Post on 16-Jul-2020
Georgia
Outpatient
Treatment
Requests
Objectives
As a result of this training, participants will be knowledgeable of:
• How to successfully complete GA OTRs
• Frequently requested GA codes
• Tips that are useful when submitting OTRs
• Common Errors to avoid with GA OTRs
OUTPATIENT TREATMENT REQUEST FORM
• Member Information
• DSM-IV Diagnosis
• Functional Outcomes
• Therapeutic Approach
• Level of Improvement
• Symptoms
• Functional Impairment
• Risk Assessment
OUTPATIENT TREATMENT REQUEST FORM
• Treatment Goals
• Requested Authorization
• Additional Information
• Name/Signature/Date
Ensure letters and fonts are legible
Complete with full name of member
Member ID number is a 12 digit member number
Enter complete provider’s name, tax id and NPI number
Complete facility phone number
Complete facility fax number to send notification to coverage
MEMBER/PROVIDER INFORMATION
DSM – IV TR DIAGNOSIS
Complete Axes I – V using the DSM IV - TR multi-axial format
DSM code and DSM description entered should match
Answer if provider has contact with the PCP, check yes/no
On each OTR, enter the first and last date seen by provider
FUNCTIONAL OUTCOMES
Complete during assessment with the member or guardian
Answers should change based on current functioning
Section should be updated on each OTR
Note: Questions 9 & 10 are for children, 11 & 12 are for adults
THERAPEUTIC APPROACH/
LEVELS OF IMPROVEMENT
Indicate Therapeutic Approach/Evidence Based Treatment used
(i.e., DBT, CBT, Reality Therapy, Play Therapy)
Level of Improvement should be updated on each OTR request
If Minor/No progress, indicate what treatment changes will be made
Indicate what is current or possible hindrances to discharge
SYMPTOMS
Check only present symptoms – within last 30 days
Indicate to what degree symptoms impact daily functioning
Check list should be updated on each OTR request
OOH Placement (if present) may be marked in space ‘other’
One box should be checked for each line, check N/A if not present
FUNCTIONAL IMPAIRMENTS
• Indicate to what degree symptoms impact daily functioning
• Check list should be updated on each OTR request
• If substance use, indicate drug of choice and date of last use
• Impairments should be addressed on OTR or treatment plan
RISK ASSESSMENT
Indicate suicidal and homicidal risks – current and historical
• Current – Ideation (thoughts, plan, imminent intent )within last 30 days
• History – Past self harming behaviors or harm to others
If risk factor is noted, please indicate if safety plan is in place
Check if member is compliant with psychotropic medication
TREATMENT GOALS
Goals should be updated and changed over time
Progress should indicate how treatment is beneficial
Should address symptoms and/or functional impairments
Use SMART technique when stating goals
Each requested service needs to have a corresponding treatment
goal
Measurable Goals/Objectives/Interventions
Objective Goals are SMART, not Vague
SPECIFIC – Who, What, When, Where, and How
MEASURABLE – Intensity, Frequency, Duration of Symptoms
Use a quantitative format – (i.e., 6X, 80%)
ATTAINABLE – Within the member’s scope or capability for the
current treatment episode?
REALISTIC – Is the bar set too high or too low for this member?
TIME-LIMITED – Is it an opportune time for the member to pursue the
identified goals? Use specific timeframes
Client will decrease anger outbursts from 15x a week to 7x a week by
using learned anger management skills, over the next 90 days
SMART GOALS
REQUESTED AUTHORIZATION
Complete for currently needed pre-authorized services only
Start Date: Date each service is started, dates may be different
Frequency: How often will client be seen? (i.e., 2x/month)
Intensity: Length of time per visit, # of units (1 unit=15 mins)
Requested start date of authorization
Anticipated completion date
Start dates can only be backdated 1 day before received date
Note modifiers for some codes
ADDITIONAL INFORMATION
Use to request H2017, if an authorized provider
Add any relevant information which supports the need for requested
services – symptoms, level of functioning, etc.
What traditional behavioral health services been attempted?
Address lack of progress by adding new interventions or new goals
It is mandatory to enter the provider’s name, signature and date
Commonly Requested Codes
• 9 Codes - Behavioral Health Outpatient Services(BHOP)
• H0004 - Group/Family Psychotherapy
• H0036 - Intensive Family Intervention
• H0039 - Assertive Community Therapy
• H2011 - Crisis Intervention Services
• H2014 - Group/Family Skills Training
• H2015 - Community Support Individuals
• H2015 HF - Addictive Disease Support
• T1016 - Targeted Case Management
• H2017 - Psychosocial Rehabilitation
Behavioral Health Outpatient Services
BHOP - 9 codes/billed as CPT codes
Description:
Individual/Group/Family Psychotherapy. Effective 8/24/2014
pre-authorization needed for clinicians who are NOT fully licensed
• Lowest Level of Care
• 9 codes units are bundled together in Cenpatico’s system
• Individual Therapy (IT) - CPT code 90837
• Family Therapy (FT) - CPT code 90847
• Group Therapy (GT) - CPT code 90853
Medical Necessity Criteria (MNC):
MNC is determined by Interqual or ASAM
Community Based Service Codes
H0004 – Behavioral Health Counseling and Therapy
(Family/Group)
Description: Family Psychotherapy involves interaction between the member, staff and
the member’s family unit. Group Psychotherapy involves services to address
specific goals/skills, concerns or issues.
• Historically used for in-home family therapy and/or by non-licensed
master level clinicians
• Presently, can be interchanged with 90847 (family therapy) and 90853
(group therapy)
Medical Necessity Criteria (MNC):
MNC is determined by Interqual or ASAM
Community Based Service Codes H0036 - Intensive Family Intervention - Youth Only
Description:
Intensive Family Intervention (IFI) Services – Intense short term services designed
to improve family functioning, stabilize living arrangement, promote reunification,
and/or prevent out-of-home placement.
Medical Necessity Criteria (MNC): A & B and either C, D, E
A. Diagnosis/duration of symptoms which classify the illness as SED and/or is
diagnosed Substance Related Disorder.
B. Risk of OOHP or in an OOHP where reunification is imminent.
C. Member and/or family lack the skills to cope with an immediate behavioral
health crisis.
D. Member and/or family behavioral health issues are unmanageable in
traditional outpatient treatment.
E. Treatment at a lower intensity has been attempted or given serious
consideration.
Community Based Service Codes H0039 - Assertive Community Treatment (ACT)
Description:
Assertive Community Treatment– A recovery-focused, high intensity service for
members discharged from multiple or extended stays in psychiatric hospitals or
who are difficult to engage in treatment. Services are available 24 hours/7 days
a week. Goals must be clearly described by the provider.
Medical Necessity Criteria (MNC): A, B & C
A. Diagnosis of a severe and persistent mental illness that seriously impairs the
ability to live in the community.
B. Significant functional impairment as demonstrated by the inability to
consistently care for self (i.e., hygiene, nutrition, housing, employment)
C. The member has continuous high-service needs that are greater than 8 hours
per month (i.e., hospitalization, recurrent severe symptoms, co-existing
disorders). Lower level of service has been tried and found inappropriate or
ineffective.
Community Based Service Codes
H2011 - Crisis Intervention Services
Description:
Crisis Intervention is a time limited service designed to prevent out of home
placement or hospitalization. It could be used to manage or de-escalate a
crisis. This code cannot be processed ‘pre-crisis’ or ‘as needed’. OTR should
be submitted within 30 days of the crisis.
Medical Necessity Criteria (MNC):
A. Member has a known or suspected mental health diagnosis or
substance related disorder.
B. Member must be in active crisis - SI/HI or severe aggressive behaviors;
where there is a risk of harm to self, others and/or property.
C. Provider must note on the OTR how the crisis was handled and what was
the outcome (1013, developed a crisis plan, etc.)
Community Based Service Codes H2014 - Family Training/Group Skills Training
Description:
In a group format, teach parenting skills and family skills training with specific
activities to enhance the member’s recovery (i.e., anger management,
substance abuse prevention, social skills)
Medical Necessity Criteria (MNC):
A. Member must have a mental illness and/or substance-related disorder diagnosis that is destabilizing (markedly interferes with the ability to carry out activities of daily living or places others in danger) or distressing (causes mental anguish or suffering).
B. The plan of care must include treatment goals that clearly indicate how the service will be utilized. Goals must be specific, measurable, attainable, realistic, and time limited.
C. When clinical/functional needs are great, there must be complementary therapeutic services.
Community Based Service Codes
H2015 - Community Support Individuals
Description:
Teach member skills to improve functioning in the community, home and
school. Code can be used for parenting skills using the UK modifier.
Medical Necessity Criteria (MNC):
A. Children/Adolescents only.
B. DSM-IV Axis I-V diagnosis and must be assigned by a licensed psychologist,
physician, or a PA or APRN working in conjunction with a physician with an approved job description or protocol or LCSW.
C. There must be complementary therapeutic services. It is not intended to be used as a stand alone service.
D. The plan of care must include treatment goals that clearly indicate how the service
will be utilized. Goals must be specific, measurable, attainable, realistic, and time limited.
Community Based Service Codes H2015 HF Addictive Diseases Support Services
Description:
Specific to adults with addictive disease issues, focuses on substance abuse recovery services/supports and skill building
Medical Necessity Criteria (MNC):
A. Individuals with one of the following: Substance-Related Disorder, Co-Occurring
Substance-Related Disorder and MH Diagnosis, or Co-Occurring Substance-
Related Disorder and DD and
B. Must be willing to enroll in a program targeted to reduce and/or stop the use of harmful substances; and one or both of the following:
• Individual may need assistance with developing, maintaining, or enhancing social supports
or other community coping skills; or
• Individual may need assistance with daily living skills including coordination to
access necessary rehabilitative/medical services , employment, education, etc.
Community Based Service Codes
T1016 Case Management
Description:
Targets adults with severe psychiatric disabilities and assist individuals w/housing,
developing self-management skills, increase social/leisure skills
Medical Necessity Criteria (MNC):
• Priority given to those individuals with a psychotic disorder (e.g.,
schizoaffective disorder) or bipolar disorder; and one or more of the following:
A. Admission to a psychiatric inpatient setting or crisis stabilization unit
(i.e. within past 2 years);
B. Released from jail or prison (i.e. within past 2 years);
C. At-risk of OOHP or history of homelessness w/in the past 2 years
Community Based Service Codes
H2017 - Psychosocial Rehabilitation: Individual or Group
Description:
A therapeutic, rehabilitative, skill building and recovery promoting service intended to assist individuals in gaining the skills such social, vocational, and etcetera necessary to allow them to remain in or return to community settings and activities (Contracted
Providers Only)
Medical Necessity Criteria (MNC): Admission criteria A-D must be met
A. Individual must have primary behavioral health issues (including a co-occurring substance abuse disorder or MR/DD) and/or no risk of danger to themselves or others. The current symptoms and impairments indicate a LOCUS score of level 3 or higher.
B. Individual lacks many functional and essential life skills such as living, social skills, vocational/academic skills and/or community/family integration; or
C. Individual needs frequent assistance to obtain and use community resources.
D. A treatment plan that includes treatment goals that clearly indicate how the service will be utilized.
3 C’s of Clinical InformationAuthorization units are based on
clear, complete and consistent clinical information
• Severity/intensity of symptoms and functional impairments noted
• SMART goals/objectives for each service code requested
• Less services requested as member improves (titration)
• On average 3 – 6 months is considered adequate to teach skills
for community based codes (H-codes)
• Codes requested are congruent with symptoms severity/intensity
• Narrative and treatment plan supports severity/intensity of symptoms
• Updated attachments – dated within 6 months for treatment plan
• Lack of progress addressed
• H-Codes: H2014 - note whether for family or group
H2017 – note if a contracted provider
H0036/T1016 – note OOHP risk & specific/potential threat
TIPS - FAQWhat are the timelines for sending OTRs?
OTRs can be sent in up to 3 weeks in advance, however, OTRs cannot
be backdated more than 1 business day
When should I expect to get a response?Providers will receive a response 7 – 14 days of submission
Where do I send OTRs and attachments?Completed OTRs and attachments are faxed to 866 694-3649
What demographic information is essential?Complete All requested demographic information for member & provider
What happens if OTR is incomplete?Submitting an incomplete OTR may result in:
OTR being returned to you
Reduced authorization of units
Denial
What happens if OTR is denied?
Provider will receive a denial letter detailing appeal options
• The most up-to-date OTR form is on our website at www.cenpatico.com
• Update all OTRs. Avoid cutting & pasting previously submitted information
• An OTR with only requested dates changed may result in a denial
• Use S.M.A.R.T. goals/objectives
• Narratives and treatment plan should address diagnosis/symptoms
• Attachments should be current, completed within 1 month for clinical
information and 6 months for treatment plan
• It is mandatory to sign and date OTRs
Summaryvague, incomplete, inconsistent, non-clinically supported/explained OTRs
EQUAL
delayed, problem letter, less units, denial
REMINDERS
PROBLEM LETTER
SAMPLE OTR (incorrect)
SAMPLE OTR (correct)
Cenpatico Website: www.cenpatico.com
Cenpatico Phone Numbers: 1-800-947-0633
Health Plan Phone Number: 1-866-847-0633
Claims Phone Number: 1-866-324-3632
Claims Address: PO Box 6400, Farmington, MO 63640
IMPORTANT CONTACT INFORMATION
QUESTIONS