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Core Services
Partnering with Health Plans and Public entities to provide
behavioral health services is our business. We believe in providing high
quality, cost efficient services 24 hours a day, 7 days a week to ensure
uninterrupted coverage to the Consumers of care. Our core services include:
CBHNP Member services staff is on site 24 hour a day, 7
days a week to answer phone calls live. They are trained extensively to:
Take calls to assist Members, families, and providers in all areas of
behavioral health
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Gather initial assessment information
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Perform basic risk assessments
Depending on the nature of the inquiry, calls may be directed
to Care Managers, Complaint and Grievance Coordinators, or other CBHNP staff
members. All Member Services Representatives have a bachelor’s degree in a
clinical discipline. Language line interpreter services and PA Relay for
assistance to deaf and hard of hearing individuals are available and staff has
direct links to crisis programs and 911/emergency services.
The CBHNP utilization review process is designed to manage
treatment from initial point of entry to discharge from care to assure that
clinically necessary treatment occurs in the least restrictive environment that
is available, safe, and clinically appropriate.
Utilization Management Process
The application of medical necessity criteria is a main
function of utilization management. The process involves:
Targeting high risk cases for more intensive treatment
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Addressing the needs of special populations (including children, adolescents,
and elderly)
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Determination of best clinical practices and standards
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Identifying utilization trends
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Assuring regulatory compliance
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Implementing innovative programs
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Focusing on outlier management and outcomes
If a service does not meet medical necessity criteria, it is reviewed by our
Medical Director or other physician level staff for care determination.
Processes are in place for Members and providers to appeal administrative and
clinical decisions for any non-authorization determinations.
Staffing and Availability
Utilization management personnel are available 24 hours a
day, 7 days a week and clinical care management is provided by licensed mental
health professionals with years of practical experience and clinical expertise.
At the initial time of contact, staff has access to Member information
regarding current treatment providers, eligibility confirmation, and
documentation of Member or provider contact and has protocols in place for
emergency inpatient admissions.
CBHNP is committed to assuring, controlling, and improving the quality of all
services based on quality improvement activities, principles, and findings.
Quality Improvement Program (QIP)
In order to ensure that quality of services and care is being
monitored and managed at every level of operation, a comprehensive QIP has been
developed to:
Integrate QIP activities into the overall operational activities
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Consistently meet or exceed established performance
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Fully implement and ensure that continuous quality improvement activities occur
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Reflect a systems oriented model that integrates function, steps, and
evaluation
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Strive for continuous improvement through the planned monitoring and evaluation
of key tasks, core processes, organizational systems, and services
Quality Improvement Committee
The work of the Quality Improvement (QI) Department is
supported through a committee structure that involves senior CBHNP staff as
well as stakeholders representing Consumers/families, providers, and
representatives of contracted provider organizations. The QI Committee reviews
reports and findings representing utilization management in the following
areas:
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Complaints and Grievances
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Provider Profiling Information
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Varied Performance Improvement Measures
The Committee is responsible for the identification and
resolution of problem areas, service improvement, and the promotion of
effective, clinically appropriate, and efficient care.
Provider Network Management
CBHNP contracts with providers for the complete continuum of
behavioral health services. This includes hospitals, substance abuse
facilities, group practices, and other behavioral health specialists who have
experience serving adults, adolescents, and children with mental health and
substance abuse needs.
Provider Network Management Activities
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Ongoing Quality Monitoring
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Provider Relations Functions of Provider Training and Provider Education
To ensure high quality care, CBHNP has a standard
credentialing procedure for admitting providers into the network. The
Credentialing Committee reviews all applicants individually to verify
credentials which include:
As part of the credentialing process, CBHNP also contracts
with an NCQA certified Credentials Verification Organization (CVO) to complete
primary source verification.
At least every three years, CBHNP providers undergo a
re-credentialing. The re-credentialing process includes an updated verification
of:
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Membership in Respective National Organizations
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Compliance with CBHNP Standards
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Clinical and Administrative
Specialized credentialing staff is available from 8:00 AM to
5:00 PM to answer questions about applications or the credentialing process.
CBHNP offers provider training on a regular basis, including
individualized training for provider agencies as well as large group forums.
Provider relations staff is available during normal business hours to provide
technical assistance around authorization procedures and administrative
requirements.
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