Department of Medical Assistance Services October/November 2008 Treatment Foster Care Case Management

Department of Medical Department of Medical Assistance ServicesAssistance Services

October/November 2008www.dmas.virginia.gov

Treatment Foster Care Case Management

22

DMAS ContactsDMAS ContactsShelley JonesShelley Jones - 804-786-1591 - 804-786-1591

[email protected]@dmas.virginia.gov

Bill O’Bier Bill O’Bier - 804-225-4050- 804-225-4050


Pat SmithPat Smith - 804-225-2412 for KePRO - 804-225-2412 for KePRO related questionsrelated questions


Tracy WilcoxTracy Wilcox - 804-371-2648 - 804-371-2648

Contract Monitor for Clifton Gunderson Contract Monitor for Clifton Gunderson


33

Training ObjectivesTraining Objectives Identify participation requirementsIdentify participation requirements Understand Medicaid documentation Understand Medicaid documentation

requirements requirements Understand locality responsibilitiesUnderstand locality responsibilities Be aware of prior authorization (PA) Be aware of prior authorization (PA)

requirements and processrequirements and process Understand changes to UAI and PA fax Understand changes to UAI and PA fax

formform Understand the utilization review processUnderstand the utilization review process Reference handouts of October 15 and Reference handouts of October 15 and

November 7, 2008 Medicaid memo and November 7, 2008 Medicaid memo and CANS summary formCANS summary form

44

ObjectivesObjectives

These slides contain only highlights These slides contain only highlights of the Virginia Medicaid of the Virginia Medicaid Psychiatric Psychiatric Services ManualServices Manual (PSM) and are not (PSM) and are not meant to substitute for or take the meant to substitute for or take the place of the material in the manuals. place of the material in the manuals. Please refer to the manual, available Please refer to the manual, available on the DMAS website, for in-depth on the DMAS website, for in-depth information on TFC-CM criteria.information on TFC-CM criteria.

55

Provider EnrollmentProvider Enrollment UnitUnit

For enrollment, agreements, change of For enrollment, agreements, change of address, and enrollment questions address, and enrollment questions contact:contact:First Health ServicesFirst Health ServicesProvider Enrollment UnitProvider Enrollment UnitP.O. Box 26803P.O. Box 26803Richmond, VA 23261Richmond, VA 23261

Toll free --Toll free -- 888-829-5373888-829-5373FaxFax -- -- 804-270-7027804-270-7027

66

General Medicaid Provider General Medicaid Provider Participation RequirementsParticipation Requirements

Have administrative and financial Have administrative and financial management capacity to meet management capacity to meet federal and state requirementsfederal and state requirements

Have ability to maintain business and Have ability to maintain business and professional documentation professional documentation

Adhere to conditions outlined in the Adhere to conditions outlined in the provider agreementsprovider agreements

Notify DMAS of any change in Notify DMAS of any change in original information submittedoriginal information submitted

andand

77

Participation Participation RequirementsRequirements

Maintain records that fully document Maintain records that fully document health care providedhealth care provided

Retain records for a period of at least Retain records for a period of at least 5 years5 years

Furnish to authorized state and Furnish to authorized state and federal personnel access to records federal personnel access to records and facilities in the form and manner and facilities in the form and manner requestedrequested

Use Medicaid designated billing formsUse Medicaid designated billing forms

andand

88


Accept as payment in full the amount Accept as payment in full the amount reimbursed by DMAS reimbursed by DMAS

Provider must be participating in the Provider must be participating in the Medicaid Program at the time the Medicaid Program at the time the service is performedservice is performed

A provider may not bill a client forA provider may not bill a client for a a covered servicecovered service regardless of regardless of whether or not the provider received whether or not the provider received payment from Medicaidpayment from Medicaid

99


Should not attempt to collect from the Should not attempt to collect from the client or family member any amount client or family member any amount that exceeds the Medicaid allowance that exceeds the Medicaid allowance or for missed appointmentsor for missed appointments

Hold all recipient information Hold all recipient information confidentialconfidential

Be fully compliant with state and Be fully compliant with state and federal HIPAA confidentiality, use and federal HIPAA confidentiality, use and disclosure requirementsdisclosure requirements

1010

Electronic SignaturesElectronic Signatures Clarification on electronic signatures was Clarification on electronic signatures was

issued in the 8-20-04 Medicaid Memo to issued in the 8-20-04 Medicaid Memo to all providers.all providers.An electronic signature that meets the An electronic signature that meets the following criteria is acceptable for clinical following criteria is acceptable for clinical documentation:documentation:

Identifies the individual signing by name and Identifies the individual signing by name and title; andtitle; and

Data system assures the documentation Data system assures the documentation cannot be altered after signature affixed, by cannot be altered after signature affixed, by limiting access to code or key sequence; limiting access to code or key sequence;

andand

1111

Electronic SignaturesElectronic Signatures

Provides for non-repudiation; that is, Provides for non-repudiation; that is, strong and substantial evidence that will strong and substantial evidence that will make it difficult for the signer to claim the make it difficult for the signer to claim the electronic representation is not valid.electronic representation is not valid.

The provider must have written policies The provider must have written policies and procedures in effect regarding use of and procedures in effect regarding use of electronic signatureselectronic signatures..

1212

Common AbbreviationsCommon Abbreviations

CAFAS/PECFASCAFAS/PECFAS-Child & Adolescent Functional -Child & Adolescent Functional Assessment Scale/Preschool & Early Assessment Scale/Preschool & Early Childhood Functional Assessment ScaleChildhood Functional Assessment Scale

CANSCANS-Child and Adolescent Needs and -Child and Adolescent Needs and StrengthsStrengths

CPMT-CPMT-Community Policy & Management Community Policy & Management TeamTeam

CSA-CSA-Comprehensive Service ActComprehensive Service Act CSB-CSB-Community Service BoardCommunity Service Board DMASDMAS-Department of Medical Assistance -Department of Medical Assistance

ServicesServices

1313

Common AbbreviationsCommon Abbreviations

DSSDSS-Department Social Services-Department Social Services FAPTFAPT-Family Assessment & Planning Team-Family Assessment & Planning Team OCSOCS-Office of Comprehensive Services-Office of Comprehensive Services PSMPSM-Psychiatric Services Manual-Psychiatric Services Manual RTFRTF-“Level C” Residential Treatment -“Level C” Residential Treatment

FacilityFacility SEDSED-Seriously Emotionally Disturbed-Seriously Emotionally Disturbed TFC-CMTFC-CM-Treatment Foster Care - Case -Treatment Foster Care - Case

Management Management

1414

DefinitionDefinition

Case management activities by child Case management activities by child placing agencies with treatment foster placing agencies with treatment foster care programscare programsLicensed/certified by DSSLicensed/certified by DSS In compliance with DMAS criteriaIn compliance with DMAS criteriaMeet provider qualificationsMeet provider qualifications

andand

1515

DefinitionDefinitionCase Management activities which Case Management activities which help SED children or those with help SED children or those with behavioral disorders under the age of behavioral disorders under the age of 21 who are at risk of placement into 21 who are at risk of placement into residential treatmentresidential treatmentGain access to necessary care and Gain access to necessary care and appropriate servicesappropriate servicesCoordinateCoordinate and monitorand monitor necessary necessary care and servicescare and services

1616

Required DocumentationRequired Documentation

FAPT ASSESSMENTFAPT ASSESSMENT Childs immediate & long range therapeutic Childs immediate & long range therapeutic

needsneeds Developmental prioritiesDevelopmental priorities Personal strengths & liabilitiesPersonal strengths & liabilities Potential for family reunificationPotential for family reunification Specific planned treatment objectivesSpecific planned treatment objectives Specific therapeutic modalities required to Specific therapeutic modalities required to

achieve objectivesachieve objectives Signed and dated by a majority (at least 3) of Signed and dated by a majority (at least 3) of

FAPT membersFAPT members

1717

Effective November 1, Effective November 1, 20082008

The state uniform assessment instrument The state uniform assessment instrument (UAI) has been the CAFAS/PECFAS since (UAI) has been the CAFAS/PECFAS since the start of the TFC-CM program in 2000 the start of the TFC-CM program in 2000

On November 1, 2008 DMAS will also begin On November 1, 2008 DMAS will also begin to accept the CANS as the state UAIto accept the CANS as the state UAI

Either the CAFAS/PECFAS or CANS can be Either the CAFAS/PECFAS or CANS can be used to meet criteria until June 30, 2009used to meet criteria until June 30, 2009

On July 1, 2009, only the CANS will be On July 1, 2009, only the CANS will be accepted as the state UAI for TFC-CMaccepted as the state UAI for TFC-CM

1818

State UAIState UAI

At a minimum:At a minimum: The CAFAS or PECFAS profile sheets The CAFAS or PECFAS profile sheets

for the youth and caregiver, for the youth and caregiver, OROR The CANS summary sheet, indicating The CANS summary sheet, indicating

the child’s behavioral and emotional the child’s behavioral and emotional needs, and risk behaviors, needs, and risk behaviors, must be available in the medical must be available in the medical record and current within 90 record and current within 90 days throughout the stay days throughout the stay

1919

Initial Plan of CareInitial Plan of Care

For Medicaid purposes the initial plan For Medicaid purposes the initial plan of care must include, at a minimum, of care must include, at a minimum, a list of services that will be provided a list of services that will be provided during the first 45 days of placementduring the first 45 days of placement

List of services to be provided must List of services to be provided must be in the medical record within the be in the medical record within the first 10 days of placementfirst 10 days of placement

2020

Comprehensive Treatment Comprehensive Treatment and Service Plan (CTSP)and Service Plan (CTSP)

Comprehensive planComprehensive plan

Completed within 45 days of placementCompleted within 45 days of placement

IndividualizedIndividualized

Developed by case manager and Developed by case manager and treatment teamtreatment team

Consult with parents when appropriateConsult with parents when appropriate

2121

CTSPCTSP

Must include the following:Must include the following: Assessment of child’s needsAssessment of child’s needs

EmotionalEmotional BehavioralBehavioral EducationalEducational MedicalMedical

Specific treatment goals and target Specific treatment goals and target dates for completiondates for completion

The CM’s program of therapies, The CM’s program of therapies, activities, and servicesactivities, and services

andand

2222

CTSPCTSP

The discharge plan and target date The discharge plan and target date For children age 16+, describe For children age 16+, describe

transition plan for independent livingtransition plan for independent living Indicate team members participation Indicate team members participation

in development of planin development of plan

Dated signature of the case managerDated signature of the case manager

CTSP should be revised annuallyCTSP should be revised annually

2323

90 Day Progress Update90 Day Progress Update

Completed 90 days from CTSP and every Completed 90 days from CTSP and every 90 days throughout the stay90 days throughout the stay

Specify time period coveredSpecify time period covered Describe progress towards treatment goals Describe progress towards treatment goals

and objectivesand objectives MetMet Continued or addedContinued or added Criteria for achievement of eachCriteria for achievement of each Target dates for eachTarget dates for each

andand

2424

90 Day Progress Update90 Day Progress UpdateSpecify problems and behaviors of childSpecify problems and behaviors of child

being addressed being addressed Specify any changes in interventions or Specify any changes in interventions or

strategies strategies Describe therapies, activities, or Describe therapies, activities, or

services providedservices providedAny changes needed for next 90 daysAny changes needed for next 90 daysServices to be provided in next 90 daysServices to be provided in next 90 daysChild’s own assessmentChild’s own assessment andand

2525

90 Day Progress Update90 Day Progress Update Contacts of child & family, where Contacts of child & family, where

appropriateappropriate Specific medical needs, treatment Specific medical needs, treatment

and medications providedand medications provided Update to discharge plans/dateUpdate to discharge plans/date Transition plansTransition plans

Annual revision of the CTSP to Annual revision of the CTSP to include all of the aboveinclude all of the above

2626

Case NarrativesCase Narratives Current within 30 daysCurrent within 30 days In chronological orderIn chronological order Include:Include:

Treatment & servicesTreatment & services All contacts related to childAll contacts related to child Visits with family Visits with family Other significant eventsOther significant eventsRecord all medications prescribed Record all medications prescribed

and all reported side effectsand all reported side effectsDated signature of case managerDated signature of case manager

2727

MEDICAL NECESSITY MEDICAL NECESSITY CRITERIACRITERIA

Documented moderate to severe Documented moderate to severe impairment & moderate to severe risk impairment & moderate to severe risk factors as recorded on the UAIfactors as recorded on the UAIFor the CANS, this would be from the For the CANS, this would be from the

Child Behavioral/Emotional Needs and/or Child Behavioral/Emotional Needs and/or Child Risk Behaviors areas on the Child Risk Behaviors areas on the summary sheetsummary sheet

The moderate to severe impairment is necessary The moderate to severe impairment is necessary for admission. Continued stay reviews require for admission. Continued stay reviews require documentation of the necessity for this level of documentation of the necessity for this level of care, not necessarily tied to the UAI score.care, not necessarily tied to the UAI score.

2828

MEDICAL NECESSITY MEDICAL NECESSITY CRITERIACRITERIA

Child’s condition must meet one of Child’s condition must meet one of the three levels listed below and the three levels listed below and supported by the providers supported by the providers documentation of current documentation of current behaviors:behaviors:

2929

LEVEL ILEVEL IModerate impairment with one Moderate impairment with one

or more risk factorsor more risk factors Needs intensive supervision to prevent Needs intensive supervision to prevent

harmful consequences;harmful consequences; Moderate/frequent disruptive or non-Moderate/frequent disruptive or non-

compliant behaviors in the home setting compliant behaviors in the home setting that increase the risk to self or others; that increase the risk to self or others;

andand Needs assistance of trained professionals Needs assistance of trained professionals

as caregivers.as caregivers.

3030

LEVEL IILEVEL II Significant impairment with authority, Significant impairment with authority,

impulsivity, and caregiver issuesimpulsivity, and caregiver issues Be unable to handle the emotional demands of Be unable to handle the emotional demands of

family living;family living; Need 24-hour immediate response to crisis Need 24-hour immediate response to crisis

behaviors; behaviors; oror Have severe disruptive peer & authority Have severe disruptive peer & authority

interactions that increase risk and impede interactions that increase risk and impede growth.growth.

3131

LEVEL IIILEVEL III

Child must display a significant Child must display a significant impairment with severe risk factors impairment with severe risk factors as documented on CAFAS.as documented on CAFAS.

Child must also demonstrate risk Child must also demonstrate risk behaviors that create significant behaviors that create significant risk of harm to self or to othersrisk of harm to self or to others..

3232

ResponsibilitiesResponsibilities of the of the

LOCALITYLOCALITYin in

TFC Case ManagementTFC Case Management

3333

Complete the state uniform assessment Complete the state uniform assessment instrument (UAI)instrument (UAI)

No older than maximum of 90 daysNo older than maximum of 90 daysCAFAS/PECFASCAFAS/PECFAS Youth’s functioningYouth’s functioning Caregiver ResourcesCaregiver ResourcesCANSCANS Summary sheetSummary sheet

Include Child Behavioral/Emotional Needs Include Child Behavioral/Emotional Needs and Child Risk Behaviors sectionsand Child Risk Behaviors sections

Be sure to include the child’s name and the Be sure to include the child’s name and the screener’s name, as well as the date screener’s name, as well as the date completedcompleted

andand

Locality ResponsibilityLocality Responsibility

3434

Locality Locality ResponsibilityResponsibility

State UAI:State UAI: ImpairmentsImpairments identified must be related identified must be related

to scores on UAIto scores on UAI CAFAS/PECFASCAFAS/PECFAS At least ONE At least ONE moderate impairment moderate impairment

noted with related noted with related risk factorrisk factor Two are required if one is in School Two are required if one is in School

subscalesubscale CANSCANS Two impairments indicated as a #2 or Two impairments indicated as a #2 or

#3 on the summary sheet#3 on the summary sheet Impairments indicated must be supported Impairments indicated must be supported

in the narrativein the narrative

3535


DSM IV DiagnosisDSM IV Diagnosis V Codes are not acceptableV Codes are not acceptable

List of services to be provided in first 45 days List of services to be provided in first 45 days of careof care

Description of child’s behavior within past 30 Description of child’s behavior within past 30 daysdays Be specific, give frequency and durationBe specific, give frequency and duration Problem behaviors should be reflected on Problem behaviors should be reflected on

the state UAIthe state UAI Alternative placement options consideredAlternative placement options considered

andand

3636


Child’s functional levelChild’s functional level Clinical stabilityClinical stability Level of family supportLevel of family support Discharge planDischarge plan FAPT assessment that reflects the need FAPT assessment that reflects the need

for level of care and the state UAIfor level of care and the state UAI Dated signatures of at least 3 Dated signatures of at least 3

members of the FAPTmembers of the FAPTandand

3737

Locality ResponsibilityLocality Responsibility And either:And either:

FAPT Certification that TFC Case FAPT Certification that TFC Case Management is medically necessaryManagement is medically necessary

OROR Written documentation that the CPMT Written documentation that the CPMT

has approved admission to TFC Case has approved admission to TFC Case ManagementManagement

3838


Be sure to submit to the provider:Be sure to submit to the provider: Copies of the current state UAICopies of the current state UAI FAPT Assessment documenting the FAPT Assessment documenting the

need for level of careneed for level of care Provide specific symptoms and/or Provide specific symptoms and/or

problem behaviors that need to be problem behaviors that need to be addressedaddressed

DSM-IVDSM-IV FAPT or CPMT CertificationFAPT or CPMT Certification 3 digit locality code that designates 3 digit locality code that designates

the fiscally responsible locality the fiscally responsible locality

3939

Components of TFC-CMComponents of TFC-CM Care Plan developmentCare Plan development Coordinate services and service Coordinate services and service

planning with others involved with planning with others involved with child, child, such as working with DSS staff, such as working with DSS staff, juvenile justice or court staff, or other juvenile justice or court staff, or other service providers, such as Mental service providers, such as Mental Health Support staffHealth Support staff

Referral for needed servicesReferral for needed services Follow up on progress to ensure service Follow up on progress to ensure service

deliverydelivery

4040

Components of TFC-CMComponents of TFC-CM Placement activitiesPlacement activities

Planning appropriate placementPlanning appropriate placementMonitoring placementMonitoring placementDischarge planningDischarge planning

Evaluating effectiveness of treatment Evaluating effectiveness of treatment plan through supervision of foster parentsplan through supervision of foster parents

AssessAssess periodically, child’s need for periodically, child’s need for services:services:

PsychosocialPsychosocial NutritionalNutritional MedicalMedical EducationEducation

4141

Ensure receipt of required documents Ensure receipt of required documents from the localityfrom the locality

Ensure the locality has provided the Ensure the locality has provided the correct locality code to reflect the correct locality code to reflect the locality that has fiscal responsibility for locality that has fiscal responsibility for the childthe child

Submit the prior authorization request Submit the prior authorization request to KePRO within 10 days of placementto KePRO within 10 days of placement

Notify the locality of Medicaid approval Notify the locality of Medicaid approval or denialor denial

TFC Case Manager Initial Responsibilities

4242

CM’s Ongoing CM’s Ongoing ResponsibilityResponsibility

The CM shall provide to the The CM shall provide to the foster family:foster family:SupervisionSupervisionTrainingTrainingSupportSupportGuidanceGuidance

To facilitate the implementation of To facilitate the implementation of the treatment planthe treatment plan

4343

Contacts with the TFC Contacts with the TFC ChildChild

Face-to-face contact with the child should be Face-to-face contact with the child should be as often as necessary, based on the CTSP as often as necessary, based on the CTSP to ensure effective, safe services.to ensure effective, safe services.

Face-to-face contacts must be no less than twice Face-to-face contacts must be no less than twice a month, one in the foster home, one with foster a month, one in the foster home, one with foster parent and child. The two minimum face-to-face parent and child. The two minimum face-to-face visits should occur on different dates.visits should occur on different dates.

GOALSGOALS Assess child’s progressAssess child’s progress Provide guidance to TFC parentsProvide guidance to TFC parents Monitor service deliveryMonitor service delivery Allow child to communicate concernsAllow child to communicate concerns

4444

Service LimitsService LimitsIf a child is temporarily out of the home, If a child is temporarily out of the home, active CM is necessary to bill for the active CM is necessary to bill for the time time out of homeout of homeNo other type of case management may be No other type of case management may be billed concurrently with TFC-CM, no matter billed concurrently with TFC-CM, no matter the payment sourcethe payment sourceCaseload limits:Caseload limits:

Case manager (full-time professional staff) to Case manager (full-time professional staff) to have a maximum of 12 childrenhave a maximum of 12 children

6 children for beginning trainees, increasing to 6 children for beginning trainees, increasing to 9 at end of first year, and 12 by end of second 9 at end of first year, and 12 by end of second yearyear

Maximum of 3 children in student intern Maximum of 3 children in student intern caseloadcaseload

4545

DocumentationDocumentation

Late EntriesLate Entries Timeliness of documentation is Timeliness of documentation is

essential. A document is considered essential. A document is considered complete by review of the dated complete by review of the dated signature of the professional who signature of the professional who develops the document. Back dating develops the document. Back dating is not acceptable. is not acceptable.

4646

Prior AuthorizationPrior Authorization KePRO KePRO is the DMAS prior is the DMAS prior

authorization contractorauthorization contractor Authorization can be approved for up Authorization can be approved for up

to one year with medical justificationto one year with medical justification KePRO will review requests for KePRO will review requests for

medical necessity, as well as medical necessity, as well as timelinesstimeliness

4747

Prior AuthorizationPrior Authorization

For questions or forms, go to the PA For questions or forms, go to the PA website or use the web address website or use the web address below:below:

DMAS.KePRO.orgDMAS.KePRO.org and click on and click on Virginia MedicaidVirginia Medicaid

Phone: Phone: 1-888-VAPAUTH1-888-VAPAUTH or or 1-888-827-28841-888-827-2884

Fax: Fax: 1-877-OKBYFAX1-877-OKBYFAX or or 1-877-652-93291-877-652-9329

Web:Web: Provider Issues @ KePRO.orgProvider Issues @ KePRO.org

4848

Prior AuthorizationPrior AuthorizationSubmitting a requestSubmitting a request

The preferred method is the The preferred method is the iEXCHANGE® web-based programiEXCHANGE® web-based program

Registration is requiredRegistration is required Information on iEXCHANGE is Information on iEXCHANGE is

available on the KePRO website, or available on the KePRO website, or call call

1-888-827-2884 or by e-mail at 1-888-827-2884 or by e-mail at [email protected]@kepro.org

4949

Prior AuthorizationPrior Authorization Additional Methods of SubmissionAdditional Methods of Submission

Requests may also be submitted by:Requests may also be submitted by: Fax to 877-652-9329Fax to 877-652-9329

The Treatment Foster Care Case The Treatment Foster Care Case Management Prior Authorization Management Prior Authorization Request Form (364) is available in Request Form (364) is available in electronically fill-able format on the electronically fill-able format on the KePRO and DMAS websitesKePRO and DMAS websites

www.dmas.virginia.govwww.dmas.virginia.gov https://dmas.kepro.orghttps://dmas.kepro.org

5050

KePROKePRO Telephone to 888-827-2884 or Telephone to 888-827-2884 or

804-622-8900 (local)804-622-8900 (local) Mail to:Mail to:

KePROKePRO

2810 North Parham Rd., Suite 3052810 North Parham Rd., Suite 305

Richmond, VA 23284Richmond, VA 23284

5151

Revised Fax FormRevised Fax Form A revised prior authorization fax form is available A revised prior authorization fax form is available

on the DMAS and KePRO websiteson the DMAS and KePRO websites The changeover from the CAFAS to the CANS The changeover from the CAFAS to the CANS

as the state UAI and the dual use period is as the state UAI and the dual use period is reflected on the revised fax formreflected on the revised fax form

Added a “Change Request” box under item 1 of Added a “Change Request” box under item 1 of the fax formthe fax form

Under current behaviors, information should Under current behaviors, information should reflect UAIreflect UAI

All other areas of the form remains the sameAll other areas of the form remains the same

5252

Revised Fax FormRevised Fax Form The effective date for the mandatory The effective date for the mandatory

use of the new fax forms has been use of the new fax forms has been revised to December 1, 2008. revised to December 1, 2008.

From December 1 forward, the 9-25-08 From December 1 forward, the 9-25-08 version of the fax form attached to the version of the fax form attached to the October 15October 15thth memo and posted on the memo and posted on the DMAS and KePRO websites will be DMAS and KePRO websites will be required. required.

5353

State UAIState UAI Must be current. For admission the state Must be current. For admission the state

UAI should reflect the requested level of UAI should reflect the requested level of carecare

To be completed at a minimum of every 90 To be completed at a minimum of every 90 days and must be available in the medical days and must be available in the medical recordrecord

Should be updated by the fiscally Should be updated by the fiscally responsible locality when the child’s level of responsible locality when the child’s level of impairment changes significantlyimpairment changes significantly

Completion information must be submitted Completion information must be submitted to KePRO for PAto KePRO for PA

Scoring notes the level of impairment that Scoring notes the level of impairment that supports the need for the level of caresupports the need for the level of care

5454

Initial ReviewInitial Review Use when in care for up to 45 daysUse when in care for up to 45 days Required to be submitted within 10 days Required to be submitted within 10 days

of admissionof admission Completed KePRO fax form to include Completed KePRO fax form to include

information on:information on:DiagnosisDiagnosisTFC-CM needTFC-CM needFAPT assessmentFAPT assessment

andand

5555

Initial ReviewInitial Review

State UAI informationState UAI informationInitial servicesInitial servicesSymptoms and behaviorsSymptoms and behaviors

Information should reflect the scoring on the Information should reflect the scoring on the state UAI. If not, explain.state UAI. If not, explain.

Locality code-this should reflect the locality Locality code-this should reflect the locality who is fiscally responsible who is fiscally responsible

For reviews not received within 10 calendar days of For reviews not received within 10 calendar days of placement, approval can begin no earlier than placement, approval can begin no earlier than the date all requested information is received.the date all requested information is received.

5656

Continued Stay ReviewContinued Stay Review

Submitted prior to the expiration Submitted prior to the expiration of the current authorization, but of the current authorization, but no earlier than 30 daysno earlier than 30 days

Information required:Information required:Confirm the locality codeConfirm the locality codeDSM-IVDSM-IVCTSP completion informationCTSP completion informationDetermination that TFC-CM required Determination that TFC-CM required

to meet child’s needsto meet child’s needs

5757

Continued Stay ReviewContinued Stay Review Information required:Information required:

Confirmation on face-to-face visitsConfirmation on face-to-face visitsSymptoms and behaviorsSymptoms and behaviors

Specify frequency, intensity and Specify frequency, intensity and duration of problem behaviorsduration of problem behaviors

If no problems indicated, give reason If no problems indicated, give reason for continuing servicesfor continuing services

Current state UAI informationCurrent state UAI informationBe sure the narrative supports the UAI Be sure the narrative supports the UAI

scores, or explain why notscores, or explain why not

5858

Preauthorization ProcessPreauthorization Process Approval based on medical necessity for Approval based on medical necessity for

TFC Case ManagementTFC Case Management Review completed with receipt of all Review completed with receipt of all

required materialsrequired materials Approval based on Virginia Medicaid Approval based on Virginia Medicaid

criteriacriteria Approval will be for a one-year period if Approval will be for a one-year period if

all criteria is metall criteria is met

5959

Prior AuthorizationPrior AuthorizationAppealsAppeals The denial of PA for services not yet The denial of PA for services not yet

rendered may be appealed in writing by the rendered may be appealed in writing by the Medicaid recipient within 30 days of receipt Medicaid recipient within 30 days of receipt of the denial.of the denial.

The provider may appeal an adverse The provider may appeal an adverse decision for a service already provided by decision for a service already provided by filing a written notice of appeal.filing a written notice of appeal.

Appeal rights and address for submission will Appeal rights and address for submission will be stated in the FHS notification. Requests be stated in the FHS notification. Requests for appeal must be submitted directly to for appeal must be submitted directly to DMAS within 30 days of the notice of denial. DMAS within 30 days of the notice of denial. andand

6060

Prior AuthorizationPrior Authorization

The provider may not bill the The provider may not bill the recipient for covered services that recipient for covered services that have been provided and have been provided and subsequently denied by DMASsubsequently denied by DMAS

6161

Utilization ReviewUtilization ReviewFederal regulations require that DMAS Federal regulations require that DMAS

review and evaluate the services review and evaluate the services provided through the Medicaid program.provided through the Medicaid program.

Purpose of Utilization Review:Purpose of Utilization Review: Ensure medical necessity Ensure medical necessity Confirm qualified provider delivered serviceConfirm qualified provider delivered service Ensure program requirements met Ensure program requirements met Address Quality of Care issues Address Quality of Care issues

6262

Utilization ReviewUtilization Review DMAS has contracted with Clifton-DMAS has contracted with Clifton-

Gunderson to complete Gunderson to complete auditsaudits of TFC- of TFC-CM and will review records to assure CM and will review records to assure DMAS criteria is being followed. DMAS criteria is being followed.

They will select providers for review by They will select providers for review by statistical sampling, exception reporting or statistical sampling, exception reporting or through referrals or complaintsthrough referrals or complaints

They will make periodic announced and They will make periodic announced and unannounced visits unannounced visits andand

6363

Utilization ReviewUtilization Review

They will do desk audits or on-site visits to They will do desk audits or on-site visits to review medical documentation to ensure review medical documentation to ensure DMAS criteria is metDMAS criteria is met

They will request provider qualification They will request provider qualification information as well as confirmation of information as well as confirmation of service deliveryservice delivery

They will assess service limits complianceThey will assess service limits compliance They will determine if retraction of paid They will determine if retraction of paid

claims is necessaryclaims is necessaryandand

6464

Utilization ReviewUtilization Review The criteria described in the earlier slides is The criteria described in the earlier slides is

critical to compliance, although it is not a critical to compliance, although it is not a complete list. See the Psychiatric Services complete list. See the Psychiatric Services Manual for a complete listing. Review all Manual for a complete listing. Review all referenced federal and state regulations, as referenced federal and state regulations, as well as Medicaid Memos that are sent to well as Medicaid Memos that are sent to providers and available on the DMAS providers and available on the DMAS website.website.

Review the sample forms provided in the Review the sample forms provided in the PSM.PSM.

6565

Duplication of ServicesDuplication of Services

Intensive In-Home Services and Treatment Intensive In-Home Services and Treatment Foster Care Services both have a case Foster Care Services both have a case management (CM) component and so should management (CM) component and so should not both be provided at the same time.not both be provided at the same time.

No other CM service should be provided to the No other CM service should be provided to the same recipient at the same time as TFC-CM, no same recipient at the same time as TFC-CM, no matter the payment source (this includes MH matter the payment source (this includes MH and MR case management or other services and MR case management or other services with a CM component) If there is no CM with a CM component) If there is no CM component it would not be a duplication of component it would not be a duplication of services.services.Duplication is subject to retraction at audit.Duplication is subject to retraction at audit.

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The Reviewer Checks:The Reviewer Checks:

Consumer’s full name or Medicaid Consumer’s full name or Medicaid number on each document in the number on each document in the record record

Medical/clinical necessity of the Medical/clinical necessity of the service service Appropriate admission to serviceAppropriate admission to service

Required documentationRequired documentationSee slides 16-30 as well as the PSM for See slides 16-30 as well as the PSM for

a complete listing a complete listing

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If a request for authorization has If a request for authorization has been approved, but:been approved, but: the child no longer meets DMAS criteria the child no longer meets DMAS criteria (does (does not have impairments indicated not have impairments indicated on the on the UAI, and there is no documented UAI, and there is no documented reason reason for continued services:for continued services:

THE PROVIDER SHOULD NOT BILL THE PROVIDER SHOULD NOT BILL MEDICAIDMEDICAID

CAUTION!CAUTION!

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Utilization ReviewUtilization Review If the UR finding is to retract prior If the UR finding is to retract prior

reimbursement, the provider has the right reimbursement, the provider has the right to reconsideration and appeal.to reconsideration and appeal.

Reconsideration is required to be Reconsideration is required to be submitted within 30 days of the audit letter submitted within 30 days of the audit letter date. All material to support why retraction date. All material to support why retraction should not be made should be included.should not be made should be included.

If the decision is to uphold the denial If the decision is to uphold the denial decision after reconsideration, the provider decision after reconsideration, the provider has the right to appeal. Appeal rights will has the right to appeal. Appeal rights will be stated in the decision letter. Requests be stated in the decision letter. Requests for appeal must be submitted within 30 for appeal must be submitted within 30 days of the notice of reconsiderationdays of the notice of reconsideration

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Questions?Questions?

Documents

Department of Medical Assistance Services October/November 2008 Treatment Foster Care Case Management