Provider Update
Please see the attached mailing that was sent to all UMP insureds who submitted health care claims with the DSM-IV diagnoses related to autism, aspergers and PDD in the last year. Please feel free to distribute.
Please keep me informed about the responses you get to the claims submitted. The offices of Ele Hamburger and Sirianni Youtz & Spoonemore are happy to help with appeals of any denials reductions terminations or approvals of services at a lower frequency or reimbursement rate than expected.
UMP/Regence will not provide pre-authorization for claims for ABA therapy. Thus, UMP/Regence patients and providers will have to submit the claims, without pre-authorization, in order to determine whether and how the services will be covered.
UMP/Regence is referring callers to three sources of information to determine whether UMP/Regence will cover the submitted claims: (1) the Regence outpatient behavioral health guidline -http://blue.regence.com/about/utilization/Outpatient_Treatment_Medical_Necessity_Criteria.pdf; (2) the UMP Certificate of Coverage definition of medical necessity http://www.ump.hca.wa.gov/medical/docs/umpcoc2011.pdf; p. 99; and (3) Regence’s provider coverage criteria http://www.wa.regence.com/provider/contracts-credentialing/credentialing/ (Regence is apparently closed to accepting new licensed mental health providers at this time - http://www.wa.regence.com/provider/contracts-credentialing/provider-types/ ).
In general, claims for behavioral health services submitted to Regence by appropriately credentialed providers will be automatically adjudicated through the first 20 visits. At the 20th visit, UMP/Regence will request a treatment plan from the provider which will be reviewed by the UMP/Regence medical director. The UMP/Regence medical director will deny continued coverage or approve continued service at a particular frequency for a set period of time, after which the service will be reviewed again.
It is almost certain that the claims will be paid at the out-of-network (60%) level, even though we do not know of any Regence in-network providers who are qualified to provide ABA therapy services. It is important that providers and patients let my office know of all claims, whether approved or denied, for ABA therapy and the rate at which the claims were paid. Patient and providers who are paid at the 60% rate should appeal, requesting the in-network rate.
We hope that patients and providers will start sending in claims to UMP/Regence for ABA therapy services consistent with the above three criteria.
Please call or email Ele Hamburger with questions.
Ele Hamburger
Sirianni Youtz
Spoonemore
999 Third Avenue, Suite 3650
Seattle, Washington 98104
Telephone: (206) 223-0303
Facsimile: (206) 223-0246
Direct Line: (206) 838-1809
E-mail: ehamburger@sylaw.com
Website: www.symslaw.com
HCANoticeABA
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Dear Providers,
Today, we reached a preliminary stipulation with Washington Health Care Authority about removing the existing ABA exclusion in the 2011 Uniform Medical Plan’s Certificate of Coverage. Here’s a copy of the settlement agreement.
If you have any patients who are Uniform Medical Plan enrollees and who intend to submit claims for ABA therapy, please let me know. I would like to track the requests that are submitted so I can monitor the process.
According to the 2011 Uniform Medical Plan Certificate of Coverage (COC), enrollees may obtain coverage of mental health services (now including ABA therapy) from either in-network and non-network providers. If the enrollee seeks coverage from a non-network provider, the reimbursement rate is lower – only 60% of Regence’s allowed amount. See COC p. 3, found at http://www.ump.hca.wa.gov/medical/docs/umpcoc2011.pdf. In-network providers are reimbursed at 85% of the allowed amount. As a result, it will be helpful for BCBA providers to investigate whether they may become in-network providers with Regence Blueshield.
Regence covers mental health services provided by both licensed and certified mental health providers, according to the COC. Only registered counselors are excluded. See COC, p. 21; 45.
UMP/Regence is required by law to have an adequate network of providers, including now, providers of ABA therapy. If there are no contracted in-network providers within 30 miles of an enrollee to provide medically necessary ABA therapy services, UMP/Regence must arrange for the services to be provided at no greater expense or travel time for the enrollee. Thus, if your claim is only covered at the 60% out-of-network rate, it is important for the enrollee to inquire as to the in-network providers of ABA therapy services in their area. If Regence cannot identify any providers who are qualified to provide ABA therapy, the enrollee should appeal the decision.
My office is available to assist with enrollees who are denied coverage, whose claims are approved but only at the out-of-network rate, or whose claims are approved for a lower frequency of the therapy than the provider believes is medically necessary. UMP/Regence enrollees who are seeking coverage of ABA therapy should call (206) 223-0303 and ask to speak with Ele Hamburger.
Thanks for your ongoing help with this!
Ele
Ele Hamburger
Sirianni Youtz
Spoonemore
999 Third Avenue, Suite 3650
Seattle, Washington 98104
Telephone: (206) 223-0303
Facsimile: (206) 223-0246
Direct Line: (206) 838-1809
E-mail: ehamburger@sylaw.com
Website: www.symslaw.com
Downloadable copy of the settlement agreement DF v WSHCA