KHS Provider Training

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KHS Provider Training
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Medical Necessity

• Criteria authority, purpose, scope, evidence,
  value
• In a nut shell the intervention is recommended
  by a clinician (authority), treats the
  condition(s) (purpose), is the most appropriate
  supply of service (scope), is known to be
  effective (evidence), is cost-effective
  (value). see pg 21 of Provider Manual
• This is Medicaids definition of medical
  necessity which is specified within the PAHP
  contract

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Identification of Members with Special Health
Care Needs

• Classified into 6 categories
• SPMI
• SED
• Dual Diagnosis (MI/Substance Abuse)
• Dual Diagnosis (MI/DD or MR)
• Pregnant abusing substances
• IV drug use (current users)

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Access Standards to Care

• See handout regarding the access categories
  time frame to meet access.

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Exceptions to Routine Access Standards

• Specialized treatments not required in licensing
  or contract (i.e., anger management, sex offender
  group, court ordered psychological evaluations)
• Member/family choice (i.e., member prefers a
  specific time or prefers to see a specific
  provider)
• Unable to reach the member/family (Provider must
  document attempts to contact)
• Member/family cancels or no-shows
• Member/family changed mind/declined services

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Services Requiring Prior Authorization

• 1915(b) Attendant Care
• 1915(b) Case Conference
• HCBS SED Waiver Services
• Any service with an annual limit which has been
  met

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Levels of Care/Service

• Outpatient Services (90 days)
• Outpatient Therapy (Individual, family, group,
  assessments, etc.)
• Medication Services
• Crisis Services
• Case Conference (requires prior authorization)

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Levels of Care/Service

• Psychiatric Rehabilitation Services (180 days)
• Outpatient Therapy (Individual, family, group,
  assessments, etc.)
• Medication Services
• Rehabilitation Services (CPST, TCM, Psychosocial
  Rehabilitation, etc.)
• Crisis Services
• Case Conference (requires prior authorization)
• Attendant Care (requires prior authorization)

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Levels of Care/Service

• SED Waiver Services (180 days)
• Same services as Psychiatric Rehabilitation but
  with 6 SED Waiver services
• Independent Living/Skills Building
• Parent Support Training
• Professional Resource Family Care
• Short Term Respite Care
• Wrap Around Facilitation
• Attendant Care

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Registration/Authorization of Members

• For new members, registration/authorization
  completed within 10 business days of first
  face-to-face contact (includes crisis contacts)
• Methods log on to ProviderConnect, fill out hard
  copy send via mail or fax, or call in to Care
  Manager
• EXCEPTION The target date for registering
  current clients is 9/1/07 we recommend
  registering clients at the time of their next 90
  day review or 9/1/07, whichever comes first

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Exceptions

• Members currently receiving 1915(b) Attendant
  Care do not need prior authorization until 8/1/07
• In Home Family Therapy completion of State
  approved training exception
• A service will not be denied exclusively on the
  GAF score. The GAF will be one of the tools to
  provide a clearer clinical picture.

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Review/Re-authorization of Members

• The review/re-authorization is much like the
  registration/authorization but is a condensed
  format

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Contact Information for Care Management Services

• Address P.O. Box 1979, Topeka, Ks 66601-1979
• Phone [phone]
• Fax [phone]