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Transcript of 1 Illinois Department of Human Services, Division of Mental Health The Illinois Mental Health...
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Illinois Department of Human Services, Division of Mental Health
The Illinois Mental Health Collaborative for Access and Choice
November 2010
Authorization Requirementsfor
Therapy Counseling, Psychosocial Rehabilitation and Community Support Group Services
Effective January, 2011
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Introductions
Lee Ann Reinert, LCSW - IL DHS/DMH Clinical Policy Specialist
Emily Sherrill, LCSW - Collaborative Clinical Director
Todd Kasdan, MD - Collaborative Medical Director
Presentation Online
Today’s presentation will be available online http://www.illinoismentalhealthcollaborative.com/provider/prv_information.htm
Be sure to share this information with your staff!
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Agenda
Overview of Utilization Management Program Medical necessity Overview of authorization processes Mental Health Assessment (MHA) requirements Individual Treatment Plan (ITP) requirements Requests for reconsideration and appeal of denial
decisions Questions and answers
Utilization Management Program Overview
Introduction: The Utilization Management (UM) Program is the vehicle
through which DHS/DMH ensures that individuals being served receive:
– the services best suited to support their recovery needs and preferences,
– cost effective services in the most appropriate treatment setting,
– services consistent with medical necessity criteria and evidence-based practices.
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Utilization Management Program Overview
By implementing the UM Program, DHS/DMH strives to achieve a balance between:
– the needs, preferences, and well-being of persons in need of mental health services
– demonstrated medical necessity – the availability of resources
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Utilization Management Program Overview
The UM Program:– does not limit medically necessary Medicaid services– is fully compliant with the Illinois Medicaid State Plan and
associated federal rules
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In developing the UM Program, DHS/DMH acknowledges the following guiding principles:
UM is dynamic and evolutionary. As additional data, new research, and other new information occurs with experience, the UM Program will evolve and change.
UM must be based on data. The UM Program must use data to identify patterns of utilization, work with clinicians to determine if the patterns and variations are desirable or not, and work with providers to make needed improvements.
Individuals accessing services should have a consistent threshold of medical necessity statewide. The UM Program must provide clear guidance for medical necessity decisions so that all individuals accessing services have consistent and equitable access to specific services.
Authorization must be clinically focused and conducted by qualified staff. Where authorization is determined to be necessary, it must be based on clinical information and reviewed by staff at the independent license level (LPHA).
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UM Program Overview, continued
The DHS/DMH Utilization Program has the following components:
Medical Necessity Guidance and Criteria
Limited External Authorization
Ongoing Data Reporting and Analysis
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UM Program Overview, continued
Medical Necessity Guidance and Criteria. DHS/DMH is initially providing medical necessity criteria for
the following services:
Assertive Community Treatment (ACT)
Community Support Team (CST)
Psychosocial Rehabilitation (PSR)
Community Support Group (CSG)
Therapy/Counseling (T/C)
Community Support Individual (CSI) For those services available to both adults and children,
separate criteria are provided for each.
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UM Program Overview, continued
These criteria may be found in the DHS/DMH Medical Necessity Criteria and Guidance Manual (within the Provider Manual)
These criteria should be used by providers to guide them in making consistent admission, continuing service, and termination of service decisions for each consumer.
Providers must use these criteria consistently, regardless of whether or not DHS/DMH or its designee externally authorizes the service.
Provider adherence to these criteria may be subject to post payment review.
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UM Program Overview, continued
Limited External Authorization. Authorization for payment by DHS/DMH or its designee will be required for
specific services, based on a review of service utilization patterns for a previous fiscal year.
– Thresholds are the same for adults and children/adolescents and are calculated by provider and consumer per fiscal year. For FY11, thresholds will be calculated for the remainder of the fiscal year, beginning with dates of service of January 3, 2011.
– Authorization for payment of services beyond the specified thresholds will be based on medical necessity criteria.
– Services will continue to be authorized as long as medical necessity is in evidence.
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UM Program Overview, continued
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For purposes of determining clinical review thresholds, PSR and CSG utilization will be managed as a combined benefit. Clinical review and continuing service authorization will be required whenever an individual’s utilization of PSR and CSG combined exceeds 800 units per fiscal year, with recognition that an individual may use one or both of these services during the year.
UM Program Overview, continued
Ongoing Data Reporting and Analysis DHS/DMH will continue to report and analyze
– utilization patterns– post payment review results– authorization impacts– other quantitative and qualitative aspects of service delivery.
These data will be used to inform – provider technical assistance efforts– training– future UM Program modifications
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Medical Necessity Criteria
Diagnosis Service Initiation Criteria Continuing Service Criteria Exclusion Criteria Service Termination Criteria
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Medical Necessity Criteria
DIAGNOSIS:– Current eligible mental health diagnosis for which the
proposed course of treatment has been determined to be effective
– Symptoms consistent with those described in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical Classification of Diseases and Related Health Problems (ICD)
– Symptoms addressed do not have their primary origin in a diagnosis of an Autism Spectrum Disorder, substance-related disorder, or a principal Axis II diagnosis of Mental Retardation
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Medical Necessity Criteria
Service Initiation Criteria– To be considered for all individuals receiving services for which
guidance is published– May be subject to Post Payment Review– Establishes basis for need for service
Continuing Service Criteria– To be utilized for determination of need for ongoing services,
once individual meets threshold– Will be basis for the Collaborative’s authorization decision
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Medical Necessity Criteria
Exclusion Criteria – Reasons for service to be considered inappropriate for an
individual– Could be cited at either Post Payment or Authorization Review
Termination Criteria– Reasons for discontinuing service– Could be cited during Clinical Practice Guidance or
Authorization Review
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Medical Necessity CriteriaTherapy/ Counseling
SERVICE INITIATION CRITERIA - Severity/complexity of symptoms and level of functional impairment require this service, as evidenced by:
Individual has an emotional disturbance and/or diagnosis that is destabilizing or distressing
Individual’s assessment identifies specific mental health problems that may be effectively addressed by Therapy/Counseling
Level of Care Utilization System (LOCUS) score equating to Level of Care 2 or higher for adults or clinician-rated Ohio scale of 16 or higher for youth age 5 and up
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Medical Necessity CriteriaTherapy/ Counseling
Continuing Service Criteria Evidence of active participation by individual Demonstrated evidence of significant benefit from this
service:– as evidenced by the attainment of most treatment goals,
but the desired outcome has not been restored – and the individual’s level of emotional stress continues to
be destabilizing, significantly interfering with daily functioning
Individual cannot be safely and effectively treated solely through the use of Community Support services, case management, and the engagement of natural support systems.
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Medical Necessity CriteriaTherapy/ Counseling
Additional Criteria for Specific Modalities Individual – necessity of one to one interventions Group – specifically identified problems with social
interactions, interpersonal difficulties, etc, for which involvement in group process is expected to be beneficial
Family – identified problems are exacerbated by family dynamics and/or can be most effectively addressed through family involvement
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Medical Necessity CriteriaTherapy/ Counseling
Exclusion Criteria Cognitive impairment, mental status or
developmental level that makes it unlikely individual would benefit
Primary problem to be addressed could be more effectively/efficiently addressed by another modality
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Medical Necessity CriteriaTherapy/ Counseling
Service Termination Treatment goals achieved Majority of goals achieved and remainder can be
safely achieved by accessing other services and/or natural supports
No significant improvement and needs to be reassessed for more effective treatment
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Medical Necessity CriteriaPsychosocial Rehabilitation
Service Initiation Criteria Significantly impaired role function in at least 2 of the following:
– Management of financial affairs– Ability to procure needed services– Socialization, communication, adaptation, problem solving and coping– Activities of daily living– Self-management of symptoms– Concentration, endurance, attention, direction following and planning
and organization skills necessary for recovery LOCUS Score equating to level of care of 3 or higher Discharge/transition plan expressly focused on increasing community
integration through the application of skills in community settings.
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Medical Necessity CriteriaPsychosocial Rehabilitation
Continuing Service Criteria Treatment plan reflects modifications in PSR services for skills
that the individual has not yet been able to successfully demonstrate
Individual cannot be safely/effectively treated through provision of alternative community-based services or engagement of natural supports
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Medical Necessity CriteriaPsychosocial Rehabilitation
Exclusion Criteria Individual under age 18 Individual chooses not to participate Primary etiology of dysfunction related to Axis II
diagnosis, or an organic process or syndrome including normal aging
Individual’s ADLs/skills are sufficient to enable progress in recovery
Individual requires more intensive contact
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Medical Necessity CriteriaPsychosocial Rehabilitation
Service Termination Criteria Individual has learned the skills and requests
termination or no longer needs active treatment Has learned most of the skills, can apply and
improve skills in natural settings Is not making progress and needs reassessment to
determine more appropriate services
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Medical Necessity CriteriaCommunity Support Group
Service Initiation Criteria Significant impairment in functioning, inability to apply skills in
natural settings, and/or to build/utilize natural supports Require small group support to facilitate more effective role
performance Identification of specific functional impairments that can only be
remediated through small group practice to reinforce target skills
LOCUS level of care recommendation of 2 or higher
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Medical Necessity CriteriaCommunity Support Group
Continuing Service Criteria Has demonstrated significant improvement with this service,
attaining most skill-building and community integration, but– Desired outcome/level of functioning has not been
restored/sufficiently improved
or– Without these services, the individual would not be able to
consolidate treatment gains or progress in recovery Cannot be safely/effectively treated through provision of
alternative services or engagement of natural supports
Medical Necessity CriteriaCommunity Support Group
Exclusion Criteria Individuals daily living skills are sufficient to enable progress in
recovery without CSG services Cognitive impairment, current mental status or developmental
level makes it unlikely to benefit from CSG services Primary etiology related to Axis II or organic processes,
including normal aging Requires more intensive services/cannot be safely treated with
CSG
Medical Necessity CriteriaCommunity Support Group
Service Termination Criteria
Individual has achieved goals and requests termination or no longer needs this service
Has successfully demonstrated most of the skills, can be safely and effectively treated without CSG
Is not making progress and needs reassessment to determine more appropriate services
Authorization in a nutshell for Therapy/Counseling, Psychosocial Rehabilitation and Community Support Group
Who – any consumer, for whom the provider is seeking reimbursement, receiving over the threshold hours/units of T/C, PSR, CSG services
When – Authorization for payment of services is required after January 3, 2011 for any consumer receiving services above and beyond the threshold hours/units of service
What – Authorization request form with a Mental Health Assessment (MHA) and Individual Treatment Plan (ITP), along with any other supporting documentation to establish Medical Necessity Criteria
How - Submit authorization request electronically through ProviderConnect and supporting clinical documentation either as secure clinical attachments with request or via facsimile
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What do I send when requesting an authorization?
Information required:– Authorization request via ProviderConnect
All required and applicable fields completed– Including age appropriate functional scales (LOCUS, Ohio Scale, DECA)– Current Axis I – V elements
– Current MHA and ITP Securely attached with ProviderConnect request or faxed to the Collaborative
(866-928-7177) within 1 business day
– Additional documentation may be necessary if the MHA and ITP do not fully support medical necessity for the request
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Authorization Process
Therapy/Counseling:
Eligible Consumers are able to initially receive up to 10 hours (40 units) of this service, if provider LPHA deems medically necessary, without submission of an authorization request
If provider deems additional hours (units) of T/C are medically necessary above and beyond the 10 hour (40 unit) threshold, a request for authorization must be submitted and authorization must be obtained in order to be reimbursed for services
Determination of additional hours (units) to be reimbursed are based upon medical necessity. This will take into consideration the number of units requested and will be based on what is medically necessary.
Authorization Process, continued
PSR & Community Support Group:
Eligible Consumers are able to initially receive up to 200 hours (800 units) of PSR, CSG, or a combination of PSR & CSG, if provider deems medically necessary, without submission of an authorization request
If provider LPHA deems additional hours (units) are medically necessary above and beyond the 200 hour (800 unit) threshold, a request for authorization must be submitted and authorization must be obtained in order to be reimbursed for services
Determination of additional hours (units) to be reimbursed are based upon medical necessity. This will take into consideration the number of units requested and will be based on what is medically necessary.
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Authorization Process, continued
Collaborative clinical care managers review submitted documents for adherence to Medical Necessity Criteria (MNC), and Rule 132.
If the MNC are met for the service(s), the Collaborative will enter an authorization.
In order for the provider to be reimbursed for services provided beyond initial thresholds, requests for authorization must be submitted and approved prior to service provision. Providers must submit requests for authorization prior to the authorization expiration date and/or the maximum number of hours/units allowed
Authorization Request
All requests for authorization MUST be submitted via ProviderConnect. The Collaborative will not review requests for authorization submitted via facsimile.
If choosing to fax, rather than attach to the on-line request, the supporting clinical documentation for the request (e.g. MHA, ITP, etc.), please ensure that each consumer’s information is faxed separately.
If choosing to fax, rather than attach to the on-line request, the supporting clinical documentation for the request (e.g. MHA, ITP, etc.), please ensure that the service being requested is noted on the fax cover sheet.
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Authorization request, continued
Authorization requests for T/C, PSR, and CSG will require completion of the following information for adults:
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Ohio/Devereaux Scale Results
Required for CSG and T/C requests for all consumers under the age of 18 Ohio Scale Results are required for youth ages 5 through 17
– Service initiation (all)– Current (if in services more than 90 days)
Devereaux Scale Results (DECA Subscale for children under the age of 5)– Protective Factor Scores
Service Initiation (all) Current (if in services more than 90 days)
– Behavioral Concern Scores (only for children over the age of 3, under the age of 5)
Service Initiation (all) Current (if in services more than 90 days)
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MHA Requirements
MHA Requirements– A consumer’s MHA is required to be submitted as
part of the authorization process– The Collaborative Clinical Care Managers will be
determining if the MHA identifies needs consistent with the service being requested.
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ITP Requirements
The consumer’s ITP is required to be submitted as a part of the authorization process to assure clinical congruence between the goals/interventions listed in the ITP, service definition criteria, and the LOCUS score/Ohio scale/DECA.
The Collaborative Clinical Care Managers will be determining if the treatment plan describes interventions and goals consistent with the service being requested.
Additionally required documentation
When MHA and ITP do not appear to fully justify or support MNC for the requested service and/or appear to have inconsistencies, additional documentation must be submitted with the request
Examples: Progress notes Psychiatric notes/evaluations MHA and/or ITP addendums A letter of statement from clinician acknowledging inconsistencies with
explanation of rationale for this request– Must be securely attached to the request or faxed to the Collaborative (866-928-
7177) within 1 business day– If information is necessary to support medical necessity but not included with
request/received within 1 business day, the Collaborative staff will contact the provider to explain the additional information that is required and the request will be closed without review. The provider must resubmit the entire request for authorization with all supporting documentation.
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Collaborative review process
Provider submits a request for authorization
Collaborative staff verifies:– Information for completeness (documents required based upon request type)– Provider’s participation status (e.g., contracted provider of IL DHS/DMH)– Provider’s certification status to provide requested service– Consumer information is in/available to the Collaborative system– The information in the request is consistent with information found in the supporting
documentation. If inconsistencies are found, the provider will be contacted regarding the inconsistencies. The request will be closed and the provider will be required to resubmit the request with all supporting documentation.
Collaborative clinical care manager (CCM) reviews submitted documents for the following 3 elements:
1. Completeness 2. Adherence to Rule 1323. Adherence to Medical Necessity Criteria (MNC)
If the above 3 elements are met for the service(s), the CCM will enter in an authorization.
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Collaborative review process, continued
If medical necessity IS established, request is authorized by CCM and communicated to provider in writing
OR If medical necessity is NOT established, the CCM contacts provider to
seek clarification and offer education/consultation regarding authorization criteria
– The Collaborative and the Provider will reach mutual agreement with respect to next steps (e.g., additional information will be submitted for review, alternative service will be considered, etc.)
OR– If mutual agreement has NOT occurred and provider believes medical
necessity is present, the CCM will forward information to a Collaborative physician advisor (PA) reviewer
PA reviews and either authorizes OR denies authorization
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Collaborative review process, continued
Turn around time (TAT) for authorization requests– The Collaborative will respond to requests
for authorizations within 7 business days of receipt of a completed authorization request.
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Provider requests for Reconsideration and Appeal related to denial of authorization
2 levels:
– 1st Request for Reconsideration
– 2nd DMH Director’s review The Collaborative staff is not involved in this level This shall be a review to ensure that all applicable
procedures have been correctly applied and followed
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Provider requests for Reconsideration and Appeal related to denial of authorization
In the case of a denial of authorization-- If the provider, consumer, or designated representative disagrees with the clinical decision, a Reconsideration may be initiated in writing or by phone.
The Reconsideration must be requested within 30 days after the denial.
– The review will be conducted by a Collaborative PA.• Not the same PA who issued the original denial• Not a subordinate of the PA who issued the original denial
– The review and notification by phone will be completed by the Collaborative within 15 days of the receipt of the reconsideration request.
– Outcome Either: Reversal of the denial decision Upholding of the denial decision
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Provider requests for Appeal related to denial of authorization
DMH Director’s review: If the provider, consumer, or designated representative
disagrees with the outcome of the Reconsideration request, an Appeal may be filed within 5 days of receipt of the outcome of the reconsideration request.
This review shall not be a clinical review, but rather a review to ensure that all applicable appeal procedures have been correctly applied and followed.
The final administrative decision shall be subject to judicial review exclusively as provided in the Administrative Review Law [735 ILCS 5/Art. III].
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Summary
Utilization Management Program is being implemented to ensure responsible management of resources
Plans of care for individuals for whom reimbursement from DMH will be sought should be based on the Medical Necessity Guidance/Criteria Manual published within the DMH Provider Manual
In order to be reimbursed for services, providers must follow the utilization management program as it applies to individual situations
Authorization request reflecting the most current clinical presentation as documented in the consumer record must be sent to the Collaborative
The Collaborative Clinical Care Managers will review authorization requests and issue a decision within 7 days.
If an authorization request is denied, the provider or consumer may request a reconsideration of that decision
If a request for reconsideration also results in denial of authorization, there is an appeals process through the Director of DMH and finally through the administrative law process at Healthcare and Family Services
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