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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements for Community Support Services New 6/14/2012.

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Presentation on theme: "INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements for Community Support Services New 6/14/2012."— Presentation transcript:

1 INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements for Community Support Services New 6/14/2012

2 Topics Services Requiring PA KEPRO SCDHHS Website Service Type Requirements Contact Information

3 Prior Authorization Services Adult (22 years old and older) H2017-Psychosocial Rehabilitation Service (PRS) S9482-Family Support Child (21 years old and younger) H2017-Psychosocial Rehabilitation Service (PRS) H2014-Behavioral Modification S9482-Family Support

4 Forms Navigate to Forms TAB to obtain Documents

5 Outpatient Fax Form

6

7 Attestation Form

8 Adult H2017 (PRS) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) Attestation Form For Continuation of Services- Individualized Plan of Care (IPOC) Mental Health-comprehensive assessment- follow-up 90 Day Progress Summary

9 Adult H2017 (PRS) Criteria For Initial Services, beneficiary must: –Diagnosed with a serious or persistent mental illness –Moderate or severe functional impairment that interferes with 2 or more of the following: Daily living Personal Relationships Work Setting School Setting Recreational Setting –Is at risk of psychiatric hospitalization, homelessness, or isolation from social supports –Exhibits behaviors that require repeated interventions by the mental health, social services, or judicial system –Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior.

10 Adult H2017 (PRS) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC; OR –Beneficiary continues to be at risk for out-of home-placement; OR –Beneficiary has achieved initial goals in the IPOC and continued services are needed in order to achieve additional goals in the IPOC; OR –Beneficiary is making some progress, but the interventions need to be modified so that greater gains can be achieved, OR –Beneficiary is not making progress or regressing and the IPOC must be modified ***Please submit for continuation of services no more than 10 days prior to the end of your current authorization

11 Adult (Family Support) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) Attestation Form For Continuation of Services- Individualized Plan of Care (IPOC) Mental Health-comprehensive assessment- follow-up 90 Day Progress Summary

12 Adult S9482 (Family Support) Criteria For Initial Services, beneficiary must: –Beneficiary has been diagnosed with a serious and persistent mental illness (SPMI), or co-occurring SPMI and substance use disorders (SUD) –Demonstrates moderate to severe functional impairment in 2 or more of the following areas: Daily Living Relationships School Work Setting Recreational Setting –Family or Caregiver agrees to be an active participant, which involves participating in interventions

13 Adult S9482 (Family Support) Criteria For Initial Services, beneficiary must (cont’d): –Service is recommended by Licensed Practitioner of the Healing Arts –Service (including frequency of the services) is recommended as result of the Diagnostic Assessment –Beneficiary is expected to benefit from the intervention and needs would not be better clinically met by any other formal or informal system or support.

14 Adult S9482 (Family Support) Criteria For continuation of services: –The family or caregiver is actively involved and engaged in the treatment process; AND –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the beneficiary’s Individual Plan of Care (IPOC); OR –Beneficiary has achieved initial goals in the IPOC and continued services are needed in order to achieve additional goals in the IPOC; OR –Beneficiary is making some progress, but the interventions need to be modified so that greater gains can be achieved, OR –Beneficiary is making progress toward meeting goals. ***Please submit for continuation of services no more than 10 days prior to the end of your current authorization

15 Child H2017 (PRS) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) CALOCUS Attestation Form For Continuation of Services- Individualized Plan of Care (IPOC) Mental Health-comprehensive assessment- follow-up 90 Day Progress Summary

16 Child H2017 (PRS) Submission Requirements Providers rendering services to children served by Continuum of Care only Submit to KEPRO for Initial Services- Cover Letter Family Story CAFAS Submit to KEPRO for Continuation of Services- Individualized Plan of Care (IPOC)

17 Child H2017 (PRS) Criteria For Initial Services, beneficiary must: –Beneficiary (ages 0-5) has been diagnosed with a serious emotional disorder (SED) or an applicable V code as per the current DSM; OR –Beneficiary (ages 6-21) has been diagnosed with a serious emotional disorder (SED) or a co-occurring SED and substance use disorder (SUD) –Meet 3 or more of the following criteria as a result of the mental illness: Moderate to severe functional impairment that interferes with performance in two or more of the following areas: –Daily living –Personal Relationships –School –Work Setting –Recreational Settings

18 Child H2017 (PRS) Criteria For Initial Services, beneficiary must (cont’d): Is not functioning at a level that would be expected or typically developing individuals their age; OR Is deemed to be at risk of psychiatric hospitalization or out-of home placement; OR Exhibits behavior that requires repeated interventions by the mental health, social services, or judicial system; OR Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior. –Has been assigned a composite CALOCUS score in the range of (or a CAFAS has been completed for CoC beneficiaries) –Service is recommended by a Licensed Practitioner of the Healing Arts (LPHA)

19 Child H2017 (PRS) Criteria For Initial Services, beneficiary must (cont’d): –The service (including the frequency of service) is recommended as result of the Diagnostic Assessment and CALOCUS (or the Family Story and CAFAS for beneficiaries served by the CoC) –Beneficiary is expected to benefit from the intervention and needs would not be better clinically met by any other formal or informal system or support.

20 Child H2017 (PRS) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC; OR –Beneficiary continues to be at risk for out-of home-placement; OR –Beneficiary has achieved initial goals in the IPOC and continued services are needed in order to achieve additional goals in the IPOC; OR –Beneficiary is making some progress, but the interventions need to be modified so that greater gains can be achieved, OR –Beneficiary is not making progress or regressing and the IPOC must be modified ***Please submit for continuation of services no more than 10 days prior to the end of your current authorization

21 Child H2014 (Behavioral Modification) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) CALOCUS Attestation Form For Continuation of Services- Individualized Plan of Care (IPOC) Mental Health-comprehensive assessment- follow-up 90 Day Progress Summary

22 Child H2014 (Behavioral Modification) Submission Requirements Providers rendering services to children served by Continuum of Care only Submit to KEPRO for Initial Services- Cover Letter Family Story CAFAS Submit to KEPRO for Continuation of Services- Individualized Plan of Care (IPOC)

23 Child H2014 (Behavioral Modification) Criteria For Initial Services, beneficiary must: –Beneficiary (ages 0-5) has been diagnosed with a serious emotional disorder (SED) or an applicable V code as per the current DSM; OR –Beneficiary (ages 6-21) has been diagnosed with a serious emotional disorder (SED) or a co-occurring SED and substance use disorder (SUD) –Engaging in behaviors which are inappropriate or undesirable and present risk of harm to self or others, and significantly impact functioning in 2 or more of the following areas: Daily Living Relationships Work Setting School Setting Recreational Setting

24 Child H2014 (Behavioral Modification) Criteria For Initial Services, beneficiary must (cont’d): –Family or caregiver agrees to be an active participant, which involves receiving behavioral management training for the purpose of maintaining progress during and after treatment –Has been assigned a minimum CALOCUS composite score of 17 (or a CAFAS has been completed for CoC beneficiaries) –Service is recommended by a Licensed Practitioner of the Healing Arts (LPHA) –Service (including frequency of the service) is recommended as a result of the Diagnostic Assessment and CALOCUS (Family Story and CAFAS for beneficiaries served by CoC) –Beneficiary is expected to benefit from the intervention and needs would not be better clinically met by any other formal or informal system or support

25 Child H2014 (Behavioral Modification) Criteria For continuation of services: –The family or caregiver is actively involved and engaged in the treatment process (if family or caregiver is unable or unwilling to be an active participant, this is clearly documented in the medical record); AND –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the beneficiary’s Individual Plan of Care (IPOC); OR –Beneficiary continues to be at risk for out-of-home placement; OR –Beneficiary has achieved initial goals in the IPOC and continued services are needed in order to achieve additional goals in the IPOC; OR –Beneficiary is making some progress, but the interventions need to be modified so that greater gains can be achieved, OR –Beneficiary is not making progress or regressing and the IPOC must be modified. ***Please submit for continuation of services no more than 10 days prior to the end of your current authorization

26 Child S9482 (Family Support) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) CALOCUS Attestation Form For Continuation of Services- Individualized Plan of Care (IPOC) Mental Health-comprehensive assessment-follow-up 90 Day Progress Summary

27 Child S9482 (Family Support) Submission Requirements Providers rendering services to children served by Continuum of Care only Submit to KEPRO for Initial Services- Cover Letter Family Story CAFAS Submit to KEPRO for Continuation of Services- Individualized Plan of Care (IPOC)

28 Child S9482 (Family Support) Criteria For Initial Services, beneficiary must: –Beneficiary (ages 0-5) has been diagnosed with a serious emotional disorder (SED) or an applicable V code as per the current DSM; OR –Beneficiary (ages 6-21) has been diagnosed with a serious emotional disorder (SED) or a co-occurring SED and substance use disorder (SUD) –Demonstrates moderate to severe functional impairment in 2 or more of the following areas: Daily Living Relationships School Work Setting Recreational Setting –Family or Caregiver agrees to be an active participant, which involves participating in interventions

29 Child S9482 (Family Support) Criteria For Initial Services, beneficiary must (cont’d): –Has been assigned a composite CALOCUS score in the range of (Or has received a CAFAS if served by CoC) –Service is recommended by Licensed Practitioner of the Healing Arts –Service (including frequency of the services) is recommended as result of the Diagnostic Assessment and CALOCUS (Family Story and CAFAS for beneficiaries served by CoC) –Beneficiary is expected to benefit from the intervention and needs would not be better clinically met by any other formal or informal system or support.

30 Child S9482 (Family Support) Criteria For continuation of services: –The family or caregiver is actively involved and engaged in the treatment process (if family or caregiver is unable or unwilling to be an active participant, this is clearly documented in the medical record); AND –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the beneficiary’s Individual Plan of Care (IPOC); OR –Beneficiary continues to be at risk for out-of-home placement; OR –Beneficiary has achieved initial goals in the IPOC and continued services are needed in order to achieve additional goals in the IPOC; OR –Beneficiary is making some progress, but the interventions need to be modified so that greater gains can be achieved, OR –Beneficiary is not making progress or regressing and the IPOC must be modified. ***Please submit for continuation of services no more than 10 days prior to the end of your current authorization

31 Eligibility MCO: –Prior authorization is required by KEPRO if the beneficiary is enrolled in an MCO Commercial Insurance: –Submit only to KEPRO after claim has been submitted to primary insurance and benefits have either been exhausted or service is not covered and primary insurance did not make any payment. Please submit EOB along with request. Medicare B: –Submit only to KEPRO after claim has been submitted to Medicare and benefits have either been exhausted or service is not covered and Medicare did not make any payment. NOTE*KEPRO will not review if the service was deemed not medically necessary by primary insurance

32 Retroactive Medicaid Eligibility A case may be submitted as a “retro” when retroactive Medicaid eligibility occurs or when Medicaid becomes the primary payer This includes : Member not eligible for coverage at the time services were provided. Member gains eligibility that is made retroactive to the date of service. NOTE** A “retro” case is NOT one that is submitted late for any reason.

33 KEPRO/Provider Turnaround Time KEPRO Upon receipt of PA request, KEPRO must render a decision within 5 business day of the request submission (excluding higher level reviews) If the PA request is submitted for higher level review, KEPRO has 1 additional day to render a decision. Provider If additional information is required for review, the request will be pended, and the Provider will have 2 business days to submit the additional information required to KEPRO.

34 Registration for Atrezzo Connect Provider Portal INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

35 How To Register For Atrezzo Connect Website Address: https://scdhhs.kepro.com https://scdhhs.kepro.com Select “ Registration For Atrezzo Connect” (Slide 3) Enter your 10 digit National Provider Identifier (NPI) number and Legacy South Carolina Medicaid provider ID Select a unique user name and password & complete required user information

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37 Atrezzo Connect Atrezzo Connect allows for: – Secure access to Atrezzo Connect (Provider Portal) – Provider will be able to access letters by Case/Request, Respond/Send messages To/From KePRO

38 Required Information for Security Verification The provider must enter information to verify authenticity for security reasons Registration Code: – SCDHHS Legacy ID

39 Simple -5 Step Registration Process Start by clicking the Atrezzo Login button on the SCDHHS-KEPRO website

40 Login Page You will be brought to this login page

41 Step 2 – Enter NPI and Legacy ID Enter your organization’s NPI number and Legacy Provider ID = Provider Registration Code Click NEXT

42 Step 3 – Terms of Agreement Review Terms of Agreement. Upon acceptance, you will be taken to setup for User information.

43 Step 4 – Verify Address Click on the correct address(s) for the new account (this associates your user information with these locations) If all apply, check all of them Click SELECT

44 Step 5 – Enter Account Information Enter user account information User Name, Password, First/Last Name, and Fax Number are required fields! Click NEXT-This will take you to the Password setup and security question Slide) Passwords do not expire. Minimum 8 characters required.

45 Successful Completion Successful Completion of setup, takes you to the Home Page

46 View all request and Create new request Click Member to search using Member id or Last name/DOB Click Request/Case to search using Case id, Member info or Request info

47 Create Preferences, Manage User accounts and New Provider Registration Use this tab to change your password or update your contact information View Atrezzo User Guide and View FAQs

48 Account Administrator All information submitted for registration under Provider/Facility Information will represent as the Provider Portal Administrator (Group Admin). The Group Admin is responsible for managing and creating all Submitting User accounts for your NPI # – Create other Group Admins’ & Admin Users – Set Preferences, i.e. Diagnosis and Procedure codes, etc

49 KEPRO Contacts

50 50 Thank You!

51 Prior Authorizations Foster Care Beneficiaries Psychosocial Rehabilitative Services (PRS) Behavior Modification Services (BMOD) Family Support (FS)

52 Private providers who serve children in foster care will receive prior authorization (PA) from the South Carolina Department of Social Services (DSS) DSS will initiate all referrals with private providers for the services of PRS, BMOD and FS

53 DSS will utilize the list of private RBHS providers published on the SCDHHS website https://www.scdhhs.gov/site- page/private-rbhs-provider-directory https://www.scdhhs.gov/site- page/private-rbhs-provider-directory Private providers will not make PA requests to DSS No CALOCUS is required for DSS referrals of beneficiaries in foster care

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