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OptumHealth NYC BHO Provider Training. Agenda. Introductions Overview of Optum Review of Contract between Optum and the Offices Admission & Discharge Review Provider Tools Tool Review Forms & Submission Process Optum/New York Web site ProviderConnect Question and Answer Session
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Agenda • Introductions • Overview of Optum • Review of Contract between Optum and the Offices • Admission & Discharge Review • Provider Tools • Tool Review • Forms & Submission Process • Optum/New York Web site • ProviderConnect • Question and Answer Session • Wrap Up and Closing
Optum New York Staff • William Fishbein, Executive Director Optum New York • Amy Freeman, Behavioral Health Clinical Manager • Margaret “Peggy” Elmer, Behavioral Health Clinical Manager • Karen Ockenholt, Behavioral Health Clinical Manager • Joni Richter, Behavioral Health Intake Manager • Erik Geizer, QI/Training Manager • Linda West, Reporting & Technology Manager
Optum Organizational Overview • Optum is a health services business dedicated to making the health system work better for everyone • We are comprised of three market-leading business segments: • OptumHealth • OptumInsight • OptumRx • Optum serves the entire health ecosystem • 250,000 health professionals and physician practices • 6,200 hospitals and facilities • more than 270 state and federal government agencies • over 2,000 health plans; two of every five FORTUNE 500 employers; and one in every five U.S. consumers.
Our Business Context UHG UNH=Publicly Traded Registrant (NYSE) UnitedHealthcare-Health Benefits Optum—Health Services • Information and technology-enabled health services platform, encompassing: • Technology solutions • Intelligence and decision support tools • Health management and interventions • Administrative and financial services • Pharmacy solutions • Health care coverage and benefits businesses, unified under a master brand • Employer and Individual • Community and State • Medicare and Retirement Helping to make the health care system work better for everyone Helping people live healthier lives
Populations covered under the program • All fee-for-service admissions to OMH-licensed psychiatric units (all ages) in general hospitals (Article 28 hospitals). • Fee-for-service children and youth admitted to OMH licensed private psychiatric hospitals (Article 31 hospitals). • Fee-for-service direct admissions to OMH State-operated children’s psychiatric centers or children’s units of psychiatric centers. • Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services (Article 28/32). • Fee-for-service OASAS certified hospital (Art 28/32) or freestanding (Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation Services.
Functions of the BHO include: • Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals. Concurrent Review Discharge Planning & Tracking • Optum will engage with the inpatient provider with respect to discharge planning for applicable admissions • Enhanced efforts will be employed for inpatients identified as “High Need Individuals” Tracking of Children with SED • Each new episode of care initiated for a Medicaid Managed Care SED child will be tracked for reporting back to the State Provider Profiling /Analytics Community Liaisons • Historical Clinical data will be provided by the Offices to the BHOs • Data elements specific to each inpatient admission and provider will be collected by the BHO and shared with the Provider and the Offices. • Metric Reporting will be provided back to the Offices Facilitation of Cross System Linkages • Optum will work with the Offices and the Providers to determine cross system linkages for adults and children with mental health conditions and substance use disorders Quality Initiative • Optum will devise a quality assurance program to monitor the quality of work performed within the contract
Review of Contract Provider Community The Offices Optum Provider Community • Notify Optum of admission • (Portal, Fax or Telephonic) • Notify Optum regarding Children with SED • Performs initial/ concurrent reviews • Monitoring discharge planning & post-discharge services • Tracking of children with SED • Provider profiling • Facilitation of cross system linkage • Quality Initiative • Treatment History Form • Follows concurrent review & discharge monitoring processes • Supplies Optum with guidance to perform tasks • Supplies historical clinical data • Supports access to cross systems
What we need from you: Partner with Us • Submit requested information to be used in initial/concurrent reviews, discharge planning/tracking, SED tracking, and cross system facilitation • Use your dedicated Care Advocate and Community Liaison as a part of your team Engage in the Process • Follow the concurrent review & discharge planning/trackingprocesses • Identify Cross System Linkages • Provide data as requested • Use the tools provided • Don’t hesitate to ask us questions • Clinical questions can be directed to the Care Advocate or to: NYCBHO.Clinical@optum.com • General questions can be directed to the Executive Director & Community Liaisons or to NYCBHO.General@optum.com • ProviderConnect technical questions/issues can be directed to: NYCBHO.tech@optum.com. Ask Questions • Let us help you! • We want your feedback. Other
Provider Tool Review- Methods for submission Fax • Individual Information Matrix • - Within 24 hours of admission • - Concurrent Review at established intervals • - Discharge by the date of discharge but no later than within 24 hours post discharge. Fax # • Clinical Fax: (877) 283-0555 Telephonic • Toll-free: (866) 505-3398 • Dedicated Care Advocate assigned by Facility Portal • New provider portal: www.optumhealthnyc.com • ProviderConnect software
Fax Submission Option • Individual Information Matrix Form • 3 components of the form: • Admission • Providers to notify their assigned BHO within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday. • Concurrent Review • Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid members within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider, whichever is later. Follow-up reviews will be conducted at regular intervals. • Discharge Planning • Provider to complete and submit by the date of discharge but no later than within 24 hours post discharge. • Form located on the Optum NYC BHO Provider Portal : www.optumhealthnyc.com • Submit forms to the Optum NYC BHO clinical fax number: (877) 283-0555
Admission Information • Date:Facility Contact Name: • Facility Contact Phone: Facility Contact Fax: • Individual Name: Medicaid ID: • Date of Birth: Gender: <drop down> • County of Residence: <drop down> • Date of Admit: Time of Admit: • Age Group of the Individual: <drop down> • Admission Type: <drop down> • Diagnosis(es) at Admission: • Axis I: • Axis II: • Axis III: • Axis IV: • Axis V: • Reason(s) for Admission (Why now?): • *Please complete & submit within 24 hours following admission or by 5 p.m. the next business day following weekend and holiday admissions. • **If this is a readmission within 30 days for inpatient/detox or within 45 days for rehabilitation, send prior discharge plan with Matrix submission.
Feedback from Optum after Admission Notification • Optum will generate a Treatment History Form regarding the Individual admitted by the Facility within 72 hours after admission or by 5pm of the next business day following notification of the admission by the provider. • See next slide
Treatment History Form Information • Facility Name: Facility Contact: • Phone: Fax: • Individual Name: Medicaid ID: • High Need Individual: MH readmission w/in 30 days: • Date of Admit: Time of Admit: • Date of History Transmission: Time of History Transmission: • Last three (3) months of behavioral health services utilized by individual: • Case manager/Care Coordinator assigned? Yes/ No. • If yes, name of provider: ___________________________ • Most recent diagnosis(es): • Axis I: • Axis II: • Axis III: • Axis IV: • Axis V: • There is/ is not additional treatment history information available on the individual. (circle one) • *Facility is responsible for gaining executed release of information and sending to OptumHealth for the release of substance abuse treatment services. • OASAS Consent Form http://www.oasas.ny.gov/mis/forms/trs/trs-51.pdf
Concurrent Review • Dedicated Care Advocate to be assigned by Facility. • Check www.optumhealthnyc.com • - Notice of Preliminary Finding- Verbal • - Notice of Clinical Determination - Letter • See next slide
Concurrent Review Information • What has worked in the past for treatment of individual? • What strengths do the individual and/or family system have that we can build on? • What is being done differently this time? • Current status of individual, including mental status examination results: • Status/Progress with Treatment Plan: • Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual? • If no, why? • Current Diagnosis(es): -Axis I: -Axis II: -Axis III: -Axis IV: -Axis V:
Concurrent Review Information Medications: • For an admission from the community, what type of housing did the individual reside in? <drop down> • If individual was admitted from an institutional setting, what type of setting was the sending facility? • Anticipated discharge date: Expected Length of Stay: Days • Barriers to Discharge (biopsychosocial): • Physical & behavioral assessment findings: • Is the individual enrolled in Managed Care? <drop down> • Is the individual enrolled in a Health Home? <drop down> • Contact with medical provider(s): • Detail? • Contact with behavioral provider(s): • Detail? • Did the individual have a care coordinator prior to admission? <drop down> • Case manager/ Care coordinator engaged in hospitalization? • Name of case manager/care coordinator: • Assessment for case management completed? • If case management is needed and individual is not currently enrolled, referral made? • Individual involved in discharge planning? • Individual’s family involved in discharge planning? • Preliminary Discharge Plan: • Referral to local peer/family services programs/supports? • If this is a readmission, key factors in why the prior discharge plan didn’t meet the member’s needs? • If child/adolescent, other systems engaged?
Discharge Planning Information • Date of Discharge: Time of Discharge: • Individual Leave Against Medical Advice? <drop down> • Diagnosis(es) at Discharge: • Axis I: • Axis II: • Axis III: • Axis IV: • Axis V: • Medications: Does the individual have a sufficient amount of medication until his/her follow up appointment? If no, why?
Discharge Planning Information Follow up appointments, inclusive of case management: • Provider #1 Name: Provider #3 Name: Provider ID: Provider ID: Contact Information: Contact Information: Date/Time of Appointment: Date/Time of Appointment: Service Type: <drop down> Service Type: <drop down> • Provider #2 Name: Provider #4 Name: • Provider ID: Provider ID: • Contact Information: Contact Information: • Date/Time of Appointment: Date/Time of Appointment: • Service Type: <drop down> Service Type: <drop down> • Was case summary and discharge plan sent to the outpatient provider? • If yes, what date? • If the individual has a care coordinator (i.e. ACT, OMH TCM, Children's CHBS Waiver, MATS, and Health Home), was he/she informed of the discharge? <drop down> • If the individual is assigned to a MCO, have they been contacted for post discharge physical health care needs? <drop down> • Peer/Family Support Service/Program Referral: • If yes, name & contact information: • For a discharge to the community, what type of residence is he/she being discharged to: • If the individual is being discharged to an institutional setting, what type? <drop down> • Has the individual been provided with written instructions for what to do in the event of a crisis prior to his/her first post-discharge appointment? • If no, why? • If individual is under 18 years, linkage of children with other service systems (e.g. juvenile justice, educational system, child welfare)? • Other Issues/Notes:
Review of Process - MH Inpatient - continued • NOTE: The Offices will waive the review requirement for maximum concurrent review intervals for individuals the BHO designates as “Long Stay” when all of the following criteria are met: • The individual meets the criteria for inpatient care • The individual presents with symptoms and/or history that demonstrates a significant likelihood of deterioration in functions/relapse if transitioned to a less intensive level of care • The BHO care manager and provider concur that the current treatment and discharge plans best meet the individual’s needs • The individual’s discharge is delayed pending availability of resources that both the provider and BHO believe are necessary to maintain the individual outside of the current hospital setting (e.g. intermediate care inpatient, residential treatment, or foster care beds) • For Long Stay individuals, the BHO care manager should schedule follow up reviews at intervals deemed appropriate based upon clinical judgment. • Notices of Preliminary Finding and Clinical Determination will not apply to individuals designated as Long Stay.
Review of Process • SA Inpatient Detox • Same process as MH Inpatient, however concurrent reviews conducted at least every 2 days • SA Inpatient Rehab • Same process as MH Inpatient, however concurrent reviews conducted within 21 days of admission
Telephonic Submission Option • Call Optum Intake at (866) 505-3398 for initial admission within 24 hours of admission, except that for admissions which occur on a weekend or holiday such notification would be required by 5 P.M. of the next business day following such week-end or holiday. • Make sure all of your information is ready when calling Optum Intake • Use Individual Information Matrix form as a guideline. Form located on the Optum NYC BHO Provider Portal : www.optumhealthnyc.com • Ongoing concurrent reviews will be conducted in partnership with assigned Optum Care Advocate.
Provider Portal Submission Optum • Provider Portal: • Use ProviderConnect via www.optumhealthnyc.com for online entry of data from Information Matrix form: • Initial Admission • Concurrent Review • Discharge Planning
