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Department of Medical Assistance Services. Residential Treatment For Children & Adolescents Level C (RTC). September & October 2010 Residential Treatment Level C. DMAS Contacts William O’Bier - 804-225-4223

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department of medical assistance services

Department of Medical Assistance Services

Residential TreatmentFor Children & AdolescentsLevel C (RTC)

September & October 2010

residential treatment level c
Residential TreatmentLevel C

DMAS Contacts

  • William O’Bier - 804-225-4223

  • Pat Smith - 804-225-2412 for KePRO related questions

  • Tracy Wilcox-804-371-2648

Contract Monitor for Clifton Gunderson Audits

training objectives
Training Objectives:
  • Identify participation requirements
  • Understand Medicaid documentation requirements
  • Be aware of Service Authorization (SA) requirements and process
objectives cont
Objectives cont:
  • These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual (PSM) and are not meant to substitute for the comprehensive information available in the manual.
  • Please refer to the manual, available on the DMAS website, for in-depth information on psychiatric residential treatment criteria.
provider enrollment unit
Provider EnrollmentUnit
  • For enrollment, agreements, change of address, and enrollment questions contact:

Provider Enrollment Unit

P.O. Box 26803

Richmond, VA 23261

    • Toll free -- 888-829-5373
    • Fax -- 804-270-7027
provider agreements
Provider Agreements
  • A Restraint & Seclusion (R&S) attestation letter must be submitted to DMAS by July 1 each year or sooner if change in CEO
  • Sample R&S attestation letter in manual
general medicaid provider participation requirements
General Medicaid Provider Participation Requirements
  • Have administrative and financial management capacity to meet federal and state requirements
  • Have ability to maintain business and professional documentation
  • Adhere to conditions outlined in the provider agreements
  • Notify DMAS of any change in original information submitted and
participation requirements
Participation Requirements
  • Maintain records that fully document health care provided
  • Retain records for a period of at least 5 years
  • Furnish access to records and facilities in the form and manner requested
  • Use Medicaid designated billing forms
  • Accept as payment in full the amount reimbursed by DMAS. Provider must be participating in the Medicaid Program at the time the service is performed and
participation requirements1
Participation Requirements
  • A provider may not bill a client for a covered service regardless of whether or not the provider received payment from the state
  • Should not attempt to collect from the client or family member any amount that exceeds the Medicaid allowance or for missed appointments
  • Hold all recipient information confidential
  • Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements
definition level c rtf
Definition-Level C RTF
  • Program for children under age 21 to treat severe mental, emotional and behavioral disorders
  • When outpatient and day treatment fails
  • Provides inpatient psychiatric treatment
  • 24-hours per day program
  • Child-specific care and treatment planning and
definition level c rtf1
Definition-Level C RTF
  • Highly organized and intensive services
  • Planned therapeutic interventions
  • All services required to be provided on-site, including academic program
  • Physician-directed mental health treatment
restraint seclusion
Restraint & Seclusion
  • Remain in compliance with signed agreement regarding seclusion and restraint
  • In case of injury requiring medical attention off-site or a suicide attempt, DMAS must be notified by fax within one business day of occurrence:
    • child’s name, Medicaid number
    • facility name & address of incident
    • location & date of incident


restraint seclusion cont d
Restraint & Seclusion Cont’d
  • Notification continued
    • names of staff involved
    • description of incident
    • outcome, including persons notified
    • current location of child
  • Fax to William O’Bier at 804-612-0059
  • Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and of provider enrollment
out of state facility enrollment
Out-of-State Facility Enrollment
  • Border-state facility (within 50 miles)
  • Provides a service not available in Virginia; or
  • No in-state facility willing to admit a specific child


    • Contact DMAS at 804/225-4223 to discuss

child-specific, out-of-state placement need

    • DMAS can enroll facility for single placement,

if appropriate


out of state placement criteria
Out-of-State Placement Criteria
  • Requires prior authorization for Medicaid coverage
  • Recipient specific information required to be sent to DMAS:
    • Demographics
    • Referral source information
    • Current placement and services and why these are not adequate
    • Current documentation on diagnosis, behaviors, discharge plan
    • Current psychological evaluation -within past year and
out of state placement criteria1
Out-of-State Placement Criteria
  • Social and Service History pertinent to placement needs
  • Out-of-state facility information-website, documentation
  • List of Virginia facilities explored, and reasons for admission denial

This will be reviewed by DMAS staff to assess the appropriate level of care and facility placement, and who will coordinate with provider enrollment if out-of state placement is approved

electronic submission of claims
Electronic Submission of Claims
  • Claims should be submitted electronically
  • For CSA cases, when submitting SA information to KePRO, the 3-digit locality code and the Reimbursement Rate Certification rate are required. This will facilitate electronic submission of claims

For NON-CSA cases, reimbursement will be at the rate established at enrollment.

    • All providers are expected to have a rate established at enrollment
electronic signatures
Electronic Signatures
  • Clarification on electronic signatures issued in the 8-20-04 Medicaid Memo
  • An electronic signature that meets the following criteria is acceptable for clinical documentation:
  • Identifies the individual signing by name and title; and
electronic signatures1
Electronic Signatures
  • Data system assures the documentation cannot be altered after signature affixed, by limiting access to code or key sequence;
  • Provides for non-repudiation; that is, strong and substantial evidence that will make it difficult for the signer to claim the electronic representation is not valid; and
  • The provider must have written policies and procedures in effect regarding use of electronic signatures.
required documentation
Required Documentation
  • The following slides describe the required documents for admission
  • All documents must be complete, timely and include all required dated signatures
  • Sample forms are available in the manual
reimbursement rate certification
Reimbursement Rate Certification

For CSA Cases Only

  • Negotiated rate between locality and facility
  • Total rate can be no more than the Medicaid maximum
  • Payment from any other source such as Title IV-E, must be deducted prior to establishing the rate


reimbursement rate certification continued
Reimbursement Rate Certification continued
  • Identify responsible locality
    • Locality code must be sent in for PA
    • If rate is revised by the locality, must be sent in to KePRO within 1 week to update the PA
  • Payment based on the rate on the certification which is entered by KePRO into the MMIS
  • All versions of the rate certification must be available at the facility for review
csa or non csa
  • If the case is an Adoption Subsidy case, it is NON-CSA
    • The education payment source is not considered
  • If the education is paid for by the Dept. of Education/CSA funded, it is a CSA case
  • If a child has been receiving CSA funding for other services, it is a CSA case
  • If the child is in foster care, it is a CSA case
certification of need
Certification of Need
  • CSA Cases
    • CON must be completed by both the physician and the FAPT
    • Must include dated signatures of physician and at least 3 members of the FAPT
    • Authorization can begin no earlier than the date of the latest signature
    • Must be child-specific and relate to the need for RTF level of care
    • Must be available in the medical record
certification of need independent team certification
Certification of Need(Independent Team Certification)
  • NON-CSA Cases
    • The CSB is responsible for completing the Independent Team Certification
    • The CSB completes the DMH224 and must include a physician’s dated signature, as well as the screener’s dated signature
      • The CSB may use the sample CON in the manual in place of the DMH224


certification of need1
Certification of Need
  • NON-CSA Cases
    • CON may be completed by the FAPT and must include a physician’s dated signature, as well as a member of the FAPT

Authorization can begin no earlier than the date of the latest signature

    • Must be child-specific and relate to the need for RTF level of care
    • Must be available in the medical record
certification of need2
Certification of Need


  • Should reflect the child’s current condition and must be completed within 30 days of admission
  • Is required to be completed prior to admission with all necessary dated signatures
  • If discharged and readmitted, a new CON is required
  • If the child transfers to an acute psychiatric facility, the acute care team can do the new CON
state uniform assessment instrument
State Uniform Assessment Instrument

The CANS is the only uniform assessment instrument that is accepted

state uai
State UAI
  • CSA Cases Only
    • Must be current. For admission the state UAI should reflect the requested level of care
    • To be completed at least every 90 days

and must be in the medical record

    • Should be updated by the fiscally responsible locality when the child’s level of impairment changes significantly
    • Completion information must be submitted to KePRO for SA and
state uai1
State UAI
    • Scoring notes the level of impairment that supports the need for the level of care

At a minimum:

  • The CANS summary sheet, indicating the child’s behavioral and emotional needs, and risk behaviors
  • The CANS must be available in the medical record and current within 90 days throughout the stay
initial plan of care
Initial Plan of Care
  • Must be completed within 24 hours of admission
  • Requires a dated physician’s signature signifying the physician has had a face-to-face visit with the child (Authorization can begin no earlier than the date of the signature)
  • All required elements must be in the plan
    • See sample form in PSM-DMAS 371
    • Be sure to specify the number and type of child-specific therapies
  • Must be in the medical record
comprehensive individual plan of care cipoc
Comprehensive Individual Plan of Care (CIPOC)
  • Must be completed within 14 days of admission
  • Must include dated signatures of the team responsible for the care (physician & at least one other team member specified in regulations)
  • Must include all required elements
    • See sample form in PSM-DMAS 372
    • Be sure to include specific orders for therapies
  • Must be in the medical record
cipoc 30 day progress updates
CIPOC 30-Day Progress Updates
  • Must be updated every 30 days
  • Must have dated signatures of team members
  • Must include all required elements
    • See sample form in PSM-DMAS 373
  • List Individual and Family Therapy dates
    • If the therapy is not provided by a qualified professional, or the session was not at least 20 minutes, or there is no note, it should not be considered a delivered service
  • Address progress, or lack of progress. If no progress, how is this being addressed?


therapeutic interventions
Therapeutic Interventions

Individual, Family and Group Psychotherapy must be physician-ordered, provided by a licensed Medicaid enrolled provider and addressed in the treatment plan

  • Individual Psychotherapy
    • Must occur 3 times every 7 days. Facility determines the 7-day count.
    • Sessions must be, at a minimum, 20 minutes
    • If the session includes more than the therapist and the patient it is not considered individual psychotherapy
    • Telephone calls to family members are not considered individual psychotherapy and


therapeutic interventions cont d
Therapeutic Interventions Cont’d
  • Family Psychotherapy
    • Must occur at a minimum of 2 times a month if there is family involvement
    • If there is family dysfunction that impacts the child, therapy should be at least once a week.
    • Must be provided as is ordered in the treatment plan
  • Group Psychotherapy
    • Group Psychotherapy billed to Medicaid must not consist of more than 10 patients


therapeutic interventions1
Therapeutic Interventions

Individual, Family and Group Psychotherapy notes must be completed by a qualified therapist

  • If therapy is provided by an individual who has completed his or her graduate degree and is working towards licensure, they may do so under direct supervision


  • Appropriately licensed under state law and is a Medicaid-enrolled provider
  • Supervision meets requirements of individual profession



supervision of unlicensed therapists
Supervision of Unlicensed Therapists
  • Does not need to be the same person who is supervising for licensing purposes
  • Reviews patient’s medical history
  • Approves and signs Plan of Care indicating the need for the specific service
  • Countersigns Plan of Care updates
  • Reviews each therapy note
  • Must be in the facility during the session, but not required to be in the session and
supervision of unlicensed therapists1
Supervision of Unlicensed Therapists
  • Dated signature on each therapy note on date of service indicating note was reviewed
  • Meet regularly with supervisee (every sixth session or every 90 days, whichever comes first, to include all types of therapies )
    • Discuss Plan of Care
    • Review record
    • Assess patient’s progress
    • Document supervisory meetings
  • A Physician’s Assistant, under supervision, is not eligible to provide psychotherapy


therapeutic interventions including 21 weekly interventions
Therapeutic Interventions (including 21 weekly interventions)
  • Notes must contain, at a minimum:
    • Child’s name
    • Type of session (Individual, group, medication management)
      • If this is a group session, the type of group must be stated, such as Anger Management or Coping Skills
    • Treatment Modality
    • Start and stop time for session


therapeutic interventions cont d1
Therapeutic Interventions Cont’d
  • Pre-printed forms with date and time of session already printed is not acceptable
  • Written on the date service is provided
  • Activity of session-what therapeutic intervention/ interaction occurred, and how does it relate to goals
    • Purpose of note is to document service,and
therapeutic interventions cont d2
Therapeutic Interventions Cont’d
    • as well as to assist staff in providing focused ongoing therapeutic services to the child
  • Level of participation (a check box is not sufficient)
  • Plan for next session
  • Dated signature of provider
  • All notes should be child-specific
21 treatment interventions documentation
21 Treatment Interventions Documentation
  • 21 Treatment Interventions every 7 days
    • May count group psychotherapy
    • Must not include individual and family therapy
    • Must be documented on a daily basis
      • Each intervention must be documented
    • Forms with check boxes as the majority of the note are not acceptable


  • Must document child-specific therapeutic intervention
    • Interventions that are not billable separately may include more than 10 residents (this does not include the group psychotherapy that may be billed separately)
  • Must include the dated signature of the provider for each intervention
    • This does not need to be licensed staff
documentation cont d
Documentation Cont’d

Late Entries---

  • Timeliness of documentation is essential. A document is considered complete by review of the dated signature of the professional who develops the document. Back dating is not acceptable.
restraint seclusion1
Restraint & Seclusion
  • Reports must be sent to DMAS reporting any injury requiring medical attention. These should be sent in within one business day of the occurrence. (See slide 9)
  • Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and provider enrollment.
staffing and signatures
Staffing and Signatures
  • All signatures must be dated, and should include the professional title of the author
  • All medical documentation must include dated signatures on the date of service delivery
  • Auditors will request a staffing list with proof of licensure if license is required to provide a Medicaid reimbursed service
service authorization contractor
Service Authorization Contractor

KePRO is the DMAS contractor for SA

For questions go to the SA website: and click on Virginia Medicaid

Phone: 1-888-VAPAUTH or


Fax: 1-877-OKBYFAX or 1-877-652-9329

Web:Provider Issues @

service authorization contractor1
Service Authorization Contractor

Submitting a request

  • The preferred method is the iEXCHANGE® web-based program
  • Registration is required
  • Information on iEXCHANGE is available on the KePRO website, or call

1-888-827-2884 or by e-mail at

  • Telephone to 888-827-2884 or

804-622-8900 (local)

  • Mail to


2810 North Parham Rd., Suite 305

Richmond, VA 23284

service authorization
Service Authorization
  • Requests for SA are required to be submitted to KePRO prior to services being rendered, but no sooner than 10 days prior
  • Authorization can be for up to 90 days with medical justification
  • KePRO will review requests for medical necessity, as well as timeliness
    • KePRO will apply McKesson InterQual® Behavioral Health Criteria and DMAS supplemental criteria
service authorization1
Service Authorization


  • Must have a NON-CSA rate established by DMAS in order to request PA from KePRO
  • Contact Provider Reimbursement at

804-686-7931 to establish a rate. This should be done at the time of enrollment as a provider.

  • If no rate has been established, the request for PA will be rejected by KePRO.
    • If a rate is later established, the request will not be retroactive


service authorization2
Service Authorization
  • For CSA cases only:
    • CANS is acceptable as the state UAI and continue to be required at least every 90 days
    • the Reimbursement Rate Certification is no longer required to be attached
    • The locality code and the rate on the RRC must be provided to KePRO
service authorization3
Service Authorization
  • For both CSA and non-CSA requests:
    • No attachments are required, but information on the CON, IPC and CIPOC and updates are required
    • Severity of Illness questions are critical to authorization
service authorization4
Service Authorization
  • Narrative must address the need for level of care:

Initial Review

-symptoms and behaviors within past 7 days, frequency, intensity and duration

    • current functioning
    • support system
service authorization5
Service Authorization

Continued Stay

  • Symptoms and behaviors in past 30 days
  • Level of function in past 30 days
  • Describe recipient investment in treatment
  • Describe progress or lack of progress
    • If no progress, how is this addressed?
service authorization6
Service Authorization

Initial Review--

CSA cases only

  • 3-digit locality code
  • Reimbursement Rate Certification information
  • State UAI information

CSA and NON-CSA cases

Confirmation of completion:

  • Certificate of Need
  • Initial Plan of Care
service authorization7
Service Authorization

Continued Stay Review--

CSA Cases

  • Current UAI information
  • Confirm locality code
  • Reimbursement Rate Certification update if revised

CSA and NON-CSA Cases

Confirmation of completion:

  • 30-Day Update-most recent
service authorization8
Service Authorization


  • The denial of SA for services not yet rendered may be appealed in writing by the Medicaid recipient within 30 days of receipt of the denial.
  • The provider may appeal an adverse decision for a service already provided by filing a written notice of appeal within 30 days of receipt of the denial.


service authorization9
Service Authorization
  • Appeal rights will be stated in the SA notification letter. Requests for appeal must be submitted to:

Appeals Division

Department of Medical Assistance Services

600 East Broad Street, 11th Floor

Richmond, Virginia 23219

  • The provider may not bill the recipient for covered services that have been provided and subsequently denied by DMAS
utilization review
Utilization Review

Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program.

Purpose of Utilization Review:

  • Ensure medical necessity
  • Confirm qualified provider delivered service
  • Ensure program requirements met
  • Address Quality of Care issues
utilization review1
Utilization Review
  • DMAS has contracted with Clifton-Gunderson to complete audits of RTFs and will review records to assure DMAS criteria is being followed