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Clinical Quality Review Team (CQRT) A Guide to the Authorization Process for Alameda County Behavioral Health Plan Members.

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Presentation on theme: "Clinical Quality Review Team (CQRT) A Guide to the Authorization Process for Alameda County Behavioral Health Plan Members."— Presentation transcript:

1 Clinical Quality Review Team (CQRT) A Guide to the Authorization Process for Alameda County Behavioral Health Plan Members

2 CQRT Purpose Providers are expected to attend a CQRT sponsored by the County in the first year of operation. And, then develop an internal policy and procedure to guide the chart review process. The purpose of the CQRT is to review medical necessity, service necessity, review the quality of the chart, and authorization of services. The BHCS CQRT committees meet a minimum of one time per month representing the Adult Outpatient, Children’s Outpatient, Day Treatment and Outpatient EPSDT Expansion Programs in their first year of operation. Day Treatment Authorization is ongoing.

3 Learning Objectives Understand the purpose of the CQRT and its function in improving compliance with documentation standards. Understand the distinction between the Clinical & Quality Review. Understand the expectations of how to prepare and participate in Alameda County BHCS CQRT meetings.

4 Learning Objectives Understand the forms and paperwork necessary to participate in Alameda County BHCS CQRT meetings. Understand the Clinical Review Cycles of charts and how they guide clinical practices. Be able to facilitate and/or improve ongoing internal Clinical Quality Review Teams.

5 BHCS CQRT Process Does not eliminate audit risk but assists the provider in reducing risk of audit disallowances. Is not a substitute for a provider’s internal Quality Assurance (QA) process. The DHCS has the ultimate authority regarding Medi-Cal audits.

6 The Clinical Quality Review Teams will: Review the chart to ensure that adequate treatment and discharge planning are documented Approve the continuation of services

7 CQRT Members are: BHCS CQRT Chairpersons are licensed clinicians CQRT trained agency supervisors or their designees who provide their staff with direction regarding Quality Assurance requirements and issues/concerns identified by the CQRT Licensed clinicians, waivered psychologist candidates, or registered interns, Licensed Practitioners of the Healing Arts (LPHA)

8 The BHCS CQRT Meeting Representatives are apart of a team and review other’s charts. Participants will be reviewing charts from other agencies. Agency representatives are to receive training and orientation to the CQRT procedures by their agency staff Prior to their actual participation in the CQRT meeting

9 Schedule for Treatment Chart Review Charts are reviewed based on the date of the case episode opening. The review cycle begins on the first of the month in which the episode was opened. Outpatient and Rehabilitative Day Treatment charts are reviewed every six months. Day Treatment Intensive charts are reviewed every three months. The review cycles will always remain the same! MHS Report 485 notifies providers that the UC Authorization is expiring and due for a reauthorization

10 Timeline Examples for Outpatient and Rehabilitative Day Treatment Month Episode is Opened Period for Review Bring to the Chart to the CQRT during the month With a revised or new TX plan to start beginning And not signed before this date January Jan 1-June 30 July 1-Dec 31 June December 7/1 1/1 6/1 12/1 February Feb 1-July 31 Aug 1-January 31 July January 8/1 2/1 7/1 1/1 MarchMar 1- Aug 31 Sept 1-Feb 28 August February 9/1 3/1 8/1 2/1

11 Chart Review Cycle Exercise What is the Episode Opening Date? What is the Review Cycle & Dates? When is the Assessment due? When is the Client Plan due? When is the Chart due in the CQRT?

12 Guide to Chart Content for CQRT Charts must contain all of the elements required by Medi-Cal Documentation Guidelines.

13 Clinical Review The Clinical Review ensures that ongoing Medical & Service Necessity has been documented. Is there a Treatment Plan, included diagnosis, and corresponding Progress Notes? Is there evidence that progress is being made toward the goals/objectives and is the client is benefitting from treatment? Is there an appropriate discharge plan or tentative discharge plan? Are the required dated signatures, Community Function Evaluations, and Informing Materials present?

14 Quality Review The Quality Review is more comprehensive: The chart is reviewed using the Regulatory Compliance checklist on the back of the CQRT Review Request Form It includes a Clinical Review There must be a continuity between the Assessment & Included Diagnosis, the Treatment plan, and the treatment documented in the Progress notes

15 CQRT Fifteen percent (15%) of all charts presented at CQRT meetings will be randomly chosen for Quality Review.

16 Deficient charts In the BHCS CQRT, charts with deficiencies are given a month’s authorization and must be corrected prior to return. Medical Necessity has not been established Service Necessity has not been established Intervention Criteria Impairment Criteria Client Plan Missing Signatures Missing on TP, Client Plan, Progress Notes Progress Notes are found to be out of compliance Other recurring patterns of non-compliance

17 Meeting Schedules BHCS CQRT meetings are organized by the type of provider or primary treatment mode. Meeting assignment is determined by the BHCS. Schedules are posted on the BHCS website at

18 Final CQRT Advice Train and familiarize your staff with the CQRT process. Develop a written agency QA Policy & Procedure Manual. Supervisors reviewing charts and returning to staff for correction prior to reviews will reduce deficiencies and the need for time consuming 30 day returns. Reach out to other providers and develop a inter-agency CQRT process.

19 Questions and Answers Questions

20 Post Training Questions? QA Contact Information For questions, limit 1 contact person per provider to maintain consistency of information at your agency. Michael De Vito, MFT, MPH Tiffany Lynch, QA Secretary


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