APS Healthcare: Utilization Review for Children s Services. October 2014

Transcription

1 APS Healthcare: Utilization Review for Children s Services October 2014

2 Training Objectives APS Healthcare: ASO for the State of Maine Medical Necessity Utilization Review Process and Documentation Top Provider Calls and s Questions 2009 APS Healthcare, Inc. 2

3 APS Healthcare APS Healthcare, a subsidiary of Universal American Administrative service organization for the State of Maine since 2007 APS Healthcare is contracted through the Office of MaineCare Services (OMS) Utilization Management System (not managed care system) 2009 APS Healthcare, Inc. 3

4 Medical Necessity Definition of Medical Necessity from the MaineCare Benefits Manual, Chapter 1 Medical Necessity or Medically Necessary services are those reasonably necessary medical and remedial services that are: 1.provided in an appropriate setting; 2.recognized as standard medical care, based on national standards for best practices and safe, effective, quality care; 3.required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well being; 4. MaineCare covered service (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter II, Section 94 of this Manual); 5.performed by enrolled providers within their scope of licensure and/or certification; and 6.provided within the regulations of this Manual 2009 APS Healthcare, Inc. 4

5 Utilization Review Process Care Managers are independently licensed professionals with years of experience working in the Maine provider community. Care Managers are cross trained but have primary responsibility for service specific areas. Care Managers use MaineCare rules/criteria and clinical documentation to make determinations. Internal Quality Assurance measures include routine peer consultation, clinical supervision and consultation. Clinical back up and supervision is provided on site by the Clinical Team Lead, Clinical Manager, and Medical Director APS Healthcare, Inc. 5

6 Clinical Documentation Create a thread between diagnosis, current presentation, service objectives and discharge plan. Completed review should enable reader to have current clinical snap shot of member. Completed review should demonstrate intensity, frequency, and duration of the service APS Healthcare, Inc. 6

7 Clinical Documentation Clinical summary should include: o Demographics (age, gender, family composition) o Presenting Symptoms/Reason for Referral o Duration of Symptoms o Developmental Issues impacting functioning o Treatment History o Social Environment History o Strengths o Clinical Rationale for this Level of Care 2009 APS Healthcare, Inc. 7

8 Member Information APS CASE ID: This number will change every time you start a new review. These numbers change so that the reviewer and the provider can identify which portion of a member s treatment is being referenced. MEMBER S INFORMATION: This information is generated from the MaineCare information which is uploaded to the CareConnection system on a regular basis. ELIGIBILITY INFORMATION: Please double check the members eligibility. If there is limited eligibility you will need to contact MaineCare to determine the limitation. APS does not have any ability to edit eligibility or demographics This is a direct feed that is uploaded daily 2009 APS Healthcare, Inc. 8

9 Guardian Information Please complete this page for all children ouse the choice Family Member for Parent othis information is utilized when a parent or guardian calls into APS Healthcare for information 2009 APS Healthcare, Inc. 9

10 Administrative Start Date for Current Authorization Request: This date refers to the start of this authorization period not the start of treatment. Please note the following submission requirements for each type of review. These are the maximum grace period to allow for administrative error, vacations, sick time, holidays, etc. Registrations: Maximum backdate of 15 days from the date of submission Prior Authorizations: Maximum backdate of 5 days from the date of submission Continued Stay Reviews: Maximum backdate of 10 days from the date of submission 2009 APS Healthcare, Inc. 10

11 Requesting Agency Please add the phone number and e mail address of the person you would like us to contact if there were any clinical questions about the request. Is this agency/individual the treating provider? This question needs to be answered with Yes APS Healthcare, Inc. 11

12 Multiaxial Assessment ICD 9 is used as it is consistent with federal Medicaid requirements Use the DARK BLUE Box to find the ICD 9 code or search by DSM code or title Primary diagnosis is the diagnosis you are currently treating Co Occurring diagnosis relates to mental health/substance abuse AXIS III Text box for medical issues AXIS IV Psychosocial stressors Drop down indicates Mild, Moderate or Severe AXIS V GAF Global Assessment of Functioning: Free Text APS Healthcare will update to DSM V criteria once the MaineCare Benefits Manual has been updated for a service 2009 APS Healthcare, Inc. 12

13 Services Requested Multiple Code Requests: MODIFY Use this function to change the start and/or end date and the number of units NO ACTION Use this function when you are not wanting to extend the particular service code SUBSEQUENT CONTINUED STAY REVIEWS If you want to reactivate a service code click on modify even though there is a gray line. This will allow you to open that service code APS Healthcare, Inc. 13

14 Symptoms and Behaviors Agency Involvement Important to select all providers to the best of your knowledge Family Social Involvement Indicate all supports that apply and then rate the overall support of family/natural supports 2009 APS Healthcare, Inc. 14

15 Medications Medications, both psychiatric and medical, should be entered with the medication type as applicable Additional Medication Info Section can also be used to capture any relevant medication that cannot be found in the list 2009 APS Healthcare, Inc. 15

16 Clinical Indicators Clinical Indicators help to justify the service requested. Choose most current symptoms and behaviors that member has experienced over previous authorization period. History of Severity is service specific. Please document only the symptoms which member has experienced from previous authorization period to current date. Any additional risk factors/clinical indicators should be added to the additional information field. Developmental issues and functional impairments may also be listed here APS Healthcare, Inc. 16

17 Treatment and Service History This Section may be skipped if questions are not relevant to the clinical picture and request for service Please note that Co occurring questions refer to Mental Health and Substance Abuse 2009 APS Healthcare, Inc. 17

18 RDS This Section does not need to be completed and can be skipped. It is required for Section 17 services only APS Healthcare, Inc. 18

19 Individual Treatment Plan Use CTRL Key to select more than one option under Strengths and Skills. Complete the Treatment Plan Goals as related to service provided. The Criteria for Discharge section should be updated at every request. There is a maximum of 150 characters in these spaces. It is recommended that providers use Comments section to provide more depth and clarity to their clinical presentation APS Healthcare, Inc. 19

20 Treatment Plan Goals Problem Statement should mirror reason for referral Long Term Goal Reverse of problem statement; What is the overall identified need of the member? Short Term Goal Focus of TCM or HCT to assist member in meeting identified needs. (not a restatement of the long term goal) Objectives Action Steps: Who, What, When, Where, and How? Goals and target dates should be modified to reflect progress made since last review 2009 APS Healthcare, Inc. 20

21 Additional Reporting Data This section may be skipped if not applicable 2009 APS Healthcare, Inc. 21

22 Additional Information It is recommended that this section be used to provide a clinical rationale for the service requested. Information included should be relevant for purposes of utilization review. This section can assist with capturing any information that was unable to be reflected in other sections to demonstrate medical necessity. o Presenting Symptoms/Reason for Referral o Duration of Symptoms and/or functional impairments o Treatment History Example: For HCT Services: What lower level of care options have been attempted? Is this a step down from higher LOC (crisis, residential, hospital)? Has the member/family had HCT in the past? If so, when was the last time the family received HCT services? o Family/Social Environment o Strengths 2009 APS Healthcare, Inc. 22

23 Submit to APS Once you submit a review it cannot be edited by the provider. If additional information is required you must contact APS at Cases on Hold for Provider Information: Five business days to respond to hold note Lack of response requires action by APS Healthcare. Request will then be shortened or sent to MD for further review Contact APS Provider Relations for assistance on how to view download notification if needed 2009 APS Healthcare, Inc. 23

24 Top Provider Calls and s Early care connection submissions Lack of measurable discharge criteria Submissions without a YOQ or CANS score Can a member be open for HCT and Child Outpatient Services? Can a member be open for HCT and Trauma Focused CBT? 2009 APS Healthcare, Inc. 24

25 Top Provider Calls and s Continued Section 28 waitlists: Providers manage referrals who have designated a preferred provider; APS manages the waitlist for all other referrals Incomplete ITRT packets What if a provider does not agree with the MD decision to decrease/titrate units for a service? Who can request a reconsideration? Who can request an appeal? 2009 APS Healthcare, Inc. 25

26 APS Contact Information For CareConnection assistance contact Provider Relations Team Phone Option 1 For Member Services contact Roger Lavigne, Member Liason Phone Option 3 To respond to clinical questions contact Care Managers Team Phone: Option 4 For Reconsiderations and Appeals contact Appeals Team Phone Option 5 APS Provider Relations Team: MaineCare Prov@apshealthcare.com 2009 APS Healthcare, Inc. 26