Important Provider Manual Bulletin
WellCare of New York Behavioral Health Updates
Effective October 1, 2015 WellCare members who were getting behavioral health services using their Medicaid card will access those services through WellCare.
Behavioral health care includes mental health and substance use (alcohol and drugs) treatment and rehabilitation services. All of our members have access to services to help with emotional health, or to help with alcohol or other substance use issues.
Behavioral Health Provider as a PCP
If enrollee is using behavioral health clinic that also provides primary care services, enrollee may select lead provider to be PCP.
Appointment and Availability Times for Behavioral Health Services
- For CPEP, inpatient mental health and Inpatient Detoxification Substance Use Disorder services and Crisis Intervention services: immediately upon presentation at a service delivery site.
- For urgently needed Substance Use Disorder inpatient rehabilitation services, stabilization treatment services in OASAS certified residential settings and mental health or Substance Use Disorder outpatient clinics, Assertive Community Treatment (ACT), Personalized Recovery Oriented Services (PROS) and Opioid Treatment Programs: within 24 hours of request.
- For Behavioral health specialist referrals (not urgent):
- CDT, IPRT, and Rehabilitation services for residential Substance Use Disorder treatment services: within two to four weeks of request
- PROS programs other than clinic services: within two weeks of request.
- Following an emergency, hospital discharge or release from incarceration, if known, follow-up visits with a behavioral health Participating Provider (as included in the Benefit Package): within five days of request, or as clinically indicated.
- Non-urgent mental health or Substance Use Disorder visits with a Participating Provider that is a Mental Health and/or Substance Use Disorder Outpatient Clinic, including a PROS with clinical treatment : within one week of request.
Level of Care Guidelines
Effective October 1, 2015, WellCare uses the following guidelines for making medical necessity determinations associated with the following Levels of Care and Services:
| Level of Care / Service | Level of Care Guidelines / Criteria Used | Prior Authorization Required (Y/N) | Concurrent Review | |||
|---|---|---|---|---|---|---|
|
InterQual (Mental Health) Adult Psychiatry, Geriatric Psychiatry CCG - Outpatient Treatment for Mental Health and Substance Use Disorders HS-271
|
No |
Yes |
|||
|
InterQual (Mental Health) Adult Psychiatry, Geriatric Psychiatry CCG-Use of Psychological and Neuropsychological Testing
|
Yes |
N/A |
|||
|
PROS and other OMH Licensed Programs Guidance
|
No |
Yes |
|||
|
LOCUS (Mental Health) |
Yes |
Yes |
|||
|
LOCUS (Mental Health) |
Yes |
Yes |
|||
|
LOCUS (Mental Health) |
Yes |
Yes |
|||
|
InterQual (Mental Health) Adult Psychiatry, Geriatric Psychiatry |
Yes |
Yes |
|||
|
InterQual (Mental Health) Adult Psychiatry, Geriatric Psychiatry |
Yes |
Yes |
|||
|
Assertive Community Treatment |
|
Yes |
Yes |
|||
|
LOCADTR (Substance Abuse) |
No |
Yes |
|||
|
Medically Supervised Outpatient Substance Withdrawal |
LOCADTR (Substance Abuse) |
No |
Yes |
|||
|
Opioid Treatment Program (OTP) Services |
LOCADTR (Substance Abuse) |
No |
Yes |
|||
|
Substance Use Disorder Intensive Outpatient |
LOCADTR (Substance Abuse) |
No |
Yes |
|||
|
Substance Use Disorder Day Rehabilitation |
LOCADTR (Substance Abuse) |
No |
Yes |
|||
|
Stabilization and Rehabilitation services for residential SUD treatment |
LOCADTR (Substance Abuse) |
Yes |
Yes |
|||
|
Comprehensive Psychiatric Emergency Program (CPEP)/Inpatient Psychiatric Services |
InterQual (Mental Health) Adult Psychiatry, Geriatric Psychiatry Acute Psychiatric Inpatient Services CCG |
No |
Yes |
|||
|
Intensive Psychiatric Residential Treatment Services (IPRT) |
InterQual (Mental Health) Adult Psychiatry, Geriatric Psychiatry |
Yes |
Yes |
|||
|
Behavioral Health Crisis Intervention |
N/A |
No |
No |
|||
|
Medically Managed IP Withdrawal |
LOCADTR (Substance Abuse) |
No |
Yes |
|||
|
Peer Supports |
N/A |
No |
No |
For additional information regarding Level of Care guidelines beyond the summary grid above, please refer to the following websites:
For OASAS Services which require the use of LOCADTR, providers and the plan generally follow these steps:
- The plan Utilization Manager calls the provider to discuss the provider’s proposed LOC and clinical rationale used to make the LOC determination.
- If both parties still do not agree, the Plan Utilization Manager arranges for a secondary review, which is to be a Peer-to-Peer review/discussion.
- If there still isn’t consensus, the Provider may request an Appeal of the plan’s decision.
Guidelines for Requesting Higher Level of Care (HLOC) Services
For HLOC Services, WellCare uses McKesson InterQual™ , Level of Care Utilization System (LOCUS) criteria and WellCare Clinical Coverage Guidelines (CCGs) as tools to assist in determining medical necessity for mental health and LOCADTR for all OASAS services.
HLOC Definition: This includes acute inpatient, crisis stabilization, partial hospitalization services and intensive outpatient programs as covered by the specific contract.
Service Requests: Providers can find the appropriate HLOC service request forms in our Medicare behavioral health section and Medicaid behavioral health section of the WellCare of New York website. Providers may fax these request forms 24/7 to the number assigned to your contract. Emergency Services do not require prior authorization, but notice is required to facilitate claims payments and determine ongoing treatment. Therefore, WellCare requests notice of all emergency services within 24 hours.
Please be certain that all the necessary information to complete the review has been provided. Incomplete or lack of adequate information will delay the response and in certain circumstances, may result in your request being denied.
Inpatient Concurrent Review: After the initial authorization is approved, concurrent review is needed for additional inpatient services. Inpatient concurrent review is done telephonically, though providers may fax updated clinical information to be used in the review. The WellCare behavioral health licensed clinician will confirm admission data, discuss the plan of treatment, the discharge plan and any treatment barriers. Please be prepared to discuss the following data:
Presenting Situation and Current Clinical Status, including:
- Current precipitant, history of treatment
- Current mental status including risks and safety issues
- Diagnoses: Primary and Secondary diagnoses upon admission and changes
- Medical Issues
- Medications: (All) reasons, effects, side effects and changes
- Plan of treatment to stabilize the crisis, evaluation of changes implemented and effectiveness
Living Situation and Family/Other Supports
Where was the member living, can he/she go back, the living situation and conditions, and what kind of support/influence the situation provided.
Discharge Plan
- The current discharge plan, with updates upon each review;
- Any barriers to discharge and what’s being done to resolve these issues;
- Summary of medications, including quantity provided, prescriptions given and affirmation that any prior authorizations for medications has been obtained
- A concrete final plan with specific follow-up appointments for medical/behavioral health support that meets requirements. NCQA standards are that appointments are made within seven days (within five days for NY members)
- Within 24 hours of discharge, the provider must fax the WellCare discharge form to the number indicated or call in the information to the designated staff member
Guidelines for Submitting Outpatient Service Requests that require Prior Authorization
The following tips and guidelines will assist providers with submission of accurate and appropriate service requests that will be successfully approved.
- Number of requested services: Please ask for only the types and number of services you expect to need.
- Do not leave blanks on the form. Blanks are interpreted as an incomplete request, which will delay processing. Please indicate an answer that lets us know you reviewed each field and did not simply skip sections.
- In general, we are looking for strength-based, individualized, culturally competent, and medically integrated services that are designed to promote Recovery and Resiliency. Your answers on the form need to demonstrate how you are doing that. For example, under Purpose of Treatment: "John needs individual counseling, skills building and assistance creating and maintaining an active support system to meet his goal of finding a job and moving to his own apartment."
- Axes I-V: Please complete all Axes. For Axis V, please indicate GAF or CAFAS as used by your state to show the overall functional rating of the member.
Treatment Goals
- Must be individualized and should come directly from your treatment plan.
- It’s always best if your treatment plan includes ‘I’ statements from the member about what they want to achieve.
Handling of Emergency Behavioral Health Calls
Behavioral health providers are expected to assist members in accessing emergent, urgent, and routine behavioral services as expeditiously as the member’s condition requires. Members also have access to a toll free behavioral crisis hotline that is staffed 24 hours a day. The behavioral crisis phone number is printed on the member’s card and is available on our website, and can be accessed by calling 1-855-582-6265.
WellCare Customer Service Representatives (CSRs) are trained evaluate the severity of the call and to listen for crisis warning signs. If a CSR suspects that the member or another person is in danger or may commit suicide, the CSR is trained to obtain critical information, including the member’s physical location, the phone number they are calling from and if the member is alone.
The CSR makes every attempt to connect the member to the BH Crisis Line or 9-1-1.
If the member refuses to get help from a BH representative, the CSR is trained to escalate the call, and remain engaged with the member as long as needed until help arrives.
Once the call has been connected, the CSR notifies a supervisor or manager and remains on the line until the clinician has given instructions to release the call. The call is also tracked in the WellCare CAREConnects program.
If the member is connected to the BH Crisis Line, the BH clinician evaluates whether the circumstance warrants engagement with local mobile crisis responders or is emergent, and requires 9-1-1 dispatch. In the event that a mobile crisis responder or program is available and can be engaged, the BH clinician may connect the member with a mobile crisis responder or program to assist the member.
If the circumstance either becomes or is emergent, the BH clinician contacts 9-1-1 for immediate assistance, and remains on the line with the caller at all times.
For all members who contact the crisis line in active crisis or if the crisis was resolved during the crisis call assessment are referred to WellCare’s internal case management program and are assigned to the behavioral health case manager. This case manager will outreach the member to assess their needs and make additional applicable referrals based upon the member’s unique needs to help achieve their crisis management and recovery goals.
Emergency Services
Emergency services, including CPEP, are not subject to prior approval. Crisis Intervention and OMH/ OASAS specific non-urgent ambulatory services are not subject to prior approval.
Self-Referral
There is no limit on self-referrals for behavioral health and substance use assessments (except for ACT, inpatient psychiatric hospitalization, partial hospitalization, HCBS services).
Behavioral Health Quality Improvement Committee (BHQIC)
Purpose: WellCare of New York’s Behavioral Health Quality Improvement Committee (BHQIC) oversees the quality management (QI) of Behavioral Health programs and reports regularly to the New York State Board of Directors. It is responsible for promoting our goals and objectives of our Behavioral Health program and its integration with medical programs. The BHQIC is dedicated to promoting the goals and objectives of the Behavioral Health QI program through oversight and approval of all Behavioral Health QI activities. The BHQIC is tasked with monitoring, assessing, evaluating and analyzing progress toward Behavioral Health QI goals; providing general direction and oversight for Behavioral QI activities; and recommending courses of action for improvement.
Location: The BHQIC physically meets in New York, New York and includes a teleconferencing option so that committee members may attend meetings telephonically.
Chairperson: New York’s Behavioral Health Medical Director acts as the chairperson of the BHQIC
Additional Membership: The Behavioral Health Medical Director, medical director, and QI Director collaborate to provide oversight of all Behavioral Health QI activities. The Behavioral Health QI Project Manager shall lead this committee meeting. Other committee members include member(s) having had a Behavioral Health diagnosis, family relatives of member(s) having had a Behavioral Health diagnosis, peer specialists, and Behavioral Health provider representatives. Other committee members include Behavioral Health Case Management, Behavioral Health Provider Relations, QI staff, and other staff deemed appropriate.
Credentialing criteria for OMH-licensed and OASAS certified behavioral health providers
- When credentialing OMH-licensed, OMH-operated and OASAS-certified providers, plan will accept OMH and OASAS licenses and certifications in place of any credentialing process for individual employees, subcontractors or agents of such providers. The Contract shall collect and will accept program integrity related information as part of the licensing and certification process.
- Plan requires that such providers not employ or contract with any employee, subcontractor or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in the Medicare or Medicaid program.
Confidentiality
Each healthcare provider must develop policies and procedures to assure confidentiality of mental health and substance abuse related information. The policies and procedures must include:
- Initial and annual in-service education of staff and contractors;
- Identification of staff allowed access and the limitations on that access;
- Procedure to limit access to trained staff (including contractors);
- Protocols for secure storage (including electronic storage); and
- Procedures for handling requests for behavior health and substance abuse information as well as protocols to protect persons with behavioral health and/or substance use disorder from discrimination.
Provider Education and Training
The WellCare of New York BH Provider Training Plan outlines required provider training topics, including Cultural Competency. See the Provider Training Plan as well as all available BH Provider Training modules and supporting materials for more information.
Reporting to OMH and OASAS
WellCare of New York, Inc. has a policy that requires the plan to submit to OMH and OASAS a quarterly report of any deficiencies in performance and corrective action taken with respect to OMH and OASAS licensed certified or designated providers. In addition, WellCare will report any serious or significant health and safety concerns to OMH and OASAS immediately upon discovery.
Identification and Prompt Referral of Individuals with First Episode Psychosis (FEP)
Members experiencing FEP have a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder NOS (DSM-IV), or other specified/ unspecified schizophrenia spectrum and other psychotic disorder (DSM-5). FEP generally occurs in individuals age 16-35 and are members who have psychotic symptoms that have occurred within the previous two years and remain in need of mental health services. Members who experience FEP may also include Transition Aged Youth (TAY).
Members identified as experiencing FEP are to be promptly referred to appropriate network providers and programs who can address the member’s needs. This may include OnTrackNY teams which offer recovery-oriented services such as case management for social and community needs, supported employment and education, FEP-relevant psychotherapy and support, pharmacotherapy and primary care coordination. On-TrackNY programs incorporate peer support and a staff-to-client ratio of approximately 1:10.
Current OnTrackNY sites include the following:
|
Program |
County
|
|---|---|
|
Washington Heights Community Service |
Manhattan |
|
North Shore/Long Island Jewish |
Queens |
|
Kings County Hospital Center |
Kings |
|
Mental Health Association of Westchester |
Westchester |
|
Catholic Charities of Broome County |
Broome |
|
Jewish Board of Family and Children Services |
Manhattan |
|
Bellevue Hospital Center |
Manhattan |
|
Parsons Northern Rivers |
Rensselaer |
|
Suffolk County Farmingville Clinic |
Suffolk |
|
Lakeshore Behavioral Health |
Erie |
|
Hutchings Psychiatric Center |
Onondaga |
|
Elmira Psychiatric Center |
Chemung |
|
Chautauqua Tapestry |
Chautauqua |
Emergency Pharmacy Protocols for Enrollees with Behavioral Health Condition
Except where otherwise prohibited by law:
- WellCare allows immediate access without prior authorizations to a 72 hour emergency supply of the prescribed drug or medication for an individual with a behavioral condition experiences an emergency condition as defined in the Contract
- Will immediately authorize a seven day supply of a prescribed drug or medication associated with the management of opioid withdrawal and/or stabilization
Ongoing Course of Care Policy
WellCare will not deny coverage of an ongoing course of care unless an appropriate provider of alternate level of care is approved for such care.
Monitoring of Need for Care Management Services
To maintain continuity of care, patient safety and member well-being, communication between behavioral health care providers and medical care providers is critical, especially for members with co-morbidities receiving pharmacological therapy. Fostering a culture of collaboration and cooperation will help sustain a seamless continuum of care between medical and behavioral health and positively impact member outcomes. This involves monitoring for a member’s care management needs, including the review of provider documentation for evidence of:
- HH/HCBS/HARP eligible triggers
- AOT orders (and encourage enrollment in a HARP if court order does not already require it)
- Frequent use of crisis/emergency departments
- Repeat admissions
- Crisis prevention plans
- Correctional system involvement
- Lack of treatment engagement
- Clinical appropriateness of care / effectiveness of treatment / evidenced based practices (EBP)
- Environmental / community / family / peer supports
- Assessment of tobacco use, education and referral
- Care gaps
Behavioral health utilization care managers have an active role during the utilization review process. They will evaluate and consider the above components during their concurrent review process and actively assist when clinically appropriate with:
- Care shaping
- Suggestion/reinforcement of provider EBPs
- Suggestion of crisis plan development or revision of existing crisis plan
- Referrals to HH/HCBS/HARP and / or additional ancillary supports
- Discharge planning process
In addition to the above care management activities the BH UM care manager will identify and pursue opportunities to communicate with treating providers regarding utilization review process, Medical Director Peer-to-Peer interactions, additional member appropriate referrals/care coordination and case conferences (IDTs).
Denial, Grievance and Appeal Decisions
All denial, grievance, and appeal decisions must be peer-to-peer and are subject to specific BH requirements including:
- A physician board certified in general psychiatry must review all inpatient level of care denials for psychiatric treatment
- A physician certified in addiction treatment must review all inpatient level of care denials for SUD treatment
Health Home Program
It is WellCare’s policy to partner with New York’s Approved Health Homes in an effort to reduce the inappropriate utilization of Medicaid covered services by identifying and managing WellCare members with a combination of medical and behavioral health diagnoses, through increased coordination of services performed by Health Homes and designated Care Management agencies. WellCare coordinates and co-manages the care of members in the Health Home program by providing the Health Home with utilization data for members assigned. This facilitates services intended to reduce the overutilization of behavioral health services, including substance and alcohol abuse. Members who are identified for participation in the Health Home Program are ensured access to medically necessary quality health care, while avoiding unnecessary costs to the Medicaid program.
It is expected that WellCare providers work with both the plan and Health Homes as an integrated team to carry out care management activities that require focus on members with SMI, SUD, co-occurring physical health, co-occurring MH and/or SUD disorders and I/DD when appropriate.
