Support for Friends and Family
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Resources on Live and Work Well
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Quick Links on Live and Work Well
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Additional Quick Link Resources
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Outcomes
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The End Result
Members who received Peer Coaching services:
 Have a Significant Decrease in the number of behavioral health
hospital admissions
 Have a Significant Decrease in the number of behavioral health
inpatient days
 Have a Significant Increase in outpatient behavioral health visits
 Have Significantly Decreased total behavioral health care costs
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Evaluation of data
The Recovery Community Services Program (RCSP) project funded
through SAMHSA showed the following data from intake to six month
follow up for recovery support services:
75% reported no substance use (increase of 19%)
96% reported no arrests at six month follow up
50% reported being employed (increase of 31%)
52% reported being housed (increase of 27%)
Clients experiencing serious depression decreased 21%
Clients experiencing serious anxiety decreased 21%
Clients experiencing trouble understanding, concentrating or remembering
decreased 26%
Clients attempting suicide decreased 29%
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Summary of Preliminary Utilization & Cost Findings
6 months pre-post, members who enroll in the program in New York
and Wisconsin show:
 Significant Decreases in % who use inpatient services
NY: 47.9% decrease (from 92.6% to 48.2%)
WI: 38.6% decrease (from 71.5% to 43.9%)
 Significant Decreases in # of inpatient days
NY: 62.5% decrease (from 11.2 days to 4.2)
WI: 29.7% decrease (from 6.4 days to 4.5)
 Significant Increases in # of outpatient visits
NY: 28.0% increase (from 8.5 visits to 11.8)
WI: 22.9% increase (from 9.1 visits to 11.8)
 Significant Decreases in total BH costs
NY: 47.1% decrease (from $9,998.69 to $5,291.59)
WI: 24.3% decrease (from $7,555.49 to $5,716.31)
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The Conclusion
►Peer support services are being recognized in a number of health and
behavioral health environments.
►They are also implemented in criminal justice, adolescent services and
HIV/AIDS.
►Prevention, intervention, treatment and recovery support services for
substance use problems are highly effective and yield impressive
savings to society.
►Outcomes for substance use treatment are as effective as outcomes for
other chronic disease, i.e., hypertension, diabetes and asthma.
(Briefing on Substance Use Treatment and Recovery in the U.S., Partners for Recovery)
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Thank you.
Kelly Champ, Northeast Regional Vice President
Optum Specialty Network Services
January 30, 2015
The Chicken or The Egg
 How do I get paid, or
 How do I get in?
 Who here is a Participating provider with Optum?
 Who has Peer services they want to bring on board?
 Who is looking to expand into Peer Services?
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Reimbursement for Peer Support Services
New York
• Historically, peer services were grant funded through NYS
• Peer services are now covered under the HARP benefit Home and Community
Based Services waiver (formerly known as 1915i)
Optum
• Effective 1/1/2015 peer services are a covered benefit for the New York Fully
Integrated Dual Advantage Plans (FIDA)
• Optum is actively recruiting for peer support services through peer run entities
and behavioral health provider groups that meet contracting and credentialing
criteria
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Submitting Claims for Peer Supports
• Similar to any other outpatient behavioral heath claim submission
• Coding to be used is: H0038 Self help/peer services
• Services are on a Per Unit basis, with a Unit being in 15 minute increments.
• Diagnosis code requirements: A valid behavioral health diagnosis must be
included on the claim form (Source may vary based on Referral)
• Authorization by Optum Care Advocacy may be required
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Submitting Claims for Peer Supports
Providers may submit claims through:
• www.providerexpress.com (Preferred)
• Clearinghouse
– Provider can use vendor of choice
– Optum Electronic Payor ID is 87726
• CMS 1500 for paper claims
– P.O. Box 30760,Salt Lake City, UT 84130-0760
• Claims must be submitted within 90 days of the date of service unless
otherwise specified by contract
• Clean claims processed within contractual time guidelines/requirements
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Peer Support Credentialing Process for Organizations: FYI
• Once potential organizations who employ Peer Support Specialists are identified, the
Network Manager distributes the applicable application and supporting materials to the
agency.
• The organization completes the application and supporting materials and submits them
back to the Network Manager.
• Once the Network Manager receives the application and materials from the organization
they submit a request to have a program audit conducted.
• All Peer Support organizations will need to pass a program audit prior to being
credentialed.
• Once the audit of the organization has been completed, the Network Manager confirms
the agency passed the audit and forwards the agency application and contract materials
to the credentialing team for review and approval by the Credentialing Committee.
• The Credentialing Team Confirms all the Peer Support Specialists of the organization
meet the certification, training, and credentialing criteria/requirements applicable to the
state requirements, agency licensure type, accreditation, liability insurance, and is in
good standing with applicable state and federal agencies
• Credentialing Committee for review and approval
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Contracting and Credentialing for Peer Supports
• Training programs not on the approved list can be submitted for review but
must be approved by Optum prior to credentialing or contracting the
organization for peer support services
• If required by state regulation, peer support staff are supervised by an
independently licensed mental health professional
• To provide peer support services, new providers must participate in a group
contract; providers with existing contracts would require an addendum
• Rates for peer support services will be determined by the state and in
accordance with your provider agreement
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Contracting & Credentialing for Peer Supports
• State certification required, in states where it exists
• In states where certification is not required, the staff must have completed peer
support training from an approved program and passed an exam
• The training program must be completed through any of the following approved
programs which also must be approved by the applicable state office of
mental/behavioral health
– Appalachian Consulting
– Depression and Bipolar Support Alliance
– Recovery Innovations
– Mental Health Association of Southeastern Pennsylvania
– NAZCARE of Northern Arizona
– The Connecticut Community for Addiction Recovery (CCAR)
– Transformation Center
– Mountain States
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Peer Support Organization – Audit Process
• The Peer Support Program audit focuses on general agency policies, the specific
supervision plan, hiring practices, and recordkeeping protocols (contact records) for peer
support specialists
• The audit may be completed through a desktop review, or in the case of an unaccredited
organization, may be completed on-site (audit team determines)
• The record keeping protocols include a review of:
– Initial data gathering
– Coordination of Care
– Recovery Planning
– Case Notes
– Discharge Planning
– General Record Development
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Peer Support Organization - Audit Process
Reviewing the Record Tool
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