HEALTHCHOICES BEHAVIORAL HEALTH PROGRAM PROGRAM STANDARDS .

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COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF HUMAN SERVICESHEALTHCHOICES BEHAVIORALHEALTH PROGRAMPROGRAM STANDARDS ANDREQUIREMENTSPRIMARY CONTRACTOR

Table of Contents . ii-ivHealthChoices Behavioral Health Definitions . v-xviAcronyms. xvii-xxivPART I. GENERAL INFORMATION. 1I-1PURPOSE . 1I-2ISSUING OFFICE . 1I-3SCOPE . 1I-4TYPE of AGREEMENT . 1I-5ON-SITE REVIEWS .3I-6INCURRING COSTS . 3I-7HEALTHCHOICES RATE INFORMATION . 3I-8RESPONSIBILITY TO EMPLOY CASH ASSISTANCE BENEFICIARIES . 3I-9SMALL DIVERSE BUSINESS INFORMATION . 3I-10 CONTRACTOR RESPONSIBILITY and OFFSET PROVISIONS . 4I-11 LOBBYING CERTIFICATION and DISCLOSURE . 5I-12 CONTRACTOR’S CONFLICT OF INTEREST . 5I-13 PROHIBITED AFFILIATIONS. 5I-14 INTEREST OF THE COMMONWEALTH AND OTHERS . 6I-15 PRIMARY CONTRACTOR RESPONSIBILITIES . 6I-16 FREEDOM OF INFORMATION AND PRIVACY ACTS . 6I-17 NEWS RELEASES . 6I-18 COMMONWEALTH PARTICIPATION . 7I-19 PROJECT MONITORING . 7I-20 Changes to Certain Appendices . 71-21 Accreditation by a Private Independent Accrediting Entity . 7PART II. WORK STATEMENT – STANDARDS & REQUIREMENTS . 9OVERVIEW . 9II-1II-2OBJECTIVES . 9A.General . 9B.Specific Objectives . 9NATURE AND SCOPE OF THE PROJECT . 11II-3A.Enrollment Process . 11B.HealthChoices Program Eligible Groups . 12C.Rating Period . 14D.Termination/Cancellation . 15E.Compliance with Federal and State Laws, Regulations,Department Bulletins, and Policy Clarifications . 16F.False Claims . 17G.Major Disasters or Epidemics . 17H.Performance Standards and Damages . 17Page iiHC BH Program Standards and Requirement – Primary Contractor July 1, 2019

II-4TASKS . 18A.State Plan Services . 18B.In Lieu Of and In Addition To Services . 22C.Coordination of Care . 23D.Member Services/Member Rights . 30E.Member Disenrollment . 36F.Complaint and Grievance System . 36II-5. REQUIREMENTS . 39A.General . 39B.Executive Management . 39C.Administration . 42D.Provider Network/Relations . 46E.Provider Enrollment - Credentialing/Recredentialing. 51F.Service Access. 52G.Utilization Management and Quality Management (UM/QM) . 56H.Advanced Directives . 60II-6. PROGRAM OUTCOMES and DELIVERABLES . 61A.Outcome Reporting . 61B.Deliverables . 61II-7. FINANCIAL AND REPORTING REQUIREMENTS . 62A.Financial Standards . 62B.Capitation Payment . 70C.Acceptance of Department Capitation Payments . 70D.Physician Incentive Arrangements . 73E.Claims Payment and Processing . 73F.Retroactive Eligibility Period . 75G.(Member) Copays . 75H.Financial Responsibility for Dual Eligibles . 75I.Risk and Contingency Funds . 76J.Return of Funds . 78K.In-Network Services . 78L.Third Party Liability (TPL). 80M.Performance Management Information System and SystemReporting . 84N.Audits . 88O.Restitution . 88P.Claims Processing and Management Information System (MIS) . 88Q.Data Support . 89Page iiiHC BH Program Standards and Requirement – Primary Contractor July 1, 2019

AppendicesCertified Community Behavioral Health Clinics Demonstration . AStandard Grant Terms and Conditions for Services . BAddendum to Standard Contract Terms and Conditions . CLobbying Certification and Disclosure of Lobbying Activities. DPay for Performance – Integrated Care Plan Program . EFraud and Abuse Program Requirements . FHealthChoices Enrollment Program . GComplaint, Grievance and Fair Hearing Process . HIndicators of the Application of CASSP and CSP Principles . IBureau of Drug and Alcohol Programs: Principles of Effective Treatment . JBH-MCO Performance/Outcome Management System (POMS) . KGuidelines for Consumer/Family Satisfaction Teams and MemberSatisfaction Surveys . LBehavioral HealthChoices Data Reporting Requirements Non-Financial . MHealthChoices Behavioral Health Program Requirements for CountyReinvestment Plans . NHealthChoices Data Support for BH-MCOs . OHealthChoices Behavioral Health Financial Reporting Requirements. PHealthChoices Behavioral Health Services Priority Populations . QEncounter Data Submission Requirements and Liquidated Damagesfor Noncompliance . RMedical Necessity Guidelines for Applied Behavioral Analysis Using BSC-ASDand TSS Services for Children and Adolescents with ASD . SHealthChoices Behavioral Health Medical Necessity Criteria . TValue Based Purchasing . UHealthChoices Behavioral Health Recipient Coverage Document . VBehavioral Health Audit Clause . WHealthChoices Category/Program Status Coverage Chart . XACA Health Insurance Provider’s Fee . YHealthChoices Procedures for Medical Assistance Enrollment . ZDepartment of Human Services Prior Authorization Requirements for ParticipatingBehavioral Health Managed Care Organizations in the HealthChoices Program. AARegulations and Policies Not Applicable to the HealthChoices Program . BB.1Regulations and Policies That Must Not Be Enforced Within HealthChoices . BB.2Behavioral Health Program Indicators of the Application of Cultural CompetencyPrinciples. CCPage ivHC BH Program Standards and Requirement – Primary Contractor July 1, 2019

HealthChoices Behavioral Health DefinitionsActuarially Sound Capitation Rate – Actuarially sound Capitation rates are projected to providereasonable, appropriate and attainable costs that are required under the terms of the contract andfor the operation of the Primary Contractor for the time period and the population covered underthe terms of the contracts, and such Capitation rates are developed in accordance with therequirement in paragraph (b) of Section §438.4.Actuary – An individual who meets the qualification standards, established by the AmericanAcademy of Actuaries for an actuary and follows the practices established by the ActuarialStandard Board.Adjudicate - A determination to pay or reject a claim.Administrative Services Organization (ASO) An uninsured health plan is where an administratorperforms administrative services for a third party that is at risk but has not issued an insurancepolicy. The health plan bears all of insurance risk, and there is no possibility of loss or liability tothe administrator caused by claims incurred related to the plan. Under an ASO plan, claims arepaid from a bank account owned and funded directly by the uninsured plan sponsor; or, claimsare paid from a bank account owned by the administrator, but only after receiving funds from theplan sponsor that are adequate to fully cover the claim payments.Advanced Directives - means a written instruction, such as a living will or durable power ofattorney for health care, recognized under State law (whether statutory or as recognized by thecourts of the State), relating to the provision of health care when the individual is incapacitated.Affiliate - Any individual, corporation, partnership, joint venture, trust, unincorporated organizationor association, or other similar organization (hereinafter "Person"), controlled by or under commoncontrol with a Private Sector BH-MCO, including a Private Sector BH-MCO subcontracting with acounty, Joinder, or a Private Sector BH-MCO's parent(s), whether such common control be director indirect. Without limitation, all officers, or persons, holding five (5%) percent or more of theoutstanding ownership interest of the Private Sector BH-MCO's or Private Sector BH-MCO'sparent(s), directors and subsidiaries of the Private Sector BH-MCO, shall be presumed to beAffiliates for purposes of this Agreement. For purposes of this definition, "control" means thepossession, directly or indirectly, of the power (whether or not exercised) to direct or cause thedirection of the management or policies of a Person, whether through the ownership of votingsecurities, other ownership interest, or by contract or otherwise, including but not limited to thepower to elect a majority of the directors of a corporation or trustees of a trust, as the case maybe.Agreement – The HealthChoices Behavioral Health Agreement.Alternative Payment Arrangement (APA) – refers to any of the various contractual agreementsfor reimbursement that are not based on a traditional fee for service model. Types ofarrangements include but are not limited to the following: retainer payments; case rates; andsubcapitation.Behavioral Health Managed Care Organization (BH-MCO) - An entity, which manages thepurchase and provision of Behavioral Health Services under this Agreement.Page vHC BH Program Standards and Requirement – Primary Contractor July 1, 2019

Behavioral Health Rehabilitation Services for Children and Adolescents (BHRS) (formerly EPSDT"Wraparound") - Individualized, therapeutic mental health, substance abuse, or behavioralinterventions/services developed and recommended by an Interagency Team and prescribed bya physician or licensed psychologist.Behavioral Health Residential Treatment Facility – A mental health or drug and alcohol residentialtreatment facility.Behavioral Health Services – Services that are provided to Members to treat mental health and/orsubstance abuse diagnoses/disorders.Behavioral Health (BH) Services Provider - A Provider, practitioner, or vendor/supplier whichcontracts with a BH-MCO to provide Behavioral Health Services or ordering or referring thoseservices and is legally authorized to do so by the Department under the HealthChoices BehavioralHealth Program.Business Day – Normal business operations Monday through Friday except for those daysrecognized as federal holidays and/or Pennsylvania state holidays and business closures at theGovernor’s discretion.Cancellation - Discontinuation of the Agreement for any reason prior to the expiration date.Capitation - A payment the Department makes periodically to a Primary Contractor on behalf ofeach Member enrolled under a contract and based on the actuarially sound Capitation rate forthe provision of services under the State Plan. The Department makes the payment regardlessof whether the particular beneficiary receives services during the period covered by the payment.Care Management/Manager - see Service Management/Manager.Children and Adolescents in Substitute Care (CISC) - Children and adolescents living outsidetheir homes in the legal custody of a public agency, in any of the following settings: shelters, fosterfamily homes, group homes, supervised independent living, residential treatment facilities,residential placement (other than youth development centers) for children and adolescents whohave been adjudicated dependent or delinquent.Clean Claim – A claim that can be processed without obtaining additional information from theProvider of the service or from a third party. It includes a claim with errors originating in thePrimary Contractor’s claims processing computer system, and those originating from humanerrors. It does not include a claim under review for Medical Necessity, or a claim that is from aProvider who is under investigation by a governmental agency or the Primary Contractor or BHMCO for fraud or abuse. However, if under investigation by the Primary Contractor or BH-MCO,the Department must have prior notification of the investigation.Client Information System (CIS) - The Department's automated file of Medical Assistance eligiblerecipients.Community HealthChoices (CHC) – Pennsylvania’s managed care program that will usemanaged care organizations to coordinate physical health care and long-term services andsupports (LTSS) for older persons, persons with physical disabilities, and persons who are duallyPage viHC BH Program Standards and Requirement – Primary Contractor July 1, 2019

eligible for Medicare and Medicaid (dual eligibles).Community HealthChoices Managed Care Organization (CH-MCO) – A Commonwealth-licensedrisk-bearing entity which has entered into an Agreement with the Department to manage thepurchase and provisions of physical health and long-term services and supports (LTSS) underCommunity HealthChoices.Complaint – A dispute or objection regarding a participating health care Provider or the coverage,operations, or management of a BH-MCO, which has not been resolved by the BH-MCO and hasbeen filed with BH-MCO or with the Department of Health or the Insurance Department, including,but not limited to: 1) a denial because the requested service is not a covered service; 2) the failureof the BH-MCO to meet the required time frames for providing a service; 3) the failure of the BHMCO to decide a Complaint or Grievance within the specified time frames; 4) a denial of paymentby the BH-MCO after a service(s) has been delivered because the service(s) was provided withoutauthorization by a provider not enrolled in the Pennsylvania Medical Assistance Program; 5) adenial of payment by the BH-MCO after a service(s) has been delivered because the service(s)is not a covered services(s) for the member; (6) a denial of a Member’s request to dispute afinancial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, andother Member financial liabilities; or (7) a member’s dissatisfaction with the BH-MCO or a provider.Complaints do not include requests to reconsider a decision concerning the medical necessityand appropriateness of a covered health care service.Concurrent Review - A review conducted by the BH-MCO during a course of treatment todetermine whether services should continue as prescribed or should be terminated, changed oraltered.Co-Occurring Disorder Professional – An individual who is certified by a state or nationalcertification body to provide integrated co-occurring psychiatric and substance use treatment, ortrained in a recognized discipline, including but not limited to psychiatry, psychology, social work,or addictions, and has one year of clinical

Behavioral Health (BH) Services Provider A Provider, practitioner, or vendor/supplier which -contracts with a BH-MCO to provide Behavioral Health Services or ordering or referring those services and is legally authorized to do so by the Department under the HealthChoices Behavioral Health Program.

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