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Provider Information Forum Applied Behavior Analysis (ABA)

April 2020 Behavioral Health Team

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Topics of Discussion

• ABA Overview and MCO Basics • ABA Services and Codes • ABA Unit Guidance and Allowable Specialties • Authorizations • NaviNet • Network – Credentialing and Demographic Information Updates • 21st Century Cures Act • Claims • Additional Supports

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• The management of Applied Behavior Analysis (ABA) services has transitioned from the Division of Medical Assistance and Health Services, Children’s System of Care (CSOC) to the Managed Care Organizations as of 4/1/20.

• Effective 4/1/20, Horizon New Jersey Health (HNJH) covers all medically necessary ABA

services for eligible Horizon Medicaid members.

• Services are available to any child diagnosed with an Autism Spectrum Disorder (ASD) as defined by ICD-10 diagnoses F84.0 – F84.9

ABA – Managed Care Organization Basics

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• Providers should contact Horizon to ensure eligibility and benefits by contacting Horizon

member services at 1-800-682-9091

• For eligible Horizon members already receiving ABA services through CSOC, Horizon will honor authorizations up until the current authorization end date to ensure services continue uninterrupted

• Prior authorization will be required to continue services after the authorization end date

• Providers should bill Horizon for ABA services for all dates of service 4/1/20 and beyond

ABA – Managed Care Organization Basics (cont.)

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ABA Services and Codes CPT Code CPT Code Definition

97151 Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or other QHP's time face-to-face with patient, and/or guardian(s) administering assessments and discussing findings and recommendations, and non face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan

97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face to face with the patient, each 15 minutes.

0362T Behavior identification supporting assessment, each 15 minutes of technician's time face-to-face with a patient requiring the following components: *administered by the physician or other qualified healthcare professional who is on-site, * with the assistance of two or more technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP, face-to-face with one patient, each 15 minutes

97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP , face-to-face with 2 or more patients, each 15 minutes

97155 Adaptive behavior treatment, with protocol modification, administered by physician or other QHP, which includes simultaneous direction of technician, face-to-face with one patient, each 15 minutes

97156 Family adaptive behavior treatment guidance administered by physician or other QHP (with or without the patient present), face-to-face with guardians(s)/caregiver(s), each 15 minutes

97157 Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) face-to-face with multiple sets of guardians(s)/ caregiver(s)

97158 Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP , face to face with multiple patents', each 15 minutes

0373T Adaptive behavior treatment with protocol modification, each 15 minutes of technician's time face-to-face with a patient requiring the following components: *administered by the physician or other qualified healthcare professional who is on site, * with the assistance of two or more technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

H0032 Mental Health service plan development by a non-physician, per 15 minutes

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Authorization Unit Guidance and Allowable Specialties

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• Provider submits the ABA Authorization Request Form via Utilization Management Request Tool accessible in

NaviNet NOTE: Providers can obtain a copy of the ABA Authorization Request Form from the horizonblue.com website:

Click on Provider Tab Select Products and Programs, then Horizon Behavioral Health Click on Frequently used forms Applied Behavior Analysis (ABA) Authorization Request https://www.horizonnjhealth.com/securecms-documents/900/ABA_Authorization_Request_Form_40001.pdf

• Request for assessment includes a copy of the Autism Spectrum Diagnosis (ASD) script with recommendation for

ABA therapy as completed by a Qualified Health Professional (QHP)

• Acceptable QHPs for the treatment planning for adaptive behavior services shall include: • Physicians • Psychologists trained and certified in behavior analysis, and • Board Certified Behavior Analysts

• Horizon checks eligibility and benefits, confirms diagnosis and completes the assessment authorization for 32 units

of 97151 for 30 days

Process for Obtaining Authorization

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• After completing the assessment, provider submits the ABA Request Form via the Utilization

Management Request Tool, accessible via NaviNet • Horizon, again, checks eligibility and benefits pursuant to internal processes

• A Horizon Behavioral Health Utilization Management (UM) Clinician reviews request form

against MCG Medical Necessity Criteria o If clinical information meets medically necessary criteria, Horizon BH Clinician creates

authorization o If clinical information does not meet medical necessity criteria, the Horizon BH

Clinician calls provider to discuss o If necessary, Horizon BH Clinician sends the case to the Horizon Medical Director

Review for a Medical Necessity Review

• For cases that do meet criteria – once approved – Horizon BH clinician creates authorization for 6 months

Process for Obtaining Authorization (cont.)

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• Horizon NJ Health offers multiple online services via NaviNet that can greatly benefit providers • This is a free, secure website that offers a single sign-on where providers can access

transactions and services for multiple health plans • NaviNet helps providers reduce administrative costs and time • When providers have a claim inquiry, they can go to NaviNet • By joining NaviNet, providers will get access to:

Administrative Reports

Utilization Management Tools

Claims Appeals Checks and Status inquiries

Search Eligibility and Benefit information

NaviNet

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Providers can access the Utilization Pre-authorization Management Tool through NaviNet. Simply select Horizon NJ Health from the Plan Central page; mouse over Referrals and Authorization on the left-hand navigation; then select Utilization Management requests. Please refer to the Utilization Management Request Tool Tutorial by visiting www.horizonblue.com:

• Under the Provider’s tab, select Products & Programs • Click on Horizon Behavioral Health • Under Training, click on Utilization Management Request Tool Tutorial

• NaviNet Support: 1-888-482-8057

NaviNet (cont.)

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Credentialing

• BCBAs and BCBA-Ds are required to successfully complete the credentialing process prior to being

accepted as a network provider. Recredentialing is required every 3 years. • Bachelor’s level behavior analysts and support staff/technicians are not required to complete

credentialing with Horizon. Services they provide are required to be under the supervision of the QHP. Horizon is not requiring Behavior Technicians to be Registered Behavioral Technicians, but it is preferred.

• Please visit https://www.horizonnjhealth.com/for-providers/provider-recruitment

for more information and Horizon NJ Health Applications. - Agreements are accessible via NaviNet’s Horizon BCBSNJ

plan central page. If you don’t have access to this page, email EnterprisePDM@horizonblue.com to request an Agreement.

• A complete application can take between 45 and 90 days from date of receipt to process.

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Credentialing

Helpful Hints • CAQH Tips

• Current attestation • Horizon authorized to access the application • Assure that new practitioners joining your group have the group’s location information included in the

practice locations • Ensure consistency in formatting of office locations

• Leave the effective dates blank in the agreements

• Include all pages of the agreements

• All documents must be sent via mail

• Include all documents on the checklist

• Ensure all documents are up to date

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Updating Your Demographic Information

• Use CAQH ProviewTM

• Or email Demographic Update requests to EnterprisePDM@horizonblue.com – Submit requests & supporting documentation at least 30 days before the effective date of

the change. – Always include the submitter’s name, email & telephone # with all email requests. – EnterprisePDM@horizonblue.com is not managed by a representative who reads &

responds immediately to your emails. Emails received are converted to Service Requests which are then addressed offline by our Provider team.

– Submit ONLY demographic Updates to this email address. DO NOT email initial credentialing submissions, claims, questions, etc.

– To help ensure that you are getting these responses (and that they are not flagged as spam), please add EnterprisePDM@HorizonBlue.com to your list of safe or approved senders/contacts. This will keep emails from us out of your junk/spam folder.

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21st Century Cures Act

• Effective January 1, 2018, the 21st Century Cures Act 114 P.L. 255 requires that all Medicaid managed care network providers must enroll with the State Medicaid program or risk being removed from the provider network. This is both a federal and state requirement.

• Each individual BCBA is required to register for a Medicaid number. Providers do not need to wait for their Medicaid number to be assigned to submit the credentialing applications to Horizon for network participation. Please notify us of your Medicaid number once received so we can update our systems accordingly.

• Registering as an NJ FamilyCare provider does not require you to service NJ FamilyCare Fee-for-Service

beneficiaries. • To register, Go to the NJ Medicaid Management Information System’s (NJMMIS) website at njmmis.com and select

Provider Enrollment Application on the left blue bar OR use the following direct link njmmis.com/onlineEnrollment.aspx. Under the Your Information section, click the down arrow in the Provider Type field and select 21st Century Cures Act.

• Please note: If you select your specialty from the drop down menu, the fee-for-service 20 page application will generate. However, by selecting the 21st Century Cures Act option, the 4-page application needed to satisfy the law’s requirement will appear.

• You can submit your application and credentials by: Fax: 1-609-584-1192 Mail: P.O. Box 4804, Trenton, NJ 08650

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Horizon’s participating providers are assigned to a Network Specialist based on their county. Your Network Specialist is available via phone or email and is your primary point of contact for the following areas:

• General Education • Requests for a Site/Education Visit • NaviNet Training • Network Status Inquiries

Please continue to contact Customer Service for all claims related concerns.

Network Management

Behavioral Health Provider Relations: Horizon NJ Health

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Dottie Laisi LaTanya McLean Barkley Michelle McCusker Olivia Inniss

Atlantic Hunterdon Burlington Bergen

Cape May Mercer Camden Essex

Cumberland Morris Middlesex Hudson

Gloucester Somerset Salem Passaic

Monmouth Sussex

Ocean Union

Warren

856-638-3215 856-638-3228 856-638-3223 973-466-4609

Dorothy_Laisi@horizonblue.com

LaTanya_Barkley@horizonblue.com

Michelle_McCusker@horizonblue.com Olivia_Inniss@horizonblue.com

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• Horizon NJ Health encourages all health care professionals to submit claims electronically

• Claims should be submitted with the BCBAs name and NPI as the rendering provider

• HNJH members to not have copays and/or coinsurance • We utilize the TriZetto Provider Solutions (TTPS) Direct Data Entry (DDE) SimpleClaim system • For more information on registering, please go to https://www.trizettoprovider.com/horizon/simpleclaim. If you have any further

questions about registering with TTPS for DDE claims submission, please contact TriZetto at 1-800-556-2231 or email ttpssupport@cognizant.com. Payer Number: 22326

• While Horizon NJ Health strongly encourages submitting claims via EDI, if a paper claim is necessary, please submit red and white

paper claims only for all services to Horizon NJ Health at the following address:

Horizon NJ Health Claims Processing Department PO BOX 24078 Newark, NJ 07101-0406

• Electronic Funds Transfer forms for providers who wish to use EFT to receive payments can be found by visiting

https://www.horizonnjhealth.com/for-providers/resources/forms/electronic-funds-transfer-eft-forms • EDI Technical Support Team is available during regular business hours, 8 a.m. through 5 p.m., Monday through Friday at 1-800-556-

2231

Claims

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• Horizon’s Case Management can also help facilitate linkages to care and coordinate care with

other providers and caretakers in the member’s environment

• Provider referrals can also be found via Horizon’s Doctor & Hospital Finder – our on-line Provider Directory (https://www.horizonnjhealth.com/findadoctor)

• Provider Referrals can also be given by calling Horizon Customer Service at 1-800-682-9091 • For any additional questions, please contact Vincent_Visioli@horizonblue.com

Applied Behavioral Analysis – Additional Supports

Thank you for your time today

Network - BHNetworkRelations@horizonblue.com Clinical – Vincent_Visioli@horizonblue.com

Q & A

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Sample MLTSS Member ID Card

Confirm eligibility at NaviNet.net or call MLTSS Provider Services at 1-855-777-0123.

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Sample FIDE-SNP Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at 1-855-955-5590.

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Sample NJ FamilyCare Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at 1-800-682-9091.

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Products are provided by Horizon Insurance Company and/or Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. All are independent licensees of the Blue Cross and Blue Shield Association. ECN00524 (0720)