Department of Medical Assistance Services

1. Department of Medical Assistance Services

2. 2 DMAS Contacts Shelley Jones - 804-786-1591 Shelley.jones@dmas.virginia.gov Bill O’Bier - 804-225-4050 William.obier@dmas.virginia.gov Pat Smith - 804-225-2412 for KePRO related questions Patty.smith@dmas.virginia.gov Tracy Wilcox - 804-371-2648 Contract Monitor for Clifton Gunderson Tracy.wilcox@dmas.virginia.gov

3. 3 Training Objectives Identify participation requirements Understand Medicaid documentation requirements Understand locality responsibilities Be aware of prior authorization (PA) requirements and process Understand changes to UAI and PA fax form Understand the utilization review process Reference handouts of October 15 and November 7, 2008 Medicaid memo and CANS summary form

4. 4 Objectives These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual (PSM) and are not meant to substitute for or take the place of the material in the manuals. Please refer to the manual, available on the DMAS website, for in-depth information on TFC-CM criteria.

5. 5 Provider Enrollment Unit For enrollment, agreements, change of address, and enrollment questions contact: First Health Services Provider Enrollment Unit P.O. Box 26803 Richmond, VA 23261 Toll free -- 888-829-5373 Fax -- 804-270-7027

6. 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. 7 Participation Requirements Maintain records that fully document health care provided Retain records for a period of at least 5 years Furnish to authorized state and federal personnel access to records and facilities in the form and manner requested Use Medicaid designated billing forms and

8. 8 Participation Requirements 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 A provider may not bill a client for a covered service regardless of whether or not the provider received payment from Medicaid

9. 9 Participation Requirements 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

10. 10 Electronic Signatures Clarification on electronic signatures was issued in the 8-20-04 Medicaid Memo to all providers. An electronic signature that meets the following criteria is acceptable for clinical documentation: Identifies the individual signing by name and title; and Data system assures the documentation cannot be altered after signature affixed, by limiting access to code or key sequence; and

11. 11 Electronic Signatures 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. The provider must have written policies and procedures in effect regarding use of electronic signatures.

12. 12 Common Abbreviations CAFAS/PECFAS-Child & Adolescent Functional Assessment Scale/Preschool & Early Childhood Functional Assessment Scale CANS-Child and Adolescent Needs and Strengths CPMT-Community Policy & Management Team CSA-Comprehensive Service Act CSB-Community Service Board DMAS-Department of Medical Assistance Services

13. 13 Common Abbreviations DSS-Department Social Services FAPT-Family Assessment & Planning Team OCS-Office of Comprehensive Services PSM-Psychiatric Services Manual RTF-“Level C” Residential Treatment Facility SED-Seriously Emotionally Disturbed TFC-CM-Treatment Foster Care - Case Management

14. 14 Definition Case management activities by child placing agencies with treatment foster care programs Licensed/certified by DSS In compliance with DMAS criteria Meet provider qualifications and

15. 15 Definition Case Management activities which help SED children or those with behavioral disorders under the age of 21 who are at risk of placement into residential treatment Gain access to necessary care and appropriate services Coordinate and monitor necessary care and services

16. 16 Required Documentation FAPT ASSESSMENT Childs immediate & long range therapeutic needs Developmental priorities Personal strengths & liabilities Potential for family reunification Specific planned treatment objectives Specific therapeutic modalities required to achieve objectives Signed and dated by a majority (at least 3) of FAPT members

17. 17 Effective November 1, 2008 The state uniform assessment instrument (UAI) has been the CAFAS/PECFAS since the start of the TFC-CM program in 2000 On November 1, 2008 DMAS will also begin to accept the CANS as the state UAI Either the CAFAS/PECFAS or CANS can be used to meet criteria until June 30, 2009 On July 1, 2009, only the CANS will be accepted as the state UAI for TFC-CM

18. 18 State UAI At a minimum: The CAFAS or PECFAS profile sheets for the youth and caregiver, OR The CANS summary sheet, indicating the child’s behavioral and emotional needs, and risk behaviors, must be available in the medical record and current within 90 days throughout the stay

19. 19 Initial Plan of Care For Medicaid purposes the initial plan of care must include, at a minimum, a list of services that will be provided during the first 45 days of placement List of services to be provided must be in the medical record within the first 10 days of placement

20. 20 Comprehensive Treatment and Service Plan (CTSP) Comprehensive plan Completed within 45 days of placement Individualized Developed by case manager and treatment team Consult with parents when appropriate

21. 21 CTSP Must include the following: Assessment of child’s needs Emotional Behavioral Educational Medical Specific treatment goals and target dates for completion The CM’s program of therapies, activities, and services and

22. 22 CTSP The discharge plan and target date For children age 16+, describe transition plan for independent living Indicate team members participation in development of plan Dated signature of the case manager CTSP should be revised annually

23. 23 90 Day Progress Update Completed 90 days from CTSP and every 90 days throughout the stay Specify time period covered Describe progress towards treatment goals and objectives Met Continued or added Criteria for achievement of each Target dates for each and

24. 24 90 Day Progress Update Specify problems and behaviors of child being addressed Specify any changes in interventions or strategies Describe therapies, activities, or services provided Any changes needed for next 90 days Services to be provided in next 90 days Child’s own assessment and

25. 25 90 Day Progress Update Contacts of child & family, where appropriate Specific medical needs, treatment and medications provided Update to discharge plans/date Transition plans Annual revision of the CTSP to include all of the above

26. 26 Case Narratives Current within 30 days In chronological order Include: Treatment & services All contacts related to child Visits with family Other significant events Record all medications prescribed and all reported side effects Dated signature of case manager

27. 27 MEDICAL NECESSITY CRITERIA Documented moderate to severe impairment & moderate to severe risk factors as recorded on the UAI For the CANS, this would be from the Child Behavioral/Emotional Needs and/or Child Risk Behaviors areas on the summary sheet The moderate to severe impairment is necessary for admission. Continued stay reviews require documentation of the necessity for this level of care, not necessarily tied to the UAI score. The moderate to severe impairment is necessary for admission. Continued stay reviews require documentation of the necessity for this level of care, not necessarily tied to the UAI score.The moderate to severe impairment is necessary for admission. Continued stay reviews require documentation of the necessity for this level of care, not necessarily tied to the UAI score.

28. 28 MEDICAL NECESSITY CRITERIA Child’s condition must meet one of the three levels listed below and supported by the providers documentation of current behaviors:

29. 29 LEVEL IModerate impairment with one or more risk factors Needs intensive supervision to prevent harmful consequences; Moderate/frequent disruptive or non-compliant behaviors in the home setting that increase the risk to self or others; and Needs assistance of trained professionals as caregivers.

30. 30 LEVEL II Significant impairment with authority, impulsivity, and caregiver issues Be unable to handle the emotional demands of family living; Need 24-hour immediate response to crisis behaviors; or Have severe disruptive peer & authority interactions that increase risk and impede growth.

31. 31 LEVEL III Child must display a significant impairment with severe risk factors as documented on CAFAS. Child must also demonstrate risk behaviors that create significant risk of harm to self or to others.

32. 32 Responsibilities of the LOCALITY in TFC Case Management

33. 33 Complete the state uniform assessment instrument (UAI) No older than maximum of 90 days CAFAS/PECFAS Youth’s functioning Caregiver Resources CANS Summary sheet Include Child Behavioral/Emotional Needs and Child Risk Behaviors sections Be sure to include the child’s name and the screener’s name, as well as the date completed and

34. 34 Locality Responsibility State UAI: Impairments identified must be related to scores on UAI CAFAS/PECFAS At least ONE moderate impairment noted with related risk factor Two are required if one is in School subscale CANS Two impairments indicated as a #2 or #3 on the summary sheet Impairments indicated must be supported in the narrative For the CANS, see the Child Behavioral/Emotional Needs and/or Child Risk Behaviors section of the summary sheetFor the CANS, see the Child Behavioral/Emotional Needs and/or Child Risk Behaviors section of the summary sheet

35. 35 Locality Responsibility DSM IV Diagnosis V Codes are not acceptable List of services to be provided in first 45 days of care Description of child’s behavior within past 30 days Be specific, give frequency and duration Problem behaviors should be reflected on the state UAI Alternative placement options considered and V codes are V codes are

36. 36 Locality Responsibility Child’s functional level Clinical stability Level of family support Discharge plan FAPT assessment that reflects the need for level of care and the state UAI Dated signatures of at least 3 members of the FAPT and The FAPT assessment can include all of the aboveThe FAPT assessment can include all of the above

37. 37 Locality Responsibility And either: FAPT Certification that TFC Case Management is medically necessary OR Written documentation that the CPMT has approved admission to TFC Case Management

38. 38 Locality Responsibility Be sure to submit to the provider: Copies of the current state UAI FAPT Assessment documenting the need for level of care Provide specific symptoms and/or problem behaviors that need to be addressed DSM-IV FAPT or CPMT Certification 3 digit locality code that designates the fiscally responsible locality Be sure to check the locality code. If only providing the name of the locality, if you are a CSA managing a number of localities, be sure to give the correct locality name.Be sure to check the locality code. If only providing the name of the locality, if you are a CSA managing a number of localities, be sure to give the correct locality name.

39. 39 Components of TFC-CM Care Plan development Coordinate services and service planning with others involved with child, such as working with DSS staff, juvenile justice or court staff, or other service providers, such as Mental Health Support staff Referral for needed services Follow up on progress to ensure service delivery

40. 40 Components of TFC-CM Placement activities Planning appropriate placement Monitoring placement Discharge planning Evaluating effectiveness of treatment plan through supervision of foster parents Assess periodically, child’s need for services: Psychosocial Nutritional Medical Education

41. 41 Ensure receipt of required documents from the locality Ensure the locality has provided the correct locality code to reflect the locality that has fiscal responsibility for the child Submit the prior authorization request to KePRO within 10 days of placement Notify the locality of Medicaid approval or denial

42. 42 CM’s Ongoing Responsibility The CM shall provide to the foster family: Supervision Training Support Guidance To facilitate the implementation of the treatment plan

43. 43 Contacts with the TFC Child Face-to-face contact with the child should be as often as necessary, based on the CTSP to ensure effective, safe services. Face-to-face contacts must be no less than twice a month, one in the foster home, one with foster parent and child. The two minimum face-to-face visits should occur on different dates. GOALS Assess child’s progress Provide guidance to TFC parents Monitor service delivery Allow child to communicate concerns

44. 44 Service Limits If a child is temporarily out of the home, active CM is necessary to bill for the time out of home No other type of case management may be billed concurrently with TFC-CM, no matter the payment source Caseload limits: Case manager (full-time professional staff) to have a maximum of 12 children 6 children for beginning trainees, increasing to 9 at end of first year, and 12 by end of second year Maximum of 3 children in student intern caseload

45. 45 Documentation 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.

46. 46 Prior Authorization KePRO is the DMAS prior authorization contractor Authorization can be approved for up to one year with medical justification KePRO will review requests for medical necessity, as well as timeliness

47. 47 Prior Authorization For questions or forms, go to the PA website or use the web address below: 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 VAPAUTHVAPAUTH

48. 48 Prior Authorization 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 providerissues@kepro.org

49. 49 Prior Authorization Additional Methods of Submission Requests may also be submitted by: Fax to 877-652-9329 The Treatment Foster Care Case Management Prior Authorization Request Form (364) is available in electronically fill-able format on the KePRO and DMAS websites www.dmas.virginia.gov https://dmas.kepro.org

50. 50 KePRO Telephone to 888-827-2884 or 804-622-8900 (local) Mail to: KePRO 2810 North Parham Rd., Suite 305 Richmond, VA 23284

51. 51 Revised Fax Form A revised prior authorization fax form is available on the DMAS and KePRO websites The changeover from the CAFAS to the CANS as the state UAI and the dual use period is reflected on the revised fax form Added a “Change Request” box under item 1 of the fax form Under current behaviors, information should reflect UAI All other areas of the form remains the same

52. 52 Revised Fax Form The effective date for the mandatory use of the new fax forms has been revised to December 1, 2008. From December 1 forward, the 9-25-08 version of the fax form attached to the October 15th memo and posted on the DMAS and KePRO websites will be required.

53. 53 State UAI Must be current. For admission the state UAI should reflect the requested level of care To be completed at a minimum of every 90 days and must be available 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 PA Scoring notes the level of impairment that supports the need for the level of care If the CAFAS is out of date at the time of audit, there will be retractions for those dates. The CAFAS should include the screener’s name, the child’s name and the date completed. If the CAFAS is out of date at the time of audit, there will be retractions for those dates. The CAFAS should include the screener’s name, the child’s name and the date completed.

54. 54 Initial Review Use when in care for up to 45 days Required to be submitted within 10 days of admission Completed KePRO fax form to include information on: Diagnosis TFC-CM need FAPT assessment and

55. 55 Initial Review State UAI information Initial services Symptoms and behaviors Information should reflect the scoring on the state UAI. If not, explain. Locality code-this should reflect the locality who is fiscally responsible For reviews not received within 10 calendar days of placement, approval can begin no earlier than the date all requested information is received.

56. 56 Continued Stay Review Submitted prior to the expiration of the current authorization, but no earlier than 30 days Information required: Confirm the locality code DSM-IV CTSP completion information Determination that TFC-CM required to meet child’s needs

57. 57 Continued Stay Review Information required: Confirmation on face-to-face visits Symptoms and behaviors Specify frequency, intensity and duration of problem behaviors If no problems indicated, give reason for continuing services Current state UAI information Be sure the narrative supports the UAI scores, or explain why not

58. 58

59. 59 Prior Authorization Appeals The denial of PA 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. Appeal rights and address for submission will be stated in the FHS notification. Requests for appeal must be submitted directly to DMAS within 30 days of the notice of denial. and

60. 60 Prior Authorization The provider may not bill the recipient for covered services that have been provided and subsequently denied by DMAS

61. 61 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

62. 62 Utilization Review DMAS has contracted with Clifton-Gunderson to complete audits of TFC-CM and will review records to assure DMAS criteria is being followed. They will select providers for review by statistical sampling, exception reporting or through referrals or complaints They will make periodic announced and unannounced visits and

63. 63 Utilization Review They will do desk audits or on-site visits to review medical documentation to ensure DMAS criteria is met They will request provider qualification information as well as confirmation of service delivery They will assess service limits compliance They will determine if retraction of paid claims is necessary and

64. 64 Utilization Review The criteria described in the earlier slides is critical to compliance, although it is not a complete list. See the Psychiatric Services Manual for a complete listing. Review all referenced federal and state regulations, as well as Medicaid Memos that are sent to providers and available on the DMAS website. Review the sample forms provided in the PSM. CG will also be doing auditing of other Medicaid services as well.CG will also be doing auditing of other Medicaid services as well.

65. 65 Duplication of Services Intensive In-Home Services and Treatment Foster Care Services both have a case management (CM) component and so should not both be provided at the same time. No other CM service should be provided to the same recipient at the same time as TFC-CM, no matter the payment source (this includes MH and MR case management or other services with a CM component) If there is no CM component it would not be a duplication of services. Duplication is subject to retraction at audit.

66. 66 The Reviewer Checks: Consumer’s full name or Medicaid number on each document in the record Medical/clinical necessity of the service Appropriate admission to service Required documentation See slides 16-30 as well as the PSM for a complete listing

67. 67 If a request for authorization has been approved, but: the child no longer meets DMAS criteria (does not have impairments indicated on the UAI, and there is no documented reason for continued services: THE PROVIDER SHOULD NOT BILL MEDICAID CAUTION!

68. 68 Utilization Review If the UR finding is to retract prior reimbursement, the provider has the right to reconsideration and appeal. Reconsideration is required to be submitted within 30 days of the audit letter date. All material to support why retraction should not be made should be included. If the decision is to uphold the denial decision after reconsideration, the provider has the right to appeal. Appeal rights will be stated in the decision letter. Requests for appeal must be submitted within 30 days of the notice of reconsideration

69. 69 Questions?