Section 65 Day Treatment Services Provided in an Educational Setting Documentation Training

1. Section 65 Day Treatment Services Provided in an Educational SettingDocumentation Training APS Healthcare December 2013

2. Training Objectives APS Healthcare Introduction Transition of Existing Members Utilization Review Process Overview of Medical Necessity Clinical Documentation for Utilization Review Additional Training Opportunities

3. APS Healthcare-Maine’s Behavioral Health ASO • APS Healthcare is a national specialty healthcare management company in 24 states & Puerto Rico. • APS Healthcare has been contracted with the State of Maine since September 1, 2007 as a Behavioral Health Administrative Service Organization (ASO). APS’ service center is located in South Portland.

4. APS Healthcare-Maine’s Behavioral Health ASO • APS conducts Prior Authorization, Utilization Management, Member Services, Provider Services, Quality Management for: • MaineCare mental health services • State grant funded adult mental health services • Nursing facility screenings for mental illness, intellectual disabilities and other related conditions (PASRR) • Long term supported employment utilization management • Mental health services for Baxter Fund class members

5. Goals of the APS Healthcare -Maine Program • 1. Improve outcomes of mental health services • 2. Reduce the costs and increase the value of MaineCare funded services • 3. Ensure State of Maine compliance with Federal & other legal requirements

6. Utilization Review Process • APS Care Managers are independently licensed professionals with years of experience working in the provider community of Maine • Care Managers are cross-trained but have primary responsibility for service-specific areas • Care Managers use MaineCare Rule and providers’ clinical documentation to make determinations • Internal Quality Assurance measures include routine peer consultation among Care Managers and the Medical Director • Clinical back-up and supervision is provided on-site by the Clinical Manager and Medical Director

7. Types of Authorizations • The initial request for Section 65 Day Treatment Service Provided in an Educational Setting is a Prior Authorization and requires clinical information supporting level of care at the time of first request. The IEP will be required to support documentation. The review is for a maximum of 30 days. • For the first period after the Prior Authorization request is authorized, a Continued Stay Review must be entered at least once every 180 days by the provider who is providing the service. • A Continued Stay Review must be entered at least once every 180 days until services end. • A Discharge Review must be entered once the member has terminated service.

8. Medical Necessity Criteria • Definition of Medical Necessity from the MaineCare Benefits Manual, Chapter 1 • Medical Necessity or Medically Necessary services are those reasonably necessary medical and remedial services that are: • provided in an appropriate setting; • recognized as standard medical care, based on national standards for best practices and safe, effective, quality care; • required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being; • MaineCare covered service (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter II, Section 94 of this Manual); • performed by enrolled providers within their scope of licensure and/or certification; and • provided within the regulations of this Manual

9. Eligibility 65.06-13 Children’s Behavioral Health Day Treatment A covered service is a specific service determined to be medically necessary by Qualified Staff licensed to make such a determination and subsequently specified in the Individual Treatment Plan (ITP) and for which payment to a provider is permitted under the rules of this Section. This Qualified Staff must assume clinical responsibility for medical necessity and the ITP development. The Behavioral Health Day Services described below are covered when (1) provided in an appropriate setting as specified in the ITP, (2) supervised by an appropriate professional as specified in the ITP, (3) performed by a qualified provider, and (4) billed by that provider. Behavioral Health Day Treatment Services must be delivered in conjunction with an educational program in a School as defined in 65.03-4. Behavioral Health Day Treatment Services are structured therapeutic services designed to improve a member’s functioning in daily living and community living. Programs may include a mixture of individual, group, and activities therapy, and also include therapeutic treatment oriented toward developing a child’s emotional and physical capability in area of interpersonal functioning. This may include behavioral strategies and interventions. Services will be provided as prescribed in the ITP. Involvement of the member’s family will occur in treatment planning and provision. Behavioral Health Day Treatment Services may be provided in conjunction with a residential treatment program. Services are provided based on time designated in the ITP but may not exceed six (6) hours per day, Monday through Friday, up to five days per week. Medically Necessary Services must be identified in the ITP.

10. Eligibility continued The member must be aged twenty (20) or under, and must be referred by the Qualified Staff, as defined below. Additionally, the member must need treatment that is more intensive and frequent than Outpatient but less intense than hospitalization. Within thirty (30) days of the start of service, the member must have received a multi-axial evaluation and must have been diagnosed either with an Axis I or Axis II behavioral health diagnosis based on the most recent Diagnostic and Statistical Manual of Mental Disorders or with an Axis I diagnosis based on the most recent Diagnostic Classification of Mental Health or Development Disorders of Infancy and Early Childhood Manual (DC-03); and In addition, based on an evaluation using the Battelle, Bayley, Vineland or other tools approved by DHHS, as well as other clinical assessment information obtained from the member and family, the member must either have a significant functional impairment (defined as a substantial interference with or limitation of a member’s achievement or maintenance of one or more developmentally appropriate, social, behavioral, cognitive, or adaptive skills); or Have a competed evaluation establishing that the member has 2 standard deviations below the mean in one domain of development or 1.5 standard deviations below the mean in at least two areas of development on the Battelle, Bayley, Vineland, or other tools approved by DHHS and other clinical assessment information obtained from the member and family.

11. Clinical Documentation Create a thread across diagnosis, current presentation, treatment progress, and the benefit of the service to support level of utilization Provide sufficient evidence of cognitive and functional deficits to support the level of services requested Completed review should enable the reader to have a current snap-shot of the members current needs related to the goals and progress of the service requested A current IEP will be required to be faxed to APS Healthcare at 1-866-325-4752 at the time of Prior Authorization and Continued Stay

12. Clinical Documentation A clinical summary that supports the service should include: Demographic information as it relates to the service Reason for referral: symptoms and behaviors, (including frequency, intensity, duration) and level of functioning Treatment history as it relates to current service Social history/environment Strengths and areas for growth Functional Impairments Clinical rationale: Service should “retain or improve functional abilities which have been negatively impacted the effects of cognitive or functional impairment and are focused on behavior modification and management, social development, and acquisition and retention of developmentally appropriate skills.”(MECARE Rule 28.04) Discharge criteria, plan and timeline—how will progress be measured, and what measurable outcomes will be achieved

13. Multiaxial Assessment ICD9 is used as it is consistent with the federal Medicaid requirements Please update the “date of diagnostic assessment” Use the dark blue box to find the ICD9 code. Search by DSM code or title Primary Diagnosis is should reflect the focus of the service you are providing Co-Occurring diagnosis relates to mental health/substance abuse diagnosis Axis III text box is for medical issues Axis IV Psychosocial stressors—the dropdown menu asks for mild, moderate or severe descriptors Axis V Global Assessment of Functioning is a free text field

14. Clinical Indicators Use this page to describe history of symptoms/behaviors, check all that apply and indicate severity and history as applicable Specific information regarding the nature of current symptoms and behaviors can be included in the “Additional Information” section

15. Treatment Plan Tip—Be Brief! Some fields allow only a limited number of characters. *Treatment plan should include “specific medically necessary treatment services to be provided with methods, frequency and duration of services.” (MECARE Rule 28.5) Problem statement—Behaviors/symptoms, frequency, duration, triggers when the problem occurs Long-term goal—What symptoms/behaviors will be reduced or eliminated, at what functional or behavioral level will the client/member be at? Add target date for the end of treatment Short-term goal—Goals for the next 180 days. Describe the goal more in terms of the service, rather than the symptoms, behavior, and functioning. Add target date (short-term) Progress since last review. Describe in a way that threads back through goals and presenting problems Interventions: include teaching skills, specific modalities Each time you extend the service, please update all of these fields. If a treatment goal is no longer active, please indicate that either in the goal box as “Not Active” or the progress box as “Goal met.” You may also delete the goal altogether, as it will be in prior CSRs for reference

16. Transition Discharge Plan Is discharge anticipated during this authorization period? Projected date of transition/discharge “Identify natural and other supports necessary for the member and family to maintain the safety and well-being of the member, as well as to sustain progress made during the course of treatment”(MECARE Rule 28.05) Plan for Transition Discharge. This is an important field, it is required in every review. Please include: Specific but brief description of what symptoms/behaviors/functioning will be improved How will the frequency or intensity of the interventions be phased out or reduced over time What services will be recommended after discharge What are the current or expected barriers for discharge If discharge is planned before treatment goals are achieved, or if discharge is happening unexpectedly or against advice of provider, please include explanation

17. Additional Information Include a brief summary of the progress during the last authorization period with a focus on the cognitive and functional limitations that precipitated the service Plans for the upcoming review period Factors that are impacting treatment (negatively or positively) and how those will be addressed If a discharge had been planned for the prior review period and it is decided that the member needs to continue, please explain the barriers or new factors that contribute to that in “Additional Information” There is a tendency for providers to describe the client/member’s history in detail or to describe the member or family’s needs in this field in detail. If the need for this level of service has already been established, we only need a brief description of history if it directly impacts this episode of care

18. Additional Information Treatment Progress menu—select progress since last review. In the text box, please describe the progress in terms of: How is service benefiting the member If progress is minimal, briefly describe barriers to progress, and plan to re-evaluate interventions In what areas the member has progressed and in what areas progress is slower or not happening Have there been or will there be any adjustments to the delivery of service that will support progress Has there been a change in the family’s knowledge, skills, or ability to support member during or after treatment

19. Additional Training Opportunities APS Helathcare Website: www.qualitycareforme.com APS CareConnection Training Modules: http://www.qualitycareforme.com/MaineProvider_Training.htm APS CareConnection technical assistance and ongoing training needs can also be requested through the provider relations department at 1-866-521-0027 or via email: mainecare-prov@apshealthcare.com

20. APS Healthcare Contact Information1-866-521-0027Fax: 1-866-325-4752Option 1—Provider Relations:for technical support or to make administrative changesOption 3—Member Services:you may give this phone number to the guardian if they have questions about an authorizationOption 4—Clinical ServicesFor questions about clinical documentation requirementsEmail: mainecare-prov@apshealthcare.com