1. Qualis Health Presents Alaska Behavioral Health Inpatient Psychiatric Review Provider Training Anchorage, Alaska March 31, 2009

2. 2 Welcome from Qualis Health Alaska Medicaid Mental Health Review Linda Rasmussen, LCSW Program Manager

3. 3 Qualis Health Background Qualis Health is a private, nonprofit healthcare quality improvement and care management organization headquartered in Seattle, with offices in, Alaska, California, Idaho, Nebraska and South Carolina. Qualis Health has more than 30 years of experience providing healthcare utilization, case management and quality assessment/improvement services to public and private sector customers. Qualis Health has collaborated with healthcare providers in Alaska since 1984.

4. 4 Goals for this Presentation Overview of Qualis Health Describe utilization review resources on Qualis Health’s website Provide updates for utilization review processes for the Alaska Medicaid Inpatient Psychiatric Program Demonstrate collaboration with the State and providers in the utilization review process

5. 5 Care Management Is Our Core Business Vision: To be recognized for leadership, innovation and excellence in improving the health of individuals and populations Mission: To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes Values: Integrity, professionalism, collaboration and stewardship

6. 6 Qualis Health Accreditations Certified by Medicare as a Quality Improvement Organization (QIO) Accredited by URAC for compliance with nationally recognized standards in: –Case Management –Health Utilization Management –Independent/External Review Certified as an IRO (Ind. Review Org) in Washington State

7. 7 Care Management Services for Alaska Medicaid Inpatient Acute Residential Psychiatric Utilization Review Services – Admission Review –Continued Stay Review –Peer Review –Retrospective Review –Appeals Care Coordination Services

8. 8 Utilization and Quality of Care Services Utilization Management –Review medical necessity, quality of care, appropriateness of treatment, plan of care and discharge plans –Ensure appropriate use of resources and level of care, while upholding recognized standards of quality of care –Assistance to identify appropriate healthcare service availability

9. 9 Payment is Contingent Upon Eligibility as determined by the Alaska Medicaid Program –Providers are to call the Eligibility Verification System (800) 884-3223 (24 hour access) In Alaska, toll free number (800) 770-5650 –8 am to 5 pm Compliance with the rules and regulations that govern Medical Assistance in Alaska Completion of the Medical Necessity Prior Authorization Review

10. 10 Tools to Assist with your Review Process

11. 11 Tools to Support Your Review Go to http://www.qualishealth.org/cm/alaska- medicaid/behavioral-health/tools.cfm to find: –Provider Manual –Provider Training –Late Submission/Retro Review Request Forms –Questionnaires for Review Processes –Contact Information for Qualis Health –Alaska Map of “Home” Regions –RPTC Bed Availability in State of Alaska –Link to State Website

12. 12 Website Orientation www.qualishealth.org Click on: Alaska

13. 13 Click on: Tools & Forms

14. 14 List of Tools and Forms Provider Manual Inpatient Psychiatric Review Provider Manual Inpatient Psychiatric Retrospective Review Request Form Questionnaires Admission Review Questionnaire (word) Admission Review Questionnaire (pdf) Continued Stay Review Questionnaire (word) Continued Stay Review Questionnaire (pdf)

15. 15 Provider Responsibilities

16. 16 Review Submission Providers to submit timely reviews via iEXCHANGE ®, fax, mail or phone Providers to submit reviews for recipients who are also covered by other Third Party Liability (TPL) resources.

17. 17 Review Submission (continued) Required list of demographics and other information Comprehensive answers to the appropriate review questionnaire See updated review questionnaires at http://www.qualishealth.org/cm/alaska- medicaid/behavioral-health/tools.cfm

18. 18 Exclusions from Review Process Substance abuse as primary disorder Age 21 limit exception for RPTC Adults aged 21-64 are not covered in a free-standing institute for behavioral health Alaska Medicaid Chronic and Acute Medical Assistance Program (CAMA) Medicare Part B

19. 19 Prior Authorization Submission Timelines Acute care admissions In-State RPTC admissions Out of State RPTC admissions

20. 20 Continued Stay Submission Timeline Next review date Continued stay reviews submitted beyond 30 days

21. 21 Timeframes for Pended Reviews Qualis Health will notify the provider via iEXCHANGE and/or phone. Seven calendar days to submit the requested information

22. 22 Providers’ Reporting Requirements for Sentinel Events What is a sentinel event?

23. 23 Providers’ Reporting Requirements for Sentinel Events Medical –Incidents that require outside medical attention –Burns –Lacerations requiring medical attention –Bone fractures or breaks –Substantial hematoma –Injuries to internal organ whether self inflicted or by someone else

24. 24 AWOL (Absent without Leave) –If gone overnight –If anything significant occurred during the AWOL Police intervention Use of substances Suspected abuse Providers’ Reporting Requirements for Sentinel Events

25. 25 Sexual Acting Out/Physical Aggression –Any activity or occurrence which must be reported to state Child Protective Service agencies –Any time an Alaskan youth is the victim or the offender –Suicidal attempt or serious suicidal gesture Providers’ Reporting Requirements for Sentinel Events

26. 26 Sentinel event form Providers also notify Qualis Health of these serious events. Further review may be taken based on seriousness of incident Providers’ Reporting Requirements for Sentinel Events

27. 27 Steps for Placements to Out-of-State RPTCs Referring facility to contact Behavioral Health Behavioral Health will research available in-state services and notify Qualis Health of their determination. Upon approval, referring facility will proceed with transition plan. The receiving facility may submit the prior authorization admission review.

28. 28 Reporting Discharges iEXCHANGE, fax or call the actual date the recipient was discharged Discharge information to be submitted: –The identified services recommended for follow-up care. Include considerations regarding: Placement Family Educational services Individual, family and group psychotherapies, as well as other identified therapeutic interventions that may be needed at time of discharge –The identified provider for services upon discharge –The actual discharge date

29. 29 Travel Authorization Provider is responsible for submitting the prior authorization review When certification (approval) is given, use the PA number assigned to the case Qualis Health PA numbers for travel –Admissions –Trial Discharge Home Passes Affiliated Computer Services, Inc. (ACS) is the authorized agency for travel –Toll-free in Alaska (800) 770-5650 –Outside of Alaska (907) 644-6800

30. 30 Acute Care Review Criteria Updates

31. 31 Acute Care Criteria Overview This overview is a condensed summary of the recent changes to the State acute care criteria. For a full copy of the new acute care criteria, please refer to the Providers’ Manual Appendix B. Provider training available on April 7 th.

32. 32 Summary of Criterion A A1. Documentation that the diagnosed mental illness presents a likelihood of serous harm… or A2. Documentation that the recipient’s condition is severely impaired as a result of the mental illness… and A3. Documentation that a less restrictive available level of care does not meet the treatment needs of the recipient

33. 33 Summary of Criterion B B1. Certificate of Need (CON) B2. Limitation on maximum allowable payment for the following: –7 day maximum for Oppositional Defiant Disorder or Conduct Disorder –14 day maximum for Depression NOS, Mood Disorder NOS or Unspecified Mental Health Disorder Non-Psychotic

34. 34 Criterion B continued B3. GAF B4. Documentation of acute disturbances – Impaired thought processes that create imminent risk of harm o Hallucinations o Delusions o Loose associations o Paranoia –Severely dysfunctional patterns of behavior related to diagnoses –Recent psychotropic medication changes that put patient at high risk for acute disturbances if not monitored in inpatient setting

35. 35 Summary of Criterion C C1. Diagnostic evaluation C2. Individualized Plan of Care (IPOC) clearly documents goals and measurable objectives related to diagnostic evaluation

36. 36 Summary of Criterion C. Continued C3. IPOC formulated in consultation C4. IPOC documents appropriate therapies, activities, and experiences designed to develop the recipient’s ability to function independently in their own environment.

37. 37 Summary Criterion C. Continued C5. The IPOC clearly documents a comprehensive discharge plan – based on treatment goals and objectives – approximate discharge date – post discharge services needs and providers – continually updated to reflect changes and progress in treatment planning

38. 38 Review Questionnaire Changes

39. 39 Updated question # 52 - Plan of Care formulated in consultation Updated question # 56 - Discharge planning Changes on Admission Questionnaire

40. 40 Admission Questionnaire (continued) New question # 10 - Ethnicity New question # 53 - Diagnostic Evaluation

41. 41 Changes on Continued Stay Questionnaire Updated question # 7 - acute disturbances Updated question #8 - plan of care treatment goals Updated question # 13 - updated discharge plan

42. 42 Changes on Master Plan of Care Questionnaire Updated # 27 - Discharge Plan

43. 43 Review Reminders

44. 44 Admission Review All five digits of the diagnostic codes All demographics answered in the admissions questionnaire in full

45. 45 Admission Review (continued) Mental Status Exam Within 7 days prior to anticipated admission Issues from the Mental Health Exam –that are pertinent to the diagnostic considerations within the treatment planning –are to be submitted in the Admission Review Questionnaire

46. 46 Plan of Care (POC) Review RPTC level of care Acute level of care Required Elements to be Addressed in the POC

47. 47 Continued Stay Review Updates on the diagnostic evaluation Updates on medication changes and effectiveness Updates on current behavioral impairments Updates on Measurable Treatment Goals

48. 48 Continued Stay Reviews Updates on assessments and treatment progress –List update for each type of therapy separately –Must include Individual, Family and Group psychotherapies –Must include documentation of contact with OCS or JJ if recipient is in state custody

49. 49 Discharge Planning –Begins upon admission –Updated with each review –Includes specificity –Family/Guardian is actively involved –Available lower level of care services

50. 50 Trial Discharge Home Pass Goals and objectives Outpatient therapy appointment Crisis Plan Visit with the school system needed

51. 51 Trial Discharge Home Pass Trial Discharge Home Pass dates will be within 1 to 3 months, and not less than 30 days, of the projected discharge date. Trial discharge home passes may end in discharge from the facility.

52. 52 Late Submission Continued Stay Review Request Definition When to request it Require form Possible technical denial

53. 53 Delayed Eligibility Reasons for Late Submission Reviews Definition Submit all at once –Use the admission questionnaire –Include the plan of care –Divide the review into weekly increments

54. 54 Tips for the Review Process Submit current information Clearly outline impaired behaviors Clearly document the measurable goals and objectives Clearly update progress in all therapies

55. 55 We Want to Hear from You How the review process works for you How well Care Coordination works for you Any issues or concerns that may arise Additional ways Qualis Health can assist you Process improvement opportunities

56. 56 Contact Information Anchorage Office Toll Free Phone: (877) 200-9046 Toll Free Fax: (877) 200-9047 www.qualishealth.org Qualis Health Mailing Address: PO Box 243609 Anchorage, Alaska 99524

57. 57 Contact Information Linda Rasmussen, LCSW Program Manager, Alaska Medicaid Mental Health Qualis Health (877) 200-9046 or (907) 562-5670 lindar@qualishealth.org Grace Ingrim, RN, BSN, CCM Director, Medicaid Services Qualis Health (877) 200-9046 or (907) 562-2123 gracei@qualishealth.org Alaska State Department of Health & Social Services –Contact information is available at www.qualishealth.org

58. Questions??