IIH Service Review Checklist updated 7-21-17



Assertive Community Treatment TeamIn Lieu of Service CriteriaService Code H0050 HA U5Encounter H0050 HA U5 ENPre-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”.?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 ACTT for Youth, 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PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate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 (MD/DO/Psychologist/PA/NP). 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 between the ages of 12 - 18, review for EPSDT.?Met?Not MetLOCUS/CALOCUS/ASAM score is noted and in SAR or other documentation.?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 Management 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. (1 unit per week; expected to complete service within 24 weeks maximum). Child ACTT team services may be billed for up to 30 days in accordance with the Person-Centered Plan for beneficiaries who are transitioning to or from Intensive In-Home, Day Treatment, Residential levels 2-4, TASK, MST.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:Previously requested documentation from prior authorizationsPlease note here:?Met?Not Met?N/AEvidence of use/intended use of Evidence Based Practices.For ACTT-Youth, the EBP must be from one of the following disciplines:- Trauma Systems Therapy (underlying agency-wide treatment model)- Trauma Focused Cognitive Behavioral Therapy (TF-CBT)- Dialectical Behavior Therapy (DBT)- Cognitive Behavioral Therapy (CBT)- Motivational Interviewing (Ml)- Attachment Self-Regulation and Competency (ARC)- Wellness Recovery Action Plan (WRAP)- Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)- Seven Challenges- Other models as determined by youth/family needs?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: State funding does not pay for ACTT - Youth.?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 in member 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.? Service exclusions for ACTT-Youth are the following:A beneficiary who is appropriate does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, out of home placement, substance use, victimization, and juvenile justice involvement. The beneficiary needs assertive engagement to develop treatment motivation. A fundamental charge is to be the first line (and generally sole provider) of all the services that a beneficiary needs.Beneficiaries with a primary diagnosis of a substance use disorder, intellectual developmental disabilities, traumatic brain injury, or an autism spectrum disorder are not the intended beneficiary group.?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 systemAssertive Community Treatment TeamIn Lieu of Service CriteriaService Code H0050 HA U5Encounter H0050 HA U5 ENEligibility CriteriaA member is eligible for this service when all of the following criteria are met:?Met?Not MetThere is an MH diagnosis (as defined by the DSM-5 or its successors). Children ages 12-18 with a major depressive disorder, psychotic disorder, anxiety disorder, disruptive behavior disorder and/or bipolar disorder because these illnesses more often cause long term psychiatric disability. Beneficiaries with other psychiatric illnesses are eligible dependent on the level of the long-term disability, co-occurring disorders, and complex trauma. However, individuals diagnosed with Mental Health conditions and co-occurring Moderate or Mild Intellectual disabilities or Autism will be assessed on a case by case basis for participation in Child ACTT but are not the intended recipients of this service.As evidenced by: FORMTEXT ????? ?Met?Not MetThis service is used to meet the needs of youth that are high risk for out-of-home residential treatment due to a psychiatric disorder, have a history of multiple hospitalizations or long term hospitalization(s) at a state facility, have a history of multiple episodes of Residential treatment, who are unresponsive to conventional outpatient treatment (outpatient therapy, Intensive In-home services, etc.) after discharge from Residential treatment even when evidenced based models were utilized, and/ or symptoms are at a severity where typically Psychiatric Residential treatment would be recommended, but based on team approach and planning for crisis intervention, Child ACTT would be appropriate to implement.As evidenced by: FORMTEXT ??????Met?Not MetSignificant functional impairment as demonstrated by at least one of the following conditions:Significant difficulty consistently performing the range of routine tasks required for basic child/adolescent functioning in the community (for example, demonstrating safety skills, self- regulation, and basic social interaction) or persistent or recurrent difficulty performing daily living tasks except with significant support or assistance from others such as friends, family, or relatives;Significant difficulty maintaining consistent educational/vocational performance at a self-sustaining level (such as regular attendance, regular participation without expulsion or repeated suspension)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 ?????Assertive Community Treatment TeamIn Lieu of Service CriteriaService Code H0050 HA U5Encounter H0050 HA U5 ENContinued 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. If the beneficiary is functioning effectively with this service and discharge would otherwise be indicated, The Child ACTT team services must be maintained when it can be reasonably anticipated that regression is likely to occur if the service is withdrawn. The decision must be based on either of the following:The beneficiary has a documented history of regression in the absence of Child ACTT team services, or attempts to titrate team services downward have resulted in regression; orThere is an epidemiologically sound expectation that symptoms will persist and that ongoing outreach treatment interventions are needed to sustain functional gains.Assertive Community Treatment TeamIn Lieu of Service CriteriaService Code H0050 HA U5Encounter H0050 HA U5 ENDischarge 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 ACTT for Youth 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:Child Focused Assertive Community Treatment (Child ACTT) is a team-based multidisciplinary approach to serve children in their homes, kinship placement Child Focused Assertive Community Treatment (Child ACTT) is a team-based multi-disciplinary approach to serve children in their homes, kinship placements, DSS foster homes, or may begin during transition from a more restrictive residential setting. Similar to the ACTT service for adults, this service uses a community-based team approach to meet the needs of youth with Serious Emotional Disturbance (SED). This service is used to meet the needs of youth that are high risk for out-of-home residential treatment due to a psychiatric disorder, have a history of multiple hospitalizations or long term hospitalization(s) at a state facility, have a history of multiple episodes of Residential treatment, who are unresponsive to conventional outpatient treatment (outpatient therapy, Intensive In-home services, etc.) after discharge from Residential treatment even when evidenced based models were utilized, and/ or symptoms are at a severity where typically Psychiatric Residential treatment would be recommended, but based on team approach and planning for crisis intervention, Child ACTT would be appropriate to implement. ................
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