VALUEOPTIONS PROVIDER HANDBOOK FOR ARKANSAS PROVIDERS

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2 TABLE OF CONTENTS Title page Table of Contents Section 1.0 Introduction to ValueOptions, Inc. 1.1 Welcome 1.2. Purpose 1.3 Background 1.4 Arkansas Service Center 1.5 Compliance Section 2.0 Program Overview 2.1 Inpatient 2.2 Outpatient Section 3.0 Service Descriptions 3.1 Acute Inpatient 3.2 RSPMI 3.3 SBMH 3.4 LMHP 3.5 RSYC Section 4.0 Medical Necessity Best Practices 4.1 Acute Inpatient Services 4.2 Residential 4.3 Outpatient 4.4 General Prior Authorization Procedures 4.5 Medicaid Eligibility Verification Section 5.0 Retroactive Reviews 5.1 Acute Inpatient 5.2 Inpatient Residential 5.3 RSPMI Outpatient Section 6.0 Determination Notifications 6.1 Determination Notifications Copyright 2010 Page 2 of 50

3 Section 7.0 Clinical Guidelines 7.1 Discharges 7.2 Claims Payment Section 8.0 Site Visits/Inspections of Care 8.1 Inpatient 8.2 Outpatient Section 9.0 Care Coordination 9.1 Care Coordination 9.2 Who are the Beneficiaries Serviced by the Care Coordination Program? 9.3 Functions of Care Coordination Section 10.0 Grievances, Reconsiderations and Fair Hearing & Appeals Process 10.1 Grievances Procedure 10.2 Fair Hearing & Appeals Process 10.3 Reconsiderations Section 11.0 Retrospective Reviews 11.1 Inpatient 11.2 RSPMI Section 12.0 Appendices Appendix A Resources Appendix B Service Codes and Descriptions Appendix C Clinical Guidelines Appendix D Certification of Need Link to ValueOptions Participating Handbook Note: Please reference the ValueOptions Participating Provider Handbook to review policies and procedures as well as administrative processes germane to all ValueOptions providers. Link to Arkansas Provider Manuals Crossover: Inpatient: Copyright 2010 Page 3 of 50

5 SECTION 1.0 INTRODUCTION TO VALUEOPTIONS 1.1 Welcome Welcome to ValueOptions. This handbook answers questions specific to ValueOptions - Arkansas and explains how we serve as the Quality Improvement Organization (QIO) to provide utilization and quality control for inpatient and outpatient psychiatric services. The Arkansas handbook was developed as a supplement to the National Participating Provider Handbook located on our Provider site at and the state provider manuals at: The handbook begins with a ValueOptions overview and describes our policies and procedures as it pertains to our administrative processes. Your adherence to the guidelines contained in this handbook will assist you in obtaining timely service authorizations. Required forms are accessible via the Forms section of the Provider site. For additional provider information, program updates, and training opportunities please visit the ValueOptions website for Arkansas providers at If you have any questions or comments about the material in this guide, feel free to contact us at our Arkansas toll free number at (877) a.m. to 5 p.m. Central Time. 1.2 Purpose ValueOptions is certified by the Centers for Medicare and Medicaid Services (CMS) as a Quality Improvement Organization (QIO) or QIO-like organization. ValueOptions serves as the Arkansas contracted QIO for the Department of Human Services, Division of Medical Services (DMS). This contract focuses on inpatient behavioral health for Arkansas Medicaid beneficiaries under the age of twenty-one (21) as well as outpatient behavioral health services for all Arkansas Medicaid beneficiaries. The inpatient contract with Arkansas is for utilization and quality control peer review activities including the certification of need and determination of medical necessity for admission, continued stay and quality of care for inpatient psychiatric treatment by providers who are enrolled in the Arkansas Medicaid inpatient psychiatric program. Additional activities include care coordination in connection with admission diversion, discharge planning, and de-institutionalization for beneficiaries meeting predefined benchmarks. ValueOptions is responsible for retrospective audit activities including technical (policy) and medical necessity components, provider tracking, educational Copyright 2010 Page 5 of 50

6 outreach and technical assistance to providers and regional wrap around care councils to meet state goals. The outpatient contract with Arkansas is for utilization and quality control peer review activities including prior authorization; on-site retrospective review activities including program policy compliance, extension of benefit reviews, medical necessity, and quality of care components; provider tracking and ongoing educational outreach to providers to meet state goals. ValueOptions will determine program compliance, medical necessity and quality of care for a range of behavioral health treatment services, continuing medical necessity and quality care. ValueOptions has no responsibility to determine beneficiary eligibility for Medicaid. 1.3 Background ValueOptions has assembled and administered more public sector provider networks in the U.S. than any other company. We have a proven record of success, in large part due to input from educated consumer survivors who have truly become the voice of our program design and improvement. As the largest privately-held behavioral health care company in the nation, ValueOptions provides services to twenty-two (22) million individuals through contracts with federal, state, and county agencies and with health plans and employers. We are the second largest managed behavioral health care company overall. ValueOptions was incorporated in April, 1987, and is wholly-owned by FHC Health Systems, Inc. (FHC) with Ronald I. Dozoretz, MD as Chairman and Founder. We offer the State of Arkansas an impressive track record of learning while doing and a true commitment to public sector partnerships. ValueOptions maintains an extensive and experienced staff of behavioral health specialists devoted to providing exceptional behavioral health services. This expertise is woven into all aspects of our behavioral health programs and extends to our clients as unparalleled industry knowledge regarding behavioral health issues and plan management. Currently, ValueOptions employs over two thousand employees. Our full-time equivalent employees engaged in providing services as part of our public sector behavioral health and substance abuse management contracts includes more than one thousand employees. 1.4 Arkansas Service Center Copyright 2010 Page 6 of 50

7 The ValueOptions Service Center is located in Little Rock, Arkansas. The service center will have a full executive management team headed by two (2) Project Directors. The office is located at the following address: ValueOptions, Inc W. Capitol Avenue Suite 330 Little Rock, AR You may contact ValueOptions at the following toll-free numbers and fax numbers: (TTY) Clinical Fax: Hours of Operation: 8 am 5 pm Central Time Provider Relations: [email protected] This location serves as the hub for our clinical and administrative activities. To streamline operations, ValueOptions delegates operational authority of our senior management staff located in Arkansas. The senior management staff is accountable for ensuring that ValueOptions operations are well run. 1.5 Compliance It is the policy of ValueOptions to comply with all local, state, and federal laws governing its operations; to conduct its affairs in keeping with the moral, legal and ethical standards of our industry; and to support the government's efforts to reduce healthcare fraud and abuse. The ValueOptions Corporate Compliance Program establishes a culture within the organization that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law, and federal, state, and private payor health care program requirements. Agents, subcontractors, vendors, and consultants who represent the company are expected to adhere to the Compliance Program. ValueOptions is also a HIPAA-compliant organization. Under HIPAA Privacy Rule at (h) a covered entity prior to making any disclosure permitted under the privacy regulations must (1) verify the identity of a person requesting protected health information (PHI) and the authority of such Copyright 2010 Page 7 of 50

8 person to have access to protected health information under this regulation, if the identity or any such authority of such person is not known to the covered entity. Accordingly, ValueOptions requires that anyone requesting access to PHI be appropriately identified and authenticated. Beneficiaries and personal representatives, for example, are required to provide the beneficiary identification number or subscriber number and the beneficiaries or subscriber s date of birth. You or your administrative staff are identified and authenticated in a number of ways and may be asked for your federal tax identification number (TIN), your national provider identification number (NPI), or physical address as part of this verification process. Having this information available prior to making contact with ValueOptions will expedite your request. For more information, please read the Compliance section on Copyright 2010 Page 8 of 50

9 SECTION 2.0 PROGRAM OVERVIEW ValueOptions has contracted with the Arkansas Department of Human Services, Division of Medical Services (DMS), to provide utilization and quality control peer review for outpatient behavioral health services to qualifying Arkansas Medicaid beneficiaries as well as utilization and quality control peer review for inpatient psychiatric services for Arkansas Medicaid beneficiaries under the age of twenty-one (21). 2.1 Inpatient ValueOptions, Inc., under contract as the Medicaid Agency Review Team to the Arkansas Department of Human Services, Division of Medical Services, will review all requests for inpatient acute psychiatric services and evaluate each beneficiary s need for inpatient and residential psychiatric services for beneficiaries under age twenty-one (21).These reviews will include Certification of Need, prior authorizations and continuing stay reviews. 2.2 Outpatient ValueOptions, Inc., under contract to the Arkansas Department of Human Services, Division of Medical Services, will provide prior authorization and Extension of Benefit reviews of the Rehabilitative Services for Persons with Mental Illness (RSPMI) for all beneficiaries (under the age of twenty-one (21) and age twenty-one (21) and over). ValueOptions will also provide review for school based mental health (SBMH) services, licensed mental health practitioner (LMHP) services and rehabilitative services for youth and children (RSYC). Copyright 2010 Page 9 of 50

10 SECTION 3.0 SERVICE DESCRIPTIONS 3.1 Acute Inpatient Services A complete description of program coverage information for Acute Inpatient services can be found in the Inpatient Psychiatric Section II { } of the Arkansas Medicaid Provider Manual. 3.2 RSPMI Services A complete description of program coverage information for RSPMI services can be found in the RSPMI Section II { } of the Arkansas Medicaid Provider Manual. 3.3 SBMH Services A complete description of program coverage information for School-based Mental Health Services can be found in the SBMH Section II { } of the Arkansas Medicaid Provider Manual. 3.4 LMHP Services A complete description of program coverage information for LMHP Services can be found in the LMHP Section II { } of the Arkansas Medicaid Provider Manual. 3.5 RSYC Services A complete description of program coverage information for RSYC Services can be found in the RSYC Section II { } of the Arkansas Medicaid Provider Manual. Copyright 2010 Page 10 of 50

11 SECTION 4.0 MEDICAL NECESSITY BEST PRACTICES Refer to Service code definitions and medical necessity definition in the ARK Medicaid manual 4.1 Acute Inpatient services All beneficiaries with a current Arkansas Medicaid number must be certified prior to admission by ValueOptions. To receive a Certificate of Need (CON), the admitting facility must submit the required information to ValueOptions within two (2) business days of the date of admission for acute psychiatric hospitalization. The Certification of Need (CON) form can be found in Appendix D of this handbook. The provider must utilize the ValueOptions inpatient treatment review (ITR) form. The provider must fax any information required by Arkansas Medicaid Inpatient Psychiatric provider policy, which cannot be transmitted electronically due to original signature requirements. Medical necessity criteria must be documented on the ValueOptions request in order to receive authorization of services. ValueOptions has one (1) calendar day to make a determination or issue an authorization for services for acute inpatient program type. In some cases, additional information may be requested from the provider. Failure to provide requested information within the required time frame of five (5) calendar days may result in a clinical denial. A physician is the only one who can issue a denial for services. If the physician issues an initial denial, providers may submit a request for reconsideration within thirty (30) calendar days of the receipt of the denial. If a provider or beneficiary is not satisfied by the reconsideration decision, he or she may appeal the denial by following the appeals procedure. See Section11.0 Grievances, Reconsiderations and Appeals. The initial authorization period may be from one (1) to fourteen (14) calendar days. The beneficiary must meet admission criteria on the date of admission, regardless of the date of the CON determination. Continuing Stay may be requested by submitting the inpatient treatment review form to ValueOptions within two (2) business days before the end of the authorization period. Continuing stay approval is based upon the symptoms and behaviors submitted in the Continued Stay Review and the discharge plan submitted to ValueOptions. 4.2 Residential Treatment Services Copyright 2010 Page 11 of 50

12 All beneficiaries with a current Arkansas Medicaid number must be certified prior to admission by ValueOptions. To receive a Certificate of Need, the admitting facility must submit the required information to ValueOptions. The provider must utilize the ValueOptions Inpatient treatment request form (ITR). Providers must simultaneously fax any information required by Arkansas Medicaid Inpatient Psychiatric provider policy, which cannot be transmitted electronically due to original signature requirements. Medical necessity criteria must be documented on the ValueOptions request in order to receive authorization of services. A CON issued by the ValueOptions Medical Director or his designee will expire ten (10) calendar days after the date of approval, unless the Medicaid beneficiary is admitted on or before the tenth day. In those cases where it does expire, the provider must submit a new request to ValueOptions when the beneficiary is admitted to the facility. ValueOptions has seven (7) calendar days to make a determination or issue an authorization for services for beneficiaries not admitted from an inpatient facility. For beneficiaries admitted from an inpatient facility ValueOptions has one (1) calendar day. In some cases, additional information may be requested from the provider. Failure to provide requested information within the required time frame of five (5) calendar days may result in a clinical denial. The physician is the only person who can issue a denial for services. The initial authorization period may be from one (1) to thirty (30) calendar days. The beneficiary must meet admission criteria on the date of admission, regardless of the date of the CON determination. Continuing Stay may be requested by submitting ValueOptions inpatient request form ITR to ValueOptions at least seven (7) calendar days before the end of the authorization period. Continuing stay approval is based upon the symptoms and behaviors submitted in the Continued Stay Review and the discharge plan submitted to ValueOptions. 4.3 Outpatient Service Authorization Process For all services, authorization requests consist of three (3) basic components: Initial Requests Unscheduled Revisions/Amendments Continued Stay Requests These requests are sequential in nature and allow the provider the ability to manage the beginning and end dates of each authorization period, as well as the number of units and services needed. These topics are outlined in detail in this section and are subject to specific requirements, based on fiscal agent transaction rules and edits, and State policy. These components are the same for both Prior Authorizations and Extensions of Benefits. Prior Authorization Procedures (initial requests and continued stay requests) Copyright 2010 Page 12 of 50

13 Before beginning services, the provider will submit the required Outpatient treatment request forms such as the ORF2 (see provider forms section of the website for further instructions) to ValueOptions for authorization. Form submission will be accepted through the ValueOptions Online ProviderConnect sm application. This application is Web-based and secured through a unique user ID. Documentation and training materials for use of ProviderConnect may be reviewed at For an initial request, the provider should submit data on the website no earlier than fifteen (15) calendar days, and preferably no less than five (5) business days prior to the anticipated initiation (start date) of services. The licensed clinical reviewer will evaluate the information provided for medical necessity. The form must be completed in its entirety with sufficient and accurate information to make a determination. The information must meet clinical guidelines related to medical necessity. When these guidelines are met, the licensed clinical reviewer will approve service code(s) and numbers of units requested. All requests will be completed within nine (9) calendar days. Should the beneficiary require continued services beyond the first certified period, the provider will complete an outpatient treatment request form for a concurrent or continued-stay review. Continued Stay Prior Authorization requests are accepted no earlier than fifteen (15) business days and preferably no later than five (5) business days, prior to the expiration of the current certified period of treatment. Prior Authorization requests may encompass up to a one-hundred and eighty (180) calendar day benefit period. ValueOptions licensed clinical reviewers will review requests and complete the review within nine (9) calendar days of receipt. If the information submitted is insufficient to make a determination, the request may be returned to the provider for submission of additional information. Authorization requests that are missing information may lead to a denial of services requested. Notification of determination is available online upon completion of the review. Electronic information on determinations is maintained in a secure online environment, and may be viewed electronically by each registered provider user on-demand. If the information is insufficient or unclear, the licensed clinical reviewer will request additional documentation. The provider must submit this additional information within seven calendar days. Failure to provide requested information within the required time frame of five calendar days may Copyright 2010 Page 13 of 50

14 result in a clinical denial If the information submitted to the reviewer does not further support an approval of either the requested service(s) or units of service, the reviewer will defer the request to a physician advisor who will render the final determination. 4.4 General Prior Authorization Procedures Data and Research Correction Procedure When data errors are discovered, corrections must be made as soon as discovered, and prior to completion of the authorization period. Corrections can be requested via the web at ValueOptions.com by using the send inquiry function in ProviderConnect to ask for a data correction. The provider must clearly identify the changes that are required. Examples of data requiring correction include, but are not limited to, incorrect Medicaid beneficiary and/or provider identification numbers, incorrect dates of service, incorrect service code requests, etc. Each data correction event for existing authorization records requires a minimum of two (2) business days to complete correction transactions between ValueOptions and the State fiscal agent. Each transaction cycle is tracked by the system and additional steps, if required, may slow the time to resolution. Online Prior Authorization (PA) Review Status The online ProviderConnect application allows users to track the progress of request for authorization submissions throughout the review process. Each status change in a request for authorization is displayed online and the provider can obtain and print determination information and authorization letters if desired, as well as save electronic copies of a submitted request upon their first submission of the request. Additional information about the ProviderConnect application process may be reviewed through the online demo. Once entered online, a case will advance through the following statuses: DRAFT The case has not yet been submitted by the provider to ValueOptions for review, but has been saved by the provider and may be edited further before the review process begins. The ValueOptions clinical reviewer is not able to review the clinical material. Copyright 2010 Page 14 of 50

15 SUBMITTED The case has been submitted for review. The provider is no longer able to edit the clinical material. The authorization can be accessed online to verify the status of the authorization request. Statuses that will display on the authorization request include: Pending The review has been submitted for consideration. The ValueOptions reviewer will review the information and if additional information is required, will be outreaching to the provider telephonically. Approved - All requested services and units are approved. Partial approval- Request is modified in either frequency and or duration Denied Requested services/units are not approved. Final Determinations All ValueOptions determinations are based on medical necessity, as defined by the Arkansas Department of Human Services, Division of Medical Services. After assessing a prior authorization request, a licensed clinical reviewer or physician for ValueOptions will make one of the following final determinations for each service code requested: Approval: An approval is determined when the requested information submitted meets medical necessity for services, in the frequency and duration identified. Authorization of services is approved for a specified period, not to exceed one-hundred and eighty (180) days. Review determination results may be viewed online upon completion of the review. Partial Approval: The ValueOptions physician advisor denies service(s) in the frequency and/or duration requested, and approves the service(s) at less frequent and/or more limited duration. The Notice of action contains a note explaining the provider s option of the requesting reconsideration and the beneficiary s option to appeal See Section 11.2 Reconsiderations & Appeals for more information. Notices are also posted to the web within one (1) business day of the decision. Denial: A licensed, board-certified ValueOptions physician advisor makes the final decision to deny service requests. When the information submitted does not support medical necessity, authorization of service(s) is denied. A letter of determination is mailed to the beneficiary or legal guardian, and to the provider. The Notice of action contains a note explaining the provider s option of the requesting reconsideration and the beneficiary s option to appeal. Notices are also posted to the web within one (1) business day of the decision. Unscheduled Revisions Copyright 2010 Page 15 of 50

16 An unscheduled revision is required if there are significant changes in the beneficiary s status during the authorized period. This may include changes in functional impairment or mental status and/or premature cessation of treatment due to transfer, move, or hospitalization. The outpatient treatment request form ORF2 Request Form must be resubmitted as a revision to the existing authorization. The request must be for the exact dates and service previously requested, and must document and justify the need for change in the amount of services required. An unscheduled revision can be completed on line by using an ORF2. The provider completes the ORF2 ensuring the revision box is checked on the form. The new information regarding the beneficiary s change in status is detailed out in the form allowing the care management staff to compare previously submitted and new information. Requests are completed within standard turnaround time and decisions posted on the web. Renegotiations: When a ValueOptions care manager receives a request for prior authorization that could more appropriately be served by authorizing a different program, frequency or duration than what has been requested they will contact the provider to offer a renegotiation of the service for that beneficiary. If the provider does not agree with the renegotiation and would like to stay at the requested program, frequency or duration, the case will be referred for a physician advisor review. Providers can contact care management staff to discuss renegotiations. Messages can be left on voice mail as all information is confidential as voice mail is password protected. 4.5 Medicaid Eligibility Verification Verifying beneficiary Medicaid eligibility is the responsibility of the provider agency. Service authorization is not a guarantee of payment eligibility. Copyright 2010 Page 16 of 50

17 SECTION 5.0 RETROACTIVE REVIEWS 5.1 Inpatient Acute Retroactive review for authorization of payment is available to providers when 1.) Inpatient psychiatric services have been provided to a beneficiary who did not have an active/current Medicaid number or 2.) Inpatient psychiatric services are being provided to a beneficiary by a facility who receives their Medicaid provider number while providing treatment. ValueOptions will start the requested authorization on the date that the beneficiary became eligible for Medicaid Request for retroactive authorization of payment occurs once the beneficiary has received a Medicaid number. The provider must submit the request for authorization to ValueOptions within thirty (30) calendar days of the Medicaid number being issued. If the beneficiary is currently inpatient for less than seven (7) calendar days, an inpatient treatment review form (ITR) can be completed via the web. To make a request for Retroactive Authorization for beneficiaries that are currently inpatient or have been discharged, the provider is required to: Attach a complete medical record to a ProviderConnect request form or Send a copy of the entire medical record to ValueOptions. Include in your request the date the beneficiary became eligible for services and a statement verifying you are requesting a retroactive review. ValueOptions will process the request within one (1) business day of receiving the entire medical record if the beneficiary is currently receiving services. If the beneficiary has been discharged from the inpatient facility prior to the Retroactive Authorization -Acute form submission, ValueOptions has thirty (30) calendar days to process the request for authorization once all beneficiary information has been received. 5.2 Inpatient Residential Retroactive review for authorization of payment is available to providers when 1.) Residential psychiatric services have been provided to a beneficiary who did not have an active/current Medicaid number or 2.) Residential psychiatric services are being provided to a beneficiary by a facility who receives their Medicaid provider number while providing treatment. ValueOptions will start the request authorization on the date that the beneficiary became eligible for Medicaid Copyright 2010 Page 17 of 50

18 Request for retroactive authorization of payment can occur after the beneficiary has received a Medicaid number. The provider must submit the request for authorization to ValueOptions within thirty (30) calendar days of the Medicaid numbers being issued. If the beneficiary is currently in Residential treatment for less than seven (7) calendar days an inpatient treatment review form can be completed via the web along with supporting documentation. To make a request for Retroactive Authorization, the provider is required to: Attach a complete medical record to a ProviderConnect request form or Send a copy of the entire medical record to ValueOptions Include in your request the date the beneficiary became eligible for services and a statement verifying you are requesting a retroactive review. ValueOptions will process the request within seven (7) business days of receiving the entire medical record if the beneficiary is currently receiving services. If the beneficiary has been discharged from the inpatient facility prior to the Retroactive Authorization-Residential form submission, ValueOptions has thirty (30) calendar days to process the request for authoriz a tion once all beneficiary information has been received. 5.3 RSPMI Outpatient Retroactive review for authorization of payment is available to providers when services have been provided to a beneficiary who does not have Medicaid and they have now been issued a Medicaid number, or when the provider has been providing services during the time period after application for a Medicaid Provider number and that number has now been issued. ValueOptions will start the requested authorization on the date that the beneficiary became eligible for Medicaid. Request for retroactive authorization of payment can only occur after the beneficiary has received a Medicaid number. The provider must submit the request for authorization of payment to ValueOptions within sixty (60) days of the Medicaid number being issued. To make a request for Retroactive Authorization, the provider is required to: Attach a complete medical record to a ProviderConnect request form or Send a copy of the entire medical record to ValueOptions. Include in your request the date the beneficiary became eligible for services and a statement verifying you are requesting a retroactive review. ValueOptions will process the request within nine (9) calendar days of receiving the entire medical record if the recipient is currently receiving services. If the beneficiary has been discharged from the Copyright 2010 Page 18 of 50

19 RSPMI facility prior to the Retroactive Authorization form submission, ValueOptions has thirty (30) days to process the request for authorization once all beneficiary information has been received. Copyright 2010 Page 19 of 50

20 SECTION 6.0 DETERMINATION NOTIFICATIONS 6.1 Determination Notifications Upon completion of all reviews, ValueOptions provides written notification of decisions to the provider. If the service(s) is authorized, written notification of service authorization is posted on line within one (1) business day. If Services are denied a letter of service denial is posted on line within one (1) business day. A letter is also mailed to the provider and beneficiary. The determination letter will contain a statement of right to reconsideration and a description of the reconsideration process. Only licensed, board-certified ValueOptions physician advisors will make the decision to deny a service request. Denial letters are mailed to the provider and beneficiary in hard copy form as required by state and federal law. Electronic copies of letters may be found within the ProviderConnect authorization application for providers. Electronic copies are generated prior to printing; therefore, the provider may access the determination letter online before the paper copy is delivered. Copyright 2010 Page 20 of 50

21 SECTION 7.0 CLINICAL GUIDELINES 7.1 Discharges ValueOptions expects that active discharge planning begins at the point of admission and continues throughout the treatment course. The discharge criteria reflect the circumstances under which a beneficiary is able to transition to a less intensive program type or can be discharged from care. In the majority of these cases, the beneficiary s documented treatment plan, goals and objectives will have been substantially met, or a safe continuing care program has been arranged and deployed at an alternate program type. It is expected that the beneficiary and significant others, as appropriate, are actively involved in both treatment and discharge planning. Discharge decisions and treatment alternatives are discussed with the beneficiary throughout the course of treatment, and especially when discharge determinations are being considered. For some beneficiaries whose condition has not stabilized but has intensified (e.g., exhibits severe behavior such as a suicide/homicide attempt), discharge will involve transition to a more intensive program type. For children/adolescents in out-of-home placements, discharge may be prompted by reunification with parent(s), transition to an alternative living situation (e.g., foster care), or an independent living situation, or by symptoms (e.g., psychosis) that require a more highly structured setting. DISCHARGE PROCESS INSTRUCTIONS Discharge review forms are available on line at or can be completed via ProviderConnect and should be completed as soon as a provider becomes aware of a beneficiary leaving treatment. In no case should the discharge review be received later than five (5) days from completion of treatment. 7.2 Claims Payment While ValueOptions may authorize a service based on the fundamental clinical disposition of each beneficiary, claims payment is subject to beneficiary eligibility, billing limits, and other requirements outlined by Medicaid policy. Please refer to the Arkansas Medicaid Provider Manual for more information at Service authorization is not a guarantee of payment. Copyright 2010 Page 21 of 50

22 SECTION 8.0 SITE VISITS/INSPECTIONS OF CARE 8.1 Site Visits/Inspections of Care Inpatient The Arkansas Department of Human Services, Division of Medical Services, has contracted with ValueOptions to perform annual on site audits of services provided to Medicaid beneficiaries under the age of twenty-one (21) in inpatient hospitals and residential treatment centers. These audits are unannounced. A complete description of the Inpatient Inspection of Care process can be found in the Inpatient Section II { } of the Arkansas Medicaid Provider Manual. 8.2 Site Visits/Inspections of Care Outpatient As with inpatient facilities, Value Options of Arkansas will conduct site visits of outpatient providers for the purpose of assessing care and services provided to Medicaid beneficiaries. These audits will be announced no longer than forty-eight (48) hours prior to the beginning of the audit. At each of the sites, a statistically valid random sample of records will be pulled for review. A complete description of the Outpatient Inspection of Care purpose can be found in the RSPMI Section II { } of the Arkansas Medicaid Provider Manual. Copyright 2010 Page 22 of 50

23 SECTION 9.0 CARE COORDINATION 9.1 Care Coordination ValueOptions has designed an intensive Care Coordination Program to meet the needs of Arkansans under age twenty-one (21) that may be at-risk for out of home placement, increasing intensity of service and/or institutionalization. The mission of the ValueOptions Care Coordination Program is to assure that services to those in need occur in the least restrictive setting necessary to address and improve the presenting behavioral health needs. This will occur through identification of specific Medicaid beneficiaries who may benefit from improvements to the appropriateness, quality, efficiency and effectiveness of the treatment services that they receive. A Care Coordination approach will assist the target population in gaining access to needed medical, behavioral health, social, educational and other services with the goal of treatment in the least restrictive setting. Care Coordination staff will achieve these goals through assessment, service plan evaluation and monitoring, advocacy, linkage and referral. In addition, ValueOptions will assist providers in linking to the local Child/Adolescent Service System Program (CASSP), promote the development of an integrated plan of care and provide consultation as needed. The end result is an individualized, effective treatment plan for beneficiaries who are at high risk of long term services with poor outcomes. By addressing individual needs, there is also the opportunity to review the functioning of the entire system of care for Medicaid beneficiaries under age twenty-one (21) in Arkansas. These opportunities include: Assessment of system strengths and weaknesses regarding the effectiveness of behavioral health care for children; Assessment of service by ValueOptions that result in the need to access more restrictive program types; Assessment of whether treatment modalities reflect best practices in behavioral healthcare; and Recommendations to DBHS, DMS, and Quality Improvement Committee (QIC) for system changes, based on these assessments. While improving the services and outcomes to individual beneficiaries, ValueOptions anticipates that Care Coordination will have an ongoing positive impact on the aggregate system of care. Copyright 2010 Page 23 of 50

24 9.2 Who are the Beneficiaries Served by the Care Coordination Program? The selection of beneficiaries for Care Coordination is an ongoing process of data analysis, assessment of system goals and stakeholder input. The Division of Behavioral Health Services and Division of Medical Services, in conjunction with ValueOptions have defined the eligible population for this program as follows: Beneficiaries under age six (6) who are admitted to acute or residential inpatient services; Beneficiaries who are admitted to acute inpatient services two (2) or more times within a Three (3) month period of time; Beneficiaries whose length of stay for their first acute inpatient hospitalization is more than twenty-eight (28) calendar days; Beneficiaries who are admitted to Residential treatment programs and have a length of stay of greater than twelve (12) months. Beneficiaries in out of State Residential placements (excludes boarder facilities) Care Coordinators will be strategically located to provide coverage of the three (3) regions of Arkansas. Those regions are defined as: 1) Central, 2) North and 3) Lower Arkansas. By being purposefully situated, Care Coordinators will be able to develop working, supportive relationships with beneficiaries/families and providers in that region. They will be knowledgeable about the resources currently available in the community as well as in services that are needed for that community/region. Care Coordinators will act as a resource for specialized services throughout the state and surrounding areas. Using laptop/pc computers and accessing ValueOptions via Internet, Care Coordinators can assure that services are a collaborative, multiagency endeavor to address the needs of high utilizer beneficiaries. As Care Coordinators will be regionally based, eligible beneficiaries will be selected based on their county of residence. 9.3 Functions of Care Coordination Care Coordinators will assist in facilitating and coordinating comprehensive inter-agency treatment planning for identified beneficiaries. Care Coordinators will be closely involved with beneficiaries and their families/significant others. They will collaborate with an array of providers, including but not limited to, mental health providers, Primary Care Physicians, advocacy organizations, juvenile justice, child welfare, education, and social service agencies. This integrated approach ties together all components of the treatment process to achieve the best treatment outcomes in the least restrictive program type. Copyright 2010 Page 24 of 50

25 SECTION 10.0 GRIEVANCES, RECONSIDERATIONS AND FAIR HEARING & APPEALS PROCESS 10.1 Grievances Procedure: A. Receipt of Grievance 1. The Grievance Coordinator receives the grievance orally or in writing. Upon receipt of the grievance and verification that the grievance was filed timely, the issue is entered into the ValueOptions database. ValueOptions makes available reasonable assistance for the beneficiary in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. Grievances received orally will be tracked and resolved as they occur however; written resolution will not be provided. 2. The Grievance Coordinator logs the grievance in the database documenting the date received, name of the grievant and nature of the grievance. 3. The Grievance Coordinator acknowledges all written grievances with an acknowledgement letter within five (5) business days of receipt. The acknowledgement letter includes the ValueOptions address and phone number and the expected date of resolution. 4. The Grievance Coordinator works toward resolution with other ValueOptions staff as necessary, including but not limited to the following: a. Provider Relations b. Clinical Operations Department c. Medical director 5. If a potential Quality of Care issue is identified, the case is forwarded to the Manager of Quality Management, or designee, for oversight and investigation. 6. If a resolution of written grievances cannot be completed within thirty (30) calendar days, the grievant and DMS are contacted either telephonically or in writing prior to the thirtieth (30 th ) day and advised of the status of the grievance. a. The resolution timeframe may be extended if the beneficiary or provider requests the extension or if ValueOptions demonstrates that there is need for additional information and the extension is in the beneficiary s interest. b. Requests for an extension must be prior authorized by DMS. c. Timeframes for written responses to DMS, including correspondence about complaints received in connection with the contract may be adjusted at the discretion of DMS. Copyright 2010 Page 25 of 50

26 7. The written resolution response to the beneficiary contains all required information including but not limited to: a. All information considered in the investigation of the grievance; b. Findings and conclusions based on the investigation; c. Information about fair hearings; and d. The disposition of the grievance. 8. The Grievance Coordinator updates the grievance database to include the resolution date of the grievance and the disposition. B. Reporting, Tracking, and Trending 1. The Manger of Quality Management, or designee, is responsible for ensuring the timely resolution of grievances through regular review of the tracking database. 2. Grievances are tracked according to the following categories: a. Access to Care/Services b. Clinical Issues c. Care Disruption Issues/Terminations of Care d. Claims/Invoice Issues e. Formulary Issues f. Quality Issues g. Utilization Review Issues h. Other categories as needed 3. The Manager of Quality Management, or designee, reviews all grievances on a monthly basis to identify patterns. a. Action plans are developed as issues are identified. b. Patterns of poor quality are forwarded to the ValueOptions Clinical Quality Committee as necessary. 4. The Grievance Coordinator provides the ValueOptions Clinical Quality Committee with monthly summary reports for review and recommendation. 5. The Manager of Quality Management submits grievance reports to DMS, as required by contract. C. All documentation related to the grievance is maintained through the grievance file in accordance with confidentiality requirements. 1. ValueOptions documents the following information, (but not limited to): a. Date of filing of grievance; b. Type of grievance (verbal or written); c. Name, identifier, and nature of the grievance; d. Date of the acknowledgment letter; e. Dates of decision to extend the timeframe as well as DMS approval and provider or beneficiary notification; Copyright 2010 Page 26 of 50

27 f. The determination made including the date of the resolution, the title(s) of the personnel and credentials of any clinical personnel who participated in each determination; g. Date the resolution letter is mailed to the grievant; h. All correspondence between ValueOptions and the grievant, including notices of final resolution and all other pertinent information. 2. The grievance file is released to the beneficiary (or their representative) upon request as permitted by federal and state confidentiality laws and regulations Fair Hearing & Appeals Process The beneficiary or his or her legal guardian may request an appeal/fair hearing within (thirty) 30 calendar days of the denial notification letter date. This request is submitted to the Arkansas Department of Human Services/Appeals and Hearing Section. The request for a Fair Hearing must be made in writing and sent to: Department of Human Services Appeals and Hearing Section Post Office Box 1437, Slot N401 Little Rock, Arkansas Reconsiderations When a request for authorization of services is denied or modified as not meeting medical necessity both the Medicaid beneficiary and the service provider are formally notified in writing. An Arkansas Department of Human Services, Division of medical Services, Notice of Action outlining the request that was denied, the reason for the denial posted on line and mailed. The notice of action contains information explaining the provider s option of requesting reconsideration and the beneficiary s option to appeal. Reconsiderations: If the provider disagrees with the initial physician s denial of their request, the provider may request a reconsideration by a second physician review. The provider has up to 30 thirty calendar days from the date of the denial receipt to request reconsideration along with additional information. The Copyright 2010 Page 27 of 50

28 request for reconsideration must be in writing and contain a copy of the denial notice and the additional information. Submit reconsideration requests to ValueOptions : Via Fax: (877) Use specific fax cover sheet located: Or mail to: ValueOptions Reconsiderations Attention: Clinical Data Entry 1401 W. Capitol Ave Suite 330 Little Rock, AR Additional information about Reconsiderations and Appeals can be found in the General Policy Section I { } of the Arkansas Medicaid Provider Manual. Additional information about the Inpatient Psychiatric Provider reconsideration process can be found in the Inpatient Psychiatric Section II { & } of the Arkansas Medicaid Provider Manual. Additional information about the RSPMI request for reconsideration can be found in the RSPMI Section II { } of the Arkansas Medicaid Provider Manual. Copyright 2010 Page 28 of 50

29 SECTION 11.0 RETROSPECTIVE REVIEWS 11.1 Retrospective Reviews 11.1 Inpatient Additional information about Retrospective Reviews for Inpatient level of care can be found in the Inpatient Section II { } of the Arkansas Medicaid Provider Manual RSPMI Additional information about Retrospective Reviews for RSPMI level of care can be found in the RSPMI Section II { } of the Arkansas Medicaid Provider Manual. Copyright 2010 Page 29 of 50

30 SECTION 12.0 APPENDICES Appendix A: Resources ProviderConnect Users Guide _External_Users_Guide3.pdf Arkansas Department of Human Services: Arkansas Division of Medical Services: Arkansas Division of Behavioral Health Services: Arkansas Advocates for Children and Families: Code of Federal Regulations: Medicaid Fairness Act: Centers for Medicare and Medicaid Services: ValueOptions : Copyright 2010 Page 30 of 50

31 APPENDIX B: Service Codes and Descriptions ADULT Codes RSPMI Out Patient Description Marital/family psychotherapy beneficiary is not present Prior Authorization Required And/or number of units allowed prior to an extension of benefits PA U7 Marital/family psychotherapy beneficiary not present: PA Telemedicine Group OP Psychotherapy PA HA HQ Group OP Pharmacologic Management by Physician PA HA Collateral intervention, MHP PA U7 Collateral intervention, MHP; Telemedicine PA HA UB Collateral intervention, MHPP PA H2012 UA Therapeutic Day /Acute Day Age 21 and over Therapeutic Day/Acute Day Treatment: Shortterm daily array of continuous, highly structured, intensive outpatient services provided by MHP PA H2015 U2 Intervention MHPP PA Copyright 2010 Page 31 of 50

32 H2015 U6 Intervention MHP PA H2015 U7 Intervention MHP Telemedicine PA H2017 Adult Rehabilitative Day Service PA U7 MH evaluation/diagnosis; Telemedicine Max 8 units daily HA U1 MH evaluation/diagnosis Max 8 units daily Marital/Family Therapy beneficiary is present Max 48 units yearly U7 Marital/Family Therapy beneficiary is present Telemedicine - Max 48 units yearly Pharmacologic Management by physician Max 24 units yearly UB Pharmacologic Management, including prescription use and review if medication,no more than minimal medical psychotherapy Max 24 units yearly HA UB Pharmacologic Management by Psych MH CNS/APN Max 24 units yearly U7 Pharmacologic Management by Physician; Telemedicine Max 24 units yearly Copyright 2010 Page 32 of 50

33 90885 HA Periodic review Master Treatment Plan by physician Max 10 units yearly HA U1 Periodic review Master Treatment Plan by non Physician Max 10 units yearly HA U2 Master Treatment Plan Max 8 units yearly HA U2 Interpretation of Diagnosis Max 16 units yearly U3 U7 Interpretation of Diagnosis; Telemedicine Max 16 units yearly HA SA,99202,99203, 99204, 99212,99213, Physical Exam by Psychiatric MH CNS or Psychiatric MH APN Max 12 units yearly HA UB, 99202,99203, 99204, 99212,99213, Physical Exam by Physician Max 12 units yearly H0004 Individual Psychotherapy Max 48 units yearly H0004 U7 Individual Psychotherapy; Telemedicine Max 48 units yearly H2011 HA Crisis Intervention, unscheduled immediate, short term for bnf experiencing psych or beh hlth crisis Max 72 units yearly Copyright 2010 Page 33 of 50

34 H2011 U1 Crisis Stabilization intervention MHPP Max 72 units yearly H2011 U2 Crisis Stabilization Intervention By MHP Max 72 units yearly H2011 U2 U7 Crisis Stabilization intervention by MHP; Telemedicine Max 72 units yearly H2011 U7 Crisis Intervention; Telemedicine Max 72 units yearly T1023 U7 Psychiatric Diagnostic Assessment; Telemedicine Max 1 unit T1023 HA U1 Psychiatric Diagnostic Assessment Max 1 unit T1502 Medication Administration by a licensed Nurse Max 366 units yearly HA UA Psychological Evaluation Max 32 units yearly HA Routine venipuncture for specimen collection Max 12 units yearly U21 RSPMI Outpatient Description Preauthorization requirements/number of units allows prior to extension of Copyright 2010 Page 34 of 50

35 Codes HA U HA U HA HQ Marital/family psycho therapy beneficiary not present Group OP (0-20) (Under age 4 by prior authorized medically needy exception) Group OP Pharmacologic Management by Physician (18 thru 20 yrs of age) HA Collateral intervention, MHP PA HA UB Collateral Intervention MHPP PA H2012 HA Therapeutic Day/Acute Day Treatment: H2015 HA U1 Intervention MHPP PA H2015 HA U5 Intervention MHP PA H2017 H2017 HA U1 Rehabilitative day (ages 18 thru 20) Rehabilitative day (ages 0 thru 17) HA U1 MH evaluation/diagnosis HA U HA HA UB HA Marital/family psycho-therapy beneficiary is present - Pharmacologic Management by a Physician Group OP Pharmacologic Management by Psych CNS/APN Periodic review of Master Treatment Plan benefits Copyright 2010 Page 35 of 50 PA PA PA PA- PA PA Max 8 units yearly Max 48 units yearly Max 24 units yearly Max 24 units yearly

36 Max 10 units yearly HA U1 Periodic review Master Treatment Plan by non Physician HA U2 Master Treatment Plan HA U2 Interpretation of Diagnosis HA SA, 99202,99203, ,99213, HA UB, 99202,99203,99204 Physical Exam by Psychiatric MH CNS or Psychiatric MH APN 99212,99213, Physical Exam by Physician H0004 HA (except <3 yrs old) H2011 HA H2011 HA U5 H2011 HA U6 Individual Psychotherapy (Not for beneficiaries under age of 3 except in documented exceptional cases) Crisis Intervention, unscheduled, immediate, intensive, short term Crisis Stabilization MHPP Crisis Stabilization by MHP HA UA Psychological Evaluation T1023 HA U1 T1502 Psychiatric Diagnosis Assessment Medication Administration by Max 10 units yearly Max 8 units yearly Max 16 units yearly Max 12 units yearly Max 12 units yearly Max 48 units yearly Max 72 units yearly Max 72 units yearly Max 72 units yearly Max 32 units yearly Max 1 unit Copyright 2010 Page 36 of 50

37 36415 HA Licensed Nurse Routine venipuncture for specimen collections Max 366 units yearly Max 12 units yearly Inpatient Program Type Services Under 21 Inpatient Psychiatric Hospital Only 0114 PA Residential Treatment Center Only 0124 PA Residential Treatment Unit Only 0129 PA Sexual Offender Program Only 0128 PA School Based Mental Health Services (SBMH) Individual Out Patient Therapy H0004 PA Marital/Family Therapybeneficiary is present U6 PA Group Out Patient Psychotherapy PA Rehabilative Services For Children And Youth (RSYC) Individual Psychotherapy U1/ PA Group Psychotherapy PA Licensed Mental Health Practitioner (LMHP) Individual Outpatient Therapypsychologist/ LSCW/LMFT/LPC H0004 PA 4 unit max per day PA Marital/Family Therapy w/o U1 PA Copyright 2010 Page 37 of 50

38 beneficiary present- 6 unit max per day LSCW/LMFT/LPC Marital And Family w/o beneficiary present/psychologist U2 PA 6 unit max per day Marital And Family Therapy beneficiary is present LSCW/LMFT/LPC U1 PA 6 unit max per day Marital And Family beneficiary is present -psychologist U2 PA 6 unit max per day Group Outpatient Therapy- LSCW/LMFT/LPC PA 6 unit max per day Group Outpatient Therapypsychologist U1 PA 6 unit max per day Group Outpatient Therapy- LSCW/LMFT/LPC PA 6 unit max per day Copyright 2010 Page 38 of 50

39 APPENDIX C: CLINICAL GUIDELINES Procedure Codes Requiring Prior Authorization HA U Martial/Family Psychotherapy Beneficiary is not present Group Outpatient Group Therapy HQ Group Outpatient Pharmacologic Management by a Physician Prior Authorization is required for services in which the client is not present. The clinical utility of the service must be demonstrated with respect to the treatment plan and goals for the client. Concurrent review is required for services in which the client is not present. The clinical utility of the service must continue to be demonstrated with respect to the treatment plan and goals for the client. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: Mild symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning: Concurrent review criteria are a continuation of the requirement listed above. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: Mild symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning: The beneficiary must be on psychotropic Although the patient is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning, AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning, AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of Copyright 2010 Page 39 of 50

40 H2012-UA Therapeutic Day/Acute Day Treatment medication and the group focus must be directly related to the beneficiary s condition or medication. Concurrent review criteria are a continuation of the requirement listed above. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: independent functioning, AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. Moderate to severe symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning: The beneficiary is at risk of acute decompensation and hospitalization. The beneficiary has the capacity to engage in treatment and the development and implementation of the treatment plan Concurrent review criteria are a continuation of the requirement listed above AND All of the following must be met: Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., Considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning, And The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. H2015-U2 Intervention, Mental Health Paraprofessional Continued or persistent symptoms of sufficient severity to warrant ongoing treatment with this service to prevent worsening of the beneficiary s condition to the point that no other outpatient service will ameliorate the described symptoms and prevent placement in an acute inpatient hospital setting. An alternative plan to be implemented if the beneficiary does not make substantial progress toward the given goals in a specified period of time. Examples of an alternative plan are a second opinion or introduction of adjunctive or alternative therapies. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: A qualified DSM-IV, DSM-IVTR or All of the following must be met: Although the beneficiary is no longer symptomatic, additional services are needed Copyright 2010 Page 40 of 50

41 H2015-U6 H2015-U7 Intervention, Mental Health Professional ICD-9 diagnosis as defined in the Arkansas Rehabilitative Services for Persons with Mental Illness (RSPMI) manual. Moderate symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning; The beneficiary has the capacity to engage in treatment and the development and implementation of the treatment plan. Concurrent review criteria are a continuation of the requirements listed above. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: A qualified DSM-IV, DSM-IVTR or ICD-9 diagnosis as defined in the Arkansas Rehabilitative Services for Persons with Mental Illness (RSPMI) manual. Moderate symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning; The beneficiary has the capacity to engage in treatment and the development and implementation of the treatment plan. Concurrent review criteria are a continuation of the requirements listed above. Additional justification may be required according to the unique disposition of the beneficiary. to support termination (i.e. stopping the service)., Considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning, The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. Intervention is indicated on the treatment plan as medically necessary to treat the beneficiary s presenting psychiatric/behavioral problems. All of the following must be met: Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., Considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning,; AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment; AND Intervention is indicated on the treatment plan as medically necessary to treat the beneficiary s presenting psychiatric/behavioral problems. H2017 Adult Rehabilitative Day Service, 120 units per week maximum Prior authorization IS required. All of the following requirements must be met: A qualified DSM-IV, DSM-IVTR or ICD-9 diagnosis as defined in the Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., Considerations during service Copyright 2010 Page 41 of 50

42 Arkansas Rehabilitative Services for Persons with Mental Illness (RSPMI) manual; AND Moderate symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning; AND The beneficiary has the capacity to engage in treatment and the development and implementation of the treatment plan. termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning,; AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment; U1 Collateral Intervention, Mental Health Professional Concurrent review criteria are a continuation of the requirements listed above. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: A qualified DSM-IV, DSM-IVTR or ICD-9 diagnosis as defined in the Arkansas Rehabilitative Services for Persons with Mental Illness (RSPMI) manual; AND Moderate symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning; AND The beneficiary has the capacity to engage in treatment and the development and implementation of the treatment plan; AND Intervention is indicated on the treatment plan as medically necessary to treat the beneficiary s presenting psychiatric/behavioral problems. Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., Considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning,; AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment; Concurrent review criteria are a continuation of the requirements listed above. Additional justification may be required according to the unique disposition of the beneficiary. Prior authorization IS required. All of the following requirements must be met: Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. Copyright 2010 Page 42 of 50

43 90887-UB Collateral Intervention, Mental Health Paraprofessional A qualified DSM-IV, DSM-IVTR or ICD-9 diagnosis as defined in the Arkansas Rehabilitative Services for Persons with Mental Illness (RSPMI) manual; AND Moderate symptomatic distress or impairment in functioning or behavior due to a primary psychiatric or cooccurring substance abuse illness that is manifested by deficits in: self-care, occupational, scholastic, social, or cognitive functioning; AND The beneficiary has the capacity to engage in treatment and the development and implementation of the treatment plan; AND Intervention is indicated on the treatment plan as medically necessary to treat the beneficiary s presenting psychiatric/behavioral problems. stopping the service)., Considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning,; AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment; Concurrent review criteria are a continuation of the requirements listed above. Additional justification may be required according to the unique disposition of the beneficiary. Procedure Codes Requiring Extension of Benefits: Nat l Code + Modifier Description of Services Prior Authorization and Concurrent Requirement Extension of Benefit Requirement HA U U7 Mental Health Evaluation Diagnosis Prior authorization is not required. 16 service units are allowed per fiscal year for each beneficiary. Concurrent review is not required for services rendered at or below the annual benefit limit. Sudden, significant change in mental status, behavior, or symptoms requiring a change in the treatment plan and therapeutic service mix: OR Lapse in treatment greater than 6 months; OR Documentation of the beneficiary s election to go to a new service provider. Copyright 2010 Page 43 of 50

44 96101-HA UA Psychological Evaluation Prior authorization is not required. 32 service units are allowed per fiscal year for each beneficiary. Concurrent review is not required for services rendered at or below the annual benefit unit limit. Previous testing has failed to clarify the referral question: OR Recent changes or deterioration in the client s mental status, behavior or functioning in the community that cannot be determined through an interview, observation or assessment at a mental health facility; AND An evaluation is needed to recommend a course of treatment due to a lack of progress with past or current mental health services HA U2 Master Treatment Plan Prior authorization is not required. 8 service units are allowed each fiscal year for each beneficiary. Concurrent review is not required for services rendered at or below the annual benefit unit limit. Sudden, significant change in mental status, behavior, or symptoms requiring a change in the treatment plan and therapeutic service mix. Lapse in treatment greater than 6 months: OR Documentation of the beneficiary s election to go to a new service provider HA U2 Interpretation of Diagnosis Prior authorization is not required. 16 service units are allowed each year for each beneficiary. Concurrent review is not required for services rendered at or below the annual benefit unit limit. New psychological evaluation conducted due to significant changes in behavior, symptoms, and condition, OR New diagnosis or change in functioning that requires explanation to the beneficiary s primary caregivers/family beneficiaries. Although the beneficiary is no longer symptomatic, Copyright 2010 Page 44 of 50

45 H0004 H0004 HA Individual Psychotherapy Prior authorization is not required. 48 units of individual therapy are allowed per fiscal year. Concurrent review is not required for services rendered at or below the annual benefit unit limit. additional services are needed to support termination (i.e. stopping the service). Considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning, AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. H2011-HA Prior authorization is not required. 72 service units are allowed per fiscal year. All requests for extension will be automatically approved up to the following limits: HAUB HA SA HA UB HA SA HA UB HA SA HA- UB HA SA UB Crisis Intervention Physical Examination Psychiatrist or Physician And Physical Examination Psychiatric Mental Health Clinical Nurse Specialist or Psychiatric Mental Health Advanced Nurse Concurrent review is not required for services rendered at or below the annual benefit unit limit. Prior authorization is not required. 12 service units are allowed per fiscal year. Concurrent review is not required for services rendered at or below the annual benefit unit limit. 12 units per day x 14 days These extensions will be placed on 100% retrospective review for medical necessity. The provider must provide all documentation required to establish the medical necessity of the service. The beneficiary exhibits one or more symptoms of comorbidity or clinical complexity that require ongoing medical monitoring to coordinate and preserve the integrity of his or her psychiatric treatment, AND The beneficiary is expected to benefit from the proposed course of treatment and is Copyright 2010 Page 45 of 50

46 99211-SA UB HA SA HA UB 99213HA - SA HA UB 99214HA - SA HA UB UB Practitioner Pharmacologic Management by Physician OR Psychiatric Mental Health Clinical Nurse Specialist OR Psychiatric Mental Health Advanced Nurse Practitioner Prior authorization is not required. 24 service units are allowed per fiscal year. Concurrent review is not required for services rendered at or below the annual benefit unit limit. able to participate in treatment. All of the following must be met: Persistent symptomatic distress or impairment; OR Persistent DSM-IV, DSM- IVTR or ICD-9CM diagnosis for which maintenance treatment is required to maintain optimal symptom relief or functioning, AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment HA HA U1 Periodic Review of Master Treatment Plan Routine Venipuncture of Collection of Prior authorization is not required. 10 service units are allowed per fiscal year. Concurrent review is not required for services rendered at or below the annual benefit unit limit. Prior authorization is not required. 12 service units are allowed per fiscal year. Sudden, significant change in mental status, behavior, or symptoms requiring a change in the treatment plan and therapeutic service mix, OR Lapse in treatment greater than 6 months; OR Documentation of the beneficiary s election to go to a new service provider AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. Persistent symptomatic distress or impairment; OR Persistent DSM-IV, DSM- IVTR or ICD-9CM HA Copyright 2010 Page 46 of 50

47 Specimen Concurrent review is not required for services rendered at or below the annual benefit unit limit. diagnosis for which maintenance treatment is required to maintain optimal symptom relief or functioning. The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in treatment. T1023 HA U1 H2011-U2 H2011 HA U6 Diagnostic Assessment by Physician Crisis Stabilization Intervention, Mental Health Professional Prior authorization is not required. 1 service unit is allowed per fiscal year per beneficiary. Concurrent review is not required for services rendered at or below the annual benefit unit limit. Prior authorization is not required. 72 service units are allowed per fiscal year per beneficiary. Concurrent review is not required for services rendered at or below the annual benefit unit limit. There has been a significant change in the beneficiary s presenting symptoms or behaviors or functioning in the community; OR Documentation of the beneficiary s election to go to a new service center. All requests for extension will be automatically approved up to the following limits: 12 units per day x 14 days These extensions will be placed on 100% retrospective review for medical necessity. The provider must provide all documentation required to establish the medical necessity of the service HA U Martial/Family Psychotherapy Beneficiary is present Prior authorization is not required for Marital and Family therapy with the client in attendance. 48 service units are allowed each fiscal year. Concurrent review is not required for services rendered at or below the annual benefit unit limit. Although the beneficiary is no longer symptomatic, additional services are needed to support termination (i.e. stopping the service)., considerations during service termination include relapse history (frequency and severity), current psychosocial stressors and level of independent functioning, AND The beneficiary is expected to benefit from the proposed course of treatment and is able to participate in Copyright 2010 Page 47 of 50