CBH State of Georgia
Provider Orientation
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Cenpatico Behavioral Health
Today’s Presenters:
Clinton Shedd
CBH Network Development Manager
Central & SW Region
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Agenda
Overview of CBH
CBH Provider Network
CBH Georgia Provider Directory
The Provider Role
The Referral Process
CBH Provider Specialty & Cultural Competency
Geo-Access Requirements and Wait Times
Member Benefits
Case Management
Authorization Process
Outpatient Treatment Report (OTR)
Claims Submission
EDI
Credentialing & Re-Credentialing
Network Management & Provider Relations
Provider Manual and Online Resources
Future Provider Training & Forums
Open Q&A
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Centene Organizational Chart
Centene
Corporation
Superior
Health
Plan
Texas
AirLogix
First Guard
Health
Plan
Kansas
Missouri
I
US Scripts
CenCorp
Health
Solutions, Inc.
Cenpatico
Behavioral
Health
University
Health
Plans, Inc.
New Jersey
NurseWise
Managed
Health
Services
Indiana
Peach State
Health Plan
Georgia
Buckeye
Community
Health Plan
Ohio
Managed
Health
Services
Wisconsin
ScriptAssist
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Cenpatico Behavioral Health,
LLC
Cenpatico
Behavioral
Health, LLC
National Service
Center
CBH, Arizona
Academic
Behavioral
Alternatives
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Cenpatico History
 CBH began as a staff model behavioral health delivery
system in 1994 in Texas.
 The Centene Corporation, a St. Louis-based healthcare
organization (CNC on the NYSE), acquired CBH in 2003.
 CBH service offerings include UM, including assessment
and triage, crisis intervention, intensive case management,
QI, network development, credentialing, customer service
and claims processing and payment.
 We currently serve over 900,000 Medicaid consumers in
the following markets; Arizona, Indiana, Kansas, Missouri,
Ohio, Texas, and Wisconsin.
 Offer special education school-based services in Arizona.
 Received URAC health plan accreditation in January 2005.
 CBH Corporate office is located in downtown Austin, TX.
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The CBH Executive Team
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•
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Sam Donaldson, PhD- President & CEO
Alan Adkins, MD, MMM- VP Medical Affairs
Cindy Peterson, ACSW- VP Operations
Greg Shulman, LPC- Executive Account Manager
Sara Neale, RN- Director, Compliance & Government
Affairs
• Suzanne Feay, RN- Director, Corporate QI &
Credentialing
• Francis Terway- Finance Manager
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CBH NSC Leadership Team
• W. Mark Konyecsni, MD- NSC Medical Director
• Claudia Sumrall, ACSW- Clinical Director
• Lilli Olive, MA,LPC-Georgia Clinical manager
• Agnes Ponce - Customer Service Manager
• Melanie Howard, RN - Quality Improvement Manager
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CBH Georgia Operations
• CBH is headquartered in Austin, Texas and the
National Service Center is also located in Austin.
• CBH will has Licensed Master Level Personnel as
Case managers and Care coordinators in Austin
and Atlanta.
• CBH will have dedicated network management
staff in Georgia to provide local provider assistance
and training.
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CBH Provider Network
 CBH Network Development contracts with clinically-licensed
behavioral health clinicians, hospitals, community mental
health centers, community service boards (CSB’s), freestanding psychiatric facilities, & significant traditional
providers (STP’s).
 CBH clinicians include, but are not limited to; MD, DO,
ARNP, PhD, EdD, PsyD, LPC, LCSW, and LMFT.
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The Provider Role
 Provide quality covered behavioral health services within
all accepted clinical, legal and ethical standards to CBH
members.
 Follow CBH Clinical Practice Guidelines and Medical
Necessity Criteria.
 Ensure members are able to avail themselves of their
rights to execute Behavioral Health Advance Directives.
 Abide by CBH Authorization, Claims, QI, UM and
Credentialing/Re-Credentialing policies and procedures.
 Abide by CBH contractual obligations.
 Treat CBH clients as fairly and equally as any other
clients.
 Ensure HIPAA compliance.
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Provider Directory
 CBH providers and facilities will be listed in the
Peach State Health Plan, Inc. (PSHP) online provider
directory. The online directory will be updated to
reflect the most current information.
 CBH clinicians, agencies, CSB’s, and hospitals are
listed in the Provider Directory. Information includes,
but is not limited to: provider name, address, phone,
and office hours.
 The Directory is intended to reflect our current
network and to provide another avenue for our
providers and members to make informed referral
decisions.
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Referral Process
 CBH employs a team of customer service
representatives to provide referrals and eligibility
verification to our members and our providers.
 Providers and members are encouraged to visit the
PSHP online directory at www.pshpgeorgia.com or
visit the CBH directory at www.cenpaticoga.com
(which is currently in its final stages of development).
 CBH refers to in-network, or actively participating,
providers and facilities.
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Provider Specialty &
Cultural Competency
 CBH recognizes the uniqueness of each member, their needs,
and treatment requests.
 Consideration of a member’s race, country of origin, native
language, social class, religion, mental or physical abilities,
heritage, acculturation, age, gender, sexual orientation and other
characteristics should be included when developing their
treatment plan.
 CBH requests that providers share their languages spoken other
than English, handicap accessibility, and treatment specialties
with us so that we can tailor each referral to best meet our
member’s needs.
 Office sites should have posted and printed materials in English,
Spanish, or other prevailing languages within the region.
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Provider Accessibility,
Availability, & Wait Times
Current CBH access standards are as follows:
 Routine appointments-within 14 business days
 Urgent appointments-within 24 hours
 Emergent-non-life threatening appointments within six (6) hours
 Discharge (from hospital) follow-up appointments within seven (7) days of discharge
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Covered Behavioral Health
Services
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Traditional Outpatient Services
Medication Management
Group and Family Therapy
Inpatient Hospitalization
Detoxification
23-Hour Observation
Electroconvulsive Therapy (ECT)
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
Specific Community-Based Services
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Case Management
CBH has developed an Intensive Case Management
program to:
 Identify members with complex or chronic behavioral health
conditions that require coordination of services and periodic
monitoring in order to achieve desired outcomes.
 Work collaboratively with the member, physician,
family/significant others and providers of healthcare and
support services to implement an individualized plan of care.
 Maximize efficiency in utilization of available resources and
plan benefits.
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Components of Case Management
 Early identification of cases
 Assessment of cases to identify the needs of
those at high risk
 Referral to the appropriate providers and
services
 Provision of effective interventions in conjunction
with providers to improve clinical outcomes
 Coordination of support services
 Member/Family education
 Measurement of the intervention outcomes and
use of those measures to improve the program’s
effectiveness
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Service Codes Not Requiring PreAuthorization
Medication Management services billed with the
following codes do not require pre-authorization;
 90801/90802- Diagnostic Interview Examination
 90862- Pharmacologic Management
 90805- Individual Therapy (20-30 minutes) with med
eval/mgmt services
 90811- Individual Therapy, interactive (20-30
minutes) with med eval/mgmt services
 90813- Individual Therapy, interactive (45-50
minutes) with med eval/mgmt services
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Services Requiring
Pre-Authorization
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Inpatient Hospitalization
23-Hour Observation
Detoxification
PHP & IOP
Psychological Testing
In-Home Therapy
Community-Based Services (Rehabilitative Services)
IFI Services
All covered outpatient therapy services greater than
six (6) visits
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Pre-Authorizing Care
 Prior Authorization is required for inpatient (non-emergent)
and higher levels of care such as ECT, PHP, IOP, Day
Treatment programs, Psychological Testing, and in-home or
community-based treatment.
 Prior Authorization is NOT required for emergency services,
post-stabilization and urgent care services. PLEASE NOTE:
You must contact CBH Care Management within 24 hours
of rendering these types of services for authorization and
review.
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Outpatient Treatment Report (OTR)
 The initial six (6) visits of outpatient psychotherapy (CPT CODES 90804)
do not require pre-authorization but do count against the member’s benefit
limitations. Billing codes must be Covered Behavioral Health Services.
 To approve all sessions beyond the initial six (6) will require that the
provider submit an Outpatient Treatment Report (OTR). The form is in the
back of the provider manual.
 The OTR MUST be completed in its entirety for consideration. This
includes the five (5) axis diagnoses as well as all other clinical information.
 The OTR’s can be faxed to CBH or completed online for clinical review and
additional sessions will be approved based upon medical necessity.
 CBH WILL NOT retroactively approve sessions. Treatment must occur
within the dates on the authorization. Any changes must be sent to CBH
prior to the sessions occurring.
 Failure to submit a timely OTR can result in delays in authorization and
may result in payment denials.
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Claims Submission
 What is a Clean Claim? It’s a claim received by CBH for adjudication
in a nationally accepted format in compliance with standard coding
guidelines and which requires no further information, adjustment, or
alteration by the provider.
 It is critical that we have current and correct information to assure
claims payment. This includes; W-9, Medicaid Number, Service
Address, Tax ID #, & Billing name and address.
 Ensure the member is effective on date of service, the service is a
covered behavioral health service under the member’s benefit, and all
CBH referral & authorization processes were followed and approved.
 Claims Address;
CBH
Attn: Claims Department
PO BOX 6700
Farmington, MO 63640-3816
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Claim Submission Do’s
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Do use the correct mailing address and PO Box number
Do submit all claims in 9”x12” envelope (or larger).
Do type all fields completely and correctly.
Do use black or blue ink only.
Do submit on proper form (CMS 1500 or CMS 1450).
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Common Billing Errors
 Remember to use SPECIFIC CPT-4 or HCPCS codes.
 Avoid the use of non-specific or “catch-all” codes such as
99070.
 Use the most current CPT-4 and HCPCS codes which can be
found on your contracted Exhibit 2 (Compensation Schedule)
 Use the 4th or 5th digit when required for ALL ICD-9 codes.
 Submit all claims/encounters with your Medicaid Number and
Tax Id Number.
 Submit all Claims/encounters with the Member’s complete
Medicaid Number or the Members PSHP ID Number.
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Electronic Claims Submission
 CBH has two national clearinghouses that are approved
for EDI electronic claims submission. Payer Path and
Emdeon (formally Web MD)
Please contact the Centene EDI Department at the
following to inquire or discuss EDI and your options;
By phone:
By e-mail:
1-800-225-2573, ext. 25525
[email protected]
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Credentialing & Re-Credentialing
 As CBH is URAC accredited, CBH is obligated to follow URAC
credentialing and re-credentialing guidelines.
 A list of required credentialing materials can be found on pages 65
and 66 of the CBH Provider Manual.
 Facilities and Health Delivery Organizations must be CARF,
JCAHO, or COA accredited. If not, CBH must conduct an onsite
facility site review.
 CBH requires that you provide our Credentialing Department with
updates to your license, insurance, and DEA (if applicable), as
you receive them.
 Each provider must be re-credentialed at least once every three
years from the date of the initial approval.
 Failure to complete the re-credentialing process may result in
termination from the CBH network.
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Network Manager & Provider
Relations
CBH has employed a dedicated regional Network
Manager in each of our service delivery regions;
Atlanta-Carla Menchion- [email protected]
Central- Clinton Shedd- [email protected]
Southwest- Clinton Shedd- [email protected]
Provider Specialist-Latisa Kidd- [email protected]
Network Development can assist with any questions
regarding CBH or your Agreement, schedule trainings and
forums, conduct site visits, and assist in conflict resolution.
CBH Georgia Provider Relations staff at our Corporate
Office are an extension of the Network Development
Manager and are available to assist at any time.
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Provider Manual & Online Resources
CBH’s Provider Manual contains specific policies and
procedures regarding credentialing, authorization, appeals, and
claims.
Our Medical Necessity Criteria and Clinical Practice
Guidelines can be found in the Provider Manual.
CBH Corporate Information can be found on our website at
www.cenpatico.com.
CBH will have a direct CBH Georgia provider website;
www.cenpaticoga.com, which is in final development stages.
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Future CBH Training & Forums
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CBH will conduct provider/facility trainings and forums
in our service regions.
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CBH will conduct at least one large event in your area
per year, though we are open to schedule one- on-one
trainings with your group or facility on an as needed
basis.
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CBH will notify all providers of upcoming events via
mail, by phone, or in our Provider Newsletter.
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Your suggestions for training and forum topics are
always welcome!
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Member Card- Front
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Member Card-Back
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Questions and Answers
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