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Home Health Agency Registered Services

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1. 4 Complete the form and fax it back to the Provider Relations department at 855 750 9862 Completed forms can also be scanned and emailed back to Provider Relations at ctbhp 2valueoptions com 5 User ID s and passwords will be created within 48 hours Once the ID and password are created you will be sent an email with your ProviderConnect login details 6 If you have any questions feel free to contact the CT BHP Provider Relations department at 1 877 552 8247 _ gt a Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies R Accessing ProviderConnect continued Logging In The ProviderConnect web application can be found on the CT BHP website 1 Go to www ctbhp com 2 Click on For Providers Connecticut Behavioral Health Partnership Welcome to the CT Behavioral Health Partnership You can use this site to find information on accessing and providing behavioral health Connecticut B H P and support services Supporting Health and Recovery NETTEN a 3 Click on Log In Provider Online Services ProviderConnect Login or register with ProviderConnect an online tool that allows you to check member eligibility enter authorization requests for CT BHP services view authorization letters and more ProviderConnect is easy C onnecticut BHP to use secure and available 24 7 New users should complete the Online Services Account Request Form using the link below
2. Current Bisks Screen Next are the key actions for completing this step Any field with an asterisk indicates that the field is required Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Step Action Click the radio button for the appropriate rating for Current Risks MEMBER S RISK TO SELF MEMBER S RISK TO OTHERS Click the radio button for the appropriate rating for Current Impairments MOOD DISTURBANCES DEPRESSION OR MANIA WEIGHT LOSS ASSOCIATED WITH AN EATING DISORDER ANXIETY MEDICAL PHYSICAL CONDITIONS PSYCHOSIS HALLUCINATIONS DELUSIONS SUBSTANCE ABUSE DEPENDENCE THINKING COGNITION MEMORY CONCENTRATION PROBLEMS JOB SCHOOL PERFORMANCE PROBLEMS IMPULSIVE RECKLESS AGGRESSIVE BEHAVIOR SOCIAL FUNCTIONING RELATIONSHIPS MARITAL FAMILY PROBLEMS ACTIVITIES OF DAILY LIVING PROBLEMS LEGAL Complete additional required information when the rating is a 2 or 3 for the following fields A sub section will expand to display the fields that need to be completed WEIGHT LOSS ASSOCIATED WITH AN EATING DISORDER SUBSTANCE ABUSE DEPENDENCE LEGAL Complete additional required information when the LEGAL impairment rating is a 1 2 or 3 A sub section will expand to display the fields that need to be completed MENTAL HEALTH AND SUBSTANCE ABUSE CONDITIONS The Tr
3. Services The Requested Services Screen allows Home Health Agency providers to enter a listing of the services modifiers and number of units that they are requesting First Select the Box Click Here to Add or Modify Services Codes pcrilstg pc review RequestCT HHAcceptReject do QC Q Search PAGEG of 7 BEEEEE Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 04 20 2015 HLOC IVANNA TEMP PROVIDER VCB003159 Save Request as Draft Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization INITIAL TEMPOO0981335 CBHPO02120 TEMPFAC SELECT v Level of Service Type of Service Level of Care Type of Care Authorized User OUTPATIENT COMMUNITY BASED Mental Health Outpatient Home Health All fields marked with an asterisk are required Note Disable pop up blocker functionality to view all appropriate links For certain types of care further clinical review is required before units can be determined In these cases the total number of units available as displayed on the bottom of this page will be zero Please indicate the CPT codes and any modifiers for services that are being requested Units should remain as zero on request until this further clinical review is completed Click Here to Add or Modify Service Codes Requested Services SELECT 443 SELECT SELECT SELECT SELECT SELECT m A new Window will then Open Select Service
4. 3913 TEMPFAC C CBHPOO02120 TEMP PROVIDER VCBOO5769 STE 40 ROCKY HILL CT 06067 3913 oo 12 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Key Step 2 Complete Initial Entry Request Screen The second key step is to complete the initial entry screen of the request where the requested start date of the service is entered and the specific level of care and service is selected This screen displays for all types of requests However the information entered determines which clinical screens will display and which authorization parameters will be applied to the request Any field with an asterisk indicates that the field is required 9 Enter the Requested Start Date The Requested Start Date is the date for the authorization to begin in order to cover requested services 10 Select the Level of Service Outpatient Community Based When the level of service is selected the screen will update with the required fields specific to the level of service 11 Select the Type of Service Mental Health 12 Select the Level of Care Outpatient 13 Select the Type of Care Home Health Requested Services Header All fields marked with an asterisk are required Note Disable pop up blocker functionality to view al appropriate links Requested Start Date MMDDYYYY 02262011 E OUTPATIENT COMMUNITY BASED Level
5. Codes Mozilla Firefox mle jm S ee pcrlistg pc review showRequestedServicecC odes do VVIMDCHAN MOTE Select codes for this authorization request by checking the box mext to the services being requested prior to sawing the selection Units being requested may be adjusted after sawing codes To de select a code uncheck the box A limit of 10 services can be requested wia this form if additional services are required please indicate the services within the free test Fones of Care boxe or as an attachment to the a Mod 1 Mod 4 F7 MEDICATION ADMIN VISIT F7 SH NURSING CARE IM THE HOME BY RM E T1004 MSG AIDE SERVICE UP TO LSMIN F7 HH AIDE GOR CH AIDE PER VISIT E M421 PHYSICAL THERAPY VISIT CHARGE F7 0431 COCUPATIONAL THERAPY VISIT CHARGE E 0441 SPEECH LANGUAGE PATHOLOGY VISIT CHARGE a Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Step 5 OA LLIIJT 5 To complete this section please check the box to the left of the Code you are requesting 2 Once the codes are selected click on Save to proceed per stag pc review showhRequestedServiceCodes do CLOSE WINDOWS NOTE Select codes for this authorization request by checking the box next to the services being requested prior to saving the selection Units being reque
6. Date 8 On the Customer Service Inquiry Page under Contact Details 9 Enter Contact Name optional 10 Enter narrative in the State your reason for the Inquiry field Max 1500 characters 11 Click on the Attach a Document link and the screen will expand Contact Details Provider ID CBHPO002120 Provider Narne TEMP PROVIDER Contact Name if other than provider State your reason for the inquiry Maximum characters 1500 You have 1500 characters left Jick here to attach a document m Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing a Concurrent Inquiry for Home Health Services cont 12 Choose DOCUMENT CONTAINTING CLINICAL INFORMATION ABOUT MEMBER from the Type of Document you are attaching Drop down Menu 13 Your selection will auto populate the Document Description Field 14 Click Upload File Attach a Document Complete the form below to attach a document with this Inquiry If this is an Authorization Request it must be initiated by clicking the Enter an Authorization Request link Document Type Type of Document you are attaching Select Document Description UploadFile Click to attach a document Delete Click to delete an attached document Attached Document Submit 15 A pop up window Upload File window will appear 16 Click Browse a Search for the file document you want to attach b Double click on the fi
7. E OTHER EFFECTS OF EST CAUSES OTHER INJURY PO ISOM I MG E OTHER EFFECTS OF EXT CALUSES TEI PILUSA AL SYSTEM B CONNECTIVE TISSUE NER SYSTEM CHRONIC PAIN OTHER NER WIS SYSTEM MIGRAINE EPILEPSY STROKE SYSTEM MULTIPLE SCLEROSIS WIS SYSTEM OTHER SYSTEM PARKINS ONS EPS PERINATAL PER ID PR EGNA Y CaAILOBIRTH 4N0 THE PUER PER ILUM RESPIRATORY SYSTEM COPD ASTHMA EMPHYSEMA RESPIRATORY SYSTEM OTHER GEIN SUB CUTANEUS TISSUE SYMPTOMS SENS E ABNORMAL CLINICALS LAB MOME n A Partial Description We suggest for those system users that are new or unfamiliar to the ICD 10 Medical Diagnoses to first enter a partial description of the medical condition then click the Description hyperlink Primary Medical Diagnosis Disgnostic Category 1 SELECT nr Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont 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 CLOSE WINDOW Category CIRCULATORY SYSTEM ESSENTIAL PRIMARY HYPERTENSION HYPERTENSION CIRCULATORY SYSTEM I12 HYPERTENSIVE CHRONIC KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE Til HYPERTENSIVE HEART DISEASE C
8. Once a user clicks on the appropriate code in the pop up window all other fields will populate Primary Medical Diagnosis Primary medical diagnosis 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 110 Essential primary hypertension There is additionally an open text field for other specific medical conditions You can then enter information such as Behavioral Health Rule Outs and In Remissions and other specific Medical Conditions Other specific medical conditions 28 of 2000 ANY HISTORY AND IM REMISSION _ m Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Registered Services continued 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 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 be selected If there are no social elements impacting the member select the None checkbox If social elements have not been assessed yet select the Unknown checkbox If Other Psychosocial and Environmental Probl
9. Services cont 1 Click the Process Continuing Care Concurrent Request to complete the Concurrent Request stig Requested Services Header Requested Start Date Member Name rovider Name Vendor ID 08 08 2010 TOMPKINS JOUFU ELER CLINIC INC CB003370 Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization CONCURRENT TEMP000700081 CBHP000766 004039368 SELECT v el Type of Service Level of Care Type of Care Level of Service INPATIENT HLOC Mental Health Group Home Group Home 2 0 There is an existing authorization that bridges this date range s this a request for continuing care concurrent request or do you wish to enter Discharge information Process Continuing Care Concurrent Request Enter Discharge Information Key Step 3 The Type of Services screen is the first screen that will display after the Initial Entry Complete the screen Clinical Screens ORF2 The same screens are completed for initial and concurrent requests However as noted any data that is not expected to be updated for a concurrent request will auto populate from the initial or last request pre populated fields can be overwritten with new data Please go to page 15 and complete the Concurrent Request Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Discharge Information for Home Health Agency Services Overview Home Health Providers will e
10. blocker functionality to view alf appropriate fn For certain types of care further clinical review at gone e UR RA TERRIER In these cases the total number of units available as displayed on the bottom of this page will be rero Please indicate the CPT codes and any modifiers for services that are being requested Units should remain zs zero on request until this further clinical review is completed Click Here to Add or Modify Service Codes Requested Services Sy Ss C r HCPC Code Modifier 1 If Applicable Modifier 2 If Applicable Modifier If Applicable Modifier 4 If Applicable E TS 4 MEDICATION ADMIN VISIT HOME SN NURSING CARE IN THE BY RN SELECT Y SELECT v SELECT _ Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont For example I will be requesting 62 units of MA 31 days x 2 Months and 2 units of SN 1 units X 2 Months 6 7 HEHHEE Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 04 20 2015 HLOC IVANNA TEMP PROVIDER VCB003159 SSS Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization INITIAL TEMP000981335 CBHP002120 TEMPFAC SELECT v rel of Serv Type of Service Level of Care Type of Care Authorized User ur Tc COMMUNITY BASED Mental Health Outpatient Hom
11. of Care OUTPATIENT zl Provider 14 Attach a document a Home Health Agency authorization requests that are within auto approved parameters will not require additional documentation Proceed to Step 22 15 To attach a document a Indicate Yes or No for DOES THIS DOCUMENT CONTAIN CLINICAL INFORMATION ABOUT THE MEMBER b Choose ADDITIONAL CLINICAL or ASSESMENT EVAL from the Document Description Drop down Menu c Click Upload File Attach a Document Complete the form below to attach a document with this Request The folowing Fela are only required if you are uploading a document Document Type Does this Document contain clinical information about the Member Yes No Document Description SELECT UploadFile Glick to attach a document Delete Attached Document 13 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Key Step 2 ey Step 2 16 A up window to Upload File window will appear omplete Initia Entry Request 17 Click Browse Screen a Search for the file document you want to attach b Double click on the file F Upload File Windows Internet Explorer zia x Click the browse Button to find the file you want to Attach Click Upload when dons 18 The pop up window will now list the file chosen 19 Click Upload Upload File Windows Internet Exp
12. request will auto populate from the initial or last request Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1 The first key step is to initiate the request for authorization function which starts from Initiate a Request the ProviderConnect Homepage The function can also be initiated when the for Authorization Member record is located first and then the Enter an Auth Request button is clicked Follow Steps 1 9 on Pages 9 11 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Concurrent Requests for Home Health Services cont Key Step 2 The second key step is to complete the initial entry screen of the request where the Complete Initial requested start date of the service is entered and the specific level of care and Entry Request service is selected This screen displays for all tyoes of requests However the Screen information entered determines which clinical screens will display and which authorization parameters will be applied to the request Any field with an asterisk indicates that the field is required 22 Enter the Requested Start Date The Requested Start Date is the date for the authorization to begin in order to cover requested services 23 Select the Level of Service Outpatient Community Based When the level of service is selected the screen will update with the requ
13. screen is the first screen that will display after the Initial Entry Complete the screen Much of the information is required for completion on this screen Clinical Screens ORF2 Type of Below are the key actions for completing this step Any field with an asterisk Services Screen _ Mo indicates that the field is required Action Indicate the Contact Name and phone number In case additional information is needed by the Home Health Clinicians to authorize care Members Guardian If available please enter Not required Is this a new registration for a client already in outpatient treatment within your agency practice Yes or No Select the REFERRAL SOURCE from the drop down menu Enter First Name Last Name and Credentials of licensed prescribing practitioner Select the REFERRAL TYPE from the drop down menu Emergent Routine Urgent Enter Date of First Appointment Accepted by the Member mmddyyyy Click the Next button The Diagnosis screen will display next Key Step 5 The Level of Diagnosis screen is the first screen that will display after the Initial Entry Complete the screen Much of the information is required for completion of this screen Clinical Screens ORF2 Documentation of Primary Behavioral Condition is required Provisional working Diagnosis Screen condition and diagnosis should be documented if necessary Documentation of secondary co occurring behavioral conditions that
14. the member s plan and or summary plan description including covered diagnoses Behavioral Diagnoses Primary Behavioral Discharge Diagnosis Diagnostic Category 1 Diagnosis Code 1 Description ANXIETY DISORDERS 300 00 Unspecified Anxiety Disorder Additional Behavioral Diagnoses E Am Di Descripti OBSESSIVE COMPULSIVE AND RELATED DISORDERS v 300 3 Obsessive Compulsive Disorder Diagnostic Category 3 Diagnosis Code 3 Description SELECT Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Discharge Information for Home Health Services cont Key Step 6 The Discharge Information screen provides essential information about the client s Complete the discharge from services Discharge Information Screen Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Step Action Enter the Actual Discharge Date mmddyyyy Behavioral Diagnosis will prepopulate from the last review please make updates if needed Medical Diagnosis will prepopulate from the last review please make updates if needed Social Elements will prepopulate from the last review please make updates if needed Functional Assessments will prepopulate from the last review please make updates if needed Not Required Discharge Condition click the radio button that best describes Improved No Change Worse Unknown
15. HIZOPHRENIA SPECTRUM AND F29 UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER OTHER PSYCHOTIC DISORDERS Behavioral Diagnoses Primary Behavioral Diagnosis Diagnostic Category 1 Diagnosis Code 1 Description SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORL F20 9 Schizophrenia Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont 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 Pome medica d ismmaesis amp required Select pnay medica dagqnostc category LU arepdowr or select medical deqioss code and descen Diagnostic Category 1 SELECT Diagnosis Code 1 Description Diggnostic Category 2 Diagnosis Code gt Desorption SELECT C3ETJITGCSLIFEIPIZAAFY SYSTEM KIDNEY GENI TOUR INAR Y SYSTEM THER INFECTIOUS E PARASITIC INFECTIOUS amp PARASITIC OTHER INJURY POISONING
16. ProviderConnect Registered Services Connecticut BHP Home Health Agency User Manual Supporting Health and Recovery Y VALUEOPTIONS CONNECTICUT Revised 10 1 2015 This page was intentionally left blank Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Table of Contents MOUCINA 3 Provider ONC Casares gees ceca 5 PRO VIGCT COMM 21 55 7 Ecl TT 9 Completing Initial Requests for Home Health Agency 10 Completing a Concurrent Inquiry for Home Health Agency Services 28 Completing Concurrent Requests for Home Health Agency Services 33 Completing Discharge Information for Home Health Agency 37 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Introduction Introduction The ProviderConnect application provides a variety of self service functions to help providers access and view information about members and authorizations For CT BHP providers additional functionality is available including Obtaining authorizations for CT Home Health Agency Registered Services Completing Re Registrations Concurrent Reviews for Home Health Agency Services What is Covered This module co
17. Required fields are denoted by an asterisk adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below xMember ID spaces or dashes Last Name First Name Date of Birth g MMDDYYYY As of Date 22011 MMDDYYYY 4 Click the Next button on the Member record to continue Hie rnb er i Menmber ID TEMP ER 7 ODOH Alternate ID Member Mame O O DG G Ii HMOORE Cate of Birth Maier as 13905 Soo gress S00 ENTERPRISE OR HARTFORD He EYP Alternate Address Marital Status Home Phone Work Phone Relationship Gender 5 The Select Service screen will display Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont 6 Locate and select the Service Address Vendor 7 Click the radio button next to the Service Address to select record The record that is selected will be attached to the request and authorization that will be created 8 Click the Next button to continue The Requested Service Header will display Provider Provider Last Name TEMP PROVIDER Provid er Vendor si Provider ID ID 2 Hame DEL LEE ID Address Paid To Vendor ID CE n PROVIDER VCB003155 500 ENTERPRISE DR OTP STE 4D ROCKY HILL CT 06067
18. Type of Discharge click the radio button Planned or Unplanned Discharge Reason check all that apply No further treatment indicated Member dropped out Medication management follow up only Transfer to more intensive level of Care Referral to other outpatient service s Member no longer eligible or moved Other Medication at Discharge Open text field for Narrative Entry 250 Character limit Click the radio button for the appropriate rating for Current Risks MEMBER S RISK TO SELF MEMBER S RISK TO OTHERS Complete additional required information when the rating is a 2 or 3 i e Ideation Intent Plan Means Current Serious Attempts etc Click the radio button for the appropriate rating for Current Impairments MOOD DISTURBANCES DEPRESSION OR MANIA WEIGHT LOSS ASSOCIATED WITH AN EATING DISORDER Complete additional required information when the rating is a 2 or 3 A sub section will expand to display the fields that need to be completed ANXIETY MEDICAL PHYSICAL CONDITIONS PSYCHOSIS HALLUCINATIONS DELUSIONS SUBSTANCE ABUSE DEPENDENCE THINKING COGNITION MEMORY CONCENT RATION PROBLEMS JOB SCHOOL PERFORMANCE PROBLEMS IMPULSIVE RECKLESS AGGRESSIVE BEHAVIOR SOCIAL FUNCTIONING RELATIONSHIPS MARITAL FAMILY PROBLEMS ACTIVITIES OF DAILY LIVING PROBLEMS LEGAL i Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Action Click the radio button for the app
19. Yes or No N 9v Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Step Action Please Note If this is an Initial Request please do not enter information in the Re Registration Only section Click Next button The Psychotropic Medications screen will display next Please Note If a 485 is attached to the Authorization Request and it lists all of the Psychotropic Medications please enter See 485 in the Describe usually Adherent open text box The medication fields are not required but should be completed if applicable Key Step 9 Once the Next button is clicked from the final clinical screen the Submit Request will Accept Request display Submit Request Step Action CT BHP providers should always click the Accept Button on the confirm submission screen o When the Accept buiton is clicked the user will be advanced to the Requested Services screen to indicate the services that they are requesting CT BHP users should not click the Reject button If a user clicks Reject the request will NOT be approved Rather it will be pended to the CT BHP clinical staff delaying authorization and billing nm Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Key Step 10 Once the Accept button is clicked the Requested Services Screen will display Requested
20. e Health All fields marked with an asterisk are required Note Disable pop up blocker functionality to view all appropriate links For certain types of care further clinical review is required before units can be determined In these cases the total number of units available as displayed on the bottom of this page will be zero Please indicate the CPT codes and any modifiers for services that are being requested Units should remain as zero on request until this further clinical review is completed Cli ck Here to Add or Modify Service Codes Requested Services Modifier 1 If Applicable Modifier 2 If Applicable Modifier 3 If Applicable Modifier 4 If Applicable Visits Units HOME MA MEDICATION ADMIN VISIT HOME X SN NURSING CARE IN THE HOME BY RN SELECT v SELECT v SELECT v SELECT v Step Action To complete this section please update the open text box with the units you are requesting 2 Once the codes are entered click on Next to proceed Instructions This request must include detailed information about CPT HCPC procedure code s and the modifier place of service and number of visits units requested for each procedure Please enter the details on this screen Note TOTAL OF UNITS CANNOT EXCEED 443 sce oe lt 2015 ValueOptions ProviderConnect v5 01 00 E After selecting Next you will be brought to the final page where you will describe add
21. eatment Plan screen will display next Key Step7 The Treatment Plan screen captures information specific to the member s plan for Complete the treatment while they are receiving services from the provider Clinical Screens ORF2 Treatment Plan Screen Note The Re registration section can be skipped for initial requests This section is only required for concurrent requests Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Step Action Indicate Yes or No for DO FAMILY MEMBERS OR SIGNIFICANT OTHERS ACTIVELY PARTICIPATE IN THE MEMBER S TREATMENT AND RECOVERY f YES is selected complete the follow up question IF YES ARE ANY OF THE FAMILY MEMBERS SIGNIFICANT OTHERS RECEIVING THEIR OWN MH OR SA TREATMENT Select valid options to indicate the consent obtained for contact e MEDICAL PROVIDER Yes No Denied N A e PREVIOUS BEHAVIORAL HEALTH TREATMENT PROVIDER Yes No or Denied Are Home Health Services intended to treat primarily a medical not behavioral health condition s Yes or No If Yes please abort this request and call CHNCT to request an authorization If No PLEASE PROVIDE RATIONALE FOR HOME HEALTH SERVIES 2000 Character limit Complete required information about the member s trea
22. elds 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 Cardiovascular 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 01 4 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
23. ems is selected an open text field will open and require you to enter what the other is Problems with access to Housing problems IV Problems related to the social health care services Not Homelessness environment y problems Problems related to interaction problems Homelessness wjlegal system crime Financial problems IV K with primary support Other psychosocial and Unknown group environmental problems Medical disabilities that impact diagnosis or must be accommodated for in treatment 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 1 Tocomplete this section simply click the dropdown 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 Ifan Assessment Measure is 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 Functional Assessment Please indicate the functional assessment tool utilized or select Other to write in other specific tool Assessment score for specific tool should be noted in the Assessment Score field Ass
24. essment Measure Secondary Assessment Measure SELECT Assessment Score SELECT Assessment Score Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Registered Services continued 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 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 Key Step 6 The Current Risks screen captures a snapshot of the member s current mental Complete the status by allowing providers to complete ratings for the member s risk to self and risk Clinical Screens t5 others and twelve 12 different impairments ORF2
25. firm submission of request o For pended requests the 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 pdf format or xml Exit the Request for Authorization function Click the Return to Provider Home to exit the Request for Authorization function Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing a Concurrent Inquiry for Home Health Agency Services Overview There are 2 methods for concurrent re registration requests for Home Health Providers 1 Creating an Inquiry i Users will use the Inquiry function when requesting additional units before the end date of the initial authorization has been reached 2 Entering an Authorization Request i Users will enter an Authorization Request when the time frame of the initial authorization has ended and the provider is requesting additional time and units for the client in care Key Step 1 The first key step is to
26. iew Member Auths on the Member s Demographic Page 5 Once the screen expands Click Search Enter Auth Request View Clinical Drafts View Referrals View Treatment Plans View Crisis Plans Provider ID CBHPOO2Z120 Auth X digits no spaces or dashes Service From 031 12010 HEP MMDDYYYY Service Through 031 12011 EP MMDDYYYY 6 Click the Authorization Link on the Authorization you are requesting additional units for Auth T Member ID Member Provider ID Vendor ID DOE 01 117310 26 71 TEMP0O0740525 01 01 1935 CBHPOO2170 VCBO005765 SUPPORT ANITA 999999999 01 117310 17 42 7410525 01 01 1595 CBHPOO2170 VCBO005 769 4 SUPPORT ANITA _ Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing a Concurrent Inquiry for Home Health Services cont 7 On the Authorization Summary page click Send Inquiry S AuthSummary Auth Details The information displayed indicates the most current information we have on file It may not reflect claims or other information that has not been received by ValueOptions Authorization Header Member ID TEMP000740625 Member Name SUPPORT ANITA Authorization 01 112310 26 21 Return to search results Client Auth 00271540 Send Inquiry NPI for Authorization N A Authorization Status O Open Complete Discharge Review From Provider TEMP PROVIDER Admit Date 11 23 2010 Discharge
27. impact or are a focus of treatment mental health substance use personality intellectual disability is 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 require Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies Completing Initial Requests for Home Health Agency Services cont Step Action 55 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 Diagnosis Code 1 Description F20 9 System users can enter a partial diagnosis and then click on the hyperlink to view a filtered list of ICD 10 codes that match their search criteria Primary Behavioral Diagnosis Diagnostic Category 1 SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORL Description F28 ER SP CIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC OTHER PSYCHOTIC DISORDERS aT SCHIZOPHRENIA SPECTRUM AND 20 9 SCHIZOPHRENIA OTHER PSYCHOTIC DISORDERS SC
28. ion for 30 days from the initial date the record was saved If the record is not submitted within the 30 days it is automatically expired 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 CBHPODO454 Search Drafts Saved Clinical Request Drafts eee Saved request drafts will automatically expire 30 days after the Initial Saved Date Delete Request Drafts 2 Initial Saved Date Member ID Member Manne Provider ID LewelofSerwice Level of Care Type of Care Authorized User Requested Start Date A 08 16 2010 000700058 W OODSIM MOONEY 000454 OP Outpatient Family Support Teams FST Home 08 16 2010 View pen Nent gt gt When a record is saved as a draft it is NOT available for CT BHP clinical staff to review _ Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services KeyStep1 The first key step is to initiate the request for authorization function which starts from Initiate a Request the ProviderConnect Homepage The function can also be initiated when the for Authorization Member record is located first and then the Enter an Auth Request button is clicked Below are the key actions for completing this step Any field w
29. ired fields specific to the level of service 24 Select the Type of Service Mental Health 25 Select the Level of Care Outpatient 26 Select the Type of Care Home Health Requested Services Header All fields marked with an asterisk are required Note Disable pop up blocker functionality to view al appropriate links Provider 27 Attach a document a Home Health Agency authorization requests that are within the approval parameters will not require additional documentation Proceed to Step 22 b Home Health Agency authorization requests that are not within auto approved parameters will require additional documentation 28 To attach a document a Indicate Yes or No for DOES THIS DOCUMENT CONTAIN CLINICAL INFORMATION ABOUT THE MEMBER b Choose ADDITIONAL CLINICAL or ASSESMENT EVAL from the Document Description Drop down Menu c Click Upload File 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 x I j Does this Document contain clinical information about the Member Yes 7 f Document Description SELECT x UploadFile feck to attach a document Delete Click to c Attached Document 35 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Concurrent Requests for Home Health Services cont 29 A pop up windo
30. is important to us and will be investigated by a customer service professional Once our investigation is complete you will receive response in your Message Center Inbox within 5 business days Your Inquiry Number is 03112011 2955602 050000 33 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Concurrent Requests for Home Health Agency Services Overview Entering a Concurrent Authorization Request Users will enter an Authorization Request when the time frame of the initial authorization has ended and the provider is requesting additional time and units for the client in care In ProviderConnect Concurrent Re registration requests follow the same process as completing a new request but with some variations within each step This is because ProviderConnect will automatically determine when a request is initial or concurrent by checking for existing authorizations on file for the same member provider and other matching criteria If the system finds an existing authorization that matches the criteria and the request is determined to be concurrent then the system will Pre populate some information from the last request into fields in the new concurrent request The pre populated fields can be overwritten with new data Require additional information The same screens are completed for initial and concurrent requests however any data that is not expected to be updated for a concurrent
31. isk adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below spaces or dashes Last Mama First Name x Date of Birth As of Date 3 Click Search Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Discharge Information for Home Health Services cont 4 Click View Member Auths 5 Once the screen expands Click Search Enter Auth Request View Clinical Drafts View Treatment Plans View Crisis Plans Provider ID CBHPOO2Z120 Auth X digits no spaces or dashes Service From 031 12010 ts MMDDYYYY Service Through 031 12011 ts MMDDYYYY Search 6 Click the Authorization Link on the Authorization you are requesting additional units for Auth Member ID Member Provider ID Vendor ID DOE D1 117310 25 21 740525 01 01 1995 CBHPOO2170 VCBO005765 SUPPORT ANITA 999999999 01 117310 17 42 740625 01 01 1595 CBHPOO2170 VCB005765 SUPPORT ANITA 593999995 39 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Discharge Information for Home Health Services cont 7 the Authorization Summary page click Complete Discharge Review Auth Summary Auth Details The information displayed indicates the most current information we have on file It may not reflect claims or other information that has no
32. ith an asterisk indicates that the field is required 1 Click enter an Authorization Request link from either the left navigational or Home page of ProviderConnect v gaging Home Scare aaa Soa 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 a Enter an Authorization Request Enter Bed Tracking Information Review an Authorization m View Clinical Drafts Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont 2 Review the Disclaimer and click the Next Button Disclaimer Please note that ValueOptians recagnizes only fully completed and submitted requests as formal requests for autharizatior recognize or retain data far partially completed requests Upon full completion of the Enter an Authorization Request pre notification that your request has been received by ValueOptians 3 Search for Member Record a Enter Member s Medicaid ID and Date of Birth b Click Next Eligibility amp Benefits Search
33. itional details for this request that will pend for further review a Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont ging Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 04 20 2015 HLOC IVANNA TEMP PROVIDER VCB003159 Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization INITIAL 00981335 002120 TEMPFAC SELECT v Level of Service Type of Service Level of Care Type of Care Authorized User OUTPATIENT COMMUNITY BASED Mental Health Outpatient Home Health Describe additional details for this request that will pend for review Rationale for continued request 82 of 1000 ac Enter Rational for continued request here you have a 1000 character limit to use Back submit 44 Step Action To complete this section please update the required open text boxes with the units you are requesting the start auth date the end auth date and the Rationale for continued request 2 Once the values are entered click on Submit to proceed Key Step 11 Once the Submit button is clicked from the final clinical screen the confirmation Submit Request screen will display and Confirm Submission For Home Health Agency Services all requests will auto pend Pended Requests Step Action Con
34. le F Upload File Windows Internet Explorer E 5 x Click the browse Button to find the file you want to Attach Click Upload when done Fil Browse Upload 17 The pop up window will now list the file chosen 18 Click Upload Upload File Windows Internet Explorer ioj x Click the browse Button to find the file you want to Attach ask Upload when done 19 The attached file will be listed on the page a If the wrong file was selected users can click the checkbox next to the document click Delete and Repeat steps 13 17 a Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing a Concurrent Inquiry for Home Health Services cont 20 Click Submit Attach a Document Complete the form below to attach a document with this Inquiry If this is an Authorization Request it must be initiated by clicking the Enter an Authorization Request link Document Type Type of Document you are attaching Document Containing Clinical Information abou r Docurnent Description Document Containing Clinical Information about Member UploadFile Click to attach document Delete Click to delete an attached document Attached Document 485 Smith Jane VNA doc Document Containing Clinical Information about Member 21 Aconfirmation of your inquiry will display Customer Service Inquiry Thank you for your inquiry Your request
35. lorer Click the browse Button to find the file you want to Attach Upload when done File 2XSWSetup ciarn lc 20 The attached file will be listed the page a If the wrong file was selected users can click the checkbox next to the document click Delete and Repeat steps 18 21 21 Click the Next Button a If a document has not been attached a warning message will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed Attach a Document fe the form below fo attach a document wih fihi Request The fofewing fields are only required f you are uploading a document Document Does this Document contain clinical information about the Member Yes No imt Document Description SELECT UploadFile Cist te sttsch document Delete cic Attached Document 485 Smith Jane VMA doc Secure Clinical Document Additional Clinical Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Key Step 3 For Home Health Agency Service requests the clinical screens for the Home Health Complete the Agency CTHH workflow will display This workflow consists of five 5 clinical Clinical Screens Screens The amount of information collected within each screen varies and not all ORF2 fields are required Type of Services Diagnosis C
36. n the Home page Staging H EE Welcome THE HARTFORD DISPENSARBY Thank vou for using Valu Authorization Listing Enter an amp utharizatian Request YOUR MESSAGE CENTER View Clinical Drafts Recent Inquires Responded to by Vvalueoptians Review Referrals Enter Bed Tracking DATE RECEIVED SUBJECT Information REFERRAL My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits 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 Required fields are denoted by an asterisk J adjacent to the label a patient s eligibility and benefits information by entering search criteria E Merber ID Vo spaces or dashes Last Hame First Hamme xO ate of Birth roo rrr As of Date 08162010 foo yer a Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b ProviderConnect Basics continued Review Members record details 3 Demographics Displays basic member information i e address phone etc 4 Enrollment History Displays active and expired enrollment records for member 5 COB Display information on other insurance policies 6 Additional Information Displays claims mailing address for the member Demographics Enrollment His
37. nter discharge information on client s that are no longer receiving behavioral health services 1 Entering Discharge Information a Users will use the Discharge function on the client s authorization summary page _ Key Step 1 first key step is to search for the client s existing authorization which starts from Navigating to the the ProviderConnect Homepage The function can be initiated when the Specific Discharge Member Search button is clicked Information Page Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1 Click Specific Member Search from the navigational bar or Find a Specific Member on the Home page Staging Home ene Member Search Welcome THE HARTFORD DISPENSARY Thank you for using Valu Specific Member Search Authorization Listing Enter an 4uthorization Request YOUR MESSAGE CENTER View Clinical Drafts Recent Inquires Responded to bv valueoptians Review Referrals Enter Bed Tracking DATE RECEIVED SUBJECT Information 07 28 10 REFERRAL My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits 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 Required fields are denoted by an aster
38. ropriate rating 1 2 3 or N A ABILITY TO SELF ADMINISTER MEDS W O ASSISTANCE OR SUPERVISION ABILITY OF FAMILY NATURAL SUPPORTS OTHER TO SUPERVISE MEDICATIONS Check all applicable options for Notified of Discharge BH Provider PCP Medical ASO LMHA N A If Other indicate notifications in the text box 250 character limit Click the Save Discharge Information button Determination Status screen will display next indicating that Discharge has been completed Key Step3 Submitted Once the Save Discharge Information button is clicked from the Discharge dp o e Information screen the Determination Status screen will display ontim Submission Action Print the request Users can select the Print Discharge Result button to print a copy of the Results page Exit the Discharge Completed page Select the ProviderConnect Home to exit the Discharge Information Screen and return to the Home Page _ Revised 10 1 2015
39. search for the client s existing authorization which starts from Creating an the ProviderConnect Homepage The function can be initiated when the Specific Inquiry Member Search button is clicked Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1 Click Specific Member Search from the navigational bar or Find a Specific Member on the Home page Staging Home rsen Member Search Welcome THE HARTFORD DISPENSARY Thank you for using Valu Specific Member Search Authorization Listing Enter an Authorization Request YOUR MESSAGE CENTER View Clinical Drafts Recent Inquires Responded to by Valuecptions Enter Bed Tracking DATE RECEIVED SUBJECT Information k 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 Eligibility amp Benefits Search Required fields are denoted by an asterisk adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below xMember ID 005555555 o spaces or dashes Last Name First Name xDate of Birth 01011 955 MMDDYYYY As of Date 05022011 MMDDYYYY 3 Click Search 0 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing a Concurrent Inquiry for Home Health Services cont 4 Click V
40. sted may be adjusted after saving codes To de select a code uncheck the box A limit of 10 services can be requested via this form if additional services are required please indicate the services within the free text Focus of Care box or as an attachment to the ES 4 MA MEDICATION ADMIN VISIT FIR 5 NURSING CARE IN THE HOME BY RN F T1004 NSG AIDE SERVICE UP TO 15MIN T1021 HH AIDE OR CN AIDE PER VISIT F 0421 PHYSICAL THERAPY VISIT CHARGE 0431 OCCUPATIONAL THERAPY VISIT CHARGE F 0441 SPEECH LANGUAGE PATHOLOGY VISIT CHARGE Eee eene The screen will then update to the below snapshot Please note The Visits Units will always populate to 443 under MA and a blank for the SN Please update these areas accordingly to what you are requesting for the 2 month authorization period L perllstg pe revi RequestORF2RequestedServices do draftAuthorizedUserID c arch Yr 6 of 7 NENNEN Requested Services Header quested Start Date 00000 Mm ber Narr Provider Name Vendor ID t 04 20 2015 HLOC IVANNA TEMP PROVIDER vcnhnoo3159 Save Request as Draft Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization INITIAL TEMPOOO981335 cCHHPOO2120 SELECT v Level of Service Type of Service Level of Care Type of Care Authorized User OUTPATIENT COMMUNITY BASED Mental Health Outpatient Home Health A fields marked with an asterisk are required Note Disable pop up
41. t been received by ValueOptions Authorization Header Member ID TEMP000740625 Member Name SUPPORT ANITA Authorization 01 032511 1 13 Return to search results Client Auth U0307763 NPI for Authorization N A Authorization Status O Open From Provider TEMP PROVIDER Admit Date 03 25 2011 Discharge Date 8 The Discharge Information Page will display pcrilstg pc eProvider discharge do providerAuthBranchCode 01 amp providerAuthBatchDate 041415 amp providerAuthBatchSequence 1 amp providerAutt Q Search Staging Requested Services Header Requested Start Date Level of Service Member Name Provider Name Vendor ID 04 14 2015 O OUTPATIENT PROVIDER ANITA TEMP PROVIDER VCB003159 Type of Request Member ID Provider ID Provider Alternate ID INITIAL TEMP000981338 002120 Discharge Information Actual Discharge Date MMDDYYYY Type of Service 06302015 E t P MENTAL HEALTH 4 Diagnosis Documentation of primary behavioral condition is required Provisional working condition and diagnosis should be documented if necessary Documentation of secondary co occurring behavioral conditions that impact or are a focus of treatment mental health substance use personality intellectual disability is 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 ined in
42. that field Click inside of the circle to select the value Save Request as M 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 will submit the record when clicked Member s Guardian Any open text box indicates that free form text can be entered into the box Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Accessing ProviderConnect Obtaining an ID and Password In order to obtain a ProviderConnect login ID and password complete the following steps 1 Go to the CT BHP website at www CTBHP com 2 Click on the For Providers button Connecticut Behavioral Health Partnership Welcome to the CT Behavioral 7 Health Partnership You can use this site to find information on accessing Connecticut B Sl P and providing behavioral health and Supporting Health and Recovery support services For Members For Providers 3 Under the forms section click on the Online Services Account Request Form hyperlink Click the button Forms 1 Registered Services Template 3 Registered Services Re Registration Template 7 Registered Services Retroactive Eligibility Review Template 3 Psychological Testing Registration Template
43. tment plan THE TREATMENT PLAN WAS DEVELOPED WITH THE MEMBER OR HIS HER GUARDIAN AND HAS MEASURABLE TIME LIMIT GOALS Yes or No DOES A DOCUMENTED GOAL ORIENTED TREATMENT PLAN EXIST Yes or No ANTICIPATED TARGET DATE FOR ACHIEVEMENT OR CURRENT TREATMENT PLAN GOALS MMDDYYYY Enter information into Narrative Entry field CURRENT PLAN OF TREATMENT GOALS OF SERVICES REQUESTED AND DISCHARGE PLAN 1000 Character limit Indicate Yes or No for HOME HEALTH AIDE e f Yes select FREQUENCY from drop down menu gt 14 HRS Week OR lt or 14 HRS Week Indicate Yes or No for NURSING MED ADMIN e f Yes select FREQUENCY from drop down menu Less or 2 Visits Week Daily QD 3X Day TID 2X Daily BID 3 Visits Week 4 6 Visits Week Prompting Indicate Yes or No for SKILLED NURSING Indicate Yes or No for PHYSICAL THERAPY ndicate Yes or No for SPEECH Indicate Yes or No for OCCUPATIONAL THERAPY Select PRIMARY PLACE HOME HEALTH SERVICES WILL BE PROVIDED from drop down menu FAMILY HOME HOMELESS SHELTER INDEPENDENT LIVING MENTAL HEALTH GROUP HOME RESIDENTIAL CARE HOME SUPERVISED HOUSING SUPPORTIVE HOUSING Click the radio button for the appropriate rating 0 1 2 3 OR n a ABILITY TO SELF ADMINISTER MEDS W O ASSISTANCE OR SUPERVISION ABILITY OF FAMILY NATURAL SUPPORTS OTHER TO SUPERVISE MEDICATIONS Indicate if there is a PLAN IN PLACE TO PROMOTE INDEPENDENCE IN MED ADMINISTRATION
44. to get their ID and Password Supporting Health and Recovery 4 Enter User ID and Password WPI CONNECT ValueOptio VALUEOPTIONS Please Log In Please log in by entering your User ID and password below User ID If you do not remember your User ID plege contact our e Support Help Line Password Forgo Log In The informat and re ces provided gh the ValueO te are yided ma a eha al hea ders utilizing the ValueO e Provide appropriatene and manne zing ValueOpt 5 rces pro g service e atients I matio resource provided through the ValueOptio 1 judgment of a behavioral health professional Providers are solely responsible for determining whether use of a resource provided through ValueOptions is consistent with their scope of andard It is recommended that you use Internet Explorer when using ProviderConnect Other internet browsers may not be compatible and may result in formatting or other visible differences 5 Click Log In nm Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b ProviderConnect Basics Searching for One function that is used often to for various ProviderConnect functions is searching and Viewing and viewing member records Member Records Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1 Click Specific Member Search from the navigational bar or Find a Specific Member o
45. tory 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 an Authorization Initiates the Request for Services 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 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Features Saving Requests 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 valueoOptians Enter Bed Tracking DATE RECEIVED SUBJECT Information E Re EN 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 submiss
46. urrent Risks Treatment Plan Psychotropic Medications PON gt Below is information for completing each screen Key Step 3 The screens will display in the order listed above when the Next button is clicked Complete the within each screen Clinical Screens Requests must be completed in order All required fields must be completed to A aa eden move to the next screen v the Clinical Previous screens can be accessed by clicking the Back button However you Screens must click the Next button to proceed forward Within any clinical screen the request can be saved as draft by clicking the Save Request as Draft button within the screen header ProviderConnect Home IMPORTANT Once the clinical NOTE Saving screens in Requests as ProviderConnect have Draf n been accessed TROPIC REQUESTED RESULTS providers have the IONS SERVICES ability to save a request as a draft in the event that they cannot complete it at the time BNEEMEEEEEEEBBD pR 5B D the request was started Users can click Save Save Request as Draft Request as Draft on the top right of the screen Saved drafts can be viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage See pg 11 Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Initial Requests for Home Health Agency Services cont Key Step 4 The Type of Services
47. vers general functions within ProviderConnect as well as requests for in this Module Home Health Agency services which includes the following key functions Registering Initial Home Health Agency Services This process focuses on completing a registration authorization for initial Home Health Agency services Registering Concurrent Home Health Agency Services This process focuses on completing a registration authorization request for concurrent Home Health Agency services Training As a result of this training module you will be able to Objectives Log in to ProviderConnect Search for and view Member records Complete a request for a Home Health Agency service authorization Complete a request for a concurrent Home Health Agency service authorization n m Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Introduction continued Navigation Throughout the ProviderConnect screens navigation features are available to make Features it easier to move 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 fi
48. w to Upload File window will appear omplete Initia Entry Request 30 Click Browse Screen a Search for the file document you want to attach b Double click on the file Upload File Windows Internet Explorer Click the browse Button to find the file you want to Attach Click Upload when dons Upload 31 The pop up window will now list the file chosen 32 Click Upload Upload File Windows Internet Explorer Click the browse Button to find the file you want to Attach ask Upload when done 33 The attached file will be listed on the page a If the wrong file was selected users can click the checkbox next to the document click Delete and Repeat steps 18 21 34 Click the Next Button a lfa document has not been attached a warning message will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed Attach a Document Erde ie fir Id a document with this Request The following feta are only required if kou are uploading s document Document Type Does this Document contain clinical informabon about the Member Yes No UC Document Description SELECT UploadFile Click fo alach 8 document Delete Cua Attached Document 485 Smith Jane VMA doc Secure Clinical Document Additional Clinical Revised 10 1 2015 CT BHP ProviderConnect User Manual Home Health Agencies b Completing Concurrent Requests for Home Health

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