Community Support Team Service Review Checklist



Community Support Team (CST)Clinical Coverage Policy 8A-6State-Funded MH/SA/DD Service DefinitionsService Code H2015HTPre-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) selectedon 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 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 includes CST, frequency and provider. Relevant diagnostic information must be obtained and documented in the member’s Person-Centered Plan (PCP). 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PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate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. For CST, the service order must be completed by a physician, licensed psychologist, physician assistant, or nurse practitioner, per his or her scope of practice.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). The CCA is completed by a licensed clinician. If not included, then document call to provider. If not provided by deadline, “administratively deny”.?Met?Not Met?N/AFor concurrent requests, when it is medically necessary for services to be authorized for more than six months, a new comprehensive clinical assessment (CCA) or an addendum to the original CCA must be completed and submitted with a new service authorization request. The CCA does not have to be completed by an independent practitioner. If 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 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 2-4 Recommended ASAM Level 1-2.5If necessary, review and/or request LOCUS/CALOCUS/ASAM worksheet; If not present, can NOT administratively deny.Please note here: FORMTEXT ??????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: FORMTEXT ??????Met?Not MetThe Member’s Name, DOB, MRN and MID number are present and accurate in necessary places (ie. PCP, CCA, Service Notes, etc)? If not contact Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. Please note here: FORMTEXT ??????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.Please note here: FORMTEXT ??????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? (For CST, initial 30-day pass-through available once per tx episode, per fiscal year; Initial Auth: up to 128 units for 60-calendar days; Concurrent Auth: up to 192 units for a 90-day reauthorization). 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/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 AlphaMCS. 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)”?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: FORMTEXT ??????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 systemCommunity Support Team (CST)Clinical Coverage Policy 8A-6State-Funded MH/SA/DD Service DefinitionsService Code H2015HTEligibility CriteriaMedicaid and NCHC shall cover Community Support Team (CST) when ALL following criteria are met:?Met?Not MetThe beneficiary has a mental health or substance use disorder (SUD) diagnosis as defined by the DSM-5, or any subsequent editions of this reference material, other than a sole diagnosis of intellectual and developmental disability. As evidenced by: FORMTEXT ?????AND?Met?Not MetThere is documented, significant impairment in at least two of the life domains (emotional, social, safety, housing, medical or health, educational, vocational, and legal). This impairment is related to the beneficiary’s diagnosis and impedes the beneficiary’s use of the skills necessary for independent functioning in the community. As evidenced by: FORMTEXT ?????AND?Met?Not MetFor a beneficiary with a primary substance use disorder diagnosis, the American Society for Addiction Medicine Criteria Level I or higher level is met. As evidenced by: FORMTEXT ?????AND?Not Met?Not MetThe beneficiary is capable of developing skills to manage symptoms, make behavioral changes, and respond favorably to therapeutic interventions; and there is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards.As evidenced by: FORMTEXT ?????AND?Met?Not MetTwo or more of the following conditions related to the diagnosis are present:As evidenced by: FORMTEXT ?????The beneficiary requires active rehabilitation and support services to achieve the restoration of functioning and community integration and valued life roles in social, employment, daily living, personal wellness, educational or housing domains.Deterioration in functioning in the absence of community-based services and supports would lead to hospitalization, other long-term treatment setting or congregate care, such as adult care or assisted living.The beneficiary’s own resources and support systems are not adequate to provide the level of support needed to live safely in the community.One or more admissions in an acute psychiatric hospital or use of crisis or emergency services per calendar year, or a hospital stay more than 30-calendar days within the past calendar year.Pending discharge (less than 30-calendar days) from an adult care home, acute psychiatric hospital, emergency department or other crisis setting.Traditional behavioral health services alone, are not clinically appropriate to prevent the beneficiary’s condition from deteriorating (such as missing office appointments, difficulty maintaining medication schedules).Legal issues related to the beneficiary’s mental or substance use disorder diagnosis.Homeless or at high risk of homelessness due to residential instability resulting from the beneficiary’s mental health or substance use disorder diagnosis or has difficulty sustaining a safe stable living environment.Clinical evidence of suicidal gestures, persistent ideation, or both in past three munity Support Team (CST)Clinical Coverage Policy 8A-6State-Funded MH/SA/DD Service DefinitionsService Code H2015HTContinued Stay 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 Person Centered Plan; or the member continues to be at risk for relapse 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 Person Centered Plan 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 Person Centered Plan. The member is making some progress, but the specific interventions in the Person Centered Plan need to be modified so that greater gains, which are consistent with the member’s premorbid level of functioning, are possible.The member fails to make progress, demonstrates regression, or both in meting goals through the interventions outlined in the Person Centered Plan. The member’s diagnosis should be reassessed to identify any unrecognized co-occurring disorder, and treatment recommendations should be revised based on the findings. Community Support Team (CST) Clinical Coverage Policy 8A-6State-Funded MH/SA/DD Service DefinitionsService Code H2015HTTransition or Discharge Criteria?Met?Not MetThe member meets the criteria for discharge if any ONE of the following applies:As evidenced by: FORMTEXT ?????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 has achieved positive life outcomes that support stable and ongoing recovery and is no longer in need of CST services.The member has made limited or no progress, and all reasonable strategies and interventions have been exhausted, indicating a need for more intensive services. The member or person legally responsible for the member requests a discharge from the service. Clinical Review:?Approved ?Send to peer reviewClinical Justification/Reason for Peer Clinical Review: FORMTEXT ?????Reviewer Name, Credentials: FORMTEXT ?????Date: FORMTEXT ????? ................
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