You can watch a thematic videoHealth Care Account Sample Mock Call- Call Center Philippines 11.22.2021
The March Network Bulletin includes updates for medical and reimbursement policy updates, along with updates on prior authorization for Radiology, Cardiology, Radiation Therapy and facet Injections. There are also updates on home health, electronic payments, site of service review and more.Read Full Article
02/2021: February 2021 Network Bulletin Overview
Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc.
In Virginia, CareFirst MedPlus and CareFirst Diversified Benefits are is the business names of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Global capital markets Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only.
“World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC.
New UnitedHealthcare provider portal offers integrated self-service workflow.Read Full Article
06/2021: June 2021 Network Bulletin overview
Last Modified 11.22.2021
The June Network Bulletin includes updates for medical and reimbursement policy updates. Along providerexpress com optum health genetic and molecular testing prior authorization, antiemetics prior authorization, outpatient procedure grouper annual update and more.Read Full Article
03/2021: March 2021 Network Bulletin overview
Network Manual January 2016 U. S. Behavioral Health Plan, California, doing business as OptumHealth Behavioral Solutions of California Important Notice The Network Manual applies to all types of business managed by Optum1 and OptumHealth Behavioral Solutions of California2. Throughout the Manual, the name “Optum” is generally used to refer to both Optum and OptumHealth Behavioral Solutions of California. In a few specific instances, there are procedural or regulatory differences that apply specifically to OptumHealth Behavioral Solutions of California business that is regulated by the California Department of Managed Health Care (DMHC). In those situations, you will note separate, bold headings for OptumHealth Behavioral Solutions of California and Optum. It is important to note that DMHC regulations may not apply to all California residents, clinicians or facilities in all cases. 1 United Behavioral Health, operating under the brand name Optum 2 U. S. Behavioral Health Plan, California, doing business as OptumHealth Behavioral Solutions of California i Table of Contents Introduction . 1 About OptumHealth Behavioral Solutions of California . 2 Resource Guide . 4 California Contact List . 8 Frequently Asked Questions . 9 Glossary of Terms . 18 USBHPC Network Requirements . 31 Benefit Plans, Authorization, EAP, and Timely Access to Care . 40 Treatment Philosophy . 55 Treatment Record Documentation Requirements . 61 Privacy Practices . 67 Quality Management and Improvement . 69 Achievements in Clinical Excellence (ACE) Facilities . 74 Achievements in Clinical Excellence (ACE) Clinicians . 76 Compensation and Claims Processing . 77 Anti-Fraud, Waste and Abuse . 82 Appeals and Provider Dispute Resolution . 87 Member Complaints/Grievances . 94 Manual Updates and Governing Law and Providerexpress com optum health . 95 ii Appendices OptumHealth Behavioral Solutions of California Enrollee Rights and Responsibilities (English) . A OptumHealth Behavioral Solutions of California Enrollee Rights and Responsibilities (Spanish) . B Optum Member Rights and Responsibilities . C OptumHealth Behavioral Solutions of California Member Grievance Form and Notice . D DMHC Language Assistance Program Long Notice . E CDI Language Assistance Program Long Notice . F iii Introduction Welcome! We are pleased to have you in our network. We are focused on creating and maintaining a structure that helps people live their lives to the fullest. At a time of great need and change within the health care system, we are energized and prepared to meet and exceed the expectations of consumers, customers and partners like you. Our relationship with you is foundational to the recovery and well-being of the individuals and families we serve. We are driven by a compassion that we know you share. As we work together, you will find that we seek and pursue opportunities to collaborate with you to set the standard for industry innovation and performance. We encourage you to make use of our industry-leading website, providerexpress.com, where you can get news, access resources and conduct a variety of secure transactions at the time and pace you most prefer. We continuously expand our online functionality to better support your day-to-day operations. Visit us often! Please take time to familiarize yourself with all aspects of the Network Manual. We’ve included an easy reference Resource Guide and FAQs to get you started. There is much work to be done. We are interested in your contributions to constructive innovation. Let us hear from you! Deb Adler S.V.P. Behavioral Network Services Optum providerexpress.com January 2016 1 About U. S. Behavioral Health Plan, California and Optum U. S. Behavioral Health Plan, California (USBHPC) is a wholly owned subsidiary of United Behavioral Health (UBH). UBH was officially formed on February 2, 1997, via the merger of U.S. Behavioral Health, Inc. (USBH) and United Behavioral Systems, Inc. (UBS). UBH is a wholly owned subsidiary of UnitedHealth Group. U.S. Behavioral Health Plan, California was incorporated on May 6, 1988 in the state of California. It is licensed as a specialized health care services plan under the Knox-Keene Health Care Service Plan Act of 1975, as amended (Knox-Keene Act). UBH, now operating under the brand Optum, and USBHPC, doing business as OptumHealth Behavioral Solutions of California, offer a comprehensive array of innovative and effective behavioral health care programs, including integrated behavioral and medical programs, depression management, employee assistance, work/life management, disability support and pharmacy management programs. Today, our customers include small businesses, Fortune 100 companies, school districts, health plans, and disability carriers. At the time of this publication, Optum and OptumHealth Behavioral Solutions of California support more than 43 million Members nationwide. Throughout this Manual, the name “Optum” is used to refer to both OptumHealth Behavioral Solutions of California (USBHPC) and Optum (UBH) business unless specifically stated otherwise. Optum Optum is a health services business dedicated to making the health system work better for everyone. We have aligned our businesses and are focused on helping ensure that people receive the right care at the right time from the best practitioners. Optum supports population health management solutions that address the physical, mental and financial needs of organizations and individuals. We provide health information and services to nearly 60 million Americans – educating them about their symptoms, conditions and treatments, helping them to navigate the system, finance their health care needs, and stay on track with their health goals. We serve people throughout the entire health system, allowing us to bring a uniquely broad yet experienced perspective. We have the ability and scale to help our clients both envision and implement new approaches that drive meaningful, enduring and positive change. Optum serves people throughout the entire continuum of healthcare, from promoting wellness and prevention, to servicing those that provide care, to delivering and managing prescription solutions, to being an industry-leader in healthcare research and technology. providerexpress.com January 2016 2 Mission and 1st birthday party ideas for boys themes Our Mission is to help people live their lives to the fullest. Our Vision is to be a constructive and transformational force in the health care system. Core Values Integrity - Honor commitments - Never compromise ethics Compassion - Relationships - Build trust through collaboration Innovation - Walk in the shoes of the people we serve and those with whom we work Invent the future, learn from the past Performance - Demonstrate excellence in everything we do providerexpress.com January 2016 3 Resource Guide Websites providerexpress.com Our industry-leading Provider website includes both public and secure pages. Public pages include general updates and useful information. Secure pages are available only to network Providers and require registration. The password-protected secure “Transactions” gives you access to Member and Provider specific information. To Register for Access Select the “First-time User” link in the upper right hand corner of the home page, then click on “Register” and follow the prompts. Secure Transactions Provider Express offers blackberry key2 le t mobile range of secure transactions, including: Check eligibility and authorization or notification of benefits requirements Obtain initial authorization or notification requests, if applicable Create and maintain My Patients list Submit professional claims and view claim status Make claim adjustment requests Register for Electronic Payments and Statements (EPS), including Electronic Funds Transfer (EFT) Update practice information - Add NPI - Add Taxonomy Code(s) - Update languages spoken - Update e-mail address - Update gender - Add Medicaid/Medicare Numbers - Update expertise - Don jose pollos asados ethnicity - Manage address locations, including practice, remit, credentialing and admitting privileges providerexpress.com January 2016 4 - Update phone and fax numbers - Availability status - Accessibility – practice hours, wheelchair accessibility, public transportation, etc. Send secure messages to a number of Optum departments Admin-level users can add and manage other users’ access View performance and ALERT Online Scorecards Obtain pre-populated Wellness Assessments Link the reach key west spa Clinician version of liveandworkwell.com to obtain patient education resources in English and Spanish (see liveandworkwell.com below) Public Pages The Provider Express home page includes “Quick Links” to our most frequently accessed pages as well as recent news and updates. Access the latest information about ALERT® Obtain ACE Clinicians and ACE Facility program updates Download standard forms (see “Frequently Used Forms…” section below) Find staff contacts Review clinical guidelines Locate current and archived issues of Network Notes, the provider newsletter Training Www bbt com checks Information includes Webinar offerings and Guided Tours of secure transaction features such as: Claim Entry, Eligibility and Benefits, and Secure Message Center. The Guided Tours provide quick overviews of key transactions. liveandworkwell.com You may use this member site to: Obtain patient behavioral health education information (access Clinician version of site from Provider Express or at liveandworkwell.com using anonymous access code, “Clinician”) Refer patients to appropriate benefit specific online resources - Members may register and log in or use the anonymous access does assigned to their company/organization - There is an access code lookup tool located above the entry field Our 22.7 c to f Member website makes it simple for eligible Members to: Manage behavioral health benefits - Check eligibility/benefits - Submit/track claims - Obtain visit authorizations, if required providerexpress.com January 2016 5 - Quick Links Claims & Coverage Request services Identify network clinicians and facilities Take self-assessments Send out caring, positive eCards Use Computer Based Trainings - Depression - Anxiety - Stress - Screening, Brief Intervention, and Referral to Treatment (SBIRT) Find articles on a variety of wellness and daily living topics Parent/Teen/Child integrated medical/behavioral information on adolescent health Locate community resources Eligible Members can explore topics by category: Azealia banks braces Well: supportive information on relationships, parenting, safety, military Be Well: healthy living, recovery & resiliency and behavioral health condition information Work Well: education and work related concerns Liveandworkwell provides resources and patient education in English and Spanish. Website content varies according to Member benefit packages so advise Members to use the access code assigned to their company/organization for personalized information. Frequently Used Forms and What you Need to Know You may obtain forms by going to Provider Express. Employee Assistance Program (EAP) Services Upon completion of EAP services, you may request most routine MH/SUD authorization for outpatient services using the Provider Express Auth Request feature Statement of Understanding – A mandatory form that describes the scope and limitations of EAP services, signed by both you and the Member EAP Claim Submission through Provider Express secure “Transactions” ALgorithms for Effective Reporting and Treatment (ALERT®) The one-page Wellness Assessment (WA) is a reliable, confidential, consumer-driven instrument used to help identify targeted risk factors in addition to establishing a baseline providerexpress.com January pnc bank locations towson md 6 for tracking clinical change and outcomes. The WA is routinely administered at the beginning of the first session and then again at session three, four or five. The completed form is faxed to Optum. Detailed instructions and copies of the WA are available at Provider Express. Wellness Assessments are also available in Spanish. Adult Wellness Assessment –– The adult seeking treatment completes this form Youth Wellness Assessment –– The parent or guardian completes this form when the individual you are seeing is a minor For questions and/or comments about ALERT, feel free to e-mail us at [email protected] Claims and Customer Service Contact sanderling vacation rentals duck nc for Claims and Customer Service issues can be found in the “Contact Us” section of Provider Express. To ensure proper processing of claims, it is important to promptly contact Network Management if you change your Tax ID number. You may make changes to your practice address online (see secure “Transactions” above). For Further Assistance For general information and contractual questions, contact Network Management or your Facility Contract Manager using the Provider Service Line at (877) 614-0484. providerexpress.com January 2016 7 CALIFORNIA PROVIDER CONTACT LIST providerexpress.com OptumHealth Behavioral Solutions of California Optum PO Box 880609 San Diego, CA 92168-0609 Phone: (877) 614-0484 Behavioral Network Services Fax: (855) 833-3724 [email protected] Wellness Assessments PO Box 27430 Houston, TX 77277 Phone: (877) 369-2198 Fax: (800) 985-6894 Wellness Assessment Forms (ALERT®) Care Advocacy Teams and Inpatient Authorizations (All inpatient care must be preauthorized) (800) 333-8724 Phones are answered 24 hours a day, 7 days a week In the event of an emergency, notify us immediately Facilities will providerexpress com optum health admission and discharge summaries to OptumHealth Behavioral Solutions of California/Optum for the purpose of ongoing treatment planning (800) 888-2998 24-Hour Intake Line Scheduling Appointments (Clients referred to you must be seen within the following time frame) We highly recommend that claims be submitted electronically at providerexpress.com If you are unable to file electronically, please use the appropriate address shown on the right. Appeals & Grievances Appointment Type Mental Health EAP Routine/Non- Emergency Within 10 business days Within 3 business days Urgent Within 48 hours Within 24 hours Emergency Same day N/A University of California, Care1st Optum (UBH) Members & Wells Fargo Members PO Box 30760 Salt Lake City, UT 84130-0760 PO Box 30755 Salt Lake City, UT 84130-0755 Mail Handlers UnitedHealthcare PO Box 30756 Salt Lake City, UT 84130-0756 PO Box 30757 Salt Lake City, UT 84130-0757 OptumHealth Behavioral Solutions of California & Optum Appeals & Grievances PO Box 30512 Salt Lake City, UT 84130-0512 Phone: (800) 999-9585 Fax: (855) 312-1470 Claims & Eligibility (800) 333-8724 Provider Express Support (866) 209-9320 Language Assistance Program Hearing & Speech Impaired Line providerexpress.com (866) 374-6060 (800) 842-9489 (TTY) 8 Frequently Asked Questions Network Requirements Who can I contact with specific questions or comments? For general information and contractual questions, azealia banks download 212 Network Management at (877) 614-0484 or your Facility Contract Manager. What is a Payor? Our Payor definition is the entity or person that has the financial responsibility for funding payment of covered services on behalf of a Member, and that is authorized to access MH/SUD services in accordance with the Agreement. How do Network Lease Partnerships work? Some patients may have access to Optum network discounts through Network Lease Partners. All claims for Members accessing your services through these arrangements are processed, paid by, and the responsibility of the Network Lease Partners and not Optum. Please submit claims directly providerexpress com optum health these Network Lease Partners for processing. Claims submission information is available on the back of the Member’s ID card. Do I have to notify anyone if I change my name, address, telephone number, language capability, or Tax Identification Number? Yes. You are required to notify us within 10 calendar days, in writing, of any changes to your practice information. This is especially important for accurate claims processing. We encourage you to make such changes by going to Provider Express to update your practice demographics. As a contracted facility, are we required to notify Optum in the event that we discontinue or change a program or service? Yes. Contracted facilities providerexpress com optum health required to provide us with written notification of changes in the services they offer within 10 calendar days. As a contracted facility, would the addition of programs, services or locations require review of our current contract with USBHPC? Yes. Contact your Facility Contract Manager to initiate a review. If I am individually contracted with USBHPC, can I be considered a participating clinician at one practice location and non-participating at another? No. Your Agreement with us requires that you see all Members eligible to access this Agreement and is not specific to a location or Tax Identification Number. It is important to provide us with all practice locations and the Tax Identification Numbers under which you submit claims. providerexpress.com January 2016 9 Since our facility or practice group is contracted, does that mean all of our affiliated clinicians are considered participating network clinicians? No. Generally, only clinicians credentialed with Optum are considered network clinicians. The Google play store gift card codes india network status of a facility or group does not guarantee that all clinicians in practice there are network clinicians. In situations where an Agency is credentialed by Optum, their affiliated clinicians are not credentialed, but are considered participating under the Agency’s Agreement. May I bill for Mental Health/Substance Use Disorder (MH/SUD) services that another practitioner, intern or assistant provides to Optum Members in my office? No. You can bill only for services which you personally provide. Please follow the Optum Psychological and Neuropsychological Testing Guidelines regarding the use of psychometrists. These are available on Provider Express under “Guidelines and Policies”. If my practice is filling up or if I am going to take a leave of absence from my practice, may I choose to be unavailable for new Optum referrals? Yes. You may request to be listed in our database as unavailable at one or more of your practice locations for a period of up to six months. You are required to notify Network Management within 10 calendar days of your lack of availability for new referrals. Group practices and facilities / agencies that wish to be made unavailable should contact Network Management. Are there procedures to follow if I withdraw from the Optum network? Yes. The terms and conditions for withdrawal from the network are outlined in your Agreement. For additional details, or to initiate the process, contact Network Management or your Facility Contract Manager. Please also see information about Continuation of Services after Termination in the “Network Requirements” chapter of this Manual. Benefit Plans, Authorizations and Access to Care Should I routinely contact Optum regarding eligibility, benefits, and language assistance needs? Yes. You can inquire about eligibility, benefits and language assistance needs at Provider Express or by calling the phone number on the back of the Member’s ID card. Services and/or conditions not covered under the Member’s specific Benefit Plan are not eligible for payment. We comply with regulatory requirements related to coverage election periods and payment grace periods. These requirements can lead to delays in our knowledge of a Member’s eligibility status. As a result, the Member is the best source for timely information about eligibility, coverage changes and services utilized to-date. Can Members initiate authorization of benefits for routine outpatient MH/SUD services? Yes. The authorization for routine outpatient services, when required, is typically obtained through a telephone contact between the Member or family member fifth third bank personal account login Intake staff. It can also be initiated by eligible Members via the Member website. providerexpress.com January 2016 10 However, if a required authorization has not been issued at the time you inquire about eligibility, then you need to request it. You may do this through Provider Express or by calling the phone number on the back of the Member’s ID card. Do all Members require prior authorization for outpatient treatment? No. For Members whose Benefit Plan does not require prior authorization, there is no need to obtain an authorization. To inquire about a Member’s Benefit Plan requirements, contact us through Provider Express or by calling the number on the back of the Member’s ID card. Are all the services I provide covered under the MH/SUD Authorization? No. Authorization that is issued to Members (when required) covers most common but not all routine outpatient MH/SUD services you provide. Non-routine services include, but are not limited to, psychological testing and intensive outpatient care. These services may still require clinician-specific or program-specific authorization providerexpress com optum health benefits prior to providing those services. To obtain those authorizations, please call the number on the back of the Member’s ID card. Do the 2013 CPT codes 90837/+90838 require prior authorization? Yes. As described in the American Psychological Association 2013 Chase personal credit card number code crosswalk, the CPT codes for extended sessions (90808/90809 – 78-80 minutes) have been replaced by the new codes 90837/+90838 (53 minutes or more) and will continue to require prior authorization. For authorizations, call the toll-free number on the back of the Providerexpress com optum health ID card. What if I see someone for an extended period due to an unforeseen crisis? For unforeseen crises for which there may be an unanticipated need for an extended office visit, you should use the new crisis code, 90839, to bill for the first 30-74 minutes of psychotherapy. Prior authorization is not required for crisis sessions. Is the Wellness Assessment (WA) administered more than once? Yes. The WA is administered at the first session or in the second session if the Member presents in crisis during the first session. It is administered again preferably at the third visit, but may be given at either the fourth or fifth visit. The exact timing is at the clinician’s discretion. Is there a way to ensure confidentiality with the WA for emancipated minors who are requesting services? Yes. In these circumstances, you should only interest rate for houses today the demographic sections located at the top of the WA and return it to Optum. Fill in the bubble labeled “MRef” for Member refusal. A follow-up assessment will not be sent to the adolescent’s home. Where can I get more information about ALERT and Wellness Assessments? Please refer to the “Benefit Plans, Authorization, EAP and Access to Care” chapter fedex holiday schedule 2020 this Manual or to the ALERT information on Provider Express. Is there a time limit in which an authorization of routine services is valid? Yes. The authorization of routine services is valid for one year from the date of issue providerexpress.com January 2016 11 up to the benefit limit as long as the Member’s eligibility remains active. Can I make referrals directly to other Optum network clinicians without prior authorization of benefits? Yes, in some cases. The authorization for routine services is open to any Optum network clinician and allows you to transfer a Member to another network clinician for routine outpatient MH/SUD services. Additionally, if you are referring a Member to a network clinician for routine medication evaluation and management, prior authorization is not required. However, a prior authorization is still required for services such as psychological testing, intensive outpatient services and other levels of care. Employee Assistance Program (EAP) Procedures Do EAP services require prior authorization? Yes. EAP benefits require prior authorization and an initial authorization may be obtained by the Member or by the Provider. Members may make the authorization request by phone or through liveandworkwell.com. Providers making an authorization request on behalf of a Member should call the number on the back of the Member’s ID card or obtain the EAP toll-free number from the member. The Member will receive an EAP authorization letter and is providerexpress com optum health to bring that to their initial session. Do I need to obtain prior authorization for Members who transition from EAP to Optum MH/SUD benefits for routine psychotherapy services? Some Members have a managed behavioral health care benefit through Optum in addition to their EAP benefit. In some instances, an authorization or notification may be necessary for those Members who transition from EAP to MH/SUD benefits for routine psychotherapy services. To obtain an authorization or notification, use the “Auth Request” function through Provider Express. Upon completion of the “Auth Request”, Optum will generate an MH/SUD benefit authorization. When a Member is referred to me following an EAP session, am I required to ensure that an MH/SUD authorization is in place before the Member begins MH/SUD services with me? Yes. The EAP clinician should have requested MH/SUD authorization, if required. However, you need to verify that a required authorization has been obtained. If not, you should obtain the authorization. Does use of EAP benefits change authorization or notification requirements for MH/SUD services? No. You may inquire about benefit requirements through Provider Express or by calling the number on the back of the Member’s ID card. If a Member I am seeing through EAP benefits requires medication management services, is prior authorization of MH/SUD benefits required? No. Medication management services providerexpress com optum health MH/SUD benefits do not require prior authorization. providerexpress.com January 2016 12 Should EAP Members be given the Wellness Assessment at their initial visit? Yes. All Optum Members should be asked to complete the WA. Am I required to give a Wellness Assessment (WA) to a Member transitioning from EAP benefits? Yes. All Optum Members should be offered the WA. If the Member reports having already completed a WA with the EAP clinician, it is not necessary to complete an initial session WA. However, you should administer the WA at either session three, four or five. Do EAP benefits require a new authorization when a new benefit year begins? Yes. You will need to obtain a new EAP authorization when a new benefit year begins. Remember to ask the Member for a copy of the EAP authorization letter to note the expiration date of the authorization. Is there a time frame in which I may seek a retrospective review of services that were provided but not previously authorized? Yes. On occasion, emergent or other unusual circumstances will interfere with the pre-authorization processes. In those cases, requests for a retrospective review of services must be submitted within 180 calendar days of the date(s) of service unless otherwise mandated by applicable law. Treatment Philosophy Are Optum’s Guidelines accessible online? Yes. Guidelines/Policies are posted under “Quick Links” on the home page of Provider Express. You may also contact Network Management (see the “Resource Guide” https www t online de login of this Manual under “For Further Assistance”) to have a paper copy of these documents mailed to you. Am I expected to coordinate care with a Member’s primary care physician or other health care professionals? Yes. We require network clinicians, both in and out of facilities, to pursue coordination of care with the Member’s primary physician as well as other treating medical or behavioral health clinicians. A signed release of information should be maintained in the clinical record. In the event that a Member declines consent to the release of information, his or her refusal should be documented along with the reason for refusal. In either case, the education you provide regarding risks and benefits of coordinated care should be noted. How can I learn more about Recovery & Resiliency? Optum considers Recovery & Resiliency to be important in the provision of behavioral health services. For more information, see the Recovery & Resiliency Toolkit on Provider Express. providerexpress.com January 2016 13 Privacy Practices Do HIPAA Regulations allow me to exchange Protected Health Information (PHI) with Optum? Yes. The HIPAA Privacy Rule permits clinicians and Optum to exchange PHI, with certain protections and limits, for activities involving Treatment, Payment, and Operations (TPO). An individual’s authorization for ROI is not required when PHI is being exchanged with a network clinician, facility or other entity for the purposes of Treatment, Payment or Health Care Operations as enumerated in HIPAA (and consistent with applicable law)1. Do I need a National Provider Identification (NPI) to submit electronic claims? Yes. We require the billing clinician to include NPI information on all electronic claims. In addition to all electronically submitted claims, some states mandate that the NPI be used on all claims (whether paper or electronic submission is used). Quality Management and Improvement Does Optum audit clinicians and facilities? Optum representatives conduct site visits at clinician offices, agencies, such as community mental health centers (CMHCs), facilities and group provider locations. On-site audits are routinely completed with CMHCs and facilities without national accreditation. In addition, audits are completed to address specific quality of care issues or in response to Member complaints about the quality of the office or facility environment. For additional information, how to get a fake phone number for verification see the “Quality Management and Improvement” chapter of this Manual. Compensation and Claims Can Members be billed prior to claims submission? No. Members are never to be charged in advance of the delivery of services, with the exception of applicable copayment. Members should be billed for deductibles after claims processing yields an Explanation of Benefits indicating Member responsibility. Is there one format to be used for diagnosis on claims? Yes. Submit your claims using the industry-standard ICD code as mapped to DSM defined conditions. 1 “Treatment, Payment, or Health Care Operations” as defined by HIPAA include: 1) Treatment – Coordination or management of health care and related services; 2) Payment purposes – The activities of a health plan to obtain premiums or fulfill responsibility for coverage and provision of benefits under the health plan; and 3) Health Care Operations – The activities of a health plan such as quality review, business management, customer service, and claims processing. providerexpress.com January 2016 14 Are there different methods or claim forms I should use when submitting claims to Optum? Yes. See below. Electronic Claims: Optum recommends electronic submission of claims for the most efficient claim processing. Network clinicians and group practices can submit MH/SUD and EAP claims electronically through Provider Express using the “Claim Entry” function. This and other secure transactions are accessed through a registered User ID. To obtain a User ID, go online to "chat" with a Provider Express representative or call toll-free (866) 209-9320. In addition, any clinician, group practice or facility provider can submit claims electronically through an EDI clearinghouse using Payer ID #87726. Clinician Claim Forms: Paper claims for MH/SUD or EAP services should be submitted to Optum using the 1500 claim form, the UB-04 claim form, or their successor forms as based upon your contract. All paper claims must be typewritten. Facility Claim Forms: Paper claims should be submitted to Providerexpress com optum health using the UB-04 billing format, or any successor forms as appropriate. With all of the different products that Optum manages, is there some easy way for me to determine where to send my claim? Yes. Claims submitted electronically through Provider Express are automatically routed to the appropriate claims office. You may also elect to submit electronically through an EDI vendor. EDI claims are also automatically routed to the correct claims offices. We pay claims for Members using a number of different claims systems. In order to assure prompt and accurate payment for claims submitted using the U.S. Postal Service, you should verify the mailing address for your claim by calling the number on the back of the Member ID card. Often, the claims payment address for a medical claim is different than the address for a behavioral health claim. Do I have to providerexpress com optum health my claims within a certain time frame in order for them to be paid? Yes. All information necessary to process claims must be received by Optum no more than 90 calendar days from the date of service, or as required by applicable law or specific Member Benefit Plans. Am I responsible for coordination of benefits? Yes. You are responsible for determining if other pnc bank legal department contact number coverage is in effect and for billing the primary insurance carrier first, then notifying Optum of your findings. Optum is required to process claims using industry-wide Coordination of Benefits (COB) standards and in accordance with benefit contracts and applicable law. Can I bill a Member when treatment is not authorized, as required, but the Members elects to receive services? Yes. In the event that you seek prior authorization of benefits for behavioral health services, or authorization for continued treatment when required, and Optum does not authorize the requested services, the Member may be billed under limited circumstances. For more detailed information, providerexpress com optum health review the “Billing for NonCovered Services and No Shows” section in the “Compensation and Claims providerexpress.com January 2016 15 Processing” chapter of this Manual. May I submit a claim to Optum for "no-shows"? No. However, the Member may be billed if a written statement explaining your billing policy for appointments not kept or cancelled is signed by the Member prior to such an occurrence. You may bill the Member no more than your contracted rate. Note that some plans and government funded programs prohibit billing for no-shows under any circumstances. May I submit a claim to Optum for telephone counseling or after-hours calls? Optum covers telephone counseling in some situations when clinically necessary and appropriate and in accordance with the Member’s Benefit Plan. Telephone counseling must be pre-authorized by Optum. May I balance bill the Member above what Optum pays me? No. You may not balance bill Members for services provided during eligible visits, which means you may not charge Members the difference between your billed usual and customary charges and the aggregate amount reimbursed by Optum and Member expenses. Anti - Fraud, Waste and Abuse (FWA) Am I required to participate in all Anti - Fraud, Waste and Abuse programs? Yes. All FWA investigation activities are a required component of your Agreement. This includes, but is not limited to, providing medical records as requested and timely response to inquiries. Do I have to complete Anti - Fraud, Waste and Abuse or Compliance training? All Providers and Affiliates working on Medicare Advantage, Part D or Medicaid programs must provide compliance program training and FWA training within 90 days of employment and annually thereafter (by the end of the year) to their employees and/or contractors. The training is subject to certain requirements and may be obtained through any CMS approved source. What should I do if I suspect Fraud, Waste or Abuse? Any time there is a suspicion of Fraud, Waste or Abuse, please report it immediately. The faster we know about it, the faster we can intervene. We need your assistance to maximize success. How do I contact the Optum Program and Network Integrity Department? Telephone: (877) 972-8844 E-mail: [email protected] Mail: P. O. Box 30535, Salt Lake City, UT 84130-0535 Fax: (248) 733-6379 General Inquiries: [email protected]