Family Centered Treatment Service Review Criteria updated ...



Family Centered Treatment (FCT)In Lieu of Service DefinitionState-Funded MH/SA/DD Service DefinitionsService Code H2022Z1 and H2022HEPre-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: FORMTEXT ??????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 start date does not precede the submission date of the 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: FORMTEXT ??????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 MetThe PCP is present, which includes frequency and provider. 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PCP/Treatment Plan contains the appropriate signatures:For Initial review, Annual review, or when a service is added/withdrawn from the plan:Member and/or Legally Responsible Person signaturePerson Responsible for Treatment Plan signatureService Order signature by the appropriate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. 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). If not included, then document call to provider. If not provided by deadline, administratively deny.Other Items for Review:?Met?Not Met?N/AIf Medicaid member is 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 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 Coordination 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 decisions/recommendations and need for clinical staffing.Please note here: FORMTEXT ??????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: FORMTEXT ??????Met?Not Met?N/ALength of stay in current service.Note here: FORMTEXT ??????Met?Not Met?N/AIF DSS/DJJ/Legal involvement, a tag has been created in Alpha MCS. 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)” ?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 inpatient 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.? 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:?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 systemFamily Centered Treatment (FCT)In Lieu of Service DefinitionState-Funded MH/SA/DD Service DefinitionsService Code H2022Z1 and H2022HEEligibility CriteriaA member is eligible for this service when ALL of the following criteria are met:?Met?Not MetChild is between ages 3 and 20.?Met?Not Metthere is a mental health or substance use disorder 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 ANDAs evidenced by: FORMTEXT ??????Met?Not Metthere are significant family functioning issues that have been assessed and indicated that the member would benefit from family systems work (to include access to service issues and family multi-stress situations) as evidenced by one or more of the following:a step down from a higher level of care there has been DSS involvement in the last yearthere has been Juvenile Justice involvement in the last 6 monthsthere has been a behavioral health Emergency Room visit and/or hospitalization in the last 6 monthsthere have been multiple school suspensions there has been crisis intervention in the last 6 months to include (but not exclusive of) law enforcement involvement, crisis line calls, mobile crisis service, emergency crisis bed stayphysical abuseverbal abusesexual abusephysical neglectemotional neglectparent or caretaker that abuses substancesparent or caretaker that is the victim of domestic violenceparent or caretaker that has a mental health diagnosisthe loss of a parent or caretaker to divorce, abandonment or deatha parent of caretaker that is incarcerateda significant other traumatic event to include (but not exclusive of) watching a sibling being abused, homelessness, surviving and recovering from a severe accident. As evidenced by: FORMTEXT ?????Family Centered Treatment (FCT)In Lieu of Service DefinitionState-Funded MH/SA/DD Service DefinitionsService Code H2022Z1 and H2022HEContinued Criteria?Met?Not MetThe individual continues to meet the eligibility criteria, and meets at least one of the following criteria: The 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 ??????Met?Not MetAND one of the following applies:AND one of the following applies: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 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 demonstrates 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 consideration of alternative or additional services.As evidenced by: FORMTEXT ?????Family Centered Treatment (FCT)In Lieu of Service DefinitionState-Funded MH/SA/DD Service DefinitionsService Code H2022Z1 and H2022HEDischarge Criteria?Met?Not MetAny one of the following applies:As evidenced by: FORMTEXT ?????Reduce hurtful/harmful behaviors affecting family functioningThe member has achieved goals and is no longer in need of FCT 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 FCT services; orThe 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: ................
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