Presentation on theme: "Welcome to Health Care Excel. Who We Are Ann Carter, RN, BSN – Project Director Kim Smith, LPCC-S – Project Leader June Green, LSW – Clinical Advisor."— Presentation transcript:
Welcome to Health Care Excel
Who We Are Ann Carter, RN, BSN – Project Director Kim Smith, LPCC-S – Project Leader June Green, LSW – Clinical Advisor
Who We Are We are clinicians. We respect your clinical judgment. We want your client to receive the necessary and appropriate services.
What We Do We contract with the ODMH to review prior authorizations for Partial Hospitalization (PH) and Community Psychiatric Supportive Treatment (CPST) Services. We answer clinical and technical questions related to the prior authorization process. We offer telephonic and on-site provider education.
What We Don’t Do We do not receive financial incentive to deny or limit services.
Our Goal To ensure the right service for the right client in the right setting at the right level of care.
HCE and ODMH HCE Manages the prior authorization program Conducts provider education Identifies utilization trends ODMH Oversees the Medicaid program for mental health services Answers MACSIS and billing questions Interprets Ohio Administrative Codes and State laws and regulations
Determinations Our determinations are based on the current State-approved definition for medical necessity.
Medical Necessity Ohio Administrative Code 5101: Medicaid: Medical Necessity “Medical necessity” is a fundamental concept underlying the Medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, “medically necessary services” are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.
Medical Necessity A Medically Necessary Service Must: (1) Meet generally accepted standards of medical practice; (2) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome; (3) Be appropriate to the intensity of service and level of setting; (4) Provide unique, essential, and appropriate information when used for diagnostic purposes; (5) Be the lowest cost alternative that effectively addresses and treats the medical problem; and (6) Meet general principles regarding reimbursement for Medicaid covered services found in rule 5101: of the Administrative Code.
Medical Necessity (continued) (B) Preventive health care, though not customarily thought of as a “medically necessary” service, is available through the department’s early periodic screening, diagnosis and treatment (EPSDT, also known as Healthchek) program or through managed care plans (MCPs) that have contracted with the department.
Community Psychiatric Supportive Treatment Ohio Administrative Code CPST services are community based and mobile. CPST is a service comprised of individualized mental health activities which are delivered in a variety of locations based on the natural environment(s) of the individual, i.e. home and community locations. These services are provided to children, teens, adults, and families and will vary with respect to hours, type, and intensity of services depending on the changing needs of each individual.
CPST (continued) The purpose of CPST services is to provide specific, measurable, and individualized services to each client served. These services are focused on the client’s ability to succeed in the community and demonstrate improvement in major life areas such as school, work and family. The goal is to minimize the negative effects of the symptoms of mental illness which interfere with the client’s baseline functioning and activities of daily living by assisting the client in identifying effective treatment options.
Partial Hospitalization Program Ohio Administrative Code (A) A Partial Hospitalization Program (PHP) is an intensive, structured, goal-oriented, distinct, and identifiable treatment service that utilizes multiple mental health interventions that address the individualized mental health needs of the client. Partial hospitalization services are clinically indicated by assessment with clear criteria. The environment at this level of treatment is highly structured and there should be an appropriate staff-to-client ratio in order to guarantee sufficient therapeutic services and professional monitoring, control, and protection.
PH (continued) The purpose and intent of Partial Hospitalization services is to stabilize, increase, or sustain the highest level of functioning and promote movement to the least restrictive level of care. The outcome is for the individual to develop the capacity to continue to work toward an improved quality of life with the support of an appropriate level of care.
Prior Authorization (PA) Process Provider The PA request is completed by the provider on- line. If the provider is unable to complete the form on- line, a hard copy of the form is available and may be faxed. Please note: all documentation must provided on the PA form. We cannot accept additional documents.
Health Care Excel Using the approved Medical Necessity Criteria, Ohio-licensed clinical specialists review the application and render a determination.
Process for Providers The provider is notified of the determination within the following timeframes. 24 hours for PH requests 72 hours for CPST requests The provider is notified via of the determination with authorization number and approved number of units.
Approved Case A PA number is assigned to the case. Determinations will contain the following. UCI number Authorization number Number of units approved
Denial If clinical documentation on the PA form does not support the need for continued services, the clinical reviewer defers the case to the HCE Medical Director.
HCE Medical Director The HCE Medical Director has a contractual obligation to follow all State and Federal Medicaid laws including the Medical Necessity rule. The HCE Medical Director and all physician consultants are Ohio-licensed, board certified psychiatrists in active practice.
Physician Review The Medical Director reviews the case and renders a determination. If approved, the case is assigned an authorization number.
Denial If denied, the Medical Director’s rationale for denial will be cited in the determination. The provider and client are provided written information regarding the right to a State Hearing.
Appeal Process The client may request a State Hearing in the following ways. 1.Mail the request to: Ohio Department of Job and Family Services Bureau of State Hearings P.O. Box Columbus, Ohio Fax the request to ODJFS Bureau of State Hearings at
Appeal Process 3.Client may send an to the ODJFS Bureau of State Hearings at 4.Client may telephone the ODJFS Consumer Access Line at and follow the instructions for State Hearings. 5.Client may contact Legal Aid at LAW-OHIO.
Implementation Start Date For On-line Registration and Prior Authorization Submissions Monday, December 5, 2011
How to Submit Click on Ohio Medicaid/Ohio CMH Download instructions for PA submission Download registration form Obtain hard copy of the PA form.
Completing the PA Form The PA form was designed to capture pertinent and relevant clinical information.
Demographic Information Client name Client Medicaid number Client UCI number Social Security number Date of birth Race and gender Responsible party Provider UPI number
Clinical Information Diagnosis (Axis I, II, III, IV, and V required) Baseline Current functioning Treatment goals Progress Lack of progress Need for continued service
Clinical Information Risk factors Legal Mental status examination Abuse Substance use Medications Prior inpatient and outpatient treatment
Client’s Baseline Describe the client’s usual or optimal level of functioning. What is the client’s typical level of independence? Can the client take his/her own medication? Can the client meet his/her own basic needs? Does the client require routine care or supervision?
Current Functioning Describe current functioning as compared to baseline. Address factors that could affect functioning. Treatment compliance Medication compliance Increase in symptoms Decrease in independence Use of or dependence on support system Risk factors
Treatment Goals Questions to consider. What are the goals for continued treatment? Are the goals specific and measurable? What are the target dates for completion of goals?
Progress Indicators of progress may include the following. Participation/motivation Attendance Compliance Response to interventions
Lack of Progress Indicators of lack progress may include the following. Participation/motivation Attendance Compliance Response to interventions
Need for Continued Service Summarize the need for continued services.
Questions About PA Who can complete the PA form? Completion of the prior authorization request is at the discretion of the provider. A clinical contact person must be provided.
Units of Service Request How many units will be authorized? What is the maximum amount of units authorized? What is the minimum amount of units authorized? How many times can the provider submit a PA for the same client?
Answer PA’s may be submitted at anytime. Determinations are on an individualized, case-by-case basis. Authorizations are based on current medical necessity criteria.
When Do Prior Authorizations Expire? Prior authorizations expire the end of the current State fiscal year (June 30, 2012).
Ohio CMH Provider Handbook A handbook will be mailed to each provider by the week of November 18 th, *Outlines the PA process. *Contains hard copies, examples, and instructions on everything we have reviewed.
Provider Education Health Care Excel staff are available Monday through Friday from 8:00a.m. to 5:00p.m. to answer questions. Health Care Excel staff are available for the following. Community trainings On-site education
How to Contact Health Care Excel Mailing Address Health Care Excel Ohio CMH Program 30 East Broad Street, 7th Floor Columbus, OH (614) Toll-free number
How to Contact Health Care Excel Toll-free Fax Hours of Operation Monday through Friday 8:00 a.m. to 5:00 p.m. Web Site
How to Contact Health Care Excel Our All correspondence will be addressed within one business day.