IIH Service Review Checklist updated 7-21-17



Intensive In-Home CriteriaMedicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2022Pre-Review?Met?Not Met?N/AReview for HUM 26: immediate health/safety concerns. If MET, refer to medical staff and outreach phone 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”.Submitted ?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 not here:?Met?Not MetThe number of units as well as the date range requested coincide with what is allowed per the service definition. 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 MetPCP is present, which includes IIH, frequency and provider. If none present, then contact the provider to request and give deadline to submit. If not 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PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate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.?Met?Not MetReview for Comprehensive Crisis Plan. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request.?Met?Not MetComprehensive Clinical Assessment and/or Addendum is present and support request (to include DSM 5 diagnosis). If not included, then document call to provider. If not provided by deadline, “administratively deny”.Other Items of Review:?Met?Not Met?N/AIf Medicaid member and under 21, review for EPSDT.?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 Coordination 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 not 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/AFor concurrent request, ask for the following information:# of face to face contacts with member and family provided by licensed clinician during previous auth,Previously requested documentation from prior authorizationsPlease note here:?Met?Not Met?N/AEvidence of use/intended use of Evidence Based Practices.List EBP here:*For IIH, the EBP must be from one of the following disciplines:Cognitive Behavioral Therapy with Outcome MeasureEco-Systemic Family TherapyFeedback Informed TherapyStrategic Family TherapyStrengthening Families?Met?Not Met?N/AIf DSS/DJJ/Legal involvement, a tag has been created in Alpha MCS.Note status of involvement here:?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: (Benefit Plan)”. State funding does not pay for IIH at this time.?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-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 as 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 systemIntensive In-Home ServicesMedicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2022Eligibility CriteriaA member is eligible for this service when all of the following criteria are met:?Met?Not MetThere is an MH/SU diagnosis (as defined by the DSM-5 or its successors), other than a sole diagnosis of intellectual and developmental disability.As evidenced by: FORMTEXT ????? ?Met?Not MetBased on the current comprehensive clinical assessment, this service was indicated and out-member treatment services were considered or previously attempted, but were found to be inappropriate or not effective.As evidenced by: FORMTEXT ??????Met?Not MetThe youth has current or past history of symptoms or behaviors indicating the need for a crisis intervention as evidenced by suicidal/homicidal ideation, physical aggression toward others, self-injurious behavior, serious risk taking behavior (running away, sexual aggression, sexually reactive behavior, or substance use).As evidenced by: FORMTEXT ??????Met?Not MetThe youth’s symptoms and behaviors are unmanageable at home, school or in other community settings due to the deterioration of his or her mental health or substance abuse condition, requiring intensive, coordinated clinical interventions.As evidenced by: FORMTEXT ??????Met?Not MetThe youth is at imminent risk of out-of-home placement based on the child or adolescent’s current mental health or substance abuse clinical symptomatology or is currently in an out of-home placement and a return is imminent.As evidenced by: FORMTEXT ??????Met?Not MetThere is no evidence to support that alternative interventions would be equally or more effective, based on North Carolina community practice standards (Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Society of Addiction Medicine).As evidenced by: FORMTEXT ?????Intensive In-Home ServicesMedicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2022Continued Service Criteria?Met?Not MetThe desired outcome or level of functioning has not been restored, improved or sustained over the time frame outlined in the member’s PCP; or the member continues to be at risk for out-of-home placement based on current clinical assessment, history, or the tenuous nature of the functional gains;As evidenced by: FORMTEXT ?????AND?Met?Not MetOne of the following applies:As evidenced by: FORMTEXT ?????The member has achieved current PCP goals and additional goals are indicated as evidenced by documented symptoms;The member is making satisfactory progress toward meeting goals and there is documentation that supports that continuation of this service will be effective in addressing the goals outlined in the PCP;The member is making some progress, but the specific interventions in the PCP need to be modified so that greater gains, which are consistent with the member’s premorbid are possible; orThe member fails to make progress or demonstrate regression in meeting goals through the interventions outlined in the PCP. The member’s diagnosis should be reassessed to identify any unrecognized co-occurring disorders, and interventions or treatment recommendations should be revised based on the findings. This includes considerations of alternative or additional services. Intensive In-Home ServicesMedicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2022Discharge Criteria?Met?Not MetAny one of the following applies:As evidenced by: FORMTEXT ?????The member has achieved goals and is no longer in need of IIH services;The member’s level of functioning has improved with respect to the goals outlined in the PCP, inclusive of a transition plan to step down to a lower level of care; The member is not making progress or is regressing, and all reasonable strategies and interventions have been exhausted, indicating a need for more intensive services;The member or legally responsible person no longer wishes to receive IIH services; or The member, based on presentation and failure to show improvement despite modifications in the PCP, requires a more appropriate best practice treatment modality based on North Carolina community practice standards (for example, National Institute of Drug Abuse, American Psychiatric Association.)Clinical Review:?Approved ?Send to peer reviewClinical Justification/Reason for Peer Clinical Review:Reviewer Name, Credentials: Date: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download