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MARYLAND MEDICAID ADVISORY COMMITTEE

EARLY & PERIODIC SCREENING, DIAGNOSIS & TREATMENT (EPSDT)

Employed Individuals with Disabilities Program (EID) Information 

MESSAGE TO COMMUNITYCHOICE ADVISORY GROUP 

Updated
November 28, 2007

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Substance Abuse Improvement Initiative (SAII)

Visitors to Date

Self-Referral Protocols                            Contact Information                                         Initial Treatment Plan Outpatient                Standard Information - Partial Hosp.           Standard Information - ICF-A                        Outpatient Concurrent Review                     Discharge Summary                                          Fee-for-Service Rates                               ICF-A Continued Care Authorization      Contracting and Credentialing                Billing Information

Substance Abuse Improvement Initiative

Under the HealthChoice Substance Abuse Initiative (SAII), HealthChoice enrollees are able to self-refer to substance abuse treatment providers that are not part of their Managed Care Organization (MCO) provider network.  Providers who do not have contracts with an individual’s MCO or Behavioral Health Organization (BHO) may be reimbursed for services to these individuals.  The SAII, implemented January 1, 2001, expands the limited option for self-referral for a comprehensive substance abuse assessment.  This document explains the SAII procedures, contains links to the necessary SAII documents.

Since 1999, HealthChoice enrollees could self-refer for a comprehensive substance abuse assessment if the following conditions are met:

	The recipient is not in substance abuse treatment.
	The recipient has not received a self-referred comprehensive substance abuse assessment that calendar year.
	The assessment provider is an ADAA-certified substance abuse treatment provider who is qualified to conduct the assessment using the required tools:
	Addiction Severity Index (ASI) for enrollees aged 20 or older
	Problem Oriented Screening Instrument for Teenagers (POSIT) for enrollees under age 20
	American Society of Addictions Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders to determine appropriate level and intensity of care treatment.

MCOs or their BHOs will reimburse any ADAA-certified provider $50 for an assessment which meets the conditions described above.  The provider does not have to be a Medicaid enrolled provider to bill the MCO for this service. 

While HealthChoice enrollees are now able to self-refer for treatment rather than just for assessment, the limitation of one-self referral for assessment is still in force and providers should be aware of its provisions.

	Self-Referral according to a protocol and other documents that explain responsibilities, provides a reimbursement schedule, and lists contact numbers.
	Prompt Payment.
	Expansion of Networks.

Under the SAII, HealthChoice enrollees may self-refer for substance abuse treatment. The purpose of the Initiative is to increase access to substance abuse treatment and to minimize disagreements between treatment providers and Managed Care Organizations (MCOs) and Behavioral Health Organizations (BHOs).  Key features of the self-referral under the SAII are:

1.		A HealthChoice enrollee can self refer for substance abuse treatment to any appropriate, willing substance abuse treatment provider.

	The provider need not be part of the enrollee’s MCO/BHO network.
	A provider is not required to accept the enrollee as a patient or a client, but does have a professional obligation to refer the individual to the appropriate provider.

	The out-of-network provider must agree to accept Medicaid fee-for-service rates.
	Out-of-network Local Health Departments have special rates. These rates only apply to HealthChoice services delivered under the SAII.
	Network providers are paid at the rate specified in their MCO contract

3.   The Self-Referral Protocol

 

	Substance abuse treatment providers, MCOs, BHOs, and State staff developed a detailed SAII protocol that lays out the rules that treatment providers, MCOs, and BHOs will follow.
	The protocol includes preauthorized units of service, the notification process for each treatment modality, and other important information. When a HealthChoice enrollee presents, the provider should identify the ASAM level of care and follow the provisions for the appropriate treatment modality.
	Familiarity with the protocol, including the guidelines and footnotes, is crucial.  Providers not following these procedures could be denied authorization and/or payment.  An MCO or BHO that does not follow the procedures could be obligated to pay for services it might not otherwise have authorized.
	The protocol for ICF-A Continued Care Authorizations is found in a separate document.

Providers, MCO/BHO, and DHMH staff developed five forms to streamline communications between providers and all MCO/BHOs.  These forms satisfy the requirement for a treatment plan for the Office of Health Care Quality.  These forms are on the HealthChoice web site.  They are:

		PDF	Word
	Initial Treatment Plan for Ambulatory Detox, Intensive Outpatient Treatment, Methadone Maintenance, Traditional Outpatient Treatment
	Standard Information Required for Progress Report and Assessment of Continued Stay for Partial Hospitalization
	Standard Information Required for Telephonic Authorization for Intermediate Care Facility Treatment, Acute Inpatient Treatment
	Outpatient Concurrent Review Authorization of Care
	Discharge Summary

II.   Prompt Payment

MCOs/BHOs will promptly pay clean bills submitted by providers within 30 days. If they do not pay providers within 30 days, MCOs/BHOs are penalized and have to pay interest to the provider. Network providers will be reimbursed at the rate specified by the contract. In the absence of a contract, that is, for non-network providers, reimbursement consists of the Medicaid fee-for-service rate.

III.   Expansion of Networks

As a result of the Initiative, MCOs/BHOs are more willing to contract with appropriate providers, which greatly enhances patient access. Appropriate providers include DHMH certified addictions programs or independent practitioners for whom substance abuse treatment is within the scope of their practice according to the Health Occupations Act.  See Core Elements in Contracting and Credentialing.  

The HealthChoice Substance Abuse Workgroup meets every the second Thursday of the month to resolve SAII issues and give MCOs, BHOs, providers, and State representatives an opportunity to share information on emerging issues.  It meets from 1:00-3:00, generally at a substance abuse treatment facility or an MCO office.  All are welcome.   For information, contact Mike Franch at franchm@dhmh.state.md.us.