Assertive Community Treatment Team (ACT)



Professional Treatment Services in Facility-Based Crisis ProgramClinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code S9484Pre-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 effective start date does not precede the submission date of request. If so, “unable to process” the request.?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 SAR is submitted with ICD-10 codes. If not met, then “unable to process”. FORMTEXT ?????Review for Administrative Denial: ?Met?Not MetFollowing 7 day pass-through, service order is present and date of signature of MD or DO is prior to or on the date this episode of care began. 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 3-5 Recommended ASAM Level 3.5If necessary, review and/or request LOCUS/CALOCUS/ASAM worksheet; If not present, can NOT administratively deny.?Met?Not MetCheck to see if a Care 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 (i.e. PCP, CCA, Service Notes, etc)? If not contact Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. ?Met?Not MetIs there evidence of active discharge planning with any concurrent requests?Consider reviewing for the following elements:anticipated discharge datebarriers to discharge anticipated 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: ?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/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 systemProfessional Treatment Services in Facility-Based Crisis ProgramClinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code S9484Eligibility Criteria The member is eligible for this service when ALL of the following apply:?Met?Not MetThere is an Axis I or II diagnosis present or the member has a condition that may be defined as an intellectual and developmental disability as defined in GS 122C-3 (12a)As evidenced by: FORMTEXT ??????Met?Not MetMeets Level of Care Criteria, Level D NC-SNAP (NC Supports or Needs Assessment Profile) or ASAM (American Society of Addiction Medicine)As evidenced by: FORMTEXT ??????Met?Not MetThe member is experiencing difficulties in at least one of the following areas: 1. functional impairment, 2. crisis intervention, diversion, or after-care needs, or 3. at risk for placement outside of the natural home setting;As evidenced by: FORMTEXT ?????AND?Met?Not MetThe member’s level of functioning has not been restored or improved and may indicate a need for clinical interventions in a natural setting if any one of the following apply:Unable to remain in family or community setting due to symptoms associated with diagnosis, therefore being at risk for out of home placement, hospitalization, or institutionalization.Intensive, verbal and limited physical aggression due to symptoms associated with diagnosis, which are sufficient to create functional problems in a community setting.At risk of exclusion from services, placement or significant community support systems as a result of functional behavioral problems associated with diagnosis.As evidenced by: FORMTEXT ?????Professional Treatment Services in Facility-Based Crisis ProgramClinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code S9484Continued 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 service plan or the member continues to be at risk for relapse based on history or the tenuous nature of the functional gains or any one of the following apply:Member has achieved initial service plan goals and additional goals are indicated.Member is making satisfactory progress toward meeting goals.Member is making some progress, but the service plan (specific interventions) needs to be modified so that greater gains, which are consistent with the member’s pre-morbid level of functioning, are possible or can be achieved.Member is not making progress; the service plan must be modified to identify more effective interventions.Member is regressing; the service plan must be modified to identify more effective interventions.As evidenced by: FORMTEXT ?????Professional Treatment Services in Facility-Based Crisis ProgramClinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code S9484Discharge Criteria?Met?Not MetMember’s level of functioning has improved with respect to the goals outlined in the service 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:Member has achieved goals, discharge to a lower level of care is indicated.Member is not making progress or is regressing and all realistic treatment options with this modality have been exhausted.As evidenced by: FORMTEXT ?????Professional Treatment Services in Facility-Based Crisis ProgramClinical Coverage Policy 8AState-Funded MH/SA/DD Service DefinitionsService Code S9484Service Maintenance Criteria?Met?Not MetIf the member is functioning effectively with this service and discharge would otherwise be indicated, Facility-based crisis service should be maintained when it can be reasonably anticipated that regression is likely to occur if the service is withdrawn. The decision should be based on ANY of the following:Past history of regression in the absence of facility-based crisis service is documented in the service recordIn the event there are epidemiologically sound expectations that symptoms will persist and that ongoing treatment interventions are needed to sustain functional gains; the nature of the member’s DSM-IV diagnosis necessitates a disability management approach.As evidenced by: FORMTEXT ?????Clinical Review: ?Approved ? Send to peer reviewClinical Justification: Reviewer Name, Credentials: Date: Click or tap to enter a date. ................
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