An Administrative
Provider Orientation
for
Horizon New Jersey Health
Medicaid Managed Long Term
Services and Supports
Copyright 2014 ValueOptions.® All rights reserved.
Objectives
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2
Overview of MLTSS,
Horizon Behavioral
Health
and ValueOptions
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Overview of MLTSS, Horizon Behavioral Health
and ValueOptions
•
Medicaid Managed Long term Services and Supports
(MLTSS) is a set of services and supports for individuals who
meet specific clinical, categorical and financial criteria.
 Services are designed to support a member in maximizing their
ability to live independently.
 MLTSS replaces many of the waiver programs in New Jersey
and transfers management of the programs to the
Managed Care Organizations as of July 1, 2014.
•
Effective July 1, 2014, Horizon Behavioral Health selected
ValueOptions to manage behavioral health benefits for
members covered by Horizon NJ Health and enrolled in
MLTSS.
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MLTSS Member Eligibility Criteria
Members must meet the following criteria:
• Meet Medicaid Guidelines for financial eligibility
• Age 65 years or older
• Blind or disabled

•
If under age 65, must be determined blind or disabled by
the Social Security Administration or the State of New
Jersey
Meet clinical criteria based upon assessment with the NJ
Choice
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Exclusion Criteria
•
Members with Division of Developmental Disabilities
Community Care Waiver
•
People with Pervasive Developmental Disabilities
•
PACE Program beneficiaries
•
Persons enrolled in Dual Eligible Special Needs Plans
•
Fee-for-service Medicaid beneficiaries who are in a Nursing
Facility on or before 7/1/14
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Overview of ValueOptions
•
Founded in 1983
•
Largest independent behavioral health company
•
Serving over 32 million members; contracts with 20 health
plans
•
More than 50 Medicaid contracts in 14 states
•
Committed to principles of recovery and resiliency
•
Diverse client base
 Commercial Division - Employer Groups, Health Plans
 Federal Division
 Public Sector Division
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ValueOptions’ National Presence
Commercial Membership Only
Shared Commercial and Public Program/
Medicaid Membership
Major service
centers
Regional support, EAP staff and corporate
support 8offices
8
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Customer Service
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Customer Service
•
Horizon MLTSS Call Center will be handling all Customer
Service inquiries from providers pertaining to authorizations
and care management
800-682-9094
(8 am - 5 pm ET Monday – Friday/
Central Night Services
will take calls from 5 pm – 8 am
for Care Management)
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Clinical Care
Management
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11
Referrals and Authorizations
•
Members will not need a referral from their PCP to see a
behavioral health or substance use provider. Prior authorization is
needed for all Behavioral Health MLTSS benefits which include:
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Care Management and Referral Assistance
•
Licensed care management staff is available 24 hours a
day/seven days a week for referral and utilization management.
 Member referral process:
 Emergencies are followed until disposition
 Urgent referrals are offered appointments within 48 hours and are
called to ensure appointment is kept
 Providers can contact Horizon NJ Health for referral assistance if
needed
 Providers should contact Horizon NJ Health 24 hours a day/seven
(7) days a week if members require higher level of care or
increased visit frequency
 Care Management staff will assist with referral to inpatient or
specialty programs

Contact Information:
For all care management inquiries, contact 800-682-9094
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Appointment Standards
Participating providers are required to adhere to the
following appointment standards:
Appointment Type Timeframe
Emergent
Within 48 hours of request
Urgent
Within 48 hours of request
Routine
Within 30 calendar days of request
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Discharge Reviews
• Providers can complete discharge reviews by calling the
dedicated Care Manager
• Providers should contact ValueOptions if they need
assistance scheduling discharge appointments
• Providers should make every effort to schedule a discharge
appointment within one to two days of discharge, but in all
cases within seven (7) days.
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Utilization Management Program
•
Utilization Management (UM) Program defines process for
the following:
•
Prior authorizations
•
Concurrent review
•
Post-services (retrospective review)
•
Discharge planning
•
Case management
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Case Management Program
•
Case Management Program involves assessment of
members’ mental and behavioral health needs to
determine resources, ensure delivery of services and
develop of case management plans
•
Elements of program include:





Dedicated case management team
Coordination of Care planning
Utilization review decisions and denials
Peer to peer review
Authorization notifications and denials
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Clinical Resources for Providers
•
Clinical information is available at www.valueoptions.com
 ValueOptions Medical Necessity criteria
 Changes to Substance Use Medical Necessity Criteria
 Treatment Practice guidelines
 PCP Consult Line 9 am to 5 pm (Eastern Time)
 877-241-5575
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Overview of
ProviderConnect®
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ProviderConnect® Functionality

ValueOptions’ secure and HIPAA-compliant provider portal:
• Verify Member Eligibility
• View Authorization Status
• Download and Print Authorization Letters
• Enter or Review Referrals Authorized by ValueOptions
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ProviderConnect® Registration Process
•
New and Current ProviderConnect Users need to fax a completed
Account Request form to 1-866-698-6032
•
Providers who already have a ProviderConnect account need to
submit a new form to request an additional login id to access Horizon
member information
•
Horizon providers need to mark the box for Horizon Behavioral Health
Authorizations
•
Providers who do not know their Provider ID can contact the Provider
Services Line at 1-800-397-1630, 8 a.m. – 8 p.m., Mon-Fri
•
Account Request form located at
http://www.valueoptions.com/providers/Forms/Administrative/Online_
Services_Account_Request_Form-Editable.pdf
•
Questions: Contact the EDI Helpdesk at 1-888-247-9311,
8 a.m.-6 p.m., Mon-Fri
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ProviderConnect® Resources

ValueOptions.com > Providers>ProviderConnect
•
Free demonstration:
http://www.valueoptions.com/PMC_prototype/ProviderConne
ct/pvd.html
•
Quick Start Guide and Comprehensive User Guide
•
Short Video Tutorials:
 Viewing Member’s Eligibility
 Submitting Authorizations
 Submitting an Inpatient or Higher Level of Care Request
 Responding to Requests for Additional Clinical Information
 Recredentialing
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ProviderConnect ® Resources
•
Training webinars
 Scheduled monthly
 Topics include: Authorizations, Role-based security, Recredentialing, Viewing Patient Info, etc.
 Upcoming webinars:
• July 16, 2014 / 10-11 am Overview of ProviderConnect
• July 22, 2014 / 2-3 pm – Overview of Authorizations in
ProviderConnect

Customized training
 Scheduled at your convenience
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Quality Management
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Quality Management
•
Quality Management Program Oversight provided by Regional
Medical Director/CMO Commercial Division and Director of
Quality Management
•
Key Quality Indicators include but are not limited to:
 Satisfaction Survey measures.
 Access and Availability of Services – geographic access;
phone statistics; appointment availability; etc.
 Complaints and Grievances tracking and reporting.
 Patient Safety – (adverse incidents and quality of care).
 Coordination of Care.
 Quality Improvement Activities/Projects.

Accredited with URAC and NCQA
Standards
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Quality Management, cont’d.
• Examples of Ongoing Quality Improvement Activities
(QIAs)
 Clinical QIAs
• Ambulatory Follow-up and Increasing Rate of
Psychiatric Evaluations for Members Diagnosed with
Moderate or Severe Depression and in Outpatient
Treatment with a Non-Prescribing Behavioral Health
Practitioner
 Service QIAs
• Average Speed of Answer
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Critical Incident Reporting

Any critical incident must be reported by contacting 800-682-9094

Qualifying Critical Incidents:
•
•
•
•
•
•
•
Unexpected death of a member (e.g. relatively healthy
member choked while being fed by their caregiver)
Missing person or unable to contact
Suspected or evidenced physical or mental abuse (Including
seclusion and restraints, both physical and chemical)
Theft with law enforcement contact
Law enforcement contact
Severe injury or fall resulting in the need for medical treatment
Medical or psychiatric emergency, including suicide attempt
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Critical Incident Reporting, cont’d.
•
•
•
•
•
•
•
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•
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Medication errors with serious consequences
Inappropriate or unprofessional conduct by a provider involving
the member
Suspected or evidenced physical or mental abuse (including
seclusion and restraints, both physical and chemical)
Sexual abuse and/or suspected sexual abuse
Neglect/Mistreatment, including self-neglect, caregiver
overwhelmed, environmental
Exploitation, including financial, theft, destruction of property
Failure of member’s back-up plan
Elopement/wandering from home or facility
Eviction/loss of home
Facility closure, with direct impact to member’s health and welfare
The potential for medical involvement
Cancellation of utilities
Natural disaster, with direct impact to member’s health and welfare
Other
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Provider Relations
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Provider Relations
• Local Provider Relations presence in New Jersey
• Responsibilities:
•

Ensuring that members’ behavioral health care needs are met through
a geographically and clinically robust network whose providers are
readily available;

Ensuring the maintenance of network composition by engaging in
assertive retention strategies and recruitment, and

Engaging in professional, consistent, and educative communications
with our provider community and staff.
Contact Information:

Provider Services Line at ValueOptions
1-800-397-1630 (8 am - 8 pm ET Monday – Friday)

E-mail:
horizonbehavioralhealthproviderrelations@valueoptions.com
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Credentialing and
Recredentialing
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Credentialing and Recredentialing
•
Horizon Behavioral Health/ValueOptions responsible for
ensuring credentialing/recredentialing processes completed
for:
 Practitioners (Professionals)
 Ancillary Facilities
(Acute care hospitals will continue to be credentialed by Horizon)
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Recredentialing
Notification every three years through:
•

CAQH-Universal Provider Datasource (UPD) (for CAQH members)
• Uses system reminders to prompt providers to update and attest to
their information every 120 days
• Telephonic message via Provider Pulse 4 months prior to due date
that application is available

Telephone, fax, e-mail (for paper submitters)
• Telephonic message via Provider Pulse 4 months prior to due date
that application is available
• Follow up email or fax approximately 1 week later with instructions
for accessing application in ProviderConnect
(to access application, click on link titled “Provider Data Sheet”)
• 60 and 90 day reminder notices
Failure to respond to requests from CAQH or Horizon Behavioral
Health/ValueOptions may
result in disenrollment from the network
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33
Credentialing
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Contracting
Provider Contracting


ValueOptions managing contracting process, although
providers will be contracted on Horizon New Jersey Health
paper.

Questions about Contracting and Credentialing?
Call Provider Services Line at
1-800-397-1630, 8am – 8pm Eastern Time
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Claims and Payments
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Claims Submission and Payments
•
Horizon NJ Health retains ownership of claims processing
and claims and payment inquiries from providers and
members.
•
Horizon NJ Health will continue to assist with all claim related
questions and issues.
•
For new providers not familiar with the claims procedures of
Horizon NJ Health, visit http://www.horizonnjhealth.com/forproviders/resources/claims.
•
Contact Information:
 Horizon NJ Health Provider Service Center - 855-777-0212
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Electronic Resources
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ValueOptions.com
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ValueOptions.com
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ValueOptions.com
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Communications
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Communication Channels

Email Alerts

Webinars

Video Tutorials

Monthly Valued Provider eNewsletter

Provider PulseSM Messages

Fax Communications

Provider Mailings
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Contact Information
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44
Provider Contacts
•
Provider Relations, Credentialing and Contracting
Questions:
 Provider Services Line:
1-800-397-1630 (8 am - 8 pm ET Monday – Friday)
 E-mail:
horizonbehavioralhealthproviderrelations@valueoptions.com
•
Authorizations and Care Management
 800-682-9094
(8 am - 5 pm ET Monday – Friday/Central Night Services will
take calls from 5 pm – 8 am for Care Management)
•
Claims
 855-777-0123 (8 am - 5 pm ET Monday – Friday)
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45
Provider Contacts
•
Appeals, Records, etc. – Mail Request to:
 Appeals Department
PO Box 783
Latham, NY 12110

ProviderConnect Technical Questions/EDI Help Desk
 Phone: 1-888-247-9311 (8 am - 6 pm ET Monday – Friday)
Copyright 2014 ValueOptions.® All rights reserved.
46
Helpful Links
 Network-specific website for Horizon New Jersey
Health
• Provider Orientation Schedule
• Orientation Presentation
 Provider Frequently Asked Questions
 Horizon NJ Health Website
 Manual
 Medical Necessity Criteria
Copyright 2014 ValueOptions.® All rights reserved.
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Thank You
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