Provider Handbook - georgiacollaborative.com

Provider Handbook
Provider Handbook

Serving Individuals and Families through
The Georgia Collaborative ASO

Important Notice: This handbook is offered as a tool for providers of Behavioral Health and

Intellectual Developmental Disabilities (IDD) services who are partnered with the Department

of Behavioral Health and Developmental Disabilities (DBHDD) to provide Medicaid and State

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The Georgia Collaborative ASO Provider Handbook 1
Effective: December 1, 2015

   THE GEORGIA COLLABORATIVE ASO
PROVIDER HANDBOOK

Table of Contents
Overview
About The Georgia Collaborative ASO
Contact Information
Provider Enrollment and Provider File Maintenance
Provider Information
Electronic Resources
Access to Services
Clinical Services
Informal Reviews and Fair Hearings of Adverse Determinations
Discharge Planning
Claims Procedures & Electronic Submissions
Quality Management Program (QMP)
Provider Grievances & Appeals

Appendices
Appendix 1: Handbook Glossary
Appendix 2: Helpful Online Resources

Resource Documents
 Batch Registration, Authorization Discharge and Claim Guides
 EDI Resource Document – E-Support Services for ProviderConnect
and Electronic Claims (PDF)

The Georgia Collaborative ASO Provider Handbook 2
Effective: December 1, 2015

 ICD-10 Diagnosis Code List

 Individual Rights

 Provider Summary Voucher Form Sample (PDF)

 DBHDD Provider Manuals for Community Behavioral Health and
Community Developmental Disabilities Providers

The Georgia Collaborative ASO Provider Handbook 3
Effective: December 1, 2015

OVERVIEW

Welcome to the Georgia Collaborative Administrative Services Organization (Georgia Collaborative),
which assists the Georgia Department of Behavioral Health & Developmental Disabilities’ (DBHDD) in
its management of services and supports to Georgians. The Georgia Collaborative’s Provider Handbook
is designed to provide guidance on how your organization will work with the Georgia Collaborative to
provide high quality care to some of Georgia’s most vulnerable citizens. We expect this provider
handbook, in addition to the information contained on the Georgia Collaborative’s website
(www.georgiacollaborative.com) and links to other resources, will provide you with the tools necessary
to ensure your success in providing high quality care that leads to lives of independence and recovery
for the Individuals we serve.

DBHDD provides direction to providers via the contracts and agreements with the Department as well
as the policies posted on DBHDD PolicyStat and the Provider Manuals. This handbook outlines the
requirements and procedures applicable to providers in DBHDD’s provider network as administered by
the Georgia Collaborative.

Italicized terms are terms included in the Glossary section of this Handbook located in Appendix 1.

Forms referenced in this Handbook are available for download or printing through the ‘Provider’ section
of the website.

Changes and updates to this Handbook, educational materials, news and other online services are
posted and/or available through the ‘Provider’ section of the website. Changes and updates become
effective as indicated on the document or as required to be in compliance with statutory, regulatory
and/or accreditation requirements to which the Georgia Collaborative is or may be subject.

Links to the website, other information and forms referenced throughout this Handbook are included for
convenience purposes only and such information and/or forms may be subject to change without notice.
Providers should access and download the most up-to-date information and/or forms from the website
at the time needed.

Questions, comments and suggestions regarding this Handbook should be directed to the Georgia
Collaborative Provider Relations Department via email at
[email protected].

ABOUT THE GEORGIA COLLABORATIVE ASO

The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) awarded a
contract to ValueOptions, Inc., a Beacon Health Options company (Beacon), to provide an administrative
services organization (ASO) for the Department. ValueOptions provides state of the art technologies to
support an efficient, accountable, and effective continuum of care to serve Georgians with behavioral
health challenges, and intellectual and developmental disabilities. Operating as the Georgia
Collaborative ASO, we have partnered with longtime healthcare contractors Behavioral Health Link
(BHL) and the Delmarva Foundation (Delmarva). BHL provides telephonic and mobile crisis single-point-
of-entry services for the Georgia Crisis and Access Line (GCAL), as well as first level utilization review
process for state contracted beds and crisis stabilization units. Delmarva conducts Person-Centered
Reviews, Quality Enhancement Provider Reviews and other quality oversight and reporting services
relevant to the IDD quality management system and support.

The Georgia Collaborative ASO Provider Handbook 4
Effective: December 1, 2015

The Georgia Collaborative will provide infrastructure focused on access to services, quality management
and improvement, utilization management and review, data reporting and information technology. The
functions of the Georgia Collaborative satisfy federal and Medicaid requirements associated with both
behavioral health and developmental disability services via the external review and quality management
systems.

In addition to increasing efficiency for DBHDD, the Georgia Collaborative also helps the Department’s
approved providers by reducing unnecessary administrative burdens. The Georgia Collaborative will:

 Integrate access with the authorization process, using Individuals’ recent service histories to
determine the best resources to support current needs in both treatment and recovery models.
The Georgia Collaborative will also integrate authorization and claims systems in order to
efficiently process electronic submissions.

 With appropriate permissions from Individuals in care, share information between providers to
encourage partnerships and to provide informed coordination of care based on treatment goals.

 Provide easy access to information and data that will help providers manage their own
performance.

 Create a single information system for behavioral health and IDD services to improve efficiency
for providers who serve populations with dual diagnoses.

 Provide focused utilization management for intensive services and a streamlined process for less
intensive services (behavioral health).

The Georgia Collaborative will also assist Individuals with intellectual and developmental disabilities and
their families in their respective communities. Delmarva Foundation, a collaborative partner, will provide
expertise around utilization review, quality assurance, and quality review for programs serving
Individuals with developmental disabilities. Their guidance will enhance our effort to support choice,
community integration, person – centered practice and Individual rights of those we serve.

Beacon and the Georgia Collaborative are major proponents of the “Recovery and Resiliency Model”
philosophy of delivering integrated services to Individuals with long term behavioral health needs. The
Georgia Collaborative endorses individual self-help groups, educational programs, drop-in centers,
advocacy programs and other individual-led activities that help Individuals to become actively involved
in achieving their personal goals within their respective communities.

The review activities of the Georgia Collaborative utilization management program includes
determinations of:

a) Medical necessity
b) Preauthorization
c) Certification
d) Concurrent review
e) Retrospective review
f) Care / case management
g) Discharge planning
h) Coordination of care

The Georgia Collaborative utilization management program includes processes to address:
a) easy and early access to appropriate treatment

The Georgia Collaborative ASO Provider Handbook 5
Effective: December 1, 2015

b) working collaboratively with participating providers in promoting delivery of quality care according
to best practice standards;

c) identification of high – risk needs for intensive care management and
d) Screening, education and outreach.

Decisions are based on objective clinical criteria and treatment guidelines supplied by provider and/or
Individual. Beacon and the Georgia Collaborative do not offer rewards or incentives, financial or
otherwise, to its utilization management staff, contractors, providers, Clinical Care Managers (CCMs),
Peer Advisors or any other Individuals or entities involved in making decisions. These decisions include
medical necessity, any action resulting in denial of coverage or service or intended to encourage
determination that results in underutilization.

Contact information is located in the “Contacts” section of this Handbook. Additional information about
locations, email addresses, and toll-free numbers of the Georgia Collaborative ASO and Beacon offices
are conveniently located on the Contact page of the website.

CONTACT INFORMATION

Administrative Appeal To request an administrative appeal, call the toll free number included
on the administrative denial letter received.

Changing your Providers may update the following demographic information via
Provider Mailing ProviderConnect:
address, email,
telephone or fax  Mailing Address
information  Telephone
 Email
 Fax
Any other changes, refer to the Provider Enrollment section on the
Collaborative website. This includes:
 Service Location Changes or Additions
 Addition of Services

Claims and Encounters State-Funded Claim Submission beginning December 1, 2015:
for State Funded
Services for Behavioral For technical questions related to submitting a claim via
Health ProviderConnect or using ValueOptions’ EDI Claims Link® software,

please contact the EDI Help Desk at:

 Telephone: 888.247.9311 from 8 a.m. – 6 p.m. ET
 Fax: 866.698.6032
 E-mail: [email protected]

Clinical Appeals To request a clinical appeal on an Individual’s behalf, call the toll-free
number included on the adverse determination.

Clinical Contacts PASRR Fax: 855.858.1965
PASRR Email: [email protected]

Clinical Phone: 855.606.2725

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Effective: December 1, 2015

Care Coordination Fax: 855.858.1966

Inpatient Fax: 855.858.1967
Inpatient Email: [email protected]

PRTF / CBAY Fax: 855.858.1968
PRTF / CBAY Email: [email protected]

Outpatient Community Based Services Fax: 855.858.1969

Complaints/Grievances Contact the Georgia Collaborative ASO Customer Service at
855.606.2725, Monday through Friday, between 8:00 a.m. and 6:00
p.m. ET.

Provider Enrollment To obtain information pertaining to enrollment application status or
Status/Provider your 9 digit alpha-numeric (GAC123456) Connects ID contact our
Identification Numbers National Provider Services Line at 800.397.1630 between 8 a.m. and
8 p.m. ET, Monday through Friday or email
[email protected].

Fraud, Waste and Bernadette Calhoun, Compliance Officer
Abuse Email: [email protected]
Phone: 404.836.1679

Report by Mail:
Beacon Health Options
Attn: Compliance Officer
229 Peachtree Street NE
International Tower, Suite 1800
Atlanta, Georgia 30303

Report by Email or Phone:
[email protected]
Phone: 888.293.3027

Georgia Office of the State Inspector General:

Report by Mail:
Office of Inspector General
Attn: Special Investigations Unit
2 Peachtree Street, NW 5th Floor
Atlanta, GA 30303

Report by E-mail:
[email protected] or
[email protected] or
Report fraud using online form.

Individual Eligibility, Behavioral Health providers with questions about Individual eligibility,
Registrations and
registrations, or benefits can submit an inquiry via ProviderConnect by
selecting the “Eligibility and Benefits” option. For questions about

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Effective: December 1, 2015

Authorizations for authorization status, providers can select the “Review an
Behavioral Health Authorization” option via ProviderConnect

Individual Customer Columbus Information Systems will continue to support Intellectual
Service and Developmental Disability providers for these activities until a date
to be determined in 2016.

To reach Individual Customer Service, call 855.606.2725 between 8
a.m. and 6 p.m. ET, Monday through Friday.

PROVIDER ENROLLMENT

The Georgia Collaborative will manage the application process for providers seeking approval by the
state of Georgia. DBHDD has retained provider contracting and final approval for those providers and
agencies seeking to enroll as a provider for DBHDD. The Georgia Collaborative enrollment processes
for new providers seeking to contract with DBHDD or those seeking to contract additional locations
and/or services are designed to comply with DBHDD standards as well as other state and/or federal
laws, rules and regulations. The enrollment process requires formal approval for all behavioral health
and IDD providers, including without limitation, Individual practitioners and agencies (clinics, facilities or
programs).

Providers are reviewed and approved for designated services. Should providers render services for
which they are not approved, authorization and payment are subject to denial. Providers should seek
approval through the Georgia Collaborative enrollment process to add additional services and site
locations to existing contracts with DBHDD, prior to delivery of service to avoid denial and non-payment.

As provided for in DBHDD policy, decisions to approve or deny initial Letters of Intent (LOIs) or
applications and/or to submit a given enrollment application for further review are made by DBHDD and
communicated to Georgia Medicaid as well as the Georgia Collaborative. For further details, please
review the following DBHDD policies:

Behavioral Health: Policy (01-111) https://gadbhdd.policystat.com/policy/1574803/latest/

Intellectual and Developmental Disabilities: Policy (02-701)
https://gadbhdd.policystat.com/policy/1564479/latest/

Providers have the right to: (a) request review of information submitted in support of enrollment
applications; (b) correct erroneous information collected during the enrollment processes; and (c)
request information about the status of enrollment applications. All requests to review information must
be submitted in writing to:

GA Collaborative Enrollment
240 Corporate Blvd, Suite 100

Norfolk VA 23502

Please contact the National Provider Services Line at 800.397.1630, Monday through Friday, 8:00 a.m.
to 8:00 p.m. ET, for additional enrollment process questions.
Additional information, including answers which can be found in our Frequently Asked Questions
document, can be found on the website under the Provider Enrollment section.
Letter of Intent

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Effective: December 1, 2015

The enrollment process for new providers begins with required management attendance of the Provider
Enrollment Forum. Providers must then submit a complete and signed Letter of Intent including all
required supporting documentation. Please visit our website to see when the next Provider Enrollment
Forum is scheduled to occur. A Letter of Intent (LOI) and a list of the required supporting documentation
can be obtained from http://dbhdd.georgia.gov/applications-new-existing-providers or under the
Provider Enrollment section.

LOIs must be typed, then printed and mailed with copies of supporting documents to the following
address:

GA Collaborative Enrollment
240 Corporate Blvd, Suite 100

Norfolk VA 23502

Providers will receive an email from the Georgia Collaborative Enrollment Department
[email protected] within five (5) business days acknowledging receipt of the
completed LOI. Email will be the standard form of communication, therefore it is imperative that the
applicant identify a contact person and supply a correct email address that is regularly checked. This
will ensure receipt of information and timeliness of additional submissions that may be required during
the process. OIs will be reviewed to ensure each Pre-Qualifier is included in submission. The Georgia
Collaborative Enrollment Department will determine if applicants meet all applicable pre-qualifiers set
forth by DBHDD within thirty (30) business days of receipt. During this time, deficiencies will be
communicated to the provider via email. The provider will have five (5) business days to correct identified
deficiencies and return via email to the Enrollment Team. Failure to respond or submit requested
documentation may result in a determination that may close the LOI.

Providers who receive approval of their LOIs will receive an email notification that they may proceed
with submitting an Application. The Application process will mimic the LOI timeframes for review and
approval. Notifications will be sent to the provider via email confirming the next steps in the process
including submission of the provider’s application to DCH to obtain their Medicaid provider number and
scheduling of a site visit. The entire process for a new provider to become contracted with DBHDD,
including their Medicaid application and approval may take from 120 to 180 days depending upon the
volume of applications received.

Failure of a provider to submit a complete and signed enrollment application, including all required
supporting documentation, within the specified amount of time outlined in email notification may result
in rejection of request for participation.

Current DBHDD Contracted Provider Requests to Expand Services or Locations

Contracted DBHDD providers who wish to add services or locations may do so at any time through the
application process and will not be required to attend a Provider Enrollment Forum prior to submitting
their application. The application may be completed online, printed or saved, and then submitted with
all required supporting documentation. An Application for Existing Providers can be obtained from the
Georgia Collaborative website.

All Applications from existing enrolled providers must be typed and emailed to
[email protected] or printed and mailed with copies of supporting documents
to the following address:

GA Collaborative Enrollment
240 Corporate Blvd, Suite 100

The Georgia Collaborative ASO Provider Handbook 9
Effective: December 1, 2015

Norfolk VA 23502

Providers will receive an email from the Collaborative Enrollment Department
[email protected] within five (5) business days acknowledging receipt of the
Application. Applications will be reviewed for required elements. The Georgia Collaborative
Enrollment Department will determine if they meet DBHDD standards for approval within thirty (30)
business days of receipt. Deficiencies will be communicated to the provider, via email. The provider
must correct deficiencies within five (5) business days. Failure to do so may result in closure of
application. Providers who receive approval of application will receive an email notification from the
Enrollment Department, defining next steps in the process, which may include a site visit and DCH
application, if applicable.

Failure to submit a complete and signed enrollment application and all required supporting
documentation within specified timeframe provided in email communication, may result in rejection of
request for addition of services/locations.

Site Visits

As part of approval process, the applicable DBHDD Field Office staff may conduct a structured site visit
of all offices/locations. Site visits include an inspection using DBHDD site and operations standards.
Providers will be notified via email with instructions from the Enrollment Department if they are required
to schedule a site visit. Site visit must be scheduled by provider with Regional Office within fourteen (14)
days receipt of notice. DBHDD Regional Field Office has thirty (30) days to complete inspection and
submit to [email protected].

Provider Profile File Maintenance

Change of Information

All providers are required to report changes to the Georgia Collaborative to maintain provider files for
DBHDD. The Change of Information form must be submitted along with DCH Change of Information
form for approved Medicaid services. Providers are asked to notify
[email protected] at least thirty (30) days prior to a planned change when
practical. Changes that need to be reported are:

 Current Provider Identification (Required)
 New Agency Name/Location/Name Information
 New Address/ Telephone Number Information (Required)
 Effective Date of Change(s) (Required)
 Expiration, non-renewal and/or decrease Commercial Comprehensive/General Liability

coverage (Required)
 Attestation Statement (Required)

Change of Ownership And / Or Change of Entity

Providers who wish to change ownership and/or entity must submit a request to
[email protected]:

 If same legal entity will remain in place, but ownership will change, submit a Change of
Ownership Request Form

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Effective: December 1, 2015

 Provider will be replaced by different legal entity, provider must submit LOI as new agency
during specified enrollment period

Additional information can be found at https://gadbhdd.policystat.com

Adding a Service

New programs or services offered by an agency provider with an existing DBHDD contract requires
completion of an Agency Existing Application for Continued Participation. Failure of a provider to submit
a complete and signed enrollment application, and all required supporting documentation within
specified time frame outlined in email communication, may result in rejection of the application request
and recommendation of adverse action to the Department of Community Health.

All applications from existing contracted providers must be typed (not handwritten) and can either be
emailed to [email protected] or mailed to the following address:

GA Collaborative Enrollment
240 Corporate Blvd, Suite 100

Norfolk VA 23502

The Georgia Collaborative ASO / Beacon Provider Identification Numbers

Once approved, the Georgia Collaborative ASO provider number is nine (9) digit number comprised of
a unique six (6) digit number with a three (3) letter contract prefix (e.g. GAC123456) assigned by Beacon.
The provider number identifies a provider in the Connects system and is used for giving access to
ProviderConnect (pg. 17), an easy online portal that providers can use to complete everyday request 24
hours a day/7days a week. The provider number is on file with Beacon. Providers should contact
Beacon’s National Provider Services line at 800.397.1630 during normal business hours Monday
through Friday, 8 a.m. to 8 p.m. ET for questions regarding Provider Identification Numbers and/or for
assistance in obtaining a Provider Identification Number. Existing providers were given this unique
number when loaded into Beacon system. New Providers will be assigned number when invited to join
Provider Network.

The provider’s service location vendor number is a number that identifies where services are or were
rendered. A provider may have multiple vendor locations and each vendor location is given a five-digit
number preceded by two (2) letters. (e.g. GA23456).

The pay-to vendor number is a vendor number issued by Beacon and indicates the mailing address for
all payments and also when using our electronic payments service through PaySpan Health. A provider
can have more than one pay-to vendor number and each number needs to be registered with PaySpan.

The National Provider Identifier (NPI) is different from what Beacon calls the provider number. The NPI
is a unique 10-digit identification number issued to health care providers in the United States by the
CMS. The NPI is a single provider identifier that replaces the different identifiers used in standard
electronic transactions. HHS adopted the NPI as a provision of HIPAA. This number is also contained
in the Connects system and can be used to locate a provider record for claims, referrals and
authorization purposes with in ProviderConnect.

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Effective: December 1, 2015

Policies & Procedures

Pursuant to the terms of the provider’s agreement and/or contract with DBHDD providers must comply
with DBHDD’s standards, policies, and procedures and the Georgia Collaborative’s policies and
procedures as outlined in this Handbook.

As more specifically detailed in other sections of this Handbook, the Georgia Collaborative maintains
continuous quality improvement and utilization management programs that include policies and
procedures and measures designed to provide for ongoing monitoring and evaluation of services
rendered to individuals (e.g., clinical review criteria, , Individual and provider surveys, quality reviews,
evaluations and audits). Provider involvement is an integral part of these programs. Providers must
cooperate with and participate in the Georgia Collaborative’s quality improvement and utilization
management programs and activities.

Individual’s Rights & Responsibilities

The Individual’s Rights and Responsibilities’ Statement is available in English and Spanish for
download from the DBHDD website

Please see:

Policy 24-103: Patient and Clients’ Rights:
https://gadbhdd.policystat.com/policy/303970/latest/

Policy 02-1101: Human Rights Council for Developmental Disabilities Services:
https://gadbhdd.policystat.com/policy/147874/latest/

Access to Individualized Recovery Plans & Individualized Service Plans

The Georgia Collaborative may request access to and/or copies of Individualized recovery Individual
plans and/or Individualized service plans to conduct reviews:

1. on a random basis as part of continuous quality improvement and/or monitoring activities;
2. as part of routine quality and/or billing audits;
3. as may be required by DBHDD;
4. in the course of performance under a client contract;
5. as may be required by a given government or regulatory agency;
6. in response to an identified or alleged specific quality of care, professional competency or

professional conduct issue or concern;
7. as may be required by state and/or federal laws, rules and/or regulations;

The Georgia Collaborative record standards and guidelines for Individual record reviews conducted as
part of quality management activities are set out in the quality management section of this Handbook.

Unless otherwise specifically provided in the contract or agreement with DBHDD, access to and any
copies of Individual treatment records requested by the Georgia Collaborative or designees of the
Georgia Collaborative shall be at no cost.

Providers will grant access for the Georgia Collaborative and/or designees of the Georgia Collaborative
to the Individual’s medical records upon written request and with appropriate identification.

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Effective: December 1, 2015

Confidentiality, Privacy & Security of Identifiable Health Information

Providers and their business associates interacting with the Georgia Collaborative staff should make
every effort to keep protected health information secure. If a provider does not use email encryption, the
Georgia Collaborative recommends sending protected health information to Beacon through an inquiry
in ProviderConnect or by secure fax.

This expectation does not in any way relieve the provider of reporting in accordance with DBHDD Policy
regarding HIPAA.

Covered Services

Pursuant to the terms of the contract or agreement with DBHDD, providers are approved to provide
identified covered services to Individuals. Covered services should be rendered in: (a) the same manner
as services rendered to other Individuals; (b) accordance with the DBHDD Provider Manual, (c) accepted
medical standards, (d) all applicable state and/or federal laws, rules and/or regulations; and (e) a quality
and cost-effective manner.

Contracted Behavioral Health providers:
 Provide continuous care for Individuals or arrange for on-call coverage by other Georgia
Collaborative ASO providers.
 Adhere to the accessibility and availability standards established by contracted entity
 Provide services to Individuals in a non-discriminatory manner, regardless of source of
payment or coverage type.
 Update demographic, office and/or provider profile information via Email or ProviderConnect
beginning December 1, 2015.
 Notify the Georgia Collaborative of potential inpatient discharge challenges
 Notify the Georgia Collaborative of Individuals who may be candidates for potential Care
Coordination.
 Coordinate care with an Individual’s other health/medical care provider(s), either behavioral,
intellectual and development disability and/or medical providers who are treating the same
or related (co-morbid) conditions.
 Refer Individuals to other providers when alternative or different services are required
 Upon written request by the Georgia Collaborative, submit copies of Individualized recovery
plans or Individualized service plans without charge (unless otherwise expressly provided for
in the DBHDD provider agreement or contract).
 Make resources available to Individuals who require culturally, linguistically, and/or disability
competent care (as indicated in the Provider Manual).

Referrals

Providers of inpatient services will only receive referrals from the Georgia Crisis and Access Line (GCAL)
via the BHL Web Electronic Referral Status Board. Prior authorization numbers will be given to the
inpatient provider at the time of the Individual’s acceptance for inpatient care on the electronic board.

Providers needing to refer an Individual for other community services should access “Find a Provider”
on the website. This application is a provider directory intended for informational purposes with regard
to referrals within the DBHDD provider network.

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Effective: December 1, 2015

Coordination with Primary Care/Treating Providers

As part of care coordination activities, providers should identify all providers involved in the medical
and/or mental health, intellectual and developmental disabilities, and substance use support and
treatment of an Individual. Subject to any required consent or authorization from the Individual, providers
should coordinate the delivery of care to the Individual with these providers.

Fraud, Waste and Abuse

The Georgia Collaborative interacts with employees, clients, vendors, providers and Individuals using
standard clinical and business ethics seeking to establish a culture that promotes the prevention,
detection and resolution of possible violations of laws and unethical conduct. In support of this, the
Georgia Collaborative’s compliance and anti-fraud plan was established to prevent and detect fraud,
waste or abuse in the behavioral health system through effective communication, training, review and
investigation. The plan which includes the ValueOptions code of conduct, is intended to be a systematic
process aimed at the monitoring of operations, subcontractors’ and providers’ compliance with
applicable laws, regulations, and contractual obligations, as appropriate. Providers are required to
comply with provisions of the ValueOptions code of conduct where applicable, including without
limitation cooperation with claims billing audits, post-payment reviews, benefit plan oversight and
monitoring activities, government agency audits and reviews, and participation in training and
education. The ValueOptions code of conduct is accessible on the website.

ELECTRONIC RESOURCES

ProviderConnect

Links to information and documents important to providers are located on the Provider section of the
website.

ProviderConnect is a secure, password protected site where contracted providers conduct certain online
activities for the Georgia Collaborative ASO directly with ValueOptions, a Beacon Health Options’
company, twenty-four (24) hours a day, seven (7) days a week (excluding scheduled maintenance and
unforeseen systems issues).

 registration
 authorization requests for all levels of care
 concurrent review requests and discharge reporting
 single and multiple electronic claims submission
 claim status review for electronic claims submitted through the Georgia Collaborative
 verification of eligibility status
 submission of inquiries to Customer Service
 updates to practice profiles/records
 electronic access to authorization letters from the Collaborative and provider summary vouchers.

ReferralConnect is a web-based application that enables individuals, families and providers to locate
DBHDD providers/agencies through a searchable online database. Users of this application can
search for providers and agencies who meet the individual needs including within an acceptable
driving distance.

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Effective: December 1, 2015

Access to ReferralConnect for the Georgia Collaborative is located at the following URL:
https://www.valueoptions.com/referralconnect/doLogin.do?j_username=gacm&j_password=gacm
or through the website link.

GeorgiaCollaborative.com

The Georgia Collaborative ASO website (www.GeorgiaCollaborative.com) contains information about
the Collaborative and its business. Links to information and documents important to providers are
located in the For Provider section on home page. In addition, this site will include many links to external
stakeholder sites, such as ValueOptions.com. (ValueOptions is a Beacon Health Options’ company).

Appendix 2 contains a list of forms and documents available for download or printing through the ‘For
Provider’ section of the website.

Access to ProviderConnect and Achieve Solutions® is available here as well.

Beacon’s Notice of Privacy of Practices regarding use of the ValueOptions’ website is located on the
website.

Please note, the ValueOptions.com Terms and Conditions, including but not limited to limitations on
liability and warranties, apply to the installation and use of, and any technical assistance related to the
installation or use of this software. Technical assistance includes but is not limited to any guidance,
recommendations, instructions or actions taken by ValueOptions or its employees, including where such
activity is performed directly on your system, device or equipment by a ValueOptions, Inc. employee or
other representative.

Achieve Solutions

Achieve Solutions is an educational behavioral health and wellness information website. This website is
educational in nature and is not intended as a resource for emergency crisis situations or as a
replacement for medical care or counseling.

Intellectual and Developmental Disabilities

With the numerous websites available regarding Intellectual and Developmental Disabilities (IDD), it
can be difficult to find what you are looking for or to know which site contains good information. To
assist with this, on the Collaborative’s website, there is a section for individuals with IDD and their
families and other stakeholders to access a number of web resources that may be helpful. They can
be found at the following link: http://www.georgiacollaborative.com/individual/ind_resources.html.

The resources include information specific to Georgia and national organizations. Each are
categorized such as Health, Employment, Technology, Safety, Person Centered Planning and others.
Each resource has a brief explanation of the type of information contained on the website.

Bhlweb.com

Bhlweb.com is a secure, HIPAA-compliant website used to facilitate referrals to Mobile Crisis Teams for
behavioral health and developmental disabilities, Crisis Stabilization Units, State Contracted Inpatient
Beds and State Hospitals.

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Referrals to all of these levels of care require referral through bhlweb.com or through the Georgia Crisis
and Access Line with the exception of walk-ins to Crisis Stabilization Units and Third Party Affidavits
(Orders to Apprehend) issued by Probate Court.

Technical support for bhlweb.com users is available 24 / 7 via [email protected].

ACCESS TO SERVICES

Individuals can access DBHDD funded services directly through the provider they choose or through the
Georgia Crisis and Access Line (GCAL) 24/7 at 1.800.715.4225. DBHDD has policies in place that
address contractual expectations related to access to services for Individuals and sets forth acuity
guidelines to specify timeframe expectations based on the urgency of the Individual’s needs.

Comprehensive Community Provider (CCP) Standards for Georgia’s Tier 1 Behavioral Health
Safety Net, Policy 01-200

Community Medicaid Provider (CMP) Standards for Georgia's Tier 2 Behavioral Health Services,
01-230

When accessing care through the Georgia Crisis and Access Line (GCAL), clinicians use the acuity
guidelines listed below to guide decisions related to the severity of an Individual’s symptoms and

appropriate timelines for receipt of care.

Acuity Guidelines

Emergent A life threatening condition exists as caller presents: For an Emergency
 Suicidal/homicidal intent Crisis:
 Actively psychotic  Immediately
 Active withdrawal (Alcohol, Benzos, Barbiturates)
 Disorganized thinking or reporting hallucinations which arrange to be seen
within 2 hours
may result in harm to self/others  If suicidal/homicidal
 Imminent danger to self/others with means, call
 Unable to care for self 911/Police
 If active withdrawal,
Urgent  No suicidal/homicidal intent send to nearest ER
 Denies suicidal plan/means/capability for medical
 Expresses hopelessness, helplessness, sense of clearance

burdensomeness, disconnectedness or anger For Severe Situation:
 May develop suicidal intent without immediate help  Offer Mobile Crisis
 Potential to progress to need for emergent services  Offer an urgent
 May express distress/impairments that compromise
appointment in no
functioning, judgment and/or impulse control later than 3
 May have withdrawal signs/symptoms from non-life calendar days
 Instruct caller to re-
threatening substances: Cocaine, Methadone, Heroin contact BHL if
condition worsens

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Routine  Dependence on Alcohol, Benzodiazepines or For Distressed Caller:
 Assist in identifying
Barbiturates, but not in active withdrawal and no history
a provider and
withdrawal seizures or DTs warm transfer to the
 Impacts caller’s ability to participate in daily living provider during
 Markedly decreased the caller’s quality of life business hours or
 Caller acknowledges some distress/concerns give the phone
 No evidence of danger of harm to self/others number after hours
 No marked impairments in judgment or impulse control Re-contact
 Severity warrants assessment and possibly services BHL/GCAL if
 SA issues with possibility of substance dependence condition worsens

Provider Interface with GCAL

Emergent Services
When GCAL identifies an Individual with emergent needs, a referral may be made for Mobile Crisis
Response Services (MCRS), Crisis Stabilization Unit, Behavioral Health Crisis Center walk-in
evaluation, connection to ACT team (if the Individual is already enrolled in ACT), State-Contracted
Inpatient Facility, or State Hospital. All communications between GCAL and the agency being referred
to are made electronically, in real-time using bhlweb.com and tracked until the provider confirms receipt
of services by the Individual.

Urgent Services
Individuals requiring urgent services are Individuals who need connection to a provider within 72 hours.
If an Individual is already enrolled with a provider, GCAL will recommend reconnection and notify the
provider of the Individual’s call to GCAL using a secure alert email with the triage of the situation
addressed attached. All Tier 1 and Tier 2+ providers are required to provide electronic urgent
appointment slots with the agency for GCAL’s use. GCAL will document the distribution of those
appointments, by sending an alert email at the time the appointment is made with the triage attached.

Routine Services
Individuals identified as needing routine services will be given a choice of providers. During business
hours, GCAL will warm transfer the caller to the identified agency access point to secure an
appointment. After hours, GCAL will give the Individual the agency phone number to contact on the
next business day. In both cases, GCAL will place the triage on an access table on bhlweb.com for
the provider to access the reason for referral and initial clinical information when the Individual arrives
for services.

CLINICAL SERVICES

Utilization Management

The Georgia Collaborative’s utilization management program encompasses management of care from
the point of entry through discharge using objective, standardized, and widely-distributed clinical
protocols. Intensive utilization management activities may apply for high-cost, highly restrictive levels of
care and cases that represent clinical complexity and risk. Behavioral Health providers are required to
comply with utilization management policies and procedures and associated review processes.

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Providers of Intellectual Developmental Disabilities (IDD) services currently do not engage with the
Georgia Collaborative’s utilization management program. Utilization of IDD services will remain with the
DBHDD Field Offices.

Examples of review activities included in the Georgia Collaborative’s utilization management program
are determinations of medical necessity, pre-authorization, concurrent review, retrospective review,
discharge planning and coordination of care.

The Georgia Collaborative’s utilization management program includes processes to address:
1. easy and early access to appropriate treatment;
2. working collaboratively with providers in promoting delivery of quality care according to
accepted best-practice standards;
3. addressing the needs of special populations, such as children, Individuals with IDD or other
comorbid conditions and the elderly; (d) identification of common illnesses or trends of illness;
4. identification of high-risk cases for care coordination; and
5. prevention, education and outreach (PE&O).

Crisis and urgent/emergent services may be accessed by contacting GCAL at 1.800.715.4225. For non-
crisis situations (routine services), at the beginning of treatment for Individuals, providers must contact
the Collaborative by using ProviderConnect to verify Individual eligibility, registration of the Individual
and obtain authorization (where applicable). Alternatively this process can be completed through the
batch process for those services where batch submission is established.

In order to verify Individual eligibility, the contracted provider will need to have the following information
available: (i) the Individual’s name, (ii) date of birth, (iii) Individual identification number (CID), and (iv)
information about other or additional insurance or health benefit coverage. Based on the most recent
data provided by DBHDD & Medicaid eligibility files, the Georgia Collaborative ASO will: (1) verify
Individual eligibility; and (2) identify eligibility for services and associated funding. Note: Verification of
eligibility and/or identification of benefits is not a clinical process, authorization nor guarantee of
payment.

Clinical Review Process

Provider cooperation in efforts to review care prospectively is an integral part of care coordination
activities. Subject to the terms of DBHDD’s provider requirements and applicable state and/or federal
laws and/or regulations, providers must register the Individual and request authorization from the
Georgia Collaborative. Providers should have an initial and/or concurrent authorization prior to a request
for claims payment. The Georgia Collaborative may request clinical/rehabilitative information at various
points to ensure the ongoing need for services is appropriate and effective in improving outcomes for
Individuals.

In all cases, providers are encouraged to contact the Georgia Collaborative when initiating any non-
emergency treatment to verify Individual eligibility and registration, or for any needed clarification
including the prior authorization requirements for the proposed service.

For a non-crisis service, a registration is completed and a prior authorization request is submitted via
ProviderConnect or via batch submission. In many cases the request will be electronically reviewed and
authorized for the service or services requested. Other services or continuation of previously authorized
services may be sent to a Clinical Care Manager (CCM) for review. The CCM reviews the information
submitted and assures all required documentation is provided. Additional information may be requested
as needed. Once the information is completed, the CCM determines whether the services and treatment
meets criteria for medical necessity. The CCM may authorize levels of services that are specified as

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covered services in DBHDD Provider Manual for Community Behavioral Health Providers (e.g., acute
inpatient, residential, intensive outpatient, etc.) for the fund(s) for which the Individual is eligible.
Authorizations are for a specific number of services/units of services/days and for a specific time period
based on the Individual’s clinical needs and the guidelines as outlined in the Manual.

Prior to initial determinations of medical necessity, providers should verify the Individual’s eligibility for
Medicaid, Medicare or other funding sources. Verifying the member’s eligibility will facilitate a smoother
process in determining services under each funding source.

When a provider requests a retrospective review for services previously rendered, the Georgia
Collaborative will first determine whether such a retrospective review is available under DBHDD policy.
In cases where a retrospective review is available, services will be reviewed as noted above. In cases
where a retrospective review is not available under the guidelines, the provider will be informed of this
status. These service requests must meet medical necessity criteria and may require additional
information and/or the complete clinical record to be submitted to the Georgia Collaborative.

Clinical Care Manager Reviews

Discussions with providers in the course of the review process will address deviation from the best
practice guidelines for the respective conditions including over or underutilization of services, differing
types of care or intensity of service. CCMs will promote Individual engagement in the plan of care
process, a recovery orientation, and identification of natural supports in addition to the services provided.
In addition, the CCM’s will coach the provider by encouraging, on a case-by-case basis, consistent
application of these best practice guidelines. Over time provider specific reporting can be used to
identify providers who appear to be outliers, based on the in the Quality of Care provided who may
benefit from additional training and technical assistance.

Clinical Criteria / Medical Necessity

The clinical criteria used by the Georgia Collaborative to make admission, level of care, and continuing
service decisions reflect DBHDD’s and the Georgia Collaborative’s philosophy and clinical values. To
determine the appropriate level of care during a review the Clinical Care Manager (CCM) evaluates the
pertinent clinical information relative to the level of care (or service) criteria.

The Georgia Collaborative reviewers, Clinical Care Managers, Peer Advisors, and other Individuals
involved in the Georgia Collaborative’s utilization management processes, determine medical necessity
based on the most recent version of the Georgia DBHDD Provider Manual for Community Behavioral
Health Providers. PRTF and CBAY criteria is based on the most recent version of the Georgia DBHDD
PRTF / CBAY policy.

Access to current clinical criteria is available on the Georgia DBHDD website. Access to service criteria
may be obtained through the following link: http://dbhdd.org/files/Provider-Manual-BH.pdf.

Urgent / Emergent Services

Initial Authorizations

Providers seeking initial authorizations for urgent / emergent services can request these DBHDD
funded services directly through the Georgia Crisis and Access Line (GCAL) 24/7 at
1.800.715.4225. GCAL clinicians use medical necessity guidelines listed above to guide
decisions related to the severity of an Individual’s symptoms, appropriate timelines for receipt of

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care, and known strengths and natural resources. The following are some of the levels of care
that might be recommended for an Individual to receive an admission assessment.

Crisis Stabilization Units (CSUs)

Admissions to CSUs must be reviewed clinically and pre-certified through a GCAL clinician. As
of December 1, 2015 all BHCCs, CSUs, State Contracted Hospitals and State Hospitals will use
the electronic resources on www.bhlweb.com for referrals and bed tracking. All facilities will
receive referrals via www.bhlweb.com on either the CSU/State Contract Bed Referrals Status
Boards, BHCC Notification Boards, and State Hospital Notification Boards. These applications
are in electronic communication with the CONNECTS platform, allowing all data to come together
for the benefit of continuity of care and higher level analysis. Effective during the first quarter of
FY 2016, all referrals from outside entities are to be made through GCAL. CSUs attached to
CSBs can and should admit directly from their own clinics and own field staff (i.e. ACT staff, IFI
staff). BHCCs, state hospitals, and CSUs can and should admit walk-ins who meet criteria.

Additional information may be found at the following links:
CSU: Operation Scope of Services
Medical Evaluation Guidelines and Exclusion Criteria for Admission to State Hospitals and CSUs

The utilization request for admissions to a contracted inpatient facility must be reviewed clinically
and pre-certified through a GCAL clinician. Because of the limited access to this benefit, all
referrals for inpatient admissions or state hospital beds for adults must go through GCAL. Prior
to an Individual being admitted for an inpatient level of care, the Georgia Collaborative will work
to refer the Individual to available CSU resources in the region and to coordinate care via the
Individual’s provider for those being served by ACT, CST, or IFI teams. GCAL will provide the
initial authorization decision and will follow up with an authorization number that should be
included with the claims submission.

Concurrent Reviews

A concurrent review refers to all reviews after the initial authorization is requested and approved
for a service. Providers seeking concurrent authorizations for urgent / emergent services can
request these via batch or ProviderConnect. Providers are encouraged to be as thorough and
precise as possible with completing the required data fields in ProviderConnect. Should the CCM
need additional information to make the determination, a phone call will be made to the
requesting facility.

Concurrent CSU requests can be submitted via batch or ProviderConnect. Any request for
concurrent services must be submitted on or just before the last authorized day for clinical review.
All concurrent requests for CSU level of care will be reviewed. Reviews will be completed within
four (4) business hours of receipt of the request. If the information necessary to make a
determination is not made available or does not appear to meet medical necessity, the request
will be escalated for additional review.

Concurrent reviews for State contracted beds should be submitted via ProviderConnect on the
last covered day for clinical review. All concurrent requests for contracted inpatient reviews will
pend for CCM review. Reviews will be completed within four business hours of receipt of the
request. If the information necessary to make a determination is not made available or does not
appear to meet medical necessity the request will be escalated for additional review.

Authorization Determination Timeframes

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Level of Care Type of Review Standard
Inpatient, CSU, Initial
Residential Detox 30 minutes from time of complete info, 120
Initial minutes total from initiation of peer review
PRTF Concurrent process
Inpatient, CSU, 5 business days including time for peer review
Residential Detox Concurrent
PRTF 4 business hours, max of 2 hours additional from
Retrospective initiation of peer review process
Inpatient, CSU, (Individual no 5 business days inclusive of peer review process
Residential, PRTF longer in if indicated
treatment) 30 calendar days from receipt of request for
All Outpatient Initial review; Notification: written notice to provider and
the Individual within decision timeframe
All Outpatient Concurrent
5 business days inclusive of peer review process
if indicated
5 business days inclusive of peer review process
if indicated

Definitions: Initial Review refers to the first review for the service. Concurrent Review refers to all reviews
after the initial. Retrospective Review refers to a review request after an Individual has been engaged
in services for some period of time OR is no longer in treatment for that service.

Psychiatric Residential Treatment Facility (PRTF) / Community Based Alternatives for Youth
(CBAY)

PRTF is a separate, stand-alone entity providing a range of comprehensive services to treat the

psychiatric condition of youth in an intensive residential structure under the direction of a physician; the
purpose of the service is to improve the resident’s condition or prevent further regression so that services

are no longer necessary. Medical necessity criteria for this level of care is outlined in DBHDD contract

and policy documents.

Initial Authorizations

Admissions to a PRTF / CBAY level of care must be reviewed clinically and pre-certified through
a CCM clinician. DBHDD CSUs and providers treating a child who appears to be in need of PRTF
level of care may complete a PRTF referral by submitting the necessary documentation through
ProviderConnect. Once all documentation is received and complete, a medical necessity
determination will be made within five (5) business days by the medical director and the clinical
UM team. Requesting providers will be notified via ProviderConnect of the referral outcome. The
referring provider should use that information to coordinate admission to a PRTF / CBAY
provider. Once the PRTF or CBAY provider agrees to admission, the PRTF or CBAY provider
will submit an admission request to the Georgia Collaborative. This request will be reviewed by
a CCM to confirm that an initial level of care review was completed and the youth was pre-
certified for PRTF/CBAY level of care and the admission falls within the 30 day allowable time
frame. Once confirmed, an authorization will be issued. This process will be completed within
five (5) business days of the request.

PRTF Concurrent Reviews

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Concurrent reviews should be submitted via ProviderConnect. Any request for concurrent
services must be submitted five (5) business days before the last covered day for clinical review.
All concurrent requests for PRTF reviews will pend for CCM review. Reviews will be completed
within five (5) business days of receipt of the request. Providers are encouraged to be as
thorough and precise as possible with completing the required data fields in ProviderConnect.
Should the CCM need additional information to make the determination a phone call will be made
to the PRTF facility. If the information necessary to make a determination is not made available
or does not appear to meet medical necessity the request will be escalated for additional review.

PRTF Appeals and Non-authorizations

There may be times when a youth does not appear to meet the admission or continued stay
criteria for PRTF level of care. When this happens the youth, the guardian, the referring provider
and DBHDD will be notified in writing of the outcome and any applicable appeal rights. See Policy
01-105: Denial and Appeals Process for Psychiatric Residential Treatment Facility (PRTF) Level
of Care for Children and Adolescents with a Mental Health Diagnosis

Routine / Intensive (Non-Crisis) Services

All outpatient/community based services should be requested via ProviderConnect or the batch process
after confirming that the Individual is registered and has appropriate funding sources available to support
those services being requested. Services that are available for a given type of care along with
authorization timeframes and max units available for request can be reviewed on the Georgia
Collaborative’s Covered Services and Level of Care Guideline page and in the DBHDD Provider Manual
for Community Behavioral Health Providers. These are guidelines to assist in planning, providers
should request only those services and units they anticipate needing for successful treatment for the
given timeframe.

Initial Authorizations

Algorithms designed in conjunction with DBHDD will determine if the request will be authorized or pend
for CCM review. These algorithms are based on service design, access considerations, and diagnostic
and functional information provided in the authorization request process.

Authorized using algorithm process
Non-Intensive Outpatient Services – (initial and concurrent)
Crisis Services – (initial and concurrent)
Treatment Court – MH - (initial and concurrent)
Treatment Court – AD - (initial and concurrent)

Ambulatory Detox - Initial Auth Only

Addictive Disease Independent Residential - Initial Auth Only

Addictive Disease Semi-Independent Residential - Initial Auth Only
Addictive Disease Intensive Residential – Initial Auth Only
Mental Health Independent Residential – Initial Auth Only
Mental Health Semi-Independent Residential– Initial Auth Only

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Mental Health Intensive Residential

Residential Detox

Women’s Treatment Residential Services - Residential

Women’s Treatment Residential Services Outpatient

ACT – first three concurrent

Case Management

Community Support Team

Intensive Case Management

Psycho-Social Rehab

Substance Abuse – Intensive Outpatient Program

Supported Employment

Providers will need to identify those services that they wish to request for the Individual, keeping in mind
that specific Individual’s needs/preferences and planning for services that may be needed during that
authorization period. For instance, if someone is not initially in Group Counseling, but the goal is to begin
Group Counseling in another month, a provider may want to request that service at the time of the initial
authorization request. Individuals do not progress in a straight linear manner in their treatment and
recovery; therefore, it is best to anticipate some variability in service needs based on the Individual’s
history, trends and available resources and anticipate additional services may be needed to support
their needs. If a request pends for CCM-UM review, the complete submission will be reviewed for medical
necessity with the potential for outreach calls to the provider to clarify the clinical condition and the most
appropriate service for the Individual. If it is determined that a true exception is needed to DBHDD criteria,
Georgia Collaborative leadership will contact DBHDD to determine how best to proceed on a case-by-case
basis.

Concurrent authorization requests should be submitted prior to the expiration timeframe. The concurrent
authorization request can be up to thirty (30) days prior to the expiration date of the existing
authorization. At times, services may be added prior to the next concurrent review timeframe or
additional units will be needed to continue services during the current authorization. In these scenarios,
the provider should request a concurrent review. This will terminate the existing services/authorization
and all services needed for the new concurrent timeframe should be requested to allow for service to
continue without disruption. For Intensive (non-crisis) services, all concurrent requests are pended for
utilization review by a CCM UM staff, regardless of specifics of the clinical presentation or diagnosis
submitted. The request is reviewed in its entirety with adherence to the process and medical necessity
guidelines described in this document.

Intensive (Non-Crisis) BH UM Services
Addictive Disease Independent Residential - concurrent
Addictive Disease Intensive Residential – concurrent
Mental Health Residential Independent – concurrent
Mental Health Residential Semi-independent – concurrent
Residential Detox – concurrent
Women’s Treatment Recovery Services Residential – concurrent

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Assertive Community Treatment– concurrent
Case Management – concurrent
Community Support Team – concurrent
Crisis Respite Apartments – concurrent
Intensive Family Intervention – initial & concurrent
Intensive Case Management - concurrent
Psychosocial Rehabilitation – concurrent
Substance Abuse Intensive Outpatient Program – concurrent
Supported Employment – concurrent

A CCM will review the clinical documentation presented in the request inquiry based on prioritization of
requests received. If the request meets medical necessity based on the review of information provided in
the attached documents and there are not noted exclusions preventing authorization, the CCM authorizes
the services requested. In instances where a review does not meet clinical criteria and/or where questions
arise as to elements of the Individual Recovery and Resiliency Plan, the request and supporting
documentation may be forwarded to a Peer Advisor for review. (See adverse clinical determination
section)

Utilization Trending

The data collected will be used to determine outliers which may call for additional focus from the
Collaborative clinical staff to promote safe, effective, and accountable practice. If high risk indicators are
noted along with a lower level of care service request and no additional higher level of care services are
identified as having been provided to the Individual within a brief time frame, a follow-up outreach call may
be made to first determine the current clinical status of the Individual and then to assist in identifying any
additional treatment needs.

Recovery Planning/ Individual Service Planning

Providers must develop Individualized Recovery Plans for Individuals receiving behavioral health
services and Individualized Service Plans for Individuals receiving IDD services. These plans should
utilize assessment data, address the Individual’s current impairments related to the behavioral health
diagnosis, and actively include the Individual and significant others, as appropriate, in the planning
process. Clinical Care Managers (CCMs) may request and review the plans to assure that the following
are included:

a. Measurable goals and objectives;

b. Use of relevant services;

c. Evidence of appropriate involvement of pertinent community agencies;

d. Discharge planning from the time of admission;

e. Timely and clinically impactful response to interventions; and

f. Documented active involvement of the Individual and significant others as appropriate.

These plans and documentation of interventions and progress towards interventions may be requested
as part of the authorization process when conducting authorization reviews for specific services or in
specific situations.

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Adult Needs and Strengths Assessment (ANSA) / Child and Adolescent Needs and Strengths
(CANS)

The ANSA/CANS functional assessment cumulative data will be used to determine the match between the
services requested and intended population for the service. For example, elements from the ANSA which
indicate that the Individual has significant substance use impairments for Individuals only authorized for
mental health services may be used to suggest providers to address a treatment need in a singular case
or a more generally quality improvement opportunity if found to be specific are of concern for a provider
agency.

Care Coordination Program

The Georgia Collaborative Care Coordination Program is a community-based program designed to
monitor, support, and serve Individuals with behavioral health and/or developmental disability. The
program uniquely targets Individuals with the most complex care needs those experiencing critical
transition periods to best support care coordination with all involved community-based providers. The
Care Coordination Program uniquely targets Individuals by identifying potential Individuals via report
profiling, seeing priority engagement to Individuals with the highest needs, and identifying one of the
specific four types care coordination based on individualized criteria. These are as follows:

1. Data Reporting and Analytics

2. Community Transition Specialists

3. Complex Care Coordination

4. Certified Peer Specialists (specific to Individuals with Behavioral Health conditions)

Data Reporting and Analysis

Data Reporting and Analysis is the monitoring of an Individual’s services and utilization to ensure the
“right care, at the right time”. All Individuals covered under this contract will be monitored for higher level
of care utilization. Other examples of data trending that will take place within the care coordination
program include monitoring length of stay (example: admissions lasting longer than 25 days); over/under
utilization, and Individuals with complex diagnoses.

Community Transition Specialists

The Care Coordination Program’s Community Transition Specialist (CTS) provides outreach and
discharge appointment coordination for targeted individuals to support the transition from a High Level
of Care (HLOC) to subsequent services. We want to recognize that these levels of care transitions
can be significant and the mission of the CTS is to connect the unconnected. CTS will facilitate the
individual’s engagement with a community provider within seven and 30 days post discharge from a
higher level of care. The CTS will outreach to Individuals to assist in coordination of aftercare
appointments to ensure access to care. They may also attend discharge planning meetings to
strengthen transitions, assist Individuals connections with community providers and identify Individuals
with treatment barriers. At every point of contact, a CTS will review an Individual’s progress with an
eye toward current engagement with his/her provider and recovery plan to reduce the risk of the
Individual needing a return to a HLOC. Roles of CTSs provide assistance to Individuals and their
families to obtain appointments and ensure access to care, coordinate with Care Management Entities

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/ Intellectual Developmental Disabilities / Primary Care Physicians, etc. involved with Individuals
should they be a part of the recovery plan, and link to a Specialized Care Coordinator should an
Individual be identified for additional support. For any Immediate Urgent or Crisis situations, the CTS
will link the Individual to all available resources through GCAL to ensure the Individual receives
immediate services to ensure safety.

Inpatient facilities are encouraged to support this service by:

 Using accurate diagnoses when submitting information regarding inpatient treatment. If the
diagnosis on admission is a mental health diagnosis but subsequent evaluation during the stay
confirms that the primary diagnosis is substance use, please use the substance use diagnosis
on information submitted at discharge

 Assisting in scheduling or ensuring that follow-up visits are within seven (7) calendar days of
discharge. NOTE: It is important to notify the providers that the appointment is a post-hospital
discharge and that an appointment is needed in seven (7) calendar days.

Outpatient providers are encouraged to support critical pieces of this measure by:

Making every attempt to schedule appointments within seven (7) calendar days for Individuals being
discharged from inpatient care. Providers are encouraged to contact those Individuals who are “no show”
and reschedule another appointment.

Specialized Care Coordination Services

Specialized Care Coordination is the engagement of licensed mental health clinicians that provide
clinical oversight to vulnerable Individuals with complex clinical histories and/or multiple hospitalizations.
Specialized Care Coordinators (SCC) seek to outreach and engage the entire provider, support, and
community-based service network to best support the system of care around the Individual. Care
Coordination staff will routinely outreach to community-based providers and medical providers to support
the Individual’s recovery, resolve service barriers, and to partner with providers to create innovative
ways to maximize the Individual’s community tenure and recovery.

When requesting this service, please:
1. Discuss the recommendation with the Individual and gain permission for referral to the program

2. Contact the CCM managing the Individual’s inpatient care and refer the Individual for Specialized
Care Coordination

3. Alert the Georgia Collaborative ASO, via the CCM, of the discharge plans and assure any
barriers to a success of the plan are known to the care coordinator

Certified Peer Specialists

Certified Peer Specialists (CPS) are Individuals living with mental health/substance abuse challenges
who are certified in Georgia who have meaningful “lived experience” which allows them to uniquely
connect with Individuals showing by example and mutuality that long-term recovery is attainable. They
are also trained in principles of recovery and resiliency, wrap-around services, and traditional peer
support. The role of the CPS in Community Transition services is:

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 Assist Individuals with identifying barriers to stability and mirror and teach self-advocacy so
Individuals can engage with services and/or supports to reduce those barriers.

 Connect Individuals to community resources and support by identifying both traditional and non-
traditional resources.

 Attend provider meetings, IRP development sessions, and treatment meetings as an ally to the
Individual.

 Provides coaching to the Individual as he/she with applies for resources and services

 Encourage Individuals to focus on their strengths and abilities for long range health and wellness

 Coach Individuals about self-care, medications, and ways to advocate to achieve their stated
goals.

 Facilitate Individuals building a self-directed Wellness Recovery Action Plan (WRAP)

Pre-Admission Screening and Resident Review (PASRR), Level II for Individuals in need of
Nursing Facility Services

The Pre-Admission Screening and Resident Review (PASRR) Level II process is initiated when a Level
I referral identifies that a person may have a mental illness (MI), intellectual/developmental disability
(IDD), or related condition (RC) and evaluates whether the person requires specialized services for MI,
IDD, and/or an RC. The Level I PASRR process and referral for Level II (if indicated) is made through
the Georgia Medical Care Foundation (GMCF)/Alliant. GMCF/Alliant will contact the Georgia
Collaborative when a Level II review is indicated. The Georgia Collaborative will request and gather
pertinent medical records within 24 hours. Once medical records are received by the Georgia
Collaborative, a clinical review is conducted, and outcome determination is made. If there is not enough
detail in the medical record or if clinical indication warrant, a face-to-face evaluation is completed (at the
person’s convenience). Following a scheduled face-to-face evaluation, a determination of nursing
facility level of care and any necessary specialized services is made. The completed Summary of
Findings will be sent to all applicable parties along with the Omnibus Budget Reconciliation Act (OBRA)
code, and any recommendations for specialized services if warranted.

The outcome determination is made within seven (7) business days of receipt of the original referral. In
case of denial, a first level appeal must be submitted to the Georgia Collaborative within ten (10)
business days of receipt of the denial. Results of the appeal will be provided within seven (7) business
days of the receipt of the appeal by the Georgia Collaborative.

A second level appeal for a PASRR Level II decision can also be requested and should be submitted to
the Georgia Collaborative within ten (10) business days. Results of the second level appeal will be
provided within five (5) business days by DBHDD. (See adverse clinical determination section)

Should a request for Specialized Services be also recommended as part of the Level II determination,
PASRR Specialized Service providers may request these services through ProviderConnect. (See using
ProviderConnect).

DETERMINATION TIMEFRAME

Level of Care Type of Review Standard
Nursing Home
Initial 7 business days from receipt of Level II

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Adverse Clinical Determination / Peer Review

If a does not meet medical necessity criteria at the requested level of care, the CCM attempts to discuss
the Individual’s needs with the provider and to work collaboratively with the provider to find an
appropriate alternative level of care. If no alternative is agreed upon, the CCM cannot deny a request
for services. Requests that do not appear to meet medical necessity criteria or present quality of care
issues are referred to a peer advisor for second level review. It is important to note that only a licensed
physician, and/or doctoral level peer advisor (M.D., Psy.D or Ph.D.) can clinically deny an initial request
for services at the same licensure category as the ordering provider. Depending upon the services
requested and the clinical situation, the peer advisor either reviews the available provided information
or may conduct a Peer-to-Peer Review, which involves a direct telephone conversation with the
attending or primary provider to discuss the determination. Through this communication, the peer
advisor may obtain clinical data that were not available to the CCM at the time of the review. This
collegial clinical discussion allows the peer advisor the opportunity to explore alternative treatment plans
with the provider and to gain insight into the attending provider’s anticipated goals, interventions and
timeframes. The peer advisor may request more information from the provider to support specific
treatment protocols and ask about treatment alternatives.

When an adverse determination is made, the treating provider (and hospital, if applicable) is notified
telephonically of the decision and asked to notify the Individual. For those services covered by Medicaid,
PRTF and CBAY level of care determinations, and PASRR Level II an adverse decision letter will be
provided.

All written or electronic adverse determination notices include:
a. The principal reason(s) for the determination not to certify

b. A statement that the clinical rationale (or copy of the relevant clinical criteria), guidelines, or
protocols used to make the decision will be provided, in writing, upon request,

c. Rights to and instructions for initiating an Informal Review of the Denial, including the opportunity
to request an expedited review if applicable, and information about the Fair Hearing process

d. The right to request an Informal Review verbally, in writing, or via fax transmission

e. The timeframe for requesting an Informal Review

f. The opportunity for the Individual and/or provider to submit, for consideration as part of the
Informal Review process, written comments, documents, records, and other information relating
to the case

g. The Individual’s right to request a fair hearing through the state

h. The right of the provider to request a reconsideration within three (3) business days of receipt of
the notice when a medical necessity denial is issued without a Peer-to-Peer conversation having
taken place, or when an administrative denial is issued because of the failure of a provider to
respond to a request for Peer-to-Peer conversation within a specified timeframe

INFORMAL REVIEWS AND FAIR HEARINGS OF ADVERSE DETERMINATIONS

When authorized by the Individual and/or when an Individual assigns rights in writing to a provider, the
provider may request an Informal Review and a Fair Hearing (for Medicaid recipients only) of an adverse

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determination rendered by the Georgia Collaborative on behalf of the Individual. Providers must inform
the Individual of adverse determinations and any subsequent review rights.

Individual rights to subsequent review are limited to those available under the Individual’s funding
source, and include one level of Informal Review, followed by one level of Fair Hearing (if applicable).

The type of Informal Review is based on the nature of the adverse determination. The Individual’s care
circumstances at the time of the request for Informal Review determine the category of review as urgent,
non-urgent, or retrospective. The Individual funding source and applicable state and/or federal laws and
regulations determine the timing of the appeal as expedited, standard, or retrospective. For example, if
a provider requests an Informal Review on behalf of an Individual in urgent care, the review is processed
as an expedited review.

If available by the individual’s funding source, a request for an Informal Review maybe requested. The
Provider and/or the Individual (or the Individual’s authorized representative) can make this request for
up to ten (10) calendar days from the date of the original adverse determination. These requests may
be made verbally, in writing, or via fax transmission.

The Individual’s authorized representative, and/or the provider may submit any information they feel is
pertinent to the review request and all such information is considered in the Informal Review, whether
or not it was available to the Georgia Collaborative’s reviewers during the initial determination.

The date of the request for an Informal Review of the adverse determination is considered the date and
time the request is received by the Georgia Collaborative.

When a provider, Individual, or the Individual’s authorized representative requests an Informal Review
of an adverse determination, the provider may not bill or charge the Individual until all reviews available
to the Individual have been exhausted by the Individual, and/or where applicable by the provider where
the Individual has authorized the provider to pursue the subsequent reviews on the Individual’s behalf.

Written notice of determinations for all Informal Reviews of adverse determinations will be made to the
Individual and the provider where required in accordance with all applicable state or federal laws or
regulations.

Unless otherwise provided for in the applicable state or federal law or regulation, the chart below sets
out the time frames for completion of Informal Reviews of adverse determinations conducted by the
Georgia Collaborative.

Informal Reviews

Standard Informal Review - Upon being assigned a case for review of an adverse
determination, a Peer Advisor will investigate the substance of the review request, including
aspects of the clinical care involved, and review of documents, records, or other information
submitted with the request for the review, regardless of whether such information was also
submitted or considered in the original adverse determination and the applicable clinical criteria.
The Peer Advisor will attempt to contact the provider (or the clinical representative of facility or
program providers) directly to conduct a telephonic review as appropriate. Based on
consideration of all pertinent information, including relevant clinical criteria and guidelines, the
Peer Advisor will make a determination to reverse (i.e., overturn) the original adverse
determination in whole or part, or to uphold the original adverse determination.

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When an adverse determination Informal Review is conducted and completed telephonically, the
Peer Advisor will verbally inform the provider of the determination. If the determination is to
reverse the original adverse determination, the Peer Advisor will identify the length of stay, level
of care and/or number of service units or sessions determined to be medically necessary. If the
determination is to uphold the adverse determination, the Peer Advisor includes any
recommendations for treatment for which medical necessity could be confirmed and information
regarding Fair Hearing.

Expedited Informal Review - An expedited review is a request to review an adverse
determination concerning admission, continued stay, or other behavioral healthcare services for
an Individual who has received urgent services but has not been discharged from a facility, or
when a delay in decision making might seriously jeopardize the life or health of the Individual.
The Georgia Collaborative follows the same determination procedures outlined above for
standard Informal Reviews, but issues the decision and verbal notification for all expedited
reviews within seventy-two (72) hours of the review request. Reviews are conducted by a Peer
Advisor not involved in the original adverse determination. Determinations are communicated by
telephone on the same day as the determination, with written notification sent within seventy-two
(72) hours of the verbal notification.

Retrospective Informal Review - A retrospective Informal Review is one requested after the
Individual has been discharged from the level of care or treatment service under consideration.
Retrospective Informal Reviews of adverse determinations require that the provider send in
specific sections of the treatment record for review. Retrospective Informal Review determination
notices are issued within the decision timeframe and contain the required information outlined
above under ‘Standard Informal Review’ outlined in the chart below.

Final Review Level

Final stages of review may include reviews by medical directors or other review entities and/or
processes. Information about and procedures for such final review level, if any, will be included in notice
of Informal Review determination for the last level of review available before final level.

ADVERSE CLINICAL DETERMINATION TIMEFRAMES

Level of Care Type of Review Standard
Inpatient, CSU, Informal Review Within 72 hours of receipt of the request.
Residential Detox Expedited Notification: Verbal notice to provider and the
(Individual still in Individual within the decision timeframe. written
PRTF treatment) notice to the Individual and provider within 72
Nursing Home hours of the verbal notification
Informal Review 15 days
All Outpatient (Individual still in
treatment) 7 business days from receipt of appeal. Appeal
Informal Review must be received within 10 business days of initial
denial. Level 2 appeal must be received within 10
Informal Review calendar days of level 1 denial upheld and is
completed by DBHDD within 5 business days.
Within 14 calendar days of the receipt of the
request for review Notification: written notice to

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Inpatient, CSU, Informal Review the provider and the Individual within the decision
Residential Detox, (Retrospective, timeframe
PRTF Individual no
longer in 30 calendar days from receipt of request for
treatment) review; Notification: written notice to provider and
the Individual within decision timeframe

DISCHARGE PLANNING

Discharge planning is an integral part of treatment and begins with the initial review. As an Individual is
transitioned from inpatient and/or higher levels of care, the Clinical Care Manager (CCM) will
review/discuss with the provider the discharge plan for the Individual with a focus on promoting the
Individual’s engagement in the recovery process. The following information may be requested and must
be documented:

1. Discharge date

2. Aftercare date

3. Date of first post-discharge appointment (must occur within 7 days of discharge)

4. With whom (name, credentials)

5. Where (level of care, program/facility name)

6. Other treatment resources to be utilized: types, frequency

7. Medications

8. Individual/family education regarding purpose and possible side effects

9. Medication plan including responsible parties

10. Support systems

11. Familial, occupational and social support systems available to the Individual. If key supports are
absent or problematic, how has this been addressed

12. Community resources/self-help groups recommended (note purpose)

13. Medical aftercare (if indicated, note plan, including responsible parties)

14. Family/work community preparation

15. Family illness education, work or school coordination, or other preparation done to support
successful community reintegration. Note specific plan, including responsible parties and
their understanding of the plan.

Providers are expected to complete discharge reviews at the end of treatment. These reviews can be
completed via the batch process or by utilizing ProviderConnect.

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CLAIMS PROCEDURES & ELECTRONIC SUBMISSION

Beacon Health Options processes the claims for DBHDD state-funded services on behalf of the Georgia
Collaborative and maintains claims processing procedures designed to comply with the requirements of
state, and federal rules and/or regulations. Medicaid claims for non-managed care-covered lives
continue to be submitted in accordance with processes set forth by the DCH through its GAMMIS
system.

We strongly recommend that DBHDD behavioral health providers in the Georgia Collaborative ASO
network electronically submit all claims.

To electronically submit claims, providers are encouraged to use ProviderConnect, or one of the
electronic claims resources detailed further in the section titled “Electronic Resources.” Electronically
submitting claims will allow for more efficient claims processing. Electronic claim submission is also
accepted through clearinghouses. When using the services of a Clearinghouse, providers must
reference ValueOptions’ Payer ID, FHC &Affiliates, to ensure Beacon receives those claims.

Another option for providers for electronic claim submission is to install ValueOptions’ Electronic Data
Interchange Claims Link for Windows® Software on their computer(s).

For information on these resources, please refer to the ProviderConnect User Guide or Provider page
of the website.

NOTE: The Georgia Collaborative ASO does not process claims for the provision of Medicaid services
to Medicaid beneficiaries. The Department of Community Health, through its GAMMIS vendor, pays
those claims directly to providers and these instructions do not apply to those service claims. When
these claims are submitted to GAMMIS, the claims must be submitted with the GA Client Authorization
# beginning with a “9” (12 digit number).

Claim Submission Guidelines
Unless otherwise identified in the contract or provider agreement, providers must file or submit claims
within ninety (90) calendar days from the date of service or the date of discharge for inpatient
admission. Claims after the above noted ninety (90) day time period after the date of service maybe be
denied due to lack of timely filing. Claims must match the authorization applicable to covered services
for which the claim applies. To electronically submit claims, Collaborative providers are required to use
ProviderConnect or one of the electronic claims resources detailed further in the Electronic Resources
section of the Handbook. These resources will expedite claims processing.

Separate claim submissions must be entered for each Individual for whom the provider bills and it
must contain all of the required data elements. Each billing line should be limited to one date of
service and one procedure code.

When billing for CPT codes that include timed services in the code description (e.g., 90832; 90833;
90834; 90836; 90837; 90838; 90839 and appropriate Evaluation and Management codes, the actual
time spent must clearly be documented within the Individual’s treatment record. This time should be
documented indicating a session’s start and stop times (e.g., 9:00-9:50).

All billings by the provider are considered final unless adjustments or a request for review is received
by the Collaborative within the time period identified in the provider agreement, or if no time period is
identified within the provider agreement within sixty (60) calendar days from the date indicated on the

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Provider Summary Voucher (PSV). Payment for covered services is based upon authorization),
coverage under the Individual’s benefit plan and the Individual’s eligibility at the time of service.

Required Claim Elements for Behavioral Health Providers Effective December, 2015

Claims for covered services rendered to Individuals should be submitted electronically or by using the
electronic equivalent of a UB-04/CMS-1450 or CMS-1500 or successor forms, with all applicable fields
completed and all elements/information required by the Collaborative included. The following lists
capture the required claim fields to make a clean claim for the UB04/CMS-1450 and CMS-1500.

Please refer to the electronic claims submission guidelines and batch submission companion guides
located at on the Collaborative’s Batch Resource page.

Electronically submitted claims must be in a HIPAA 5010 compliant format and conform to the
ValueOptions companion guide utilizing ICD-10 diagnosis codes for dates of service beginning October
1, 2015 to be considered clean. The following is a link to our ICD-10 Provider Frequently Asked
Questions document.

In addition, the claim should be free from defect or impropriety (including lack of required substantiating
documentation) or circumstance requiring special treatment that prevents timely payment. If additional
information is required, the provider will forward information reasonably requested for the purpose of
consideration and in obtaining necessary information relating to coordination of benefits (COB),
subrogation, and verification of coverage, and health status.

Requests for Additional Information

Upon request by the Georgia Collaborative, or its authorized designee, providers must promptly furnish
requested documentation or information related to and/or in support of claims submitted. Failure to do
so may result in denial of payment for covered services rendered to Individuals.

Claim Processing

The Georgia Collaborative will process complete and accurate claims submitted by approved providers
for covered services rendered to Individuals in accordance with normal claims processing policies and
procedures, the payment terms included in the provider contract/agreement, and/or applicable state
and/or federal laws with respect to timeliness of claims processing.

Normal claims processing procedures may include, without limitation, the use of automated systems
which compare claims submitted with diagnosis codes and/or procedure codes and associated billing or
revenue codes. Automated systems may include edits that result in an adjustment of the payment to the
provider for covered services or in a request for submission of clinical records.

No payment is due for covered services or claims submitted unless the covered services are clearly and
accurately documented in the clinical record prior to submission of the claim in accordance with the
DBHDD Provider Manual for Community Behavioral Health.

Payment for services rendered to Individuals is impacted by the terms in the provider
contract/agreement, the Individual’s eligibility at the time of the service, whether the services were

covered services, if the services were medically necessary, compliance with any pre-

authorization/notification requirements, Individual expenses, timely submission of the claim, claims

processing procedures, overpayment recovery, and/or coordination of benefits activities.

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Clearinghouses

Electronic claim submission is also accepted through clearinghouses. When using the services of a
Clearinghouse, the Payer ID you will use for the Georgia Collaborative is FHC & Affiliates to ensure
we receive those claims.

PaySpan® Health

For electronic funds transfer, providers must use PaySpan Health. PaySpan Health enables providers
to receive payments automatically in their bank account of choice, receive email notifications
immediately upon payment, view remittance advices online, and download an 835 file to use for auto-
posting purposes.

ValueOptions Electronic Data Interchange (EDI) Claims Link for Windows® Software

The EDI Claims Link for Windows application is another tool providers or their designated
representatives have to submit HIPAA compliant electronic claims. This tool requires installation on a
computer and creation of a database of providers and Individuals. Refer to the EDI Claims Link for
Windows User Handbook.

Provider Summary Vouchers

Provider Summary Vouchers (PSVs) or remittance advices are the documents that identify the
amount(s) paid. Providers can access PSVs through PaySpan or ProviderConnect. Additional
information regarding access to PSVs is available at the ‘Provider’ section on the website.

Overpayment Recovery

Providers should routinely review claims and payments in an effort to determine if the provider has
received any overpayments. The Georgia Collaborative will notify providers of overpayments identified
by Beacon, the Georgia Collaborative, clients and/or government agencies, and/or their respective
designees. Overpayments include, but are not limited to: (a) claims paid in error; (b) claims allowed/paid
greater than billed; (c) duplicate payments; (d) payments made for Individuals whose authorization is or
was terminated; (e) payments made for services in excess of applicable benefit limitations; (f) payments
made in excess of amounts due in instances of third party liability and/or benefits; and (g) Payments
made without sufficient documentation as required by DBHDD.

Subject to the terms of the provider contract/agreement and applicable state and/or federal laws and/or
policies, the Georgia Collaborative or its designee (Beacon) will pursue recovery of overpayments
through: (i) adjustment of the claim or claims in question creating a negative balance reflected on the
Provider Summary Voucher (PSV) (claims remittance); and/or (ii) written notice of the overpayment and
request for repayment of the claims identified as overpaid. Failure to respond to any written notice of
and/or request for repayment of identified overpayments in the time period identified in the notice/request
is deemed approval and agreement with the overpayment; thereafter the Georgia Collaborative will
adjust the claim or claims in question creating a negative balance. Any negative balance created will be
offset against future claims payments until the negative balance is zeroed out and the full amount of the
overpayment is recovered. The Georgia Collaborative may use automated processes for claims
adjustments in the overpayment recovery process.

In those instances in which there is an outstanding negative balance as a result of claims adjustments
for overpayments for more than ninety (90) calendar days, the Georgia Collaborative reserves the right

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to issue a notice for re-payment. Should a provider fail to respond and/or provide amounts requested
within the thirty (30) calendar days of the date of the notice for re-payment, the Georgia Collaborative
will pursue all available legal and equitable remedies, including without limitation placing the outstanding
overpayment amount (negative balance) into collections.

If the provider disagrees with an overpayment recovery and/or request for re-payment of an
overpayment, the provider may request review to the Georgia Collaborative in writing such that the
written request for review is received by the Georgia Collaborative on or before the date identified in the
notice of overpayment recovery or request for re-payment of an overpayment. Please attach a copy of
your written demand or request letter to your request for review and include the following information;
provider’s name, identification number and contact information, Individual name, and number, a clear
identification of the disputed items to include the date of service and the reason the disputed
overpayments are being contested.

Requests for Review

Providers may request review of the Georgia Collaborative’s claims determination. All requests for
review must be submitted in writing or made telephonically to the address and/or telephone number on
the Georgia Collaborative’s website within sixty (60) calendar days or the time period specified in the
provider agreement (if any) from the date of the Georgia Collaborative’s original claim determination.

Requests for review received beyond the above noted time period will not be reviewed and are
considered ‘expired.’

Claims Disputes

Providers must exhaust all administrative processes concerning unresolved claims disputes pursuant to
the terms of the provider contract/agreement, and more specifically any dispute resolution provisions,
prior to pursuing any legal or equitable action.

Claims Billing Audits

The Georgia Collaborative reviews and monitors claims and billing practices of providers in response to
referrals. Referrals may be received from a variety of sources, including without limitation: (a) Individuals
and families; (b) external referrals from state, federal and other regulatory agencies; (c) internal staff;
(d) data analysis; and (e) whistleblowers. The Georgia Collaborative also conducts random audits.

The Georgia Collaborative conducts the majority of its audits by reviewing records providers either scan
or mail to Beacon, but in some instances on-site audits are performed as well. Record review audits, or
discovery audits, entail requesting an initial sample1 of records from the provider to compare against
claims submission records. Following the review of the initial sample, the Georgia Collaborative and/or
Beacon may request additional records and pursue a full/comprehensive audit. Records reviewed may
include, but are not limited to, financial, administrative, current and past staff rosters, and clinical records.
For the purposes of the Georgia Collaborative’s audits, the ‘clinical record’ includes, but is not limited to,
assessments, treatment plans, progress notes, medication prescriptions and monitoring, the modalities
and frequency of treatment furnished, and results of clinical tests. It may also include summaries of the:
diagnosis; functional status; strengths; symptoms; prognosis; and progress to date.

1 Unless otherwise required by a specific client or a government agency, Beacon utilizes the Office of Inspector
General’s (OIG) Random Sample Determination Tool (RAT-STATS) to select a random and statistically valid

sample of eligible records.

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Providers must supply copies of requested documents to the Georgia Collaborative within the required
time. The required time will vary based on the number of records requested but will not be less than ten
(10) business days when providers are asked to either scan or mail records to the Georgia Collaborative.
For the purpose of on-site audits, providers must make records available to the Georgia Collaborative
staff during the provider’s audit. Providers are required to sign a form certifying all requested records
and documentation were submitted or made available for the audit. The Georgia Collaborative will not
accept additional or missing documentation and/or records once this form is signed, including for the
purposes of a request for appeal. The Georgia Collaborative will not reimburse providers for copying
fees related to providing of documents and/or treatment records requested in the course of a claims
billing audit, unless otherwise specifically required by applicable state or federal law, rule or regulation.

In the course of an audit, documents and records provided are compared against the claims submitted
by the provider. Claims must be supported by adequate documentation of the treatment and services
rendered. Providers’ strict adherence to these guidelines is required. Documentation guidelines are set
forth in the DBHDD Provider Manual for Behavioral Health Providers. The Georgia Collaborative
coordinates claims billing audits with appropriate Collaborative clinical representatives when necessary.
The lack of proper documentation for services rendered could result in denial of payment, or, if payment
has already been issued, a request for refund.

Following completion of review of the documents and records received, the Georgia Collaborative will
provide a written report of the findings to the provider. In some instances, such report of the findings
may include a request for additional records.

The Georgia Collaborative has established an audit error rate threshold of 10% to determine whether
the provider had accurate, complete and timely claim/encounter submissions for the audit review period.
Depending on the audit error rate and the corresponding audit results, the Georgia Collaborative’s report
of findings may include specific requirements for corrective action to be implemented by the provider if
the audit identifies improper or unsubstantiated billings. Requirements may include, but are not limited
to:

 Education/Training – The Georgia Collaborative may require the provider to work with the
Provider Relations team to develop an educational/training program addressing the deficiencies
identified. The Georgia Collaborative may provide tools to assist the provider in correcting such
deficiencies.

 Repayment of Claims - The audit report will specify any overpayments to be refunded. The
overpayment amount will be based on the actual deficiency determined in the audit process, or
the value of the claims identified as billed without accurate or supportive documentation. The
Georgia Collaborative does not use extrapolation to determine recovery amounts. The provider
will be responsible for paying the actual amount owed, based on the Georgia Collaborative’s
findings within (10) business days, unless the provider has an approved installment payment
plan.

 Monitoring – The Georgia Collaborative may require monitoring of claim submissions and
treatment records in 90-day increments until compliance is demonstrated. The provider’s
monitored claims are not submitted for payment until each is reviewed for accuracy and
correctness.

** Please note, the above does not supersede Program Integrity processes which may be enacted by
the Georgia Department of Community Health (DCH) or by DBHDD.

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Appeals of Program Integrity Audits

Program Integrity performs claims audits and issues audit reports. If the provider disagrees with the
findings from an audit report, the provider may request an appeal of the audit report of findings. All
appeals must be submitted in writing and received by the Georgia Collaborative on or before the due
date identified in the report of findings letter. Appeals must include: a copy of the audit report of
findings letter; the provider’s name and identification number; contact information; identification of the
claims at issue, including the name or names of the Individuals, dates of service, and an explanation
of the reason/basis for the dispute. The Georgia Collaborative will not accept additional or missing
documentation and/or records associated with billing errors once the signed form certifying the original
documentation was submitted prior to the audit.

The provider’s appeal will be presented to ValueOptions’ National Compliance-Program Integrity
Subcommittee within forty-five (45) days of receiving the provider’s request for appeal. The
Subcommittee is comprised of ValueOptions employees who have not been involved in reaching the
prior findings. The Subcommittee will review the provider’s appeal documentation, discuss the facts of
the case, as well as any applicable contractual, state or federal statutes. The ValueOptions staff
member/auditor who completed the provider’s audit will present his/her findings to the Subcommittee
but will not vote on the appeal itself. The Subcommittee will uphold, overturn, uphold in-part or pend
the appeal for more information. Once a vote is taken, it will be documented and communicated to the
provider/participating provider within ten (10) business days of the Subcommittee’s meeting. If
additional time is needed to complete the appeal, ValueOptions will submit a letter of extension to the
provider requesting additional information required of the provider and estimating a time of
completion. If repayments or a corrective action plan (CAP) are required, the provider must submit the
required repayments or CAP within ten (10) business days of receiving the Subcommittee’s findings
letter, unless an installment payment plan is approved.

Reporting Fraud, Waste and Abuse

The Georgia Collaborative will notify DBHDD and the provider if a provider fails to supply requested
documentation and Individual records or fails to cooperate with the Collaborative’s investigation or
corrective action plan. The Georgia Collaborative will report any suspicion or knowledge of fraud,
waste or abuse to the appropriate authorities or regulatory agency as required or when appropriate.

Providers should report fraud, waste and abuse, or suspicious activity thereof, such as inappropriate
billing practices (e.g., billing for services not rendered, use of CPT codes not documented in the medical
record, etc.). Reports and questions may be made in writing to the Georgia Collaborative at the address
below or by calling the following hotlines:

Beacon Health Options: 37

Report by Mail:
Beacon Health Options
Attn: Bernadette Calhoun, Compliance Officer
229 Peachtree Street NE
International Tower, Suite 1800
Atlanta, Georgia 30303

The Georgia Collaborative ASO Provider Handbook
Effective: December 1, 2015

Report by Email: [email protected]
Report by Phone: 404.836.1679

Georgia Office of the State Inspector General:

Report by Mail:
Office of Inspector General
ATTN: Special Investigations Unit
2 Peachtree Street, NW 5th Floor
Atlanta, GA 30303Report By E-mail:
[email protected] or [email protected] or
Report fraud using online form.

QUALITY MANAGEMENT PROGRAM (QMP)

The Georgia Collaborative’s Quality Management Program (QMP) includes those quality activities that
are delegated by DBHDD to serve Individuals receiving Behavioral Health (BH) and Individual
Developmental Disability (IDD) Services in the State of Georgia. Individuals served have Medicaid or
state funded services and the goal is to ensure high quality services are both provided and received.
The QMP promotes recovery, resilience, independency, community integration, wellness and
identification of best and/or promising practices across the regions. The role of the QMP is to identify
systemic quality concerns or issues, develop strategies for improvement and support providers through
technical assistance and training.

The QMP is founded on the belief that a person-directed and person-centered approach to service
delivery is an integral part of the quality management program and activities. The quality oversight and
monitoring process will identify how well Individuals are supported to direct their own care and services
through an interview process, record review, and on-site observations. Georgia Collaborative staff are
trained to conduct these activities and will have an opportunity to provide suggestions and feedback to
BH and IDD providers related to how supports and services are being rendered. Best practices,
recommendations and resources will be shared across all regions to help improve the service delivery
system as it relates to this critical area of service [See Supplemental Attachment].

The QMP includes policies and procedures applicable to all DBHDD providers, strategies to improve
services, and major activities performed, the provision of which allow for consistency and excellence in
the delivery of services. This includes a program description, annual quality improvement plan with goals
and objectives, specific activities for the upcoming year and evaluation of the effectiveness of those
activities. Participating providers are responsible for adhering to requirements set forth in DBHDD
Provider Manuals. The Quality Enhanced Provider Review (QEPR) process, conducted by the Georgia
Collaborative, provides an opportunity to ensure adherence to these requirements through an oversight
monitoring process.

Quality Management Committees

The Georgia Collaborative Quality Management Program has a committee structure that:
 Recommends policy decisions
 Analyzes and evaluates the results of Quality Improvement (QI) activities
 Ensures practitioner participation in the QI program, (typically accomplished through
planning design, implementation or review)
 Identifies needed actions
 Ensures follow-up, as appropriate

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With oversight by DBHDD, the Georgia Collaborative Quality Management Committee (QMC) reports
up to the Beacon Health Options Corporate Quality Committee (CQC). The CQC is the body responsible
for coordinating all national level Quality Management activities as well as reviewing and approving the
Georgia Collaborative’s Quality Management Program. This committee provides oversight, direction,
resources and consultation to the local Georgia Collaborative’s quality structure.

The Georgia Collaborative QMC meets on a regular basis and has representation from a number of
areas, including: other functional departments, providers offering services, Individuals and families
receiving services, advocates, and various other stakeholders. This representation can be, but is not
limited to, participation in focused work groups, subcommittees, feedback from surveys and/or activities
occurring in the regions.

In addition, Regional and State Quality Improvement Councils, consisting of representatives from all
stakeholder groups, offer a forum to evaluate the quality of services using data collected and presented
by the Georgia Collaborative. These groups are charged with developing quality improvement initiatives
to promote changes at the Regional and/or state level. They report to the DBHDD quality councils.

Effectiveness of the QMP is evaluated at least annually to ensure that the organization demonstrates
improvements in the clinical care and service it renders to Individuals. The evaluation can include
measures meaningful in both clinical care and service delivery.

Scope of the Georgia Collaborative Quality Management Program

The focus of the Georgia Collaborative Quality Management Program (QMP) is to monitor and evaluate
quality across the entire range of services provided by DBHDD network of providers. Along with the
trending of quality issues, the QMP is intended to ensure that structure and processes are in place to
lead to desired outcomes for Individuals, providers, and the State of Georgia.
The following are within the scope of the Georgia Collaborative QMP:

 Assessing/supporting DBHDD providers to ensure accessibility
 Ensuring that cultural and linguistic needs of Individuals are embedded in services delivered
 Promoting health literacy (i.e. supporting choice, encourage use of self-management tools,

supporting autonomy)
 Assessing adherence to service guidelines and program requirements by DBHDD
 Gathering and communicating information on Individual/provider experience and satisfaction
 Engaging with DBHDD and providers on Quality Improvement Activities (QIA’s)
 Collaborating with clinical, as well as other functional departments, along with external

stakeholders to identify useful self-management tools
 Promoting screening programs that are based on scientific literature that results in risk

reduction and increased safety of Individuals served
 Monitoring and assessing coordination of care, transitions of care and supports and services

to ensure that adequate resources are available to the Individuals served
 Reporting on Outcome Measurement and data analysis from a variety of sources
 Reporting on Experience of Individual and Provider Satisfaction Surveys
 Provider Record Review and program integrity reviews as part of Quality Reviews
 Evaluating, via valid methodologies, complaints and grievances regarding the Georgia

Collaborative services
 Monitoring the protection of Individual rights and responsibilities
 Monitoring the safety of Individuals served- which includes timely reporting to DBHDD on

critical/adverse incidents

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See Clinical Services Section for additional details on utilization review process, denials and appeals.

Service Availability and Access to Care

The Georgia Collaborative uses a variety of mechanisms to measure the following:

 Analysis of Individual complaints and grievances related to accessibility and access as
directed by DBHDD

 Individual experience/satisfaction surveys specific to accessing care, supports and services
and routine appointment availability

 Analysis and trending of information on appointment availability obtained during site visits

Continuity and Coordination of Care

The QMP incorporates monitoring for continuity and coordination of services throughout the continuum
of behavioral health and IDD programs. Monitoring may include reviews of the following:

 records,
 Coordination of discharge planning between inpatient and outpatient, and
 Provider performance regarding continuity of services.

Subject to any Individuals consent or authorization required by applicable state and/or federal laws
and/or regulations, providers should coordinate services as appropriate, sharing information with other
providers, within the context of providing quality care and within the guidelines of protecting Individual’s
privacy and confidentiality.

Individual Record Standards & Guidelines

Individual records should be maintained in compliance with all applicable medical standards, laws, rules
and regulations, as well as DBHDD’s requirements outlined in the DBHDD Provider Manuals and policy
states in a manner that is current, comprehensive, detailed, organized and legible to promote effective
care and quality review. Record requirements, standards and guidelines are dependent upon the
services an Individual receives, and may look different depending on whether behavioral health services
or intellectual/developmentally disabled services are provided.

Compliance with Individual Records is required, whether written or electronic, without limitation to:
medical records; charts; medication records; physician/practitioner notes; test and procedure reports
and results; the Individual Recovery Plan (IRP); the Individual Service Plan (ISP); recovery and/or crisis
plans and any other documentation of services and/or treatment of the Individual. These requirements
can be found in the DBHDD Provider Manual for Behavioral Health Providers. Documentation
requirements for IDD records can be found in the Provider Manual for Community Developmental
Disabilities Providers.

Individual records are subject to focused and random review by the Georgia Collaborative Quality
Management Department, in addition to audits conducted by DBHDD, local and federal regulatory
agencies and accreditation entities to which the Georgia Collaborative may be subject.

Quality Review Processes (see Quality Management Program Appendix)

The Georgia Collaborative will conduct various quality reviews for all provider types. Behavior health
providers will receive a Behavioral Health Quality Review. IDD providers will participate in Quality

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Enhancement Provider Reviews, Person Centered Reviews and Quality Technical Assistance
Consultations.

For further information, please refer to the QM Appendix.

DBHDD BH/IDD providers are required to cooperate with the quality reviews conducted by the
Georgia Collaborative. The following equipment and supports must be provided for the review:

 Tables and chairs to accommodate number of assessors
 Any computers or electronic equipment needed to access the provider’s electronic records
 Access to a copy machine/printer and paper.

In most circumstances, providers are notified of review dates at least two weeks prior to their review.
However, in some instances, provider notification will be dependent on the type of review conducted.

During the review, Georgia Collaborative staff will examine records, conduct interviews of staff and
Individuals served, and assess program plans and agency program policies and procedures.
Any inconsistencies between services provided and standards outlined in the state DBHDD
Provider Manual and Medicaid Manual are noted and scored in the review tool.

For the purpose of conducting retrospective case reviews, records should be maintained for the time
period(s) required by applicable state and/or federal laws and/or regulations, DBHDD, and as detailed
in the provider agreement.

Quality reviews may be conducted as desk reviews and/or onsite. Selection for quality reviews can be:
 on a random basis as part of continuous quality improvement (CQI) and/or monitoring
activities;
 as part of routine quality and/or billing reviews;
 as required by DBHDD;
 in the course of performance under a given DBHDD contract;
 as may be required by a given government or regulatory agency;
 in response to an identified or alleged specific quality of services, professional competency
or professional conduct issue or concern;
 as may be required by state and/or federal laws, rules and/or regulations;
 in the course of claims reviews and/or compliance audits; and/or
 as may be necessary to verify compliance with the provider agreement.

Reviews will include agency program documentation reviews, staff interviews, Individual interviews,
onsite observations, treatment Plan (s) and personnel and training record reviews.

The Georgia Collaborative will use and maintain Individual records in a confidential manner and in
accordance with applicable laws and regulations regarding the privacy or confidentiality of protected
health information and/or Individual identifying information. If records are requested to be sent to the
Georgia Collaborative, providers are instructed to never send original records as they will not be returned
at the completion of the review or compliance audit.

BH records are reviewed by an interdisciplinary team, including licensed clinicians and registered
nurses. IDD records are reviewed by highly trained IDD staff. Record reviews conducted as part of
Quality Management activities include application of objective tools. The tools are continuously under
study and revision by both the Georgia Collaborative and DBHDD, along with providers and other

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stakeholder input. As part of the continuous quality improvement cycle, tools will be revised/updated
discontinued and/or replaced as appropriate.

Following completion of quality reviews, providers are given a written performance report that details the
findings. If necessary, the report will include acknowledgement of best/promising practices, and specific
recommendations that will enable the provider to more fully comply with DBHDD standards.

Appeals of Review Findings

If the provider disagrees with a review report’s findings, the provider may request an appeal. For more
detailed information, please see the Quality Management Program Appendix.

Improving Individual Safety

When quality of care and/or quality of service issues (QOC/QOS) are identified, they are immediately
reported to DBHDD, according to their policies, by the Georgia Collaborative. Monitoring of quality of
care and service issues and trends is intended to decrease the likelihood of non-desired health
outcomes that are inconsistent with current practices. These types of issues may be identified from a
variety of sources, including Individual/family and provider complaints, internal reviews, government
agencies and others.

In an effort to be transparent and to ensure that providers understand our processes, if a Georgia
Collaborative employee, who during the course of conducting business identifies a suspected quality of
care concern, he/she will immediately notify their supervisor. Some examples of quality care concerns
are:

1. Any suspected abuse, neglect or exploitation of an Individual
2. Any situation where during the course of service provision or treatment the individual’s safety

appears to have been compromised
3. Any situation where during the course of service provision or treatment an individual’s actions

appear to compromise the safety of others
4. The Georgia Collaborative staff will further review records, if possible to determine if there is

documentation to demonstrate that the proper intervention and reporting of the incident
occurred.
5. If there is any suspicion that the incident was not identified and/or properly addressed by the
provider, Georgia Collaborative management staff will summarize their findings and report
the quality of care concern to DBHDD per policy.
6. DBHDD will make the determination if further investigation is warranted.
7. If an investigation is initiated, the Georgia Collaborative will provide all relevant information
and documentation upon request.

When DBHDD requests support for the investigative process, the Georgia Collaborative Medical Director
or designee participates utilizing the Georgia Collaborative resources for investigation and resolution of
these issues through to completion.

As part of the initiative to analyze the quality of care to Individuals served by the provider network,
Critical/Adverse Incidents may be part of the quality review process. Providers may be asked to present
policies and procedures related to reporting Critical/Adverse Incidents.

Complaints about the services provided by the Georgia Collaborative may also be investigated through
to resolution by the Georgia Quality Management Team.

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Quality Improvement Activities/Projects

A primary goal of the QMP is to continuously improve care and services. Through data collection,
measurement and analysis, aspects of care and services that demonstrate opportunities for
improvement are identified and prioritized for quality improvement activities. Data collected for quality
improvement projects and activities are frequently related to key industry measures of quality that tend
to focus on high-volume diagnoses or services and at high-risk or special populations. Data collected
are valid, reliable and comparable over time. The Georgia Collaborative ASO takes the following steps
to ensure a systematic approach to the development and implementation of quality improvement
activities:

 Monitoring of clinical quality indicators
 Review and analysis of the data from indicators
 Review and analysis of the data from the National Core Indicators (for IDD)
 Analysis and trending of provider performance reports
 Identification of opportunities for improvement
 Prioritization, based on risk assessment, ability to impact performance, and resource

availability of opportunities to improve processes or outcomes of behavioral healthcare
delivery
 Identification of the affected population
 Identification of the measures to be used to assess performance
 Establishment of performance goals or desired level of improvement over current
performance
 Collection of valid data for each measure and calculation of the baseline level of performance
 Thoughtful identification of interventions that are powerful enough to impact performance
 Analysis of results to determine where performance is acceptable and, if not, the identification
of current barriers to improving performance

Experience/Satisfaction Surveys

The Georgia Collaborative, either directly or through authorized designees, conducts experience and/or
satisfaction surveys to identify areas for improvement as a key component of the QMP. Satisfaction
survey participation may include Individuals, providers and/or DBHDD. The results of these surveys are
summarized on at least an annual basis. Where appropriate, corrective actions are implemented in the
Georgia Collaborative functional department(s) or as applicable.

PROVIDER COMPLAINTS, GRIEVANCES & APPEALS

The Quality Management Program (QMP) will identify opportunities for improvement in processes and
services provided by the Georgia Collaborative through the complaints and grievances procedures.
Complaints and grievances regarding providers and/or DBHDD will be referred to DBHDD for
appropriate follow up. The QMP will collect and analyze the content of complaints when received and
will provide a timely response to resolve all issues related to services provided by the Georgia
Collaborative. The process includes categorizing complaints, tracking/trending and reporting up to the
Quality Management Committee (QMC). The QMC in turn makes recommendations for remedial action
and/or other improvement actions. Complaints and grievances are also reported to DBHDD for their
review and recommendations.

General Provider Complaints and Grievances

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