Individual Placement and Support (IPS)-Supported Employment



State-Funded Individual Placement and Support (IPS) for AMH/ASASTATE Service Code YP630 -- Supported Employment STATE Service Code YP630 (BC) - Supported Employment Benefits CounselingSTATE Service Code YP630 (BC) (DJ) - Supported Employment Benefits Counseling and TCLI MemberPre-Review?Met? Not Met?N/AReview for HUM 26: immediate health/safety concerns. If MET, refer to medical staff and outreach phone call to Provider.Please note concerns here and in the Clinical Justification:?Met? Not Met?N/AFunding Source (Medicaid/State) selected on SAR is confirmed to be accurate. ? Met? Not Met? N/AReview for expedited criteria. If Not Met, notify provider and take off expedited status.Review for Unable to Process Criteria? Met? Not MetThe requested effective start date does not precede the submission date of request. If unjustified retro request, then “unable to process”.? Met? Not MetThe dates of the request do not overlap with an existing authorization for the same service. If not met, make documented contact with provider to verify intended request dates. Can adjust authorized dates as requested by provider.? Met? Not MetThe SAR is submitted no more than 30 days before requested start date. If not met, then unable to process. ? Met? Not MetThe SAR is submitted with ICD-10 codes. If not met, then “unable to process”.Review for Administrative Denial ? Met? Not MetA Person-Centered Plan (PCP) and/or Employment Plan is present, which includes IPS-SE frequency and provider. If the person receives an enhanced service, employment and other services received must be identified on the integrated Person-Centered Plan with an attached in-depth Employment Plan. If none present, then contact the provider to request and give deadline to submit. If no response, “administratively deny” the request.? Met? Not MetThe submitted PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate licensed professional as dictated by the service definition. Service Orders are valid for one year. For PCP/Treatment Plan reviews resulting in no changes to the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureIf not met, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request.? Met?Not Met? N/AIf applicable, the Comprehensive Crisis Plan is present and complete. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request.Other Items of Review:? Met? Not MetLOCUS/CALOCUS/ASAM score is noted and in SAR or other documentation.?If child is age 5 or younger, CANS assessment is provided. If not, then contact the provider to request and give deadline to submit. If no response, input Quality of Care comment. Recommended LOCUS/CALOCUS Level 3-5 Recommended ASAM Level 1-2.5If necessary, review and/or request LOCUS/CALOCUS/ASAM worksheet; If not present, can NOT administratively deny.? Met? Not MetCheck to see if a Care Manager has been assigned to the member. If so, indicate whether you have reviewed the most recent Care Management notes here:? Met? Not MetThe Member’s Name, DOB, MRN and MID number are present and accurate in necessary places (i.e. PCP, CCA, Service Notes, etc.)? If not contact Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. ? Met? Not Met? N/AIs there evidence of active discharge planning with any concurrent requests?Consider reviewing for the following elements:anticipated discharge datebarriers to discharge anticipated discharge level of careefforts made to coordinate discharge appointmentIf not, then make documented call to provider to request. ? Met? Not Met? N/AReview for past denials or partial approvals within this current episode of care. Consider implications of previous decisions/recommendations and need for clinical staffing. Please note here: FORMTEXT ?????? Met? Not MetAre the requested days/units within the MCO guidelines? If not, make documented contact with provider to verify intended request dates/units. Can adjust authorized dates/units as requested by provider or educational notice to match Clinical Coverage Policy.Please note here: FORMTEXT ?????? Met? Not Met ? N/ALength of stay in current service. List EBP here: FORMTEXT ?????? Met? Not Met? N/AIf DSS/DJJ/Legal involvement, a tag has been created in AlphaMCS.Note status of involvement here: FORMTEXT ?????? Met? Not Met?N/AEvidence of use/intended use of Evidence Based Practices. Note here: FORMTEXT ?????? Met? Not Met?N/AFOR STATE FUNDED, is the State funded Benefit Plan accurate? Please add the following verification statement to the Justification Statement: There is evidence to support the member meets the eligibility criteria of the Benefit Plan identified: FORMTEXT Insert Benefit Plan? Met? Not Met?N/AReview for Service Exclusions. Check Claims for participation in & billing of other services. Check SARs for approved services. If there are Service Exclusions, contact Provider for clarification.? For Child Medicaid (under age 21) EPSDT criteria may apply.? For Adult Medicaid (age 21 & over) staff with supervisor for possible peer review. State Benefit Plan does not allow exclusionary services, resulting in UTP. Indicate the date you checked the claims module here, if applicable. Also, note services and provider explanation, if applicable:? Met? Not Met?N/AReview for High Priority Diagnosis including Autism Spectrum Disorder; Schizophrenia, Paranoid Type; or Opioid Use Disorder (moderate and severe).Member has the diagnosis of:? Autism Spectrum Disorder? Schizophrenia, Paranoid Type? Opioid Use Disorder (moderate and severe)ANDThe specialized needs associated with their diagnosis are being specifically addressed in the member’s treatment plan. ? Yes?No**If no please consult a UM Supervisor or Clinical Team Lead (I/DD only) and document in the system.?? Create a Clinical Tag for any member with a High Priority Diagnosis.? Clinical Tag Created: ? Yes ?No ?Tag already in systemState-Funded Individual Placement and Support (IPS) for AMH/ASA—STATE Service Code YP630 -- Supported Employment STATE Service Code YP630 (BC) - Supported Employment Benefits CounselingSTATE Service Code YP630 (BC) (DJ) - Supported Employment Benefits Counseling and TCLI MemberEligibility Criteria The individual is age (16) sixteen and older and who:? Met? Not MetHas a primary diagnosis of a serious mental illness (SMI) that includes severe and persistent mental illness (SPMI), or a primary diagnosis of substance use disorder (State funded individuals only). ANDExperiences difficulties in at least two or more of the following areas:In or at risk of placement in a congregate setting or difficulty maintaining safe living situations, including homelessness; Co-occurring mental health and substance use disorders; High risk of crisis diversion, intervention, including hospital transitions;Difficulty effectively using traditional office-based outpatient services; Difficulty with daily living, communication, interpersonal skills, self-care, self-direction; High risk or recent history (within the past 12 months) of criminal justice involvement (such as arrest, incarceration, probation); ANDExpresses the desire to work at the time of admission to the program, and has an established pattern of unemployment, underemployment, or sporadic employment; and requires assistance in obtaining or maintaining employment in addition to what is typically available from the employer because of functional limitations as described above and behaviors associated with the individual’s diagnosis. As evidenced by: FORMTEXT ?????State-Funded Individual Placement and Support (IPS) for AMH/ASA—STATE Service Code YP630 -- Supported Employment STATE Service Code YP630 (BC) - Supported Employment Benefits CounselingSTATE Service Code YP630 (BC) (DJ) - Supported Employment Benefits Counseling and TCLI MemberContinued Service CriteriaThe individual shall continue receiving IPS services if they meet at least one of the following requirements:? Met? Not MetThe individual has made little progress in meeting employment goals and there is documentation that supports that continuation of IPS services will be effective in meeting employment goals identified in service plan. The individual is making progress in meeting employment goals, but the interventions identified in the PCP and/or Employment Plan need to be modified to achieve competitive employment.The individual has obtained a job, it has been less than a year since starting employment and requires follow-along supports as identified in the PCP and/or Employment Plan. The individual needs follow-along support in learning how to manage benefits, such as Social Security, Ticket to Work, etc. The individual needs support to change jobs, increase hours of employment, or advance in his or her career. As evidenced by: FORMTEXT ?????State-Funded Individual Placement and Support (IPS) for AMH/ASA—STATE Service Code YP630 -- Supported Employment STATE Service Code YP630 (BC) - Supported Employment Benefits CounselingSTATE Service Code YP630 (BC) (DJ) - Supported Employment Benefits Counseling and TCLI MemberDischarge Criteria? Met? Not MetThe Individual’s level of functioning has improved with respect to the goals outlined in the PCP and/or Employment Plan and follow along services have been provided to ensure long-term job maintenance and ongoing behavioral health support as needed by the individual. When applicable, an IPS team shall initiate a transfer to another provider. The decision to discharge should be based on one or more of the following and documented in the service record:The individual has requested IPS be discontinued. The individual has moved outside of the LME/MCO catchment area. The individual has long-term medical issues and work is not an option at the time.The individual no longer meets criteria for this service.As evidenced by: FORMTEXT ?????Clinical Review: FORMCHECKBOX Approved FORMCHECKBOX Send to peer review FORMCHECKBOX Administrative Denial FORMCHECKBOX UTPClinical Justification/Reason for Peer Clinical Review: Reviewer Name, Credentials: FORMTEXT ????? 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