Psychealth, LTD.

1. Psychealth, LTD.

2. MANAGING CHANGES IN HEALTHCARE FOCUS MANAGED BEHAVIORAL HEALH

3. PsycHealth Ltd. Background • URAC Accredited • Minority and women’s certified business • Established is 1989 • Multi-Award Winning • Clinical care coordination model based on: • Recovery-oriented practices • Principles of good medicine, “least medicine for the cure or stabilization” • Treatment in accordance with human rights to be treated in the least restrictive setting • Responsive, Hopeful, Member Centered

4. We Believe…. …that compassion and consideration is of utmost importance. We recognize that as we help each person, we help our families, our friends, and ourselves.

5. PsycHealth Providers • Providers not contracted with PH are out of network (OON) • PH utilizes a continuum of providers: • Psychiatrists • Psychologists • Social workers • Substance abuse counselors • Professional counselors • Psychiatric nurses • Psychiatric Facilities • PH Providers or community/DASA agency must be: • Licensed or certified • Credentialed by PH • Clean history of service provision without sanctions

6. PH Expectations for Interfacing Health Care Organizations • Policies and Procedures • Each organization should have their own policies and procedures • Policies and procedures guide operations • Engaging with PsycHealth PsycHealth has a provider manual. It includes policies and procedures. These policies are reviewed annually, approved by the Executive- Quality Improvement Committee as well as URAC

7. Documentation • Emergency evaluations do not require pre-auth • Initial evaluation session does not require pre-authorization • PsycHealth has managed members for many years and supports the industry standard: • Diagnostic evaluation and treatment plan can be completed in one session • Testing is not necessary to make a diagnosis • PsycHealth expects industry standard initial evaluations and care coordination with PsycHealth to determine treatment plan and set authorizations for continued care. • Please note - this standard is much shorter than current State expectations. Try to provide a snap shot of the member. This will help PCP, too, and supports care coordination!

8. Minimal Requirements • Presenting Problem/Symptoms/Reason for Visit • History including good psychosocial/early history and treatment history • Medical Issues/Medication • Diagnosis, Recommendations/Treatment plan, Prognosis/Barriers • Treatment records are subject to review and audit and need to reflect industry standards for quality • Further information re: client hx and/or tx plan, if needed, can be obtained via concurrent review between PsycHealth Care Coordination team, PCP and the provider as well as the member.

9. From UM to Case Management to Care Management Utilization Review (UR): the critical examination of health-care services provided to patients especially for the purpose of controlling costs (as by identifying unnecessary medical procedures) and monitoring the quality of care Case Management builds upon that model to include the member, the member’s support team, the treating team and resources for health PsycHealth provides Care Management which includes case management, UR, specialized care services and programs designed to help members better manage their overall care and treatment

10. Mental Health vs. Medical Benefits • Certain services are mental health • Other may be under mental health umbrella but are, in fact, “medical” • Detox • Methadone maintenance • Pain treatments • Treatments with devices • Important: Be aware of the Scope of Benefit, which may vary from plan to plan

11. Contracting/Credentialing • Provider and organizations must comply with PH credentialing requirements • Providers are not IN Network until credentials are reviewed and approved • Incomplete credentialing applications are not approved • Providers must maintain credentials and comply with requests for updates

12. Quality Initiatives • Quality Care is good member care • Has your organization provided quality care that is documented? If so, share that. • Find areas of need and develop programming to address – such as housing, home services, special outreach, integrated care, community resources connection, groups PsycHealth coordinates at least two Quality Improvement Projects (QIP) each year Past QIPs have become standard programming

13. Providing Data and Timely Claims • Past windows for billing may have been long • Most managed organizations work with a tighter time frame • 90 - 120 days is common • Clearing houses or portals for claims • PsycHealth uses a portal • Ensure accurate information • Chart audits

14. Getting to Know Your Key Contacts • Depending on the size of the organization, there may be many interfacing people Learn names, positions and best ways to contact for effective and timely communication

15. Newsletter • Most companies have a newsletter • Information regarding the company • Tips for working with the company • Educational articles • Familiarize yourself with these resources • PsycHealth Provider Newsletter can be found on website

16. Importance of Medical Necessity Criteria • Driver of national healthcare • Medically necessary services • Apollo, Interqual, ASAM • Couch your requests in terms of medical necessity • Learn to use criteria for continued care requests based on progress or need • Reduce frequency as member progresses and work to empower members

17. Parallel Processes • Change is not easy • Manage stress through health and wellness techniques • Some changes are grounded in the law • How we treat one another affects how we treat the members • Direct communication is healthy

18. FAQs • Can members self-refer? Yes • Is preauthorization or preapproval of services necessary? • Preauthorization is not necessary for emergencies or initial evaluations • For continued services, preauthorization as based on medical necessity is required • PsycHealth uses - Apollo as nationally recognized medical necessity criteria • Please use our portal for referrals and billing • Coordinate care or special authorizations for intensified services or higher levels of care support coordination of care with medical

19. FAQs • Are there any limits in the number of authorized sessions or services? • No - as medically necessary and authorized • If a member is in need of psychiatric services or on medication, yes, please request authorization as based at that time • Can members be placed on a waiting list? • No. Please notify PH if you can not make timely arrangements for treatment for members and PsycHealth will reassign. • Timely access and connecting members to services is extremely important to us and to quality care.

20. Thank you! Dr. Madeleine Y. Gomez mygomez@psychealthltd.com Office: 847.864.4961 www.psychealthltd.com 20 20