Virginia BHSA Handbook Supplement - Magellan Provider

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Magellan Healthcare, Inc.*Provider Handbook Supplement forVirginia Behavioral Health ServiceAdministrator (BHSA)*Magellan Healthcare, Inc. and its respective affiliates and subsidiaries are affiliates of Magellan Health, Inc. (collectively “Magellan”). 2013-2021 Magellan Health, Inc. 6/21

Virginia BHSA Provider Handbook SupplementTable of ContentsSection 1: Introduction . 4Welcome . 4Covered Benefits . 4Contact Information . 5Section 2: Magellan’s Behavioral Health Network . 6Network Provider Participation. 6Types of Providers . 8Credentialing . 10Recredentialing . 12Reporting Changes in Practice Status . 13Updating Practice Information . 14Medicaid Marketing Materials . 16Contracting with Magellan . 18Appealing Decisions That Affect Network Participation Status . 20Contract Termination . 21Section 3: The Role of the Provider and Magellan . 23Care Management Overview . 23Before Services Begin . 25Psychological Testing . 27Continued Stay . 28Appealing Care Management Decisions . 30Member Access to Care . 31Continuity, Coordination and Collaboration . 33Advance Directive . 36Medical Necessity Criteria. 37Clinical Practice Guidelines . 38Clinical Monographs . 39New Technologies . 40Provider Website . 41Section 4: The Quality Partnership . 43A Commitment to Quality . 43Cultural Competency . 452— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementMember Safety . 47Accreditation. 48Prevention/Screening Programs . 49Outcomes. 50Provider Input . 51Member Rights and Responsibilities . 52Confidentiality. 53Site Visits . 54Treatment Record Reviews . 56Member Satisfaction Surveys. 57Provider Satisfaction Surveys . 58Adverse Outcome Reporting . 59Inquiry and Review Process . 61Fraud, Waste and Abuse . 63Provider Exclusion from Federally or State-Funded Programs . 65HIPAA Transaction Standards. 68Section 5: Provider Reimbursement . 69Claims Filing Procedures . 69Appendix A: Service Registration/Authorization GridAppendix B: Submission Timeframes and Guidelines3— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 1: INTRODUCTIONWelcomeWelcome to the Virginia Behavioral Health Services Administrator (BHSA) Provider HandbookSupplement. This document supplements the Magellan National Provider Handbook, addressingpolicies and procedures specific for the Virginia BHSA plan. This provider handbook supplement is to beused in conjunction with the Magellan National Provider Handbook (and Magellan organizationalprovider supplement, as applicable). When information in this supplement conflicts with the nationalhandbook, or when specific information does not appear in the national handbook, the policies andprocedures in the Virginia BHSA supplement prevail.Covered BenefitsMagellan administers the traditional and non-traditional behavioral health and substance use servicesfor all members covered through any Virginia Department of Medical Assistance Services (DMAS)behavioral health fee-for-service program. Magellan also administers the residential behavioral healthservices for members enrolled with a Medicaid/FAMIS (Family Access to Medical Insurance Security)Managed Care plan.Covered Mental Health BenefitsAssertive Community Treatment (start July 1, 2021)Crisis Intervention (end Nov. 30, 2021)Crisis Stabilization (end Nov. 30, 2021)EPSDT Behavioral Therapy (ABA) in Residential SettingsEPSDT Therapeutic Group HomeEPSDT Psychiatric Residential Treatment FacilityEPSDT 1:1 Support ServicesIndependent Initial and Follow-up Assessment (IACCT)Inpatient Psychiatric Hospital Services - Freestanding Psychiatric HospitalInpatient Psychiatric Hospital Services - General Acute Care Hospital w/PsychiatricUnitIntensive Community Treatment (end June 30, 2021)Intensive In-Home ServicesMental Health Case ManagementMental Health Intensive Outpatient Services (start July 1, 2021)Mental Health Partial Hospitalization (new medical necessity criteria start July 1, 2021)Mental Health Skill-building ServicesOutpatient Psychiatric ServicesPeer Support Services, Mental HealthPsychiatric Residential Treatment FacilityPsychosocial RehabilitationTherapeutic Day Treatment for Children & AdolescentsTherapeutic Group Home4— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementTreatment Foster Care Case ManagementCovered Substance Use Disorder BenefitsDrug ScreeningsMedication Assisted Treatment (MAT) (Non-OTP/OBOT)Opioid Treatment Program (OTP)Office Based Opioid Treatment (OBOT)Outpatient Substance Use Disorder Treatment Services ASAM 1.0Substance Use Case ManagementSubstance Use Care Coordination (OTP/OBOT Setting Only)Intensive Outpatient, Substance Use ASAM 2.1Partial Hospitalization, Substance Use ASAM 2.5Clinically Managed Low Intensity Residential Services ASAM 3.1Clinically Managed Population-Specific High Intensity Residential Services ASAM 3.3Clinically Managed High Intensity Residential Services (Adult) & Clinically ManagedMedium Intensity (Adolescent) ASAM 3.5Medically Monitored Intensive Inpatient Services (Adult) & Medically Monitored HighIntensity Inpatient Services (Adolescent) ASAM 3.7Medically Managed Intensive Inpatient Services ASAM 4.0Peer Support Services, Substance UseContact InformationIf you have questions, Magellan is eager to assist you. We encourage you to visit our Virginia website atwww.MagellanofVirginia.com and our Magellan provider website at www.MagellanProvider.com. Youcan look up authorizations and verify the status of a claim online at this provider site, in addition tocompleting other key provider transactions. We have designed our websites for you to have quick andeasy access to information, and answers to questions you may have about Magellan.You also can reach us at the Magellan of Virginia Care Management Center: Phone: 1-800-424-4046 Customer Service Phone: 1-800-424-4536 Provider Relations Email: VAProviderQuestions@MagellanHealth.com Email for Medicaid marketing materials: VAMarketing@MagellanHealth.com5— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKNetwork Provider ParticipationOur PhilosophyMagellan is dedicated to selecting behavioral healthcare professionals,groups, agencies and facilities to provide member care and treatmentacross a range of covered services as defined by DMAS.Our PolicyTo be a network provider of clinical services with Magellan under theBHSA program, you must be credentialed and enrolled according toMagellan and DMAS standards and must be contracted with Magellan.Providers are subject to applicable licensing requirements.What You Needto DoYour responsibility is to: Provide medically necessary covered services to members whosecare is managed by Magellan; Follow the policies and procedures outlined in this handbook, anyapplicable supplements and your provider participationagreement(s) as well as DMAS policies and regulations; Provide services in accordance with applicable Commonwealth andfederal laws and licensing and certification bodies. Contractedproviders for the BHSA network are required to abide by DMASregulations and manuals, and maintain active licensure for theircontracted provider type and specialty for community-basedservices as well as at each service location; Agree to cooperate and participate with all care management,quality improvement, outcomes measurement, peer review, andappeal and grievance procedures; Make sure only providers currently credentialed with Magellanrender services to Magellan members; and Follow Magellan’s credentialing and recredentialing policies andprocedures.What MagellanWill DoMagellan’s responsibility is to: Provide assistance 24 hours a day, seven days a week; Assist providers in understanding and adhering to our policies andprocedures, the payer’s applicable policies and procedures, and therequirements of our accreditation agencies including but notlimited to the National Committee for Quality Assurance (NCQA),Utilization Review Accreditation Commission (URAC); and6— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook Supplement Maintain a credentialing and recredentialing process to evaluateand select network providers that does not discriminate based on amember’s benefit plan coverage, race, color, creed, religion,gender, sexual orientation, marital status, age, national origin,ancestry, citizenship, physical disability or any other statusprotected by applicable law.7— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKTypes of ProvidersOur PhilosophyMagellan is dedicated to recruiting and retaining individualpractitioners and institutional providers with the behavioral healthcarecredentials to provide care and treatment across a range of productsand services to members in the Virginia Medicaid/FAMIS programs.Magellan refers members to credentialed and contracted practitionersin private practice, practitioners in a group practice, and providerorganizations including facilities and agencies.Our PolicyMagellan refers members to credentialed and contracted providers inthe following categories: Individual Practitioner – a clinician who is licensed by the VirginiaDepartment of Health Professions and who provides behavioralhealthcare services and bills under his or her own TaxpayerIdentification Number. Individual practitioners must meet Magellanand/or other applicable credentialing criteria (See ProfessionalProvider Selection Criteria for Individual Providers within theappendix of the Magellan National Handbook) and have a fullyexecuted provider agreement with Magellan. Group Practice – a practice contracted with Magellan as a groupentity and as such, bills as a group entity for the services performedby its Magellan-credentialed clinicians. Clinicians affiliated with thegroup must complete the individual credentialing process, and thegroup must have at least one active/credentialed group member inorder to be eligible to receive referrals from Magellan. Organization – a facility or agency licensed and/or certified inVirginia to provide behavioral health services. Examples oforganizations include but are not limited to: general hospitals withpsychiatric programs, freestanding behavioral health facilities,federally qualified and rural health clinics, community serviceboards, outpatient mental health clinics, agencies which providecommunity mental health rehabilitation services such as mentalhealth skill- building services, intensive in-home and treatmentservices and therapeutic day treatment. Please refer to theOrganization Provider Handbook Supplement for additionalinformation about facility/ organization providers includingorganization provider credentialing criteria.8— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook Supplement Out-of-State Providers – Out of state providers applying for networkinclusion must hold the appropriate DBHDS licensure for delivery ofcommunity-based services in Virginia. For those delivering servicesoutside of Virginia to members with Virginia Medicaid, providers musthold the appropriate licensure in their home state. Out of stateproviders are held to the same service authorization processing rulesas in-state providers and must be enrolled with Magellan prior tosubmitting a request for out of state services. Enrollment of providersfor Psychiatric Residential Treatment Facilities and Therapeutic GroupHomes are generally limited to those located in Virginia or within 50miles of the state line. If an individual requires psychiatric residentialservices that are not available in Virginia, an out-of-state provider mayenroll for a specific individual only for the duration of the admission.What You Needto DoYour responsibility is to: Provide Magellan with a complete Form W-9 for the contractingentity to facilitate referrals and claims processing; Notify Magellan and complete a new Form W-9 if your contractedentity changes legal name or ownership; Notify Magellan of any changes to the list of practitioners in yourgroup within 10 business days; For organizations, update changes to your staff roster no less thanquarterly; Notify Magellan of changes in your service location, mailing and/orfinancial address information; and Adhere to the credentialing policies outlined in this handbook.What MagellanWill DoMagellan’s responsibility is to: Review providers and prospective providers for credentialing orrecredentialing without regard for race, color, creed, religion,gender, sexual orientation, marital status, age, national origin,ancestry, citizenship, physical disability, or any other statusprotected by law; Develop and implement recruitment activities to solicit qualitybehavioral health providers to participate in the VirginiaMedicaid/FAMIS programs; and Make and maintain website-based tools available to providers sothey can update their practice information in a convenient onlinefashion.9— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKCredentialingOur PhilosophyMagellan is committed to the provision of quality care to our members.In support of this commitment, practitioners and organizations mustmeet or exceed a set of credentialing criteria to be eligible to provideservices to our members.Our PolicyMagellan employs credentialing criteria and decision-making processesin the review and selection of behavioral healthcare practitioners andorganizations for inclusion in our provider network. Our providercredentialing criteria satisfies the requirements of applicable regulatorybodies and our customers.What You Needto DoYour responsibility is to: Complete and submit all required application materials and relateddocuments, including any documentation of current accreditation,and attest to their accuracy. We cannot process incompleteapplications. Be in good standing with state and federal regulatory entities, asapplicable. Hold current licensure or certification in accordance with applicablestate and federal laws. For organizations, providers must hold appropriate currentaccreditation, CMS Medicare Certification, and/or for applicableservice delivery and service locations in Virginia, hold Departmentof Behavioral Health and Developmental Services (DBHDS),Department of Social Services (DSS), or Virginia Department ofHealth (VDH) licensure for covered behavioral health services. Thislicense shall be provided to Magellan during credentialing andrecredentialing as evidence of a current state license site visit thatwill be used in lieu of an accreditation and/or a Magellan site visitfor those covered services. Provide primary source verification (PSV) of professional licenses ofyour medical, behavioral health and clinical staff members. Thismeans contacting state licensing boards to verify that professionalshold a current license, education and training to practice withoutrestrictions or sanctions. Additional required queries include theNational Practitioner Data Bank (NPDB), the Health Inquiry andProtection Data Bank (HIPDB), System for Award Management10— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook Supplement What MagellanWill Do(SAM), Social Security Death Master File (SS DMF) and the Office ofInspector General/General Services Administration (OIG/GSA)databases for Medicare/Medicaid sanctions. For physicians, PSValso includes verification of Board Certification, and current, DrugEnforcement Agency (DEA) registration, and, if applicable, stateControlled Dangerous Substance (CDS) registration.Attest that there are no Medicare or Medicaid sanctions orexclusions from participation in federally funded healthcareprograms by the organization, its staff, subcontractors, agents,directors, officers, partners or owners with 5 percent or morecontrolling interest. Immediately report to Magellan should anysanction or exclusion information be discovered.Fulfill Magellan requirements for malpractice claims history review.Meet Magellan’s minimum requirements for professional andgeneral liability insurance coverage. For the Virginia BHSA program,providers are required to maintain minimum of 1 million peroccurrence and 1 million aggregate coverage for both general andprofessional liability. Coverage may be obtained through acommercial insurance carrier, unless, for organizations, theprovider can show evidence of a fully funded self-insurance policywhich meets the minimum coverage requirements.Participate in a site visit upon request.Participate in recredentialing every three years or in compliancewith regulatory and/or customer requirements.Participate in any applicable Center for Medicare and MedicaidServices (CMS) validation and revalidation process per the ProviderScreening Regulations outlined in 42 CFR 455, subpart E.Magellan’s responsibility to you is to: Provide you with initial application and recredentialing materialswith instructions for completion. Complete the credentialing and recredentialing process in a timelymanner that is, at a minimum, within industry, state- or customerestablished timeframes. Have your credentialing or recredentialing application reviewed bya Magellan Regional Network and Credentialing Committee (RNCC). Notify you in writing upon completion of the credentialing process. Perform site visits as needed.11— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKRecredentialingIMPORTANT NOTE: This section has been left in as a placeholder, for your information. This section isincluded in the Magellan national provider handbook; any sections that are identical in content are notduplicated within this handbook supplement. Providers will use the national handbook in conjunctionwith this supplement.REFER TO NATIONAL HANDBOOK FOR THIS SECTION12— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKReporting Changes in Practice StatusIMPORTANT NOTE: This section has been left in as a placeholder, for your information. This section isincluded in the Magellan national provider handbook; any sections that are identical in content are notduplicated within this handbook supplement. Providers will use the national handbook in conjunctionwith this supplement.REFER TO NATIONAL HANDBOOK FOR THIS SECTION13— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKUpdating Practice InformationOur PhilosophyWe are committed to maintaining current, accurate providerpractice information in our database in order to offer qualifiedproviders to our members, and to enable our providers to receiveimportant communications from Magellan in a timely manner.Our PolicyMagellan’s policy is to maintain accurate databases, updated in atimely manner, with information received from our providers tofacilitate efficient and effective provider selection, referral andclaims processing, and to provide accurate and timely information inprovider-related publications, e.g., provider directories. The mostefficient and effective way to communicate administrative informationchanges and to keep provider information up to date is through ouronline provider portal.Providers are required to notify Magellan of changes inadministrative practice information using our online Provider DataChange Form (PDCF). Phone requests and faxes are no longer accepted.By using the PDCF, providers can update information online in realtime, a method more efficient and accurate than other forms ofcommunication.Note: Some changes to provider information may result in the need fora contract amendment and/or credentialing such as facility or groupname changes, changes of ownership, adding a new service or servicelocation for a facility or a change to Taxpayer Identification Numbers;these still require notification to your network management specialist.The PDCF application will direct you when these notifications need tooccur. Requesting authorization, providing or billing for services in anyof these situations should NOT commence until you have notifiednetwork staff and received written confirmation from Magellan that allrequired changes have been implemented, which could include theamending of existing agreements, credentialing new service locationsor practitioners, adding new services or the need for new agreementsto be issued.What You Needto DoYour responsibility is to: Update changes in your administrative practice information listedbelow using our online Provider Data Change Form by signing in towww.MagellanProvider.com and selecting Display/Edit PracticeInformation;14— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook Supplement Notify us within 10 business days of any changes in your practiceinformation including, but not limited to, changes of:- Service, mailing or financial address,- Telephone number,- Business hours,- Email address, and- Taxpayer Identification Number; Promptly notify us if you are unable to accept referrals for anyreason including, but not limited to:- Illness or maternity leave,- Practice full to new patients,- Professional travel, sabbatical, vacation, leave of absence, etc.; Promptly notify us of any changes in group practices, including, butnot limited to:- Practitioners departing from your practice,- Practitioners joining your group practice,- Changes of service, mailing or financial address,- Changes in practice ownership, including a change in TaxpayerIdentification Number (TIN), and/or National Provider Identifier(NPI),- Telephone number,- Business hours, and- Email address; Contact your network management specialist if directed to do thisby the online application; some changes may require a contractamendment and/or credentialing before you can initiate, requestprior authorization or bill for services; Update and maintain your provider profile information (enablesyou to enhance your profile, which members see in online providersearches, by uploading your photo, a personal statement,professional awards, etc.); Promptly review and revise for accuracy any confirmation ofProvider Data Change Forms you receive from Magellan.What MagellanWill DoMagellan’s responsibility for provider data changes is to: Maintain our online Provider Data Change Form resulting in realtime information with minimum additional verificationrequirements and contact you for clarification, if needed.15— 2013-2021 Magellan Health, Inc. 06/21

Virginia BHSA Provider Handbook SupplementSECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORKMedicaid Marketing MaterialsOur PhilosophyTo ensure that Medicaid members and their families are marketed toby providers of Community Mental Health Rehabilitative Services(CMHRS) and Early Periodic Screening, Diagnostic, and Treatment(EPSDT) supplement services in ways that best serve the member and,in accordance with 12VAC30-130-2000.Our PolicyTo review all Medicaid marketing materials and marketing plans forCMHRS and EPSDT providers, in accordance with 12VAC30-130-2000and provide written response within a timely manner.What You Needto DoYour responsibility is to: Ensure any Medicaid marketing materials and marketing plans arecreated in compliance with 12VAC30-130-2000. New providers to the Magellan Virginia BHSA provider networkmust submit any Medicaid marketing materials, websites andmarketing plan for Magellan’s review prior to acceptance into theVirginia Medicaid Network. Existing providers are to submit any written content changes toMedicaid marketing materials, websites and marketing plan prior tothe materials use or dissemination. Changes to non-written content, such as graphics, logos,formatting, etc. do not require review and approval. Providers are to cooperate with any submission requests byMagellan for Medicaid marketing materials, websites andmarketing plans. Providers must submit Medicaid marketing materials, websites andmarketing plans for review via fax (1-888-656-1409) or e-mailVAMarketing@magellanhealth.com. Correct any deficiencies indicated by Magellan’s review ofsubmitte

Virginia BHSA Provider Handbook Supplement 6— 2013-2021 Magellan Health, Inc. 06/21 SECTION 2: MAGELLAN’S BEHAVIORAL HEALTH NETWORK Network Provider Participation Our Philosophy Magellan is dedicated to selecting behavioral healthcare professionals, groups, age

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