INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

QIO Request Submission Requirements

New 6/14/2012

Topics

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Service Type(s)

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KePRO SCDHHS Website

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Service Type Requirements

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Contact Information

Prior Authorization Service Types

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PRTF-Psychiatric Residential Treatment Facility (under 21)

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Freestanding Inpatient Psychiatric (under 21 YO & over 65)

Navigate to Forms TAB to obtain Documents

Forms

PRTF Fax Form

PRTF Fax Form

PRTF Fax Form

Freestanding Psychiatric Inpatient (under 21) Fax Form

PRTF

PRTF

Psychiatric Residential Treatment Facilities (PRTFs) are facilities, other than a hospital, that provide psychiatric services to children under age 21 in an inpatient setting. PRTFs provide Inpatient Psychiatric Services to children under 21 who do not need acute inpatient psychiatric care, but need a structured environment with intensive treatment services.

PRTF admissions must be prior authorized by KEPRO

PRTF

Required Documentation for Provider’s Records

: CALOCUS Must be completed and current within 90 days prior to requested start date Certificate of Need (CON) Valid for 45 days from the date it is completed 30 day treatment plan Plan must be created within first 14 days

Required documentation to submit to KePRO

: PRTF Fax form Provider will attest to information from CALOCUS and CON 30 day treatment plan Plan must be created within first 14 days Additional clinical

LENGTH OF APPROVAL

• Requests initially approved for a 21-day stay. • Continued stay requests approved for a 30-day stay. • Time limits apply to SUBCLASS recipients.

OVERLAPPING REQUESTS

• Requests for services will not be approved with overlapping dates.  If for same facility, new approval period will not be approved until the old approval has ended.  If for a different facility, the first-approved facility must send in notice of discharge prior to new approval being issued.

PRTF

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Initial Admission

Criteria

– McKesson Interqual Psychiatric Residential Treatment Level of Care Functioning criteria – SCDHHS Psychiatric Hospital Services Provider Manual

CRITERIA FOR PRTF ADMISSION

• Current diagnosis • Symptoms/behaviors (length experienced and intensity) • Prior treatment history • Support system • Functioning – How illness affects performance of ADLs and relationships with others.

PRTF - CONTINUED STAY REQUESTS

For initial continued stay request, please submit by day #14 of current authorization. Requires treatment plan which has been updated within previous 90 days. Initial continued stay review must include documentation of: • Psychiatric Evaluation within 60 hours of admit • Psychological Evaluation within 30 days of admit

PRTF - CONTINUED STAY REQUESTS

All Continued Stay Requests must include documentation/attestation of: • Individual Psychotherapy at least 90 minutes per week • Group Psychotherapy at least 3 times a week • Family therapy at least once a month for face-to-face sessions (or documentation as to why this has not occurred).

• Face-to-face meeting once per month with facility physician/psychiatrist.

PRTF - CONTINUED STAY REQUESTS

After 12 months (365 days), a new case will need to be set up and a new review completed. Documentation must include: • New CALOCUS • Treatment plan updated within previous 90 days. • Meet McKesson Interqual for continued stay

FREESTANDING PSYCHIATRIC INPATIENT

(UNDER 21 & OVER 65)

AUTHORIZATION

Effective 9/11/2014 Requests to Freestanding Psychiatric Facilities will be authorized for a one-day duration, (instead of 30 days).

DOCUMENTATION

• If submitting by FAX, use Inpatient Prior Authorization Fax Form. • In Box 16, mark Service Type as Freestanding Inpatient Psychiatric

DOCUMENTATION

• Submission of Certificate of Need (CON) is required or attestation of CON on fax form, box 23 . This form is valid for 45 days. • Submitted clinical information will be used to meet criteria in McKesson Interqual to substantiate medical necessity of inpatient admission.

CRITERIA

• Inpatient Freestanding Psychiatry • Must meet criteria for either: – Immediate Safety Risk – Potential Safety Risk

IMMEDIATE SAFETY RISK

• Symptoms within previous 48 hours. • Recipient is exhibiting symptoms that lead to immediate concern of decreased safety for recipient or other people. Example: Suicidal with definite plan

POTENTIAL SAFETY RISK

• Symptoms present within last week that lead to concern over recipient’s safety. • As this is less urgent, requires more detailed documentation of medical necessity.

POTENTIAL SAFETY RISK

• Clinical to be submitted includes: – Symptoms/circumstances that cause concern – Social risk; changes within previous month in relationships with others, role performance (school) or residence – Is recipient expected to adhere to treatment plan? – Why is current support system inadequate to provide care as an outpatient?

ADOLESCENT SUBSTANCE USE

• Freestanding Inpatient Psychiatry admissions for substance use issues have a separate set of criteria that must be met. • Requirements include submission of the recipient’s history of substance use as well as behaviors exhibited as a result of substance use.

CRITERIA – ADOLESCENT SUBSTANCE USE

• Require evidence of impairments in: – Relationships – such as a negative peer group or gang involvement, or increased conflicts with others. – Role performance – How has substance use affected education?

CRITERIA – ADOLESCENT SUBSTANCE USE

• Admission to a residential treatment center for substance use issues also requires information on: – Prior treatment history – Issues in current social/home setting that places the recipient at increased risk – Support system

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

Registration for Atrezzo Connect Provider Portal

How To Register For Atrezzo Connect

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Website Address: https://scdhhs.kepro.com

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Select “ Registration For Atrezzo Connect” (Slide 3)

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Enter your 10 digit National Provider Identifier (NPI) number and Legacy South Carolina Medicaid provider ID

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Select a unique user name and password & complete required user information

Atrezzo Connect Atrezzo Connect allows for:

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Secure access to Atrezzo Connect (Provider Portal)

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Provider will be able to access letters by Case/Request, Respond/Send messages To/From KePRO

Required Information for Security Verification

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The provider must enter information to verify authenticity for security reasons

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Registration Code:

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SCDHHS Legacy ID

Simple -5 Step Registration Process

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Start by clicking the Atrezzo Login button on the SCDHHS-KePRO website

Login Page

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You will be brought to this login page

Step 2 – Enter NPI and Legacy ID

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Enter your organization’s NPI number and Legacy Provider ID = Provider Registration Code

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Click NEXT

Step 3 – Terms of Agreement

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Review Terms of Agreement. Upon acceptance, you will be taken to setup for User information.

Step 4 – Verify Address

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Click on the correct address(s) for the new account (this associates your user information with these locations)

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If all apply, check all of them

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Click SELECT

Step 5 – Enter Account Information

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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

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Successful Completion of setup, takes you to the Home Page

View all request and Create new request

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Click Member to search using Member id or Last name/DOB

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Click Request/Case to search using Case id, Member info or Request info

Create Preferences, Manage User accounts 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

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All information submitted for registration under Provider/Facility Information will represent as the Provider Portal Administrator (Group Admin).

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The Group Admin is responsible for managing and creating all Submitting User accounts for your NPI #

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Create other Group Admins’ & Admin Users

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Set Preferences, i.e. Diagnosis and Procedure codes, etc

KePRO Contacts

Thank You!

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