PROVIDER HANDBOOK
2022
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
2
Table of Contents
I. INTRODUCTION ........................................................................................................................................................... 5
Mission ........................................................................................................................................................................... 5
Company History .......................................................................................................................................................... 5
Accreditations ................................................................................................................................................................ 6
II. ACCESS BEHAVIORAL HEALTH STAFF/TITLES/CONTACT INFORMATION ............................................... 7
III. ACCESS STANDARDS ............................................................................................................................................. 7
IV. ABH COMMUNICATIONS ........................................................................................................................................ 8
Toll-free information Line ............................................................................................................................................. 8
Fax .................................................................................................................................................................................. 8
Email ............................................................................................................................................................................... 8
Non-English Speaking Members ................................................................................................................................ 8
Hearing Impaired .......................................................................................................................................................... 8
V. NETWORK MANAGEMENT ...................................................................................................................................... 9
Provider Network .......................................................................................................................................................... 9
Provider Quality Enhancement Program .................................................................................................................. 9
Availability and Accessibility Standards .................................................................................................................. 10
Provider Training ........................................................................................................................................................ 10
VI. CREDENTIALING AND RECREDENTIALNG ..................................................................................................... 11
Medical Records Standards ...................................................................................................................................... 12
Provider and Practitioner Rights ................................................................................................................................... 12
VII. QUALITY MANAGEMENT ..................................................................................................................................... 12
Program Structure ...................................................................................................................................................... 13
Oversight of QI Activities by the Quality Management Committee ..................................................................... 15
Subcommittees of QMC ............................................................................................................................................. 16
QMC Roles .................................................................................................................................................................. 17
Continuity and Coordination of Care ....................................................................................................................... 18
Cultural Competence ................................................................................................................................................. 18
Member Safety ............................................................................................................................................................ 19
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
3
Member Complaints, Grievances, and Appeals .................................................................................................... 19
ABH Privacy and Security of Information ................................................................................................................ 20
Guiding Principles of Information Security and Privacy .................................................................................... 20
Principles Specific to Information in Electronic Form ........................................................................................ 21
Principles Specific to Information in Paper Form ............................................................................................... 21
When You Believe There May Be a Problem ..................................................................................................... 22
Members’ Rights and Responsibilities .................................................................................................................... 22
Identifying and Reporting Abuse, Neglect and Exploitation of Members ........................................................... 23
Fraud, Waste and Abuse Prevention ....................................................................................................................... 23
VIII. TELEMEDICINE/TELEHEALTH .......................................................................................................................... 25
UTILIZATION MANAGEMENT ..................................................................................................................................... 26
Scope and Goals ........................................................................................................................................................ 26
Principles ...................................................................................................................................................................... 26
Staff Qualifications ...................................................................................................................................................... 28
UM Staff Responsibilities ........................................................................................................................................... 28
Conflicts of Interest ..................................................................................................................................................... 29
Access to UM Services .............................................................................................................................................. 30
Clinical Criteria ............................................................................................................................................................ 30
Medical Necessity ....................................................................................................................................................... 31
Authorization and Notification for Behavioral Health Services ............................................................................ 31
In-network non-emergent outpatient services .................................................................................................... 31
Out-of-network non-emergent outpatient services ............................................................................................ 32
Submitting Authorization Requests for Inpatient Psychiatric Hospitalization .................................................... 32
Information needed when requesting preauthorization .................................................................................... 32
Additional information............................................................................................................................................. 32
Questions ................................................................................................................................................................. 32
Peer Clinical Review .................................................................................................................................................. 33
Determination of No Medical Necessity .................................................................................................................. 33
Peer-to-Peer Conversation ....................................................................................................................................... 34
Appeal Process ........................................................................................................................................................... 35
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
4
Practitioner Satisfaction with Access Behavioral Health UM Processes ........................................................... 35
IX. CLAIMS ...................................................................................................................................................................... 36
Claims Processing ...................................................................................................................................................... 36
Claims Submission ..................................................................................................................................................... 36
Paper Claims ............................................................................................................................................................... 36
Electronic Claims ........................................................................................................................................................ 36
Clean Claims ............................................................................................................................................................... 36
Covered Diagnosis Codes ......................................................................................................................................... 36
Authorization Numbers .............................................................................................................................................. 37
Claims Payment .......................................................................................................................................................... 37
Claims Remittance ..................................................................................................................................................... 37
Medicaid Benefit Limits .............................................................................................................................................. 37
Member Responsibility............................................................................................................................................... 37
Disaster Planning ........................................................................................................................................................ 37
Claims Questions ........................................................................................................................................................ 38
Corrected Claims ........................................................................................................................................................ 38
Provider Complaints ................................................................................................................................................... 38
Provider Claims Related Complaints ................................................................................................................... 38
Provider Non-Claim Related Complaints ............................................................................................................ 38
Provider Change Notifications .................................................................................................................................. 39
X. PROVIDER CONTRACTS ....................................................................................................................................... 39
XI. Appendix 1: Humana Medical Plan ........................................................................................................................ 40
XII. Appendix 2: Lighthouse Health Plan ................................................................... Error! Bookmark not defined.
XIII. Appendix 3: Wellcare (Staywell Health Plan of Florida) ................................................................................... 41
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
5
I. INTRODUCTION
Mission
“Helping people throughout life’s journey by connecting them to hope and recovery”
Access Behavioral Health (ABH) is an operating division of Lakeview Center, which is a 501 (c) (3) not-for-
profit organization, incorporated Chapter 617, F.S. Lakeview Center, Inc. is an affiliate of Baptist Health
Care Corporation, which is also a 501(c) (3) not-for-profit organization, incorporated Chapter 617, F.S. As
not-for-profit organizations, neither Lakeview Center nor Baptist Healthcare have shareholders who benefit
financially from the performance of the organization. Rather, both organizations are ‘owned’ by the
community and any financial gains are retained by the organization and reinvested into furthering the
mission of helping people overcome life’s challenges.
Company History
Lakeview Center, Inc., (Lakeview Center) the corporate entity of which Access Behavioral Health is a
division, was initially established in 1954 as the Escambia County Child Guidance Clinic, the result of the
vision and effort of many community leaders and the Pensacola Junior Women's Club. In 1959, the Clinic’s
charter was amended to include services for adults, and the center was renamed the Escambia County
Guidance Clinic. In 1963, with the passing of the federal Mental Retardation Facility/Community Mental
Health Center Construction Act, the Clinic became one of the first comprehensive community mental health
centers (CMHCs) in southeastern United States, and was renamed the Community Mental Health Center of
Escambia County, Inc.
In the 1970’s and 1980’s the Center expanded its service offerings to include crisis stabilization, residential,
day treatment, emergency services, outpatient, case management, and prevention services and began
offering a full range of substance abuse services, as well as vocational services. In 1982, the center was
renamed as Lakeview Center, Inc., a change made in recognition of the wide array of services that Lakeview
was providing. In 1996, Lakeview Center and Baptist Health Care Corporation (also a 501(c) (3) organization
that operates numerous healthcare facilities in northwest Florida) entered into an affiliation agreement.
During the 1990s, Lakeview Center operated numerous at-risk managed care behavioral health contracts for
commercial health insurers. As a result, Lakeview Center was able to significantly expand its managed care
administrative services including utilization management services, provider credentialing, network
management, claims adjudication, and quality management and improvement services. This experience set
the foundation for future growth in the managed behavioral healthcare arena, culminating in being awarded a
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
6
Prepaid Limited Health Service Organization license (PLHSO) in February 2001 by the State of Florida
Department of Insurance.
Access Behavioral Health (ABH), a separate division of Lakeview Center, was established in February 2001
to manage the Region 1 PMHP contract. Lakeview Center organized ABH to manage risk-bearing contracts
and in August 2001, was awarded a contract with AHCA to operate the PMHP in Region 1. ABH’s
organizational, governance, and administrative structure ensures that there is no conflict of interest between
Lakeview Center, which serves as one of the many contracted provider agencies, and ABH, which manages
the contract.
ABH has managed the contract with integrity and efficiency since it began operations on November 1, 2001
and this has been recognized by AHCA by having the contract renewed in October 2004 and in October
2007 as well as yearly renewals.
In 2014, Access Behavioral Health contracted with Statewide Medicaid Managed Care (SMMC) health plans
in Region 1 to serve as the Managed Behavioral Health Organization for Florida Medicaid members enrolled
in the plans. In 2019, ABH expanded its health plan contracts to Florida’s Region 2.
Statewide Medicaid Managed Care (SMMC) is the program where most Florida Medicaid recipients receive
their Medicaid services. Florida Medicaid is the state and Federal partnership that provides health coverage
for selected categories of people in Florida with low incomes. Its purpose is to improve the health of people
who might otherwise go without medical care for themselves and their children.
Accreditations
Access Behavioral Health has maintained full accreditation status under the Health Utilization Management
(HUM) module with URAC from 2005 – 2017.
In 2017, ABH attained full accreditation status as a Managed Behavioral Healthcare Organization (MBHO)
with the National Committee for Quality Assurance (NCQA). In 2020, ABH was re-accredited by NCQA for
an additional three years and will undergo the reaccreditation survey in late 2022.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
7
II. ACCESS BEHAVIORAL HEALTH CONTACT INFORMATION
Access Behavioral Health may be contacted through our toll-free phone number, (866) 477-6725, or through
our general email address: [email protected]. Contact information for Access Behavioral Health staff is
available on our website, www.abhfl.org.
III. ACCESS STANDARDS
Emergency mental health services are defined as those services that are required to meet the needs of an
individual who is experiencing an acute crisis, resulting from mental illness, which is at the level of severity
that would meet the requirements for involuntary hospitalization pursuant to Chapter 394.463, F.S., and
who, in the absence of a suitable alternative or psychiatric medication, would require hospitalization.
Members with emergencies have access to behavioral healthcare immediately and/or 24 hours per day 7
days per week.
Urgent appointments:
Life threatening emergency: Seen immediately
Non-life threatening emergency: Seen within 6 hours of the request
Within 48 hours of the request (if no prior authorization is required); seen within 96 hours (if prior
authorization is required)
Non-Urgent Appointments:
Within fourteen days of the request for initial outpatient behavioral health treatment
Within 7 (seven) days post discharge from an inpatient behavioral health admission for follow up
behavioral health treatment
Within 60 days of the request for a prescriber.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
8
IV. ABH COMMUNICATIONS
Toll-free information Line
Access Behavioral Health operates a toll-free information line for members and providers through the ABH
Call Center. This information line is available 24 hours per day, 7 days per week and is staffed by
experienced, qualified member services representatives and backed up by the ABH Care Management
team. Representatives assist members with finding a network provider and scheduling appointments, and
assist providers with eligibility and benefit inquiries.
Fax
ABH operates a fax line for sending and receiving communication: (850) 595-0258
Email
ABH receives communication via email using the address: [email protected]. This email address is a
group email delivered to several ABH staff.
Non-English Speaking Members
A telephonic translation service is available for non-English speaking members through Language Line
Solutions, a telecommunications company equipped to interpret over 175 different languages. Language
Line Solutions interpreters are medically certified.
Hearing Impaired
ABH offers interpreter services for the deaf, hard of hearing, or speech-impaired members when needed at
no charge to the member. Telephone services for the hearing impaired are provided through the Florida
Relay Center and include both TTY ASCII and TTY Baudot phone numbers.
In addition, our Community Behavioral Health Providers operate TTY lines in their emergency services
departments, 24 hours/day, and seven days per week. These centers also have staff “language banks”
where staff may turn for help when a member who does not speak English presents for services.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
9
V. NETWORK MANAGEMENT
Provider Network
The diversity and breadth of our network ensures that members have the flexibility to choose a provider that
meets their behavioral health, social, and cultural needs. Our focus on evidence based practice, recovery and
resiliency approach, and member rights ensures that members actively participate in the treatment process
and contribute to the treatment plan and their short and long term treatment goals. Over the past two
decades, we have expanded and further refined this network to provide members with a variety of needed
services, ranging from basic inpatient and outpatient services, including infant mental health services, to
psycho-educational groups and aftercare services. We have invested resources to provide optimal care while
also giving members broader discretion in how treatment decisions are made. The treatment process requires
that members be involved in making treatment decisions and ABH provides training on this important concept
to providers and reviews for this type of inclusion as part of our quality management activities. Our wide range
of services coupled with our focus on member empowerment and recovery and resiliency has allowed us to
transform the system of care and provider network in Regions 1 and 2 from one focused on alleviating and
reducing symptoms to one that focuses on increasing a member’s ability to overcome life’s challenges by
being an active participant in their treatment and self-management process.
Provider Quality Enhancement Program – The Medicaid Community Behavioral Health
Home
ABH contracts with the large community behavioral health systems in the region on a capitated basis. Each
of these behavioral health systems, called Regional Care Centers (RCCs) serves as a Medicaid Community
Behavioral Health Home. Under the capitated financial system, ABH and a participating Community
Behavioral Health Home enters into a contract to provide the full range of Medicaid benefits to members in
the RCC’s capitated geographic area. Community Behavioral Health Homes receive a per-member-per-
month payment for all of the required Medicaid services and they bear the financial risk for their patients for
the specified services. The capitation rate reflects the behavioral health services required by Florida Medicaid
and provides incentive for a fully integrated, outcomes based delivery of Medicaid services. This approach
incentivizes investments in care coordination, quality improvement efforts, and efficiency across the full
continuum of care, including coordination of care with hospitals, and multi-specialty provider groups. The
value-based model establishes a reimbursement system designed to manage the needs of Medicaid
members who have persistent complex behavioral health conditions. ABH requires by contract that the
Medicaid Community Behavioral Health Home be accountable for the full range of behavioral health services
based on clinical outcome oriented services, rather than simply on utilization of services.
Overall, this capitation model payment methodology offers the following:
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
10
• Alignment of incentives;
• Flexibility for providing behavioral health services;
• Improved quality of and access to behavioral health care services for members; and
Controls costs
With value-based contracts, ABH demonstrates that it has the capacity to serve the expected enrollment in its
service Regions in accordance with the State's standards for access to care and quality performance
outcomes. ABH maintains a network of providers, with Community Behavioral Health Homes as the
cornerstones, that is sufficient in number, specialty mix, and geographic distribution to meet the needs of the
anticipated number of members in the service area.
Availability and Accessibility Standards
Access Behavioral Health conducts network analyses on an ongoing basis. Availability standards are
analyzed throughout the year utilizing a variety of means to include monitoring of member satisfaction
surveys and complaints.
In addition, a network analysis is conducted prior making any new credentialing recommendations, to
determine if there is a need in the network. Geospatial availability is also calculated periodically to assure that
members have access to care within the required timeframes. Additions to the network may include new
specialties, location, language(s) spoken, and cultural/ethnic background. Geospatial access standards are
reviewed to assure that members are able to access services in the required typical travel times.
ABH Network
The ABH network is reviewed on an ongoing basis to assure the network meets the health plans’
requirements of the MMA programs and meets and provides members a choice of qualified behavioral health
care providers.
Provider Training
The ABH Quality Department conducts training with providers and practitioners bi-annually. As a Behavioral
Health network provider, organizational providers, individual providers, and individual members of provider
groups must regularly participate in trainings offered by ABH. The Provider Handbook is made accessible to
all newly credentialed providers via the ABH website.
Annual Provider Training may include, but is not limited to, the following topics:
ABH Operational Updates
Quality Management and Improvement
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
11
Medicaid Documentation and Medical Records Requirements
HEDIS, Clinical Improvement Activities, and other Contract Performance Measures
Member Experience and Satisfaction
Authorizations and Claims Payment
Critical Incident Reporting
Member and Provider Complaints
Eligibility
Benefit Plan Limitations
Timely Access to Services
Coordination of Care of BH and BH Services
Coordination of Care of BH and Medical Services
Cultural Competence
Health, Safety, and Welfare Education
Fraud, Waste and Abuse/Corporate Compliance
VI. CREDENTIALING AND RECREDENTIALNG
The ABH credentialing process ensures that providers of behavioral health services meet minimum standards
of practice and are capable of meeting the quality of care required by Access Behavioral Health. The
credentialing process ensures adequate member choice, adequate capacity within the ABH network, timely
access to services, and prevents discrimination in the ABH provider Network. To participate as a Behavioral
Health network provider, organizational providers, individual providers, and individual members of provider
groups must meet established criteria as set forth by ABH and outlined in the policies and procedures, and
successfully complete the credentialing review process. ABH requires that all applicants meet all state
standards and requirements regarding background screenings. ABH will not credential any individual or
organization that is excluded from participation in Federal health care programs.
Practitioners must post their liability insurance in a prominent location that is visible to members. Providers
must post the AHCA Consumer Help Line number (888-419-3456) in a prominent location in the waiting
areas.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
12
Medical Records Standards
All providers and practitioners are required to understand and adhere to the medical documentation
standards set forth by the most current version of the Agency for Healthcare Administration (AHCA)’s
Community Behavioral Health Services Coverage and Limitations Handbook the Provider General Handbook
(July 2012), and any other relevant AHCA handbook that governs service delivery and medical necessity.
Providers are also required to participate in medical record audits to ensure documentation follows Medicaid
guidelines, that documentation matches services billed, and to monitor for fraud, waste, and/or abuse.
Provider and Practitioner Rights
If a provider or practitioner chooses to appeal a credentialing decision the following steps are to be taken:
All appeal requests must be in writing within 30 days of the adverse decision;
The request should include a detailed explanation of the reasons for reconsideration and provide new,
supporting documentation;
The ABH Director of Quality Management and Improvement will review the appeal and make a
recommendation to the Quality Management Committee’s appropriate subcommittee (i.e. Quality,
Credentialing, etc.)
If the ensuing decision is again adverse, the individual may request in writing, a review of the decision by
the Lakeview Center CFO. The Lakeview Center CFO will review the documentation and render a final
decision which shall be binding. The Director of Quality Management and Improvement will send written
notification, containing specific reasons for the outcome, of the appeal decision within 30 days. If the
provider or practitioner chooses to utilize the appeals process, that individual or organization may be
represented by an attorney, or another person of their choosing.
VII. QUALITY MANAGEMENT
The Quality Improvement Program at Access Behavioral Health provides a formal mechanism whereby ABH
can systematically and objectively monitor, evaluate, improve, and impact the quality, efficiency, safety, and
effectiveness of care to our members. Through this process ABH is able to identify and focus on opportunities
for improving the quality of clinical service delivery by our network of providers. The Quality Improvement
program approach enables ABH to focus on opportunities for improving clinical care to our members, service
quality, member safety, and customer satisfaction. The Quality Improvement plan helps ensure accountability
of staff and network providers for the quality of care and services provided to ABH members.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
13
Access Behavioral Health maintains a network of contracted behavioral healthcare providers. The Quality
Improvement Department governs the quality assessment and improvement activities of network providers
and spans the system to any function that impacts the quality of service delivered to our members. The ABH
QI Department accomplishes this governance via internal and external monitoring of care management,
utilization management, the development and maintenance of a provider network, member safety, and
monitoring of clinical services to ensure that all members receive the highest quality care and service.
Program Structure
The Quality Improvement Program provides a means whereby all functions of ABH, both clinical and non-
clinical, can be tracked, trended, and reviewed by the oversight body, opportunities for improvement
identified, and interventions to address those opportunities applied.
The Quality Improvement program is designed to monitor, evaluate, and continually improve the care and
services to all ABH consumers and encompasses services delivered in both outpatient and inpatient settings.
ABH integrates quality improvement into all functional areas. Participation in the QI program is required of all
contracted network providers. All staff, network providers, and members are asked to participate in the quality
management process through satisfaction surveys, committee meetings, and corrective action plans which
are implemented as part of the overall quality plan whenever barriers and opportunities for improvement are
identified.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
14
The primary goals of the Quality Management program are to ensure safe, quality, timely, and effective
behavioral health services to our Members. Improvements in these areas are measured using Health Plan
Effectiveness Data Information Set (HEDIS) information, internal quality studies, and other health outcomes
data and utilized to improve Member Experience and System Effectiveness.
The major responsibilities of the four components of the ABH QI Program are:
1. Quality Management and Improvement (QMI)
Provider and practitioner monitoring/medical records audits
Member Safety
Member Satisfaction
Member and Provider Complaints Resolution
HEDIS and Performance Measures
Monthly, Quarterly, and Annual Quality Reports, and annual Committee Approval
Credentialing and Re-Credentialing
Quality of Care and Incident Reporting,
Fraud, Waste, and Abuse monitoring,
Self-Management Tools,
Screening Programs,
Access to services, and
Facilitation of Quality Management Committee Meetings Quarterly.
2. Utilization Management (UM)
UM Authorizations and utilization review
Short-term Case management for inpatient and SIPP services
Care Coordination
Provider Satisfaction with the UM process
Call Center Communication and
Daily, Monthly, Quarterly, and Annual UM Reports
3. Network Management
Manage network provider negotiations and contracting
Provider network analysis that meets health plan requirements
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
15
Provider network performance management in conjunction with ABH Quality Management
Department and health plan and
Ensure Culturally, Ethnically, Racially, and Linguistically Competent Network
4. Data Analysis and Reporting
HEDIS and Performance Measure Analysis
GAP Reports for Underperforming Providers
Population Assessments
Intervention Analysis and Re-Measurement
Oversight of QI Activities by the Quality Management Committee
The Quality Management Committee (QMC) is the governing body of the ABH QI Program and is responsible
for oversight of the Quality Improvement program, along with its subcommittees. The QMC is responsible for
ensuring the quality improvement processes outlined in the QI Program Description are implemented
measured, re-measured, reviewed on a regular basis, and updated as needed. The QMC also serves as an
advisory group and communication forum for all ABH Quality Improvement components.
The QMC is the decision making body ultimately responsible for implementation, coordination, and integration
of all QI activities for ABH. The QMC reviews and approves all ABH Policies and Procedures, Program
Descriptions, Work Plans, and the Annual Evaluation. The QMC is also the designated anti-fraud unit for
Access Behavioral Health’s Anti-Fraud Plan.
The Quality Management Committee meets quarterly and Ad hoc meetings may be called when necessary.
The Director of Quality Management and Improvement is responsible for conducting the meeting.
The QMC is comprised of ABH Directors and Managers who work together to achieve program goals and
objectives. The QMC’s focus is on key quality outcome areas designed to improve overall system
effectiveness of service delivery to ABH members. Although each component and subcommittee operates to
achieve specific objectives and processes that are operationalized through the ABH QI Program, all
components operate as a whole to create the ABH Quality Program.
Quality Management Committee Members include:
Medical Director (designated Behavioral Health Care Practitioner)
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
16
Director of Access Behavioral Health
Director of Quality Management & Improvement
Accreditation and Quality Improvement Manager
Director of Care Management
Director of Network Management and Contracting
The authority to implement the ABH Quality Improvement Program plan is held by the QMC. The ABH
Medical Director is the designated behavioral health staff member and senior member staff designated to
oversee all components of the QI plan. The QMC is assigned oversight responsibilities to all ABH quality
improvement efforts.
Quarterly reports, pertinent reports, data analysis, and recommendations or actions are presented to the
QMC for consideration. This process allows ABH to routinely monitor the activities and effectiveness of the
Quality Improvement program. This monitoring includes, but is not limited to:
Reviewing data and reports to identify trends that may require corrective action
Ensuring practitioner participation in the QI process
Analyzing and evaluating the results of QI activities
Monitoring the implementation and effectiveness of corrective actions
Identifying needed actions
Determining the need for follow up and/or ad hoc committees
Reporting conclusions and actions as appropriate to meet the goals of ABH QI.
Subcommittees of QMC:
Quality Improvement-Utilization Management (QI-UM)
Credentialing
Member Rights, Responsibilities, and Safety
Quality
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
17
QMC Roles
The QMC consists of the following voting members:
The Director of Access Behavioral Health is responsible for the overall operations of Access Behavioral
Health. The Director of Access Behavioral Health ensures that the ABH network has the capacity and
capability of meeting the behavioral healthcare needs of members.
The ABH Medical Director is the designated Behavioral Health Care Practitioner who provides supervision
and oversight to the Quality Improvement program, the Quality Management Committee, and all
subcommittees. The Medical Director reports to the Director of Access Behavioral Health. The Medical
Director oversees the utilization review functions for the Care Management Department and the ABH
Utilization Management Plan. The Medical Director provides support and consultation to ABH and provider
staff
The Director of Quality Management and Improvement is the senior level quality staff person responsible for
and with the authority to manage Quality policies and procedures (including Credentialing and Rights and
Responsibilities). This role reports directly to the ABH Director. The Director of Quality Management and
Improvement coordinates the Quality Management Committee, compliance and quality monitoring activities,
and other activities related to quality management of the ABH network. This position is also responsible for
leading the QMC meetings.
Accreditation and Quality Improvement Manager reports to the Director of Quality Management and
Improvement. The Accreditation and Quality Improvement Manager is responsible for designing, building and
strategizing quality programs that meet NCQA, CMS, and Health Plan requirements and that improve
performance and population health outcomes for ABH members. This position is also responsible for
oversight of quality interventions for HEDIS and other performance measures.
The Director of Network Management and Contracting reports to the Director of Access Behavioral Health.
The Director of Network Management and Contracting is responsible for provider negotiations, contracting
and network management, ensuring that the provider network meets the needs of the Medicaid members for
access to services, and meets contractual requirements for provider and practitioner to member ratios. The
Director of Network Management and Contracting is responsible for updating contract terms that meet CMS,
Florida Medicaid, and NCQA requirements.
The Director of Care Management is responsible for the functions and operations of the Care Management
Department. This position reports to the ABH Director. The Director of Care Management oversees the
utilization review, utilization management, care coordination, and authorization processes for ABH. The
Director of Care Management works closely with the Medical Director in coordination of care and outreach to
primary care physicians, to medical providers, and to other behavioral health care providers.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
18
Minutes are recorded at each meeting using a standardized format which includes topic, discussion,
recommendations, follow up, and applicable graphs or associated reports. Follow up items become topics for
the next meeting. The minutes are reviewed and approved at the beginning of the subsequent meeting with
any changes or corrections noted. All members of the QMC annually sign a confidentiality attestation.
Continuity and Coordination of Care
Continuity of Care is a key element contributing to a successful treatment outcome. Intra- and inter-agency
communication of relevant clinical information is vital as ABH members move through a continuum of care or
services to minimize disruption to the member and to the treatment plan. All communication is within federal
and state laws, rules and regulations, contract requirements, and ABH Policy and Procedures.
Cultural Competence
ABH expects services to be provided within a framework of cultural competence. Cultural Competence is a
set of congruent practice skills, behaviors, attitudes, and policies that comes together in a system, agency, or
among professionals and enables that system, agency, or those professionals to work effectively in cross-
cultural situations. Cultural Competence is about adapting mental health care to meet the needs of members
from diverse cultures. One key aim is to improve their access to care. Others are to build trust and to promote
their engagement and retention in care.
Above all, cultural competence aims to improve the quality of care and to help members recover quicker and
better. Its broader societal purpose is to reduce or eliminate mental health disparities affecting
disenfranchised groups.
The following steps are offered to Providers as a means of becoming Culturally Competent:
Understand the racial, ethnic, and cultural demographics of the population served
Become most familiar with one or two of the groups most commonly encountered
Create a cultural competence advisory committee consisting of members, family and community
organizations
Translate your forms and brochures
Offer to match a member with a practitioner of a similar background
Have access to trained mental health interpreters
Ask each client about their cultural background and identity
Incorporate cultural awareness into the assessment and treatment of each member
Tap into natural networks of support, such as the extended family and community groups representing the
culture of a member
Reach out to religious and spiritual organizations to encourage referrals or as another network of support
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
19
Offer training to staff in culturally responsive communication or interviewing skills.
Understand that some behaviors considered in one culture to be signs of psychopathology are acceptable
in a different culture
Be aware that a member from another culture may hold different beliefs about causes and treatment of
illness
To request a full copy of the ABH Cultural Competence Plan at no cost, please contact the Quality
Improvement Director at [email protected].
Member Safety
The Access Behavioral Health Quality Management Committee retains the following subcommittees:
Quality and Member Rights, Responsibilities and Safety to ensure safe clinical practices across the system
of care. Data reviewed and analyzed by this these subcommittees includes:
Member complaints regarding potential safety concerns;
Critical Incidents
Quality of Care
Environment of Care;
HIPAA Compliance;
Confidentiality of members;
Review of clinical records, and
Review of site monitoring findings.
All quality of care and/or member safety concerns are reported to the Quality Management Department. The
investigation is initiated within one business day from when the concern is received. Suspension or
restriction of clinical privileges may occur when a potential quality of care or member safety incident has a
direct and imminent impact on the health or well-being of any Access Behavioral Health member.
Member Complaints, Grievances, and Appeals
Access Behavioral Health works at the direction of the Member’s Health Plan for resolution of any complaint,
grievance, or appeal. Members may contact Access Behavioral Health for assistance in reaching their Health
Plan to file a complaint, grievance, or appeal by calling 850.469.3870.
Members have the right to request continuation of benefits while utilizing the grievance and appeal system in
accordance with 42 CFR 438.414.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
20
Members may also contact the AHCA Consumer Help Line at 888-419-3456 to file a complaint or grievance.
The address and toll-free telephone number for Medicaid Fair Hearings are:
Agency for Health Care Administration
Medicaid Hearing Unit
P.O Box 60127
Ft. Myers, FL 33906
(877) 254-1055 (toll-free)
239-338-2642 (fax)
ABH Privacy and Security of Information
The purpose of the Privacy and Security Program is to ensure the confidentiality, integrity and availability of
the information we collect and use for health care and business purposes. The program extends to all
information regardless of location or storage medium and it applies to both paper and electronic based
information.
Confidential information is protected by federal and state law and must receive the highest degree of
protection. For our purposes, we’ve grouped this information into two categories:
Confidential Personal Information – Any information that can be considered personal in nature, such as
diagnosis and treatment information, individual names, social security numbers, insurance numbers,
credit card numbers, drivers’ license numbers, dates of birth, automobile tags and registration information.
Sensitive Business Data – Any information that we collect and use for business purposes such as
budgeting and financial data, staffing schedules and turnover statistics.
Guiding Principles of Information Security and Privacy
We will become familiar and comply with policies and procedures relating to information security and
privacy.
We will safeguard confidential information regarding our customers and coworkers from misuse, theft or
unauthorized access.
We will share confidential information as necessary to provide prompt and effective treatment to our
customers.
When sharing confidential information for purposes other than treatment we will adhere strictly to the
minimum necessary standard and only disclose the minimum information necessary to accomplish the
task.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
21
We will use reasonable steps to ensure unauthorized persons do not overhear or see confidential
information.
We will not place any confidential information in public areas where the information can be easily seen by
unauthorized persons.
We will become familiar with the Notice of Privacy Practices and adhere to the consumer privacy rights it
contains.
We will use approved procedures for obtaining our own confidential information or that belonging to our
dependents.
We will not access any confidential information, including our own unless we are doing so as part of our
official duties.
We will not discuss any confidential information pertaining to our coworkers or others that we obtain in our
official capacity unless doing so is ethical and necessary to complete our duties.
We will promptly report any theft or loss of confidential information to our supervisor.
Principles Specific to Information in Electronic Form
We will access computer systems that contain confidential information by using our own unique
identification (user ID).
We will not share our user IDs and passwords and will take reasonable steps to protect them from
unauthorized disclosure.
We will not allow vendors or contractors to access any ABH computer unless approved by Information
Services.
We will not load any unauthorized computer programs onto any ABH computer.
We will not disable or try to defeat any security device or procedure utilized by ABH.
We will not connect any unauthorized device to an ABH computer.
We will only use approved methods for storing confidential information electronically.
We will properly dispose of media such as floppy disks, DVDs, or CDs that contain confidential
information.
We will not allow unauthorized persons such as family members to use any ABH computer.
Principles Specific to Information in Paper Form
We will properly dispose of confidential information by placing it in approved containers or by shredding.
We will store confidential information in a way that prevents unauthorized access. When it is necessary to
store confidential information, we will follow ABH record retention policies and we will ensure the
information is properly destroyed when the retention period has expired.
We will strictly adhere to company policy regarding the faxing of confidential information, including the
verification of fax numbers and the use of approved fax cover sheets.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
22
When You Believe There May Be a Problem
If you believe you have information about health care providers, practitioners, entities, or other persons
engaging in improper types of activities or arrangements, it is your responsibility to report these concerns.
Persons reporting information in good faith will not receive any kind of reprisal or retribution. This provision,
however, cannot be used to absolve or clear any personal confessions of wrongdoing.
Discuss concern with your immediate supervisor. The management structure (starting with your
immediate supervisor) and existing policies and procedures should be used as the first approach.
Contact the Human Resource Manager or the Corporate Compliance Officer at your facility.
If you receive an unacceptable response or if you are unsuccessful using the initial reporting mechanism,
the Human Resource Manager or Corporate Compliance Officer will arrange for you to meet with the area
department head. If your concern is related to your treatment as an employee, you should meet directly
with the Human Resources Manager or Corporate Compliance Officer. Should the settlement continue to
be unsatisfactory, the Human Resources Manager or Corporate Compliance Officer will, in agreement
with the employee, present the grievance to the Administrator.
Contact the ABH Quality Department. The ABH Director of Quality Management and Improvement will be
available to discuss any concerns with you and can be reached at (850) 469-3924.
Your identity will be protected to the limit of the law. Concerns brought to the attention of the ABH Quality
Department will be promptly and thoroughly evaluated and investigated for prompt resolution. Due to the
nature of the concerns, detailed feedback may be difficult or impossible to provide due to confidentiality.
The Director of Quality Management and Improvement serves as the Corporate Compliance Officer for ABH.
Also, each organizational provider is required to have a Compliance Liaison who can be contacted if you
believe there is a problem that needs to be addressed.
Members’ Rights and Responsibilities
All ABH members must receive a copy of their rights and responsibilities upon initial enrollment into services
and then when requested thereafter. ABH Member Rights and Responsibilities are also located on the ABH
website (www.abhfl.org). Rights and Responsibilities provided to members must include and be materially
similar to the following:
1. The right to free exercise of rights, receive information about the organization, its providers and
practitioners, its services, and the members’ rights and responsibilities.
2. The right to be treated with respect and recognition of dignity and right to privacy.
3. The right to participate in decisions about their care, including the right to refuse treatment.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
23
4. The right to a candid discussion of appropriate or medically necessary treatment options and alternatives
for their condition, presented in a manner appropriate to the members’ condition and ability to understand,
regardless of cost or benefit coverage.
5. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation, as specified in other Federal regulations on the use of restraints and seclusion.
6. The right to request and receive a copy of his or her medical records.
7. The right to voice complaints or appeals about their provider, practitioner, or organization, and/or the care
provided.
8. The right to make recommendations regarding the organization’s member rights and responsibilities policy
Members Have the Following Responsibilities:
1. To supply information (to the extent possible) that their chosen organization and providers and practitioners
need in order to provide care.
2. To follow plans and instructions for care they have agreed upon with their Healthcare practitioners and
providers.
3. To understand their health problems and participate in the development of mutually agreed-upon treatment
goals, to the degree possible.
Identifying and Reporting Abuse, Neglect and Exploitation of Members
Professionally mandatory reporters are required to contact the Florida Abuse Hotline when they know or have
reasonable cause to suspect that a child or a vulnerable adult has been abused, abandoned, neglected, or
exploited, including suspected victims of human trafficking. The Abuse Hotline Counselor will determine if the
information provided meets legal requirements to accept a report for investigation.
There are four ways to make a report:
1. By Telephone 1-800-96ABUSE 800-962-2873
2. By Fax 800-914-0004
3. Florida Relay 711
4. By TTY 800-955-8771
5. Web Reporting https://reportabuse.dcf.state.fl.us
Fraud, Waste and Abuse Prevention
Access Behavioral Health works with the Health Plans to prevent, detect, and correct fraud, waste, and abuse
activities. The ABH Compliance Program is intended to establish methods for consistent adherence to
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
24
applicable laws, regulations, and requirements governing Corporate Compliance as well as for preventing,
detecting, and investigating fraud, abuse, and overpayment. ABH has established a centralized mechanism
via the Corporate Compliance Program, the Anti-Fraud Unit, and the Quality Management Committee (and
subcommittees), to track compliance and achieve the goal of preventing fraud and abuse. These mechanisms
have created a corporate culture of strict adherence to federal, state, and local laws. The ABH Fraud, Waste
and Abuse Plan is structured to demonstrate our commitment to the highest standards of ethical conduct, to
prevent and deter criminal activity, and to encourage employees to report potential problems that will allow for
appropriate internal inquiry and corrective action.
The purpose of the ABH compliance plan is to create and maintain a corporate culture that:
Promotes integrity and ethical behavior;
Establishes formal standards that comply with increased governmental regulation; and
Demonstrates the commitment of Lakeview Center, Inc. d/b/a Access Behavioral Health to act in
compliance with all legal and ethical responsibilities.
The ABH Compliance Plan ensures that the organization as a whole has ethics, culture, and values which are
consistent with the highest standards of business conduct and provides uniform guidance for fraud, abuse,
and overpayment activities.
This plan is a broad and comprehensive strategy to ensure that:
The risk for fraud, abuse, or overpayment is eliminated and/or reduced;
All employees of ABH, their contracted network providers and their employees conduct themselves in
accordance with the high standards of business and professional conduct established by ABH;
Encounter data accurately reflects the documented services provided; compliance with all general
regulatory matters;
Reporting of potential violations of applicable laws, rules and regulations is encouraged; and
Network providers take responsibility for the actions of their employees.
Providers may request a copy of the ABH Corporate Compliance Plan and Anti-Fraud, Abuse, and
Overpayment Plan for more information by contacting the ABH Quality Management and Improvement
Director.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
25
VIII. TELEMEDICINE/TELEHEALTH
Telemedicine is the practice of health care delivery by a practitioner who is located at a site other than the site
where a recipient is located for the purposes of evaluation, diagnosis, or treatment.
Services must be delivered from a facility that is enrolled in Medicaid as a community behavioral health
services provider for Medicaid to reimburse for services delivered through telemedicine. Services that can be
provided through telemedicine are listed in the Medicaid Handbook for Community Behavioral Health Services
Procedure Codes and Fee Schedule, found in the appendices.
The following interactions do not constitute reimbursable telemedicine services:
• E-mail messages
• Facsimile transmission
Providers utilizing telemedicine must implement technical written policies and procedures for telemedicine
systems that comply with the Health Insurance Portability and Accountability Act privacy regulations as well as
applicable state and federal laws that pertain to patient privacy. Policies and procedures must also address the
technical safeguards required by Title 45, Code of Federal Regulations, section 164.312, where applicable.
Services provided via Telemedicine and Telehealth must adhere to the Agency for Health Care
Administration’s (AHCA) Community Behavioral Health Services Coverage and Limitations Handbook
guidelines and requirements and must only be rendered by a practitioner who meets the AHCA qualifications
for that service. Appropriate services codes with the GT modifier must be used for billing.
Documentation for Telemedicine and/or Telehealth should follow standard documentation protocols and should
include justification as to why the service is being provided via Telemedicine and/or Telehealth instead of in
person. Telemedicine and/or Telehealth services must be provided to members in a secure office location. The
member must consent in writing to service delivery via Telemedicine and/or Telehealth. The computer used to
provide Telemedicine and Telehealth must not be able to access any client records or information. If the
member is using an in-facility computer, staff must assist the member with computer operation to ensure
proper operation and assist the member, if needed, to address any computer or other problems, or if the
member has questions.
Access Behavioral Health reimburses for telehealth services at the same rate as equivalent services offered
face-to-face.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
26
UTILIZATION MANAGEMENT
Scope and Goals
The clinical philosophy at Access Behavioral Health (ABH) is to provide a care management system that offers
easy and immediate access to the most appropriate, quality mental health, services for members, and a
utilization management system that supports providers in delivering clinically necessary and effective care with
minimal administrative barriers. The Utilization Management Plan encompasses management of care from the
point of entry into care through discharge from care. ABH believes in macro-management of care as much as
possible through the use of objective, standardized, widely distributed clinical protocols and outlier
management programs. Intensive utilization management is reserved for high-cost, highly restrictive levels of
care and cases that represent clinical complexity and risk. The Care Management team bases its reviews on
clear and concise criteria developed specifically to guide level of care, treatment and length of stay
determinations. Care Management staffs are trained to match the needs of patients to appropriate services,
levels of care, and community supports. This requires a careful consideration of the intensity and severity of
clinical data presented with the goal of quality treatment in the least restrictive environment. The clinical
integrity of the Utilization Management Program ensures that members who present for care are appropriately
monitored. Those cases that appear to be outside of best practice guidelines are referred for specialized
reviews. These may include peer clinical review, peer-to-peer conversation, or more frequent care manager
review.
Access Behavioral Health has designed a system of care that is not only based on principles of quality care,
but also one that is flexible in meeting the needs of diverse populations, communities and customers.
Access Behavioral Health:
Provides easy and early access to appropriate treatment;
Works collaboratively with providers in delivering quality care according to accepted best-practice
standards;
Addresses the special needs of children in the mental health system;
Identifies common illnesses or trends of illness;
Targets high risk cases for intensive care management; and
Emphasizes prevention, education and outreach.
Principles
ABH Clinical Management staff adheres to the following principles:
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
27
All persons shall be treated with respect and dignity;
The person directs the recovery process; therefore, the individual’s input is essential throughout the
process;
Individuals are able to recover more quickly when their hope is encouraged, enhanced, and/or maintained;
life roles with respect to work and meaningful activities are defined; spirituality is considered; culture is
understood; educational needs as well as those of their family/significant others are identified; and
socialization needs are identified;
Individual differences are considered and valued across the life span;
Recovery from mental illness is most effective when a holistic approach is considered;
To the maximum extent possible, members shall be offered a choice of direct service providers;
Services to members shall be tailored to the individual and provided in the least restrictive and most
natural setting environment as possible, preferably in the member’s own community;
For children, services and treatments must be family centered, geared to give families real and meaningful
choices about treatment options and providers; care must focus on increasing the child’s ability to
successfully cope with life’s challenges and on building resilience, not just on managing symptoms;
Services to members are built on the strengths of the member and the member’s family and foster
independence;
Utilization review shall follow established best-practice guidelines and industry standards;
Grievance procedures shall be developed for the member or provider to resolve issues according to
established timeframes;
The confidentiality and privacy of the member shall be protected at all times.
Information shall be collected, analyzed, and disseminated to foster system accountability and quality
improvement;
Patient rights and other member information shall be communicated in a manner understood by the abh
member; and
Access behavioral health does not discriminate against individuals eligible to enroll on the basis of race,
color, or national origin, and does not use any policy or practice that has the effect of discriminating on the
basis of race, color, or national origin.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
28
Staff Qualifications
Access Behavioral Health places high value on the selection, training, and performance evaluation of clinical
staff performing utilization management services. All staff involved in utilization management activities
possesses terminal degrees and licensure in their field. The ABH Medical Director and Physician Advisors are
experienced, senior level clinicians, many of whom remain active in private practice. They are board certified in
their specialty areas, and are required to maintain a current knowledge of behavioral health research findings
and nationally recognized practice guidelines.
Care Management staff are multidisciplinary and are able to manage care in all general psychiatric, psychiatric
subspecialty, and substance abuse areas. ABH requires that all Care Management staff be fully licensed
mental health professionals with a minimum of three years' prior clinical experience in a mental
health/substance abuse setting providing direct patient care. First-level review staff are licensed nurses with
experience in psychiatric nursing (RN). These reviewers complete all types of reviews, including
precertification, concurrent review, discharge planning, and care coordination. The status of current licensure is
maintained within the Lakeview Center, Inc. Human Resources Department for all actively employed clinical
staff.
ABH ensures that compensation to individuals or entities that conduct utilization management activities is not
structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically
necessary services to any member.
The ABH Quality Management Committee is responsible for the development of clinical policy and standards
for the Utilization Management department, the standardization of operational systems, and the assurance of
clinical integrity throughout all lines of business.
UM Staff Responsibilities
The overall clinical responsibility within ABH rests with the Medical Director. The Medical Director reports to
the ABH Director of Access Behavioral Health. The Medical Director provides medical and clinical leadership
for the day-to-day clinical operations, oversees the UM Program implementation and ensures the application of
policies and procedures and participates in training of clinical staff. The Medical Director participates in the
continuous quality improvement program, which includes the ongoing development and monitoring of key
indicators, outcome studies, provider quality profiling, and best practices. The Medical Director routinely
reviews utilization and quality improvement reports to help identify quality practices that can be shared with
other providers, and to identify aberrant practices and participate in corrective actions. The Medical Director
helps design, monitor and control utilization targets. The Medical Director assists in the development and
implementation of necessary corrective action plans related to utilization. In addition, the Medical Director
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
29
oversees the certification process and appeals decisions and serves as a Physician Advisor in the peer
review/appeals process.
Physician Advisors are independently contracted employees and perform their reviews as designees of the
Medical Director, but are not subordinate to the ABH Medical Director.
The Director of Care Management collaborates with the Medical Director to identify and resolve clinical issues
related to referral, care management, and peer review processes. The Director of Care Management manages
the day-to-day operations of the Care Management Department and provides direct clinical and administrative
supervision to the Care Management staff. Additionally, the Director of Care Management monitors
departmental productivity and utilization statistics. This position works closely with the ABH Director of Quality
Management and Improvement to ensure that care management and referral processes are performed at or
above established performance benchmarks. The Director of Care Management reports to the ABH Director of
Managed Care.
ABH Clinical Care Coordinators provide clinical assessment and referral services as well as concurrent
inpatient, alternative levels of care, and outpatient reviews. The primary function of the Clinical Care
Coordinator is to ensure that members receive quality services in the most appropriate level of care. Clinical
Care Coordinators inform clinical management of problem cases and resolve these issues in consultation with
the Director of Care Management and the Medical Director. Clinical Care Coordinators receive clinical
supervision from the Medical Director and the Director of Care Management and report directly to the ABH
Director of Care Management.
Conflicts of Interest
No person may participate in the review and evaluation of any case or clinical activities in which he or she has
been professionally involved or where judgment may be compromised. Utilization Management decision-
making is based solely on the clinical appropriateness of the care and services needed. Access Behavioral
Health does not offer incentives to individuals engaged in utilization review for issuing denials of coverage or
service, or for rendering decisions that result in underutilization. Psychiatrists and other mental health
professionals who carry out care management or peer review activity must be free from conflict of interest
when reviewing the work of providers. Among other things, this means that clinical staff, including peer
reviewers, must not review the work of any health care facility or entity where they have active staff privileges
and treat patients or from which they derive any income.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
30
Access to UM Services
A member or provider has access to a toll-free number for referral to a network provider for assessment, 24
hours per day, 7 days per week, and 365 days per year through the ABH Call Center. ABH Care Management
staffs are available for consultation for urgent as well as non-urgent circumstances 24 hours per day, 7 days
per week, 365 days per year via the ABH Call Center. After normal business hours, 8am to 5pm CST, non-
urgent messages may be left on the confidential voice mail of the Care Management staff or may be submitted
electronically to ABH CCM staff at [email protected]. Response to telephonic and electronic general
administrative communications to ABH Care Management staff will occur immediately in most cases, but in no
less than one business day.
Clinical Criteria
The clinical criteria used by ABH to make admission, level of care and continuing treatment decisions reflects
ABH’s philosophy and clinical values. These criteria are assessed and revised at least annually by the ABH
Quality Management Committee. Prior to a criterion set being approved for use it is reviewed to ensure
adherence to clinical best practices guidelines and overall core criteria standards. Clinical criteria are reviewed
and approved by the ABH Quality Management Committee.
Sources for various criteria include:
Florida Medicaid Coverage and limitations Handbooks for Behavioral Health:
o Community Behavioral Health
o Specialized Therapeutic Services
o Targeted Case Management
o Statewide Inpatient Psychiatric Services
Florida Medicaid Statewide Inpatient Psychiatric Program Coverage Policy (Dec 2015)
American Society of Addiction Medicine (ASAM) criteria
Florida Medicaid Drug Therapy Management Program for Behavioral Health
Diagnosis-based treatment guidelines for adults
o American Psychiatric Association
Diagnosis-based treatment guidelines for Children and adolescents
o American Academy of Child and Adolescent Psychiatry
Clinical criteria are routinely disseminated to ABH providers via provider forums, the ABH website, and at
individual or group training sessions. The criteria are accompanied by the following statement, “The materials
provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under your contract."
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
31
To determine the appropriate level of care, Care Management staff evaluates the clinical information relative to
the levels of care clinical criteria.
A hard copy of UM decision-making criteria may be requested by contacting Access Behavioral
Health.
Medical Necessity
It is the policy of ABH to authorize payment only for services that are medically necessary and provided for the
identification and/or treatment of a member's illness. ABH considers medically necessary treatment as that
which is:
Necessary to protect life, to prevent significant relapse of a mental illness or significant disability, or to
alleviate severe pain;
Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under
treatment, and not in excess of the member’s needs;
Consistent with generally accepted professional medical standards as determined by the Medicaid
program, and not experimental or investigational;
Reflective of the level of service that can be safely furnished, and for which no equally effective and more
conservative or less costly treatment is available, statewide; and
Furnished in a manner not primarily intended for the convenience of the member, the member’s caretaker,
or the provider.
Authorization and Notification for Behavioral Health Services
Access Behavioral Health manages authorization requests for the following services:
Inpatient behavioral health services in a psychiatric bed (both in- and out-of-network; notification is
requested by the first business day after the admission)
Statewide Inpatient Psychiatric Programs (SIPP)
Psychological and psychiatric testing (both in- and out-of-network)
Electroconvulsive therapy (ECT) treatments (Note: ECT treatments rendered while a member is in an
inpatient setting are included as part of the DRG payment to the facility.)
In-network non-emergent outpatient services
All non-emergent outpatient services rendered within the regions where ABH operates are to be provided
by in-network providers.
No prior authorization is required for in-network providers.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
32
Out-of-network non-emergent outpatient services
No prior authorization is required for out-of-network providers outside the regions where ABH operates who
participate in the Florida Medicaid program and provide transition benefit services to ABH members.
Submitting Authorization Requests for Inpatient Psychiatric Hospitalization
Authorization requests can be made by Access Behavioral Health or by faxing clinical information directly to
ABH at (850) 595-0258, or by secure email to abhbhreferral@bhcpns.org. All information and documentation
noted below should be included in the authorization request.
Information needed when requesting preauthorization
To obtain authorization through ABH, supporting clinical documentation, containing the following information,
needs to be faxed to ABH or be available when calling ABH:
Member name, date of birth, Medicaid identification number
Member diagnosis
Clinical information relevant to the admission, such as:
o Significant clinical history, including mental status exam and history of present illness, Baker Act
status, significant comorbidities, current medications and adherence
o Current relevant laboratory reports
o Treatment plan, including inpatient days requested and expected discharge placement and
outpatient follow-up
Please note: Screening intake and physician history and physical forms are usually sufficient.
Additional information
Following Access Behavioral Health’s review of the submitted information, the health care provider will be
given an authorization number, the number of approved days, and the date of the next review. If the request is
incomplete or does not meet evidence-based criteria for the level of care requested, the health care provider
will be asked for additional information.
Continued stay reviews are not required for hospitals paid by DRG (Diagnosis Related Groups).
If Access Behavioral Health requests medical records as a result of an authorization request, prompt return of
the information will facilitate the timely processing of the authorization request.
Questions
Questions about this program may be directed to Access Behavioral Health from 8 a.m. to 5 p.m. CST,
Monday through Friday.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
33
Peer Clinical Review
Physician Advisors provide clinical case review of those cases that do not meet medical necessity or that
present quality of care issues. For after hour's coverage, a clinical supervisor, and Medical Director are on call
to deal with any emergencies. ABH's Medical Director’ who is responsible for the clinical decisions’ is a board
certified psychiatrist and provides case consultation in general adult psychiatry at all levels of care. Physician
Advisors utilize Access Behavioral Health's clinical criteria for determining medical necessity decisions.
Specialists are available for adult and child/adolescent to assist in the determination of clinical
appropriateness.
Resources available through the Utilization Management Program and utilized by ABH Care Management staff
include the following:
Informal discussions with the Medical Director or the Access Behavioral Health Physician Advisors on a
daily basis.
Weekly case rounds for case review and monthly in-service training.
Review of "outlier" cases on every level of care.
Determination of No Medical Necessity
If the Care Management staff questions the medical necessity and/or appropriateness of the treatment as
outlined in Access Behavioral Health’s clinical criteria, or if there are quality of care concerns, the case is
referred to the ABH Medical Director or a Physician Advisor (PA). The ABH Medical Director or Physician
Advisor reviews the available information, and may offer to speak directly with the attending or primary provider
to discuss the case. Through this communication, the ABH Medical Director or Physician Advisor may obtain
clinical data that was not available to the care management staff at the time of the review. This collegial clinical
discussion allows the ABH Medical Director or Physician Advisor the opportunity to explore alternative
treatment plans with the provider and to gain insight into the attending providers anticipated goals,
interventions and time frames. The ABH Medical Director or Physician Advisor may request more information
from the provider to support specific treatment protocols and ask about treatment alternatives. Determinations
of no medical necessity are rendered only by the ABH Medical Director or a Physician Advisor and only if the
ABH Medical Director or Physician Advisor and the attending provider are unable to reach an agreement. It is
always possible for the treating provider to provide additional written or verbal information prior to the peer
review decision. This additional information may alter the medical necessity determination.
Disagreement may be a result of anyone or a combination of the following:
the current level of care;
the frequency of a specific treatment modality;
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
34
the duration of care; and/or
the treatment modality being utilized
ABH is not delegated sending notices of adverse determination. When a determination of no medical necessity
is made in a case, the treating provider (and hospital, if applicable) is notified telephonically of the decision.
Written notification of a determination of no medical necessity is provided to the member and the member’s
treating practitioner by the member’s MMA plan. The notification letter specifies the level of care for which a
determination of no medical necessity has been made, the reason(s) why the determination has occurred and
instructions on how to initiate an appeal. Access Behavioral Health Care Management staff always work with
providers in finding alternatives when a given level or type of care is not determined to be medically necessary,
and this is documented in the case review notes.
Peer-to-Peer Conversation
Based on criteria for medical necessity, Care Management staff concludes that the proposed treatment of a
member does not appear to meet the clinical criteria. The Care Management staff reviews these concerns with
the facility UR staff or treating provider on the same business day. If the Care Management staff and the
treating provider are not able to resolve these concerns, the process for referral of the case for peer to peer
review is initiated, if not already completed as described above.
The peer review process follows core policies and procedures which are established by the Access Behavioral
Health QI/UM Committee. The procedure is as follows:
An appointment is scheduled for the Physician Advisor and the treating provider by an ABH Care Management
Department staff member. If the treating provider cannot be reached, a message is left, indicating that the call
pertains to a question of medical necessity determination, and unless a call is received within (24) hours, a
non-certification decision is issued unless special circumstances are identified that prevent the treating
physician from returning the call. After reviewing the information with the treating provider, the Physician
Advisor determines whether the treatment services the provider intends to render (or has already rendered)
are medically necessary. If so, the case is referred back to the ABH Care Management staff for continued
review. If not, the provider is informed of the determination of no medical necessity and of the appeal process.
Peer review decisions are usually rendered immediately, but in all cases within 24 hours of the review. Note: It
is always possible for the treating provider to provide additional written or verbal information prior to the peer
review decision. This additional information may alter the medical necessity determination. However, once
Access Behavioral Health has sent a no medical necessity determination letter according to contractual
standards, the case is governed by the protocols established for an appeal. The determination remains valid
until and/or unless it is overturned by an appeal.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
35
Appeal Process
Access Behavioral Health is not delegated member or provider Grievances, Complaints and Appeals. Provider
Complaints and all aspects of the grievance and appeal process are handled by the member’s MMA Health
Plan. In the event an appeal or complaint is received by Access Behavioral health, it will be forwarded
immediately to the member’s MMA plan.
Practitioner Satisfaction with Access Behavioral Health UM Processes
Satisfaction surveys are sent, on an annual basis, to those providers who regularly use the ABH Care
Management services. Data are aggregated, trended and used to identify improvement opportunities including
areas in which our administrative and clinical practices need revision. Results are presented to the Quality
Management Committee and are shared with providers.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
36
IX. CLAIMS
Claims Processing
Access Behavioral Health is committed to processing all claims accurately and in a timely manner by following
all rules and regulations set forth by federal and state requirements.
Claims Submission
Per provider contracts, all claims must be submitted to Access Behavioral Health within ninety (90) days from
the date of service. Non-contracted providers have 6 months or 180 days from the date of service in which to
submit claims. Claims are not denied for late file unless received beyond 1 year (365 days) of the date of
service.
Paper Claims
Outpatient services must be billed on a CMS-1500. Inpatient services are billed on a UB-04.
All fee-for-service claims must be submitted on paper claims to:
Access Behavioral Health
ATTN: Claims
1221 W. Lakeview Avenue
Pensacola, FL 32501
Electronic Claims
Providers should contact Access Behavioral Health for questions regarding filing claims electronically.
Electronic claims must be submitted with a single type procedure code per claim. Secondary claims may not
be submitted electronically. Secondary claims must be submitted via paper claim with the completed
explanation of benefits/remittance advice from the primary payer attached
Clean Claims
A clean claim form means a standard, original and legible claims form UB04, CMS 1500, 837 or successor
forms which has been accurately completed by inserting all the correct information required to answer each
data element needed to immediately process claims within the time period stated for services rendered and to
promptly approve or deny payment.
Covered Diagnosis Codes
ABH covers both mental health and substance abuse diagnosis codes with the following exceptions:
ABH does not authorize community behavioral health services for the treatment of autism, pervasive
developmental delay, non-emotional or non-behavioral based developmental disability, or mental retardation.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
37
Services are not considered to be medically reasonable when the recipient has an organic brain disorder
(dementia or delirium) or other psychiatric or neurological conditions that have produced a cognitive deficit
severe enough to prohibit benefit to the recipient.
ICD-10 Reimbursable behavioral health diagnosis codes: F01.50 – F53.1; F55.0 – F63.9; F68.10 – F69;
F80.82, F88 – F99; Z03.89
Authorization Numbers
Authorization numbers are not required to be on the claim for claims payment.
Claims Payment
Electronic claims are processed within 15 days. Paper claims (fee-for service claims) are processed within 20
days.
Claims Remittance
Claims payments to providers is accompanied by an itemized accounting of the individual claims included in
the payment including but not limited to, the member’s name, the date of service, the procedure code, service
units, the amount of reimbursement and the identification of the managed care plan.
Medicaid Benefit Limits
The ABH claims payment system does not allow payment beyond the limitations set forth in the Florida
Medicaid Provider handbooks. Medicaid recipients may not be billed for services rendered that are denied by
ABH for plan benefit limits.
Member Responsibility
Florida Medicaid does not require any co-payments or cost sharing for covered services to plan members.
Members may not be billed for services rendered or for missed appointments unless the member agrees in
writing prior to the delivery of the services.
Disaster Planning
In the event of a disruption in the ability of service providers to contact ABH for authorizations due to an
emergency, providers are instructed to provide medically necessary services. ABH will conduct retrospective
reviews on these cases and authorize appropriate claims. ABH will pay claims and not hold members
responsible for any medically necessary services that incurred during a time of disaster regardless of whether
or not prior authorization was obtained. Consumer health and safety is of utmost concern and is not to be
jeopardized by an inability of providers to communicate with ABH.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
38
Claims Questions
Providers are encouraged to contact Access Behavioral Health with any questions regarding claims payment.
Telephone: (850) 469-3631; email: [email protected]
Corrected Claims
For handling and addressing corrections concerning claims issues, a provider has 35 days after receipt of
notification to resubmit a claim to:
Access Behavioral Health
Attention: Claims Corrections
1221 W. Lakeview Avenue
Pensacola, FL 32501
Provider Complaints
Provider complaints (including overpayment disputes) for Humana Healthy Horizons must be issued in writing
to:
Access Behavioral Health
1221 West Lakeview Avenue
Pensacola, FL 32501
Provider complaints (including overpayment disputes) for Lighthouse Health plan and Staywell Health Plan of
Florida must be issued in writing to the member’s health plan (see addresses in appendices at the end of this
document).
Provider Claims Related Complaints
Providers are allowed ninety (90) days from the date of final determination of the primary payer to file a written
complaint for claims issues. Within three (3) business days of receipt of a claim complaint, the provider is
notified (verbally or in writing) that the complaint has been received and the expected date of resolution. Within
fifteen (15) days of receipt of a claim complaint, the provider is given written notice of the status of the
complaint, and again every thirty (30) days thereafter until the complaint is resolved. Complaints related to
claims are resolved within sixty (60) days of receipt and written notice of the disposition and the basis of the
resolution is sent to the provider within three (3) business days of resolution.
Provider Non-Claim Related Complaints
Providers may file a complaint regarding any aspect of their experience as a provider of service to ABH
members. Providers have forty-five (45) days to file a written complaint for issues that are not related to claims.
The member’s Health Plan will
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
39
Within three (3) business days of receipt of a complaint, notify the provider (verbally or in writing) that
the complaint has been received and the expected date of resolution;
Document why a complaint is unresolved after fifteen (15) days of receipt and provide written notice of
the status to the provider every thirty (30) days thereafter; and
Resolve all complaints within ninety (90) days of receipt and provide written notice of the disposition
and the basis of the resolution to the provider within three (3) business days of resolution.
Provider Change Notifications
Prompt notification of Access Behavioral Health in the event of any demographic change such as provider
name or address by calling the ABH claims department at (850) 469-3631 or emailing [email protected] will
facilitate timely claims payment.
X. PROVIDER CONTRACTS
It is the responsibility of each contracted provider to familiarize themselves with the requirements in his/her
signed contract with Access Behavioral Health. Contract questions will be addressed promptly by contacting
the ABH Director of Network Management directly listed in the staff directory.
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
40
XI. Appendix 1: Humana Healthy Horizons
Access Behavioral Health is contracted with Humana Healthy Horizons in Florida’s Regions 1 and 2.
SMMC Plan Contact:
Email: LTCProviderrelations@humana.com
Phone: 561-860-8660
MMA Provider contact:
Email: FLMedicaidProviderRelations@humana.com
Phone: 305-626-5006
Address:
Humana Healthy Horizons
PO Box 14546
Lexington, KY 40512-4546
Access Behavioral Health
A division of Lakeview Center, Inc.
1221 West Lakeview Avenue • Pensacola • Florida • 32501 • Tel: 1.866.477.6725 • Fax: 1.850.469.3661
www.abhfl.org
Reviewed/Revised 2022
41
XII. Appendix 2: Sunshine Health
Access Behavioral Health is contracted with Sunshine Health in Florida Region 1.
Address:
Sunshine Health
P.O. Box 459087
Fort Lauderdale, FL 33345-9087
Provider Services: 1-844-477-8313
