MST Service Review Criteria updated 7-21-17

?Multisystemic Therapy (MST)Medicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2033?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: FORMTEXT ??????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: FORMTEXT ??????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 MetThe PCP is present, which include MST, 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PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate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.?Met?Not MetThe 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.?Met?Not MetThe Comprehensive Clinical Assessment and/or Addendum is present and supports 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 19, 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 MetIs 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. Note here: FORMTEXT ??????Met?Not Met?N/AEvidence of use/intended use of Evidence Based Practices. List EBP here: FORMTEXT ??????Met?Not Met?N/AIf DSS/DJJ/Legal involvement, a tag has been created in Alpha MCS.Note status of involvement 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: (Benefit Plan)”?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 systemMultisystemic Therapy (MST)Medicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2033Entrance CriteriaMust meet ALL off the following criteria:?Met?Not MetThere is an MH/SU diagnosis present as indicated by the DSM 5 other than a sole diagnosis of intellectual and developmental disability.As evidenced by: FORMTEXT ??????Met?Not MetThe member should be between the ages of 7 through 17. As evidenced by: FORMTEXT ??????Met?Not MetThe member displays willful behavioral misconduct (e.g., theft, property destruction, assault, truancy or substance use or abuse or juvenile sex offense), when in conjunction with other adjudicated delinquent behaviorsAs evidenced by: FORMTEXT ??????Met?Not MetThe member is at imminent risk of out-of-home placement or is currently in out-of-home placement due to delinquency and reunification is imminent within 30 days of referral.As evidenced by: FORMTEXT ??????Met?Not MetThe member has a caregiver that is willing to assume long term parenting role and caregiver who is willing to participate with service providers for the duration of the treatment.As evidenced by: FORMTEXT ?????Multisystemic Therapy (MST)Medicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2033Continued 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 youth’s Person Centered Plan; or the youth continues to be at risk for out-of-home placement, based on current clinical assessment, history, and the tenuous nature of the functional gains.As evidenced by: FORMTEXT ?????OR?Met?Not MetANY of the following applies:As evidenced by: FORMTEXT ?????Member continues to exhibit willful behavioral misconductANDThere is a reasonable expectation that the member will continue to make progress in reaching overarching goals identified in MST in the first 4 weeks.ORMember is not making progress; the PCP must be modified to identify more effective interventions.ORMember is regressing; the PCP must be modified to identify more effective interventions.Multisystemic Therapy (MST)Medicaid Clinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code H2033Discharge Criteria?Met?Not MetMember’s level of functioning has improved with respect to the goals outlined in the PCP, or no longer benefits from this service. The decision should be based on one of the following:As evidenced by: FORMTEXT ?????Member has achieved 75% of the PCP goals, discharge to a lower level of care is indicated.Member is not making progress or is regressing, and all realistic treatment options within this modality have been exhausted.The member or family requests discharge and is not imminently dangerous to self or othersThe member requires a higher level of care (i.e., hospitalization or PRTF).Clinical Review: ?Approved ? Send to peer reviewClinical Justification/Reason for Peer Clinical Review: Reviewer Name, Credentials: FORMTEXT ????? Date: FORMTEXT ????? ................
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