Providers
These providers have contractually agreed to see members within 5 business days of a requested appointment - a crucial benefit for members.
What is Express Access Providers?
Clinical criteria used to make medical necessity determinations for substance-related disorder benefits.
What is ASAM?
For calls marked urgent or emergent, after completing the Appointment Offered Note, this note needs to then be completed.
What is an Outreach Note?
This virtual platform provides counseling and psychiatry to members by connecting members with licensed professionals, making BH care convenient and accessible. Members can send unlimited text, audio, and video messages to their dedicated therapist anywhere, at any time.
What is TalkSpace?
Non-emergent sub-acute inpatient or outpatient services received from an OON provider outside of the member's state of residence, bordering/adjacent state, or the state where the dependent attends school.
What is OON/OOA exclusion?
In Linx, a red "N" indicates a provider or facility is this type and may result in a denial.
What is Unavailable or Unable to Authorize?
Nurses visit a Medicare member in their home and assess their health, including their MH. If the nurse feels that the member would benefit from further assessment or endorses SI, the nurse will refer to our team.
What is the HouseCalls program?
Care Advocates complete this process when there is a discrepancy or question about a member's eligibiliy or benefits.
What is SURF?
A medication in the form of a nasal spray that is used to treat Treatment Resistant Depression.
What is Spravato?
What is Extended Individual sessions (90837)?
Out-of-Network providers are not contracted with Optum and therefore can and often do charge members more than what they may be reimbursed for. This is known as ____.
What is balance billing?
Optum service provided to members who need assistance finding an INN provider with availability.
This process involves the Care Advocate completing a red note in the front of mbr's chart, and if HLOC, completing a FBI Care Advocate Note.
What is OON permission call?
A completed suicide, serious suicide attempt, unexpected death, serious injury, or serious assault of a member while receiving behavioral health care is considered this.
What is a sentinel event?
Care Advocates use this system to research member eligibility with DSNP plans and other payor contact.
What is DMEVS?
When in-network providers who decide to leave the network and become OON, the member who is in continuous, active treatment with this provider, may request this.
What is Continuity of Care authorization (TOC)?
Connects members to a Mobile Crisis Team who are trained to provide a compassionate response at the right level of care for members' needs during moments of crisis.
What is the Crisis Support Tool?
A federal mandate effective on 1/1/22 requires we initiate a Dismissal Letter for a member with this type of plan who calls in to withdraw/rescind a request prior to a decision being made.
What is Medicare?
Allows a designated person to perform any action that a member would perform.
What is an Appointment of Representative form?
Optum has authorized coverage for the virtual modality of care for routine outpatient BH and EAP services since 2013 and will continue to allow this modality of care as part of our standard care offering for certain services.
What is telehealth?
The state of TX has created a new mandate that INN providers who meet certain criteria do not need authorization and no authorization is allowed to be entered for these providers.
What is the Texas Gold Card Mandate?
Organized under Optum Behavioral Health Operations, this team works to connect members with outpatient services and resources, help to coordinate care between facility-based care and OP care, develop member-centric plans of care, provide coaching, mentoring and education to members about BH conditions and how to be more involved in self-care and monitoring strategies.
What is Behavioral Health Care Coordination Advocacy (case management).
When determining the Turn-Around-Time (TAT) for a member request, Care Advocates use this tool.
What is DARE?
Sublocade, Methadone, Campral, and Vivitrol are just a few examples of this.
What is MAT?
A determination made for a type of service that is specifically excluded in a member's benefit plan.
What is admin ABD/denial?