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 Shelley Jones - 804-786-1591 shelley.jones@dmas.virginia.gov Bill O’Bier - 804-225-4050 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 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.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 prior authorization (PA) requirements and process Understand changes to UAI and PA fax form Understand the utilization review process Handouts of October 15 and November 7, 2008 Medicaid memo and CANS summary form

4. 4 Objectives 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: First Health Services Provider Enrollment Unit P.O. Box 26803 Richmond, VA 23261 Toll free -- 888-829-5373 Fax -- 804-270-7027

6. 6 Provider Agreements On July 31, 2008 DMAS mailed out new provider agreements for provider completion. A new restraint & seclusion attestation was required to be submitted with the new agreement. The new provider agreements are posted on the DMAS website. and

7. 7 Provider Agreements 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 the PSM A new restraint & seclusion attestation is required to be submitted July 1 each year or sooner if there is a change in the person responsible for the attestation. A new restraint & seclusion attestation is required to be submitted July 1 each year or sooner if there is a change in the person responsible for the attestation.

8. 8 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

9. 9 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

10. 10 Participation Requirements A provider may not bill a client (or fiscally responsible adult or locality) for a covered service regardless of whether or not the provider received payment from Medicaid Should not attempt to collect from the client, family, or legal guardian (locality), any amount that exceeds the Medicaid allowance or for missed appointments (No co-pays allowed for Medicaid-covered services)

11. 11 Participation Requirements Hold all recipient information confidential Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements If a facility or provider is closing, both Provider Enrollment and the Hospital UR Supervisor must be notified prior to closing

12. 12 Definition-Level C RTF Program for children under age 21 to treat severe mental, emotional and behavioral disorders that have been present for at least 6 months and expected to persist for longer than 1 year without treatment When outpatient and day treatment fails Provides inpatient psychiatric treatment 24- hours per day Child-specific care and treatment planning

13. 13 Definition-Level C RTF Highly organized and intensive services Planned therapeutic interventions All services required to be provided on-site, including academic program (Medicaid does not reimburse for education-it is not a covered service) Physician-directed mental health treatment If a recipient turns 21 while in an RTC, and medical necessity continues, the recipient can remain until their 22nd birthday. Discharge plan should be in place at admission. It may change overtime, but there should be a discharge goal as part of the focus of treatment. Discharge plan should be in place at admission. It may change overtime, but there should be a discharge goal as part of the focus of treatment.

14. 14 Definition-Level C RTF Dually diagnosed children in RTC should have their substance abuse problems addressed, but it should not be a major focus of residential treatment. If a child requires only SA treatment on a non-acute inpatient basis, it may be covered through the EPSDT program. Contact Brian Campbell, EPSDT Coordinator, at 804-786-0342 to discuss options.

15. 15 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. If a child goes to the emergency room due to an illness, this is not required to be reported.Federal regulations require notification should be received within one business day. If a child goes to the emergency room due to an illness, this is not required to be reported.

16. 16 Restraint & Seclusion Notification continued names of staff involved description of incident outcome, including persons notified current location of child Fax to Shelley Jones 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.

17. 17 Out-of-State Provider 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 804/786-1591 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.

18. 18 Out-of-State Placement Criteria Requires true prior approval 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

19. 19 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 It may be that the child’s needs would not be met in the psychiatric residential treatment program, but that residential care does seem appropriate or that the out of state placement does not meet our program criteria. This may require a referral to the EPSDT unit to assess what service or placement might be more appropriate. DMAS will make this referral. It may be that the child’s needs would not be met in the psychiatric residential treatment program, but that residential care does seem appropriate or that the out of state placement does not meet our program criteria. This may require a referral to the EPSDT unit to assess what service or placement might be more appropriate. DMAS will make this referral.

20. 20 Electronic Submission of Claims On October 9, 2007 a Medicaid Memo was distributed covering the changes necessary to submit RTF claims electronically For CSA cases, when submitting PA 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.

21. 21 Electronic Signatures Clarification on electronic signatures was issued in the 8-20-04 Medicaid Memo to all providers. An electronic signature that meets the following criteria is acceptable for clinical documentation: Identifies the individual signing by name and title; and The electronic signature should be date and time stamped. Any changes to the document would need to include a new date/time stamped signature.The electronic signature should be date and time stamped. Any changes to the document would need to include a new date/time stamped signature.

22. 22 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. The provider must have written policies and procedures in effect regarding use of electronic signatures. During an audit we will ask for the written policies on electronic documentation.During an audit we will ask for the written policies on electronic documentation.

23. 23 Required Documentation The following slides describe the required documents that will be assessed at audit. All documents must be complete and timely and include all required dated signatures. Sample forms are available in the PSM

24. 24 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 $414.04 is the current rate.$414.04 is the current rate.

25. 25 Reimbursement Rate Certification 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 FHS MMIS All versions of the rate certification must be available at the facility at the time of audit 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, or the provider gives the wrong number to KePRO, 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, or the provider gives the wrong number to KePRO, 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.

26. 26 CSA or NON-CSA? If the case is an Adoption Subsidy case, it is NON-CSA The education payment source is not considered The CON will be completed by the FAPT, not the CSB 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

27. 27 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.

28. 28 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 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. The DMH224 is the same form that is completed for a TDO.

29. 29 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

30. 30 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, and the child is to return to RTC, the acute care team must 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.

31. 31 State Uniform Assessment Instrument Effective November 1, 2008, a new state UAI will be acceptable. either the Child and Adolescent Functioning Scale (CAFAS)/Preschool and Early Childhood Functioning Scale (PECFAS) or the Child and Adolescent Needs and Strengths (CANS) assessment tools will meet the State UAI requirement. Beginning July 1, 2009 only the CANS will be acceptable. In October, DMAS sent out a memo outlining the changes from the CAFAS to CANS. This will be a transition process over the next 8 months. The decision to change assessment tools was a joint effort by the Office of Comprehensive Services, the localities, and other stakeholder groups, that determined the CANS would be a more useful tool for the localities. In October, DMAS sent out a memo outlining the changes from the CAFAS to CANS. This will be a transition process over the next 8 months. The decision to change assessment tools was a joint effort by the Office of Comprehensive Services, the localities, and other stakeholder groups, that determined the CANS would be a more useful tool for the localities.

32. 32 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 PA 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.

33. 33 State UAI Scoring notes the level of impairment that supports the need for the level of care At a minimum: the CAFAS or PECFAS profile sheets for the youth and caregiver, OR The CANS summary sheet, indicating the child’s behavioral and emotional needs, and risk behaviors, Both the CAFAS/PECFAS and CANS must be available in the medical record and current within 90 days throughout the stay The CAFAS/PECFAS should have at least one moderate impairment in other than school. The CANS must have at least two impairments noted on the summary sheet under the sections child’s behavioral and emotional needs and risk behaviors. The score must be supported by the narrative on current behaviors. The CAFAS/PECFAS should have at least one moderate impairment in other than school. The CANS must have at least two impairments noted on the summary sheet under the sections child’s behavioral and emotional needs and risk behaviors. The score must be supported by the narrative on current behaviors.

34. 34 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

35. 35 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 and 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.

36. 36 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.

37. 37 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.

38. 38 Therapeutic Interventions Family Psychotherapy Must occur at a minimum of 2 times a month if there is family involvement If there is any 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 Family therapy is required to occur if there is family involvement. If there is any family dysfunction, the sessions must be weekly. If the child is to return home the sessions must be weekly, whether the return will be immediately, or after a step-down placement. This is the time intensive treatment should be occurring, not after discharge. Telephonic family therapy is acceptable, but is not billable. At least one session a month must be face-to-face.Family therapy is required to occur if there is family involvement. If there is any family dysfunction, the sessions must be weekly. If the child is to return home the sessions must be weekly, whether the return will be immediately, or after a step-down placement. This is the time intensive treatment should be occurring, not after discharge. Telephonic family therapy is acceptable, but is not billable. At least one session a month must be face-to-face.

39. 39 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

40. 40 Supervision of Unlicensed Therapist 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.

41. 41 Supervision of Unlicensed Therapist 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

42. 42 Therapeutic Interventions (including the 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 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.

43. 43 Therapeutic Interventions 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

44. 44 Therapeutic Interventions 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 The progress notes are the only method of assuring services were provided as required. The notes should tell the reader the status of the child’s progress in therapy, what is being worked on, what has been resolved, what the plan is for future sessions. The progress notes are the only method of assuring services were provided as required. The notes should tell the reader the status of the child’s progress in therapy, what is being worked on, what has been resolved, what the plan is for future sessions.

45. 45 Psychotherapy Notes Sample Therapy Note #1 Date, Individual Therapy, 12:15pm to 12:50pm. Cognitive Behavioral Technique Adolescent shared her journal entries for past week. She identified one method of self-calming after reprimand from bus driver, which she implemented twice since last session. Prior to session, parent reported anger outbursts in the home have decreased from 3 per day to once per day over the past 3 weeks, and outbursts have decreased at school. Medication compliance confirmed. and

46. 46 Psychotherapy Notes Practiced a new relaxation technique and explored how this might be used to prevent escalation at home. Discussed upcoming overnight visit at friend’s home and reviewed repertoire of techniques to help maintain friendship. Homework for next session is to continue journaling episodes of anger and use of coping skills, and how this effects adolescent’s peer and parental relations. Dated signature of provider on date of session

47. 47 Psychotherapy Notes Sample Therapy Note #2 Date. Individual Therapy. Length of session 45 minutes. Therapy focused on client’s impulsivity and aggressive behaviors occurring in the classroom and towards family members. Client angry today at loss of TV due to negative teacher report; avoided eye contact at the onset of therapy, kept arms folded and head down. Was slow to engage but improved upon talking about incident that occurred at school. Processed with client about the incident where he threw a book at another classmate. Focused on triggers. Used a cognitive behavioral and

48. 48 Psychotherapy Notes approach to assist client with problem-solving. Client able to describe safer alternatives to release frustration. Role played to practice these alternatives. Assisted client with identifying other situations where he could use new alternatives. Continue to focus on a cognitive behavioral approach to improve low frustration tolerance and aid in identifying triggers to aggression. Next session, create with client’s input a behavior modification plan in attempts to reduce the number of aggressive behaviors in the classroom and home. Dated signature of provider on date of session

49. 49 Psychotherapy Notes Sample Therapy Note #3 Date, Length of session Individual psychotherapy Therapy focused on the anxiety John Smith experiences when in public places such as a grocery store or shopping mall. Mr. Smith reported following through with recommendations made during last session in regards to increasing the amount of time spent in a store while practicing relaxation exercises. Plan is to continue relaxation training in office coupled with systematic desensitization along with increased exposure to feared situations outside the office. Dated signature of therapist

50. 50 Medication Management Sample Therapy Note #4 January 15, 2008, 15 minutes Modality: Medication Management Medication: Abilify, 10 mg tab by mouth every morning Jake Smith and mother report his taking medication regularly, no side effects, no changes necessary since behaviors stabilized Plan for follow up in two months, mother to contact office if behaviors escalate or side effects noted Dated signature of provider

51. 51 21 Treatment Intervention Notes The following notes are samples shared by an RTC provider. The notes meet DMAS criteria: Date, start and stop time: 11/05/08, 1430-1500 Group/Activity Name: Community Group Activity: Review day, set goal for the shift cont’d

52. 52 21 Treatment Intervention Note Sample How does activity relate to Treatment Goals: To chose a goal that will help her choose healthy methods of coping instead of cutting. Level of Participation/Response: After guidance from staff, Felicia set a goal to come to staff when feeling anxious or having thoughts to cut. She acknowledged that when she thinks about her family or has cont’d

53. 53 First Sample Note conflicts with her peers, she has thoughts to hurt herself. Plan/Follow Up: Check with Felecia throughout the shift regarding her feelings, and assist in resolving negative feelings. Dated Signature

54. 54 21 Treatment Intervention Note-2nd Sample Date, start/stop time: 11/05/08, 1800-1830 Group/Activity Name: Social Skills Activity: Group discussion: Characteristics of Healthy vs. Unhealthy Relationships How does activity relate to Treatment Goals: Felicia has difficulties maintaining positive interactions with her peers due to becoming overly involved and being easily swayed to join in negative behavior. cont’d

55. 55 2nd Sample Level of Participation/Response: Full participation with some initial prompts to join discussion. Was able to identify healthy (a teacher, and Aunt) and unhealthy relationships (friends at school and in neighborhood) she has been involved in the various outcomes (positive/negative) of each. Plan/Follow Up: Will help Felicia identify opportunities for positive interactions as well as opportunities to set appropriate boundaries. Will discuss in future social skills group. Dated Signature

56. 56 21 Treatment Intervention Note-3rd Sample Date, start/stop time: 11/05/08, 1900-1930 Group/Activity Name: Community Group Activity: Discuss events of the day and progress in meeting her goal How does activity relate to Treatment Goals: Demonstrate an awareness of areas of growth and areas of struggle Level of Participation/Response Felicia was agitated and resisted talking about here day. Was able to remain in the Cont’d

57. 57 3rd Sample group and tolerate staff reflection of times during the day she was able to meet her goal. Plan/Follow Up: Continue to provide support and guidance in this area. Dated Signature

58. 58 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

59. 59 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 The full 21 treatment interventions are required each week. If the child is on an overnight pass, or is unwilling to participate, this must be documented, and sessions should be rescheduled during the 7-day period. If the session notes are incomplete, the session will not be counted by DMAS auditors. The sessions must be planned, therapeutic, and child-specific. If a child does not have a substance abuse problem, an SA group weekly is not appropriate. The full 21 treatment interventions are required each week. If the child is on an overnight pass, or is unwilling to participate, this must be documented, and sessions should be rescheduled during the 7-day period. If the session notes are incomplete, the session will not be counted by DMAS auditors. The sessions must be planned, therapeutic, and child-specific. If a child does not have a substance abuse problem, an SA group weekly is not appropriate.

60. 60 Documentation 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. One-to-one supervision is not billable separately. Supervision is included in the Medicaid per diem reimbursement.

61. 61 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 14-15) 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.

62. 62 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.

63. 63 Prior Authorization Contractor KePRO is the DMAS contractor for PA For questions or forms, go to the PA 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

64. 64 Prior 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

65. 65 Prior Authorization Contractor Additional Methods of Submission Requests may also be submitted by: Fax to 877-652-9329 The Residential Treatment Prior Authorization Request Form (365) is available in electronically-fill-able format on the KePRO and DMAS websites www.dmas.virginia.gov https://dmas.kepro.org

66. 66 KePRO Telephone to 888-827-2884 or 804-622-8900 (local) Mail to KePRO 2810 North Parham Rd., Suite 305 Richmond, VA 23284

67. 67 Prior Authorization Requests for PA are required to be submitted to KePRO within 1 business day of admission. Requests for continued stay reviews must be received prior to the end of the current authorization 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.

68. 68 Prior 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.

69. 69 Revised Fax Form The RTF PA fax form has been revised and posted on the DMAS and KePRO websites The Medicaid memo dated 10-15-08 is posted on the DMAS website and describes the changes related to the state UAI, as well as no longer requiring attachments for PA requests The Medicaid memo dated 11-7-08 is posted on the DMAS website and describes the extension to mandatory use of the new fax forms

70. 70 Revised Fax Form The effective date for mandatory use of the new fax forms has been revised to December 1, 2008. KePRO will accept both the current version of the fax form and the revised form until December 1. From December 1 forward, the revised version of the PA request form attached to the October 15th memo and posted on the DMAS and KePRO websites will be required.

71. 71 Revised Fax Form Fax Form Changes For CSA cases only: both the CAFAS and CANS are 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, but all versions must be available at the facility for audit The locality code and the rate on the RRC must be provided to KePRO The next few slides relate to the revised fax form. The UAI must be in the medical record and timely. The next few slides relate to the revised fax form. The UAI must be in the medical record and timely.

72. 72 Revised Fax Form 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

73. 73 Revised Fax Form 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

74. 74 Revised Fax Form 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? All other areas of the fax form remain the same Describe why continued stay is need, specifically for each childDescribe why continued stay is need, specifically for each child

75. 75 Prior 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. The reimbursement rate cert must be current, within the fiscal year. 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. 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. The reimbursement rate cert must be current, within the fiscal year. 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.

76. 76 Prior 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 or CANS is required every 90 days. At a minimum the CAFAS/CAFAS profile sheets or CANS summary must be in the medical record. CAFAS/PECFAS scores must include the caregiver scores. 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 or CANS is required every 90 days. At a minimum the CAFAS/CAFAS profile sheets or CANS summary must be in the medical record. CAFAS/PECFAS scores must include the caregiver scores. 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.

77. 77 Prior Authorization Appeals The denial of PA 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

78. 78 Prior Authorization Appeal rights will be stated in the PA 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

79. 79 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 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.

80. 80 Utilization Review DMAS has contracted with Clifton-Gunderson to complete audits of RTFs and will review records to assure DMAS criteria is being followed. They will: select providers for review by statistical sampling, exception reporting or through referrals or complaints make periodic announced and unannounced visits

81. 81 Utilization Review They will: do desk audits or on-site visits to review medical documentation to ensure DMAS criteria is met request provider qualification information as well as confirmation of service delivery assess service limits compliance determine if retraction of paid claims is necessary CG will also be doing auditing of other Medicaid services as well.CG will also be doing auditing of other Medicaid services as well.

82. 82 Utilization Review The criteria described in the earlier slides is critical to compliance, although it is not a complete list. See the Psychiatric Services Manual for a complete listing. Review all referenced federal and state regulations, as well as Medicaid Memos that are sent to providers and available on the DMAS website. Review the sample forms provided in the PSM. Authorization does not guarantee payment. If a required document is not available, or the dated signatures do not meet DMAS criteria, retraction will occur.

83. 83 Utilization Review Individual, Family and Group Psychotherapy The full week of RTF reimbursement will be retracted if: Fewer than 3 Individual Psychotherapy sessions occur Notes are not completed by a qualified therapist An unqualified therapist provides the therapy and there is no documentation of supervision every 6th session (includes individual, family and group psychotherapy) Group therapy not provided by a qualified provider, or with lack of supervision on its own would not lead to retraction. The group sessions could count towards the 21 treatment interventions. But if not provided by a licensed, enrolled provider, it should not be billed to Medicaid.Group therapy not provided by a qualified provider, or with lack of supervision on its own would not lead to retraction. The group sessions could count towards the 21 treatment interventions. But if not provided by a licensed, enrolled provider, it should not be billed to Medicaid.

84. 84 Utilization Review The full week of RTF reimbursement will be retracted if: The required 21 treatment interventions are not provided, or are not documented as described in slides 42-44 and 51-59 and in the PSM Family therapy is not provided and is indicated in the treatment plan, or is necessary due to the child’s condition If the treatment plan does not specify the type and frequency of therapeutic interventions, retraction is likely.If the treatment plan does not specify the type and frequency of therapeutic interventions, retraction is likely.

85. 85 Staffing and signatures All signatures must be dated, and should include the professional title of the author. 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.

86. 86 Utilization Review Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and provider enrollment. The previous slides describe only some of the possible reasons for retraction. The PSM describes all required criteria in detail.

87. 87 Utilization Review If the UR finding is to retract prior reimbursement, the provider has the right to reconsideration and appeal. Reconsideration is required to be submitted within 30 days of the audit letter date. All material to support why retraction should not be made should be included. If the decision is to uphold the denial decision after reconsideration, the provider has the right to appeal. Appeal rights will be stated in the decision letter. Requests for appeal must be submitted within 30 days of the notice of decision to uphold the denial.

88. 88 Wrap Up If all required information is contained within the record, no retractions will result. DMAS staff is available to do on-site training on facility-identified areas of concern regarding DMAS criteria. Contact Shelley Jones or Bill O’Bier to arrange on-site training.

89. 89 Questions?