Transcript Slide 1

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
QIO Request Submission
Requirements for
Community Support
Services
New 6/14/2012
Topics
• Services Requiring
PA
• KEPRO SCDHHS
Website
• Service Type
Requirements
• Contact
Information
Prior Authorization
Services
Adult (22 years old and older)
•
H2017-Psychosocial Rehabilitation
Service (PRS)
• S9482-Family Support
Child (21 years old and younger)
• H2017-Psychosocial Rehabilitation
Service (PRS)
• H2014-Behavioral Modification
• S9482-Family Support
Forms
Navigate to Forms TAB
to obtain Documents
Outpatient Fax Form
Outpatient Fax Form
Attestation Form
Adult H2017 (PRS) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• Attestation Form
For Continuation of Services• Individualized Plan of Care (IPOC)
• Mental Health-comprehensive assessmentfollow-up
• 90 Day Progress Summary
Adult H2017 (PRS) Criteria
For Initial Services, beneficiary must:
– Diagnosed with a serious or persistent mental illness
– Moderate or severe functional impairment that interferes with 2 or more
of the following:
•
•
•
•
•
Daily living
Personal Relationships
Work Setting
School Setting
Recreational Setting
– Is at risk of psychiatric hospitalization, homelessness, or isolation from
social supports
– Exhibits behaviors that require repeated interventions by the mental
health, social services, or judicial system
– Experiences impaired cognitive ability to recognize personal or
environmental dangers or significantly inappropriate social behavior.
Adult H2017 (PRS) Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC; OR
– Beneficiary continues to be at risk for out-of home-placement; OR
– Beneficiary has achieved initial goals in the IPOC and continued
services are needed in order to achieve additional goals in the IPOC;
OR
– Beneficiary is making some progress, but the interventions need to be
modified so that greater gains can be achieved, OR
– Beneficiary is not making progress or regressing and the IPOC must
be modified
***Please submit for continuation of services no more than 10 days prior
to the end of your current authorization
Adult (Family Support) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• Attestation Form
For Continuation of Services• Individualized Plan of Care (IPOC)
• Mental Health-comprehensive assessmentfollow-up
• 90 Day Progress Summary
Adult S9482 (Family Support) Criteria
For Initial Services, beneficiary must:
– Beneficiary has been diagnosed with a serious and persistent mental
illness (SPMI), or co-occurring SPMI and substance use disorders
(SUD)
– Demonstrates moderate to severe functional impairment in 2 or more
of the following areas:
•
•
•
•
•
Daily Living
Relationships
School
Work Setting
Recreational Setting
– Family or Caregiver agrees to be an active participant, which involves
participating in interventions
Adult S9482 (Family Support) Criteria
For Initial Services, beneficiary must
(cont’d):
– Service is recommended by Licensed Practitioner of the Healing Arts
– Service (including frequency of the services) is recommended as result
of the Diagnostic Assessment
– Beneficiary is expected to benefit from the intervention and needs
would not be better clinically met by any other formal or informal
system or support.
Adult S9482 (Family Support) Criteria
For continuation of services:
– The family or caregiver is actively involved and engaged in the
treatment process; AND
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame outlined in the beneficiary’s
Individual Plan of Care (IPOC); OR
– Beneficiary has achieved initial goals in the IPOC and continued
services are needed in order to achieve additional goals in the IPOC;
OR
– Beneficiary is making some progress, but the interventions need to be
modified so that greater gains can be achieved, OR
– Beneficiary is making progress toward meeting goals.
***Please submit for continuation of services no more than 10 days prior
to the end of your current authorization
Child H2017 (PRS) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• CALOCUS
• Attestation Form
For Continuation of Services• Individualized Plan of Care (IPOC)
• Mental Health-comprehensive assessmentfollow-up
• 90 Day Progress Summary
Child H2017 (PRS) Submission
Requirements
Providers rendering services to children
served by Continuum of Care only
Submit to KEPRO for Initial Services• Cover Letter
• Family Story
• CAFAS
Submit to KEPRO for Continuation of Services• Individualized Plan of Care (IPOC)
Child H2017 (PRS) Criteria
For Initial Services, beneficiary must:
– Beneficiary (ages 0-5) has been diagnosed with a serious emotional
disorder (SED) or an applicable V code as per the current DSM; OR
– Beneficiary (ages 6-21) has been diagnosed with a serious emotional
disorder (SED) or a co-occurring SED and substance use disorder
(SUD)
– Meet 3 or more of the following criteria as a result of the mental illness:
• Moderate to severe functional impairment that interferes with performance
in two or more of the following areas:
–
–
–
–
–
Daily living
Personal Relationships
School
Work Setting
Recreational Settings
Child H2017 (PRS) Criteria
For Initial Services, beneficiary must
(cont’d):
• Is not functioning at a level that would be expected or typically developing
individuals their age; OR
• Is deemed to be at risk of psychiatric hospitalization or out-of home
placement; OR
• Exhibits behavior that requires repeated interventions by the mental health,
social services, or judicial system; OR
• Experiences impaired cognitive ability to recognize personal or
environmental dangers or significantly inappropriate social behavior.
– Has been assigned a composite CALOCUS score in the range of 1519 (or a CAFAS has been completed for CoC beneficiaries)
– Service is recommended by a Licensed Practitioner of the Healing Arts
(LPHA)
Child H2017 (PRS) Criteria
For Initial Services, beneficiary must
(cont’d):
– The service (including the frequency of service) is recommended as
result of the Diagnostic Assessment and CALOCUS (or the Family
Story and CAFAS for beneficiaries served by the CoC)
– Beneficiary is expected to benefit from the intervention and needs
would not be better clinically met by any other formal or informal
system or support.
Child H2017 (PRS) Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC; OR
– Beneficiary continues to be at risk for out-of home-placement; OR
– Beneficiary has achieved initial goals in the IPOC and continued
services are needed in order to achieve additional goals in the IPOC;
OR
– Beneficiary is making some progress, but the interventions need to be
modified so that greater gains can be achieved, OR
– Beneficiary is not making progress or regressing and the IPOC must
be modified
***Please submit for continuation of services no more than 10 days prior
to the end of your current authorization
Child H2014 (Behavioral Modification)
Submission Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• CALOCUS
• Attestation Form
For Continuation of Services• Individualized Plan of Care (IPOC)
• Mental Health-comprehensive assessmentfollow-up
• 90 Day Progress Summary
Child H2014 (Behavioral Modification)
Submission Requirements
Providers rendering services to children
served by Continuum of Care only
Submit to KEPRO for Initial Services• Cover Letter
• Family Story
• CAFAS
Submit to KEPRO for Continuation of Services• Individualized Plan of Care (IPOC)
Child H2014 (Behavioral Modification)
Criteria
For Initial Services, beneficiary must:
– Beneficiary (ages 0-5) has been diagnosed with a serious emotional
disorder (SED) or an applicable V code as per the current DSM; OR
– Beneficiary (ages 6-21) has been diagnosed with a serious emotional
disorder (SED) or a co-occurring SED and substance use disorder
(SUD)
– Engaging in behaviors which are inappropriate or undesirable and
present risk of harm to self or others, and significantly impact
functioning in 2 or more of the following areas:
•
•
•
•
•
Daily Living
Relationships
Work Setting
School Setting
Recreational Setting
Child H2014 (Behavioral Modification)
Criteria
For Initial Services, beneficiary must
(cont’d):
– Family or caregiver agrees to be an active participant, which involves
receiving behavioral management training for the purpose of
maintaining progress during and after treatment
– Has been assigned a minimum CALOCUS composite score of 17 (or a
CAFAS has been completed for CoC beneficiaries)
– Service is recommended by a Licensed Practitioner of the Healing Arts
(LPHA)
– Service (including frequency of the service) is recommended as a
result of the Diagnostic Assessment and CALOCUS (Family Story and
CAFAS for beneficiaries served by CoC)
– Beneficiary is expected to benefit from the intervention and needs
would not be better clinically met by any other formal or informal
system or support
Child H2014 (Behavioral Modification)
Criteria
For continuation of services:
– The family or caregiver is actively involved and engaged in the
treatment process (if family or caregiver is unable or unwilling to be an
active participant, this is clearly documented in the medical record);
AND
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame outlined in the beneficiary’s
Individual Plan of Care (IPOC); OR
– Beneficiary continues to be at risk for out-of-home placement; OR
– Beneficiary has achieved initial goals in the IPOC and continued
services are needed in order to achieve additional goals in the IPOC;
OR
– Beneficiary is making some progress, but the interventions need to be
modified so that greater gains can be achieved, OR
– Beneficiary is not making progress or regressing and the IPOC must
be modified.
***Please submit for continuation of services no more than 10 days prior
to the end of your current authorization
Child S9482 (Family Support) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• CALOCUS
• Attestation Form
For Continuation of Services• Individualized Plan of Care (IPOC)
• Mental Health-comprehensive
assessment-follow-up
• 90 Day Progress Summary
Child S9482 (Family Support) Submission
Requirements
Providers rendering services to children
served by Continuum of Care only
Submit to KEPRO for Initial Services• Cover Letter
• Family Story
• CAFAS
Submit to KEPRO for Continuation of Services• Individualized Plan of Care (IPOC)
Child S9482 (Family Support) Criteria
For Initial Services, beneficiary must:
– Beneficiary (ages 0-5) has been diagnosed with a serious emotional
disorder (SED) or an applicable V code as per the current DSM; OR
– Beneficiary (ages 6-21) has been diagnosed with a serious emotional
disorder (SED) or a co-occurring SED and substance use disorder
(SUD)
– Demonstrates moderate to severe functional impairment in 2 or more
of the following areas:
•
•
•
•
•
Daily Living
Relationships
School
Work Setting
Recreational Setting
– Family or Caregiver agrees to be an active participant, which involves
participating in interventions
Child S9482 (Family Support) Criteria
For Initial Services, beneficiary must
(cont’d):
– Has been assigned a composite CALOCUS score in the range of 1519 (Or has received a CAFAS if served by CoC)
– Service is recommended by Licensed Practitioner of the Healing Arts
– Service (including frequency of the services) is recommended as result
of the Diagnostic Assessment and CALOCUS (Family Story and
CAFAS for beneficiaries served by CoC)
– Beneficiary is expected to benefit from the intervention and needs
would not be better clinically met by any other formal or informal
system or support.
Child S9482 (Family Support) Criteria
For continuation of services:
– The family or caregiver is actively involved and engaged in the
treatment process (if family or caregiver is unable or unwilling to be an
active participant, this is clearly documented in the medical record);
AND
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame outlined in the beneficiary’s
Individual Plan of Care (IPOC); OR
– Beneficiary continues to be at risk for out-of-home placement; OR
– Beneficiary has achieved initial goals in the IPOC and continued
services are needed in order to achieve additional goals in the IPOC;
OR
– Beneficiary is making some progress, but the interventions need to be
modified so that greater gains can be achieved, OR
– Beneficiary is not making progress or regressing and the IPOC must
be modified.
***Please submit for continuation of services no more than 10 days prior
to the end of your current authorization
Eligibility
MCO:
– Prior authorization is required by KEPRO if the beneficiary is enrolled
in an MCO
Commercial Insurance:
– Submit only to KEPRO after claim has been submitted to primary
insurance and benefits have either been exhausted or service is not
covered and primary insurance did not make any payment. Please
submit EOB along with request.
Medicare B:
– Submit only to KEPRO after claim has been submitted to Medicare and
benefits have either been exhausted or service is not covered and
Medicare did not make any payment.
NOTE*KEPRO will not review if the service was deemed not
medically necessary by primary insurance
Retroactive Medicaid Eligibility
A case may be submitted as a “retro” when
retroactive Medicaid eligibility occurs or
when Medicaid becomes the primary payer
This includes:
• Member not eligible for coverage at the time services were
provided.
• Member gains eligibility that is made retroactive to the date of
service.
NOTE** A “retro” case is NOT one that is submitted late for any
reason.
KEPRO/Provider Turnaround Time
KEPRO
• Upon receipt of PA request, KEPRO must render a
decision within 5 business day of the request
submission (excluding higher level reviews)
• If the PA request is submitted for higher level review,
KEPRO has 1 additional day to render a decision.
Provider
• If additional information is required for review, the
request will be pended, and the Provider will have 2
business days to submit the additional information
required to KEPRO.
INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Registration for
Atrezzo Connect
Provider Portal
How To Register For
Atrezzo Connect
• Website Address:
https://scdhhs.kepro.com
• Select “ Registration For Atrezzo
Connect” (Slide 3)
• Enter your 10 digit National
Provider Identifier (NPI) number
and Legacy South Carolina
Medicaid provider ID
• Select a unique user name and
password & complete required
user information
Atrezzo Connect
Atrezzo Connect allows for:
– Secure access to Atrezzo
Connect (Provider Portal)
– Provider will be able to
access letters by
Case/Request,
Respond/Send messages
To/From KePRO
Required Information for
Security Verification
• The provider must enter
information to verify
authenticity for security
reasons
• Registration Code:
– SCDHHS Legacy ID
Simple -5 Step Registration Process
• Start by clicking the
Atrezzo Login
button on the
SCDHHS-KEPRO
website
Login Page
• You will be brought to this login page
Step 2 – Enter NPI and Legacy ID
• Enter your
organization’s
NPI number and
Legacy Provider
ID = Provider
Registration
Code
• Click NEXT
Step 3 – Terms of Agreement
• Review Terms of
Agreement. Upon
acceptance, you will
be taken to setup for
User information.
Step 4 – Verify Address
• Click on the correct address(s) for the
new account (this associates your user
information with these locations)
• If all apply, check all of them
• Click SELECT
Step 5 – Enter Account Information
• Enter user account
information
• User Name, Password,
First/Last Name, E-mail
and Fax Number are
required fields!
• Click NEXT-This will
take you to the
Password setup and
security question Slide)
• Passwords do not
expire. Minimum 8
characters required.
Successful Completion
• Successful
Completion of
setup, takes
you to the
Home Page
View all request and Create new request
•Click Member to search using Member id or Last
name/DOB
•Click Request/Case to search using Case id,
Member info or Request info
Create Preferences, Manage User account
and New Provider Registration
Use this tab to change your password or
update your contact information
View Atrezzo User Guide and View FAQs
Account Administrator
• All information submitted for
registration under
Provider/Facility Information will
represent as the Provider Portal
Administrator (Group Admin).
• The Group Admin is responsible
for managing and creating all
Submitting User accounts for
your NPI #
– Create other Group Admins’ &
Admin Users
– Set Preferences, i.e. Diagnosis
and Procedure codes, etc
KEPRO Contacts
Thank You!
50
Prior Authorizations
Foster Care Beneficiaries
•
•
•
Psychosocial Rehabilitative Services (PRS)
Behavior Modification Services (BMOD)
Family Support (FS)
• Private providers who serve children
in foster care will receive prior
authorization (PA) from the South
Carolina Department of Social Services
(DSS)
• DSS will initiate all referrals with
private providers for the services of
PRS, BMOD and FS
• DSS will utilize the list of private RBHS
providers published on the SCDHHS
website
• https://www.scdhhs.gov/sitepage/private-rbhs-provider-directory
• Private providers will not make PA
requests to DSS
• No CALOCUS is required for DSS referrals
of beneficiaries in foster care