Department of Department of Medical Assistance Medical Assistance ServicesServices

September & October 2010

www.dmas.virginia.gov

Residential TreatmentFor Children & Adolescents

Level C (RTC)

22

Residential TreatmentResidential TreatmentLevel CLevel CDMAS ContactsDMAS Contacts William O’Bier - 804-225-4223William O’Bier - 804-225-4223

william.obier@dmas.virginia.govwilliam.obier@dmas.virginia.gov Pat Smith - 804-225-2412 for KePRO related Pat Smith - 804-225-2412 for KePRO related

questionsquestions

patty.smith@dmas.virginia.govpatty.smith@dmas.virginia.gov Tracy Wilcox-804-371-2648 Tracy Wilcox-804-371-2648

Contract Monitor for Clifton Gunderson AuditsContract Monitor for Clifton Gunderson Audits

tracy.wilcox@dmas.virginia.govtracy.wilcox@dmas.virginia.gov

33

Training Objectives:Training Objectives:

Identify participation Identify participation requirementsrequirements

Understand Medicaid Understand Medicaid documentation requirements documentation requirements

Be aware of Service Authorization Be aware of Service Authorization (SA) requirements and process(SA) requirements and process

44

Objectives cont: Objectives cont:

• These slides contain only highlights of the These slides contain only highlights of the Virginia Medicaid Virginia Medicaid Psychiatric Services Psychiatric Services ManualManual (PSM) and are not meant to (PSM) and are not meant to substitute for the comprehensive substitute for the comprehensive information available in the manual. information available in the manual.

• Please refer to the manual, available on Please refer to the manual, available on the DMAS website, for in-depth the DMAS website, for in-depth information on psychiatric residential information on psychiatric residential treatment criteria.treatment criteria.

55

Provider EnrollmentProvider Enrollment UnitUnit For enrollment, agreements, For enrollment, agreements,

change of address, and change of address, and enrollment questions contact:enrollment questions contact:

Provider Enrollment UnitProvider Enrollment UnitP.O. Box 26803P.O. Box 26803Richmond, VA 23261Richmond, VA 23261– Toll free --Toll free -- 888-829-5373888-829-5373– FaxFax -- -- 804-270-7027804-270-7027

66

Provider AgreementsProvider Agreements

A Restraint & Seclusion (R&S) A Restraint & Seclusion (R&S) attestation letter must be attestation letter must be submitted to DMAS by July 1 each submitted to DMAS by July 1 each year or sooner if change in CEOyear or sooner if change in CEO

Sample R&S attestation letter in Sample R&S attestation letter in manualmanual

77

General Medicaid General Medicaid Provider Provider Participation Participation RequirementsRequirements Have administrative and financial Have administrative and financial

management capacity to meet federal management capacity to meet federal and state requirementsand state requirements

Have ability to maintain business and Have ability to maintain business and professional documentation professional documentation

Adhere to conditions outlined in the Adhere to conditions outlined in the provider agreementsprovider agreements

Notify DMAS of any change in original Notify DMAS of any change in original information submittedinformation submitted andand

88

Participation Participation Requirements Requirements

Maintain records that fully document Maintain records that fully document health care providedhealth care provided

Retain records for a period of at least 5 Retain records for a period of at least 5 yearsyears

Furnish access to records and facilities in Furnish access to records and facilities in the form and manner requestedthe form and manner requested

Use Medicaid designated billing formsUse Medicaid designated billing forms Accept as payment in full the amount Accept as payment in full the amount

reimbursed by DMAS. Provider must be reimbursed by DMAS. Provider must be participating in the Medicaid Program at participating in the Medicaid Program at the time the service is performedthe time the service is performed andand

99

Participation Participation RequirementsRequirements

A provider A provider may not bill a client for a may not bill a client for a covered servicecovered service regardless of whether or not regardless of whether or not the provider received payment from the state the provider received payment from the state

Should not attempt to collect from the client or Should not attempt to collect from the client or family member any amount that exceeds the family member any amount that exceeds the Medicaid allowance or for missed appointmentsMedicaid allowance or for missed appointments

Hold all recipient information confidentialHold all recipient information confidential Be fully compliant with state and federal HIPAA Be fully compliant with state and federal HIPAA

confidentiality, use and disclosure requirementsconfidentiality, use and disclosure requirements

1010

Definition-Level C RTFDefinition-Level C RTF Program for children under age 21 to Program for children under age 21 to

treat severe mental, emotional and treat severe mental, emotional and behavioral disordersbehavioral disorders

When outpatient and day treatment When outpatient and day treatment failsfails

Provides inpatient psychiatric treatmentProvides inpatient psychiatric treatment 24-hours per day program24-hours per day program Child-specific care and treatment Child-specific care and treatment

planningplanningandand

1111

Definition-Level C RTFDefinition-Level C RTF

Highly organized and intensive Highly organized and intensive servicesservices

Planned therapeutic interventionsPlanned therapeutic interventions All services required to be provided All services required to be provided

on-site, including academic programon-site, including academic program Physician-directed mental health Physician-directed mental health

treatmenttreatment

1212

Restraint & SeclusionRestraint & Seclusion

Remain in compliance with signed Remain in compliance with signed agreement regarding seclusion and agreement regarding seclusion and restraintrestraint

In case of injury requiring medical In case of injury requiring medical attention off-site or a suicide attention off-site or a suicide attempt, DMAS must be notified by attempt, DMAS must be notified by fax within one business day of fax within one business day of occurrence:occurrence:– child’s name, Medicaid numberchild’s name, Medicaid number– facility name & address of incidentfacility name & address of incident– location & location & datedate of incident of incident

andand

1313

Restraint & Seclusion Restraint & Seclusion Cont’dCont’d

Notification continuedNotification continued– names of staff involvednames of staff involved– description of incidentdescription of incident– outcome, including persons notifiedoutcome, including persons notified– current location of childcurrent location of child

Fax to William O’Bier Fax to William O’Bier at 804-612-at 804-612-00590059

Restraint & Seclusion reporting is a Restraint & Seclusion reporting is a condition of participation and non-condition of participation and non-reporting subject to retraction for paid reporting subject to retraction for paid claims and of provider enrollmentclaims and of provider enrollment

1414

Out-of-State Facility Out-of-State Facility EnrollmentEnrollment

Border-state facility (within 50 miles)Border-state facility (within 50 miles) Provides a service not available in Virginia; Provides a service not available in Virginia;

oror No in-state facility willing to admit a No in-state facility willing to admit a

specific childspecific child

Procedure:Procedure:– Contact DMAS at 804/225-4223 to discuss Contact DMAS at 804/225-4223 to discuss

child-specific, out-of-state placement needchild-specific, out-of-state placement need– DMAS can enroll facility for single DMAS can enroll facility for single

placement, placement,

if appropriateif appropriate

andand

1515

Out-of-State Placement Out-of-State Placement CriteriaCriteria

Requires prior authorization for Medicaid Requires prior authorization for Medicaid coveragecoverage

Recipient specific information required to be Recipient specific information required to be sent to DMAS:sent to DMAS:– DemographicsDemographics– Referral source information Referral source information – Current placement and services and why Current placement and services and why

these are not adequatethese are not adequate– Current documentation on diagnosis, Current documentation on diagnosis,

behaviors, discharge planbehaviors, discharge plan– Current psychological evaluation -within Current psychological evaluation -within

past yearpast year andand

1616

Out-of-State Placement Out-of-State Placement CriteriaCriteria

−Social and Service History pertinent to Social and Service History pertinent to placement needsplacement needs

– Out-of-state facility information-Out-of-state facility information-website, documentationwebsite, documentation

– List of Virginia facilities explored, and List of Virginia facilities explored, and reasons for admission denialreasons for admission denial

This will be reviewed by DMAS staff to This will be reviewed by DMAS staff to assess the appropriate level of care assess the appropriate level of care and facility placement, and who will and facility placement, and who will coordinate with provider enrollment coordinate with provider enrollment if out-of state placement is if out-of state placement is approvedapproved

1717

Electronic Submission of Electronic Submission of ClaimsClaims Claims should be submitted Claims should be submitted

electronicallyelectronically For CSA cases, when submitting SA For CSA cases, when submitting SA

information to KePRO, the 3-digit locality information to KePRO, the 3-digit locality code and the Reimbursement Rate code and the Reimbursement Rate Certification rate are required. This will Certification rate are required. This will facilitate electronic submission of claimsfacilitate electronic submission of claims

For NON-CSA cases, reimbursement will For NON-CSA cases, reimbursement will be at the rate established at enrollment.be at the rate established at enrollment.– All providers are expected to have a All providers are expected to have a

rate established at enrollmentrate established at enrollment

1818

Electronic SignaturesElectronic Signatures

Clarification on electronic signatures Clarification on electronic signatures issued in the 8-20-04 Medicaid Memo issued in the 8-20-04 Medicaid Memo http://www.dmas.virginia.gov/downloads/pdfs/mm-http://www.dmas.virginia.gov/downloads/pdfs/mm-use_electronic_signatures.pdfuse_electronic_signatures.pdf

An electronic signature that meets the An electronic signature that meets the following criteria is acceptable for following criteria is acceptable for clinical documentation:clinical documentation:

Identifies the individual signing by name Identifies the individual signing by name and title;and title; andand

1919

Electronic SignaturesElectronic Signatures

Data system assures the documentation Data system assures the documentation cannot be altered after signature affixed, cannot be altered after signature affixed, by limiting access to code or key by limiting access to code or key sequence;sequence;

Provides for non-repudiation; that is, Provides for non-repudiation; that is, strong and substantial evidence that will strong and substantial evidence that will make it difficult for the signer to claim the make it difficult for the signer to claim the electronic representation is not valid; andelectronic representation is not valid; and

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

2020

Required Required DocumentationDocumentation The following slides describe the The following slides describe the

required documents for admission required documents for admission All documents must be complete, All documents must be complete,

timely and include all required timely and include all required dated signaturesdated signatures

Sample forms are available in the Sample forms are available in the manualmanual

2121

Reimbursement Rate Reimbursement Rate CertificationCertificationFor CSA Cases OnlyFor CSA Cases Only Negotiated rate between locality Negotiated rate between locality

and facility and facility Total rate can be no more than the Total rate can be no more than the

Medicaid maximumMedicaid maximum Payment from any other source Payment from any other source

such as Title IV-E, must be such as Title IV-E, must be deducted prior to establishing the deducted prior to establishing the raterate

andand

2222

Reimbursement Rate Reimbursement Rate Certification continuedCertification continued

Identify responsible localityIdentify responsible locality– Locality code must be sent in for PALocality code must be sent in for PA– If rate is revised by the locality, must If rate is revised by the locality, must

be sent in to KePRO within 1 week to be sent in to KePRO within 1 week to update the PAupdate the PA

Payment based on the rate on the Payment based on the rate on the certification which is entered by certification which is entered by KePRO into the MMISKePRO into the MMIS

All versions of the rate certification All versions of the rate certification must be available at the facility for must be available at the facility for reviewreview

2323

CSA or NON-CSA?CSA or NON-CSA?

If the case is an Adoption Subsidy case, If the case is an Adoption Subsidy case, it is NON-CSAit is NON-CSA– The education payment source is not The education payment source is not

consideredconsidered If the education is paid for by the Dept. If the education is paid for by the Dept.

of Education/CSA funded, it is a CSA caseof Education/CSA funded, it is a CSA case If a child has been receiving CSA funding If a child has been receiving CSA funding

for other services, it is a CSA casefor other services, it is a CSA case If the child is in foster care, it is a CSA If the child is in foster care, it is a CSA

casecase

2424

Certification of NeedCertification of Need

CSA CasesCSA Cases– CON must be completed by both the CON must be completed by both the

physician and the FAPTphysician and the FAPT– Must include dated signatures of Must include dated signatures of

physician and at least 3 members of the physician and at least 3 members of the FAPTFAPT

– Authorization can begin no earlier than Authorization can begin no earlier than the date of the latest signature the date of the latest signature

– Must be child-specific and relate to the Must be child-specific and relate to the need for RTF level of careneed for RTF level of care

– Must be available in the medical recordMust be available in the medical record

2525

Certification of NeedCertification of Need(Independent Team (Independent Team Certification)Certification)

NON-CSA CasesNON-CSA Cases– The The CSBCSB is responsible for is responsible for

completing the Independent Team completing the Independent Team CertificationCertification

– The CSB completes the DMH224 The CSB completes the DMH224 and must include a physician’s and must include a physician’s dated signature, as well as the dated signature, as well as the screener’s dated signaturescreener’s dated signature The CSB may use the sample CON in The CSB may use the sample CON in

the manual in place of the DMH224the manual in place of the DMH224andand

2626

Certification of NeedCertification of Need NON-CSA CasesNON-CSA Cases

– CON may be completed by the FAPT CON may be completed by the FAPT and must include a physician’s dated and must include a physician’s dated signature, as well as a member of the signature, as well as a member of the FAPTFAPT

Authorization can begin no earlier than Authorization can begin no earlier than the date of the latest signaturethe date of the latest signature

– Must be child-specific and relate to the Must be child-specific and relate to the need for RTF level of careneed for RTF level of care

– Must be available in the medical recordMust be available in the medical record

2727

Certification of NeedCertification of Need

CSA and NON-CSACSA and NON-CSA Should reflect the child’s current condition and Should reflect the child’s current condition and

must be completed within 30 days of must be completed within 30 days of admissionadmission

Is required to be completed prior to admission Is required to be completed prior to admission with all necessary dated signatures with all necessary dated signatures

If discharged and readmitted, a new CON is If discharged and readmitted, a new CON is requiredrequired

If the child transfers to an acute psychiatric If the child transfers to an acute psychiatric facility, the acute care team can do the new facility, the acute care team can do the new CONCON

2828

State Uniform State Uniform Assessment Assessment InstrumentInstrument

The CANS is the only uniform The CANS is the only uniform assessment instrument that is assessment instrument that is acceptedaccepted

2929

State UAIState UAI CSA Cases OnlyCSA Cases Only

– Must be current. For admission the state Must be current. For admission the state UAI should reflect the requested level of UAI should reflect the requested level of carecare

– To be completed at least every 90 days To be completed at least every 90 days

and must be in the medical recordand must be in the medical record– Should be updated by the fiscally Should be updated by the fiscally

responsible locality when the child’s level responsible locality when the child’s level of impairment changes significantlyof impairment changes significantly

– Completion information must be Completion information must be submitted to KePRO for SAsubmitted to KePRO for SA andand

3030

State State UAIUAI

– Scoring notes the level of Scoring notes the level of impairment that supports the impairment that supports the need for the level of careneed for the level of care

At a minimum:At a minimum: The CANS summary sheet, indicating The CANS summary sheet, indicating

the child’s behavioral and emotional the child’s behavioral and emotional needs, and risk behaviorsneeds, and risk behaviors

The CANS must be available in the The CANS must be available in the medical record and current within 90 medical record and current within 90 days throughout the staydays throughout the stay

3131

Initial Plan of CareInitial Plan of Care

Must be completed within 24 hours of Must be completed within 24 hours of admission admission

Requires a dated physician’s signature Requires a dated physician’s signature signifying the physician has had a face-signifying the physician has had a face-to-face visit with the child to-face visit with the child (Authorization can begin no earlier than (Authorization can begin no earlier than the date of the signature) the date of the signature)

All required elements must be in the All required elements must be in the planplan– See sample form in PSM-DMAS 371See sample form in PSM-DMAS 371– Be sure to specify the number and type Be sure to specify the number and type

of child-specific therapies of child-specific therapies Must be in the medical recordMust be in the medical record

3232

Comprehensive Comprehensive Individual Plan of Care Individual Plan of Care (CIPOC)(CIPOC)

Must be completed within 14 days of Must be completed within 14 days of admissionadmission

Must include dated signatures of the Must include dated signatures of the team responsible for the care (physician team responsible for the care (physician & at least one other team member & at least one other team member specified in regulations)specified in regulations)

Must include all required elementsMust include all required elements– See sample form in PSM-DMAS 372See sample form in PSM-DMAS 372– Be sure to include specific orders for Be sure to include specific orders for

therapiestherapies Must be in the medical recordMust be in the medical record

CIPOC 30-Day Progress CIPOC 30-Day Progress UpdatesUpdates Must be updated every 30 daysMust be updated every 30 days Must have dated signatures of team Must have dated signatures of team

membersmembers Must include all required elementsMust include all required elements

– See sample form in PSM-DMAS 373See sample form in PSM-DMAS 373 List Individual and Family Therapy datesList Individual and Family Therapy dates

– If the therapy is not provided by a qualified If the therapy is not provided by a qualified professional, or the session was not at least 20 professional, or the session was not at least 20 minutes, or there is no note, it should not be minutes, or there is no note, it should not be considered a delivered serviceconsidered a delivered service

Address progress, or lack of progress. If no Address progress, or lack of progress. If no progress, how is this being addressed?progress, how is this being addressed? 34

Therapeutic Therapeutic Interventions Interventions

Individual, Family and Group Individual, Family and Group Psychotherapy must be physician-Psychotherapy must be physician-ordered, provided by a licensed ordered, provided by a licensed Medicaid enrolled provider and Medicaid enrolled provider and addressed in the treatment planaddressed in the treatment plan

Individual PsychotherapyIndividual Psychotherapy– Must occur 3 times every 7 days. Facility Must occur 3 times every 7 days. Facility

determines the 7-day count.determines the 7-day count.– Sessions must be, at a minimum, 20 minutesSessions must be, at a minimum, 20 minutes– If the session includes more than the therapist If the session includes more than the therapist

and the patient it is not considered individual and the patient it is not considered individual psychotherapypsychotherapy

– Telephone calls to family members are not Telephone calls to family members are not considered individual psychotherapy considered individual psychotherapy andand

35

3535

Therapeutic Interventions Therapeutic Interventions Cont’d Cont’d

Family PsychotherapyFamily Psychotherapy– Must occur at a minimum of 2 times a Must occur at a minimum of 2 times a

month if there is family involvement month if there is family involvement – If there is family dysfunction that If there is family dysfunction that

impacts the child, therapy should be impacts the child, therapy should be at least once a week.at least once a week.

– Must be provided as is ordered in the Must be provided as is ordered in the treatment plan treatment plan

Group PsychotherapyGroup Psychotherapy– Group Psychotherapy billed to Group Psychotherapy billed to

Medicaid must not consist of more Medicaid must not consist of more than 10 patientsthan 10 patients

andand

Therapeutic Therapeutic InterventionsInterventionsIndividual, Family and Group Individual, Family and Group Psychotherapy notes must be completed Psychotherapy notes must be completed by a qualified therapistby a qualified therapist

If therapy is provided by an individual who If therapy is provided by an individual who has completed his or her graduate degree has completed his or her graduate degree and is working towards licensure, they may and is working towards licensure, they may do so under direct supervisiondo so under direct supervision

SUPERVISORSUPERVISOR Appropriately licensed under state law and Appropriately licensed under state law and

is a Medicaid-enrolled provideris a Medicaid-enrolled provider Supervision meets requirements of Supervision meets requirements of

individual professionindividual professionandand 37

3737

Supervision of Unlicensed Supervision of Unlicensed TherapistsTherapists

Does not need to be the same person Does not need to be the same person who is supervising for licensing purposeswho is supervising for licensing purposes

Reviews patient’s medical historyReviews patient’s medical history Approves and signs Plan of Care Approves and signs Plan of Care

indicating the need for the specific indicating the need for the specific service service

Countersigns Plan of Care updatesCountersigns Plan of Care updates Reviews each therapy noteReviews each therapy note Must be in the facility during the Must be in the facility during the

session, but not required to be in the session, but not required to be in the session session andand

Supervision of Unlicensed Supervision of Unlicensed TherapistsTherapists Dated signature on each therapy note on Dated signature on each therapy note on

date of service indicating note was date of service indicating note was reviewedreviewed

Meet regularly with supervisee (every sixth Meet regularly with supervisee (every sixth session or every 90 days, whichever comes session or every 90 days, whichever comes first, to include all types of therapies )first, to include all types of therapies )– Discuss Plan of CareDiscuss Plan of Care– Review recordReview record– Assess patient’s progressAssess patient’s progress– Document supervisory meetingsDocument supervisory meetings

A Physician’s Assistant, under A Physician’s Assistant, under supervision, is not eligible to provide supervision, is not eligible to provide psychotherapypsychotherapy

39

3939

Therapeutic Interventions Therapeutic Interventions (including 21 weekly (including 21 weekly interventionsinterventions))

Notes must contain, at a minimum:Notes must contain, at a minimum:– Child’s nameChild’s name– Type of session (Individual, group, Type of session (Individual, group,

medication management)medication management) If this is a group session, the type of If this is a group session, the type of

group must be stated, such as Anger group must be stated, such as Anger Management or Coping SkillsManagement or Coping Skills

– Treatment ModalityTreatment Modality– Start and stop time for sessionStart and stop time for session

andand

4040

Therapeutic Interventions Therapeutic Interventions Cont’dCont’d

Pre-printed forms with date and time Pre-printed forms with date and time of session already printed is not of session already printed is not acceptableacceptable

Written on the date service is Written on the date service is providedprovided

Activity of session-what therapeutic Activity of session-what therapeutic intervention/ interaction occurred, intervention/ interaction occurred, and how does it relate to goalsand how does it relate to goals– Purpose of note is to document Purpose of note is to document

service,service, andand

4141

Therapeutic Interventions Therapeutic Interventions Cont’d Cont’d

– as well as to assist staff in as well as to assist staff in providing focused ongoing providing focused ongoing therapeutic services to the childtherapeutic services to the child

Level of participation (a check box Level of participation (a check box is not sufficient)is not sufficient)

Plan for next sessionPlan for next session Dated signature of providerDated signature of provider All notes should be child-specificAll notes should be child-specific

4242

21 Treatment 21 Treatment Interventions Interventions DocumentationDocumentation

21 Treatment Interventions every 7 21 Treatment Interventions every 7 daysdays– May count group psychotherapyMay count group psychotherapy– Must not include individual and family Must not include individual and family

therapytherapy– Must be documented on a daily basisMust be documented on a daily basis

Each intervention must be documentedEach intervention must be documented– Forms with check boxes as the Forms with check boxes as the

majority of the note are not acceptablemajority of the note are not acceptableandand

4343

DocumentationDocumentation Must document child-specific Must document child-specific

therapeutic interventiontherapeutic intervention– Interventions that are not billable Interventions that are not billable

separately may include more than 10 separately may include more than 10 residents (this does not include the residents (this does not include the group psychotherapy that may be group psychotherapy that may be billed separately)billed separately)

Must include the dated signature of the Must include the dated signature of the provider for each intervention provider for each intervention – This does not need to be licensed staffThis does not need to be licensed staff

4444

Documentation Cont’dDocumentation Cont’d

Late Entries---Late Entries--- Timeliness of documentation is Timeliness of documentation is

essential. A document is essential. A document is considered complete by review of considered complete by review of the dated signature of the the dated signature of the professional who develops the professional who develops the document. Back dating is not document. Back dating is not acceptable. acceptable.

4545

Restraint & SeclusionRestraint & Seclusion Reports must be sent to DMAS Reports must be sent to DMAS

reporting any injury requiring reporting any injury requiring medical attention. These should be medical attention. These should be sent in sent in within one business day within one business day of the occurrenceof the occurrence. (See slide 9). (See slide 9)

Restraint & Seclusion reporting Restraint & Seclusion reporting is a condition of participation is a condition of participation and non-reporting subject to and non-reporting subject to retraction for paid claims and retraction for paid claims and provider enrollmentprovider enrollment..

4646

Staffing and SignaturesStaffing and Signatures

All signatures must be datedAll signatures must be dated, , and should include the and should include the professional title of the authorprofessional title of the author

All medical documentation must All medical documentation must include dated signatures on the include dated signatures on the date of service deliverydate of service delivery

Auditors will request a staffing list Auditors will request a staffing list with proof of licensure if license is with proof of licensure if license is required to provide a Medicaid required to provide a Medicaid reimbursed servicereimbursed service

4747

Service Authorization Service Authorization ContractorContractorKePRO is the DMAS contractor for SAKePRO is the DMAS contractor for SA

For questions go to the SA website:For questions go to the SA website:

DMAS.KePRO.orgDMAS.KePRO.org and click on and click on Virginia MedicaidVirginia Medicaid

Phone: Phone: 1-888-VAPAUTH1-888-VAPAUTH or or

1-888-827-28841-888-827-2884

Fax: Fax: 1-877-OKBYFAX1-877-OKBYFAX or or 1-877-652-93291-877-652-9329

Web:Web: Provider Issues @ KePRO.orgProvider Issues @ KePRO.org

4848

Service Authorization Service Authorization ContractorContractor

Submitting a requestSubmitting a request The preferred method is the The preferred method is the

iEXCHANGE® web-based programiEXCHANGE® web-based program Registration is requiredRegistration is required Information on iEXCHANGE is Information on iEXCHANGE is

available on the KePRO website, or available on the KePRO website, or call call

1-888-827-2884 or by e-mail at 1-888-827-2884 or by e-mail at providerissues@kepro.orgproviderissues@kepro.org

4949

KePROKePRO

Telephone to 888-827-2884 or Telephone to 888-827-2884 or

804-622-8900 (local)804-622-8900 (local) Mail to Mail to

KePROKePRO

2810 North Parham Rd., Suite 2810 North Parham Rd., Suite 305305

Richmond, VA 23284Richmond, VA 23284

5050

Service AuthorizationService Authorization

Requests for SA are required to be Requests for SA are required to be submitted to KePRO prior to services submitted to KePRO prior to services being rendered, but no sooner than being rendered, but no sooner than 10 days prior10 days prior

Authorization can be for up to 90 Authorization can be for up to 90 days with medical justificationdays with medical justification

KePRO will review requests for KePRO will review requests for medical necessity, as well as medical necessity, as well as timelinesstimeliness– KePRO will apply McKesson KePRO will apply McKesson

InterQual® Behavioral Health Criteria InterQual® Behavioral Health Criteria and DMAS supplemental criteriaand DMAS supplemental criteria

Service AuthorizationService AuthorizationNON-CSA CasesNON-CSA Cases Must have a NON-CSA Must have a NON-CSA raterate established established

by DMAS in order to request PA from by DMAS in order to request PA from KePRO KePRO

Contact Provider Reimbursement atContact Provider Reimbursement at804-686-7931 to establish a rate. This 804-686-7931 to establish a rate. This should be done at the time of enrollment should be done at the time of enrollment as a provider.as a provider.

If no rate has been established, the If no rate has been established, the request for PA will be rejected by KePRO. request for PA will be rejected by KePRO. – If a rate is later established, the request will If a rate is later established, the request will

not be retroactivenot be retroactive 59

5252

Service AuthorizationService Authorization

For CSA cases only:For CSA cases only:– CANS is acceptable as the state UAI CANS is acceptable as the state UAI

and continue to be required at least and continue to be required at least every 90 daysevery 90 days

– the Reimbursement Rate Certification the Reimbursement Rate Certification is no longer required to be attachedis no longer required to be attached

– The locality code and the rate on the The locality code and the rate on the RRC must be provided to KePRORRC must be provided to KePRO

5353

Service AuthorizationService Authorization

For both CSA and non-CSA requests:For both CSA and non-CSA requests:– No attachments are required, but No attachments are required, but

information on the CON, IPC and information on the CON, IPC and CIPOC and updates are requiredCIPOC and updates are required

– Severity of Illness questions are Severity of Illness questions are critical to authorizationcritical to authorization

5454

Service AuthorizationService Authorization

Narrative must address the need Narrative must address the need for level of care:for level of care:

Initial ReviewInitial Review--symptoms and behaviors within symptoms and behaviors within

past 7 days, frequency, intensity past 7 days, frequency, intensity and durationand duration

– current functioningcurrent functioning– support systemsupport system

5555

Service AuthorizationService Authorization

Continued StayContinued Stay– Symptoms and behaviors in past 30 daysSymptoms and behaviors in past 30 days– Level of function in past 30 daysLevel of function in past 30 days– Describe recipient investment in Describe recipient investment in

treatmenttreatment– Describe progress or lack of progressDescribe progress or lack of progress

If no progress, how is this If no progress, how is this addressed?addressed?

5656

Service AuthorizationService AuthorizationInitial Review--Initial Review--

CSA cases onlyCSA cases only– 3-digit locality code3-digit locality code– Reimbursement Rate Certification Reimbursement Rate Certification

informationinformation– State UAI informationState UAI information

CSA and NON-CSA casesCSA and NON-CSA casesConfirmation of completion:Confirmation of completion:– Certificate of NeedCertificate of Need– Initial Plan of CareInitial Plan of Care

5757

Service AuthorizationService Authorization

Continued Stay Review--Continued Stay Review-- CSA CasesCSA Cases– Current UAI informationCurrent UAI information– Confirm locality codeConfirm locality code– Reimbursement Rate Certification Reimbursement Rate Certification

update if revisedupdate if revised

CSA and NON-CSA CasesCSA and NON-CSA CasesConfirmation of completion:Confirmation of completion:– CIPOCCIPOC– 30-Day Update-most recent30-Day Update-most recent

5858

Service AuthorizationService Authorization

AppealsAppeals The denial of SA for services not yet The denial of SA for services not yet

rendered may be appealed in writing rendered may be appealed in writing by the Medicaid recipient within 30 by the Medicaid recipient within 30 days of receipt of the denial.days of receipt of the denial.

The provider may appeal an adverse The provider may appeal an adverse decision for a service already decision for a service already provided by filing a written notice of provided by filing a written notice of appeal within 30 days of receipt of appeal within 30 days of receipt of the denial. the denial.

andand

5959

Service AuthorizationService Authorization

Appeal rights will be stated in the SA Appeal rights will be stated in the SA notification letter. Requests for appeal notification letter. Requests for appeal must be submitted to:must be submitted to:

Appeals DivisionAppeals DivisionDepartment of Medical Assistance ServicesDepartment of Medical Assistance Services

600 East Broad Street, 11600 East Broad Street, 11thth Floor FloorRichmond, Virginia 23219Richmond, Virginia 23219

The provider may not bill the recipient for The provider may not bill the recipient for covered services that have been provided and covered services that have been provided and subsequently denied by DMASsubsequently denied by DMAS

6060

Utilization ReviewUtilization Review

Federal regulations require that Federal regulations require that DMAS review and evaluate the DMAS review and evaluate the services provided through the services provided through the Medicaid program.Medicaid program.

Purpose of Utilization Review:Purpose of Utilization Review: Ensure medical necessity Ensure medical necessity Confirm qualified provider delivered Confirm qualified provider delivered

serviceservice Ensure program requirements met Ensure program requirements met Address Quality of Care issues Address Quality of Care issues

6161

Utilization ReviewUtilization Review

DMAS has contracted with Clifton-DMAS has contracted with Clifton-Gunderson to complete Gunderson to complete auditsaudits of of RTFs and will review records to RTFs and will review records to assure DMAS criteria is being assure DMAS criteria is being followedfollowed

6262

Questions?Questions?