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.

2 Rev. 11/18 Table of Contents SECTION 1: INTRODUCTION .. 6 Welcome .. 6 Provider Orientation .. 6 Contact Information .. 7 SECTION 2: MAGELLAN S NETWORK PARTICIPATION .. 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).

3 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 ..24 Functional Behavioral Assessment ..24 Family Based Services for Children and Adolescents.

4 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.

5 32 CASSP Principles ..33 Principles of Cultural Competence ..33 Community Support Program in Pennsylvania ..34 Treatment of Addictions ..35 Coordination of Care ..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.

6 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 ..48 Provider Performance Inquiry and Review (Quality of Care) Concerns ..48 Accreditation and External Review of Quality ..48 Site Visits ..49 Member Satisfaction Surveys.

7 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.

8 58 Pennsylvania Law ..59 Procedures Relating to Provider Exclusion from Federally or State-Funded Programs .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.

9 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. 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.

10 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.