Metro area behavioral health providers

Metro Area Behavioral Health Provider Transition FAQs

• Contracts & Rates

  Q. I’m currently contracted with Health Share. Do I need to ask CareOregon for a new contract?
  A. No, for your convenience and in the interest of continuation of member care, your current Health Share Pathways contract will be assigned to CareOregon. Most amendments require no provider signatures.

  Q. Will my contract rates change once the contract is under CareOregon?
  A. No, rates and payment methodology will remain intact.

  Q. Will there be any changes to case rate structures or payments (e.g. lengths of authorizations, payments, fee for service equivalents, risk corridor parameters, etc.)?
  A. No. All elements of the case rates and risk corridor will remain the same after the transition.

  Q. I’m not currently contracted. How do I start the contract process?
  A. New contracts are not being offered at this time. CareOregon and Health Share are currently focused on the transition of existing contracts. Doing so allows the proper focus to be placed on member transition of care and safety.

  Q. As a non-contracted Provider, can I still get paid for services?
  A. Non-contracted Providers are eligible for payment with an approved authorization. No Single Case Agreement (SCA) is needed. 

  Q. I’m a non-contracted Provider but I have an SCA in effect from Health Share of Oregon. What do I need to do to ensure this transition to CareOregon?
  A. Providers who are currently seeing Health Share members through an SCA can continue to do so. The current SCA will be honored through its end date with an approved authorization.

  Q. What are the 2020 rates for CareOregon for HSO members?
  A. We are still waiting for the Health Share board to approve the budgets for the IDS and ICN contracts. There are many factors at play in the new budget allocation with the advent of the county safety net and public health services coming off the top of the global budget. Given that, we will likely not be sharing the PMPM for the behavioral health benefit as it is not comparable to previous years’. We should be able to share whether it is an increase or decrease over 2019 and by how much.

  Q. My contract with CareOregon shows the wrong risk corridor floor of 80 percent. Is the risk corridor still 70 percent with CareOregon, and when will my contract reflect the 70 percent?
  A. Some contracts do include the previous risk corridor floor of 80 percent. CareOregon is honoring the same risk corridor of 70 percent, which is reflected in our Provider Manual. Updated contracts will be sent to providers.

  Q. Which providers received contract amendments that require signatures, and which received contract transfer notices?
  A. Providers that had contracts with Health Share on behalf of Pathways received transfer notices. Providers that had contracts with the counties directly received new contracts. Some providers received both for different scopes of work.

  Q. Will there be any changes to the risk corridor for 2020?
  A. No.

• Authorization Rules and Fee Schedules

  Q. Will I have to get new authorizations to replace my existing ones?
  A. No. Existing authorizations will be honored through their end date. 

  Q. How do I request an authorization?
  A. Please continue to follow the current process.

  Q. Who will conduct utilization/concurrent review for services needing an authorization?
  A. As of Dec. 18, 2019 CareOregon has taken over the review process. 

  Q. What medical necessity decision making tool will CareOregon be using for authorization decisions?
  A. CareOregon will be using Interqual for medical necessity decision making. The current Pathways Level A-D levels of care criteria for outpatient Mental Health will also be in place with no changes to the current clinical criteria.

  Q. How does an authorization work when a member is in WRAP services and a level of care is recommended by the WRAP team?
  A. CareOregon will honor authorization requests from WRAP teams as part of the member’s plan of care. These services will be reviewed for medical necessity and approved as a benefit exception if criteria are not met.

  Q. What will the length of the initial SUD residential authorization be? What will the length of ongoing authorizations for SUD residential extended admissions be?
  A. There will be no change. This will remain in its current state.

  Q. What will the length of the initial medically monitored SUD residential authorization be? What will the length of ongoing authorizations for medically monitored SUD residential extended admissions be?
  A. There will be no change. This will remain in its current state.

  Q. Can authorization be approved for a Level D spot without having to put a client in a contracted ICM spot?
  A. Yes, for providers who have Level D services in addition to ICM programs.

  Q. Will our fee schedule be posted on the CareOregon website?
  A. The fee schedule will be posted on the PhTech/CIM site. Providers with access can access the fee schedule through that portal.

  Q. Are there changes to the level of care form? Does CareOregon require that it to be included in the clinical record?
  A. There are no changes to the form or procedures at this time.

  Q. Can I download fee schedules?
  A. Yes. They can be downloaded via CIM.

  Q. If a patient has Kaiser Health Share for physical health, but CareOregon for mental health, and we hold a contract with CareOregon for behavioral health but do not hold a Kaiser Health Share contract, are we able to still see the patient for mental health services?
  A. Yes. CareOregon will handle the authorizations and claims for all Health Share members, including members assigned to one of the integrated delivery systems of Health Share such as Kaiser or Providence.

  Q. Is there one central email to submit forms? HSTAR emails? Right now we email HSTAR to ASOC for Multnomah County, and fax HSTAR for Clackamas County. Is there going to be one central email to submit HSTAR?
  A. CareOregon has new forms that replace the HSTAR. All requests, regardless of county, will be processed by one centralized team within CareOregon.

  Q. Will authorization requests go through CIM or the CareOregon portal we currently use for JCC, CPCCO or CareOregon Advantage (Medicare) authorizations?
  A. Specialty behavioral health authorizations for Health Share members will be managed in CIM and all other authorizations related to other CareOregon lines of business will remain in our other portal, CareOregon Connect..

  Q. Will authorizations roll over from the counties to CareOregon?
  A. Yes.

• Behavioral Health Medications

  Q. Are there any changes to Behavioral Health medications?
  A. Behavioral Health medications are still carved out and covered by the state (OHA) and not CareOregon. People taking Behavioral Health medications may still have a small copay.

  Q. What do I do if a member’s Behavioral Health medication is denied or rejected?
  A. Please contact the state directly as CareOregon does not manage the medications used for Behavioral Health. This process is not changing.

  Q. Does this transition have anything to do with the DMAP assignments from the state?
  A. While providers do need a DMAP ID from the state, the Behavioral Health benefit transition to CareOregon does not impact OHA’s expectations around providers needing a DMAP ID.

• Care Coordination and Member Safety

  Q.  Will the counties continue to provide care coordination services?
  A. Behavioral Health care coordination services will transition over to CareOregon for all Health Share members. This page will be updated with details and contact information for the CareOregon and county care coordination teams. Multnomah, Clackamas and Washington counties will partner with CareOregon to provide Intensive Care Coordination services to members identified with intensive care coordination needs.

  Q.  Why will care coordination be managed by the counties rather than CareOregon?
  A. CareOregon worked closely with the counties on the transition of the management of the Behavioral Health benefit. Due to the nature of intensive care coordination, wraparound and CHOICE for members with Behavioral Health issues, we collaboratively agreed that it would be most successful remaining at the county level. This assures that the intricate relationships with local child welfare, juvenile justice, jails, schools and crisis systems will remain intact, supporting the coordination of care across systems by those who are currently doing this work. We are developing a robust operating agreement to ensure we have solid, well-communicated workflows for access to care coordination, and referrals from ICC to the larger Regional Care Teams within CareOregon. The ICC teams will be closely connected to and part of the Regional Care Team infrastructure.

• Health Related Services - Flex Funds

  Q. How will CareOregon respond to emergent requests for flex funds when a decision is needed in less than one business day, afterhours or on weekends?
  A. We are working on a pathway for emergent requests. For the most part, we anticipate only a few isolated experiences — such as bridging to a higher level of care — that would be emergent. Currently, we have some streamlined reviews in place to be able to respond quickly to medically vulnerable cases where things like a hotel stay, housing applications or cell phones may be needed urgently. We are also considering what options are available for teams that operate 24/7 to use funds as appropriate. This may include a clinical review after the purchase has been made.

  Q. What medical documentation is required to make a request for flex funding?
  A. A completed request form and chart notes from visits, care plan or treatment plan information. Any of those will work for medical documentation. If there are chart notes explicitly citing the HRSF need or information in the plan of care, that is ideal. Otherwise, we need any medical documentation that highlights the diagnosis driving the flex request. The medical records needed are primarily in relationship to the need for HRSF, not necessarily the history of the condition/ driving diagnosis.

  Q. Will there be an option for reimbursement for flex funds when providers cover the cost initially?
  A. Our primary concerns as we consider this option are serving member needs and adhering to regulatory requirements. If we can balance these two, we should be able to work out a reimbursement process with specific criteria.

  Q. Will CareOregon send out information about flex funds to the metro area provider network?
  A. CareOregon will not send out information about billing/admin to the provider network. CareOregon will manage the bulk of health-related-services payments directly. As a pathway is developed for potential clinic reimbursement, we will provide more information and identify the best pathways with billing staff.

  Q. Will care coordination staff be able to submit requests for flex funds for CareOregon members?
  A. Care coordination staff can submit requests in partnership with clinicians on the member’s care team. If the member of the care coordination team can be considered a licensed clinician providing services, they are likely able to submit the request. The best practice is to have the provider whose information will be on the medical documentation sign the request form and partner with the care coordinator.

  Q. Does the primary diagnosis (a required part of the flex funds process) differ — e.g., whether it is a physical or behavioral health diagnosis — depending on who is making the referral?
  A. The primary diagnosis is different depending on which treatment plan is driving the request. If the request is based around a medical need, physical health records and a request form around this need should be submitted by the primary care team supporting this diagnosis. The same is true for behavioral health diagnoses driving HRSF requests. If there are multiple diagnoses between physical and behavioral health driving the request, providers should identify the best person to provide care coordination for the request or the most clinically compelling elements of the member’s needs.

  Q. Will an adjustment to the flex funds request form be made to include more detail (e.g., wrap, choice, ICC) including contact information for the care coordinator?
  A. The option to identify whether the request is a wrap or choice request will be added to the form for 2020. There is a space provided for care coordinator information on the current form: “Requesting Party Information.”

  Q. There is an “override” option for wraparound for cases in which the wrap team has recommended a specific service/level of care and CareOregon Utilization Management disagrees. Does that same option apply to HRS for wraparound youth?
  A. No, wrap teams do not approve HRSF requests, but the wrap plan of care does count as a “treatment plan” when they are submitted/requested.

• Claim Submission

  Q.  How do I submit Claims?
  A.   As of Jan. 1, 2020, Providers wanting electronic funds transfer (EFT) will need to update their registration with PaySpan.  If this is not completed ahead of your first payment made on or after Jan. 1, 2020, then you will get a paper check and your voucher will have information on how to register for EFT.

  Q.  How will providers receive EFT payment?
  A.   If providers want EFT, they will have to register with PaySpan for this account. If providers don’t do this ahead of their first payment, they will get a paper check and the voucher will have information on how to register for EFT.

  Q.  Is CareOregon moving physical health claims into CIM as well?
  A.   No. These will remain in our other portal, CareOregon Connect.

  Q. Who will be paying the Behavioral Health claims for Health Share members when CareOregon transitions to managing the Behavioral Health benefit?
  A.  Payments will be made by CareOregon (regardless of date of service). Providers should have received communication from PaySpan in November/December that explained how to sign up for EFT for the new account. The RA will still be the same, as it will come from PhTECH for the Behavioral Health claims.

  Q. Is there a claims customer service number that providers can call about claims issues?
  A. There is one phone number for all provider customer service needs.

  Q. If a member is dual-enrolled in Medicare and Medicaid, does the provider have to submit the claim to Medicare first?
  A.   CareOregon will maintain the current Pathways requirements related to Medicare billing. Please see the CareOregon fee schedule in CIM for details.

  Q. Can providers still email questions/needs about claims through CIM?
  A.  Yes

  Q. How will outstanding claims for dates of service prior to January 1, 2020 be dealt with?
  A.  CareOregon will be responsible for all claims, including those prior to January 1, 2020.

  Q. Will the payer ID stay the same in PhTech?
  A.  Yes, the payer ID will stay the same in PHTech.

  Q. Who should we contact with coding questions, or if a provider needs consultation on billing/coding topics?
  A.  CareOregon is actively working to establish a contract with an external entity that will be available to answer providers’ billing and coding questions. More information on how to access this service will be posted on our website as available.

  Q: In terms of the plan name, will there be any changes to the explanation of benefits other than the change from Pathways to CareOregon? 
  A: There will not be any changes to remittance advice/payment vouchers, including the plan name. It remains Health Share. 

• General Questions

  Q. Is there a separate provider customer service phone number for behavioral health vs. physical health?
  A.  No.

  Q: When reserves are being built, providers suffer because things move slower in terms of alternative payment strategies, etc. Will CareOregon have to rebuild their reserves or will the reserves held at Health Share transfer? 
  A: CareOregon has adequate reserves to support the transition of the Behavioral Health benefit and will continue to work with providers in developing value-based payment methodologies that support the goals of the CCO 2.0 contract. 

  Q: Where do I direct my questions about my current contract or inquiring about applying for a new contract? 
  A: Please email BHContracts@careoregon.org with any questions. 

  Q: What is the contact information for CareOregon billing support? 
  A: Email: BHContracts@careoregon.org
  Phone: 503-416-4100 or toll-free 800-224-4840  

  Q: Health Share Behavioral Health providers are currently getting payments delivered on Tuesday. What day will Behavioral Health providers receive payment? 

  A: CareOregon will pay Behavioral Health providers on Friday beginning January 3, 2020.