Provider Network Newsletter


National Plan and Provider Enumeration System (NPPES)

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)mandated the adoption of standard unique identifiers for health care providers, as well as the adoption of standard unique identifiers for health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.

If you are a Health Care Provider, the National Provider Identifier (NPI) is your standard unique identifier.

About NPPES….
CMS has contracted with Fox Systems, Inc. to serve as the NPI Enumerator.
The NPI Enumerator is responsible for dealing with health plans and providers on issues relating to unique identification.

HIPAA Enforcement

HIPAA and state privacy and security laws (eg. the Michigan Mental Health Code) are concerned with sharing protected health information (PHI) and electronic records in the behavioral health arena. There are some differences between HIPAA and the Michigan Mental Health Code which has been the source of some confusion.  Behavioral health providers and service delivery organizations/providers should continue to follow the Mental Health Code which is more protective regarding customer PHI. It is expected that new legislation will be created to allow for a better understanding of the federal and state laws and hopefully reduce or eliminate any confusion.

Since HIPAA Privacy and Security law became effective there has been little or no legal action taken against offenders. It is predicted that there will be an increase in legal action against non-compliance of PHI security and privacy.  There is increased pressure on HHS/CMS to inflict civil penalties against covered entities that have violated the privacy rule

Specialized Residential Items of Interest

Emergency Bags in Specialized Residential Settings

According to MDCH Site Reviewers Emergency bags should minimally contain a radio, Flash light, batteries, depends (as appropriate), gloves van and house keys, rain coats/ponchos, blankets (thermal), Snacks and bottled water with purchase or expiration dates clearly identified, sugar free snack (for diabetics), staff and guardians telephone numbers, consumer profiles

Many emergency bags are very heavy and difficult to transport.  Homes may want to purchase wheeled emergency bags to promote ease of movement during emergencies. This may be particularly helpful for those homes with non-ambulatory individuals.

Incident Reports

When no documented incident reports of any kind are found during a site review it raises concerns that staff are not aware of how and when to complete an incident report.  The agency is encouraged to evaluate staff competency in this area and provide training as indicated.

Deficit Reduction Act

State and Federal False Claims Acts

It is your responsibility to report any/all suspected or known violations of Medicaid/Medicare false claims submissions.

The Federal and State False Claims Acts grant you protection from retaliation from your employer or the employer organization.

Reporting: For all suspected or know false claims submissions, you are to report your information to Mary Farrington, Compliance Officer, a member of the Compliance Committee, a member of administrations, and/or your direct supervisor.

Grievance & Appeals

What is a “Grievance”?
A Grievance can be filed regarding anything a consumer is unhappy about at the place he or she receives mental health and substance abuse services from.  We want to hear from our customers if they are having problems so that we can assure they receive the best care possible.  Customers can file a Grievance with Liz Courtney the Van Buren Community Mental Health Customer Service Representative.  The Customer Service Representative will make sure that the right people are aware of their grievance and make changes and/or fix the problem if they are able to.

What is a “State Fair Hearing Appeal”?
Customers can file a request for a State Fair Hearing Appeal with the state of Michigan Administrative Tribunal if they have Medicaid and they were denied a requested Medicaid service, or Medicaid services they were previously getting were suspended, reduced or terminated.  Customers can file both State Fair Hearing as well as a local Appeal at the same time.  They must request this hearing within 90 days from this action.  If requested within calendar 12 days from the date of the notice of action, Van Buren CMH must reinstate the Medicaid services until disposition of the hearing by the Administrative law judge.  Expedited hearings are available as well.

What is a “Local Appeal”?
A local appeal is an impartial local level CMHSP of a Medicaid beneficiary’s appeal of an action (denial, suspension termination or reduction of a Medicaid services) presided over by individuals at Van Buren Community Mental Health who were not involved with decision making or the previous level of review.  Customers, or their provider or their behalf, must request this hearing within 45 days from this action.  If requested within 12 calendar days from the date of the notice of action, Van Buren CMH must reinstate the Medicaid services until disposition of the hearing.  Expedited hearings are available as well.

If you are a provider for Van Buren Community Mental Health your role is to ensure the Customer Services Representative is contacted whenever a customer makes known a complaint to you, regardless of how big or small.

To assist a customer in filing a Grievance or Appeal, please contact Sandy Thompson 269-427-6602