|
|
Following are some questions most frequently asked by providers.
If you have reviewed our Common Questions and still have questions, feel free to contact Provider Services.
1. Is a cover letter necessary in order to request an appeal?
2. Can failure to obtain pre-authorization be appealed?
3. Can an appeal be requested after the time frame has expired?
4. Is the full medical record required for clinical appeals?
5. Is there any appeal beyond the Level I Appeal?
6. Is the confidentiality of clinical records maintained throughout the appeals process?
7. How can my practice partners get an application to become part of this network?
8. How long does the credentialing process take?
9. Why do you need to collect so much information for the credentialing process?
10. Is there an application or processing fee to join Optima Behavioral Health's network?
11. What is the status of my application?
12. Can I see members before I receive a provider number?
13. How will I get referrals?
14. If I have been approved recently by the Credentialing Committee, when can I begin receiving reimbursement for seeing members? Is it retroactive to the date I was approved by the committee?
15. Do you have different networks for different plans?
16. How do I know which members I can see?
17.Is there anything I can do to increase the likelihood of receiving referrals from Optima Behavioral Health?
18. Does my participation in Optima Behavioral Health's network prevent from participating with any other managed care firm?
19. Can I file electronically to Optima Behavioral Health?
20. What are the timely filing limits for claim submission and reconsideration?
21. Where do I send my claims?
22. What should I do if I am changing practices or tax ID number?
23. How do I make an appointment to meet with my Optima Behavioral Health Network Educator?
Is a cover letter necessary to request an appeal?
Yes. It should clearly state the appealing party, the member’s name and ID number, the dates in dispute, and the rationale for the appeal. A letter from the attending provider is most helpful for clinical appeals.
Can failure to obtrain pre-authorization be appealed?
Yes. However, evaluation of the reason for the failure to obtain pre-authorization will be the initial basis for our decision. The reason should be clearly indicated and explained. If the stated reason allows us to waive the pre-authorization requirement, we will then review for medical necessity.
Can an appeal be requested after the time frame has expired?
Yes. The reason for the late request must be clearly explained. If the stated reason allows us to waive the pre-authorization requirement, we will then review for medical necessity.
Is the full medical record required for clinical appeals?
Yes. The full record for the episode of care covering the dates in dispute must be submitted. Incomplete or illegible records, or portions of records, may result in an unfavorable decision.
Is there any appeal beyond the Second Level Appeal?
The member's plan may allow an appeal or grievance directly to the plan after the Optima Behavioral Health process is exhausted. Optima Behavioral Health provides notice of additional appeal rights in the Second Level Appeal decision letter.
Is the confidentiality of clinical records maintained throughout the appeal process?
Yes. The Optima Behavioral Health confidentiality policies fully apply to the appeal process and require strict adherence to confidentiality or treatment records. In addition, submitted records are reviewed only by licensed clinicians.
How can my practice partners get an application to become part of this network?
Any licensed behavioral health provider may submit a written request to Optima Behavioral Health for an application. The provider will receive a response to their application request based on network development needs and requirements. Submit a request online.
How long does the credentialing process take?
The credentialing process usually takes 90 – 120 days. Please note this time frame is contingent upon completion and submission of all the requested information.
Why do you need to collect so much information for the credentialing process?
NCQA (National Committee on Quality Assurance), a national quality assurance organization that accredits managed care organizations and managed behavioral healthcare organizations, stipulates what material is required for provider credentialing. The information regarding your clinical experience and expertise is verified and reviewed by the Optima Behavioral Health Credentialing Committee as required by NCQA. The information is then used to assist us in effectively matching patient needs with provider expertise, as part of our provider-Member Matching Program.
Is there an application or processing fee to join Optima Behavioral Health’s network?
Not at this time.
What is the status of my application?
You can find out the status of your application by contacting Provider Services.
Can I see members before I receive a provider number?
You may see a member before you are credentialed only if the member’s plan has an out-of-network benefit. However, this is likely to result in a higher cost to the member.
To avoid any unnecessary out-of-pocket costs to the member or claims reimbursement issues, contact Member Services to verify the member’s benefits.
How will I get referrals?
Many of Optima Behavioral Health’s plans require the member to contact Optima Behavioral Health to pre-authorize care. Our staff will refer the member to care based on certain criteria, including geographical location, provider specialty expertise, and the ability of the provider to respond promptly. Other Optima Behavioral Health plans allow members to contact you directly or access out-of-network benefits.
However, please be aware that most plans require pre-authorization for payment whether the member is accessing in-network or out-of-network benefits.
To identify the specific type of coverage a member has, contact Member Services.
If I have been approved recently by the Credentialing Committee, when can I begin receiving reimbursement for seeing members? Is it retroactive to the date I was approved by the committee?
You may not be billed for authorized services prior to receiving your provider number. Optima Behavioral Health is committed to processing "clean" claims (claims having all information required from the provider for processing) within 40 days. You cannot receive retroactive reimbursement at the in-network rate for services delivered prior to becoming a credentialed and contracted network provider.
If you unsure about your provider status, please contact Provider Services.
Do you have different networks for different plans?
While the majority of our plans use our entire statewide provider network, there are a few exceptions. Optima Health Plan, for example, is served by a select network of provider groups who are contracted by Optima Behavioral Health to specifically serve this population. The Optima Family Care Medicaid program includes a network of community based public providers who are contracted directly for these members.
How do I know which members I can see?
When a member presents seeking mental health services, just check the member’s I.D. Card for plan type. If you need additional information, contact Member Services.
If you are in doubt about your status as a provider in any particular plan, call Optima Behavioral Health Member Services, and they will assist you in verifying provider status, benefits, exclusions, access procedures, etc.
Is there anything I can do to increase the likelihood of receiving referrals from Optima Behavioral Health?
Yes, you can keep us informed of any changes related to your practice. Many providers have not advised us, by their application, notification or update, etc. that they offer a particular service, specialty or program offering. We encourage you to keep us updated regarding your current office locations, services, and resources by directing this information to our attention in Provider Services. We ask that complete the Provider Update Form whenever you experience any of these changes. You may also call Provider Services, and we will be happy to ensure that your provider file is appropriately updated. We must be advised in writing of any change of address or if you decide to withdraw from the network.
Does my participation in Optima Behavioral Health’s network prevent me from participating with any other managed care firm?
No. Your contract with Optima Behavioral Health is a non-exclusive arrangement and does not prevent you from participating in other managed care firms.
Can I file electronically to Optima Behavioral Health?
Optima Behavioral Health accepts electronic filing from Payer Path. For more information visit their website at www.payerpath.com call 804-560-2400.
What are the timely filing limits for claim submission and reconsideration?
Claims must be received by Optima Behavioral Health within 365 days of the date of service to be considered for reimbursement. Requests for reconsideration of a claim payment or denial must be received within 60 days of the payment/denial.
Where do I send my claims?
The claims submission address for all behavioral health claims, except for Optima Medicare and Optima Medicare Plus, is:
Optima Behavioral Health
C/O HOV, Inc.
PO Box 1440
Troy, MI 48099-1440
For information on Optima Medicare claims submission, please call the contact number on the member’s ID card.
What should I do if I am changing practices or tax ID number?
It is very important to inform Optima Behavioral Health of changes in practice, address or tax ID in order to assure correct disbursement of payments. Complete a Provider Update Form by following the link “Update Your Address & Other Information.” If you are changing your tax ID number, complete a W-9 or Substitute W-9 and fax to the attention of Provider Services at 1-888-576-9675. Depending on your individual situation, you may need to sign a new contract with Optima Behavioral Health, or obtain new authorizations for any members transferring to the new practice. Please call Provider Services for specific information.
How do I make an appointment to meet with my Optima Behavioral Health Network Educator?
Call Optima Behavioral Health Provider Services ask to speak to the Network Educator for your area. They will be happy to set up a time to meet with you or your office staff.
|