Partners Health Management - Provider Knowledge Base ...



State Funded, B3, and LTCS ServicesAdministrative ReviewMetNot MetN/ARequired Elements for Review of PCP/Treatment Plan and Update/Revisions???State Funded only - Individual has been referred to the RUN (Registry of Unmet Needs). (Admin Denial process)??Recipient Name, Address, DOB are present. (UTP process)??Psychological evaluation is on file which supports IDD eligibility including:? evidence of mental/physical impairment or combination manifested prior to age 22, or TBI after age 22;? disability is severe and chronic and likely to continue indefinitely;? substantial limitations in 3 or more of the 7 areas of major life activity as listed in NC G.S. §122C-3, 12a (or 3 of 6 areas as listed in CCP 8E if request is for B3 services which require Innovations eligibility);? for children under age 4, may be evidenced as Global Developmental Delay (Admin Denial process)??Eligibility for IDD and/or B3 has been documented on the appropriate Functional Eligibility checksheet and is on file. DATE: _________???LTCS only – Eligibility for ICF- IID Functional Eligibility is documented on file. DATE: _________*For initial requests or a gap in authorization of 30 days or more, Functional Eligibility will need to be re-determined. Or? Individual is grandfathered/transferred from State Funded Services and ICF-IID Functional Eligibility has been determined using any psychological evaluation on file. DATE: _________???The Annual PCP or Treatment Plan with all elements is present with all pages (Admin Denial process), ORUpdated PCP or Treatment Plan Revision with indication that goals have been reviewed is present (Admin Denial process).???For LTCS:The Treatment Plan/ PCP includes a goal/goals for each individual service type in the LTCS level requested ORTreatment Plan Revision /PCP Revision indicates goals have been reviewed OR a progress summary is attached (signed by QP).???If a PCP is used all services are on a Unified Plan if they are provided by different agencies. (UTP Process)??Diagnoses are entered using ICD-10 coding. (UTP process)???State Funded only - ADSN or CDSN Target Pop is present and valid. If not present or expired, notify the provider that it must be updated. DO NOT UTP. Notify with CM note.???LTCS and B3 ONLY - The person is eligible for Medicaid as verified in Alpha or NCTRACKS. (UTP process)??NC-SNAP OR SIS is present, current, and includes all pages. (Admin Denial process)Type of form: ___________________ DATE: _______________ **NC-SNAP is good for 365 days.???LOCUS or CALOCUS is present and current if required. (Admin Denial process)??Service/ Procedure Code on the SAR matches the plan. (UTP process)??The Service Provider on the SAR matches the provider identified in the plan. (UTP process)??The plan includes a goal/goals for the requested service. (Admin Denial process)??Requested Start date and End date are identified in the plan and match the SAR (UTP process).??Requested start date does not precede the date the SAR was submitted unless policy criteria for Retro requests are met. (UTP process)??Requested start date is within 30 days of SAR submission. (UTP process)??Requested end date on the SAR does not extend beyond the end date of the valid plan. (UTP process)??Requested units in the plan match the SAR. (UTP process)???Requests for Individualized Rates have been processed. Outcome for Individualized Rate: Date Letter sent, if applicable: ______________???There is a current authorization for services that are closed to new admissions. (A lapse of 2 days or more is considered an Initial Request.) (UTP process)???Crisis plan is present and complete within the PCP (if used). (Admin Denial process)Or, health and safety is addressed in the treatment plan.???LTCS only - Behavior Support Plan and Behavioral data are present and current, if applicable???PCP or PCP Update/Revision signature page is signed and dated by the individual or their legally responsible person if the individual is adjudicated incompetent AND appropriate Check boxes are checked. (Admin Denial process). ???PCP or Updated PCP or Revisions signature page Section II is signed and dated by the Person Responsible for the PCP (Qualified Professional). The date of the QP/LP signature should coincide with the “PCP Completed on” date. (Admin Denial process).*The QP signature in Section II does NOT constitute the Service Order.???QP signature in Part III (Section B) is present. -Recommended to serve as the Service Order for State-funded services contained in the PCP. -Required for B3 services which require Service Order. Per DMA, TCM should be crossed out and B3 written in on the Service Order section of the PCP Signature Page (Admin Denial process). *B3 Respite and B3 Community Guide do not require a Service Order. *LTCS see below.???Treatment Plans are signed and dated by the individual or their legally responsible person if the individual is adjudicated incompetent. (Admin Denial process)???For Treatment Plans, the QP signature serves as a service order for IDD State Funded and B3 services.*LTCS see below.???LTCS only - Service Orders are required for each individual service (e.g. Residential, Day Supports, SE) and may be written by a medical doctor (MD), Doctor of Osteopathic Medicine (DO), licensed psychologist (PhD), nurse practitioner (NP), or a physician assistant (PA).Backdating of service orders is not allowed.Each service order must be signed and dated by the authorizing professional and must indicate the date on which the service is ordered.A service order must be in place prior to or on the day that the service is initially provided to bill Medicaid for the service. Even if the individual is retroactively eligible for Medicaid, the provider cannot bill Medicaid without a valid service order.Service Orders are valid for one year from the date of last required signature. Medical necessity must be reviewed, and services must be ordered at least annually based on the date of the treatment plan.If using a PCP, the Service Order must be signed in Section III- A by a MD, DO, PhD, NP or PAIf using a Treatment Plan it may be signed by the MD, DO, PhD, NP or PA to constitute the Service Order or a separate form may be used with all services listed. ???Review 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 evaluation (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:? 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-? Been expelled or is at risk of expulsion from school due to disruptive or dangerous behaviors; ? Child is unable to participate in any structured educational setting based on current behaviors-OR-? 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. If Yes, Create tag in Alpha Clinical Tag Created: ? Yes ?No ?Tag already in system**Not included in Initial Review Criteria for Approval???Review 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 system**Not included in Initial Review Criteria for ApprovalMH/SU services: Member is receiving an MH/SU service other than Medication Management or Inpatient. ? YES- Review with Clinical Reviewer ? NO **Not included in Initial Review Criteria for Approval???Check to see if SAR was appropriately marked as Initial or Reauth. If not marked correctly, change the button in Alpha before closing out the SAR and document the change below. ??Note here:? ?????Initial Review: All Criteria Met: ? Proceed to Medical Necessity Review ? Unable to Process ? Administrative DenialNOTE: All new IDD individuals requesting initial IDD services must be sent to Second Level Review.NOTE: All individuals requesting initial LTCS services must be sent to Second Level Review if ICF-IID Functional Eligibility needs to be determined. Comments: UM Reviewer Name, Credentials: Date: Second Level Review: ? Approved ? Send to Peer Review ? Administrative Denial Comments: Clinical Reviewer Name, Credentials: Date: ................
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