HealthChoice

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Substance Abuse Improvement Initiative (SAII)

 
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General:

gold bullet  Self-Referral Protocols Chart, effective 1/1/2010 New Item!

gold bullet  Self-Referral Protocols Narrative, effective 1/1/10 New Item!

gold bullet  1500 Billing Instructions, eff. 1/1/2010

gold bullet  Substance Abuse Treatment Fee Schedule, eff. 1/1/2010

gold bullet  Self-Referral Protocols, eff. before 1/1/2010 

gold bullet  Initial Treatment Plan Outpatient              Microsoft Word document

gold bullet  Standard Information - Partial Hosp.         Microsoft Word document

gold bullet  Standard Information - ICF-A                      Microsoft Word document

gold bullet  Outpatient Concurrent Review                   Microsoft Word document

gold bullet  Discharge Summary                                        Microsoft Word document

gold bullet  Substance Abuse Treatment Fee Schedule, eff. before 1/1/2010

gold bullet  Standardized Form for Treatment Planning

gold bullet  Alcohol and Drug Abuse Administration Website

gold bullet  EVS Tips: Determining if a Client is Eligible for   Substance Abuse Services

gold bullet  Substance Abuse Provider Application Instructions

gold bullet  Substance Abuse Provider Application Effective 5/16/11

gold bullet  Substance Abuse Provider Agreement Effective 5/16/11

   

Managed Care Organizations:

gold bullet  Contact Information                              

gold bullet  Contracting and Credentialing             

gold bullet   Applications This is a html web page

gold bullet   Disclosure of Ownership Statement New Item!

gold bullet  Billing Information                                           This is a html web page

gold bullet   American Society of Addictions Medicine     This is a html web page

gold bullet  ICF-A Continued Care Authorization   

 

 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, expanded the limited option for self-referral for a comprehensive substance abuse assessment. This document updates the SAII procedures beginning January 1, 2010, includes information about coverage for individuals in the Primary Adult Care (PAC) Program, and contains links to the necessary SAII documents.

Before the SAII: Comprehensive Substance Abuse Assessment. 

Under the self-referral initiative, an MCO or the Behavioral Health Organization (BHO) which administers the substance abuse services for certain MCOs will cover a Comprehensive Substance Abuse Assessment once per enrollee per provider per 12-month period, unless there is more than a 30-day break in treatment. If a patient returns to treatment after 30 days, the MCO/BHO will pay for another CSAA. This is a new feature of the initiative which begins on January 1, 2010.

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.

The main components of the SAII are:
gold bullet Self-Referral according to a protocol and other documents that explain responsibilities, provides a reimbursement schedule, and lists contact numbers.
gold bullet Prompt Payment.
gold bullet Expansion of Networks.
I.  Self Referral Process:  To Increase Access to Substance Abuse Treatment and to Minimize Disagreements between Providers and MCOs/BHOs

 

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.
gold bullet  The provider need not be part of the enrollee’s MCO/BHO network.
gold bullet 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.

 

2.   Agreed-upon reimbursement.
gold bullet The out-of-network provider must agree to accept Medicaid fee-for-service rates. This is a .pdf file and requires Acrobat Reader
gold bullet Network providers are paid at the rate specified in their MCO contract
3.   The Self-Referral Protocol This is a .pdf file and requires Acrobat Reader
 
gold bullet 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.
gold bullet The protocol includes preauthorized units of service, the notification process for each treatment modality, and other important information. When a HealthChoice or PAC enrollee presents, the provider should identify the ASAM level of care and follow the provisions for the appropriate treatment modality.
gold bullet 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.
gold bullet The protocol for ICF-A Continued Care Authorizations is found in a separate document. This is a .pdf file and requires Acrobat Reader
4.   Standardized forms. 

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:

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.  

 

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This site contains links to other Internet sites only for the convenience of World Wide Web users. DHMH is not responsible for the availability or content of these external sites, nor does DHMH endorse, warrant or guarantee the products, services or information described or offered at these other Internet sites.

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