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Welcome to the Smoky Mountain LME/MCO Provider Network Bulletin. This monthly bulletin features news you need to know as a provider in the Smoky network and information you need to do business with Smoky.
Smoky manages public funds for mental health, substance use and intellectual or developmental disability services in 23 counties in western North Carolina. It is our pleasure to work with you to serve the needs of our local residents. |
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It was 1970, and I was a 12-year-old girl in western North Carolina. The radio played Diana Ross and Three Dog Night. We were just getting over the breakup of the Beatles and celebrating the splashdown of Apollo 13 when the tragedy of the Kent State shootings left the country stunned and scared. I had just started volunteering at the regional developmental center, where my first assignment was bathing eight adult men. They stood side by side in a shower as I used the one white washcloth and single bar of Ivory soap I was provided to bathe them all. I was embarrassed, but dutiful. In my 12-year-old mind, I thought, 'the nurses know best and I should just follow the directions I have been given.'
No one told me the men's names. No one introduced me to them nor told me how the men liked to be bathed. After the shower, they had no choice about what they wore. All eight men put on identical blue gowns, incontinence products and white socks. At mealtime, I placed a clothing protector on each person and fed them all the same pureed food with spoons. There were smells in the air I had never experienced, and when I asked about them, I was told, "Don't worry about it; you'll get used to it."
Despite this experience, I knew I liked the people who lived at the center. Being young and curious, I wondered about their lives-where they came from, who they were and how they got to the center. But most of all, I wondered why no one came to visit. I was 12. I had no idea that these men had been born in a time when their families were told that the best thing for their loved one with a disability would be to take them to a place where they would be cared for and to forget about them. These families heard from their medical physicians that their loved ones would "never learn anything" and they would "never get any better."
There was no person-centeredness, no choice, no independence, no assistive technology and no community placements. Looking back, it was obvious that we were doing for people, not with people. Years later, I returned to the regional developmental center and worked there for 10 years. During my tenure, I witnessed a new set of values, a new level of care and a clear understanding of how to create a better quality of life with people. I still carry those values and that vision with me today.
Services and supports for persons living with intellectual and developmental disabilities (I/DD) have changed significantly over the past 50 years. Advocacy groups fought for legislation that evolved from institutional reform in the '60s and '70s to the creation of home and community-based services in the '80s. The strong movement to increase inclusion of persons living with I/DD in their community led to the passage of the Americans with Disabilities Act of 1990. The Olmstead v. L.C. decision at the end of the 20th century maintained that persons living with I/DD have the right to receive home and community-based services in the least restrictive setting possible.
In North Carolina, home and community-based services are more widely used than ever before. Presently, more persons living with I/DD receive services in their community rather than in institutional settings. Though we have done a wonderful job of moving persons living with I/DD into community settings, we have not done a stellar job in helping persons with I/DD build the connections and real relationships that support them in becoming equal in their communities. Persons living with I/DD have the same rights to citizenship and relationships as anyone.
The HCBS Final Rule states that the Home and Community-Based Setting must be integrated in and support full access to the greater community, including:
1. opportunities to seek employment and work in competitive integrated settings; 2. engage in community life; 3. control personal resources; and 4. receive services in the community, to the same degree of access as individuals not receiving Medicaid HCB services. With the implementation of the HCBS Final Rule, services and supports for persons living with I/DD are at a transformative time. The rule will require significant changes in practice over the next four years, including detailed assessments of the system. It is sure to be a challenge; more work for professionals, but better lives for many people. As professionals dedicated to improving the lives of persons living with I/DD, we must embrace the positive change that the HCBS Final Rule will bring.
During the civil rights movement, Martin Luther King, Jr. remarked that "the moral arc of the universe is long, but it bends towards justice." The HCBS Final Rule is a mechanism to continue the moral arc. Please join Smoky in this march towards justice for all persons living with I/DD.
I would like to offer my sincere gratitude to Jesse Smathers, Innovations Technical Director and Patty Wilson, Senior Director of Contract Performance and Special Investigations for their wisdom and consultation on this article.
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Smoky general information
All Smoky departments and staff can be reached at 828-225-2785.
Administrative headquarters
Smoky Mountain LME/MCO
200 Ridgefield Court, Suite 206
Asheville, NC 28806
Provider questions
Call 1-866-990-9712, send an email to
or contact your account specialist
Confidential Compliance Hotline
(To report suspected fraud or abuse): Report online or call 1-866-916-4255, 24 hours a day
AlphaMCS technical support
Call 828-225-2785, ext. 1500, 8:30 a.m. to 5 p.m. Monday through Friday
Incident reporting
More information
Visit the Smoky website for more about:
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UPDATES: PROVIDER
ADVISORY
COUNCIL
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Smoky's Provider Advisory Council is representative of different types of providers practicing throughout our 23-county catchment area. To find out more, view Council meeting minutes and get information about upcoming events, go to the Council's page on the Smoky website.
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UPCOMING TRAININGS & EVENTS
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Monday, September 21, 2015
10:00 a.m. to 4:30 p.m.
31 Woodfin Street
Asheville, NC 28801
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Saturday, September 19, 2015
10:00 a.m. to 2:00 p.m.
Open Air Gym
Lake Junaluska, NC 28745
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Visit these sites for additional training opportunities:
Click here to view the NC Council of Community Programs calendar
Click here to view the MAHEC calendar
Click here to view the Northwest AHEC calendar |
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National accreditation and Innovations Waiver services
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Certain services under the Innovations Waiver require national accreditation.
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General Services
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National Accreditation Required?
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Specialty Services
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National Accreditation Required?
| | Community Networking |
Yes
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Assistive technology equipment and supplies
| No | |
Day Supports*
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Yes
| Community Guide | Yes | | In-Home Intensive Supports |
Yes
| Transition from a facility to the community | No | | In-Home Skill Building | Yes | Crisis Services | Yes | | Personal Care Services | Yes | Home Modifications | No | | Respite | Yes | Natural Supports Education | No | | Supported Employment | Yes | Specialized Consultation Services | No | | Residential Supports | Yes | Vehicle Modifications | No |
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| Individual goods and services needed to live independently | Yes |
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| Financial Supports | No |
*National accreditation is not required for services provided under Employer of Record, Adult Day Health, or Adult Day Care programs under the Day Supports definition.
The waiver notes the following requirements under each of the above definitions that are not listed as excluded:
"Upon enrollment with the PIHP, the organization must have achieved national accreditation with at least one of the designated accrediting agencies. The organization must be established as a legally constituted entity capable of meeting all of the requirements of the PIHP. Not required for Adult Day Health and Adult Day Care Programs."
According to the Division of Medical Assistance (DMA), accreditation should include all modules that are the closest fit to the services provided by the agency. For example, if an agency provides Personal Care and Respite services, the closest Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation categories may be Personal Supports Services and Respite. Providers should consult with accrediting bodies on the modules and waiver definitions to determine what is needed. Smoky is responsible for ensuring that provider agencies in the Smoky network hold accreditation in the appropriate areas and will make the determination on a case by case basis, consulting with DMA as needed.
Providers who are accredited for some, but not all services they provide must be accredited for all services they provide by August 19, 2016.
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Determination of consumer eligibility
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Adhering to eligibility and enrollment determinations is critical for state-funded contracts for services. As a reminder, all contracts for state-funded services between Smoky and providers include specific guidelines to ensure compliance.
Coordination of benefits: Providers agree to assist in the coordination of each individual's healthcare benefits to avoid delay in the provision of services and to ensure that public funds shall be used only if and when other sources of first and third-party payment have been exhausted. Providers shall make every reasonable effort to verify all insurance and other third-party benefit plan details during first contact. This will ensure consumers are directed to appropriate providers and to comply with North Carolina law.
The state of North Carolina is clear on the intent for use of state funds, and Smoky policies ensure compliance.
From Smoky Policy # 2462, "NCTracks and Consumer Eligibility":
Providers are required to establish an initial target population group for each consumer when completing a new enrollment and are required to update them at least annually by submitting a Client Update Request (CUR) into the AlphaMCS system. Consumers must meet the specific eligibility criteria and diagnosis code(s) of the assigned target populations.
From Smoky Policy # 2782, "Non-Medicaid Fund Use":
State funds eligibility is limited to those consumers who meet both financial and clinical criteria. Generally, state funds are reserved for the uninsured; dual eligibility is intended to be used sparingly, and only when state-funded/non-Medicaid services are appropriate for a consumer clinically and financially.
To consider any request for state funds on behalf of a consumer currently enrolled in Medicaid, sufficient detail and justification are required. Such information includes financial and clinical criteria, as well as a statement of the non-Medicaid eligible services requested. Without sufficient documentation, a request will not be approved.
Maintenance requirements for both provider and Smoky staff are increased when consumers have more eligibility layers than necessary. Multiple layers require more routine maintenance and review. Consumers with no services or claims who are Medicaid-eligible and have a state layer will eventually land in the discharge queues, slowing Smoky's overall responsiveness to providers and other consumer enrollment and eligibility requests.
Restricting the use of state enrollment to consumers who clearly meet the criteria allows providers and Smoky to focus limited resources for more effective treatment. Contact your Provider Network account representative with any questions or concerns.
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Format testing for ICD-10
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 If your organization is interested in participating in Smoky's ICD-10 testing and you have not already done so, please send an email request to ICD10@smokymountaincenter.com. Use "Interest in Testing" as the subject line and include the following information in the body:
* Provider name
* AlphaMCS ID
* Claims system and/or clearinghouse
* Contact information (name, phone, email address) for the person representing your organization
Smoky will contact you to proceed with testing. Your organization will then follow the steps outlined below.
- Create an 837 claims file that contains representative ICD-10 and ICD-9 codes. Please limit the number of claims in your file to a maximum of 12.
- Claims should use October 1, 2014, as the presumed implementation date for ICD-10. It should be expected that claims filed with an ICD-9 diagnosis after this date will deny. (Please note: October 1, 2014, is not the actual ICD-10 implementation date but is the operational date in the AlphaMCS test system.)
- Email the encrypted file to ICD10@smokymountaincenter.com. For HIPAA Security purposes, the email must be encrypted.
- Send a password to access the file in a separate email to ICD10@smokymountaincenter.com
- On receipt of your file, you will receive an email acknowledgement. Please allow a minimum of five business days for processing time.
- Smoky will send confirmation after the file has been processed and format testing results are available. Format testing verifies that the data filed conforms to the expected data requirements. Providers should expect a pass or fail result based on whether the claims filed conform. The format testing will not actually process the claim to either a denial or approval and payment.
For general questions regarding ICD-10, please consult the Smoky website.
Thank you for your consideration and assistance in testing for ICD-10 readiness.
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Clarification: Refund check process
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Providers occasionally receive overpayment on a service, need to correct the billing of a service that has previously been paid after a self-audit or receive payment that cannot be posted.
Before sending a refund check to Smoky for any of these transactions, we urge providers to submit a void or replacement claim. This results in a more efficient process for both the provider and Smoky, ensuring the appropriate claims have been identified in the refund process. When a provider submits a void claim and/or replacement claim, the AlphaMCS system will identify the initial and final payments and will handle both transactions in a timely process. The remittance advice (RA) or 835 file will supply details of both voided and paid claims. Any recoupment amounts are applied to other claims payments; therefore, a refund check is not necessary.
If you feel you have an exceptional case or questions about how to submit a replacement or void claim, please contact your claims specialist or call the general claims line at 828-586-5501, ext. 2455.
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Transforming Care Conference: Evidence-Based Medicine
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Smoky and the Mountain Area Health Education Center (MAHEC) will sponsor a conference October 27-28, 2015 to improve the practice of evidence-based medicine.
The event, "Transforming Care Conference: Evidence-Based Medicine and the Future of Behavioral Health and Intellectual Developmental Disabilities Care," is designed for mental health professionals, including substance use counselors, social workers, psychologists, marriage and family therapists, school counselors, intellectual or developmental disabilities (I/DD) professionals and anyone else interested in the subject. Early registration is open through October 20 at $125 per person for both days or $75 per person for the second day only. Group rates and discounted rates for supporters, peer support specialists and students are also available.
Practicing evidence-based medicine (EBM) incorporates provider expertise, clinical evidence and the values, culture and needs of the person receiving care. To help build strong and healthy communities all three components of EBM are needed to effectively support people with mental illnesses, substance use disorders and/or intellectual or developmental disabilities. The aim of the conference is to increase participants' competence in delivering truly person-centered, collaborative care while implementing evidence-based treatment in a way that improves care and outcomes for individuals and reduces the per capita costs of care.
Discounted room rates are available for conference participants at the DoubleTree Hotel (828-274-1800) and the Biltmore Village Lodge (828-277-1800). Please be sure to ask for the Smoky Evidence-Based Medicine Conference. The discounted rate offer expires October 3, 2015.
Take a virtual tour of these facilities at biltmorefarmshotels.com.
If you have questions or concerns about your room reservation, please contact Karen Lambert at 828-257-4481 or karen.lambert@mahec.net.
Parking will be limited. Please carpool when possible.
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Reminders from Smoky's Care Management team
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State-funded outpatient therapy changes:
As of October 1, 2015, all basic outpatient therapy codes will require prior authorization. The following codes are affected by this change:
| 90832 | PSYCHOTHERAPY 30 MINUTES | | 90832AH | PSYCHOTHERAPY 30 MINUTES CLINICAL PSYCH | | 90832AJ | PSYCHOTHERAPY 30 MINUTES LCSW/LPC/LMFT | | 90833 | PSYCHOTHERAPY 30 MINUTES ADD ON TO EVALUATION & MANAGEMENT (E&M) | | 90833GT | PSYCHOTHERAPY 30 MINUTES ADD ON TO E&M - TELECOMMUNICATION | | 90834 | PSYCHOTHERAPY 45 MINUTES | | 90834AH | PSYCHOTHERAPY 45 MINUTES CLINICAL PSYCH | | 90834AJ | PSYCHOTHERAPY 45 MINUTES LCSW/LPC/LMFT | | 90834GT | PSYCHOTHERAPY 45 MINUTES TELECOMMUNICATION | | 90836 | PSYCHOTHERAPY 45 MINUTES ADD ON TO E&M | | 90836GT | PSYCHOTHERAPY 45 MINUTES ADD ON TO E&M - TELECOMMUNICATION | | 90837 | PSYCHOTHERAPY 60 MINUTES | | 90837AH | PSYCHOTHERAPY 60 MINUTES CLINICAL PSYCH | | 90837AJ | PSYCHOTHERAPY 60 MINUTES LCSW/LPC/LMFT | | 90837SR | IN-HOME PSYCHOTHERAPY 60 MINUTES | | 90838 | PSYCHOTHERAPY 60 MINUTES ADD ON TO E&M | | 90838GT | PSYCHOTHERAPY 60 MINUTES ADD ON TO E&M - TELECOMMUNICATION | | 90839 | PSYCHOTHERAPY FOR CRISIS 60 MINUTES | | 90846 | FAMILY THERAPY WITHOUT PATIENT | | 90847 | FAMILY THERAPY WITH PATIENT |
For more information, please refer to the Smoky Benefit Plans on our website, or contact a care manager by calling 1-866-990-9712.
Psychological testing guidelines:
Updated information regarding comprehensive clinical assessments:
Smoky has created a presentation based on the Comprehensive Clinical Assessments provider training offered last fiscal year. The document explains the required elements of a comprehensive clinical assessment. Please review and note that Smoky does not require or review for any additional elements beyond what is specified in the Clinical Coverage Policy and related implementation updates.
Changes to Assertive Community Treatment service definition:
The Department of Medical Assistance has approved a final version of the new, standalone Assertive Community Treatment (ACT) service definition in Clinical Coverage Policy 8A-1, which went into effect on August 1, 2015. Changes in this service definition will impact Care Management's review of ACT services in the following ways:
- The new service definition has placed an upper age limit on those who can receive this service (ages 65 and older). Initial requests for consumers who are above this age limit, or who will age out of the service within the first authorization period will be returned as "unable to process".
- For affected consumers, services that are otherwise medically necessary will continue to be authorized to allow for step-downs to appropriate services. Providers should begin assessing appropriate step-down services for these consumers.
- The new service definition allows for two weeks of service delivery to occur prior to creation of the Person Centered Plan (PCP). Therefore, Care Management will no longer require a copy of the PCP to be submitted with the initial Service Authorization Request (SAR).
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Workshop: Mental health, substance use and aging
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Baby boomers are the leading adult age group in having been diagnosed with depression at any point in their lives. By the year 2030, more than 15 million adults over age 65 will be diagnosed with a psychiatric disorder. Currently, 4 million older adults need substance use treatment. It is estimated the number of adults age 50 and older in need of alcohol or drug treatment will increase to 5.7 million by 2020.
The workshop, "Mental Health, Substance Use and Aging: How Baby Boomers Will Change the Face of Getting Older", will provide an overview of mental health and substance use needs of older adults. Those who provide care and services to older adults are encouraged to attend this program to learn how to better prepare for these challenges.
Greenville
September 21, 2015
8:00 a.m. to 4:00 p.m.
Pitt Count Agricultural Extension Center
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Kannapolis
October 16, 2015
8:00 a.m. to 4:00 p.m.
Daniel R Coughlin Conference Center at Cardinal Innovations
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Asheboro
October 29, 2015
8:00 a.m. to 4:00 p.m.
Corporate Training Center at Randolph Community College
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Asheville
November 17, 2015
8:00 a.m. to 4:00 p.m.
Eliada Children's Home
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Agenda
| 8:00 a.m. | Registration | | 9:00 a.m. | Welcome/introduction | | 9:30 a.m. | What we need to know about good mental health for the Baby Boomer to Centenarian | | 12:00 p.m. | Lunch (provided) | | 1:00 p.m. | Substance use and aging | | 3:30 p.m. | Wrap-up | | 4:00 p.m. | Adjourn |
To register, or for more information, please visit the event page of the NAHEC website.
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5th Annual Regional Transition into Adulthood fair
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A Journey Toward Independence: Positive outcomes for youth with disabilities
 Mission Children's Hospital and the Family Support Network of WNC will host the 5th Annual Regional Transition into Adulthood Fair on October 3 in Asheville. The fair features topics including high school transition planning, navigating adult community services and planning for the future when a family member has a disability.
Agenda
| 11:00 to 11:45 a.m. | High school transition planning | | 11:00 a.m. to 3:00 p.m. | Community exhibitor's fair | | 12:00 to 12:45 p.m. | Navigating adult community services | | 1:00 to 2:00 p.m. | Youth benefits and services training | | 2:15 to 2:45 p.m. | Puberty is coming. Are you Ready? | | 3:00 to 4:00 p.m. | Planning for the future when your family includes a member with a disability |
View the event flyer to learn more. For more information, contact Kerri Eaker, Family Support Network Education Outreach Coordinator, by calling 828-213-0047 or emailing kerri.eaker@msj.org.
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Smoky Mountain LME/MCO manages publicly funded services for mental health, substance use and intellectual and developmental disabilities in the North Carolina counties of Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Watauga, Wilkes and Yancey.
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For immediate help in a crisis, information about services, screenings and treatment referrals, call 1-800-849-6127, 24 hours a day,
seven days a week (TTY: Call Relay NC 711). Visit us online at www.smokymountaincenter.com.
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