Provider Training Portal

Once you have finished a training, please proceed to the next one. To navigate the training material, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

Enhanced Utilization Management Model

(This is a text version of the Training. Click Here for the print version)

Enhanced Utilization Management Model at ATA-FL

Why are we improving our model now?

  • We want providers to submit all visit encounters as required by state and federal agencies, so we are linking subsequent level payments to the submission of all visit encounters. This is already required/complied with by provider under a FFS model.
  • We want to reduce administrative burden for our provider network from multiple submissions of similar documentation to one submission per episode of care.
  • We want to remain compliant with AHCA requirements.
  • We want to introduce new evidence-based criteria in our UM process.

What is Changing?

  • NEW As we continue to improve our UM model, we have recently adopted use of standardized test scores in conjunction with Milliman Care Guidelines to authorize levels of service.
  • NEW Using the submitted diagnosis, the results of standardized test scores, Milliman Care Guidelines, and the clinical record, ATA-FL will authorize levels of service. In the authorization process we will provide you with “reasonable” or “expected” ranges in the number of visits that correspond to the payment level. The provider may proceed with more visits than the “reasonable” or “expected” number contained within our authorization letter; however, actual visits should align with the Plan of Care.
  • NEW The manner of payment under the new model is a pure case rate model. We will cease issuing an initial number of subsequent visits at a FFS rate. The evaluation will no longer be paid separately. The evaluation will fall under the first level assignment along with all of the other DOS as set forth in the plan of care in the first 60 days of the certification period.
  • The Management of therapy services at ATA-FL via a case rate model will not change. This means that levels are assigned and payment is based on those levels.
  • NEW Each of these levels will correspond to a range of visits.
  • After the evaluation, an authorization must be obtained from ATA-FL before treatment begins and you will not be paid for services prior to this date. You do not need to request authorization to complete the evaluation. However, remember that all services rendered , including an evaluation only, must have a certification number in order for the claims to process. The evaluation will no longer be paid separately.

Milliman Care Guidelines(MCG)

Upon receipt of the authorization request an ATA-FL clinician will review the request and issue a Level based upon the diagnosis, Standardized Test Scores, MCG and clinical record.

  • Nationally recognized and widely used clinical guidelines.
  • Provides observed ranges of visits based upon diagnosis
  • Eight of the ten largest U.S. health plans use Milliman Care Guidelines.
  • Improves healthcare effectiveness with evidence-based care guidelines.
  • MCG’s clinical editors analyze and classify peer-reviewed research in support of the guidelines.
  • Annually more that 140,000 references are reviewed.

Upon receipt of the authorization request an ATA-FL clinician will review the request and issue a Level based upon the diagnosis, Standardized Test Scores, MCG and clinical record.

  • Level 1 – Evaluation only/within normal limits
  • Level 2 – Mild impairment level
  • Level 3 – Moderate impairment level
  • Level 4 – Severe impairment level
  • Level 5 – Profound impairment level

Tertiary, Medically Complex patients are covered by the health plan. Our UM team will assist providers in referring any patients identified as such to the health plan for appropriate authorization and services.

Using test scores to assign levels Speech Therapy examples:

ATA-FL reviews the diagnosis, results of standardized test scores, MCG and clinical record, and assigns a level.

Requesting an Authorization: 4 Critical Elements

All treating providers MUST submit the following 4 Critical Elements with the authorization request. Providers may submit via the Provider Web Portal @ ataflorida.com/hs1portal or via fax to ATA-FL at 1-855-410-0121.

  1. Prescription or Referral Form
  2. A completed ATA-FL Intake Form (N/A to Providers using the Provider Web Portal) including 3 attestations
  3. POC with diagnosis signed/dated by the referring physician and/or Letter of Medical Necessity (LMN)
    • The Plan of Care must include the evaluation and the start and stop dates
    • The Plan of Care must include the Signature of the referring physician recorded on or after the recorded date of the treating therapist
    • The therapist that develops the POC must sign and date the document on the date it is completed. The therapist must sign and date the POC prior to the PCP’s signature and date. The PCP may sign and date the POC on the same date the therapist signs and dates the POC.
  4. Standardized Assessment Scores clearly denoted

CRITICALLY IMPORTANT: If any of the above elements are missing, ATA-FL will not approve the authorization request. Based on ATA-FL delegated responsibilities, the case will either be denied by ATA-FL or referred to the health plan with recommendation for denial.

Failure to provide all required documentation could result in the delay of treatment of your patient.Retrospective requests will not be authorized.

Plan of Care Documentation

  • ATA-FL will not accept ranges from providers when indicating the following in the Plan of Care: number of visits, the duration of the visit, or the duration of the treatment.
  • Acceptable examples
    • 2 visits per week
    • 30 mins per visit
    • 6 weeks of treatment
  • Unacceptable examples
    • 1 – 2 visits per week
    • 30 mins – 60 mins per visit
    • 4 – 6 weeks of treatment

Case Scenarios

When an ATA-FL clinician identifies a significant deviation in the Plan of Care from the range in number of visits according to the diagnosis, standardized test scores, Millman Clinical Guidelines and clinical record reviewed, the provider will be contacted.

Outcomes of Peer to Peer:

  • Approved - If after Peer to Peer, clinician agrees with Plan of Care, authorization is provided.
  • Provider agrees to withdraw current request and resubmit with documentation to support medical necessity.
  • Provider chooses NOT to withdraw the current request. Provider refuses to accept the level issued. Case is referred to the Medical Director. If the Medical Director is in agreement with the clinician, and based on ATA-FL delegated responsibilities, the case will either be denied by ATA-FL or referred to the health plan with recommendation for denial.

Request for an Upgrade of an Existing Authorization

  • ATA-FL will only issue authorizations for upgrades when a change in diagnosis or a change in test scores is submitted. (In rare clinical circumstances upgrades may be authorized without a change in either diagnosis or test scores.)
  • Upgrades will not be authorized retrospectively (after the treatment period).
  • The provider must submit the Upgrade request via fax to ATA-FL at 877-583-6440.
  • The Upgrade Request must include the following:
    • The completed ATA-FL Upgrade Request Form
    • New POC, signed/dated by the referring physician, in addition to the original Plan of Care.
    • Change in Standardized Test Scores or
    • Change in Medical Diagnosis
    • Documented patient progress in metrics/quantitative data

Review Process for an Upgrade Request

ATA-FL will submit the Upgrade request to a clinician (a licensed therapist in the same discipline) for review.

If Approved:

  • ATA-FL will modify the existing authorization to a higher level.
  • The provider will receive the authorization via facsimile with the Certification Number referencing the higher level.

If NOT Approved:

  • If medical necessity is not established based on the information received, a peer-to-peer consultation with a clinician is offered to the treating provider.
  • If after the peer-to-peer, a decision cannot be agreed upon, the request for an upgrade will be submitted to the Medical Director for review.

If the Medical Director is in agreement with the clinician, based on ATA-FL delegated responsibilities, the case will either be denied by ATA-FL or referred to the health plan with recommendation for denial.

How will we notify the treating provider of an authorization?

  • Via the Provider Web Portal at https://www.ataflorida.com/hs1portal
  • In addition, ATA-FL will fax the treating provider an authorization indicating the Level and the authorization period.
  • Expedited/Urgent Requests are completed within 24 hours for Medicaid members.
  • Authorization Requests Received without the 4 Critical Elements (Slide 7) will not be approved and will be referred to the health plan with recommendation for denial.

An expedited/urgent request is only warranted when applying the standard time (7 days) for making a determination could seriously jeopardize the enrollee’s health, life, or ability to regain maximum function.

Requesting a New Authorization After the Authorization Period Has Ended

If a member requires further therapy after the authorization period has expired, the provider may request another authorization, following the steps below:

  • Perform a re-evaluation of the patient to create a new POC with diagnosis signed/dated by the referring physician.
  • Request an authorization via the Provider Web Portal at https://www.ataflorida.com/hs1portal or via fax to ATA-FL at 1-855-410-0121 .
  • Submit the 4 Critical Elements as stated on Slide 7 including the re-evaluation and the following 5th item
  • Documented patient progress in metrics/quantitative data in the form of a progress Report, which demonstrates the patient’s progress to date. The Report must include comprehensive quantitative data regarding ALL goals targeted for the previous authorization period as established in the POC.

Requesting Authorizations for Multiple Therapy Disciplines

  • If a patient requires treatment for more than one type of therapy during the same treatment period, such as both Occupational and Speech Therapy, follow the steps outlined below:
    • Request two separate authorizations via the Provider Web Portal at https://www.ataflorida.com/hs1portal or via fax to ATA-FL at 1-855-410-0121.
    • All documentation requirements, including the 4 Critical Elements as outlined in Slide 7 must be included for both disciplines with each request.
    • All requests of this kind, for more than one therapy discipline, will be submitted to Clinicians for the review of medical necessity.
  • ATA-FL does not issue a separate episode level for symptoms or conditions associated with the main diagnosis. For example, for a therapy request for Status Post Total Knee Replacement, ATA-FL assigns a level according to date of surgery. Concurrent requests for pain, including back pain, gait, instability, muscle weakness, etc.; would be considered related to the main diagnosis, and ATA-FL will not issue a separate level.

Payment of Levels for Developmental Delay

Payment of Levels for Developmental Delay may result in a maximum of three (3) Level payments during the episode of care (180 days).

  • After receipt of the first claim encounter after issuance of the level by ATA-FL the first case rate will be paid to the rendering provider.
  • After receipt of the claims encounters during the initial sixty day period and after receipt of the first claim encounter following day 60 of the 180 day authorization period the second case rate will be paid. Payment of levels will be contingent upon the performance of services and receipt of encounters consistent with the Plan of Care.
  • After receipt of the claims encounters during the second sixty day period and after receipt of the first claim encounter following day 120 of the 180 day authorization period the third case rate will be paid. Payment of levels will be contingent upon the performance of services and receipt of encounters consistent with the Plan of Care.

Payment of Levels when Upgrade is Approved for Developmental Delay

  • If at any time during the 180 day treatment period the provider requests an Upgrade and ATA-FL increases the level assigned, the current level AND all subsequent levels will be paid at the higher level during the 180 day treatment period.
  • Upgrades may not be applied retrospectively (after the 180 day treatment period has ended).

Payment of Levels for Non-Developmental Delay

After receipt of the first claim encounter after issuance of the level by ATA-FL the case rate will be paid to the rendering provider.

Payment of Levels when Upgrade is Approved for Non-Developmental Delay

  • If ATA-FL approves an upgrade, the current level assigned will be increased.
  • The level increase will be paid after receipt of the next claim encounter within the 60 day treatment period.
  • Upgrades may not be applied retrospectively (after the 60 day treatment period has ended).

Provider Relations Territory Distribution

Rosanna Briggs
Provider Relations Representative
North Florida
T 386-898-1151
F 305-620-5973
BriggsR@healthnetworkone.com

Region 1: Escambia, Okaloosa, Santa Rosa, and Walton
Region 2 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington
Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union
Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia


Luis Martinez
Provider Relations Representative
South Florida
Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
Region 9: Palm Beach
Region 10:Broward
Region 11: Miami-Dade and Monroe


April Jung
Provider Relations Representative
Central Florida
T 954-955-0738
F 305-620-5973
Region 5: Pasco and Pinellas
Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk
Region 7: Brevard, Orange, Osceola, and Seminole
Region 9: Indian River, Martin, Okeechobee, and St. Lucie

Important ATA-FL Contact Numbers

Jessica Quintana
Network Director
T 305-614-0100 Ext 4202
F 305-614-0369
QuintanaJ@healthnetworkone.com

Note: After reviewing the training material, please select the next training or if you have completed all trainings, please proceed to check the attestation checkbox below and then press SUBMIT.

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

2018 Supplemental Fraud, Waste, and Abuse and Compliance Training

(This is a text version of the presentation. Click Here for the print version)

Overview

This supplemental training is intended to provide you with the methods for reporting Compliance, Ethics, and Fraud Waste and Abuse violations (suspected or confirmed). You can report these violations to ATA of Florida directly, the Federal Government, or to the affected Health Plan(s). The methods for reporting to ATA of Florida and the affected Health Plan(s) are contained in the remaining slides of this presentation.

ATA of Florida Contact Information

Fraud, Waste, and Abuse Hotline

866-321-5550 (Toll-Free)
You can also file an anonymous report, if you want.

MAIL your report to:

Marjorie Henderson
Special Investigative Unit
2001 S. Andrews Avenue
Fort Lauderdale, Florida 33316

FAX your report to:

Attention: Marjorie Henderson
(866)276-3667
This is a dedicated Compliance line

E-MAIL your report to:

SIU@healthsystemone.com

To review the training material below, place your mouse over the training material to enable the scrolling feature (if you are on a mobile device, touch the training material to enable the scrolling feature).

Abuse, Neglect, Exploitation and Human Trafficking Provider Training

(This is a text version of the Training. Click Here for the print version)

Agenda

Page 2
  • Introduction
  • Physical abuse
  • Signs and symptoms of physical abuse
  • Sexual abuse
  • Signs and symptoms of sexual abuse
  • Emotional/psychological abuse
  • Signs and symptoms of emotional/psychological abuse
  • Neglect
  • Signs and symptoms of neglect
  • Abandonment
  • Signs and symptoms of abandonment
  • Financial or material exploitation
  • Signs of financial or material exploitation
  • Reporting abuse
  • Human sex trafficking
  • Signs of adult sex trafficking
  • Signs of child sex trafficking
  • Human labor trafficking
  • Signs of human labor trafficking
  • Reporting human trafficking

Introduction

Page 3

As part of our new Statewide Medicaid Managed Care Managed Medical Assistance contract, all direct-service providers are required to complete abuse, neglect and exploitation training to identify victims in human trafficking.

You, as a health care professional, can make a difference in the lives of thousands of victims by understanding the different forms of abuse, neglect, exploitation and human trafficking amongst our communities.

This training will provide guidance on what signs and symptoms to look for when interacting with members and how to report any concerns or findings that will help provide potential victims the resources they need.

Physical abuse

Page 4

Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain or impairment.

Physical abuse may include but is not limited to such acts of violence as:

  • Striking (with or without an object)
  • Pushing
  • Slapping
  • Pinching
  • Shaking
  • Hitting
  • Shoving
  • Burning
  • Beating
  • Kicking

Inappropriate use of drugs and physical restraints, force-feeding and physical punishment of any kind also are examples of physical abuse.

Signs and symptoms of physical abuse

Page 5

Signs and symptoms of physical abuse include but are not limited to:

  • Bruises
  • Cuts
  • Signs of being restrained
  • Rope marks
  • Sprains
  • Skull fractures
  • Open wounds
  • Physical signs of being subjected to punishment
  • Lacerations
  • Open wounds
  • Sudden changes in behavior
  • Internal injuries/bleeding
  • Broken eyeglasses/frames
  • Welts
  • Untreated injuries in various stages of healing
  • Report of being hit, slapped, kicked or mistreated
  • Broken bones
  • The caregiver’s refusal to allow visitors to potential victim
  • Black eyes
  • Punctures
  • Laboratory findings of medication overdose or under utilization of prescribed drugs
  • Bone fractures
  • Dislocations

Sexual abuse

Page 6

Sexual abuse is defined as nonconsensual sexual contact of any kind. Sexual contact with any person incapable of giving consent is also considered sexual abuse.

It includes but is not limited to unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity and sexually explicit photographing.

Signs and symptoms of sexual abuse

Page 7

Signs and symptoms of sexual abuse include but are not limited to:

  • Bruises around the breasts or genital areas
  • Unexplained venereal disease or genital infections
  • Unexplained vaginal or anal bleeding
  • Torn, stained or bloody underclothing
  • A report of being sexually assaulted or raped

Emotional/psychological abuse

Page 8

Emotional or psychological abuse is defined as the infliction of anguish, pain or distress through verbal or nonverbal acts.

Emotional/psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation and harassment.

In addition, isolating a person from his/her family, friends or regular activities; giving a person the silent treatment; and enforced social isolation are examples of emotional/psychological abuse.

Signs and symptoms of emotional/psychological abuse

Page 9

Signs and symptoms of emotional/psychological abuse include but are not limited to:

  • Being emotionally upset or agitated
  • Being extremely withdrawn and noncommunicative or nonresponsive
  • Unusual behavior usually attributed to dementia (for example, sucking, biting, rocking)
  • A report of being verbally or emotionally mistreated

Neglect

Page 10

Neglect is defined as the refusal or failure to fulfill any part of a person's obligations or duties. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for a person (for example, pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care.

Neglect typically means the refusal or failure to provide a person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to a person.

Signs and symptoms of neglect

Page 11

Signs and symptoms of neglect include but are not limited to:

  • Dehydration, malnutrition, untreated bed sores and poor personal hygiene
  • Unattended or untreated health problems
  • Hazardous or unsafe living conditions/arrangements (for example, improper wiring, no heat or no running water)
  • Unsanitary and unclean living conditions (for example, dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing)
  • A person’s report of being mistreated

Abandonment

Page 12

Abandonment is defined as the desertion of a person by an individual who has assumed responsibility for providing care or has custody.

Signs and symptoms of abandonment

Page 13

Signs and symptoms of abandonment include but are not limited to:

  • The desertion of a person in a hospital, nursing facility or other similar institution
  • The desertion of a person at a shopping center or other public location
  • Report of being abandoned

Financial or material exploitation

Page 14

Financial or material exploitation is defined as the illegal or improper use of a person’s funds, property or assets.

Examples include but are not limited to:

  • Cashing a person’s benefit check without authorization.
  • Forging a person’s signature.
  • Misusing or stealing a person’s money or possessions.
  • Deceiving a person into signing any document (for example, contracts or will).
  • Improper use of guardianship or power of attorney.

Signs of financial or material exploitation

Page 15

Signs and symptoms of financial or material exploitation include but are not limited to:

  • Sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the victim
  • The inclusion of additional names on a person’s bank signature card
  • Unauthorized ATM card withdrawals
  • Abrupt changes in a will or other financial documents
  • Unexplained disappearance of funds or valuable possessions
  • Forged signature for financial transactions or for the titles of his/her possessions
  • Sudden appearance of previously uninvolved relatives claiming their rights to a person’s affairs and possessions
  • Unexplained sudden transfer of assets to a family member or someone outside the family
  • The provisions of services that are not necessary
  • A person’s report of financial exploitation

Please report abuse

Page 16

There are four ways to make a report:

Telephone
1-800-96ABUSE (22873)

Fax
1-800-914-0004

Florida Relay
711

TTY
1-800-955-8771

Web reporting
https://reportabuse.dcf.state.fl.us

Human sex trafficking

Page 17

Human sex trafficking: The recruitment, harboring, transportation, provision or obtaining of a person for a commercial sex act in which a commercial sex act is induced by force, fraud or coercion, or in which the person induced to perform such an act has not attained 18 years of age.

Signs of adult sex trafficking

Page 18

Physical signs

  • Multiple or recurrent STIs
  • Abnormally high number of sexual partners
  • Trauma to vagina and/or rectum
  • Impacted tampon in vagina
  • Signs of physical trauma
  • Somatization symptoms (recurring headaches, abdominal pain, etc.)
  • Suspicious tattoos or branding

Behavioral signs

  • Depressed mood/flat affect
  • Anxiety/hypervigilance/panic attacks
  • Affect dysregulation/irritability
  • Frequent emergency care visits
  • Unexplained/conflicting stories
  • Using language from “the life”
  • Signs of drug or alcohol abuse

Signs of child sex trafficking

Page 19

Physical signs

  • Pregnancy at young age
  • Evidence of abortions at young age
  • Early sexual initiation
  • Trauma to vagina and/or rectum
  • Symptoms of STIs and/or UTIs
  • Abnormal number of sexual partners for young age
  • Suspicious tattoos or branding

Behavioral signs

  • History of running away from home
  • or foster care placements
  • Truancy/stops attending school
  • Highly sexualized behavior or dress
  • Angry/aggressive with staff
  • Depressed mood/flat affect
  • Signs of drug or alcohol abuse

Human labor trafficking

Page 20

Labor trafficking: The recruitment, harboring, transportation, provision or obtaining of a person for labor or services through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery.

Signs of human labor trafficking

Page 21

Physical signs

  • Musculoskeletal and ergonomic injuries
  • Malnutrition/dehydration
  • Lack of routine screening and preventive care
  • Poor dental hygiene
  • Untreated skin infections/inflammations
  • Injuries or illness from exposure to harmful chemicals/unsafe water
  • Ophthalmology issues or vision complaints
  • Somatization

Behavioral signs

  • Anxiety/panic attacks (for example, shortness of breath, chest pain)
  • Unexplained/conflicting stories
  • Overly vigilant or paranoid behavior
  • Inability/aversion to make decisions independent of employer
  • Inability/aversion to speak with out an interpreter
  • Affect dysregulation/irritability

Reporting human trafficking

Page 22

Patient presents at clinic with one or more trafficking indicators

Primary health and safety needs are met

  • Mandated reporting warranted or the patient wishes to report
  • Report to designated contacts and/or contact the NHTRC Hotline (1-888-373-7888)

Primary health and safety needs are met

  • Reporting not warranted and the patient does not wish to report
  • Provide referrals and contact the NHTRC Hotline (1-888-373-7888)

References and resources

Page 23
  • http://www.ncoa.org/public-policy-action/elder-justice/faqs-on-elder- abuse.html
  • http://www.dcf.state.fl.us/programs/abuse/howtoreport.shtml
  • http://www.iue.edu/area9/Elder-Abuse-Fact-Sheet.pdf
  • http://www.helpguide.org/mental/elder_abuse_physical_emotional_sexual_neglect.htm
  • http://elderaffairs.state.fl.us/doea/docs/APS_Training_for_Professionals_2 013.pdf
  • http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx
  • http://www.napsa-now.org/policy-advocacy/eja-implementation/
  • http://gerontology.usc.edu/news-resources/news/what-is-the-elder- justice-act/
  • https://humantraffickinghotline.org/resources/recognizing-and- responding-human-trafficking-healthcare-context

Provider attestation

Page 24

  • Provider attestation is required.
  • Please print the next slide of this presentation attesting that you have
  • reviewed this presentation and have an understanding of the content.
  • Don’t forget your attestation on the next page.

Abuse, Neglect, Exploitation and Human Trafficking Provider Training Attestation

Page 25

As the below provider, I attest that my practice has reviewed the Abuse, Neglect, Exploitation and Human Trafficking presentation.

I understand:

This presentation and attestation are yearly requirements.

  • Provider name
  • ID#
  • Address
  • Phone
  • Fax
  • Signature
  • Date

Please sign and fax to [PR fax number].

Thank you

Page 26

www.simplyhealthcareplans.com/provider

www.clearhealthalliance.com/provider

Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract.

SFLPEC-0738-19 February 2019

?

Technical difficulties?

If you are experiencing any technical difficulties submitting your training, please contact our technical support team at: websupport@healthsystemone.com