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ProviderConnect User Manual

1. Key Step 6 Documentation of Primary Behavioral Condition is required Provisional working Complete the condition and diagnosis should be documented if necessary Documentation of Clinical Screens secondary co occurring behavioral conditions that impact or are a focus of errr treatment mental health substance use personality intellectual disability is agnosis strongly recommended to support comprehensive care Authorization if applicable does NOT guarantee payment of benefits for these services Coverage is subject to all limits and exclusions outlined in the members plan and or summary plan description including covered diagnoses Below are the key actions for completing this screen Any field with an asterisk indicates that the field is required Step Action The Primary Diagnostic Category 1 is the main diagnosis and should be the reason for the members decompensation to Inpatient Care 2 Enter the Diagnosis Code 1 or a brief Description and select the hyperlink Primary Behavioral Diagnosis Diagnostic Category 1 SELECT 19 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Step Action system users can enter a partial diagnosis and then click on the hyperlink to view a filtered list of those DSM IV and DSM 5 codes that match their search criteria Once a user clicks on the appropriate code in any of the pop up
2. Narrative Entry 0 cf 2000 Medications If member is currently not on Medication s this field is not required on the Initial Request The Medication field is required on the Concurrent review Step Action lf MEMBER is CURRENTLY ON PSYCHOTROPIC MEDICATIONS please indicate the following required fields Enter each of the Medications the field as necessary Medication name Start date date discontinued the date added will populate to today s date How to Enter the Medication First select the hyperlink above the medication name field It will bring up a list of psychotropic medications sorted by class If the medication is found select the Medication from the list If a medication is not listed in this list users can choose Other and then enter the name of the medication in the Other open text field below the Medication field Please indicate in the open text field for each of the following Medications For this medication please enter any details concerning dosage side effects adherence effectiveness prescribing provider and any specific target symptoms 4 If Additional Medications need to be added then Select the Add Medication Box 30 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Medications For this medication please enter any details concerning dosage side effects Start Date adherence effect
3. Logging In The ProviderConnect web application is found on the CT BHP website 1 Goto www CTBHP com 2 Select For Providers ef V EOPTIONS N VALUEOPTIONS Connecticut BHP Supporting Health and Recovery News amp Events For Providers For Members 3 Select Log In 4 Providers should never select Register Prowider Online Services Welcome to the Connecticut Behavioral Health Partnership CT BHP Online Services ProwiderConnect Login or register with ProviderConnect an online tool that allows you to check member eligibility enter authorization requests for CT BHP registered services view authorization letters and more Providerlonnect is easy to use secure and available 24 7 5 New Users without an ID refer to page 5 otherwise 6 Enter User ID and Password Please Log In Required fields are denoted by an asterisk adjacent to the label Please log in by entering your User ID and password below User ID If you do not remember your User ID please contact our e Support Help Line Password Forget Your Password Log In The information and resources provided through the ValueOptions site are provided for informationa ValueOptions site Providers are solely responsible for determining the appropriateness and man 7 Select Log In 8 Select Accept on the User Agreement page to proceed to the home page 6 Revised 4 14 2015 CT BHP ProviderCon
4. SOCIAL BEHAVIOR IS THERE A DUTY TO WARN WILL PROVIDER DO THE DUTY TO WARN NOTE IF PROVIDER WILL NOT DO DUTY TO WARN SPEAK WITH YOUR SUPERVISOR BASELINE DESCRIBE ANY HISTORY OF VIOLENCE INCLUDING IF MEMBER HAS EVER ATTEMPTED TO KILL OR INFLICT SERIOUS HARM LEGAL INVOLVEMENT PAST OR PRESENT TREATMENT HISTORY ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST 27 Revised 4 14 2015 Step 28 CT BHP ProviderConnect User Manual Inpatient Reviews Action If Psychosis Symptom Complex is Required Indicate the following PRESENTING PROBLEM BEHAVIORAL DESCRIPTION OF SYMPTOMATOLOGY DELUSIONS HALLUCINATIONS COMMAND HALLUCINATIONS THOUGHT DISORDER BASELINE FIRST EPISODE NEUROLOGICAL WORKUP NEEDED IS MEMBER MEDICATION COMPLIANT HAS PROVIDER EXPLORED PAST MEDICATIONS COMPLIANCE AND EFFECTIVENESS IS THERE A NEED FOR DIFFERENT MEDICATION S DESCRIBE PLAN FOR MEDICATION COMPLIANCE INCLUDING SUPPORTS TO ASSIST PRN TREATMENT HISTORY ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST If Child Adolescent Behavior Symptom Complex is Required Indicate the following PRESENTING PROBLEM BEHAVIORAL DESCRIPTION OF BEHAVIORAL ISSUES WHEN DO THESE BEHAVIORS TEND TO HAPPEN WHEN WAS THE LAST TIME THESE BEHAVIORS OCCURRED DO THESE BEHAVIOR
5. goo Lek nee 7 Select the Next button to continue The Requested Service Header will display 15 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Key Step 2 The second key step is to complete Requested Services Header screen This Complete screen displays for all tyoes of requests However the information entered here Initial Entry determines which clinical screens will display and which authorization parameters joe will be applied to the request The fields with an asterisk indicate the field is required 1 Enter the Requested Start Date This field automatically populates with today s date but can be modified if needed by changing the date or the calendar icon 2 Select the Level of Service INPATIENT HLOC When the level of service is selected the screen will update with the required fields specific to the level of Service 3 Select the Type of Service MENTAL HEALTH or SUBSTANCE ABUSE 4 If Level of Care INPATIENT PARTIAL HOSP 23 HOUR OBS Select the Type of Care INPATIENT then select INPATIENT INPATIENT HOSPITAL 1 Note Inpatient IP Psych Facility Natchaug Hospital Only 2 Note For Inpatient Detox Type of Service Substance Use Level of Care Inpatient Type of Care Inpatient Detox 3 Note For Partial Hospital of Service MH or SA Level of Care Partial Hospital Type of Care Partial Hospital P
6. X VALLE ETIONS Recovery Reform Connecticut BHP Service Supporting Health and Recovery Support Wellness Care Coordination For Providers For Members 3 Under the forms section select the Online Services Account Request Form hyperlink Provider Online Services ProviderConnect Login or register with ProviderConnect an online qe LOG IN tool that allows you to check member eligibility enter authorization requests for BHP registered i services view authorization letters and more REGISTER ProviderConnect is easy to use secure and available 24 7 e Online Services Account Request Form Provider Home e Registered Services Template n Bulletins e Registered Services Re Registration Template Registered Services Retroactive Eligibility Review Template Covered Services e Psychological Testing Registration Template 4 Complete the form and fax it to the Provider Relations Department at 855 750 9862 Completed forms can also be emailed to the Provider Relations Department at ctbhp 2valueoptions com 5 User Accounts are created within 2 business days Once the Account is created you will be sent an email with your ProviderConnect ID and password If you have any questions please contact the CT BHP Provider Relations department at 1 877 552 8247 5 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews
7. able to use a Temporary member ID if the member doesn t have a Medicaid ID Then select Search x Member ID Last Hame Date af Birth As of Date First Required fields are denoted by an asterisk J adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below temp0O0 00056 Mo spaces or dashes 01151995 MMDDYYYY 08172010 MMDOYYYY 4 Select the Next button on the Member record to continue Member Member ID Alternate ID Member Hame Date of Birth Address Alternate Address Marital Status Home Phone wwork Phone Relationship Gender TEMP 0 0 0 77 D DI 5 E WOODSIN MOONE 01 15 1995 300 ENTERPRISE OF HARTFORD WE EFH 5 The Select Service Address screen will display 35 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Inpatient HLOC Concurrent Requests continued 6 Capture the Service Address Vendor by selecting the radio button next to the Provider ID The record that is selected will be attached to the request and authorization that will be created NOTE You must select the same Service Address Vendor that was used on the Pre Cert for the system to recognize this as a Concurrent Review Select Service Address Provider Capture Provider ID Last Name Vendor ID Vendor Last Name First Name Vendor First Name 002120 TEMP PROVIDER VCBO03159 TEMP PROVIDER 500 EN
8. be selected 2 If there are no social elements impacting the member select the None checkbox 3 If social elements have not been assessed yet select the Unknown checkbox If Other Psychosocial and Environmental Problems is selected an open text field will open and require you to enter what the other is Social Elements Impacting Diagnosis lt Check all that apply None Problems with access to 7 Housing problen 7 Problems related to the health care services Hot Ho 55 5 social environment Educational problems Problems related to interaction Occupational problems systeny crime Financial problems Problems with primary support Other psychosocial and Unknown group environmental problems 22 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued The next section is named Functional Assessment and will allow users to enter up to 2 different assessment measures and scores While 2 assessments can be entered users are not required to enter any information in this section as it is optional Step Action To complete this section simply click the droodown for the Assessment Measure If an Assessment Measure is selected in the drop down then an Assessment Score must be entered into the corresponding field as well 3 If an Assessment Measure is
9. etc 4 Enrollment History Displays active and expired enrollment records for member 5 Coordination of Benefits Display information on other insurance policies 6 Additional Information Displays claims mailing address for the member Demographics Enrollment History COB Additional Information Member eligibility does nat guarantee payment Eligibility is as of today s date and is provided by our clients View Member Auths Displays member specific authorizations Enter Auth Request Initiates the authorization process View Clinical Drafts Display member specific Clinical Drafts 0 View Referrals For Residential Group Home Providers Only e ce cM Wark Phone Relationship Gender View Member Authz Enter Auth Request View Clinical Drafts View Referrals 8 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews b ProviderConnect Functions Viewing Providers have the ability to view and print authorizations as well as view Authorizations authorizations that have been pended to the CT BHP for further review Authorizations and authorization requests can be viewed and opened by providers from the Authorization Listing on the ProviderConnect homepage Once logged into ProviderConnect select Authorization Listing from the Home Page NY PROVIDERCONNECT VALUEOPTIONS Home Authorization Listing Enter an Authorization Request Enter a Treatment Plan YOUR MESSAGE CENTER View C
10. for completing this process The Concurrent fields with an asterisk indicate that the field is required Request for Authorization 1 Select Enter an Authorization Request link from either the left navigational menu or the middle of the ProviderConnect homepage Staging Home Welcome Thank you for using ValueOptions ProviderConnect Authorization Listing Request YOUR MESSAGE CENTER view Clinical Drafts Review Referrals Your Recent Inquinez box is empty Enter Bed Tracking Information WHAT DO YOU WANT TO DO TODAY My Online Profile Eligibility and Benefits Review Referrals m Find a Specific Member m Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters Review an Authorization m View Clinical Drafts 34 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Inpatient HLOC Concurrent Requests continued 2 Review the Disclaimer and select the Next Button Disclaimer Please note that Valueoptions recognizes only fully completed and submitted requests as formal requests for authorization recognize or retain data for partially completed requests Upon full completion of the Enter an Authorization Request prc notification that your request has been received by ValueOptians 3 Search for Member s Record by entering the Member s 9 digit Medicaid ID OO and Date of Birth MMDDYYYY You may also be
11. information below Medication Treat Please explain the reason for current admission describe symptoms and ment Screen Aclude the precipitant what stressor or situation led to this decompensation If this is a concurrent request please list both the progress that has been made to date and what symptoms still remain PROVIDERCONNECT VALUEOPTIONS gt LEVEL OF CARE DIAGNOSIS iss ar NBC Peis RR 1 NH alae ADDITIONAL MTPPR INFORMATION Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 04 15 2015 PROVIDER IVANNA TEMP PROVIDER VCBOO3159 Save Request as Draft Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization INITIAL TEMP000981339 2120 SELECT Level of Type of Service Level of Care Type of Care Authorized User of Service INPATIENT HLOC Mental Health Inpatient Inpatient Hospital Inpatient Hospital Symptomatology eason for cur explain the n rent admission describe symptoms and include the precipitant what stressor or situation led to this decompensation If this is a concurrent request please list both the progress that has been made to date and what symptoms still remain 0 of 2000 Narrative Entry wa Below the Symptomatology is an abbreviated risks section O None 1 Mild or Mildly Incapectating 2 Moderate or Moderately Incapectating 3 Severe
12. not listed in the dropdown Other can be selected If Other is selected an open text box will appear Please enter the Other test and the Assessment score of that test Please indicate the functional assessment too utilized or select Other to write in other specific tool Assessment score for specific too should be noted in the Assessment Score field Assessment Measure Secondary Assessment Measure SELECT Assessment Score SHET Assessment Score A Select the appropriate Assessment Measure from the drop down menu and enter the Assessment Score Assessment Measure Secondary Assessment Measure SELECT Assessment Score 75 SELECT Assessment Score SELECT CDC HRQOL B Users can select from the following assessment measures If you are using a different assessment measure then select Other from the drop down menu Below is a Key for the Assessment Measure List CDC HRQL Center for Disease Control Health Related Quality of Life CGAS Children s Global Assessment Scale FAST Functional Assessment Staging Test GAF Global Assessment of Functioning OMFAQ Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire SF12 Quality of Life Assessment Using the Short Form 12 Questions SF36 Quality of Life Assessment Using the Short Form 36 Questions WHO DAS World Health Organization Disability Assessment Schedule 23 Revised 4 14 2015 CT BHP Pr
13. the field is required 1 Select Enter an Authorization Request link from either the left navigational menu or the middle of the ProviderConnect homepage Staging Home dece Welcome Thank you for using ValueOptions ProviderConnect Authorization Listing Request YOUR MESSAGE CENTER View Clinical Drafts Review Referrals Your Recent Inquiries box is empty Enter Bed Tracking Information WHAT DO YOU WANT TO DO TODAY My Online Profile Eligibility and Benefits Review Referrals m Find a Specific Member m Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters Review an Authorization m View Clinical Drafts 13 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued 2 Review the Disclaimer and select the Next Button Disclaimer Please note that Valueoptions recognizes only fully completed and submitted requests as formal requests for authorization recognize or retain data for partially completed requests Upon full completion of the Enter an Authorization Request prc notification that your request has been received by ValueOptians 3 Search for Member s Record by entering the Member s 9 digit Medicaid ID OO and Date of Birth MMDDYYYY You may also be able to use a Temporary member ID if the member doesn t have a Medicaid ID Then select Search x Member ID La
14. 5 12 Completing Inpatient HLOC Concurrent Requests continued CT BHP ProviderConnect User Manual Inpatient Reviews Microsoft Internet Explorer WARNING You have not attached a document to this Request Please click CANCEL to return to the screen to attach document or click to proceed with your request without attaching a document 13 Select the Process Continuing Care Concurrent Request button to complete the Concurrent Request There is an existing authorization that bridges this date range 15 this a request for continuing care concurrent request or do you wish to enter Discharge information Process Continuing Care Concurrent Request Enter Discharge Information Cancel If you do not see the Process Continuing Care Concurrent Request button DO NOT continue Return to the previous page and re enter the information again making sure the Requested Start Date and Admit Date fields are correct If you are not prompted with the button above please call the CT BHP to troubleshoot your situation Please go to page 18 of the User Manual and Proceed Thank you 38 Revised 4 14 2015
15. 804350 Pended Authorization Client Autharzation Type of Request 071112 1 1 U0532077 CONCURRENT Auto Pended Requests Action Confirm submission of request o status would indicate Pended at the top of the screen with a message indicating that the request requires further review The Results screen provides a summary of information about the request Print the request Click the Print Authorization Result button to print a copy of the Results page Click the Print Authorization Request button to print a copy of all the screens fields completed for the request including the clinical screens and the Results page Download the request Click the Download Authorization Request button to save a copy of the request either in odf format or xml Exit the Request for Authorization function Click the Return to Provider Home to exit the Request for Authorization function Authorization Printing amp Downloading Options For the best print results please print in Landscape format Print Authorization Request Download Authorization Request Print the entire Authorization Request Download the entire Authorization Request 33 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Inpatient HLOC Concurrent Requests Key Step 1 Entering an Inpatient Concurrent Authorization is very similar to entering an Initial Initiate a npatient Authorization Below the key actions
16. CT BHP ProviderConnect User Manual Inpatient Reviews D ProviderConnect Inpatient HLOC Registration User Manual Connecticut BHP Supporting Health and Recovery 1 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Table of Contents 3 PCCESSING PTO Vd HOO IB 5 Provider onneci BaSiOS 7 ProviderGorineet FUNCIONS t perde oe GOL Recent od ew el dI Rad d 9 Completing Inpatient HLOC REqQuESTS cccccceececececseeeeceeeesseeeeseeeesaeeeeseeeessaeeeseeeetaeees 13 Completing Inpatient HLOC Concurrent 26 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews b Introduction Introduction The ProviderConnect application provides a variety of self service functions to help providers access and view information about members and authorizations as well as complete requests for service authorizations What is Covered This module covers general functions within ProviderConnect as well as the Initial in this Module and Concurrent Review processes for Inpatient Psychiatric authorizations Training As a result of this training module you will be able to Objectives Log into ProviderConnect Search for and view Member records Complete an Inpatient HLOC Initial Request Complete an Inpatient HLOC C
17. G ORGANS DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS CHRONIC PAIN DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS MIGRAINE DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS MULTIPLE SCLEROSIS DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS OTHER DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS PARKINSON S ENDOCRINE NUTRITIONAL AND METABOLIC DISEASES AND IMMUNITY DISORDERS DIABETES ENDOCRINE NUTRITIONAL AND METABOLIC DISEASES AND IMMUNITY DISORDERS OTHER ENDOCRINE NUTRITIONAL AND METABOLIC DISEASES AND IMMUNITY DISORDERS THYROID GENITOURINARY SYSTEM KIDNEY GENITOURINARY SYSTEM OTHER INFECTIOUS amp PARASITIC HIV INFECTIOUS amp PARASITIC OTHER INJURY AND POISONING OTHER INJURY AND POISONING TBI MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE NEOPLASMS RESPIRATORY SYSTEM COPD ASTHMA EMPHYSEMA RESPIRATORY SYSTEM OTHER SKIN amp SUBCUTANEOUS TISSUE SUPPLEMENTARY CLASSIFICATI RINAL CAUSES OF INJURY AND POISONING SYMPTOMS SIGNS AND I ED CONDITIONS A Partial Description We suggest for those system users that are new or unfamiliar to the DSM 5 Medical Diagnoses to first enter a partial description of the medical condition then click the Description hyperlink Primary medical diagnosis is required Select primary medical diagnostic category from dropdown or select medica Mdagnosis code and description Diagnostic Category 1 Diagnosis Code 1 Description SELECT Hypertensio Diagnosti
18. HP 5 Enter the Admit Date VV AMDDYYY Y Answer Yes or No for Has Member Been Admitted to Your Facility field 7 Attach a document CT BHP Inpatient HLOC registered services do not require attached documents 8 Ifthe Admit Time field is not auto populated users should enter 00 00 military time 9 Select the Next button Staging Requested Services Header o All fields marked with an asterisk are required Note Disable pop up blocker functionality to view all appropriate links Requested Start Date MMDDYYYY Level of Service 04142015 3 INPATIENT HLOC Type of Service Level of Care Type of Care Admit Date MMDDYYYY MENTAL HEALTH INPATIENT v INPATIENT INPATIENT HOSPITAL v 04142015 lt the member already been ed to the facility Admit Time HHmm 0000 Provider Tax ID Provider Last Name Vendor ID Provider ID CBHP002120 TEMP PROVIDER VCB003159 Member Member ID Last Name First Name Date of Birth MMDDYYYY 000981339 PROVIDER IVANNA 01011995 Attach a Document Complete the form below to attach a document with this Request The following fields are only required if you are uploading a document Document Type Does this Document contain clin Document Description SELECT v UploadFile Click to attach a document 16 Revised 4 14 2015 10 A warning message will display to confirm whether you want to proceed without attaching a document Select the OK button to pr
19. S OCCUR IN THE SCHOOL IS SCHOOL INVOLVED IN CURRENT TREATMENT PLAN DESCRIBE COORDINATION WITH SCHOOL IS MEMBER INVOLVED WITH SPECIAL ED DO THESE BEHAVIORS OCCUR IN THE HOME HAVE FAMILY SESSIONS OCCURRED AS OFTEN AS NECESSARY DO THE BEHAVIORS OCCUR IN THE COMMUNITY LEGAL SOCIAL SERVICE INVOLVEMENT BASELINE TREATMENT HISTORY SPECIFIC TO BEHAVIOR PLAN WHAT ASSISTANCE WILL FAMILY GUARDIANS NEED IN ORDER TO MAINTAIN BEHAVIOR PLAN ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST If Eating Disorder Symptom Complex is Required Indicate the following PRESENTING PROBLEM DESCRIBE ANY BINGING PURGING RESTRICTING OVER EXERCISING FOOD RITUALS ETC IBW ORTHOSTATIC BP STANDING SITTING __ EKG ELECTROLYTES OTHER LAB INFO CO MORBID MEDICAL ISSUES CO MORBID PSYCHIATRIC ISSUES BASELINE TREATMENT HISTORY ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST Revised 4 14 2015 29 CT BHP ProviderConnect User Manual Inpatient Reviews Action If Neurocognitive Symptom Complex is Required Indicate the following PRESENTING PROBLEM BEHAVIORAL DESCRIPTION OF ACUITY MEDICAL WORK UP NEEDED TO RULE OUT CAUSALITY OF SYMPTOMS HAS A NEUROLOGICAL WORK UP BEEN COMPLETED DOES MEMBER HAVE A UTI OTHER LABS COMPLETED WHAT IS THE MEMBER S BA
20. SELINE AND WHEN WAS S HE LAST AT BASELINE IS THE OP MED REGIMEN MONITORED FOR UNDER OR OVER MEDICATING TREATMENT HISTORY DOES THE FAMILY HAVE REASONABLE EXPECTATIONS ABOUT MEMBER S ABILITY TO RETURN TO BASELINE OR INABILITY TO RETURN TO BASELINE IS THE MEMBER FROM A NURSING HOME IF SO WILL THE NURSING HOME HOLD THE BED FOR MEMBER 5 RETURN IF MEMBER WAS LIVING AT HOME WILL MEMBER BE ABLE TO RETURN HOME IF RECENT BASELINE IS ACHIEVED ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST If Substance Use Symptom Complex is Required Indicate the following PRESENTING PROBLEM DRUG S OF CHOICE ROUTE OF ADMINISTRATION AMOUNT OF USE FREQUENCY OF USE AGE OF FIRST USE DATE OF LAST USE ETC PSYCHOLOGICAL amp LEGAL CONSEQUENCES OF USE BASELINE TREATMENT HISTORY PREVIOUS ATTEMPTS AT TREATMENT amp OUTCOME ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC HISTORY OF DTS OR SEIZURES COULD THE PATIENT BE USING DRUGS THAT WOULDN T SHOW ON UDS OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST If SA Complex was required then continue to indicate the ASAM Other Patient Placement Criteria then complete the 6 Dimension Checkboxes Required Action Indicate Dimension 1 Intoxication Withdrawal Potential Low Medium or High Indicate Dimension 6 Recovery Environment Low Medium or High If Mood Disorder Sympt
21. TERPRISE DR 500 ENTERPRISE DR OTP STE 4D STE 4D ROCKY HILL CT 06067 3913 ROCKY HILL CT 06067 3913 TEMPFAC 002120 TEMP PROVIDER VCBO005769 TEMP PROVIDER STE 4D STE 4D ROCKY HILL CT 06067 3913 ROCKY HILL CT 06067 3913 999999999 Lek 7 Select the Next button to continue The Requested Service Header will display 36 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews b Completing Inpatient HLOC Concurrent Requests continued Key Step 2 The second key step is to complete the Requested Services Header screen This Complete screen displays for all types of requests However the information entered the determines which clinical screens will display and which authorization parameters will be applied the request The fields with an asterisk indicate the field is required R t ean 1 Enter the Requested Start Date The Requested Start Date is the last date authorized on the current authorization 2 Select the Level of Service INPATIENT HLOC When the level of service is selected the screen will update with the required fields specific to the level of Service Select the Type of Service MENTAL HEALTH 4 Select the Level of Care z INPATIENT 5 Select the Type of Care INPATIENT INPATIENT HOSPITAL Note Inpatient IP Psych Facility Natchaug Hospital Only 6 Enter the Admit Date VVMDDYYYY The Admit Date is the start date on the
22. ag tel Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 04 15 2015 PROVIDER IVANNA TEMP PROVIDER VCB003159 e Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization TEMP000981339 002120 TEMPFAC SELECT Level of Service Type of Service Level of Care Type of Care Authorized User INPATIENT A Mental Health Inpatient Inpatient Hospital Inpatient Hospital This tab is Wt required for this type of request Back Submit The Additional MTPPR Information screen is only required for DCF Residential and Group Homes please Select SUBMIT 32 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews b Completing Initial Inpatient HLOC Requests continued a T 10 the Submit button is selected from the final clinical screen the submission screen will ubmi Display Inpatient Requests will be pended to the CT BHP clinical team for further review equest an Submission The services requested require additional review You will be contacted regarding the status of this request if further information is needed An authorization decision will be made within the required timeframes and details of that decision may be found under the member s authorization history Member Name Member ID Member DOB Subscriber Name Subscriber ID ANITA IMDFOUR TEMP000804350 01 01 1991 ANITA IMDFOUR TEMP000
23. be Clinical Section redirected to the Achieve Solutions Website which offers additional Additional information to share with the member regarding the condition Information on Selected Conditions Below are the key actions for completing the next steps Any field with an asterisk indicates that the field is required Step Action 1 Selectall members ofthe Care Planning Team 1 1 1 O Is there a child or adult in member s household in need of any support or services Yes or No If Yes Please answer the following e Select primary support services needed from the dropdown e Select additional support services if needed from the dropdown e Yes describe support services recommended open text field 250 char Is service requested for HLOC because appropriate not available Yes or No If Yes e What LLOC was needed and not available for member Indicate from Dropdown menu e Reason why appropriate LLOC not available Check all that apply If Other then describe in the open text field 250 character limit 4 Planned Discharge Level Care dropdown menu 1 1 1 i Planned Discharge Residence drown down menu 6 Expected Discharge Date MMDDYYYY format or use calendar icon Se the Next button The Additional MTPPR Information screen will display next NY PROVIDERCONNECT VALUEOPTIONS gt LEVEL OF CARE DIAGNOSIS CLINICAL PRESENTATION MEDICATION TREATMENT 188
24. c Category 2 Diagnosis Code 2 Description SELECT Zl Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued B A partial description will bring up a pop up window where users can view a filtered list of those descriptions that match their search criteria E Select Diagnosis Code Windows Internet Explorer 2 CLOSE WINDOW CIRCULATORY SYSTEM HYPERTENSION ESSENTIAL HYPERTENSION CIRCULATORY SYSTEM HYPERTENSION SECONDARY HYPERTENSION COMPLICATIONS OF PREGNANCY HYPERTENSION COMPLICATING PREGNANCY CHILDBIRTH AND THE PUERPERIUM CHILDBIRTH AND THE PUERPERIUM C Once a user clicks on the appropriate code in the pop up window all other fields will populate Primary Medical Diagnoses Primary medical diagnosis i amp required Select primary medical diagnostic category from dropdown or select medical diagnosis code and description Diagnostic Category 1 Diagnosis Code 1 Description CIRCULATORY SYSTEM HYPERTENSION 401 Essential hypertension The next section has been named Social Elements Impacting Diagnosis Additionally the Housing Problems checkbox has been divided into Housing Problems Not Homelessness and Homelessness Step Action To complete this section simply click the check boxes for any of the factors that impact the member It is okay to select more than one check box At least 1 check box must
25. cular Problem field Click inside of the box to select the value Expand Collapse Any title with an arrow gt to the left of the title t Narrative Entry indicates that it is a section that can be expanded to display fields or information Click on the title to expand or collapse the section Hyperlinked Any underlined codes that are input options for a field Codes 301 3 will populate the field when clicked Hyperlinked Diagnosis Code 1 Any underlined field title will open screens help text a Field Titles MES list of codes etc when clicked Radio buttons Any data items with radio buttons next to them O Yes No OD Unknown indicate that only one data item can be selected for that field Click inside of the circle to select the value Save Request as A Save Request as Draft button IS available on the Draft Request for Services screens which will save the record when clicked As a saved record it is only available within ProviderConnect and is not available to access in CareConnect A Submit button is available on some screens which heerlen will submit the record when clicked Text Boxes Members Guardian Any open text box indicates that free form text can be entered into the box 4 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews b Accessing ProviderConnect Obtaining an ID and Password 1 Goto the CT BHP website at www CTBHP com 2 Select the For Providers button R
26. drug screen Please Indicate Yes No or Unknown Select the radio button for the following fields not required unless SA Primary Outcome of UDS Please Indicate Positive Negative or Pending Enter the Date of Urine Drug Screen not required unless SA Primary MMDDYYYY format or select the calendar button and select the date Enter the COWS amp CIWA not required unless SA Primary COWS scale for Opiate Withdrawal 5 12 mild 13 24 moderate 25 36 moderately severe gt 36 severe withdrawal 6 for ETOH withdrawal lt 8 no concern 9 15 mild to moderate concern 16 needs aggressive intervention potential delirium Positive for Check all that apply not required unless SA Primary Select Check boxes Cannabis Opiates Cocaine Amphetamines Tricyclic Antidepressants Phenylpropanolamine Benzodiazepines Barbiturates Methamphetamine PCP phencyclidine LSD Lysergic acid diethylamide Methadone or Other Enter the Blood Alcohol if unknown then select the checkbox N A Positive For Check all that apply Benzodiazepines Date of Urine Drug Screen Barbiturates Methamphetamine Amphetamines PCP Phencyclidine Tricyclic Antidepressants LSD lysergic acid diethylamide Phenylpropanolamine Methadone Other 26 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Key Step 7 The Primary Issues Symptoms Addressed i
27. ested Approved 0 0 Indicates that the request has been pended for further review o Visits Requested Approved 0 Indicates that the request has been denied Submitted Initial and Concurrent Requests for Inpatient Psychiatric care will PEND to the CT BHP Clinical Team for further review Users will follow the above steps to view the status of the authorization within 24 hours of a request being submitted 11 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews ProviderConnect Functions is While working with requests for authorizations in ProviderConnect providers have as Drafts the ability to save a request as a draft in the event that they cannot complete it at the time the request was started Saved drafts can be viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage View Clinical Drafts Recent Inquires Responded ta by valueoptians Enter Bed Tracking DATE RECEIVED SUBJECT Information S N N S A 07 25 10 REFERRAL My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Find a Specific Member Enter or Review Authorization Requests Enter an 4uthorization Request Review an Authorization B View Clinical Drafts Saved drafts are available for completion and submission for 30 days from the initial date the record was saved If the record is not submitted
28. in any clinical screen the request can be saved as a draft by clicking the Save Request as Draft button within the screen header We recommend you click this button at least once on each page of the authorization request SERVICES RESULTS SERVICES Save Request as Draft 18 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Key Step 5 The Level of Care Diagnosis screen is the first screen that will display after the Initial Complete the Entry screen Much of the information is required for completion of this screen Clinical Screens Below are the key actions for completing this screen Any field with an asterisk Levelof Care indicates that the field is required Screen Action Enter the CALLING PROVIDER FACILITY open text field If Member s LMHA is involved Select LMHA from the dropdown Enter the Aftercare Follow up contact information for the member Please provide at least one method for contacting member for follow up If not available please clarify reason Complete Phone if not available select box and enter reason why Enter the Member s email and then validate email to the right not required 7 8 Enter the Name of Place Facility Institution who referred member please be specific 9 Complete the IF CHILD DCF LEGAL STATUS field drop down 10 TheDiagnosissectionisnex
29. iveness prescribing provider and any specific target symptoms Date Discontinued gt Narrative Entry 0 of 250 Date Added 04152015 Add Medication zvPREX zvPREXA OLANZAPINE 2 LEXAPR LEXAPRO ESCITALOPRAM pRISTIQ DESVEMLAFAXINE SstCS CS lt C lt C PAXILC PAXIL CR PAROXETINE Step Action Please provide an overview with respect to all medications above please enter any additional details that would assist in coordinating care Note The Open text field will allow up to 2000 characters 6 Indicate if there are Med changes this month Yes or No Not Required Meds Require serum blood levels Yes or No Not Required Date of most recent blood draw Enter date MMDDYYY format or use the calendar icon or select Unknown Not Required The Best Practices Endorsement Step Action Please select the hyperlink Best Practice Guidelines Related to Primary Behavioral Diagnosis Please Read Do you endorse that follow Best Practice Guidelines for the Primary Diagnosis Yes or No If No Please enter the reason why in the open text field 1000 character limit 3l Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Key Step 9 Based on the members current Primary Behavioral and Medical Diagnosis you Complete the will encounter Hyperlinks that appear By selecting the hyperlink you will
30. linical Drafts Review Referrals Your Recent Inquiries box is empty Enter Bed Tracking Information Search Beds Openings My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Enter or Review Referrals m Find a Specific Member m Review Referrals Enter or Review Authorization Requests Enter Bed Tracking Information Enter the Client Authorization number i e UXXXXXX in the field Search Authorizations Click the Wiew All button below to see all authorizations regardless of effective and expiration dates The Search Resul by effective and expiration date enter the effective E expiration dates in the appropriate field and click on the Search H authorizations for the specified date range Required fields are denoted by an asterisk adjacent to the label Please select a Provider ID below to perform any one of the Authorization Search transactions below Provider ID PROVIDER TEMP CBHPOO2Z120 MPI for Select Authorization 7 Member ID Authorization No spaces or dashes Client Authorization LJI1073342 Effective Date 04142014 MMDOYYYY Expiration Date 04742015 MMOOYYYY Only display EAP cases where final billing and or disposition has not occurred a To search for and retrieve a downloadable authorization file listing within a specific date range enter the desired activity From amp To dates below choose the delimiter type and click on the Download button ote Please clea
31. n Treatment Complete the Clinical Screens Clinical Presentation s m Medication Treat ease Note Symptom complexes are utilized for gathering clinical information ment Screen specific to the primary behavioral diagnosis and or risk At times more than one complex may be identified for completion Providing all the requested information in the identified complex es will assist in completing the authorization process and determining medical necessity If this is a concurrent request please update the identified complexes with any new information for each complex based on the individual s current symptomatology Below are the key actions for completing this screen Action If Danger to Self Symptom Complex is Required Indicate the following PRESENTING PROBLEM BEHAVIORAL DESCRIPTION OF ACUITY DESCRIBE ANY ATTEMPT RESCUE SELF RESCUE LETHALITY MEDICAL TREATMENT RECEIVED IDEATION PLAN BASELINE INCLUDE ANY SUICIDALITY PARASUICIDALITY OR SELF INJURIOUS BEHAVIOR AT BASELINE DESCRIBE ANY HISTORY OF ATTEMPTS TREATMENT HISTORY ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST If Danger to Others Symptom Complex is Required Indicate the following PRESENTING PROBLEM WHO IS THE INTENDED VICTIM WHY DOES THE MEMBER WANT TO COMMIT HOMICIDE OR HARM IDEATION PLAN INTENT MEANS HOW IS THIS REFLECTIVE OF MENTAL ILLNESS VERSUS MALADAPTIVE
32. nect User Manual Inpatient Reviews b ProviderConnect Basics Searching for allows users to search for specific members to view additional and Viewing information about that member Member Records Below are the key actions for completing this step The fields with an asterisk indicate that the field is required 1 Select Specific Member Search from the navigational bar or Find a Specific Member on the Home page Staging eccttc Member Search Welcome THE HARTFORD DISPENSARY Thank you for using Valu Authorization Listing Enter an Autharizatian Request YOUR MESSAGE CENTER View Clinical Drafts Review Pererrale Recent Inquires Responded to by valueoptians Enter Bed Tracking DATE RECEIVED SUBJECT Information 07 26 10 REFERRAL My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits B Find a Specific Member 2 Enter values for the Member ID and Date of Birth a Note The As of Date MBR Eligibility Date will auto populate with today s date To search a previous eligibility date users can enter a previous date Eligibility amp Benefits Search hlernber ID Last Hamme First Hamme Date of Birth AO ee As of Date OHelbeoid r fDDYYYY 7 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews ProviderConnect Basics continued Review Members record details 3 Demographics Displays basic member information i e address phone
33. nt Disorder There is additionally an open text field to enter information such as Rule Outs and In Remissions Additional Diagnosis Information 0 of 250 20 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Primary Medical Diagnoses Primary medica dagnass amp required Select primary medical deanestic category dropdown or select medical diagnosis code and desaiptian Diagnostic Category 1 SELECT Diagnosis Code 1 Description Diagnostic Category 2 Diagnosis Code 2 Description SELECT Action System users may choose to first select a Medical Diagnostic category and then utilize the Diagnosis Code and or Description field hyperlinks to locate the appropriate Medical Diagnosis System users can enter a partial medical diagnosis and then click on the hyperlink to view a filtered list of those codes that match their search criteria If there is no medical diagnosis or it is unknown please select one of the options under the Diagnostic Category No Diagnosis Code or Description are needed if the selection is None or Unknown Diagnostic Category 1 Disgnosis Code 1 Descriptio CIRCULATORY SYSTEM HYPERTENSION CIRCULATORY SYSTEM OTHER COMPLICATIONS OF PREGNANCY CHILDBIRTH AND THE PUERPERIUM CONGENITAL ANOMALIES DIGESTIVE SYSTEM LIVER DIGESTIVE SYSTEM OTHER DISEASES OF THE BLOOD AND BLOOD FORMIN
34. oceed CT BHP ProviderConnect User Manual Inpatient Reviews Microsoft Internet Explorer 2 WARNING You have not attached a document to this Request Please click CANCEL to return to the screen to attach a document or click OK to proceed with your request without attaching 4 document Very Important Saving Your Work IMPORTANT Once the clinical screens NOTE Saving in ProviderConnect have Requests as been accessed providers Drafts have the ability to save a request as a draft in the event that they cannot complete it at the time the request was started Users can click Save Request as Draft on the top right of the screen Saved be Save Request as Draft viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage A page is not saved unless you see Draft Request successfully saved ee eee CLINICAL PRESENTATION MEDICATION TREATMENT ADDITIONAL MTPPR INFORMATION Requested Services Header Requested Start Date M er Name Provider Name Vendor ID 04 15 2015 PROVIDER IVANNA TEMP PROVIDER VCBO03159 Type of Request Member ID Provider ID Provider Alternate ID INITIAL TEMPOOO09881339 CBHPOD2120 TEMPFAC Level af Service Type of Service Level of Care Type of Care IMPATIENT HLOC Mental Health Inpatient Inpatient Hospital Inpatient Hospital e Draft Request successfully saved 4 felos marked with an asterisk are req
35. om Complex is Required Indicate the following PRESENTING PROBLEM BEHAVIORAL DESCRIPTION OF ACUITY BASELINE TREATMENT HISTORY IF THERE ARE ANY PSYCHOTIC SYMPTOMS HOW ARE THEY BEING ADDRESSED IF AN ANTIPSYCHOTIC IS BEING USED FOR PSYCHOSIS OR AS A MOOD STABILIZER HAS METABOLIC TESTING BEEN DONE IS THERE A SEASONAL COMPONENT IS THIS POSTPARTUM ONSET ICM NEEDS INCLUDING COMMUNITY VO CM DM ETC OTHER INFORMATION PERTINENT TO MEMBER S HISTORY AND CURRENT TREATMENT REQUEST Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Recovery and Resiliency Key Step 8 Please outline the recovery and resiliency environment to support this individual s Complete the long term recovery plan Please include personal strengths support systems Clinical Screens available to support the recovery and details around living environment as well as Recovery and outline any identified needs or supports that need to be put in place to assist in the Resiliency successful recover Screen Recovery and Resiliency Please outline the recovery and resiliency environment fo support this individual s long term recovery plan Please include personal strengths support systems available fo support the recovery and details around living environment as well as outline any identified needs or supports that need to be put in place fo assist in the successful recovery
36. ommendation is to follow up details around the 5 follow up when available in the open text field oelect Next at the bottom of the page to move to the next Tab Metabolic Assessment Tool 5 0 Current Weight Height amp in Naist Ci BMI Categories Underweight lt 18 5 Normal weight 18 5 24 9 Overweight 25 29 9 Obese BMI of 30 or greater in BMI Results of BMI indicate that the member may be Recommendation Additional information on Metabolic Syndrome and assessment tools are available at http www valueoptions com broviders Protools htm A direct link to the page is available on the Provider Home Page of ProviderConnect under Clinical Support Tools or you may dick on the above link to open directly in a separate browser window Results of Metabolic Syndrome Assessment BMI not assessed Please provide additional information on reason for not obtaining BMI or if recommendation is to follow up details around the follow up wh 0 of 2000 gt Narrative Entry d esci ness 24 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews b Completing Initial Inpatient HLOC Requests continued Key Step 7 The Clinical Presentation Medication Treatment screen captures a snapshot of the Complete the member s current mental status by allowing providers to first enter the Clinical Screens Symptomatology The Narrative entry is required and is looking for the following
37. oncurrent Review request 3 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Introduction continued Navigation Throughout the ProviderConnect screens navigation features are available to Features simplify movement through the fields and screens Below are a few basic features available Feature What it Looks Like Description Breadcrumbs T Tabs with titles of each request screen will display on all of the request screens to show progress through the process Any field with an asterisk next to it indicates that the field is required and a data item must be entered or selected in order to complete the request Conditionally required fields will not have asterisks Back Button A Back button is available on most ProviderConnect screens to help navigate to previous screens The Back button on the ProviderConnect screens should only be used when navigating to the previous screen Do not use the back button on your Internet browser Calendar Icon Ez For date fields a pop up calendar can be accessed by clicking the calendar icon When the calendar opens click the date desired and the date field will automatically update with the selected date Cancel Button A Cancel button is available within some screens to allow a user to exit from the function Checkboxes Any data items with checkboxes next to them indicate that more than one data item can be selected for that Cardiovas
38. or Severely Incapacitating N A Not Assessed Member s Risk to Self Member s Risk to Others 0 ui 2 3 0 31 72 5 r eoa Lega 0 ul Action Select the radio button for the following field Members Risk to Self Please Indicate 1 2 3 or N A Please note By indicating 2 or 3 will open up a Danger to Self Symptom Complex Box narrative in the primary Issues Symptoms addressed in Treatment Area Select the radio button for the following fields Members Risk to Others Please Indicate 1 2 3 or N A Please note By indicating 2 or 3 will open up a Danger to Others Symptom Complex Box narrative in the primary Issues Symptoms addressed in Treatment Area Select the radio button for the following fields Substance Use Please Indicate 1 2 3 or N A Please note By indicating 2 or will open up a Substance Use Symptom Complex Box narrative in the primary Issues Symptoms addressed in Treatment Area Select the radio button for the following fields Legal Please Indicate 1 2 3 or N A Please note By indicating 1 2 or 3 will open up a field which requires the user to indicate the following legal issue Juvenile Justice Parole Probation or Other Court 25 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Step Action Select the radio button for the following field not required unless SA Primary Urine
39. original pre certification IT MUST MATCH OR AN ERROR WILL OCCUR 7 Answer Yes for Has Member Been Admitted to Your Facility field 8 Attach a document CT BHP registered services do not require attached documents 9 Ifthe Admit Time field is not auto populated users should enter 00 00 Military Time only 10 Select the Next button Staging Requested Services Header 5 5 All fields marked with an asterisk are required Note Disable pop up blocker functionality to view all appropriate links Requested Start Date MMDDYYYY evel of Service 04142015 INPATIENT HLOC 4 of Service Level of Care Type of Care Admit Date MMDDYYYY INPATIENT M INPATIENT INPATIENT HOSPITAL vy 04142015 E Admit Time HHmm 0000 Tax ID Provider Last Name Vendor ID CBHP002120 TEMP PROVIDER VCB003159 Provider Member Member ID Last Name First Name Date of Birth MMDDYYYY TEMP000981339 PROVIDER IVANNA 01011995 Attach a Document Complete the form below to attach a document with this Request The following fields are only required if you are uplosding a document Document Type Does this Document contain clinical information about the Member qu Document Description SELECT UploadFile Click to attach a document Attached Document 11 A warning message will display to confirm whether you want to proceed without attaching a document Select the OK button to proceed 37 Revised 4 14 201
40. other information that has not been received by ValueOptions Authorization Member ID TEMP000981339 Member Name PROVIDER IVANNA Authorization 01 040715 1 3 Return to search results Client Auth 2 01073342 Send Inquiry NPI for Authorization N A Authorization Status D Open Complete m 1 Chal From Provider TEMP PROVIDER Admit Date 04 07 2015 Discharge Date Select the Authorization Details Auth Details tab to view the authorization details 10 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews ProviderConnect Functions Viewing Authorizations continued Authorization Header Member ID TEMP000981339 Return to search results Member Name PROVIDER IVANNA Authorization 01 040715 1 3 Complete Discharge Review Client Auth 12 U1073342 NPI amp for Authorization N A Authorization Status O Open Authorization Latter s 3 click to view Visits Requested Visits Actually Used Approved As of Today 04 07 2085 INPATIENT HOSPITAL 04 07 2015 04 14 2015 o Note The Authorization Details screen will list the Dates of Service and the Visits Requested Approved for each service line The Visits Requested Approved will detail the status of each authorization by the following o Visits Requested Approved Indicates the number of units days that were requested and the number of units days that were approved o Visits Requ
41. oviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued The next section is named Medical Implications and will ask users to answer 2 questions Step Action To complete this section simply click the radio button that best answers the question for the member Are there comorbid medical conditions that impact the treatment of the diagnosed Mental Health Substance Use conditions Yes No or Unknown Is the member receiving appropriate medical care for the comorbid medical conditions Yes No or Unknown Medical Implications Are there any comorbid medical conditions that impact the treatment of the diagnosed MHSU conditions Yes g No 7 Unknown Yes ig Unknown Is the member receiving appropriate medical care for the comorbid medical conditions The next section is named Metabolic Assessment Tool it is not required Step Action To complete this section simply enter the members weight Ibs height feet inches amp waist circumference inches The BMI number will auto generate along with Results of BMI indicate the member may be amp the Recommendation The Results of the Metabolic Syndrome m Assessment will also auto populate 3 If BMI not assessed please indicate by selecting the check _ _ Z And if the BMI was not assessed then please provide additional information on m reason for not obtaining BMI or if rec
42. r the effective and expiration date Fields abowe in order to enable the download authorization function Activity Date span cannot exceed seven 7 days Activity Date Range can only be entered without value in the Effective or Expiration Date fields abowe or vice wersa Activity Date From TF I IMDDYYYY Activity Date To Delimiter Type Xie All Download Select Search to view the client s authorization s 9 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews ProviderConnect Functions Viewing Authorizations continued Authorization Search Results This may not be the full list of EAP cases and may only show open EAP cases based on your search criteria The information displayed indicates the most current information we have on file It may not reflect claims or other information that has nq EAP non medical counseling services select the authorization related to the services and enter the request via either the Auth Details tab q Auth amp Y Member ID Provider ID View Letter Member Mame Provider Alt ID Ol 040715 1 3 TEMPOD0381333 01 01 1995 CBHP002120 i PROVIDER IVANNA TEMPFAC Once the correct authorization is located select the internal Authorization the blue hyperlink starting With 01 Date to the left of the member s ID above the document icon Anth Summary The information displayed indicates the most current information we have on file It may nat reflect claims or
43. st Hame Date af Birth As of Date First Required fields are denoted by an asterisk J adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below temp0O0 00056 Mo spaces or dashes 01151995 MMDDYYYY 08172010 MMDOYYYY 4 Select the Next button on the Member record to continue Member Member ID Alternate ID Member Hame Date of Birth Address Alternate Address Marital Status Home Phone wwork Phone Relationship Gender TEMP 0 0 0 77 D DI 5 E WOODSIN MOONE 01 15 1995 300 ENTERPRISE OF HARTFORD WE EFH 5 The Select Service Address screen will display 14 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued 6 Capture the Service Address Vendor by selecting the radio button next to the Provider ID The record that is selected will be attached to the request and authorization that will be created Select Service Address Capture Provider ID Last Name First Service Address gik 002120 TEMP PROVIDER 003159 TEMP PROVIDER 500 ENTERPRISE DR 500 ENTERPRISE DR OTP STE 4 STE 40 ROCKY HILL CT 06067 3913 ROCKY HILL CT 06067 3913 r cem TEMP PROVIDER VCB005769 TEMP PROVIDER 999999999 500 ENTERPRISE DR 500 ENTERPRISE DR STE 4D STE 4D ROCKY HILL CT 06067 3913 ROCKY HILL 06067 3913
44. uired Note Disable pop up blocker functionality fo view all appropriate links See page 12 for information on how to access saved draft 17 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Initial Inpatient HLOC Requests continued Key Step 3 For initial inpatient service requests there are two 2 clinical screens Please note Complete the that the third tab additional MTPPR information is only for Residential amp GH Clinical Sreens providers The amount of information collected within each screen varies and not all fields are required 1 Level of Care Diagnosis 2 Clinical Presentation Medication Treatment 3 Additional MTPPR Information Not Required WY PROVIDERCONNECT VALUEOITIONS dha td CLINICAL PRESENTATION MEDICATION TREATMENT ADDITIONAL MTPPR INFORMATION Below is information for completing each screen Key Step 4 screens will display in the order listed above when the Next button _ Complete the is clicked within each screen Clinical Screens Tips for Working Requests must be completed in order All required fields must be through the completed move to the next screen Clinical Screens Previous screens be accessed by clicking the Back button at the BOTTOM of each page Do not click the Back button on the top left corner of your browser window You must click the Next button to proceed forward Again with
45. windows all other fields will populate Note If a DSM IV Diagnosis Code is chosen the Category will be listed as Z CT NON DSM 5 CODES Behavioral Diagnoses Primary Behavioral Diagnosis i Diagnostic Category 1 Diagnosis Code 1 Description OBSESSIVE COMPULSIVE AND RELATED 312 39 TRICHOTILLOMANIA HAIR PULLING DISORDER DISORDERS OTHER NEURODEVELOPMENTAL 315 8 OTHER SPECIFIED NEURODEVELOPMENTAL DISORDER DISORDERS OTHER NEURODEVELOPMENTAL 415 9 UNSPECIFIED NEVRODEVELOPMENTAL DISORDER DISORDERS OTHER NEURODEVELOPMENTAL 315 8 DEVELOPMENTAL DISORDER OTHER DISORDERS PERSONALITY DISORDERS 310 1 PERSONALITY CHANGE DUE TO ANOTHER MEDICAL CONDITION SOMATIC SYMPTOM AND RELATED 316 PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS DISORDERS SPECIFIC LEARNING DISORDER 15 2 DEVELOPMENTAL COORDINATION DISORDER SPECIFIC LEARNING DISORDER 315 1 SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN MATHEMATICS SPECIFIC LEARNING DISORDER 315 00 SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN READING SPECIFIC LEARNING DISORDER 315 27 SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN WRITTEN EXPRESSION SPECIFIC LEARNING DISORDER 415 2 SPECIFIC LEARNING D O W IMPAIRED WRITTEN EXPRESS TRAUMA AND STRESSOR RELATED 313 80 DISINHIBITED SO CLAL ENGAGEMENT DISORDER DISORDERS Behavioral Diagnoses Primary Behavioral Diagnosis Diagnostic Category 1 Diagnosis Code 1 Description TRAUMA AND STRESSOR RELATED DISORDERS 313 89 Reactive Attachme
46. within the 30 days it will automatically expire Click View to see what sections of a request you have completed and click Open to reopen your request so you can complete and submit your information to the CT BHP clinical team Log Out View Clinical Drafts Please select the Provider ID below to view and click the Search Drafts button to view Saved and Expired Clinical Requests or Saved and Expired Plans for a different provider Provider ID cCBHP ODU454 v Search Drafts Saved Clinical Request Drafts Saved request drafts will automatically expire 30 days after the Initial Saved Date Delete Request Drafts Nent 2 Initial Saved Date Member ID Member Mame Provider ID Lewelof Service Lewel of Care Type of Care Authorized User Requested Start Date E 08 16 2010 TEMPOOO 00053 WOODSIN MOONEY 000454 Op Outpatient Family Support Teams FST Home 0816 2010 View Open Nent gt gt When a record is saved as a draft it is NOT available for CT BHP clinical staff to review 12 Revised 4 14 2015 CT BHP ProviderConnect User Manual Inpatient Reviews Completing Inpatient HLOC Initial Authorization Requests Key Step 1 The first key step is to initiate the request for an initial Inpatient HLOC review which Initiate a can be done from the ProviderConnect Homepage Concurrent Request for Authorization Below are the key actions for completing this step The fields with an asterisk indicate that

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