magellan training medicaid rehabilitation option l.
Skip this Video
Loading SlideShow in 5 Seconds..
Magellan Training: Medicaid Rehabilitation Option PowerPoint Presentation
Download Presentation
Magellan Training: Medicaid Rehabilitation Option

Loading in 2 Seconds...

play fullscreen
1 / 29

Magellan Training: Medicaid Rehabilitation Option - PowerPoint PPT Presentation

  • Uploaded on

Magellan Training: Medicaid Rehabilitation Option. Magellan. NBHS. Medicaid. Initial Auth. What information do I need when I call? Current diagnosis (onset) Rehabilitation Assessment Functional Limitations Rehab Plan Licensed clinician contact. MRO Re-Auth Form. Client Name and SS#

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Magellan Training: Medicaid Rehabilitation Option' - teryl

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
initial auth
Initial Auth
  • What information do I need when I call?
    • Current diagnosis (onset)
    • Rehabilitation Assessment
      • Functional Limitations
    • Rehab Plan
    • Licensed clinician contact
mro re auth form
MRO Re-Auth Form
  • Client Name and SS#
  • Agency Name and Contact Person
  • Auth End Date
  • Medications and Number of Face to Face
  • Current Dx
  • Program Type or Service
  • Medicaid ID# and Service Location
mro re auth form4
MRO Re-Auth Form
  • Rehabilitation Need
  • Measureable Goal
  • Progress on Goal
  • Crisis Plan (include something other than ER or 911)
  • Discharge Plan and ELOS
  • Hospitalizations or ER visits in report period
  • Psychiatrically Stable (if not a brief description)
  • Specific Functional Limitations R/T Major Mental Health Diagnosis
specific functional limitations
Specific Functional Limitations
  • Must be the result of long term mental illness
  • Must be present for one year
  • Must be pervasive across life skills areas
  • Must require life skills training to improve client’s quality of life
  • Medicaid Chapter 35
  • PRR, ACT, DR, CS
  • Active Life skill training
  • Assessment based
  • Client centered
  • Realistic goals
  • Crisis plan
medicaid rehab option guidelines
Medicaid Rehab Option Guidelines
  • Must meet SPMI status
  • Must have functional limitations
  • May have other diagnosis as secondary
spmi guidelines
SPMI Guidelines
  • At risk of institutionalization if services not provided
  • Seriously interferes with functioning
  • Has had one year or will have
  • Results in functional deficits in two of three life skills areas.
spmi con t
SPMI Con’t
  • Not primary substance abuse
  • Not primary developmental disabilities
major life skills areas
Major Life Skills Areas
  • Voc/Educational
  • Social Skills
  • Activities of Daily Living
vocational educational
  • Inability to be employed
  • Inability to pursue education
  • Inability to carry out home management tasks (meals, laundry, budgeting, child care)
social skills
Social Skills
  • Inappropriate
  • Inadequate
  • Participates only with extensive support
  • History of dangerousness
activities of daily living
Activities of Daily Living
  • Inability to consistently perform
    • Hygiene, grooming, meals
    • Personal business
    • Transportation, care of residence
    • Medical, legal, housing
    • Avoidance of common dangers
mro authorization considerations
MRO Authorization Considerations
  • Careful examination of functional limitations.
  • Focus on where the limitations can best be addressed (home or club house).
  • Compensatory training not cure.
  • Not a life time service (except ACT)
  • Without assessment and diagnosis we cannot authorize these services.
authorization considerations
Authorization Considerations
  • A major mental illness alone is not sufficient for SPMI
  • Presence of symptoms is not sufficient
  • Provider must link functional deficits to Axis I disorder
  • NOS not acceptable
considerations con t
Considerations con’t
  • Brain injury
  • Typically developmentally delayed have not met milestones
  • Axis I typically have met milestones
considerations con t17
Considerations con’t
  • Across settings
  • Long term
  • Requires support/intervention
  • Medication
  • Our case notes/hx of care
  • Compensation not cure
considerations con t18
Considerations con’t
  • Long term sub abuse and homelessness often look like SPMI, because many SPMI have both.
  • TBI often look like SPMI
psychiatric residential rehab
Psychiatric Residential Rehab
  • SPMI
  • These deficits require 24 hour psychiatric residential setting
  • The need is 24 behavioral monitoring
day rehab
Day Rehab
  • Day Rehab
    • The need: Day structure to work on socialization/self care/pre-voc
  • Community Support
    • The need: Case management
      • In home work on self care
      • Household/ADL tasks
community support
Community Support
  • The need: Case management and
    • In home work on self care
    • Household/ADL tasks
authorization considerations22
Authorization Considerations
  • PRR and DR are authed together for those who have both needs
  • CS and DR are authed together for those who have high social needs plus in home needs.
  • CS is not authed with PRR (except 30 days in/out)
  • Two in Omaha
  • One in Lincoln
  • One in Hastings
act guidelines
ACT Guidelines
  • The need: SPMI plus high utilization of emergency/hospital services
  • Poor response to lower levels of care
  • 24 hour available intervention
  • Poor response to other treatment
general mro admission
General MRO Admission
  • Meets Admit guidelines
  • Does not require a higher LOC
  • A lower LOC is not indicated
  • Likelihood of benefit from service
  • Is making progress
general mro continuing stay
General MRO Continuing Stay
  • Meets Admission guidelines
  • Does not require a higher LOC
  • A less intensive LOC is not appropriate
  • Reasonable likelihood of benefit
  • Is making some progress in rehabilitation goals
general mro exclusion
General MRO Exclusion
  • Not SPMI
  • Primary substance abuse or DD
  • Does not have functional deficits in two or three areas
  • Resides in a Nursing Home or PRR
  • Needs a higher LOC
general mro discharge
General MRO Discharge
  • Maximum benefit
  • Sustainability plan in place
  • Supports in place
  • Crisis relapse plan in place
  • Or the individual requests discharge