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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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The world has changed. It's a bold statement, wouldn't you agree? Bold and true. On September 23, 2015, House bill 372 was signed into law. Medicaid transformation and reorganization is coming to North Carolina. But for a gentleman I met at the Inaugural Western Regional Recovery Rally earlier in the month, the world changed on September 15, 2015.
Six days into his recovery journey, that gentleman was one of more than 500 people who gathered in Haywood County to bring addiction and mental illness recovery out of the shadows. I witnessed families, friends, neighbors, health care professionals, elected officials and law enforcement officers come together in a sea of solidarity. To celebrate lives that are changed, the culture must change. Stigma must give way to understanding, tolerance, acceptance, compassion and yes, tough love and care. Waynesville Police Chief-and Recovery Ally of the Year-Bill Hollingsed sees that changing the approach to addiction (like one small town in Massachusetts is doing) can heal a community and save lives. Chief Hollingsed shared a story with me that portrayed the essence of recovery and community. He and his officers recognized an increase in arrests over recent months. People with addictive disease were on a revolving door in and out of jail, suggesting incarceration wasn't a viable solution. After many conversations and openness to understanding recovery and the importance of support systems, law enforcement decided to give recovery a try. Today, the Haywood County law enforcement community believes in recovery and has embraced seeing people challenged with addictive disease as having potential to build a life worth living. The world has changed... A third validation the world has changed came on September 21, 2015, when Smoky held its second annual Provider Summit. A panel discussion on Medicaid reform gave providers an opportunity to gain insight from leading experts from across the state. Dave Richards, DHHS Deputy Secretary of Medical Assistance urged providers to start thinking about outcomes, an idea Karen McLeod, President and CEO of Benchmarks expanded upon when she stressed the importance of presenting those outcomes in a compelling way. What are you doing that sets you apart from other providers? Smoky's own CEO, Brian Ingraham, advised providers to assess their capabilities and look for partnerships that would foster whole person care. That same consideration was encouraged by Dr. Jeff Heck, President and CEO of Mountain Area Health Education Center, and Marc Malloy, Senior Vice President of Health Plan Solutions for Mission Health, both of whom identified the shift from acute to collaborative care as a way of ensuring people get the help they need when they need it. Like many people throughout the state, your feelings on the transformation and reorganization of Medicaid in North Carolina most likely vacillate between concern and confusion. At Smoky, we strive to understand and forecast health care policy, enabling us to respond to challenges accordingly. I encourage you as a provider and fellow member of our community to practice mindfulness and tolerance as transformation takes place. The world has changed, but our values remain the same. The foundation of our state's public service delivery system for mental health, substance use and intellectual and developmental disabilities is person-centered practices, and the essence of any change must be continued improvement of our ability to deliver innovative, personalized care with optimal outcomes. We live and work in a time of great opportunity. The world has changed, and we are ready... are you?
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Smoky general information
All Smoky departments and staff can be reached at 828-586-5501.
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 828-586-5501, 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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For professionals in Human Services only
Tuesday evenings 6:00 to 7:00 p.m.
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October 15-16, 2015
9:00 a.m. to 4:00 p.m.
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October 27-28, 2015
8:00 a.m. to 4:45 p.m. (both days)
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October 29-30, 2015
9:00 a.m. to 4:00 p.m. (both days)
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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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Provider Network Department reorganization
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A Message from Steve Timmons, Chief Business & Marketing Officer...
With the recent resignation of Sean Jones, Senior Director, of the Provider Network Department, I have been working with the department leadership to reorganize to better align with our future focus.
The Provider Network (PN) Department going forward will be organized with functions in four critical areas; Provider Relations, Provider Services, Network Development and Credentialing. Below is a summary of the Provider Network Leadership and how the departmental functions have been realigned; - Donald Reuss will supervise the PN management positions and his new title to reflect this functional change is Provider Operations Director
- Danny Fulmer will supervise the provider relations and services functions as Provider Relations Manager
- Jesse Smathers functions have expanded to include network development with MH/SU responsibilities in addition to Innovations. Jesse's title will change to Network Development Director to more accurately reflect the functions assigned
- Melissa Faulkner's functions remain the same and her title remains Credentialing Director
We will continue to explore the best possible means to effectively meet the needs of our Provider Network and the delivery of services to our consumers and families. We will continue to provide you with additional information on any enhancements to Provider Network as they occur. If you have any questions, please email provider.info@smokymountaincenter.com.
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Reminder: Grievance process
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Smoky's grievance team sincerely appreciates your efforts to improve the quality of care for the people we serve. One way we partner with our providers is by responding to, and resolving grievances filed by or on behalf of consumers. The grievance team reviews and follows-up on all grievances, regardless of the type or source.
Smoky operates a "no wrong door" approach to the grievance process. Any employee of Smoky can receive information regarding a grievance, but it is the responsibility of Smoky's grievance team to follow-up on all reports we receive. We strive to reach a resolution within 30 days of receiving a grievance. Although it requires extra effort on your part to respond to our requests quickly and completely, provider assistance is critical in helping us achieve the 30-day goal.
After a grievance is a filed, a grievance resolution worksheet is sent to the provider to obtain more information, offering an opportunity to collaborate with Smoky in resolving the grievance. If the provider does not complete the worksheet, the grievance team must resolve the concern without provider input and the grievance may be subject to further investigation for resolution.
On behalf of the grievance team, thank you for the work you do to help resolve grievance reports as they arise. If you have any questions, please call 828-586-5501 to speak with a member of the grievance team or email them at grievances@smokymountaincenter.com.
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Care Management team updates
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(b)(3) Supported Employment reminder
An earlier communication incorrectly informed providers that a Service Authorization Request (SAR) is not needed for the first 64 units of Supported Employment. While these first 64 units do not require a clinical review to have claims paid, a "notification" SAR must be submitted within seven calendar days of the initial contact with consumer. The start and end date should not exceed more than 30 calendar days and the number of units should not exceed 64. Notification SARs should only contain required information, along with a statement in the justification section identifying the units as unmanaged. No other clinical information is needed.
State-funded Basic Benefits require authorization
Please note that most state-funded outpatient services, with the exception of group outpatient therapy, require authorization as of October 1, 2015. Refer to the authorization guidelines on the Smoky website for more detail.
Accurate medication lists
Smoky care managers frequently encounter SARs with out of date medication lists, resulting in unnecessary calls to providers and mistaken referrals for pharmacy consultations. Please ensure that the list of medications included in a consumer's SAR is up to date and matches the list included in the comprehensive crisis plan.
(b)(3) Respite for MH/SU child and adolescent consumers
Please remember that (b)(3) Respite service definitions have been updated to reduce barriers to service delivery. No service order is required. Respite is often appropriate for consumers who are at risk for out of home placement, such as those who qualify for Intensive In-Home (IIH) services, and may be delivered concurrently with IIH. Contact your Smoky Provider Network account specialist or the Smoky Provider Services line at 1-866-990-9712 with questions.
Trauma-Focused Cognitive Behavioral Therapy enhanced rates In alignment with Smoky's Clinical Plan, we now offer an enhanced rate for Trauma-Focused Cognitive Behavioral Therapy (TFCBT) delivered by North Carolina Child Treatment Program (NC-CTP) rostered clinicians. This change will go into effect November 1, 2015. TFCBT is an evidence-based practice that targets trauma symptoms experienced by children and adolescents. Providers billing this service should use code 90837Z1 at a rate of $125.00. Only rostered clinicians are eligible to bill this code.
Smoky will monitor the effectiveness of this program as it relates to adherence to the defined treatment model. In addition to meeting eligibility criteria for outpatient treatment as outlined in Clinical Coverage Policy 8C, the requirements below must be met: - Prior to the initiation of the treatment, an assessment including a standardized trauma assessment instrument (e.g. University of California Los Angeles Posttraumatic Stress Disorder (PTSD) Index) should be performed and results should indicate the need for this intervention;
- Children who are experiencing serious conduct or behavioral problems that existed prior to the occurrence of traumatic events may require interventions focused on stabilization prior to receiving this treatment.
Level of Care evaluations for consumers receiving I/DD services Consumers who receive services through the Innovations Waiver are only required to have updated Level of Care (LOC) evaluations if the treatment team recognizes the consumer's functioning has changed to an extent that would merit another assessment. For consumers receiving state-funded residential services, there is no requirement mandating assessments must be conducted within a certain timeframe. Smoky will review any evaluation available, regardless of age, and if it sufficiently addresses all criteria in NC GS 122C-3 (12a) definition of Intellectual/Developmental Disability (I/DD), it will be accepted. Situations in which Smoky may request an updated evaluation include, but are not limited to, the following:
- A consumer has an evaluation that gives an outdated diagnosis (e.g. Asperger syndrome);
- An evaluation may have been administered when a consumer was a child, but he/she is now an adult;
- An evaluation may not have yielded sufficiently clear results (e.g. does not have clear adaptive functioning levels).
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Procedure code for State Benefit Plan (Target Pop) mappings
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 Smoky recently updated the State Benefit Plan (Target Pop) mappings procedure code to place them in alignment with the Division of Mental Health, Substance Use and Developmental Disabilities service array dated July 15, 2015. This change is effective for claim dates of service July, 1, 2015 forward. You may notice that previously adjudicated claims are being recouped. A refiled claim must be submitted within Smoky's regular timeframe for timely filing. The timeframe will not be extended. Please review your Remittance Advice (RA) accordingly.
If you have questions contact your Smoky claims specialist, if you do not know who your claims specialist is email claims@smokymountaincenter.com.
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Innovations Waiver Amendment stakeholder forums
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The Division of Medical Assistance (DMA) has posted the final draft of the NC Innovations Waiver amendment, which is ready for submission to the Centers for Medicare and Medicaid Services. Smoky will host informational sessions throughout our region to review resource allocation, new service definitions and changes to existing service definitions. Providers of Innovations services, people receiving Innovations services and those who have family members receiving Innovations services are encouraged to attend.
Meeting Information
| October 12, 2015 | 6:00 to 8:00 p.m. | Caldwell County Public Library, 120 Hospital Drive, Meeting room 6, Lenoir, NC 28645 | | October 14, 2015 | 6:00 to 8:00 p.m. | Smoky Mountain LME/MCO, 895 State Farm Road, Building #400, Boone, NC 28607
| | October 21, 2015 | 6:00 to 8:00 p.m.
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Smoky Mountain LME/MCO, 200 Ridgefield Court, Suite 206, Asheville, NC 28801
| | October 27, 2015 | 6:00 to 8:00 p.m. |
Rutherford Health Center, 187 West Main Street, Spindale, NC 28160
| | November 9, 2015 | 6:00 to 8:00 p.m. |
Macon County Public Library, 149 Siler Farm Road, Franklin, NC 28734
| | November 16, 2015 | 6:00 to 8:00 p.m. |
Haywood County Department of Social Services, 157 Paragon Parkway, Clyde, NC 28721
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Thanks to the Innovations Stakeholders Committee for their input in shaping the sessions. If you have questions, please email Jesse Smathers at jesse.smathers@smokymountaincenter.com.
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Attention Assertive Community Treatment (ACT) providers
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A recent DHHS joint communication bulletin clarified the upper age limits on adult enhanced Medicaid services. As long as medical necessity and other qualifying eligibility criteria are met, a beneficiary can continue to receive adult enhanced Medicaid funded services, regardless of age.
The intent of Clinical Coverage Policy 8A-1 for Assertive Community Treatment (ACT) is to cover a beneficiary 18 years of age and older as long as they meet medical necessity and the required eligibility criteria. Medicaid is currently updating this section of its policy to correctly reflect eligibility for beneficiaries 18 years of age and older. In the interim, LME/MCOs have the flexibility to be less restrictive than the policy. It is recommended that beneficiaries over 64 years of age who are currently authorized for ACT services continue to receive the services.
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Previous Bulletin reminders
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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. Please review the training brochure and register by visiting the MAHEC website.
Attention providers: The Smoky Provider Operations manual is open for comment
has been posted for a 30-day comment period. Providers, consumers, family members, community stakeholders and Smoky staff may review and provide comments and feedback. Please send all comments and questions to manuals@smokymountaincenter.com no later than 5:00 p.m. on Friday, October 30, 2015. All comments will be carefully reviewed and considered. Necessary revisions will be made and the final manual will be posted to the website the week of November 2, 2015.
Please remember, the manual is incorporated into your contract as a binding requirement. This is your opportunity to provide feedback. We look forward to hearing from you.
Site-specific NPI Implementation Suspension
In the June 2, 2015 Provider Communication Bulletin, Smoky notified all contracted providers that they were required to obtain a National Provider Identifier (NPI) for each billable site that provides services to Smoky consumers.
Due to multiple implementation issues with NCTracks, Smoky has decided to suspend this requirement until further notice. Once all of these issues have been resolved, Smoky will provide additional guidance.
If your agency has questions or concerns call 1-866-990-9712, dial 3 for a provider relations team member or email your questions or concerns to providerinfo@smokymountaincenter.com.
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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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