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1. 1 3 4 E E E EB E Bg E 5 Back Subrnit Key Step 4 Once the Submit button is clicked from the final clinical screen the confirmation Submit Request screen will display and the request will auto pend meaning the authorization has not and Confirm been approved and further review is required by CT BHP RCT Submission Action Confirm submission of request After the final clinical screen when the request is to be pended the request Results screen will display where the Determination Status displays 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 rint the MTPPR Form Click the Print MTPPR Form buiton to print only the MTPPR form fields with the Signature fields Download the request RECOMMENDED Click the Download Authorization Request button to save a copy of the request either in pdf format or xml You can then print as many times as needed Exit the Request for Authorization function Click the Return to Provider Home button to exit the Request for Authorizati
2. staging Requested Services Header 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 04082015 EJ INPATIENT HLOC Type of Service Level of Care Type of Care Admit Date MMDDYYYY MENTAL HEALTH gt RESIDENTIAL X RESIDENTIAL TREATMENT CENTER OTHER gt 04082015 E Has the member already been admitted to the facility Admit Time HHmm Yes No 0000 Provider Tax ID Provider ID Provider Last Name Vendor ID Provider Alternate ID CBHPO002120 TEMP PROVIDER 159 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 clinical information about the Member Yes 7 2 er Doc Dec SELECT UploadFile Click to attach a document Click to delete an attached document Attached Document m 2015 ValueOptions ProviderConnect v5 01 00 6 Attach a Document Not Required for Residential Group Home Requests Adocument can be sent to CT BHP along with the request Complete the information about the Document Type and select the Document Description Click the Upload File button to search for and atta
3. Admit Date Requested Start Date Has the member already been admitted to the Facility Below are the key steps for completing this process Any field with an asterisk indicates that the field is required 1 Enter the requested start date This field will default to the current date Staging Requested Services Header Belts marked with an asterisk are required Note Disable pop up blocker functionality to view aff appropriate Jinks Level of Service SELECT Provider Tax ID der ID Provider Last Name Vendor ID Provider Alternate ID 060646668 P002134 HARTFORD HOSPITAL VCB003426 000050079 Member Memb First Name Date of Birth MMDDY Y Y Y 995 mber ID Last Name TEMP000700074 WOODSIN LAMONYNE 02281 Attach a Document Complete the form below to attach document with Mis Request The following Selos are only required if you are uploading a document Document Type Does this Document contain clinical information about the Member Yes vs E Documen t Description SELECT UploadFile Click to attach document elete Attached Document IMPORTANT PLEASE NOTE The Requested Start Date must be the following day of the last authorized end date in order for the MTPPR request be considered a concurrent Users should always verify the last authorized end date on the Auth Summary tab of the member s authorization before beginning the member s MTPPR Example 1 The memb
4. Home Life Work amp Study Work Life Career Planning Social Relationships Communication Assessment of Progress Employment Summer Jobs on campus Open Narrative Field Complete the Incidents for this Reporting Period section All fields with an asterisk are required For date fields the number of dates completed must equal the value selected for number of interventions requests visits etc for the reporting period See Below e Number of AWOLS Number of Police Interventions Number of Arrests Safety Number of Requests for 1 1 staffing Number of Restraints Number of Restraint related injuries Number of Seclusions Number of Seclusion related injuries Number of Mechanical Restraints Number of Mechanical Restraint related injuries Number of PRN Meds Administered Number of Suicidal SIB assessments Internal Number of ED Visits Number of Inpatient Admissions 52 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued INCIDENTS FOR THIS REPORTING PERIOD Number of AWOLS for this reporting period AWOL Information SELECT Narrative History Dates of AWOLS 0 of 500 Narrative Entry Number of Inpatient Admissions for this reporting period SELECT gt Narrative History a lt 0 of 500 Dates of Inpatient Admissions Narrative Entry
5. 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 Welcome THE HARTFORD DISPENSARY Thank you for using ValueOptions ProviderConnect YOUR MESSAGE CENTER Recent Inquires Responded to by valueOptions DATE RECEIVED SUBJECT MEMBER NAME STATUS 07 28 10 REFERRAL SHAMARI SMITH COMPLETED WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Review Referrals m Find a Specific Member W gt Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters W Enter an Authorization Request Enter Bed Tracking Information W Review an Authorization m 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 within the 30 days it is automatically expired When a record is saved as a draft it is NOT available for clinical staff to review 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 000454 Search Drafts Saved Clinical Request Drafts Saved request drafts will automatically expire 30 da
6. Enter Bed Tracking DATE RECEIVED SUBJECT MEMBER NAME STATUS Information gt 07 28 10 REFERRAL SHAMARI SMITH COMPLETED My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Review Referrals m Find a Specific Member Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters 2 Search for a referral record Search for an individual referral by o Provider ID Required Will auto populate o Referral Type Required The only option is Bed Match o Referral Date Not required but can be entered if desired 3 Click Search Referrals or View All button Staging Home Specific Member Search AE Search Referrals Authorization Listing zone Authorization Required fields are denoted by an asterisk adjacent to the label View Clinical Drafts To search a specific member s referral please select Specific Member Search from the menu on the left Review Referrals Enter Bed Tracking CBHPO00454 v Information Referral Type SELEC My Online Profile Referral Date MMDDYYYY Search Referrals View All 6 Click the Update button on the member specific referral Note The View Request for Care CANS is only available when e The status of the referral is Open or e The status of the referral is Closed and the Match Decision and Admission Decision is Accept Referral Search Results The information displayed indicates th
7. Match Decision The above client has been matched to your program for RTC GH services He She has been identified as an appropriate match to receive treatment from your program The Area Office Social Worker 40S Parole Probation Officer will contact you within 3 business days from the date of this notification to verify the pre admission appointment at your agency IF you do not receive a call from the AOSw within this timeframe you should notify the supervisor and the Behavioral Health Program Director RCT Liaison or RCT Clinical Manager as this will delay the youth from being placed at your program in a timely manner IF this match is not accepted no additional referrals will be made to your program uni the Fed Matoh referral is completed and submitted to CT BHP Match Decision Date of Match Decision Date that Referring Party Contacted Facility ACCEPT 08062010 08062010 Date of Match Decision must be within 3 business days of Date of Matos Notification Pre Admission Pre Placement Appointment Date Time MMDDYYY Pre Placement Appointment Location Admission Decision Admission Decision Date of Admission Decision SELECT 08062010 Plate of dain iesing aca 4 di 2 Se d 18 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Bed Ma
8. Tabs with titles of each request screen will display TYPE DF 250 all of the request screens to show progress through SERVICES the process Id 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 A Back button is available on most ProviderConnect PAES ENON screens to help navigate to previous screens The Back button on the ProviderConnect screens should always be used when navigating to the previous screen Do not use the back button on the Internet browser menu Calendar Icon 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 a allow a user to exit from the function Checkboxes Num Any data items with checkboxes next to them indicate that more than one data item can be selected for that IF Cardiovascular Problem field Click inside of the box to select the value Expand Collapse ea Any title with an arrow gt to the left of the title MEIN 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 f
9. 3 Click Log In Provider Online Services ProviderConnect Login or register with ProviderConnect an online tool that allows you B to check member eligibility enter authorization requests for CT BHP services view authorization letters and more ProviderConnect is easy to use secure and available 24 7 New users should complete the Connecticut B HP Online Services Account Request Form using the link below to get Supporting Health and Recovery their ID and Password Log In Register 3 Click on Log In 4 New Users without an ID refer to page 7 otherwise 5 Enter User ID and Password VALUEOPTIONS Please LogIn Required fields are denoted by an asterisk adjacent to the label Please log in by entering your User ID and password below User ID you your User ID pl ntact our e Support Help Line P d Forgot Your Password asswor Log In lt _ The information and resources provided through the ValueOptions site are provided for informational purposes only Behavioral health providers utilizing the ValueOptions site Provide appropriateness and manner of utilizing ValueOptions information and resources i roviding services to their patients No information or resource provided through the ValueOptions sil judgment of a behavioral health professional Providers are solely responsible for determining whethe e of a resource provided through ValueOptions is consistent with their scope of stan
10. 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 HOW IS THIS REFLECTIVE OF MENTAL ILLNESS VERSUS MALADAPTIVE 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 43 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Step 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 INF
11. Match Decision and or Admission Decision are pending o Inactive Indicates that the match has been removed Referrals with this status will display for 30 days after the Date of Match has been removed Closed Indicates that the Match Decision and the Admission have been made Referrals with this status will only display for 30 days after the Date of Match Decision or Date of Admission Decision Match Decision Displays the decision the provider made about the admission accept or not accept Admission Decision Displays the decision the provider made about the admission accept or not accept Not Accept or Match Remove Reason Displays the reason a match or admission was not accepted or why a match has been removed Date Submitted Displays the date the provider received the Bed Match referral Referral Search Results The information displayed indicates the most current information we have on file Click the Referral Number for more detail on the referral To update a referral click the Update button Referral Member Name Referral Type Referral Match Admission Not Accept or Match Remove Date x Status Decision Decision Decision Submitted 01 101210 1 31 FRANKS APPLE Bed Match Open 10 12 2010 Update 1 Referral View Request for Care CANS 17 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual Viewing and Updating Bed Match Referrals cont
12. 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 I Registered Services Template I Registered Services Re Registration Template I Registered Services Retroactive Eligibility Review Template 3 Psychological Testing Registration Template 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 ctohp valueoptions 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 6 IT Product Support Reston Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Accessing ProviderConnect continued Overview 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 7 Welcome to the CT Behavioral Health Partnership You can use this site to find information on accessing and providing behavioral health Connecticut BHP and support services Supporting Health and Recovery For Members For Providers
13. all fields will be blank Screens and must be completed However for subsequent concurrent requests the majority Additional MTPPR of data will be pre populated m m a fn Below are the key actions for completing this step Any field with an asterisk nformation gt S indicates that the field is required creen a pcrilstg pc review itr2flow additionallnformationView action Requested Start Date Member Name Provider Name 06 09 2015 PROVIDER IVANNA TEMP PROVIDER 159 Save Request as Draft Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization CONCURRENT 00981339 002120 TEMPFAC SELECT Level of Service Type of Service Level of Care Type of Care Authorized User INPATIENT HLOC Mental Health Residential Treatment Center Residential Treatment Center Other All Fields marked with an asterisk are required when Type of Care is RTC GH and review is concurrent ADDITIONAL MTPPR INFORMATION Date Monthly Reporting Date Monthly Reporting _ Period Starts MMDDYYYY Period Ends MMDDYYYY 04212015 06042015 MTPPR Required By MMDDYYYY Review Information CT BHP Care Manager Phone THERAPY amp HOME PASSES Number of Individual Treatment Sessions Focus of Individual Therapy for this reporting period SELECT Narrative History Number of Individual Treatment Hours NU _ 0 of 250 for this reporting period Narrative Entry SELECT
14. 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 ae 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 Assessment Measure Secondary Assessment Measure SELECT X Assessment Score SH ECT 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 CGAS 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 39 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC G
15. approved for admission by the facility J Held Beds Match Admit Decision _____ ___ ___ Name Dateof Birth Type Notified Decision _ 005555551 Smith John 09091996 CURRENT VACANCY 08172010 ACCEPT 005555552 Doe Jane 09211995 CURRENT VACANCY 08282010 ACCEPT 23 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Introduction RTC GH Requests MTPPR Form Introduction This section focuses on RTC GH Review Auth MTPPR Form of the Residential and Group Home Care Management Process ProviderConnect provides the ability for providers to complete concurrent requests for authorizations for Residential Treatment Center RTC or Group Home GH care in an easy to follow workflow For providers the completion of a request for RTC or GH authorization is how they will submit the latest MTPPR information Within the request process critical clinical information can be documented through reportable fields some of which are required for completing the request Once all clinical information is entered the request is submitted and pended for further review by CT BHP The request submitted will be used as the concurrent review authorization What is Covered This section covers the RTC GH Requests MTPPR Form process which includes in this Section the following key function Completing RTC GH Requests M
16. bed availability information for Bed Tracking purposes As a result of this section you will be able to Access and View Bed Match referrals View associated Request for Care CANS records associated with Bed Match referrals Update Bed Match referral information Access Bed Tracking form Update bed availability information 11 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Bed Match Referrals Key Steps The key steps for viewing and updating a Bed Match referral include 1 Access list of referrals 2 Locate and review referral information 3 Update and save referral Details about each key step follow Key Step 1 The first key step is to access the list of Bed Match referrals sent to the provider Access Listof There are a 3 ways providers can access the list of referrals Referrals 1 From the Message Center Inbox 2 Through the Review Referrals link 3 From the Member Demographics Screen Below are the key actions for completing this step for each method of access Any field with an asterisk indicates that the field is required 1 From the ProviderConnect Message Center Inbox 1 Click the Inbox icon on the ProviderConnect homepage A list of all messages will display If the referral is recent the referral can be directly accessed by clicking the hyperlink record listed under Your Message Center on the homepage
17. days after the Date of Admission Decision If the Admission decision is Not Accept then An Inquiry is automatically generated and pended to CT BHP staff to alert them of the decision referral status will change to Closed and the referral and the Request for Care CANS record will no longer be available to view and or edit 20 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Updating Bed Availability Information Overview To help DCF effectively match members to providers facilities providers can submit bed availability information This can be done through the Bed Tracking form in ProviderConnect The form is completed for each provider location The Bed Tracking form consists of two different sections that a provider can view and update depending on the services they are contracted to provide The two sections include RTC GH This section is specific to providers where Residential and Group Home services are provided It allows these providers to submit projected discharge dates for members currently at their location update information about other beds occupied by non CT BHP members as well as view beds currently being held for future members Inpatient This section is specific to providers where Inpatient services are provided It allows these providers to submit bed availability information for their location Key Steps The key
18. diagnostic category from dropdown or select medical diagnosis cogging Diagnostic Category 1 Diagnosis Code 1 Description SELECT hyper 37 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued B A partial description will bring up a pop up window where users can view a filtered list of ICD 10 codes and descriptions that match their search criteria CLOSE WINDOW Category CIRCULAT ORY SYSTEM ESSENTIAL PRIMARY HYPERTENSION HYPERTENSION CIRCULATORY SYSTEM HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE HYPERTENSION CIRCULATORY SYSTEM Iii HYPERTENSIVE HEART DISEASE HYPERTENSION C 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 The next section has been
19. pended or approved status of y quest Receipt of this screen is an Authorization Reques P 27 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued 3 Search for member Record ENTER THE MEDICAID ID AND DATE OF BIRTH ONLY PLEASE LEAVE THE AS OF DATE WITH TODAYS DATE Staging Search a Member Required fields are denoted by an asterisk adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below Member ID No spaces or dashes Last First Date of Birth 01011995 HMDDYYYY As of Date 04202015 MMDDYYYY 4 Click the Next button on the Member record below to continue The Select Service Address screen will display next staging Demographics Enrollment History COB Additional Information Member eligibility does not guarantee payment Eligibility is as of today s date and is provided by our clients Member Eligibility Member ID TEMP000700074 Effective Date 08 04 2010 Alternate ID Expiration Date Member Name WOODSIN LAMONYNE COB Effective Date Date of Birth 02 28 1995 Address 500 ENTERPRISE DR HARTFORD CT 06103 Subscriber Alternate Address Subscriber ID TEMP000700074 Marital Status Subscriber Name WOODSIN LAMONYNE Home Phone Work Phone Relationship Gender 28 IT Product Sup
20. 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 Action Select the radio button for the following field not required unless SA Primary Urine 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 CIWA for ETOH withdrawal 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 Positive For Check all that apply Benzodiazepines Barbiturates Methamphetamine Amphetamines PCP Phencyclidine Tricyclic Antidepressants LSD lysergic acid die
21. v Type of Service Level of Care Type of Care Admit Date MMDDYYYY MENTAL HEALTH RESIDENTIAL v RESIDENTIAL TREATMENT CENTER OTHER v 04082015 Ey M Admit Time HHmm 0000 Provider Tax ID Provider ID Provider Last Name Vendor ID Provider Alternate ID CBHP002120 TEMP PROVIDER VCB003159 TEMPFAC Member Member ID Last 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 uploading a document Document Type Does this Document contain clinical information about the Member Yes No sm ipti SELECT X UploadFile Glick to attach a document Tyta ME Attached Document 2015 ValueOptions ProviderConnect v5 01 00 29 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step 2 The second key step is to complete the initial entry screen of the request The Complete Initial information entered on this screen is critical for the system to determine if the Entry Request request should be concurrent Specifically ProviderConnect will check for existing Screen authorizations where the following information matches Member ID of Service Provider ID Level of Care Vendor ID Type of Care Level of Service
22. will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed or the CANCEL button to upload an attachment C Q search iw ea pcrlistg pc review reloadReviewEntry do Soe WARNING You have not attached a documentto this Request Please click CANCEL to return to the screen to attach a document or click OK to proceed with your request without attaching a document If the request is considered concurrent a screen will display with following options Process Continuing Care Concurrent Request When clicked the request will continue as a concurrent request and the first clinical screen will display Process Discharge When clicked the Inpatient Discharge screen will display and the request will NOT be continued Cancel When clicked you are returned to the Initial Entry Request Screen request is expected but the message Initial Request not allowed for this Level of Care displays then exit and restart the request or contact the CT BHP at 1 877 552 8247 TT Sage Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 08 08 2010 TOMPKINS JOUFU WHEELER CLINIC INC VCB003370 Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization CONCURRENT TEMPO000700081 CBHPO000766 004039368 SELECT Level of Service Type of Service Level of Care Type of Care INPATIENT HLO
23. C Mental Health Group Home Group Home 2 0 There is an existing authorization that bridges this date range Is this a request for continuing care concurrent request or do you wish to enter Discharge information Process Continuing Care Concurrent Request Enter Discharge Information 33 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step 3 Complete Clinical Screens There are ten 3 screens within the CT BHP IP HLOC clinical review workflow which is the flow used for RTC and GH requests 1 Level of Care Diagnosis 2 Clinical Presentation Medication Treatment 3 Additional MTPPR Information For concurrent RTC GH requests all screens will need to be completed and providers will not be able to skip any screens The providers must complete all screens and the amount of information collected within each screen varies and not all fields are required X PROVIDERCONNECT VALUEOFPTIONS FCLINICAL PRESENTATION MEDICATION TREATMENT ADDITIONAL MTPPR INFORMATION Requested Services Header IMPORTANT NOTE Saving Requests as Drafts Once the MTPPR screens in ProviderConnect have been accessed providers 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 Dr
24. Care Management Process A Bed Match referral is created when it has been determined that a member requires RTC or GH placement Determination is based on the Request for Care CANS submitted by CT State Agencies The referral is electronically sent to providers for response and also links to the provider s bed availability and tracking which is essential for determining availability of beds for other members in need of placement Referrals are completed by CT BHP Once the referral is saved the provider will receive a secure message in ProviderConnect and will be able to access review and update the bed match referral with the Match and Admission decision As part of working on Bed Match referrals CT BHP and CT State Agencies rely on updated bed availability information submitted by providers through the Bed Tracking function This information is compiled into a report that DCF uses to match members to providers with available or soon to be available beds Providers are asked to update bed availability information twice a week which they can do through ProviderConnect This section covers the Bed Match Referral process which includes the following key functions View and Update Bed Match Referrals This function focuses on accessing viewing and opening bed match referrals in ProviderConnect as well as viewing associated Request for Care CANS records Update Bed Availability Information This function focuses on entering and updating
25. H Requests MTPPR Form continued 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 e SF36 Quality of Life Assessment Using the Short Form 36 Questions WHO DAS World Health Organization Disability Assessment Schedule The next section is named Medical Implications and will ask users to answer 2 questions 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 Are there any comorbid medical conditions that impact the treatment of the diagnosed MHSU conditions pes M CO Is the member receiving appropriate medical care for the comorbid medical conditions Yes Unknown 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 i
26. 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 Indicate Dimension 1 Intoxication Withdrawal Potential Low Medium or High If Mood Disorder Symptom 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 45 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b 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 ong 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 d Recovery and Resiliency Pleas
27. If Other then describe in the open text field 250 character limit __4 __5 __6 Planned Discharge Level of Care drop down menu Planned Discharge Residence drown down menu Expected Discharge Date MMDDYYYY format or use calendar icon Below are the key actions for completing the next steps Any field with an asterisk indicates that the field is required Step Action Update Preliminary Discharge Plan Open text field Update Preliminary Efforts taken to affect discharge Open text field Update Preliminary Significant Barriers identified for achieving any of the discharge goals Open text field Update Current Recommended discharge plan Open text field Current Significant Barriers identified for achieving any of the discharge goals Open text field Projected Discharge date MMDDYYYY Name Relationship with whom child will be placed open text field 1 E __4 5 OCurrent efforts taken to affect discharge Open text field 48 IT Product Support Reston VA Revised 10 1 2015 Step 17 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Select all who have discussed and are in agreement with discharge plan check all that apply Family Guardian DCF RRT Liaison CTBHP DCF Area Office Parole Office Post Discharge Provider DMHAS DDS Regional Case Manager Other Please specify Open text box Will new congregate treatment setting be required post discharge Y
28. IfAdditional Medications need to be added then Select the Add Medication Box 46 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing Initial Inpatient HLOC Requests continued Medications For this medication please enter any details concerning dosage side effects Start Date adherence effectiveness prescribing provider and any specific target symptoms Date Discontinued Narrative Entry p 9 Date Added 04152015 E Add Medication zvPREX ZYPREXA OLANZAPINE 20000 E SYMBYX SYMBYAX OLANZAPINE FLUOXETINE ABILIFY ARIPIPRAZOLE Antidepressants LEXAPR LEXAPRO ESCITALOPRAM mur murmmememarma S paxuc PAXIL CR PAROXETINE 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 8 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 Guideli
29. MTPPR Residential Bed Tracking User Manual Residential amp Group Home Providers Connecticut BH Supporting Health and Recovery Y VALUEOPTIONS CONNECTICUT This page was intentionally left blank CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Table of Contents 4 ACCOSSINO FO oz NN E E 6 Provider Connect BASICS sese iretur hue ord met ense eee Satu Ores n t 8 Introduction Bed Match Referrals cccccccsececsecceeeeceeeeceeeeeeeeseeeeseeeseeeeseeeeseeeseeeesseesaeeess 11 Viewing and Updating Bed Match Referrals cccccccccsececeeeeeeeeseeeeceeeeeeeeseueeseeesaueesaees 12 Updating Bed Availability n 21 Introduction RTC GH Requests MTPPR FOrm cccsccccseeeeeeeceeeeeeseeeeseeeeeseeeessaeeeeaes 24 Features RTC GH Requests MTPPR Form 25 Completing RTC GH Requests MTPPR Form 26 3 IT Product Support Reston Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Introduction Introduction The ProviderConnect application provides a variety of self service functions to help congregate care providers access and view information about members and authorizations For CT BHP congregate care providers func
30. ORMATION 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 BEHAVIORS 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 44 IT Product Support Reston VA Revised 10 1 2015 CT BHP Pr
31. TPPHR Form This function focuses on completing and submitting concurrent RTC GH Requests for Authorizations which is how MTPPR Forms are submitted by providers Phase 3 Training As a result of this section you will be able to Objectives Access the Request for Services function Complete a request for RTC or GH authorization i e MTPPR form 24 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Features RTC GH Requests MTPPR Form Validations and Checks Saving Requests as Drafts Concurrent MTPPR Requests When completing RTC GH requests for authorization there are a few system checks that are completed at the beginning of the request to help prevent providers from proceeding with a request where for example the member is not DCF funded or the provider isn t contracted to provide the service While working with requests for authorizations in ProviderConnect providers 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 Page 36 Saved drafts can be viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage When a record is saved as a draft it is NOT available in CareConnect for clinical staff to review The record is only accessible and available to providers in ProviderConnect until the provider submits the record Once
32. Welcome THE HARTFORD DISPENSARY Thank you for using ValueOptions ProviderConnect YOUR MESSAGE CENTER Recent Inquires Responded to by ValueOptions WHAT DO YOU WANT TO DO TODAY 2 Locate referral message to review e Records can be sorted by the Date Received with the most recent record listed first e The subject for Bed Match referrals will be Referrals 3 Click on the Inquiry Number to access the Referral Message Center Inbox Thank fou for your recent web inquiry Listed below the responses sent within the past 30 days SET TE g wal trash ioon wil delete the message permanently ae Date Received T Subject 10132010 18 7094 3 0 10000 10 13 2010 REFERRAL 10132010 18704 4 010000 10 13 2010 REFERRAL 10132010 18 7048 3 0 10000 10 13 2010 REFERRAL 12 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Match Referrals continued 4 Open referral message Click the Referral hyperlink to open message Message Center Inquiry Details Your Inquiry Details Date Received Inquiry Member Name 07 28 2010 Bed Match Admit Notification Form 07282010 8756455 010000 Subject REFERRAL SMITH Inquiry Message THE HARTFORD DISPENSARY 07282010 22 09 25 ET Member Name Provider ID CBH Bed Match Admit Notification Form CUSTOMER SERVICE 07282010 00 00 00 ET Member Name DELL SMITH Pr
33. aft on the top right of the screen Saved drafts can be ProviderConnect Home TROPIC FREQUESTED RESULTS TIONS SERVICES Save Request as Draft viewed and opened by users or an authorized user supervisor from the View Clinical Drafts screen accessible from the ProviderConnect homepage See pg 12 34 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step 4 The Level of Care screen is the first screen that will display after the Initial Entry Complete Clinical screen For RTC and GH requests the RTC GH Information section will Screens Level automatically expand and display all the fields that must be completed For the first of Care Screen Concurrent request most fields will be blank and must be completed However for subsequent concurrent requests most data will be pre populated Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Step Action Enter the calling Provider Facility into the open text entry field If member s LMHA involved Select the LMHA from the drop down selection Enter the Aftercare Follow Up contact information for member please provide at least one method for contacting member for follow up e Phone Number e If not available please clarify reason e Email Address if available Enter the Ut
34. ch the document staging Requested Services Header AS Selde marked with an asterisk are required Note Disable pop up blocker funclionalip to view af appropriate ROKS Requested Start Date MMDDY YYY Level of Service 08302010 INPATIENT HLOC Type of Service Level of Care Type of Care Admit Date MMDDYYYY MENTAL HEALTH RESIDENTIAL RESIDENTIAL TREATMENT CENTER OTHER 08272010 E Provider Tax ID ider ID Provider Last Name Vendor ID Provider Alternate ID 060646668 HARTFORD HOSPITAL vCB003426 000050079 Member Last Name irst Name Date of Birth MIMDD Y Y Y Y ember ID F TEMP000700074 WOODSIN LAMONYNE 02281995 Attach a Document Complete the form below to attach a document wits tie Request The following are only required if you are uploading a document Does this Document contain clinical information about the Member Yes No O HIGHER LEVEL OF CARE TREATMENT REQUEST UploadFile Cink to attach a document Click ro celere an attached document Attached Document 32 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued 7 Click the Next button he system will complete request validations and warning messages will display at this time if the validations are not passed f no document has been attached warning messages
35. concurrent request please list both the progress that has been made to date and what symptoms stil remain 2 gt Narrative Entry 0 of 2000 Below the Symptomatology is an abbreviated risks section Key O0 Mone 1 Mild Mildly Incapacitatinmg 2 Moderate or Moderately Incapectating 3 Severe or Severehy Incapacitating N A Not Assessed Member s Risk to Self Member s Risk to Others 0 dx i 72 753 Ny mo 71 sw SF SNA Gubstance Use 0 1 2 amp 41 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing Initial Inpatient HLOC Requests continued 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 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
36. ction All fields with an asterisk are required Number of Individual Treatment Sessions for this reporting period 0 30 or no family resource per DCF Number of Individual Treatment Hours for this reporting period 0 30 Focus of Individual Therapy Open text field Is the Child s Primary Language English Yes or No If No did the child receive services in primary language Yes or No Is family s primary language English Yes or No If No did family receive services in primary language Yes or No Number of Recreational Treatment Sessions for this reporting period 0 30 or no family resource per DCF Number of Recreational Treatment Hours for this reporting period 0 30 Focus of Recreational Therapy Open Narrative field Complete the Family Therapy section All fields with an asterisk are required Number of Scheduled Family Treatment Sessions during this reporting period Scheduled by facility as per treatment plan 0 30 or no family resource per DCF Focus of family Treatment Open Narrative Field Number of Family Treatment Hours during this reporting period Scheduled by facility as per treatment plan 0 30 Results Progress Barriers Open Narrative Field Number of Attended Family Treatment Sessions during this reporting period 0 30 or no family resource per DCF Names of Family Treatment Open Narrative Field Number of Family Visits scheduled during this reporting period Scheduled by facility as per treatment
37. dards 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 6 Click Log In 7 Accept the User Agreement to proceed to the home page 7 IT Product Support Reston Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b ProviderConnect Basics Searching for One function that is used often to complete various CT BHP specific functions is and Viewing searching for locating 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 on the Home page Staging H recommen Welcome THE HARTFORD DISPENSARY Thank you for using ValueOptions ProviderConnect Authorization Listing Enter an Authorization Request YOUR MESSAGE CENTER View Clinical Drafts Recent Inquires Responded to by ValueOptions Review Referrals Enter Bed Tracking DATE RECEIVED SUBJECT MEMBER NAME STATUS Information 07 28 10 REFERRAL SHAMARI SMITH COMPLETED My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Review Referrals W Find a Specific Member gt Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters Enter an Authorization Re
38. de are only required i you are uploading document Documen t Type Does this Document contain clinical information about the Member Yes Documen t Description SELECT UploadFile Clic to attach a document Attached Document 3 Select the Type of Service Level of Care and Type of Care for this request The options available for the Level of Care field are based on the value selected for the Type of Service Fields The options available for the Type of Care field are based on the value selected for the Level of Care For RTC or GH the following value combinations can be selected Level of Care Type of Care Type of Service Mental Health Residential Treatment Center Residential Treatment Center Other Group Home 2 0 Group Home Group Home 1 0 Group Home 1 5 Substance Abuse Residential Treatment Center Residential Treatment Center Other The values selected must match the values selected on the initial request in order for the request to be considered concurrent 31 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued 4 Enter the Admit Date The ADMIT DATE must match the Admit Date on the initial review in order for the request to be considered concurrent Providers can verify the ADMIT DATE on the Auth Summary tab of the member s authorization
39. duct Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Action Complete the Relational Progress section and indicate an OVERALL ASSESSMENT OF PROGRESS All fields with an asterisk are required Note For subsequent concurrent requests the response from the last request will display next to each field Ratings Very Good Good Fair Poor N A Interactions with Peers Willingness for change Respects rights property of others Interactions with Adults Authorities Personal Hygiene Complete the Academic Achievement section and indicate an OVERALL ASSESSMENT OF PROGRESS All fields with an asterisk are required Note For subsequent concurrent requests the response from the last request will display next to each field Ratings Very Good Good Fair Poor N A Interactions with Teachers Interactions with class peers Days Absent 0 30 or N A Completes Assignments If Regular Ed Student progress in achieved grade level If Special Ed Student progress in achieve IEP goals Number of School Suspensions 0 30 or N A Complete the Skills of Independent Living section and indicate an OVERALL ASSESSMENT OF PROGRESS fields with an asterisk are required Note For subsequent concurrent requests the response from the last request will display next to each field Ratings Very Good Good Fair Poor N A Self Care Daily Living Housing amp Home Management
40. e most current information we have on file Click the Referral Number for more detail on the referral To update a referral click the Update button Referral Member Name Referral Type Referral Match Admission Not Accept or Match Remove Date us Status Decision Decision Decision Submitted O1 101210 1 31 FRANKS APPLE Bed Match Open 10 12 2010 1 Referral Proceed to Updating Completing Match Decision Pg 19 14 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Match Referrals continued 3 From the Member Demographics 1 Access the Member Search function Click Specific Member Search link from either the left navigational bar or the Home page of ProviderConnect The Eligibility amp Benefits Search screen will display Staging Home Specific Member Search Authorization Listing Enter an Authorization Request YOUR MESSAGE CENTER View Clinical Drafts Recent Inquires Responded to by ValueOptions Review Referrals Enter Bed Tracking DATE RECEIVED SUBJECT MEMBER NAME STATUS Information gt 07 28 10 REFERRAL SHAMARI SMITH COMPLETED My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Review Referrals W Find a Specific Member gt Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters m Enter an Authorization Request Enter Bed Tracking Information W Rev
41. e of the options under the Diagnostic Category No Diagnosis Code or Description are needed if the selection is None or Unknown Omary medica d iugnaosis amp required Select pinay medica dagqnoestc category dropdown o select medical deqiass code and descen Diagnostic Category 1 SELECT Diagnosis Code 1 Description Diagnostic Category 2 Diagnosis Code 2 Description SELECT GENI SYSTEM KIDNEY GENITOURINARY SYSTEM OTHER INFECTIOUS E PARASITIC HIM INFECTIOUS amp PARASITIC OTHER INJURY POISONING EFFECTS OF EST CAUSES OTHER INIUR YY POLSON E OTHER EFFECTS OF EXT TEBI PALIECTLIE SYSTEM E CONNECTIVE TISSUE 5 SYSTEM CHRONIC PAIN OTHER NERWU S SYSTEM MIGRAINE EPILEPSY STROKE MER WOLS SYSTEM MULTIPLE SCLEROSIS NER WIS SYSTEM OTHER SYSTEM PAREKINS ONS EPS PERINATAL PER ID PR EGHAM CCEAILBDDOSEIFTE SPD THE PUER PER RESPIRATORY SYSTEM COPD ASTHMA EMPHYSEMA RESPIRATORY SYSTEM OTHER GEIN ES SUB CUTANEUS TISSUE SYMPTOMS SENS E ABNOR MAL CLINICALS TL AE MONE Partial Description We suggest for those system users that new 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 Primary medical diagnosis is required Select primary medical
42. e outline the recovery and resilency environment to support this individuals long ferm recovery plan Please include personal strengths support systems available to support the recovery and details around living environment as well as outline any identified needs or supports that need ta be put in place to assist in the successful recovery 0 of 2000 Narrative Entry 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 in 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
43. er is authorized for Residential Group Home Services from 11 01 14 12 01 14 for 30 units The Requested Start Date for the first MTPPR should be 12 02 2014 Example 2 The member was authorized for Residential Group Home Services from Auth line 1 11 01 14 12 01 14 for 30 units Auth line 2 12 02 14 01 02 15 for 30 units The Requested Start Date for the next MTPPR should be 1 03 15 30 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued 2 Select the Level of Service Inpatient Higher Level Of Care When the level of service is selected the screen will update with the required fields specific to the level of service selected staging Requested Services Header Al Belts marked with an asterisk are required Note Disable pop up blocker functionality to view aff appropriate inks Requested Start Date MMDDYYYY Level of Service 08302010 E SELECT v SELECT INPATIENT HLOC SELECT __________ _ _ Provider OUTPATIENT COMMUNITY BASED Tax ID Provider ID Vendor ID Provider Alternate ID Provid 060646668 CBHP002134 HARTFORD HOSPITAL CB003426 000050079 Member Member ID Last Name First Name Date of Birth MMDDYYY TEMP000700074 WOODSIN LAMONYNE 02281995 Attach a Document Complete the form below to attach a document with this Request The following Sel
44. erral Note The View Request for Care CANS is only available when e The status of the referral is Open or he status of the referral is Closed and the Match Decision and Admission Decision is Accept Referral Search Results The information displayed indicates the most current information we have on file Click the Referral Number for more detail on the referral To update a referral click the Update button Referral Member Name Referral Type Referral Match Admission Not Accept or Match Remove Date Status Decision Decision Decision Submitted ID 01 101210 1 31 FRANKS APPLE Bed Match Open 10 12 2010 Update i Referral View Request for Care CANS Proceed to Updating Completing Match Decision Pg 19 16 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Bed Match Referrals continued Key Step 2 The second key step is to locate the Bed Match referral to view and or update Below are the key steps for completing this process esults Information The search results will include the following information Referral Number Displays the number of the referral record Member Name and ID Displays the name and ID of the member referred o This information will not display when the list is accessed from the member demographics screen Referral Status The referral status will either be o Open Indicates that the
45. es or NO If Yes the following questions are required Family peer Specialist Referral made Yes or No If Yes Date of referral MMDDYYY Y Date of CANS submission MMDDYYY Y LOC Determined RTC GH 1 5 GH 2 0 Other DDS Referral Indicated Yes or NO If Yes Date MMDDYYY Y DMHAS Referral Indicated Yes or No If Yes Date MMDDYYYY Child Specific Conference Needed held Yes or No If Yes Date MMDDYYYY If Yes Purpose of Conference Open text field Case Specific Conference Needed Held Yes or No If Yes Date MMDDYYY Y If Yes Purpose of Conference Open text field PPT Needed Yes or No If Yes the following questions are required Date of for PPT MMDDYYY Y Additional Comments Open Text Field Has Member been Discharged Yes or No If Yes the following questions are required Actual date of Discharge MMDDYYYY Child family Case Worker Needs Describe Needs Why By Whom By When Open text Field Date Completed MMDDYYYY Date Completed MMDDYYYY Click the Next button Additional MTPPR Information screen will display 49 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step 3 The Additional MTPPR Information screen is a screen that is only completed when Complete Clinical the request is concurrent Thus for the first concurrent request
46. iew an Authorization m Clinical Drafts 2 Enter the Member ID and Date of Birth 3 Click Search Eligibility amp Benefits Search Required fields are denoted by an asterisk adjacent to the label Werify a patient s eligibility and benefits information by entering search criteria below s member ID Wo spaces or dashes Last Marne First Marne MMDDYYYY As of Date 06162010 roo yy ry 15 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Match Referrals continued 4 Click the View Referrals button a Thereferral Search Results will display with a listing of all referrals that are for the specific CT BHP member Demographics Enrollment History COB Additional Information Member eligibility does not guarantee payment Eligibility is as of today s date and is provided by our clients Member Eligibility Member ID 00700058 Effective Date 08 04 2010 Alternate ID Expiration Date Member Name WOODSIN MOONEY COB Effective Date 7 Date of Birth 01 15 1995 Address 500 ENTERPRISE DRIVE HARTFORD NB E7M 5H9 Subscriber Alternate Address Subscriber ID 00700058 Marital Status Subscriber Name WOODSIN MOONEY Horne Phone Work Phone Relationship Gender View Member Enter Auth Request View Clinical Drafts View Referrals 5 Click the Update button on the member specific ref
47. ilization Review Contact Name Enter the Utilization Review Contact Phone Enter the Utilization Review Contact Fax Enter the Preparers Phone Number the clinician who is entering this review Child s Guardian If Child Legal status select the check box that applies MEE NAE 04 5 __6 __8 9 10 od 12 _ 13 Enterthe Name of Place Facility Institution who Referred member 44 15 16 18 19 20 21 22 23 24 25 26 28 29 35 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step 5 The Diagnosis screen is the first screen that will display after the Initial Entry screen Much of the information is required for completion of this screen creens ELS 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 Below are the key actions for completing this screen Any field with an asterisk indicates that the field is require Step Action uU BHO ii
48. inued Key Step3 There are two key times providers will need to update the Bed Match Referral Update and Save Referral 1 Completing the Match Decision 2 Completing the Admission Decision For each update an inquiry is automatically generated and pended to CT BHP to alert the staff that a decision has been made regarding the Bed Match referral Below are the key steps for completing this process for a Match Decision and Admission Decision Any field with an asterisk indicates that the field is required 1 Completing the Match Decision 1 Review Bed Match details The top section of the Bed Match form displays the Bed Match information completed by CT BHP including the Level of Care determined for the member the specific site or program the member is matched to at the provider facility the referring party and contact information Bed Match Admit Notification Referral A Selos marked wil an asterisk are reguired Note Disable pop up blocker functionality to view ai appropriate finks Level of Care Decision Date Specific Site Program Matched To 0 0806201 BRIGHTSIDE INC Link Person 222222222 Referral Parby Contact Name Contact Phone DCF AREA OFFICE DDDDDD 1111111111 EXT Date of Match Notification 08062010 RCT Liaison who made Match Type DDDDDDDDDD PROJECTED VACANCY 2 Complete the Match Decision information Select the Match Decision Enter the Date of Match Decision
49. is members decom pensation to In patient Care ee Primary Behavioral Diagnosis Diagnostic Category 1 Diagnosi Code 1 Description SELECT F20 9 Step Action system users can enter a partial diagnosis and then click on the hyperlink to view a filtered list of those ICD 10 codes that match their search criteria Primary Behavioral Diagnosis Diagnostic Category 1 SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORL SCHIZOPHRENTA SPECTRUM AND OTHER PSYCHOTIC DISORDERS SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS SCHIZOPHRENTA SPECTRUM AND 29 UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER OTHER PSYCHOTIC DISORDERS 36 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Behavioral Diagnoses Primary Behavioral Diagnosis Diagnostic Category 1 Diagnosis Code 1 Description SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORL F20 9 Schizophrenia 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 ICD 10 codes that match their search criteria If there is No Medical Diagnosis or it is Unknown please select on
50. ls will be made to your program the Fed Matoh referral ie completed and submitted to CT BHP Date that Referring Party Contacted Facility 08062010 Date of Match Decision Match Decision ACCEPT 08062010 _ Date of Match Decision must be within 3 business days of Date oFMalch Notification Pre Admission Pre Placement Appointment Location Pre Placement Appointment Date Time MMDDY YYY HHmm Admission Decision Date of Admission Decision Admission Decision 08062010 late of drimiccing Aa within 7 n SELECT 19 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Bed Match Referrals continued 2 Completing the Admission Decision 1 Complete the Admission decision information Select the Admission decision o Admission decision is Accept complete the IF Accept Admission Date o If the decision is Not Accept select IF Not Accept What is the primary reason Enter the Date of Admission Decision Match Decision The above client has been matched to your program for RTC GH services He She has been identified as an appropriate match to receive treatment from your program The Area Office Social Worker AOSW Parole Probation Officer will contact you within 3 business days from the date of this notification
51. 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 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 38 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Problems with access to E Housing problems related to the social health care services Not Homelessness environment Fl a problems Problems related to interaction Gi tupational problems Homelessness wl legal system crime 7 Financial problems primary support 7 Other psychosocial and 7 Unknown group environmental problems 7 Medical disabiities 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
52. nches 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 Assessment will also auto populate And if the BMI was not assessed then please provide additional information on reason for not obtaining BMI or if recommendation is to follow up details around the follow up when available in the open text field Select Next at the bottom of the page to move to the next Tab If BMI not assessed please indicate by selecting the check box 5 40 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Metabolic Assessment Tool Current Weight Height ft in Waist Circumference in inches BMI Categories Underweight lt 18 5 Normal weight 18 5 24 9 Overweight 25 29 9 Obese BMI of 30 or greater 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 providers 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 Please provide additional information on reason for not obtaining BMI or recommendation is to follow u
53. nes for the Primary Diagnosis Yes or No If No Please enter the reason why in the open text field 1000 character limit 47 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b 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 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 j Selectallmembers ofthe Planning Team 1 1 1 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 LLOC 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
54. o Ta D _______ e RR Address endor ID a s To Address Emm Alternate ID 002120 PROVIDER 159 TEMP 4 501 ENTERPRISE DR 501 ENTERPRISE DR TEMPFAC C CBHP002120 TEMP PROVIDER CBO0S769 TEMP PROVIDER 999999999 500 ENTERPRISE DR 500 ENTERPRISE DR STE 4D STE 4D ROCKY HILL CT 06067 3913 ROCKY HILL CT 06067 3913 TEMPFAC Note If no contract is listed contact the CT BHP at 1 877 552 8247 suging Bed Tracking Provider Name Vendor ID HARTFORD HOSPITAL CBO04968 Please select the contract For which you are completing Bed Tracking information BEHAVIORAL HEALTH PARTNERS KIDCARE 6 Select the section to update Click the sign next to the Level of Care Residential or Group Home that is being updated Bed Tracking Provider Name Vendor ID Temp Provider VCB007022 gt RESIDENTIAL Contract Code 38 Contract Association CBHP Parent Back Cancel 22 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Bed Availability Information continued 7 The section will expand and display bed availability information fields a Total Number of Licensed Beds Displays the number of Licensed Beds at the providers Residential Group Home service location that was chosen b Beds Occupied by Other Insu
55. on function Please Note When exiting you will no longer be able to print or save the MTPPR request if it has not been already 53 IT Product Support Reston VA Revised 10 1 2015
56. or a field Codes 201 3 will populate the field when clicked Hyperlinked Diagnosis Code 1 Any underlined field title will open screens help text a Field Titles T list of codes etc when clicked Radio buttons Any data items with radio buttons next to them O ves O No O 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 will submit the record when clicked Member s Guardian Any open text box indicates that free form text can be Breadcrumbs entered into the box 5 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual 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 7 Welcome to the CT Behavioral Health Partnership You can use this site to find information on accessing Connecticut BHP and providing behavioral health and
57. ovider ID CBH Bed tch Admit Return to Inbox Return to Sent 5 Click the Update button Note The View Request for Care CANS is only available when e he status of the referral is Open or e status of the referral is Closed and the Match Decision and Admission Decision is Accept Referral Search Results The information displayed indicates the most current information we have on file Click the Referral Number for more detail on the referral To update a referral click the Update button Referral Member Name Referral Type Referral Match Admission Not Accept or Match Remove Date Status Decision Decision Decision Submitted 01 101210 1 31 FRANKS APPLE Bed Match Open 10 12 2010 1 Referral E ques J JU Proceed to Updating Completing Match Decision Pg 19 13 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Match Referrals continued 2 Through the Review Referrals Link 1 Click Review Referrals link from either the left navigation or Homepage of ProviderConnect The Search Referral Screen will display Staging Home Welcome THE HARTFORD DISPENSARY Thank you for using ValueOptions ProviderConnect Specific Member Search Authorization Listing Enter an Authorization Request YOUR MESSAGE CENTER View Clinical Drafts Recent Inquires Responded to by ValueOptions
58. oviderConnect MTPPR Residential Bed Tracking User Manual b 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 BASELINE 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 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
59. p details around the follow up when available gt Narrative Entry 0 of 2000 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 e ae information below o Medication Treat Please explain the reason for current admission describe symptoms and ment Screen nclude 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 Y PROVIDERCONNECT ProviderConnect Home VALUEOPTIONS gt LEVEL OF CARE DIAGNOSIS Rie S iss ag ete te gt gg ADDITIONAL MTPPR INFORMATION Requested Services Header Requested Start Date 04 15 2015 PROVIDER IVANNA Save Request as Draft Type of Request Member ID rovider ID Provider Alternate ID NPI for Authorization INITIAL TEMPOO0981339 TEMPFAC SELECT Level of Service Type of Service v n Type of Care Authorized User INPATIENT HLOC Mental Health Inpatient Inpatient Hospital Inpatient Hospital Symptomatology Please explain the reason for current admission describe symptoms and include the precipitant what stressor or situation led to this decompensation If this amp a
60. plan 0 30 or no family resource per DCF Detail of Family Visits scheduled Open Narrative Field Number of Family Visits Attended during this reporting period Scheduled by facility as per treatment plan 0 30 or no family resource per DCF Family Treatment Results Progress Barriers Open Narrative Field Complete the Family Readiness section All fields with an asterisk are required Note For subsequent concurrent requests the response from the last request will display next to each field Ratings Very Good Good Fair Poor N A e How prepared to parent does the family family resource feel e How well has family family resource developed new improved skills Complete the Family Family Resource FFR Interactions section All fields with an asterisk are required Note For subsequent concurrent requests the response from the last request will display next to each field Ratings Very Good Good Fair Poor N A e Your rating of FFR interactions with child youth e FFR ratings of Interactions with child youth e Child youth rating of interactions with FFR Complete the Home Passes section All fields with an asterisk are required An unlimited number of Home Passes can be documented To add a section click the Add Home Pass button A new set of Home Pass fields will be added to the screen for completion Provide a description for OTHER THERAPEUTIC INTERVENTIONS FOCUS Enter description in the Narrative Entry field 51 IT Pro
61. port Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued 5 Locate and select the Service Address Vendor Click the radio button next to the address to select the record The record that is selected will be attached to the request and authorization that will be created Click the Next button to continue The Initial entry Request screen will display Provider ID Provider Last Name Provider First Name PROVIDER TEMP CBHP002120 v TEMP PROVIDER Select Service Address CBHP002120 TEMP PROVIDER VCB003159 TEMP PROVIDER 500 ENTERPRISE DR TEST 500 ENTERPRISE DR TEST STE 4D STE 4D ROCKY HILL CT 06067 3913 ROCKY HILL CT 06067 3913 TEMPFAC CBHP002120 TEMP PROVIDER VCB005769 TEMP PROVIDER 999999999 500 ENTERPRISE DR 500 ENTERPRISE DR STE 4D STE 4D ROCKY HILL CT 06067 3913 ROCKY HILL CT 06067 3913 2015 ValueOptions ProviderConnect v5 01 00 On the Requested Services Header the 1 required field is the requested start date This date should be obtained via the MTPPR Scheduling Tool The Admit Date must match the original intake date for the MTPPR Concurrent to Attach staging Requested Services Header Al fields marked with an asterisk are required Note Disable pop up blocker functionalty to view all appropriate links Requested Start Date MMDDYYYY Level of Service 04082015 58 INPATIENT HLOC
62. quest Enter Bed Tracking Information W Review an Authorization m View Clinical Drafts 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 adjacent to the label Werify a patient s eligibility and benefits information by entering search criteria below Mermber ID Juv paces oF dashes Last Hame First Marne Bate of Birth AO Ye As of Date 08162010 CTO yy rr 8 IT Product Support Reston Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b ProviderConnect Basics continued Review Members record details 3 Demographics Displays basic member information such as address phone etc 4 Enrollment History Displays all active and expired enrollment records for which the member is part of 5 Display information on other insurance policies 6 Additional Information Displays claims mailing address for the member Member eligibility does not guarantee payment Eligibility is as of today s date and is provided by our clients Member Member ID Alternate ID Member Name Date of Birth Address TEMP000700058 WOODSIN MOONEY 01 15 1995 500 ENTERPRISE DRIVE Eligibility Effective Date 08 04 2010 Expiration Da
63. r authorization function can be accessed from the ProviderConnect Homepage when the Enter an Auth Request button is clicked Below are the key steps for completing this process Any field with an asterisk indicates that the field is required 1 Access the Authorization Request Function Click Enter Authorization Request Link from either the left navigation or Homepage of ProviderConnect The Disclaimer screen will display Welcome TEMP PROVIDER Thank you for using ValueOptions ProviderConnect YOUR MESSAGE CENTER Click on inbox to view your messages WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Enter or Review Referrals m Find a Specific Member m Review Referrals Enter Bed Tracking Information Search Beds Openings View My Recent Authorization Letters Enter an Authorization Request w Enter a Treatment Plan m Review an Authorization m View Clinical Drafts Enter Member Reminders Enter Case Management Referral 2 Review the Disclaimer and click the Next button f you do not want to continue click the ProviderConnect Home button in the upper right corner to exit the Authorization Request function ProviderConnect Home formal requests for authorization Exiting or aborting the process process ill receive as prior to completion will not result in a completed request ValueOptions does no t t our re quests as ts Upon full completion of the Enter you will creen noting the
64. red Open text field for users to update for the weekly bed availability information update 8 Users can Click the sign next to each section to view update information e Projected Discharges Section will list all members currently authorized at this service location Users enter the projected actual discharge date and if the bed will be reserved for Other Insured as applicable Q Projected R RESIDENTIAL Discharges Estimated Discharge Projected or Bed Reserved for Date of Birth Eaten il e Other sure TEMPCT4321 Sparrow Jack 11241997 09212010 000700118 MULL 01012000 08312010 8 m e Other Insured Occupied Beds for Discharge Section allows users to enter the projected actual discharge date of Other insured if that projected discharge bed will be reserved for Other Insured and the gender of that member Projected or Actual Discharge Bed Reserved for Other Insured r r Gender serecr aj SELECT Projected Admissions When expanded this section will list member that has been matched and approved for admission by the facility with their projected admission date 3 Projected Admissions CT005555555 j Doe John 04271338 CURRENT VACANCY Projected Admission Date 10052010 e Held Beds for Match Admit Decision When expanded this section will list any member that has been matched and
65. steps for updating existing Bed Match referrals 1 Access Bed Tracking form 2 Update and save bed availability information Key Step 1 The first key step is to access the Bed Tracking form and the specific section to Access Bed update bed availability information Tracking Form 1 Access the Bed Tracking function Click Enter Bed Tracking Information link from either the navigation menu the Homepage of ProviderConnect Vendor Selection screen will display Welcome Thank you for using ValueOptions ProviderConnect g YOUR MESSAGE CENTER Your Recent Inquiries box is empty WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits Review Referrals m Find a Specific Member m Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters Manim am A aad aei dm a 21 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Viewing and Updating Bed Availability Information continued 2 Locate and select the Service Vendor 3 Click the radio button next to the service address to select the record record that is selected will be the location for which bed availability will be updated 4 Click Next Select Service Address Emm I A un M Capture Provider ID Last Name Vendor ID Yendor Last Name First Name SE ru c First Name
66. submitted the provider can no longer access the record for updates or changes in ProviderConnect but it becomes available to internal staff through CareConnect For RTC GH requests providers will have the ability to submit concurrent MTPPR requests ProviderConnect will automatically determine when an MTPPR request is concurrent by a validation check on the Requested Start Date and Admit Date field entered The validation process will check for existing MTPPR on file for the same member provider and other matching criteria For RTC GH requests the first MTPPR will most likely have very little pre populated data since much of the information required has not been completed yet However for subsequent concurrent MTPPR reports much of the MTPPR data completed will auto populate to the next MTPPR request which leaves the ability to quickly update the information as needed 25 IT Product Support Reston VA Revised 10 1 2015 Completing RTC GH Requests MTPPR Form CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Overview Providers use the Request for Authorization process to complete and submit RTC GH Requests which equates to completing the MTPPR Form Once the request is submitted CT BHP staff determines if the request will be used for a concurrent review Regardless of what the request is used for the process for completing the request or the MTPPR form is the same for providers in ProviderConnect Ke
67. tch Referrals continued Key Step 3 Continued Update and Save Referral 3 Save the Bed Match referral If the Match Decision is Accept then An Inquiry is automatically generated and pended to CT BHP staff to alert them of the decision CT BHP will enter the Pre Admissions information on the Bed Match referral The referral status will remain Open and the referral and the Request for Care CANS record will continue to be available to view and or update 4 Ifthe Match decision is Not Accept then An Inquiry is automatically generated a pended to CT BHP staff to alert them of the decision The referral status will change to Closed and the referral and the Request for Care CANS record will no longer be available to view and or edit Match Decision The above client has been matched to your program for RTC GH services He She has been identified as an appropriate match to receive treatment from your program The Area Office Social Worker AOS Parole Probation Officer will contact you within 3 business days from the date of this notification to verify the pre admission appointment at your agency If you do not receive a call from the AOSW within this timeframe you should notify the AOS W s supervisor and the AO Behavioral Health Program Director RCT Liaison or RCT Clinical Manager as this will delay the youth from being placed at your program in a timely manner If this match is not accepted no additional referra
68. te COB Effective Date HARTFORD NB E7M 5H9 Subscriber Alternate Address Marital Status 7 Subscriber Name WOODSIN MOONEY Home Phone Subscriber ID TEMP000700058 Work Phone Relationship Gender View Member Auths Enter Auth Request View Referrals 7 View Member Auths Displays Member specific authorizations 8 Enter an Authorization Initiates the Request for Services process 9 View Clinical Drafts Display member specific Clinical Drafts 10 View Referrals Displays Bed Match Referrals Demographics Enrollment History COB Additional Information Member eligibility does not guarantee payment Eligibility is as of today s date and is provided by our clients Member 2 Eligibility Member ID TEMP000700058 Alternate ID Effective Date 08 04 2010 Expiration Date Member Name WOODSIN MOONEY 01 15 1995 COB Effective Date Date of Birth Address 500 ENTERPRISE DRIVE HARTFORD NB EFM 5H9 Subscriber Alternate Address Subscriber ID Marital Status TEMPO00700058 Subscriber Name WOODSIN MOONEY Home Phone Work Phone Relationship Gender View Member 4uths Enter Auth Request View Clinical Drafts View Referrals 9 IT Product Support Reston Revised 10 1 2015 Features CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Saving Requests While working with requests for authorizations in ProviderConnect providers have as Drafts Designating Authorized User
69. thylamide Phenylpropanolamine Methadone Other 42 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step7 The Primary Issues Symptoms Addressed in Treatment Complete the Clinical Screens Clinical Presentation n 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 INTENT MEANS 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
70. tions include Submitting requests for Monthly Treatment Planning Progress Report Viewing and updating Bed Matching referrals Submitting Bed Tracking updates What is Covered This module covers the Residential Treatment and Group Home Care Management in this Module process for congregate care providers which includes the following key phases Phase 1 Bed Match Referral This phase focuses on viewing and updating received Bed Match referrals and viewing Request for Care CANS records associated with Bed Match referrals This phase also involves managing bed availability information Phase 2 RTC GH Review Auth MTPPR Form This process focuses on completing and submitting a request for RTC GH authorizations which equates to completing and submitting the MTPPR form Training Goals As a result of this training module you will be able to Navigate through basic ProviderConnect functions Update Bed Match referrals Update bed availability information Complete a request for RTC or GH authorization i e MTPPR form 4 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual 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
71. to verify the pre admission appointment at your agency If you do not receive a call from the amp OSW within this timeframe you should notify the amp OSW s supervisor and the 40 Behavioral Health Program Director RCT Liaison or RCT Clinical Manager as this will delay the youth from being placed at your program in a timely manner If this match is not accepted no additional referrals will be made to your program uni fe Fed Matoh referral ie completed and submitted to CT BHP Match Decision Date of Match Decision Date that Referring Party Contacted Facility ACCEPT 08062010 08062010 _ Date of Matoh Decision must be within 3 business days of Date of Match Notification Pre Admission Pre Placement Appointment Date Time MIMDDY YYY HHmm Pre Placement amp ppointment Location imd Admission Decision Date of Admission Decision 08062010 _ Date of Admission must within Z business days of Pre Placement Appointment If Accept Admission Date If Not Accept what is the primary reason If Other please specify 08072010 _ SELECT vi 2 Save the Bed Match referral If the Admission Decision is Accept then An Inquiry is automatically generated and pended to CT BHP staff to alert them of the decision referral status will change to Closed However the referral and the Request for Care CANS records will remain available to view 30
72. v Number of Group Treatment Sessions Focus of Group Therapy for this reporting period SELECT v gt Narrative History 0 of 250 Number of Group Treatment Hours for this reporting period SELECT v Narrative Entry Action View the DATE MONTHLY REPORTING PERIOD STARTS This field cannot be modified For the first concurrent request the date will populate with the ADMIT DATE For subsequent concurrent requests the field will populate with the DATE MONTHLY REPORTING PERIOD ENDS from the last request plus 1 day View the DATE MONTHLY REPORTING PERIOD ENDS This field cannot be modified For the first concurrent request the field will populate with the DATE MONTHLY REPORTING PERIOD STARTS of the current request plus 45 days For subsequent concurrent requests the field will populate with the DATE MONTHLY REPORTING PERIOD STARTS of the current request plus 30 days Update the NEXT MTPPR REQUIRED This field cannot be modified For the all concurrent requests the field will populate with the DATE MONTHLY REPORTING PERIOD ENDS of the current request plus 5 days 50 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Step Action Complete the Review Information section All fields with an asterisk are required m CT BHP Care Manger Name CT BHP Care Manager Phone Number Complete the Therapy amp Home Passes se
73. y Steps The key steps for completing RTC GH Requests MTPPR Form include 1 Initiate a Request for Authorization 2 Complete the initial entry request screen 3 Complete the clinical screens MTPPR Only screens 4 Submit Request and confirm submission Details about each key step follow Workflow Completing RCT GH Requests MTR Form Complete Initial Entry Request Screen Only Screens Complete Clinical Screens MTR Initiate Request for Authorization submit Request and Confirm Submissian 26 IT Product Support Reston VA Generate Pended Authorization NN UTE Auto generate and Pend Inquiry to Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Completing RTC GH Requests MTPPR Form continued Key Step 1 Initiate a Request for Authorization staging Home Specific Member Search Authorization Listing Enter an Authorization Request Enter a Treatment Plan View Clinical Drafts Enter Case Management Referral Review Referrals Enter Bed Tracking Information Search Beds Openings Enter Member Reminders Print Spectrum Release of Information Form My Online Profile Provider Data Sheet Staging Disclaimer Please note that ValueOptions reco recognize or retain data for partially completed reques notification that your request has been receiv nizes only fully completed and submitted re The request fo
74. ys after the Initial Saved Date Delete Request Drafts Next gt gt Initial Saved Date Member ID Member Name Provider ID Level of Service Level of Care Type of Care Authorized User Requested Start Date A Providers can designate an Authorized User within an MTPPR request which allows associated provider to access view and edit saved drafts This allows for instance a supervisor who would be the Authorized User to view and edit requests completed by their staff prior to submitting the request Users can enter the id of their Supervisor in the Authorized User Box before Saving the Clinical Draft to allow their supervisor access Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 12 10 2010 VAASOUE Z DARISMARIEL MAFI CT INC VCBOO3112 Save Request as Draft Type of Request Member ID Provider ID Provider Alternate ID NPT for Authorization CONCURRENT cT003668136 CBHP002593 000058354 SeLect 8 Level of Service Type of Service Lewel of Care Type of Care Authorized User INPATIENT HLOC Mental Health Residential Treatment Center Residential Treatment Center Othe 10 IT Product Support Reston VA Revised 10 1 2015 CT BHP ProviderConnect MTPPR Residential Bed Tracking User Manual b Introduction Bed Match Referrals Introduction What is Covered in this Section Phase 2 Training Objectives This section focuses on Phase 1 Bed Match Referrals of the Residential and Group Home

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