State of Maryland
Department of Health and
Mental Hygiene &
VALUEOPTIONS®
Clinical Training
For
PRP/RRP Providers
October 2009
Welcome to ValueOptions®
2
Presenters
• Nancy Calvert, Director, ValueOptions®
Maryland Provider Relations
• Jennifer Lowther, ValueOptions® Maryland
Clinical Director
• Jennifer Soethe, ValueOptions® Maryland
Care Manager
Agenda
• Overview of ProviderConnect
• Update
• Requesting Authorizations
• Questions
• Survey
ProviderConnect
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ValueOptions® ProviderConnect
ProviderConnect is an online tool that increases
convenience & decreases administrative burden.
• Free, secure, online application
• Easy access 24 hours a day, 7 days a week
• Complete multiple transactions in a single sitting
ValueOptions® ProviderConnect Features
With ProviderConnect providers can:
• Verify Consumer eligibility
• Register Uninsured Consumers
• Request Authorizations
• View Authorizations
• Submit Claims (Batch and Direct/On-line claim)
• View Claim Status
• View and Print Provider Summary Voucher
• Submit inquiries to Customer Service
• Access and print forms
Accessing ProviderConnect
• Each provider has a secure login and online
registration, including a provider ID number via
the ProviderConnect Web site.
• Additional logins for other providers in the
same practice are available through
ProviderConnect. Contact:
ValueOptions® EDI Helpdesk
(888) 247-9311, Option 3
Monday through Friday
8 a.m. – 6 p.m. EST
Turn around time for additional logins is 48 hours.
September 25th Upgrade
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Online Uninsured Eligibility Registration (request function) is
now available to providers.
Axis 1-V diagnoses are now required on concurrent reviews
The “Individual Care Plan”
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Additional Reporting:
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The Plan tab has been added to the Mobile Treatment auth request screen.
The Service Code Field has been removed
Providers now have the option to print the Plan separately.
“MCO” is no longer a required field.
“Education Level” has been deleted
“Living Situation” and “employment status will pre-populate on concurrent
reviews
“N/A” is no longer an option to the “Race” question on concurrent reviews.
“diagnosis on file?” not required if the consumer was referred
by a licensed clinician.
Updates
• ValueOptions® Maryland Website
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http://maryland.valueoptions.com
– Provider Alerts
• MHA Policy Clarification Memos and Announcements
• ValueOptions® Maryland Updates and Announcements
– Training Schedule
– ProviderConnect “tips”
– Maryland Specific ProviderConnect “demo”
– Provider Forms – including a hard copy concurrent review form
– Coming Soon:
• Provider Manual
• Diagnostic Crosswalk
• Fee Schedule
• Service Grid
– Consumer Information
PRP Authorizations
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*Place of Service – from the drop down box in ProviderConnect,
select the place of service where the service will be provided. The first
column on the grid “ProviderConnect Narrative Description of Place of
Service” lists the Place of Service choices appropriate for PRP. The last
column “Service Description” describes the type of PRP services,
including the location(s) where the service is provided. Cross
reference the first column to the last column to make the correct
choice for the service request.
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*CPT or HCPC Code – Enter the appropriate code using column 2,
“CPT/HCPC Code”, as a guide. With the exception of H0002,
Behavioral Health Screening, the correct code for PRP services is
H2018.
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*Modifier I - Using the last column, “Service Description” as a guide,
choose the correct Modifier from column 3.
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*Visits - For this field, the number of visits equates to the number of
months requested.
PRP Place of Service Codes
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When submitting a claim to report PRP encounters,
only the following Place of Service (POS) codes may be
used:
• POS 15 - off site
• POS 52 - on site
EXAMPLE:
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To request a minimum of 6 encounters of
combined on and off-site PRP services, for six
months, for a consumer living independently in the
community, you would select
*Place of Service
*CPT or HCPC
Code
Modifier I (If
Applicable)
*Visits
Independent Clinic
H2018
U3
6
PRP Codes and POS Descriptions
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Available on the ValueOptions® Maryland website:
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http://maryland.valueoptions.com
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For Providers
Provider Alerts
ValueOptions Alerts
http://maryland.valueoptions.com/provider/alerts/090409_PRP_Codes_and_POS_Descriptions.pdf
Priority Population Diagnoses
• Required for PRP adult, RRP, or mobile services
• Additionally, PRP must include 2 of:
– Inability to maintain employment
– Behaviors resulting in MHS intervention
– Inability, due to impairment to obtain financial assistance to
support living in community
– Severe inability to obtain/maintain social support
– Need for assistance w/ ADLs
• Can be waived if:
– committed as not criminally responsible & conditionally released
from MHA facility
– individual in MHA facility with stay of greater than 6 months who
requires RRP, but doesn’t have a targeted diagnosis (excludes DD
eligible)
Priority Population Diagnoses
Required for PRP adult, RRP, or mobile services
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295.10 Schizophrenia, Disorganized
295.20 Schizophrenia, Catatonic
295.30 Schizophrenia, Paranoid
295.40 Schizophrenoform Disorder
295.60 Schizophrenia, Residual
295.70 Schizoaffective Disorder
295.80 Schizophrenia, Unspecified
295.90 Schizophrenia, Undifferentiated
(to include all dx from 295.10 – 295.95)
296.33 MDD, Recurrent, Severe, W/O
296.34 MDD, Recurrent, Severe, W/
297.10 Delusional Disorder
298.90 Psychotic Disorder, NOS
301.22 Schizotypal Personality
301.83 Borderline Personality
296.43 BP I, MRE Manic, Severe, W/O
296.44 BP I, MRE Manic, Severe, W/
296.53 BP I, MRE Dep, Severe, W/O
296.54 BP I, MRE Dep, Severe, W/
296.63 BP I, MRE Mixed, Severe, W/O
296.64 BP I, MRE Mixed, Severe, W/
296.80 Bipolar NOS
296.89 Bipolar II Disorder
Excluded Diagnoses
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The following diagnoses are not in the domain of the Public
Mental Health System (PMHS). Individuals with co-occurring covered
PMHS diagnosis are eligible for services for the co-occurring diagnosis:
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Mental Retardation
Learning Disorders
Motor Skills Disorders
Communication Disorders
Pervasive Developmental D/Os
Tic Disorders
Delirium, Dementia, Amnesic, and Cognitive Disorders
D/Os due to GMC
– Except Personality changes due to GMC
Substance related D/Os
Substance Induced D/Os
Sexual dysfunction
– Except paraphilias and gender identity D/O
Sleep Disorders
– Except parasomnia
Antisocial Personality Disorder
Psychological factors affecting GMC
Relational problems
V codes
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Authorized by ValueOptions or CSA?
• U2 and U3 – authorized by ValueOptions
– Request H2018 CPT Code and H0002
Medicaid:
• 7 units (to include the H0002 assessment) on a pre-auth
• 6 units on a concurrent
Uninsured:
• 4 units (to include the H0002 assessment) on a pre-auth
• 3 units on a concurrent
• U5, U6, U7 – authorized by Core Service Agencies
– PRPs are authorized for 12 months (13 units to include the H0002
assessment)
– T2048 Residential Room and Board does not require an
authorization (can bill for 365 days to match 12 month PRP auth)
Authorization Time Spans
• Medicaid = 6 months
• Uninsured Eligible = 3 months
• The end date of any authorization period should be the
last day of the 6th month (for Medicaid) and 3rd month
(for Uninsured)
– For example, for a Medicaid authorization requested with a start
date of 10/16/09, will be authorized for: 10/16/09- 3/30/09
Uninsured PRP Contact
• Jennifer Soethe, Clinical Care Manager
• Phone: 410-691-4030
• Jennifer.Soethe@valueoptions.com
• Office Hours 8:30am-5:00pm
Billing Tips
• Authorizations are not required for encounters
• Encounters (H2016):
– Use correct POS – 15, 49, 52, not 11
– Report encounters using $1per encounter
• Uninsured Eligibility co-payments
– Not applicable to RRP bed Charges (T2048)
– Based on the minimum service level required for the billed service.
• E.g. H2018-U6, POS 49, Minimum = 17 encounters
co-payment = $34, regardless of the number of encounters
beyond 17.
Requesting an Authorization
PRP/RRP
Questions
valueoptionstransition@dhmh.state.md.us
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Thank You!
Please complete the survey which will appear
shortly.
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