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Utilization Review and Clinical Documentation December 2011
© 2009 APS Healthcare, Inc. 2 Training Objectives Overview of Medical Necessity Utilization Review Process Clinical Documentation for Utilization Review of Targeted Case Management and HCT Services
© 2009 APS Healthcare, Inc. 3 Medical Necessity Definition of Medical Necessity from the MaineCare Benefits Manual, Chapter 1 Medical Necessity or Medically Necessary services are those reasonably necessary medical and remedial services that are: 1.provided in an appropriate setting; 2.recognized as standard medical care, based on national standards for best practices and safe, effective, quality care; 3.required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being; 4. MaineCare covered service (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter II, Section 94 of this Manual); 5.performed by enrolled providers within their scope of licensure and/or certification; and 6.provided within the regulations of this Manual
© 2009 APS Healthcare, Inc. 4 Utilization Review Process Care Managers are independently licensed professionals with years of experience working in the Maine provider community. Care Managers use MaineCare rules/Criteria and clinical documentation to make determinations. Internal Quality Assurance measures include routine peer consultation among Care Managers and APS Medical Director Clinical back-up and supervision is provided on-site by the Clinical Team Lead, Clinical Director, and Medical Director
© 2009 APS Healthcare, Inc. 5 Clinical Documentation Create a thread between diagnosis, current presentation, service objectives and discharge plan. Completed review should enable reader to have current clinical “snap-shot” of member. Completed review should demonstrate intensity, frequency, and duration of the service.
© 2009 APS Healthcare, Inc. 6 Clinical Documentation Clinical summary include: oDemographics (age, gender, family composition) oPresenting Symptoms/Reason for Referral oDuration of Symptoms oDevelopmental Issues impacting functioning oTreatment History oSocial Environment History oStrengths oClinical Rationale for this Level of Care
© 2009 APS Healthcare, Inc. 7 Member Information APS CASE ID: This number will change every time you start a new review. These numbers change so that the reviewer and the provider can identify which portion of a member’s treatment is being referenced. MEMBER’S INFORMATION: This information is generated from the MaineCare information which is uploaded to the CareConnection® system on a regular basis. ELIGIBILITY INFORMATION: Please double-check the members eligibility. If there is limited eligibility you will need to contact MaineCare to determine the limitation.
© 2009 APS Healthcare, Inc. 8 Guardian Information Please complete this page for all children oUse the choice Family Member for Parent
© 2009 APS Healthcare, Inc. 9 Administrative Start Date for Current Authorization Request: This date refers to the start of this authorization period not the start of treatment. Much of the review will pre-populate from the previous review.
© 2009 APS Healthcare, Inc. 10 Requesting Agency Please add the phone number and address of the person you would like us to contact if there were any clinical questions about the request. “Is this agency/individual the treating provider?” This question needs to be answered with “Yes.”
© 2009 APS Healthcare, Inc. 11 Multiaxial Assessment ICD 9 is used as it is consistent with federal Medicaid requirements Use the DARK BLUE Box to find the ICD 9 code oSearch by DSM code or title Primary diagnosis is the diagnosis you are currently treating Co-Occurring diagnosis relates to mental health/substance abuse AXIS III Text box for medical issues AXIS IV Psychosocial stressors-Drop down indicates Mild, Moderate or Severe AXIS V GAF Global Assessment of Functioning: Free Text
© 2009 APS Healthcare, Inc. 12 Services Requested MODIFY-Use this function to change the start and/or end date and the number of units NO ACTION-Use this function when you are not wanting to extend the particular service code SUBSEQUENT CONTINUED STAY REVIEWS-If you want to reactivate a service code click on modify even though there is a gray line. This will allow you to open that service code.
© 2009 APS Healthcare, Inc. 13 Symptoms and Behaviors For Behavioral Health TCM Only: When entering the CAFAS scores, the CAFAS Rater ID must be entered into the “Rater ID” field. Submit the date this CAFAS was completed in the “Date LOCUS Completed (most recent)” field. Although this field is labeled “LOCUS,” for TCM it is reported as “Date CAFAS Completed.” For Developmental Disabilities TCM ‐ The CHAT score must be entered on the Additional Information page so you may skip the CAFAS section. Please be sure to include the date CHAT was completed in the additional information section. For HCT services: Enter CAFAS score, if applicable, and Rater ID#. If YOQ screening is used instead of CAFAS, enter zero in the rater ID field and CAFAS score fields. YOQ scores can be added on the Additional Info page. Agency Involvement-Important to select all providers to the best of your knowledge Family Social Involvement-Indicate all supports that apply and then rate the overall support of family/natural supports
© 2009 APS Healthcare, Inc. 14 Medications All medications, both psychiatric and medical, should be entered with the medication type. Additional Medication Info Section can also be used to capture any relevant medication that cannot be found in the list
© 2009 APS Healthcare, Inc. 15 Clinical Indicators Clinical Indicators help to justify the service requested Choose most current symptoms and behaviors that member has experienced over previous authorization period. History of Severity is service specific. Please document only the symptoms which member has experienced from previous authorization period to current date. Any additional risk factors/clinical indicators should be added to the additional information field. Developmental issues and functional impairments may also be listed here.
© 2009 APS Healthcare, Inc. 16 Treatment and Service History This Section may be skipped if questions are not relevant to the clinical picture and request for service Report on how long the member has been receiving this service can be captured in this section or in Additional Information Please note that Co-occurring questions refer to Mental Health and Substance Abuse
© 2009 APS Healthcare, Inc. 17 RDS This Section does not need to be completed and can be skipped. It is required for Section 17 services only.
© 2009 APS Healthcare, Inc. 18 Individual Treatment Plan Use CTRL Key to select more than one option under Strengths and Skills Complete the “Treatment Plan Goals” as related to service provided. The “Criteria for Discharge” section should be updated at every request. It is recommended that providers use Comments section to provider more depth and clarity to their clinical presentation.
© 2009 APS Healthcare, Inc. 19 Treatment Plan Goals All information in treatment goal section should be completed. –Problem Statement- should mirror reason for referral –Long Term Goal- Reverse of problem statement; What is the overall identified need of the member? –Short Term Goal- Focus of TCM or HCT to assist member in meeting identified needs. (not a restatement of the long term goal) –Objectives- Action Steps: Who, What, When, Where, and How? –Goals and target dates should be modified to reflect progress made since last review
© 2009 APS Healthcare, Inc. 20 Additional Reporting Data This section may be skipped for TCM and HCT service requests
© 2009 APS Healthcare, Inc. 21 Additional Information It is recommended that this section be used to provide a succinct clinical rationale for the service requested. Information included should be relevant for purposes of utilization review. This section can assist with capturing any information that was unable to be reflected in other sections to demonstrate medical necessity. oPresenting Symptoms/Reason for Referral oDuration of Symptoms and/ or functional impairments oTreatment History For HCT Services: What lower level of care options been attempted? Is this a step down from higher LOC (crisis, residential, hospital)? Has the member/family had HCT in the past? If so, when was the last time the family received HCT services? oFamily/Social Environment oStrengths
© 2009 APS Healthcare, Inc. 22 Submit to APS Once you submit a review it cannot be edited by the provider. If additional information is required you must contact APS at
© 2009 APS Healthcare, Inc. 23 APS Contact For CareConnection® assistance contact Provider Relations Phone Option 1 To respond to clinical questions please contact Care Managers Phone: Option 4
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