MAD Applied Behavior Analysis (ABA) Services Application Guidance

Transcription

1 Overview MAD Applied Behavior Analysis (ABA) Services Application Guidance The Applied Behavior Analysis (ABA) Provider Application is the mechanism for a provider to demonstrate that it has the infrastructure to support the operationalization and implementation of ABA services in accordance with MAD ABA Billing Instructions. Providers meeting the requirements set forth in this application will be considered MAD Applied Behavior Analysis Providers (APs), and after being credentialed with Human Services Department (HSD) contracted Managed Care Organizations (MCOs), APs will be authorized to render ABA Stage 2 and 3 services to eligible recipients or members who are at-risk of developing ASD or who have a diagnosis of ASD which meets MAD s ABA Level of Care (LOC) Guidelines. (Note: MAD strongly encourages providers to pursue credentialing with all identified MCOs.) The MAD ABA Billing Instructions (ABA BIs), which are prescriptive and detailed, provide the necessary elements for rendering and being reimbursed for MAD ABA services. A provider applying to be an AP is strongly encouraged to use the ABA BIs to develop or refine its infrastructure, operationalize high-quality ABA service delivery, and create systems for documenting the delivery of services. While it may seem unnecessary to develop policies and procedures for rendering and documenting ABA services before the applicant is approved to render such services, MAD is committed to providing high-quality ABA services to eligible recipients. This rigorous application process, which requires the AP to have a well-designed behavior analytic service delivery system in place, is one way by which MAD can ensure that eligible recipients receive the empirically supported, medically necessary services that are recommended by their Autism Evaluation Providers (AEPs). An additional benefit of APs having their staff hired and their policies and procedures in place prior to submitting their application is that APs can immediately proceed with service delivery following approval with MAD and credentialing with the MCOs. Specific application instructions are offered below. Completed applications must include narrative information, copies of policies and procedures, copies of forms and report templates, and one or more mock client files illustrating adherence to the applicant s established policies and procedures and meaningful use of the established forms and templates. Applicants may already deliver a variety of services, and therefore may have existing policies and procedures that govern its overall operations. Such applicants should only include policies and procedures relevant to MAD ABA services. Instructions SECTION 1. General Information (A) Agency Description

2 1. The applicant must submit a concise, narrative agency overview. Information may include, but is not limited to: a description of the nature of the agency; history; management team; legal structure and ownership; location and facilities; mission statement; etc. 2. If the agency has multiple sites at or through which ABA services will be provided, the applicant must detail how each site will operate independently and cooperatively with the agency s central business location. Specifically, the applicant must describe how the agency s policies and procedures are designed to ensure consistent, high-quality services at each site and how each site interacts or is supported by the provider agency. (B) Organizational Chart 1. The applicant must provide an organizational chart that includes all staff associated with rendering MAD ABA services. If the agency is sizable and renders multiple other services, two charts may be necessary: one to illustrate the overall agency structure, and one to illustrate the structure of the division/department that renders ABA services. Within the later, the lines of supervision and authority must be clear, and if position titles differ from those delineated in the Billing Instructions for MAD ABA Services, the applicant must clearly note which position or job title corresponds to each MAD provider type noted in the ABA Billing Instructions. (C) Job Descriptions 1. Behavior Analyst (BA) a. The applicant must submit a copy of the agency s job description(s) for the position(s) meeting the provider requirements for Behavior Analyst. It is anticipated that applicants may use different staff titles and may have more than one position for which the job requirements meet or exceed those outlined in the ABA Billing Instructions for Behavior Analysts. Regardless of the titles used by the agency, the information should be offered in a manner that allows the application reviewer to clearly identify that the applicant s Job Description(s) align with the identified provider requirements. If not unquestionably clear, the applicant must offer an accompanying narrative explanation. b. If the applicant plans to utilize an Interim ABA Provider/Supervisor, the applicant must provide explanation of how the agency will ensure that it has one or more BAs in place by the deadline defined in the ABA Billing Instructions. 2. Behavior Technician (BT) a. If the applicant anticipates using a tiered service delivery model, the applicant must submit a copy of the agency s Job Description(s) for the position(s) meeting the provider requirements for Behavior Technician. It is anticipated that applicants may use different staff titles and may have more than one position for which the job requirements meet or exceed those outlined in the ABA Billing Instructions for Behavior Technicians. Regardless of the titles used by the agency, the information should be offered in a manner that allows the application reviewer to clearly identify that the applicant s Job Description(s) align with the identified provider requirements. If not unquestionably clear, the applicant must offer an accompanying narrative explanation.

3 b. If the applicant plans to utilize BTs who are pursuing registration with the BACB, the applicant must provide explanation of how the agency will ensure that BTs are registered with the BACB on or before the deadline defined in the ABA Billing Instructions. (D) Attestations of Provider Qualifications 1. Behavior Analyst (BA) a. The applicant must provide written attestation from each Behavior Analyst (BA); attestations must clearly indicate that the BA meets all the provider requirements outlined in the MAD ABA Billing Instructions, AND the BA must clearly and separately attest (in the affirmative or negative) to each of the following: i. Staff member has the competency to work with a very young child 12 months up to 3 years who is at-risk for the development of ASD. ii. Staff member has the competency to work with a very young child 12 months through 5 years of age with a diagnosis of ASD. iii. Staff member has the competency to work with a school aged child kindergarten up to age 18 years with a diagnosis of ASD. iv. Staff member has the competency to work with a young adult age 18 up to 21 years with a diagnosis of ASD. b. If the BA meets the time-limited provider requirements, he/she must clearly indicate the date by which it is expected that he/she will meet full, continuing requirements for service provision. c. BAs must attest for themselves (via signed documentation), and the applying AP must sign the BA s attestation indicating that the applicant has done its due diligence to confirm the validity of the training and experience requirements to which the BA attests. d. Documentation supporting the training and experience requirements (e.g., official university transcripts, copy of license and/or certification, etc.) must be secured and added to the BA s permanent employment record and made available to MAD upon request. 2. Behavior Technician (BT) a. The applicant must provide written attestation that each Behavior Technician (BT) meets all the provider requirements outlined in the MAD ABA Billing Instructions. b. If one or more BTs meet the time-limited provider requirements, the applicant must clearly indicate in the attestation the date by which it is expected that each BT will meet full, continuing requirements for service provision. c. Each BT does not have to provide his/her own attestation; rather, the applicant will attach the attestation for each BT when submitting a MAD 312 on behalf of the BT. d. Documentation supporting the training and experience requirements (e.g., official high school or university transcripts, documentation of registration with the BACB, certificates of completion for training, etc.) must be secured and added to the BT s permanent employment record and made available to MAD upon request.

4 (E) Record Keeping 1. The applicant must provide information regarding the agnecy record-keeping practices. This information may be provided in narrative form and/or in flowchart or process map form. Copies of forms and report templates that are referenced within the narrative and/or noted in the flowchart or process map are required. 2. The applicant must clearly describe what information is collected and documented. Additionally, the applicant must specify when, within the context of the three stages of ABA service delivery, this documentation occurs. Who collects the information, as well as how the information is stored in compliance with rules and regulations for Protected Health Information (PHI) and employee records, is also required. 3. In preparing this portion of the application, applicants are encouraged to organize the information submitted into the following broad categories: a. Operational record-keeping, which would include personnel records, billing records, etc. b. Clinical record-keeping, which would include intake documentation, treatment plans, progress notes, contact/service delivery records, etc. 4. If the agency has multiple sites, the applicant must detail how each site will operate independently and cooperatively with the AP s central business location. 5. If services will be rendered outside of a clinic setting (e.g., home, community location), the applicant must detail how PHI will be transferred to the central or secondary site for storage. SECTION 2. Referral, Intake, and Planning for Stage 2 Services The applicant must describe the process and corresponding policies and procedures utilized from the point at which a referral is received until Stage 2 services begin. At minimum, the application must include the following: (A) Referral and Eligibility Determination 1. The applicant must provide the policies and procedures the AP will follow to determine if a referred member or recipient meets MAD ABA eligibility/admission criteria. Policies and procedures must identify: a. Specific staff performing each step of the admission process; b. Process for gathering necessary admission criteria documentation; c. Process for reviewing the documentation in order to determine if criteria have been met; and d. Process for securing the prior authorization that is required before proceeding with behavior analytic assessment and treatment planning. (B) Additional Intake Responsibilities 1. The applicant must indicate how the agency will ensure that it meets its responsibilities to an ABA eligible recipient or member and his/her parent(s)/legal guardian(s), as well as others involved in the recipient or member s care. The applicant must also indicate when, within the initial intake process, these responsibilities will be clearly communicated to the recipient or member and/or his/her parent(s)/legal guardian(s). Within the application, specifically describe responsibilities to the following:

5 a. Primary Care Provider (PCP). Please provide the policies and procedures for sharing information between the agency and the eligible recipient or member s PCP. b. Parents or Legal Guardians. Please provide the policies and procedures for communicating the roles and rights of an eligible recipient or member and the roles and right of his/her parent(s)/legal guardian(s). c. Other providers rendering services to the eligible recipient or member (such as Part C and B providers, or PED Special Education). Please provide the policies and procedures for coordinating services with other service providers. SECTION 3. Delivery of Stage 2 Services: Behavior Analytic Assessment and ABA Treatment Plan Development The applicant must provide the policies and procedures the agency will follow once prior authorization for Stage 2 services is received. These policies and procedures should be detailed enough that every BA within the agency accurately and reliably follows the same process for every eligible recipient or member. In other words, the agency should offer details for how they have standardized its delivery and documentation of behavior analytic assessment and treatment planning services in order to ensure quality and efficiency. (A) Assessment and Treatment Plan. Although not limited to the following, the applicant must outline policies and procedures for determining and documenting: 1. The service model (focused and comprehensive) as well as the number of hours of service that will be rendered; 2. Whether specialty care services are clinically indicated and how this will impact Stage 2 and 3 services as provided by the primary AP; 3. The assessment methods and specific measures necessary to appropriately assess skill acquisition and behavior reduction needs of the eligible member or recipient; 4. How goals will be selected and measured, and how progress will be evaluated over time; 5. How efficacious treatment strategies will be identified and incorporated into the eligible member or recipient s treatment plan in a highly individualized manner; 6. Plans for discharge, crisis management, recovery/resiliency, and adherence to advanced directives, if applicable; 7. How the treatment plan will be reviewed, and how parent/guardian signature (and when appropriate, signature of the eligible member or recipient) will be secured; 8. How the provider will ensure that billing is not submitted for non-covered services. SECTION 4. Delivery of Stage 3 Services: ABA Intervention Services The applicant must provide the policies and procedures the agency will follow once prior authorization for Stage 3 services is granted. These policies and procedures should be detailed enough that every BA and BT within the providing agency accurately and reliably follows the same process for every eligible recipient or member. In other words, the agency should offer details for how it has standardized its delivery and documentation of behavior analytic intervention services (including clinical management and case supervision) to ensure quality and efficiency.

6 (A) Delivery of Intervention. Although not limited to the following, the applicant must outline policies and procedures for determining and documenting: 1. The roles and responsibilities of the BA during intervention delivery; 2. The roles and responsibilities of the BT during intervention delivery, if applicable; 3. How the essential practice elements of ABA, as outlined in the Billing Instructions, will be assured; 4. How adherence to the approved Treatment Plan will be monitored; 5. How both billable and non-billable clinical service delivery will be documented and tracked to ensure the medically necessary delivery of clinical care, and to ensure compliance with the established Billing Instructions; 6. How eligible recipient or member progress will be tracked/charted, and 7. How the BA will review data to determine changes to the treatment plan and to determine the medical necessity of securing additional authorization for services. (B) Clinical Management and Case Supervision. The applicant must provide the policies and procedures a BA follows in providing and documenting clinical management and case supervision for each eligible recipient or member. The policies and procedures should be detailed enough to support the BA in determining when to seek additional hours for clinical management and case supervision, and how to request these additional hours. The policies and procedures must include: 1. Specific responsibilities of the BA and the BT in relation to clinical management and case supervision; 2. Process for documenting clinical management; 3. Process for documenting case supervision; 4. Process for determining additional clinical management hours; 5. Process for determining additional case supervision hours; (C) Requests for Additional Prior Authorizations. The applicant must provide the policies and procedures the AP will follow when seeking additional prior authorizations. The policies and procedures should be detailed enough to guide the BA on how to navigate his or her agency s systems to document the need for changes in prior authorization; how to submit this documentation to the UR to support the additional prior authorization request; and how to render or coordinate the additional service(s), if authorized. The policies and procedures must include prior authorization guidance for: 1. Targeted evaluations and reports; 2. Updated ISP; 3. Updated behavior analytic assessment; 4. Updated treatment plan; 5. Specialty care; 6. Change in clinical management hours; and 7. Change in case supervision hours. (D) Discharge. The applicant must provide the policies and procedures the agency follows as the eligible recipient or member nears discharge. These policies and procedures should ensure a successful transition out of ABA services.

7 SECTION 5. Mock File(s) (A) Mock file. One or more mock files must be submitted as part of the AP s application. The file(s) must reflect the AP s policies and procedures, and be inclusive of the forms and reports, noted in the aforementioned sections. If the agency employs BAs who have attested to having competency to work with eligible recipients and members of varying ages, a mock file must be provided for each age category. This will allow the application reviewer to evaluate how the AP tailors service design and delivery to meet the unique needs of individuals of different age groups. (NOTE: If the application does not include a mock file for a particular age group, the AP will not be approved to provide services to members/recipients within that age group. As such, applicants are encouraged to submit multiple mock files, as appropriate given the training and experience of their employed BAs. However, APs must not over-represent their capacity to serve children; if staff do not have the competency to serve a particular age group, a file should not be submitted for review.) One or more of the following files must be submitted: 1. A mock file representing services rendered to a very young child 12 months up to 3 years who is at-risk for the development of ASD. 2. A mock file representing services rendered to a very young child 12 months through 5 years of age with a diagnosis of ASD. 3. A mock file representing services rendered to a school aged child (kindergarten up to age 18 years) with a diagnosis of ASD. 4. A mock file representing services rendered to a young adult (age 18 up to 21 years) with a diagnosis of ASD.