Developmental Therapy - Partners Health Management



State Funded ServicesDevelopmental Therapy – Professional - H2014 (Adults only); Paraprofessional - H2014HMInitial Review CriteriaMetNot MetN/ARequired Elements to Approve Service???The request is for H2014HM Developmental Therapy Paraprofessional AND the individual was previously receiving IPRS Day Supports AND has a CDSN Target Pop. Otherwise no new admissions to DT Paraprofessional effective 7/1/17.???The request is for H2014 Developmental Therapy Professional AND the individual has an ADSN Target Pop.??The person has a condition that may be defined as a developmental disability as defined in GS 122C-3 (12a) AND??The person has an NC-SNAP and other documents per the Partners BHM Benefit Plan AND??The person is experiencing difficulties in at least one of the following areas based on the current admission assessment, comprehensive clinical assessment and/or psychological evaluation:Functional impairments reflecting the need for instruction, training, or functional developmental intervention activities that include,Addressing behavioral challenges, and/orSkill building in areas such as self-care, socialization, independent living, etc.???The service goals/interventions are strictly habilitative and require ongoing training and skill building during service delivery. ???The service goals/interventions include individually designed instruction, training or functional developmental intervention activities based on the assessment of, and unique strengths and needs of the individual child or adult. ???The service goals/interventions are designed to support the individual in the acquisition of skills that the person has not gained during the developmental stages of life, and is not likely to develop without additional training and supports. ???The service goals/interventions do not include support and supervision for example, attending a football game after school.???For children and youth, the focus of service goals/interventions is directed toward improving or increasing functional development in areas such as self-help, language and cognitive development, and psychosocial skills.???For adults, the service goals/interventions may include training in activities to strengthen appropriate developmental functioning in areas such as self-care, mobility, socialization, independent living, and self-advocacy and rights.???The request indicates that natural supports and community supports have been assessed and attempted.???The service goals/interventions take place in a range of settings such as the individual’s home, individual’s family home and community settings.???The service goals/interventions are not being provided in an ADVP facility or in a school setting.???Individuals receiving this service to off-set residential costs will gradually transition to a residential rate that reflects the cost of their needs.???If Professional level DT is requested, the request indicates services will be provided by a QP???If Professional level DT is requested, the request indicates service interventions include the following types of activities: Development of outcomes and strategies; Provision of direct support to individuals with more intense needs. ???The request indicates paraprofessional level service interventions focus on training and skill building.???The request is for services that are not provided by parents, guardians or other family members. ???The PCP clearly demonstrates the need for one to one services in settings where two or more individuals receive the service at the same time of day.???The service is requested up to 618 units per 90 days per Partners BHM Benefit Plan based on the current treatment plan.???The service goals/interventions are not expected to continue for a period of longer than 4 h/d, especially with younger children.???If the service is provided beyond 4 h/d the following must be submitted:Documentation supporting the need for additional hours including evidence the additional hours are substantially more effective and clearly support the ability of the individual to tolerate sustained training and skill building beyond 4 h/d. Step-down plan written into the PCP, including timelines for moving the individual back to a maximum of 4 hours per day.???The service goals/interventions do not include educational skills taught in the primary or secondary school setting; e.g., reading math, writing. The service goals/interventions can include some functionally related skill development in areas such as recognizing familiar people, street signs, knowing how to get help in an emergency or related developmentally appropriate self-care, making a mark for a signature, or using a calculator to balance a checkbook, for adults who are or were not able to acquire these skills in an educational setting.???The service goals/interventions do not include vocational services directed toward assessing a person’s work skills or aptitudes, or training in specific job skills directed toward employment. The service goals/interventions can provide training in prevocational areas such as staying on task, safety, being on time, etc. These skills can be taught in other functional settings or simulated work settings as long as the primary purpose of the training is not to train the person in specific job skill.???The service goals/interventions do not include participation in recreational or leisure activities or attendance at such activities for recreational or leisure purposes only. The service goals/interventions may be used to teach the person to access the community, including recreational activities; (e.g., for children and youth to learn to participate in developmentally appropriate inclusive activities that teach life and social skills, learn to ride the bus to a fitness center). It is expected this type of training is time limited. The service must focus on the primary goals of the person.???Person Centered Planning has resulted in goals/outcomes based on the service definition criteria.Developmental Therapy – Professional - H2014; Paraprofessional - H2014HMContinuation/ Utilization Review CriteriaMetNot MetN/ARequired Elements to Approve Service??The person has a condition that may be defined as a developmental disability as defined in GS 122C-3 (12a) AND??The person has an NC-SNAP and other documents per the Partners BHM Benefit Plan AND???The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the person’s service plan OR???The person continues to be at risk for regression based on the history or the tenuous nature of the functional gains OR???Any of the following apply:The person has achieved initial Person-Centered Plan goals and services are needed to achieve additional goals. The person is making satisfactory progress toward meeting goals.The person is making some progress, but the Person-Centered Plan (specifics interventions) needs to be modified so greater gains can be achieved.The person is not making progress; the Person-Centered Plan must be modified to identify more effective interventions.The person is regressing the Person-Centered Plan must be modified to identify more effective interventions.Service Maintenance Criteria???The person is functioning effectively with this service and discharge would otherwise be indicated, Developmental Therapy should be maintained when it can be reasonably anticipated that regression is likely to occur if the service is withdrawn. ???The decision is based on one of the following:Evidence that gains will be lost in the absence of Developmental Therapy is documented in the service record ORIn the event there are epidemiologically sound expectations that symptoms will persist and that ongoing treatment interventions are needed to sustain functional gains, the presence of a DSM-IV-TR (or its successors) diagnosis would necessitate a disability management approach. Developmental Therapy – Professional - H2014; Paraprofessional - H2014HMDischarge CriteriaMetNot MetN/ARequired Elements to Approve Request???The person’s level of functioning has improved with respect to the goals outlined in the Person Centered Plan, inclusive of a transition plan to step down, or no longer benefits or has the ability to function at this level of care AND???Any of the following apply:The person has achieved goals and is no longer eligible for Developmental Therapy.The person is not making progress, or is regressing, and all realistic treatment options within this modality have been exhaustedPerson/family no longer wants Developmental Therapy.Initial Review: All Criteria Met: ? YES – APPROVE ? NO - Review with Clinical ReviewerComments: UM Reviewer Name, Credentials: Date: Clinical Review: ? Approved ? Send to Peer ReviewComments: Clinical Reviewer Name, Credentials: Date: ................
................

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

Google Online Preview   Download