Illinois Department of Human Services Division of Mental

Illinois Department of Human Services, Division of Mental Health The Illinois Mental Health Collaborative for Access and Choice Authorization Requirements for Therapy Counseling, Psychosocial Rehabilitation and Community Support Group Services Effective January, 2011 November 2010 1

Introductions 2 l Lee Ann Reinert, LCSW - IL DHS/DMH Clinical Policy Specialist l Emily Sherrill, LCSW - Collaborative Clinical Director l Todd Kasdan, MD - Collaborative Medical Director

Presentation Online Today’s presentation will be available online http: //www. illinoismentalhealthcollaborative. com/provider/prv_informati on. htm Be sure to share this information with your staff! 3

Agenda l l l l 4 Overview of Utilization Management Program Medical necessity Overview of authorization processes Mental Health Assessment (MHA) requirements Individual Treatment Plan (ITP) requirements Requests for reconsideration and appeal of denial decisions Questions and answers

Utilization Management Program Overview Introduction: l The Utilization Management (UM) Program is the vehicle through which DHS/DMH ensures that individuals being served receive: – the services best suited to support their recovery needs and preferences, – cost effective services in the most appropriate treatment setting, – services consistent with medical necessity criteria and evidence-based practices. 5

Utilization Management Program Overview l 6 By implementing the UM Program, DHS/DMH strives to achieve a balance between: – the needs, preferences, and well-being of persons in need of mental health services – demonstrated medical necessity – the availability of resources

Utilization Management Program Overview l The UM Program: – – 7 does not limit medically necessary Medicaid services is fully compliant with the Illinois Medicaid State Plan and associated federal rules

In developing the UM Program, DHS/DMH acknowledges the following guiding principles: l l 8 UM is dynamic and evolutionary. As additional data, new research, and other new information occurs with experience, the UM Program will evolve and change. UM must be based on data. The UM Program must use data to identify patterns of utilization, work with clinicians to determine if the patterns and variations are desirable or not, and work with providers to make needed improvements. Individuals accessing services should have a consistent threshold of medical necessity statewide. The UM Program must provide clear guidance for medical necessity decisions so that all individuals accessing services have consistent and equitable access to specific services. Authorization must be clinically focused and conducted by qualified staff. Where authorization is determined to be necessary, it must be based on clinical information and reviewed by staff at the independent license level (LPHA).

UM Program Overview, continued The DHS/DMH Utilization Program has the following components: 9 l Medical Necessity Guidance and Criteria l Limited External Authorization l Ongoing Data Reporting and Analysis

UM Program Overview, continued Medical Necessity Guidance and Criteria. l DHS/DMH is initially providing medical necessity criteria for the following services: Assertive Community Treatment (ACT) Community Support Team (CST) Psychosocial Rehabilitation (PSR) Community Support Group (CSG) Therapy/Counseling (T/C) Community Support Individual (CSI) l For those services available to both adults and children, separate criteria are provided for each. 10

UM Program Overview, continued l l 11 These criteria may be found in the DHS/DMH Medical Necessity Criteria and Guidance Manual (within the Provider Manual) These criteria should be used by providers to guide them in making consistent admission, continuing service, and termination of service decisions for each consumer. Providers must use these criteria consistently, regardless of whether or not DHS/DMH or its designee externally authorizes the service. Provider adherence to these criteria may be subject to post payment review.

UM Program Overview, continued 12 Limited External Authorization. l Authorization for payment by DHS/DMH or its designee will be required for specific services, based on a review of service utilization patterns for a previous fiscal year. – Thresholds are the same for adults and children/adolescents and are calculated by provider and consumer per fiscal year. For FY 11, thresholds will be calculated for the remainder of the fiscal year, beginning with dates of service of January 3, 2011. – Authorization for payment of services beyond the specified thresholds will be based on medical necessity criteria. – Services will continue to be authorized as long as medical necessity is in evidence.

UM Program Overview, continued l 13 For purposes of determining clinical review thresholds, PSR and CSG utilization will be managed as a combined benefit. Clinical review and continuing service authorization will be required whenever an individual’s utilization of PSR and CSG combined exceeds 800 units per fiscal year, with recognition that an individual may use one or both of these services during the year.

UM Program Overview, continued Ongoing Data Reporting and Analysis l DHS/DMH will continue to report and analyze – utilization patterns – post payment review results – authorization impacts – other quantitative and qualitative aspects of service delivery. l These data will be used to inform – provider technical assistance efforts – training – future UM Program modifications 14

Medical Necessity Criteria l l l 15 Diagnosis Service Initiation Criteria Continuing Service Criteria Exclusion Criteria Service Termination Criteria

Medical Necessity Criteria l 16 DIAGNOSIS: – Current eligible mental health diagnosis for which the proposed course of treatment has been determined to be effective – Symptoms consistent with those described in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical Classification of Diseases and Related Health Problems (ICD) – Symptoms addressed do not have their primary origin in a diagnosis of an Autism Spectrum Disorder, substance-related disorder, or a principal Axis II diagnosis of Mental Retardation

Medical Necessity Criteria l Service Initiation Criteria – – – l Continuing Service Criteria – – 17 To be considered for all individuals receiving services for which guidance is published May be subject to Post Payment Review Establishes basis for need for service To be utilized for determination of need for ongoing services, once individual meets threshold Will be basis for the Collaborative’s authorization decision

Medical Necessity Criteria l Exclusion Criteria – – l Termination Criteria – – 18 Reasons for service to be considered inappropriate for an individual Could be cited at either Post Payment or Authorization Review Reasons for discontinuing service Could be cited during Clinical Practice Guidance or Authorization Review

Medical Necessity Criteria Therapy/ Counseling SERVICE INITIATION CRITERIA - Severity/complexity of symptoms and level of functional impairment require this service, as evidenced by: l l l 19 Individual has an emotional disturbance and/or diagnosis that is destabilizing or distressing Individual’s assessment identifies specific mental health problems that may be effectively addressed by Therapy/Counseling Level of Care Utilization System (LOCUS) score equating to Level of Care 2 or higher for adults or clinician-rated Ohio scale of 16 or higher for youth age 5 and up

Medical Necessity Criteria Therapy/ Counseling Continuing Service Criteria l l l 20 Evidence of active participation by individual Demonstrated evidence of significant benefit from this service: – as evidenced by the attainment of most treatment goals, but the desired outcome has not been restored – and the individual’s level of emotional stress continues to be destabilizing, significantly interfering with daily functioning Individual cannot be safely and effectively treated solely through the use of Community Support services, case management, and the engagement of natural support systems.

Medical Necessity Criteria Therapy/ Counseling Additional Criteria for Specific Modalities l Individual – necessity of one to one interventions l Group – specifically identified problems with social interactions, interpersonal difficulties, etc, for which involvement in group process is expected to be beneficial l Family – identified problems are exacerbated by family dynamics and/or can be most effectively addressed through family involvement 21

Medical Necessity Criteria Therapy/ Counseling Exclusion Criteria l l 22 Cognitive impairment, mental status or developmental level that makes it unlikely individual would benefit Primary problem to be addressed could be more effectively/efficiently addressed by another modality

Medical Necessity Criteria Therapy/ Counseling Service Termination l l l 23 Treatment goals achieved Majority of goals achieved and remainder can be safely achieved by accessing other services and/or natural supports No significant improvement and needs to be reassessed for more effective treatment

Medical Necessity Criteria Psychosocial Rehabilitation Service Initiation Criteria l l l 24 Significantly impaired role function in at least 2 of the following: – Management of financial affairs – Ability to procure needed services – Socialization, communication, adaptation, problem solving and coping – Activities of daily living – Self-management of symptoms – Concentration, endurance, attention, direction following and planning and organization skills necessary for recovery LOCUS Score equating to level of care of 3 or higher Discharge/transition plan expressly focused on increasing community integration through the application of skills in community settings.

Medical Necessity Criteria Psychosocial Rehabilitation Continuing Service Criteria l l 25 Treatment plan reflects modifications in PSR services for skills that the individual has not yet been able to successfully demonstrate Individual cannot be safely/effectively treated through provision of alternative community-based services or engagement of natural supports

Medical Necessity Criteria Psychosocial Rehabilitation Exclusion Criteria l Individual under age 18 l Individual chooses not to participate l Primary etiology of dysfunction related to Axis II diagnosis, or an organic process or syndrome including normal aging l Individual’s ADLs/skills are sufficient to enable progress in recovery l Individual requires more intensive contact 26

Medical Necessity Criteria Psychosocial Rehabilitation Service Termination Criteria l Individual has learned the skills and requests termination or no longer needs active treatment l Has learned most of the skills, can apply and improve skills in natural settings l Is not making progress and needs reassessment to determine more appropriate services 27

Medical Necessity Criteria Community Support Group Service Initiation Criteria l Significant impairment in functioning, inability to apply skills in natural settings, and/or to build/utilize natural supports l Require small group support to facilitate more effective role performance l Identification of specific functional impairments that can only be remediated through small group practice to reinforce target skills l LOCUS level of care recommendation of 2 or higher 28

Medical Necessity Criteria Community Support Group Continuing Service Criteria l Has demonstrated significant improvement with this service, attaining most skill-building and community integration, but Desired outcome/level of functioning has not been restored/sufficiently improved or – Without these services, the individual would not be able to consolidate treatment gains or progress in recovery – l Cannot be safely/effectively treated through provision of alternative services or engagement of natural supports

Medical Necessity Criteria Community Support Group Exclusion Criteria l l Individuals daily living skills are sufficient to enable progress in recovery without CSG services Cognitive impairment, current mental status or developmental level makes it unlikely to benefit from CSG services Primary etiology related to Axis II or organic processes, including normal aging Requires more intensive services/cannot be safely treated with CSG

Medical Necessity Criteria Community Support Group Service Termination Criteria l l l Individual has achieved goals and requests termination or no longer needs this service Has successfully demonstrated most of the skills, can be safely and effectively treated without CSG Is not making progress and needs reassessment to determine more appropriate services

Authorization in a nutshell for Therapy/Counseling, Psychosocial Rehabilitation and Community Support Group l l 32 Who – any consumer, for whom the provider is seeking reimbursement, receiving over the threshold hours/units of T/C, PSR, CSG services When – Authorization for payment of services is required after January 3, 2011 for any consumer receiving services above and beyond the threshold hours/units of service What – Authorization request form with a Mental Health Assessment (MHA) and Individual Treatment Plan (ITP), along with any other supporting documentation to establish Medical Necessity Criteria How - Submit authorization request electronically through Provider. Connect and supporting clinical documentation either as secure clinical attachments with request or via facsimile

What do I send when requesting an authorization? Ø Information required: – Authorization request via Provider. Connect l – Current MHA and ITP l – 33 All required and applicable fields completed – Including age appropriate functional scales (LOCUS, Ohio Scale, DECA) – Current Axis I – V elements Securely attached with Provider. Connect request or faxed to the Collaborative (866 -928 -7177) within 1 business day Additional documentation may be necessary if the MHA and ITP do not fully support medical necessity for the request

Authorization Process Therapy/Counseling: l l l 34 Eligible Consumers are able to initially receive up to 10 hours (40 units) of this service, if provider LPHA deems medically necessary, without submission of an authorization request If provider deems additional hours (units) of T/C are medically necessary above and beyond the 10 hour (40 unit) threshold, a request for authorization must be submitted and authorization must be obtained in order to be reimbursed for services Determination of additional hours (units) to be reimbursed are based upon medical necessity. This will take into consideration the number of units requested and will be based on what is medically necessary.

Authorization Process, continued PSR & Community Support Group: l l l 35 Eligible Consumers are able to initially receive up to 200 hours (800 units) of PSR, CSG, or a combination of PSR & CSG, if provider deems medically necessary, without submission of an authorization request If provider LPHA deems additional hours (units) are medically necessary above and beyond the 200 hour (800 unit) threshold, a request for authorization must be submitted and authorization must be obtained in order to be reimbursed for services Determination of additional hours (units) to be reimbursed are based upon medical necessity. This will take into consideration the number of units requested and will be based on what is medically necessary.

Authorization Process, continued 36 l Collaborative clinical care managers review submitted documents for adherence to Medical Necessity Criteria (MNC), and Rule 132. l If the MNC are met for the service(s), the Collaborative will enter an authorization. l In order for the provider to be reimbursed for services provided beyond initial thresholds, requests for authorization must be submitted and approved prior to service provision. Providers must submit requests for authorization prior to the authorization expiration date and/or the maximum number of hours/units allowed

Authorization Request 37 l All requests for authorization MUST be submitted via Provider. Connect. The Collaborative will not review requests for authorization submitted via facsimile. l If choosing to fax, rather than attach to the on-line request, the supporting clinical documentation for the request (e. g. MHA, ITP, etc. ), please ensure that each consumer’s information is faxed separately. l If choosing to fax, rather than attach to the on-line request, the supporting clinical documentation for the request (e. g. MHA, ITP, etc. ), please ensure that the service being requested is noted on the fax cover sheet.

Authorization request, continued Authorization requests for T/C, PSR, and CSG will require completion of the following information for adults: 38

Identifying information 39

Diagnosis 40

LOCUS (Functional Impairment) 41

Services Requested- PSR & CSG 42

Services Requested- T/C 43

Transition or Service Termination Plan 44

Ohio/Devereaux Scale Results l l l 45 Required for CSG and T/C requests for all consumers under the age of 18 Ohio Scale Results are required for youth ages 5 through 17 – Service initiation (all) – Current (if in services more than 90 days) Devereaux Scale Results (DECA Subscale for children under the age of 5) – Protective Factor Scores l Service Initiation (all) l Current (if in services more than 90 days) – Behavioral Concern Scores (only for children over the age of 3, under the age of 5) l Service Initiation (all) l Current (if in services more than 90 days)

Ohio/Devereaux Scale Results continued 46

MHA Requirements l MHA Requirements – – 47 A consumer’s MHA is required to be submitted as part of the authorization process The Collaborative Clinical Care Managers will be determining if the MHA identifies needs consistent with the service being requested.

ITP Requirements l l 48 The consumer’s ITP is required to be submitted as a part of the authorization process to assure clinical congruence between the goals/interventions listed in the ITP, service definition criteria, and the LOCUS score/Ohio scale/DECA. The Collaborative Clinical Care Managers will be determining if the treatment plan describes interventions and goals consistent with the service being requested.

Additionally required documentation l 49 When MHA and ITP do not appear to fully justify or support MNC for the requested service and/or appear to have inconsistencies, additional documentation must be submitted with the request Examples: l Progress notes l Psychiatric notes/evaluations l MHA and/or ITP addendums l A letter of statement from clinician acknowledging inconsistencies with explanation of rationale for this request – Must be securely attached to the request or faxed to the Collaborative (866 -928 -7177) within 1 business day – If information is necessary to support medical necessity but not included with request/received within 1 business day, the Collaborative staff will contact the provider to explain the additional information that is required and the request will be closed without review. The provider must resubmit the entire request for authorization with all supporting documentation.

Collaborative review process l Provider submits a request for authorization l Collaborative staff verifies: – – – l Collaborative clinical care manager (CCM) reviews submitted documents for the following 3 elements: 1. 2. 3. 50 l Information for completeness (documents required based upon request type) Provider’s participation status (e. g. , contracted provider of IL DHS/DMH) Provider’s certification status to provide requested service Consumer information is in/available to the Collaborative system The information in the request is consistent with information found in the supporting documentation. If inconsistencies are found, the provider will be contacted regarding the inconsistencies. The request will be closed and the provider will be required to resubmit the request with all supporting documentation. Completeness Adherence to Rule 132 Adherence to Medical Necessity Criteria (MNC) If the above 3 elements are met for the service(s), the CCM will enter in an authorization.

Collaborative review process, continued l l If medical necessity IS established, request is authorized by CCM and communicated to provider in writing OR If medical necessity is NOT established, the CCM contacts provider to seek clarification and offer education/consultation regarding authorization criteria – The Collaborative and the Provider will reach mutual agreement with respect to next steps (e. g. , additional information will be submitted for review, alternative service will be considered, etc. ) OR – If mutual agreement has NOT occurred and provider believes medical necessity is present, the CCM will forward information to a Collaborative physician advisor (PA) reviewer l 51 PA reviews and either authorizes OR denies authorization

Collaborative review process, continued l 52 Turn around time (TAT) for authorization requests – The Collaborative will respond to requests for authorizations within 7 business days of receipt of a completed authorization request.

Provider requests for Reconsideration and Appeal related to denial of authorization l 2 levels: – 1 st Request for Reconsideration – 2 nd DMH Director’s review l l 53 The Collaborative staff is not involved in this level This shall be a review to ensure that all applicable procedures have been correctly applied and followed

Provider requests for Reconsideration and Appeal related to denial of authorization l l 54 In the case of a denial of authorization-- If the provider, consumer, or designated representative disagrees with the clinical decision, a Reconsideration may be initiated in writing or by phone. The Reconsideration must be requested within 30 days after the denial. – The review will be conducted by a Collaborative PA. • Not the same PA who issued the original denial • Not a subordinate of the PA who issued the original denial – The review and notification by phone will be completed by the Collaborative within 15 days of the receipt of the reconsideration request. – Outcome Either: l Reversal of the denial decision l Upholding of the denial decision

Provider requests for Appeal related to denial of authorization DMH Director’s review: l l l 55 If the provider, consumer, or designated representative disagrees with the outcome of the Reconsideration request, an Appeal may be filed within 5 days of receipt of the outcome of the reconsideration request. This review shall not be a clinical review, but rather a review to ensure that all applicable appeal procedures have been correctly applied and followed. The final administrative decision shall be subject to judicial review exclusively as provided in the Administrative Review Law [735 ILCS 5/Art. III].

Summary l l l l 56 Utilization Management Program is being implemented to ensure responsible management of resources Plans of care for individuals for whom reimbursement from DMH will be sought should be based on the Medical Necessity Guidance/Criteria Manual published within the DMH Provider Manual In order to be reimbursed for services, providers must follow the utilization management program as it applies to individual situations Authorization request reflecting the most current clinical presentation as documented in the consumer record must be sent to the Collaborative The Collaborative Clinical Care Managers will review authorization requests and issue a decision within 7 days. If an authorization request is denied, the provider or consumer may request a reconsideration of that decision If a request for reconsideration also results in denial of authorization, there is an appeals process through the Director of DMH and finally through the administrative law process at Healthcare and Family Services

Questions? 57

Thank you! Illinois Mental Health Collaborative for Access and Choice 58