Value Behavioral Health of Pennsylvania,
Inc.
Auto Approvals for Outpatient and
Clozapine Supports Services via
ProviderConnect
The webinar will begin at 10:00 AM
We are waiting for the other participants to join
Value Behavioral Health of Pennsylvania
Presenters
Shar Whitmire, Director of Provider and
Member Services
Jim Friend, Special Projects Manager
Gary Kordes, VBH-PA Clinical Manager
Kim Keller, OTR Authorization Specialist
Lori Raling, OTR Authorization Specialist
Tracy Phelps, OTR Authorization Specialist
Pennsylvania Service Center
Webinar Rules
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All lines are open so we ask that all attendees place there phones on mute at this
time by pressing *6 or the mute button on your phone. Again, please mute
your phone by pressing *6 or we will be able to hear any background
noise. We appreciate you keeping your line muted.
If you have to take a call please disconnect from this call. DO NOT use
HOLD. We will have to talk over the music.
If you happen to get disconnected from the audio portion please call back
into the same number you just dialed.
The visual portion of this presentation is web based. Of course you can
choose the audio portion only but if you would like to join/login to see the
webinar presentation/PowerPoint,the login information is located on the
invite you received after you registered. If you are experiencing any
problems with that particular link to join you can also go to
www.joinwebinar.com and enter the web ID:233933123
There will be a designated question and answer portion at the end of
today’s presentation. We ask attendees to hold their questions for this
designated question/answer period.
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Audio Component of the Webinar
For the audio component the call in number
is 1-877-329-0172 and the participant
code is 9429776
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Agenda
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Outpatient Authorizations
Evaluations Authorizations
Medication Management Authorizations
Clozapine Support Services
Authorizations
• ProviderConnect Demonstration
• Questions and Answers
• Contact Information
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Auto Approvals for Outpatient and
Clozapine Supports Services via
ProviderConnect
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Outpatient Registration ORF1 Form
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Auto Authorized Services
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Outpatient individual psychotherapy
Outpatient group therapy
Outpatient family psychotherapy
Psychiatric Evaluation / Examination
Medication Management
Clozapine Support
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Value Behavioral Health of PA Homepage
For Providers Only
• Go to: www.vbh-pa.com
• Click on: For Providers
• Click on:
ProviderConnect
• Enter: User ID
• Enter Password
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Value Behavioral Health of PA Web-Site
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ProviderConnect Logon Homepage
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After logging in, providers will initially view their home page.
Authorization Requests are started by utilizing the Enter an
Authorization Request
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After selecting Enter an Authorization Request providers will be directed to a
disclaimer page and then to a Search a Member page where Member ID and
Date of Birth are required elements. The system defaults to the current date for
“As of Date” but can be changed as needed. The Member ID is the nine digit
Medicaid ID number.
Providers will be offered a page to confirm the consumer information.
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Next, the provider must select the correct service address
on the Select a Service Address page. This address
needs to be a match to the primary location where the
consumer will receive services, and is the key to successful
navigation through the request process. Funding streams,
program codes and provider types are linked to this
selection.
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Submitting Outpatient (OUT) Authorization Requests
• There are two options for providers requesting
authorizations for OUT services. The provider must
select either Mental Health or Substance Abuse (Type
of Service field)
• On the Requested Services Header screen the
provider must provide the following information to
successfully enter the Outpatient (OUT) authorization.
• Requested Start Date– the date the provider wishes to
begin this authorization request.
• Level of Service – select Outpatient
• Type of Service –select Mental Health or Substance
Abuse
• Type of Care – for Mental Health select “Psychiatric”
and for Substance Abuse leave blank “Select”
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Level of Service
Select Outpatient or Medication
Management
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Type of Service: Select Mental Health or Substance Abuse
Select Mental Health or Substance Abuse
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Below is an example of a Mental Health request
For Mental Health select the Type of
Care field Psychiatric
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Below is an example of a Substance Abuse Outpatient Service
request
For Substance Abuse the Type of Care
field is left blank (Select)
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Click OK to proceed with Auth Approval
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Enter Contact Name and Telephone Number
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Use of hyperlinks to search with pop ups – entering partial information in a
field may assist in narrowing search for desired information. However, if
the information is known and the field allows free text, the information can
data entered.
If Mental Health is selected (TOS), a Mental Health diagnosis code must be
entered.
If Substance Abuse is selected (TOS), a Substance Abuse diagnosis code
must be entered.
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The provider requesting Outpatient services will be offered the
Accept/Reject option for 72 units. These requests may approve or pend
depending on the type of services being requested and if the member has
exceeded the 72 units within a 12 month period, or there has been
previous outpatient requests during the course of the year. Accepting
these units will allow the process to move forward.
Accept 72 units of Outpatient
Services
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Requested Service Screen
• The provider will be asked to enter the specific Place of Service,
Service Class and Units. Place of service must always be
“Office”.
• Leave CPT and Modifier blank
• Options for Outpatient Services are as follows:
• Service Class-options are as follows: (1) Outpatient Services, (2)
Examinations, (3) Medication Management. Total units can not
exceed 72 units for all three Outpatient services combined.
• Please Note: The Place of Service (POS), Service Class and Units
selections will result in an authorization request for the service class.
This service class allows providers to bill any of the service codes
and modifiers for that class on the VBH-PA service class grid.
However, in order to be paid for that service you must first be
contracted for that service. This allows for flexibility in providing
services to the consumer.
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Requested Service Screen
Note: OUT, EXM, and RXM
can be combined
Outpatient=OUT
Examinations / Evaluations= EXM
Medication Management= RXM
Can not exceed 72 units
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Approved authorizations will span 12 months.
Authorization will span 12
months
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Pended Confirmation for Further Review
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Printing and Saving Options on
Confirmation Page
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Submitting Clozapine (CME, CS1,CS2, PRC)
Authorization Requests
• On the Requested Services Header screen the
provider must provide the following information to
successfully submit a Clozapine authorization.
• Requested Start Date– the date the provider wishes to
begin this authorization request.
• Level of Service – select Outpatient
• Type of Service –select Mental Health
• Type of Care –select Clozapine Support
• An example of a Clozapine request is displayed below:
• Must select Clozapine in the Type of Care drop down
to get the 104 maximum number of units
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Clozapine (CME, CS1,CS2, PRC) Requests
Must select Clozapine Support
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Enter Contact Name, Telephone Number and
Diagnosis Code 1
Axis 1 Diagnosis Code 1 needs completed
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Clozapine (CME, CS1,CS2, PRC) Requests
• The provider will be asked to enter the specific Place of
Service, Service Class and Units. Place of service
must always be “Office”.
• Please Note: The Place of Service (POS), Service Class
(Clozapine Services) and Units selection will result in an
authorization request for the service class. This service
class allows providers to bill any of the service codes
and modifiers for that class on the service class grid.
However, in order to be paid for that service you must
first be contracted for that service. This allows for
flexibility in providing services to the consumer.
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Clozapine (CME, CS1,CS2, PRC) Requests
Can choose CME, CS1, CS2 or
PRC in any combination
CME = Clozaril Monitoring and Support
CS1 = Clozaril Support Services-CS1
CS2 = Clozaril Support Services –CS2
PRC = Clozaril Support -PHP
104 units will be offered for Clozapine
Support services
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Clozapine Support level of care is programmed to offer a maximum of
104 units, in any combination of CME, CS1, CS2, or PRC service
classes. Select “Accept” to continue with the rest of the authorization
process.
104 units will be offered for Clozapine Support services
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Clozapine Support approval
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Submitting Medication Management (RXM)
Authorization Requests
• There are two options for providers requesting authorizations for
Medication Management services (RXM).
• The provider can combine RXM with the 72 units as described in the
Outpatient (OUT) example. However, if the member only needs
medication management and no other services, RXM can be
authorized separately. The provider must follow the work-flows
below for either Mental Health or Substance Abuse (Type of Care
field)
• On the Requested Services Header screen the provider must
provide the following information to successfully enter the
Medication Management (RXM) authorization.
• Requested Start Date– the date the provider wishes to begin this
authorization request.
• Level of Service – select Medication Management
• Type of Care –select “Psychiatric” for Mental Health and for
Substance Abuse select “SWPA Substance Abuse Drug and
Alcohol”
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Submitting Medication Management (RXM) Authorization Requests (MH)
Select Medication Management
Select Psychiatric for Mental Health
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Medication Management (RXM) Request-(SA)
Select Medication Management
Select SWPA Substance Abuse Drug and Alcohol for SA
services
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Enter Contact Name and Telephone Number and
Diagnosis Code 1
Axis 1 Diagnosis Code 1 needs completed
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Medication Management (RXM) Requestcontinued
24 units will be auto authorized for Medication
Management for a 12 month period
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Medication Management (RXM) Requestcontinued
• Select Place of Service (Office), Service Class (Medication
Management), and Units (24), and click Submit.
• The provider will be asked to enter the specific Place of Service,
Service Class and Units. Place of service must always be
“Office”.
• Please Note: The Place of Service (POS), Service Class and Units
selection results in an authorization request for the service class.
This service class allows providers to bill any of the service codes
and modifiers for that class on the service class grid. However, in
order to be paid for that service you must be contracted for that
service. This allows for flexibility in providing services to the
consumer.
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Medication Management (RXM) Requestcontinued
Select Place of Service (Office), Service Class
(Medication Management), and Units (24), and
click Submit.
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The confirmation page has the Level of Service
(Medication Management), authorization effective and
expiration dates, authorization reason code A71, and the
number of units (24).
Approved
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Continuing authorizations
If the member needs additional
Outpatient services (more than the 72
that were auto approved) you will have
to complete the ORF1 form and / or
answer the risk assessment questions
on-line via ProviderConnect.
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RFS Form required
• Services that need reviewed
• Non-Acute Partial Hospitalization
• Intensive Case Management / Resource
Coordination (ICM/RC)Intensive
• Intensive Outpatient (IOP )
• Methadone Maintenance-use form**
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Enter an Authorization using the Request for
Service (RFS) form
• The Authorization Request function shown
below in the screen shot enables users to
electronically submit requests for services (RFS)
for all the services listed above.
• Please use the ProviderConnect RFS form
found on the VBH-PA website, on the Provider
Forms page. Select “Outpatient Request Form”
from the drop down list. Click “Yes” if it contains
clinical information on the member. Click
“Upload file” to attach your request for
authorization.
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To request additional services a RFS form must
be attached.
Browse and find, then upload the RFS form
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Request for Service (RFS)
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Tips for successful submission/navigating
screens include
• ProviderConnect works best with Internet Explorer 6 or IE7 for your
browser – if you are having issues with the screens not displaying or
pop ups, etc. not working correctly you may be using a newer
version of IE or using Fire Fox. If you are using IE8, you can follow
the below steps to help with the issue:
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–
–
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Click on the Tools menu at the top of your browser
Click on Compatibility View Settings
Type in: valueoptions.com, and click the Add button
Click the Close button
• Do not use the browser Back button – use the Back button on the
screen itself – using the Back on your browser can result in errors
and loss of data.
• Required fields are indicated by “*”. These fields must be
completed each time an authorization is requested. Some fields are
dependent on other fields – a positive or negative response to a
question may result in other fields being required
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Pass Through Units
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Starting on March 1, 2010 Providers will be able to view their recent
authorization letters with a simple click. All authorization letters within
the last 30 days will be accessible on the Provider homepage. See the
hyperlink below entitled “View My Recent Authorization Letters
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The second enhancement enables providers to run their
own weekly authorization reports via ProviderConnect.
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ProviderConnect Demonstration
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Frequently Asked Questions
• Q: Can I request Outpatient (OUT), Medication Management (RXM)
and Examinations/Evaluations (EXM) in the same request?
• A: Yes. VBH-PA has programmed it so that a combined 72 units will
be auto authorized. You can use all 72 units for Outpatient, or break
it out into 48 OUT, 22 RXM, and 2 EXM, or any combination of the
above. However, the units can not exceed 72.
• Q: Can I auto auth Clozaril, and Outpatient at the same time on the
same request.
• A: No. Since they are in two different Service Classes, two different
requests need to be submitted, but the member can receive services
at the same time.
• Q: If I have an auth for Medication Management that overlaps to the
next year can I Auto Auth just OUT?
• A: Yes, OUT will Auto Auth 72 units
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Frequently Asked Questions
• Q: What will happen if I choose one of the other selections in the
“Type of Care” drop down list.
• A: You have only two choices for Outpatient Service for Mental
Health , Clozapine Support and Psychiatric. The other selections
will pend.
• Q: I noticed there is no Psychiatric “Type of Care” selection for
Substance Abuse. What “Type of Care” do I choose?
• A: Leave the “Type of Care” field at the default which is Select.
• Q: The member already was authorized 72 units for Mental Health
Outpatient. Can the member now get Substance Abuse Outpatient?
• A: Yes, 72 units will be offered, the same as Mental Health.
• Q: If I have an auth for Methadone Maintenance that overlaps to the
next year, can I Auto Auth OUT?
• A: Yes, OUT will Auto Auth 72 units.
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Question and Answer Period for Providers
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Contact Information
Jim Friend - Special Projects Manager
724-744-6372
[email protected]
Contacts
VBH-PA Provider Line
Toll Free
1-877-615-8503
Hours: 8:00 a.m. – 5:00 p.m. EST
Monday – Friday
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Thank you!
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Provider Relations Communications Plan Overview