Department of Medical Assistance Services

1. Department of Medical Assistance Services Program has been in existence since 2000Program has been in existence since 2000

2. 2 Residential TreatmentLevel C DMAS Contacts William O’Bier - 804-225-4223 william.obier@dmas.virginia.gov Pat Smith - 804-225-2412 for KePRO related questions patty.smith@dmas.virginia.gov Tracy Wilcox-804-371-2648 Contract Monitor for Clifton Gunderson Audits tracy.wilcox@dmas.virginia.gov I am the Behavioral Health Advisor for MH services with a specialty in RTC and TFC-CM. Bill is the supervisor for hospital and community based services UR.I am the Behavioral Health Advisor for MH services with a specialty in RTC and TFC-CM. Bill is the supervisor for hospital and community based services UR.

3. 3 Training Objectives: Identify participation requirements Understand Medicaid documentation requirements Be aware of Service Authorization (SA) requirements and process

4. 4 Objectives cont: These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual (PSM) and are not meant to substitute for the comprehensive information available in the manual. Please refer to the manual, available on the DMAS website, for in-depth information on psychiatric residential treatment criteria.

5. 5 Provider Enrollment Unit For enrollment, agreements, change of address, and enrollment questions contact: Provider Enrollment Unit P.O. Box 26803 Richmond, VA 23261 Toll free -- 888-829-5373 Fax -- 804-270-7027

6. 6 Provider Agreements A Restraint & Seclusion (R&S) attestation letter must be submitted to DMAS by July 1 each year or sooner if change in CEO Sample R&S attestation letter in manual

7. 7 General Medicaid Provider Participation Requirements Have administrative and financial management capacity to meet federal and state requirements Have ability to maintain business and professional documentation Adhere to conditions outlined in the provider agreements Notify DMAS of any change in original information submitted and

8. 8 Participation Requirements Maintain records that fully document health care provided Retain records for a period of at least 5 years Furnish access to records and facilities in the form and manner requested Use Medicaid designated billing forms Accept as payment in full the amount reimbursed by DMAS. Provider must be participating in the Medicaid Program at the time the service is performed and

9. 9 Participation Requirements A provider may not bill a client for a covered service regardless of whether or not the provider received payment from the state Should not attempt to collect from the client or family member any amount that exceeds the Medicaid allowance or for missed appointments Hold all recipient information confidential Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements

10. 10 Definition-Level C RTF Program for children under age 21 to treat severe mental, emotional and behavioral disorders When outpatient and day treatment fails Provides inpatient psychiatric treatment 24-hours per day program Child-specific care and treatment planning and If a recipient turns 21 while in an RTC, and medical necessity continues to be met, the recipient can remain until their 22nd birthday.If a recipient turns 21 while in an RTC, and medical necessity continues to be met, the recipient can remain until their 22nd birthday.

11. 11 Definition-Level C RTF Highly organized and intensive services Planned therapeutic interventions All services required to be provided on-site, including academic program Physician-directed mental health treatment

12. 12 Restraint & Seclusion Remain in compliance with signed agreement regarding seclusion and restraint In case of injury requiring medical attention off-site or a suicide attempt, DMAS must be notified by fax within one business day of occurrence: child’s name, Medicaid number facility name & address of incident location & date of incident and Federal regulations require notification should be received within one business day.Federal regulations require notification should be received within one business day.

13. 13 Restraint & Seclusion Cont’d Notification continued names of staff involved description of incident outcome, including persons notified current location of child Fax to William O’Bier at 804-612-0059 Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and of provider enrollment Please note the fax number. Please note the fax number.

14. 14 Out-of-State Facility Enrollment Border-state facility (within 50 miles) Provides a service not available in Virginia; or No in-state facility willing to admit a specific child Procedure: Contact DMAS at 804/225-4223 to discuss child-specific, out-of-state placement need DMAS can enroll facility for single placement, if appropriate and If an out-of-state provider contacts provider enrollment they will usually refer the provider to me.If an out-of-state provider contacts provider enrollment they will usually refer the provider to me.

15. 15 Out-of-State Placement Criteria Requires prior authorization for Medicaid coverage Recipient specific information required to be sent to DMAS: Demographics Referral source information Current placement and services and why these are not adequate Current documentation on diagnosis, behaviors, discharge plan Current psychological evaluation -within past year and

16. 16 Out-of-State Placement Criteria Social and Service History pertinent to placement needs Out-of-state facility information-website, documentation List of Virginia facilities explored, and reasons for admission denial This will be reviewed by DMAS staff to assess the appropriate level of care and facility placement, and who will coordinate with provider enrollment if out-of state placement is approved

17. 17 Electronic Submission of Claims Claims should be submitted electronically For CSA cases, when submitting SA information to KePRO, the 3-digit locality code and the Reimbursement Rate Certification rate are required. This will facilitate electronic submission of claims For NON-CSA cases, reimbursement will be at the rate established at enrollment. All providers are expected to have a rate established at enrollment

18. 18 Electronic Signatures Clarification on electronic signatures issued in the 8-20-04 Medicaid Memo http://www.dmas.virginia.gov/downloads/pdfs/mm-use_electronic_signatures.pdf An electronic signature that meets the following criteria is acceptable for clinical documentation: Identifies the individual signing by name and title; and

19. 19 Electronic Signatures Data system assures the documentation cannot be altered after signature affixed, by limiting access to code or key sequence; Provides for non-repudiation; that is, strong and substantial evidence that will make it difficult for the signer to claim the electronic representation is not valid; and The provider must have written policies and procedures in effect regarding use of electronic signatures.

20. 20 Required Documentation The following slides describe the required documents for admission All documents must be complete, timely and include all required dated signatures Sample forms are available in the manual

21. 21 Reimbursement Rate Certification For CSA Cases Only Negotiated rate between locality and facility Total rate can be no more than the Medicaid maximum Payment from any other source such as Title IV-E, must be deducted prior to establishing the rate and

22. 22 Reimbursement Rate Certification continued Identify responsible locality Locality code must be sent in for PA If rate is revised by the locality, must be sent in to KePRO within 1 week to update the PA Payment based on the rate on the certification which is entered by KePRO into the MMIS All versions of the rate certification must be available at the facility for review The locality code is a critical element. The locality will be held financially responsible for some portion of the Medicaid paid claims, so if the incorrect locality name is given to the provider, the wrong locality will be held responsible. For a CSA coordinator who manages a few localities, please be sure to give a single locality name, and preferably the 3-digit code. Fixing an incorrect locality code is easy, up until there is a paid claim, then it becomes problematic for the provider. Contact KePRO to revise a rate or locality code. First Health System Medical Management Information System.The locality code is a critical element. The locality will be held financially responsible for some portion of the Medicaid paid claims, so if the incorrect locality name is given to the provider, the wrong locality will be held responsible. For a CSA coordinator who manages a few localities, please be sure to give a single locality name, and preferably the 3-digit code. Fixing an incorrect locality code is easy, up until there is a paid claim, then it becomes problematic for the provider. Contact KePRO to revise a rate or locality code. First Health System Medical Management Information System.

23. 23 CSA or NON-CSA? If the case is an Adoption Subsidy case, it is NON-CSA The education payment source is not considered If the education is paid for by the Dept. of Education/CSA funded, it is a CSA case If a child has been receiving CSA funding for other services, it is a CSA case If the child is in foster care, it is a CSA case

24. 24 Certification of Need CSA Cases CON must be completed by both the physician and the FAPT Must include dated signatures of physician and at least 3 members of the FAPT Authorization can begin no earlier than the date of the latest signature Must be child-specific and relate to the need for RTF level of care Must be available in the medical record Authorization does not guarantee payment. If a required document is not available, or the dated signatures do not meet DMAS criteria, retraction will occur.Authorization does not guarantee payment. If a required document is not available, or the dated signatures do not meet DMAS criteria, retraction will occur.

25. 25 Certification of Need(Independent Team Certification) NON-CSA Cases The CSB is responsible for completing the Independent Team Certification The CSB completes the DMH224 and must include a physician’s dated signature, as well as the screener’s dated signature The CSB may use the sample CON in the manual in place of the DMH224 and The DMH224 is the same form that is completed for a TDO. DMHMRSAS and DMAS entered into agreement at the beginning of this program start up that the CSB would complete the certification. The expectation is a parent would ask the CSB for certification for RTF. The CSB would assess the need for the service, and make a recommendation on which service would be most appropriate. If RTF is the recommendation, the CSB would provide the parent with the CON or DMH224 signed by the screener and a physician. The DMH224 is the same form that is completed for a TDO. DMHMRSAS and DMAS entered into agreement at the beginning of this program start up that the CSB would complete the certification. The expectation is a parent would ask the CSB for certification for RTF. The CSB would assess the need for the service, and make a recommendation on which service would be most appropriate. If RTF is the recommendation, the CSB would provide the parent with the CON or DMH224 signed by the screener and a physician.

26. 26 Certification of Need NON-CSA Cases CON may be completed by the FAPT and must include a physician’s dated signature, as well as a member of the FAPT Authorization can begin no earlier than the date of the latest signature Must be child-specific and relate to the need for RTF level of care Must be available in the medical record

27. 27 Certification of Need CSA and NON-CSA Should reflect the child’s current condition and must be completed within 30 days of admission Is required to be completed prior to admission with all necessary dated signatures If discharged and readmitted, a new CON is required If the child transfers to an acute psychiatric facility, the acute care team can do the new CON If a child requires acute medical care, is on runaway, or goes to detention for more than 7 days a discharge notice should be sent in to KePRO. A new CON will be required if the child is to return to an RTF after 7 days away. If the child goes to acute psychiatric care during an admission, if the child is to transfer back to the facility, the acute care treatment team should complete the CON. None of the days away will be reimbursed for residential.If a child requires acute medical care, is on runaway, or goes to detention for more than 7 days a discharge notice should be sent in to KePRO. A new CON will be required if the child is to return to an RTF after 7 days away. If the child goes to acute psychiatric care during an admission, if the child is to transfer back to the facility, the acute care treatment team should complete the CON. None of the days away will be reimbursed for residential.

28. 28 State Uniform Assessment Instrument The CANS is the only uniform assessment instrument that is accepted . .

29. 29 State UAI CSA Cases Only Must be current. For admission the state UAI should reflect the requested level of care To be completed at least every 90 days and must be in the medical record Should be updated by the fiscally responsible locality when the child’s level of impairment changes significantly Completion information must be submitted to KePRO for SA and If the UAI is out of date at the time of audit, there will be retractions for those dates. The UAI should include the screener’s name, the child’s name and the date completed. If the UAI is out of date at the time of audit, there will be retractions for those dates. The UAI should include the screener’s name, the child’s name and the date completed.

30. 30 State UAI Scoring notes the level of impairment that supports the need for the level of care At a minimum: The CANS summary sheet, indicating the child’s behavioral and emotional needs, and risk behaviors The CANS must be available in the medical record and current within 90 days throughout the stay

31. 31 Initial Plan of Care Must be completed within 24 hours of admission Requires a dated physician’s signature signifying the physician has had a face-to-face visit with the child (Authorization can begin no earlier than the date of the signature) All required elements must be in the plan See sample form in PSM-DMAS 371 Be sure to specify the number and type of child-specific therapies Must be in the medical record

32. 32 Comprehensive Individual Plan of Care (CIPOC) Must be completed within 14 days of admission Must include dated signatures of the team responsible for the care (physician & at least one other team member specified in regulations) Must include all required elements See sample form in PSM-DMAS 372 Be sure to include specific orders for therapies Must be in the medical record If the CIPOC does not include dated signatures of, at a minimum, the two required professionals retraction will be made.If the CIPOC does not include dated signatures of, at a minimum, the two required professionals retraction will be made.

33. CIPOC 30-Day Progress Updates Must be updated every 30 days Must have dated signatures of team members Must include all required elements See sample form in PSM-DMAS 373 List Individual and Family Therapy dates If the therapy is not provided by a qualified professional, or the session was not at least 20 minutes, or there is no note, it should not be considered a delivered service Address progress, or lack of progress. If no progress, how is this being addressed? 30-Day Update can be a separate form, or may be a revised CIPOC. All required elements and timely dated signatures are necessary.30-Day Update can be a separate form, or may be a revised CIPOC. All required elements and timely dated signatures are necessary.

34. Therapeutic Interventions Individual, Family and Group Psychotherapy must be physician-ordered, provided by a licensed Medicaid enrolled provider and addressed in the treatment plan Individual Psychotherapy Must occur 3 times every 7 days. Facility determines the 7-day count. Sessions must be, at a minimum, 20 minutes If the session includes more than the therapist and the patient it is not considered individual psychotherapy Telephone calls to family members are not considered individual psychotherapy and The seven day count remains the same for the full stay.The seven day count remains the same for the full stay.

35. 35 Therapeutic Interventions Cont’d Family Psychotherapy Must occur at a minimum of 2 times a month if there is family involvement If there is family dysfunction that impacts the child, therapy should be at least once a week. Must be provided as is ordered in the treatment plan Group Psychotherapy Group Psychotherapy billed to Medicaid must not consist of more than 10 patients and Units or coding is not acceptable in lieu of start and stop times. Units or coding is not acceptable in lieu of start and stop times.

36. Therapeutic Interventions Individual, Family and Group Psychotherapy notes must be completed by a qualified therapist If therapy is provided by an individual who has completed his or her graduate degree and is working towards licensure, they may do so under direct supervision SUPERVISOR Appropriately licensed under state law and is a Medicaid-enrolled provider Supervision meets requirements of individual profession and

37. 37 Supervision of Unlicensed Therapists Does not need to be the same person who is supervising for licensing purposes Reviews patient’s medical history Approves and signs Plan of Care indicating the need for the specific service Countersigns Plan of Care updates Reviews each therapy note Must be in the facility during the session, but not required to be in the session and The supervisor is not necessarily the supervisor for licensing. The supervisor, for DMAS purposes, is the one supervising the Medicaid billable therapy. They are ultimately the person responsible for the therapy. The supervisor does not have to be in the room during the session, but must be in the building.The supervisor is not necessarily the supervisor for licensing. The supervisor, for DMAS purposes, is the one supervising the Medicaid billable therapy. They are ultimately the person responsible for the therapy. The supervisor does not have to be in the room during the session, but must be in the building.

38. Supervision of Unlicensed Therapists Dated signature on each therapy note on date of service indicating note was reviewed Meet regularly with supervisee (every sixth session or every 90 days, whichever comes first, to include all types of therapies ) Discuss Plan of Care Review record Assess patient’s progress Document supervisory meetings A Physician’s Assistant, under supervision, is not eligible to provide psychotherapy All signatures must be dated. A typed date at the top of the page is not sufficient. Not a new requirement. A Physician’s assistant is not eligible by license to provide psychotherapy, with or without supervisionAll signatures must be dated. A typed date at the top of the page is not sufficient. Not a new requirement. A Physician’s assistant is not eligible by license to provide psychotherapy, with or without supervision

39. 39 Therapeutic Interventions (including 21 weekly interventions) Notes must contain, at a minimum: Child’s name Type of session (Individual, group, medication management) If this is a group session, the type of group must be stated, such as Anger Management or Coping Skills Treatment Modality Start and stop time for session and

40. 40 Therapeutic Interventions Cont’d Pre-printed forms with date and time of session already printed is not acceptable Written on the date service is provided Activity of session-what therapeutic intervention/ interaction occurred, and how does it relate to goals Purpose of note is to document service, and

41. 41 Therapeutic Interventions Cont’d as well as to assist staff in providing focused ongoing therapeutic services to the child Level of participation (a check box is not sufficient) Plan for next session Dated signature of provider All notes should be child-specific

42. 42 21 Treatment Interventions Documentation 21 Treatment Interventions every 7 days May count group psychotherapy Must not include individual and family therapy Must be documented on a daily basis Each intervention must be documented Forms with check boxes as the majority of the note are not acceptable and

43. 43 Documentation Must document child-specific therapeutic intervention Interventions that are not billable separately may include more than 10 residents (this does not include the group psychotherapy that may be billed separately) Must include the dated signature of the provider for each intervention This does not need to be licensed staff

44. 44 Documentation Cont’d Late Entries--- Timeliness of documentation is essential. A document is considered complete by review of the dated signature of the professional who develops the document. Back dating is not acceptable.

45. 45 Restraint & Seclusion Reports must be sent to DMAS reporting any injury requiring medical attention. These should be sent in within one business day of the occurrence. (See slide 9) Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and provider enrollment. If reports are not made, the full RTF stay is subject to retraction.If reports are not made, the full RTF stay is subject to retraction.

46. 46 Staffing and Signatures All signatures must be dated, and should include the professional title of the author All medical documentation must include dated signatures on the date of service delivery Auditors will request a staffing list with proof of licensure if license is required to provide a Medicaid reimbursed service If only a pre-printed date is provided, this is not acceptable. Signatures must be dated by the signer, on the date the note is written. If only a pre-printed date is provided, this is not acceptable. Signatures must be dated by the signer, on the date the note is written.

47. 47 Service Authorization Contractor KePRO is the DMAS contractor for SA For questions go to the SA website: DMAS.KePRO.org and click on Virginia Medicaid Phone: 1-888-VAPAUTH or 1-888-827-2884 Fax: 1-877-OKBYFAX or 1-877-652-9329 Web: Provider Issues @ KePRO.org VAPAUTHVAPAUTH

48. 48 Service Authorization Contractor Submitting a request The preferred method is the iEXCHANGE® web-based program Registration is required Information on iEXCHANGE is available on the KePRO website, or call 1-888-827-2884 or by e-mail at providerissues@kepro.org

49. 49 KePRO Telephone to 888-827-2884 or 804-622-8900 (local) Mail to KePRO 2810 North Parham Rd., Suite 305 Richmond, VA 23284

50. 50 Service Authorization Requests for SA are required to be submitted to KePRO prior to services being rendered, but no sooner than 10 days prior Authorization can be for up to 90 days with medical justification KePRO will review requests for medical necessity, as well as timeliness KePRO will apply McKesson InterQual® Behavioral Health Criteria and DMAS supplemental criteria Retroactive authorization due to recipient eligibility only. If the provider is aware of a Medicaid application, they should make sure the required documentation is available to assure retroactive authorization, once recipient eligibility is established. Retroactive authorization due to recipient eligibility only. If the provider is aware of a Medicaid application, they should make sure the required documentation is available to assure retroactive authorization, once recipient eligibility is established.

51. Service Authorization NON-CSA Cases Must have a NON-CSA rate established by DMAS in order to request PA from KePRO Contact Provider Reimbursement at 804-686-7931 to establish a rate. This should be done at the time of enrollment as a provider. If no rate has been established, the request for PA will be rejected by KePRO. If a rate is later established, the request will not be retroactive The non-CSA rate should be established at the time of enrollment. The non-CSA rate should be established at the time of enrollment.

52. 52 Service Authorization For CSA cases only: CANS is acceptable as the state UAI and continue to be required at least every 90 days the Reimbursement Rate Certification is no longer required to be attached The locality code and the rate on the RRC must be provided to KePRO The UAI must be in the medical record and timely. The UAI must be in the medical record and timely.

53. 53 Service Authorization For both CSA and non-CSA requests: No attachments are required, but information on the CON, IPC and CIPOC and updates are required Severity of Illness questions are critical to authorization

54. 54 Service Authorization Narrative must address the need for level of care: Initial Review -symptoms and behaviors within past 7 days, frequency, intensity and duration current functioning support system Provide details that support the need for this intensive level of careProvide details that support the need for this intensive level of care

55. 55 Service Authorization Continued Stay Symptoms and behaviors in past 30 days Level of function in past 30 days Describe recipient investment in treatment Describe progress or lack of progress If no progress, how is this addressed? Describe why continued stay is need, specifically for each childDescribe why continued stay is need, specifically for each child

56. 56 Service Authorization Initial Review-- CSA cases only 3-digit locality code Reimbursement Rate Certification information State UAI information CSA and NON-CSA cases Confirmation of completion: Certificate of Need Initial Plan of Care 3-digit locality code is the Medicaid FIPS code. The list of localities and codes is in the instructions for the fax PA form. Should be the locality that has fiscal responsibility for the case. The rate cert must exclude payment from any other source, such as Title IV-E. If the rate is revised at some later date, the revised rate cert must be submitted to KePRO as a change. CAFAS/PECFAS scores must include the caregiver scores. 3-digit locality code is the Medicaid FIPS code. The list of localities and codes is in the instructions for the fax PA form. Should be the locality that has fiscal responsibility for the case. The rate cert must exclude payment from any other source, such as Title IV-E. If the rate is revised at some later date, the revised rate cert must be submitted to KePRO as a change. CAFAS/PECFAS scores must include the caregiver scores.

57. 57 Service Authorization Continued Stay Review-- CSA Cases Current UAI information Confirm locality code Reimbursement Rate Certification update if revised CSA and NON-CSA Cases Confirmation of completion: CIPOC 30-Day Update-most recent The CAFAS/PECFAS is required every 90 days. At a minimum the profile sheets must be in the medical record. At least one full CAFAS/PECFAS should be in the record to ensure the meaning of the scores is apparent. The locality code is the 3-digit code that reflects the locality responsible financially for the child’s care. The reimbursement rate cert must be current, within the fiscal year. The rate must exclude all other payment sources, such as Title IV-E. The cert must be signed by the CPMT chair of the responsible locality. It must also be in the record, as well as any updated certifications. The CIPOC must be completed within 14 days of admission. A sample form is in the PSM. It must include dated signatures of the team. The 30-day Update can be a revised CIPOC, but all versions must be in the medical record. The required elements are noted in the sample form provided in the PSM, Chapter 4, exhibits.The CAFAS/PECFAS is required every 90 days. At a minimum the profile sheets must be in the medical record. At least one full CAFAS/PECFAS should be in the record to ensure the meaning of the scores is apparent. The locality code is the 3-digit code that reflects the locality responsible financially for the child’s care. The reimbursement rate cert must be current, within the fiscal year. The rate must exclude all other payment sources, such as Title IV-E. The cert must be signed by the CPMT chair of the responsible locality. It must also be in the record, as well as any updated certifications. The CIPOC must be completed within 14 days of admission. A sample form is in the PSM. It must include dated signatures of the team. The 30-day Update can be a revised CIPOC, but all versions must be in the medical record. The required elements are noted in the sample form provided in the PSM, Chapter 4, exhibits.

58. 58 Service Authorization Appeals The denial of SA for services not yet rendered may be appealed in writing by the Medicaid recipient within 30 days of receipt of the denial. The provider may appeal an adverse decision for a service already provided by filing a written notice of appeal within 30 days of receipt of the denial. and

59. 59 Service Authorization Appeal rights will be stated in the SA notification letter. Requests for appeal must be submitted to: Appeals Division Department of Medical Assistance Services 600 East Broad Street, 11th Floor Richmond, Virginia 23219 The provider may not bill the recipient for covered services that have been provided and subsequently denied by DMAS

60. 60 Utilization Review Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program. Purpose of Utilization Review: Ensure medical necessity Confirm qualified provider delivered service Ensure program requirements met Address Quality of Care issues

61. 61 Utilization Review DMAS has contracted with Clifton-Gunderson to complete audits of RTFs and will review records to assure DMAS criteria is being followed

62. 62 Questions?