LBHA Functions
Draft for NTBHA Board Presentation
February 10, 2016
Clinical Operations: Consumer Services
Key Function
Existing Operations
Development
Member services call
center: information and
referrals
Value Options (VO) and
NTBHA
NTBHA needs to enhance
existing processes to
meet increased consumer
services function,
investigate rights
complaints, and violations
as required by
regulations.
Registering complaints /
grievances / Ombudsman
NTBHA formally registers
complaints & grievances;
maintains ombudsman
program oversight, and
tracks complaints.
NTBHA will confirm
compliance with
requirements.
2
Clinical Operations: OSAR
Key Function
Outreach, screening,
assessment and referral to
SUD services
Existing Operations
Value Options (VO)
Development
NTBHA needs to develop
this function for the six
county region.
3
Clinical Operations: Crisis Management
Key Function
Existing Operations
Single Portal Authority Delegated to VO
Function
through an MOU
Development
NTBHA will facilitate procurement
process and provide direct contract
management and oversight of the
subcontractor and all SPA activities.
Inpatient and
Emergency Room
System
Oversees VO’s P&Ps for NTBHA will determine a locally
care coordination and managed system of inpatient
tracks coordination
services and create a system for
authorization and management.
Crisis Alternatives
VO currently contracts
with providers
NTBHA will develop crisis
alternatives to hospitalization such
as crisis respite, crisis residential,
and 23-hour observation.
Indigent and Medicaid VO contracts with
NTBHA will continue to provide
Services
provider with oversight oversight and will contract for crisis
from NTBHA
services, including hotline and
MCOT.
4
Clinical Operations: Care Management
Key Function
Existing Operations
Development
Mental Health Service
planning and linkages
Oversees VO’s P&Ps and
standards for service
planning
NTBHA needs to develop.
Chemical Dependency
Service planning and
linkages
Oversees VO’s P&Ps and
standards for service
planning
NTBHA needs to develop.
Care coordination among
provider services
Oversees VO’s P&Ps for
care coordination and
tracks coordination
NTBHA needs to develop.
5
Clinical Operations: Utilization Management
Key Function
Existing Operations
Development
Centralized
Medical Director
oversight
VO provides medical direction,
including oversight of CM, UM,
QM, and pharmaceutical care
Position would likely be
half-time. Could be
contracted.
Medical necessity
determinations
Oversight of medical necessity
criteria and determinations with
input from a Clinical Advisory
Committee with NTBHA
participation
NTBHA will need to develop
P&Ps and functions for UM
oversight.
Care
authorization,
management of
appeals
Performed by VO; NTBHA
manages appeals through case
review and use of independent
physician advisors
Will be an internal function
at NTBHA. Need to develop
P&Ps and functions for
appeals.
Annual Utilization VO develops Annual UM Plan
Management Plan
New NTBHA Care Managers
will provide input into
annual UM Plan.
6
Clinical Operations: Provider Network Management
Key Function
Existing Operations
Development
Network Development –
Annual Network
Development Plan
Currently performed by VO;
processes identify regionwide network needs (service
gaps) and writes plan
Establish a Planning and
Network Advisory
Committee. Develop staff
responsible for network
development processes.
Network Management –
recruitment, site
visits/credentialing,
contracting and claims
payment
VO currently maintains P&Ps
to meet state requirements
and manages contracting,
credentialing (agency with
oversight), and claims
payment
NTBHA will need staff
responsible for network
management; currently
initiating provider open
enrollment.
Provider Relations,
including orientation,
training and complaints
VO function currently
NTBHA will need to
perform provider
relations functions locally.
Provider Quality – in
collaboration with
Quality Management
VO maintains P&Ps for
provider quality in
collaboration with QM
NTBHA will need to
conduct provider on-site
reviews and give provider
quality feedback.
7
Clinical Operations: Quality Management
Key Function
Existing Operations
Development
QI Committee(s); Annual
Quality Management
(QM) Plan
VO develops annual QM
Plan with input from the
QM committee
NTBHA needs to develop.
Quality reporting –
state, federal, and health
plan requirements;
quality of care concerns,
outcomes
NTBHA and VO collect and
produce quality reporting
and address quality of
care concerns; focus on
improving outcomes
Will be NTBHA’s
responsibility to produce
quality reporting. NTBHA
needs to develop.
Internal review of clinical
operations
Currently performed by
VO with oversight
activities by NTBHA
Will be a NTBHA
responsibility in the
future. NTBHA needs to
develop.
External review of
provider quality in
collaboration with
Network Management
Currently performed by
VO with oversight
activities by NTBHA
Will be a NTBHA
responsibility in the
future. NTBHA needs to
develop.
8
Administrative Operations: General Administrative
Functions
Key Function
Existing Operations
Development
Financial management
NTBHA-contracted CPA
Financial management
solution will be needed
(with staff).
Human Resources – currently
has an HR vendor
NTBHA-contracted
vendor
NTBHA-contracted
vendor
Compliance oversight
VO
NTBHA
Legal Affairs
Consultant services
Consultant services
Public
Affairs/Communications
NTBHA function
NTBHA function
Establishing Consumer
Eligibility, e.g. Medicaid
No formal processes in
place today
Organized processes for
consumer benefits
required.
9
Administrative Operations: Systems Support
Key MH and CD Function
Existing Operations
Development
Information technology to
support clinical and
administrative operations
VO
Claims management
VO
NTBHA will need to develop
a provider payment solution.
Reporting
VO (provider and
service reporting)
NTBHA’s reporting
requirements and solutions
will be more complex.
NTBHA has limited
internal IT staff and
contracting services
NTBHA will hire and train
additional staff to support
operations. Software
consulting services may be
engaged to implement new
systems as required.
NTBHA (financial and
quarterly)
Disaster Planning
NTBHA contracts this
service today
NTBHA’s expanded
infrastructure will need a
more robust disaster
recovery solution.
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