PAS/SDPAS

1. PAS/SDPAS Framework of Responsibility I

2. Acronym BINGO Every time you hear a speaker use on of the acronyms on your bingo card during the training, check the box. Get five across, up/down or diagonal. • Call out BINGO to receive your prize. • There will be three winners!

3. Ensuring Quality and Compliance

4. Flowchart of Responsibility

5. Community Services BureauSenior Long Term Care Red= Central Office Blue= Field Office

6. The mission of the Community Services Bureau is to address the needs of Medicaid eligible Montanans who require assistance and support in meeting their on-going health needs, by developing, managing, funding and ensuring quality home based services that foster independence and dignity, contain costs, and provide options to consumers. Mission Statement

7. Program Manager Abby Holm (406) 444-4564 abholm@mt.gov • Program oversight and direction • Liaison to CMS • Provider enrollment • Budget Management • Policy Development • Data Analysis • Quality Assurance Manager • Support to RPOs • Implement legislative initiatives

8. Program SpecialistAnnette Marron (406) 444-4142 amarron@mt.govCraig Bender (406) 444-4376 cbender@mt.gov • Claims Resolution, i.e. timely filing, adjustments, address problems in billing (PAS and HCBS) • Liaison with ACS • Run utilization reports • Recovery Specialist

9. Regional Program Officer • Liaison between local providers/consumers and state office staff • Clarify/interpret rules • Provide training to providers (scheduled and as needed) • Troubleshooting/problem solving • Technical assist for MPQHF (HCBS Level of Care and PAS programs) • Fair Hearing Process – Administrative Reviews • Consumer visits – part of QA process • Quality Assurance Reviews

10. Mountain Pacific Quality HealthContract/Quality Manger: Myrna Seno, RN Guides and manages the day-to-day activity of the PAS team • Education • Contract Compliance • Internal QA • Staff Supervision • Conflict Resolution • Database Management

11. Nurse Co-ordinatorsKarlynn Halden, Rona Meyer, Mary Danelson, Linda Birkoski, Barbara Carvajal, Jennifer Zody, Michelle Norman, Karen Berland • 1. Initial onsite review/prescreen • 2. Secondary telephone or on-site reviews Annual and Amendments) Review of the consumer’s perspective of service delivery is a component of this activity. • 3. Resolution of problems This may include review of additional information gathered during the appeal process.

12. Administrative Specialist Teresa Smith457-5830 or 800-268-1145 ext 5830 • Timely entry of consumer demographics • Review of data to ensure accurate information is sent to the provider. • Telephone contact to gather pertinent consumer or provider information. • Routing information to the appropriate nurse and authorization to the provider of choice. • Filing forms into consumer records. • Generate and review reports as required by contract or internal standards. Monica Bartlett also works with Teresa

13. Counties on the outside border of each region may be intermittently covered by the neighboring nurse Northwestern Karlynn Halden, RN Northcentral Linda Birkoski,RN Northeasten Mary Danelson,RN Southwestern BarbaraCarvajal RN Missoula County Karen Berland Central Jennifer Zody,RN Southeastern Rona Meyer,RN Southcentral Michelle Norman,RN Mountain-Pacific Quality Health Foundation Montana Personal Care Assistance and Self Direct Services Map Myrna Seno, RN Statewide Manager

14. MPQH Authorization of Services Risk is a Consumer’s Right! Compliance and life style- consumer choice VII

15. Authorization Process (PAS/SDPAS 503 and 504) The Department of Public Health and Human Services Contracts with MPQH to conduct authorizations for PAS A Medicaid PAS provider cannot delivery services without a current MPQH authorization, unless: Services delivery will be less than 21 days High Risk Intake is completed Montana is one of a handful of states where the authorization is done by the Quality Improvement Organization (QIO), which is MPQH

16. Montana’s Standardized Approach Assess each person in his/her environment Observe, listen, clarify and learn Understand limitations and strengths Get to know the individual’s needs Authorize Determine functional impact and the scope of consumer’s problems. Learn Why something is a problem and what needs to be different -How are ADL needs being met? What assistance is used other than Medicaid State Plan (family, social supports, other services) Provide the agency a complete picture

17. LOOK at the BIG Picture Provide assistance with the tasks that are necessary, when they are needed, and within authorized time Profile establishes service limit based on tasks and frequency of those tasks How hours for the week are used varies from day to day. Some days one task takes longer due to condition Total time allows flexibility without being stuck to a number of minutes for each task

18. The positives of a Standardized approach Assurance that every consumer with comparable impairments, independent of what region they reside get similar amounts of service Data Analysis Single point of contact MARS-information to assist with appropriate level of care

19. A BALANCING ACT AUTHORIZE TIME FOR CONSUMER NEEDS THAT FALL WITHIN THE RULE DON’T UNDERAUTHORIZE AND PUT A CONSUMER’S HEALTH AT RISK DON’T OVER AUTHORIZE AND PUT THE MEDICAID BUDGET AT RISK And so it is!

20. The Manual: Your Friend • First created in 1995 • Designed to support providers • Outlines Department views on various subjects • Sometimes it is vague for a reason….

21. The Manual – How to Use It • CSB/PAS/SDPAS 001 – Manual Program • Basic organization of the manual • Read cover – to - cover once • Cookbook concept • well-worn, well-used • Mark frequently used sections • Revisions, pen and ink corrections • Look in manual first • if that doesn’t answer your question, call RPO • If RPO needs further interpretation, they call Program Manager