1. MDwise Behavioral Health
2018 IHCP Annual Workshop
MDwise Behavioral Health
HHW-HIPP0580 (9/18)

2. Agenda
MDwise History
Updates
Contracting
Eligibility & Benefits
Prior Authorization (PA)
Claims
Drug Screening
ABA Services
SUD Residential Services
Opioid Treatment Program (OTP)
Contact
Resources
Questions

3. 2007: MDwise selected to provide care through the Healthy Indiana Plan
MDwise History
1994: MDwise founded as Indiana-based nonprofit health care company Central Indiana Managed Care Organization, Inc. (CIMCO), utilizing a delivery system model
2001: CIMCO teamed up with IU Health Plan and formed into MDwise, Inc., serving more than 55,000 Hoosier Healthwise members.
2007: MDwise begins service Care Select (now Hoosier Care Connect) members
2007: MDwise selected to provide care through the Healthy Indiana Plan
2018: MDwise acquired by Michigan-based McLaren Health Care; one of Michigan’s largest integrated health systems
MDwise’s history began back in 1994 when we were founded as CIMCO. From 2001 to 2014, MDwise offered medical coverage to Indiana residents through the Hoosier Healthwise, Hoosier Care Connect, formerly Care Select, HIP and Marketplace programs. Our focus shifted over the last couple of years from all 4 medical programs to just Hoosier Healthwise and HIP. And in 2017, MDwise was purchased by McLaren Health Care, a Michigan-based health system with a significant health plan operation across the state of Michigan.

4. Who Is McLaren Health Care?
Is one of the largest integrated health care systems in Michigan
Owns 15 hospitals, including Barbara Ann Karmanos, nationally renowned for their cancer care and outcomes
Employs over 500 physicians
Trains over 550 residents annually
Has a workforce of over 20,000
Owns McLaren Health Plan, who covers over 265,000 members in Medicaid, commercial, and Medicare Supplemental markets.

5. MDwise – McLaren Synergies
Sharing Best Practices between MDwise and McLaren Health Plan, such as:
Care Management
Opioid Crisis Management
Effectively managing inappropriate ER utilization
Streamlining Prior Authorizations
Pay for Value Physician Incentive programs
Claims adjudication
Results are Demonstrating:
Improvement in health care outcomes for our members
Enhanced access for members
Greater administrative efficiencies, which allow more health care dollars to be spent on the actual delivery of medical care

6. Updates
Effective 1/1/19:
MDwise is restructuring it’s Delivery System model to:
Improve claim payment timeliness and accuracy
Streamline and reduce administrative redundancy for providers
Provide greater access for our members
One standard authorization list
One point of contact for all authorization requests
One claim submission address
Non-Excel Delivery System contracts
Providers not contracted with MDwise Excel must contract to stay in network.
Effective January 1, 2019, MDwise will begin operating as a single network, MDwise Excel. This will show when checking eligibility in the MDwise Portal as well as the state systems. Along with this change, MDwise delivery system contracts will expire December 31, If you are not currently contracted as a MDwise Excel provider and want to be able to see MDwise members, you will need to contract as a MDwise excel provider. Please reach out to your dedicate provider representative to begin this process. Also changing will be out claims processing, our prior authorization process and requirements, and our MDwise portal access. All of these items are covered in this presentation, so lets get started!

7. To become a MDwise Behavioral Health Provider:
Contracting
To become a MDwise Behavioral Health Provider:
Complete the Behavioral Health Contract Inquiry Form
Submit to
A ticket number (ex: PR000xxxxx) will be issued for your request
Questions or inquiring on a current contract request?
Provider Relations: ext. 5800
Be sure to reference the ticket number in you call
If you are currently a MDwise provider for our medical benefits and would like to become a Behavioral Health provider, or if you are not currently contracted at all for Behavioral Health, complete the Contract inquiry form on our Behavioral Health providers page. IF you have any questions on the contracting process or have questions on your current inquiry, please call the provider relations line at the number listed bere.

8. Eligibility & Benefits
Effective 1/1/19:
When determining eligibility, verify:
Is the member eligible for services today?
Which Indiana Health Coverage Program plan are they enrolled?
If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise?
Who is the member’s Primary Medical Provider (PMP)?
Beginning in January, you will be able to utilize the state website for the members Program and MCE. The assigned network or delivery system will always be MDwise Excel. To verify a PMP, you will use the MDwise provider portal, as you do now.
Provider Healthcare Portal
MDwise Provider Portal
IHCP Program
Delivery System: MDwise Excel
MCE
Assigned PMP History
Assigned PMP

9. Eligibility & Benefits
Services covered based on member’s benefit package:
Inpatient psychiatric services
Emergency/crisis services
Alcohol and drug abuse services (substance abuse)
Psychotherapy and counseling (individual, group or family)
Psychiatric drugs included on MDwise PDL
Laboratory and radiology services for medication regulation and diagnosis
Screening and evaluation and diagnosis
Transportation (medically necessary or emergent)
Neuropsychological and psychological testing
All Behavioral Health services are self-referral.
Also as important as checking the members eligibility, is knowing what benefits are covered for the member. Listed here are some of the behavioral health benefits offered to MDwise members. Once you have verified your services are covered, you will need to check if authorization is required.

10. Effective 1/1/19 Prior Authorization One standard authorization list
One point of contact for all authorization requests
Submission timelines and process will not change
Go to MDwise.org for most up-to-date version of PA lists
MDwise.org
For Providers
Forms
Prior Authorization
Effective January 1st, our PA guides will update. There will be one PA list per program. The PA lists will still be housed on the Prior Authorization page. The current 2017 and prior PA lists will remain on this page to allow for review after the new year. Be sure you are reviewing the correct PA guides in the new year.

11. Prior Authorization
You will need two key items when filing a request for Medical Prior Authorization (PA):
Universal Prior Authorization Form
Located on our website
Documentation to support the medical necessity for the service you are requesting to prior authorize:
Lab work
Medical records/physician notes
Test results
Therapy notes
Tips:
Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number.
Be sure to note if PA is for a retroactive member.
Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe.
When submitting a prior authorization, always be sure your form is completely filled out and required documentation in included. IF a form is incomplete or documentation is missing, your request will be returned to you and your review timeframe will start over. Also, if you are requesting a PA for a retro active member, be sure to note this in the notes section of the form.

12. Prior Authorization Turn-Around Time
All emergency inpatient admissions require authorization within 2 business days of the admission.
Urgent prior authorizations can take up to 3 business days
Requests for non-urgent prior authorization will be resolved within 7 calendar days.
It is important to note that resolved could mean a decision to pend for additional information.
If you have not heard response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue.
PA Inquiry Line
Turn around time for authorizations depends on the urgency of the request. Emergency requests must have a PA requested within 2 business days of the date of service; urgent requests will have an outcome within 3 business days, and a non-urgent request will have a decision made within 7 business days. If you have an inquiry on a current PA, please regerence the PA quick contact guide on our website.

13. Hoosier Healthwise & Healthy Indiana Plan
Claims
Effective 1/1/19:
Claim Submission is date of service driven.
Electronic Submission
Please note: Paper claims must be on red/white form with black ink.
Hoosier Healthwise & Healthy Indiana Plan
MDwise/McLaren Health Plans
P.O. Box 1575
Flint, MI 48501
Effective January 1st, we will go to one claim submission address and Payer ID per program, as shown here. Please remember this is date of service driven. Claims with date of service 12/31/18 being submitted after January 1st will still need to be sent to the correct delivery system and program, as shown on the previous page. Again, for this updated claim submission information, go to MDwise.org and click on Provider contact information.
Hoosier Healthwise
Healthy Indiana Plan
Payer ID: 3519M
Payer ID: 3135M

14. Claims Claim Timelines: Claim Submission:
Primary: 90 days from the date of service
Secondary: 90 days from the date of the explanation of benefits (EOB)
Effective 1/1/19, non-contracted providers will have 180 days for claim submission.*
MDwise Adjudication: (clean claims)
Electronic Claims: 21 days
Paper Claims: 30 days
Claim Disputes:
60 days from the date of the explanation of benefits (EOB)
Dispute Response: 30 business days from date of submission
*Reference BT for more information
Claim submission timelines and response times are not changing in the new year. Primary claims are still due 90 days from the date of service, secondary 90 days from the date of the primary EOP. Due to state changes announced in bulletin BT201829, providers who are not contracted with MDwise Excel will have 180 days to file claims.
MDwise will adjudicate all clean claims within 21 days for electronic submission, and 30 days for paper submission.
If you receive a claim denial that you would like to dispute, the dispute is due within 60 days of the date of the EOB. MDwise will respond back within 30 business days with an outcome.
If you would like to inquire about a claim in process, you can do so at any time. A response will be made to you within 30 business days of your submission. We do ask that you allow the full 21 or 30 days adjudication time before submitting an inquiry, to allow adequate time for the claim to be reviewed.
Moving on from claims….

15. Presumptive drug testing no longer requires authorization (no limit)
Drug Screening
Effective 7/1/18
Presumptive drug testing no longer requires authorization (no limit)
Definitive drug screening requires PA every time
G0480, G0481, G0482, G0483
Updates are based on the date of service
Review authorization guides for most recent versions

16. ABA Services
Applied Behavioral Analysis (ABA) Therapy is for the treatment of Autism Spectrum Disorder (ASD) for members ages 20 and under:
Authorization is required for persons diagnosed with Autism Spectrum Disorder:
Diagnosis Codes: F84.0 or F84.9
Authorizations will be given in accordance with the members treatment plan.
Authorization is required every 6 months.
Be sure to check the Authorization guide on our website for the most up to date listing of authorization requirements.

17. ABA Therapy Codes and Modifiers
ABA Services
ABA Therapy Codes and Modifiers
CPT codes:
Authorization required except for with modifier U1 or U2
U modifier (U1, U2, U3) required to designate the provider level rendering services.
Claims must be billed on CMS 1500 claim form
Please reference the following IHCP Bulletins for additional information:
Bulletin BT201606
Bulletin BT201774
Bulletin BT201705
Please note: MDwise does not reimburse ABA providers for education.

18. ABA Specific Providers:
ABA Services
ABA Specific Providers:
Providers must be registered with IHCP as provider type 11 and specialty type 615.
HSPP = Health Service Provider in Psychology, Psychologist
BCBA = Board Certified Behavior Analyst
BCBA-D = Doctoral Level Board Certified Behavior Analyst
The following providers must bill under one of the above supervising providers:
BCaBA = Bachelor Level Board Certified Behavioral Analyst
RBT = Credentialed Registered Behavior Technician

19. SUD Residential Services
MDwise Covered Treatment
Mental Health/Substance Abuse Services rendered in one of the following:
State Psychiatric Hospital
Freestanding Psychiatric Facility
Substance Abuse Residential Treatment Center
Coverage by Program
Hoosier Healthwise:
Package A: Covered when medically necessary for members under 21
Package C: Coverage is reimbursed when deemed medically necessary and is subject to the same coverage policies and limitations as Package A
Healthy Indiana Plan:
HIP Basic Plan: Covered
HIP Plus Plan: Covered
HIP State Plan: Covered
MDwise covers these treatments and other substance abuse services when offered through a state psychiatric hospital or a free standing psych facility.
Coverage for these services is based on the members Medicaid program and package.
If you have a question on covered services or on the members program, contact the MDwise customer service department.

20. SUD Residential Services
Low-Intensity Residential Treatment:
Procedure Code: H2034
Includes individual/group therapy, medication training and support, case management, drug testing and peer recovery supports
American Society of Addiction Medicine (ASAM) Level 3.1
High-Intensity Residential Treatment:
Procedure Code: H0010
Includes individual/group therapy, medication training and support, case management, drug testing, peer recovery supports and skills training and development
ASAM Level 3.5 (considered medium-intensity treatment for adolescents & high-intensity treatment for adults)
Modifiers:
U1: Adult members (19 years and older)
U2: Adolescent members (0-18 years older)
Residential treatment can include low and high intensity treatment that have therapy, medication training and support and peer recovery support. Please note that providers registered to provide low-intensity treatment cannot provide high-intensity treatment, unless they are also registered to do so, and vice versa.
When billing these services, correct modifiers must be used to avoid claim denials.

21. Opioid Treatment Program (OTP)
The Opioid Treatment Program (OTP) is a specific bundled service that includes the administration of Methadone. Only approved providers are able to provide this service.
Opioid Use Disorder: A problematic pattern of opioid use leading to clinically significant impairment or distress.
Common Opiates:
Oxycodone
Hydrocodone
Fentanyl
Heroin
Our Opioid Treatment Program or OTP, is offered to members who have or are exhibiting the uncontrollable urge to use highly addictive opioids such as Oxycodone, Hydrocodone, Fentanyl and even heroine. Treatment for opioid use disorder can include outpatient therapies such as group or individual therapy, or medication assisted treatment.

22. Opioid Treatment Program (OTP)
OTP Specific Codes
H0020: Alcohol and/or drug services
Methadone administration and/or service (provision of the drug by a licensed program) for each day a member presents for treatment
Reimbursement for code H0020 will be based on a daily bundled rate
Includes reimbursement for the following services:
Oral medication administration, direct observation, daily
Methadone, daily
Drug testing, monthly
One office visit every 90 days
Providers that allow members take-home doses of methadone must bill code H0020 with modifier UA – for each DOS a take-home dose of methadone is dispensed (42 CFR 8-12).
Additional therapy codes are allowed outside of bundle when a relapse occurs.
Reference BT for services billable outside of the bundled rate.
The OTP procedure codes for the use of methadone to treat addiction is HCPCS code H0020.
This code is reimbursed based on a daily bundled rate that includes the reimbursement for the following services: oral medication administered directly to the patient daily, monthly drug testing and one office visit each 90 days.
Providers who allow the take-home doses of methadone must include the appropriate modifier for reimbursement.

23. Opioid Treatment Program (OTP)
OTP Provider Requirements:
Must be Division of Mental Health and Addiction (DMHA) certified and hold DEA license to prescribe Methadone
Registered and active with IHCP
Enrolled as Type 35, Addiction Services and Specialty 835, Opioid Treatment Provider
Contracted and enrolled with MDwise Behavioral Health
Be an Health Service Provider in Psychology (HSPP) or under the supervision of an HSPP/Physician to provide services within bundle
Licensed Psychologist
Licensed Clinical Social Worker (LCSW)
Licensed Marriage and Family Therapist (LMFT)
Licensed Mental Health Counselor (LMHC)
Licensed Clinical Addiction Counselor (LCAC)
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist
Providers who are eligible to provide these services must first be DMHA, Division of Mental Health and Addiction, certified and hold a DEA license to administer Methadone. They must also be a registered and active IHCP provider with a provider type 35 and specialty type 835, enrolled as an Addiction Services/Opioid Treatment Provider, and contracted with MDwise for Behavioral Health. The providers eligible to provide these services, if they If you are currently contracted as a medical provider and would like to add Behavioral Health to your contract, or would like to know how you are contracted, contact our Provider Relations department.

24. Opioid Treatment Program (OTP)
Prior Authorization
Review services for authorization prior to rendering services
Authorization not required for contracted, IHCP/DMHA approved providers
Authorization required for non-contracted, IHCP/DMHA approved providers
Request blocks of dates for outpatient care to include additions to the members treatment plan
List treatment plan goals that are diagnosis specific and measurable to facilitate the review and approval of services.
Claim Submission
File OTP and Behavioral Health claims following the same process for medical claims
Check eligibility prior to rendering services
Copays may apply to OTP services, depending on the member’s health plan
Also, to receive reimbursement, an authorization may be required for services, so it is important to review our PA guidelines and obtain authorization prior to rendering services.
To file claims for OTP and BH services, providers should use the same submission guidelines used for medical claims. Checking eligibility prior to rendering services will also make sure you obtain an authorization from the correct delivery system and will indicate where claims should be sent.
Provider should also be aware of any copays that may apply to services rendered.

25. Opioid Treatment Program (OTP)
Reimbursement for OTP Providers
Hoosier Healthwise Providers
Contracted Providers: 100% IHCP Medicaid Fee Schedule amount
Non-contracted Providers: 98% of the IHCP fee schedule for medically necessary services
Healthy Indiana Plan Providers
MDwise will cover and reimburse medically necessary mental health care services, including substance abuse services.
Contracted Providers:
Medicare reimbursement if available
130% of Medicaid rates if the service does not have a Medicare reimbursement rate
90% of billed charges if there is no Medicare or Medicaid rate
Non-contracted Providers: 98% of the Medicare rate or IHCP fee schedule for medically necessary services if no Medicare rate is available
Reimbursement for HHW and HIP members is based on the program and the appropriate fee schedule: IHCP for HHW and the CMS fee schedule when available, or 130 of the Medicaid rate for HIP. Non-contracted providers receive 98% of the available rate for each program.

26. Opioid Treatment Program (OTP)
Opioid Treatment Program Education
Please reference the following IHCP Bulletins and Banners for more information:
BT201755
BT201744
BR201738
Code of Federal Regulations
42 CFR 8-12
MDwise Behavioral Health Resources (Member and Provider)
IHCP Provider Module
Mental Health and Addiction Services
0addiction%20services.pdf
Finally on OTP services, IHCP has published recent banners and bulletins on OTP services and provider education.
Here are additional avenues for education on OTP services available for members and provider.
Our next topic is also for fighting addiction in our members: residential treatment.

27. Contact 1 2 5 3 4 9
If you have questions on these forms or on the contracting process for MDwise Excel, be sure to contact your dedicated Provider Relations representative for your region, as shown here. 6 8 7

28. Contact Representative Territory Phone Email Paulette Means Region 1
Garrett Walker
Region 2
Michelle Phillips
Region 3, Hospice, Home Health
Jamaal Wade
Region 4
David Hoover
Region 5
Tonya Trout
Region 6
Rebecca Church
Region 7
Sean O’Brien
Region 8
Whitney Burnes
Region 9
Nichole Young
Behavioral Health
(CMHC, OTP, IMD or Residential)
Michelle Phillips, our dedicate Home Health and Hospice rep is now covering region 3 as well. If you are a DME provider, please reach out to the Representative in you respective region. Also, territory reps are now covering ABA providers as well. For behavioral health, Nichole young covers CMHC’s, OTP’s, IMD’s and residential providers. All other BH providers should contact their territory reps.

29. Behavioral Health Providers
Resources
MDwise Website
MDwise Provider Page
Behavioral Health Providers
Behavioral Health Forms
Contact Information

30. Questions