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Provider Council Updates | |
The Provider Advisory Council is representative of providers in the entire 23-county catchment area of Smoky Mountain LME/MCO.
Click here for information on meetings and events |
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Data for ImpriovTrainings | |
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LOCUS/CALOCUS Train-the-Trainer
Clinical Pearls in the Assessments and Treatment of Dementia Challenges
Using Outcomes-Based Data for Improving Service Quality and Monitoring Across All Populations
Person Centered Thinking
Being and Becoming a Trauma Informed Agency
TBI: Hidden in Plain Sight
Ethics: Matters of Conscience or Matters of Law?
March 27, 2015
LOCUS/CALOCUS
Person Centered Thinking: A 12 Hour Training on The National Learning Community Curriculum
David vs. Goliath: What Smaller Providers Need to Know
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| Smoky Mountain LME/MCO Has a New Address | |
Smoky Mountain LME/MCO is relocating our administrative headquarters in Asheville. Please send all notices and correspondence to the below address effective April 1, 2015:
Smoky Mountain LME/MCO
200 Ridgefield Court, Suite 206
Asheville, NC 28806 |
| N.C. Peer Support Specialists | |
This bulletin addresses changes in the process for becoming a North Carolina peer support specialist. Certification is required by the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) and the N.C. Division of Medical Assistance (DMA) to work as a peer specialist. It also reviews new requirements and timelines for implementation of the changes. Click here for more information. |
| News from Smoky's Incident Report Team | |
Training
Smoky is planning an IRIS training. If you are interested, email us at incidentreport@smokymountaincenter.com with the subject line "Training." Please include any specific questions, concerns or topics you would like answered during the training.
IRIS
All incidents should be submitted within 72 hours of the "provider learned" date. Our goal is to be at 93 percent; for the month of December, we had a 66 percent provider submission compliance. If you are having trouble submitting incidents, please contact us:
Ayofemi Powell: ayofemi.powell@smokymountaincenter.com, 828-586-5501, ext. 1104
Tashia Shamwell: tashia.shamwell@smokymountaincenter.com, 828-586-5501, ext. 5094
Backup Staff Incident Reporting (BUS)
Here are some things to know about BUS to prevent incidents from being sent back:
County of Provision
- This is the county where the service is provided.
- The top right-hand corner of the report features a drop-down option labeled "County of provision." If this field is left blank, it will default to "ALL". If "ALL" is on the incident, we will sent it back for correction.
Description Fields
- We are working to make all description fields mandatory in AlphaMCS. If "other" is selected, or there is a description box, please fill in a description. It does not have to be lengthy: something as simple as "natural supports" is appropriate for some boxes.
- Three easy steps to check if a report has been sent back to you:
- Filter
- Status - hand over to provider
- Search
Please be aware: only the person who entered the incident can correct it. |
| Relative as Direct Support Employee (RaDSE) | |
The N.C. Innovations Waiver is designed to leverage existing natural and community supports while fostering the development of stronger natural support networks. This enables Innovations participants to be less reliant on formal support systems. However, there are times when it is necessary for relatives or legally responsible persons who share a home with the waiver participant ("relative") to provide paid supports to ensure that the participant is able to remain in the home and community of his or her choice, particularly in more rural communities. "Legally responsible person" is the court-appointed guardian of an adult who has been adjudicated incompetent.
For this reason, DMA Clinical Coverage Policy No. 8P - NC Innovations allows for Innovations providers to employ relatives to provide certain Innovations services (in-home skill-building, personal care, in-home intensive supports and residential supports) within specific parameters. (Residential supports may not be provided by parents, step-parents, adoptive parents or other individuals living in the participant's natural home.) Innovations providers must acquire prior approval from Smoky before employing a relative to provide services to a participant.
With feedback from the Smoky Innovations Stakeholders Committee, Smoky has created a fully electronic prior approval procedure. The procedure is initiated by the Innovations provider. The provider must complete the new electronic request form, through DocuSign, available at Relative as Direct Support Provider (RaDSE).
The form requires the provider to enter detailed information to supply Smoky's Provider Network Department with the information needed to approve or deny the request. Completion of the form will generate a prior approval request. The form will be reviewed for complete information and a decision rendered within 14 calendar days. Please note that this form must be submitted annually in conjunction with the Individual Support Plan (ISP). Approval in any year does not guarantee approval in subsequent years.
Smoky will review location information and attestations indicated on the request form and make an authorization decision based on this information. For approvals, the provider will receive the approved DocuSign form. For denials, the provider will receive the denied DocuSign form and a formal letter explaining the decision. Rejections will not be followed by a formal letter. If the request is rejected due to incomplete information, the provider may resubmit. Please note that the N.C. Office of Administrative Hearings has determined that RaDSE decisions are not appealable, but providers may file a grievance by calling Smoky Customer Services at 1-888-757-5726.
Relatives providing paid supports is not a preferred option for adults on the Innovations Waiver. Smoky believes relatives should be allowed to be just that - relatives - and provide the same natural supports as they would for any family member. Family members and employing providers should consider the following questions:
- Is this about the participant's wishes, desires and needs or about supplementing a family member's income?
- Is it appropriate or best for the adult participant to still have parents with him or her throughout the day?
- If a family member supports an individual from birth into adulthood, does the person learn to adapt to different people and increase his or her flexibility and independence?
- If a participant is always supported by a family member, what happens when that caregiver becomes unable, through age, disability or death, to care for the participant? Who else knows how to interact with and care for the participant?
- Can a family member pose a barrier to increased community integration or friendship development?
- Does having a family member as direct support staff expand the participant's circle of support or risk shrinking it?
In general, there are only two circumstances in which a relative should provide paid supports. They are when:
- No other staff is reasonably available to provide the service; or
- A qualified staff is only willing to provide the service at an extraordinarily higher cost than the fee or charge negotiated with the qualified family member or legal guardian.
Requests for relatives to provide paid supports will require documented efforts of attempts to find direct support professionals through multiple Innovations providers.
Ordinarily, a relative will not be approved to provide more than 40 hours of paid supports per week (or seven daily units per week). Additional paid supports by a relative may be authorized if another provider is unavailable or it is necessary to ensure the participant's health and welfare.
The Innovations provider is responsible for communicating Smoky's RaDSE decision to the affected participant and relative. Please remember that relatives who are direct support professionals are employees of the Innovations provider and must comply with all requirements applicable to provider staff. The Innovations qualified professional is required to provide supervision as outlined in DMA Clinical Coverage Policy No. 8P - NC Innovations. Supervision includes clear communication about authorization decisions concerning the relative as direct support employee prior approval procedure.
Smoky will review RaDSE data collected quarterly. This data is used to inform network development decisions. Smoky is invested in ensuring a quality network of Innovations providers that, to the fullest extent possible, works toward increasing natural home and community connections for participants. Requests to employ relatives should be made only after all other options have been exhausted with multiple providers.
Submitting the RaDSE Prior Approval Request
The supervising qualified professional should follow the below steps to submit a RaDSE prior approval request:
- Access the form at Relative as Direct Support Provider (RaDSE).
- Enter the name of person making request and email address, then click "begin signing."
- Smoky will deliver an email including a validation code via DocuSign.
- Open the email, click "resume signing" and enter the validation code.
- Click "validate," and the form will appear.
- Click "continue."
- Complete the form by entering required information as indicated by red text boxes. This includes the number of hours/daily units of relative paid supports requested for each authorized service. The procedure will not allow submission of an incomplete form.
- Under "services provided," enter "0" in any column not applicable.
- Attest to the following by clicking the initial boxes in the attestation column:
- Click on the signature line to sign the form.
- Click "finish" to submit the form.
- The requester will receive an electronic decision within 14 calendar days of submission from a Smoky staff person via DocuSign.
- The electronically signed decision form should be maintained in the waiver participant and employee record.
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| Benefits Coordination and Provider Responsibility | Federal law and the Medicaid 1915 (b)(c) Waiver require all providers to file claims in accordance with Coordination of Benefits requirements. Providers must show evidence of filing claims with any payer who has responsibility as the consumer's primary payer before seeking payment from the secondary payer. [Note: The sole exception is services on the N.C. DMA-issued Medicare By-Pass List. These services may be filed directly to the MCO as the primary payer.] Smoky recently became aware of a segment of the Global Eligibility File that failed to download. This impacted approximately 100 consumers who had a primary insurance record in NCTracks. Once corrected, these consumers' eligibility records included a primary insurance present between July and December 2014. Smoky's Claims Department initiated a recoupment of the original claims processing and payment. This was initiated January 9, 2015, and is expected to be reflected on provider RAs beginning the week of January 21, 2015.
Providers affected by these recoupments are advised to file the claim with the consumer's primary insurance and, upon adjudication, refile with Smoky as the secondary payer. All providers are reminded of the COB obligations. Please be aware of Smoky's continued requirements and expectations. These directives remain in place:
- Providers are responsible for managing and reporting consumer eligibility appropriately. Upon learning of a primary insurance or a change in that insurance, providers should complete a Consumer Update Request (CUR) to add the eligibility record to the AlphaMCS system.
- Other insurance records on file in NCTracks will automatically download to AlphaMCS through the Global Eligibility File (GEF) download.
- If a provider believes an Other Insurance record in the GEF is incorrect, he or she must report this with a correction request to the eligibility staff in the Department of Social Services of the county of consumer eligibility. Smoky cannot change the GEF.
You may contact your assigned claims specialist or the claims (ext. 2455) and eligibility and enrollment (ext. 2355) lines at Smoky for more information or assistance. Thank you for your consideration and continued efforts. |
| Operations at a Glance | Smoky publishes data about its monthly performance for various waiver functions in Smoky Operations at a Glance. This document is shared with the Consumer and Family Advisory Committee (CFAC), the board of directors and the public through Smoky's News You Can Use email newsletter. Based on provider satisfaction survey feedback, Smoky leadership decided to also share this information in provider communications. View the January 2015 data here. |
| NC-TOPPS Updated February 2015 | |
Thanks to the Smoky provider network! Our network's NC-TOPPS compliance rating was above the 90-percent threshold. Keep up the excellent work, and let us know how we can support you.
CNDS numbers
North Carolina has delayed full implementation of the CNDS number requirement. The implementation deadline is July 1, 2015. Please do not wait until then to request numbers for your agency's consumers. You can obtain CNDS numbers through Smoky for non-Medicaid consumers. If you need to request a number, email nctopps@smokymountaincenter.com with the following information:
- The consumer's first name, middle initial and last name
- Date of birth
- Gender
- Social Security number
- Race and ethnicity
- Primary language spoken
- Provider agency name and address of location of services received
Please use secured or encrypted email to send this information to Smoky as it contains PHI. The LME/MCO Superusers will funnel those requests to eligibility and enrollment and provide you with a number. The CNDS number for Medicaid recipients is the Medicaid identification number.
New Feature Available for NC-TOPPS Users
The state has introduced the capability for provider agencies to run simple queries on outcomes data for consumers served. The Simple Query Report provides LME/MCO and provider agency Superusers with an expanded outcomes dashboard including demographics of the population served, treatment demographics, substance use, employment, education, housing, maternal/perinatal outcomes and service needs/satisfaction. Access this feature here.
For NC-TOPPS assistance, email nctopps@smokymountaincenter.com.
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| State-Funded Residential Services Referral Process | Providers needing to make referrals for state-funded residential services can use this document to expedite the determination of eligibility. |
| NCTracks Records | |
Providers are now able to update their provider record in NCTracks via the managed change request process, accessible through the provider portal. |
| Credentialing/Enrollment Information for CAQH | CAQH is making changes effective February 2015. You will soon receive important information related to these changes directly from CAQH. Please pay close attention to any communication from CAQH. To help with the transition to the upgraded system, please be aware of the following information: - Incomplete providers: Providers with incomplete applications must complete and attest to any outstanding applications prior to the transition to CAQH ProView. Unattested data will not convert to CAQH ProView.
- Email required: CAQH ProView requires an email address for all providers as a primary method of contact. Providers should enter an email address in the UPD now.
- Paper applications discontinued in February 2015: Providers must enter and complete information online. Paper versions of the credentialing application will no longer be accepted.
Questions: CAQH has established a CAQH ProView Provider Transition Support Center. Providers may email proview@caqh.org or call 844-259-5347. |
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Associate-Level Licensed Provider Changes | |
As outlined in MCO Communication Bulletin #J116, effective July 1, 2015, DMA will revise Clinical Coverage Policy No. 8-C (Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers) and remove the section allowing "incident to" billing for associate-level licensed providers, as well as the section allowing associate-level licensed providers to bill HCPCS codes (H0001, H0004 + modifiers, H0005 and H0031) through LME/MCOs.
Also effective July 1, 2015, DMH/DD/SAS will no longer permit associate-level licensed providers to bill HCPCS codes for state-funded outpatient services. The "incident to" policy change will not impact providers receiving state-funded reimbursement, as DMH/DD/SAS does not currently allow "incident to" billing.
This means that no later than July 1, 2015, associate-level licensed providers must be credentialed by Smoky and either be contracted directly with Smoky or employed/contracted by an agency that contracts directly with Smoky to bill for services. Smoky will no longer accept billing "incident to" a supervising physician or billing of HCPCS codes by associate-level licensed providers after June 30, 2015.
Associate-level licensed providers are required to have their own National Provider Identifier (NPI) number and register under the taxonomy code of their respective profession. For example, the Associate Level Licensed Clinical Social Worker will register under the taxonomy code for a Licensed Clinical Social Worker. To apply for an NPI number, please see the instructions on the NPPES website.
For more information, review Smoky's provider participation section or call us at 1-866-990-9712.
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| NC-TOPPS News |
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Thanks to all providers submitting NC-TOPPS interviews. The number of delinquent interviews has declined significantly since we began sending weekly updates in July.
Top NC-TOPPS issues
- NC-TOPPS interviews are expected to be completed in person. This allows for more accurate data collection and reporting. Performance data generated by NC-TOPPS submissions influence decision-making about services on a local and state level. It is important to have complete, accurate data.
- CNDS numbers become a required field starting January 1, 2015. If your agency has a large number of state-funded consumers, please be sure you are requesting CNDS numbers early. To obtain a CNDS number for non-Medicaid (or non-NC Health Choice) consumers, email the following information to nctopps@smokymountaincenter.com:
- First name, middle initial, last name
- Date of birth
- Social Security number
- Language spoken
- Ethnicity
- Gender
- Site address for your agency
For Medicaid and NC Health Choice consumers, the CNDS number is the participant's Medicaid identification number.
- The Smoky NC-TOPPS superusers cannot assist with:
- Claims
- SARS
- NCTracks
- Contract issues
- Payment issues
These issues must be addressed by your agency's assigned account specialist or claims specialist. If you are unsure whom to contact, call the provider helpline at 1-866-990-9712.
For NC-TOPPS issues and questions, contact Smoky at nctopps@smokymountaincenter.com. |
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| 2015 N.C. SNAP Certification Schedule | |
Please review the 2015 N.C. SNAP Examiners Certification Schedule. Registration information is available here. |
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