Provider Handbook Supplement for

1 1 - 2004-2018 Magellan Health, Inc. rev. 11/18 Magellan Behavioral Health of pennsylvania , Inc.* Provider Handbook Supplement for HealthChoices Program Providers for Bucks, Cambria, Delaware, Lehigh, Montgomery and Northampton Counties * Magellan Healthcare, Inc. f/k/a Magellan Behavioral Health, Inc.; Magellan Behavioral Health of pennsylvania , Inc.; and their respective affiliates and subsidiaries are affiliates of Magellan Health, Inc. (collectively Magellan ). pennsylvania HealthChoices Program Provider Handbook Supplement 2 2004-2018 Magellan Health, Inc. rev. 11/18 Table of Contents SECTION 1: INTRODUCTION .. 6 Welcome .. 6 Provider Orientation .. 6 contact Information .. 7 SECTION 2: MAGELLAN S NETWORK PARTICIPATION.

2 9 Network Provider Participation .. 9 Medical Assistance Enrollment Procedures .. 9 Contracting with Magellan ..10 Credentialing/Re-Credentialing ..10 SECTION 3: THE ROLE OF THE Provider AND MAGELLAN .. 12 Obligations of Provider ..12 Hours of Operation ..12 Magellan s eMbraceCare Care Model ..13 Community Intensive Care Coordination (ICC) ..14 Clinical Procedures ..15 Authorization Process ..15 Member Referral and Preauthorization Procedures ..15 Emergency Services ..15 Access Standards and Initial Authorization Determination Timelines ..16 Authorization Processes ..18 Second Opinion ..20 Emergency Services ..20 Behavioral Health Rehabilitation Services for Children and Adolescents (BHRSCA) ..21 Act 62 ..24 Extended Assessment Program for Delaware and Montgomery Counties.

3 24 Functional Behavioral Assessment ..24 Family Based Services for Children and Adolescents ..25 Residential Treatment Facilities (RTF) and Community Residential Rehabilitation (CRR) ..25 Electroconvulsive Therapy (ECT) ..26 Psychological Testing ..27 Court Ordered Evaluation/Treatment ..27 Discharge Summary ..27 pennsylvania HealthChoices Program Provider Handbook Supplement 3 2004-2018 Magellan Health, Inc. rev. 11/18 Retrospective Review ..28 PA Performance Outcomes Management System (POMS) Reporting ..30 Clinical Assessments and Care Reviews ..30 Treatment Planning ..31 Recovery and Resiliency ..32 CASSP Principles ..33 Principles of Cultural Competence ..33 Community Support Program in pennsylvania ..34 Treatment of Addictions ..35 Coordination of Care.

4 36 Mental Health Advance Directives ..36 contact with PCPs and Other Providers ..37 Coordination of Care with Collateral Agencies/Interagency Team Meetings ..38 Laboratory Services ..38 Transportation Services ..38 Language Assistance Services ..39 Pharmacy Services ..39 Transfer of Care ..40 Member Rights and Responsibilities ..40 Child Protective Services Law and Reporting Child Protective Service Law - Reporting Requirement ..42 Elder Abuse - Reporting Requirement ..42 Complaints and Grievances ..43 Filing a Provider Complaint ..43 Member Complaints and Grievances ..45 Provider Responsibility in the Event of a Denial ..45 Provider Initiated Grievances ..45 SECTION 4: THE QUALITY PARTNERSHIP .. 47 Network Provider Participation ..47 Incident Reporting.

5 48 Provider Performance Inquiry and Review (Quality of Care) Concerns ..48 Accreditation and External Review of Quality ..48 Site Visits ..49 Member Satisfaction Surveys ..50 Provider Satisfaction Surveys ..50 pennsylvania HealthChoices Program Provider Handbook Supplement 4 2004-2018 Magellan Health, Inc. rev. 11/18 Confidentiality ..50 General Guidelines ..51 Informed Disclosure ..51 Guidelines for Establishing Office Protocol ..52 Communication with Members ..52 Authorization to Use and Disclose Protected Health Information (AUD) ..52 Member Records ..53 Records of Disclosures ..54 Documentation ..54 Fraud, Waste and Abuse ..55 Compliance Requirements ..57 Program The Effect of an Exclusion ..58 pennsylvania Law ..59 Procedures Relating to Provider Exclusion from Federally or State-Funded programs .

6 60 Self-Auditing Protocol ..61 How to Report Suspected Fraud, Waste and Abuse ..62 contact Information for Fraud & Abuse (F&A) Reporting ..63 County HealthChoices Fraud & Abuse Hotline ..63 Value Based Reimbursement ..63 SECTION 5: Provider REIMBURSEMENT .. 65 Submission of Claims ..65 Third Party Liability ..66 Ordering Referring & Prescribing (ORP) ..66 If you have any questions related to ORP, contact our Provider question email box at: ..67 Resubmitting Claims ..67 Timely Claims Submission ..67 Alternative Payment Arrangements ..68 Proper Claims Forms and Codes ..68 Claims Review ..68 Claims Resolution ..68 Electronic Funds Transfer (EFT) ..70 Eligibility Verification System ..70 pennsylvania HealthChoices Program Provider Handbook Supplement 5 2004-2018 Magellan Health, Inc.

7 Rev. 11/18 National Provider Identifier (NPI) Numbers ..71 SECTION 6: MAGELLAN 74 HealthChoices Specific Website ..74 Website ..74 *To access Appendix A Forms and Processes as well as Appendix B County Specific Forms please go to: pennsylvania HealthChoices Program Provider Handbook Supplement 6 2004-2018 Magellan Health, Inc. rev. 11/18 SECTION 1: INTRODUCTION Welcome Welcome to Magellan Behavioral Health of pennsylvania , Inc. (Magellan). This Provider Handbook Supplement is designed to give Magellan network providers specific information on the delivery of behavioral health care services to members of the HealthChoices Program in Bucks, Cambria, Delaware, Lehigh, Montgomery and Northampton Counties in pennsylvania . Only providers that are actively enrolled for the Provider type specialty at the appropriate service location are eligible to receive Medicaid reimbursement.

8 If you are not contracted with Magellan and are accessing this Handbook for information regarding a non-participating agreement, the requirement of active MA enrollment extends to all services and providers that are accessed by our members. This Handbook supplements the Magellan Health, Inc. National Provider Handbook , addressing policies and procedures specific to the HealthChoices Program for members in Bucks, Cambria, Delaware, Lehigh, Montgomery and Northampton Counties. It should be used in conjunction with the national Handbook . When information in this Supplement conflicts with the national Handbook , or when specific information does not appear in the national Handbook , policies and procedures in this Supplement prevail. It is important that providers review this Supplement and follow its procedures when providing services to members in the HealthChoices Program.

9 This Supplement provides information from Magellan on authorization procedures, clinical and administrative systems, and documentation requirements. It is to be used with the: Department of Human Services (DHS ) Medical Necessity Criteria (available at in the DHS Appendix T); pennsylvania Client Placement Criteria III for Adults (Appendix A); and Adolescent Patient Placement Criteria of the American Society for Addiction Medicine, Second Edition (ASAM-PPC-2). Provider Orientation In addition, we encourage you to review the presentation for the pennsylvania HealthChoices program that we have posted online under pennsylvania HealthChoices in the Plan-Specific area at We developed this orientation in collaboration with our providers. We designed it for providers who are new to Magellan; but, it also has proven to be a helpful overview for more tenured providers who want to refresh their knowledge of Magellan s policies and procedures.

10 We also encourage you to pennsylvania HealthChoices Program Provider Handbook Supplement 7 2004-2018 Magellan Health, Inc. rev. 11/18 visit our pennsylvania -specific website at , for additional information on Compliance, Training, and county-specific information. We look forward to working with you in the delivery of quality behavioral health care services to HealthChoices members in Bucks, Cambria, Delaware, Lehigh, Montgomery and Northampton Counties. contact Information If you have questions, Magellan is eager to assist you. We encourage you to visit our Provider website at You can look up authorizations and verify the status of a claim online at this site, in addition to completing other key Provider transactions. We have designed our website for you to have easy and quick access to information and answers to questions you may have about Magellan.