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Institutions for Mental Disease (IMD) – Non-Substance Use Disorders forMedicaid Beneficiaries Ages 21–64 onlyMedicaid Clinical Coverage Policy 8BIMD Therapy Codes (CPT): 0160Pre 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/AReview for expedited criteria. If not met, notify provider and take off of 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 number of units requested match service requested. 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 MetMinimum standard is a shift note for every 8 hours of services provided that includes the beneficiary’s full name, birth date, date of service, purpose of contact, describes the provider’s interventions, the time spent performing the intervention, the effectiveness of interventions and the signature of the staff providing the service.Other Items of Review:?Met?Not MetCheck to see if a Care Coordinator 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 (ie. PCP, CCA, Service Notes, etc.)? If not contact Provider for clarification. Report to appropriate HIPPA 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 note here: none noted ?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: ?Met?Not Met?N/AEvidence of use/intended use of Evidence Based Practices.List EBP here: ?Met?Not Met?N/AIf DSS/DJJ/Legal involvement, a tag has been created in AlphaMCS.Note status of involvement here:?Met?Not Met?N/ACheck Claims for participation in & billing of other services. Check SARs for approved services. If there are Service Exclusions, contact Provider for clarification.? Note date you checked the claims module, also, the service(s) and provider explanation here:Institutions for Mental Disease (IMD) – Non-Substance Use Disorders forMedicaid Beneficiaries Ages 21–64 only Medicaid Clinical Coverage Policy 8BIMD Therapy Codes (CPT): 0160Preadmission Review CriteriaThe following are criteria for preadmission review for psychiatric treatment of adult non-substance use disorders and all other conditions: Any DSM-5, or any subsequent editions of this reference material, diagnosis and one of the following:As evidenced by:?Met?Not Meta. Impaired reality testing (e.g., delusions, hallucinations), disordered behavior or other acute disabling symptoms not manageable by alternative treatment?Met?Not Metb. Potential danger to self or others and not manageable by alternative treatment?Met?Not Metc. Concomitant severe medical illness or substance use disorder necessitating inpatient treatment?Met?Not Metd. Severely impaired social, familial, occupational or developmentalfunctioning that cannot be effectively evaluated or treated by alternativetreatment?Met?Not Mete. Failure of or inability to benefit from alternative treatment, in the presence of severe disabling psychiatric illnessf. Need for skilled observation, special diagnostic or therapeutic procedures or therapeutic milieu necessitating inpatient treatmentInstitutions for Mental Disease (IMD) – Non-Substance Use Disorders forMedicaid Beneficiaries Ages 21–64 only Medicaid Clinical Coverage Policy 8BIMD Therapy Codes (CPT): 0160Entrance CriteriaMedicaid and NCHC shall cover the procedure, product, or service related to this policywhen medically necessary, and:?Met?Not Meta. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs;?Met?Not Metb. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and?Met?Not Metc. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary’s caretaker, or the provider Specific Criteria CoveredInstitutions for Mental Disease (IMD) – Non-Substance Use Disorders forMedicaid Beneficiaries Ages 21–64 only Medicaid Clinical Coverage Policy 8BIMD Therapy Codes (CPT): 0160Continued 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 treatment plan and the beneficiary continues to be at risk of harming self or others as evidenced by direct threats or clear and reasonable inference of serious harm to self violent, unpredictable or uncontrollable behavior which represents potential for serious harm to the person or property of others; demonstrating inability to adequately care for own physical needs; orrequires treatment which is not available or is unsafe on an outpatient basis. The beneficiary’s condition must require psychiatric and nursing interventions on a 24 hour basis.?Met?Not Met?N/ALength of stay in current service.Note here: ?Met?Not Met?N/AInitial: 1-3 days maximum request. Concurrent: 1-8 days maximum request; submit on the last day of the current authorized timeframe or on the 1st day of the concurrent request. Maximum 15 days per calendar month. **IMD admissions spanning 2 consecutive months, the total length of stay may exceed 15 days, but no more than a 15-day LOS each month is eligible for authorization.Institutions for Mental Disease (IMD) – Non-Substance Use Disorders forMedicaid Beneficiaries Ages 21–64 only Medicaid Clinical Coverage Policy 8BIMD Therapy Codes (CPT): 0160Discharge Criteria?Met?Not MetThe beneficiary no longer meets the continued stay criteria.Clinical Review: ? Approved?Send to peer reviewReviewer Name, Credentials:Date: Clinical Justification/Reason for Peer Clinical Review:Medicaid:**STAFFED W/ MD OR UM SUPERVISOR** Based on clinical review, member meets [Entrance/Continued Stay] Criteria for [SERVICE], outlined in Clinical Coverage Policy 8B, as evidenced by: [CLINICAL RATIONAL]. Authorized from [Date Range] with the next review date being [DATE].? Staffed on [DATE] w/ [Chief Medical Officer or Associate Medical Director/PREST medical staff/BHM Medical Staff/UM Supervisor/IP Team Lead] by [UM Reviewer].?? Authorization is not a guarantee of payment.? Claims payment is dependent upon member funding eligibility during authorization period and contract of the service provider.**NOT STAFFED W/ MD**Based on clinical review, member meets [Entrance/Continued Stay] Criteria for [SERVICE], outlined in Clinical Coverage Policy 8B, as evidenced by: [CLINICAL RATIONAL]. Authorized from [Date Range] with the next review date being [DATE]. Authorization is not a guarantee of payment.? Claims payment is dependent upon member funding eligibility during authorization period and contract of the service provider. [UM Reviewer Name and Credentials] ................
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