1. OptumHealth NYC BHO Provider Training

2. Agenda Introductions Overview of Optum
Review of Contract between Optum and the Offices
Admission & Discharge Review
Provider Tools
Tool Review
Forms & Submission Process
Optum/New York Web site
ProviderConnect
Question and Answer Session
Wrap Up and Closing

3. Optum New York Staff
William Fishbein, Executive Director Optum New York
Michael Silver, Psychiatrist
Marc Minick, Community Liaison
Mark Simmons, Community Liaison
Amy Freeman, Behavioral Health Clinical Manager
Margaret “Peggy” Elmer, Behavioral Health Clinical Manager
Joni Richter, Behavioral Health Intake Manager
Erik Geizer, QI/Training Manager
Linda West, Reporting & Technology Manager

4. Optum Overview

5. Optum Organizational Overview
Optum is a health services business dedicated to making the health system work better for everyone
We are comprised of three market-leading business segments:
OptumHealth
OptumInsight
OptumRx
Optum serves the entire health ecosystem
250,000 health professionals and physician practices
6,200 hospitals and facilities
more than 270 state and federal government agencies
over 2,000 health plans; two of every five FORTUNE 500 employers; and one in every five U.S. consumers.

6. UnitedHealthcare-Health Benefits Optum—Health Services
Our Business Context
UHG
UNH=Publicly Traded Registrant (NYSE)
UnitedHealthcare-Health Benefits
Optum—Health Services
Health care coverage and benefits businesses, unified under a master brand
Employer and Individual
Community and State
Medicare and Retirement
Information and technology-enabled health services platform, encompassing:
Technology solutions
Intelligence and decision support tools
Health management and interventions
Administrative and financial services
Pharmacy solutions
UNITEDHEALTHCARE: Employer and Individual --Health benefit plans for individuals, small- and mid-sized businesses, and large multi-site employers.
Working with individuals, small- and medium-sized businesses, and large multi-site employers to find health care benefits that work well for everyone.
UnitedHealthcare coordinates network-based health and well-being products and services that are innovative, affordable, and keep individuals involved in their own health and wellness. After all, informed consumers make better decisions, and that leads to lower medical costs.
In addition to health benefit plans, UnitedHealthcare offers specialty care programs such as vision and dental care, as well as HSAs (health savings accounts) and HRAs (health reimbursement accounts).
UnitedHealthcare National Accounts creates customized health benefits solutions to meet the often complex needs of large sophisticated multi-location employers and also provides health care services for employees located overseas.
In a complex and ever-evolving health care environment, UnitedHealthcare works to make the health care experience simpler and better for individuals, physicians and employers.
UnitedHealthcare Community and State--High-quality, personalized, public sector health care programs.
Health care benefits and services for beneficiaries of Medicaid and other government-sponsored health care programs.
Public sector health care operates under a unique set of business imperatives. By investing in the systems and personnel required to successfully provide quality service to these customers, UnitedHealthcare Community & State can offer health plans that meet the unique needs of the beneficiaries of Medicaid and other government-sponsored health care programs.
UnitedHealthcare Medicare and Retirement—Serving the health care needs of seniors.
Providing health care choices and peace of mind to a growing market.
UnitedHealthcare Medicare & Retirement is dedicated to providing innovative health and well-being solutions that help senior Americans achieve healthier and more secure lives.
Serving 9 million seniors and one-in-five Medicare beneficiaries, UnitedHealthcare Medicare & Retirement is the largest business dedicated to the health and well-being needs of seniors. UnitedHealthcare Medicare & Retirement manages a full array of products and services, which include Medicare Advantage plans, Medicare Supplement plans, Part D prescription drug plans, employer retiree health services, chronic disease management and care coordination programs.
UnitedHealthcare Medicare & Retirement products, services and programs are designed to meet the individual needs of its customers, their families, physicians and communities.
SecureHorizons by UnitedHealthcare – A leading provider of quality health care plans serving more than 1.6 million Medicare beneficiaries through a variety of Medicare Advantage plans and other value-added services. Learn more at SecureHorizons.com.
Medicare Part D plans – The nation’s largest provider of Medicare prescription drug benefits (Part D) on a stand-alone basis to 4.2 million beneficiaries throughout the United States and its territories. Learn more at AARPMedicareRx.com and UnitedHealthRx.com.
Insurance Solutions – Operates the nation’s largest Medicare Supplement business in association with AARP. Learn more at AARPHealthcare.com.
Evercare by UnitedHealthcare – Provides one of the largest care coordination programs for individuals living with disabilities, long-term or advanced illness. Evercare serves individuals and families nationwide through its Medicare Special Needs Plans, hospice and caregiver programs and services. Learn more at EvercareHealthPlans.com.
UnitedHealthcare Retiree Services – Providing employers with high-quality, affordable health care solutions for retirees such as Medicare Advantage, Medicare Supplement and Medicare Part D plans.
Helping people live healthier lives
Helping to make the health care system work better for everyone

7. Contract Review

8. NYC BHO – Contracted Region

9. Populations covered under the program
All fee-for-service admissions to OMH-licensed psychiatric units (all ages) in general hospitals (Article 28 hospitals).
Fee-for-service children and youth admitted to OMH licensed private psychiatric hospitals (Article 31 hospitals).
Fee-for-service direct admissions to OMH State-operated children’s psychiatric centers or children’s units of psychiatric centers.
Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services (Article 28/32).
Fee-for-service OASAS certified hospital (Art 28/32) or freestanding (Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation Services.

10. Functions of the BHO include:
Concurrent
Review
Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals.
Discharge Planning & Tracking
Optum will engage with the inpatient provider with respect to discharge planning for applicable admissions
Enhanced efforts will be employed for inpatients identified as “High Need Individuals”
Tracking of Children with SED
Each new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the State
Provider Profiling /Analytics
Community Liaisons
Historical Clinical data will be provided by the Offices to the BHOs
Data elements specific to each inpatient admission and provider will be collected by the BHO and shared with the Provider and the Offices.
Metric Reporting will be provided back to the Offices
Facilitation of Cross System Linkages
Optum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disorders
Quality Initiative
Optum will devise a quality assurance program to monitor the quality of work performed within the contract

11. (Portal, Fax or Telephonic) Notify Optum regarding Children with SED
Review of Contract
Provider Community
The Offices
Optum
Provider Community
Notify Optum of admission
(Portal, Fax or Telephonic)
Notify Optum regarding Children with SED
Supplies Optum with guidance to perform tasks
Supplies historical clinical data
Supports access to cross systems
Performs initial/ concurrent reviews
Monitoring discharge planning & post-discharge services
Tracking of children with SED
Provider profiling
Facilitation of cross system linkage
Quality Initiative
Treatment History Form
Follows concurrent review & discharge monitoring processes 11

12. What we need from you: Partner with Us Engage in the Process
Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitation
Use your dedicated Care Advocate and Community Liaison as a part of your team
Engage in the Process
Follow the concurrent review & discharge planning/tracking processes
Identify Cross System Linkages
Provide data as requested
Use the tools provided
Ask Questions
Don’t hesitate to ask us questions
Clinical questions can be directed to the Care Advocate or to:
General questions can be directed to the Executive Director & Community Liaisons or to
ProviderConnect technical questions/issues can be directed to:
Other
Let us help you!
We want your feedback.

13. Provider Tools & Submission Processes

14. Provider Tool Review- Methods for submission
Fax
Individual Information Matrix
- Within 24 hours of admission
- Concurrent Review at established intervals
- Discharge by the date of discharge but no later than within 24 hours post discharge.
Fax #
Clinical Fax: (877)
Telephonic
Toll-free: (866)
Dedicated Care Advocate assigned by Facility
Portal
New provider portal:
ProviderConnect software

15. Fax Submission Option Individual Information Matrix Form
3 components of the form:
Admission
Providers to notify their assigned BHO within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday.
Concurrent Review
Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals.
Discharge Planning
Provider to complete and submit by the date of discharge but no later than within 24 hours post discharge.
Form located on the Optum NYC BHO Provider Portal :
Submit forms to the Optum NYC BHO clinical fax number: (877)

16. Admission Information
Is there OASAS consent on File? YES / NO
Date:       Facility Name:
BHO Care Advocate Assigned:   
Facility Contact Name:
Facility Contact Phone:       Facility Contact Fax:      
Individual Name:       Medicaid ID:      
Date of Birth:       Gender:
County of Residence:
Date of Admit:       Time of Admit:      
Age Group of the Individual:
Admission Type: Inpatient Psychiatric, Substance Abuse Rehab, Inpatient Detox
Diagnosis(es) at Admission:
Axis I:                  
Axis II:                  
Axis III:                  
Axis IV:      
Axis V:      
Reason(s) for Admission (Why now?):  
Readmission to Facility within 30 days for Inpatient Psychiatric/45 days for SA Rehab or Detox?      
Readmission to same facility:
*Please complete & submit within 24 hours following admission or by 5 p.m. the next business day following weekend and holiday admissions.
**If this is a readmission within 30 days for inpatient/detox or within 45 days for rehabilitation, send prior discharge plan with Matrix submission.

17. Feedback from Optum after Admission Notification
Optum will generate a Treatment History Form regarding the Individual admitted by the Facility within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider.
See next slide

18. Treatment History Form Information
Facility Name:       Facility Contact:      
Phone:       Fax:      
Individual Name:       Medicaid ID:      
High Need Individual:       MH readmission w/in 30 days:      
Date of Admit:       Time of Admit:      
Date of History Transmission:       Time of History Transmission:       
Last three (3) months of behavioral health services utilized by individual:                                       
Most recent diagnosis(es):
Axis I:                  
Axis II:                  
Axis III:                  
Axis IV:      
Axis V:      
There is/ is not additional treatment history information available on the individual. (circle one)
*Facility is responsible for gaining executed release of information and sending to OptumHealth for the release of substance abuse treatment services.
OASAS Consent Form
Facility/ Provider
Dates of Service
Type of Service

19. Concurrent Review
Dedicated Care Advocate to be assigned by Facility.
Check
- Notice of Preliminary Finding- Verbal
- Notice of Clinical Determination - Letter
See next slide

20. Concurrent Review Information
What has worked in the past for treatment of individual?      
What strengths do the individual and/or family system have that we can build on?      
What is being done differently this time?      
Current status of individual, including mental status examination results:      
Status/Progress with Treatment Plan:      
Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual?
If no, why?      
Current Diagnosis(es):
-Axis I:                  
-Axis II:                  
-Axis III:                  
-Axis IV:      
-Axis V:      

21. Concurrent Review Information
Physical & behavioral assessment findings:    
Current Status of Individual, including mental status examination results?
Current Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
For an admission from the community, what type of housing did the individual reside in?
If individual was admitted from an institutional setting, what type of setting was the sending facility?
What has worked in the past for treatment of individual?
What strengths do the individual and/or family system have that we can build on?
What is being done differently this time?      
Status/Progress with Treatment Plan:     
Assessment for case management completed?
If case management is needed and individual is not currently enrolled, referral made?
 Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual?      
If no, why?      
Preliminary Discharge Plan:      
If this is a readmission, key factors in why the prior discharge plan didn’t meet the member’s needs?      
Anticipated discharge date:       Expected Length of Stay:       Days
Barriers to Discharge (biopsychosocial):      
Referral to local peer/family services programs/supports?

22. Concurrent Review Information
Individual involved in discharge planning?
Individual’s family involved in discharge planning?
Contact with medical provider(s):
Detail?      
Contact with behavioral provider(s):
Detail?  
Is the individual enrolled in Managed Care?
Is the individual enrolled in a Health Home?   
Did the individual have a care coordinator prior to admission?
Case manager/ Care coordinator engaged in hospitalization?
Name of case manager/care coordinator:      
If child/adolescent, other systems engaged?
Other Issues / Notes?
Medications
Name
Dosage
Frequency
If more rows are needed to list medications, please list them here:      
Discontinued?

23. Discharge Planning Information
Date of Discharge:       Time of Discharge:   
CM/Care Coordinator?   
Individual Leave Against Medical Advice?
Diagnosis(es) at Discharge:
Axis I:               
Axis II:            
Axis III:                 
Axis IV:      
Axis V:   
Medications:     
Name
Dosage
Frequency
Does the individual have a sufficient amount of medication until his/her follow up appointment?
If no, why?  
Was case summary and discharge plan sent to the outpatient provider?
If yes, what date?       

24. Discharge Planning Information
If the individual has a care coordinator (i.e. ACT, OMH TCM, Children's HCBS Waiver, MATS, and Health Home), was he/she informed of the discharge? <drop down>
If the individual is assigned to a MCO, have they been contacted for post discharge physical health care needs? <drop down>
Peer/Family Support Service/Program Referral:
If yes, name & contact information:      
For a discharge to the community, what type of residence is he/she being discharged to:
If the individual is being discharged to an institutional setting, what type? <drop down>
Has the individual been provided with written instructions for what to do in the event of a crisis prior to his/her first post-discharge appointment?
If no, why?      
If individual is under 18 years, linkage of children with other service systems (e.g. juvenile justice, educational system, child welfare)?
Follow up appointments, inclusive of case management:
Provider #1 Name:       Provider #3 Name:      
Provider ID:       Provider ID:      
Contact Information:       Contact Information:      
Date/Time of Appointment:       Date/Time of Appointment:      
Service Type: Service Type:
Provider #2 Name:       Provider #4 Name:      
Date/Time of Appointment:       Date/Time of Appointment:      
Service Type: Service Type:  

25. Review of Process - MH Inpatient
Action
Time Frame
Report in
Provider
Profile
Medicaid FFS beneficiary admitted for inpatient mental health treatment
Admitting facility submits Individual Information Matrix via provider portal, fax or telephone to NYC BHO
Within 24 hrs of admission or by 5 p.m. the next business day following weekend and holiday admissions
BHO sends Treatment History Form to facility via fax, encrypted or provider portal
BHO CA contacts designated facility clinician and conducts concurrent review; sets time for next concurrent review
Within 72 hrs of admission or by 5 p.m. the next business day following notification of the admission by the provider, whichever is later
BHO CA and designated facility clinician conduct concurrent reviews
BHO CA documents facility compliance with required elements of treatment planning, treatment and discharge planning
At least every 5 days*
Consumer’s clinical condition no longer justifies continuing
inpatient stay
During concurrent review, BHO CA tells facility liaison that continuing inpatient stay may no longer be justified and that BHO CA is sending the case for review by a BHO psychiatrist to make the determination
If the BHO psychiatrist concurs that continuing inpatient stay is no longer justified, BHO CA. CA gives verbal Notice of Preliminary Finding to the facility liaison
Within 24 hours of concurrent review

26. Review of Process - MH Inpatient - continued
Action
Time Frame
Report in
Provider
Profile
Potential Provider Responses
Provider submits request for reconsideration and additional clinical information to support the need for continuing inpatient stay;
(1) Within 24 hrs of receipt of Notice of Preliminary Finding
BHO psychiatrist completes review of additional clinical information and/
or doc-to-doc consultation to facility physician; communicates
reconsideration determination to the facility and if ongoing care is
determined to be required, BHO CA continues concurrent reviews.
Within 24 hours of receipt of Reconsideration Request
BHO issues Notice of Clinical Determination if the reconsideration
review determines that the individual does not require treatment in an
inpatient setting and the individual is not discharged by the facility. BHO
CA communicates the Notice of Clinical Determination to the facility
liaison verbally and in writing by portal, fax, or secure .
Within 72 hours of Notice of Preliminary Finding OR
Provider discharges consumer and submits required discharge information via portal, fax or secure ; BHO closes case
2) Within 48 hrs of receipt of Notice of Preliminary Finding
BHO has received no discharge information and no request for
reconsideration…
BHO issues Notice of Clinical Determination to facility-designated
representative via fax or secure and sends copy to the Offices
(3) Within 48 hours of receipt of Notice of Preliminary Finding

27. Review of Process - MH Inpatient - continued
NOTE: The Offices will waive the review requirement for maximum concurrent review intervals for individuals the BHO designates as “Long Stay” when all of the following criteria are met:
The individual meets the criteria for inpatient care
The individual presents with symptoms and/or history that demonstrates a significant likelihood of deterioration in functions/relapse if transitioned to a less intensive level of care
The BHO care manager and provider concur that the current treatment and discharge plans best meet the individual’s needs
The individual’s discharge is delayed pending availability of resources that both the provider and BHO believe are necessary to maintain the individual outside of the current hospital setting (e.g. intermediate care inpatient, residential treatment, or foster care beds)
For Long Stay individuals, the BHO care manager should schedule follow up reviews at intervals deemed appropriate based upon clinical judgment.
Notices of Preliminary Finding and Clinical Determination will not apply to individuals designated as Long Stay.

28. Review of Process SA Inpatient Detox
Same process as MH Inpatient, however concurrent reviews conducted at least every 2 days
SA Inpatient Rehab
Same process as MH Inpatient, however concurrent reviews conducted within 21 days of admission

29. Telephonic Submission Option
Call Optum Intake at (866) for initial admission within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday.
Make sure all of your information is ready when calling Optum Intake
Use Individual Information Matrix form as a guideline. Form located on the Optum NYC BHO Provider Portal :
Ongoing concurrent reviews will be conducted in partnership with assigned Optum Care Advocate.

30. Provider Portal Submission Optum
Use ProviderConnect via for online entry of data from Information Matrix form:
Initial Admission
Concurrent Review
Discharge Planning

31. OptumHealth NYC BHO Provider Portal

32. OptumHealth NYC BHO Provider Portal Page.

33. ProviderConnect Login. 33

34. ProviderConnect Login (cont.)34

35. ProviderConnect News . 35

36. ProviderConnect Main Menu. 36

37. Individual Search . 37

38. Individual Search

39. Admission Notification. 39

40. Admission Notification

41. Saving updates- Admission

42. Concurrent Review- Logging into Provider Connect

43. Individual Search - Concurrent Review

44. Concurrent Review

45. Concurrent Review

46. Concurrent Review

47. Concurrent Review

48. Concurrent Review

49. Concurrent Review

50. Concurrent Review

51. Concurrent Review

52. Concurrent Review

53. Concurrent Review

54. Current Medications

55. Adding Medications

56. Saving updates- Concurrent Review

57. Discharge- Logging into Provider Connect

58. Individual Search- Discharge

59. Discharge

60. Discharge

61. Discharge

62. Discharge

63. Saving updates- Discharge

64. Children with Serious Emotional Disturbance (SED) - Logging into Provider Connect

65. Individual Search- SED

66. Children with Serious Emotional Disturbance (SED)

67. Children with Serious Emotional Disturbance (SED)

68. Children with Serious Emotional Disturbance (SED)

69. Saving updates- SED

70. Next Steps
Complete and submit Facility Information Form, if not yet submitted, to Suzanne Feeney via:
Fax at: (518) at
Mail at: 900 Watervilet-Shaker Road, Suite 103, Albany, NY
Providers who select ProviderConnect as their submission option should contact the Optum Help Desk to request a User ID/Password at (866) /prompt 4
Optum will post Care Advocate/Facility assignments and contact information on our Provider Portal at:
Start to notify Optum of admissions as of 1/3/2012.
Fax - Clinical Fax: (877)
Telephonic - (866)
Provider Portal (ProviderConnect) -
If you are using the Optum Provider Portal ‘ProviderConnect’ and have technical questions or encounter a problem, contact Optum (866) /prompt 4 or us at

71. Questions?