Transcript Department of Medical Assistance Services www.dmas.virginia.gov September & October 2010

Department of Medical
Assistance Services
Residential Treatment
For Children & Adolescents
Level C (RTC)
September & October 2010
www.dmas.virginia.gov
Residential Treatment
Level C
DMAS Contacts
 William O’Bier - 804-225-4223
[email protected]
 Pat Smith - 804-225-2412 for KePRO related
questions
[email protected]
 Tracy Wilcox-804-371-2648
Contract Monitor for Clifton Gunderson Audits
[email protected]
2
Training Objectives:



Identify participation requirements
Understand Medicaid documentation
requirements
Be aware of Service Authorization (SA)
requirements and process
3
Objectives cont:
•
•
These slides contain only highlights of the
Virginia Medicaid Psychiatric Services
Manual (PSM) and are not meant to
substitute for the comprehensive information
available in the manual.
Please refer to the manual, available on the
DMAS website, for in-depth information on
psychiatric residential treatment criteria.
4
Provider Enrollment Unit

For enrollment, agreements, change of
address, and enrollment questions
contact:
Provider Enrollment Unit
P.O. Box 26803
Richmond, VA 23261
– Toll free -888-829-5373
– Fax
-- 804-270-7027
5
Provider Agreements


A Restraint & Seclusion (R&S)
attestation letter must be submitted to
DMAS by July 1 each year or sooner if
change in CEO
Sample R&S attestation letter in
manual
6
General Medicaid Provider
Participation Requirements




Have administrative and financial
management capacity to meet federal and
state requirements
Have ability to maintain business and
professional documentation
Adhere to conditions outlined in the provider
agreements
Notify DMAS of any change in original
information submitted
and
7
Participation Requirements





Maintain records that fully document health
care provided
Retain records for a period of at least 5 years
Furnish access to records and facilities in the
form and manner requested
Use Medicaid designated billing forms
Accept as payment in full the amount
reimbursed by DMAS. Provider must be
participating in the Medicaid Program at the
time the service is performed
and
8
Participation Requirements




A provider may not bill a client for a covered
service regardless of whether or not the
provider received payment from the state
Should not attempt to collect from the client or
family member any amount that exceeds the
Medicaid allowance or for missed appointments
Hold all recipient information confidential
Be fully compliant with state and federal HIPAA
confidentiality, use and disclosure requirements
9
Definition-Level C RTF





Program for children under age 21 to
treat severe mental, emotional and
behavioral disorders
When outpatient and day treatment
fails
Provides inpatient psychiatric treatment
24-hours per day program
Child-specific care and treatment
planning
and
10
Definition-Level C RTF




Highly organized and intensive services
Planned therapeutic interventions
All services required to be provided onsite, including academic program
Physician-directed mental health
treatment
11
Restraint & Seclusion


Remain in compliance with signed
agreement regarding seclusion and
restraint
In case of injury requiring medical
attention off-site or a suicide attempt,
DMAS must be notified by fax within one
business day of occurrence:
– child’s name, Medicaid number
– facility name & address of incident
– location & date of incident
and
12
Restraint & Seclusion Cont’d

Notification continued
– names of staff involved
– description of incident
– outcome, including persons notified
– current location of child


Fax to William O’Bier at 804-612-0059
Restraint & Seclusion reporting is a
condition of participation and non-reporting
subject to retraction for paid claims and of
provider enrollment
13
Out-of-State Facility Enrollment
Border-state facility (within 50 miles)
 Provides a service not available in Virginia; or
 No in-state facility willing to admit a specific
child
Procedure:

– Contact DMAS at 804/225-4223 to discuss
child-specific, out-of-state placement need
– DMAS can enroll facility for single placement,
if appropriate
and
14
Out-of-State Placement Criteria


Requires prior authorization for Medicaid coverage
Recipient specific information required to be sent
to DMAS:
– Demographics
– Referral source information
– Current placement and services and why these
are not adequate
– Current documentation on diagnosis, behaviors,
discharge plan
– Current psychological evaluation -within past
year
and
15
Out-of-State Placement Criteria
−Social and Service History pertinent to
placement needs
– Out-of-state facility information-website,
documentation
– List of Virginia facilities explored, and
reasons for admission denial
This will be reviewed by DMAS staff to
assess the appropriate level of care and
facility placement, and who will
coordinate with provider enrollment if
out-of state placement is approved
16
Electronic Submission of
Claims
Claims should be submitted electronically
 For CSA cases, when submitting SA
information to KePRO, the 3-digit locality code
and the Reimbursement Rate Certification rate
are required. This will facilitate electronic
submission of claims
For NON-CSA cases, reimbursement will be at
the rate established at enrollment.
– All providers are expected to have a rate
established at enrollment

17
Electronic Signatures

Clarification on electronic signatures
issued in the 8-20-04 Medicaid Memo
http://www.dmas.virginia.gov/downloads/pdfs/mmuse_electronic_signatures.pdf


An electronic signature that meets the
following criteria is acceptable for
clinical documentation:
Identifies the individual signing by name
and title;
and
18
Electronic Signatures



Data system assures the documentation
cannot be altered after signature affixed, by
limiting access to code or key sequence;
Provides for non-repudiation; that is, strong
and substantial evidence that will make it
difficult for the signer to claim the electronic
representation is not valid; and
The provider must have written policies and
procedures in effect regarding use of
electronic signatures.
19
Required Documentation



The following slides describe the
required documents for admission
All documents must be complete,
timely and include all required dated
signatures
Sample forms are available in the
manual
20
Reimbursement Rate
Certification
For CSA Cases Only



Negotiated rate between locality and
facility
Total rate can be no more than the
Medicaid maximum
Payment from any other source such
as Title IV-E, must be deducted prior
to establishing the rate
and
21
Reimbursement Rate
Certification continued

Identify responsible locality
– Locality code must be sent in for PA
– If rate is revised by the locality, must be
sent in to KePRO within 1 week to update
the PA


Payment based on the rate on the
certification which is entered by KePRO
into the MMIS
All versions of the rate certification must
be available at the facility for review
22
CSA or NON-CSA?

If the case is an Adoption Subsidy case, it
is NON-CSA
– The education payment source is not
considered



If the education is paid for by the Dept. of
Education/CSA funded, it is a CSA case
If a child has been receiving CSA funding
for other services, it is a CSA case
If the child is in foster care, it is a CSA case
23
Certification of Need

CSA Cases
– CON must be completed by both the
physician and the FAPT
– Must include dated signatures of physician
and at least 3 members of the FAPT
– Authorization can begin no earlier than the
date of the latest signature
– Must be child-specific and relate to the
need for RTF level of care
– Must be available in the medical record
24
Certification of Need
(Independent Team Certification)

NON-CSA Cases
– The CSB is responsible for completing
the Independent Team Certification
– The CSB completes the DMH224 and
must include a physician’s dated
signature, as well as the screener’s
dated signature
 The
CSB may use the sample CON in
the manual in place of the DMH224
and
25
Certification of Need

NON-CSA Cases
– CON may be completed by the FAPT and
must include a physician’s dated
signature, as well as a member of the
FAPT
Authorization can begin no earlier than the
date of the latest signature
– Must be child-specific and relate to the
need for RTF level of care
– Must be available in the medical record
26
Certification of Need
CSA and NON-CSA



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Should reflect the child’s current condition and
must be completed within 30 days of admission
Is required to be completed prior to admission
with all necessary dated signatures
If discharged and readmitted, a new CON is
required
If the child transfers to an acute psychiatric facility,
the acute care team can do the new CON
27
State Uniform
Assessment Instrument
The CANS is the only uniform assessment
instrument that is accepted
28
State UAI

CSA Cases Only
– Must be current. For admission the state
UAI should reflect the requested level of
care
– To be completed at least every 90 days
and must be in the medical record
– Should be updated by the fiscally
responsible locality when the child’s level of
impairment changes significantly
– Completion information must be submitted
to KePRO for SA
and
29
State UAI
–Scoring notes the level of
impairment that supports the need
for the level of care
At a minimum:
 The CANS summary sheet, indicating the
child’s behavioral and emotional needs, and
risk behaviors
 The CANS must be available in the medical
record and current within 90 days
throughout the stay
30
Initial Plan of Care



Must be completed within 24 hours of
admission
Requires a dated physician’s signature
signifying the physician has had a face-toface visit with the child (Authorization can
begin no earlier than the date of the
signature)
All required elements must be in the plan
– See sample form in PSM-DMAS 371
– Be sure to specify the number and type of
child-specific therapies

Must be in the medical record
31
Comprehensive Individual
Plan of Care (CIPOC)



Must be completed within 14 days of
admission
Must include dated signatures of the team
responsible for the care (physician & at least
one other team member specified in
regulations)
Must include all required elements
– See sample form in PSM-DMAS 372
– Be sure to include specific orders for therapies

Must be in the medical record
32
CIPOC 30-Day Progress Updates



Must be updated every 30 days
Must have dated signatures of team members
Must include all required elements
– See sample form in PSM-DMAS 373

List Individual and Family Therapy dates
– If the therapy is not provided by a qualified
professional, or the session was not at least 20
minutes, or there is no note, it should not be
considered a delivered service

Address progress, or lack of progress. If no
progress, how is this being addressed?
34
Therapeutic Interventions
Individual, Family and Group Psychotherapy
must be physician-ordered, provided by a
licensed Medicaid enrolled provider and
addressed in the treatment plan
 Individual Psychotherapy
– Must occur 3 times every 7 days. Facility determines
the 7-day count.
– Sessions must be, at a minimum, 20 minutes
– If the session includes more than the therapist and
the patient it is not considered individual
psychotherapy
– Telephone calls to family members are not
considered individual psychotherapy
and
35
Therapeutic Interventions
Cont’d

Family Psychotherapy
– Must occur at a minimum of 2 times a
month if there is family involvement
– If there is family dysfunction that impacts
the child, therapy should be at least once
a week.
– Must be provided as is ordered in the
treatment plan

Group Psychotherapy
– Group Psychotherapy billed to Medicaid
must not consist of more than 10 patients
and
35
Therapeutic Interventions
Individual, Family and Group Psychotherapy
notes must be completed by a qualified
therapist

If therapy is provided by an individual who has
completed his or her graduate degree and is
working towards licensure, they may do so under
direct supervision
SUPERVISOR


Appropriately licensed under state law and is a
Medicaid-enrolled provider
Supervision meets requirements of individual
profession
and
37
Supervision of Unlicensed Therapists


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Does not need to be the same person
who is supervising for licensing purposes
Reviews patient’s medical history
Approves and signs Plan of Care indicating
the need for the specific service
Countersigns Plan of Care updates
Reviews each therapy note
Must be in the facility during the session,
but not required to be in the session
and
37
Supervision of Unlicensed Therapists


Dated signature on each therapy note on
date of service indicating note was reviewed
Meet regularly with supervisee (every sixth
session or every 90 days, whichever comes
first, to include all types of therapies )
– Discuss Plan of Care
– Review record
– Assess patient’s progress
– Document supervisory meetings

A Physician’s Assistant, under supervision,
is not eligible to provide psychotherapy
39
Therapeutic Interventions
(including 21 weekly interventions)

Notes must contain, at a minimum:
– Child’s name
– Type of session (Individual, group,
medication management)
 If this is a group session, the type of
group must be stated, such as Anger
Management or Coping Skills
– Treatment Modality
– Start and stop time for session
and
39
Therapeutic Interventions Cont’d



Pre-printed forms with date and time of
session already printed is not
acceptable
Written on the date service is provided
Activity of session-what therapeutic
intervention/ interaction occurred, and
how does it relate to goals
– Purpose of note is to document service,
and
40
Therapeutic Interventions
Cont’d
– as well as to assist staff in providing
focused ongoing therapeutic services to
the child




Level of participation (a check box is
not sufficient)
Plan for next session
Dated signature of provider
All notes should be child-specific
41
21 Treatment Interventions
Documentation

21 Treatment Interventions every 7 days
– May count group psychotherapy
– Must not include individual and family
therapy
– Must be documented on a daily basis
 Each
intervention must be documented
– Forms with check boxes as the majority
of the note are not acceptable
and
42
Documentation


Must document child-specific
therapeutic intervention
– Interventions that are not billable
separately may include more than 10
residents (this does not include the
group psychotherapy that may be
billed separately)
Must include the dated signature of the
provider for each intervention
– This does not need to be licensed
staff
43
Documentation Cont’d
Late Entries-- Timeliness of documentation is
essential. A document is considered
complete by review of the dated
signature of the professional who
develops the document. Back dating is
not acceptable.
44
Restraint & Seclusion


Reports must be sent to DMAS
reporting any injury requiring medical
attention. These should be sent in
within one business day of the
occurrence. (See slide 9)
Restraint & Seclusion reporting is
a condition of participation and
non-reporting subject to retraction
for paid claims and provider
enrollment.
45
Staffing and Signatures



All signatures must be dated, and
should include the professional title of
the author
All medical documentation must
include dated signatures on the date of
service delivery
Auditors will request a staffing list with
proof of licensure if license is required
to provide a Medicaid reimbursed
service
46
Service Authorization Contractor
KePRO is the DMAS contractor for SA
For questions go to the SA website:
DMAS.KePRO.org and click on
Virginia Medicaid
Phone: 1-888-VAPAUTH or
1-888-827-2884
Fax: 1-877-OKBYFAX or 1-877-652-9329
Web: Provider Issues @ KePRO.org
47
Service Authorization
Contractor
Submitting a request
 The preferred method is the iEXCHANGE®
web-based program
 Registration is required
 Information on iEXCHANGE is available on
the KePRO website, or call
1-888-827-2884 or by e-mail at
[email protected]
48
KePRO


Telephone to 888-827-2884 or
804-622-8900 (local)
Mail to
KePRO
2810 North Parham Rd., Suite 305
Richmond, VA 23284
49
Service Authorization



Requests for SA are required to be
submitted to KePRO prior to services being
rendered, but no sooner than 10 days
prior
Authorization can be for up to 90 days
with medical justification
KePRO will review requests for medical
necessity, as well as timeliness
– KePRO will apply McKesson InterQual®
Behavioral Health Criteria and DMAS
supplemental criteria
50
Service Authorization
NON-CSA Cases
 Must have a NON-CSA rate established by
DMAS in order to request PA from KePRO
 Contact Provider Reimbursement at
804-686-7931 to establish a rate. This should
be done at the time of enrollment as a provider.
 If no rate has been established, the request for
PA will be rejected by KePRO.
– If a rate is later established, the request will not be
retroactive
59
Service Authorization

For CSA cases only:
– CANS is acceptable as the state UAI and
continue to be required at least every 90
days
– the Reimbursement Rate Certification is
no longer required to be attached
– The locality code and the rate on the RRC
must be provided to KePRO
52
Service Authorization

For both CSA and non-CSA requests:
– No attachments are required, but
information on the CON, IPC and CIPOC
and updates are required
– Severity of Illness questions are critical
to authorization
53
Service Authorization

Narrative must address the need for
level of care:
Initial Review
-symptoms and behaviors within past 7
days, frequency, intensity and duration
– current functioning
– support system
54
Service Authorization
Continued Stay
– Symptoms and behaviors in past 30 days
– Level of function in past 30 days
– Describe recipient investment in treatment
– Describe progress or lack of progress
 If
no progress, how is this addressed?
55
Service Authorization
Initial Review-CSA cases only
– 3-digit locality code
– Reimbursement Rate Certification
information
– State UAI information
CSA and NON-CSA cases
Confirmation of completion:
– Certificate of Need
– Initial Plan of Care
56
Service Authorization
Continued Stay Review-CSA Cases
– Current UAI information
– Confirm locality code
– Reimbursement Rate Certification update if
revised
CSA and NON-CSA Cases
Confirmation of completion:
– CIPOC
– 30-Day Update-most recent
57
Service Authorization
Appeals


The denial of SA for services not yet
rendered may be appealed in writing
by the Medicaid recipient within 30
days of receipt of the denial.
The provider may appeal an adverse
decision for a service already provided
by filing a written notice of appeal
within 30 days of receipt of the denial.
and
58
Service Authorization


Appeal rights will be stated in the SA
notification letter. Requests for appeal must be
submitted to:
Appeals Division
Department of Medical Assistance Services
600 East Broad Street, 11th Floor
Richmond, Virginia 23219
The provider may not bill the recipient for covered
services that have been provided and subsequently
denied by DMAS
59
Utilization Review
Federal regulations require that
DMAS review and evaluate the
services provided through the
Medicaid program.
Purpose of Utilization Review:




Ensure medical necessity
Confirm qualified provider delivered service
Ensure program requirements met
Address Quality of Care issues
60
Utilization Review

DMAS has contracted with CliftonGunderson to complete audits of RTFs
and will review records to assure DMAS
criteria is being followed
61
Questions?
62