LA Medicaid Behavioral Health Provider Manual
UnitedHealthcare Community PlanLouisiana MedicaidBehavioral Health Provider Manualfor 2022(updated April 2022)Page 1BH 4087 04/2022United Behavioral Health operating under the brand Optum
Table of ContentsIntroduction .5Welcome.5Important Notice .5Governing Law.5Clinical Overview .6Louisiana Medicaid Benefits . 6Adult Crisis Response Services .8Licensed Mental Health Professionals (LMHPs) include: . 8Description of Behavioral Health Services . 9Eligibility Requirements for Evidence–Based Practices . . 11Pharmacologic/Medication Management Services . 14Inpatient Services . 14Residential Services . 14Psychological Testing . 15Home and Community Based Services . 15Personal Care Services (PCS) 16Provider Qualifications for PCS . . 16Authorizations for PCS . . 16Individual Placement and Support (IPS) . . 16Provider Qualifications for IPS . 16Authorizations for IPS . . 16Peer Services and Supports . .17Care Advocacy . 17Care Advocate Availability . 18Affirmative Incentive Statement . 18Eligibility Inquiry . 18Utilization Management Begins at Intake . 18Assisting with Recovery . 19Assessment . 19Treatment, Recovery & Resiliency, and Discharge Planning. 19Coordination of Care . 22Page 2Communication with Primary Physicians and Other Health Care Professionals . 22BH 4087 04/2022United Behavioral Health operating under the brand Optum
Management of Outpatient Services. 23Outpatient Management . 23Quality Improvement . 24Adverse Incidents . 24Sentinel Events . 25Member Satisfaction Surveys . 25Provider Satisfaction Surveys . 25Complaint Investigation. 26Treatment Record Documentation and Quality Audits . 26Licensed Mental Health Professional (LMHP) Treatment Record Review Process . 26Assertive Community Treatment (ACT) Fidelity Monitoring Process . 27Prescription Management Program (PMP), Required Documentation by Prescribers . 27Confidentiality . 27Network Requirements . 27Network Training Requirements . 28Access to Care . 28On-Call and After-Hours Coverage . 28Access to Outpatient Mental Health and Substance Use Disorder Services. 29Geographic Access Standards. 30Credentialing .31New Enrollment Requirements for All UnitedHealthcare Community Plan Providers . 31Billing and Claims . 31Billing Guidelines . 31Claims Submission . 32Claim Reconsiderations, Appeals and Grievances . 33Denial . 33Claim Correction . 33Resubmitting a Claim . 34Level 1 Dispute — Claim Reconsideration . 35Valid Proof of Timely Filing Documentation (Reconsideration) . 36Level 2 Dispute — Appeals . 36Page 3BH 4087 04/2022United Behavioral Health operating under the brand Optum
Appeals and Grievances . 37Contact Us . 37Technical Support for Provider Express (providerexpress.com) . 39Page 4BH 4087 04/2022United Behavioral Health operating under the brand Optum
IntroductionWelcomeWe are pleased to have you working with us to serve the individuals covered underLouisiana Medicaid. We are focused on creating and maintaining a structure that helpspeople live their lives to the fullest. At a time of great need and change within the healthcare system, we are energized and prepared to meet and exceed the expectations ofconsumers, customers, and partners like you.Our relationship with you is foundational to the recovery and well-being of the individualsand families we serve. We are driven by a compassion that we know you share. As wework together, you will find that we seek and pursue opportunities to collaborate with you toset the standard for industry innovation and performance.We encourage you to make use of Provider Express, our industry-leading website,providerexpress.com and UHCprovider.com where you can get news, access resourcesand, in a secure environment, make demographic changes at the time and pace you mostprefer. We continuously expand our online functionality to better support your day-to-dayoperations. Visit us often.Important NoticeOptum provides this manual as a focused resource for clinicians serving the LouisianaMedicaid membership. This manual does not replace the primary National NetworkManual. Rather, this Louisiana Medicaid manual supplements the primary NationalNetwork Manual by focusing on the core service array, roles and responsibilities, as wellas processes and procedures specific to the State of Louisiana Medicaid programs. Inaddition, some sections of the primary National Network Manual are repeated forconvenience.The National Network Manual can be directly accessed here or by going toproviderexpress.com (Provider Express Quick Links Guidelines/Policies & Manuals Network Manual National Network Manual).Governing LawThis manual shall be governed by, and construed in accordance with, applicable federal,state and local laws. To the extent that the provisions of this manual conflict with theterms and conditions outlined in your Agreement, the subject matter shall first be readtogether to the extent possible; otherwise, and to the extent permitted by, in accordancewith, and subject to applicable law, statutes or regulations, the Agreement shall govern.Page 5BH4087 04/2022United Behavioral Health operating under the brand Optum
Clinical OverviewUnitedHealthcare Community Plan (The Plan) manages the mental health and substanceuse disorder services to help adults and children enrolled in Louisiana Medicaid accessthe most effective treatment for their needs.Optum and UnitedHealthcare are working closely with the state of Louisiana, consumers,family members, providers, and community stakeholders to develop, implement, andmaintain a utilization management program for Louisiana Medicaid to monitor theappropriate utilization of covered services and to: Simplify the administrative processes for providers, enabling them to devote morestaff time to treating Members Encourage Members to access services at the time they first recognize symptoms inthemselves or in a family member Ensure that all services provided are medically necessary, are focused onmeasurable outcomes, and are supporting the Member’s recovery and/or thefamily’s resiliencyOur focus is on improving access to treatment, expanding the array of covered services,and improving the quality of care and treatment outcomes. Our goal is to enhance thestatewide behavioral health system and make it easier for people to access care. Inaddition to adding more behavioral health care providers and programs, Optum aims toensure that Members are able to get the care they need in their community.Optum is committed to recovery, resiliency, and person-centered care. This includesassisting and supporting people in learning to manage their behavioral health andwellness challenges. Our practices are anchored in the belief that people with mentalillness are able to live, work, and participate productively in their communities despitetheir behavioral health challenges, and are resilient and able to rebound from trauma,stigma, and other stresses.We look forward to an active partnership as we all work together to improve the lives ofMembers in Louisiana.Louisiana Medicaid BenefitsUnitedHealthcare Community Plan of Louisiana administers behavioral health managedcare benefits for Louisiana Medicaid Members. All Medicaid Members shall be providedcare in the same manner, on the same basis, and in accordance with the same standardsoffered to all other Members in their provider’s care.The following covered services are available and accessible to all Medicaid Members:Page 6BH4087 04/2022United Behavioral Health operating under the brand Optum
ServiceInpatient HospitalizationPsychiatric Residential Treatment Facility(PRTF) (ages under 21)Residential Substance Use Services inAccordance with the American Society ofAddiction Medicine (ASAM) Levels of CareCrisis Stabilization23-Hour ObservationAssertive Community Treatment (ACT) (ages18 )Crisis Intervention Follow UpOutpatient Electroconvulsive Therapy (ECT)Substance Abuse Intensive Outpatient Program(SA IOP)Therapeutic Group Home (ages under 21)Community Psychiatric Support andTreatment (CPST)Psychosocial Rehabilitation (PSR)Multi-Systemic Therapy (MST) (ages under 21)Functional Family Therapy (FFT) (ages under 21)Homebuilders (ages under 21)Crisis Intervention (initial visit per diem)Outpatient Psychotherapy (individual, group,and family)Neuropsychological TestingPharmacologic ManagementEvaluation and AssessmentOutpatient Substance Abuse ServicesPeer Support ServicesPsychological TestingTable: Covered ServicesPage 7Authorization RequirementBy PhoneBy PhoneBy PhoneBy PhoneBy PhoneOnline PortalOnline PortalEmail or FaxBy PhoneEmail or FaxOnline PortalOnline PortalOnline PortalOnline PortalOnline PortalNot RequiredNot RequiredNot RequiredNot RequiredNot RequiredNot RequiredOnline PortalOnline form can be found here: OptumPsych Testing Request Form(Provider Express Quick Links Forms Optum Forms – Authorization Louisiana) For services requiring authorization request to be made by phone: 1-866-675-1607 For services requiring authorization request to be made via online portal or byemail/fax: visit Provider Express Louisiana page (Home Our Network StateSpecific Provider Information Louisiana)BH4087 04/2022United Behavioral Health operating under the brand Optum
Adult Crisis Response ServicesIt is Louisiana Department of Health’s goal to develop a statewide model for crisis response thatmaintains regional and geographic relevance and builds upon the unique and varied strengths,resources, and needs of Louisiana’s individual communities.The vision is that the system: Values and incorporates “lived experience” in designing a crisis system and crisis servicedelivery and is built on principles of recovery and resiliency using person-centeredprocesses. Encompasses a continuum of services that includes crisis prevention, acute interventionand post-crisis recovery services and supports. Provides interventions to divert individuals from institutional levels of care includinginpatient placements, emergency departments utilization, nursing facilities and other out ofhome settings; and Provides timely access to a range of acute crisis responses, including locally availablehome and community-based services and mobile crisis response. Results in a crisis continuum that includes and respects a bed-based crisis service butdoes not rely on that level of service as the foundation of the crisis continuum.This will be achieved by implementing the following services: Mobile Crisis Response (MCR) is an initial community-based, mobile crisis responseintended to provide relief, resolution and intervention to individuals where they are locatedthrough crisis supports and services during the first phase of a crisis in the community. Behavioral Health Crisis Centers (BHCC) are facility-based services that operatestwenty-four (24) hours a day, seven (7) days a week, as a walk-in center providing shortterm behavioral health crisis intervention. Community Brief Crisis Support (CBCS) is an ongoing crisis intervention responserendered for up to fifteen (15) days and designed to provide relief, resolution andintervention through maintaining the member at home / in the community, de-escalatingbehavioral health needs, referring for treatment needs, and coordinating with localproviders. Crisis Stabilization (CS) are short-term bed-based crisis treatment and support servicesfor members who have received a lower level of crisis services and are at risk ofhospitalization or institutionalization.24-hour Behavioral Health Crisis Line for UnitedHealthcare: 1-866-232-1626Licensed Mental Health Professionals (LMHPs) include: Page 8Advanced Practice Registered Nurses (APRNs must be nurse practitioner specialistsin adult psychiatric and mental health, and family psychiatric and mental health, orcertified nurse specialists in psychosocial, gerontological psychiatric mental health,BH4087 04/2022United Behavioral Health operating under the brand Optum
adult psychiatric and mental health and child-adolescent mental health and maypractice to the extent that services are within the APRN’s scope of practice.) Licensed Addiction Counselors (LAC) Licensed Clinical Social Workers (LCSW) Licensed Marriage and Family therapists (LMFT) Licensed Professional Counselors (LPC) Licensed Psychologists Medical Psychologists Psychiatrists Physician Assistants working under the protocol of a participating PsychiatristNote: Physician Addictionologists must be certified by the American Society of AddictionsMedicine (ASAM) or the American Board of Addiction Medicine (ABAM) or have addedqualifications in Addiction Psychiatry through the American Board of Psychiatry andNeurology (ABPN).All providers including individual clinicians, groups/agencies, and facilities must have valid,active state licenses to perform the levels of care under their Medicaid contract, per theLDH Behavioral Health Provider Services Manual, as applicable.For the services that can be rendered by non-independently licensed providers (e.g.,CPST, PSR, etc.), all individuals must meet education, training, and all other requirementsset forth in the LDH Behavioral Health Provider Manual. It is the agency’s responsibility toensure all non-independently licensed providers meet these criteria before they aresubmitted to Optum when adding, changing, or removing providers from the agency roster.Emergency services may be rendered without the requirement of prior authorization.Payment cannot be denied for treatment of what constitutes an emergency behavioralhealth condition on the basis of a behavioral health diagnosis or symptoms.Description of Behavioral Health ServicesThe complete Louisiana Behavioral Health Services Provider Manual maintained by theLouisiana Department of Health (LDH) is accessible online. The summary below serves asa quick reference guide only and does not replace nor supersede the requirements in theLDH Manual. All providers need to be familiar with this manual and must adhere to allrequirements within. The current version of the manual is located here:lamedicaid.com/provweb1/providermanuals/BHS Main.htmPage 9BH4087 04/2022United Behavioral Health operating under the brand Optum
ServiceAddiction ServicesAssertive Community Treatment(ACT)Community Psychiatric Supportand Treatment (CPST)Crisis Intervention (CI)Electroconvulsive Therapy (ECT)Family PsychotherapyFunctional Family Therapy (FFT)Group PsychotherapyService DescriptionIncludes an array of individual-centered outpatient,intensive outpatient and residential services consistentwith the individual’s assessed treatment needs, with arehabilitation and recovery focus designed to promoteskills for coping with and managing substance usesymptoms and behaviors.Interventions that address the functional problems ofindividuals who have the most complex and/orpervasive conditions associated with a serious mentalillness or co-occurring addictions disorder. Theseinterventions are strength-based and focused onpromoting symptom stability, increasing the individual’sability to cope and relate to others and enhancing thehighest level of functioning in the community.Community Psychiatric Support and Treatment (CPST)are goal-directed supports and solution- focusedinterventions intended to achieve identified goals orobjectives as set forth in the individualized treatmentplan.Crisis intervention (CI) services are provided to anindividual who is experiencing a psychiatric crisis andare designed to interrupt and/or ameliorate a crisisexperience; via a preliminary assessment, immediatecrisis resolution & de-escalation, and referral & linkageto appropriate community services to avoid morerestrictive levels of treatment.Electroconvulsive Therapy (ECT) is a standardpsychiatric treatment in which seizures are electricallyinduced to provide relief from psychiatric illnesses.Family members can talk with a behavioral health careprofessional about emotional problems they may behaving and learn coping skills the family can use tomanage them.FFT is an evidence-based program (EBP) targeted foryouth between ages 10 and 18, primarilydemonstrating externalizing behaviors or at risk fordeveloping more severe behaviors, which affect familyfunctioning.A group of people with similar emotional issues meetwith a behavioral health care professional; the groupmembers share experiences and practice coping skillsin order to learn how to manage issues asindependently as possible.table continuedPage 10BH4087 04/2022United Behavioral Health operating under the brand Optum
ServiceHomebuilders Individual PsychotherapyInpatient/Hospital-based CareMulti-systemic Therapy (MST)Outpatient TherapyPeer SupportPharmacologic ManagementService DescriptionHomebuilders is an intensive, in-home evidence- basedprogram (EBP) utilizing research-based strategies (e.g.,Motivational Interviewing, Cognitive and BehavioralInterventions, Relapse Prevention, Skills Training), forfamilies with children ( age 17) at imminent risk of outof home placement (requires a person with placementauthority to state that the child is at risk for out of homeplacement without Homebuilders) or being reunifiedfrom placement.Homebuilders is provided through the Institute forFamily Development (IFD).Individuals can talk with a behavioral health careprofessional about emotional issues they may be havingand learn coping skills to manage them.The need for one or more nights in a hospital foremergency treatment which cannot otherwise betreated in the community by a provider.Multi-systemic therapy (MST) is an evidence- basedprogram (EBP) that provides an intensive home/familyand community-based treatment for youth who are atrisk of out-of-home placement or who are returningfrom out-of-home placement.Individual, family, group psychotherapy and mentalhealth assessment, evaluation and testing.Provided by a Peer Support Specialist (who receivedbehavioral health services themselves) to helpindividuals learn to manage difficulties in their lives. Asof 03/01/21, Peer Support Services are a coveredbenefit when performed by Local Governing Entities(LGEs).Individuals meet with a doctor or otherprescriber to discuss medications.Table: Description of Behavioral Health Services summaryEligibility Requirements for Evidence–Based PracticesThe Louisiana Department of Health (LDH) requires UnitedHealthcare Community Plan, toidentify providers who offer specific Evidenced-Based Practices (EBPs). UnitedHealthcareCommunity Plan will validate that the provider is eligible (based on the criteria listed below)to offer the EBP at the time of credentialing and through routine roster updates the providercompletes. For each EBP, the provider must submit all required documentation inorder to be identified in provider systems, including the directory, as eligible to offerthe EBP service. If the requirements are not met then claims will deny.Page 11BH4087 04/2022United Behavioral Health operating under the brand Optum
The eligibility requirements are as follows:1.1.Functional Family Therapy1.1.1. The agency must have an FFT license from FFT, LLC.1.2.Functional Family Therapy-Child Welfare (FFT-CW) (EB01)1.2.1. The agency must have an FFT license with FFT-CW specialty from FFT,LLC.1.3.Child-Parent Psychotherapy (CPP) (EB02)1.3.1. The clinician must have a certificate stating that he/she has fulfilled therequirements of an implementation level course in Child-ParentPsychotherapy from a trainer endorsed by the University of California,San Francisco.1.4.Parent-Child Interaction Therapy (PCIT) (EB03)1.4.1. The clinician must have a certification from PCIT, International1.5.Youth PTSD Treatment (YPT) (EB04)1.5.1. The clinician must have an Advanced Certificate from Tulane Psychiatryin Youth PTSD Treatment.1.6.Preschool PTSD Treatment (PPT) (EB05)1.6.1. The clinician must have an Advanced Certificate from Tulane Psychiatryin Preschool PTSD Treatment.1.7.Homebuilders 1.7.1. The agency must be certified by the Institute for Family Development(IFD).1.7.2. The agency must contract with the IFD for training, supervision andmonitoring of services.1.8.Multi-Systemic Family Therapy (MST)1.8.1. The agency must be licensed to provide MST services by MST Services,Inc. or any of its approved subsidiaries.1.8.2. The agency must contract with MST Services for training, supervisionand monitoring of services.1.9.Assertive Community Treatment (ACT)1.9.1. Agencies offering ACT services must meet national fidelity standards asevidenced by the Substance Abuse and Mental Health ServiceAdministration (SAMHSA) Assertive Community Treatment (ACT)Evidence-Based Practice Toolkit.Page 12BH4087 04/2022United Behavioral Health operating under the brand Optum
1.9.1.1.1.10.The provider must complete the SAMHSA “Evaluating Your Program:Assertive Community Treatment” assessment tool and submit the coversheet and score sheets as part of their application.Triple P (Positive Parenting Program System) – Standard Level 4 (EB06)1.10.1. The clinician must have an Accreditation Certification in Triple P – StandardsLevel 4, issues by Triple P America.1.11.Trauma Focused – Cognitive Behavioral Therapy (TF – CBT) (EB07)1.11.1. The clinician must have a certification from the Trauma Focused CognitiveBehavioral Therapy National Therapist Certification Program1.12.Eye Movement Desensitization and Reprocessing Therapy (EMDR) (EB08)1.12.1. The clinician must have a certification from the Trauma Focused CognitiveBehavioral Therapy National Therapist Certification ProgramEvidence-BasedPracticeFunctional FamilyTherapy-Child Welfare(FFT-CW)Child-ParentPsychotherapy (CPP)Parent-ChildInteraction Therapy(PCIT)Youth PTSD Treatment(YPT)Preschool PTSDTreatment (PPT)Positive ParentingProgram System(Triple P)Trauma Focused –Cognitive BehavioralTherapy(TF – CBT)Eye MovementDesensitization andReprocessing Therapy(EMDR)Page 13BH4087 04/2022EBPValidEBP Credentialing documentationTracking CPT/HCPCSto be submitted to H0036 withmodifier HEAgency FFT License with FFT-CWspecialty from FFT, LLC90837, 90834, Certificate stating that the clinician has90832, 90847, fulfilled the requirements of an90846implementation level course in ChildParent Psychotherapy, from a trainerendorsed by the University of California,San Francisco90837, 90834, Certification from PCIT, International90832, 90847, pcit.org/united-states.html9084690837, 90834, Advanced Certificate from Tulane90832, 90847, Psychiatry in Youth PTSD Treatment9084690837, 90834, Advanced Certificate from Tulane90832, 90847, Psychiatry in Preschool PTSD Treatment9084690837, 90834, The clinician must have an Accreditation90832, 90847, Certification in Triple P – Standards Level908464, issues by Triple P America90837, 90834, The clinician must have a certification90832, 90847, from the Trauma Focused Cognitive90846Behavioral Therapy National TherapistCertification Program90837,The clinician must have a certification90834,from EMDRIA (EMDR International90832,Association)90847,90846United Behavioral Health operating under the brand Optum
Table: EBP Billing and Reference GuideServiceService DescriptionPsychiatric Residential TreatmentFacility (PRTF)A PRTF is any non-hospital facility which providesinpatient services to individuals under the age of 21ensuring that all medical, psychological, social, behavioraland developmental aspects of the individual’s situation areassessed and treated.Individuals complete written, visual or verbal tests that areadministered by a psychologist measuring thinking andemotional abilities.Psychosocial Rehabilitation (PSR) services are designedto assist the individual with compensating for or eliminatingfunctional deficits and interpersonal and/or environmentalbarriersassociated with their mental illness.Therapeutic Group Homes (TGHs) provide a communitybased residential service in a home-like setting of nogreater than eight beds, under the supervision andprogram oversight of a psychiatristor ngPsychosocial Rehabilitation (PSR)Therapeutic Group Home (TGH)Table: Service DescriptionsFor services requiring an authorization, if we deem the service medically necessary, theservice authorization will begin on the date of the request for the service.Pharmacologic/Medication Management ServicesPsychiatrists, prescribing APRNs, and Medical Psychologists are not required to obtainprior authorization for the initial consultation, routine medication management sessions andother routine outpatient services, such as: 90791, 90792, 90833, 90834 and evaluation &management (E&M) codes as applicable.Inpatient ServicesEmergency services may be rendered without the requirement of prior authorization.Payment cannot be denied for treatment of what constitutes an emergency behavioralhealth condition on the basi
Advanced Practice Registered Nurses (APRNs must be nurse practitioner specialists in adult psychiatric and mental health, and family psychiatric and mental health, or certified nurse specialists in psychosocial, gerontological psychiatric mental health, adult psychiatric and mental health and child- adolescent mental health and may
account for almost half (48 percent) of total Medicaid expenditures, yet represent only 20 percent of the total Medicaid population. iii Medicaid beneficiaries with behavioral health diagnoses and chronic physical comorbidities— hypertension, coronary heart disease, and diabetes—have significantly higher medical (non-behavioral
Hospice care may be provided only by a hospice provider licensed by the Utah Department of Health (Department), that is Medicare certified in accordance with 42 CFR Part 418, and that is enrolled to be a Medicaid provider. A hospice provider must have a valid Medicaid provider agreement in place prior to initiating hospice care for Medicaid .
Improve the behavioral health of the U.S. population by supporting proven interventions to address behavioral, social, cultural, and environmental determinants of positive behavioral health in addition to delivering higher quality behavioral health care. Affordable Care: Increase the value of behavioral health care for individuals, families,
Behavioral health service providers must also meet the requirements in the Behavioral Health Services Integrated Regulations 7 AAC 70 and 7 AAC 135. The Department of Health and Social Services (DHSS) is granted statutory authority to allow the Division of Behavioral Health (DBH) on-site access to all documents related to Medicaid service
application for enrollment. As a potential new provider to Texas Medicaid, you must follow certain claims filing procedures while completing the enrollment process. This is particularly important if you render Medicaid services to clients before you are enrolled. To access the Texas Medicaid Provider Procedures Manual and Children with Special Health
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about IMPACT provider enrollment can be answered by calling 1-877-782-5565 (select options 1, 2, 1, 1). 2 . . First, the Group or FAO should enroll as a Medicaid provider before your individual practitioners enroll as Medicaid providers (if they are not already enrolled with ano ther medical group). Medicaid services
The MAX Medicaid policy issue brief series highlights the essential role MAX data can play in analyzing the Medicaid program. MAX is a set of annual, person-level data files on Medicaid eligibility, service utilization, and payments that are derived from state reporting of Medicaid eligibility and claims data into the Medicaid Statistical Infor-
