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Clinical Communication Bulletin 047

CHANGES FOR AUTHORIZATION REQUIREMENTS FOR RESEARCH-BASED—BEHAVIORAL HEALTH TREATMENT

Trillium is making Research Based-Behavioral Health Treatment (RB-BHT) no prior authorization needed for Medicaid services effective immediately and extending through April 30, 2024. A Treatment Authorization Request (TAR) will not be required for RB-BHT claims to process.

All Medicaid members with concurrent service needs may file claims without authorization between now and April 30, 2024. Beginning on May 1, 2024, prior authorization in Trillium Business System (TBS)  will be required to file a claim for specified services. Trillium’s benefit plan can be found on our website and includes information on prior authorizations. This benefit plan will be updated prior to 2/1/2024.

Assessments codes (97151 and 97152) require an assessment supporting ASD diagnosis (utilizing valid diagnostic tool) and service order completed by MD, DO, PhD, or PsyD. Additional codes require a treatment plan. These documents should be a part of the member’s clinical record and available upon request. All services provided are subject to a post payment review to assure that medical necessity was met at the time of service delivery and all clinical information must still be completed as required by policy.

Beginning April 15, 2024, authorizations must be submitted in (TBS) Trillium Provider Direct to request services with prior approval for effective dates from May 1, 2024 going forward. All clinical documents are required according to Clinical Coverage Policies. Services must adhere to the Trillium Benefit plan posted on the Trillium website. 

Clinical Consolidation Communication Bulletin 005

This communication provides information around claims payment requirements for all Eastpointe, Sandhills, and Trillium providers beginning 2/1/2024 as a result of the consolidation.

On 12/18/2023, Secretary Kody H. Kinsley approved the consolidation agreement between Trillium Health Resources and Eastpointe Human Services, which provide managed care services to North Carolina’s Medicaid population. This approval includes the consolidation of Eastpointe and Sandhills Center. There will be a total of 46 counties in the combined region, effective January 1, 2024 that will now be operated by Trillium. For members and providers, the consolidation transition will occur on February 1, 2024.

Authorizations 

We understand this change can create anxiety for all stakeholders including members, providers, and community agencies. We want to make the change as easy as possible and transparent for all. To allow for transition to occur without members losing services, and to ensure providers are paid in a timely manner, Trillium will offer transition of care flexibilities for services that require authorization for Eastpointe, Sandhills and Trillium members. Effective February 1, 2024 through April 30, 2024 all services for all members and all providers will not require a prior authorization. All services provided are subject to a post payment review to assure that medical necessity was met at the time of service delivery and all clinical information must still be completed as required by policy. For more information about authorization of services please see Clinical Consolidation Bulletin 01.

CLAIMS BILLING AND PAYMENT FOR CONSOLIDATION

Beginning with dates of service provided to members on 2/1/2024 and thereafter, providers will be required to submit their claims to Trillium Health Resources for services provided to members/recipients with assigned coverage in one of the following counties that are consolidating with existing Trillium Health Resource counties.

·    Anson

·    Lee

·    Robeson             

·    Duplin

·    Lenoir

·    Sampson

·    Edgecombe

·    Montgomery

·    Scotland

·    Greene

·    Moore

·    Warren

·    Guilford

·    Randolph

·    Wayne

·    Hoke

·    Richmond

·    Wilson

Claims may be submitted to Trillium Health Resources by:

·    Uploading an 837I or 837P through the Trillium's secure Provider Direct Portal

·    Direct entry through the Provider Direct Portal

·    Utilizing Change Healthcare at no additional cost

·    Utilizing The SSI Group

For any dates of service provided to members 1/31/2024 and prior, providers will continue to submit claims through the appropriate LME/MCO system of Eastpointe or Sandhills based on where the member/recipient is assigned to for coverage. All timely filing and adjustment timeframes will continue to be followed.

Provider Direct

1.To obtain access to Trillium's Provider Direct portal for direct claims entry,

2.Complete the Provider Direct System Administrator training on Provider My Learning Campus.

3.Submit a certificate of completion along with the System Administrator Designee Request Form to [email protected].

4.Once you complete the training and System Administrator Designee Request Form, you will receive your login credentials.

If you need technical assistance with this process, please email [email protected].

Clearinghouses

If you are currently using a clearinghouse other than Change Healthcare or The SSI Group, and wish to continue using them, you will need to provide them with Trillium’s Payer ID – 56089 so they may connect with Change Healthcare or ID 43071 to connect with The SSI Group.

For additional information on Change Healthcare, please visit their website at www.changehealthcare.com.

For additional information on The SSI Group, please visit their website at www.thessigroup.com. 

Payment

Payment for all approved claims will be issued in accordance with the current Check Write Schedule available on Trillium’s website at www.TrilliumHealthResources.org under For Providers and Billing Codes & Rates/ Check Write Schedule.

All Remittance Advices and 835s will be available the day after the designated check write.

Provider Office Hour to Eastpointe and Sandhills providers

Do you have claims to submit?

Are you looking to get paid?

In order to do so, all providers must have a designated System Administrator to handle the submission of claims. Each designated System Administrator is required to take the Provider Direct System Admin training.

This 1-hour training is the first step in getting paid by Trillium. The Provider Office Hours during the week of January 9, 2024, will focus on this process.

You will receive a tutorial on how to register with Provider – My Learning Campus and how to access this training in My Learning Campus.

Please visit page below for the link to the office hours held each day at 12 p.m.

Non-Covered Medicaid Benefits under EPSDT 

Any Medicaid service that is a non-covered service currently provided to members through the plan must be submitted using the form found on the Trillium website on our Early and Periodic Screening Diagnosis and Treatment (EPSDT). Trillium is requesting the form to ensure we can update the TBS Trillium Business System to ensure claims may be submitted. Services remain NPA until May 31, 2024.

Clinical Consolidation Communication Bulletin 006

Consolidation Billing, Paper Claims and Enrollment/Eligibility

This communication provides information around consolidation billing requirements for claims spanning 2/1/2024, paper claims, new state funded enrollments and client updates.

Billing for dates of service spanning 2/1/2024

Providers submitting all claims including inpatient facility claims will need to split their claims by date of service. For any dates of service 1/31/2024 and prior, providers will continue to submit claims through the appropriate LME/MCO system of Eastpointe or Sandhills based on where the member/recipient is assigned to for coverage. Beginning with dates of service 2/1/2024 and thereafter, providers will be required to submit their claims to Trillium Health Resources for services provided to members/recipients with assigned coverage in one of counties that are consolidating with existing Trillium Health Resource counties. Failure to do so may result in denial of the claim.

Paper Claims for dates of service 2/1/2024 forward

Contracted providers are contractually required to submit their claims electronically via 837 HIPAA Transaction files or can be entered via direct data entry into the Provider Direct portal.

Non-contracted providers who wish to submit a paper claim can mail their claims to the address below:

Trillium Health Resources

PO Box 240909

Apple Valley, MN 55124

New State-Funded Enrollments and Client Updates

New Enrollment (State Fund requests) for dates of service and Client Updates for changes 02/01/2024 and after should be completed in Trillium’s Provider Direct system for recipients/members residing in (State Funded coverage requests) or with assigned Medicaid coverage in the following counties that are consolidating with existing Trillium Health Resource counties.

·    Anson

·    Lee

·    Robeson             

·    Duplin

·    Lenoir

·    Sampson

·    Edgecombe

·    Montgomery

·    Scotland

·    Greene

·    Moore

·    Warren

·    Guilford

·    Randolph

·    Wayne

·    Hoke

·    Richmond

·    Wilson

For dates 01/31/2024 and prior, New Enrollments and Client Updates should be submitted through the appropriate LME/MCO system of Eastpointe or Sandhills Center based on where the recipient/member should be covered.

If you have questions, please contact the Provider Support Service Line at 1-855-250-1539.

Alliance Claim System Overview/Harnett County Providers

Alliance Health uses the “Alliance Claims System” (ACS) for claims submission and processing.

We will facilitate an Alliance Claim System Overview training specifically for Harnett County providers on: Tuesday, January 30, 2024 from 10am-12noon. If interested in attending, please send list of attendees & their email addresses to: [email protected]. A link for the virtual training will be provided upon receipt of participation request. View slides here: Harnett-Slide-ACS-training

Davidson County Realignment Welcome Event

On Feb. 1, 2024, individuals in Davidson County who receive Medicaid services for intellectual or developmental disabilities, mental health or substance use disorders will be automatically enrolled with Partners.

Please join us for an information session for members, stakeholders and providers welcoming Davidson County to Partners Health Management.

Welcome Davidson County

Feb. 1, 2024, 6-7:30 p.m. (Register)

Visit the Davidson County Realignment page for updates and to find answers to Frequently Asked Questions. If you have a question that you do not see answered, please send your question to: [email protected]

Today, the Centers for Medicare & Medicaid Services (CMS) provides an at-a-glance summary of news from around the agency.

CMS Details State Spending Plans for Home & Community-Based Services Under American Rescue Plan

January 4: CMS released state spending plan summaries for section 9817 of the American Rescue Plan Act of 2021 (ARP). The spending plan summaries illustrate how states expect to spend $36.8 billion on activities to enhance, expand, or strengthen home and community-based services (HCBS) under Medicaid. States’ activities focus on workforce recruitment and retention, workforce training, quality improvement, efforts to reduce or eliminate waiting lists, expansions of the use of technology, opportunities to support caregivers, and ways to address social determinants of health and promote equity.

CMS Releases Second Annual Evaluation Report on End-Stage Renal Disease Treatment Choice Model

January 4: CMS released the second evaluation report on the End-Stage Renal Disease (ESRD) Treatment Choice (ETC) Model. ETC is a mandatory model composed of dialysis facilities and care providers aiming to increase home dialysis, transplant waitlisting, and living donor transplantation. The report shows that the model did not affect utilization of home dialysis, living donor transplantation, nor transplant waitlisting. The model also did not impact Medicare spending, in-center dialysis patient experience of care, quality, mortality, or outcomes related to health equity, nor most utilization outcomes, including hospital admissions or readmissions.

CMS Invites Proposals for the 2024 CMS Health Equity Conference, May 29-30

January 8: CMS issued a call for proposals for the 2024 CMS Health Equity Conference, scheduled for May 29 - 30, 2024. The free two-day conference will be held at the Hyatt Regency Hotel in Bethesda, Maryland, and available for online participation. This year’s conference will build on the energy and success of the inaugural 2023 conference, which attracted 500 in-person and 5,000 virtual attendees. This year’s theme is “Sustaining Health Equity Through Action.” Community organizations, academics, researchers, and others are encouraged to submit proposals through February 9. Proposals must focus on this year’s theme and align with the priority areas of the CMS Framework for Health Equity 2022-2032 or its companion document, the CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities. Information and guidelines for submitting proposals can be found here. Guidelines will also be reviewed during a “Call for Proposals Webinar” on January 18 at 2 p.m. ET. Registration for the webinar can be found here.

CMS Highlights Efforts to Address Health Disparities in Rural Communities

January 9: CMS posted the Rural Health Cross-Cutting Initiative fact sheet highlighting recent accomplishments by the Biden-Harris Administration to improve quality, equity, and outcomes across the health care system, focusing on those living in rural communities facing challenges in accessing health care.

CMS Celebrates Health Care Coverage in North Carolina

January 10: CMS Administrator Chiquita Brooks-LaSure attended an Affordable Care Act Marketplace event in Raleigh, North Carolina. The Administrator met with the North Carolina Navigator Consortium, then with Governor Roy Cooper at Martin Street Baptist Church. They discussed the importance of the Marketplace, announced the more than 20 million sign ups so far during this Open Enrollment, and celebrated North Carolina’s Medicaid Expansion, which began on December 1, 2023 and has already enrolled over 300,000 people.

CMS Releases Final Evaluation Report for Next Generation Accountable Care Organization Model

January 11: CMS released the final report for the Next Generation Accountable Care Organization (NGACO) Model, which ran from 2016-2021. The NGACO Model was designed to test whether high financial risk, more predictable payment flows, and flexibility in care delivery could reduce Medicare spending and improve value for Medicare beneficiaries. The report presents findings from a mixed methods evaluation, which found an approximate $1.7 billion reduction in Medicare Parts A and B spending without reductions in quality of care. Consistent with the model’s spending declines, the model was also associated with declines in hospital admissions, post-acute care, emergency department visits, and ambulatory visits.

CMS Announces New Innovation in Behavioral Health Model

Today, the Centers for Medicare & Medicaid Services announced the Innovation in Behavioral Health (IBH) Model.

The IBH Model will focus on improving the quality of care and the behavioral and physical health outcomes for Medicare and Medicaid populations with moderate to severe mental health conditions and/or substance use disorders.

The model seeks to bridge the gap between behavioral and physical health by supporting practice participants in the development and implementation of an interprofessional care team. This care team will be responsible for comprehensively addressing all aspects of a patient’s care, including their behavioral and physical health, and as needed social supports like housing, food, and transportation.

CMS will release a Notice of Funding Opportunity (NOFO) in spring 2024, and up to eight states will be selected to participate.

For more information about the IBH Model, please visit the model webpage and register for the model listserv.

Questions about the model can be submitted to [email protected].

CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process (Press Release)

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and strengthening access to care, the Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) today. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), (collectively “impacted payers”), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Together, these policies will improve prior authorization processes and reduce burden on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years.

“When a doctor says a patient needs a procedure, it is essential that it happens in a timely manner,” said HHS Secretary Xavier Becerra. “Too many Americans are left in limbo, waiting for approval from their insurance company. Today the Biden-Harris Administration is announcing strong action that will shorten these wait times by streamlining and better digitizing the approval process.” 

“CMS is committed to breaking down barriers in the health care system to make it easier for doctors and nurses to provide the care that people need to stay healthy,” said CMS Administrator Chiquita Brooks-LaSure. “Increasing efficiency and enabling health care data to flow freely and securely between patients, providers, and payers and streamlining prior authorization processes supports better health outcomes and a better health care experience for all.”

While prior authorization can help ensure medical care is necessary and appropriate, it can sometimes be an obstacle to necessary patient care when providers must navigate complex and widely varying payer requirements or face long waits for prior authorization decisions. This final rule establishes requirements for certain payers to streamline the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule, which add continuity of care requirements and reduce disruptions for beneficiaries.

Beginning primarily in 2026, impacted payers (not including QHP issuers on the FFEs) will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services. For some payers, this new timeframe for standard requests cuts current decision timeframes in half. The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics, similar to the metrics Medicare FFS already makes available.

The rule also requires impacted payers to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API), which can be used to facilitate a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process. Medicare FFS has already implemented an electronic prior authorization API, demonstrating the efficiencies other payers could realize by implementing such an API. Together, these new requirements for the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients, and prevent avoidable delays in care for patients.

In response to feedback received on multiple rules and extensive stakeholder outreach HHS will be announcing the use of enforcement discretion for the Health Insurance Portability and Accountability Act of 1996 (HIPAA) X12 278 prior authorization transaction standard to further promote efficiency in the prior authorization process. Covered entities that implement an all-FHIR-based Prior Authorization API pursuant to the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) who do not use the X12 278 standard as part of their API implementation will not be enforced against under HIPAA Administrative Simplification, thus allowing limited flexibility for covered entities to use a FHIR-only or FHIR and X12 combination API to meet the requirements of the CMS Interoperability and Prior Authorization final rule. Covered entities may also choose to make available an X12-only prior authorization transaction. HHS will continue to evaluate the HIPAA prior authorization transaction standards for future rulemaking.

CMS is also finalizing API requirements to increase health data exchange and foster a more efficient health care system for all. CMS values public input and considered the comments submitted by the public, including patients, providers, and payers, in finalizing the rule. Informed by these public comments, CMS is delaying the dates for compliance with the API policies from generally January 1, 2026, to January 1, 2027.

In addition to the Prior Authorization API, beginning January 2027, impacted payers will be required to expand their current Patient Access API to include information about prior authorizations and to implement a Provider Access API that providers can use to retrieve their patients’ claims, encounter, clinical, and prior authorization data. Also informed by public comments on previous payer-to-payer data exchange policies, we are requiring impacted payers to exchange, with a patient’s permission, most of those same data using a Payer-to-Payer FHIR API when a patient moves between payers or has multiple concurrent payers.

Finally, the rule also adds a new Electronic Prior Authorization measure for eligible clinicians under the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category and eligible hospitals and critical access hospitals (CAHs) in the Medicare Promoting Interoperability Program to report their use of payers’ Prior Authorization APIs to submit an electronic prior authorization request. Together, these policies will help to create a more efficient prior authorization process and support better access to health information and timely, high-quality care.

The final rule is available to review here. https://www.cms.gov/files/document/cms-0057-f.pdf.



The fact sheet for this final rule is available here. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.

Other Recent Releases:

January 9: CMS Approves New York’s Groundbreaking Section 1115 Demonstration Amendment to Improve Primary Care, Behavioral Health, and Health Equity

January 10: Under the Biden-Harris Administration, Over 20 Million Selected Affordable Health Coverage in ACA Marketplace Since Start of Open Enrollment Period, a Record High

Call for Grant Reviewers. HRSA relies on grant reviewers to select the best programs from a competitive group of applicants. Over the coming months, the Federal Office of Rural Health Policy will be competing a number of programs, including among other things: substance use disorders and opioid use disorder, rural workforce, and rural hospitals. Having reviewers with expertise in rural health greatly benefits the review process and is also an opportunity to learn about the review process itself. Reviews are typically held remotely over a period of a few days and reviewers who participate and complete their assigned duties receive an honorarium. Registration is easy and does not commit you to serving as a reviewer. Please consider lending your expertise to these important initiatives.

COVID-19 Home Tests Available. Every home in the U.S. is again eligible to receive four (4) free at-home tests ordered at www.covid.gov. Delivery is free through the U.S. Postal Service. 

Home Test to Treat is a new program funded by the National Institutes of Health focused on providing COVID-19 care and treatment for adults who are at greater risk of being affected by COVID-19. Adults who do not currently have COVID-19 or flu may enroll and receive free tests if they are uninsured or are enrolled in Medicare, Medicaid, the Veterans Affairs health care system, or the Indian Health Services. Individuals who are currently positive for COVID-19 can enroll to receive telehealth services for COVID-19 and treatment (if prescribed) at no cost. Enrollees may also be invited to participate in a completely optional research component of the program. Informational flyers are available in English and Spanish.

Mobilizing Health Care Workforce via Telehealth. ProviderBridge.org was created through the Coronavirus Aid, Relief, and Economic Security (CARES) Act by the Federation of State Medical Boards and HRSA’s Office for the Advancement of Telehealth. The site provides up-to-date information on emergency regulation and licensing by state as well as a provider portal to connect volunteer health care professionals to state agencies and health care entities. 

Online Resource for Licensure of Occupational Therapists, Physical Therapists, Psychologists, and Social Workers. The site provides up-to-date information on emergency regulation and licensing in each state.

Become a Host Site for the CDC Public Health Associate Program – February 29.  The Centers for Disease Control and Prevention (CDC) seeks host sites – including those that serve rural communities; state, tribal, local, and territorial public health agencies; community-based organizations; and academic institutions. Selected sites will host a CDC-funded Public Health Associate (apply by January 22) who will get hands-on experience as a foundation for their careers in public health. 

New Data Brief from OMH and ASPE:

Substance Use and Substance Use Disorders by Race and Ethnicity

Understanding substance use and substance use disorder (SUD) by race and ethnicity is critical to informing equitable policy and culturally effective prevention, treatment, and recovery efforts that can help address disparities in health and well-being.

The HHS Office of Minority Health (OMH) and the Office of Behavioral Health, Disability, and Aging Policy (BHDAP) within the Office of the Assistant Secretary for Planning and Evaluation (ASPE) have partnered on briefs focused on substance use treatment disparities among people of color and substance use treatment approaches.

A new brief, titled Substance Use and Substance Use Disorders by Race and Ethnicity, 2015-2019, describes findings from an analysis of National Survey on Drug Use and Health data to assess whether and how rates of substance use and substance use disorder (SUD) among adults (ages 18 and older) differ by race and ethnicity. 



Read the first brief of this partnership titled Meeting Substance Use and Social Service Needs in Communities of Color.