Department of Medical Assistance Services

1
Department of Medical Assistance Services
COMMUNITY MENTAL HEALTH REHABILATATIVE
SERVICES
Prior Authorization Implementation
April May 2009
2

• This presentation is to facilitate training of
  the subject matter in portions of the
• Virginia Medicaid manuals (and updates)
• Training material contains only
  highlights of manuals and is not meant
  to substitute for or take the place of the
  Community Mental Health
  Rehabilitative Services Manual.
• For a complete
  copy of manual

www.dmas.virginia.gov
3
Objectives of Todays Training

• Discuss Intensive Community Treatment PA

• Discuss Psychosocial Rehab PA

• Discuss Mental Health Support Services PA

• Discuss Therapeutic Day Treatment PA

• Discuss Partial Hospital PA

• Discuss Mental Health Targeted Case
  Management PA

• Questions

4
All OF THE COMMUNITY MENTAL HEALTH SERVICES..

• have four specific components

• Service Definition
• Eligibility requirements
• Activities which are required
• Limitations of the Service

5
Intensive Community Treatment (H0039)
6
SERVICE DEFINITION

• Intensive Community Treatment (ICT) is.
• an array of mental health services.
• for adults
• with a serious emotional illness
• who need intensive levels of support service
• in their natural environment to permit or
  enhance functioning in the community.

7
SERVICE DEFINITION contd.

• Intensive Community Treatment (ICT) has been
  designed to be provided through a designated
  multi-disciplinary team of mental health
  professionals
• It is available either directly or on call 24
  hours per day, seven days per week, 365 days per
  year.

8
Eligibility Criteria

• The individuals must meet one or more of the
  following criteria
• Is at high-risk for psychiatric hospitalization
  or for becoming/remaining homeless or requires
  intervention by the mental health or criminal
  justice system due to inappropriate social
  behavior.
• Has a history (3 months or more) of a need for
  intensive mental health treatment or treatment
  for serious mental illness chemical addiction
  and demonstrates a resistance to seek out and
  utilize appropriate treatment options.

9
Co-occurring Mental Health and Substance Abuse
Disorders

• If an individual has co-occurring mental health
  and substance abuse disorders, integrated
  treatment for both disorders is allowed within
  ICT services as long as the treatment for the
  substance abuse condition is intended to
  positively impact the mental health condition.

10

Required Activities

• An assessment which documents eligibility and
  need for this service shall be completed by the
  LMHP or the QMHP prior to the initiation of
  services. This assessment must be maintained in
  the individual's records
• The recipient is certified by a LMHP as being in
  need of the services.
• (Please note other required activities listed in
  the CMHRS manual)

11
Assessment Code for ICT
New

• The Assessment billing code is
  H0032, Modifier U9 (available August 1, 2009)
• Assessment codes never require PA
• Limit is 2 per provider per fiscal year
• Used for new and existing recipients (initial and
  reassessment)
• Provider bills assessment code with modifier for
  1 unit.
• Rate is the current unit rate for the service
• 139/unit (rural) 153/unit (urban)

12
For New Admissions

• Individuals that have not had treatment between
  January 1, 2009 and July 31, 2009 are considered
  new admission cases.
• Must bill the appropriate assessment code (with
  modifier) to determine needs (start Aug 1, 2009
• The provider gets the 5 units without PA only
  first time in treatment as of 8/1/09 (New admits)

13
New Admissions, contd.

• If services are to continue (beyond the allowable
  units without PA), provider must contact KePRO
  to obtain PA. PA will be allowed for up to 6
  month increments
• Provider bills service using the treatment code
  after assessment is completed (after the
  allowable service limits are used, if no PA the
  claim will deny)

14
For Existing Recipients

• Individuals currently receiving services are
  defined as those that have been receiving service
  on or after January 1, 2009.
• System edit will look to see if previous service
  claims are found, classify as existing recipient
  and PA will be required for services - there is
  no 5 unit service limit for existing
  individuals
• May bill for reassessment to determine
  continued need for services (maximum of 2 per
  provider per fiscal year for each service and
  does not require PA)

15
Prior Authorization Process for ICT
New

• Changes to the Program
• Effective August 1, 2009, Prior Authorization
  will be required for Intensive Community
  Treatment for individuals currently receiving
  treatment, as well as new cases.
• This will change from a self-approval /
  authorization process, currently performed by
  the LMHP provider, to a prior authorization
  process conducted by KePRO using DMAS criteria.
• KePRO will be describing the specific details
  regarding the PA request process.

16
Service Units Maximum Service Limitations

• A unit equals one hour.
• There is a limit of 130 units annually. Starting
  August 1, 2009 and each July 1st thereafter, all
  service limits will be set to zero.
• The fiscal year period for the start up of this
  process will be August 1, 2009 through June 30,
  2010. All subsequent fiscal years will be July 1
  through June 30.
• As of August 1 there will be a payment edit that
  cuts back or denies payment for any service
  billed beyond 130 units.

17
Prior Authorization Requirements

• For new clients admitted on or after August 1,
  2009 (after initial assessment) providers have
  five units to begin providing service. For any
  services to be paid beyond five units a PA is
  required.
• For clients currently receiving services, the
  provider should request PA after their next 6
  month re-assessment review for continued
  service. For continued payment all current
  clients must have a PA by January 1, 2010.

18
Prior Authorization Requirements

• The provider will need to submit recipients
  demographic information also include the
  following
• Procedure Code H0039
• PA Service Type - 0650
• Number of units requested
• From Through dates (span 6 months)

19
Initial Review (New Recipient to Provider)

• For ICT services, individuals must meet the
  Diagnostic Statistical Manual of Mental
  Disorders, Fourth Edition, Text Revision
  (DSM-IV-TR) diagnostic criteria for an Axis I or
  Axis II Mental Health Disorder. (DMAS
  requirement)
• If this is a dual diagnosis of Mental Health (MH)
  and SA, services must be integrated.

20
Initial Review (New Recipient to Provider)

• The individual must meet one or more of the
  following criteria (describe symptoms that
  interfere with primary activities of daily living
  ADLs that prevent independent functioning and
  intensive treatment and support)
• o Is at high risk for psychiatric
  hospitalization or for becoming or remaining
  homeless, or require intervention by the mental
  health or criminal justice system due to
  inappropriate social behavior
• ? Describe risk
• ? Describe problems in ability to form
  relationships
• ? Describe role performance at work, school and
  in caring for dependents
• ? Describe support system or lack thereof
  and/or

21
Initial PA Request contd.

• o Has a history (three months or more) of a need
  for intensive mental health treatment or
  treatment for serious mental illness and
  substance abuse and demonstrates a resistance to
  seek out and utilize traditional treatment
  options.
• ? Describe need
• ? Describe resistance to treatment

22
Initial PA Request contd.

• KePRO will prior authorize services in 6 month
  increments
• Initial requests will be approved (based on the
  medical necessity) for up to 6-months for up to
  one half the service units available.
• Denials of services for medical necessity may be
  resubmitted at a later date when the individual
  meets criteria

23
PA For Continued Treatment

• Continued PA is required within 30 days prior to
  end of previous authorization
• DSM- IV-TR, Axis I Mental Health Disorder is
  required. V codes are not acceptable as a stand
  alone diagnoses.
• Within past month
• Describe symptoms and behaviors
• Describe recipients functioning to include
• Social/interpersonal behavior
• Ability to manage IADLs
• Medication compliance (or lack)
• Program Compliance

24
PA For Continued Treatment

• Continued service requests will be approved for
  up to 6-month increments for the remaining annual
  service limit.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

25
Questions
26
Psychosocial Rehabilitation (H2017)
27
Psychosocial Rehabilitation (H2017)

• SERVICE DEFINITION
• Psychosocial Rehabilitation Services are
  provided to groups of adult individuals in a
  nonresidential setting.
• These services include assessment, education to
  teach the patient about the diagnosed mental
  illness and appropriate medications to avoid
  complication and relapse, opportunities to learn
  and use independent living skills and to enhance
  social and interpersonal skills within a
  supportive and normalizing program structure and
  environment.
• Programs must be 2 or more hours per day

28
Eligibility Criteria

• The individual must demonstrate
• clinical necessity for the service arising
  from a condition due to
• mental
• behavioral
• emotional illness
• That results in significant functional
  impairments in major life activities.

29
Eligibility Criteria contd.

• Individuals must meet at least two of the
  following on a continuing or intermittent
  basis..
• Have difficulty in establishing or maintaining
  normal interpersonal relationships to such a
  degree that they are at risk of hospitalization
  or homelessness because of conflicts with family
  or community.

30
Eligibility Criteria contd.

• Require help in basic living skills such as.
• maintaining personal hygiene
• preparing food maintaining adequate nutrition
• managing finances to such a degree that health
  or safety is jeopardized.

31
Eligibility Criteria contd.

• Exhibit such inappropriate behavior that repeated
  interventions by the mental health, social
  services or judicial system are necessary.
• Exhibit difficulty in cognitive ability such that
  they are unable to recognize personal danger or
  recognize significantly inappropriate social
  behavior.

32
Eligibility Criteria contd.

• Individuals must meet one of the following..
• Have had long-term or repeated psychiatric
  hospitalization
• or
• Lack daily living skills interpersonal skills
• or

33
Eligibility Criteria contd.

• Have a limited or nonexistent support system
  or
• Be unable to function in the community without
  intensive intervention
• or
• Require long-term services to be maintained in
  the community

34
Co-occurring Mental Health and Substance Abuse
Disorders

• If an individual has co-occurring mental health
  and substance abuse disorders, integrated
  treatment for both disorders is allowed within
  psychosocial rehabilitation services as long as
  the treatment for the substance abuse condition
  is intended to positively impact the mental
  health condition.

35
Required Activities

• Before service initiation
• A face-to-face diagnostic assessment by the QMHP
  and must be approved by a Licensed Mental Health
  Professional within 30 days
• Every 6 months services must be reassessed and
  approved by an LMHP.

36
Assessment Code for PSR
New

• The Assessment billing code is H0032, U6
• Assessment codes never require PA
• Limit is 2 per provider per fiscal year
• Used for new and existing recipients (initial and
  reassessment) Will be available 8/1/2009
• Provider bills assessment code with modifier for
  1 unit.
• Rate is the current unit rate for the service
• 24.23/unit

37
For New Admissions

• Individuals that have not had treatment between
  January 1, 2009 and July 31, 2009 are considered
  new admission cases.
• Must bill the appropriate assessment code (with
  modifier) to determine needs
• The provider gets the 10 units without PA only
  first time in treatment as of 8/1/09 (New admits)
• Provider bills using treatment code-- after
  assessment is completed (after allowable service
  limits used, if no PA the claim will deny)

38
For Existing Recipients

• Individuals currently receiving services are
  defined as those that have been receiving service
  on or after January 1, 2009.
• System edit will look to see if previous service
  claims are found, classify as existing recipient
  and PA will be required for services - there is
  no 10 unit service limit for existing
  individuals
• May bill for reassessment to determine
  continued need for services (2 per provider per
  fiscal year for each service and does not require
  PA)

39
Prior Authorization Process for PSR
New

• Changes to the Program
• Effective August 1, 2009, Prior Authorization
  will be required for PSR for individuals
  currently receiving treatment, as well as new
  cases. This will change from a self-approval /
  authorization process, currently performed by
  the LMHP provider, to a prior authorization
  process conducted by KePRO.
• KePRO will be describing the specific details
  regarding the PA request process.

40
Service Units Maximum Service Limitations
Services are limited annually to 936 units per
year. Starting August 1, 2009 and each July 1st
thereafter, all service limits will be set to
zero. The fiscal year period for the start up of
this process will be August 1, 2009 through June
30, 2010. All subsequent fiscal years will be
July 1 through June 30. 1 unit of service 2
-3.99 hours 2 units of service 4 6.99
hours 3 units of service 7 or more hours

41
Prior Authorization Requirements

• For new clients after initial assessment
  providers have ten units to begin providing
  service. For any services to be paid beyond ten
  units a PA is required.
• For clients currently receiving services, the
  provider should request PA at their next 6 month
  re-assessment review for continued service. For
  continued payment all current clients must have a
  PA by January 1, 2010.

42
Prior Authorization Requirements

• The provider will need to submit recipients
  demographic information also include the
  following
• Procedure Code H2017
• PA Service Type - 0650
• Number of units requested
• From Through dates (span 6 months)
• (Must be registered with i-EXCHANGE to submit
  requests)

43
Initial Review (New Recipient to Provider)
For PSR, individuals must meet the Diagnostic
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR) diagnostic
criteria for an Axis I Mental Health Disorder. V
codes are not acceptable as stand alone
diagnoses. If there is a dual diagnosis of
Mental Health (MH) and SA, services must be
integrated. Confirmation that a face-to-face
assessment was completed by QMHP prior to
treatment, with approval by a LMHP to be done
within 30 days of admission.
44
Initial PA Request contd.

• Describe symptoms/severity of illness
• Individual must exhibit significant functional
  impairments in major life activities due to a
  mental, behavioral, or emotional illness.
• Describe how individual meets two of the
  following
• Have difficulty establishing or maintaining
  normal interpersonal relationships to the degree
  they are at risk of hospitalization, homelessness
  because of conflicts with family or community,
  or

45
Initial PA Request contd.

• Have behaviors that require repeated
  interventions by the mental health, social
  services or judicial system or
• Be unable to recognize personal danger or
  significantly inappropriate social behavior or
• Require help in basic living skills to such a
  degree that health or safety is jeopardized.

46
Initial PA Request contd.

• Describe how individual meets one of the
  following
• Have experienced long-term or repeated
  psychiatric hospitalizations or
• Lack daily living skills and interpersonal
  skills or
• Have limited or non-existent support system or
• Be unable to function in community without
  intensive intervention or
• Require long-term services to be maintained in
  the community.

47
Initial PA Request contd.

• KePRO will prior authorize services in 6 month
  increments
• Initial requests will be approved (based on the
  medical necessity) for up to 6-months for up to
  one half the service units available.
• Denials of services for medical necessity may be
  resubmitted at a later date when the individual
  meets criteria

48
PA For Continued Treatment

• Continued PA is required prior to end of
  previous authorization
• For PR, individuals must meet DSM-IV diagnostic
  criteria for an Axis I or Axis II Mental Health
  Disorder. V codes are not acceptable as stand
  alone diagnoses

49
PA For Continued Treatment

• MUST describe how continues to meet two of the
  following
• Have difficulty establishing or maintaining
  normal interpersonal relationships to the degree
  they are at risk of hospitalization,
  homelessness, or
• Have behaviors that require repeated
  interventions by the mental health, social
  services or judicial system or

50
PA For Continued Treatment

• Be unable to recognize personal danger or
  significantly inappropriate social behavior or
• Require help in basic living skills to such a
  degree that health or safety is jeopardized.

51
PA For Continued Treatment

• Individual must continue to meet one of the
  following
• Have experienced long-term or repeated
  psychiatric hospitalizations or
• Lack daily living skills and interpersonal
  skills or
• Have limited or non-existent support system or
• Be unable to function in the community without
  intensive intervention or
• Require long-term services to be maintained in
  the community.

52
PA For Continued Treatment

• KePRO will approve continued service requests
  (based on PA criteria) for up to 6-month
  increments for the remaining annual service
  limit.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

53
Questions
54
Mental Health Support Services (H0046)
55
Service Definition

• Training and supports to enable individuals to
  achieve and maintain community stability
  independence in the most appropriate, least
  restrictive environment.
• Services may be authorized for six consecutive
  months.

56
A Minimum age for MHSS

• The treatment focus is on assisting the client
  with independent living skills training and is
  therefore appropriate for recipients that are a
  minimum of 16 years or older.

57
Eligibility Criteria

• Individuals must demonstrate a clinical need for
  this service arising from a condition due to
  mental, behavioral, or emotional illness which
  results in significant functional impairments in
  major life activities.

58
Eligibility Criteria contd.

• The individual must meet at least two of the
  following on a continuing or intermittent basis
• Experiencing difficulty in establishing or
  maintaining normal interpersonal relationships to
  such a degree that they are at risk of
  hospitalization, homelessness, because of
  conflicts with family or community, or

59
Eligibility Criteria contd.

• Exhibit such inappropriate behavior that repeated
  interventions by the mental health, social
  services, or judicial system are necessary.
• Exhibit difficulty in cognitive ability such that
  they are unable to recognize personal danger or
  recognize significantly inappropriate social
  behavior.

60
Eligibility Criteria contd.

• Require help in basic living skills, such as.
• maintaining personal hygiene
• preparing food maintaining adequate nutrition
  or
• managing finances to such a degree that health or
  safety is jeopardized.

61
Eligibility Criteria contd.

• Co-Occurring Mental Health and Substance Abuse
  Disorders
• Integrated treatment for both disorders is
  allowed as long as the treatment for the
  substance abuse condition is intended to
  positively impact the mental health condition.
• The impact of the substance abuse condition on
  the mental health condition must be documented in
  the assessment, the ISP, and the progress notes.

62
Required Activities

• The QMHP must
• Document the assessment or evaluation (or both)
  PRIOR to initiation or reauthorization of
  servicesno more than 30 days prior to the
  initiation/re-start of services.
• If the assessment is completed by a QMHP, a LMHP
  must review and sign the assessment. A LMHP must
  approve the assessment within 30 days of
  admission and every 6 months for continued care

63
Assessment Code for MHSS
New

• The Assessment billing code is H0032, U8
• Assessment codes never require PA
• Limit is 2 per provider per fiscal year
• Used for new and existing recipients (initial and
  reassessment) Will be available 8/1/2009
• Provider bills assessment code with modifier for
  1 unit.
• Rate is the current unit rate for the service
• 83/ 1 unit (rural) 91/1 unit (urban)

64
For New Admissions

• Individuals that have not had treatment between
  January 1, 2009 and July 31, 2009 are considered
  new admission cases.
• Must bill the appropriate assessment code (with
  modifier) to determine needs
• The provider gets the 5 units without PA only
  first time in treatment as of 8/1/09 (New admits)

65
For New Admissions, contd.

• If services are to continue (beyond the allowable
  units without PA), provider must contact KePRO
  to obtain PA. PA will be allowed for up to 6
  month increments
• Provider bills using treatment code-- after
  assessment is completed (after allowable service
  limits used, if no PA the claim will deny)

66
For Existing Recipients

• Individuals currently receiving services are
  defined as those that have been receiving service
  on or after January 1, 2009.
• System edit will look to see if previous service
  claims are found, classify as existing recipient
  and PA will be required for services - there is
  no 5 unit service limit for existing
  individuals
• May bill for reassessment to determine
  continued need for services (a maximum of 2 per
  provider per fiscal year for each service and
  does not require PA)

67
Prior Authorization Process for MHSS
New

• Changes to the Program
• Effective August 1, 2009, Prior Authorization
  will be required for MHSS for individuals
  currently receiving treatment, as well as new
  cases. This will change from a self-approval /
  authorization process, currently performed by
  the LMHP provider, to a prior authorization
  process conducted by KePRO.
• KePRO will be describing the specific details
  regarding the PA request process.

68
Service Units Limitations

• Services are limited annually to 372 units per
  year. Starting August 1, 2009 and each July 1st
  thereafter, all service limits will be set to
  zero.
• The fiscal year period for the start up of this
  process will be August 1, 2009 through June 30,
  2010. All subsequent fiscal years will be July 1
  through June 30.
• One unit is 1 - 2.99 hours
• Two units 3 - 4.99 hours
• Three units 5 - 6.99 hours
• Four units 7 hours
• (Time may be accumulated to a billable unit)

69
Prior Authorization Requirements

• For new clients after assessment --providers
  have five units to begin providing service. For
  any services to be paid beyond five units a PA is
  required.
• For clients currently receiving services, the
  provider should request PA at their next 6 month
  re-assessment review for continued service. For
  continued payment all current clients must have a
  PA by January 1, 2010.

70
Prior Authorization Requirements

• The provider will need to submit recipients
  demographic information also include the
  following
• Procedure Code H0046
• PA Service Type - 0650
• Number of units requested
• From Through dates (span 6 months)

71
Initial Review (New Recipient to Provider)
For MHSS, individuals must meet the Diagnostic
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR) diagnostic
criteria for an Axis I or Axis II Mental Health
Disorder. V codes are not acceptable as stand
alone diagnoses. If there is a dual diagnosis
of Mental Health (MH) and SA, services must be
integrated.
72
Initial PA Request contd.

• Describe symptoms/severity of illness
• Individual must exhibit significant functional
  impairments in major life activities due to a
  mental, behavioral, or emotional illness.
• Describe how meets two of the following
• Have difficulty establishing or maintaining
  normal interpersonal relationships to the degree
  they are at risk of hospitalization,
  homelessness, or isolation from social supports
• Have behaviors that require repeated
  interventions by the mental health, social
  services or judicial system or

73
Initial PA Request contd.

• Be unable to recognize personal danger or
  significantly inappropriate social behavior or
• Require help in basic living skills to such a
  degree that health or safety is jeopardized.
• KePRO will prior authorize services in 6 month
  increments
• Initial requests will be approved (based on the
  medical necessity) for up to 6-months for up to
  one half the service units available.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

74
PA For Continued Treatment (Same Provider)

• Continued PA is required prior to end of
  previous authorization
• For MHSS, individuals must meet DSM-IV
  diagnostic criteria for an Axis I or Axis II
  Mental Health Disorder. V codes are not
  acceptable as stand alone diagnoses

75
PA For Continued Treatment

• MUST continue to meet two of the following
• Have difficulty establishing or maintaining
  normal interpersonal relationships to the degree
  they are at risk of hospitalization,
  homelessness, or isolation from social supports
• Have behaviors that require repeated
  interventions by the mental health, social
  services or judicial system or
• Be unable to recognize personal danger or
  significantly inappropriate social behavior or
• Require help in basic living skills to such a
  degree that health or safety is jeopardized.

76
PA For Continued Treatment

• Continued service requests will be approved for
  up to 6-month increments for the remaining annual
  service limit.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

77
Questions
78
DMAS RESOURCES TO CHECK SERVICE LIMITS

• MediCall Automated Voice Response System
• A telephone voice response system to
• Confirm recipient eligibility status
• Obtain up-to-date status on a claim and
• Check on the status of recent claim remittances.
• Not for use by recipients.

79
Resources to Check Service Limits

• Accessing the system
• Have a currently active Medicaid provider number
• Limited number of inquires per session
• Call either a toll-free or local Richmond number
• 1-800-772-9996 - Toll-free
• 1-800-884-9730 - Toll-free
• 804- 965-9732 Richmond Area

80
Resources to Check Service Limits

• 2. Automated Response System (ARS)
• An Internet Web-enabled tool to
• Access current enrollee eligibility information,
  service limits, claim status, prior
  authorizations, provider check status
• Inquires submitted in real-time quickly and
  conveniently

81
Resources to Check Service Limits

• Accessing the System
• For current Medicaid and FAMIS providers
• No limit on the number of inquiries per session
• Need internet connect, PC, and a web browser
• https//uac.fhsc.com/uac/pages/unsecured/common/ho
  me.jsf

82
Resources to Check Service Limits

• 3. HELPLINE
• A telephonic (live response) tool to assist
  Providers in
• Interpreting Medicaid policy and procedures and
  in
• Resolving problems with individual claims
• Do not use the HELPLINE for recipient eligibility
  verification and eligibility questions

83
Resources to Check Service Limits

• 3. HELPLINE
• Accessing the System
• Available Monday through Friday from 830 a.m. to
  430 p.m., except on State holidays
• Medicaid Provider number must accompany all
  inquiries
• For providers only - do not give the HELPLINE
  numbers to recipients.
• Local and Toll-free numbers
• 804-786-6273 - Richmond Area and out-of-state
  long distance
• 1-800-552-8627 - In-state long distance (toll
  free)

84
Therapeutic Day Treatment for Children
Adolescents (H0035)

• SERVICE DEFINITION
• Psychotherapeutic interventions combined with
  medication education and mental health treatment
• Offered in programs of 2 or more hours per day
  with groups of children/adolescents

85
TDT Eligibility Criteria

• Individual demonstrates a
• Mental, behavioral or emotional illness
• resulting in significant functional impairments
  in major life activities
• Impairment has become more disabling over time
• Require significant intervention services
  offered over a period of time that are
• Supportive Intensive

86
TDT Eligibility Criteria

• Individuals must meet at least two
• 1. Difficulty in establishing or maintaining
  normal interpersonal relationships, at risk of
  hospitalization or out-of-home placement because
  of conflicts with family/community
• 2. Exhibit inappropriate behavior
• Repeated interventions in the community-
• by mental health agencies
• by social service agencies
• by judicial system

87
TDT Eligibility Criteria contd.

• 3. Exhibit difficulty in cognitive ability
• Unable to recognize...
• personal danger OR
• significantly inappropriate social behavior
• This service is designed for youth who meet one
  of the following
• Require year-round treatment in order to sustain
  behavioral or emotional gains,
• or

88
TDT Eligibility Criteria

• Have behavior/emotional problems so severe they
  cannot be handled in self-contained or special
  classrooms (ED) without this programming during
  the school day or as a supplement to the school
  day/year,
• or
• Would otherwise be placed on homebound
  instruction because of behavior,
• or

89
TDT Eligibility Criteria contd.

• or
• Have deficits in
• social skills
• peer relations
• dealing with authority
• are hyperactive
• have poor impulse control
• are extremely depressed
• marginally connected with reality
• or

90
TDT Eligibility Criteria contd.

• or
• Preschool child in an enrichment early
  intervention program cannot function in this
  program (due to the severity of their
  emotional/behavioral problems) without these
  additional services.

91
TDT Required Activities

• Before service initiation
• A face-to-face diagnostic assessment by QMHP
  with review authorization by LMHP prior to
  service initiation.
• The assessment must be reviewed and updated at
  least annually.
• An ISP must be completed by a QMHP, documenting
  the need for services within 30 days of service
  initiation.

92
Assessment Code for TDT
New

• The Assessment billing code is
  H0032 Modifier U7
• Assessment codes never require PA
• Limit is 2 per provider per fiscal year
• Used for new and existing recipients (initial and
  reassessment) Will be available 8/1/2009
• Provider bills assessment code with modifier for
  1 unit.
• Rate is the current unit rate for the service
• 38.05/unit

93
For New Admissions

• Individuals that have not had treatment between
  January 1, 2009 and July 31, 2009 are considered
  new admission cases.
• Must bill the appropriate assessment code (with
  modifier) to determine needs
• The provider gets the 5 units without PA only
  first time in treatment as of 8/1/09 (New admits)

94
For New Admissions

• If services are to continue (beyond the allowable
  units without PA), provider must contact KePRO
  to obtain PA. PA will be allowed for up to 6
  month increments
• Provider bills using treatment code-- after
  assessment is completed (after allowable service
  limits used, if no PA the claim will deny)

95
For Existing Recipients

• Individuals currently receiving services are
  defined as those that have been receiving service
  on or after January 1, 2009.
• System edit will look to see if previous service
  claims are found, classify as existing recipient
  and PA will be required for services - there is
  no 5 unit service limit for existing
  individuals
• May bill for reassessment to determine
  continued need for services (2 per provider per
  fiscal year for each service and does not require
  PA)

96
Prior Authorization Process for TDT
New

• Changes to the Program
• Effective August 1, 2009, Prior Authorization
  will be required for TDT for individuals
  currently receiving treatment, as well as new
  cases. This will change from a self-approval /
  authorization process, currently performed by
  the LMHP provider, to a prior authorization
  process conducted by KePRO.
• KePRO will be describing the specific details
  regarding the PA request process.

97
Service Units Limitations

• Services are limited annually to 780 units per
  year. Starting August 1, 2009 and each July 1st
  thereafter, all service limits will be set to
  zero.
• The fiscal year period for the start up of this
  process will be August 1, 2009 through June 30,
  2010. All subsequent fiscal years will be July 1
  through June 30.
• One Unit of service is defined as a minimum of
  two hours on a given day.

98
Prior Authorization Requirements

• For new clients after assessment --providers
  have five units to begin providing service. For
  any services to be paid beyond five units a PA is
  required.
• For clients currently receiving services, the
  provider should request PA at their next review
  for continued service. For continued payment all
  current clients must have a PA by January 1,
  2010.

99
Prior Authorization Requirements

• The provider will need to submit recipients
  demographic information also include the
  following
• Procedure Code H0035
• PA Service Type - 0650
• Number of units requested
• From Through dates (span 6 months)

100
Initial Review (New Recipient to Provider)

• For TDT, individuals must DSM IV Axis I Mental
  Health Disorder. V codes are not acceptable as
  stand alone diagnoses.
• If there is a dual diagnosis of Mental Health
  (MH) and SA, services must be integrated.
• Confirmation of face-to-face diagnostic
  assessment by a QMHP, with approval by a LMHP
  prior to start of service.
• Confirm plan for a minimum of two hours per day
  programming with a minimum of two therapeutic
  activities daily.

101
Initial PA Request contd.

• Describe symptoms/severity of illness
• Children must exhibit significant functional
  impairments in major life activities due to a
  mental, behavioral, or emotional illness, which
  has become more disabling over time.
• Must describe how meets two of the following
• Have difficulty establishing or maintaining
  normal interpersonal relationships to the degree
  they are at risk of hospitalization or out of
  home placement or
• Have behaviors that require repeated
  interventions by the mental health, social
  services or judicial system or
• Be unable to recognize personal danger or
  significantly inappropriate social behavior.

102
Initial PA Request contd.

• Must describe how meets one of the following
• Requires year-round treatment to sustain
  behavioral or emotional gains or
• Have problems so severe cannot be maintained in
  self-contained or resource (ED) classrooms
  without programming during the school day or as
  supplement to school day or
• Would otherwise be placed on homebound
  instruction due to severe emotional or behavioral
  problems that interfere with learning or
• Have emotional or behavioral problems so severe
  the child cannot function in preschool enrichment
  or early intervention programs without additional
  services.

103
Initial PA Request contd.

• KePRO will prior authorize services in 6 month
  increments
• Initial requests will be approved (based on the
  medical necessity) for up to 6-months for up to
  one half the service units available.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

104
PA For Continued Treatment

105
PA For Continued Treatment

• For TDT, individuals Axis I Mental Health
  Disorder. V codes are not acceptable as stand
  alone diagnoses.
• MUST describe how continues to meet two of the
  following
• Have difficulty establishing or maintaining
  normal interpersonal relationships to the degree
  they are at risk of hospitalization or out of
  home placement or
• Have behaviors that require repeated
  interventions by the mental health, social
  services or judicial system or
• Be unable to recognize personal danger or
  significantly inappropriate social behavior.

106
PA For Continued Treatment

• Must describe how individual continues to meet
  one of the following
• Requires year-round treatment to sustain
  behavioral or emotional gains or
• Have problems so severe cannot be maintained in
  self-contained or resource (ED) classrooms
  without programming during the school day or as
  supplement to school day or

107
PA For Continued Treatment

• Would otherwise be placed on homebound
  instruction due to severe emotional or behavioral
  problems that interfere with learning or
• Have emotional or behavioral problems so severe
  the child cannot function in preschool enrichment
  or early intervention programs without additional
  services.

108
PA For Continued Treatment

• Continued service requests will be approved for
  up to 6-month increments for the remaining annual
  service limit.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

109
Questions
110
Day Treatment / Partial Hospitalization (H0035)
111
SERVICE DEFINITION

• DT/PH is a combination of diagnostic, medical,
  psychiatric, psychosocial and psycho-educational
  treatment modalities for individuals age 21
  older with serious mental disorders who require
  coordinated, intensive, comprehensive, and
  multidisciplinary treatment who do not require
  inpatient treatment.
• Services are offered in programs of two or more
  hours per day provided to groups of individuals
  in a non-residential setting.

112
Eligibility Criteria

• The individual must demonstrate
• clinical necessity for the service arising
  from a condition due to
• mental
• behavioral
• emotional illness
• That results in significant functional
  impairments in major life activities.

113
Eligibility Criteria contd.

• Individuals must meet at least two of the
  following on a continuing or intermittent
  basis..
• Have difficulty in establishing or maintaining
  normal interpersonal relationships to such a
  degree that they are at risk of hospitalization
  or homelessness or conflicts with family or
  community.

114
Eligibility Criteria contd.

• Require help in basic living skills such as.
• maintaining personal hygiene
• preparing food maintaining adequate nutrition
• managing finances to such a degree that health
  or safety is jeopardized.

115
Eligibility Criteria contd.

• Exhibit such inappropriate behavior that repeated
  interventions by the mental health, social
  services or judicial system are necessary.
• Exhibit difficulty in cognitive ability such that
  they are unable to recognize personal danger or
  recognize significantly inappropriate social
  behavior.

116
Co-occurring Mental Health and Substance Abuse
Disorders

• If an individual has co-occurring mental health
  and substance abuse disorders, integrated
  treatment for both disorders is allowed within
  psychosocial rehabilitation services as long as
  the treatment for the substance abuse condition
  is intended to positively impact the mental
  health condition.

117
Required Activities

• Before service initiation
• A face-to-face diagnostic assessment
  authorization by a Licensed Mental Health
  Professional/Certified Psychiatric Nurse
• Within 30 days of service initiation
• An ISP by a QMHP, documenting the need for
  services

118
Assessment Code for DT/PH
New

• The Assessment billing code is H0032,
  Modifier U7
• Assessment codes never require PA
• Limit is 2 per provider per fiscal year
• Used for new and existing recipients (initial and
  reassessment) Will be available 8/1/2009
• Provider bills assessment code with modifier for
  1 unit.
• Rate is the current unit rate for the service
• 38.05/unit

119
For New Admissions

• Individuals that have not had treatment between
  January 1, 2009 and July 31, 2009 are considered
  new admission cases.
• Must bill the appropriate assessment code (with
  modifier) to determine needs
• The provider gets the 5 units without PA only
  first time in treatment as of 8/1/09 (New admits)

120
For New Admissions

• If services are to continue (beyond the allowable
  units without PA), provider must contact KePRO
  to obtain PA. PA will be allowed for up to 6
  month increments
• Provider bills using treatment code-- after
  assessment is completed (after allowable service
  limits used, if no PA the claim will deny)

121
For Existing Recipients

• Individuals currently receiving services are
  defined as those that have been receiving service
  on or after January 1, 2009.
• System edit will look to see if previous service
  claims are found, classify as existing recipient
  and PA will be required for services - there is
  no 5 unit service limit for existing
  individuals
• May bill for reassessment to determine
  continued need for services (2 per provider per
  fiscal year for each service and does not require
  PA)

122
Prior Authorization Process for DT/PH
New

• Changes to the Program
• Effective August 1, 2009, Prior Authorization
  will be required for DT/PHP for individuals
  currently receiving treatment, as well as new
  cases. This will change from a self-approval /
  authorization process, currently performed by
  the LMHP provider, to a prior authorization
  process conducted by KePRO.
• KePRO will be describing the specific details
  regarding the PA request process.

123
Service Units Service Limitations
Services are limited annually to 780 units per
year. Starting August 1, 2009 and each July 1st
thereafter, all service limits will be set to
zero. The fiscal year period for the start up of
this process will be August 1, 2009 through June
30, 2010. All subsequent fiscal years will be
July 1 through June 30. 1 unit of service 2 -
3.99 hours 2 units of service 4 6.99
hours 3 units of service 7 or more hours

124
Prior Authorization Requirements

• For new clients after assessment --providers
  have five units to begin providing service. For
  any services to be paid beyond five units a PA is
  required.
• For clients currently receiving services, the
  provider should request PA at their next 6 month
  re-assessment review for continued service. For
  continued payment all current clients must have a
  PA by January 1, 2010.

125
Prior Authorization Requirements

• The provider will need to submit recipients
  demographic information also include the
  following
• Procedure Code H0035
• PA Service Type - 0650
• Number of units requested
• From Through dates (span 6 months)

126
Initial Review (New Recipient to Provider)
For DT/PH individuals must have a DSM-IV Axis I
or Axis II Mental Health Disorder. V codes are
not acceptable as stand alone diagnoses. If
there is a dual diagnosis of Mental Health (MH)
and SA, services must be integrated.
127
Initial PA Request contd.

• Describe symptoms/severity of illness
• Individual must exhibit significant functional
  impairments in major life activities due to a
  mental, behavioral, or emotional illness.
• Describe how meets two of the following
• Have difficulty in establishing or maintaining
  normal interpersonal relationships to such a
  degree that they are at risk of hospitalization
  or homelessness because of conflicts with family
  or community or

128
Initial PA Request contd.

• Require help in basic living skills such as
  maintaining personal hygiene, preparing food and
  maintaining adequate nutrition, or managing
  finances to such a degree that health or safety
  is jeopardized.
• Have behaviors that require repeated
  interventions by mental health, social services,
  or judicial system are necessary.
• Be unable to recognize personal danger or
  recognize significantly inappropriate social
  behavior.

129
Initial PA Request contd.

• KePRO will prior authorize services in 6 month
  increments
• Initial requests will be approved (based on the
  medical necessity) for up to 6-months for up to
  one half the service units available.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

130
PA For Continued Treatment

• Continued PA is required within 30 days prior to
  end of previous authorization
• For DT/ PH, individuals must DSM IV Axis I or
  Axis II Mental Health Disorder. V codes are not
  acceptable as stand alone diagnoses

131
PA For Continued Treatment

• MUST continue to describe how the individual
  meets two of the following
• Have difficulty in establishing or maintaining
  normal interpersonal relationships to such a
  degree that they are at risk of hospitalization
  or homelessness because of conflicts with family
  or community or
• Require help in basic living skills such as
  maintaining personal hygiene, preparing food and
  maintaining adequate nutrition, or managing
  finances to such a degree that health or safety
  is jeopardized.

132
PA For Continued Treatment contd.

• Have behaviors that require repeated
  interventions by mental health, social services,
  or judicial system
• are necessary.
• Be unable to recognize personal danger or
  recognize significantly inappropriate social
  behavior.

133
PA For Continued Treatment

• KePRO will approve continued service requests
  (based on PA criteria) for up to 6-month
  increments for the remaining annual service
  limit.
• PA requests after denials of services for medical
  necessity may be resubmitted at a later date when
  the individual meets criteria

134
Questions
135
Mental Health Case Management (H0023)
136
Service Definition

• Mental health case management services assist
  individual children and adults in accessing
  needed medical, psychiatric, social, educational,
  vocational, and other supports essential to
  meeting basic needs.

137
Eligibility Criteria

• There must be documentation of the presence of
  serious mental illness for an adult individual or
  of serious emotional disturbance or a risk of
  serious emotional disturbance for a child or
  adolescent.
• The individual must require case management as
  documented on the ISP, which is developed by a
  qualified mental health case manager and based on
  an appropriate assessment and supporting
  documentation.
• To receive case management services, the
  individual must be an active client, which
  means that the individual has a ISP in effect
  which requires regular direct or client-related
  contacts and communication or activity with the
  client, family, service providers, significant
  others, and others, including a minimum of one
  face-to-face contact every 90 days.

138
Co-occurring Mental Health and Substance Abuse
Disorders

• If an individual has co-occurring mental health
  and substance abuse disorders, integrated
  treatment for both disorders is allowed within
  psychosocial rehabilitation services as long as
  the treatment for the substance abuse condition
  is intended to positively impact the mental
  health condition.

139
Required Activities

• An assessment must be completed by minimally by a
  qualified mental health case manager to determine
  eligibility and the need for services.

140
PA Requirement
New

• PA is required effective 01/01/10 for new and
  existing recipients. If admitted on/after
  01/01/10 there is a 1 unit (or 1 month) that does
  not require PA.
• Payment Rate is the current unit rate for the
  service (326.50)

141
PA for All Clients contd.

• If services are to continue (beyond the allowable
  unit without PA), provider must contact KePRO to
  obtain PA.
• PA will be allowed for 11 months in the 1st year
• Provider bills using H0023 code (if no PA claim
  will deny)
• KePRO will be describing the specific details
  regarding the PA request process.

142
Service Units Maximum Service
Limitations
Services are limited annually to 12 units per
year. The fiscal year period for the start up
of this process will be August 1, 2009 through
June 30, 2010. All subsequent fiscal years will
be July 1 through June 30. Case management
services for the same individual must be billed
by only ONE type of case management provider

143
Prior Authorization Requirements

• For new clients existing clients providers
  have 1 unit (calendar month) to assess the client
  and begin providing service. For any services to
  be paid beyond 1 unit a PA is required.

144
Prior Authorization Requirements

• The provider will need to submit recipients
  demographic information also include the
  following
• Procedure Code H0023
• PA Service Type - 0650
• Number of units requested
• From Through dates (span 12 months)

145
Initial Review (New Recipient to Provider)

• For MHCM, DSM-IV- Axis I or Axis II Diagnosis
  (Adjustment Disorder or V codes are not
  acceptable as stand alone diagnoses for SED
  Adults).
• If there is a dual diagnosis of Mental Health
  (MH) and SA, services must be integrated.

146
Initial PA Request contd.

• Describe symptoms/severity of illness
• Birth through age 7
• Must exhibit being at risk of serious emotional
  disturbance and meet at least one of the
  following criteria
• - The child exhibits behavior or maturity that is
  significantly different from most children of the
  childs age and that is not primarily the result
  of developmental disabilities or mental
  retardation or
• - Parents or persons responsible for the childs
  care have predisposing factors themselves, such
  as inadequate parenting skills, substance use
  disorder, mental illness, or other emotional
  difficulties, that could result in the child
  developing serious emotional or behavioral
  problems or

147
Initial PA Request contd.

• Describe symptoms/severity of illness
• Birth through age 7 (AT RISK)
• - The child has experienced physical or
  psychological stressors, such as living in
  poverty, parental neglect, or physical or
  emotional abuse, that have put him or her at risk
  for serious emotional or behavioral problems and
• - An Axis I diagnosis is required for claims
  payment. This may be a rule-out or an adjustment
  disorder diagnosis.

148
Initial PA Request contd.

• Describe symptoms/severity of illness
• Birth through age 17 -Must exhibit serious
  emotional disturbance. (SED)
• Child must exhibit all of the following
• Problems in personality development and social
  functioning that have been evident over the past
  year and
• Problems that are significantly disabling based
  on social functioning of peers and
• Problems that have become more disabling over
  time and
• Service needs that require significant
  intervention by more than one agency.

149
Initial PA Request contd.

• Adults, age 18- Must exhibit severe and
  recurrent disability from mental illness and meet
  2 of the following
• Is unemployed is employed in a shelt