Children s Medical Services Network. Title XIX, Title XXI and Safety Net. Utilization Management Provider Handbook

Transcription

1 Children s Medical Services Netwrk Title XIX, Title XXI and Safety Net Utilizatin Management Prvider Handbk Thank yu fr participating as a Children s Medical Services Netwrk (CMSN) prvider. This Utilizatin Management Prvider Handbk is a guide t the plicies and prcedures fr the Service Authrizatin Utilizatin Management Prcess. These requirements are fr all Title XXI and Title XIX enrllees. As a reminder ALL services fr the Safety Net enrllee ppulatin must be prir authrized and are limited health services. Authrizatin fr services fr the Safety Net prgram is the respnsibility f the lcal CMSN Area Office utilizatin management staff. The available health services are limited t Specialty Physician services, pharmacy, diagnstics fr the selected primary and secndary qualifying cnditins, and dental services fr thse clients wh have selected cleft lip/ cleft palate diagnsis. Fr Title XIX enrllees in Children s Medical Services Netwrk Specialty Plan, the Flrida Medicaid Handbks, prir authrizatin rules and fee schedules apply and can be lcated n the fllwing website: s/tabid/42/default.aspx/ Prir authrizatin is a cnditin f reimbursement fr identified services included in this handbk. Payment is cntingent upn receipt f prir authrizatin fr identified services and members must be eligible n the date service is prvided. Prir authrizatin fr these services may be requested by the member s primary care prvider, a treating specialist, r a treating facility. The Early Steps prgram authrizes services thrugh the Individualized Family Supprt Plan (IFSP) prcess. Services fr this prgram are excluded frm this handbk. Please cntact yur lcal Early Steps prvider with any questins. A cpy f this handbk can be fund at Please refer t this site regularly t ensure yu are accessing the mst updated cpy f this dcument. CMSN has partnered with Ped-I-Care and Suth Flrida Cmmunity Care Netwrk (SFCCN) t authrize the services described in this handbk when prvided t CMSN enrllees. These partners will make the determinatin t prvide a service based n review f submitted infrmatin and a determinatin f medical necessity. Ped-I-Care and SFCCN each supprt CMSN in different areas f the state. Please see the child s member ID card if yu wuld like t knw which entity will review yur requests. Prviders may als call r Fl-CustmerService@Med3000.cm with any questins r cncerns regarding claims payment f authrized services. CMSN requests that all Specialty Prviders cmmunicate their clinical findings t the referring prvider. Page 1

2 Table f Cntents Sectin 1.0. Cverage & Services Limitatin & Services Requiring Prir Authrizatin Cverage and Services Limitatins fr CMSN Services Requiring Authrizatin Exceptinal Service Requests Authrizatin fr Services t Children Enrlled in CMSN Safety Net Prgram 5 Sectin 2.0. Prcess fr Requesting Prir Authrizatin Submitting Prir Authrizatin Requests Respnse Time fr Prir Authrizatin Requests Appeal Prcess fr Denied, Reduced, Suspended, r Terminatin f Services Appeal Prcess fr Failure t Apprve, Furnish, r Prvide Payment fr Health Services 8 Sectin 3.0. Summary fr Selected Services fr Authrizatin, and Ntificatin 10 Authrizatin Applied Behavir Analysis By Reprt Prcedures Durable Medical Equipment Elective Surgical Prcedures - Hspitalizatins Hme Health Services Hspice/Palliative Care Services Inpatient Hspitalizatin -including mental health and skilled nursing facilities Out f Netwrk and Out f State Prviders Private Duty Nursing Therapy Services (PT, OT, Speech and Respiratry) 14 Ntificatin Emergency Services Admissins thrugh the Emergency Rm Hspitalizatins 15 Sectin 4.0. Appendices Appendix I Special Exemptin Frm fr Medically Necessary Services Outside Benefit Package Appendix II Partners in Care: Tgether fr Kids Frm Request fr Services Appendix III ICS Cverage Service Area 23 Page 2

3 Sectin 1.0 Cverage and Services Limitatins and Services Requiring Prir Authrizatin Cverage and Services Limitatins fr CMSN Children s Medical Services Netwrk will fllw the Medicaid Cverage and Service Limitatins and authrizatin requirements established by the Flrida Medicaid prgram. Fr a list f these limitatin guidelines, refer t the apprpriate Medicaid Cverage and Limitatin Prvider Handbks fund at the fllwing web site: erhandbks/tabid/42/default.aspx Services Requiring Prir Authrizatins Children s Medical Services Netwrk will fllw Flrida Medicaid plicy related t prcedures with utilizatin limitatins and services requiring prir authrizatin. Fr a list f the services requiring prir authrizatin please refer t the apprpriate Flrida Medicaid Cverage and Limitatins Prvider Handbk, and the Flrida Medicaid Prvider Fee Schedules fund at the fllwing link; hedules/tabid/44/default.aspx Prcedures requiring prir authrizatin are listed in the fee schedule and are indicated by a PA lcated in the Spec clumn fr the assciated prcedure cde. Requests fr prir authrizatin must be submitted t the apprpriate Integrated Care System (ICS) serving yur area. If unsure whether a specific prcedure/service/facility requires an authrizatin, cntact the utilizatin management department listed n the child s member ID card. Fr the services prir authrized, an authrizatin number will be assigned fr the requested service and must be n the claim fr payment. Page 3

4 Services Requiring Authrizatin fr CMS Title XXI and Title XIX MMA Specialty Plan Call r fax the CMSN UM Department assigned t the member r enter yur request via the Prvider Prtal Ped-I-Care Phne Fax (866) SFCCN Phne T21: r T19 MMA: , Fax (954) Prir Authrizatin supprting clinical dcumentatin is required Prir authrizatin requests require the submissin f supprting clinical dcumentatin fr medical review. Failure t prvide clinical infrmatin can result in a delay r denial f the request. Applied Behaviral Analysis (therapy) Services will be authrized by the lcal Area Medicaid Offices fr TXIX MMA. ICS's will authrize services fr TXXI By Reprt items per the Medicaid Fee Schedule Durable Medical Equipment Fr services that have a PA indicatr per the Medicaid Fee Schedule Elective Surgical Prcedures (including csmetic and Plastic/Recnstructive prcedures per Medicaid Physician Fee Schedule) Experimental / Investigatinal Treatment (See Definitin Belw) Thse newly develped prcedures underging systematic investigatin t establish their rle in treatment r prcedures that are nt yet scientifically established t prvide beneficial results fr the cnditin fr which they are being used. Hearing Services / Hearing Aids / Augmentative r Alternative Cmmunicative Systems Fr services that have a PA indicatr per the Medicaid Fee Schedule Hme Health Care services (including Hme Health Aids, Nursing Visits, and Infusin Services) Inpatient Admissins (including Mental Health and Skilled Nursing Facilities) In and Out f Netwrk Mental Health Day Treatment Prgrams PET scans MRIs, CTs N PA required if diagnsis cde is listed in Appendix D f the Practitiner Services Cverage and Limitatins Handbk. Fr diagnses nt listed, PA is required. Nutritinal Supplements / Enteral & Parenteral Nutritin Fr services that have a PA indicatr per the Medicaid Fee Schedule Orthtics and Prsthetics Fr services that have a PA indicatr per the Medicaid Fee Schedule Orthdntia Fr services that have a PA indicatr per the Medicaid Fee Schedule Out f netwrk / Out f State Services Page 4

5 PPEC (Signed Plan f Care Needed) Services will be authrized by eqhealth fr TXIX MMA. ICS's will authrize services fr TXXI Private Duty Nursing Request that Exceeds Medicaid Limits Therapy Services (PT, OT, Speech and Respiratry) (Signed Plan f Care Needed) This requirement includes Therapy Services fr Dually Enrlled Children in Early Steps Transplants and Related Care Prfessinal services rendered in the ffice fr participating prviders wuld nt require prir authrizatin Visin Services (Cntact Lenses Specialty (nn-standard) Glasses) Fr services that have a PA indicatr per the Medicaid Fee Schedule Ntificatin Required service des nt require prir authrizatin just ntificatin that that service was rendered fr crdinatin f care purpses nly Emergency Rm Visit - Ntificatin Only Observatin Stays Ntificatin Only Exceptinal Service Requests Authrizatin is required when the requested service meets any f the fllwing cnditins is nt a cvered benefit, exceeds Medicaid cvered allwable limits, r is t be prvided by an Out f Netwrk prvider. CMSN may pay fr services that are nt a cvered benefit r are beynd the Medicaid allwable limits, based n determinatin f medical necessity. Prviders must submit detailed medical dcumentatin supprting the need and benefit f these services. Please use the frm in Appendix I t submit these special exceptin requests. CMSN des nt pay fr experimental/ investigatinal prcedures. If apprved, an authrizatin number will be assigned fr the requested service and must be n the claim fr payment Authrizatin fr Services t Children Enrlled in CMSN Safety Net Prgram Children enrlled in CMSN Safety Net are nly eligible fr a limited selectin f services. Every service must be prir authrized fr children enrlled in CMSN Safety Net prgram. Page 5

6 Each child can be authrized t receive care fr a primary and secndary qualifying cnditin. If a child has mre than tw qualifying cnditins, the family determines which cnditins will be cvered under CMSN Safety Net prgram. Eligible services include specialty physician services t treat the qualifying cnditins, diagnstic services needed t treat the qualifying cnditins, pharmacy services needed t treat the qualifying cnditins, and dental services nly fr children with a cleft lip/cleft palate diagnsis. Primary care, durable medical equipment, emergency rm, and inpatient hspital care are nt cvered services fr this prgram. Each family must meet a sliding-fee participatin requirement befre CMSN can be authrized t pay fr any service. If yu are unsure if a service can be prvided under this prgram, please cntact yur lcal CMSN ffice. Authrizatins fr services fr the Safety Net prgram are the respnsibility f the lcal CMSN Area Office utilizatin management staff. Rest f Page Intentinally Left Blank Page 6

7 Sectin 2.0. Prcess fr Requesting Prir Authrizatin Submitting Prir Authrizatin Requests Yu may submit prir authrizatin requests thrugh the CMS-KIDS Web prtal at: r by cntacting the UM department listed n the child s member ID card. Fr services that are special exceptins (utside the Medicaid benefit package r ver Medicaid cverage limits), please use the special exceptin frm in Appendix I. The lcal CMSN area ffice may nly submit prir authrizatin requests n behalf f prviders wh prvide clinic services r wh therwise d nt have a stand-alne ffice and supprt staff. Fr children enrlled in CMSN Safety Net Prgram, if submitting the authrizatin by fax, please cntact the intended recipient at the lcal CMSN Area Office f the request prir t faxing t ensure availability f staff t receive the infrmatin. Each request must include a signed physician rder and supprting dcumentatin. The physician rder must specify the units f service, hurs per day, r time perid fr which authrizatin is being requested. Requests fr services that lack sufficient infrmatin r dcumentatin t make a determinatin may be clsed if the requested infrmatin is nt supplied within five (5) business days. A new request must be submitted fr any cntinuatin f services beynd the initial authrized time perid. These requests may be submitted up t 60 days prir t the expiratin f the current authrizatin. If an expedited request is needed after nrmal business hurs, the prvider shuld prcess the request fllwing the urgent and expedited prcesses utlined in sectin belw. CMSN will nt be respnsible fr payment f services requiring authrizatin that have nt been prir apprved r a service rendered utside the authrizatin date span. An authrizatin number will be assigned fr the requested service and required n the claim fr payment Respnse Time fr Prir Authrizatin Requests Rutine Request r Nn-Urgent Request The ICS will prcess ninety-five percent (95%) f all rutine r nn-urgent authrizatins within furteen (14) calendar days. The ICS s average turnarund time fr rutine requests shall nt exceed seven (7) days. The timeframe fr authrizatin decisins can be extended up t seven (7) additinal calendar days if the enrllee r prvider requests an extensin r the ICS justifies the need fr additinal infrmatin and hw the extensin is in the enrllee s interest. Page 7

8 Urgent Request r Expedited Requests The ICS will prcess ninety-five percent (95%) f all urgent requests within three (3) business days. The ICS s average turnarund time fr urgent r expedited requests will nt exceed (2) business days. The ICS may extend the timeframe fr urgent r expedited requests up t tw (2) additinal business days if the enrllee r the prvider requests an extensin r if the ICS justifies the need fr additinal infrmatin and hw the extensin is in the enrllee s interest Appeal Prcess fr Denied, Reduced, Suspended, r Terminatin f Services When an authrizatin request is denied, the enrllee r prvider has the right t appeal the decisin. There is nt an appeals prcess fr nn-cvered services fr Safety Net enrllees. An appeal may be filed rally r in writing within ninety (90) calendar days f the date f the ntice f actin and, except when an expedited reslutin is required, must be fllwed with a written ntice within ten (10) calendar days f any ral filing. The initial date f receipt f either an ral r written appeal shall cnstitute the date f receipt. The fllwing infrmatin will be required fr each appeal enrllee s full name and date f birth, enrllee s individual identificatin number, cmplainant s name, if nt the enrllee, name f prvider wh rdered the health service, name f prvider requesting the appeal, if applicable, type f actin in dispute (e.g., delay, denial, reductin, suspensin r terminatin) duratin and frequency f the disputed health service, if applicable, medical necessity f the health service t include additinal dcumentatin as needed t supprt the request, if the prvider is ut f netwrk, dcumentatin t substantiate that the health service cannt be perfrmed by a CMSN prvider, a cpy f the riginal ntice f actin in dispute, and if a cntinuatin f disputed health services is being requested Appeal Prcess fr Failure t Apprve, Furnish, r Prvide Payment fr Health Services An explanatin f all claims submitted frm prviders will be dcumented n the Explanatin f Benefits (EOB) sent t the prvider. Each claim submitted is nted as paid r will include an explanatin f the reasn fr nn-payment. If the prvider believes there has been an errr in the payment denial r has any questins abut the interpretatin f r disagrees with the adjudicatin, they shuld first attempt t reslve the issue thrugh the fiscal agent s custmer service at r by Fl-CustmerService@Med3000.cm If unsuccessful with this first level appeal, the prvider shuld cntact Ped-I-Care r SFCCN as identified n the member ID card. Page 8

9 Please see the member s ID card fr assistance r request infrmatin n submissin f a written frmal appeal. If a prvider submits an appeal, Ped-I-Care r SFCCN will prvide a written respnse within 45 days f receipt f the appeal. Examples f reasns fr payment denial fr actively enrlled members include but are nt limited t: n prir authrizatin where ne was required, incrrect enrllee infrmatin, use f Out f Netwrk prvider withut prir authrizatin, incmplete claims infrmatin, r insurance paid the maximum allwable fr the service r the benefit limits have been met member nt eligible n the date f service Rest f page intentinally left blank Page 9

10 Sectin 3.0. Summary fr Selected Services fr Referral, Authrizatin, and Ntificatin Authrizatin Applied Behavir Analysis Prir authrizatin is required fr Applied Behavir Analysis services necessary fr the treatment f autism spectrum disrders. Fr Title XXI enrllees request fr ABA services are submitted t the apprpriate ICS. Fr Title XIX enrllees requests fr ABA services are submitted t the lcal Area Medicaid Office. ABA services are nt included in the Safety Net limited services package. Treating prviders must meet Medicaid qualificatins and may submit a prir authrizatin request fr medically necessary services fr a child diagnsed with any f the fllwing ICD-9 diagnsis cdes: 299, 299, , , , , 299.8, , , 299.9, , r Fr Title XXI enrllees cntact the utilizatin management department listed n the child s member ID card fr prvider requirements and cvered services. Or refer t the July 6, 2012 Medicaid Cverage and Prir Authrizatin f ABA fr Children under 21 with Autism Prvider Alert at this lcatin eralerts/tabid/43/default.aspx By Reprt Special Prcedures By reprt prcedures require dcumentatin f medical necessity fr the prcedure perfrmed r infrmatin is needed in rder t review and price the prcedure crrectly. This requires a written reprt t be submitted with the claim. Please see the mst current versin f the Medicaid Practitiner Services Cverage and Limitatins Handbk, Sectin 3 fr mre detailed infrmatin. 01_Practitiner_Services_Handbk.pdf Durable Medical Equipment Prir authrizatin fr certain services is required and must include a signed written rder by the treating physician/pa/arnp r treating pdiatrist. See Medicaid DME and Medical Supply Services Cverage and Limitatin Handbk. _DME_ver1_0.pdf Page 10

11 Fr children receiving n-ging DME wh require renewals, the rdering physician r primary care prvider must evaluate the member face-t-face at a minimum f every six (6) mnths. Services will nt be reauthrized withut dcumentatin f a physician face-t-face evaluatin Elective Surgical Prcedures - Hspitalizatin Prir authrizatin is required fr all elective hspitalizatins. Elective prcedures perfrmed in the utpatient setting must fllw the prir authrizatin requirements established fr the prcedure being perfrmed. Any pst-discharge services requiring authrizatin must be cmmunicated thrugh the nrmal authrizatin prcess described abve. CMSN Safety Net prgram is a limited service package and des nt cver inpatient hspital care services Hme Health Services A request fr hme health services is generally made in tw phases, the initial assessment and the treatment plan. The primary care r specialty physician will submit a prir authrizatin request fr the initial assessment. If apprved, the hme health agency will cnduct the assessment and develp a prpsed treatment plan. Once the treatment plan is apprved and signed by the requesting prvider, the plan must be submitted fr authrizatin f services. Initial requests fr hme health care will be authrized fr n mre than 60-day duratin t allw fr any reevaluatin. Fr enrllees funded by Title XXI, requests are submitted t the apprpriate ICS Fr enrllees funded by Title XIX, eqhealth Slutins will partner with CMSN t prvide care crdinatin. Recmmended hme health care services requests are submitted t the apprpriate ICS fr authrizatin. Cntinuing private duty hme health care services will be authrized fr n mre than six (6) mnth duratin and will require a medical cnsultatin by the rdering r attending physician. During the apprval perid, if there is a change in the member s status r a change in hurs necessary t care fr the member, a new request fr authrizatin must be submitted alng with dcumentatin f the changes in the member s cnditin that necessitates the requested change. Page 11

12 Hspice/Palliative Care Services Hspice Althugh Hspice services d nt require prir authrizatin the primary care prvider is required t cmplete necessary hspice referral dcumentatin t verify client meets the requirements fr hspice care and meets the standard definitin fr hspice eligibility. Partners In Care: Tgether fr Kids (PIC:TFK) / Flrida s Prgram fr All-Inclusive Care (PACC) Fr children with life-threatening illnesses, but wh have a life expectancy f greater than six (6) mnths, the primary care prvider can submit the Physician Authrizatin/Recertificatin frm t refer a child t receive PIC:TFK services. These services are fr members with a life threatening illness that wuld benefit frm specialized palliative care services. Annual Physician Re-Certificatin will be required. This frm, unique t the palliative care prgram, is in Appendix II. Upn receipt f the Physician Authrizatin/Recertificatin frm, the CMSN ffice will prcess the referral t the PIC:TFK prvider fr evaluatin and ptential admissin int the prgram. The PIC:TFK prvider will cllabrate with the CMSN ffice n the initial Plan f Care identifying service needs, frequency f service, the family s gals and the planned interventins. Althugh the services prvided by the PIC:TFK prgram d nt require authrizatin, the physician must cmplete necessary dcuments in rder fr the child t be referred and enrlled in the PIC:TFK prgram. Fr Title XIX enrllees PIC:TFK services are billed directly t Medicaid as these services are included in the list f services that are billed utside f the CMSN Plan. Fr Title XXI enrllees PIC:TFK services are billed t the CMSN Plan. Services prvided have specified limitatin that can be fund in the PIC:TFK Prgram Guidelines Inpatient Hspitalizatin including Mental Health and Skilled Nursing Care All nn-emergent inpatient hspitalizatins require prir authrizatin apprval. Services must be medically necessary. Fr inpatient mental health needs, CMSN will reimburse prviders fr therapeutic grup care during a hspitalizatin r mental health inpatient r crisis stabilizatin placement if the setting is nt an Institutin fr Mental Diseases. CMSN will als reimburse fr services designed fr children that are prvided in a licensed residential grup hme setting. Page 12

13 Fr Title XXI children enrlled in the Behaviral Health Netwrk (BNET) prgram, please cntact the child s BNET liaisn in the lcal CMSN Area Office. Children being cnsidered fr skilled nursing care (nursing facility services) must have a staffing with the Children s Multidisciplinary Assessment Team (CMAT) t determine the mst apprpriate level f care needed, in cnsideratin f medical needs and family request. See: Hspital services cverage and Limitatins Handbk ces_handbk_december_2011.pdf Cmmunity and Behavir Heath Services Cverage and Limitatins Handbk haviral_healthhb.pdf Nursing Facility Services Cverage and Limitatins Handbk _Nursing_ver1_0.pdf Out-f-Netwrk and Out-f-State Prviders Prir authrizatin is required fr ALL nn-emergency ut-f-netwrk and ut-f-state services. Cntact the utilizatin management department listed n the child s member ID card fr any ut-f-netwrk service request Private Duty Nursing Requests fr private duty nursing must be prir authrized and services may be reimbursable if determined medically necessary. CMSN fllws the Flrida Medicaid Hme Health Services Cverage and Limitatins Handbk at this lcatin Services_Handbk_March_2013.pdf Fr enrllees funded by Title XXI, requests are submitted t the apprpriate ICS Fr enrllees funded by Title XIX, eqhealth Slutins will partner with CMSN t prvide care crdinatin. Recmmended private duty nursing requests are submitted t the apprpriate ICS fr authrizatin. During the apprval perid, if there is a change in the member s status r a change in hurs necessary t care fr the member, a new request fr authrizatin must be submitted alng with dcumentatin f changes in member s cnditin that necessitates the requested change. Page 13

14 Therapy Services (PT, OT, Speech and Respiratry) Therapy services (physical, ccupatinal, speech/language r respiratry therapy) are generally perfrmed in tw phases under ne authrizatin. The primary care r specialty physician will submit an rder /prescriptin, alng with supprting dcumentatin fr evaluatin and treatment. The evaluating therapist will perfrm the initial evaluatin and develp a prpsed plan f care t include, amunt, scpe and duratin f services, and any ther requirements set by Medicaid Once the treatment plan is apprved and signed by the requesting prvider it must be submitted fr authrizatin f services t the apprpriate ICS. Services may be requested up t sixty (60) days in advance. The authrizatin perid fr these services may nt exceed six mnths (180 days). Therapy services included n a child s Individual Family Supprt Plan thrugh the Early Steps prgram des nt need a separate authrizatin request. Ntificatins Emergency Services Emergency services d nt require prir authrizatin and are t be prvided t all members in accrdance with state and federal laws. If an emergency cnditin is determined t exist, the care, treatment, r surgery fr a cvered service by a physician that is necessary t relieve r eliminate the emergency medical cnditin within the service capability f a hspital will be a cvered service. N later than the fllwing business day after an emergency ccurrence, the prvider is required t ntify the utilizatin management department listed n the child s member ID card f the member s demgraphics, facility name, and admitting diagnsis. Member s shall nt be sent t the Emergency Department during a primary care prvider s nrmal ffice hurs fr the fllwing: rutine fllw-up care, fllw-up fr suture r staple remval, r nn-emergent care. The CMSN Safety Net prgram is a limited service package and des nt cver emergency services. Page 14

15 Admissins thrugh the Emergency Rm Hspitalizatins Prir authrizatin is NOT required fr emergent admissins. Hwever, by the fllwing business day, the hspital must ntify the utilizatin management department listed n the member s ID card and prvide member demgraphics, facility name and admitting diagnsis. Any pst-discharge services requiring authrizatin must be cmmunicated thrugh the nrmal authrizatin prcess described abve. The CMSN Safety Net prgram is a limited service package and des nt cver Inpatient hspital care services. Page 15

16 Appendix I - Special Exemptin Frm fr Title XXI and Title XIX Request fr Children s Medical Services Cverage f Medically Necessary Special Services fr a Child Under Age 21 Patient Name: Date f Birth: Medicaid ID: This sectin must be cmpleted by a physician, licensed clinician, r ther prvider Requesting Prvider Name: Natinal Prvider ID: Telephne: Fax: Requesting Prvider Name Natinal Prvider ID: Telephne: Fax: Prvider Type/Specialty: This request is fr a Prduct: Prcedure: Service: CPT/HCPCS Cde, (if nne, please describe): Expected Frequency/Duratin f Treatment: Is the request experimental r investigatinal? Yes: (If yes, prvide name and prtcl) Is the request cnsidered t be safe? Yes: N: (If n, please explain why necessary) Is the request prved effective? Yes: (If n, please explain why necessary) Is the request furnished in a manner primarily fr the cnvenience f the prvider, child, r parent/caregiver? Yes: N: (If yes, please explain why necessary) Please prvide a descriptin f hw the requested prcedure, prduct r service will crrect r amelirate the patient s defect, physical r mental illness, r cnditin. (If mre space is needed, please attach additinal cmments) N: N: Page 16

17 Requester s Signature and Credentials: License #: Date: Please attach all related medical recrds and evidence-based literature This sectin must be cmpleted by the Medical Cnsultant Cmments: Apprved: Denied: Duratin: Signature: Date: This sectin must be cmpleted by the Utilizatin Manager Prgram Assigned: Name/Title: Date: CPT/HCPCS Cde: Prvider Type: Duratin: Cmments: Page 17

18 Appendix II Palliative Care Prgram: Partners In Care: Tgether fr Kids Frms Include: Partners in Care Electrnic Frm Physician Authrizatin/Re/Certificatin Frm Rest f Page Intentinally Left Blank Page 18

19 Sectin 1: Demgraphics: PARTNERS IN CARE:TOGETHER FOR KIDS (PIC:TFK) FAX REFERRAL Child s name: SS#: DOB: Gender: M F Schl child attends: Grade: ESE: Yes N Adult living with child: Adult living with child: Parent s marital status: Relatinship: Relatinship: Legal guardian: Hme address: Hme phne: Wrk phne: Cell phne: Siblings living at hme DOB/Age Schl attends Other invlved family members & relatinship: Sectin 2: Medical and Insurance Infrmatin Primary Diagnsis: Secndary Diagnsis: Primary Care MD: Date f nset: Date f nset: Phne: Address f Primary Care MD: Other invlved MDs, Specialty, and Phne #: Medicaid Waiver/State Plan Services Frm attached: Yes N/A (child has Title XXI r Safety Net) Page 19

20 Insurance: Medicaid/ Title XIX Title XXI Safety Net Current Trajectry f Illness: New (dx within last 3 m, may/may nt be in curative care) Mid-Stage (at least 4 m pst-dx & n active treatment/interventin) End Stage (4 m r mre pst-dx & nt respnding t a nrmal curse f treatment/interventins, future ptins limited) Suggested Services (Check all that apply): Psychscial Cunseling Palliative Care Nurse Cnsult/Assessment Persnal Care Respite Pain & Symptm Management Spiritual Cunseling Bereavement Cunseling Vlunteer Services CMS staff making referral: Date faxed t PIC:TFK Prvider: Phne: CMS care crdinatr (if nt same as referring staff): Phne: Sectin 3: Dispsitin f Referral PIC:TFK prvider: Phne: If mre than 1 PIC:TFK prvider available, chice made by family: Yes N/A nly 1 PIC:TFK prvider available Date referral cmpleted: Date faxed t PIC:TFK prvider: Date & time referral received: Patient enrlled: Yes Date: N Cntact Attempt dates: Reasn if nt enrlled: PIC:TFK prvider signature: Date: Phne: Page 20

21 PHYSICIAN AUTHORIZATION/ RE-CERTIFICATION Instructins: New patients: This frm must be signed by the child s Children s Medical Services Netwrk primary care physician prir t discussing PIC:TFK with a parent/ caregiver. PIC:TFK enrlled patients: The Child s primary care physician must sign this frm every twelve mnths (annually). Please sign the frm and fax back t Children s Medical Services Netwrk (CMSN) at. (Check ne) Initial Certificatin Annual Re- Certificatin CHILD S NAME DOB DIAGNOSIS: I certify that cnditin., a CMSN enrlled child is diagnsed with a ptentially life limiting Physician s Signature Date Page 21

22 INSTRUCTIONS FOR THE PARTNERS IN CARE: TOGETHER FOR KIDS PHYSICIAN AUTHORIZATION/ RE- CERTIFICATION NOTE: The Partners in Care: Tgether fr Kids (PIC:TFK) Physician Authrizatin/Recertificatin frm cntains cnfidential infrmatin and shuld nly be used by authrized persnnel as part f the medical and administrative recrd fr the PIC:TFK participant. This frm is designed t btain written initial authrizatin and annual re-certificatin fr services prvided by the PIC:TFK prvider. This frm must be signed prir t inviting the family t participate in the PIC:TFK prgram and befre Medicaid can be billed fr services. When the frm is cmpleted and signed by the primary care physician (PCP) r specialty physician they have authrized PIC:TFK services and have certified that the child has a ptentially life limiting cnditin. A cmpleted and signed authrizatin/re-certificatin frms meets the fllwing prgram Access Indicatrs and Perfrmance Measures: Access Indicatr 2 Access Indicatr 4 Organizatinal and Administrative Structure The CMSN staff must enter the fax number prir t sending t the PCP r specialty physician. A cpy f this frm must be included in the CMSN electrnic health recrd (EHR). Page 22

23 Appendix III-ICS Cverage Service Area Page 23