TF-CBT Service Review Criteria updated 7-21-17

?Trauma Focused Cognitive Behavioral Therapy (TF-CBT)Medicaid Clinical Coverage Policy 8COutpatient Individual Therapy Code: 90837Z1Family Therapy Codes: 90846Z1; 90847Z1Pre-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.Please note here:?Met?Not MetThe number of units requested are 1 unit per session. If not met, make documented contact with provider to verify intended request units/dates. Can adjust authorized dates as requested by provider.Please note here:?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 MetThe Treatment Plan is present, which includes TF-CBT, frequency and provider. 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PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate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. Attestation boxes checked by Approved Signatory (if using PCP) for Medicaid membersFor 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.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 dischargeAnticipated 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 decision/recommendations and need for clinical staffing.Please note here:?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:?Met?Not Met?N/ALength of stay in current service.Note here:?Met?Not Met?N/AEvidence of use/intended use of TF-CBT.?Met?Not Met?N/AIf DSS/DJJ/Legal involvement, a tag has been created in Alpha MCS.Note status of involvement here:?MetCreate tag in Alpha?Not Met?N/AReview for Children with Complex Needs Criteria:Medicaid eligible children ages 5 and under 21-AND-Who have been diagnosed with a developmental disability (including Intellectual Disability and/or Autism Spectrum Disorder) and a mental health disorder; Developmental Disabilities must be confirmed via psychological eval (or medical evaluation as appropriate)Mental Health Disorders must be confirmed via Comprehensive Clinical Assessment-AND-Who are at risk of not being able to return to or maintain placement in a community setting; Based on the needs of the child, the current caregiver cannot maintain the child’s health and safety. -AND-Has a history of mental health and intellectual and/or developmental disabilities diagnoses or treatment AND 1 or more of the following risk factors will include the following:Is the child exhibiting behaviors that are a danger to self or others at this time; Behaviors must be current (within the last 30 days) and require intervention (medical intervention, physical intervention, crisis services, or inpatient treatment)-OR-Has the child been expelled or is at risk of expulsion from school due to disruptive or dangerous behaviorsChild is unable to participate in any structured educational setting based on current behaviors-OR-Has the child experienced incidents for crisis such as frequent ED visits, out of home placements, involvement with criminal justice system, or involuntary commitments.Frequent ED visits is defined as 3 or more visits in the past 12 months. Incidents of out of home placement, involvement with criminal justice system, or involuntary commitment has occurred within the last 12 months.?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 systemTrauma Focused Cognitive Behavioral Therapy (TF-CBT)Medicaid Clinical Coverage Policy 8COutpatient Individual Therapy Code: 90837Z1Family Therapy Codes: 90846Z1; 90847Z1Entrance CriteriaAll of following criteria are necessary for admission of a member to outpatient treatment services:?Met?Not MetA Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5), or any subsequent editions of this reference material, diagnosis. ANDAs evidenced by: FORMTEXT ??????Met?Not MetThe member presents behavioral, psychological, or biological dysfunction and functional impairment, which are consistent and associated with the (DSM-5) or any subsequent editions of this reference material, diagnosis. ANDAs evidenced by: FORMTEXT ??????Met?Not MetThe member does not require a higher level of care ANDAs evidenced by: FORMTEXT ??????Met?Not MetMember is capable of developing skills to manage symptoms, make behavioral changes, and respond favorably to therapeutic interventions. ANDAs evidenced by: FORMTEXT ?????AND?Met?Not MetThere is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards (e.g. Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Board of Addiction Medicine.)Trauma Focused Cognitive Behavioral Therapy (TF-CBT)Medicaid Clinical Coverage Policy 8COutpatient Individual Therapy Code: 90837Z1Family Therapy Codes: 90846Z1; 90847Z1Continued Stay CriteriaThe criteria for continued service include both A and B below:?Met?Not MetANY of the following criteriaAs evidenced by: FORMTEXT ??????Met?Not MetThe desired outcome or level of functioning has not been restored, improved, or sustained over the timeframe outlined in the member’s treatment plan, OR?Met?Not MetThe member continues to be at risk for relapse/regression based on current clinical assessment, and history, OR?Met?Not MetTenuous nature of the functional gains?Met?Not MetANY of the following criteria (in addition to ‘A’)As evidenced by: FORMTEXT ??????Met?Not MetThe member has achieved current treatment plan goals, and additional goals are indicated as evidenced by documented symptoms, OR?Met?Not MetThe member is making satisfactory progress towards meeting goals and there is documentation that supports that continuation of this service is expected to be effective in addressing goals outlined in the treatment plan. Trauma Focused Cognitive Behavioral Therapy (TF-CBT)Medicaid Clinical Coverage Policy 8COutpatient Individual Therapy Code: 90837Z1Family Therapy Codes: 90846Z1; 90847Z1Discharge CriteriaANY of the following criteria must be met:?Met?Not MetThe member’s level of functioning has improved with respect to the goals outlined in the treatment plan, ORAs evidenced by: FORMTEXT ??????Met?Not MetThe member or legally responsible person no longer wishes to receive these services, ORAs evidenced by: FORMTEXT ??????Met?Not MetThe member, based on presentation and failure to show improvement, despite modifications in the treatment plan, requires a more appropriate best practice or evidence-based treatment modality based on North Carolina community practice standards (for example, National Institute of Drug Abuse, American Psychiatric Association.)As evidenced by: FORMTEXT ?????Clinical Review: ? Approved?Send to peer reviewClinical Justification/Reason for Peer Clinical Review:Reviewer Name, Credentials: Date: ................
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