Transcript Slide 1
Sandhills Center LME/MCO Provider IPRS-Waiver Orientation CARE / UTILIZATION MANAGEMENT The Care Management/Utilization department operates using a Two (2) Tier management system. This includes: Tier I—TAR Required> Intensive Care Services, e.g., Inpatient Hospitalization, Partial Hospitalization, Assertive Community Treatment Team (ACCT), etc. Tier II—-Direct Billed> Basic services-no TAR required and goes directly to Billing, e.g., 8 Adult & 16 Child Individual Therapy sessions, Med. Mgt., etc. Standardized Forms Treatment Authorization Request (TAR) Person Centered Plan (PCP) Individual Support Plan (ISP) Level of Care LOCUS* (Deerfield Behavioral Health Licensing) CALOCUS* ASAM NC SNAP SIS Submit all required documentation electronically via PCONN UM department performs: Non-Clinical Review Initial Clinical Review Peer Clinical Review Consistent Decisions via Decision Tools Unable to Process Certify; Non-certify, Deny-Medical Dir. Standard decisions must provide notice within 14 calendar days after receipt of request. Member, Provider or SHC if sanctioned by DMA and if it is in the best interest of the member, can request an extension up to an additional 14 calendar days to receive additional information. Untimely certifications constitutes a denial and an adverse action. Notice of Adverse Action must explain: Action taken or intends to take. Reasons for action and enrollee/member’s right or designated representative to appeal. Appeal must be received within 20 days of notice. Pursuant to 42 CFr 438.402(b) Member may file, a provider acting on behalf of an member may file an appeal with written consent. Appeal-done either orally or in writing, but if oral must follow written and signed. SHC-must resolve and notify expeditiously in writing no later than 45 days from day appeal is received. Decision not wholly in member favor: ◦ I-Right to request a State fair hearing ◦ II-Inform how to request State fair hearing ◦ III-Right to continuation of benefits pending hearing ◦ IV-How to request continuation of benefits ◦ V-If SHC’s action upheld, may be liable for cost of continued benefits SHC must continue member’s benefits if: ◦ Appeal is timely (on or before 11days of notification of action). ◦ Or the intended effective date of SHC’s proposed action. SHC continues or reinstates benefits while the appeal is pending, or until one of the following occurs: ◦ Member withdraws appeal ◦ Member does not request a fair hearing with 11 day since adverse action notification decision ◦ State fair hearing decision adverse to member is made ◦ Certification expires or certification service limits are met SHC or State must pay for disputed services (State Policy) if hearing officer reverses decision to deny certification and disputed services were received. Expedited Appeal Process: Special type of appeal. Must follow standard regulations with the exception of expeditious process which is within 72 hours. SHC must inform member of their limited time to present evidence and allegations of fact or law, in person or in writing. Any extension not requested by member, must provide written notice of the reason for delay. SHC must not take any punitive action against a Provider who requests or supports an member’s request. If SHC’s denies a request for this type of appeal. It must-transfer to standard timeframe of no longer than 45 days, and give prompt notice within 2 days of the rationale. State Fair Hearing: ◦ Member may request no less than 20 days or more than 90 from the date SHC’s notice of action ◦ Standard Resolution-90 days ◦ Expedited-3 working days Phone: 1-800-241-1073 Fax: 1-910-673-0875