Department of Medical Assistance Services

1. Department of Medical Assistance Services

2. 2 This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals on Community Mental Health Rehabilitative Services and Psychiatric Services manuals. This training contains only highlights of those manuals and is not meant to substitute for or take the place of the Community Mental Health Rehabilitative Services and Psychiatric Services manuals. For a complete copy of manual:

3. 3 Objectives of Today’s Training

4. 4 Specific Staff Qualifications

5. 5 Staff Qualifications cont.

6. 6 Human Services Fields Social Work Gerontology Psychology Psychiatric Rehabilitation Special Education Sociology Counseling Vocational Rehabilitation Human Services Counseling

7. 7 Definition of“Clinical Experience” Providing direct services to individuals with: Mental illness Mental retardation Persons receiving gerontology services Persons receiving special education services Includes supervised internships, practicums and field experience.

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10. 10 bachelor’s degree in unrelated field with at least 15 semester credits in human service field & three years clinical experience; OR four years clinical experience working directly with individuals with mental illness or mental retardation. Staff Qualifications Mental Health Worker (cont’d)

11. 11 Staff Qualifications (cont’d)

12. 12 “PARAPROFESSIONAL SUPERVISION” QMHP demonstrates supervision of “Qualified Paraprofessional” by reviewing notes, progress towards achieving ISP goals & objectives and making recommendations for change. Supervision must occur & be documented in the clinical record monthly. Individual & group supervision conducted by the QMHP are acceptable.

13. 13 Paraprofessionals who do NOT meet the experience requirement described may provide services….. if they are working directly with a Qualified Paraprofessional on site and they are supervised by a QMHP. Supervision must include on site observations of services, face -to-face consultation, review of notes, etc. and be documented in the clinical record monthly. Non-Qualified Paraprofessionals

14. 14 A combination of therapeutic services in a residential setting. Only programs with 16 or fewer beds are eligible to provide this service. This service provides the child with structure for: Daily activities Psycho-education activities Therapeutic supervision Psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified on the treatment plan

15. 15 Specific Provider Requirements Daily reimbursement rate of $119.20Daily reimbursement rate of $119.20

16. 16 Program Director: QMHP with bachelor’s degree one year direct work experience with mental health clients Employed full time Direct Care Staff: 50% must meet DMAS paraprofessional criteria Staff QualificationsLEVEL A

17. 17 Specific Provider Requirements Daily reimbursement rate of $158.93 Daily reimbursement rate of $158.93

18. 18 Clinical Director: LMHP Caseload not to exceed 16 clients (all sites) Program Director: QMHP with bachelor’s degree one year clinical experience Employed full time Direct Care Staff: 50% must meet DMAS paraprofessional criteria Staff QualificationsLEVEL B

19. 19 Staff-Child Ratio LEVEL A 1 to 6 = day 1 to 10 = night (when children are scheduled to be asleep)

20. 20 RECIPIENT ELIGIBILITY (Level A & B) Medically stable Require intensive interventions in order to comply with mental health treatment Needs cannot be met with a less intense service Service at this level is expected to improve the child’s condition or prevent regression Assessment (CAFAS) demonstrates TWO areas of “moderate impairment” in major life activities CAFAS= Child & Adolescent Functional Assessment ScaleCAFAS= Child & Adolescent Functional Assessment Scale

21. 21 RECIPIENT ELIGIBILITY Level A & B (cont’d) For CSA children, CAFAS must be used (current within 30 days of placement) Non-CSA children, 2 areas of moderate impairment within past 30 days

22. 22 RECIPIENT ELIGIBILITY Level A & B (cont’d) A moderate impairment is defined as a major or persistent disruption such as……. Frequent conflict in the family setting such evidenced by credible threats of physical harm. Frequent inability to accept age appropriate direction & supervision Both/either at home & school Specific examples (listed in the manual): caretakers, family members at school or in the home or communitySpecific examples (listed in the manual): caretakers, family members at school or in the home or community

23. 23 Severe difficulties in socialization such as; Significant avoidance of appropriate social interaction Deterioration of existing relationships Refusal to participate in therapeutic interventions Moderate Impairment (cont’d)

24. 24 “Moderate Impairment” (cont’d) Impaired ability to form trusting relationship with at least one caretaker in the home, school or community Limited ability to consider the effect of one’s inappropriate conduct on others Interactions consistently involving conflict Impulsive or abusive behavior

25. 25 Certification done by Independent Team CSA children: FAPT identification of the need for service CPMT assessment for payment *** Coordination should occur with the child’s EPSDT provider (PCP) At least one member of the independent certifying team must have pediatric mental health experience. FAPT= Family Assessment and Planning Team’s CPMT=Community Policy and Management Team’s At least one member of the independent certifying team must have pediatric mental health experience. FAPT= Family Assessment and Planning Team’s CPMT=Community Policy and Management Team’s

26. 26 Non-CSA children: Independent LMHP (not affiliated with the residential provider) Child’s EPSDT provider (PCP) if the child/adolescent is away from home and cannot access the PCP/EPSDT screener, another physician who has knowledge of him/her may substitute Certification for AdmissionLevel A & B Notes on eligibility: For an individual who is already a Medicaid recipient when he/she is admitted to a facility/program, certification must be made by an independent certifying team prior to admission that includes a licensed physician: - Who has competence in the tx of pediatric mental illness Who has knowledge of the recipient’s mental health history and current situation Who signs and dates the certification along with the team **** note- for CSA children, the majority of the FAPT and a physician must sign and date the certification. For NON- CSA children, the LMHP and a physician must sign and date the certification. FOR A RECIPIENT WHO HAS APPLIED FOR MEDICAID WHILE INPT IN THE FACILITY/PROGRAM The certification must Be made by the team responsible for the CIPOC Cover any period of time before the application for Medicaid eligibility for which claims for reimbursement by Medicaid are made; and Be signed and dated by a physician and the team Notes on eligibility: For an individual who is already a Medicaid recipient when he/she is admitted to a facility/program, certification must be made by an independent certifying team prior to admission that includes a licensed physician: - Who has competence in the tx of pediatric mental illness Who has knowledge of the recipient’s mental health history and current situation Who signs and dates the certification along with the team **** note- for CSA children, the majority of the FAPT and a physician must sign and date the certification. For NON- CSA children, the LMHP and a physician must sign and date the certification. FOR A RECIPIENT WHO HAS APPLIED FOR MEDICAID WHILE INPT IN THE FACILITY/PROGRAM The certification must Be made by the team responsible for the CIPOC Cover any period of time before the application for Medicaid eligibility for which claims for reimbursement by Medicaid are made; and Be signed and dated by a physician and the team

27. 27 Assessment demonstrating need CAFAS (CSA) or Assessment with at least two moderate impairments (non-CSA)

28. 28 Certicate of need-- Child-specific description documenting that-- Available community resources do not meet this child’s specific treatment needs Proper treatment of child’s psychiatric condition requires this type program These services can reasonably be expected to improve child’s condition or prevent regression

29. 29 Diagnosis Axis I: Clinical Disorder Axis II: Personality Disorder/Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial & Environmental Problems Axis V: Global Assessment of Functioning (GAF)

30. 30 Description of problem behavior(s) Must relate to diagnosis Immediately prior to admission (30 days) Alternative placements attempted/ explored with results of each Level of family support

31. 31 Certification for Admission (A & B) Initial certification in effect for up to six (6) months Child must continue to need this level of care for billing to take place Service must be re-certified after six (6) months By LMHP, who may be affiliated with program For CSA children, also by Community Policy & Management Team (CPMT)

32. 32 Re-certification Documentation Requirements for Level A & B Comprehensive Individual Plan of Care (CIPOC)- due within thirty days of admission Summary of progress related to goals & objectives on CIPOC which demonstrate: Level of functioning not restored/ improved Risk continues for relapse Less intense services will not achieve stabilization …..any one of the following must apply:

33. 33 Either the desired outcome or level of functioning has not been restored or improved in the timeframe outlined in the child’s plan of care; or The child continues to be at risk for relapse based on history; or The tenuous nature of the functional gains and use of less intensive services will not achieve stabilization

34. 34 Prior Authorization for Medicaid Reimbursement For Levels A&B – Initial Review Starting July 1, 2008 Prior Authorization is required PA is required within 3 business days of admit Co-signed by PCP or EPSDT MD and “team” completed prior to admit CSA-3 members of FAPT and MD NON-CSA-independent LMHP and MD UAI-2 moderate impairments-current to 30 days of admit CSA-CAFAS by locality NON-CSA-Assessment-PCP/EPSDT Provider and independent LMHP Clinical information needed from provider for authorization Initial Review • For Level A & B services, individuals must have a primary diagnosis of mental illness that meets the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for an Axis I disorder. All 5 axes are required to be documented in the medical record. • If this is a dual diagnosis of Mental Health (MH) and Substance Abuse Services (SAS), the focus of treatment must be the MH problem. Medicaid does not cover inpatient or residential treatment of substance abuse disorders. • Description of symptoms and behaviors within the last week. oThe symptoms and behaviors should reflect impairments that are significant enough to support the need for out-of-home placement and are anticipated to be chronic in nature, and endangering of self or others. Descriptions should be child-specific. • Description of social risk within the last month. oFailed treatments •Specifically, what service(s) had been attempted and the reason they failed. oSupport system •Brief description of deficits that support the need for a residential placement. •Description of current level of functioning oAbility to follow directions oAbility to interact appropriately with others oAbility to maintain age-appropriate behavior •Provide date of Certification of Need (CON)/Independent Team Certification, and confirmation that all required information and appropriate dated signatures are in the medical record. The CON must be completed prior to admission. •Provide the date of the Initial Plan of Care (IPC), and confirmation that all required information and appropriate dated signatures are in the medical record. The IPC must be completed within 3 days of admission. •Provide the date of the UAI (CSA-CAFAS or PECFAS) or assessment (non-CSA) for supporting placement at this level of care. This must be completed prior to the admission. If all criteria are met, KePRO will approve for 6 months Clinical information needed from provider for authorization Initial Review • For Level A & B services, individuals must have a primary diagnosis of mental illness that meets the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for an Axis I disorder. All 5 axes are required to be documented in the medical record. • If this is a dual diagnosis of Mental Health (MH) and Substance Abuse Services (SAS), the focus of treatment must be the MH problem. Medicaid does not cover inpatient or residential treatment of substance abuse disorders. • Description of symptoms and behaviors within the last week. oThe symptoms and behaviors should reflect impairments that are significant enough to support the need for out-of-home placement and are anticipated to be chronic in nature, and endangering of self or others. Descriptions should be child-specific. • Description of social risk within the last month. oFailed treatments •Specifically, what service(s) had been attempted and the reason they failed. oSupport system •Brief description of deficits that support the need for a residential placement. •Description of current level of functioning oAbility to follow directions oAbility to interact appropriately with others oAbility to maintain age-appropriate behavior •Provide date of Certification of Need (CON)/Independent Team Certification, and confirmation that all required information and appropriate dated signatures are in the medical record. The CON must be completed prior to admission. •Provide the date of the Initial Plan of Care (IPC), and confirmation that all required information and appropriate dated signatures are in the medical record. The IPC must be completed within 3 days of admission. •Provide the date of the UAI (CSA-CAFAS or PECFAS) or assessment (non-CSA) for supporting placement at this level of care. This must be completed prior to the admission. If all criteria are met, KePRO will approve for 6 months

35. 35 Prior Authorization for Reimbursement For Levels A&B (con’t) IPC-at admission-date is start of service and to include: DSM-IV (Axes I-V) Functional level Treatment objectives w/short- and long-term goals Orders for medications, interventions, therapies, etc. Plan for discharge QMHP dated signature

36. 36 Prior Authorization for continued stays for Levels A&B PA prior to end of previous authorization (no earlier than 30 days Confirm Comprehensive Individual Plan of Care (CIPOC) completed-dated signature of QMHP and program director (LMHP) CIPOC update (every 30 days), dated signature of QMHP Confirm weekly individual psychotherapy by LMHP is provided For Level B-- Confirm group psychotherapy by LMHP is provided Concurrent Review (same provider) documentation must be submitted to KePRO no earlier than 30 days prior to end of current authorization • For Level A & B services, individuals must have a primary diagnosis of mental illness that meets the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for an Axis I disorder. All 5 axes are required to be documented in the medical record. • If this is a dual diagnosis of Mental Health (MH) and Substance Abuse Services (SAS), the focus of treatment must be the MH problem. Medicaid does not cover inpatient or residential treatment of substance abuse disorders. • Describe continuing or new symptoms and behaviors within the last month that support the need for residential care and that reflect the DSM-IV diagnosis. • Describe social and behavioral functioning within the last month. • Provide the date of the Comprehensive Individual Plan of Care (CIPOC) and confirmation that all required information and appropriate dated signatures are available in the medical record. The CIPOC must be completed within 30 days of admission. • Provide the date of the most recent CIPOC update (current to within past 30 days), and confirmation that all required information and appropriate dated signatures are available in the medical record. • Confirm all required therapeutic services are provided as the level of care requires. • Provide anticipated discharge plan and date. If this has changed, explain why. If all criterion are met, KePRO will approve for 6 months. Concurrent Review (same provider) documentation must be submitted to KePRO no earlier than 30 days prior to end of current authorization • For Level A & B services, individuals must have a primary diagnosis of mental illness that meets the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for an Axis I disorder. All 5 axes are required to be documented in the medical record. • If this is a dual diagnosis of Mental Health (MH) and Substance Abuse Services (SAS), the focus of treatment must be the MH problem. Medicaid does not cover inpatient or residential treatment of substance abuse disorders. • Describe continuing or new symptoms and behaviors within the last month that support the need for residential care and that reflect the DSM-IV diagnosis. • Describe social and behavioral functioning within the last month. • Provide the date of the Comprehensive Individual Plan of Care (CIPOC) and confirmation that all required information and appropriate dated signatures are available in the medical record. The CIPOC must be completed within 30 days of admission. • Provide the date of the most recent CIPOC update (current to within past 30 days), and confirmation that all required information and appropriate dated signatures are available in the medical record. • Confirm all required therapeutic services are provided as the level of care requires. • Provide anticipated discharge plan and date. If this has changed, explain why. If all criterion are met, KePRO will approve for 6 months.

37. 37 Confirm 7 psychoeducational activities provided each week Confirm daily documentation of service provision Confirm discharge plan in place Medically necessary services will be authorized up to six months at a time Prior Authorization for continued stays for Levels A&B (con’t)

38. 38 Children currently in Level A or B will need to have concurrent PA at their six month recertification. Follow requirements for concurrent PA just discussed All recipient’s in Level A/B must have a PA number by 1/1/09 or claim will deny. Prior Authorization for continued stays for Levels A&B (con’t)

39. 39 Facility Assessment: It is not sufficient to check a box as justification for determination of “moderate impairment.” A checked box followed by specific, dated evidence related to the identified child that supports the checked box is considered acceptable.

40. 40 Initial Plan of Care (IPOC) The Initial Plan of Care (IPOC) must be completed upon admission- signed and dated The IPOC must include: 1. Diagnoses, symptoms, indicating the need for admission; 2. A description of the functional level of the child; 3. Treatment objectives with short-term and long-term goals; 4. A listing of any medications, treatments, recommended for the health and safety of the patient; 5. Plans for continuing care, including review and modification to the plan of care; and 6. Plans for discharge. Covers the 1st 30 days of treatmentCovers the 1st 30 days of treatment

41. 41 The Comprehensive Individualized Plan of Care (CIPOC) Based on Assessment Diagnosis School, home, community input Short and long-term objectives : Frequency/type of intervention Measurable Target dates Person (s) responsible

42. 42 CIPOC (cont’d) Integrated program of therapies, activities, experiences Designed to meet treatment objectives Comprehensive discharge plan to include: -- Specific community resources -- Family -- School Signed and Dated

43. 43 Reviewed every 30 days: Client’s response to services Recommend changes to CIPOC Need for continuation of services Individualized Signed and Dated by QMHP provider CIPOC (cont’d)

44. 44 Required Activities (A & B) Provide intensive supervision & structure of daily living activities to address specific functional/behavioral deficits Treatment delivered in accordance with the CIPOC (i.e. focused on functional problems & skill acquisition). Psycho-educational program Activities – 7 per week (minimum) These may be: - Development/maintenance of daily living skills - Anger management - Social skill building - Family living skills - Communication skills - Stress management

45. 45 Daily documentation of all services must clearly reflect behaviors, activities, and treatments that indicate attention to and movement towards stated goals and objectives in the CIPOC Program sessions must be documented at the time the service is rendered and must be signed and dated by the qualified staff rendering the service; Required Activities (A & B) cont’d)

46. 46 Weekly individual psychotherapy Provided by LMHP Preauthorized Coordinate care (including discharge) with other providers Required Activities (A & B) (cont’d)

47. 47 Therapeutic Passes Purpose is to assess recipient’s ability to function in community Must be part of CIPOC Goals specifically documented to visit granted Response documented upon return Must begin with short periods (2-4 hours) Must progress to day passes

48. 48 Therapeutic Passes (cont’d) Overnight pass only after successful day passes Overnight passes only as part of discharge plan Outcomes of therapeutic leave must be documented No more than 24 overnight passes annually (service year, A & B Levels)

49. 49 Discharge Criteria Less intensive service will achieve/ maintain stabilization Level of functioning has improved With respect to goals outlined in CIPOC Child can reasonably be expected to maintain these gains at lower level of treatment Child no longer benefits from service As evidenced by lack of progress toward CIPOC goals for 60 days

50. 50 Non-Covered Services Room and board Academic costs Personal Care Non-mental health needs

51. 51 Limitations Services can only be provided in facilities/programs with no more than 16 beds Total number of beds is determined by including all beds located within the program/facility and on any adjoining campus or site

52. 52 Limitations (cont’d) If provider operates separate residences that are in different areas of a LOCALITY, the bed count only applies to each residence—each residence that is 16 beds or less is eligible for Medicaid reimbursement Programs/facilities that only provide independent living services are not reimbursable Prior authorization is required for payment of all residential services billed to Medicaid.

54. 54 Specific Provider Qualifications

55. 55 Supervision of Unlicensed Personnel SUPERVISOR Appropriately licensed under state law Supervision meets requirements of individual profession Approves and signs Plan of Care Reviews Patient’s medical history Countersigns Plan of Care updates

56. 56 Supervision of Unlicensed Personnel cont’d Reviews each progress note Countersigns each progress note on date of service indicating note was reviewed Meet regularly (every six sessions) Discuss Plan of Care Review record Note Patient’s progress Document supervisory meetings

57. 57 Criteria for Participation Recipient demonstrates: Reduction in ability to cope or adapt Demonstrates a drastic increase in personal distress Requirement for treatment for maladaptive coping strategies; Requirement for treatment to sustain behavioral or emotional gains or restore cognitive functional levels, which have been impaired; AND

58. 58 Recipient Participation (cont’d) 5. Shows - deficits in peer relations or in dealing with authority or hyperactivity or poor impulse control or clinical depression or demonstrates other dysfunctional symptoms which impact concentration, the ability to learn, or participate in educational, or social activities.

59. 59 Documentation Required in the medical record: Results of a Diagnostic Evaluation done within the past year (History) Description of functional limitations. Global Assessment Score (GAS). Medical Evaluation (evidence of coordination with the PCP, if applicable, or documentation that it is not applicable).

60. 60 Documentation Required (cont’d) Plan(s) of Care, signed and dated by the provider. ** Focus of the Plan must: Be related to the diagnosis. Indicate client-specific goals related to symptoms Indicate treatment modalities used & why the modality was chosen for this individual; Indicate estimated length that treatment will be needed & frequency of the treatments Include discharge planning The Plan of Care must be reviewed every 90 days or every sixth session, whichever time frame is shorter.

61. 61 Progress Notes for each session (must --Describe how the activities of the session relate to the client-specific goals, -Describe the length & type of the session -Describe the level of participation in treatment Documentation Required (cont’d)

62. 62 - Describe progress toward the goals, and the plan for the next treatment and must contain the signatures of the providers). Be signed and dated by therapist rendering service (if unlicensed, also by supervisor) - A Discharge Summary is required (including the reason for the discharge and any follow-up needed). Documentation Required (con’d)

63. 63 Service LimitsNo more than a grand total of three of any in this list in a seven-day period Individual psychotherapy Group psychotherapy Family psychotherapy

64. 64 Service Limits (cont’d) Individual psychotherapy Once per day (medical evaluation & management is included in the psychotherapy code and should NOT be billed separately) Group psychotherapy Once per day 10 (max) per group No sensory stimulation, recreational activities, art classes, excursions, eating together counted Family psychotherapy Once per day

65. 65 UtilizationReview

66. 66 Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program…………… Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program. Under the Participation Agreement with DMAS, the provider also agrees to give access to records and facilities to Virginia Medical Assistance Program representatives Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program. Under the Participation Agreement with DMAS, the provider also agrees to give access to records and facilities to Virginia Medical Assistance Program representatives

67. 67 Purpose of Utilization Review Ensure clinical necessity and that an appropriate provider delivers the services Purpose of Utilization Review: Ensure the provision of quality health care DMAS routinely conducts utilization reviews of community mental health, case management, and substance abuse services to ensure that services provided to Medicaid recipients are medically necessary and appropriate and are provided by the appropriate provider. Ensure the appropriate provision of services These reviews may be unannounced. During each review, an appropriate sample of the provider's total Medicaid billing will be selected for review. Ensure clinical necessity and that an appropriate provider delivers the services An expanded review shall be conducted if an excessive number of exceptions or problems are identified. Purpose of Utilization Review: Ensure the provision of quality health care DMAS routinely conducts utilization reviews of community mental health, case management, and substance abuse services to ensure that services provided to Medicaid recipients are medically necessary and appropriate and are provided by the appropriate provider. Ensure the appropriate provision of services These reviews may be unannounced. During each review, an appropriate sample of the provider's total Medicaid billing will be selected for review. Ensure clinical necessity and that an appropriate provider delivers the services An expanded review shall be conducted if an excessive number of exceptions or problems are identified.

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69. 69 Your UR Site Visit Record Review will include: Request to review program and billing records in a central location The Review may include: Observation of service delivery Face-to-face/telephone interviews with the consumer and/or family Review of staff qualifications On Site Reviews Record Review will include: Request to review program and billing records in a central location We try not to be intrusive with the UR process. We will offer time to complete any needed filing. If we cain’t locate information we will ask program staff to assist. The Review may include: Observation of service delivery Face-to-face or telephone interviews with the consumer and/or family We may request to look at staff qualifications On Site Reviews Record Review will include: Request to review program and billing records in a central location We try not to be intrusive with the UR process. We will offer time to complete any needed filing. If we cain’t locate information we will ask program staff to assist. The Review may include: Observation of service delivery Face-to-face or telephone interviews with the consumer and/or family We may request to look at staff qualifications

70. 70 Reviewers check that: Services provided meet all requirements defined and described in the DMAS Service manual Services billed match documented delivered care Services do not exceed specific service limitations

71. 71 Delivered services as documented are consistent with the recipient’s Individual Service Plan, submitted invoices and specified service limitations . “The UR “Golden Rule” Delivered services as documented are consistent with the recipient’s plan of care, submitted invoices and specified service limitations. “The UR “Golden Rule” Delivered services as documented are consistent with the recipient’s plan of care, submitted invoices and specified service limitations.

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73. 73 Process has 3 phases- Written response and reconsideration to preliminary findings (30 days to submit information) The informal conference (30 days to request informal conference) The formal evidentiary hearing (30 days to request formal hearing) Reconsideration of the findings:

74. 74 Overpayments required when: Medicaid billed contrary to regulation or statute Provider fails to maintain any record or adequate documentation to support the claim Provider bills for an unnecessary service Error found in computing billing amounts

75. 75 Please email any questions to: CMHRS@DMAS.Virginia.gov

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