Providers

Welcome to Human Behavior Institute's online provider services. At HBI we realize the demands placed on you in dealing with the challenging mental health care system, so we developed this section with you in mind. As an HBI Network Provider, you can access essential information and resources to help you in your practice, including:

Join the HBI Network!

Contact HBI’s Provider Services Department at credentialing@hbinetwork.com or submit a completed Letter of Intent with all the necessary supporting documents by fax to (702) 248-9640.

Credentialing Process

  1. Applicant provider must submit the appropriate Letter of Intent (LOI)
  2. Site Review (for certain types of providers)
  3. An invitation to the New Provider Orientation is sent to qualified applicants who meet the preliminary credentialing criteria
  4. The application packet is distributed to the individual provider at the end of the New Provider Orientation.
  5. Completed packet must be returned to HBI within 30 days.
  6. HBI conducts Primary Source Verification per NCQA and URAC standards
  7. Findings are submitted to HBI Network Credentialing Committee for approval
  8. If approved, a welcome packet is sent to the new provider.

Each of the above steps must be satisfied before proceeding to the next. Qualified applicants with clean records usually take about 60 business days to process.

If you would like to enroll into the HBI Provider Network, please contact HBI’s Provider Services Department at credentialing@hbinetwork.com or submit a completed Letter of Intent with all the necessary supporting documents by fax to (702) 248-9640.

Credentialing Criteria

HBI does not make credentialing or re-credentialing determinations based on a provider’s race, ethnic/national identity, gender, age, sexual orientation, or the types of services (e.g. Medicaid) in which the provider specializes. Practitioners are selected using the following criteria:

All HBI Providers must

  • Meet the geographic access needs of HBI.
  • Hold membership in a national professional association that ascribes to a professional code of ethics (i.e., American Psychiatric Association, American Psychological Association, National Association for Social Workers, American Nursing Association, Employee Assistance Professional Association, or National Association of Marriage and Family Therapy).

Psychiatrists and Physicians

  • Graduate of an accredited medical school.
  • Completed a psychiatric residency program accredited by the Accreditation Council for Graduate Medical Education for Psychiatry or the American Osteopathic Association.
  • Unrestricted license.
  • Board Certified or Board Eligible physicians in a primary care specialty (i.e., Internal Medicine, Family Practice, Pediatrics, or OB-GYN) with more than five years of experience working with substance abuse patients are eligible to provide services to substance abuse patients. (Note: American Society of Addictions Medicine Certification is preferred, and in the absence of this must have documentation of five years of training.)
  • Board Certified in Psychiatry/Neurology (qualified to take the exam for Board certification for the American Psychiatric Guidelines for Psychiatry and Neurology).
  • Demonstrate a minimum of two years recent clinical experience.
  • Child Psychiatry must demonstrate at least one year of supervised experience working with disturbed children, and satisfactory completion of an approved fellowship in adolescent and child psychiatry (experience and training must be documented on the specific Children Credentialing form).
  • Must be in good standing with all facilities that are contracted with the HBI network (if applicable).

Allied Practitioners

  • Graduate of an accredited school or certification program in one of these special disciplines of practice:
    • Ph.D. in Psychology
    • Master Degree in Social Work
    • Psychiatric Registered Nurse
    • Marriage and Family Therapist
    • Drug and Alcohol Counselor
    • Physician Assistants
    • Nurse Practitioners
  • Clinicians must have an unrestricted license by their selective state boards in the state in which they practice, and should have certification specific to their specialty area.
  • Demonstrate two years of recent clinical experience (post licensing).
  • Completed postgraduate internship in perspective discipline.
  • Chemical dependency must demonstrate at least one year of supervised experience working with chemically dependent patients in an inpatient setting, and have two years of experience in an outpatient setting.
  • Clinicians who provide services to children must document experience and training on the Children Credentialing form.
  • Must be in good standing in all facilities contracted with HBI (if applicable).

Contracted Plans

HBI Network serves members of several insurance plans and each plan design is unique. When you were admitted into the HBI Network, you received a welcome letter and a copy of the agreement with the insurance plans you are contracted with. It is your responsibility as a provider to understand the terms and conditions in regards to eligibilities, authorization, and claim submission, specific to each plan. A copy of the current Contracted Plan Summary Guide can be requested by e-mailing claims@hbinetwork.com.

Medicaid Plans

Whether it’s fee-for-service or managed care plans, HBI adheres to the Medicaid Services Manual – Chapter 400 in rendering services to Medicaid recipients. Medicaid plans have separate guidelines for provider eligibilities and enrollment. To verify if you are eligible to render services to Medicaid recipients as an HBI provider, please contact our Provider Service at credentialing@hbinetwork.com.

Access and Referral

Centralized scheduling enables HBI’s Intake Department to match members with the appropriate clinician on the initial call. Members can call HBI (Toll-free) 1-800-441-4483 and speak to an Intake Specialist who will obtain and determine the patient’s:

  • Demographic information
  • Preliminary clinical information to identify high-risk & special needs cases
  • Benefits and eligibility
  • High-risk / special need
    • Immediate access
    • Assign therapist & case manager
    • Establish level of care services
    • Triage to the appropriate service provider or facility
    • Expedite to case management
    • Proper referral & follow-up
  • Need for Referral to:
    • Network providers
    • County agencies
    • School coordinator
    • Medical services
  • Appointment availability and setting for providers who make their schedule accessible to our Intake Department

As an HBI Network Provider, we may refer patients to your office through one or more of the following methods:

  1. By our Intake Department.
    Referrals coming from our Intake Department are for clients that have never been seen at HBI therefore no file has been created for them. Our Intake Staff gives them your contact information and directs the patient/client to contact your office to set up the appointment for an initial evaluation.
  2. By one of HBI Rapid Assessment Clinicians.
    Referrals made by one of our Rapid Assessment Clinicians are for clients who have attended our Rapid Assessment where they are interviewed by one of our licensed clinicians to determine the services they need. This screening process is not in lieu of a full initial evaluation but merely to determine the urgency of the patient’s needs and services they may require. Our Rapid Assessment Clinician gives them your contact information and directs the patient/client to contact your office to set up an appointment for a more thorough evaluation.
  3. By one of our Therapists.
    This is for patients/clients who are already being seen or have been seen at HBI for one or more full sessions. An HBI therapist might decide, for whatever reason, that the patient/client needs to be referred to another clinician. The HBI clinician gives them your contact information and directs the patient/client to contact your office to set up an appointment

In any of the cases above, the initial evaluation session is automatically authorized, verification of eligibility is already done for you by our Intake Department and tagged with our UM Department as referred patients. However, there may be a lag of time before you actually see the patient and changes in their benefits may have occurred. Therefore, providers must always check the patient’s eligibility and benefits prior to their appointment.

Referrals for Medication Evaluation and Management

Although not specifically required by some commercial and even the public sector health plans, HBI advocates for a more holistic treatment approach for all the members/patients we serve. We have observed that a significant number of recipients requesting psychiatric medication but not psychotherapy treatment. We live in a society where drugs, whether prescribed or not, seem to be preferred as remedy in order to deal with life’s daily challenges (i.e., emotional, behavioral) but the underlying problems still remain.

HBI is committed to helping our patients to gain better understanding of their behavioral health benefits by providing a “therapeutic community” – involving providers, family support, school teachers and community agencies. We urge our network providers to be a part of this therapeutic community by utilizing care coordination services through Treatment Referrals.

  • Therapists/Counselors referring their patients for medication evaluation and management can submit a treatment referral to HBI. HBI will then process the referral for authorization and forward the information to the psychiatrist so they can contact the patient for an appointment. This process helps coordinate treatment and allows psychiatrists to focus on patient care.

    In case the therapist/counselor does not have a specific psychiatrist to refer the patient to, HBI can make the referral based on the patient’s preference (i.e. geographic location, language, etc.) and coordinate the referral with the patient.

  • To ensure that members are not only getting medication but a coordinated psychotherapy treatment as well, HBI encourages Psychiatrists to confirm if their patient is receiving counseling services. If a member/patient does not have a therapist, please advise that member/patient to contact HBI. Our Intake Staff will assist them to get connected to a qualified clinician based on their preference (i.e. geographic location, language, etc.).

Obtaining Prior Authorization

Some plans have a pre-approved number of initial sessions and some require prior authorization from the initial visit. You must verify eligibility before seeing your patient. With some plans, the initial evaluation is automatically authorized. Refer to your copy of the Contracted Plan Summary on verifying eligibility and benefits.

Providers must submit the appropriate report in order to obtain authorization for continued services. Certain plans require that authorization be issued within a specific number of days. For example, Medicaid requires that authorization be issued within 14 days of receiving the request and all required information. HBI’s turnaround time for processing properly completed requests for authorization is usually within 24 hours upon receipt.

  • Initial Mental Health Assessment

    As the name implies, this form is used to record your patient’s initial evaluation report. It must be completed and submitted to HBI in order to register the member’s visit and to request for follow-up sessions.

    If you believe that your client’s problems and symptoms indicate (SED) Severe Emotional Disturbance (for children and adolescents, age below 18) or (SMI) Severe Mental Illness (for adults), complete the SED/SMI Determination forms and submit it with the mental health assessment.

  • Outpatient Extended Care

    If you have been treating a particular member of an extended period of time and you believe that this member has a diagnosis with corresponding symptoms that need to be addressed further with additional services, you as a network provider must submit a completed Outpatient Extended Care report before additional visits can be authorized. This type of request must meet eligibility and UM Criteria.

  • Request for Testing

    Some plans allow specific network providers to request and administer a psychological or neuropsychological testing. This service is subject to medical necessity criteria and requires prior authorization. Testing may be considered medically necessary only if used to satisfy all of the following:

    1. Diagnose and assess level of cognitive functioning/improvement/assess psychopathology
    2. Establish/confirm a medical/psychiatric diagnosis,
    3. Produce a change in the treatment plan
    4. Guide therapeutic management of the patient

      5. For neuropsychological testing, a medical diagnosis or clinical symptom presentation suggesting a medical diagnosis is required in order to approve testing.

Psychiatrist/MD/DO or Psychiatric Physician’s Assistant

  • Psychiatric Initial Evaluation

    You or your patient may contact HBI in order to register the patient’s information prior to the initial visit. If you’ve already seen the patient for the initial evaluation, we ask that you submit a completed short one-page Psychiatric Initial Evaluation.

  • Medication Follow-up Report

    If you have exhausted the authorized number of visits for your patient and need to render additional sessions, submit a completed Medication Follow-up Report.

For more information on obtaining prior authorization, contact:

HBI Utilization Management
E-mail: um@hbinetwork.com
Fax: (702) 248-0079

Denial and Appeal Process

HBI’s Utilization Management (UM) Criteria are developed and approved by the Quality Improvement Committee consisting of highly-experienced clinicians, psychiatrists, psychologists, and plan representatives, and are based on established national standards from:

  • American Psychiatric Association
  • DSM IV
  • HBI clinical experience
  • ASAM for Chemical Dependency
  • Community standards/cultural sensitivity

Denial

When a requested service does not meet the UM criteria, then the case is referred to HBI’s Clinical Director and/or Medical Director for review and a written Notice of Denial is mailed to both the member and provider or facility detailing the reason for the denial and information on the appeal process.

Appeal Process

When appealing a denial of service, the provider must contact HBI’s UM Department in writing and provide additional information or documentation to substantiate the reason for more services within a specific time-frame, and request to speak with a peer reviewer.

Based on the new information received, it is HBI’s responsibility to:

  • Re-evaluate new clinical information provided;
  • Have another peer other than the original reviewer;
  • Render a decision to either overturn, or uphold the denial;
  • Send the provider and the member a written notice as to the reason for upholding the denial;
  • Respond within 45 days (for routine requests); or
  • Immediate 72-hour response for urgent requests.

For more information on obtaining prior authorization, contact:

HBI Utilization Management
E-mail: um@hbinetwork.com
Fax: (702) 248-0079

Claims Submission

Consult your copy of the Contracted Plan Summary to determine where you should send your claims for processing based on your client’s insurance plan. To avoid delay of payment, make sure you follow the plan requirements for claims submission.

Please follow these guidelines when filing a claim with HBI.

  • Bill normal charges for services rendered using CMS-1500 form
  • Make sure that all of the entries are accurate and complete
  • All claims must be received at HBI within 90 days from the date of service
  • If a claim is received after the 90-day cut off it may be denied
  • Make sure that your signature and title is on the CMS-1500 form.

If a claim is received at HBI and it doesn’t contain all of the information to process the claim, a letter will be sent to you explaining the information required to pay the claim. NO claims will be paid unless all information is documented on the CMS-1500 form.

Helpful information you might need to know when submitting a claim

Member Financial Responsibility

As a contracted provider, it is your responsible to determine what your patient’s financial obligations are based on their insurance plan.

  • You can refer to the Contracted Plan Summary to learn how to verify your client’s benefits, co-payments and deductibles.
  • Providers may collect the appropriate payment for the visit based on the member’s applicable deductible, co-insurance and/or co-pay. Providers may not collect more than the contracted fees.
  • Members are responsible for any non-covered benefits (i.e. taxes, non-covered testing, etc.)

Other very important information you need to know when submitting claims:

  • All claims are subject to eligibility & medical necessity at the time claims are received.
  • Obtaining prior authorization does NOT guarantee payment. A member may have exhausted his/her benefits, insurance may have termed, etc. at the time claims are filed and received.
  • Treatment of members must be performed by the credentialed provider that the referral was made by. You may not bill in your name when treatment is provided by another provider or assistant.
  • Patients referred to you may not be referred to another practitioner without authorization.
  • You may bill another insurance carrier at your usual and customary rate for non-covered services after the member’s benefits have been exhausted. However, any co-insurance a member pays must not exceed the difference between the amounts collected from the insurance carrier and the network’s negotiated rate.

For more information about claims processing, contact your client’s insurance plan.

Case Management

HBI believes in an integrated mental healthcare approach. This program, one of the most qualified in the State of Nevada, is comprehensive in nature and is designed to manage and reduce mental healthcare costs without compromising services. HBI offers this integrated mental health concept in a case management format where patients are introduced and guided through the system until they are discharged from treatment.

Case Management Program Features

  • Early Identification of High Risk Patients
  • Discharge Planning
  • Evaluation and Referral
  • Utilization Review
  • Counseling
  • Patient and Provider Education
  • Intervention and Follow-Up
  • Management Consultation
  • Coordination with Medical and County Agencies

Care coordination is a continuous process of systematically prioritizing member needs based on defined criteria followed by designing, implementing, and monitoring the most appropriate clinical intervention to achieve a positive outcome.

Care coordination is ideal for patients with the following conditions:

  • Dual diagnosis
  • Chronic mental illness SED/SMI
  • High dosage of anxiety / pain medication
  • Suspected abuse or neglect
  • History of non-compliance
  • Multiple failed treatments
  • Poor support system
  • Potential homelessness
  • Other

Primary Medical Care Support & Coordination

It is well known that over 50% of all primary care visits involve some level of mental health issues. Antidepressant medication is currently being prescribed at record highs, with over 70% being prescribed by general physicians. Integrating behavioral health with certain medical conditions will accelerate medical recovery, reduce medical costs, give support and consultation services to primary care physicians, and identify those patients who need behavioral health intervention.