MS., EdS, LMHCManager of Utilization/Care Management317-287-2574Christina Hurt, LCSWProvider Support Manager317-287-2855Prior Authorizations:Hoosier Healthwise:866-408-7187Healthy Indiana Plan: 866-398-1922866 398 1922Facsimile (Data Sharing Form / OTR): 877-276-50369
Behavioral Health Programsand PhilosophyTiered Case Management Program Tier I - Call Center and Outreach calls to members Tier II -Increased level of interaction with the member to assist withreferral to provider or level of care and problem-solving with themember forf any obstacles to receiving care, treatment, orambulatory care follow-up services Tier III - Intensive Case Management offers interventions on anongoing or episodic basis for members with 21 days ofhospitalization within 90 days, three or more hospital admissionswithinithi 60 ddays, complexl situationsit tiddue tto hihighh risk,i k co-morbidbidmedical and behavioral conditions placing the member in need ofintensive support and treatment, and inpatient admissions forbehavioral health or substance abuse10
Behavioral Health Programsand Philosophy Disease Management Programs Co-Existing Depression and Anxiety Program (CODA)Maternity Depression Program (MDP)Bipolar Disease ManagementAttention Deficit Hyperactivity Disorder (ADHD) ProgramAutism Program Follow up after Hospitalization Partnering with Providersand Community11
Behavioral Health andMedical Integration Provide a continuum of care management from initialcontact to coordination of care and interventions Care Managers within the Utilization Managementdepartment support Behavioral Health Services Both teams are co-located to allow for prompt and thoroughcoordination of careThey share the same medical information systemMedical case managers refer members to behavioral health forcoordination of care within our tiered Case Management ProgramAn innovative and integratedgapproachppwith medical exists for thosemembers with both behavioral health and medical problems as well asmembers with substance abuse difficulties12
Behavioral Health andMedical Integration A specialized program for assisting members with alcohol and other drug difficulties existswith behavioral health/medical triage, outreach to members, and coordination of careBehavioral Health case managers work closely with PMPsPMPs, specialists,specialists behavioral healthproviders, members, and community resources to: Provide additional education and training for both behavioral health and primary care clinicians toenhance their knowledge and skills needed to provide integrated services Quarterlyy Behavioral Health Profile which includes keyy informationProvide the PMP with a Qregarding the services his / her member is receiving such as:-Member Behavioral Health Utilization: Dates of each visit and name of treating provider;-Primary Behavioral Health Diagnosis for which the member is being treated-Detailed information regarding prescribed medications (Medication prescribed, date /dose /quantity dispensed, and name of prescribing physician Communicate directly with the PMP when any significant events occur in a member’s treatment, i.e.hospitalization, emergency services, etc. for integrated care plan development Provide the PMP with the behavioral health notification form which includes significant findings fromthe initial assessment,assessment medications prescribedprescribed, primary diagnosisdiagnosis, and other relevant information Assist the member in securing necessary community support Educate members and their family on services available within their community Encourage member and primary medical provider (PMP) interaction13
Disease Management: Co-Existing Depression &Anxiety Provides a pathway for members enrolled in medical diseasemanagementgor medical case managementgan avenue for earlyyidentification of co morbid depression Provides in depth Depression and Anxiety Screening formembers with chronic medical conditions Offers education and resources for the appropriate behavioralhealth services Ensures treatment compliance and coordination of carebetween diverse treatment team14
Disease Management:Maternity Depression Program The Maternity Depression Program’s goal is to provide depression screenings,education and support to members during pregnancy and following delivery We work with the medical providers to assist members who are experiencingdifficulties with chronic mental health and/or substance abuse disorders The program works to identify, triage, and enroll women in two distinct butcoordinated behavioral health programs Tiered Behavioral Health Case Management Maternity Depression Programs All pregnant members will be screened for perinatal and postpartum depression Both perinatal and post-partum screening for depression will include the use ofPatient Health Questionnaire 2 (PHQ-2) and/or Maternal Mental Health Survey toassess the severity and level of depression Coordination of Care is a key piece of this comprehensive program15
Disease Management: Bipolar Disorders Program Provides timely, proactive, and collaborative coordination ofbenefits and services for members enrolled in the programp gwith Bipolar DisordersUtilizes daily reports from Pharmacy to identify new starts andlate refills of pprescribed medicationsOffers direct outreach to both the member and their physicianto provide support and education to members and criticaltreatment compliance information to their physiciansOffers both member and provider interventions to support theappropriate diagnosis, treatment and referral of members withBipolar illnessFocuses on improving quality by encouraging medicationcompliance16
Disease Management: Attention DeficitHyperactivity Disorder (ADHD) Program Provides a Medication Review Card to the parents of children underthe ageg of 18 who are newlyy started on medications used to treatADHD which includes: Recommended Follow Ups Signsg / Indicators to reportp to the pprescribinggpphysiciany Educational information regarding side effects and when to contact theprescribing physician Offers resources for obtaining additional information on ADHDOffers personalized contact to discuss the Medication Review CardOutreach is conducted with parents/guardians of members age 6-12yearsyeasooldd newlye y sstarteda ed oon ADHD medicationsed ca o s The purpose of the call is to encourage follow up with prescribingprovider to monitor effectiveness of the medication17
Disease Management: Autism Program This program will offer internal and community support, information,and resources for the families of children with Autism or relatedpervasive developmental disordersA letter and brochure will be sent to the physicians of identifiedchildren, six and under, to explainpthe rangeg of services availablethrough our vendor, About Special Kids (ASK)The physician will distribute the information when appropriate to thefamilyy of identified childrenThrough ASK, parents will have access to A Parent Liaison to assist them by offering personalized support andy g resources available in their communityyidentifying Specialized consultation on complex cases Webinars18
Behavioral Health Case Management Program Members may have behavioral health needs beyond the scopeof the Disease Management Programs and are eligible for theBehavioral Health Case Management Program The behavioral health care manager will work closely with thegTeam,,“Clinical Team” which includes the Medical ManagementPrimary Medical Provider, and Behavioral Health ServiceProvider Based on the Tiered Case Management Format The “Clinical Team” will conduct clinical staffing as needed tode elop treatment/care plansdevelopplans, dedevelopelop commcommunitynit resoresources,rcesand engage the member in treatment Members can and will move to the various tier levels based onneed19
Behavioral HealthPrior AuthorizationPrior authorization is required for all facility based services, which include: Inpatient Partial Hospital Programs (PHP) Intensive Outpatient Programs (IOP) –HIP benefit onlyPrior authorization is not required for the first twelve (12) outpatient treatment sessions;HOWEVER, notification must occur in order for authorizations to be entered into the systemfor claim payment purposes(HIP outpatient services do not require authorization or notification if the provider is contracted for HIPwith Anthem)Provider must; however, notify Anthem via the “NotificationNotification Form”Form within 5 business days ofthe initial visit and provide the following information: Significant findings from the initial assessment Primary and secondary diagnosesMedication(s) prescribed to the member Psychotherapy prescribed Any other relevant informationPrior authorization for Emergency Services is not required; however,however please notify Anthemwithin 24 hours of service20
Behavioral Health Continuity of Care: Anthem andProvider ResponsibilitiespAnthem Responsibilities Ensure uninterrupted ongoing behavioral health care for those whotransition to another MCO or provider and new members to HHW /HIPUtilize HRA information pertaining to behavioral health needs of themember to proactively facilitate appropriate treatment servicesCoordination with other MCO’sQuarterly Reports to the PMPDisease Management for those members with: Co-Existing Depression and Anxiety Program (CODA)Maternity Depression Program (MDP)Bi-Polar Disease Management ProgramAttention Deficit Hyperactivity Disorder (ADHD) ProgramAutism ProgramIntegration of Physical Health and Behavioral Health Services21
Behavioral Health Continuity of Care: Anthem andProvider ResponsibilitiesTransition of Care Inpatientp Anthem will collaborate with the new MCO and treating IP facility to ensureappropriate discharge planning occursOutpatient Honor the previous MCO’s authorization for 30 daysFacilitate a smooth transfer to an Anthem network provider if the current provideris not contractedEnter into a single case agreement with the treating provider if clinically orgeographically necessaryCommunicate and coordinate with providers (medical and behavioral health)regarding the member’s ongoing care AnthemAthwillill nott releaseliinformationfti relatedl t d tot substanceb tabusebservicesiwithoutith t writtenitt consenttfrom the member MRO, transfers from other IHCP programs, and disenrollment22
Provider Responsibilities Communicate and Coordinate Care with the member’sPMP or other treating provider Encourage members to consent to the sharing ofsubstance abuse treatment information DeliverD liservicesiini a culturalltl sensitiveiti manner Make appointments available to members consistentwith their needs (emergent, urgent, routine care) Make a follow-up appointment available to all memberswithin seven days of discharge from an Inpatient facility Seek authorization for all covered services Not Balance Bill the member for covered services23
Member Rights / Responsibilities The right to be treated with respect and with due considerationfor his or her dignityg y and pprivacyyThe right to receive information on available treatment optionsand alternatives, presented in a manner appropriate to his orher condition and abilityy to understandThe right to participate in decisions regarding his or her healthcare, including the right to refuse treatmentThe rightg to be free from anyy form of restraint or seclusionused as a means of coercion, discipline, convenience orretaliation, as specified in other federal regulations on the useof restraints and seclusionThe right to request and receive a copy of his or her medicalrecords, and request that they be amended or corrected24
Behavioral Health Benefits: Hoosier HealthwiseServiceMental health/Behavioral healthservicesI ti t**Inpatient**(State PsychiatricHospital)Reimbursedby AnthemNOPackage APackage B/Package PStandard PlanPregnancy Coverage OnlyCovered for individuals under age Inpatient services available for21 if in a certified wing.Package B only. Coverage isli it d tolimitedt servicesirelatedl t d ttopregnancy (including prenatal,delivery, and postpartumservices), as well as conditionsthat may complicate theppregnancygy or urgentg careservices.Package C Children's HealthPlanCovered for individuals under age21 if in a certified wing.Mental health/Behavioral healthservices- Inpatient**(Free-standingPsychiatricHospital, 16 beds or less)YESCovered.Inpatient services available forPackage B only. Coverage islimited to services related topregnancy (including prenatal,prenataldelivery, and postpartumservices), as well as conditionsthat may complicate thepregnancy or urgent careservices.CoveredMental health/Behavioral healthservices- Inpatient**(Free-standingPsychiatricHospital, more than 16 bedssuch as institution for mentaldiseases)YESCovered for members under 21years of age, or under 22 andbegun inpatient psychiatricservices immediately beforehis/her 21st birthday.Inpatient services available forPackage B only. Coverage islimited to services related topregnancy (including prenatal,delivery, and postpartumservices), as well as conditionsthat may complicate thepregnancy or urgent careservices.Covered for members under 21years of age, or under 22 andbegun inpatient psychiatricservices immediately beforehis/her 21st birthday.25
Behavioral Health Benefits: Hoosier HealthwiseServiceMental health/ BehavioralHealth Services -OutpatientMedicaid RehabilitationOption (MRO) -CommunityCommunityMental Health CentersReimbursedby AnthemPackage AStandard PlanPackage B/Package PPregnancy Coverage OnlyYES,except MROservicesCoverage includes partialhospitalization services, ClinicOption services, mental healthservices provided by physicians,psychiatric wings of acute carehospitals, outpatient mentalhealth facilities and psychologistsendorsed as Health ServicesProviders in Psychology. Limitedto one evaluation and fivepsychotherapy visits per rolling 12months without priorauthorization. MCOs areresponsible for Methadonetreatment provided in a clinicsetting.Coverage is limited to servicesrelated to pregnancy, as well asconditions that may complicatethe pregnancy or urgent careservices. Limited to oneevaluation and fivepsychotherapy visits per rolling12 months without priorauthorization. MCOs areresponsible for Methadonetreatment provided in a clinicsetting.NOCoverage includes outpatientmental health services,services partialhospitalization (group activityprogram) and case management.Coverage is limited to servicesrelated to pregnancypregnancy, as well asconditions that may complicatethe pregnancy or urgent careservices.Package C Children's HealthPlanCoverage includes partialhospitalization services, ClinicOption services, mental healthservices provided by physicians,psychiatric wings of acute carehospitals, outpatient mentalhealth facilities and psychologistsendorsed as Health ServicesProviders in Psychology. Limitedto one evaluation and fivepsychotherapy visits per rolling 12months without priorauthorization. MCOs areresponsible for Methadonetreatment provided in a clinicsetting.Coverage includes outpatientmental health services,services partialhospitalization (group activityprogram) and case management.26
Behavioral Health Benefits: Hoosier cility (PRTF)ReimbursedPackage Aby AnthemStandard PlanNO (Member will be disenrolled Reimbursement is available forfrom Hoosier Healthwise))medicallyy necessaryy servicesprovided to children younger than21 years old in a PRTF.Reimbursement is also availablefor children younger than 22years old who began receivingPRTF services immediatelybefore their 21st birthday. Allservices require priorauthorization.Package B/Package PPregnancy Coverage OnlyPRTF services available forPackageg B only.y Coverageg islimited to services related topregnancy (including prenatal,delivery, and postpartumservices), as well as conditionsthat may complicate thepregnancy or urgent careservices.Package C Children's HealthPlanReimbursement is available formedicallyy necessaryy servicesprovided to children younger than21 years old in a PRTF.Reimbursement is also availablefor children younger than 22years old who began receivingPRTF services immediatelybefore their 21st birthday. Allservices require priorauthorization.Transportation Emergencyg yYESCoverage has no limit or priorapprovalppfor emergencyg yambulance or trips to/fromhospital for inpatientadmission/discharge, subject tothe prudent layperson standard.Coverage is limited to servicesrelated to ppregnancy,gy, as well asconditions that may complicatethe pregnancy or urgent careservices.Covers emergency ambulancetransportationpusingg the pprudentlayperson standard. 10 co-paymentapplies.Transportation –Non-emergentYESNon-emergency travel isavailable for up to 20 one-waytrips of less than 50miles per year without priorauthorization.Coverage is limited to servicesrelated to pregnancy, as well asconditions that may complicatethe pregnancy or urgent careservices.Ambulance services fornon-emergencies betweenmedical facilities are coveredwhen requested by a participatingphysician; 10 co-paymentapplies. Any other non-emergenttransportation is not covered.27
Behavioral Health Benefits: Healthy Indiana PlanService CategoryBenefitReimbursedby AnthemLimitations/Co-paySubject to POWER AccountDeductible?Inpatient FacilityMental Health/SubstanceAbuseYESCovered the same as physicalillnessYESProfessional ServicesOutpatient MentalHealth/Substance AbuseYESCovered the same as physicalillness.YESSmokingg Cessation ServicesYES,, with the exceptionpofpharmacy servicesReimbursement is available for,,at minimum, eight counselingsessions per rolling 12 months,and 24 weeks ofpharmacotherapy treatment perrolling 12 months.NOAmbulanceYESYES28
Clinical Practice Guidelines/ On-line TrainingMaterials / Medical Necessity CriteriaProvider Resources Available On-Line atwww anthem comwww.anthem.com Cultural Competency Co-Existing Disorders Anthem’s Medical Necessity Guidelines Behavioral Health Clinical Guidelines Identification and Treatment of Adult DepressivepDisorderIdentification and Treatment of Antenatal Depression and PostpartumDepression and Postpartum PsychosisIdentification and Treatment of Substance Use DisordersPreferred Practice Guidelines for the Evaluation and Treatment ofChildren with Attention Deficit/Hyperactivity DisorderPreferred Practice Guidelines for the Treatment of Bipolar Disorder29
Grievances and AppealsHoosier Healthwise and Healthy Indiana PlanGrievances and Appeals should be mailed to the address below:Anthem Blue Cross and Blue ShieldATTN: Grievances and Appeals DepartmentAnthem Blue Cross and Blue ShieldP.O. Box 6144Indianapolis,p, IN 46206-6144You may also submit your grievances and appeals via facsimile at 417888-9005 utilizing the provider form located at www.anthem.com30
Grievances and AppealsTimeframes for filing for your grievance and appeals are: Grievances: 60 calendar days from the receipt date ofAnthem’s correspondence Appeals: 30 calendar days from the receipt date of Anthem’scorrespondencedContact Numbers for inquiries:866-408-7187Facsimile: 866-387-296831
Claim Filing GuidelinesTimely Filing: Anthem Participating Providers: 90 DaysAnthem Non-Participating Providers: 365 DaysBilling Guidelines:Facility, Group, Individuals, Nurse PractitionersIHCP supervisor / Modifiers It is important that you bill with the NPI number registered with theSStateoff IndianaI dior your claiml i willill not bbe paidid For information about registering your NPI with the State of Indianaplease see their website pi.aspi didi id/ih /P id S i/ i NPI / Taxonomy: Your NPI and Taxonomy number are required onall claims32
Claim Filing GuidelinesCLAIM ADDRESS:Anthem Blue Cross and Blue ShieldP.O. Box 105187Atlanta, GA 30348-5187Providers may file claims via paper or electronicallyTo file electronically contact Anthem at 800-470-9630 or anthem.edi@anthem.com to: Learn how to get connected List of approved clearinghousesy if systemycompatiblep Submit Directly Technical AssistanceCOB claims must include third party remittance advice and the third party letter explainingdenial or reimbursementElectronic Funds Transfer (EFT) is availableYou may monitor the status of a claim on the provider website or through interactive voiceresponse (IVR) at 866-408-613233
Important Numbers and ResourcesAnthem Provider Resources available at www.Anthem.com Anthem Provider ManualClinical Practice Guidelines and Medical Necessity CriteriaMember EligibilityFFormsandd ToolsT lIndiana Medicaid Web Site: www.indianamedicaid.comHHW Pharmacy Prior Authorization: 866-879-0106HHW Pharmacy Prior Authorization: 866-879-010634
with Anthem) Provider must; however, notify Anthem via theProvider must; however, notify Anthem via the "Notification FormNotification Form" within 5 business days ofwithin 5 business days of the initial visit and provide the following information: Significant findings from the initial assessment Primary and secondary diagnoses
