DSRIP Project 3ai Rate Codes Webinar

January 2018

  • Presentation also available in Portable Document Format (PDF)

Index

Background

  • New institutional Rate Codes were created to enable full reimbursement for two Evaluation & Management Services (E&Ms) on the same day and remove the discounting of 10% that applies to multiple Behavioral Health services delivered on a single claim.
  • The Integrated Service rate codes are institutional rates designed to provide an integrated service billing mechanism for article 28, 31, & 32 licensed sites participating in DSRIP project 3ai as identified by the PPS.
  • The Integrated Service rate codes preserve the base rate of previous APG rate codes.
  • All previous APG rate codes on a provider file have remained on file and can continue to be used, but not in conjunction with the Integrated Service rate codes.
    • A combination edit is in place to prevent the billing of Integrated Service rate codes with any other APGs for the same date of service.
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3 Pathways to Integration of Primary Care and Behavioral Health

Standard 2008 Threshold A provider, whether or not participating in DSRIP Project 3.a.i, may provide services that are at or below State–established annual visit thresholds (2008 Certificate of Need (CON) Reform for Ambulatory Services).
DSRIP Project 3.a.i Licensure Threshold A provider participating in DSRIP Project 3.a.i that exceeds the 2008 CON thresholds but is providing services up to a 49% threshold must seek waiver authority from the State and submit the appropriate application to provide integrated services.
Integrated Outpatient Services (IOS) A qualifying DSRIP or non–DSRIP provider may seek Integrated Outpatient Services (IOS) licensure from its host agency or additional licensure/certification at any time.
  1. A non–DSRIP provider that is exceeding the 2008 CON threshold must obtain IOS or additional licensure/certification.
  2. A DSRIP provider that is exceeding the 49% threshold must obtain IOS or additional licensure/certification
Note: Dual Licensure A provider can apply for additional licensure at any time, but it may not be considered integrated care.
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Integrated Primary Care and Behavioral Health

This webinar will focus on Integrated Billing and Reimbursement.

These are not connected processes:

PPS reports quarterly on Project 3ai partner and patient engagement progress to the DSRIP Independent Assessor   Integrated Service Level Thresholds Monitored by OMH or OASAS or DOH
•   Standard 2008 threshold
•   DSRIP Project 3ai threshold
•   IOS threshold		   Site specific Billing and Reimbursement   Managed Care Plan Primary Care Provider Contracting and Credentialing at Project 3ai Model 2 sites; waivers of the PCP 16–hour office requirement
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PPS 3ai Rate Codes Spreadsheet

  • The PPS are responsible for tracking DSRIP 3ai participating providers and assisting those provider sites in the implementation of the project.
  • To facilitate the tracking of this new reimbursement mechanism, each PPS has received a feedback list of all Project 3ai sites from the DSRIP Team:
    • Provider Name
    • Provider Site Address
    • Operating Certificate
    • Provider Site NPI/MMIS
    • Site Host Agency Certification (Article 28, 31, or 32)
    • Services being integrated into the host model (physical health, mental health, and/or SUD services)
    • Site Locator Code
    • Site Zip+4
    • Rate Codes Loaded*
    • Effective Date*
    • CON # (where applicable) *
    • Application # (where applicable) *
    • Comments/Explanation*
    * These fields have been added by the DSRIP team

The first feedback list was provided on 1/2/18 and an article 28 feedback list was sent on 1/18/18 with additional updates
Spreadsheets due back with revisions: February 16, 2018.

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3ai Rate Codes Spreadsheet
What do these Status Codes Mean?

  • Rates Loaded
  • Ready for Rate Loading
  • Not Approved– pending revisions
  • Not Approved– not eligible
  • Surveillance Issues
  • Needs Review
  • Waiver Approval
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Status– Rates Loaded

Rates Loaded

What this means:
  • The listed rate codes have been loaded to this project 3ai site under the indicated MMIS.
  • Automated EMedNY letters were sent to the address listed on the provider file, matching the address listed in the spreadsheet.
  • The DSRIP team has sent a follow–up letter to the same address outlining the rate code usage as assigned to the site.

Rates Loaded as of 1/26/2018

  Sites
Submitted		 DSRIP Rate
Codes Loaded		 DSRIP Rate
Codes Pending		 IOS Rate
Codes Pending		 Total Rate
Codes Pending
Article 28 621 124 6 4 10
Article 31 284 117 71 40 111
Article 32 141 80 3 21 24
Total * 1190 321 80 65 145

*Totals for "Rate Codes Loaded" and "Pending" to load will not match the total of "Sites Submitted" as there have been a significant number of sites submitted without accurate fields and in need of revisions.

Rates Loaded:
Automated EMedNY Letter

  • Upon Processing of DSRIP Rate Codes, EMedNY has sent an auto–processed letter to the provider site (example at right).
  • Information Included:
    • Provider Address
    • NPI, MMIS, Provider Type
    • Rate Codes and Description
    • Effective Date
    • Rate Amount
    • Postal Code
    • Locator Code
Automated EMedNY Letter

Rates Loaded:
Provider Education Letter

  • The DSRIP Team has sent a follow–up letter providing additional guidance to providers (example at right).
  • Information Included:
    • Provider Address
    • MMIS
    • Rate Code(s)
    • Effective Date(s)
    • End Date(s) on previous APG Rate(s)
    • Additional Instruction
Provider Education Letter

Rates Loaded
Next Steps for PPS

  • Follow–up with the PPS–identified project 3ai provider site to:
    • Confirm receipt of the EMedNY automated letter and the DSRIP Provider Education Letter.
    • Confirm understanding of the rate code usage.
    • Discuss the usage of rate codes and reimbursement for services under Medicaid Fee–for–Service and Medicaid Managed Care.
  • Communicate any discrepancies, challenges, or barriers to the DSRIP Team.
  • Provide the DSRIP Team with updated designations on the services being integrated (physical health, mental health, and/or SUD services) in column G.

Note: The PPS remain the point of contact for all project 3ai provider coordination.

Status– Ready for Rate Loading

Ready for Rate Loading

What this means:
  • The project 3ai site, as identified, is pending rate code loading while awaiting final approval by host state agency financial and licensing departments.
Next Steps
  • PPS should review that the line information is correct and complete.
  • Contact the DSRIP team for any questions or with any discrepancies.
  • DOH/OMH/OASAS will complete review and provide updates to PPS.

Status– Not Approved– pending revisions

Not Approved– pending revisions

What this means:
  • The project 3ai site could not be identified with the PPS supplied information.
  • The DOH, OMH and OASAS has made a "best estimate" to identify which field may be contributing to this ´status´, indicated by red and yellow highlights and red text.
    • Please be advised that the DOH/OMH/OASAS identified field is a "best estimate" and all fields should be reviewed and coordinated with the provider site.
Common Revision Requests Description PPS Action
Incorrect information (red cells) The red highlighted cells include information which could not be found on the provider file corresponding with the other line information provided by the PPS. Provider enrollment could not determine a suitable revision. PPS should confirm that the MMIS matches the institutional MMIS for the specific project 3ai site and adjust any identifying information and send corrected information to the DSRIP BML.
Missing Information (yellow cells) In order to differentiate between multiple sites with similar information, the yellow highlighted cells are required. PPS should provide further granularity for that specific site and send corrected information to the DSRIP BML.
Adjusted information (red text) Provider enrollment has made an attempt to adjust information to match provider files. PPS should confirm the accuracy of these adjustments with the project 3ai site and send corrected information to the DSRIP BML.

Status– Not Approved– not eligible

Not Approved– not eligible

What this means:
  • The identified project 3ai site, as written, is not eligible for Integrated Service institutional APG rate codes (IOS or DSRIP 3ai)
    • The project 3ai site may not match the eligible category of services, which consists of: Hospital Based Outpatient Services (0287) and Diagnostic & Treatment Center Services (0160), and/or may not bill under APG methodology for integrated services.
    • Several models and pilot programs bill for integrated services under different billing methodologies, including: a Prospective Payment System (PPS), hourly, per–member– per–month (PMPM), or professional rates, and would not be eligible for institutional APG rate codes for integrated services.
Next Steps
  • PPS should confirm the accuracy of the project 3ai site identification and ineligibility designation. Any discrepancies should be communicated to the DSRIP Team through revisions of the spreadsheet or by contacting the BML. No other action is necessary.
Site Type Example(s)/description Methodology
Individual Practitioners COS** 0460: Physician Services
COS 0469: Nurse Practitioner
COS 0560: Clinical Social Worker Services
COS 0580: Clinical Psychology Services		 Professional rate
Groups COS 0046: Physicians Group
COS 0056: Clinical Social Worker Group		 Professional rate
Group Services COS 0062: Therapy Group Services
COS 0090: Multi Type Group Services		 varies
PROS Personalized Recovery Oriented Services (PROS) is a comprehensive model that integrates rehabilitation, treatment, and support services for people with serious mental illness Hourly rate
Crisis Medically Supervised Services Partial Hospitalization Centers Stabilization Services Inpatient Rehabilitation
Ambulatory detoxification
Outpatient rehabilitation (day rehab)		 varies
Residential Community Residential Services Supportive Living Residential Treatment Facility SNF varies
FQHC and CCBHCs Federally Qualified Health Centers (FQHCs) and Certified Community Behavioral Health Clinics (CCBHCs) Prospective Payment System (PPS) rates
Collaborative Care Model (Model 3) Primary Care Practice incorporating evidence based depression screening and management practices Medicaid Monthly Case Rate

* The Integrated Service rate codes represent a single mechanism to alleviate a barrier to same day services experienced in institutional article 28, 31, and 32 facilities. The above services bill under varying methodologies not impacted by this institutional billing barrier. Please be advised although some categories of service may be ineligible for DSRIP rate codes, that does not preclude them from participating in DSRIP project 3.a.i

** COS: Category of Service

Types of Billing

  • Professional Billing: the billing of claims generated for work performed by physicians, suppliers, and other non–institutional providers for both outpatient and inpatient services.
  • Institutional Billing: the billing of claims generated for work performed by hospitals, and other institutions for outpatient and inpatient services.
  • Prospective Payment System (PPS): a method of reimbursement in which payment is made based on a predetermined, fixed amount, with the payment amount for a particular service being derived based on the classification system of that service.
  • Monthly Case Rates/PMPM: monthly fixed payments made for each member meeting specified criteria.

Status– Surveillance Issues

Surveillance Issues

What this means:
  • Surveillance Issues are identified by the site host agency which prevent the approval for integrated service rate codes due to various compliance issues.
Next Steps:
  • Notify provider site of their surveillance status and encourage provider site to reach out to the host agency licensing or certification departments.
Common Surveillance Issues
Site on Enhanced Program Monitoring (EMP) Site being monitored for financial concerns Category of Service lapsed Provider not enrolled in Medicaid
In Conditional Status Operating Certificate expired/waiting for new Operating Certificate Physician Recruitment Issues Lack of leadership in excess of 1 year
Host Agency Contacts:

Status– Needs Review

Needs Review

  • These sites are pending further review by their host agency (DOH/OMH/OASAS).
Next Steps:
  • PPS should review that the line information is correct and complete.
  • Contact the DSRIP team for any questions or with any discrepancies.
  • DOH/OMH/OASAS will complete review and provide updates to PPS.

Status– Waiver Approval

Waiver Approval

  • These sites have received approval for an IOS or DSRIP 3ai waiver and application, but rate codes are still in the process of being loaded.
Next Steps:
  • PPS should review that the line information is correct and complete.
  • Contact the DSRIP team for any questions or with any discrepancies.
  • DOH/OMH/OASAS will complete processing and provide updates to PPS.
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Submitting Corrections

  • Once the PPS has confirmed the available information and completed revisions of the spreadsheet, please submit it to the DSRIP BML (DSRIP@health.ny.gov) by February 16, 2018.
  • Revisions will be re–processed by DOH, OMH, and/or OASAS.
  • PPS should expect additional updates periodically as submitted sites are processed.
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How to Submit Additional Sites: DSRIP 3ai Tracker

  • The PPS can submit additional sites at any time by providing the DSRIP Team with the Project 3ai Provider Site Identification spreadsheet with the following information:
  • Provider Name
  • Provider Site Address
  • Operating Certificate
  • Provider Site NPI/MMIS
  • Site Host Agency Certification
  • Site Locator Code
  • Site Zip+4
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Integrated Primary Care and Behavioral Health

This webinar focused on Integrated Billing and Reimbursement.

These are not connected processes:

PPS reports quarterly on Project 3ai partner and patient engagement progress to the DSRIP Independent Assessor   Integrated Service Level Thresholds Monitored by OMH or OASAS or DOH
•   Standard 2008 threshold
•   DSRIP Project 3ai threshold
•   IOS threshold		   Site specific Billing and Reimbursement   Managed Care Plan Primary Care Provider Contracting and Credentialing at Project 3ai Model 2 sites; waivers of the PCP 16–hour office requirement
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Policy Updates

IOS Rate Codes

  • IOS Rate Codes are pending distribution to providers awaiting Division of Budget Approval.
  • The IOS program is coordinated outside the DSRIP program. However, the DSRIP team has included project 3ai with approved IOS applications in the tracking spreadsheets to better coordinate integrated service efforts.
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DSRIP Project 3ai – Model 2 PCP Assignment at BH site

  • The goal of Model 2 is to provide access to comprehensive primary care provider (PCP) at Article 31 and 32 sites and integrate delivery of physical and behavioral health services.
  • The PCP at the behavioral health site must meet the standards of a primary care provider as articulated in the standard managed care contract and provide continuous comprehensive care.
  • The Plan PCPs at the sites are to promote primary care provider relationship for the BH population. Managed Care Plans (MCPs) may flag these PCPs as accepting current patients only.
  • Plans may seek a waiver to allow PCPs to be on site 8 hours instead of 16 hours due to the smaller volume of patients.
  • If member has an assigned or existing PCP outside of the BH clinic, members may keep the PCP they have.
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DSRIP Project 3ai Model 2 Managed Care Plan (MCP) PCP Contracting and PCP Credentialing requirements

  • Model 2 site lists were distributed to Medicaid MCPs in August and November 2017 to verify that Primary Care Provider contracting/credentialing is complete, in process, denied, or not yet requested. Responses varied in all of these areas and were provider site–specific and MCP specific.
  • Integrated Services are reimbursable in both Fee–For–Service and in Medicaid Managed Care.
  • Covered procedures/services include medical/physical and behavioral health care provided by an Integrated Service provider.
  • Plans are responsible for contracting all the services and at integrated behavioral health sites in their network.
  • PPS should be communicating with the provider site to ensure provider site contact has been made with the Plans to initiate contracting and credentialing steps at that site.
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Managed Care Plan Designated Primary Care Provider minimum 16 Hour Waiver request process

  • Model Contract Requirement: A Managed Care Designated PCP must practice a minimum of sixteen (16) hours a week at each primary care site.
  • PCPs who are practicing in Shortage Areas (areas that are defined by the DOH as areas in need of Medicaid primary care physicians) may be excluded from the 16–hour requirement.
    • PPS should coordinate with providers to determine if a waiver is needed.
    • If a waiver is needed, the provider should contact the Plans with a letter of support from the PPS to update their contracts.
    • Plans should submit a waiver request to OHIP for specific provider sites. That site–specific OHIP PCP hours waiver approval may be used to apply for PCP hours waiver request through additional Plans.
  • Plans will need the following information to submit their requests:
    • Clinic Name, NPI, Medicaid Provider ID, Host Agency Certification
    • Full name, credential (MD or NP) and License Number of the PCP(s) at the integrated BH clinics who will be working below the minimum PCP office hour requirement.
    • Reason for requesting the waiver, along with supporting documentation (documentation demonstrating that patients at the integrated behavioral health clinic are experiencing hardships in accessing their Plan assigned PCPs, and would be better served if they receive their primary care services by PCPs at that integrated behavioral health clinic).
    • Affirmation of the following:
      • PCP is available at least eight (8) hours/week at the Integrated BH clinic that the waiver request is for
      • PCP is participating in a Health Professional Shortage Area (HPSA) or other similarly determined shortage area; This requirement could be fulfilled if an integrated behavioral health clinic, working with the Plan, can demonstrate that patients at that integrated clinic are experiencing hardships as detailed above.
      • PCP is able to fulfill the responsibilities of a PCP as described in the MMC Model Contract and,
      • Waiver request must demonstrate there are systems in place to guarantee continuity of care and meet all access and availability standards (24–hr./7–day week coverage, appointment availability, etc.)
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Additional Information

DSRIP 3ai Rate Codes

  • DSRIP Fee–for–Service rate codes:
    • 1102 – DOH DTC APG ART 28 INTEGRATED SVC (DSRIP)
    • 1104 – DOH OPD APG ART 28 INTEGRATED SVC (DSRIP)
    • 1060 – DOH DTC APG ART 28 IS MR/DD/TBI (DSRIP)
    • 1062 – DOH OPD APG ART 28 IS MR/DD/TBI (DSRIP)
    • 1106 – OMH DTC APG ART 31 INTEGRATED SVC (DSRIP)
    • 1108 – OMH DTC APG ART 31 INTEGRATED SVC–SED (DSRIP)
    • 1110 – OMH OPD APG ART 31 INTEGRATED SVC (DSRIP)
    • 1112 – OMH OPD APG ART 31 INTEGRATED SVC–SED (DSRIP)
    • 1114 – OASAS DTC APG ART 32 INTEGRATED SVC (DSRIP)
    • 1116 – OASAS DTC APG MMTP INTEGRATED SVC (DSRIP)
    • 1118 – OASAS OPD APG ART 32 INTEGRATED SVC (DSRIP)
    • 1120 – OASAS OPD APG MMTP INTEGRATED SVC (DSRIP)
  • Above rate codes will not be billable until approved and loaded to the specific provider site MMIS
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IOS Rate Codes (pending distribution)

  • Integrated Outpatient Services (IOS) Fee–for–Service rate codes:
    • 1597 – DOH DTC APG ART 28 INTEGRATED OUTPATIENT SVC
    • 1594 – DOH OPD APG ART 28 INTEGRATED OUTPATIENT SVC
    • 1003 – DOH DTC APG ART 28 MR/DD/TBI INTEGRATED OUTPATIENT SVC
    • 1000 – DOH OPD APG ART 28 MR/DD/TBI INTEGRATED OUTPATIENT SVC
    • 1480 – OMH DTC APG ART 31 INTEGRATED OUTPATIENT SVC
    • 1483 – OMH DTC APG ART 31 INTEGRATED OUTPATIENT SVC–SED
    • 1122 – OMH OPD APG ART 31 INTEGRATED OUTPATIENT SVC
    • 1124 – OMH OPD APG ART 31 INTEGRATED OUTPATIENT SVC–SED
    • 1486 – OASAS DTC APG ART 32 INTEGRATED OUTPATIENT SVC
    • 1130 – OASAS DTC APG MMTP INTEGRATED OUTPATIENT SVC
    • 1132 – OASAS OPD APG ART 32 INTEGRATED OUTPATIENT SVC
    • 1134 – OASAS OPD APG MMTP INTEGRATED OUTPATIENT SVC
  • Above rate codes will not be billable until approved and loaded to the specific provider site MMIS
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Additional Resources

Integrated Services Overview Webinar

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016–07–14_integrate_serv_webinar.pdf

Approaches to Integrated Care FAQ

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2016/2016–01_integrated_care_faqs.htm

DSRIP Project 3ai Provider Education Webinar

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2017/docs/2017–09–20_ihs_3ai.pdf

September 2017 Medicaid Update

https://www.health.ny.gov/health_care/medicaid/program/update/2017/2017–09.htm

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Webinar Q&A

Questions?

DSRIP Team

DSRIP@health.ny.gov

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