Department of Medical Assistance Services

1
Department of Medical Assistance Services
Residential TreatmentFor Children
AdolescentsLevel C (RTF)
October/December 2008 www.dmas.virginia.gov
2
Residential TreatmentLevel C

• DMAS Contacts
• Shelley Jones - 804-786-1591
• shelley.jones_at_dmas.virginia.gov
• Bill OBier - 804-225-4050
• william.obier_at_dmas.virginia.gov
• Pat Smith - 804-225-2412 for KePRO related
  questions
• patty.smith_at_dmas.virginia.gov
• Tracy Wilcox-804-371-2648
• Contract Monitor for Clifton Gunderson Audits
• tracy.wilcox_at_dmas.virginia.gov

3
Training Objectives

• Identify participation requirements
• Understand Medicaid documentation requirements
• Be aware of prior authorization (PA) requirements
  and process
• Understand changes to UAI and PA fax form
• Understand the utilization review process
• Handouts of October 15 and November 7, 2008
  Medicaid memo and CANS summary form

4
Objectives

• These slides contain only highlights of the
  Virginia Medicaid Psychiatric Services Manual
  (PSM) and are not meant to substitute for the
  comprehensive information available in the
  manual.
• Please refer to the manual, available on the
  DMAS website, for in-depth information on
  psychiatric residential treatment criteria.

5
Provider Enrollment Unit

• For enrollment, agreements, change of address,
  and enrollment questions contact
• First Health Services
• Provider Enrollment Unit
• P.O. Box 26803
• Richmond, VA 23261
• Toll free -- 888-829-5373
• Fax -- 804-270-7027

6
Provider Agreements

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

7
Provider Agreements

• RS attestation letter must be submitted to DMAS
  by July 1 each year or sooner if change in CEO
• Sample RS attestation letter in the PSM

8
General Medicaid Provider Participation
Requirements

• Have administrative and financial management
  capacity to meet federal and state requirements
• Have ability to maintain business and
  professional documentation
• Adhere to conditions outlined in the provider
  agreements
• Notify DMAS of any change in original information
  submitted and

9
Participation Requirements

• Maintain records that fully document health care
  provided
• Retain records for a period of at least 5 years
• Furnish access to records and facilities in the
  form and manner requested
• Use Medicaid designated billing forms
• Accept as payment in full the amount reimbursed
  by DMAS. Provider must be participating in the
  Medicaid Program at the time the service is
  performed and

10
Participation Requirements

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

11
Participation Requirements

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

12
Definition-Level C RTF

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

13
Definition-Level C RTF

• Highly organized and intensive services
• Planned therapeutic interventions
• All services required to be provided on-site,
  including academic program (Medicaid does not
  reimburse for education-it is not a covered
  service)
• Physician-directed mental health treatment
• If a recipient turns 21 while in an RTC, and
  medical necessity continues, the recipient can
  remain until their 22nd birthday.

14
Definition-Level C RTF

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

15
Restraint Seclusion

• Remain in compliance with signed agreement
  regarding seclusion and restraint
• In case of injury requiring medical attention
  off-site or a suicide attempt, DMAS must be
  notified by fax within one business day of
  occurrence
• childs name, Medicaid number
• facility name address of incident
• location date of incident
• and

16
Restraint Seclusion

• Notification continued
• names of staff involved
• description of incident
• outcome, including persons notified
• current location of child
• Fax to Shelley Jones at 804-612-0059
• Restraint Seclusion reporting is a condition of
  participation and non-reporting subject to
  retraction for paid claims and of provider
  enrollment

17
Out-of-State Provider Enrollment

• Border-state facility (within 50 miles)
• Provides a service not available in Virginia or
• No in-state facility willing to admit a specific
  child
• Procedure
• Contact DMAS at 804/786-1591 to discuss
• child-specific, out-of-state placement need
• DMAS can enroll facility for single placement,
• if appropriate
• and

18
Out-of-State Placement Criteria

• Requires true prior approval for Medicaid
  coverage
• Recipient specific information required to be
  sent to DMAS
• Demographics
• Referral source information
• Current placement and services and why these are
  not adequate
• Current documentation on diagnosis, behaviors,
  discharge plan
• Current psychological evaluation -within past
  year
• and

19
Out-of-State Placement Criteria

• Social and Service History pertinent to placement
  needs
• Out-of-state facility information-website,
  documentation
• List of Virginia facilities explored, and reasons
  for admission denial
• This will be reviewed by DMAS staff to assess the
  appropriate level of care and facility placement,
  and who will coordinate with provider enrollment
  if out-of state placement is approved

20
Electronic Submission of Claims

• On October 9, 2007 a Medicaid Memo was
  distributed covering the changes necessary to
  submit RTF claims electronically
• For CSA cases, when submitting PA information to
  KePRO, the 3-digit locality code and the
  Reimbursement Rate Certification rate are
  required. This will facilitate electronic
  submission of claims.
• For NON-CSA cases, reimbursement will be at the
  rate established at enrollment.
• All providers are expected to have a rate
  established at enrollment.

21
Electronic Signatures

• Clarification on electronic signatures was issued
  in the 8-20-04 Medicaid Memo to all providers.
• An electronic signature that meets the following
  criteria is acceptable for clinical
  documentation
• Identifies the individual signing by name and
  title and

22
Electronic Signatures

• Data system assures the documentation cannot be
  altered after signature affixed, by limiting
  access to code or key sequence
• Provides for non-repudiation that is, strong and
  substantial evidence that will make it difficult
  for the signer to claim the electronic
  representation is not valid.
• The provider must have written policies and
  procedures in effect regarding use of electronic
  signatures.

23
Required Documentation

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

24
Reimbursement Rate Certification

• For CSA Cases Only
• Negotiated rate between locality and facility
• Total rate can be no more than the Medicaid
  maximum
• Payment from any other source such as Title IV-E,
  must be deducted prior to establishing the rate
• and

25
Reimbursement Rate Certification

• Identify responsible locality
• Locality code must be sent in for PA
• If rate is revised by the locality, must be sent
  in to KePRO within 1 week to update the PA
• Payment based on the rate on the certification
  which is entered by KePRO into the FHS MMIS
• All versions of the rate certification must be
  available at the facility at the time of audit

26
CSA or NON-CSA?

• If the case is an Adoption Subsidy case, it is
  NON-CSA
• The education payment source is not considered
• The CON will be completed by the FAPT, not the
  CSB
• If the education is paid for by the Dept. of
  Education/CSA funded, it is a CSA case
• If a child has been receiving CSA funding for
  other services, it is a CSA case
• If the child is in foster care, it is a CSA case

27
Certification of Need

• CSA Cases
• CON must be completed by both the physician and
  the FAPT
• Must include dated signatures of physician and at
  least 3 members of the FAPT
• Authorization can begin no earlier than the date
  of the latest signature
• Must be child-specific and relate to the need for
  RTF level of care
• Must be available in the medical record

28
Certification of Need(Independent Team
Certification)

• NON-CSA Cases
• The CSB is responsible for completing the
  Independent Team Certification
• The CSB completes the DMH224 and must include a
  physicians dated signature, as well as the
  screeners dated signature
• The CSB may use the sample CON in the manual in
  place of the DMH224
• and

29
Certification of Need

• NON-CSA Cases
• CON may be completed by the FAPT and must include
  a physicians dated signature, as well as a
  member of the FAPT
• Authorization can begin no earlier than the date
  of the latest signature
• Must be child-specific and relate to the need for
  RTF level of care
• Must be available in the medical record

30
Certification of Need

• CSA and NON-CSA
• Should reflect the childs current condition and
  must be completed within 30 days of admission
• Is required to be completed prior to admission
  with all necessary dated signatures
• If discharged and readmitted, a new CON is
  required
• If the child transfers to an acute psychiatric
  facility, and the child is to return to RTC, the
  acute care team must do the new CON

31
State Uniform Assessment Instrument

• Effective November 1, 2008, a new state UAI will
  be acceptable.
• either the Child and Adolescent Functioning Scale
  (CAFAS)/Preschool and Early Childhood Functioning
  Scale (PECFAS) or the Child and Adolescent Needs
  and Strengths (CANS) assessment tools will meet
  the State UAI requirement.
• Beginning July 1, 2009 only the CANS will be
  acceptable.

32
State UAI

• CSA Cases Only
• Must be current. For admission the state UAI
  should reflect the requested level of care
• To be completed at least every 90 days
• and must be in the medical record
• Should be updated by the fiscally responsible
  locality when the childs level of impairment
  changes significantly
• Completion information must be submitted to KePRO
  for PA and

33
State UAI

• Scoring notes the level of impairment that
  supports the need for the level of care
• At a minimum
• the CAFAS or PECFAS profile sheets for the youth
  and caregiver, OR
• The CANS summary sheet, indicating the childs
  behavioral and emotional needs, and risk
  behaviors,
• Both the CAFAS/PECFAS and CANS must be available
  in the medical record and current within 90 days
  throughout the stay

34
Initial Plan of Care

• Must be completed within 24 hours of admission
• Requires a dated physicians signature signifying
  the physician has had a face-to-face visit with
  the child (Authorization can begin no earlier
  than the date of the signature)
• All required elements must be in the plan
• See sample form in PSM-DMAS 371
• Be sure to specify the number and type of
  child-specific therapies
• Must be in the medical record

35
Comprehensive Individual Plan of Care (CIPOC)

• Must be completed within 14 days of admission
• Must include dated signatures of the team
  responsible for the care (physician and at least
  one other team member specified in regulations)
• Must include all required elements
• See sample form in PSM-DMAS 372
• Be sure to include specific orders for therapies
• Must be in the medical record

36
CIPOC 30-Day Progress Updates

• Must be updated every 30 days
• Must have dated signatures of team members
• Must include all required elements
• See sample form in PSM-DMAS 373
• List Individual and Family Therapy dates
• If the therapy is not provided by a qualified
  professional, or the session was not at least 20
  minutes, or there is no note, it should not be
  considered a delivered service
• Address progress, or lack of progress. If no
  progress, how is this being addressed?

37
Therapeutic Interventions

• Individual, Family and Group Psychotherapy must
  be physician-ordered, provided by a licensed
  Medicaid enrolled provider and addressed in the
  treatment plan
• Individual Psychotherapy
• Must occur 3 times every 7 days. Facility
  determines the 7-day count.
• Sessions must be, at a minimum, 20 minutes
• If the session includes more than the therapist
  and the patient it is not considered individual
  psychotherapy
• Telephone calls to family members are not
  considered individual psychotherapy
• and

38
Therapeutic Interventions

• Family Psychotherapy
• Must occur at a minimum of 2 times a month if
  there is family involvement
• If there is any family dysfunction that impacts
  the child, therapy should be at least once a
  week.
• Must be provided as is ordered in the treatment
  plan
• Group Psychotherapy
• Group Psychotherapy billed to Medicaid must not
  consist of more than 10 patients
• and

39
Therapeutic Interventions

• Individual, Family and Group Psychotherapy notes
  must be completed by a qualified therapist
• If therapy is provided by an individual who has
  completed his or her graduate degree and is
  working towards licensure, they may do so under
  direct supervision
• SUPERVISOR
• Appropriately licensed under state law and is a
  Medicaid-enrolled provider
• Supervision meets requirements of individual
  profession
• and

40
Supervision of Unlicensed Therapist

• Does not need to be the same person who is
  supervising for licensing purposes
• Reviews patients medical history
• Approves and signs Plan of Care indicating the
  need for the specific service
• Countersigns Plan of Care updates
• Reviews each therapy note
• Must be in the facility during the session, but
  not required to be in the session
• and

41
Supervision of Unlicensed Therapist

• Dated signature on each therapy note on date of
  service indicating note was reviewed
• Meet regularly with supervisee (every sixth
  session or every 90 days, whichever comes first,
  to include all types of therapies )
• Discuss Plan of Care
• Review record
• Assess patients progress
• Document supervisory meetings
• A Physicians Assistant, under supervision, is
  not eligible to provide psychotherapy

42
Therapeutic Interventions (including the 21
weekly interventions)

• Notes must contain, at a minimum
• Childs name
• Type of session (Individual, group, medication
  management)
• If this is a group session, the type of group
  must be stated, such as Anger Management or
  Coping Skills
• Treatment Modality
• Start and stop time for session
• and

43
Therapeutic Interventions

• Pre-printed forms with date and time of session
  already printed is not acceptable
• Written on the date service is provided
• Activity of session-what therapeutic
  intervention/ interaction occurred, and how does
  it relate to goals
• Purpose of note is to document service,
  and

44
Therapeutic Interventions

• as well as to assist staff in providing focused
  ongoing therapeutic services to the child
• Level of participation (a check box is not
  sufficient)
• Plan for next session
• Dated signature of provider
• All notes should be child-specific

45
Psychotherapy Notes

• Sample Therapy Note 1
• Date, Individual Therapy, 1215pm to 1250pm.
• Cognitive Behavioral Technique
• Adolescent shared her journal entries for past
  week. She identified one method of self-calming
  after reprimand from bus driver, which she
  implemented twice since last session. Prior to
  session, parent reported anger outbursts in the
  home have decreased from 3 per day to once per
  day over the past 3 weeks, and outbursts have
  decreased at school. Medication compliance
  confirmed. and

46
Psychotherapy Notes

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

47
Psychotherapy Notes

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

48
Psychotherapy Notes

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

49
Psychotherapy Notes

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

50
Medication Management

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

51
21 Treatment Intervention Notes

• The following notes are samples shared by an RTC
  provider. The notes meet DMAS criteria
• Date, start and stop time
• 11/05/08, 1430-1500
• Group/Activity Name Community Group
• Activity Review day, set goal for the shift
• contd

52
21 Treatment Intervention Note Sample

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

53
First Sample Note

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

54
21 Treatment Intervention Note-2nd Sample

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

55
2nd Sample

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

56
21 Treatment Intervention Note-3rd Sample

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

57
3rd Sample

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

58
21 Treatment Interventions Documentation

• 21 Treatment Interventions every 7 days
• May count group psychotherapy
• Must not include individual and family therapy
• Must be documented on a daily basis
• Each intervention must be documented
• Forms with check boxes as the majority of the
  note are not acceptable
• and

59
Documentation

• Must document child-specific therapeutic
  intervention
• Interventions that are not billable separately
  may include more than 10 residents (this does not
  include the group psychotherapy that may be
  billed separately)
• Must include the dated signature of the provider
  for each intervention
• This does not need to be licensed staff

60
Documentation

• Late Entries
• Timeliness of documentation is essential. A
  document is considered complete by review of the
  dated signature of the professional who develops
  the document. Back dating is not acceptable.
• One-to-one supervision is not billable
  separately. Supervision is included in the
  Medicaid per diem reimbursement.

61
Restraint Seclusion

• Reports must be sent to DMAS reporting any injury
  requiring medical attention. These should be sent
  in within one business day of the occurrence.
  (See slide 14-15)
• Restraint Seclusion reporting is a condition of
  participation and non-reporting subject to
  retraction for paid claims and provider
  enrollment.

62
Staffing and signatures

• All signatures must be dated, and should include
  the professional title of the author.
• All medical documentation must include dated
  signatures on the date of service delivery.
• Auditors will request a staffing list with proof
  of licensure if license is required to provide a
  Medicaid reimbursed service.

63
Prior Authorization Contractor

• KePRO is the DMAS contractor for PA
• For questions or forms, go to the PA website
• DMAS.KePRO.org and click on Virginia Medicaid
• Phone 1-888-VAPAUTH or
• 1-888-827-2884
• Fax 1-877-OKBYFAX or 1-877-652-9329
• Web Provider Issues _at_ KePRO.org

64
Prior Authorization Contractor

• Submitting a request
• The preferred method is the iEXCHANGE web-based
  program
• Registration is required
• Information on iEXCHANGE is available on the
  KePRO website, or call
• 1-888-827-2884 or by e-mail at
  providerissues_at_kepro.org

65
Prior Authorization Contractor

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

66
KePRO

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

67
Prior Authorization

• Requests for PA are required to be submitted
• to KePRO within 1 business day of admission.
• Requests for continued stay reviews must be
  received prior to the end of the current
  authorization
• Authorization can be for up to 90 days with
  medical justification
• KePRO will review requests for medical necessity,
  as well as timeliness
• KePRO will apply McKesson InterQual Behavioral
  Health Criteria and DMAS supplemental criteria

68
Prior Authorization

• NON-CSA Cases
• Must have a NON-CSA rate established by DMAS in
  order to request PA from KePRO.
• Contact Provider Reimbursement at
• 804-686-7931 to establish a rate. This should be
  done at the time of enrollment as a provider.
• If no rate has been established, the request for
  PA will be rejected by KePRO.
• If a rate is later established, the request will
  not be retroactive

69
Revised Fax Form

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

70
Revised Fax Form

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

71
Revised Fax Form

• Fax Form Changes
• For CSA cases only
• both the CAFAS and CANS are acceptable as the
  state UAI and continue to be required at least
  every 90 days
• the Reimbursement Rate Certification is no longer
  required to be attached, but all versions must be
  available at the facility for audit
• The locality code and the rate on the RRC must be
  provided to KePRO

72
Revised Fax Form

• For both CSA and non-CSA requests
• No attachments are required, but information on
  the CON, IPC and CIPOC and updates are required
• Severity of Illness questions are critical to
  authorization

73
Revised Fax Form

• Narrative must address the need for level of
  care
• Initial Review
• symptoms and behaviors within past 7 days
• frequency, intensity and duration
• current functioning
• support system

74
Revised Fax Form

• Continued Stay
• Symptoms and behaviors in past 30 days
• Level of function in past 30 days
• Describe recipient investment in treatment
• Describe progress or lack of progress
• If no progress, how is this addressed?
• All other areas of the fax form remain the same

75
Prior Authorization

• Initial Review
• CSA cases only
• 3-digit locality code
• Reimbursement Rate Certification information
• State UAI information
• CSA and NON-CSA cases
• Confirmation of completion
• Certificate of Need
• Initial Plan of Care

76
Prior Authorization

• Continued Stay Review
• CSA Cases
• Current UAI information
• Confirm locality code
• Reimbursement Rate Certification update if
  revised
• CSA and NON-CSA Cases
• Confirmation of completion
• CIPOC
• 30-Day Update-most recent

77
Prior Authorization

• Appeals
• The denial of PA for services not yet rendered
  may be appealed in writing by the Medicaid
  recipient within 30 days of receipt of the
  denial.
• The provider may appeal an adverse decision for a
  service already provided by filing a written
  notice of appeal within 30 days of receipt of the
  denial.
• and

78
Prior Authorization

• Appeal rights will be stated in the PA
  notification letter. Requests for appeal must be
  submitted to
• Appeals Division
• Department of Medical Assistance Services
• 600 East Broad Street, 11th Floor
• Richmond, Virginia 23219
• The provider may not bill the recipient for
  covered services that have been provided and
  subsequently denied by DMAS

79
Utilization Review

• Federal regulations require that DMAS review and
  evaluate the services provided through the
  Medicaid program.
• Purpose of Utilization Review
• Ensure medical necessity
• Confirm qualified provider delivered service
• Ensure program requirements met
• Address Quality of Care issues

80
Utilization Review

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

81
Utilization Review

• They will
• do desk audits or on-site visits to review
  medical documentation to ensure DMAS criteria is
  met
• request provider qualification information as
  well as confirmation of service delivery
• assess service limits compliance
• determine if retraction of paid claims is
  necessary

82
Utilization Review

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

83
Utilization Review

• Individual, Family and Group Psychotherapy
• The full week of RTF reimbursement will be
  retracted if
• Fewer than 3 Individual Psychotherapy sessions
  occur
• Notes are not completed by a qualified therapist
• An unqualified therapist provides the therapy and
  there is no documentation of supervision every
  6th session (includes individual, family and
  group psychotherapy)

84
Utilization Review

• The full week of RTF reimbursement will be
  retracted if
• The required 21 treatment interventions are not
  provided, or are not documented as described in
  slides 42-44 and 51-59 and in the PSM
• Family therapy is not provided and is indicated
  in the treatment plan, or is necessary due to the
  childs condition

85
Staffing and signatures

• All signatures must be dated, and should include
  the professional title of the author.
• Auditors will request a staffing list with proof
  of licensure if license is required to provide a
  Medicaid reimbursed service.

86
Utilization Review

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

87
Utilization Review

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

88
Wrap Up

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

89
Questions?