OBOT Bundle Service Review Criteria 2019-09-05



Office Based Opioid Treatment (OBOT) BundleState-Funded Alternative Service DefinitionService Code YA396 (S1) (S2) (S3)Pre-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 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 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: FORMTEXT ??????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 Treatment Plan is present, which includes Office Based Opioid Treatment, 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 Comprehensive Clinical Assessment and/or Addendum is present and supports request (to include DSM 5 diagnosis). If not included with the initial authorization, then document call to provider. If not provided by deadline, “administratively deny”.?Met?Not MetThe submitted Treatment Plan contains the appropriate signatures: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, PA, NP). Service Orders are valid for one year. If not met, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request.?Met?Not Met?N/AUrine drug screen results are present, as indicated in the service definition. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request.Other Items of Review:?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 OTPIf 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 (ie. 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 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: 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.? Note: If not duplicative, another provider may bill CPT codes with YA396 (S1), (S2), & (S3). However, the same provider should not be billing for YA396 and CPT codes simultaneously-- given this is a bundled service that includes outpatient in the established rate. Please notify supervisor should you determine same provider is billing the following codes together: H0020, H0020U3OU, YA396, CPT codes, or behavioral health counseling codes.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 systemOffice Based Opioid Treatment (OBOT) BundleState-Funded Alternative Service DefinitionService Code YA396 (S1) (S2) (S3)Entrance Criteria The member is eligible for this service when ALL of the following criteria are met:?Met?Not MetA DSM-5 (or any subsequent editions of this reference material) diagnosis of a moderate or severe Opioid Use DisorderAs evidenced by: FORMTEXT ?????AND?Met?Not MetASAM (American Society for Addiction Medicine) for Opioid Treatment Services (OTS) leveling completed and indicates appropriateness of this service; 1. D1/Acute Intoxication and/or Withdrawal Potential: The member’s current physiological dependence (in addition to a history of addiction) is confirmed by vital signs, early physical signs of narcotic withdrawal, a urine screen that is positive for opioids, the presence of old or fresh needle marks, and documented reports from medical professionals, the member or family, treatment history, or (if necessary) a positive reaction to a naloxone test. 2. D2/Biomedical Conditions and Complications: In Dimension 2, the member meets specifications in one of the following: a. The member meets the biomedical criteria for opioid use disorder, with or without the complications of opioid addiction, and requires outpatient medical monitoring and skilled care; ORb. The member has a concurrent biomedical illness or pregnancy, which can be treated on an outpatient basis with minimal daily medical monitoring; ORc. The member has biomedical problems that can be managed on an outpatient basis, such as liver disease or problems with potential hepatic decomposition, pancreatitis, gastrointestinal problems, cardiovascular disorders, HIV and AIDS, sexually transmitted diseases, and tuberculosis.3. D3/Emotional, Behavioral, or Cognitive Conditions and Complications: In Dimension 3, the member meets specifications in one of the following:a. The member’s emotional, behavioral, or cognitive problems, if present, are manageable in an outpatient structured environment; ORb. The member’s substance-related abuse or neglect of his or her spouse, children, or significant others requires intensive outpatient treatment to reduce the risk of further deterioration; ORc. The member has a diagnosed and stable emotional, behavioral, or cognitive problem or thought disorder (such as stable borderline personality disorder or obsessive-compulsive disorder) that requires monitoring, management, or medication because of the risk that the problem(s) will distract the member from his or her focus on treatment; ORd. The member poses a mild risk of harm to self or others, with or without a history of severe depression, suicidal or homicidal behavior, but can be managed safely in a structured outpatient environment; ORe. The member demonstrates emotional and behavioral stability but requires continued pharmacotherapy to prevent relapse to opioid use. 4. D4/Readiness to Change: In Dimension 4, the member meets specifications in one of the following:a. The member requires structured therapy, pharmacotherapy, and programmatic milieu to promote treatment progress and recovery; ORb. The member attributes his or her problems to persons or external events rather than to the substance-related disorder. He or she is thus uninterested in making behavioral changes in the absence of clinically directed and repeated structured motivational interventions. However, the member’s low interest in recovery does not render treatment ineffective. 5. D5/Relapse, Continued Use, or Continued Problem Potential: In Dimension 5, the member meets specifications in one of the following:a. The member requires structured therapy, pharmacotherapy, and a programmatic milieu to promote treatment progress because he or she attributes continued relapse to physiologic craving or the need for opioids; ORb. Despite active participation in other treatment interventions without provision for opioid pharmacotherapy, the member is experiencing an intensification of addiction symptoms (such as difficulty in postponing immediate gratification and related drug-seeking behavior) or continued high-risk behaviors (such as shared needle use), and his or her level of functioning is deteriorating, despite revisions of the treatment plan; ORc. The member is at high risk of relapse to opioid use without opioid pharmacotherapy, close outpatient monitoring, and structured support (as indicated by his or her lack of awareness of relapse triggers, difficulty in postponing immediate gratification or ambivalence toward or low interest in treatment); ORd. The member is pregnant and requires continued opioid pharmacotherapy to avert repeated episodes of withdrawal by the fetus and ensure its continued health. 6. D6/Recovery Environment: In Dimension 6, the member meets specifications in one of the following:a. The member has a sufficiently supportive psychosocial environment to render opioid pharmacotherapy feasible. For example, significant others are supportive of recovery efforts, the member’s workplace is supportive, the member is subject to legal coercion, the member has adequate transportation to the program, and the like; ORb. The member’s family members or significant others are supportive, but require professional intervention to improve the member’s likelihood of treatment success (such as assistance with limit-setting, communication skills, avoiding rescuing behaviors, education about opioid pharmacotherapy treatment and HIV-risk avoidance, and the like); ORc. The member does not have a positive social support system to assist with immediate recovery efforts, but he or she has demonstrated motivation to obtain such a support system or to pursue (with assistance) an appropriate alternative living environment; ORd. The member has experienced traumatic events in his or her recovery environment (such as physical, emotional, sexual or domestic abuse) or has manifested the effects of emotional, behavioral or cognitive problems in the environment (such as criminal activity), but these are manageable on an outpatient basis. As evidenced by: FORMTEXT ?????AND?Met?Not MetEligible and enrolled in State Benefit PlanAs evidenced by: FORMTEXT ??????Met?Not MetWilling to engage in Medication-Assisted Treatment (MAT)As evidenced by: FORMTEXT ?????Office Based Opioid Treatment (OBOT) BundleState-Funded Alternative Service DefinitionService Code YA396 (S1) (S2) (S3)Continued Stay CriteriaThe member shall meet the following criteria for continued service:?Met?Not MetThe member is attending office visits and counseling as required, but the desired outcome or level of functioning has not been restored, improved, or sustained over the timeframe outlined in the member’s treatment plan; As evidenced by: FORMTEXT ?????OR?Met?Not MetB. The member has attended office visits and counseling as required, has achieved current treatment plan goals, and additional goals are indicated as evidenced by documented symptoms. As evidenced by: FORMTEXT ?????Office Based Opioid Treatment (OBOT) BundleState-Funded Alternative Service DefinitionService Code YA396 (S1) (S2) (S3)Transition or Discharge CriteriaEither ONE of the following criteria must be met: ?Met?Not MetThe member or legally responsible person no longer wished to receive these services; As evidenced by: FORMTEXT ?????OR?Met?Not MetThe member, based on presentation and failure to show improvement, despite modifications in the treatment plan, requires a more appropriate level of care; As evidenced by: FORMTEXT ??????Met?Not MetThe member has achieved current treatment plan goals and the desired outcome or level of functioning has been restored, improved, or sustained over the timeframe outlined in the member’s treatment plan.Note: Any denial, reduction, suspension, or termination of services requires notification to the member or legal guardian about their appeal rights. Service is expected to last a minimum of nine months, with a year or longer preferred. A strong foundation in active recovery, and a member desire to titrate off medications are critical elements for successful discharge.Members who fail 60% or more of their appointments over 45 days, or continue to use illicit or non-prescribed substances (including alcohol) after intervention and adjustment of medication and treatment regimen may be titrated off for clinical and safety reasons after 30 days of non-improvement.Clinical Review: ?Approved ? Send to peer reviewClinical Justification/Reason for Peer Clinical Review: Reviewer Name, Credentials: ????? Date: ????? ................
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