Connecticut
Medicaid Managed Care Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-8307
www.cga.state.ct.us/ph/medicaid

MEDICAID MANAGED CARE BEHAVIORAL HEALTH ADMINISTRATIVE PROCESS

(Revised with additional information 11/03)

Service Claims

Medicaid Managed Care Organization	Community Health Network of CT Sylvia Kelly, CEO 290 Pratt St. Meriden, CT 06450	Anthem BlueCare Family Plan Gregory Maddrey, V.P. 370 Bassett RD North Haven, CT 06473-4201	Health Net Janice Perkins, Assist. VP One Far Mill Crossing, PO Box 904 Shelton, CT 06484-0944	FirstChoice/Preferred One (P-1) Douglas Hayward, CEO 23 Maiden Lane North Haven, CT 06473
Behavioral Health Subcontractor	Merit Behavioral Care/ Magellan Behavioral Health	ValueOptions	ValueOptions	Comprehensive Behavioral Care
Claims Payer	Magellan	Anthem Blue Cross and Blue Shield – BlueCare Family Plan	ValueOptions	Comprehensive Behavioral Care
OP Client Registration Process	Provider/member calls toll-free number prior to the first session	Provider calls 1-888-519-4975 or faxes initial registration form to 1-888-819-7566. If they are part of the outpatient pilot project they will receive an authorization and letter for 20 sessions and 3 case management units. Otherwise, they will receive the traditional 5 outpatient sessions. *Anthem is in the process of reviewing the outcome of the pilot and will be announcing whether the 20 sessions will become standard authorization unless the individual client needs require something different.	Provider calls 1-866-440-6820 for initial authorization. Provider will receive authorization and letter for 20 outpatient and up to 3 case- management if requested.
	*CHNCT/Magellan*	*ABCFP/ValueOptions*	*Health Net/ValueOptions*
OP Authorization/concurrent OTRs	Prior authorization required If no specific # of sessions requested, OTR required after 8 sessions	Provider will mail or fax OTR to the following locations. A screening tool is used for continued stay authorizations. Mail: ValueOptions/CHCSCT PO Box 1690 New York, NY 10116 Or Fax: 1-888-819-7566 If the OTR falls into an outlier category, it is pended to for review by the physician and the BCFP Behavioral Health Medical Director	Provider will mail the OTR to ValueOptions/ Healthnet P.O. Box 1885 New York , NY 10116-1885	Mail or FAX (877) 436-3604 after the second session.
Mailing Address for authorization/concurrent OTRs	If more than initial authorized # of sessions are needed: MBC/Magellan 199 Pomeroy *Parsippany, NJ 07054* Attn: CHNCT Re-Authorization Dept.	ValueOptions/CHCS-CT PO Box 1690 New York, NY 10116	ValueOptions/Healthnet P.O. Box 1885 NY, NY 10116-1885	200 South Hoover Blvd Building 219, Suite 200 Tampa, FL 33609
Inpatient Authorization	Precert required or notification if emergent.	Provider calls 1-888-519-4975 and speaks directly with a Clinical Care Manager who will take clinical information and authorize care following medical necessity guidelines.	Provider calls 1-866 440-6820 and speaks directly with a Clinical Care Manager who will take clinical information and authorize care following medical necessity guidelines	Call (800) 458-6139 to speak to a Care Manager 24/7/365
	*CHNCT/Magellan*	*ABCFP/VO*	*Health Net/VO*	*P-1/CompCare*
Mailing Inpatient Authorization	Same as outpatient	NA	N/A	See Above
Electronic Claims Submission Address*	*Information on web site:* *Magellanprovider.com*	Electronics Claims Submissions: HTTPS:WWW4.ANTHEM.COM/EC1 BlueCare Family Plan PO Box 1076 North Haven, CT 06473	*Electronics Claims Submissions:* www.valueoptions.comor call 888-247-9311	N/A
Type of Claims Form**	Office-based outpatient HCFA 1500; other services UB92	Outpatient – HCFA 1500 Inpatient and most hospital based services – UB92	UB92/ HCFA 1500	HCFA 1500 /UB92
Required Claims Form Field Completions (to begin claims processing)	All of the form locators are required.	All of the form locators are required.	All of the form from DOS	Industry standard all member and provider information and service information
Timely Filing (Days)	120 days	120 days	365 days from Date Of Service	60 days
Remittance Discrepancies (Days)	60 days	60 days	Claims appeals: 60 days from denial	30 days
Provider Claims Service Telephone	800-666-9578	1-800-828-2239	1-800-238-2719, press 2 for provider	Customer Service (800) 458-6139 Provider Line Option
Contact Person: problems	Customer Service Supervisor: 800-666-9578	Wanda Cardona, Claims Manager	Claims Customer Service 866-440-6820	Customer Service Team Leader Sheila Mathis
BH Medical Director	Larry Goldberg	Lois Berkowitz, Psy.D.	George Wohlreich	Dr. Jayendra Choksi
Customer Service Telephone	800-666-9578	1-800-554-1707	1-866-441-6820	(800) 458-6139 Member Line Option Provider Line Option

Medicaid Managed Care Council 11/03 * NA if electronic claims are not accepted

Credentialing Process

Medicaid Managed Care Organization	Community Health Network of CT	Anthem BlueCare Family Plan	Health Net, formerly Physician’s Health Services	FirstChoice/Preferred One
Behavioral Health Subcontractor	Merit Behavioral Care/ Magellan Behavioral Health	Value Options	ValueOptions	Comprehensive Behavioral Care
Credentialing Entity	Aperture Primary Source Only/ Magellan	Anthem Blue Cross and Blue Shield	ValueOptions	Med Advantage for primary source verification only
Professional Levels	MDs (Psychiatrists) APRNs (Psychiatric) Ph.D.s LCSWs MFTs LADCs LPCs	License Types: MDs (Psychiatrists) APRNs (Psychiatric) Ph.D.s LCSWs MFTs LADCs LPCs	LCSW, LMFT, LPC, APRN PHD (MD/DO’s credentialed through HealthNet)	Masters, PhD, MD, ARNP
Credentialing Requirements	Complete applications License Federal and State Drug License (as applicable) Malpractice Insurance Coverage ($1mil/$3mil) Board Certification (as applicable) Hospital Admitting	Complete Applications License Federal and State Drug License (as applicable) Malpractice Insurance Coverage ($1mil/$3mil) Board Certification (as applicable) Hospital Admitting Privileges (as applicable)	Complete Application License Contract Malpractice Insurance Federal and State Drug License (as applicable) Board Certification (as applicable) Hospital Admitting	NCQA Standards
	*CHNCT/Magellan*	*ABCFP/VO*	*Health Net/VO*	*P-1/CompCare*
Plan Response Time	Within 90 days of receipt of complete application	30 days from receipt of a complete application for MDs 60 days from receipt of a completed application for non-MDs	180 days from receipt of complete application	Within 60 days of complete information submitted to the CVO
Problem Contact Person	Network Representative: 800-626-5907, option 8	Joni Jones or Susan Miles Credentialing Department 203-654-3168 in state: 800-922-1742 x3168 out-of-state 800-545-0948 x3168	Nicole Woolard 203-781-3323	CompCare Provider Services Director Melanie Hendrix (800) 458-6139

Medicaid Managed Care Council/BH subcommittee 11/03

Out-Of-Network BH Services

MCO/ BH subcontractor	*CHNCT/Magellan*	*ABCFP/ValueOptions*	*Health Net/ValueOptions*	*P-1/CompCare*
Policy	Per contract with DSS, if a type of service is unavailable in network due to the specific specialty or lack of availability, an individual case agreement (ad hoc) will be negotiated with a non-par provider	Per contract with DSS, if a type of service is unavailable in network due to the specific specialty or no available slots, out-of network provider will be sought.	If needs cannot be met within the network, we will facilitate a single case agreement	Refer to 2 pass through sessions option and emergent services as defined by the state
Process	Member or provider contacts Magellan with treatment need or request to obtain service from an out of network provider. If an appropriate in network provider is not available, the request is sent to the Network Department where an ad hoc arrangement is initiated with a non-participating provider.	Member or provider contacts ValueOptions/CHCSCT with treatment need. In network provider is sought out. If unavailable in a timely way or cannot meet the member’s need in a particular region of the state, out-of network provider is sought through recommendation of member, in-network provider, member’s PCP, or out-of-network provider’s know expertise in a specific treatment area.	1. Member/provider/advocate must request coverage of the service prior to service delivery (pre-certification) Clinical review to determine if needs can be met within the network If needs cannot be met through the network, will contact OON provider to coordinate single case agreement	Claims submission for pass through sessions and appeals process for emergent services
Contact Person	Customer Service @ 800-666-9578	Lois Berkowitz, Psy.D.	Mary Ledbetter 203-781-3387 (may change to Nicole Breck)	Customer Service (800) 458-6139 Provider Line Option
Contact Person - Problem	Customer Service Supervisor@800-666-9578	Lois Berkowitz, Psy.D. 203-985-7201	Linda Pierce 203-781-3325 (may change to Nicole Breck)	Customer Service Team Leader Sheila Mathis

Medicaid Managed Care Council/BH subcommittee 11/03

HUSKY A TRANSPORTATION

Health Plan Responsibility

(Updated 3/03)

(Give 48 hour notice prior to appointment date when arranging transportation with MCO)

MCO

CHNCT

BlueCare FP

Health Net NE

Preferred One (P-1)

Policy

CHNCT transportation vendor is Coordinated Transportation Solutions, Inc. (CTS).

*48-hour notice required

*Urgent service available.

ABCFP provides services for HUSKY A through their vendor Logisticare.

Health Net provides transportation through its’ vendor Logisticare

*48- hour notice required.

*Rides longer than 31 miles require PA from member services.

P-1 transportation vendor is Coordinated Transportation Solutions, Inc (CTS).

*Requires 48 hour notice, unless an emergency.

*P-1 authorizes transportation for medically necessary services.

Process to Secure Service

Member/provider calls CTS @ 800 818-6781.

Provider or member calls BCFP for the service. BCFP confirms the appointment, connects caller to Logisticare.

Member/provider call

800-820-0210 to arrange transportation.

*Member calls vendor for ride

@ (203) 736-8810 or

(800) 818-6781.

*Provider faxes service need to P-1 @ (203) 239-2474

Plan Contact Person; phone #

Member Services: Clarissa Cruz at (800) 859-9889

Provider: 800 828-2239

Member services:

(800) 554-1707 #2

Vendor: (800) 357-2935

Member Services:

(800) 820-0210

*Vendor (CTS) (800) 818-6781

*Member Services (800) 925-3606

Person to Contact with Problems

Member Services: Clarissa Cruz at (800) 859-9889

Providers call Susan Canning, Customer Service Manager: (203) 985-7177

Nicole Hanna at Member Services (800) 820-0210

Sarah Wearing, Transportation Coordinator (800) 925-3606

Ext 3137

Medicaid Managed Care Council 4/03

199 Pomeroy

Mailing Inpatient Authorization

Credentialing Entity

ValueOptions

NCQA Standards

Policy

Process

Policy