SOUTH FLORIDA BEHAVIORAL HEALTH NETWORK UTILIZATION MANAGEMENT MANUAL

Transcription

1 SOUTH FLORIDA BEHAVIORAL HEALTH NETWORK UTILIZATION MANAGEMENT MANUAL

2 Table of Contents Table of Contents Glossary of Terms Utilization Management Overview Children s System of Care Behavioral Health Network (BNET) Children s Crisis Response Team (CCRT) Children s Crisis Stabilization Unit (CCSU) Families and Communities Empowered for Success (FACES) Functional Family Therapy (FFT) Specialized Therapeutic Group Care Statewide Inpatient Psychiatric Program (SIPP) Juvenile Incompetent to Proceed Program (JITP) Juvenile Addictions Receiving Facilities (JARF) Children s Residential Substance Abuse Services Adult System of Care Crisis Stabilization Units (CSUs) Florida Assertive Community Treatment Team (FACT) State Treatment Facilities Incidental Expenses Short-term Residential Treatment (SRT) Program - Civil Short-term Residential Treatment (SRT) Forensic Program Short-term Residential Treatment (SRT) Miami-Dade Forensic Alternative Center (MD FAC) Adult Residential Level II Mental Health Adult Forensic Services Indigent Drug Program (IDP) Projects for Assistance in Transition from Homelessness (PATH) Family Intervention Specialists (FIS) Adult Residential Levels I-II Substance Abuse General Temporary Assistance for Needy Families (TANF) Reporting and Compliance Reviews Authorizations & Denials Reconsiderations Forms Data Sharing & Consent to Release and Exchange Information Date Approved: Date Modified: - 1 -

3 Glossary of Terms DEFINITION OF TERMS: 1. Accessible. Children, families and community members should be helped to become knowledgeable about how to ask for and receive services that are timely, comprehensive and family-friendly without facing unreasonable barriers. Access to services meets individualized needs of the consumer (i.e., physical, emotional, and social needs), and are timely and geographically appropriate. Consumers have access to services regardless of race, language, cultural background, sexual orientation, age or developmental level, psychological characteristics, physical condition, spiritual beliefs, social preferences, gender or ability to pay. This also includes accessibility needs of consumers, funders, provider representatives, care practitioners, family members, volunteers, visitors, employees and community stakeholders to services contracted through and facilities operated by SFBHN. 2. Actuarial Study. Analysis of past utilization data for specific groups in order to estimate future costs. Built upon assumptions where necessary, the final analysis combines all estimates to compute the cost per member per month (PMPM). 3. American Society of Addiction Medicine Patient Placement Criteria For the Treatment of Substance Related Disorders Second Edition (ASAM PPC-2). As part of the State of Florida s movement toward a comprehensive system of managed behavioral health care, the Department of Children and Family Services Substance Abuse Program Office implemented the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2) and the Florida Supplement, on July 1, All contracted State of Florida substance abuse providers are required to use the ASAM PPC-2R, Florida Supplement, and its accompanying forms. The primary purpose of the Florida Supplement, as an extension of the ASAM PPC-2R, is to provide clinicians with an abbreviated reference document to assist them in documenting their placement decisions in accordance with Florida s system of licensable services. 4. Alternative Services. Services outside of the department s Integrated Data System cost centers that are deemed necessary to meet the objectives outlined in a consumer's treatment plan. 5. Assessment. The systematic collection and integrated review of individual-specific data and completion of evaluations for determining clinical eligibility and treatment planning. 6. Assessment Instrument. A tool used for collection of detailed information concerning an individual s substance abuse, emotional and physical health, social roles, and other areas that may reflect the severity of the individual s abuse of alcohol or drugs, as a basis for identifying an appropriate treatment regimen. 7. Average Length of Stay (ALOS). Duration of treatment in a treatment setting, expressed in units of service. Measure is calculated by dividing the sum of total days enrolled in a specific service or setting over a specific date range by the total number of consumers admitted during a same time period. 8. Behavioral Health Network (BNET) means the statewide network of Providers of Behavioral Health Services who serve non-medicaid eligible children with mental or substance-related disorders who are determined eligible for the Title XXI part of the KidCare Program. This network includes providers who are managed behavioral health care organizations, private and state funded mental health and substance-related disorders providers. The Behavioral Health Network is administered by the Department of Children and Families, Children's Mental Health State Program Office to provide a comprehensive behavioral health benefits package for children with serious mental or substancerelated disorders. 9. Behavioral Health Services. Mental health services and substance abuse prevention and treatment services as defined in chapters 394, 397 and 916, F.S. which are provided using state and federal funds. Date Approved: Date Modified: - 2 -

4 10. Case Management. This service includes assessment, coordination of service linkages, referral, and follow-up of clinically indicated treatment services required for a consumer within a holistic and costeffective system of care. This process includes coordinating all of consumers care and advocating for consumers needs. 11. Child Global Assessment Scale (CGAS) means the scale used to report the clinical judgment of a child s overall level of functioning as based on and as described in the Diagnostic and Statistical Manual of Mental Disorders, Most Current edition (DSM Axis V). 12. The Children's Functional Assessment Rating Scale (CFARS) is a way of documenting and standardizing impressions from clinical evaluations or mental status exams of children that assess cognitive, social and role functioning. 13. Consumer. Person who receives substance abuse and/or mental health services. Consumer, patient, and consumer are used interchangeably. 14. Clinical Assessment. The collection of detailed information concerning an individual s behavioral health, emotional and physical health, social roles, and other areas that may reflect the individual s overall health as a basis for identifying an appropriate treatment regimen. 15. Clinically Necessary. Services deemed appropriate and necessary to treat protect and enhance the health status of consumers based on consumers symptoms and diagnoses and if services are not provided could adversely affect the consumer. All services are to be provided in accordance with accepted standards of practice. 16. Behavioral Health Clinician. A substance abuse or mental health professional that provides one or more of the following services: assessment; individual, group, or family counseling services; or case management. 17. Community-Based Services. Behavioral health services provided outside of a state facility. 18. Community-Focused. The process of planning, management and decision-making to ensure resources are designed to build on the unique strengths and meet the specific needs of the local community. 19. Concurrent Review. Specific methodology and practices utilized periodically during the course of treatment to verify that the treatment is clinically necessary and progressing at an appropriate pace. 20. Continued Stay. An extension of services at the same level of care. A Continued Stay may be clinically indicated where consumers have not completed treatment goals and have not reached the necessary level of functioning for the next least restrictive level of care. 21. Continuous Quality Improvement. Continuous internal improvements in service provision and administrative functions. Continuous improvement is an ongoing effort to improve services and/or processes. These efforts can seek incremental improvement over time or breakthrough improvement all at once. 22. Continuum of Services. Recovery-oriented systems of care will offer a full array of services, including prevention, pretreatment, treatment, continuing care and support throughout recovery. Individuals will have a full range of stage-appropriate services from which to choose at any point in the recovery process. 23. Co-occurring Disorder. Consumers with co-occurring disorders (COD) have one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental disorders. A diagnosis of co-occurring disorders occurs when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder. Date Approved: Date Modified: - 3 -

5 24. Co-occurring Disorder Service Capability. The ability of any program to coordinate every aspect of its program infrastructure (policies, procedures, practices, documentation, and/or staff competencies), within its existing resources, to be able to provide and/or coordinate appropriately matched, integrated services to the individuals and families with co-occurring disorders that are routinely presenting for care in that program. 25. Covered Days. The authorized service units for which the Department of Children & Families, HMOs, and other managed care companies will reimburse for services rendered. Units of measure may be limited per episode of illness, per year, or per lifetime. 26. Criteria. Predetermined elements related to particular health care services with which aspects of the quality, clinical necessity, and appropriateness of a health care service may be assessed by health care professionals. 27. Data Management. Activities that use data elements to track cost, utilization, quality of care and access to services within the network of providers. CFP Department of Children & Families, Pamphlet Mental Health and Substance Abuse Measurement and Data, effective August (10th edition, version 2), or the latest revised edition thereof means a document promulgated by the department that contains required data-reporting elements for substance abuse and mental health services, hereafter referred to as CFP 155-2, and which can be found at: Day or Night Treatment. A therapeutic environment wherein services and activities are generally provided a minimum of 4 consecutive hours three or more days per week. 29. Denial. An adverse determination by the Utilization Management Program resulting in a denial of authorization for requested services. Denials are based upon a lack of clinical necessity and reasonableness and/or appropriateness of the requested treatment service. 30. Discharge Planning. Advance preparations for assuring the continuity of care for moving a consumer from one level of care to another within or outside the current agency. 31. Discharge Summary. A narrative summary of consumer treatment records which describes the consumer s accomplishments or lack thereof during the treatment episode. The summary includes the treatment interventions and activities provided and consumer s responses to the interventions, progress made, problems encountered, and reason(s) for discharge and referrals and/or treatment recommendations provided. 32. Evidence-Based Practices. Those practices that are based on accepted practices in the profession and are supported by research, field recognition, or published practice guidelines. 33. Family Intervention Specialists/Adult Intervention Specialists (FIS). Individuals employed to provide adult behavioral health outreach, screening, intervention, and case management to families involved in the child welfare system and/or the Abuse Hotline. 34. Family Intervention Specialist Service. Services designed to reduce the incidence of child abuse and neglect resulting from parents or caregivers behavioral health and to improve outcomes for families in the child welfare system and/or community based care. 35. Forensic Mental Health Services. Forensic Mental Health Services provide services to individuals with mental illness pursuant to Chapter 916, Florida Statutes. 36. Global Assessment of Individual Needs (GAIN). One of the Department approved evidenced-based assessment instruments. Information regarding this instrument is available from the following website: HIPAA. The acronym for Health Insurance Portability and Accountability Act of Privacy Act Date Approved: Date Modified: - 4 -

6 included in 45 CFR Parts 160 and High-Risk. Consumer presenting with a profile that includes a multitude of treatment requirements with at least one problem area identified as severe. Cases with Child Welfare System involvement and cases in which the consumer is either pregnant and/or an Intravenous (IV) drug user are also identified as High-Risk. High-Risk suggests increased risk that the consumer may not successfully complete the treatment episode and/or may have a poor prognosis. 39. High-Utilizer. Consumer with three or more admissions to residential level I or level 2 substance abuse treatment in a 2 year time period. 40. Incidental Cost Center. This cost center provides for incidental expenses, such as clothing, medical care, educational needs, developmental services, FACT Team housing subsidies and pharmaceuticals and other approved costs. All incidental expenses must have prior written authorization by the SFBHN s authorized staff member or be authorized in the contract. 41. Incompetent to Proceed (ITP). Unable to proceed at any material stage of a criminal proceeding, which shall include trial of the case, pretrial hearings involving questions of fact on which the defendant might be expected to testify, entry of a plea, proceedings for violation of probation or violation of community control, sentencing, and hearings on issues regarding a defendant's failure to comply with court orders or conditions or other matters in which the mental competence of the defendant is necessary for a just resolution of the issues being considered as outline in Chapter 916 of Florida Statutes. 42. Indigent Drug Program (IDP). The program that allows the Department of Children and Families to purchase medications for individuals who are indigent. 43. Individual(s) Served. Any individual who is receiving services in any substance abuse treatment or prevention program or mental health treatment program whose cost of care is paid, in part or in whole, by the Department, Medicaid, Medicaid capitated managed care entities, or local match. 44. Inmate of a public institution. An individual that is serving time for a criminal offense or confined involuntarily in state or federal prisons, jails, detention facilities, or other penal facilities. A facility is a public institution when it is under the responsibility of a governmental unit or when a governmental unit exercises administrative control. 45. Intensive Outpatient. A planned and organized service where substance abuse agency staff provide regularly scheduled sessions within a structured program, with a minimum of nine treatment hours per week. Examples include day or evening programs in which consumers attend a full spectrum of treatment programming but also spend time outside the treatment setting including residing outside of the facility. 46. Interim Services. In cases where consumers are on the wait list for behavioral health treatment, services are provided to reduce adverse effects to the consumer and the community. These services are provided until the consumer is admitted into the recommended treatment program and/or level of care. Interim Services may include placement into a lower level of care pending entry into recommended level of care. Interim Services may also include peer support services such as drop in centers and/or linkages to recovery support services. Interim services also may include a combination of services that are provided to meet the needs and desires of the individual while waiting for services. 47. Juvenile Incompetent to Proceed (JITP). A "child" or "juvenile" or "youth" as defined in chapter 985, F.S., as any unmarried person under the age of 18 who has not been emancipated by order of the court and who has been found or alleged to be dependent, in need of services, or from a family in need of services; or any married or unmarried person who is charged with a violation of law occurring prior to the time that person reached the age of 18 years deemed incompetent to proceed by virtue of mental illness. 48. Managing Entity (ME). A corporation that is organized in the State of Florida, is designated or filed as Date Approved: Date Modified: - 5 -

7 a non-profit organization under section 501(c)(3) of the Internal Revenue Code, and is under contract to the department to manage the day-to-day operational delivery of behavioral health services through an organized system of care. 49. Monitoring Subcontracts. The process whereby the managing entity conducts a systematic organized review of a network provider s performance in order to give reasonable assurance that the network provider is complying with subcontract requirements, rules, regulations and laws applicable to contract performance. 50. Outcome. The results/effects obtained as a result of a measured performance. 51. Outcome Measurement. State-Mandated and/or SFBHN required behavioral health consumer outcomes. 52. Outpatient Treatment. A therapeutic environment wherein services are provided by appointment during scheduled operating hours. Services are generally provided via individual, family and/or group sessions where the consumer does not reside at the facility. 53. Prior Authorization. The authorization required for services identified by Utilization Management Program. Authorizations are necessary for reimbursement for designated State-Funded treatment services. 54. Program Reviews. Reviews conducted by the Utilization Management Program to ensure compliance with Departmental and State requirements, as applicable. Program Reviews also ensure quality-ofcare. 55. Participant. Any individual who takes part in targeted substance abuse prevention programs, activities or services which are paid, in part or in whole, by the department. 56. Performance Measures. Quantitative indicators, outcomes and outputs that are required by the contracted and implemented by the organization to objectively measure performance of the ME and subcontractors and are used by the ME and network subcontractors to improve services. 57. Program. A structured Schedule of Activities designed so that participants will attain so far as possible, certain educational, attitudinal, social and behavioral objectives. This is an unduplicated count of participants. 58. Projects for Assistance in Transition from Homelessness (PATH). The Federal grant to support homeless individuals with behavioral health needs. 59. Promising Practices. The use of practices that incorporate the best objective information available regarding effectiveness and acceptability. 60. Protected Health Information. Any information whether oral or recorded in any form or medium that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. 61. Provider Network. The direct service agencies that are under contract with a managing entity and that together constitute a comprehensive array of emergency, acute care, residential, outpatient, recovery support, and consumer support services or other services as designated by this contract. See section , F.S. 62. Residential Treatment. A therapeutic intervention processes for individuals who cannot or do not function satisfactorily in their own home environments. Typically, this is a structured, live-in environment within a non-hospital setting which includes, at a minimum, a range of assessment, Date Approved: Date Modified: - 6 -

8 rehabilitation, and treatment services. Access to ancillary services are also provided when indicated. 63. Quality Assurance. A systematic monitoring and evaluation of the various aspects of a project, service or facility to maximize the probability that minimum standards of quality are being attained by the production process. 64. Quality Improvement. A management technique to assess and improve internal operations and network services. It focuses on organizational systems rather than individual performance and seeks to continuously improve quality. The process involves setting goals implementing systematic changes, measuring outcomes, and making subsequent appropriate improvements. Quality assurance activities will assess compliance with contract requirements, state and Federal law and associated administrative rules, regulations, and operating procedures and validate quality improvement systems and findings. 65. Recovery. An on-going process which enables a person with behavioral health issues to live a meaningful life in a community of his or her choosing while striving to achieve his or her potential. This allows individuals to improve their health, wellness, and quality of life. 66. Recovery Based. Based upon a personal process of overcoming the negative impact of substance abuse addiction or mental illness. A system of care provides treatment and supports that promote recovery and functioning in the community. 67. Retrospective Review. Review of cases retrospectively for evaluating clinical processes and outcomes, consumer satisfaction, efficiency of services and quality of care. 68. TANF Participant. A person or family member of that person defined in 45 CFR Part and section and subsection (9), F.S. 69. Temporary Assistance to Needy Families (TANF). Any family receiving cash assistance payments or TANF diversion services from the state program pursuant to the provisions of section , F.S., and Part A of Title IV of the Social Security Act. 70. Transfer Summary. A written justification of the circumstances to transfer a consumer from one treatment component to another or from one provider agency to another. 71. Treatment Plan. A plan developed by the treatment team with the consumer that details measurable goals and objectives for the consumer s treatment. The plan shall include the type and frequency of treatment interventions and the projected target dates for each objective. Treatment Plans address all indicated treatment needs. Some goals may be deferred until a later time as indicated. 72. Treatment Plan Reviews. An amendment of the original treatment plan which updates the consumer s progress in treatment and denotes any deficiencies and issues still to be addressed in treatment. 73. SAMH. The Substance Abuse and Mental Health Program within the department. 74. SOAR (SSI/SSDI Outreach, Access and Recovery). A technical assistance initiative. This strategy helps States and communities increase access to SSI and SSDI for people through training, technical assistance and strategic planning. 75. Stakeholder means individuals/groups with an interest in the provision of behavioral health services. 76. Statewide Inpatient Psychiatric Programs (SIPP). Residential inpatient facilities under contract with the Agency for Health Care Administration under the Medicaid IMD waiver for children under age 18 to provide diagnostic and active treatment services in a secure setting. 77. Substance Abuse and Mental Health Information System (SAMHIS). The department's online data system which providers are required to use to collect and report data and performance outcomes on Date Approved: Date Modified: - 7 -

9 persons served whose services are paid for, in part or in whole, by the department's Substance Abuse and Mental Health (SAMH) contract, Medicaid, or local match. Instructions on how to access the system can be found in CFP System of Care. Behavioral health services that are coordinated and developed into an integrated network of services accessible and responsive to the needs of individuals served, their families, and community stakeholders. 79. Unit of Measure. The billing component services. The unit of measure for residential levels I and II is a bed-day, for Day/Night it is a day, and for Outpatient it is a contact hour. All units of measure can be found in 65E-14 of Florida Administrative Codes. 80. Utilization Management. Is a system for the evaluation of the appropriateness, clinical need and efficiency of behavioral health services procedures and facilities according to established criteria and/or guidelines. Typically it includes new activities or decisions based upon the analysis of a case and includes discharge planning, concurrent planning, and preauthorization, for some services as well as retrospective reviews and focused reviews of individual cases. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by a consumer or subcontractor. 81. Wait List. This list includes consumers identified as waiting for placement into a behavioral health treatment program. Wait Lists are used when programs are at full capacity and unable to admit additional consumers into the prescribed service. Date Approved: Date Modified: - 8 -

10 Utilization Management Overview Utilization Management (UM) is a system for the evaluation of the appropriateness, clinical need and efficiency of behavioral health services, procedures and facilities according to established criteria and/or guidelines. For the purposes of this manual, the specific goals of utilization management include elimination/management of wait lists, the maximum utilization of treatment resources, and the delivery of clinically appropriate services in the least restrictive setting and most cost effective manner. Utilization management systems include preauthorization for some services as well as retrospective reviews and focused reviews of individuals receiving services and subcontractors whose utilization of services is outside of expected parameters. Utilization management includes methods used to manage the system of care to ensure access to the appropriate level of care, at the right frequency and for the appropriate duration. It also includes financial screening to ensure maximization of fiscal resources including other third party payors such as, but not limited to KidCare, Medicaid, Medicare, and other HMOs. These methods may include programs of intervention and/or diversion. Utilization management includes not only managerial and supervisory strategies, methods and tools to ensure timely access to care, but also includes processes to promote continuous improvement to manage resources. As the Managing Entity for South Florida, South Florida Behavioral Health Network (SFBHN) is enhancing our automated utilization management system to include additional treatment authorization and management reports for the system of care. The SFBHN conducts oversight, reporting and management of the behavioral health services for individuals served. In the event that waiting lists do develop, the managing entity implements procedures for managing the substance abuse and mental health waiting list for all applicable levels of care including provision of interim services through utilization management strategies. SFBHN strives to ensure that its core values and principles are incorporated on every level of the System of Care (SOC). One of the mechanisms SFBHN utilizes to ensure that these core values and principles are embedded into the SOC is its Utilization Management Program. SFBHN s applies its UM processes to ensure those values and principles are intrinsic to the services provided and are integrated and reflected at every level and/or entry point. These core principles and values are: Consumer Guided Individualized to meet the needs of the Consumer Family Driven Community Based Culturally and Linguistically Competent Transparent Recovery and Resiliency Focused The SFBHN conducts initial and continued stay authorizations for applicable levels of care as described in the contract with the Department and the approved Annual Action Plan in order to ensure timely access to behavioral health services and minimize the wait lists. The authorization processes include: Timeliness standards for authorization review. All authorization reviews must adhere to timeline standards for the services provided and departmental, statutory, and judicial regulations or requirements. The standards for timely access to care are along the lines of those required by Managing Entity accrediting bodies and the Medicaid prepaid plans: o Immediate/Crisis: seen immediately for life threatening behavioral health emergencies o Within 24 hours of initial contact for non-life threatening emergencies; o Urgent care: Within 48 hours; o Routine care: The availability of an appointment for routine care within 7 business days. Processes for communicating UM decision making criteria to practitioners including any standardized tools and assessments for use in determining placement and/or level of care. Date Approved: Date Modified: - 9 -

11 Provisions for providing timely reconsiderations, or second opinions, when a request for authorization for a particular service is denied. (A reconsideration differs from a grievance in that grievances are used when a recipient or member of the covered population believes that he or she has been treated improperly, whereas a reconsideration is a request to review authorization or reauthorization for a particular service.) The second opinion shall be obtained according to the timeliness standards for the service in question as outlines in the Reconsiderations section of this manual. This manual establishes written utilization management procedures inclusive of and not limited to agreed upon behavioral health services. These procedures meet the Department s requirements and defines the processes to be utilized to minimize over- and underutilization of services. Date Approved: Date Modified:

12 Children s System of Care Date Approved: Date Modified:

13 Children s Mental Health Section: 1 Behavioral Health Network (BNET) POLICY: Behavioral Health Network (BNET) is a statewide network of Providers of Behavioral Health Services who serve non-medicaid eligible children with mental or substance-related disorders who are determined eligible for the Title XXI part of the KidCare Program. This network includes providers who are managed behavioral health organizations, private and state funded mental health and substance-related disorders providers, and Lead Agencies. PURPOSE: To define the procedures necessary for eligibility determination, assessment, and access to BNET services. PROCEDURE: I. Ensuring Continuity of Services for Children Transferring Between Districts/Regions/Providers: A. SFBHN s BNET Coordinator will ensure that the region s behavioral health liaison from the sending provider shall contact the receiving region s Title XXI region coordinator, the Children s Medical Services liaison, and Behavioral Health Network HQ in Tallahassee and that the behavioral health liaison shall provide the receiving region the child s name, social security number, effective date of transfer, and the county to which the child will be transferring. Additionally, the child s parent or guardian should be given the name, phone number, and address of the new behavioral health liaison. B. Copies of the child s current treatment plan, demographic information, and all other pertinent information should be sent to the receiving provider prior to the child s transfer. Electronically transmitted confidential information shall follow established guidelines to ensure the confidentiality of this information is maintained. C. If applicable, the child should also be given enough medication to hold the child over until the receiving provider has had an opportunity to conduct their own assessment of the child s needs based on his or her presenting condition. II. Slot Transfer Scenarios: A. A child transfers from one open slot from a sending region into another open slot in the receiving region. B. Child from a sending provider transfers into receiving provider slot sometime after the current enrollment month begins. There will be no change in either region s slot allocation. C. A contract amendment is not required since the receiving provider has an available slot. D. A child transfers to a receiving region that has no available slots. E. If a slot is not available in the receiving region, the slot from the sending region will follow the child into the receiving region and will remain there until the first available slot in the receiving region becomes open. F. Children will be moved into the next available slot based on their official Children s Medical Services start date. G. Once the child is enrolled, the slot returns as a vacant slot to the sending provider. H. A contract amendment is not required since the cost of service is billed to the sending provider. I. An enrolled waiting child transfers to a region with available slots. J. An enrolled waiting child will transfer from enrolled waiting status to enrolled status taking one of the receiving region s available slots. K. A contract amendment is not required as enrolled waiting children are not considered officially enrolled in the Behavioral Health Network. L. An enrolled waiting child transfers to a region with no available slots. Date Approved: Date Modified:

14 M. An enrolled waiting child will transfer from enrolled waiting status in the sending region to enrolled waiting status in receiving region. N. Enrolled waiting children will be moved into the next available slot based on their official CMS start date. III. Payment for Services During Transfers: A. SFBHN s BNET Coordinator (in conjunction with the SFBHN contract manager, if different) must approve the prorated and/or capitation distribution and any capitation payment invoices prior to the distribution of funds. B. Conditions for payment for services when a child transfers prior to next enrollment month. C. The sending provider retains a pro-rata share of the capitation for the month up to and including the actual date of transfer. D. The pro-rata share shall be determined by dividing the monthly capitation rate by the number of days in the current enrollment month. For example $1,000/30 = $33.33 per day. If the child moves out of the district/region on the 15th day, the sending provider would receive $ for that child. The remaining balance of the capitation ($500.05) is paid to the receiving provider. E. SFBHN s BNET Coordinator (in conjunction with the SFBHN contract manager, if different) should ensure the child is still eligible and enrolled prior to the approval of the invoice. If the child is still enrolled the SFBHN s BNET coordinator (in conjunction with the SFBHN contract manager, if different) will approve the invoice as prescribed by local region practice. F. Once approved and processed the sending SFBHN s BNET coordinator or SFBHN contract manager will complete an invoice to the receiving Title XXI region coordinator that will include the child s name, social security number, month of service, and the prorated amounts to be paid to both the sending and receiving providers. G. The receiving Title XXI region coordinator will provide their network provider with a copy of the invoice. H. Conditions for payment for services after the initial transfer when there are still no available slots in the receiving district/region. I. At the end of the current enrollment month, the receiving provider will prepare an invoice with only the child s name, social security number, and month of service and send to SFBHN s BNET coordinator for signature and approval. J. SFBHN s Title XXI BNET coordinator (or SFBHN contract manager if not the same) should ensure the child is still eligible and enrolled prior to the approval of the invoice. If the child is still enrolled the SFBHN s BNET coordinator (or SFBHN contract manager) will approve the invoice and send back to the sending provider in order to process the invoice for payment as prescribed by region practice. K. Upon receipt, the sending provider will pay the receiving provider the entire monthly capitation rate based on the approved invoice from the sending provider. L. Payment for services for enrolled waiting children is done by invoicing the receiving region s local Children s Medical Services office if the provider is serving these children. SFBHN is not involved in these transactions. Enrolled waiting children s expenditures should not be reported to the SFBHN data system. SFBHN encourages its Title XXI providers to develop an agreement with their local Children s Medical Services office to be the behavioral health services provider for these children. IV. Initial Eligibility Determination and Assessment: A. Every child referred to the Behavioral Health Network shall be screened as a first step in determining the child's clinical eligibility for services. If the screening indicates the child has the potential to meet the Behavioral Health Network clinical eligibility criteria described in this section, an assessment shall be conducted. B. A child shall be considered eligible for behavioral health services from the Behavioral Health Network when the child is determined to be Title XXI eligible for the Florida KidCare Program, be at least five (5) years of age and not yet nineteen (19) years of age; and, 1. The child requires a level of care not available in other KidCare programs; and, Date Approved: Date Modified:

15 2. The child is expected to show improvement or achieve stability as a direct result of the services to be rendered under the benefit package specified in Chapter 65E- 11, Florida Administrative Code; and, 3. At the time of assessment, the child requires no more than 30 days of residential treatment; and, 4. The child's family indicates a willingness to participate in the goals and objectives outlined in the child's treatment plan; and, 5. The child meets the Title XXI Behavioral Health Network s clinical eligibility criteria. C. SFBHN s BNET coordinator is responsible for ensuring The Behavioral Health Network Screening and Eligibility Tracking Form is properly completed prior to approval and submission to the Title XXI Behavioral Health Unit in Tallahassee. Each of the following items must be legibly filled out. 1. Provider Information and Referral Source Section. The following must be indicated: a. Who is filling out the form. b. This person s phone number with area code. c. Name of lead agency that is responsible for child. d. The referral source is circled or checked. e. If this is a Florida Healthy Kids referral, the Florida Healthy Kid account number is provided. 2. Demographic Section: a. The child s social security number, last name, first name, date of birth and county of residence are indicated. b. The legal custodian s last name and first name are noted. 3. Part I Initial Screening: a. The box indicating whether or not the child meets the Title XXI Behavioral Health Network treatability criteria is checked or circled. b. The box indicating whether or not the child s parents have signed the Statement of Understanding is checked or circled. A child will not be considered for enrollment until such time that the child s custodian has signed the Statement of Understanding. c. Person conducting the screening has indicated the date of the screening and their initials are indicated. 4. Part II Assessment Clinical Eligibility. The person conducting the assessment has indicated that the child meets the following Title XXI Behavioral Health Network clinical criteria: a. The child has a DSM-IV-R Axis I clinical classification of mental disorder or substance-related disorder. b. Attention-Deficit Disorders are excluded as DSM-IV-TR Axis I mental disorders in determining clinical eligibility for the Behavioral Health Network: c. The child is experiencing significant functional impairment as a result of his or her condition as demonstrated by a CGAS score of 50 or below. d. The date of the assessment and initials of the person conducting the assessment are indicated. e. If all of the above is correctly filled out, SFBHN s BNet Coordinator signs the form, makes two copies with one going back to the liaison and one going to the Title XXI Behavioral Health staff at the Children s Mental Health state program office. V. The Statement of Understanding: A. The Statement of Understanding is intended to be used by the Behavioral Health Liaison as a tool to facilitate understanding by parents/guardians of key points about the program and their responsibilities to their child as an enrollee in the Behavioral Health Network. The form needs to be completed only once per child unless the responsible parent/guardian changes. Date Approved: Date Modified:

16 B. The Behavioral Health Liaison should plan to complete the Statement of Understanding sometime during the process of explaining the program to the parent/guardian and completing the screening/assessment instrument. The procedure requires that: 1. Each point of the Statement of Understanding is explained to, and is initialed by, the parent/guardian. 2. The form be signed and dated by the parent/guardian and signed by the Behavioral Health Liaison. 3. The form becomes part of the file maintained by the Behavioral Health Liaison on the child. 4. A copy of the completed form be provided to the SFBHN s BNet Coordinator along with the screening/assessment instrument. 5. A copy of the signed and dated form is provided to the parent/guardian. VI. Re-verification and Request for Disenrollment Form: A. SFBHN s BNET coordinator is responsible for ensuring The Behavioral Health Network Re-verification and Request for Disenrollment Form is properly completed prior to approval and submitted to the Title XXI Behavioral Health staff at the Children s Mental Health state program office. Re-verification occurs every six months. Each of the following items must be legibly filled out. 1. Provider Information and Referral Source Section. The following must be indicated. a. The person who is filling out the form. b. This person s phone number with area code. c. Name of lead agency that is responsible for child 2. Demographic Section a. The child s social security number, last name, first name, date of birth, and county of residence are indicated. b. The legal custodian s last name and first name are noted. 3. Part I Assessment Re-verification. The person conducting the assessment has indicated that the child meets the following Title XXI Behavioral Health Network clinical criteria: a. The child has a DSM-IV-R Axis I clinical classification of mental disorder or substance-related disorder. b. Attention-Deficit Disorders are excluded as DSM-IV-R Axis I mental disorders in determining clinical eligibility for the Behavioral Health Network: c. The child is experiencing significant functional impairment as a result of his or her condition as demonstrated by a CGAS score of 50 or below. d. The date of the assessment and the initials of the person conducting the assessment are indicated. 4. Part II Assessment Request for Disenrollment. The person conducting the assessment has indicated at least one of the following: a. The parent has neglected to pay the premium; or, b. The child has turned 19 years of age; or, c. The child is Medicaid eligible or obtained other insurance coverage; or, d. The child has moved out-of-state; or, e. The child has been placed in residential treatment exceeding thirty days; or, f. The child is an inmate of a public institution; or, g. At re-verification, the child no longer meets the Title XXI Behavioral Health Network s clinical or treatability eligibility criteria (completes treatment, refuses services, noncompliance, CGAS score above 50). VII. Applicant Eligibility and Ineligibility Letters: A. Applicants for the Behavioral Health Network should receive written notification that the child for whom the application was filed has been found clinically eligible or ineligible for enrollment. This notification should be consistent throughout the state and not conflict with Date Approved: Date Modified:

17 notification requirements and letters used by KidCare. Also, confusion and enrollment delay can result if the applicant does not understand the next steps in the process. The model letters to which this procedure applies satisfy all of the necessary criteria. B. The model letters are used statewide to inform Behavioral Health Network applicants that they have been screened and assessed and found to be either clinically eligible or ineligible to enroll in the network. If eligible the letter sent to the parents will briefly describe the enrollment process remaining. The ineligibility letter will describe the reasons for the child s ineligibility and briefly describe how the parent can enroll in other KidCare programs. No other language is to be substituted for the language used in the model letter. 1. The letter should be sent on lead agency letterhead by the Behavioral Health Liaison within five working days following the date that clinical eligibility/ineligibility is determined. 2. A copy of the dated and signed letter must be filed in the applicant s enrollment file retained by the Liaison. 3. A copy of the letter must be forwarded by the Liaison to the attention of the member services representative in the local Children s Medical Services Network office at the same time that the letter is sent to the applicant. VIII. Alternative Services Reporting: A. As a part of the Title XXI Behavioral Health Network benefits package, children are eligible to receive services that are not a part of the traditional state cost center/service event matrix. These services include, but are not limited to professional consultation, medication, recreation, parent assistance, home management, respite, wrap around services and other discretionary activities. B. The services allowable under this provision, and the corresponding reimbursement rates, will be reviewed by SFBHN s BNET coordinator. 1. Alternative Services shall be approved so long as they are identified as part of the child s individualized treatment plan. The treatment plan shall be based on strength based assessment and Alternative Services shall be used to enhance services that will enable the child to remain in the community and to meet the unique individualized needs of the child. 2. Documentation of approved Alternative Services shall include the name of the SFBHN s Title XXI BNET Coordinator with signature and shall contain the following elements: a. Region identifier; b. Provider name; c. Provider federal Identification number (FID); d. Description of Alternative Service; e. Unit type; and, f. Unit cost. 3. To track the provision of Pharmaceutical and approved Alternative Services, documentation shall contain the following elements: a. County in which service was provided; b. Provider federal Identification number (FID); c. Client social security number; d. Date of services; e. Name of medication, strength, and schedule if applicable; f. Units; and, g. Unit cost. 4. The number of units for a prescribed drug depends on how the unit cost is reported. If the unit cost reported is the prescription price, the number of units would be one (1). If the unit cost reported is the price per dose, the number of units would be the number of doses in the prescription. In either case, the number of units multiplied by the unit cost should equal the total cost of the prescribed drug. Date Approved: Date Modified:

18 IX. 5. Once received, SFBHN s BNET coordinator is required to forward the Alternative Services Reports to the Behavioral Health Network central office in Tallahassee. Quality Assurance Monitoring: A. The Children s Mental Health Central Office Title XXI unit is responsible for Behavioral Health Network (BNET) policy development and for liaison with Children s Medical Services Network in accomplishing the BNET enrollment process. The unit has no direct, contractual relationship with any region lead agency provider. At the same time, as BNET is a statewide program with all regions sharing common operational requirements specified by central office, it is incumbent upon the central office Title XXI unit to review BNET operations in each region periodically and to render technical assistance where appropriate. It is a goal of the central office unit to routinely review each region at least once each fiscal year. B. The Department has established a common protocol for use throughout the state by central office staff. The reviews are intended to supplement the administrative and performance reviews conducted by region contract management staff, and to focus on those elements of program operations that are unique to BNET and/or essential to successful contractor performance. C. Preparation. 1. Notification and Scheduling. Approximately 15 workdays prior to establishing a firm review date, the SFBHN s BNET Coordinator shall be apprised by of an impending review visit. The should provide an approximate date and request information on the coordinator s availability to some extent participate in the review on the approximate date(s) in question. The coordinator should be requested to determine the availability of key agency personnel, including the behavioral health liaison, on the proposed review date(s). Details of the review schedule should be worked out among all affected parties. It is important that SFBHN s Title XXI BNET coordinator and the Behavioral Health Liaison be present or available at specific times during the review. 2. Sample Considerations. Approximately two weeks prior to the agreed-upon review date, the central office Title XXI unit will query the BNET enrollment database to identify enrollees and enrollment/disenrollment dates in the region to be reviewed. Depending on criteria to be discussed below, a sample of approximately 10 enrollees should be selected for chart review. The department s data system will be queried to capture a sample of the service events to be matched with chart entries to validate the accuracy of the data system reporting. The query should span the portion of the enrollment period selected for review. Multiple service dates subsequent to the last review conducted should be reviewed for each record. Likewise, the alternative services database should be queried to identify the alternative services provided to the selected enrollees during the period selected for review. a. If the lead agency has been the region contractor for the entire period to be sampled and reviewed, any enrollee of that region should provide usable service encounters. If the contractor is relatively new to BNET in the region, the sample will be most productive if the period reviewed is that in which the current contractor has held the contract. The focus should normally be on understanding and correcting problems with current operations. b. If the contractor has not been reporting to the data system as required, some of the sample should include records of relatively long term enrollees with few or no service events on file with data system. The focus of reviewing those charts will be to see if appropriate services have been provided, despite the lack of service event reporting. If the contractor has reported to data system as required, service dates of active records should span the enrollment period. A sample of these will demonstrate the consistency and accuracy of records keeping, as well as the maintenance of regular contact with each client. Date Approved: Date Modified:

19 3. Review Logistics. It should be determined beforehand whether the charts to be reviewed are in one location, can be gathered by the contractor to one location, or if the reviewer must travel to multiple locations to review charts. If the latter is the case, the review will take longer and more time may have to be scheduled for the review. Also, it should be determined whether the charts to be made available by the contractor are clinical charts or case management charts or both. It may be that the contractor is the case management entity and provides few or no direct clinical services. The provider network may be dispersed throughout the community and may provide only limited documentation to the lead agency, principally as related to billing. a. If the clinical charts are not filed in the lead agency contractor s location, it should be determined: 1) Whether it will be possible to view the charts; and, 2) How and where that may be accomplished. The reviewer must decide on the practical feasibility of the process in the time available. b. All of the above relates to the lead time to be given the provider in pulling the charts to be reviewed. Ideally, the sample should be provided to the lead agency contractor 48 hours, excluding weekends and holidays, before the reviewer s scheduled arrival. However, if charts must be gathered from multiple locations, more time must be allowed the contractor. D. Recording Findings. 1. Chart Review Instrument. The review sample of service events resulting from the data system query should be entered on the standardized BNET Chart Review Instrument, one client per instrument. The data system query may be exported as an Excel file, allowing cutting and pasting from the Excel file to the review instrument file, which is available in either Excel or MS Word. 2. Other Review Instruments. In addition to the chart review instrument, other standard review materials include a Lead Agency Provider Questionnaire, a BNET Review Questionnaire Children s Medical Services Network, and a Participants List. The Behavioral Health Liaison must be asked to identify the Children s Medical Services Network locations and staff normally involved with BNET. The reviewer should make contact, either face-to-face or by telephone, with those locations and people and should complete the Children s Medical Services Network questionnaire with them. If face to face contact is not feasible on site, the form can be completed by telephone before or during the review, or after return to central office. a. The Participants List is intended to facilitate recording the identity, affiliation and contact telephone number of everyone encountered during the review. The information is essential to creating a complete record of the review and for writing the review report. b. The Lead Agency Provider Questionnaire is intended to ensure that all pertinent information is collected from the lead agency. However, the reviewer should not be limited to only the information requested by the questionnaire. The questionnaire asks a series of questions intended to create an understanding of how the agency manages the Behavioral Health Network in its region, and also provides ready contractor background information for the reviewer. 3. Several of each type form should be taken to the review site. With the exception of the Chart Review Instrument, the other forms are set up as tables to facilitate on line data entry, i.e., the space on each line for data entry will expand until the Enter key is pressed. Unless a laptop computer containing these forms is carried on site, copies of the forms should be expanded and printed in advance to facilitate hand written entries. Following return to central office, the information Date Approved: Date Modified:

20 collected on the forms should be converted to word processing entries for easily read attachments to the review report and a permanent electronic record. 4. Review Report to Report Findings. The review report should be completed in draft for internal review within 30 calendar days of the final date of the review and should be organized as follows: a. Table containing a summary of the district/region and contractor demographics, including all review participants. b. Standard description of the BNET program. c. Description of the district/region organization, demographics, contractor organization and BNET-related processes. d. Description of the review process actually followed. e. Review findings. 5. Recommendations a. Cover Letter. A review cover letter addressed to the region office program supervisor should be developed for the bureau chief s signature. It should recommend that the region require a corrective action plan of the contractor for any recommendations that require action by the contractor. The review letter should also request that reports of the contractor s corrective action (planned and actual) be copied to the bureau chief s attention. Subsequent on-site reviews should partially focus on the accomplishment of corrective action planned or claimed in a contractor s report of corrective action. Date Approved: Date Modified: