Utilization Management Program. Facilities Manual

Transcription

1 Utilization Management Program Facilities Manual Revised - April 2014

2 INTRODUCTION Welcome to the APS Healthcare Puerto Rico provider network. Your organization joins an elite group of facilities and other behavioral healthcare providers that deliver quality services and help improve the lives of our covered beneficiaries. This Participating Facilities Manual for APS Healthcare Puerto Rico, Inc. (APS-PR) offers information about current initiatives and processes to follow for a better coordination of services to our beneficiaries. This document also includes information related to the APS-PR Utilization Management and Quality Programs, Confidentiality and Disclosure of Personal Health Information (PHI) and certain provisions under the Mental Health Act of Puerto Rico, Act. No. 408 of October 2, 2000, as amended. This manual is not all inclusive ; your organization may have contractual arrangements that may not be addressed in this manual. Please refer to your facility agreement for further details on your facility s contractual relationship with APS-PR. APS-PR currently manages and provides behavioral health services for covered individuals of the Puerto Rico Government Health Insurance Plan (MiSalud), several Medicare Advantage Plans (American Health Medicare, Humana Gold Plus and Triple-S Selecto (Selected Medical Group Practices)), commercial plans (Humana Health Plans), and several EAP plans. APS Healthcare Inc. is an independent, non-for-profit organization, well-known as a leader in promoting health care quality programs. We are committed to quality services and serve as a framework to improve business processes by benchmarking organizations against nationally recognized standards. For more information on APS-PR programs and description of our services you may visit An Innovative Network At APS-PR, we consider ourselves an innovative managed behavioral health organization. As a participating facility you are part of a select network of facilities and treatment programs that work together to add value for the benefit of our patients and our community. APS-PR has developed its facility network to help increase the effectiveness and promote the adequate use of behavioral health and chemical dependency resources. In close collaboration with our participating facility network, processes like case management, quality improvement and utilization review help ensure that our services will promote quality and patient safety while managing costs. This manual was developed to answer some of your questions and to serve as a reference for your staff. While many questions are addressed in this document, please feel free to contact our Provider Relations Department for additional assistance at , option # 4 for pre-certifications, or extension

3 This Manual may need to be updated from time to time and APS-PR is committed to keep your organization informed of any updates. In order to provide prompt and efficient notices of any updates to this manual or changes in APS-PR policies, the following methods will be used: (1) sending replacement sections, (2) sending notices of additions and deletions to the manual, (3) sending APS-PR provider newsletters, and (4) the issuance of APS-PR informative letters. Please note that these letters may require that you take immediate action to comply with APS-PR or any other requirements as established by State & Federal law, CMS, the Puerto Rico Health Department or ASES. Provider Guidelines are revised at least annually and are available to physicians, clinicians, triage, and referral staff and members upon request. Our partnership facilitates your organization, the necessary support to properly provide the necessary behavioral health services and receive prompt reimbursement for services rendered. The information contained herein is applicable to all Inpatient facilities; however, authorization and claims-submission procedures may vary depending on Line of Business (LOB). Please refer to the enrollee s identification card to determine how to contact us and obtain eligibility information, applicable co-payments and the MCO contact information. As of April 15, 2014, APS-PR has the following lines of business: The Puerto Rico Government Health Insurance Plan Medicaid (MI Salud), Medicare Advantage Plans, Commercial Health Plans and several Employee Assistance Programs (EAP). Please note that for purposes of this document the word beneficiary and enrollee are used interchangeably. QUESTIONS OR COMMENTS Any questions or comments regarding this manual may be directed to the APS Healthcare Puerto Rico Provider Operations Department to the following address: APS Healthcare Puerto Rico, Inc. Provider Operations Department P. O. Box San Juan, P.R

4 Section I: Beneficiary s Rights and Responsibilities APS-PR facilities must be familiar with the APS-PR Beneficiary Rights and Responsibilities Statement. A copy of these should either be displayed in your location or given to the beneficiary prior to the rendering of any services. Please remember that you must accept referrals from APS-PR on the same basis as you are accepting non APS-PR beneficiaries; without regard to race, religion, gender, color, sexual orientation, place of residence, national origin, age, social status, or physical or mental health status. A. Beneficiary Rights 1. Beneficiaries have the right to be provided care and treatment with dignity and respect; as individuals who have personal needs, feelings, preferences and requirements. 2. Beneficiaries have the right to impartial services and access to treatment, regardless of race, religion, gender, ethnicity, age, or disability. 3. Beneficiaries have the right to privacy in their treatment, in their care and in fulfillment of their personal needs. 4. Beneficiaries have the right to be treated by staff/providers communicating in a language/format they understand. 5. Beneficiaries have the right to be fully informed of all services available, any charges for or limitations to those services and available alternative treatment. 6. Beneficiaries have the right to be provided an individualized treatment plan and to participate in decision making regarding their treatment planning. 7. Beneficiaries have the right to be fully informed, in a language/format they understand, of their rights as clients and of all rules and regulations governing their conduct as clients in this program. 8. Beneficiaries have the right to be fully informed of all diagnostic and/or treatment procedures, medication treatments, including the benefits and risks, any research projects involving their treatment through APS-PR and to receive information necessary to give informed consent prior to the start of any procedures, treatment or research project. 9. Beneficiaries have the right to a candid discussion of appropriate or medically necessary treatment options for their conditions. Beneficiaries have the right to know treatment options regardless of the cost and whether they are covered services. 4

5 10. Beneficiaries have the right to refuse treatment without compromising their access to the organization s services to the extent permitted by law, and to be informed of the consequences of this refusal. However, the provider reserves the right to discontinue treatment should the extent of their refusal make reasonable and responsible treatment impossible. 11. Beneficiaries have the right to continuity of care. As long as they remain eligible for services through APS-PR, beneficiaries will not be discharged or transferred except for therapeutic reasons, for their personal welfare, or for the welfare of others. Should their transfer or discharge become necessary, beneficiaries will be given the reasons and plan, as well as reasonable advance notice, unless an emergency situation exists. 12. Beneficiaries have the right to voice opinions, recommendations, complaints, or appeals in relation to APS-PR policies, beneficiaries rights and responsibilities or the care provided without fear of restraint, interference, coercion, discrimination, or reprisal. 13. Beneficiaries have the right to be free from physical, chemical and mental abuse. 14. Beneficiaries have the right to confidential treatment of their client records. Information from these sources will not be released without their prior consent, except in an emergency, or as required by law. 15. Beneficiaries have the right to refuse to perform any services for the program, or for other clients, unless they are a part of their therapeutic plan of treatment, which they have approved. 16. Beneficiaries have the right to be informed in advance of any non-staff visitors to a facility/office and the right to privacy if they do not wish to see visitors, or participate in activities while visitors are present. 17. Beneficiaries have the right to receive information necessary to give informed consent prior to being involved in activities that include the use of tape recorders, video tape equipment, one-way observation mirrors, photography, or any other similar techniques. 18. Beneficiaries have the right to request the opinion of a consultant at their expense. 19. Beneficiaries have the right to receive information regarding the authorization and certification/non-certification processes, benefit plan services included and excluded; copayments; the provider network available for their care at the time they seek to access care; clinical guidelines, beneficiary s rights and responsibilities; and how to file a claim. 20. Beneficiaries have the right to file an appeal for review by an individual uninvolved in the original determination. 5

6 B. Beneficiary s Responsibilities 1. Beneficiaries have the responsibility to provide, to the extent possible, information that APS-PR and its providers need in order to care for them. 2. Beneficiaries have a responsibility to follow the plans and instructions for care that they have agreed upon with their provider(s). 3. Beneficiaries have the responsibility to follows the administrative guidelines and codes of conduct in the provider facility. 4. Beneficiaries have the responsibility to arrive to his (her) appointment without influence of alcohol and illicit drugs. 5. Beneficiaries have a responsibility to participate, to the degree possible, in understanding their behavioral health problems and developing mutually agreed-upon treatment goals. 6. Beneficiaries have a responsibility to follow APS-PR policies and processes as described in their handbook/packet regarding authorization and certification/non-certification; benefit plan eligibility; benefit plan services included and excluded; co-payments; the provider network available to them and how to file a claim. 7. Beneficiaries can contact the Office of the Health s Advocate (Oficina del Procurador de la Salud) through its toll-free line Introduction to Utilization Management Section II: Utilization Management The Utilization Management (UM) program is designed to assure the delivery of high quality, cost-efficient health care for our beneficiaries. A benefit derived from APS managing and having both a Health Management Program (HM) and Utilization Management Program (UM) services is its ability to refer at-risk individuals (individuals who may benefit from health management, case management, counseling, or other support services) who are identified within the UM process to their corresponding programs and/or services. APS-PR does not have in place a system for reimbursement, bonuses or incentives to staff, consultants, contractors or healthcare providers based directly on consumer utilization of health care services. Utilization Management (UM) decision-making is based solely on the appropriateness of care and service and the existence of coverage. APS does not reward providers or other individuals for issuing denials of coverage or services. APS does not encourage decisions that result in underutilization. 6

7 By reviewing admissions, procedures and services, the utilization management program issues appropriate decisions that are consistent with objective clinical evidence. Medical information received by our providers is evaluated by our highly trained UM staff against nationally recognized objective and evidence-based criteria.! APS takes individual circumstances and the local delivery system into account when determining the medical appropriateness of requested health care services. Medical necessity of an admission, continued stay and/or course of treatment or service.! APS considers applicable State and Federal Laws, Milliman, American Psychiatric Association and American Psychological Association Guidelines and Medicare and Medicaid Standards, among others.! The completeness and adequacy of the discharge plan.! Efficiency of the use of healthcare services, procedures and facilities under the provisions of the applicable healthcare laws, public program regulations, APSPR rules and regulations. State and Federal regulations require reviewing any service (admission or procedure) where it is anticipated or known that the service could either be over or underutilized, or otherwise abused, by providers or beneficiaries, or easily result in excessive, uncontrollable medical costs. This is accomplished through prior authorizations for certain procedures and levels of care that are geared toward preventing that a patient be treated in a more restrictive level of care than medically necessary. As an entity that manages and pays on behalf of the State and Federal Government, APS-PR has the duty to recover any amounts in instances of fraud, abuse, overpayments, invalid payments uncovered through audit procedures, payments when there is a primary payer and when ordered to do so on behalf of the Government of the Commonwealth of Puerto Rico or the Government of the United States. A. Clinical Procedures The procedures described in this section apply only when a provider is treating a beneficiary who has a behavioral health care benefit plan managed by APS-PR. 1. Triage and Authorization Procedures APS-PR care managers conduct triage, coordination and referrals for all mental health services 24/7. This (24) hour service is available through our toll-free 800 phone line here beneficiaries, 7

8 their families, primary care physicians, behavioral health providers and facilities request behavioral healthcare services. When a facility is contacted by a patient in need of an outpatient intervention, the provider is required to call APS-PR to obtain a pre-authorization. If the beneficiary requires a service that the provider cannot offer, the provider shall contact the APS-PR Care Management Department to coordinate the required service. Puerto Rico Government Health Insurance Plan Pre-Authorizations 1 APS will have seventy-two (72) hours from the time of the beneficiary s service preauthorization request to inform the facility of the decision of whether to grant the corresponding pre-authorization. In cases where it is determined that the beneficiary s life or health could be endangered by a delay in accessing services, APS will inform its determination as expeditiously as the beneficiary s health requires within a period that will not exceed twentyfour (24) hours of the beneficiary s service pre-authorization request. Hospital may not delay or refuse to provide psychiatric emergency services in cases where the beneficiary has an alteration in the perception of reality, feelings, emotion, actions, or behavior, requiring immediate therapeutic intervention in order to avoid immediate damage to the patient, other persons, or property under the premise that APS has not provided its determination. It is expected that Hospital comply with its legal duties at all times. Clinical Care Managers conduct detailed patient screening, coordination of care and initial utilization review of medical necessity criteria. Care Mangers are duly licensed according to local and federal laws and statues and possess experience in the mental health field. Decisions requiring clinical judgment are made by licensed behavioral healthcare Clinical Care Managers according to criteria that define the level of urgency, intensity and appropriate level/setting of care based on medical necessity. APS also has Physician advisors available to make potential adverse determinations and support Care Management efforts. Medicare Advantage and Commercial Behavioral Health Insurance Plan Pre- Authorizations In the case of Medicare Advantage and Commercial BH Health Plans, APS-PR will adhere to the standards established by the Centers for Medicaid and Medicare Services (CMS) for managed care. This means that APS-PR will make timely organization determinations based on the standard and expedited timeframes established by CMS. 1 APS-PR considers the Medical Exigency Standard in responding to any request for prior authorizations or care. That is, as expeditiously as the enrollee s health condition requires irrespectively of the applicable timeframe to respond or the line of business involved. 8

9 When a facility makes a request for a service on behalf of a patient, APS will notify the facility of its determination as expeditiously as the patient s health condition requires, but no later than 14 calendar days after the date APS receives the request for a standard organization determination. APS-PR may extend the time frame up to 14 calendar days. This extension is allowed if the beneficiary requests the extension or if APS-PR justifies a need for additional information and documents how the delay is in the interest of the enrollee. If APS-PR takes such extension, it will notify the beneficiary, in writing, of the reasons for the delay, and inform the beneficiary the right to file a grievance if he or she disagrees with APS-PR s decision to grant an extension. When asking for an expedited organization determination, the beneficiary or the facility must submit a written request directly to APS-PR. APS-PR will provide an expedited organization determination if the facility indicates in writing, that applying the standard time for making a determination could seriously cause immediate damage to the patient, other persons, or property. If APS-PR decides to expedite the request, APS will inform its determination as expeditiously as the beneficiary s health requires within a period that will not exceed seventy two (72) hours of the beneficiary s service pre-authorization request. Hospital may not delay or refuse to provide psychiatric emergency services in cases where the beneficiary has an alteration in the perception of reality, feelings, emotion, actions, or behavior, requiring immediate therapeutic intervention in order to avoid immediate damage to the patient, other persons, or property under the premise that APS has not provided its determination. It is expected that Hospital comply with its legal duties at all times. Clinical Care Managers conduct detailed patient screening, coordination of care and initial utilization review of medical necessity criteria. Care Mangers are duly licensed according to local and federal laws and statues and possess experience in the mental health field. Decisions requiring clinical judgment are made by licensed behavioral healthcare Clinical Care Managers according to criteria that define the level of urgency, intensity and appropriate level/setting of care based on medical necessity. APS also has Physician advisors available to evaluate potential adverse determinations and support Care Management efforts. 2. Hospital Service Prior Authorization When a beneficiary demonstrates a need for admission to an inpatient facility, a partial Hospitalization program, a 23 hour rapid stabilization unit, ECT services or warrants an Evaluation for any other service, a call to APS-PR must be made to verify the beneficiary s eligibility, present APS-PR with the patient s situation and request a pre-authorization for such services. This will assist APS-PR to coordinate the appropriate behavioral healthcare services and determine the most appropriate level of care for the patient. Except for psychiatric emergencies, which are required to be notified within the first two hours after the patient has been evaluated and stabilized, all psychiatric hospitalizations, partial hospitalization services, 23 9

10 hour rapid stabilization unit services, ECT services or other outpatient procedures to be provided within the facility require pre-authorization. The Care Manager and the physician advisor, in conjunction with the hospital or program s attending physician or designee, will review the clinical information to determine the type and intensity of treatment that would most benefit the beneficiary. The decision to authorize an admission to a hospital will be based on medical necessity. When a Care Manager authorizes an admission, a preliminary treatment plan is formulated. 3. Emergency Room Services Neither a Referral nor a Prior Authorization is required for any Psychiatric Emergency Room Services, notwithstanding whether there is ultimately a determination that the condition for which the Enrollee sought treatment in the Psychiatric Emergency Room was not the result of a Psychiatric Emergency. In a psychiatric emergency situation participating facilities must treat all emergencies as expeditiously as the beneficiary s health requires or within 6 hours from the time the beneficiary arrives at the facility, whichever is sooner. ER services include at a minimum a psychiatric evaluation and patient stabilization. Hospital shall have up to twelve (12) hours to stabilize the patient. If the patient is not stabilized within twelve (12) hours after arriving in the hospital, hospital shall be required to present the case to APS-PR to determine the appropriate level of care for the patient. Facilities must also accept referrals from APS-PR and have the responsibility to provide twenty-four (24) hour urgent or emergency services to our beneficiaries. Patients in active treatment should be given instructions on how to contact participating facilities or in case of an emergency. Psychiatric emergency services should be delivered by a psychiatrist in cases where the facility has conducted a clinical diagnostic interview sufficient to determine that the beneficiary is harmful to self or others and in need of immediate intervention to foster beneficiary safety. Intervention may include safe transport if medical necessity applies. The corresponding psychiatric evaluation shall be documented in the patient record within the first 24 hours the patient arrives in the facility or facility ER. Once an emergency intervention is completed, the facility is required to notify APS-PR within the first two hours after the patient has been stabilized in order to report the outcome, review the requirements of the next level of care for the patient (if required) and acquire a control number to bill for the services provided. If APS-PR personnel are not available to speak with a hospital representative within the first two (2) hours, the facility will have up to twenty three (23) hours after stabilizing the patient to acquire a control number to bill for the services provided. Cases where the hospital fails to contact APS-PR within the twenty three (23) hour period after the patient has been stabilized shall be subject to retrospective review. If a 10

11 colleague or faculty staff is available to discuss the case, contacting the APS-PR care manager immediately for assistance and acquiring the corresponding control number is recommended. The beneficiary s behavioral healthcare provider is expected to triage all other urgent and emergency situations notwithstanding the type of emergency (medical or behavioral) and ascertain that the patient is taken care of in a timely manner. The facility may contact APS-PR or the Healthcare Plan directly to assist providers with emergency cases. Contact a Care Manager whenever a beneficiary requires emergency attention. For the most part, instances where the beneficiary is admitted to the facility s contracted 23 hour rapid stabilization unit or the psychiatric inpatient level of care, emergency evaluations and stabilization fees are contractually waived. Nonetheless if the facility provides emergency evaluation and stabilization services and maintains the beneficiary in the inpatient level despite the fact that they did not follow APS-PR protocol (example, did not pre-authorize inpatient (treatment), it is required that the facility make the appropriate split in the claim and use the corresponding emergency codes. Failure to do so is considered a violation of the clean claims act. APS-PR may cover such services through different fee descriptions within the facility s contract. If you have any questions regarding if your facility contract includes these codes please contact our Provider Department. 4. Discharge Planning Discharge planning begins at the initiation of all hospital services. It includes preparing the patient and the family for the next level of care and arranging for placement or provision of additional services. APS-PR reviewers will work with hospitals and programs to assure a smooth transition and the use of participating providers for follow-up care within 5 days of discharge. B. Clinical Practice Guidelines APS-PR applies objective and evidence-based criteria when determining the medical necessity and level of care considering the individual circumstances and conditions of each patient. Although there are several medical necessity criteria and care guidelines accepted in the behavioral health field, we primarily rely on the American Psychiatric Association Clinical Practice Guidelines on the Milliman Care Guidelines Behavioral Health Care, 17 th Edition for the assessment and treatment of psychiatric disorders consistent with the best practice. APS-PR clinical guidelines are developed in accordance with CMS regulations, Milliman Guidelines, American Psychiatric Association, American Psychological Association and American Medical Association standards, SAMHSA standards. These require that APS-PR adopt practice guidelines that are relevant to its beneficiaries and to the healthcare services covered under the applicable plan. In order to meet the intent of these standards, APS-PR endorses practice guidelines published by other professional organizations. APS-PR providers may be informed of the adoption of these guidelines and about how providers may obtain copies via mailings. APS- 11

12 PR provider practices are expected to conform to the treatment protocols contained in the adopted guidelines and standards of care that consider quality, patient safety and medical necessity. Compliance with the practice guidelines will be assessed via treatment record reviews conducted by APS-PR on a periodic basis. Several helpful links include:! C. APS-PR Medical Necessity and Level of Care Determination Criteria APS-PR believes and adheres to the Puerto Rico Mental Health Law, as amended, that patients are best treated in the least restrictive environment consistent with the patient s symptoms, supports and safety requirements. The treatment goal is the patient s restoration to his/her optimal functioning and independence. This document is intended to be a starting point and common reference for clinical discussion. As such, it focuses on the patient s clinical history, presenting symptoms and available resources in recommending a level of care. We recognize that resources for the full continuum of care do not exist in all locations. In those cases, we will recommend a higher level of care than medically necessary in order to assure safe, effective treatment. Medical Necessity is used here to mean care which is determined to be effective, appropriate and necessary to treat a given patient s disorder at a certain level of care. Each level of care is indicated as either Psychiatric or Substance Dependence and review for level of care determination proceeds in a logical progression to confirm:! The presence of a properly diagnosed mental health or substance abuse disorder amenable to treatment,! Symptoms of sufficient severity to meet the required criteria for admission,! The illness by accepted medical standards is expected to improve significantly through medically necessary and appropriate care as it relates to the level of care requested, and! Clinical requirements for continuing care at that level. Discharge criteria, program content, treatment interventions, etc., are not included in an attempt to avoid being too prescriptive and preempting clinical discourse. Therefore, determinations for discharge from a given level of care are clear: when the patient no longer appears to meet the required criteria for continuing care at a given level of acuity, discharge to a lower level of care is recommended. As an integral part of our quality improvement process, we will review annually and revise this document as needed based upon developments in the professional literature and feedback 12

13 from all participants in treatment reviews. However, we welcome your comments and suggestions at any time. Please refer to APS-PR Medical Necessity Criteria for specific criteria sets. They are updated annually and your input is always welcome. D. Concurrent Review APS shall have the right to conduct Concurrent reviews for beneficiaries that have been admitted to the facility. This is to facilitate the most appropriate, cost-effective and timely care for APS-PR beneficiaries. Concurrent reviews take place during the time in which patients are receiving services within the facility. The general purpose of these Concurrent reviews is to determine if the continued service is appropriate, high quality and medically necessary. Adverse determinations may be generated during concurrent reviews for clinical or administrative reasons. The following are examples of the most common reasons for administrative adverse determinations: 1. Hospital fails to evidence any of the following items required by law, within 24 hours of the patient beginning his/her behavioral health treatment in the facility: a. Physical exam b. Medical history c. Admission laboratories d. A psychiatric evaluation e. Psychiatric evaluations performed by psychologist and/or social worker f. Treatment plan completed and signed by the clinical team Within 72 hrs. g. Orders for restrictions and isolation are not documented according to Law 408 h. Discharge plan does not include post discharge appointment i. Clinical chart is not available for concurrent review The previous list is intended to serve as an example, and does not constitute a complete, exhaustive or exclusive list of all administrative denial rationales than can be performed. E. Retrospective Reviews Retrospective reviews are defined as reviews conducted after services have been provided to the patient. These reviews are conducted when a patient has received treatment in a noncontracted facility only. Retrospective reviews also include instances where APS-PR notifies the 13

14 Hospital that daily visits to the facility from an APS-PR UM Care Manager will be interrupted, before such interruption occurs. This interruption must not be greater than 5 working days. F. Post-Pay Reviews Post payment reviews are conducted after an APS-PR patient s admission, stay, or other course of treatment or service has been completed. APS-PR staff may conduct a post-payment review to evaluate medical necessity, level of care, quality of care, and under/over or inappropriate utilization of services. A complete client record for specified dates of service is requested through a medical record request letter. Post-pay reviews are conducted as follows:! Random Sample Reviews: Review of inpatient, outpatient and hospital services provided to APS-PR clients.! Outlier Reviews: Review of care from client stays that are longer than would be expected under the level-of-care guidelines.! Designated admissions are subject to post-pay reviews pursuant to any applicable State or Federal Law. A prior authorization or admission certification may be withdrawn as a result of such reviews. All components must be received via mail within 15 calendar days of the initial request. It is the responsibility of the provider to confirm that APS Healthcare has received the required documentation. G. Complaint Process All contracted facilities should provide optimal quality services at all times. APS-PR registers and responds to verbal and written complaints received from covered beneficiaries (beneficiary, beneficiary s representative). All comments are important and as such are treated as a potential opportunity for improvement in the care provided by contracted facilities. APS Healthcare will respond to all beneficiaries complaints within the timeframes specified or required by Line of Business (LOB). Usually, this period is 30 days. H. Inpatient Census Reports Contracted facilities are required to produce and submit Inpatient Census Reports (ICR). Such report must be submitted by fax (787) by 10:00 am on a daily basis. If the date of submission is not a working day, the ICR must be submitted by the close of business on the next working day. The ICR will assist APS-PR in accounting for and monitor inpatient admissions, discharges and transfers on a daily basis, as well as to identify cases where patient may benefit from additional case management services and follow up. 14

15 I. Coordination of Benefits If a client has insurance with another carrier or Medicare, the facility/provider is not required to request prior authorization from APS Healthcare unless one of the following occurs:! The client has primary insurance with another carrier or Medicare but the benefit plan does not provide benefits for the service(s) being requested. The facility/provider is required to complete the prior authorization process for clients who do not have coverage under the primary insurance carrier or Medicare.! The client has primary insurance with another carrier and the benefit has been exhausted for the service being requested. The facility is required to complete the authorization process after notification that the primary insurance has maximized the benefit. Please note that this applies only to benefits covered by APS-PR that also require prior authorization from APS Healthcare. APS-PR is considered the payer of last resort. If no prior authorization is obtained and the primary carrier does not reimburse for the services, APS-PR may deny the claim due to lack of prior authorization. J. Appeal Process APS-PR has a process in place to receive, account for and process appeals from enrollees or providers acting on behalf of the enrollees and providers acting on its own behalf (with certain limitations). Appeals in all cases will be performed by a reviewer (physician advisor) not involved in the initial determination. Facilities Appeals It is the policy of APS-PR that participating facilities as providers- acting on their own behalf will have one (1) level of appeal in instances where the facility has fully complied with all the required steps to present and handling of the case. If the hospital is deemed not to have complied with an administrative process requirement (Example; getting a pre-authorization of psychiatric inpatient services), payment for such services may be denied and any appeals received related to the determination will be classified as an administrative appeal, not subject to revision. This appeal level is granted to facilities as an administrative process that is treated independently from the beneficiary s appeal rights and process. It is the expectation of APS-PR, that facilities adhere to the UM and clinical standards stated in this manual and provide the highest level of quality, patient safety and efficiency necessary. Facilities requesting that appeals be expedited must send APS-PR all the corresponding case documentation at the time of the appeal, so that a psychiatrist revision may take place. 15

16 Puerto Rico Government Health Insurance Plan Appeals An Appeal is the request for review of an APS-PR determination or action. It is a formal petition by an Enrollee, an Enrollee s Authorized Representative, or the Enrollee s Provider, acting on behalf of the Enrollee with the Enrollee s written consent, to reconsider a decision. Appeals made by the hospital on behalf of a beneficiary must be made in writing and must be made after acquiring the beneficiary s written consent. Additionally, beneficiaries who submit expedited requests or facilities that submit expedited requests on behalf of the beneficiary must send APS-PR a written signed request for appeal. The Enrollee, the Enrollee s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee s written consent, may file an Appeal to the Contractor during a period no less than twenty (20) Calendar Days and not to exceed ninety (90) Calendar Days from the date on the APS-PR Notice of Action or Notice of Adverse determination. The facility acting on behalf of the Enrollee with the Enrollee s written consent will be given an opportunity to present evidence and allegations in writing. APS-PR will resolve each Appeal and provide written notice of the disposition, as expeditiously as the Enrollee s health condition requires but shall not exceed thirty (30) Calendar Days from the date the appeal is received. In the case where the facility requests an expedited appeal on behalf of the beneficiary, APS-PR will review the documentation sent by the facility and the individual circumstances of the case to determine whether to expedite the appeal. If APS-PR determines not to expedite the appeal, it will transfer the appeal to the timeframe for standard appeals (30 days) and shall make= reasonable efforts to give the Enrollee prompt oral notice of the denial, and follow up within two (2) Calendar Days with a written notice. If the appeal is resolved within (72) hours from the receipt of the appeal, the written notice will not be required. APR-PR shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an Appeal. For expedited reviews of an appeal APS-PR has no longer than seventy-two (72) hours or as expeditiously as the Enrollee s physical or mental health condition requires. APS-PR shall resolve expedited appeal and provide a notice of disposition, as expeditiously as the Enrollee s health condition requires within a period that shall not exceed three (3) Business Days after the appeal is received. APS-PR may extend the timeframe for standard or expedited resolution of the appeal by up to 16 fourteen (14) Calendar Days if the Enrollee, Enrollee s Authorized Representative, or the facility acting on behalf of the Enrollee with the Enrollee s written consent, requests the extension or APS-PR demonstrates that additional information is needed and that such delay is 16

17 in the Enrollee s interest. If APS-PR extends the timeframe, it shall give the Enrollee written notice of the reason for the delay. To properly submit an appeal on behalf of a beneficiary the hospital or facility will be required to contact one of our Appeals Coordinators at (787) , Extensions , or Medicare Advantage and Commercial Behavioral Health Insurance Plan Appeals In the case of Medicare Advantage and Commercial BH Health Plans, APS-PR will adhere to the standards established by the Centers for Medicaid and Medicare Services (CMS) for handling appeals. This means that APS-PR will make timely handle and process appeals based on the standard and expedited timeframes established by CMS. An Appeal is the request for review of an APS-PR determination. It is a formal petition by an Enrollee or an Enrollee s Authorized Representative. If a facility wishes to appeal a standard preauthorization, it may do so if such appeal is based on a difference of a clinical nature and not for refusing to follow APS-PR processes. Appeals made by the hospital on behalf of a beneficiary must be made in writing and must be made after acquiring the beneficiary s written consent. Additionally, beneficiaries who submit expedited requests or facilities that submit expedited requests on behalf of the beneficiary must send APS-PR a written signed request for appeal. A party may request a standard reconsideration by filing a signed, written request with the APS- PR. Facilities will have a period of sixty (60) days from the date of the notice of the organization determination sent by APS-PR to submit the corresponding appeal. The facility acting on behalf of the Enrollee with the Enrollee s written consent will be given an opportunity to present evidence and allegations in writing. Upon reconsideration of an adverse organization determination, APS-PR will make its determination as expeditiously as the enrollee s health condition requires. This must be no later than thirty (30) calendar days from the date APS-PR receives the request for standard reconsiderations (appeals). The time frame will be extended by up to 14 calendar days by APSPR if the enrollee requests the extension or if APS-PR requires additional information and documents how such delay is in the interest of the enrollee. Hospitals are required to provide APS-PR access to obtain all necessary medical records and other pertinent information within the required time limits to resolve the appeal. APS-PR will mail an acknowledgement letter to the enrollee to confirm the facts and basis of the appeal, and request that the enrollee sign and return the acknowledgement letter. The letter must explain that until the acknowledgement letter is returned, no final decision can be issued; 17

18 APS-PR will not issue a final decision on the appeal until it receives the signed acknowledgement letter, or other signed document relevant to the appeal request; and If APSPR does not receive a returned, signed acknowledgement by the conclusion of the appeal timeframe, plus extension, it will forward the case to the independent review entity with a request for dismissal (if applicable). An enrollee or any physician may request that APS-PR expedite a reconsideration (appeal) of a determination, in situations where applying the standard procedure could seriously jeopardize the enrollees life, health, or ability to regain maximum function. In light of the short time frame for deciding expedited reconsiderations, a physician does not need to be an authorized representative to request an expedited reconsideration on behalf of the enrollee. A request for payment of a service already provided to an enrollee is not eligible to be reviewed as an expedited reconsideration. If APS-PR denies a request for an expedited reconsideration, it must automatically transfer the request to the standard reconsideration process and then make its determination as expeditiously as the enrollee s health condition requires, but no later than within 30 calendar days from the date the appeal was received. APS-PR shall provide the enrollee with prompt oral notice of the denial of the request for reconsideration and the enrollee s rights, and subsequently mail to the enrollee within 3 calendar days of the oral notification, a written letter. If the Medicare health plan approves a request for an expedited reconsideration, then it must complete the expedited reconsideration and give the enrollee (and the physician involved, as appropriate) notice of its reconsideration as expeditiously as the enrollee s health condition requires, but no later than 72 hours after receiving the request. To properly submit an appeal on behalf of a beneficiary the hospital or facility will be required to contact one of our Appeals Coordinators at (787) , Extensions or A. Facility Standards Section III: Facility and Service Standards Our facility standards refer to the inpatient and outpatient sites where beneficiaries receive services. These standards address the appearance, safety and licensure, if applicable, of the office or facility. The following standards are required of APS-PR facility providers:! Visible signs that clearly identify the facility;! The exterior of the building is clean and well maintained;! Parking is adequate and conveniently located for facility access; 18

19 ! The area surrounding the facility is safe at all times specially at night;! The waiting room has adequate seating for patients;! The facility is clean and well maintained (this includes the waiting room, admission area, patient rooms and halls, offices, kitchen, dining area, rest rooms and common areas);! The facility meets the requirements of the Americans with Disabilities Act (ADA);! Beneficiary s rights to receive care at the facility should be posted in a visible area easy to read.! Emergency phone numbers (police, fire, ambulance, poisoning treatment center) are posted in common staff areas;! Fire extinguishers are maintained to optimal function and readily available for its use in the event of emergencies;! Smoking is restricted to an outdoor location from the facility with safe outdoor cigarette receptacle or a separately ventilated room;! Medications are kept in protected areas away from public access at all times;! All hospital facilities: inpatient and outpatient programs are licensed by the state and appropriate documentation should be posted on visible areas;! If eligible, the hospital or facility is accredited by the Joint Commission on Accreditation of Healthcare Organization (JCAHO) and appropriate documentation should be posted on visible areas;! If sanctioned by JCAHO, the facility has to notify APS-PR about the sanctions with a copy of the corrective action plan submitted to JCAHO;! To provide service to the Medicare population the facility has to be Medicare accredited and have readily available corresponding documentation. B. The following service standards only apply to those facilities contracted with APSPR to provide inpatient, residential, partial hospitalization, intensive outpatient services or twenty-three (23) hour evaluation and observation services:! Visitors are required to sign a confidentiality statement prior to entering patient areas;! Examination rooms are available for the History and Physical; 19

20 ! Crash carts or emergency boxes (AED) are available for the medical emergencies;! Clinical staff-to-patient ratio is adequate as defined by the State;! Clinical staff receives CPR training and recertify annually;! Staff is trained annually in protective techniques to ensure beneficiary s safety and others;! Treatment is individually tailored to meet the needs of each patient;! Adult and adolescent patients are separated by units or by patient rooms;! Adolescent and child patients are separated by units or by patient rooms;! The Initial Treatment Plan is completed within twelve (12) hours of admission;! The History and Physical is completed within twenty-four (24) hours of admission;! The Psychosocial Assessment is completed within twenty-four (24) hours of admission;! The Initial Psychiatric Assessment including Mental Status Exam and DSM-IV diagnosis is completed within twelve (12) hours of admission;! Discharge planning begins upon admission and includes scheduling a post-discharge outpatient appointment within forty-eight (48) hours of discharge. C. The following service standards apply to hospitals and programs with acute mental health units only:! Beneficiaries are seen by a licensed physician at least once within any 24 hour period or any lesser period according to the beneficiary s condition ;! Admissions are accepted twenty-four (24) hours per day, seven (7) days per week;! Acute units are locked;! All hallways can be monitored from the nursing station(s) directly or with the use of video equipment;! Patients do not have access to potentially harmful objects;! Shower heads are recessed or do not bear weight (suicide-proof);! Patient rooms are free from any weight-bearing objects; 20

21 ! Patient rooms are free of electrical cords that are twelve (12) inches or longer in length;! Medically complex patients who are at-risk for suicide and are in rooms that require electrical cords are monitored at all times;! Light fixtures are recessed or are protected by a non-breakable device;! Windows and mirrors are shatterproof or protected by a non-breakable device;! All objects within the seclusion room are secured;! One-piece toilet seats are used in the seclusion area rest room;! Patients in seclusion and in the adjacent bathroom can be viewed by staff at all times;! Staff is trained annually in the use of protective techniques to avoid the use of seclusion unless absolutely necessary.! Restraints and seclusion will only be used if a beneficiary is deemed to be at an imminent risk of self or other harm and this risk cannot be handled in a fashion that will reduce it to a minimum by less restrictive interventions that protect the beneficiary s dignity. D. The following service standards apply to only those hospitals and programs that provide substance abuse services:! Patients are seen at least once within any twenty-four (24) hour period or any lesser period according to the beneficiary s medical necessity;! If provided, admissions for medical detoxification are accepted twenty-four (24) hours per day, seven (7) days per week;! Beds dedicated to beneficiaries admitted for detoxification are the nearest to the nursing station;! Staff includes providers with substance abuse certification that is updated and verifiable;! Urine/drug screens are conducted routinely;! An aftercare or APS-PR prevention program is offered to all beneficiaries for a period of at least six (6) months or less. 21