Utilization Review Update

1. Utilization Review Update Durham Center Access February 23, 2011

2. Overview • Types of requests • Unable to process • Incomplete requests • Changes to submission time requirements • Scenarios that could effect service delivery

3. Types of Requests • Initial request: request for a service the recipient was not authorized to receive on the day immediately preceding the UR vendor’s receipt of the request • Reauthorization or continuing/concurrent request: request for a service required to be authorized for that recipient on the day immediately preceding the date of the UR vendor’s receipt of the request

4. Types of Requests • Prospective request: generally request a service that consumers not currently receiving • Concurrent request: generally requests made for a consumer to continue receiving a previously-authorized service

5. Reminders • Prior approval of Medicaid services require full clinical documentation to demonstrate medical necessity • Supplement previous information with recent clinical information to document medical necessity if necessary • recent evaluation reports from clinicians • recent treatment records • letters signed by treating clinicians

6. Unable to Process • Recipient name and address, MID number, date of birth • Identification of service requested or procedure code • Provider name/NPI/Provider number of provider to perform service or procedure • All signatures on forms required by law

7. Unable to Process • Date requested service to begin or be performed • Documents or forms required by State or federal statute • Example: Psychiatric assessment and discharge plan must be submitted as part of any request for Child Level III and IV Residential Services

8. Unable to Process • No review for medical necessity will occur when request returned “Unable to Process” • new request required with start date no earlier than date of the resubmission of the request • “Unable to Process” notice does not include appeal rights

9. Incomplete Requests • Requests for prior approval must use forms and fields required by applicable clinical coverage policy and vendor • Requests must include all necessary attachments (e.g. person centered plans) complete • Requests without minimum required clinical coverage information are incomplete

10. Examples of Incomplete Requests • Signature on PCP missing • Credentials not included with signature • Checked boxes not checked • Dates missing on signatures • Discharge plan missing • SOC (System of Care) Coordinator signature missing • Risk assessment missing

11. Examples of Incomplete Requests • Attestation missing in change of provider request • PCP not properly filled out

12. Pending • The Durham Center will no longer pend requests and ask providers for required attachments that are missing

13. Pending • Competed requests requiring additional information to determine medical necessity will be pended and information requested • provider receives written notification of what additional information needed • if requested documentation not received within 10 business days, decision will be based on available information

14. New Requirement • Beginning 00/00/11 requests for re-authorization or continuation of services must be made at least 10 calendar days prior to end of current authorization period • If request submitted properly but TDC decision not made prior to end of current authorization period, retroactive authorization will be entered when vendor decision is made

15. New Requirement • Does not apply to “Unable to Process” requests • will not serve as a “placeholder” for purposes of the 10-day requirement • Requests for CAP, inpatient, or emergent services not subject to 10-day requirement • must be submitted by current policy • if submitted before expiration of authorization period, services continue without interruption

16. Reauthorization • If provider does not request reauthorization at least 10 calendar days prior to end of current authorization period, there may be a break in authorization • Example:Recipient authorized to receive 8 units of service a week June 1-August 30. If provider believes it is medically necessary for service to continue beyond August 30, request for prior approval must be submitted by 10 calendar days prior to August 30 (August 21) for services to continue without interruption.

17. Reauthorization • Continue to provide services beyond the end of the authorization period if reauthorization request was timely • Providers paid for services provided when the authorization request is timely as specified by these instructions • Should TDC fail to authorize services as specified by these instructions, contact the DMA Appeals Unit at (919) 855-4260

18. Reauthorization • If request submitted at least 10 calendar days prior to end of current authorization period and request approved, no break in service and service authorized beginning on the first day after the end of the authorization period • Example: Recipient authorized to receive 8 units of service a week June 1-August 30. Request for prior approval of 8 units per week for additional 90 days submitted on August 15. TDC approves request on September 4. Authorization will be retroactive to September 1.

19. Reauthorization • Requests for prior approval to continue authorization of service recipient currently receiving less than 10 calendar days prior to the end of the authorization period will, if possible, be processed within The Durham Center’s required turnaround time • If approved, will be authorized beginning on date of decision, not backdated to account for late requests

20. Reauthorization • Example: Recipient authorized to receive 8 units of service a week June 1-August 30.Request for prior approval of 8 units per week for additional 90 days submitted on August 28. TDC approves request on September 4. Authorization for 8 units per week entered into the system on September 4 for 90 days. • Service is not authorized from September 1-3.

21. Reauthorization • Requests for prior approval to continue authorization of a current service received lessthan 10 calendar days prior to the end of authorization period • If denied or reduced, authorization at prior level of service entered for 10 days beginning date of decision • If recipient files timely appeal, authorization will continue through the appeal period

22. Reauthorization • Example: Recipient authorized to receive 8 units of service a week June 1-August 30. Request for prior approval of 8 units per week for additional 90 days submitted on August 28. TDC approves request on September 4. Authorization for 8 units per week entered into system effective September 4 for 10 days. • Authorization for 4 units per week for 80 days entered effective September 15.

23. Reauthorization • If appeal is requested within 10 calendar days of the decision, authorization for 8 units must continue without further interruption. • If an appeal is requested more than 10 calendar days after date of notice but within 30 days, MOS must be entered at 8 units per month effective with date of appeal and continuing until a final agency decision. • Service is not authorized from September 1-3.

24. If UM Response Not Timely • If no decision within 15 business days on request to continue authorization of service, on day 16 TDC must enter authorization for service to continue at prior level until effective date of its decision on the request • Applies as long as the request submitted before authorization period expired

25. If UM Response Not Timely • Example:Recipient authorized to receive 8 units of service a week June 1-August 30.Request for prior approval of 8 units per week of service for additional 90 days submitted on August 27. TDC unable to issue decision by September 20 (15th business day after August 27). • Authorization for 8 units per week entered on September 21 to continue until 10 days after decision issued on the request. • Service is not be authorized from September 1-20.

26. Reauthorization • If request submitted more than one day after end of current authorization period, request treated as an initial request

27. Reauthorization • Example: 20 hours per month of service authorized through May 31. Provider requests reauthorization of 20 hours per month on June 2. TDC treats request for services as initial request. • If TDC approves re-authorization, payment for service stops May 31. Authorization resumes effective date of notice because re-authorization not requested prior to end of current authorization period.

28. Reauthorization • If TDC reduces re-authorization request, payment stops on May 31. Authorization for service at new level begins effective date of notice at amount approved by TDC. • If appeal requested, services authorized at new level pending appeal because re-authorization not requested prior to the end of current authorization period.

29. Reauthorization • If TDC denies re-authorization request, payment stops on May 31. No authorization for services pending appeal because re-authorization not requested prior to end of current authorization period.

30. Final Reminders • Requests returned as Unable to Process donot afford appeal rights to consumer • Requests returned to provider as Incomplete do afford appeal rights to consumer • Appeal Form is only sent to the consumer • Notices mailed to provider via first class mail • Notices mailed to consumers via UPS as trackable mail