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Value Behavioral Health of Pennsylvania. BHRS Consumer/Family Forum Crawford, Mercer & Venango Counties June 2007. Pennsylvania HealthChoices Program. State Medical Assistance (MA) Managed Care Program The HealthChoices Program has three main goals

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value behavioral health of pennsylvania

Value Behavioral Health of Pennsylvania

BHRS Consumer/Family Forum

Crawford, Mercer & Venango Counties

June 2007

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pennsylvania healthchoices program
Pennsylvania HealthChoices Program
  • State Medical Assistance (MA) Managed Care Program
  • The HealthChoices Program has three main goals
      • To improve accessto healthcare services for MA consumers
      • To improve the quality of care available to MA consumers
      • To stabilize Pennsylvania’s MA spending

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who is value behavioral health pa vbh pa
Who is Value Behavioral Health-PA (VBH-PA)??
  • Value Behavioral Health-PA (VBH-PA) is a managed care company
  • VBH-PA is working with your county to ensure the success of the HealthChoices Program
  • VBH-PA staff will be available to answer your questions when you call the toll-free member services number established for your county

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the benefits of healthchoices
The Benefits of HealthChoices
  • Supports the enhancement, expansion & improvement of county-specific delivery of services
  • Provides a continuum of in-plan and supplemental services that promote recovery and resiliency
          • Mental Health
          • Substance Abuse
  • Provides consumers with a choice of in- network providers

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behavioral health services mental health mh
Inpatient Psychiatric

Residential Treatment Facilities (RTF) for Children & Adolescents

MH Partial Hospitalization

MH Outpatient

Behavioral Health Rehabilitation Services for Children/Adolescents (BHRS)

Behavioral Health ServicesMental Health (MH)
  • Family-Based MH
  • Intensive Case
  • Management (ICM)
  • Resource Coordination
  • (RC)
  • Blended Case Management
  • (BCM)
  • Certified Peer Specialist
  • Crisis Intervention
  • Clozapine Support Services
  • Laboratory Services

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behavioral health services substance abuse
Behavioral Health ServicesSubstance Abuse

Substance Abuse

  • Inpatient Drug & Alcohol (D&A) Detoxification/Rehabilitation
  • Non-hospital Residential Detoxification/Rehabilitation
  • Halfway House
  • D&A Outpatient, including Intensive Outpatient (IOP)
  • Outpatient Narcotic Addiction Treatment

(Methadone Maintenance)

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service access
Service Access
  • HealthChoices means you have a CHOICE of providers
  • When members call VBH-PA for a referral, they will be given at least two names of providers to choose from
  • VBH-PA does not give recommendations, but will offer members a choice of providers
  • VBH-PA clinicians will ask for information to assess the need for services (emergency, urgent, or routine)

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service access1
Service Access

There is no charge to you for

in-plan services that you receive.

  • HealthChoices members DO NOT pay for any covered services they need. There is no co-pay. (This does not include your prescriptions. Your prescriptions are paid by your physical health plan.)
  • If members receive a bill, they should report this to the VBH-PA Member Service Representative.

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toll free contact numbers
Toll-Free Contact Numbers

VBH-PA Member Services

Erie 1-866-404-4560

NWBHP 1-866-404-4561

(Northwest Behavioral Health Partnership: Crawford, Mercer & Venango Counties)

Cambria 1-866-404-4562

Toll-Free Provider Line: 1-877-615-8503

TTY Telephone Number: 1-877-615-8502

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member benefits
Member Benefits
  • All VBH-PA members are provided with a Member Handbook that includes important information on member benefits
  • Handbooks are mailed to all eligible HealthChoices members in a bright pink envelope
  • It is important to read and keep the handbook

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member benefits1
Member Benefits

The Member Handbook includes:

  • A county-specific toll-free number to call with any questions about behavioral health care services and/or the HealthChoices program
  • Information on filing a complaint or grievance
  • Information on getting help in an emergency
  • Ways to share your opinions about your services by taking a satisfaction survey
  • Member rights and responsibilities

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learn about your rights
Learn about Your Rights
  • As part of the HealthChoices Program, you have the RIGHT to:

- Be treated with dignity and respect.

- Have your medical records and conversations with people who give you care kept private.

- Take part in decisions about your care.

- Have your treatment plan explained to you.

- Help set up your treatment plan and ask for a change

to your treatment plan.

- Choose your provider from a list of HealthChoices

Program Providers.

- See your medical records and talk about them with

your provider.

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learn about your rights continued
Learn about Your Rights (continued)

- Change your provider.

- Ask your provider about his or her qualifications or any

person who is helping you.

- Receive services without regard to race, color, religion, sex,

sexual orientation, age or ethnic background.

- Make a Complaint or file a Grievance about your care or the

services you receive.

- Talk with a Consumer Family Satisfaction Team (C/FST)

member about the quality of your services.

- Receive information on available treatment services.

- You have the right to be free from any form of restraint or

seclusion during your treatment that is used as a means of

coercion, discipline, convenience or retaliation.

- You have the right to create an Advanced Directive and share

it with your treatment provider.

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learn about your rights continued1
Learn about Your Rights (continued)

- Have the side effects and risks of your medications explained to

you.

- You may also request a copy of information maintained

by VBH-PA. The information may include claims

information, complaints, referrals, disclosures and other

documented contact you and your provider have had with

us.

- You may request to amend (change) the VBH-PA

information listed above in order to correct any errors.

The decision to make a change is made by the VBH-PA

Medical Director.

- You are free to exercise your rights. Exercising your

rights will not affect how you are treated by your

provider or by VBH-PA.

- You have the right to request a second opinion about your

treatment.

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learn about your responsibilities
Learn about Your Responsibilities
  • As part of the HealthChoices program, you have the RESPONSIBILITY to:

- Respect the dignity and privacy of others.

- Give your provider the information that he or she needs

to better serve you.

- Work with your provider to help develop a treatment

plan and ask questions when you do not understand

your treatment.

- Try to follow the treatment plans you developed with your

provider.

- Keep your appointment with your provider.

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learn about your responsibilities continued
Learn about Your Responsibilities (continued)

- Contact your provider if you need to cancel or

re-schedule your appointment.

- Call the VBH-PA toll-free telephone number if you move

and/or change your address or phone number. If

you are hearing impaired, call the TTY number at

1-866-615-8502.

  • Become familiar with your Rights and Responsibilities. They are in your Member Handbook.

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cassp principles
CASSP Principles
  • Mental health services in Pennsylvania are guided by the principles of the Child and Adolescent Service System Program.
  • Central to CASSP Principles is the recognition that a child must be understood in his or her natural context—the family, the community and the child-serving systems—not just individually.
  • CASSP Principles are strengths-based and treatment-focused.

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cassp principles1
CASSP Principles
  • Child-centered
  • Family-focused
  • Community-based
  • Multi-system
  • Culturally competent
  • Least restrictive/least intrusive

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evaluation
Evaluation
  • Comprehensive Child and Adolescent Strengths-Based Evaluation—Life Domain
  • Best Practice format for initial evaluations and re-evaluations
  • Evaluation of the child’s strengths and needs
  • Review of past treatment trials and/or review of treatment goals
  • Consideration of the full continuum of care
  • Documentation to support the medical necessity of recommended level of care

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independent prescriber model
Independent Prescriber Model
  • Prescribers who are credentialed by VBH-PA to evaluate children/adolescents and make treatment recommendations
  • Criteria:
    • Pennsylvania licensed psychiatrist, Pennsylvania licensed psychologist or developmental pediatrician
    • Documented experience in evaluating children and adolescents with special needs
    • Satisfactory (85% or better) ratings on CCASBE-LD monitoring
    • No affiliation with a BHRS/FBMH provider
  • Panel of providers will be recruited for each county

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interagency service planning team ispt
Interagency Service Planning Team (ISPT)
  • Functions of the ISPT Meeting:
    • Mechanism for child-driven, family-focused treatment
    • Mechanism for individualization and positive envisioning
    • Mechanism to integrate prescriber expertise with multi-system participation

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interagency service planning team ispt1
Interagency Service Planning Team (ISPT)
  • Desired outcomes of the ISPT Meeting:
    • Achieving consensus, based on common understanding and common goals
    • Initiating and maintaining an ongoing process of collaboration and change
    • Implementing practical, workable solutions for the child, including integrated treatment and feasible sources of funding

Only possible with parent/guardian participation!

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initial ispt
Initial ISPT
  • VBH-PA will schedule meeting within seven (7) days of receipt of evaluation
  • Parent/legal guardian, CYS/JPO, child if 14 years or older, and if appropriate, county representative, case manager, education (home school district), VBH-PA reviewer and other appropriate child-serving agencies
  • Evaluators are expected to participate (by phone or in person)
  • Provider is not a participant
  • VBH-PA/County facilitates initial ISPT

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ongoing discharge ispt
Ongoing & Discharge ISPT
  • Provider is a participant and is responsible to contact county to schedule the ISPT
  • Provider takes the lead in discussing progress of treatment goals, interventions utilized, skill transfer, barriers to treatment and discharge planning
  • Discharge planning meeting within 45 days of a projected discharge date
  • Provider facilitates ongoing/discharge ISPT’s

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definition of medically necessary
Definition of Medically Necessary
  • A service, item, procedure or level or care that is necessary for the proper treatment or management of an illness, injury or disability is one that:
    • Will, or is reasonably expected to, prevent the onset of an illness, condition, or injury or disability.
    • Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
    • Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.

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medical necessity criteria
Medical Necessity Criteria
  • Licensed as an utilization review entity
  • Mandated to use Appendix T, Program Standards and Requirements
  • SI – Severity of Illness
  • IS – Intensity of Service

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peer review
Peer Review
  • Care Managers and CAFS Coordinators can only authorize care
  • Medical Necessity is questioned
  • Peer Advisors render decisions
    • Certified
    • Non-certified (denial)
  • Peer Advisors are board certified psychiatrists, licensed psychologists and addictionologists supervised by the MCO Medical Director
  • Peer Advisors are also available 24/7 and a monthly on-call schedule is maintained

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what is a denial of service
What is a denial of service?
  • A VBH-PA Peer Advisor’s decision to deny a service, to decrease a service or to approve a service different than the service requested because the care requested is not medically necessary or another level of care is more appropriate.
  • The member will be sent a denial letter on the same date the denial is given for all acute levels of care. For non-acute levels of care, the denial letter is sent to the member within two business days of the denial decision.

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what is a grievance
What is a Grievance?

A grievance is when you are unhappy about a decision made about your treatment:

  • You may be denied a service.
  • A decision was made to decrease the amount of service.
  • You want a different service than what has been approved.

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how do i file a grievance
How do I file a Grievance?
  • You will receive a letter when VBH-PA denies a service, decreases your service, or approves something different than the service requested.
  • There can be several steps to the Grievance Process including:
    • First Level Grievance
    • Second Level Grievance
    • External Grievance
    • Fair Hearing

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first and second level grievances
First and Second Level Grievances
  • You may send your Grievance in letter form or you may call VBH-PA.
  • Use the toll-free number on your card or have someone call for you.
  • Your provider may also file a Grievance for you, if you give them written permission to do so.

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how soon must i file
How Soon Must I File?
  • You have 45 days to file a Grievance after you receive written notice of the change in your service.
  • You may continue services through the Grievance process if you file within 10 days of your service being denied.

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if you are not satisfied
If you are not satisfied

File a complaint if you are unhappy with the HealthChoices program.

  • you do not like the care your provider is giving you
  • you are unhappy with the services you are receiving

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examples of complaints
Examples of Complaints
  • I waited too long in the office.
  • The staff is rude.
  • The doctor will not let me take part in deciding my care.
  • I was late because I could not get a ride or the bus was late and my appointment was cancelled.
  • I received a bill from my provider.

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how to file a complaint
How to File a Complaint
  • Call the toll-free number on your card or have someone call for you.
  • All calls are free.
  • Write a letter to:

VBH-PA

520 Pleasant Valley Road

Trafford, PA 15085

Attention: Quality Department

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need help filing
Need Help Filing...
  • A VBH-PA Member Services Representative can help you file a complaint.
  • Your complaint will be investigated within 30 days.
  • You will be sent a letter from

VBH-PA informing you of the resolution.

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what if i still don t like the resolution
What if I still don’t like the resolution?
  • You may file a Second Level Complaint by calling or writing VBH-PA.
  • You have the right to meet with the Second Level Complaint Committee to resolve your complaint.
  • This committee will meet within 30 days of your request and you will be notified of the results by a letter from VBH-PA.

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still not happy
Still not happy?
  • You have 15 days to file an External Complaint Review.
  • This complaint is handled by either the Pennsylvania Department of Health (DOH) or the Pennsylvania Department of Insurance (DOI).

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questions
Questions???
  • VBH-PA is committed to providing quality behavioral health services to all our Members.
  • VBH-PA wants its’ Members to strive for recovery and enjoy a good quality of life.

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