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UBH orientation and update. James M. Slayton, M.D., M.B.A. Medical Director, United Behavioral Health June 16, 2009 June 18, 2009. UBH related topics. Goals of today’s discussion: Brief discussion of UBH level of care criteria Update on Wellness Assessment (ALERT)

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UBH orientation and update

James M. Slayton, M.D., M.B.A.

Medical Director,

United Behavioral Health

June 16, 2009

June 18, 2009


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UBH related topics

Goals of today’s discussion:

  • Brief discussion of UBH level of care criteria

  • Update on Wellness Assessment (ALERT)

  • Update on authorization process

  • Update on use of OTRs

  • Testing questions related to behavioral health versus non-behavioral health (medical diagnoses)

  • Network management related questions


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Scope of Business

  • Over 58 million individuals managed through UHC/OptumHealth, or through UHC partners

  • Numerous external health plans partners, such as Harvard Pilgrim Health Care

  • Numerous high visibility employer groups, such as IBM

  • History of acquisition of other health plans (e.g. Oxford, PacifiCare)

  • Individuals served in all 50 states

  • Expanding scope of business in northern New England

  • United Behavioral Health is historical identity for UHC related business


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Level of Care guidelines

  • Based on principle of “least restrictive treatment setting” that is safe and effective for the member

  • Four areas covered by level of care guidelines:

    • Mental health or psychiatric services (includes dual diagnosis)

    • Substance abuse services

    • Community Support services (typically apply more to public sector populations under management; may not be available in the benefit plan for commercially insured or self-insured employer group members)

    • Testing guidelines apply to psych testing and neuropsych testing

  • Level of care guidelines are underpinned by evidence based practice (supported through adoption of best practice guidelines, such as APA Eating Disorder guideline)

  • Level of care guidelines are updated annually

  • They can be downloaded or reviewed at www.ubhonline.com

  • Revisions receive input and approval by UBH national provider advisor panel


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Wellness Assessment update

  • Product of a revision of previous UBH Wellness Survey and PacifiCare ALERT assessment in 2007

  • Based on seminal network by Michael Lambert and Jeb Brown in Utah, looking at functional impairment and improvement in function during the course of therapy

  • Derived from well-known and validated assessment scales such as SCL-90, SF-36, CAGE-AID, WHO Health and Productivity Questionnaire, Caregiver Strain Questionnaire, and Child/Adolescent Measurement Scale

  • Psychometric analysis conducted to review potential item overlap, scale validity, scale sensitivity across a range of symptom severity, and response option efficiency

  • Shorter than previous survey tools used by either company


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Wellness Assessment update (continued)

  • 2007 revision of Wellness Assessment paired with open authorization process for members (essentially, members get the annual benefit with the initial auth; authorization NOT tied to a given provider)

  • Request of care providers is to have at least 2 Wellness Assessments completed early in the episode of care

  • Final Wellness Assessment mailed to members for completion several months after initiation of the episode of care

  • Wellness Assessments sent to UBH via fax to file technology

  • Care advocates may reach out to clinicians by letter or phone if there is a potential increased risk profile, or if there is a risk of premature treatment drop-out

  • Data from Wellness Assessments is confidential, not shared with employer groups or any other parties. Members with additional concerns are encouraged to call UBH directly if they should have questions


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Authorization process and questions

  • Outpatient behavioral health care has always been a prior-authorization service.

  • Requests for retroactive authorization will be considered on a case by case basis, depending on potential “extenuating circumstances”

  • As noted previously, members receive the annual benefit in their initial authorization when they call in for a referral or to initiate treatment with an in-network provider already identified

  • It is still advisable for providers to call in to UBH if there is a question about current member eligibility or other aspects of the authorization

  • Outpatient Treatment Reviews are no longer utilized for in-network providers

  • For out-of-network providers, authorizations typically conducted with clinical care advocates up to 10 sessions at a time

  • Suggest that providers submitting OTRs by fax keep a record of their successful submission in the patient’s file (much more reliable than using US Mail, unless one requests a return receipt)

  • Given fax volume at UBH, recommend calling the receiving party to ensure that they are aware that fax was sent successfully (to avoid misdirected faxes)


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Testing Requests and questions

  • Psychological/Neuropsychological testing typically require prior authorization

  • Determination on whether it’s behavioral or medical determined by reviewing testing request

    • Assisting with treatment plan for a DSM-IV diagnosis typically viewed as behavioral

    • Unless related to a complex medical or neurological disorder

  • Level of Care guidelines followed in reviewing testing requests for approval

  • If there is a need for clarification about the testing request information, it is not uncommon for the UBH reviewer to reach out to the person submitting the request

  • Sometimes, members and loved ones may have “heightened expectations” in the testing unlocking something unique and critical about the proposed treatment

  • There may be an opportunity to “manage expectations” in terms of what to expect from testing

  • Generally, managed care organizations assume that the testing will be used to help guide treatment already underway, as opposed to being a stand-alone element not related to a current or proposed treatment

  • Generally, testing for educationally-based purposes is viewed as outside coverage provided by health plans, where the purpose of testing is should be based on active treatment of a medical or behavioral condition


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Information regarding the UBH network

  • Local UBH network manager is Wendy Smith, works out of Portland office (207-253-1017); [email protected]

  • UBH network providers can be found at www.ubhonline.com

  • UBH network providers self-identify in terms of areas of expertise; e.g. psychological testing or neuropsychological testing; eating disorders, trauma, etc.

  • Sometimes, especially with testing requests, members or families will not be certain of what they are seeking; this may lead to an errant referral

  • If your identified areas of expertise are not complete as listed in our system (or are incorrectly loaded), please be in contact with Wendy Smith

  • If there are other problems with referrals you are receiving from UBH, please let us know

  • Thank you for the opportunity to work with you on behalf of our members!


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