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

The Quality Assurance subcommittee of the Medicaid Council convened a work group of the four HUSKY managed care plans, the Departments of Social Services and Public Health and health care practitioners to address the delivery of obesity-related services in the HUSKY programs. A matrix for each HUSKY managed care organization (MCO) was developed for a practitioner’s “quick look” reference guide for covered services and MCO contact staff. When using this information matrix please note:

ü While obesity related services are specifically exempted in the DSS/MCO HUSKY A contracts:

o Such services ARE reimbursable if medically necessary as part of Medicaid ‘s (HUSKY A) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services.

o Connecticut’s SCHIP program is not an extension of Medicaid, therefore children’s well visits in HUSKY B fall within the American Academy of Pediatric guidelines and are not subject to federal EPSDT medical necessity guidelines.

o CHNCT does not differentiate children’s preventive and obesity-related services in HUSKY A and B.

ü Nutritional services are generally provided through hospital affiliated outpatient clinics, however Health Net includes School Based Health Clinics that are licensed as an outpatient medical facility and Preferred One includes network MDs, Pas, RDs and APRNs.

o Group nutritional counseling is generally associated with a specific disease (i.e. diabetes, cardiac rehabilitation). Health Net indicates such services (code 97804) apply to PCP offices including Community Health Centers.

o The provider can schedule follow- up intervention office appointments for those patients/families identified with overweight problems during a preventive well care visit.

ü Primary Care Providers can discuss authorization for other “medically necessary and appropriate’ services with the MCO’s Medical Director.

ü Behavioral health (BH) services related to obesity may be appropriate for some patients. Patients/families can self-refer for an initial BH visit as well as be referred by the provider. The BH subcontractor numbers are listed if you or your patient requires assistance in locating services within the patient’s geographic area.

Obesity Services in HUSKY Managed Care Organization: Anthem Blue Cross and Blue Shield

Anthem BCFP: Accessing Obesity Related Services in the Husky Programs
How does the MCO define: Overweight	BMI for age >85th percentile gender specific growth chart	BMI for age >85th percentile gender specific growth chart	BMI 25.0 – 29.9 Kg/m²
Obesity	BMI for age > 95^th percentile gender specific growth chart	BMI for age > 95^th percentile gender specific growth chart	BMI > 30 Kg/m²
Covered services for obesity: (Check or NA):	Service	PA (Prior Authorization) required? Yes/No	Service	PA? Yes/No	Service	PA? Yes/No
Nutritional counseling*	Hospital Affiliated Outpatient clinic only	No	Hospital Affiliated Outpatient clinic only	No	Hospital Affiliated Outpatient clinic only	No
Pharmaceuticals	Medical necessity review	Yes	Benefit exclusion	N/A	Medical necessity review	Yes
Exercise program	No	N/A	No	N/A	No	N/A
Gastric surgery	Medical necessity review	Yes	Medical necessity review	Yes	Medical necessity review	Yes
Behavioral Health Services	Client may self-refer for initial BH services	Contact ValueOptions at 888-519-4975	Client may self-refer for initial BH services	Contact ValueOptions at 888-519-4975	Client may self-refer for initial BH services	Contact ValueOptions at 888-519-4975
Other	Rehabilitative services appropriate to medical condition i.e.: cardiac rehab	No	Rehabilitative services appropriate to medical condition i.e.: cardiac rehab	No	Rehabilitative services appropriate to medical condition i.e.: cardiac rehab	No
How does the provider obtain medically necessary services that are not generally covered?	Through the Prior Authorization process and MD review	Through the Prior Authorization process and MD review	Through the Prior Authorization process and MD review
How does the Provider know which of the above services are in the patient’s geographic area?	The Provider can contact Provider Services@1-800-828-2239	The Provider can contact Provider Services @1-800-828-2239	The Provider can contact Provider Services @1-800-828-2239
What are the MCO criteria for credentialing Nutritional Providers?	· License verification or certification as required by Connecticut law · Evidence of adequate malpractice or liability insurance as appropriate · Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state	· License verification or certification as required by Connecticut law · Evidence of adequate malpractice or liability insurance as appropriate · Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state	· License verification or certification as required by Connecticut law · Evidence of adequate malpractice or liability insurance as appropriate · Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state
How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?	The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.	The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.	The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.
How can a provider be reimbursed for group nutritional counseling sessions?	Specific to disease process (e.g.: diabetes education, cardiac rehab)	Specific to disease process (e.g: diabetes education, cardiac rehab)	Specific to disease process (e.g.: diabetes education, cardiac rehab)
Is MCO case management available?	Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required	Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required	Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required
What criteria are used for case management?	Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services.	Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services.	Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services
How does the provider contact the MCO Provider Relations?	Provider Services can be reached at 1-800-828-2239	Provider Services can be reached at 1-800-828-2239	Provider Services can be reached at 1-800-828-2239
The MCO Medical Director	1-800-248-2227	1-800-248-2227	1-800-248-2227

Anthem BCFP: Accessing Obesity Related Services in the Husky Programs

Husky A Children

Husky B Children

Husky A Adults

How does the MCO define:

Overweight

BMI for age >85th percentile gender specific growth chart

BMI 25.0 – 29.9 Kg/m²

Obesity

BMI for age > 95^th percentile gender specific growth chart

BMI > 30 Kg/m²

Covered services for obesity:

(Check or NA):

Service

PA (Prior Authorization) required?

Yes/No

Service

PA? Yes/No

Service

PA? Yes/No

Nutritional counseling*

Hospital Affiliated Outpatient clinic only

Hospital Affiliated

Outpatient clinic only

Pharmaceuticals

Medical necessity review

Yes

Benefit exclusion

N/A

Medical necessity review

Yes

Exercise program

N/A

Gastric surgery

Medical necessity review

Yes

Medical necessity review

Yes

Medical necessity review

Yes

Behavioral Health Services

Client may self-refer for initial BH services

Contact ValueOptions at 888-519-4975

Client may self-refer for initial BH services

Contact ValueOptions at 888-519-4975

Client may self-refer for initial BH services

Contact ValueOptions at 888-519-4975

Other

Rehabilitative services appropriate to medical condition i.e.: cardiac rehab

How does the provider obtain medically necessary services that are not generally covered?

Through the Prior Authorization process and MD review

How does the Provider know which of the above services are in the patient’s geographic area?

The Provider can contact Provider Services@1-800-828-2239

The Provider can contact Provider Services @1-800-828-2239

What are the MCO criteria for credentialing Nutritional Providers?

· License verification or certification as required by Connecticut law

· Evidence of adequate malpractice or liability insurance as appropriate

· Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state

· License verification or certification as required by Connecticut law

· Evidence of adequate malpractice or liability insurance as appropriate

· Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state

· License verification or certification as required by Connecticut law

· Evidence of adequate malpractice or liability insurance as appropriate

· Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state

How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?

The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.

How can a provider be reimbursed for group nutritional counseling sessions?

Specific to disease process (e.g.: diabetes education, cardiac rehab)

Specific to disease process (e.g: diabetes education, cardiac rehab)

Specific to disease process (e.g.: diabetes education, cardiac rehab)

Is MCO case management available?

Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required

What criteria are used for case management?

Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services.

Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services

How does the provider contact the MCO Provider Relations?

Provider Services can be reached at

1-800-828-2239

Provider Services can be reached at

1-800-828-2239

Provider Services can be reached at

1-800-828-2239

The MCO Medical Director

1-800-248-2227

*Any BCFP participating provider can bill for nutritional counseling using recognized E&M CPT and ICD codes for obesity.

CHNCT: Accessing Obesity Related Services in the Husky Programs
How does the MCO define: Overweight	BMI for age >85th percentile gender specific growth chart	BMI for age >85th percentile gender specific growth chart	>25kg/m*
Obesity	BMI for age > 95^th percentile gender specific growth chart	BMI for age > 95^th percentile gender specific growth chart*	> 30 kg/m2*
Covered services for obesity: (Check or NA):	Service	PA(Prior Authorization) Required? Yes/No	Service	PA(Prior Authorization) Required? Yes/No	Service	PA(Prior Authorization) Required? Yes/No
Nutritional counseling	X (if medically necessary)	Yes - Always	X (if medically necessary)	Yes - Always	X (if medically necessary, ex: co-morbidity)	Yes - Always
Pharmaceuticals	X (if medically necessary, ex: co-morbidity)	Yes - Always	X (if medically necessary, ex: co-morbidity)	Yes - Always	X (if medically necessary, ex: co-morbidity)	Yes - Always
Exercise program	N/A	N/A	N/A	N/A	N/A	N/A
Gastric Surgery	Based on Medical Necessity Review	Yes - Always	Based on Medical Necessity Review	Yes - Always	Based on Medical Necessity Review	Yes - Always
Behavioral Health Services	Client may self-refer for initial BH services	Magellan Health 800-666-9578	Client may self-refer for initial BH services	Magellan Health 800-666-9578	Client may self-refer for initial BH services	Magellan Health 800-666-9578
Other	NA		N/A		N/A
How does the provider obtain medically necessary services that are not generally covered?	Appeals process or submits supporting clinical evidence for consideration	Appeals process or submits supporting clinical evidence for consideration	Appeals process or submits supporting clinical evidence for consideration
How does the Provider know which of the above services are in the patient’s geographic area?	Nutritional Counselors are not credentialed. Hospital based nutritional counseling services are covered as part of treatment for covered medical conditions.	Nutritional Counselors are not credentialed. Hospital based nutritional counseling services are covered as part of treatment for covered medical conditions.	Nutritional Counselors are not credentialed. Hospital based nutritional counseling services are covered as part of treatment for covered medical conditions.
What are the MCO criteria for credentialing Nutritional providers?	Not Credentialed. Their services are only covered when hospital based.	Not Credentialed. Their services are only covered when hospital based.	Not Credentialed. Their services are only covered when hospital based.
How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?	Non-PCP must have PA	Non-PCP must have PA	Obesity is not a covered expense. Diet and other services for treatment of obesity are only covered if obesity is caused by related to or seriously affecting another covered medical condition. Non-PCP must have PA
How can a provider be reimbursed for group nutritional counseling sessions?	Nutritionists not credentialed. Hosp may bill for their services.	Nutritionists not credentialed. Hosp may bill for their services.	Nutritionists not credentialed. Hosp may bill for their services.
Is MCO case management available?	Yes	Yes	Yes
What criteria are used for case management?	Chronic or acute medical and/or psychological conditions requiring case management coordination, intervention	Chronic or acute medical and/or psychological conditions requiring case management coordination, intervention	Chronic or acute medical and/or psychological conditions requiring case management coordination, intervention
How does the provider contact the MCO Provider Relations?	Through their provider relations representative, 1-800-440-5071	Through their provider relations representative, 1-800-440-5071	Through their provider relations representative, 1-800-440-5071
The MCO Medical Director	John Federico, MD 203-949-4000 X4007	John Federico, MD 203-949-4000 X4007	John Federico, MD 203-949-4000 X4007

CHNCT: Accessing Obesity Related Services in the Husky Programs

Husky A Children

Husky B Children

Husky A Adults*

How does the MCO define:

Overweight

BMI for age >85th percentile gender specific growth chart

>25kg/m*

Obesity

BMI for age > 95^th percentile gender specific growth chart

BMI for age > 95^th percentile gender specific growth chart*

> 30 kg/m2*

Covered services for obesity:

(Check or NA):

Service

PA(Prior Authorization)

Required?

Yes/No

Service

PA(Prior Authorization)

Required?

Yes/No

Service

PA(Prior Authorization)

Required?

Yes/No

Nutritional counseling

X (if medically necessary)

Yes - Always

X (if medically necessary)

Yes - Always

X (if medically necessary, ex: co-morbidity)

Yes - Always

Pharmaceuticals

X (if medically necessary, ex: co-morbidity)

Yes - Always

X (if medically necessary, ex: co-morbidity)

Yes - Always

X (if medically necessary, ex: co-morbidity)

Yes - Always

Exercise program

N/A

Gastric Surgery

Based on Medical Necessity Review

Yes - Always

Based on Medical Necessity Review

Yes - Always

Based on Medical Necessity Review

Yes - Always

Behavioral Health Services

Client may self-refer for initial BH services

Magellan Health

800-666-9578

Client may self-refer for initial BH services

Magellan Health

800-666-9578

Client may self-refer for initial BH services

Magellan Health

800-666-9578

Other

NA

N/A

How does the provider obtain medically necessary services that are not generally covered?

Appeals process or submits supporting clinical evidence for consideration

How does the Provider know which of the above services are in the patient’s geographic area?

Nutritional Counselors are not credentialed. Hospital based nutritional counseling services are covered as part of treatment for covered medical conditions.

What are the MCO criteria for credentialing

Nutritional providers?

Not Credentialed. Their services are only covered when hospital based.

How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?

Non-PCP must have PA

Obesity is not a covered expense. Diet and other services for treatment of obesity are only covered if obesity is caused by related to or seriously affecting another covered medical condition.

Non-PCP must have PA

How can a provider be reimbursed for group nutritional counseling sessions?

Nutritionists not credentialed. Hosp may bill for their services.

Is MCO case management available?

Yes

What criteria are used for case management?

Chronic or acute medical and/or psychological conditions requiring case management coordination, intervention

How does the provider contact the MCO Provider Relations?

Through their provider relations representative,

1-800-440-5071

Through their provider relations representative,

1-800-440-5071

Through their provider relations representative,

1-800-440-5071

The MCO Medical Director

John Federico, MD

203-949-4000 X4007

John Federico, MD

203-949-4000 X4007

John Federico, MD

203-949-4000 X4007

*For HUSKY A adults, treatment of obesity is a non-covered expense except when it is caused by, associated with or adversely impacting a covered medical condition.

Health Net: Accessing Obesity Related Services in the Husky Programs
How does the MCO define: Overweight	BMI for age >85th percentile gender specific growth chart	(Health Net does not participate in HUSKY B) NA	25-30Kg/m²
Obesity	BMI for age > 95^th percentile gender specific growth chart	NA	BMI >30Kg/m²
Covered services for obesity: (Check or NA):	Service	PA (Prior Authorization) required? Yes/No	Service	PA? Yes/No	Service	PA? Yes/No
Nutritional counseling	Hospital affiliated Outpatient clinic or School Based Clinic licensed as an outpatient medical facility. (If medically necessary and ordered as per EPSDT)	No	N/A		Hospital affiliated Outpatient clinic (For treatment of diabetes, metabolic disorders and lipid abnormalities, all except diabetes are limited to 3 visits)	Yes
Pharmaceuticals	Covered if Medically necessary (obesity is caused by a medical condition and ordered by a plan physician)	Yes Supporting documentation of medical necessity required	N/A		Covered if Medically necessary (obesity is caused by a medical condition and ordered by a plan physician)	Yes Supporting Documentation of medical necessity required
Exercise program	Not covered		N/A		Not covered
Gastric Surgery	Medical necessity review*	Yes	N/A		Medical necessity review *	Yes
Behavioral Health Services	Client may self-refer for initial BH services	ValueOptions 866-440-6820	N/A		Client may self-refer for initial BH services	ValueOptions 866-440-6820
Other	N/A	N/A	N/A	N/A	N/A	N/A
How does the provider obtain medically necessary services that are not generally covered?	Must request service, submit clinical information and obtain prior approval	N/A	Must request service, submit clinical information and obtain prior approval
How does the Provider know which of the above services are in the patient’s geographic area?	Can contact Health Net Provider Service 1-800-438-7886	N/A	Can contact Health Net Provider Service 1-800-438-7886
What are the MCO criteria for credentialing Nutritional providers?	Nutritional providers are not credentialed. Services must be delivered through an Outpatient Hospital Based Program or School Based Clinic licensed as an outpatient medical facility.	N/A	Nutritional providers are not credentialed. Services must be delivered through an Outpatient Hospital Based Program
How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?	Healthy Options members do not need a referral from their PCP. Members can schedule their own appointments with participating providers. Any request for services with a non-participating provider would require prior approval.	N/A	Healthy Options members do not need a referral from their PCP. Members can schedule their own appointments with participating providers. Any request for services with a non-participating provider would require
How can a provider be reimbursed for group nutritional counseling sessions?**	Reimbursement for CPT Code 97804 With restrictions PA required	N/A	Reimbursement for CPT Code 97804 With restrictions PA required
Is MCO case management available?	Yes	N/A	Yes
What criteria are used for case management?	Members are reviewed for high risk profile with acute needs or complex medical problems and situational triggers	N/A	Members are reviewed for high risk profile with acute needs or complex medical problems and situational triggers
How does the provider contact the MCO Provider Relations?	1-800-438-7886	N/A	1-800-438-7886
The MCO Medical Director	1-800-848-4747 X8610		1-800-848-4747 X8610

Health Net: Accessing Obesity Related Services in the Husky Programs

Husky A Children

Husky B Children

Husky A Adults

How does the MCO define:

Overweight

BMI for age >85th percentile gender specific growth chart

(Health Net does not participate in HUSKY B)

25-30Kg/m²

Obesity

BMI for age > 95^th percentile gender specific growth chart

BMI >30Kg/m²

Covered services for obesity:

(Check or NA):

Service

PA (Prior Authorization) required?

Yes/No

Service

PA? Yes/No

Service

PA? Yes/No

Nutritional counseling

Hospital affiliated Outpatient clinic or School Based Clinic licensed as an outpatient medical facility.

(If medically necessary and ordered as per EPSDT)

N/A

Hospital affiliated Outpatient clinic

(For treatment of diabetes, metabolic disorders and lipid abnormalities, all except diabetes are limited to 3 visits)

Yes

Pharmaceuticals

Covered if Medically necessary (obesity is caused by a medical condition and ordered by a plan physician)

Yes

Supporting documentation of medical necessity required

N/A

Covered if Medically necessary (obesity is caused by a medical condition and ordered by a plan physician)

Yes

Supporting

Documentation of medical necessity required

Exercise program

Not covered

N/A

Not covered

Gastric Surgery

Medical necessity review*

Yes

N/A

Medical necessity review *

Yes

Behavioral Health Services

Client may self-refer for initial BH services

ValueOptions

866-440-6820

N/A

Client may self-refer for initial BH services

ValueOptions

866-440-6820

Other

N/A

How does the provider obtain medically necessary services that are not generally covered?

Must request service, submit clinical information and obtain prior approval

N/A

Must request service, submit clinical information and obtain prior approval

How does the Provider know which of the above services are in the patient’s geographic area?

Can contact Health Net Provider Service

1-800-438-7886

N/A

Can contact Health Net Provider Service 1-800-438-7886

What are the MCO criteria for credentialing Nutritional providers?

Nutritional providers are not credentialed.

Services must be delivered through an Outpatient Hospital Based Program or School Based Clinic licensed as an outpatient medical facility.

N/A

Nutritional providers are not credentialed.

Services must be delivered through an Outpatient Hospital Based Program

How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?

Healthy Options members do not need a referral from their PCP. Members can schedule their own appointments with participating providers. Any request for services with a non-participating provider would require prior approval.

N/A

How can a provider be reimbursed for group nutritional counseling sessions?**

Reimbursement for CPT Code 97804

With restrictions

PA required

N/A

Reimbursement for CPT Code 97804

With restrictions

PA required

Is MCO case management available?

Yes

N/A

Yes

What criteria are used for case management?

Members are reviewed for high risk profile with acute needs or complex medical problems and situational triggers

N/A

Members are reviewed for high risk profile with acute needs or complex medical problems and situational triggers

How does the provider contact the MCO Provider Relations?

1-800-438-7886

N/A

1-800-438-7886

The MCO Medical Director

1-800-848-4747 X8610

* Services in connection with obesity could be covered if clinical criteria are met.

** These services are not covered at school based health clinics. (The 97804 code applies to PCP provider offices, including FQHC’s.)

Preferred One: Accessing Obesity Related Services in the Husky Programs
How does the MCO define: Overweight	BMI for age >85th percentile gender specific growth chart	BMI for age > 85^th percentile gender specific growth chart with co-morbid conditions	BMI 25-29.9 kg/m² with co-morbid conditions
Obesity	BMI for age > 95^th percentile gender specific growth chart	BMI for age >95^th percentile gender specific growth chart with co-morbid conditions	BMI 30 kg/m² and above With co-morbid conditions
Covered services for obesity: (Check or NA):	Service	PA (Prior Authorization) required? Yes/No	Service	PA? Yes/No	Service	PA? Yes/No
Nutritional counseling	Yes individual	Yes, if out of network provider	Yes individual	Yes	Yes Individual	Yes, if out of network provider
Pharmaceuticals	Yes	Yes	Yes	Yes	Yes	Yes
Exercise program	No	No	No	No	No
Gastric surgery	Based on Med Necessity for over age 18	Yes	Based on Med Necessity for over age 18	Yes	Yes based on med Necessity	Yes
Behavioral Health Services	Client may self-refer for initial services	CompCare at 800-435-5348	Client may self-refer for initial services	Comp Care at 800-435-5348	Client may self-refer for initial services	CompCare at 800-435-5348
Other	N/A		N/A		N/A
How does the provider obtain medically necessary services that are not generally covered?	Submit Letter of Med Necessity For Medical Director Review	Submit Letter of Med Necessity for Medical Director Review	Submit Letter of Medical Necessity for Medical Review
How does the Provider know which of the above services are in the patient’s geographic area?	Provider Directory or call UM Dept @1 800-925-3606	Same	Same
What are the MCO criteria for credentialing Nutritional Providers?	Must be in network MD, PA, RD, APRN	Same	Same
How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?	A participating PCP provider can refer to another participating provider without authorization otherwise they must Submit a Letter of Medical Necessity	same	same
How can a provider be reimbursed for group nutritional counseling sessions?	Specific to disease process (e.g.: diabetes education, cardiac rehab)	Specific to disease process (e.g.: diabetes education, cardiac rehab)	Specific to disease process (e.g.: diabetes education, cardiac rehab)
Is MCO case management available?	Yes	Yes	Yes
What criteria are used for case management?	Members are reviewed for high risk profile with acute needs or complex medical problems and situational triggers, or can be referred by provider or member/member’s parent or guardian	same	same
How does the provider contact the MCO Provider Relations?	1 800 925-3606	same	same
The MCO Medical Director	David Wilcox MD 203-239-7444 X3114	David Wilcox MD 203-239-7444 X3114	David Wilcox MD 203-239-7444 X3114

Preferred One: Accessing Obesity Related Services in the Husky Programs

Husky A Children

Husky B Children

Husky A Adults

How does the MCO define:

Overweight

BMI for age >85th percentile gender specific growth chart

BMI for age > 85^th percentile gender specific growth chart with co-morbid conditions

BMI 25-29.9 kg/m²

with co-morbid conditions

Obesity

BMI for age > 95^th percentile gender specific growth chart

BMI for age >95^th percentile gender specific growth chart with co-morbid conditions

BMI 30 kg/m² and above

With co-morbid conditions

Covered services for obesity:

(Check or NA):

Service

PA (Prior Authorization) required?

Yes/No

Service

PA? Yes/No

Service

PA? Yes/No

Nutritional counseling

Yes individual

Yes, if out of network provider

Yes individual

Yes

Yes Individual

Yes, if out of network provider

Pharmaceuticals

Yes

Exercise program

Gastric surgery

Based on Med Necessity for over age 18

Yes

Based on Med Necessity for over age 18

Yes

Yes based on med Necessity

Yes

Behavioral Health Services

Client may self-refer for initial services

CompCare at

800-435-5348

Client may self-refer for initial services

Comp Care at 800-435-5348

Client may self-refer for initial services

CompCare at

800-435-5348

Other

N/A

How does the provider obtain medically necessary services that are not generally covered?

Submit Letter of Med Necessity For Medical Director Review

Submit Letter of Med Necessity for Medical Director Review

Submit Letter of Medical Necessity for Medical Review

How does the Provider know which of the above services are in the patient’s geographic area?

Provider Directory or call UM Dept @1 800-925-3606

Same

What are the MCO criteria for credentialing Nutritional Providers?

Must be in network MD, PA, RD, APRN

Same

How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?

A participating PCP provider can refer to another participating provider without authorization otherwise they must Submit a Letter of Medical Necessity

same

How can a provider be reimbursed for group nutritional counseling sessions?

Specific to disease process (e.g.: diabetes education, cardiac rehab)

Is MCO case management available?

Yes

What criteria are used for case management?

Members are reviewed for high risk profile with acute needs or complex medical problems and situational triggers, or can be referred by provider or member/member’s parent or guardian

same

How does the provider contact the MCO Provider Relations?

1 800 925-3606

same

The MCO Medical Director

David Wilcox MD 203-239-7444 X3114

David Wilcox MD

203-239-7444 X3114

David Wilcox MD

203-239-7444 X3114

Anthem BCFP: Accessing Obesity Related Services in the Husky Programs
	Husky A Children		Husky B Children		Husky A Adults
How does the MCO define: Overweight	BMI for age >85th percentile gender specific growth chart		BMI for age >85th percentile gender specific growth chart		BMI 25.0 – 29.9 Kg/m²
Obesity	BMI for age > 95^th percentile gender specific growth chart		BMI for age > 95^th percentile gender specific growth chart		BMI > 30 Kg/m²
Covered services for obesity: (Check or NA):	Service	PA (Prior Authorization) required? Yes/No	Service	PA? Yes/No	Service	PA? Yes/No
Nutritional counseling*	Hospital Affiliated Outpatient clinic only	No	Hospital Affiliated Outpatient clinic only	No	Hospital Affiliated Outpatient clinic only	No
Pharmaceuticals	Medical necessity review	Yes	Benefit exclusion	N/A	Medical necessity review	Yes
Exercise program	No	N/A	No	N/A	No	N/A
Gastric surgery	Medical necessity review	Yes	Medical necessity review	Yes	Medical necessity review	Yes
Behavioral Health Services	Client may self-refer for initial BH services	Contact ValueOptions at 888-519-4975	Client may self-refer for initial BH services	Contact ValueOptions at 888-519-4975	Client may self-refer for initial BH services	Contact ValueOptions at 888-519-4975
Other	Rehabilitative services appropriate to medical condition i.e.: cardiac rehab	No	Rehabilitative services appropriate to medical condition i.e.: cardiac rehab	No	Rehabilitative services appropriate to medical condition i.e.: cardiac rehab	No
How does the provider obtain medically necessary services that are not generally covered?	Through the Prior Authorization process and MD review		Through the Prior Authorization process and MD review		Through the Prior Authorization process and MD review
How does the Provider know which of the above services are in the patient’s geographic area?	The Provider can contact Provider Services@1-800-828-2239		The Provider can contact Provider Services @1-800-828-2239		The Provider can contact Provider Services @1-800-828-2239
What are the MCO criteria for credentialing Nutritional Providers?	· License verification or certification as required by Connecticut law · Evidence of adequate malpractice or liability insurance as appropriate · Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state		· License verification or certification as required by Connecticut law · Evidence of adequate malpractice or liability insurance as appropriate · Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state		· License verification or certification as required by Connecticut law · Evidence of adequate malpractice or liability insurance as appropriate · Verification that provider has not been suspended or terminated from participation in the Medicaid program in any state
How can a non-PCP provider (i.e. School Based Health Clinic) refer the patient for services?	The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.		The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.		The member’s primary care physician coordinates referrals for specialty care. Contact the member’s PCP for referrals.
How can a provider be reimbursed for group nutritional counseling sessions?	Specific to disease process (e.g.: diabetes education, cardiac rehab)		Specific to disease process (e.g: diabetes education, cardiac rehab)		Specific to disease process (e.g.: diabetes education, cardiac rehab)
Is MCO case management available?	Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required		Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required		Care management is available to all members based on risk assessment. Members in care management receive nutritional teaching as required
What criteria are used for case management?	Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services.		Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services.		Proactive Care Management uses a predictive modeling tool for targeted member identification as well as a Care Management referral trigger list. Each member is then assessed individually for services
How does the provider contact the MCO Provider Relations?	Provider Services can be reached at 1-800-828-2239		Provider Services can be reached at 1-800-828-2239		Provider Services can be reached at 1-800-828-2239
The MCO Medical Director	1-800-248-2227		1-800-248-2227		1-800-248-2227

Anthem BCFP: Accessing Obesity Related Services in the Husky Programs

Husky B Children

Husky A Adults

BMI > 30 Kg/m2

Medical necessity review

Client may self-refer for initial BH services

CHNCT: Accessing Obesity Related Services in the Husky Programs

Husky B Children

Husky A Adults*

Yes/No

N/A

N/A

N/A

N/A

N/A

N/A

Based on Medical Necessity Review

Yes - Always

Based on Medical Necessity Review

Yes - Always

Based on Medical Necessity Review

Yes - Always

NA

N/A

N/A

The MCO Medical Director

Health Net: Accessing Obesity Related Services in the Husky Programs

Husky B Children

Husky A Adults

Pharmaceuticals

PA required

Preferred One: Accessing Obesity Related Services in the Husky Programs

Husky B Children

Husky A Adults

Nutritional counseling

BMI > 30 Kg/m²