Texas Foster Care Outpatient Treatment Requests (OTRs)

Transcription

1 Texas Foster Care Outpatient Treatment Requests (OTRs)

2 Recovery Are the interventions built on client strengths and intended to reduce or eliminate the impact of the mental health condition so the client can live in their community with a sense of respect, hope, empowerment, and selfdetermination? Resiliency Do the interventions harness, or promote the development of inner strengths that will help clients rebound from and adapt to current and future trauma, adversity, or stressors? Results Are the interventions based upon evidence-based standards of care with demonstrated efficacy in addressing the problems for which the client sought services?

3 Purposes Of The OTR Process To help ensure that services rendered are medically necessary and reflective of current evidence-based practices and accepted standards of care. To provide a process for selecting individualized, solution-focused services that are rendered in the most appropriate, least restrictive setting. To monitor progress throughout the treatment process, as well as to ensure that treatment goals, objectives, and interventions are measurable and clearly linked to the member s clinical presentation and diagnosis. To ensure that appropriate discharge planning occurs, including measurable criteria for determining when a treatment episode should be concluded. To provide a process for identifying potential quality of care issues and topics for follow-up provider trainings.

4 Medical Necessity Does the clinical information provided clearly document the severity of the functional impairments being experienced as a result of the mental health diagnosis? If the client is a child or adolescent, is at least one adult (or custodial caregiver) in the household committed to being actively involved in the treatment process? Is there adequate documentation that the client is making progress in treatment, as evidenced by a reduction in symptoms and improvement in psychosocial functioning? Are the services being titrated in a manner that supports a planned termination and the development of an individualized aftercare/followup plan?

5 When To Submit an OTR If you are not a participating provider you should submit an OTR before providing any service. If you are a par provider you are granted one initial assessment and 9 ongoing sessions for a total of 10 visits prior to needing to submit an OTR. Your first OTR should be submitted 7-14 calendar days before you expect to complete your 9 th regular session/ 10 th total visit. You should fax in the completed OTR with a future or current start date. By your first OTR submission you should have clearly determined the diagnosis and have formulated a treatment plan with measurable goals.

6 Member Information Confirm spelling of member s name. Make sure name provided on the OTR matches the name on the member s Medicaid card. Please write legibly (typed OTRs are preferred and help expedite the review process). Member ID Number = Member Medicaid Number. Check the appropriate box: STAR Health (Foster Care)

7 Provider Information Check appropriate box ( agency / group or provider ). Provide the same name that is listed on your provider contract. Indicate credentials (i.e. LPC, LMSW). Provide a daytime phone number where the provider conducts business please indicate on your voic if it is confidential please make sure your voic greeting identifies yourself Provide current, working fax number. Provide NPI and Tax ID as listed on your provider contract.

8 DSM-IV Multiaxial Diagnosis Provide all five axes (No Blanks) Axis I: list primary diagnosis first multiple diagnoses are permitted Use DSM-IV language Axis II: if no Axis II diagnosis, write V71.09 if insufficient information to make a diagnosis, write Axis III: if no medical conditions relevant to treatment, write deferred Axis IV: Use only DSM-IV categories for describing psychosocial and environmental problems Axis V: Include both the current GAF score AND the highest in the past year Update GAF score on every OTR submission

9 Requested Authorization Identify the specific type of service you are requesting (individual, family, and/or group). If you intend to provide multiple services, please complete appropriate information for each service. Date Service Started refers to the first contact with you (provider) and client (member). Frequency: How often seen? indicate structured treatment by providing a set frequency for sessions 2-4 times a month versus a set frequency of 2 times a month

10 Suicidal check appropriate box complete past attempt dates information (if applicable) Homicidal check appropriate box complete past attempt dates information (if applicable) Current Risk/Lethality Safety Plan if asterisk next to any checked box, please complete this section Current assaultive/violent behavior indicate the behaviors that occurred since the last OTR submission Risk box provide narrative (if applicable)

11 Presentation/Symptoms Why did the Member ORIGINALLY present for treatment provide narrative what brought member into counseling initially? Describe current situation and symptoms what symptom(s) is the member currently exhibiting? what behavior(s) is the member currently exhibiting? Impact on current functioning (occupational, academic, social, etc.)? check most appropriate box MH/SA Treatment History complete the appropriate box if treatment has occurred complete the narrative section

12 Current Psychotropic Medications Please check the appropriate box for who prescribed the medication. In addition to medication name, include the dose and frequency of each medication. Please check the appropriate box for whether a psychiatric evaluation was completed. If the answer is no, please provide details on the status of the pending evaluation or reasons why one was not completed.

13 Substance Abuse Check the appropriate box. Enter the names of all drugs/substances the member has abused and complete table as appropriate. Indicate if member is actively participating in AA / NA and provide corresponding information (if applicable).

14 Treatment Details Indicate which specific evidence-based practice or therapeutic model is being used. Indicate if family / caregiver / support is involved in treatment. If not, explain Provide the location(s) where services are being rendered. List any other services member receives through other providers. Indicate whether services are being coordinated with other providers. Indicate if information has been shared with member s current primary care physician. If not, explain Indicate member s current level of care (LOC).

15 thorough assessment Treatment Goals accurate diagnosis effective treatment

16 Goals, Objectives, and Interventions should be: Treatment Goals SPECIFIC MEASURABLE ATTAINABLE REALISTIC TIME-LIMITED

17 Treatment Goals List current treatment goals (using the S.M.A.R.T. format) Include date the treatment goal was initiated, not when counseling began. Indicate current progress including specific areas of progress (i.e. decrease of symptoms, increase in positive coping skills). If goal is completed, indicate under current progress section. Services provided should be time-limited assist in developing client autonomy advocate for the least restrictive environment Focus should be on skill acquisition or symptom reduction within a specific time period.

18 Treatment Goals (continued) SPECIFIC: Who, What, When, Where, and How For instance, if you indicate you will be addressing coping skills in treatment, identify specific types of coping skills (anger management, communication, etc.). Identify specific clinical interventions you will use.

19 Treatment Goals (continued) MEASURABLE: Intensity, Frequency, Duration of Symptoms Indicate what sort of objective, quantifiable behavioral indicators will be used to determine if progress is being made in treatment. The measurable component will determine if the goal has been completed. Choose a quantitative format that best translates what treatment you are hoping to accomplish (Example:...five out of seven days... versus...60% of the time... ).

20 Treatment Goals (continued) ATTAINABLE: Is the member capable of what is being expected of him/her? Is the treatment goal within the member s power or control? Member s developmental and intellectual abilities should be considered.

21 Treatment Goals (continued) REALISTIC: Is your treatment goal a fair expectation? Is the bar set too high or too low for this member? Is what you are expecting something a productive, functional member of society would be able to do? (Example: Expecting a 100% reduction in aggression (not realistic) versus an identified appropriate response...to anger triggers in three out of four instances (realistic).

22 Treatment Goals (continued) TIME-LIMITED: What is a realistic timeframe to have the treatment goal(s) completed? Time-limited is based on time periods expected of best practices, not never-ending therapy. Emphasize gaining the maximum benefit within a specified timeframe.

23 Treatment Changes Regardless of progress or lack thereof, indicate any changes that have occurred in the member s status, treatment focus, and clinical interventions

24 Discharge Criteria Appropriate discharge planning begins on the first day of treatment How will you know when you are done? How will the client, foster parent, and/or CPS worker know when therapy is completed? Discharge planning may include referrals to other providers and/or agencies. Discharge criteria should also adhere to the S.M.A.R.T. model.

25 Requested Authorization H-coded and G-coded services are ONLY to be indicated by MHMR facilities and substance abuse treatment facilities Intensity: Number of units per visit applies only to H-coded/G-code services Indicate number of units per code (EX: H0004 x 36 units, H0005 x 36 units) Requested Start Date of Authorization Include actual date you will begin services Services can be back-dated only to 24-hours prior to receipt of OTR. If needing authorization to start before that, a retrospective review may be requested do not request future date more than 21 calendar days in advance Anticipated Completion Date of Service Estimate clinically-appropriate completion date of the current treatment episode

26 Concluding Information Additional Information Any other information or documentation that you believe may be relevant to making a determination should be attached. All OTR submissions require the signature of the treating provider and the date. Whoever signs the OTR is responsible for the content and the indicated treatment.

27 Contact Information Official website: Cenpatico STAR Health: Superior HealthPlan: Claims: