Autism stakeholders meeting presentation (1)
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Transcript of Autism stakeholders meeting presentation (1)
Became operational November 1, 1979
Chartered in West Virginia and domiciled in Ohio as a 501-C-4 Non-Profit Corporation
Licensed to do business in Ohio & West Virginia
Expanded into North Central WV in 1994
Expanded Statewide 2010 / 2011
UPSHUR
LEWIS
RANDOLPH
BARBOUR
PLEASANTS
WYOMING
RALEIGH
WOOD RITCHIE
WIRT
WAYNE
BRAXTON
HARRISON
SUMMERSMONROE
MERCER
ROANE
KANAWHA
CLAYPUTNAM
CABELL
PRESTON
WEBSTER
POCAHONTASNICHOLAS
DODDRIDGE
TYLER
MONONGALIAWETZEL
MARSHALL
MINGOLOGAN
MCDOWELL
MASON
JACKSON
LINCOLN
BOONE
GILMER
FAYETTE
GREENBRIER
CALHOUN
BERKELEYMORGAN
JEFFERSON
HANCOCK
OHIO
BROOKE
PENDLETON
TUCKER
HARDY
GRANT
MINERALHAMPSHIRETAYLOR
MARION
OHIO
PENNSYLVANIA
MARYLAND
VIRGINIA
KENTUCKY
24 additional West Virginia CountiesOver 2100 New Providers27 New Hospitals
Tertiary Facilities Include:
All contracting and service items (new providers, claims inquiries, questions, etc.) serviced by Health Plan directlyNo Programs or Services Carved Out
Health Plan requires credentialing of all providers including extendersContact Provider Relations (800) 624-6961Ext. 7633 for contracting information
WV Legislative mandate for coverage effective January 2012Large employer groups required to cover: in preceding year averaged over 25 eligible employeesCoverage effective upon reenrollment of large groups throughout the yearDiagnosis of ASD prior to age 8Coverage applies to children age 18 months to 18 years.
Coverage of Autism Spectrum Disorder
Establishing the Diagnosis of Autism Spectrum Disorder
Primary Care Physician (PCP) completes ASD screenings as per AAP and AAN guidelines as part of the preventive health visitsMultidisciplinary approach to establishing diagnosisReferrals to specialists, ancillary support, and testing are directed by the PCPDiagnosis of ASD based on DSM-IV-TR
Establishing the Diagnosis of Autism Spectrum Disorder
Once diagnosis is confirmed, coverage for autism treatment is initiated as per the member’s insurance benefit plan.
To assure payment of treatment and therapy under the benefit, services related to ASD require preauthorization
Applied Behavior Analysis provided and/or supervised by a Board Certified Behavior Analyst (BCBA)Information found at www.healthplan.org > provider services > additional BHU resources > Initial Authorization for ABA and Concurrent Authorization for ABAMedically necessary treatments, such as OT, ST, PT
Covered services:
Coverage of ABA
Initial authorization:
Results of screening and scalingFunctional Behavioral AssessmentGoalsRisk AssessmentTargeted interventions aimed at specific behaviorsParental training
Continuation of ABA
Behaviors and interventions identified on initial authorization formImprovements and achievementsSupporting documentation
Billing for ABA
Evaluation and Management Codes from Current Procedural Terminology have been assigned to various levels of treatment
Billing details will be in your contract