FY09 Wake LME Provider Operations Manual Training

1. 1 FY09 Wake LME Provider Operations Manual Training February 17, 2009

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3. 3 Today’s Focus Revisions to: Target Populations Benefit Plans UR (Authorization) Procedures QM Procedures Revisions Revised Manual is posted on www.wakegov.com/lme

4. 4 IPRS Simplification Fewer Target Pops New Target Pops No Concurrency allowed (i.e., in what the LME reports to the State) However, since consumers still have concurrency, you need to report all Target Pop eligibility to Wake LME!

5. 5 Target Population Changes

6. 6 Developmental Disability Target Population Changes No changes to Child with Developmental Disability (CDSN) Target Population. ADMRI no longer exists.

7. 7 ADSN ADSN – Adult with Developmental Disability Adult, age 18 and over, who is: Screened eligible by the LME as Developmental Disabled in accordance with the current functional definition in GS 122C-3(12a). OR Meets the State definition of Developmental Disabled and having a co-occuring diagnosis of Mental Illness OR Was confirmed Thomas S. class member and was receiving MR/MI funded services at the dissolution of the Thomas S. lawsuit. These individuals must have a Developmental Disability Assessment based on NC SNAP 1 through 5.

8. 8 Child Mental Health Target Populations CMMED, CMDEF no longer exist CMSED – Child with Serious Emotional Disturbance Revised to consolidate the eligibility criteria for the above target populations Includes individuals who are homeless or at imminent risk of homelessness Wake County will continue to use the previous CMSED criteria as an indicator for eligibility for residential treatment

9. 9 Child Substance Abuse Target Populations CSCJO, CSWOM, and CSDWI no longer exist CSSAD – Child with a substance abuse or substance related disorder Revised to consolidate the eligibility criteria for the above target populations Must be assessed for service eligibility utilizing adolescent ASAM criteria

10. 10 Child Substance Abuse Target Populations, Cont. CSMAJ – Child with a substance abuse or substance related disorder and is involved in the Juvenile Justice System Revised to include youth who are adjudicated undisciplined or on a diversion contract with DJJDP Must be assessed for service eligibility utilizing adolescent ASAM criteria

11. 11 Adult Substance Abuse Target Population Changes ASHMT, ASDWI, ASDHH and ASHOM no longer exist ASTER – Adult Substance Abuse Treatment Engagement and Recovery Consolidates the above Broadens eligibility – substance abuse or dependency diagnoses Includes individuals in need of engagement, assessment, “formal” treatment and other treatment services and supports necessary for relapse prevention and continued recovery

12. 12 Adult SA Target Population Changes, Cont. Other ASA target populations remain the same – ASCDR, ASDSS, ASCJO and ASWOM

13. 13 Adult Mental Health Target Population Changes AMSPM and AMSMI no longer exist AMI – Adult with Mental Illness Replaces AMSPM and AMSMI Uses higher GAF limitation from AMSMI of 50

14. 14 Target Pop Form Begin using Wake’s new Target Pop form immediately (SmartWorks HS-3051) Staff must review the Target Pop eligibility criteria on Division’s website: http://www.ncdhhs.gov/mhddsas/iprsmenu/index.htm Current caseloads are being administratively changed to new Target Pops – see your March caseload report.

15. 15 Authorization and Utilization Review Procedures

16. 16 Utilization Review Changes Wake LME participated in a Standardization Project with 10 LME’s to create a number of uniform procedures for handling Service Authorization Requests (“SAR”). Changes are summarized in chart titled “MHSA Authorization Paperwork Requirements and Timeframes, by Type of Request” in Provider Manual (Section III, 4 p. 17).

17. 17 Changes to MHSA Authorization Procedures (Section III, 4) LME will process all properly completed and submitted routine IPRS authorization requests within 14 days. Within 14 days of the receipt of a complete and accurate SAR packet (includes all required forms), the LME will either authorize, deny, reduce, suspend, terminate, or “pend” awaiting additional clinical information.

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20. 20 Changes to MHSA Authorization Procedures (Section III, 4), Cont. REMEMBER: Submit only complete packets, all required forms at once!! Respond promptly to requests or notices. You WILL get a timely response to your authorization request (within 14 days) if your paperwork is complete/accurate!

21. 21 Types of Authorization Requests Current Consumer to receive a new service (same or different provider) Transferring a consumer to another agency (when referring agency has a current auth) Requests for additional service units to an existing and active authorization Emergency Authorization requests

22. 22 Transferring a consumer Referring Provider contacts assigned UR Care Manager to request a transfer. Referring Provider submits written documentation explaining the reason for the transfer and the effective date. Referring Provider completes “Contract Agency Discharge Data form” if referring agency is ending all services to the consumer. UR Care Manager sends the referring Provider a “Receipt of Initial Request for Services” form.

23. 23 Transferring a consumer, Cont. Referring Provider sends copy of “Receipt” to the accepting agency. Accepting agency completes bottom section of “Receipt” and faxes it and a Consumer Enrollment form to the LME UR Team (919) 250-3761. Upon receipt of these completed forms, the UR Care Manager will generate an authorization for that service to the accepting agency. Note: A current, completed Fee Application will need to be on file.

24. 24 Additional Service Units Submit a completed SAR to the LME UR Care Manager. Check box indicating “Request to add units to current auth”. Clinical need must be clear, with an estimated “step down” plan included. Requests must be submitted prior to the end date of the current authorization.

25. 25 MHSA Benefit Plans

26. 26 Objectives of Benefit Plans Stewardship and accountability for public funds Effective management of limited funding Placement in most appropriate and effective level of care and intensity of services Clinical guidance regarding practice models and standards of care Public awareness of available services

27. 27 Objectives of Benefit Plans Improved planning of care and communication of benefits with consumers Increased consistency in UR review Better communication between LME and providers about expected course of treatment Planned step-down in services vs. denials Tool for use in Non-Medicaid appeals process

28. 28 General Expectations Discharge and step-down planning begin at intake Plan of care is based upon a comprehensive clinical assessment Well-documented plan of care Treatment reflects an emphasis on recovery principles, promotion of community inclusion and tenure, and use of natural supports

29. 29 Adult MH/SA Benefit Plan Highlights Benefits Eligibility Screening Authorization is 1 - 8 units within 45 days, no reauth Applicable only in conjunction with BHO, SAIOP or SACOT Covers the actual time spent by staff assisting the client with completing the Fee Application and/or acquiring needed documentation

30. 30 Adult MH/SA Benefit Plan Highlights Behavioral Health Outpatient – BHO or OPTX Authorization includes clinical/psychiatric evaluations, assessments, individual, group and family/couples therapies, medication management Expected duration is 6 – 18 months Adults with a substance use disorder must meet an ASA target population and ASAM Level I criteria Adults with mental illness must meet AMI or AMSRE target population and specific diagnostic criteria

31. 31 Adult MH/SA Benefit Plan Highlights Community Support – Adults Expected duration is 4 – 10 months Adults with a substance use disorder must meet an ASA target population and ASAM Level I criteria Adults with mental illness must meet AMI or AMSRE target population and specific diagnostic criteria Not intended to be a “stand alone” service Emphasis is expected on linkage, referral and coordination activities that reduce barriers to progress and support clinical goals

32. 32 Adult MH/SA Benefit Plan Highlights Community Support Team – CST Expected duration is 4 – 10 months Adults with a substance use disorder must meet an ASA target population and ASAM Level I criteria, at a minimum Adults with mental illness must meet AMI or AMSRE target population and specific diagnostic criteria More intensive than Community Support, provides treatment and other interventions to reduce psychiatric and/or addiction symptoms and attain self-sufficiency

33. 33 Adult MH/SA Benefit Plan Highlights Assertive Community Treatment – ACT Duration is variable Adults must meet diagnostic criteria for a severe and persistent mental illness that results in serious functional impairment Limited to individuals with the most severe symptoms and at highest risk for inpatient hospitalization

34. 34 Adult MH/SA Benefit Plan Highlights Psychosocial Rehabilitation – PSR Duration is variable Intended for adults with severe psychiatric disabilities who require daily interventions to improve their functioning and develop skills necessary to live as independently as possible

35. 35 Adult MH/SA Benefit Plan Highlights Substance Abuse Intensive Outpatient Program – SAIOP No changes in duration Basic admission criteria include: dependency diagnosis and ASAM Level II.1 criteria (structured setting, lower levels of care ineffective, mental health symptoms present, unstable working/living environment)

36. 36 Adult MH/SA Benefit Plan Highlights Substance Abuse Comprehensive Outpatient Treatment – SACOT Duration decreased to two 30-day authorizations Basic admission criteria include: dependency diagnosis and ASAM Level II.5 criteria (same as above, except more severe) Continued involvement in some type of care is essential for most people to be successful in their recovery.

37. 37 Child MH/SA Benefit Plan Highlights Benefits Eligibility Screening  Authorization is 1 - 8 units within 45 days, no reauth Applicable only in conjunction with BHO Covers the actual time spent by staff assisting the client with completing the Fee Application and/or acquiring needed documentation

38. 38 Child MH/SA Benefit Plan Highlights Behavioral Health Outpatient – BHO or OPTXAuthorization includes clinical/psychiatric evaluations, assessments, individual, group (only for specific evidence based models) and family, medication management Expected duration is 6 – 18 months Children/adolescents with a substance use disorder must meet a CSA target population and ASAM Level I criteria Children/adolescents with behavioral or emotional disorders must meet CMSED

39. 39 Child MH/SA Benefit Plan Highlights Community Support – Children and Adolescents Expected duration is 6 – 12 months Children/adolescents with a substance use disorder must meet a CSA target population any ASAM Level of Care criteria as long as this service is in coordination with other appropriate services Children/adolescents with behavioral or emotional disorders must meet CMSED Should be provided with BHO rather than as a “stand alone” service Emphasis is expected on linkage, referral and coordination activities that reduce barriers to progress and support clinical goals

40. 40 Child MH/SA Benefit Plan Highlights Intensive In-Home – IIH Expected duration is 3-5 months Children/adolescents with a substance use disorder must meet a CSA target population and ASAM Level I or II criteria Children/adolescents with behavioral or emotional disorders must meet CMSED and service specific criteria

41. 41 Child MH/SA Benefit Plan Highlights Multisystemic Therapy – MST Expected duration is 3-5 months Children/adolescents with a substance use disorder must meet a CSA target population and ASAM Level I or II criteria

42. 42 Child MH/SA Benefit Plan Highlights Day Treatment for children and Adolescents – Day Tx  Expected duration is 5-9 months Intended for children and adolescents who are unable to function in their academic setting due to functional impairments caused by emotional or behavioral disorders Primary goal is to transition back into a normal academic setting

43. 43 Child MH/SA Benefit Plan Highlights Respite Expected duration is 1 year Intended for children and adolescents to support continued living in their home, or, transition from higher levels of care to the home setting Clinical home service provider expected to monitor progress in treatment and development of other informal resources to prevent out of home placement or recidivism to higher levels of care

44. 44 Child MH/SA Benefit Plan Highlights Residential Treatment Level I Expected duration is 6 – 9 months Intended for children and adolescents who no longer meet medical necessity for therapeutic foster care but out of home care is required to prevent loss of therapeutic gains Clinical home service provider expected to monitor progress in treatment to assure appropriate and timely step-down

45. 45 Child MH/SA Benefit Plan Highlights Level II Therapeutic Foster Care Expected duration is 6 – 9 months Intended for children and adolescents with behavioral or emotional profiles with inability to manage stress and relationships at home Clinical home service provider expected to monitor progress in treatment to assure appropriate and timely step-down

46. 46 Child MH/SA Benefit Plan Highlights Level II Residential Treatment Expected duration is 8 – 14 months Intended for children and adolescents with behavioral profiles including need for increased supervision beyond the family’s capacity related functioning in life domains Clinical home service provider expected to monitor progress in treatment to assure appropriate and timely step-down

47. 47 Child MH/SA Benefit Plan Highlights Level III Residential Treatment Expected duration is 10 – 16 months Intended for children and adolescents with behavioral profiles including severe functional problems not improved through outpatient and home based interventions Clinical home service provider expected to monitor progress in treatment to assure appropriate and timely step-down

48. 48 Child MH/SA Benefit Plan Highlights Residential Treatment Level IV Expected duration is variable 60 authorization only (interim while 5045 Medicaid application is initiated Intended for children and adolescents with behavioral profiles including potentially life threatening & chronic high risk behaviors Clinical home service provider expected to monitor progress in treatment to assure appropriate and timely step-down

49. 49 Child MH/SA Benefit Plan Highlights Psychiatric Residential Treatment Facility (PRTF) Expected duration is variable 60 authorization only (interim while 5045 Medicaid application is initiated Intended for children and adolescents with behavioral profiles including failed treatment attempts across multiple settings Clinical home service provider expected to monitor progress in treatment to assure appropriate and timely step-down

50. 50 Obtaining Medicaid Eligibility for Youth Needing Residential Treatment Services See Section III.4 pages 20-23 of the revised Provider Manual

51. 51 What is 5045 Medicaid? Time limited, Medicaid eligibility based solely on the consumer’s clinical needs and personal income

52. 52 5045 Medicaid Application Process Facilitated by clinical home service provider Requires coordinated work of: -- the legal guardian -- the residential treatment provider -- the clinical home service provider -- the Wake LME

53. 53 Clinical Home Service Provider Reviews consumer’s financial benefits with legal guardian Facilitates 5045 Medicaid application completion Obtains residential treatment admission date Submits complete application to Wendy Wodarski at Wake LME

54. 54 Wake LME Reviews Application for All Required Elements Notifies the clinical home service provider of application acceptance Authorizes the first 45 days of the admission according to the admission date Submits the 5045 application on the 1st of the month following admission to the WCHS Medicaid office Returns incomplete application to the clinical home service provider with explanation Denies IPRS authorization Notifies legal guardian and residential treatment provider that self-pay is necessary

55. 55 5045 Medicaid Application Approval Reviewed and processed by the WCHS Medicaid office Granted for the duration of the authorized residential treatment Ends the day of discharge

56. 56 Temporary IPRS Funding Authorization granted by the Wake LME to support the first 45 days of residential treatment when no other benefits exist If the consumer completed income verification And meets medical necessity criteria for the service And A complete 5045 application has been accepted by the Wake LME

57. 57 FormsAvailable on Smart Works 5045 Medicaid Application Instruction Packet Division of Medical Assistance Certification of Need for Institutional Care for Individual Under Age 21 Health Check/Health Choice Application for Children State Residence Verification Supplement Initial or Continuing Request for Room and Board Authorization Form Notice of Out of Home Community Placement Form Notice of Out of Home Community Placement Form Sample

58. 58 Developmental Disabilities Authorization and Utilization Review

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60. 60 Developmental Disability Authorization Procedure Entire process will take 14 days if: all required documentation is submitted the service requested is appropriate the requested service frequency follows the Benefits Plan the Unified Person-Centered Plan is clinically sound

61. 61 DD Authorization Procedure, Cont. Data Support Specialists receive the requests. The Data Support Specialists send a written Notice to the Requesting Provider if there is missing documentation. The Requesting Provider has 3 business days from receipt of the written Notice to submit the required documentation to the Data Support Specialist. If the required information is not received, the request will be shredded.

62. 62 DD Authorization Procedure, Cont. Care Managers review the request. If changes are needed to the Unified Person-Centered Plan, the Care Manager will send a written Notice to the Requesting Provider. The Requesting Provider has 15 calendar days from the date of the Notice to make the requested changes and re-submit the corrected plan to the Care Manager in order to have the original requested effective date of the authorization be approved.

63. 63 DD Authorization Procedure, Cont. If the requested changes are received after 15 days, the effective start date of the authorization will be the date the Care Manager receives the changes. If the Care Manager does not receive the requested changes from the Requesting Provider within 30 calendar days, the request will be denied and an appeal letter will be sent to the consumer.

64. 64 DD Benefit Plan In January 2009 the Benefit Plan was changed for Developmental Therapy for the ADSN Target Pop. Plan is now included in the manual for reference.

65. 65 Referral and Acceptance TimelinesDevelopmental Disability Services

66. 66 Non-Medicaid Appeals Process

67. 67 Authorization Decisions that Result in Appeal Notification Denial – On an Initial Request, the service is determined not clinically necessary or not the appropriate level of care Reduction – Units authorized are less than requested Termination – Denial of a Continuing Request Suspension – Termination or Denial due to incomplete information for clinical decision-making

68. 68 Non-Medicaid Appeals Process When an SAR is denied, reduced, terminated or suspended, a “UM Decision Letter” will be sent to the consumer (copy to Provider), giving the reason for the decision (per “Standardization Project) and instructions for filing an appeal request.

69. 69 Non-Medicaid Appeals Process, cont. An appeal request can only be filed by the consumer, a legal representative of the consumer, or any other individual who does not have a conflict of interest and has been selected by the consumer and/or their legal representative. The LME UR Team must receive the appeal request in writing with 15 working days of the date of the UM Decision Letter.

70. 70 Non-Medicaid Appeals Process, cont. If the UM decision under appeal pertains to a reauthorization request, the end date of the existing and active authorization will be extended 15 days with the same rate of service units, to accommodate the appeal process. If the last authorization has expired, it cannot be extended.

71. 71 Non-Medicaid Appeals Process, cont. The LME Medical Director or designee with credentials comparable to the prior reviewer shall complete the clinical review and may uphold or overturn the original decision. A written clinical review decision will be sent in a letter dated and mailed within 7 working days of receipt of the appeal request. The Clinical Reconsideration Review will be based on the criteria contained in DMH/DD/SAS Communication Bulletin #038.

72. 72 Non-Medicaid Appeals Process, cont. In cases in which the reviewer overturns the original decision, the requested services may be authorized in those instances when Non-Medicaid funds will be made available for such services, and an authorization letter will be issued stating the date on which the denied service shall be authorized or the date on which the suspended, reduced, terminated or denied service shall be partially or fully reinstated.

73. 73 Non-Medicaid Appeals Process, cont. If the original decision is upheld, an appeal may be filed with the Division of Mental Health, Developmental Disabilities and Substance Abuse Services. Clinical Review Decision letters sent to consumers upholding original decisions will include a DMH/DD/SAS appeal request form with instructions. Providers will receive a copy of Clinical Review Decision letters.

74. 74 Non-Medicaid Appeals Process, cont. Non-Medicaid funded services are not an entitlement; therefore, please be advised that filing a request for an appeal in no way guarantees the consumer the specified service regardless of the outcome of the review. Payment can be denied for services based on allowable limits in the Benefit Plan, or by other budgetary limitations of Non-Medicaid funding.

75. 75 Non-Medicaid Appeals Process, cont. Please Note: Prior to the Wake County LME issuing a written denial, reduction, suspension or termination of funding for services, Wake LME may contact the service provider regarding an authorization decision. The service provider can verbally advise the Wake LME Utilization Review Team Care Manager that both the provider and consumer are in agreement with proposed modifications to the services requested in the Service Authorization Request (“SAR”).

76. 76 Non-Medicaid Appeals Process, cont. In instances of such agreement, notification of appeal rights to the consumer may not be required. The service provider will document the consumer’s agreement in the medical record, and the UR Care Manager will document the provider’s verbal agreement in the UR chart notes.

77. 77 Revised Rates

78. 78 Revised Rates Rates changes are documented in Section IV.3 Reimbursement Rate Table, changes are highlighted CPT Code Rates changed effective 1/1/2009. MD rates changed, but rates for other specialties didn’t Most rates increased 3 – 5% H0001, H0004, H0005, H0031 rates did not change

79. 79 Revised Rates, Cont. Community Support transitioned to “tiered” rates in January Tiers determined by qualifications of provider QP- Licensed- $22.04 / 15 min QP Unlicensed- $18.25 / 15 min unit QP Associate Professional $10.29 / 15 min QP Paraprofessional $5.92 / 15 min Authorization at aggregate level, not by tier Community Support limited to 32 units per week

80. 80 Revised Rates, Cont. Some Enhanced Service Rates Increased! H0015 SAIOP, H2035 SA COT, H0035 PH, H2017 PSR, H2015 CS Team Some Rates Decreased: H0020 Opioid Tx, H0040 ACTT, T1017 Targeted Case Management

81. 81 Time Limit Over-Ride Process

82. 82 Time Limit Over-Ride Process Submit any Pre-Approved Time Limit Overrides along with the claims; this expedite payment and prevents unnecessary denials. Providers can still submit regular Time Limit Override Requests, but the claims may be held to the end of the fiscal year for payment if funding is available.

83. 83 Time Limit Over-Ride Process EXCEPTION: Claims submitted with a Time Limit Override Request due to the provider having to wait to get an EOB or denial from the primary insurance are processed as received. However, the EOB must clearly show the claim was filed timely to the primary insurance. Otherwise, it will be held to the end of the fiscal year.

84. 84 Wake’s New Computer Systemand What it Will Mean for YOU!

85. 85 New Computer System Implementing Netsmart Avatar MSO System Effective June 2009 Significant Changes for Provider Network IPRS Authorizations Requested and Issued Using Carelink Web Portal Wake LME will issue auths using Carelink Providers will request auths using Carelink

86. 86 New Computer System, Cont. Referral Process will Change Referrals via Carelink through “Notification” authorization Standard PCP Admission form, Financial Assessment and other required forms sent to LME as e-attachments via Carelink

87. 87 New Computer System, Cont. IPRS Claims submitted though Carelink or by using 837 electronic claims transaction New format for Remittance Advise/EOB Hard copy RA will change Electronic RA (835) can be provided upon request

88. 88 New Computer System, Cont. For Outpatient Services, Clinicians Must be Registered Licensure and specialty information will be required Carelink Training Planned for May 2009 

89. 89 QM Procedure Revisions

90. 90 Section VI.3 Complaints New LME Director Ad Hoc Appeal Review Committee New procedures for Plan of Correction from the State http://www.dhhs.state.nc.us/mhddsas/provider_monitor_tool/appendix-m1-09.pdf

91. 91 Section VI.5 Incident Reporting LME Monitoring of Providers’ incidents processes No emailing of any forms that include consumer information NEW phone number for LME Medical Director Quarterly reports on Level I incidents (QM 11) must be submitted no later than the 10th day of the month they are due.

92. 92 Section VI.8 Monitoring Frequency Extent Monitoring Tool (FEM) to determine providers’ need for routine monitoring. New standardized State wide tool http://www.dhhs.state.nc.us/mhddsas/provider_monitor_tool/appendix-m1-09.pdf

93. 93 Section VI.10 Appeals An appeal of an out-of-compliance finding does not negate the requirement for a POC. · Appeals associated with a revocation of endorsement by the LME will be made in accordance with North Carolina General Statutes and will supersede any appeal rights associated with endorsement withdrawal. ·For Community Support, the Appeal Rights can be found Session Law 2008-107 House Bill 2436 Section 10.15A. (e2) .

94. 94 Section VI.11 Endorsement Updated to reflect new policy 12.3.07 http://www.ncdhhs.gov/mhddsas/stateplanimplementation/providerendorse/index.htm

95. 95 Section VI.13 First Responder ·         First Responder phone number on main agency line ·         2 hour face-to-face capacity ·         Referrals to CAS

96. 96 Section VI.14 Letter of Support (NEW section) ·         Requirements for acquiring a letter of support

97. 97 Section VI.15 NCcareLINK (NEW Section) Requirements for providers and NCcareLINK (a web-based Information and referral system located at: (http://www.wakegov.com/lme) 

98. 98 Print your Manual! Revised Manual is posted on www.wakegov.com/lme

99. 99 The End!