Collaboration: Magellan Supporting Provider Compliance Caliber Virginia February 12, 2016 Presented by DMAS & Magellan Oketa Winn, LPC, DMAS, Behavioral Health Advisor James Forrester, EdD, LPC, Magellan, Director, System of Care Tricia Van Rossum, LCSW, CSOTP, Magellan, Mgr. Clinical Services

Overview Welcome Magellan as DMAS BHSA Care Coordination Model BHSA Components Provider Resources available to assist with Compliance 1.DMAS Manuals 2.Provider Handbook 3.Provider Website 4.Magellan of Virginia Website 5.Service Request Application 6.Treatment Record Review 7.Additional Resources February 12, 2016Caliber Virginia2

Magellan as DMAS BHSA Magellan Health serves as the Behavioral Health Services Administrator or "BHSA" and is responsible for the management and direction of the behavioral health benefits program under contract with DMAS. Magellan is authorized to: -constitute, oversee, enroll, and train a provider network; -perform service authorization; -adjudicate claims; process claims; -gather and maintain data; -perform quality assessment and improvement; -conduct member outreach and education; -resolve member and provider issues; -perform utilization management including care coordination for the provision of Medicaid-covered behavioral health services. February 12, 2016Caliber Virginia3

Care Coordination Model Care coordination: means collaboration and sharing of information among health care providers, who are involved with an individual's health care, to improve the care. (CMHRS, Chapter IV, p ) DMAS and Magellan of Virginia agree that care coordination has two (2) main goals: 1) To improve the health and wellness of individuals with complex and special needs; and 2) To integrate services around the needs of the individual at the local level by working to make sure members receive appropriate services and experience desirable treatment outcomes. February 12, 2016Caliber Virginia4

BHSA Components Departments at Magellan Network Support providers: Network Management Specialists are available to assist providers with credentialing and provider practice issues Customer Service within the Call Center Assist providers and members: Customer Service Associates are available to help with general inquiries in addition to eligibility and authorization inquiries Clinical Care Mangers (Licensed Mental Health Professionals) Review service authorizations requests: Care Managers issue authorization decisions, provide utilization management, care management and care coordination Quality Department Assist with quality improvement, grievances, appeals, reconsideration, treatment record reviews, standards of care Claims Customer Service Associates adjudicate claims and process claims February 12, 2016Caliber Virginia5

Provider Resources

1) DMAS Web Portal- Accessing Provider Manuals February 12, 2016Caliber Virginia7

1) DMAS Web Portal- Accessing Provider Manuals February 12, 2016Caliber Virginia8

Manual References Program RequirementsManual Reference (dated 12/2/15) Intensive In-Home (IIH)CMHRS, chapter 4, pages Therapeutic Day Treatment (TDT)CMHRS, chapter 4, pages Level A Group HomesCMHRS, chapter 4, pages Level B ResidentialCMHRS, chapter 4, pages Partial Hospitalization (PHP)CMHRS, chapter 4, pages Intensive Community Treatment (ICT)CMHRS, chapter 4, pages Mental Health Skill-building (MHSS)CMHRS, chapter 4, pages Substance Abuse Services for Pregnant Women (residential & day treatment) CMHRS, chapter 4, pages Mental Health Case ManagementCMHRS, chapter 4, pages February 12, 20169Caliber Virginia

Manual References Program RequirementsManual Reference (dated 12/2/15) Substance Abuse Intensive OutpatientCMHRS, chapter 4, pages Opioid TreatmentCMHRS, chapter 4, pages Acute Inpatient/Level C ResidentialPsychiatric Services, chapter 4, pages 4-18 Treatment Foster Care-Case ManagementPsychiatric Services, chapter 4, pages Outpatient Psychiatric and Substance Abuse Services Psychiatric Services, chapter 4, pages Provider Participation RequirementsCMHRS, chapter 2 Utilization Review ControlCMHRS, chapter 6 February 12, Caliber Virginia

2) Provider Handbook Magellan’s authority shall include entering into or terminating contracts with providers and imposing sanctions upon providers as described in any contract between a provider and the designated BHSA. DMAS shall retain authority for and oversight of the BHSA entity or entities. Magellan network providers must be familiar with and follow the policies and procedures contained in the National Provider Handbook and the Virginia BHSA Provider Handbook Supplement. Providers under contract with Magellan of Virginia should consult Magellan’s National Provider Handbook, the Magellan Virginia Provider Handbook or contact Magellan of Virginia at or or visit the provider website at Magellan main line: Demonstration: How to access the Magellan Provider handbook February 12, 2016Caliber Virginia11

3) Provider Website February 12, 2016Caliber Virginia12

4) Magellan of Virginia website February 12, 2016Caliber Virginia13

5) Service Request Application (SRA) The SRA is the primary way a provider communicates clinical information to Magellan about the service they are requesting. Magellan uses the information on the SRA to help them determine if medical necessity criteria is met Care Managers may reach out to providers if additional information is needed to determine if medical necessity criteria is met. Magellan has updated the SRAs to reflect regulation changes Demonstration: Compare a Magellan SRA (IIH and MHSS) and the manual February 12, 2016Caliber Virginia14

6) Treatment Record Review Treatment Record Review (TRR) is a method used to evaluate care being provided to members and to identify opportunities for improvement that will assist providers with addressing the overall quality of care that members receive. Magellan reviews a sample of treatment records from randomly selected providers. We conduct routine TRRs to monitor network provider treatment record documentation and record keeping practices against Magellan standards. Demonstration: How to access recent training on TRR February 12, 2016Caliber Virginia15

7) Additional Resources Reach out to your Network Management Specialist or send an to asking to be placed on the notification list. You should include: group or organization name, name of staffing submitting the request, address, telephone number. Check the Magellan of Virginia website frequently to access recent trainings and communications. Participate in the provider call held every Friday. questions to Get Involved: look for opportunities to participate in workgroups, meetings, and trainings. February 12, 2016Caliber Virginia16

Confidentiality Statement for Educational Presentations February 12, 2016Caliber Virginia17 By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc. The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

Thank You