Transcript Individualized Service Agreements (ISA) – Funding Process

Individualized Service
Agreements (ISA)
State of Alaska
Division of Behavioral Health
Policy and Planning
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Individualized Service Agreement
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What is it 
A provider Agreement with the State of
Alaska for the purpose of providing
individual, specialized services for severely
emotionally disturbed (SED) children.
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Individualized Service Agreements
(ISA) – Funding Process
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Client Eligibility
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A resident of the state
Under 22 years of age
Been assessed by a MH professional and meets
criteria for SED
Is at imminent risk of being removed from the
home
Been assessed to meet residential level of care
Has been approved by DHSS for services
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Individualized Service Agreements
Examples of
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Acceptable Uses
Non-Medicaid services such as:
For Non-MC recipients – all MC covered services
Services that allow recipient to maintain at least restrictive level of care
Services that would normally be covered by Medicaid for non-resourced
recipients
Room and board for non-custody kids in level 2-4 BRS facilities,
continued need reviewed every 90 days.
Vocational rehabilitation
Rent including utilities not to exceed 90 days
Start up costs for individual living settings
Specialized treatments – private practitioners physician clinic services
(Must Contract thru Community Behavioral Health center CBHC).
Transportation
Parenting classes
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Individualized Service Agreements
Examples of
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Acceptable Uses (cont.)
Care coordination for non Medicaid recipients or case management?
Case management for recipient 90 days (60 days payable) prior to
discharge from inpatient facilities. (Last 30 days should be billable to
Medicaid)
Respite
Expert consultations e.g. sexual acting out,
Limited home modifications necessary to maintain child in home
Life management skills
After school programs
Family home assessment
Social activities
Mentoring
Tuition
Other services determined to be clinically appropriate.
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Individualized Service Agreements
Non-Acceptable Uses:
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Individualizes services dollars will not
pay for or augment:
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foster care rates
substance abuse treatments
Capital Funding/substantial home
renovations
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Individualized Service Agreements
(ISA)
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Other billing mechanisms must be
utilized
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Medicaid
Private Insurance
5% Set Aside Funds for CBHCs with SED
Grants*
SED Grants do not need to be “spent down” prior to
receiving ISA funds
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Individualized Service Agreements
(ISA) – Funding Process
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Service provider must be a CBHC
Medicaid provider.
CBHC may contract with other agencies
for identified services.
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Individualized Service Agreements
(ISA) – Funding Process
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Providers complete the Referral & Billing
Form which includes requested services,
# of unit(s) and costs of services (for
initial referral and every 90 days)
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[ ] Initial Referral
[ ] Continuation of Services
[ ] Billing Invoice (Billings Must Be Submitted Monthly)
DIVISION OF BEHAVIORAL HEALTH
INDIVIDUAL SERVICE AGREEMENTS
Referral & Billing Form
Agency Name:
Service Period: (Not to Exceed 90 Days)
From:
Thru:
Phone Number
Address:
FAX Number:
Zip Code:
[
]
Initial Request for ISA
Attach Treatment Plan
[
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Client Name:
Provider Agreement #:
Continuation of Services (Must be submitted every 90 days for continuation of Services
Attach Treatment Plan Review
Medicaid #:
SS#:
DOB:
3rd Party Payor:
Address:
Custody:
Name:
Zip Code:
[ ] Parent
[ ] OCS
[ ] DJJ
Phone Number:
Address:
Requested Services
# of *Units
Cost Per Unit
(specified as # of days, hrs, etc.)
Total Cost
Of Service
Total:
Approved by
DBH UR
Not Approved by
DBH UR
Total Award:
*Unit is defined as # of days, hours, cab fares, etc. requested for the service period.
Approved By:
Date:
CERTIFICATION By Provider Agency
I certify these funds are requested for a client designated as SED meets
the individual Service Agreement client eligibility.
DBH APPROVAL
______________________________________________
Name
_____________________________________________
Name/Title
____________________________________________
Signature
_____________________________________________
Date
______________________________________________
Title
_______________________________________________
Signature
_______________________________________________
Collation Code
Date
Original – To Fiscal
FAX TO: (907) 269-8166
DHSS/DBH
Policy & Planning
3601 C Street, Suite 878
Anchorage, Alaska 99503
Attn: Utilization Review Specialists
Phone #: (907) 269-3600
Copy – to Agency
Copy- To UR Files
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Form Rev. 11-29-06
Individualized Service Agreements
(ISA) – Funding Process
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Referral & Billing Form faxed to DBH UR
staff along with initial Treatment Plan or
quarterly Treatment Plan Review
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Individualized Service Agreements
(ISA) – Funding Process
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Billing – submitted by provider every 30 days
to DBH
For initial funding requests, provider submits
Treatment Plan to DBH UR staff
For continued funding requests, provider
submits quarterly Treatment Plan Review to
DBH UR staff
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Individualized Service Agreements
(ISA) –Website to download
Agreement
http://www.hss.state.ak.us/publicnotice/grants.htm
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Individualized Service Agreements
(ISA) – Utilization Review Staff
Southeast Region and Matsu Valley - Reta Sullivan (907)
269-8869/ [email protected]
Northern Region- Judy Helgeson (907) 269-3697
[email protected]
Anchorage- Maureen McGlone (907) 269-3793
[email protected]
Southcentral Region (excluding Matsu)- Anne Gibson
(907) 269-8867/ [email protected]
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