Mandatory Orientation Training for
New Network Providers
Welcome to CenterPoint Human
Services’ Provider Network
CenterPoint Human Services is a managed care organization
(MCO) managing the delivery of Medicaid and State-funded
mental health, intellectual/developmental disabilities and
substance abuse services through a network of providers.
CenterPoint works closely with providers, clients, family
members and community partners to meet the needs of
people in Forsyth, Stokes, Davie and Rockingham Counties.
We are People in Partnership Making a Difference!
Orientation
 It is required that all Solo practitioners and at least one representative from
an agency or group participates in this mandatory orientation training for
new network providers. They are then expected to share information with
remaining employees. Additional information can be found in the Provider
Manual posted on the CenterPoint website:
www.cphs.org
 This training session highlights many LME/MCO topics and references
resources where providers can find additional information. CenterPoint
contacts are also listed to address any questions providers may have.
 You can log into the course as many times as you wish. Please allow a minimum
of 45 minutes to complete this course. Once you have finished reviewing all
course material you must also complete the attestation form and evaluation to
get credit for your participation.
 Please be sure to “submit” when you complete the form.
What will be covered in this course?
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Customer Services
Care Coordination
Utilization Management
Appeals Process
Quality Management
Corporate Compliance
 Contracts, Claims and
Billing
 Administrative and
 Professional Competence
 Network Operations
 Monitoring Process
 Disputes
 IRIS
Customer Services
Customer Services
Also known as STR or ACCESS
3 Main Functions:
1. Maintain 24/7/365 ACCESS Line (Call Center)
dedicated for clients - 1-888-581-9988
2. Maintain 24/7/365 Provider Line dedicated for
Providers - 1-888-220-5280
3. Client Follow Up – If client “no shows” for
appointment, we follow up with them.
ACCESS Call Center Overview
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Receives 150-200 calls a day
13 staff during day / 2 in evening / 1 overnight
Average call time is 8 – 10 minutes
Goals are to:
 Answer calls in 30 seconds / Average is 22 seconds
 Have less than 5% Abandonment (Hang ups) / Average is 1% – 2%
 When all of our call center agents are on a call and unavailable
to take a new call, then calls “overflow” to a backup call center
vendor called ProtoCall, Inc.
 We triage calls into 4 different categories: Emergent, Urgent,
Routine, Non-threshold
ACCESS Line: Emergent Calls
Call received regarding client being dangerous to self or
others:
 If mobile crisis is not appropriate then we will dispatch
police or EMS to given address.
 If mobile crisis is requested or seems appropriate then
we will dispatch mobile crisis.
 If person is able to safely get to an emergency provider
then we will refer to crisis services provider.
 We will follow-up until we know client has been seen by
someone face-to-face.
Access Line: Urgent
 The Access Standard for Urgent Services is to arrange
for services within 48 hours of contact with the
Customer Services access line.
 Any caller who presents with moderate risk in
physical, cognitive, or behavioral functioning.
 North Carolina treats any Substance Abuse Client as
an “Urgent” and offers an appointment within 48
hours.
Access Line: Routine
 The Access Standard for Routine Services is to
arrange for services within 14 days of contact with the
Customer Services access line.
 We refer for assessment – NOT for enhanced
benefits.
 If caller does not have a provider of choice, we offer
provider choice based on requested services, funding
source, and location.
Provider Line:
1-888-220-5280
 Need basic Information or not sure who to call? Call
us, we will be glad to help.
 Provider needing Emergent/Urgent Authorizations
(Mobile Crisis, Inpatient, Detox, authorization to
assess in ED, etc…) can call Provider Line
 Hospital D/C appointments
 Emergency Respite
 If call goes to Voicemail, we will call you back within
30 minutes
ProtoCall:
 If all of our agents are busy, then call will go to
company called ProtoCall.
 They will triage call and take care of Emergent Call
(get police out, dispatch mobile crisis, get person to
emergency provider etc…).
 All other calls, they will take information and forward
report to CenterPoint staff.
 Within 30 minutes CenterPoint staff will make
contact.
Follow-Up:
 For each triage disposition (Emergent 2 hrs., Urgent 48 hrs.,
and Routine 14 days) Customer Services will be responsible
for seeing if client made scheduled appointment or not.
 For Emergent, Customer Service staff will contact provider
to see if client made appt.
 For Urgent and Routine appointments, Providers will enter
compliance data into Alpha System.
 We will run a “No-Show” report daily and attempt to make
contact with clients to reschedule an appointment.
Important for Providers:
 If Provider decides to have a shared calendar with
CenterPoint, please update it as frequently as you
can.
 Please keep CenterPoint informed of changes to your
agency. For example, if capacity changes, if programs
change, if funding sources change, let CenterPoint
know.
 Compliance data entry must occur daily by 10:00 AM
for previous day appointments.
Customer Services Questions?
CenterPoint Human Services Contact:
Mike Bridges, LCSW
mbridges@cphs.org
(336) 714-9104
Care Coordination
What is Care Coordination?
Care Coordination is a person centered, assessment-based
approach to integrating mental health and substance abuse
services, primary health care and natural/community supports.
CenterPoint’s care coordination department provides care
coordination services to enrollees who are considered high
cost/high risk (hc/hr) and/or Special Health Care Needs
Populations as defined in the 1915 (b)/(c) waivers.
What is MH/SA Care Coordination?
Care Coordination in an LME/MCO provides a wide range of duties/roles to
increase the integration of Behavioral Health and Physical Health. It is
typically provided on a short term basis (average 3 to 6 months).
Some of the supports provided to clients:
 Education about all available MH/SA/DD services and supports, as well as
education about all types of Medicaid and state funded services
 Linkage to needed psychological, behavioral, educational and physical
evaluations
 Facilitate access to care for clients who do not have an established
clinical home.
 Monitors hospital admissions and discharges
Who is Eligible?
Individuals with special health care needs and those who are
high cost/high risk will be eligible for care coordination.
High Cost/High Risk Overview:
High Cost: Clients whose treatment expenses place them in
the top 20% of all client expenditures for the catchment area;
High Risk: Clients who have been assessed to need emergent
services three or more times within the previous 12 months.
MH/SA Care Coordination
Additional indicators for enrollees to be considered
MH/SA High Cost/High Risk may include the following factors:
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A pattern of failed appointments
Two or more jail bookings in a ninety day period
Entry into the crisis system via a crisis service
Out-of-catchment area residential services
Obstacles in finding appropriate placement, treatment and/or funding due to
circumstantial variables
 A history of behaviors placing the enrollee at risk to self or others
 Co-occurring MH and/or SA along with significant medical problems, i.e.,
CCNC Quadrant IV enrollee
 Identified by UM as a “case of concern”
Special Health Care Needs Definition – MH/SA
(This section will be update with DSM 5 language upon receipt of changes from the state.)
Child Mental Health:
Children who have a diagnosis within the diagnostic ranges
defined below: 293-297.99, 298.8-298.9, 300-300.9, 302-302.6,
302.8-302.9, 307-307.99, 308.3, 309.81, 311-312.99,
313.81,313.89,995.5-995.59, V61.21
AND
Current CALOCUS Level of VI, OR
Who are currently or have been in the past 30 days, in a facility
(including a Youth Developmental Center and Youth Detention
Center) operated by the DJJDP or DOC for whom the LME has
received notification of discharged.
Special Health Care Needs Definition - Cont’d
(This section will be update with DSM 5 language upon receipt of changes from the state.)
Adult Mental Health:
Adults who have a diagnosis within the diagnostic ranges of:
295-295.99, 296-296.99, 298.9, 309.81
AND
Current LOCUS Level of VI.
Special Health Care Needs Definition - Cont’d
(This section will be update with DSM 5 language upon receipt of changes from the state.)
Substance Dependent:
Individuals with a substance dependence diagnosis
AND
Current ASAM PPC Level of III.7 or II.2-D or higher.
Opioid Dependent:
Individuals with an opioid dependence diagnosis AND who
have reported to have used drugs by injection within the
past 30 days
Special Health Care Need Definition - Cont’d
(This section will be update with DSM 5 language upon receipt of changes from the state.)
Co-Occurring Diagnoses:
 Individuals with both a mental illness diagnosis and a substance abuse diagnosis
AND Current LOCUS or CALOCUS of V or higher OR current ASAM PPC Level of III.5 or
higher
 Individuals with both a mental illness diagnosis and an intellectual or developmental
disability diagnosis
AND Current LOCUS/CALOCUS of IV or higher
 Individuals with both an intellectual or developmental disability diagnosis and a substance
abuse diagnosis
AND Current ASAM PPC Level of III.3 or higher
Department of Justice Settlement
Individuals involved in the United States Department of Justice and North Carolina
Settlement Agreement/Transitions to Community Living Initiative.
HC/HR Intellectual and Developmental
Disability (I/DD)
I/DD High Cost/High Risk Overview:
 High Cost: I/DD enrollees whose treatment plan expenses fall
within the top 20% of expenditures for all enrollees in the
MCO’s catchment area.
 High Risk: I/DD enrollees who have been assessed to need
emergent crisis services 3 or more times in the previous
twelve months.
HC/HR Intellectual and Developmental
Disability (I/DD)
Additional indicators for enrollees to be considered
I/DD High Cost/High Risk may include the following factors:
 Co-occurring I/DD and significant medical problems
 Obstacles in finding appropriate placement, treatment and/or
funding due to circumstantial variables
 A history of behavior placing the enrollee at risk of exploitation
 Entry into the crisis system via a crisis service
 NC START admission
 Therapeutic Respite Addressing Crisis for Kids (TRACK) referral
and/or admission
Special Health Care Needs
Definition- I/DD
Intellectual and/or Developmental Disabilities:
Individuals who are functionally eligible for, but not enrolled in,
the Innovations waiver, who are not living in an ICF-MR facility;
OR
Individuals with an intellectual or developmental disability
diagnosis who are currently, or have been within the past 30
days, in a facility operated by the Department of Correction
(DOC) or the Department of Juvenile Justice and Delinquency
Prevention (DJJDP) for whom the LME has received notification
of discharge.
Collaboration with Health Home
 The Four Quadrant Model
 Work with CCNC to develop integrated care practices
 Coordination of care with enrollee’s PCP/CCNC physician
/Health Home
 Monthly meetings with regional CCNC network- Northwest
Community Care Network (Forsyth, Davie, Stokes) and
Partnership for Health Management (Rockingham)
Four Quadrant
Care Management Model
Quad I:
Low MH/SA/DD Health
Quad II:
High MH/SA/DD Health
Low Physical Health Complexity /Risk
Low Physical Health Complexity/Risk
Quad III:
Low MH/SA/DD Health
Quad IV:
High MH/SA/DD Health
High Physical Health Complexity/Risk
High Physical Health Complexity /Risk
Linkage to Care Coordination
To link an individual to care coordination, please contact
CenterPoint’s Customer Service line: 888-581-9988
Questions:
I/DD Care Coordination: Jeff Payne, I/DD Clinical Director
336-714-9171 or jpayne@cphs.org
MH/SA Care Coordination: Katy Horne, Care Coordination Director
336-714-9173 or khorne@cphs.org
Utilization Management
LOCUS/CALOCUS
Authorizations
EPSDT
Appeals
LOCUS/CALOCUS
Information Sources:
© American Association of Community Psychiatrists
© American Academy of Child & Adolescent Psychiatry
LOCUS/CALOCUS
 LOCUS: Level of Care Utilization System
Psychiatric and Addiction Services
 CALOCUS: Child and Adolescent Level of Care
Utilization System Psychiatric and Addiction
Services (Has not been “normed” for ages 0-5)
• Developmental status determines the cut-off
between LOCUS and CALOCUS
LOCUS/CALOCUS
 With the arrival of managed care programs and principles,
the use of quantifiable measures to guide assessment,
level of care placement decisions , continued stay criteria,
and clinical outcomes is increasingly important.
 It provides a common language and set of standards with
which to make judgments and recommendations.
 It incorporates developmental, family, and community
systems of care perspectives.
LOCUS/CALOCUS
Main Objectives
 LOCUS/CALOCUS assesses the enrollee’s needs based on
level of functioning, rather than diagnosis and psychiatric
risk alone.
 LOCUS/CALOCUS assesses the enrollee’s needs and
allocate resources based on six evaluation dimensions.
 LOCUS/CALOCUS determines a recommendation for level
of care. It is not a substitute for clinical judgment.
The Six Dimensions
1) Risk of harm to self or others, including potential for victimization or accidental harm
2) Functional status-ability to function in all age-appropriate roles, as well as basis daily living activities
3) Co-morbidity of other conditions that has the potential to exacerbate the primary presenting problem
4) Recovery environment in terms of strengths/weaknesses of the family, neighborhood and
community (including services). Two subscales:
a) Environmental Stress
b) Environmental Support
5) Treatment history in terms of a history of successful use of treatment
a) LOCUS identifies the adult’s extent of recovery in response to prior treatment
b) CALOCUS identifies the child's innate or constitutional emotional strength and capacity
for successful adaptation [resiliency] as well as treatment history
6) Engagement
a) LOCUS identifies the patient’s degree of engagement.
b) CALOCUS identifies the child and family's acceptance and engagement in treatment.
i) Scale A -- Child/Adolescent
ii) Scale B -- Parents/Primary Caretaker
A five-point scale is constructed for each dimension
Levels of Care
LOCUS/CALOCUS assesses service needs and matches them to the clinically appropriate
level of care, where level of care refers to intensity of services, not to bricks-and-mortar
programs.
This permits a broad range of treatment options that:
 are adaptable to the available continuum in each service area;
 allows for variations in practice patterns and resources among communities and
agencies;
 Recognizes traditional services, as well as newer forms of care.
Levels of Care
1.
Recovery Maintenance and Health Management
2.
Low Intensity Community Based Services
3.
High Intensity Community Based Services
4.
Medically Monitored Non-Residential Services
5.
Medically Monitored Residential Services
6.
Medically Managed Residential Services
LOCUS/CALOCUS Links
LOCUS
http://communitypsychiatry.org/publications/clinical_and_administrative_t
ools_guidelines/locus.aspx
CALOCUS
http://communitypsychiatry.org/publications/clinical_and_administrative_t
ools_guidelines/CALOCUS_Instrument_2010.pdf
Authorizations
Authorizations
 Clinical information is reviewed and compared against the pertinent Service
Definition
 If the information presented does not appear to meet the criteria for the service
being requested, and the UM staff are not able to approve the request, the case
is forwarded to the Medical Director, or qualified designee for peer clinical
review
 All non-certification decisions are made by the Medical Director or their designee
 For Medicaid Enrollees, extensions for certification decisions are processed
according to DMA requirements and URAC standards for Medicaid Enrollees
 Non-Medicaid (IPRS) funded requests , extensions of certification decisions are
not allowed by the North Carolina Division of Mental Health/Developmental
Disability/Substance Abuse Services
 Certification decisions are viewable in the Provider Portal with the ability to print
out certification letters
Pass Through Services
In certain circumstances as defined by the LME/MCO or Clinical Coverage Policies, prior
authorization is not required. These requests are processed one of two ways.
 Pass through without Notification: Substance Abuse Intensive Outpatient Program,
Substance Abuse Comprehensive Outpatient Treatment Program and Mobile Crisis can be
provided up to a set limit without any prior contact with the LME/MCO. Limits are defined
within the related Clinical Coverage Policy. Once the limit is reached, a complete Service
Authorization Request with supporting documentation must be submitted.
 Pass through with Notification: Providers must submit a Service Authorization Request
(SAR) for notification for Inpatient Behavioral Health Services (Initial 72 hours), Supported
Employment /Long Term Vocational Supports (SE/LTVS) and Peer Support Services. Limits for
SE/LTVS and Peer Support Services are defined within the related Clinical Coverage Policy.
Once the limit is reached, a complete Service Authorization Request with supporting
documentation must be submitted. They are submitted to alert the LME/MCO of the
initiation of the service and to assure payment via AlphaMCS. These SARs do not require
clinical review and are processed within the non-urgent timeframe described below.
Authorizations
Urgent Requests: those related to inpatient behavioral
health services when the provider does not utilize the
pass through request, partial hospitalization,
detoxification and emergency respite
 Processed via a telephone call.
 These requests are processed 24 hours a day, 7 days a
week.
 In most cases a determination is made by the end of
the phone call, but a determination is always made and
verbal notification provided no later than 24 hours from
the request.
Authorizations
Non-urgent requests:
 Non-urgent requests are submitted via a web-based portal
 A complete request includes the following:
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Comprehensive clinical assessment
Service Authorization Request completed in the Provider Portal
Person Centered Plan or a service plan with a service order
If the client has a Mental Health diagnosis, a LOCUS or CALOCUS
If the client has a Substance Use diagnosis, an ASAM Level
If the client has a Developmentally Disabled, a SNAP score or SIS™
Reviews of ICF/MR services will include an annual review of the
Level of Care
If these components are not present, the provider is notified the
request was not complete and additional information is requested
via the Provider Portal
Authorizations
Non-urgent requests continued:
 A Utilization Management Clinician/Specialist will conduct a review. If
after review, it is determined that the services requested meet medical
necessity criteria, an authorization is entered into the MCO/LME’s MIS
system, and the provider is able to view this via the web based portal.
The determination is issued within 14 calendar days of the request.
 For requests involving Medicaid Enrollees, this time period will be
extended one time for an additional 14 days if the enrollee requests the
extension or the provider requests one on behalf of the enrollee.
 In cases where the initial clinical reviewer cannot make a clinical
determination to certify, the case is referred to the Medical Director (or
another designated M.D./PhD) for the purpose of peer clinical review.
Continued Authorization/Concurrent Reviews
 It is the provider or facility's responsibility to submit a request for
concurrent authorization to CenterPoint’s UM Department prior to the
expiration of the current authorization.
Authorizations
Post-service/Retrospective Reviews
In most cases pre-authorization is required. Since the Customer Services
Department is available 24 hours daily, 7 days weekly there should be few situations
where a provider is unable to obtain authorization prior to the provision of services.
Authorization of care after the client/enrollee has been admitted to the level of care
or after the treatment has been completed (retroactive authorization) may be
considered under certain specific circumstances as described below:
 The enrollee is found to be eligible for Medicaid with a retroactive effective date;
 The request for authorization of emergency inpatient hospitalization is made within 72
hours of the client's admission;
 The service authorization entry is delayed pending the verification of eligibility or execution
of completed provider contract;
 An error on the part of a UM staff person is indicated in the call or case record;
 Additional funding becomes available after a service has been provided
Authorizations
When the request for retroactive authorization does not fall into
Categories above, and the UM Manager/Director, Chief Clinical Officer or
Chief Operations Officer does not find a valid reason for the retrospective
request, the determination is made via one of two processes:
 Requests for all retrospective dates of service: Returned as unable to
process
 Requests with overlapping request for retrospective and future dates
of service: Retrospective dates will be considered as unable to process.
A clinical review will be completed with a start date no earlier than the
date of submission
Appeal rights are not applicable when a request is unable to be processed.
The provider will be advised that they may follow the formal grievance
processes.
Authorizations
It is the Provider’s responsibility to submit a request for Postservice/Retrospective review to CenterPoint's UM Department.
 A utilization management determination is made no later than
30 calendar days
 If the utilization reviewer determines that the request meets
established benefits and medical necessity criteria, an
authorization is issued and is viewable via the Provider Portal
 In cases where the utilization reviewer cannot make a
determination to authorize, the case is referred to the Medical
Director (or designee)
Authorizations
Tips for submitting requests from the UM staff:
 Ask for the correct units and timeframes for the services
requested with close attention to begin and end dates.
 Consider writing requests using the language from the
Service Definitions
 Check that the PCP has been signed and dated by all
parties
 Submit current clinical information on concurrent reviews
 PCP’s will be reviewed with each request evaluating it to
see if it matches current clinical needs
Early and Periodic Screening,
Diagnostic and Treatment (EPSDT)
Medicaid for Children
EPSDT
U.S. Department of Health and Human Services Definition.
 The Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
Program is the child health component of Medicaid. It’s required in
every state and is designed to improve the health of low-income
children, by financing appropriate and necessary pediatric services
 Early- Identifying problems early, starting at birth
Periodic – Checking children’s health at periodic, age-appropriate
intervals
Screening – Doing physical, mental, developmental, dental, hearing,
vision, and other screening tests to detect potential problems
Diagnosis – Performing diagnostic tests to follow up when a risk is
identified
Treatment – Treating the problems found
EPSDT
 Defined by Federal Law
 Available for all individuals under age 21 who are
enrolled in Medicaid
 Allows for Medically necessary health care that will
“correct or ameliorate a defect, physical or mental
illness or a condition (health problem) identified
through a screening to be approved even if not
covered by or exceeds the benefit plan
EPSDT
Criteria
 Must be within the scope of those listed in the
Federal Law at 42 U.S.C. § 1396d(a) [1905 (a) of the
Social Security Act
 Must be medically necessary to correct or ameliorate
a defect, physical or mental illness or a condition
(health problem) identified through a screening
 Cannot be experimental/investigational, unsafe or
considered ineffective
EPSDT
Requests for non-covered services
 If a child's physician or another licensed clinician
determines that a child needs a treatment service that is
not normally covered by Medicaid, the provider must
submit a Non-Covered State Medicaid Plan Services
Request Form for Recipients under 21 Years of Age on
behalf of the recipient to:
CenterPoint Human Services: EPSDT Request
Attn: UM Director
4045 University Parkway
Winston-Salem, NC 27106
EPSDT
Important Points to remember
 Requests for ESPDT do NOT have to be labeled as such. Any
complete request for services is reviewed with ESPDT criteria
applied to the review
 If the service requires prior approval, the fact that the recipient is
under 21 does NOT eliminate the requirement for prior approval
 Requests for prior approval for services must be fully
documented to show medical necessity, including current
information from enrollee’s physician, other licensed clinicians,
requesting qualified provider and or family members
 Requests for Medical and Dental services must be forwarded to
the appropriate vendor (Medical or Dental)
EPSDT
See below link for more information on EPSDT
http://www.ncdhhs.gov/dma/epsdt/
Appeals Process
What is an Appeal?
If CenterPoint determines it is appropriate to change a
service or deny a request for a service, the client will receive
a letter explaining the decision and their appeal rights. The
letter will also include an Appeal request form.
If the enrollee disagrees with the decision, they have the
right to appeal any changes to the services.
How that is done depends on how their services are funded.
Who can request an Appeal?
Standard Appeals:
 Must be requested by client/guardian.
 If an client/guardian wishes for a provider to represent
then during the appeal process there must be signed
written consent from the client/guardian.
Expedited Appeals:
 Can be requested by a provider or an client/ guardian
verbally or in writing
The Process –Medicaid Appeals
There are 3 levels of the Medicaid Appeals Process:
 Level 1: Reconsideration Review
 Completed within CenterPoint
 Level 2: Mediation
 Mediation Network of NC
 Level 3: OAH Hearing
 State Fair Hearing Process
Level 1: Reconsideration Facts
 Local impartial review of CenterPoint’s decision to
take an action.
 The reconsideration decision is determined by a
health care professional who has appropriate clinical
expertise in treating the client’s condition or disorder.
 The reviewer was not involved in CenterPoint’s initial
decision
 Reconsideration must be completed before the
client/guardian can request a hearing or mediation
with the NC OAH.
Level 1: Reconsideration Process
 CenterPoint receives client/guardian’s request
 Appeal Coordinator contracts client/guardian to
acknowledge receipt of request
 Client/guardian or provider has 10 days to submit
additional or new information
 Reconsideration Review is scheduled with a reviewer.
 Decision will be made within 30 days of request
What’s Next?
 If initial decision is overturned:
 UM is notified and authorization is created
 Client/guardian notification via US mail
 Provider notified via Alpha
 If initial decision is upheld:
 Client/guardian are notified via US mail
 Provider notified via Alpha
 If client/guardian disagrees they can request a State Fair
Hearing within 30 days of when the Reconsideration notices
was sent.
Level 2: Mediation Facts
 Mediation is voluntary and client/guardian may accept or
decline Mediation.
 May be resolved quicker than a State Fair Hearing
 Case referred to the Mediation Network of NC.
 The mediator is a neutral party who guides the mediation
process, facilitates communication, and assist the parties
to generate and evaluate possible outcomes.
 The recipient does not have to accept any offer made
during mediation.
 Offers that are accepted during Mediation are legally
binding.
Level 2: Mediation Process
 After requesting a State Fair Hearing, the
client/guardian is offered an opportunity to accept
Mediation.
 The Mediation Network of NC will contact
client/guardian and CenterPoint to schedule
Mediation.
 Mediation usually occurs via conference call with all
involved parties
 Mediation must be completed with 10 days of receipt
of request
What’s Next?
 If Mediation is successful with all parties agreeing on
the outcome:
 Appeal process ends here.
 The decision is legally binding
 UM is notified if an authorization is needed
 If Mediation is declined or unsuccessful:
 Appeal continues to a hearing at OAH
Level 3: OAH Hearing Facts
 The hearing will be held by an ALJ.
 The client/guardian (recipient) may represent
himself/herself or may hire an attorney or use a legal aid
attorney, or ask a relative, friend, or other spokesperson
(including provider or case manager) to speak for them.
 Continuances will NOT be granted on the day of the
hearing except for good cause
 If OAH provides proper notice and the recipient fails to
make an appearance, the hearing will be IMMEDIATELY
DISMISSED unless the recipient presents good cause
explaining why they failed to appear for the hearing within
three business days of the date of the dismissal
Level 3: OAH Hearing Facts (cont.)
 The hearing will be held by telephone unless the recipient
specifically requests an in-person or videoconference
hearing.
 The recipient may present new evidence at the hearing.
This includes medical records and written reports (even if
obtained after Medicaid made its decision), testimony
from physicians and other providers about why the
recipient needs the service, and testimony by family and
friends.
 If new evidence is submitted at the hearing that
CenterPoint has not reviewed, CenterPoint may request
additional time for review.
Level 3: OAH Hearing Process
 The recipient or legal representative will be notified in
advance of the day and time of the hearing.
 After the Hearing the Administrative Law Judge (ALJ)
will make a decision regarding the case.
 The ALJ will notify all parties in writing of the
decision.
What’s Next?
 If the ALJ’s final decision is not decided in favor of the
client/guardian the client/guardian can appeal the
case to the Superior Court.
Expedited Appeals
 May be requested by client/guardian or provider on
behalf of the client
 May be requested verbally or in writing
 Expedited Appeals are for urgent cases typically
defined as:
 Cases related to psychiatric hospitalization, partial
hospitalization or detoxification where the life or health
of the client would be jeopardized by a delay
Expedited Appeal Timeline
 CenterPoint will provide a decision for written
request within three (3) calendar days and 72 hours
for verbal requests.
 If the decision is to UPHOLD CenterPoint’s original
decision:
 The client/guardian can proceed with the State Fair
Hearing Process
 The State Fair Hearing Process will follow timeline for
standard appeals
Expedited Appeals –Non Urgent Cases
 If an expedited appeal is requested for a non-urgent
case, UM will review to determine if an expedited
appeal is indicated.
 If denied: The appeal will be transferred to Appeals
Coordinator and will follow standard Appeal timelines
 If Approved:
The appeal will follow timeline for
Expedited appeals
Non-Medicaid Appeals: Facts
 A client/guardian has a right to appeal an Adverse
Action
 Client/guardian has 15 days to request an appeal
 CenterPoint is not required to provide MOS for NonMedicaid Appeals
The Process: Non-Medicaid Appeals
 Level 1: Local Appeal – Completed within CenterPoint
 Level 2: State Appeal – Completed by NC Division of
MH/DD/SAS
Level 1: Local Appeal
 CenterPoint receives client/guardian’s request
 Appeals Coordinator contracts client/guardian to
acknowledge receipt of request
 Client/guardian or provider can submit additional or
new information
 Local Appeal is scheduled with a reviewer.
 Decision will be made within 7 days of request
What’s Next?
 If initial decision is overturned:
 UM is notified and authorization is created
 Client/guardian notified via US mail
 Provider notified via Alpha
 If initial decision is upheld:
 Client/guardian is notified via US mail
 Provider notified via Alpha
 If client/guardian disagrees they can appeal the decision
to the Division of MH/DD/SAS
Level 2: DMH/DD/SAS Appeal
 DMH/DD/SAS must receive the request within 11 days
from the date on the Local Appeal decision letter.
 Hearing is scheduled including all parties
 The Hearing findings are sent to CenterPoint within
60 days of request for DMH/DD/SAS appeal.
 CenterPoint will issue a final decision to the
client/guardian within 10 days of receipt of findings
If private insurance pays for your
services:
 Appeal goes through the insurance company.
 Each company has their own process.
 For more information you can:
 Call the customer service number on the card
 Check their website for more information
 Review any written letters that were received
Need assistance with Appeals?
Contact the Appeals Coordinator
336-778-3633 or 1-888-581-9988
Quality Management
Quality Improvement
Outcomes
Grievances
Quality Improvement
CenterPoint is required to participate in strategic projects to
improve care to clients. Such projects can be called
 Quality Improvement Projects- QIP’s
 Performance Improvement Projects- PIP’s or
 Quality Improvement Activities- QIA’s




PLAN: assess data and decide the change
DO: implement the change
STUDY: collect outcome data to assess the impact
ACT: decide to continue or alter the plan
What does this mean for Providers?
 If a current project involves your agency or service
line:
 Your expertise may be needed to plan
 You may be asked to test a change implementation
 You may be asked to submit data
 Comparison data
 Outcome data
 Reports
Performance Indicators
Why measure outcomes?


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To ensure quality of care for enrollees
To assess current state
To identify what is working well
To identify what needs improvement
To learn from others who are providing similar services
“Work smarter – not harder”
What does this mean for Providers?
 CenterPoint may ask you to provide “outcome data” on a periodic basis
 You decide how to collect the data
 Electronically
 Manually
 Suggestion: Make it part of the flow of work
 Submit it electronically to CenterPoint by a specific deadline
 You could receive feedback of how your data compares to others
offering similar services
 Use this result to:
 Offer feedback to staff…..celebrate successes!
 Assess what changes to make in your day to day practice
Together we can make a difference!


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Develop Best Practices
Educate and Train Staff
Assist Families and Enrollees
Create cost effective solutions
Improve work flow for providers
Fill in “gaps” of service for enrollees
Improve the lives of the people we serve!
What is a grievance?
Per the Division of Medical Assistance (DMA) Contract:
 A GREIVANCE is an expression of dissatisfaction about
matters involving CenterPoint.
 CenterPoint’s grievance system must meet all regulatory
requirements in 42 CFR 438 Subpart F
 Possible Subjects of Grievances:
 Quality of Services provided through CenterPoint.
 Aspects of interpersonal relationships such as rudeness of
a Network Provider or CenterPoint employee.
 Failure of CenterPoint or Network Provider to respect
enrollee rights.
CenterPoint Policy on Grievances
 All CenterPoint employees are responsible for
receiving and recording grievances.
 Clients and providers may file grievances.
 Grievant has the right to be anonymous.
 Grievances are tracked and trends identified using the
Alpha system.
When a grievance is made….
 CenterPoint staff attempt to resolve immediately
 If unable to resolve, the grievance is triaged by Quality
Management Staff
 All are responded to within three business days
 Grievances that may adversely impact the health, safety and welfare of the
client will receive immediate attention. This might include a call to DSS,
DHSR or the police
Resolving the Grievance
If appropriate, the grievance may be referred directly
to the provider for resolution. When that occurs,
CenterPoint staff will:
 Obtain consent of the complainant to talk to the
provider on their behalf
 Contact the provider, explain the concern, and request
their aid in satisfying the complainant
 Conduct any necessary follow-up activities to assure
resolution
Providers should expect…
 Phone call as initial contact
 Identify a point person for resolution
 An expectation of collaboration with the grievance and
CenterPoint Staff
 Sense of urgency to resolve
We strive to resolve all grievances in 10 Days!
Investigations
Referral to External Agency:
 Division of Health Service Regulation: If CenterPoint
receives a grievance related to a licensed facility/program
we are required to report to DHSR for investigation.
 Department of Social Services: Any grievance involving
an allegation of Abuse, Neglect, or Exploitation MUST be
reported to the appropriate DSS office.
CenterPoint Network Investigations:
 If the Network Operations staff determines an
investigation is appropriate the provider monitoring team
will be assigned accordingly.
What should Provider expect during
a Network Operations investigation?
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
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
Announced or unannounced site visit
Possible record review
Possible staff and client interviews
Timely decision (less then 30 days)

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
Unsubstantiated
Substantiated
Partially Substantiated
You will receive documentation
 Plan of Correction may be necessary
Resolution Achieved!
 Letter is sent to the grievant
 Data is recorded
 Information pertaining to grievances is shared with:


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CenterPoint’s Global Continuous QI Committee
CenterPoint’s Human Rights Committee
Appropriate CenterPoint Internal Committees (CFTs)
Credentialing Committee
NC Division of MH/DD/SAS
Including Program Integrity
Corporate Compliance Program
CENTERPOINT COMPLIANCE POLICY
STATEMENT
• Compliance is….
– Either a state of being in accordance with established guidelines,
specifications, or legislation; or the process of becoming so.
• CenterPoint is……
– Dedicated to maintaining excellence and integrity in all aspects of
operations including professional and business conduct.
– Committed to compliance with relevant laws and regulations
governing the management of behavioral health services.
– Committed to high ethical standards in conducting its business
affairs and dealings with employees, providers, payers and the
community.
• CenterPoint employees, officers and contractors assume personal
responsibility for honoring this commitment.
CORPORATE COMPLIANCE
CODE OF CONDUCT “BIG 8”
1.
2.
3.
4.
5.
6.
7.
8.
Employee Responsibility
Legal Compliance
Business, Billing and Coding Ethics
Confidentiality
Conflict of Interest
Business Relationships
Protection of Assets
Corporate Culture
Any and all suspected violations of the code of conduct must be reported.
CORPORATE COMPLIANCE/PROGRAM INTEGRITY
FRAUD, WASTE AND ABUSE
REFERENCES/AUTHORITY
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42 CFR 438 (Managed Care)
42 CFR 434 (Contracts)
42 CFR 455 and 456 (Program Integrity and Utilization Control)
NC Medicaid State Plan
NC G.S. 108A- 70.1 thru 70.17 (False Claims)
NC G.S. 108C (Medicaid and Health Choice Provider
Requirements)
 10A NCAC 22F (Program Integrity)
FRAUD, WASTE AND ABUSE/ PUBLIC
CONCERN
 Fraud, waste and abuse takes money from persons in need, including
children, elderly and the disabled. Identifying, investigating and
recovering Medicaid monies that are billed inappropriately is
important to make sure individuals receive needed services and
supports. Prevention and education is equally important to prevent
fraud, waste and abuse from ever occurring in the first place.
 Fraud, waste and abuse costs taxpayers millions of dollars every year.
 The majority of providers and their billings are honest and accurate;
however all it takes is one dishonest provider consistently billing
inappropriately, over a period of time, to cost the system millions of
dollars and to prevent services from being accessible to those who
need them.
PROGRAM INTEGRITY/ MCO RESPONSIBILITY
 Ensure integrity in the Medicaid Managed Care Program.
 Establish clear policies and procedures for the selection and retention of
providers, including credentialing and re-credentialing.
 Monitor providers regularly to determine compliance and to take
corrective action if there is a failure to comply.
 Provide education to enrollees, providers and MCO staff regarding fraud,
waste and abuse including reporting requirements.
 Implement mechanisms to prevent, identify, investigate and remediate
instances of fraud, waste and abuse.
 Conduct claims audits, clinical reviews and site reviews to determine
quality of care, appropriateness of care, accuracy of billing and outliers of
utilization of services.
 ALL staff must report any suspected case of fraud, waste and abuse.
PROGRAM INTEGRITY/ PROVIDER
RESPONSIBILITY
 Comply with all State and Federal regulations.
 Develop agency specific Corporate Compliance Plan to include method of
preventing, detecting and addressing fraud, waste and abuse.
 Conduct regular quality assurance activities and self-audits to prevent,
detect and address fraud, waste and abuse.
 Submit claims that are accurate & consistent with submission guidelines.
 Provide training on fraud, waste and abuse, to include reporting methods.
 Designate someone to be your compliance officer.
 Promote open lines of communication between corporate compliance
officer, staff and MCO.
 Corporate compliance plan and training should include areas specific to
behavioral health including professional conduct, ethics and conflict of
interest.
PROGRAM INTEGRITY/TERMS
 PROVIDER ABUSE
◦ 10a NCAC 22F .0301
 “Includes any incidents, services, or practices inconsistent with
accepted fiscal or medical practices which cause financial loss to the
Medicaid program or its beneficiaries, or which are not reasonable or
which are not necessary.” (i.e. provision of services that are not
medically necessary)
 PROVIDER FRAUD
◦ Deliberate submission of claims for services not actually rendered, or
billing for higher-priced services than those actually delivered.
◦ Submission of claims for payment for which there is no documentation.
◦ Billing for services that are provided by an unqualified or unauthorized
person.
◦ Double billing and excessive billing beyond 24 hour period.
PROGRAM INTEGRITY/TERMS
 CONFIDENTIALITY
10A NCAC 22F .0106
◦ “All investigations by the North Carolina Division of Medical
Assistance concerning allegations of provider fraud, waste,
abuse, over-utilization, or inadequate quality of care shall be
confidential, and the information contained in the files of such
investigations shall be confidential.” Exceptions as required by
legal proceedings apply.
◦ Any individual who reports suspected cases of fraud, waste and
abuse may request to remain anonymous and the MCO will make
every effort to maintain this anonymity when requested.
MEDICAL ASSISTANCE PROVIDER FALSE
CLAIMS ACT (MAPFC) OF 1997
 The False Claims Act makes it unlawful for any Medicaid provider to
knowingly make or cause to be made, a false claim for payment.
Under MAPFC, “knowingly” is defined as:
◦ Has actual knowledge of the information.
◦ Acts in deliberate ignorance of the truth or falsity of the
information.
◦ Acts in reckless disregard of the truth of falsity of the
information.
CREDIBLE ALLEGATION OF FRAUD
 PER 42 CFR 455….
CREDIBLE ALLEGATION OF FRAUD = SUSPENSION OF MEDICAID PAYMENTS
 DMA must suspend all Medicaid payments to a provider after the
agency (DMA) determines there is credible allegation of fraud for
which an investigation is pending under the Medicaid program
against an individual provider or entity unless the agency (DMA) has
good cause to not suspend payments or to suspend payment only in
part.
 Only DMA can suspend Medicaid payments based on credible
allegation of fraud, waste and abuse; however the MCO may
suspend payment based on administratively based concerns.
PROVIDER SANCTIONS & REMEDIAL
MEASURES
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Termination of provider’s participation
Suspension of payment
Recoupment of overpayment
Warning letters
Suspension of a provider for a period of time
Probation of provider participation
Pre-payment reviews
Post-payment reviews
Corrective action plans
Additional training and/or technical assistance
Focused monitoring reviews
Provider lock-out
TO REPORT PROVIDER FRAUD, WASTE AND ABUSE
 Contact CenterPoint Human Services- Corporate Compliance
Officer at 336-714-9114 or our dedicated email address at
compliance@cphs.org or
 Contact the Division of Medical Assistance by calling the DHHS
Customer Service Center at 1-800-662-7030 (English, Spanish) or
 Call the Medicaid fraud, waste and program abuse tip line at 1-877DMA-TIP1 (1-877-362-8471) or
 Call the Health Care Financing Administration Office of Inspector
General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477) or
 Call the State Auditor’s Waste Line at 1-800-730-TIPS (1-800-7308477)
TO REPORT RECIPIENT FRAUD, WASTE AND ABUSE
 Contact CenterPoint Human Services- Corporate Compliance
Officer at 336-714-9114 or our dedicated email address at
compliance@cphs.org or
 Contact your local County Department of Social Services or
 Contact the Division of Medical Assistance by calling the DHHS
Customer Service Center at 1-800-662-7030 (English, Spanish) or
 Call the Medicaid fraud, waste and program abuse tip line at
1-877-DMA-TIP1 (1-877-362-8471)
Contracts, Claims and Billing
As of February 1, 2013 CenterPoint became a closed provider
network. Therefore, to be reimbursed for services rendered to
Medicaid and state funded clients, YOU must complete the
credentialing process for each practitioner, location and
service you wish to deliver, and make SURE you have a
contract in place that specifically lists those sites and services.
Any and all services (including the sites they are
delivered from) that you expect to be reimbursed
for must be included in your contract.
Contract
Auth
Provider Changes
Contact CenterPoint’s Network Department for any of the following
changes:
 Change in ownership
 Subcontracting
 Any changes in a site, including your corporate address
 If you want to discontinue a service or close a site (you must submit
written information)
 If you want to add a service or a site (you MUST submit a written
request IN ADVANCE)
Claims Submission – First Steps
 Provider is contracted to deliver services.
 Complete Provider data is submitted. This includes sites, clinical
staff, credentials, NPI’s , and taxonomy numbers.
 Services delivered are in your contract.
 client is eligible for services.
 Service Authorizations – if needed – has been requested and
approved.
Claims Submission – Eligibility Verification
 Verify that Client’s Medicaid originated within CenterPoint’s catchment area
- Forsyth, Davie, Stokes and Rockingham Counties and obtain appropriate
authorization .
 Medicaid eligibility may change from month to month. At each visit,
Providers should verify current eligibility.
 Medicaid is payer of last resort.
 Coordination of Benefits is required – bill all primary third party
payers prior to billing CenterPoint.
 Authorization does not guarantee payment of claim
Claims Submission
 All Providers are required to file claims electronically in
one of the two following formats.
 HIPAA Compliant Standard EDI Transaction Files
 837 Institutional Health Care Claim (version 5010)
 837 Professional Health Care Claim (version 5010)
 Direct Data entry through Alpha MCS Provider Portal
 CMS 1500 for Professional claim
 UB 04 for Institutional claims
Claims Submissions - Clearinghouses
 For 837 billers
 If you use a Clearinghouse to submit your claims, you
will need to direct the claims submissions to Emdeon.
 Emdeon is the only Clearinghouse that CenterPoint
will accept claims from.
 835 is not being sent by via Emdeon, that will need to
be downloaded from AlphaMCS Provider Portal.
Claims Submission
 Time limits for filing Claims
All inpatient and outpatient claims must be received by CenterPoint within 90
days of the service date to be accepted for processing and payment.
 Claims Payment
The Checkwrite Schedule will be published on our Website and for the first
contract year we are following DMA’s Medicaid Schedule.
All claims payments will be made electronically by automatic deposit to the
account specified by the Provider’s Electronic Funds Transfer(EFT) Agreement.
 Claim Status
To check the status of a claim, you will need to log on Alpha MCS Provider Portal
and search by client under the Claims module.
Claims Submission
Denials and Claim Inquiries
 Denial reasons are listed on your Alpha MCS RA report. All denial codes will be
published on our website.
 If you need help with denials or have claim inquiries that can not be resolved
after reviewing Alpha MCS Claims module, you may contact us via secure Email
claims@cphs.org
 All emails with Protected Health Information must be sent to securely via
CenterPoint Zixmail.
 Contact your assigned Claims Specialist by phone.
Alpha Training
 AlphaMCS Provider Portal training is required for access.
 Please register for AlphaMCS training via our website:
http://www.cphs.org/AlphaProviderTraining.aspx
For EDI transaction files 837 –P or 837 I ( version 5010)
To initiate testing processes for format and content please contact:
CenterPoint Human Services’ IT Help Desk by either: Phone - (336)
714-9139 or e-mail - HelpDesk@cphs.org.
Network Operations
Routine Monitoring Process
Incident Reporting Process
Disputes
NC TOPPS
Monitoring Process
 Effective on 3/1/14, all LME-MCOs will use the revised
Routine Monitoring Process to conduct provider
monitoring.
 Routine monitoring occurs at least every 2 years.
 Routine monitoring is required for all unlicensed
services and for licensed services that are not
monitored annually by DHSR.
Monitoring Process (cont’d)
 Only routine post payment reviews are completed for
licensed services reviewed by DHSR annually.
 The MCOs do not currently have monitoring
responsibilities for Therapeutic Foster Care, Hospitals
or ICF-IDD facilities.
Monitoring Tools
 All MCOs in NC use the same monitoring tools.
 Tools are found at
http://www.ncdhhs.gov/mhddsas/providers/provider
monitoring/index.htm.
Current Tools
 Routine Monitoring Tool for Provider Agencies
 Routine review, site health and safety review, post
payment review
 Routine Monitoring Tool for Licensed Independent
Practitioners (solo and group)
 Office site review, LIP review, post payment review
Review Scoring
 The minimum overall score for the routine review tool
is 85%.
 The threshold for passing each section is also 85%.
 A Plan of Correction may be requested for identified
systemic issues even for providers scoring 85% or
greater.
IRIS – Incident Response
Improvement System
WHAT IS IRIS?
 Web based incident reporting system for reporting
and documenting responses to Level II and Level III
incidents involving clients receiving Mental Health,
Intellectual/Developmental Disabilities and Substance
Abuse (MH/DD/SAS) services.
WHO MUST REPORT?
 Category A Providers: providers licensed under NC
General Statutes 122c (except hospitals)
 Category B Providers: providers of non-licensed
periodic or community based MH/DD/SAS services
Quarterly Provider Incident Report
 Category A and B providers must also submit a
“Quarterly Provider Incident Report” each quarter
(due on the 10th day of the month following each
quarter) which summarizes Level I as well as Level II
and Level III incident data per provider site.
Important Information
Incident Reporting page on the NC Division of MH/DD/SAS website:
http://www.ncdhhs.gov/mhddsas/providers/NCincidentresponse/index.htm
Contacts for Incident Reporting
 Provider Quarterly Incident Reports : Ed Eklund eeklund@cphs.org, 714-9135
 IRIS / Technical Assistance: Ed Eklund (A-M) eeklund@cphs.org , 714-9135
Claudia Salgado (N-Z) csalgado@cphs.org , 714-9133
Karen Dingwall kdingwall@cphs.org , 714-9116
Disputes
Provider Administrative Disputes
(Examples)
•
•
•
•
Issues related to timely filing of claims
Network accessibility issues
Failure to submit requested medical records
Appeals of administrative denials
Processing Administrative Disputes
Complainant:
 Contacts Provider Affairs Specialist (PAS) via phone/fax/e-mail/letter
or walk in
 Completes Provider Dispute Form and returns to PAS along with
supplemental materials (optional) that support his/her case within 15
calendar days
PAS:
 Reviews the form/returned materials and consults with other
CenterPoint staff as needed
 Completes mediation of case, obtains approval from management
and sends decision via certified mail to complainant within 20
business days from receipt of the Provider Dispute Form and
supplemental materials, as applicable
Provider Professional Competence
Disputes (Examples)
 Participating (contracted) provider’s status within the
provider network
 Potential quality of care or client safety issues
 Ethics
 Clinical Boundaries
 Dual Relationships
 Professional competence to perform contracted services
 Professional competence or conduct that could result in a
change in provider status
Primary Difference with Provider
Professional Competence Disputes
 1st and 2nd level panels: Comprised of two Provider
Council, Steering Committee members and one
clinical peer (licensed CenterPoint staff)
 PAS randomly selects 1st and 2nd level panel members,
as applicable, and facilitates the review and
deliberation of the case (20 business days, plus 5
business days for each level involved).
Accessing Necessary Forms
The Provider Administrative Dispute and Provider
Professional Competence Dispute procedure and form(s)
are available on the CenterPoint website.
www.cphs.org
 At top of home page, click on the “Providers” tab
 In left margin, click on Provider Network
 Click on applicable entry under Provider Resources
NC-TOPPS
NC-TOPPS
 The NC-TOPPS interview is required for clients formally admitted
to the LME/MCO and who are receiving qualifying MH and/or SA
services from a publicly funded source. Managed by NC
DMH/DD/SAS
 NC-TOPPS is a self-guided, web-based system for gathering
outcome and performance data on behalf of MH/SA clients
 It provides reliable information used to measure the impact of
treatment and improve service quality
 Provider Agencies and LME/MCO Superusers have oversight
responsibilities: manage user requests, track submissions and due
dates, and change a client’s Qualified Professional (QP)
 Approved QPs and Data Entry Users (DEUs) can enter NC TOPPS
interview data
NC-TOPPS
The NC-TOPPS system provides a One-Stop format to:
 Register with NC-TOPPS and create secure account-keep
your user name and password for all future interactions
 Enter, update and search client data
 Create and manage personal information
 Complete Interviews and manage Episodes of Care
 Access Tracking and Reporting features
NC-TOPPS RESOURCES
NC-TOPPS
 Website: www.ncdhhs.gov/mhddsas/providers/NCTOPPS
 Help Desk- nctopps@ncsu.edu
CenterPoint
 John Coble, Provider Affairs Specialist, Network Operations
(336) 714-9117, jcoble@cphs.org
Completion of Course
 In order for you to receive credit for this course with
CenterPoint Human Services, you MUST click on the link
below and complete the provider information,
attestation, and evaluation.
 Please be sure you hit “submit” when you complete the
form. Thank you.
Attestation and Evaluation
(http://www.cphs.org/attestation)