Autism stakeholders meeting presentation (1)

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Became operational November 1, 1979

Chartered in West Virginia and domiciled in
Ohio as a 501-C-4 Non-Profit Corporation

Licensed to do business in Ohio & West Virginia

Expanded into North Central WV in 1994

Expanded Statewide 2010 / 2011

HANCOCK

BROOKE

OHIO

PENNSYLVANIA
MARSHALL

WETZEL
MONONGALIA MARYLAND
MORGAN
MARION BERKELEY
OHIO TYLER PRESTON

MINERAL
HARRISON HAMPSHIRE
PLEASANTS TAYLOR JEFFERSON
DODDRIDGE
WOOD RITCHIE
BARBOUR GRANT
TUCKER
HARDY
WIRT
GILMER LEWIS
JACKSON CALHOUN UPSHUR

MASON RANDOLPH
ROANE
BRAXTON
PENDLETON

PUTNAM WEBSTER
CLAY
VIRGINIA
CABELL
KANAWHA
NICHOLAS POCAHONTAS

WAYNE
LINCOLN

BOONE FAYETTE

GREENBRIER

LOGAN
MINGO
RALEIGH

SUMMERS
WYOMING MONROE

KENTUCKY MERCER

MCDOWELL

24 additional West Virginia Counties
Over 2100 New Providers
27 New Hospitals

Tertiary Facilities Include:

All contracting and service items (new
providers, claims inquiries, questions, etc.)
serviced by Health Plan directly
No Programs or Services Carved Out

Health Plan requires credentialing of all
providers including extenders
Contact Provider Relations (800) 624-6961
Ext. 7633 for contracting information

Coverage of Autism Spectrum
Disorder
WV Legislative mandate for coverage effective
January 2012
Large employer groups required to cover: in
preceding year averaged over 25 eligible
employees
Coverage effective upon reenrollment of large
groups throughout the year
Diagnosis of ASD prior to age 8
Coverage applies to children age 18 months to
18 years.

Establishing the Diagnosis of Autism
Spectrum Disorder
Primary Care Physician (PCP) completes ASD
screenings as per AAP and AAN guidelines as
part of the preventive health visits
Multidisciplinary approach to establishing
diagnosis
Referrals to specialists, ancillary support, and
testing are directed by the PCP
Diagnosis of ASD based on DSM-IV-TR

Establishing the Diagnosis of Autism
Spectrum Disorder
Once diagnosis is confirmed, coverage for
autism treatment is initiated as per the
member’s insurance benefit plan.

To assure payment of treatment and therapy
under the benefit, services related to ASD
require preauthorization

Covered services:
Applied Behavior Analysis provided and/or
supervised by a Board Certified Behavior
Analyst (BCBA)
Information found at www.healthplan.org >
provider services > additional BHU resources >
Initial Authorization for ABA and Concurrent
Authorization for ABA
Medically necessary treatments, such as OT, ST,
PT

Coverage of ABA

Initial authorization:

Results of screening and scaling
Functional Behavioral Assessment
Goals
Risk Assessment
Targeted interventions aimed at specific behaviors
Parental training

Continuation of ABA
Behaviors and interventions identified on initial
authorization form
Improvements and achievements
Supporting documentation

Billing for ABA
Evaluation and Management Codes from
Current Procedural Terminology have been
assigned to various levels of treatment
Billing details will be in your contract

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Autism stakeholders meeting presentation (1)

2. Became operational November 1, 1979 Chartered in West Virginia and domiciled in Ohio as a 501-C-4 Non-Profit Corporation Licensed to do business in Ohio & West Virginia Expanded into North Central WV in 1994 Expanded Statewide 2010 / 2011

3. HANCOCK BROOKE OHIO PENNSYLVANIA MARSHALL WETZEL MONONGALIA MARYLAND MORGAN MARION BERKELEY OHIO TYLER PRESTON MINERAL HARRISON HAMPSHIRE PLEASANTS TAYLOR JEFFERSON DODDRIDGE WOOD RITCHIE BARBOUR GRANT TUCKER HARDY WIRT GILMER LEWIS JACKSON CALHOUN UPSHUR MASON RANDOLPH ROANE BRAXTON PENDLETON PUTNAM WEBSTER CLAY VIRGINIA CABELL KANAWHA NICHOLAS POCAHONTAS WAYNE LINCOLN BOONE FAYETTE GREENBRIER LOGAN MINGO RALEIGH SUMMERS WYOMING MONROE KENTUCKY MERCER MCDOWELL

4. 24 additional West Virginia Counties Over 2100 New Providers 27 New Hospitals Tertiary Facilities Include:

5. All contracting and service items (new providers, claims inquiries, questions, etc.) serviced by Health Plan directly No Programs or Services Carved Out Health Plan requires credentialing of all providers including extenders Contact Provider Relations (800) 624-6961 Ext. 7633 for contracting information

7. Coverage of Autism Spectrum Disorder WV Legislative mandate for coverage effective January 2012 Large employer groups required to cover: in preceding year averaged over 25 eligible employees Coverage effective upon reenrollment of large groups throughout the year Diagnosis of ASD prior to age 8 Coverage applies to children age 18 months to 18 years.

8. Establishing the Diagnosis of Autism Spectrum Disorder Primary Care Physician (PCP) completes ASD screenings as per AAP and AAN guidelines as part of the preventive health visits Multidisciplinary approach to establishing diagnosis Referrals to specialists, ancillary support, and testing are directed by the PCP Diagnosis of ASD based on DSM-IV-TR

9. Establishing the Diagnosis of Autism Spectrum Disorder Once diagnosis is confirmed, coverage for autism treatment is initiated as per the member’s insurance benefit plan. To assure payment of treatment and therapy under the benefit, services related to ASD require preauthorization

10. Covered services: Applied Behavior Analysis provided and/or supervised by a Board Certified Behavior Analyst (BCBA) Information found at www.healthplan.org > provider services > additional BHU resources > Initial Authorization for ABA and Concurrent Authorization for ABA Medically necessary treatments, such as OT, ST, PT

11. Coverage of ABA Initial authorization: Results of screening and scaling Functional Behavioral Assessment Goals Risk Assessment Targeted interventions aimed at specific behaviors Parental training

12. Continuation of ABA Behaviors and interventions identified on initial authorization form Improvements and achievements Supporting documentation

13. Billing for ABA Evaluation and Management Codes from Current Procedural Terminology have been assigned to various levels of treatment Billing details will be in your contract

Editor's Notes

10/03/12 15:47 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.
10/03/12 15:47 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.
10/03/12 15:47 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.
10/03/12 15:47 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.
10/03/12 15:47 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.
10/03/12 15:47 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Autism stakeholders meeting presentation (1)

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Editor's Notes