CARE MANAGEMENT DEPARTMENT UTILIZATION MANAGEMENT PLAN

Transcription

1 CARE MANAGEMENT DEPARTMENT UTILIZATION MANAGEMENT PLAN 2015

2 Table of Contents I. Overview... 3 A. Purpose... 3 B. Scope and Goals... 3 C. Mission Statement... 3 D. Principles... 3 E. Services... 4 II. ORGANIZATIONAL STRUCTURE AND STAFF ACCOUNTABILITY... 6 A. Staff Qualifications... 6 B. Staff Responsibilities... 6 C. Committee Structure... 8 D. Interdepartmental Coordination... 8 E. Role of the Care Management Program in Quality Management and Improvement... 9 F. Utilization Management Department Quality Improvement Projects (QIPs)... 9 III. INFORMATION UPON WHICH UTILIZATION MANAGEMENT IS CONDUCTED...11 A. Medical Necessity...11 B. Medically Recommended...11 D. Level of Care Clinical Criteria...11 E. Application of Standardized Clinical Criteria...12 IV. UTILIZATION MANAGEMENT DECISIONS...14 A. Member Eligibility and Benefits...14 B. Access to UM Services...14 E. Medical Necessity Decisions...14 V. SYSTEMATIC PROCESS FOR CONDUCTING UM ACTIVITIES...17 A. Data Collection...17 B. Inpatient Review...18 C. Peer Clinical Review...19 D. Determination of No Medical Necessity...19 E. Peer-to-Peer Conversation...20 F. Appeal Process...20 H. Utilization Management for Out-of-plan Providers...21 I. Delegated Utilization Review Activities...21 VI. SUPERVISION AND TRAINING OF STAFF...22 A. Confidentiality...22 B. Conflicts of Interest...22 C. State and Federal Reporting Requirements...23 D. Care Management Staff Orientation...23 VII. CLINICAL DATA SOURCES AND SYSTEMS...26 VIII. PREVENTION, EDUCATION & OUTREACH (PE&O)...27 IX. UTILIZATION MANAGEMENT PLAN EVALUATION AND GOALS...28 A. Mechanism to Evaluate the Effects of the UM Program...28 B. Annual Evaluation...29 C. Utilization Management Plan Goals

3 I. Overview A. Purpose The purpose of Access Behavioral Health's Utilization Management Program Description is to outline the utilization system highlighting the processes, procedures, criteria, staff qualifications and information/data collection required for ABH to conduct utilization/care management activities. B. Scope and Goals The clinical philosophy at Access Behavioral Health (ABH) is to provide a care management system that offers easy and immediate access to the most appropriate, quality behavioral health, services for members, and a utilization management system that supports providers in delivering clinically necessary and effective care with minimal administrative barriers. The Utilization Management Plan encompasses management of care from the point of entry into care through discharge from care. ABH believes in macro-management of care as much as possible through the use of objective, standardized, widely distributed clinical protocols and outlier management programs. Intensive utilization management is reserved for high-cost, highly restrictive levels of care and cases that represent clinical complexity and risk. The Care Management team bases its reviews on clear and concise criteria developed specifically to guide level of care, treatment and length of stay determinations. Care Management staffs are trained to match the needs of patients to appropriate services, levels of care, and community supports. This requires a careful consideration of the intensity and severity of clinical data presented with the goal of quality treatment in the least restrictive environment. The clinical integrity of the Utilization Management Program ensures that enrollees who present for care are appropriately monitored. Those cases that appear to be outside of best practice guidelines are referred for specialized reviews. These may include peer clinical review, peer-to-peer conversation, or more frequent care manager review. Access Behavioral Health has designed a system of care that is not only based on principles of quality care, but also one that is flexible in meeting the needs of diverse populations, communities and customers. ABH serves members of the Statewide Managed Medical Assistance (MMA) Plans, Integral Quality Care and Humana Health Plan, in region 1 of the state of Florida. Access Behavioral Health: provides easy and early access to appropriate treatment; works collaboratively with providers in delivering quality care according to accepted bestpractice standards; addresses the special needs of children in the mental health system; identifies common illnesses or trends of illness; targets high risk cases for intensive care management; and emphasizes prevention, education and outreach. C. Mission Statement Helping People Overcome Life s Challenges by connecting them to Hope and Recovery D. Principles ABH Clinical Management staff adheres to the following principles: all persons shall be treated with respect and dignity; 3

4 the person directs the recovery process; therefore, the individual s input is essential throughout the process; individuals are able to recover more quickly when their hope is encouraged, enhanced, and/or maintained; life roles with respect to work and meaningful activities are defined; spirituality is considered; culture is understood; educational needs as well as those of their family/significant others are identified; and socialization needs are identified; individual differences are considered and valued across the life span; recovery from mental illness is most effective when a holistic approach is considered; to the maximum extent possible, members shall be offered a choice of direct service providers; services to members shall be tailored to the individual and provided in the least restrictive and most natural setting environment as possible, preferably in the member s own community; for children, services and treatments must be family centered, geared to give families real and meaningful choices about treatment options and providers; care must focus on increasing the child s ability to successfully cope with life s challenges and on building resilience, not just on managing symptoms; services to members are built on the strengths of the member and the member s family and foster independence; utilization review shall follow established best-practice guidelines and industry standards; grievance procedures shall be developed for the member or provider to resolve issues according to established timeframes; the confidentiality and privacy of the member shall be protected at all times. information shall be collected, analyzed, and disseminated to foster system accountability and quality improvement; patient rights and other member information shall be communicated in a manner understood by the ABH member; and Access Behavioral Health does not discriminate against individuals eligible to enroll on the basis of race, color, or national origin, and does not use any policy or practice that has the effect of discriminating on the basis of race, color, or national origin. E. Services The ABH Care Management Department is responsible for all utilization management activities related to compliance with Plan contracts and URAC accreditation standards, including: coordination of ABH Call Center operations as related to plan members and providers; entering accurate and complete authorizations into the ABH MCO system and notification of providers of authorizations according to established timeframes; providing provider oversight through: completion of initial, concurrent and discharge reviews for all members admitted to an inpatient psychiatric facility according to established timeframes; identifying provider s utilization patterns of concern and reporting to the ABH Director and the ABH Medical Director; reporting quality of care concerns to the ABH Medical Director and the ABH Quality Management and Improvement Department; and maintaining accurate records and logs of utilization management activities; assisting with issues related to claims processing, capitation transfers, and eligibility; coordination of interagency linkage as needed by both in and out-of network providers to better meet the needs of the members enrolled in the plan; assisting providers in transitioning members from out of net work to in-network providers; 4

5 coordinating and arranging case staffings for difficult cases; assisting with the development of age specific admission, exclusion, continued stay, and discharge criteria for levels of care; assisting with the development of treatment guidelines and clinical tools to use as aids to providers in developing treatment services/programs and improve clinical and administrative decision-making and performance; assisting with the development and distribution of manuals and outreach materials to members and providers; providing outreach to both providers and members through day-to-day UM activities as well as other planned outreach activities; assisting in quality improvement studies designed to improve the plan s utilization management program and/or the plan s overall system of care; and reviewing and updating all Care Management related documents as needed, but no less than annually. 5

6 II. ORGANIZATIONAL STRUCTURE AND STAFF ACCOUNTABILITY A. Staff Qualifications Access Behavioral Health places high value on the selection, training, and performance evaluation of clinical staff performing utilization management services. All staff involved in utilization management activities possesses terminal degrees and licensure in their field. The ABH Medical Director and Physician Advisors are experienced, senior level clinicians, many of whom remain active in private practice. They are board certified in their specialty areas, and are required to maintain a current knowledge of behavioral health research findings and nationally recognized practice guidelines. Care Management staffs are multidisciplinary and are able to manage care in all general psychiatric, psychiatric subspecialty, and substance abuse areas. ABH requires that all Care Management staff be fully licensed mental health professionals with a minimum of three years prior clinical experience in a mental health/substance abuse setting providing direct patient care. First-level review staffs are licensed nurses with experience in psychiatric nursing (RN), Licensed Mental Health Counselors (LMHC), Licensed Clinical Social Workers (LCSW) or equivalent. These reviewers complete all types of reviews, including precertification, concurrent review, discharge planning, care coordination, and case management. The status of current licensure is maintained within the Lakeview Center, Inc. Human Resources Department for all actively employed clinical staff. ABH ensures that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The utilization management component of the Quality Management and Improvement Department at the corporate level consists of the ABH Medical Director, a Director of Quality Management and Improvement, and the Director of Care Management. This corporate department, which reports directly to the Director of Managed Care, is responsible for the development of clinical policy and standards, the standardization of operational systems, and the assurance of clinical integrity throughout all lines of business. B. Staff Responsibilities The following is a brief summary of staff functions in relation to the ABH Care Management Department. Complete job descriptions that are reviewed and revised annually are maintained for each ABH role. 1. ABH Director The ABH Director is responsible for the overall management of ABH. His chief area of responsibility is to ensure contract compliance in all areas of operation, including the medical budget. Other duties include development and implementation of policies and procedures, management of the behavioral health care delivery system within budgetary goals, and coordination of relationships with members, as well as with plan members, members in care, participating providers, partners, and the community. The ABH Director reports directly to the Lakeview Center, Inc. Chief Financial Officer. 2. ABH Medical Director The overall clinical responsibility within ABH rests with the Medical Director. The Medical Director reports to the Director of ABH. The Medical Director provides medical and clinical 6

7 leadership for the day-to-day clinical operations. He oversees the UM Program implementation. He ensures the application of policies and procedures and participates in training of clinical staff. The Medical Director participates in the continuous quality improvement program, which includes the ongoing development and monitoring of key indicators, outcome studies, provider quality profiling, and best practices. He routinely reviews utilization and quality improvement reports to help identify quality practices that can be shared with other providers, and to identify aberrant practices and participate in corrective actions. He helps design, monitor and control utilization targets. The Medical Director assists in the development and implementation of necessary corrective action plans related to utilization. In addition, he oversees the certification process and appeals decisions and serves as a Physician Advisor in the peer review/appeals process. 3. ABH Physician Peer Advisors Physician Advisors are independently contracted employees and perform their reviews as designees of the Medical Director, but are not subordinate to the ABH Medical Director. 4. ABH Director of Care Management The Director of Care Management collaborates with the Medicall Director to identify and resolve clinical issues related to referral, care management, and peer review processes. The Director of Care Management manages the day-to-day operations of the Care Management Department and provides direct clinical and administrative supervision to the Care Management staff. Additionally, the Director of Care Management monitors departmental productivity and utilization statistics. This position works closely with the ABH Director of Quality Management and Improvement to ensure that care management and referral processes are performed at or above established performance benchmarks. The Director of Care Management reports to the Director of ABH. 5. ABH Clinical Care Coordinators ABH Clinical Care Coordinators provide clinical assessment and referral services as well as concurrent inpatient, alternative levels of care, and outpatient reviews. The primary function of the Clinical Care Coordinator is to ensure that members receive quality services in the most appropriate level of care. Clinical Care Coordinators inform clinical management of problem cases and resolve these issues in consultation with the Director of Care Management and the Medical Director. Clinical Care Coordinators receive clinical supervision from the Medical Director and report directly to the Director of Care Management. 6. ABH Director of Quality Management and Improvement The Director of Quality Management and Improvement provides quality management oversight to all clinical management initiatives. She provides leadership in developing and integrating quality improvement activities and thus serves as an important linkage between Quality Management and Utilization Management. She is responsible for and/or participates in performance guarantee reporting, client deliverables, validation of all clinical indicators, tracking and coordination of the resolution of critical incidents, quality of care issues, oversight and performance of documentation audits, communicating results of outcome studies/validation efforts to providers. The Director of Quality Management and Improvement coordinates interaction between the Clinical and Quality Departments, participating in the appropriate committees from both departments. The Director of Quality Management and Improvement reports directly to the Director of ABH. 7

8 The Director of QMI and the staff of the ABH Quality Department are responsible for the tracking of applicable laws and regulations and ensure that ABH adheres to all applicable laws and regulations. The Director of QMI serves on the Lakeview Center, Inc. Compliance Committee and acts as the ABH Corporate Compliance officer. 7. ABH Grievances Coordinator The ABH Grievances Coordinator is responsible for the documentation, analysis, and coordination of responses to grievances that are received from members, providers, or clients. The Grievances Coordinator provides assistance/consultation to respective counterparts within specific contracts and participates in quality improvement activities. The Grievances Coordinator reports to the Director of Quality Management and Improvement C. Committee Structure 1. Quality Management Committee (QMC) To ensure that the needs of its member population are addressed, ABH operates a Quality Management Committee (QMC). The QMC meets no less than quarterly (may meet more often, if needed). The QMC is comprised of representatives from key operational units within ABH. The QMC is also a collaborative operation that allows for Area wide quality initiatives to be identified and addressed. Providers have the opportunity to benchmark best practices in the Area. Communication between providers and between providers and ABH is fostered. The meetings allow ABH to receive feedback on the plan. The QMC is responsible for ensuring the quality, cost effectiveness and continuous improvement of clinical care and utilization management and other services delivered to members for which ABH is responsible. The QMC: assists in the establishment of standards, criteria and policies and procedures provides direction to the clinical staff for all CQI policies and procedures, state and accrediting body standards utilization management initiatives reviews and analyzes all indicators identifies individual and aggregate quality and utilization problems and sets priorities for investigation and resolution. develops corrective action resolution. Minutes are kept of each meeting and are approved by the QMC members. The agenda varies according to need. Some standing items include: Review and approval of minutes Quality Management Reports Care Management Reports Network Performance Plan report Satisfaction reports Monitoring activities Performance Improvement Projects Utilization Management Reports Other items as indicated by the QMC or ABH D. Interdepartmental Coordination The ABH Care Management department promotes collaboration, coordination and communication across disciplines and departments within ABH and the network. The interdepartmental ABH staffs meeting minutes and ABH outreach reports reflect this collaboration. 8

9 E. Role of the Care Management Program in Quality Management and Improvement The ABH Care Management and Quality Management departments are integrated functions. Integration occurs through: the committee reporting structure; cross-representation on the Quality Management Committee by both the Quality Department and the Utilization Management Department; overlap of committee responsibilities for both quality management and utilization management functions; sharing of data across quality and utilization management departments; and the Care Management Department has responsibility for operationalizing quality standards set by the Quality Management and Improvement Committee. The ABH Care Management department is responsible for reporting important utilization management activities (overall UM authorizations and denials, retrospective reviews, initial denials and appeals, and QIP updates) to the ABH Quality Management Committee for review and recommendations. ABH monitors the use of both inpatient and outpatient services with service utilization triggers that assist the ABH Care Management department in identifying plan members in need of more intense care coordination. Care Management staff will review with the Medical Director cases that have potential for high-risk based on identified utilization triggers. These trigger events include, but are not limited to: o Members with an inpatient readmission within 30 days o Members with a Developmental Disorder and no indication of a primary mental illness who have an inpatient admission o Members ages 0-5 who have an inpatient admission o Members with a current or previous inpatient length of stay of over 7 days Additional high utilization triggers: o Members with a complex medical condition who have an inpatient admission o Members with more than 4 inpatient admissions within the past 12 months o Members with 3 or more inpatient admissions in the past 3 months o Members who may be difficult to place upon discharge from inpatient admission o o Members in the child welfare system who have an inpatient admission Members identified as high risk or as a problematic case by the Clinical Advisory Committee Cross-representation on the QMC also enhances the integration of utilization and quality management activities. For example, the ABH Director of Quality Management and Improvement, Medical Director and Director of Care Management typically participate in all committees described. F. Utilization Management Department Quality Improvement Projects (QIPs) Quality improvement projects exemplify the process of continuous quality improvement, allowing ABH to refine and maintain quality enrollee and provider services and health care services. ABH tracks and trends data related to enrollee and provider services in order to proactively manage problems. 9

10 The ABH UM department maintains no less than two quality improvement projects addressing program related issues at any given time. At least one quality improvement project is clinical in nature, focuses on enrollee safety, and involves a senior clinical staff person (generally the ABH Medical Director) in judgments about clinical aspects of performance. Improvement strategies are designed to have a reasonable expectation of producing desired improvement. The ABH UM department quality improvement projects are identified through: grievances; provider surveys; member surveys; quarterly UM record reviews tracking and trending of valid UM data; and staff input. For each quality improvement project, ABH utilizes valid techniques that are comparable over time to: develop quantifiable measures; measure baseline level of performance; re-measure performance at least annually; and establish measurable goals for quality improvement. For each quality improvement project, ABH designs and implements strategies to improve performance; establishes projected time-frames for meeting goals for quality improvement; documents changes or improvements relative to the baseline measurement; conducts at least one re-measurement prior to URAC re-accreditation; and conducts a barrier analysis if the performance measures are not met. Documentation of quality improvement projects includes the following: project start date; identifiable quantifiable baseline measure(s) for the indicator and relevance to the provider and/or enrollees served; quantifiable goals associated with the measure; improvement strategies and dates these were implemented; periodic progress measurements and the documented discussions; any changes in improvement strategy and a brief description of changes; and a project end date. 10

11 III. INFORMATION UPON WHICH UTILIZATION MANAGEMENT IS CONDUCTED Utilization Management (UM) is defined as the evaluation of medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. UM encompasses prospective, concurrent, and retrospective review in which clinical review criteria are applied to a request. UM is sometimes referred to as utilization review. A. Medical Necessity It is the policy of ABH to authorize payment only for services that are medically necessary and provided for the identification and/or treatment of a member's illness. ABH considers medically necessary treatment as that which is: necessary to protect life, to prevent significant relapse of a mental illness or significant disability, or to alleviate severe pain; individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the member s needs; consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available, statewide; and furnished in a manner not primarily intended for the convenience of the member, the member s caretaker, or the provider. B. Medically Recommended ABH supports the concept of Medically Recommended and its parallel standard with Medical Necessity. ABH considers social objectives as part of its medically recommended utilization management process, especially for individuals with a serious and persistent mental illness, children with special needs due to physical and/or mental illnesses, adults age 65 and older, foster care children, and non-elderly adults who are disabled or chronically ill with developmental or complex physical needs; and understands that often addressing the members social objectives outweighs the risk of recommending a lower level of care. Criteria for services that are age appropriate and sensitive to the developmental level of the member may be expanded based on social objectives rather than strict medical necessity. ABH identifies members presenting with sub-clinical symptoms and address these symptoms in order to prevent the member from needing a more restrictive level of care. development of social skills, including social interaction family intervention, including development of parenting skills connection to community resources and services Vocational Rehabilitation housing, living arrangements major life stressors such as family dysfunction, relationship losses, legal problems, economic issues, school conflicts, humiliating events, or severe medical problems. family/community concerns such as lack of adequate support, inadequate housing, lack of improvement despite provision of community interventions, or the family environment is causing escalation of symptomology D. Level of Care Clinical Criteria The clinical criteria used by ABH to make admission, level of care and continuing treatment decisions reflects ABH s philosophy and clinical values. These criteria are assessed and revised at least annually by the ABH Quality Management Committee. Prior to a criterion set being 11

12 approved for use it is reviewed to ensure adherence to clinical best practices guidelines and overall core criteria standards. Clinical criteria are reviewed and approved by the ABH Quality Management Committee. Sources for various criteria include: Diagnostic and Statistical Manual-IV-TR; American Accreditation HealthCare Commission/URAC Standards; American Psychiatric Association treatment guidelines; American Academy of Child and Adolescent Practice Parameters; Substance Abuse and Mental Health Service Administration evidence-based practice guidelines; American Society of Addiction Medicine standards; discussions with senior consultants in the field and practicing professionals; and various criteria sets from other utilization management firms and third party payers. Clinical criteria are routinely disseminated to ABH providers via the ABH Manual of Operations, provider forums, the ABH website, and at individual or group training sessions. Each Community Behavioral Health Provider has ultimate responsibility for incorporation of these levels of care clinical criteria into their criteria sets. To determine the appropriate level of care, Care Management staff evaluates the clinical information relative to the levels of care clinical criteria. E. Application of Standardized Clinical Criteria Each Care Management staff is expected to consistently apply the clinical criteria. Mechanisms for monitoring compliance are as follows: Upon hire and during the orientation process, each Clinical Care Coordinator receives a copy of the ABH clinical criteria. After completion of training, a new Clinical Care Coordinator is oriented to the review process (a period which typically takes 2 weeks). The Clinical Care Coordinator is preceptored by a supervisor or a more experienced Clinical Care Coordinator and his or her certification decisions are closely monitored on a case by case basis. When the trainer deems the Clinical Care Coordinator able to function more independently, cases are monitored by the ABH Medical Director during clinical rounds. Feedback regarding integrity of clinical information gathered and decisions being based upon clinical criteria are given to the Care Coordinator. Individual supervision tapers gradually, depending upon the progress of the Clinical Care Coordinator, and is replaced with supervision provided through other established avenues. Clinical rounds are conducted by the ABH Medical Director. This provides an open forum in which Care Management staffs can discuss challenging cases with peers, the Director of Care Management, and the Medical Director, to ensure consistency in application of the criteria, and to assure case oversight for quality, appropriateness and congruency of care being delivered within the parameters of the reported symptoms, diagnosis, and treatment. Each day, Clinical Care Coordinators confer with their peers, Director of Care Management or the Medical Director on any case that does not appear to meet the criteria for the level of care being requested by the provider, or any complex or challenging case. Care Management staffs are not able to deny care; denials are only issued by the ABH Medical Director or Physician Advisors. Regular audits of case activity documentation of Care Management staff are conducted on an ongoing basis. Inherent in this audit process is an inter-rater reliability component to 12

13 ensure consistency across physician reviewers and Care Management staff. The assessment addresses the following areas: timeliness of review process; completeness/adequacy of documentation; adherence to clinical policy guidelines; consistent application of clinical criteria; and clinical appropriateness of decision-making. 13

14 IV. UTILIZATION MANAGEMENT DECISIONS A. Member Eligibility and Benefits Member eligibility is provided to Access Behavioral Health by the plans. ABH does not enroll or disenroll plan members. Plan eligibility is determined through the ABH eligibility file and is confirmed via the Agency for Healthcare Administration s online Medicaid eligibility portal. When discrepancies occur, information on the on-line lookup prevails. Member benefits are those services covered in the Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbooks. Although Access Behavioral Health can provide flexible services, the service limits and medical necessity criteria are not more restrictive than those in Medicaid policy as stated in Medicaid Mental Health Targeted Case Management Coverage & Limitations Handbook and the Community Behavioral Health Services Coverage & Limitations Handbook (Handbooks). B. Access to UM Services The ABH care management system provides multiple channels of access to care for members. Ease of access to appropriate care is central to our philosophy and clinical values. A member or provider may access the care system through any of the following avenues: 24 hour toll-free emergency care/clinical referral line; direct certification of all levels of care through referral by ABH Care Management staff; face-to-face evaluations by network providers; emergency services through free-standing psychiatric hospitals, medical hospitals with psychiatric units, emergency rooms, Crisis Stabilization Units (CSU) or crisis response teams. E. Medical Necessity Decisions Medical necessity determinations are made in a timely manner, depending on the urgency of the request. Referral protocols are as follows: Emergency Requests A member has access to the toll-free number for assessment and referral 24 hours per day, 365 days a year. A psychiatric emergency is identified and defined by ABH as existing when an individual is assessed to be at extreme or high risk: Extreme Risk (Emergency/Extreme Risk) The member demonstrates one or more of the following: o Failure to obtain immediate care would place the patient's life, another's life, or property in jeopardy, or cause serious impairment of bodily functions. o Member/caller indicates that failure to obtain immediate care would place the patient's life, another's life, or property in jeopardy, or cause serious impairment of bodily functions. Required Action (Emergency/Extreme Risk) o The ABH Care Management staff must assure immediate emergency intervention. o The ABH Care Management staff must maintain telephonic contact with the caller or otherwise assure safety until the emergency intervention is provided. If telephonic contact is not maintained, the Care Management staff must confirm provision of emergency intervention as soon as clinically indicated, usually within I hour. 14

15 o The ABH Care Management staff must clearly document all actions taken, times at which they occurred and the rationale supporting them. High Risk (Emergency/High Risk) The member demonstrates one or more of the following o Potential danger to self or others as indicated by behavior, plan or ideation. o Is labile and unstable and demonstrates significant impairment in judgment, impulse control and/or functioning. o Appears to have immediate and severe medical complications concurrent with, or as a consequence of, psychiatric illness and its treatment. o The member indicates he/she is without prescribed psychiatric medication. o Member/caller indicates a need to be seen on an emergency basis. Required Action - (Emergency/High Risk) o High-risk emergency assessments must be completed immediately. If network staffs are not available to complete an assessment, the member may be referred to the closest emergency room. At all times, the safety of the member is the primary concern of the ABH Care Management staff. o If the member is suffering from medical complications, ABH Care Management staff must arrange for a psychiatric assessment in a setting (e.g., emergency room, multispecialty clinic) where there is immediate access to other medical specialists who can adequately address a medical emergency. Depending on the nature and imminence of the risk, the following may be required: o Emergency hospitalization or police and/or social service intervention to safeguard the patient and others, and to assure that a psychiatric assessment is conducted. o In all cases, ABH Care Management staff must ensure that the member has accessed emergency care in order to safeguard the member or others. ABH Care Management staff must clearly document all steps that were taken, the times at which they occurred and the rationale supporting them. Serious Risk (Urgent) The member demonstrates one or more of the following: o Is upset and distressed, but not in immediate danger of harm to self or others, and while there is evidence of adequate pre-morbid functioning, social/family supports have significantly changed or diminished and the patient can be expected to further decompensate within the next 24 hours (e.g. requests for appointments due to reports of non-emergent allergic reactions or serious side effects). o Moderate impairment in judgment, impulse control and/or functioning, which is expected to further diminish. o Member/caller indicates an urgent need to be seen. Required Action (Urgent) o ABH Care management staff must arrange for a face-to-face assessment by a licensed mental health professional within 23 hours of the call. o If there is no provider available to assess the patient, the care manager must treat the situation as an emergency. o ABH Care Management staff must document the timing, rationale, outcomes and key persons involved with the disposition. Mild/Moderate Risk (Routine) The member demonstrates one or more of the following: o Experiences some distress, but the precipitants of the distress and associated stressors can be easily identified (e. g. routine medication appointments such as for 15

16 prescription renewals are scheduled in a manner as to not avoid disruption of the medication for the member). o Some impairment in judgment, functioning and/or impulse control is evidenced. Required Action (Routine) o ABH Care management staff must provide the caller with the name of a therapist who can assess the patient's condition and level of functioning within 7 calendar days. o ABH Care Management staff must document the timing, rationale, outcomes and key persons, involved with the disposition. Prior to initial determination of medical necessity for a member, the Care Management staff checks the member's eligibility status in the MCO eligibility files. Care Management staff works with members who are in need of care regardless of eligibility status. If a member's benefits have been exhausted, the Care Management staff refers the member to appropriate community supports and programs such as local or state funded agencies or facilities offering sliding scale discounts for continuation in outpatient therapy. This coordination is intended to appropriately transition the member to other care and guard against patient abandonment. When ABH Care Management staff receives a call from a provider requesting a medical necessity determination for services, clinical information is obtained from the provider or designee in a prescribed format. This interview format is shared with all ABH providers at the time of initial orientation and subsequently in the provider handbook. This may take the form of sharing the medical necessity criteria or actual questions/information required to make a medical necessity determination. Once it is established that the patient is ABH eligible, the clinician reviews the clinical data that is provided and determines if the patient's severity of symptoms meet criteria for the requested level of care. This is done through the use of standardized criteria which specifically outline the level of care appropriate for a particular constellation of symptoms. Services are approved for a specific number of units. Inpatient authorizations are approved for up to 5 days, depending on severity of symptoms. Calls received from members requesting mental health services by ABH Care Management staff are assessed to determine the level of care needed by the member: emergent, urgent, or routine. Following this initial triage, the member is referred to the most appropriate network provider for services, based on the member s preference, symptoms, and cultural needs. 16

17 V. SYSTEMATIC PROCESS FOR CONDUCTING UM ACTIVITIES A. Data Collection The utilization management process assures that appropriate care is delivered to members according to clinical criteria in the context of an individualized treatment plan. ABH Care Management staff consult collaboratively with providers, PCPs, members, and UM/UR personnel, as appropriate, to obtain relevant clinical information about members' clinical status, treatment plans, treatment goals and response to interventions. Clinical data relating to the need for a requested level of care and treatment planning considerations specific to these needs are collected by ABH Care Management staff via fax or telephonic review. ABH Care Management staff may certify inpatient levels of care. Lower levels of care such as residential, case management, or outpatient do not require pre-certification or continued stay review. Clinical data is obtained according to the following documentation guidelines for inpatient levels of care: Clinical data received from the provider or designee relating to the need for a requested level of care and treatment planning specific to these needs are collected by ABH Care Management staff according to the following documentation guidelines. ABH Care Management staff may request clinical documents from the provider such as a screening assessment or the physician s History and Physical in lieu of initial review. Diagnosis (DSM - IV, Axis I-V; for GAF score, note current and highest in past year, if available) Reason for admission Suicidal/Homicidal Ideation Plan Intent Psychotic/non-psychotic (e.g. command hallucinations, paranoid delusions CD/SA History (e.g., type, amount, withdrawal symptoms, vital signs, date(s) of initial and last use, date(s) of periods of sobriety) Medical Problems (e.g., medical history, organic cause of psychiatric symptoms behaviors, medical problems which exacerbate psychiatric or substance abuse symptoms behaviors) Current Medications (e.g., type, dosage, dates, duration, response, provider) Primary Care Physician (PCP) interface, if applicable General Level of Functioning (e.g., sleep, appetite, mental status, ADLs) Job/School Functioning (e.g., job/role category, job/school status, job/role issues) Psychological Stressors and Supports (e.g., socioeconomic, family, legal, social, abuse/neglect, domestic violence) Response to Previous Treatment (e.g., previous treatment history, most recent treatment, past treatment failures, relapse/recidivism, motivation for treatment, indications of compliance) Treatment Plan (e.g., ELOS, treatment goals, planned interventions, family involvement, precautions for risk behaviors) Discharge Plan (e.g., alternative level of post-discharge care, obstacles to discharge) For Concurrent Review(s): ABH Care Management staff review documentation in the initial or previous review and denotes current condition, response to treatment, and any changes to the treatment or discharge plan. Treatment for congruity is also reviewed for aggressiveness with reported symptomatology. Additionally, ABH Care Management staff request and document the 17

18 current diagnosis and the patient's disposition. Based upon this information and any changes to the diagnosis, additional care is confirmed as medically necessary. If care cannot be confirmed as medically necessary, the case is referred for peer clinical review. ABH Care Management staff document with whom the review was done, what additional care was confirmed as medically necessary, and the date of the next review. Finally, ABH Care Management staff document the date, time and their own name in the review. When medical necessity is established, ABH Care Management staff specifies what criteria are met, referencing clinical criteria, and an authorization is generated. Care is certified for a specific number of services/days for a specific time period. ABH determines its own certification limits, but typically the higher levels of care are certified for shorter intervals, and therefore reviewed more frequently. ABH Care Management staff has some flexibility in the certification limit, based on an individual patient's clinical needs and provider characteristics. Inpatient stays are certified for up to 5 days per review. Members who are court committed to long term care are reviewed every 7 days. When a provider receives a pre-certification for treatment, specific treatment goals and objectives are agreed upon with the Care Manager or Physician Advisor and these serve as the focus of the next concurrent review. The provider is instructed to contact ABH Care Management staff within 24 hours of the expiration of the certification date, leaving enough time for concurrent review and re-certification so as not to interrupt benefit coverage of the patient's treatment services. ABH Care Management staff conducts the continued stay review with a focus on continued severity of symptoms, appropriateness and intensity of treatment plan, patient progress and discharge planning. This is accomplished by reviewing the member's case records, discussions with the provider or appropriate facility staff, or other behavioral health practitioners. Cases not meeting clinical criteria are referred for Peer Clinical Review. Any questionable or absent treatment plans, discharge plans or questions related to the quality and appropriateness of care being delivered are referred for Peer Clinical Review. Protocols are developed to coordinate care for complex, chronic cases. The ABH Clinical Care Coordinators fax a list of members who are currently receiving inpatient services to the Comprehensive Behavioral Health Providers on a daily basis. The Case Management department at each Comprehensive Behavioral Health Provider uses this list to ensure integrated services through ongoing communication with the provider(s) involved in the case, and establish linkages to family service agencies, community services organizations, the court system, schools, external care management providers, and any other appropriate resources needed to facilitate discharge planning. The following describes the utilization review process: B. Inpatient Review ABH Care Management staff is available 7 days a week, 24 hours a day, 365 days a year to provide assessment and referral and conduct certification review. Providers are expected to ensure the safety of patients and may request certification of inpatient care by the first business day following an admission to an inpatient unit. A review is conducted with the requesting provider, and decisions are based on ABH clinical criteria for the specified level of care. ABH Care Management staff conducts the continued stay review with a focus on continued severity of symptoms, appropriateness and intensity of treatment plan, patient progress and discharge planning. This is accomplished by reviewing member case records and discussions with the provider or appropriate facility staff, or other behavioral health practitioners. The clinical 18

19 information is documented and certified according to ABH clinical criteria. Cases not meeting clinical criteria require referral for Peer Clinical Review. Any questionable or absent treatment or discharge plans, or questions related to the quality and appropriateness of care being delivered are also referred for Peer Clinical Review. C. Peer Clinical Review Physician Advisors provide clinical case review of those cases that do not meet medical necessity or that present quality of care issues. For after hour's coverage, a clinical supervisor, and Medical Director are on call to deal with any emergencies. ABH's Medical Director who is responsible for the clinical decisions is a board certified psychiatrist and provides case consultation in general adult psychiatry at all levels of care. Physician Advisors utilize Access Behavioral Health's clinical criteria for determining medical necessity decisions. Specialists are available for adult and child/adolescent to assist in the determination of clinical appropriateness. Resources available through the Utilization Management Program and utilized by ABH Care Management staff include the following: Informal discussions with the Medical Director or the Access Behavioral Health Physician Advisors on a daily basis. Weekly case rounds for case review and monthly in-service training. Review of "outlier" cases on every level of care. D. Determination of No Medical Necessity If the Care Management staff questions the medical necessity and/or appropriateness of the treatment as outlined in Access Behavioral Health s clinical criteria, or if there are quality of care concerns, the case is referred to the ABH Medical Director or a Physician Advisor (PA). The ABH Medical Director or Physician Advisor reviews the available information, and may offer to speak directly with the attending or primary provider to discuss the case. Through this communication, the ABH Medical Director or Physician Advisor may obtain clinical data that was not available to the care management staff at the time of the review. This collegial clinical discussion allows the ABH Medical Director or Physician Advisor the opportunity to explore alternative treatment plans with the provider and to gain insight into the attending providers anticipated goals, interventions and time frames. The ABH Medical Director or Physician Advisor may request more information from the provider to support specific treatment protocols and ask about treatment alternatives. Determinations of no medical necessity are rendered only by the ABH Medical Director or a Physician Advisor and only if the ABH Medical Director or Physician Advisor and the attending provider are unable to reach an agreement. It is always possible for the treating provider to provide additional written or verbal information prior to the peer review decision. This additional information may alter the medical necessity determination. However, once Access Behavioral Health has sent a no medical necessity determination letter according to contractual standards, the case is governed by the protocols established for an appeal. The determination remains valid unless it is overturned by an appeal. Disagreement may be a result of anyone or a combination of the following: the current level of care; the frequency of a specific treatment modality; the duration of care; and/or the treatment modality being utilized When a determination of no medical necessity is made in a case, the treating provider (and hospital, if applicable) is notified telephonically of the decision. Written notification of a 19

20 determination of no medical necessity is comprised of notification being sent to the patient (or the guardian, if the patient is a minor), and facility/treating provider on the same day the decision is made. The notification letter specifies the level of care for which a determination of no medical necessity has been made, the reason(s) why the determination has occurred and instructions on how to initiate an appeal. The Access Behavioral Health Care Management staff always work with providers in finding alternatives when a given level or type of care is not determined to be medically necessary, and this is documented in the case review notes. E. Peer-to-Peer Conversation Protocol for Peer Review Process: 1. Based on criteria for medical necessity, Care Management staff concludes that the proposed treatment of a member does not appear to meet the clinical criteria. 2. The Care Management staff reviews these concerns with the facility UR staff or treating provider on the same business day. If the Care Management staff and the treating provider are not able to resolve these concerns, the process for referral of the case for peer to peer review is initiated. Entry into the peer-to peer review process: The peer review process follows core policies and procedures which are established by the Access Behavioral Health Care Management Department and the Quality Management Committee. The procedure is as follows: An appointment is scheduled for the Physician Advisor and the treating provider by an ABH Care Management Department staff member. If the treating provider cannot be reached, a message is left, indicating that the call pertains to a question of medical necessity determination, and unless a call is received within (24) hours, a non-certification decision is issued unless special circumstances are identified that prevent the treating physician from returning the call. After reviewing the information with the treating provider, the Physician Advisor determines whether the treatment services the provider intends to render (or has already rendered) are medically necessary. If so, the case is referred back to the ABH Care Management staff for continued review. If not, the provider is informed of the determination of no medical necessity and of the appeal process. Peer review decisions are usually rendered immediately, but in all cases within 24 hours of the review. Note: It is always possible for the treating provider to provide additional written or verbal information prior to the peer review decision. This additional information may alter the medical necessity determination. However, once Access Behavioral Health has sent a no medical necessity determination letter according to contractual standards, the case is governed by the protocols established for an appeal. The determination remains valid until and/or unless it is overturned by an appeal. F. Appeal Process Access Behavioral Health is not delegated appeals. Any appeal received by Access behavioral health is forwarded to the appropriate Health Plan on the same day it is received. All authorization letters receive a quality check by the care management staff preparing the letter prior to mailing or faxing that includes the following: right member; right provider; right fund source; 20