REVISIONS NOTE This information has been updated as of 6102016 Providers should review this information thoroughly as some of it has revised July 1 2016 Transition Based upon current assessed risk ID: 676378
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Slide1
Tier One Providers
Fee-for-Service InitiativeSlide2
REVISIONS
NOTE:
This information has been updated as of 6/10/2016. Providers should review this information thoroughly as some of it has revised.Slide3
July 1, 2016 Transition
Based upon current assessed risk:
Limited roll-out of Fee-For-Service effective July 1, 2016
Adult MH Core Benefit Package
Adult AD Core Benefit
Package
Substance
Abuse Intensive Outpatient
Program
Psychosocial
Rehabilitation - Individual and
Group
Peer
Support – Individual and Group and Whole Health and
Wellness
Phased transition of other Specialty Services beginning in calendar year 2017
Phased transition of remaining GIA-based services to Fully Costed Reimbursement contracts beginning in calendar year 2017
Implementation of approval-based Supplemental Support Funds requests July 1, 2017Slide4
Adult BH Core Benefits Package
BH Assessment and Service Plan Development
Psychological Testing
Diagnostic Assessment
Crisis Intervention
Psychiatric Treatment (E&M)
Nursing Services
Medication Administration
Psychosocial Rehabilitation - Individual
Addictive Diseases Support Services
Case Management
Outpatient Services – Individual and Group
Outpatient Services – Family
Community Transition Planning
Peer Support – Individual
Peer Support – Whole Health and WellnessSlide5
Tier One Provider Funding
Maximum Reimbursement Limits
Maximum reimbursement limits are being
assigned
to
providers
as a statewide budgetary control mechanism. This limit provides a reasonable assurance that the state allocation for community behavioral health services is not exceeded on an annual basis.
Initial limits for FY17 will be based upon FY16 contracted values for the
core benefit package and other selected services transitioning
to FFS on July 1, 2016.
Maximum reimbursement limits will be reviewed for potential adjustment to allow for possible redirects of funding at mid-year and year-end.
Reviews will be based upon actual utilization data collected.Slide6
Tier One Provider Funding
Minimum Reimbursement Limits
Tier One providers will be eligible
for one year of transitional revenue protection in the form of guaranteed minimum levels of
reimbursement.
M
inimum reimbursement limits for FY17 will be set based on
70
%
of
a provider’s FY16
funding levels for the
core benefit package and other services being transitioned
to FFS
on July
1,
2016. Actual earned
revenues will
be reviewed and
compared to
initial Minimum Reimbursement Limits at mid-year
and
year-end.
Any
shortfall
between actual earned revenues
and
Minimum Reimbursement Limits will
be addressed through an increase in supplemental support
funding at year-end or upon approved intermediate request by contractor.Slide7
Tier One Provider Funding
Supplemental Support Funding
Supplemental Support funding for
FY17
contracts will carry forward from
FY16 contracts
Adjustments will be made
based
upon
required additional
funding resulting
from minimum reimbursement
limits, if applicable
Future FFS Transitions
Remaining services not transitioning to FFS on July 1, 2016 will transition to FFS or to fully-
costed
reimbursement beginning in calendar year 2017Slide8
Provider MRL Accumulators
Claims payment will be applied to provider’s Maximum Reimbursement Limit
(MRL) accumulators
based on diagnosis codes on claim (MH or AD
).
The
diagnosis code(s) on a claim should represent the principle condition, problem or other reason the service being billed was intended to address.
Claims paid under the fund sources SFAD (State Funds – Adult) and GACF (State Funds – Crisis) are included. Services falling under SFCA (State Funds – C&A), WTSO/WTSR (Women’s Treatment Outpatient & Residential), and TCMH/TCDC (Treatment Court – not required to report) are not included
.
The
accumulators
will add all claims paid until the MRL is reached
.
Once the MRL is reached, claims will become “pre-pay” and utilization is then tracked as state encounters
.Slide9
Providers with both MRL Accumulators
MH and
AD:
The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have an accumulator set up for both Mental Health and Addictive Disease services.
Provider MRL Accumulators Slide10
Providers with both MRL Accumulators
MH and AD
How claims are applied:
A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.
Claims with two diagnosis codes will be split and 50% applied to each
MRL when applicable (providers with both MH and AD funding accumulators). If one accumulator has been reached then only 50% of the claim will be paid.
Once the MRL has been reached, claims will
be
processed in pre-pay
status and no payment will occur. The claim processes similar to state encounters
and is tracked for utilization purposes.
The scenarios on the next slides depict claims paying against MRL’s for MH and AD. Slide11
Providers with both MRL Accumulators
MH and AD
Scenario
Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
1a
$150
$100,000
$150
$99,850
$50,000-$50,0001b$125-$99,850$125$49,875
Remaining balances carried forward to next slide.Slide12
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
2a
$84
$100,000
$84
$99,766
$50,000
-
$49,875
2b$54-$99,766$54$49,821Remaining balances carried forward to next slide.
Providers with both MRL Accumulators
MH and ADSlide13
Providers with both MRL Accumulators
MH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
3a
$90
$100,000
$45
$99,721
$50,000
$45$49,7763b$156$78$99,643$78$49,698
Remaining balances carried forward to next slide.Slide14
Providers with both MRL Accumulators
MH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
4a
$66
$100,000
$66
$99,577
$50,000
-$49,6984b$112-$99,577$112$49,586
Remaining balances carried forward to next slide.Slide15
Providers with both MRL Accumulators
MH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
5a
$70
$100,000
$0
$0
$50,000
$35$49,5865b$32$16$99,850$0$0See next slide for total accumulation.Slide16
Applying Claims to Accumulators
Once an accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service.
Scenario
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
Cap
Amt
Applied to MRL
AD Balance
1a
$150
$100,000
$150
$99,850
$50,000
-$50,0001b$125-$99,850$125$49,8752a
$84
$84
$99,766
-
$49,875
2b
$54
-
$99,766
$54
$49,821
3a
$90
$45
$99,721
$45
$49,776
3b
$156
$78$99,643$78$49,6984a$66$66$99,577-$49,6984b$112-$99,577$112$49,586…..…..…..5a$70$0$0$35$49,586…..…..…..5b$32$32$99,542$0$0
Note: The rows below the dashed line assume that the MRL has been reached.Slide17
Providers with
one MRL Accumulator
MH
or AD:
The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have a single accumulator set up for either Mental Health or Addictive Disease services.
Provider MRL Accumulators Slide18
Providers with one MRL Accumulator
MH or AD
How claims are applied:
A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.
Claims with two diagnosis codes will be
applied
to
the MRL accumulator regardless of the diagnosis on the claim.
For example, if a provider has AD funding only, one accumulator is set up. If a claim is to be paid the total amount of the claim is applied to the AD accumulator.
Once the MRL has been reached, claims will
be
processed in pre-pay
status and no payment will occur. The claim processes similar to state encounters
and is tracked for utilization purposes.
The scenarios on the next slides depict claims paying against a single MRL accumulator. Slide19
Providers with one MRL Accumulator
MH or AD
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$150
$100,000
$150
$99,850
1b
$125
$125
$99,725
Remaining balance carried forward to next slide.Slide20
Remaining balance carried forward to next slide.
Providers with one MRL Accumulator
MH or AD
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$84
$100,000
$84
$99,641
1b
$54
$54
$99,587Slide21
Providers with one MRL Accumulator
MH or AD
Remaining balances carried forward to next slide.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$90
$100,000
$90
$99,497
1b
$156
$156
$99,341Slide22
Providers with one MRL Accumulator
MH or AD
Remaining balances carried forward to next slide.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$66
$100,000
$66
$99,275
1b
$112
$112
$99,163Slide23
Providers with one MRL Accumulator
MH or AD
See next slide for total accumulation.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$70
$100,000
$0
$0
1b
$32
$0
$0Slide24
Applying Claims to Accumulators
Once the accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$150
$100,000
$150
$99,850
1b
$125
$125
$99,725
2a
$84
$84
$99,641
2b$54$54$99,5873a$90$90$99,497
3b
$156
$156
$99,341
4a
$66
$66
$99,275
4b
$112
$112
$99,163
….
….
….
5a
$70
$0
$0
5b$32$0$0Note: The rows below the dashed line assume that the MRL has been reached.Slide25
Questions?
Please
submit any questions to
FFS.questions@dbhdd.ga.gov