Illinois Department of Human Services, Division of Mental Health The Illinois Mental Health Collaborative for Access and Choice

1
Illinois Department of Human Services, Division
of Mental Health The Illinois Mental Health
Collaborative for Access and Choice
Authorization Requirements for Therapy
Counseling, Psychosocial Rehabilitation and
Community Support Group Services Effective
January, 2011

• November 2010

2
Introductions

• Lee Ann Reinert, LCSW - IL DHS/DMH Clinical
  Policy Specialist
• Emily Sherrill, LCSW - Collaborative Clinical
  Director
• Todd Kasdan, MD - Collaborative Medical Director

3
Presentation Online

• Todays presentation will be available online
• http//www.illinoismentalhealthcollaborative.com
  /provider/prv_information.htm
• Be sure to share this information with your staff!

4
Agenda

• Overview of Utilization Management Program
• Medical necessity
• Overview of authorization processes
• Mental Health Assessment (MHA) requirements
• Individual Treatment Plan (ITP) requirements
• Requests for reconsideration and appeal of denial
  decisions
• Questions and answers

5
Utilization Management Program Overview

• Introduction
• The Utilization Management (UM) Program is the
  vehicle through which DHS/DMH ensures that
  individuals being served receive
• the services best suited to support their
  recovery needs and preferences,
• cost effective services in the most appropriate
  treatment setting,
• services consistent with medical necessity
  criteria and evidence-based practices.

6
Utilization Management Program Overview

• By implementing the UM Program, DHS/DMH strives
  to achieve a balance between
• the needs, preferences, and well-being of persons
  in need of mental health services
• demonstrated medical necessity
• the availability of resources

7
Utilization Management Program Overview

• The UM Program
• does not limit medically necessary Medicaid
  services
• is fully compliant with the Illinois Medicaid
  State Plan and associated federal rules

8
In developing the UM Program, DHS/DMH
acknowledges the following guiding principles

•  
• UM is dynamic and evolutionary. As additional
  data, new research, and other new information
  occurs with experience, the UM Program will
  evolve and change.
• UM must be based on data. The UM Program must
  use data to identify patterns of utilization,
  work with clinicians to determine if the patterns
  and variations are desirable or not, and work
  with providers to make needed improvements.
• Individuals accessing services should have a
  consistent threshold of medical necessity
  statewide. The UM Program must provide clear
  guidance for medical necessity decisions so that
  all individuals accessing services have
  consistent and equitable access to specific
  services.
• Authorization must be clinically focused and
  conducted by qualified staff. Where
  authorization is determined to be necessary, it
  must be based on clinical information and
  reviewed by staff at the independent license
  level (LPHA).
•  

9
UM Program Overview, continued

• The DHS/DMH Utilization Program has the following
  components
• Medical Necessity Guidance and Criteria
• Limited External Authorization
• Ongoing Data Reporting and Analysis

10
UM Program Overview, continued

• Medical Necessity Guidance and Criteria.
• DHS/DMH is initially providing medical necessity
  criteria for the following services
• Assertive Community Treatment (ACT)
• Community Support Team (CST)
• Psychosocial Rehabilitation (PSR)
• Community Support Group (CSG)
• Therapy/Counseling (T/C)
• Community Support Individual (CSI)
• For those services available to both adults and
  children, separate criteria are provided for
  each.

11
UM Program Overview, continued

• These criteria may be found in the DHS/DMH
  Medical Necessity Criteria and Guidance Manual
  (within the Provider Manual)
• These criteria should be used by providers to
  guide them in making consistent admission,
  continuing service, and termination of service
  decisions for each consumer.
• Providers must use these criteria consistently,
  regardless of whether or not DHS/DMH or its
  designee externally authorizes the service.
• Provider adherence to these criteria may be
  subject to post payment review.

12
UM Program Overview, continued

• Limited External Authorization.
• Authorization for payment by DHS/DMH or its
  designee will be required for specific services,
  based on a review of service utilization patterns
  for a previous fiscal year.
• Thresholds are the same for adults and
  children/adolescents and are calculated by
  provider and consumer per fiscal year. For
  FY11, thresholds will be calculated for the
  remainder of the fiscal year, beginning with
  dates of service of January 3, 2011.
• Authorization for payment of services beyond the
  specified thresholds will be based on medical
  necessity criteria.
• Services will continue to be authorized as long
  as medical necessity is in evidence.

13
UM Program Overview, continued

• For purposes of determining clinical review
  thresholds, PSR and CSG utilization will be
  managed as a combined benefit. Clinical review
  and continuing service authorization will be
  required whenever an individuals utilization of
  PSR and CSG combined exceeds 800 units per fiscal
  year, with recognition that an individual may use
  one or both of these services during the year.

14
UM Program Overview, continued

• Ongoing Data Reporting and Analysis
• DHS/DMH will continue to report and analyze
• utilization patterns
• post payment review results
• authorization impacts
• other quantitative and qualitative aspects of
  service delivery.
• These data will be used to inform
• provider technical assistance efforts
• training
• future UM Program modifications

15
Medical Necessity Criteria

• Diagnosis
• Service Initiation Criteria
• Continuing Service Criteria
• Exclusion Criteria
• Service Termination Criteria

16
Medical Necessity Criteria

• DIAGNOSIS
• Current eligible mental health diagnosis for
  which the proposed course of treatment has been
  determined to be effective
• Symptoms consistent with those described in the
  current edition of the Diagnostic and Statistical
  Manual of Mental Disorders (DSM) or the
  International Statistical Classification of
  Diseases and Related Health Problems (ICD)
• Symptoms addressed do not have their primary
  origin in a diagnosis of an Autism Spectrum
  Disorder, substance-related disorder, or a
  principal Axis II diagnosis of Mental Retardation

17
Medical Necessity Criteria

• Service Initiation Criteria
• To be considered for all individuals receiving
  services for which guidance is published
• May be subject to Post Payment Review
• Establishes basis for need for service
• Continuing Service Criteria
• To be utilized for determination of need for
  ongoing services, once individual meets threshold
• Will be basis for the Collaboratives
  authorization decision

18
Medical Necessity Criteria

• Exclusion Criteria
• Reasons for service to be considered
  inappropriate for an individual
• Could be cited at either Post Payment or
  Authorization Review
• Termination Criteria
• Reasons for discontinuing service
• Could be cited during Clinical Practice Guidance
  or Authorization Review

19
Medical Necessity CriteriaTherapy/ Counseling

• SERVICE INITIATION CRITERIA - Severity/complexity
  of symptoms and level of functional impairment
  require this service, as evidenced by
• Individual has an emotional disturbance and/or
  diagnosis that is destabilizing or distressing
• Individuals assessment identifies specific
  mental health problems that may be effectively
  addressed by Therapy/Counseling
• Level of Care Utilization System (LOCUS) score
  equating to Level of Care 2 or higher for adults
  or clinician-rated Ohio scale of 16 or higher for
  youth age 5 and up

19
20
Medical Necessity CriteriaTherapy/ Counseling

• Continuing Service Criteria
• Evidence of active participation by individual
• Demonstrated evidence of significant benefit from
  this service
• as evidenced by the attainment of most treatment
  goals, but the desired outcome has not been
  restored
• and the individuals level of emotional stress
  continues to be destabilizing, significantly
  interfering with daily functioning
• Individual cannot be safely and effectively
  treated solely through the use of Community
  Support services, case management, and the
  engagement of natural support systems.

21
Medical Necessity CriteriaTherapy/ Counseling

• Additional Criteria for Specific Modalities
• Individual necessity of one to one
  interventions
• Group specifically identified problems with
  social interactions, interpersonal difficulties,
  etc, for which involvement in group process is
  expected to be beneficial
• Family identified problems are exacerbated by
  family dynamics and/or can be most effectively
  addressed through family involvement

22
Medical Necessity CriteriaTherapy/ Counseling

• Exclusion Criteria
• Cognitive impairment, mental status or
  developmental level that makes it unlikely
  individual would benefit
• Primary problem to be addressed could be more
  effectively/efficiently addressed by another
  modality

23
Medical Necessity CriteriaTherapy/ Counseling

• Service Termination
• Treatment goals achieved
• Majority of goals achieved and remainder can be
  safely achieved by accessing other services
  and/or natural supports
• No significant improvement and needs to be
  reassessed for more effective treatment

24
Medical Necessity CriteriaPsychosocial
Rehabilitation

• Service Initiation Criteria
• Significantly impaired role function in at least
  2 of the following
• Management of financial affairs
• Ability to procure needed services
• Socialization, communication, adaptation, problem
  solving and coping
• Activities of daily living
• Self-management of symptoms
• Concentration, endurance, attention, direction
  following and planning and organization skills
  necessary for recovery
• LOCUS Score equating to level of care of 3 or
  higher
• Discharge/transition plan expressly focused on
  increasing community integration through the
  application of skills in community settings.

24
25
Medical Necessity CriteriaPsychosocial
Rehabilitation

• Continuing Service Criteria
• Treatment plan reflects modifications in PSR
  services for skills that the individual has not
  yet been able to successfully demonstrate
• Individual cannot be safely/effectively treated
  through provision of alternative community-based
  services or engagement of natural supports

26
Medical Necessity CriteriaPsychosocial
Rehabilitation

• Exclusion Criteria
• Individual under age 18
• Individual chooses not to participate
• Primary etiology of dysfunction related to Axis
  II diagnosis, or an organic process or syndrome
  including normal aging
• Individuals ADLs/skills are sufficient to enable
  progress in recovery
• Individual requires more intensive contact

27
Medical Necessity CriteriaPsychosocial
Rehabilitation

• Service Termination Criteria
• Individual has learned the skills and requests
  termination or no longer needs active treatment
• Has learned most of the skills, can apply and
  improve skills in natural settings
• Is not making progress and needs reassessment to
  determine more appropriate services

28
Medical Necessity CriteriaCommunity Support Group

• Service Initiation Criteria
• Significant impairment in functioning, inability
  to apply skills in natural settings, and/or to
  build/utilize natural supports
• Require small group support to facilitate more
  effective role performance
• Identification of specific functional impairments
  that can only be remediated through small group
  practice to reinforce target skills
• LOCUS level of care recommendation of 2 or higher

28
29
Medical Necessity CriteriaCommunity Support Group

• Continuing Service Criteria
• Has demonstrated significant improvement with
  this service, attaining most skill-building and
  community integration, but
• Desired outcome/level of functioning has not been
  restored/sufficiently improved
• or
• Without these services, the individual would not
  be able to consolidate treatment gains or
  progress in recovery
• Cannot be safely/effectively treated through
  provision of alternative services or engagement
  of natural supports

30
Medical Necessity CriteriaCommunity Support Group

• Exclusion Criteria
• Individuals daily living skills are sufficient to
  enable progress in recovery without CSG services
• Cognitive impairment, current mental status or
  developmental level makes it unlikely to benefit
  from CSG services
• Primary etiology related to Axis II or organic
  processes, including normal aging
• Requires more intensive services/cannot be safely
  treated with CSG

31
Medical Necessity CriteriaCommunity Support Group

• Service Termination Criteria
• Individual has achieved goals and requests
  termination or no longer needs this service
• Has successfully demonstrated most of the skills,
  can be safely and effectively treated without CSG
• Is not making progress and needs reassessment to
  determine more appropriate services

32
Authorization in a nutshell for
Therapy/Counseling, Psychosocial Rehabilitation
and Community Support Group

• Who any consumer, for whom the provider is
  seeking reimbursement, receiving over the
  threshold hours/units of T/C, PSR, CSG services
• When Authorization for payment of services is
  required after January 3, 2011 for any consumer
  receiving services above and beyond the threshold
  hours/units of service
• What Authorization request form with a Mental
  Health Assessment (MHA) and Individual Treatment
  Plan (ITP), along with any other supporting
  documentation to establish Medical Necessity
  Criteria
• How - Submit authorization request
  electronically through ProviderConnect and
  supporting clinical documentation either as
  secure clinical attachments with request or via
  facsimile

33
What do I send when requesting an authorization?

• Information required
• Authorization request via ProviderConnect
• All required and applicable fields completed
• Including age appropriate functional scales
  (LOCUS, Ohio Scale, DECA)
• Current Axis I V elements
• Current MHA and ITP
• Securely attached with ProviderConnect request or
  faxed to the Collaborative (866-928-7177) within
  1 business day
• Additional documentation may be necessary if the
  MHA and ITP do not fully support medical
  necessity for the request

34
Authorization Process

• Therapy/Counseling
• Eligible Consumers are able to initially receive
  up to 10 hours (40 units) of this service, if
  provider LPHA deems medically necessary, without
  submission of an authorization request
• If provider deems additional hours (units) of T/C
  are medically necessary above and beyond the 10
  hour (40 unit) threshold, a request for
  authorization must be submitted and authorization
  must be obtained in order to be reimbursed for
  services
• Determination of additional hours (units) to be
  reimbursed are based upon medical necessity.
  This will take into consideration the number of
  units requested and will be based on what is
  medically necessary.

35
Authorization Process, continued

• PSR Community Support Group
• Eligible Consumers are able to initially receive
  up to 200 hours (800 units) of PSR, CSG, or a
  combination of PSR CSG, if provider deems
  medically necessary, without submission of an
  authorization request
• If provider LPHA deems additional hours (units)
  are medically necessary above and beyond the 200
  hour (800 unit) threshold, a request for
  authorization must be submitted and authorization
  must be obtained in order to be reimbursed for
  services
• Determination of additional hours (units) to be
  reimbursed are based upon medical necessity.
  This will take into consideration the number of
  units requested and will be based on what is
  medically necessary.

36
Authorization Process, continued

• Collaborative clinical care managers review
  submitted documents for adherence to Medical
  Necessity Criteria (MNC), and Rule 132.
• If the MNC are met for the service(s), the
  Collaborative will enter an authorization.
• In order for the provider to be reimbursed for
  services provided beyond initial thresholds,
  requests for authorization must be submitted and
  approved prior to service provision. Providers
  must submit requests for authorization prior to
  the authorization expiration date and/or the
  maximum number of hours/units allowed

37
Authorization Request

• All requests for authorization MUST be submitted
  via ProviderConnect. The Collaborative will not
  review requests for authorization submitted via
  facsimile.
• If choosing to fax, rather than attach to the
  on-line request, the supporting clinical
  documentation for the request (e.g. MHA, ITP,
  etc.), please ensure that each consumers
  information is faxed separately.
• If choosing to fax, rather than attach to the
  on-line request, the supporting clinical
  documentation for the request (e.g. MHA, ITP,
  etc.), please ensure that the service being
  requested is noted on the fax cover sheet.

38
Authorization request, continued

• Authorization requests for T/C, PSR, and CSG will
  require completion of the following information
  for adults

39
Identifying information
40
Diagnosis
41
LOCUS (Functional Impairment)
42
Services Requested- PSR CSG
43
Services Requested- T/C
44
Transition or Service Termination Plan
45
Ohio/Devereaux Scale Results

• Required for CSG and T/C requests for all
  consumers under the age of 18
• Ohio Scale Results are required for youth ages 5
  through 17
• Service initiation (all)
• Current (if in services more than 90 days)
• Devereaux Scale Results (DECA Subscale for
  children under the age of 5)
• Protective Factor Scores
• Service Initiation (all)
• Current (if in services more than 90 days)
• Behavioral Concern Scores (only for children over
  the age of 3, under the age of 5)
• Service Initiation (all)
• Current (if in services more than 90 days)

46
Ohio/Devereaux Scale Results continued
47
MHA Requirements

• MHA Requirements
• A consumers MHA is required to be submitted as
  part of the authorization process
• The Collaborative Clinical Care Managers will be
  determining if the MHA identifies needs
  consistent with the service being requested.

48
ITP Requirements

• The consumers ITP is required to be submitted as
  a part of the authorization process to assure
  clinical congruence between the
  goals/interventions listed in the ITP, service
  definition criteria, and the LOCUS score/Ohio
  scale/DECA.
• The Collaborative Clinical Care Managers will be
  determining if the treatment plan describes
  interventions and goals consistent with the
  service being requested.

49
Additionally required documentation

• When MHA and ITP do not appear to fully justify
  or support MNC for the requested service and/or
  appear to have inconsistencies, additional
  documentation must be submitted with the request
• Examples
• Progress notes
• Psychiatric notes/evaluations
• MHA and/or ITP addendums
• A letter of statement from clinician
  acknowledging inconsistencies with explanation of
  rationale for this request
• Must be securely attached to the request or faxed
  to the Collaborative (866-928-7177) within 1
  business day
• If information is necessary to support medical
  necessity but not included with request/received
  within 1 business day, the Collaborative staff
  will contact the provider to explain the
  additional information that is required and the
  request will be closed without review. The
  provider must resubmit the entire request for
  authorization with all supporting documentation.

50
Collaborative review process

• Provider submits a request for authorization
• Collaborative staff verifies
• Information for completeness (documents required
  based upon request type)
• Providers participation status (e.g., contracted
  provider of IL DHS/DMH)
• Providers certification status to provide
  requested service
• Consumer information is in/available to the
  Collaborative system
• The information in the request is consistent with
  information found in the supporting
  documentation. If inconsistencies are found, the
  provider will be contacted regarding the
  inconsistencies. The request will be closed and
  the provider will be required to resubmit the
  request with all supporting documentation.
• Collaborative clinical care manager (CCM) reviews
  submitted documents for the following 3 elements
• Completeness
• Adherence to Rule 132
• Adherence to Medical Necessity Criteria (MNC)
• If the above 3 elements are met for the
  service(s), the CCM will enter in an
  authorization.

51
Collaborative review process, continued

• If medical necessity IS established, request is
  authorized by CCM and communicated to provider in
  writing
• OR
• If medical necessity is NOT established, the CCM
  contacts provider to seek clarification and offer
  education/consultation regarding authorization
  criteria
• The Collaborative and the Provider will reach
  mutual agreement with respect to next steps
  (e.g., additional information will be submitted
  for review, alternative service will be
  considered, etc.)
• OR
• If mutual agreement has NOT occurred and provider
  believes medical necessity is present, the CCM
  will forward information to a Collaborative
  physician advisor (PA) reviewer
• PA reviews and either authorizes OR denies
  authorization

52
Collaborative review process, continued

• Turn around time (TAT) for authorization requests
• The Collaborative will respond to requests for
  authorizations within 7 business days of receipt
  of a completed authorization request.

53
Provider requests for Reconsideration and Appeal
related to denial of authorization

• 2 levels
• 1st ? Request for Reconsideration
• 2nd? DMH Directors review
• The Collaborative staff is not involved in this
  level
• This shall be a review to ensure that all
  applicable procedures have been correctly applied
  and followed

54
Provider requests for Reconsideration and Appeal
related to denial of authorization

• In the case of a denial of authorization-- If the
  provider, consumer, or designated representative
  disagrees with the clinical decision, a
  Reconsideration may be initiated in writing or by
  phone.
• The Reconsideration must be requested within 30
  days after the denial.
• The review will be conducted by a Collaborative
  PA.
• Not the same PA who issued the original denial
• Not a subordinate of the PA who issued the
  original denial
• The review and notification by phone will be
  completed by the Collaborative within 15 days of
  the receipt of the reconsideration request.
• Outcome ? Either
• Reversal of the denial decision
• Upholding of the denial decision

55
Provider requests for Appeal related to denial of
authorization

• DMH Directors review
• If the provider, consumer, or designated
  representative disagrees with the outcome of the
  Reconsideration request, an Appeal may be filed
  within 5 days of receipt of the outcome of the
  reconsideration request.
• This review shall not be a clinical review, but
  rather a review to ensure that all applicable
  appeal procedures have been correctly applied and
  followed.
• The final administrative decision shall be
  subject to judicial review exclusively as
  provided in the Administrative Review Law 735
  ILCS 5/Art. III.

56
Summary

• Utilization Management Program is being
  implemented to ensure responsible management of
  resources
• Plans of care for individuals for whom
  reimbursement from DMH will be sought should be
  based on the Medical Necessity Guidance/Criteria
  Manual published within the DMH Provider Manual
• In order to be reimbursed for services, providers
  must follow the utilization management program as
  it applies to individual situations
• Authorization request reflecting the most current
  clinical presentation as documented in the
  consumer record must be sent to the Collaborative
• The Collaborative Clinical Care Managers will
  review authorization requests and issue a
  decision within 7 days.
• If an authorization request is denied, the
  provider or consumer may request a
  reconsideration of that decision
• If a request for reconsideration also results in
  denial of authorization, there is an appeals
  process through the Director of DMH and finally
  through the administrative law process at
  Healthcare and Family Services

57

Questions?
58
Thank you!
Illinois Mental Health Collaborative for Access
and Choice