department of medical assistance services n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Department of Medical Assistance Services PowerPoint Presentation
Download Presentation
Department of Medical Assistance Services

Loading in 2 Seconds...

play fullscreen
1 / 69

Department of Medical Assistance Services - PowerPoint PPT Presentation


  • 146 Views
  • Uploaded on

Department of Medical Assistance Services. Treatment Foster Care Case Management. October/November 2008 www.dmas.virginia.gov. DMAS Contacts. Shelley Jones - 804-786-1591 Shelley.jones@dmas.virginia.gov Bill O’Bier - 804-225-4050 William.obier@dmas.virginia.gov

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

PowerPoint Slideshow about 'Department of Medical Assistance Services' - tibor


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
department of medical assistance services

Department of Medical Assistance Services

Treatment Foster Care Case Management

October/November 2008

www.dmas.virginia.gov

dmas contacts
DMAS Contacts

Shelley Jones - 804-786-1591

Shelley.jones@dmas.virginia.gov

Bill O’Bier - 804-225-4050

William.obier@dmas.virginia.gov

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

Patty.smith@dmas.virginia.gov

Tracy Wilcox - 804-371-2648

Contract Monitor for Clifton Gunderson

Tracy.wilcox@dmas.virginia.gov

training objectives
Training Objectives
  • Identify participation requirements
  • Understand Medicaid documentation requirements
  • Understand locality responsibilities
  • Be aware of prior authorization (PA) requirements and process
  • Understand changes to UAI and PA fax form
  • Understand the utilization review process
  • Reference handouts of October 15 and November 7, 2008 Medicaid memo and CANS summary form
objectives
These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual (PSM) and are not meant to substitute for or take the place of the material in the manuals.

Please refer to the manual, available on the DMAS website, for in-depth information on TFC-CM criteria.

Objectives
provider enrollment unit
Provider EnrollmentUnit

For enrollment, agreements, change of address, and enrollment questions contact:

First Health Services

Provider Enrollment Unit

P.O. Box 26803

Richmond, VA 23261

Toll free -- 888-829-5373

Fax -- 804-270-7027

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 to authorized state and federal personnel access to records and facilities in the form and manner requested
  • Use Medicaid designated billing forms

and

participation requirements1
Participation Requirements
  • 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
  • A provider may not bill a client fora covered service regardless of whether or not the provider received payment from Medicaid
participation requirements2
Participation Requirements
  • 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
electronic signatures
Electronic Signatures
  • Clarification on electronic signatures was issued in the 8-20-04 Medicaid Memo to all providers.

An electronic signature that meets the following criteria is acceptable for clinical documentation:

  • Identifies the individual signing by name and title; and
  • Data system assures the documentation cannot be altered after signature affixed, by limiting access to code or key sequence;

and

electronic signatures1
Electronic Signatures
  • 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.
  • The provider must have written policies and procedures in effect regarding use of electronic signatures.
common abbreviations
Common Abbreviations
  • CAFAS/PECFAS-Child & Adolescent Functional Assessment Scale/Preschool & Early Childhood Functional Assessment Scale
  • CANS-Child and Adolescent Needs and Strengths
  • CPMT-Community Policy & Management Team
  • CSA-Comprehensive Service Act
  • CSB-Community Service Board
  • DMAS-Department of Medical Assistance Services
common abbreviations1
Common Abbreviations
  • DSS-Department Social Services
  • FAPT-Family Assessment & Planning Team
  • OCS-Office of Comprehensive Services
  • PSM-Psychiatric Services Manual
  • RTF-“Level C” Residential Treatment Facility
  • SED-Seriously Emotionally Disturbed
  • TFC-CM-Treatment Foster Care - Case Management
definition
Definition

Case management activities by child placing agencies with treatment foster care programs

  • Licensed/certified by DSS
  • In compliance with DMAS criteria
  • Meet provider qualifications

and

definition1
Definition
  • Case Management activities which help SED children or those with behavioral disorders under the age of 21 who are at risk of placement into residential treatment
    • Gain access to necessary care and appropriate services
    • Coordinateand monitornecessary care and services
required documentation
Required Documentation

FAPT ASSESSMENT

  • Childs immediate & long range therapeutic needs
  • Developmental priorities
  • Personal strengths & liabilities
  • Potential for family reunification
  • Specific planned treatment objectives
  • Specific therapeutic modalities required to achieve objectives
  • Signed and dated by a majority (at least 3) of FAPT members
effective november 1 2008
Effective November 1, 2008
  • The state uniform assessment instrument (UAI) has been the CAFAS/PECFAS since the start of the TFC-CM program in 2000
  • On November 1, 2008 DMAS will also begin to accept the CANS as the state UAI
  • Either the CAFAS/PECFAS or CANS can be used to meet criteria until June 30, 2009
  • On July 1, 2009, only the CANS will be accepted as the state UAI for TFC-CM
state uai
State UAI

At a minimum:

  • The CAFAS or PECFAS profile sheets for the youth and caregiver, OR
  • The CANS summary sheet, indicating the child’s behavioral and emotional needs, and risk behaviors,

must be available in the medical record and current within 90 days throughout the stay

initial plan of care
Initial Plan of Care
  • For Medicaid purposes the initial plan of care must include, at a minimum, a list of services that will be provided during the first 45 days of placement
  • List of services to be provided must be in the medical record within the first 10 days of placement
comprehensive treatment and service plan ctsp
Comprehensive Treatment and Service Plan (CTSP)
  • Comprehensive plan
  • Completed within 45 days of placement
  • Individualized
  • Developed by case manager and treatment team
  • Consult with parents when appropriate
slide21
CTSP

Must include the following:

  • Assessment of child’s needs
    • Emotional
    • Behavioral
    • Educational
    • Medical
  • Specific treatment goals and target dates for completion
  • The CM’s program of therapies, activities, and services

and

slide22
CTSP
  • The discharge plan and target date
  • For children age 16+, describe transition plan for independent living
  • Indicate team members participation in development of plan
  • Dated signature of the case manager
  • CTSP should be revised annually
90 day progress update
90 Day Progress Update
  • Completed 90 days from CTSP and every 90 days throughout the stay
  • Specify time period covered
  • Describe progress towards treatment goals and objectives
      • Met
      • Continued or added
      • Criteria for achievement of each
      • Target dates for each

and

90 day progress update1
90 Day Progress Update
  • Specify problems and behaviors of child

being addressed

  • Specify any changes in interventions or strategies
  • Describe therapies, activities, or services provided
  • Any changes needed for next 90 days
  • Services to be provided in next 90 days
  • Child’s own assessment and
90 day progress update2
90 Day Progress Update
    • Contacts of child & family, where appropriate
    • Specific medical needs, treatment and medications provided
    • Update to discharge plans/date
    • Transition plans
  • Annual revision of the CTSP to include all of the above
case narratives
Case Narratives
  • Current within 30 days
  • In chronological order
  • Include:
    • Treatment & services
    • All contacts related to child
    • Visits with family
    • Other significant events
    • Record all medications prescribed and all reported side effects
    • Dated signature of case manager
medical necessity criteria
MEDICAL NECESSITY CRITERIA
  • Documented moderate to severe impairment & moderate to severe risk factors as recorded on the UAI
    • For the CANS, this would be from the Child Behavioral/Emotional Needs and/or Child Risk Behaviors areas on the summary sheet
  • The moderate to severe impairment is necessary for admission. Continued stay reviews require documentation of the necessity for this level of care, not necessarily tied to the UAI score.
medical necessity criteria1
MEDICAL NECESSITY CRITERIA
  • Child’s condition must meet one of the three levels listed below and supported by the providers documentation of current behaviors:
level i moderate impairment with one or more risk factors
LEVEL IModerate impairment with one or more risk factors
  • Needs intensive supervision to prevent harmful consequences;
  • Moderate/frequent disruptive or non-compliant behaviors in the home setting that increase the risk to self or others;

and

  • Needs assistance of trained professionals as caregivers.
level ii
LEVEL II
  • Significant impairment with authority, impulsivity, and caregiver issues
  • Be unable to handle the emotional demands of family living;
  • Need 24-hour immediate response to crisis behaviors;
  • or
  • Have severe disruptive peer & authority interactions that increase risk and impede growth.
level iii
LEVEL III

Child must display a significant impairment with severe risk factors as documented on CAFAS.

Child must also demonstrate risk behaviors that create significant risk of harm to self or to others.

slide32
Responsibilities

of the

LOCALITY

in

TFC Case Management

slide33

Locality Responsibility

  • Complete the state uniform assessment instrument (UAI)
  • No older than maximum of 90 days

CAFAS/PECFAS

  • Youth’s functioning
  • Caregiver Resources

CANS

  • Summary sheet
    • Include Child Behavioral/Emotional Needs and Child Risk Behaviors sections
  • Be sure to include the child’s name and the screener’s name, as well as the date completed

and

locality responsibility
Locality Responsibility

State UAI:

  • Impairmentsidentified must be related to scores on UAI
  • CAFAS/PECFAS
  • At least ONE moderate impairment noted with related risk factor
    • Two are required if one is in School subscale
  • CANS
  • Two impairments indicated as a #2 or #3 on the summary sheet
    • Impairments indicated must be supported in the narrative
locality responsibility1
Locality Responsibility
  • DSM IV Diagnosis
    • V Codes are not acceptable
  • List of services to be provided in first 45 days of care
  • Description of child’s behavior within past 30 days
    • Be specific, give frequency and duration
    • Problem behaviors should be reflected on the state UAI
  • Alternative placement options considered

and

locality responsibility2
Locality Responsibility
  • Child’s functional level
  • Clinical stability
  • Level of family support
  • Discharge plan
  • FAPT assessment that reflects the need for level of care and the state UAI
    • Dated signatures of at least 3 members of the FAPT

and

locality responsibility3
Locality Responsibility
  • And either:
    • FAPT Certification that TFC Case Management is medically necessary
    • OR
    • Written documentation that the CPMT has approved admission to TFC Case Management
locality responsibility4
Locality Responsibility

Be sure to submit to the provider:

  • Copies of the current state UAI
  • FAPT Assessment documenting the need for level of care
    • Provide specific symptoms and/or problem behaviors that need to be addressed
    • DSM-IV
  • FAPT or CPMT Certification
  • 3 digit locality code that designates the fiscally responsible locality
components of tfc cm
Components of TFC-CM
  • Care Plan development
  • Coordinate services and service planning with others involved with child, such as working with DSS staff, juvenile justice or court staff, or other service providers, such as Mental Health Support staff
  • Referral for needed services
  • Follow up on progress to ensure service delivery
components of tfc cm1
Components of TFC-CM
  • Placement activities
      • Planning appropriate placement
      • Monitoring placement
      • Discharge planning
  • Evaluating effectiveness of treatment plan through supervision of foster parents
  • Assess periodically, child’s need for services:
      • Psychosocial
      • Nutritional
      • Medical
      • Education
slide41

TFC Case Manager

Initial Responsibilities

  • Ensure receipt of required documents from the locality
  • Ensure the locality has provided the correct locality code to reflect the locality that has fiscal responsibility for the child
  • Submit the prior authorization request to KePRO within 10 days of placement
  • Notify the locality of Medicaid approval or denial
cm s ongoing responsibility
CM’s Ongoing Responsibility
  • The CM shall provide to the foster family:
    • Supervision
    • Training
    • Support
    • Guidance

To facilitate the implementation of the treatment plan

contacts with the tfc child
Contacts with the TFC Child

Face-to-face contact with the child should be as often as necessary, based on the CTSP to ensure effective, safe services.

  • Face-to-face contacts must be no less than twice a month, one in the foster home, one with foster parent and child. The two minimum face-to-face visits should occur on different dates.

GOALS

  • Assess child’s progress
  • Provide guidance to TFC parents
  • Monitor service delivery
  • Allow child to communicate concerns
service limits
Service Limits
  • If a child is temporarily out of the home, active CM is necessary to bill for the time out of home
  • No other type of case management may be billed concurrently with TFC-CM, no matter the payment source
  • Caseload limits:
    • Case manager (full-time professional staff) to have a maximum of 12 children
    • 6 children for beginning trainees, increasing to 9 at end of first year, and 12 by end of second year
    • Maximum of 3 children in student intern caseload
documentation
Documentation
  • 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.
prior authorization
Prior Authorization
  • KePRO is the DMAS prior authorization contractor
  • Authorization can be approved for up to one year with medical justification
  • KePRO will review requests for medical necessity, as well as timeliness
prior authorization1
Prior Authorization

For questions or forms, go to the PA website or use the web address below:

DMAS.KePRO.organd click on Virginia Medicaid

Phone: 1-888-VAPAUTH or

1-888-827-2884

Fax: 1-877-OKBYFAX or

1-877-652-9329

Web:Provider Issues @ KePRO.org

prior authorization2
Prior Authorization

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 providerissues@kepro.org
prior authorization3
Prior Authorization
  • Additional Methods of Submission
  • Requests may also be submitted by:
  • Fax to 877-652-9329
    • The Treatment Foster Care Case Management Prior Authorization Request Form (364) is available in electronically fill-able format on the KePRO and DMAS websites
  • www.dmas.virginia.gov
  • https://dmas.kepro.org
kepro
KePRO
  • Telephone to 888-827-2884 or

804-622-8900 (local)

  • Mail to:

KePRO

2810 North Parham Rd., Suite 305

Richmond, VA 23284

revised fax form
Revised Fax Form
  • A revised prior authorization fax form is available on the DMAS and KePRO websites
  • The changeover from the CAFAS to the CANS as the state UAI and the dual use period is reflected on the revised fax form
  • Added a “Change Request” box under item 1 of the fax form
  • Under current behaviors, information should reflect UAI
  • All other areas of the form remains the same
revised fax form1
Revised Fax Form
  • The effective date for the mandatory use of the new fax forms has been revised to December 1, 2008.
  • From December 1 forward, the 9-25-08 version of the fax form attached to the October 15th memo and posted on the DMAS and KePRO websites will be required.
state uai1
State UAI
  • Must be current. For admission the state UAI should reflect the requested level of care
  • To be completed at a minimum of every 90 days and must be available 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 PA
  • Scoring notes the level of impairment that supports the need for the level of care
initial review
Initial Review
  • Use when in care for up to 45 days
  • Required to be submitted within 10 days of admission
  • Completed KePRO fax form to include information on:
    • Diagnosis
    • TFC-CM need
    • FAPT assessment

and

initial review1
Initial Review
  • State UAI information
  • Initial services
  • Symptoms and behaviors
    • Information should reflect the scoring on the state UAI. If not, explain.
  • Locality code-this should reflect the locality who is fiscally responsible

For reviews not received within 10 calendar days of placement, approval can begin no earlier than the date all requested information is received.

continued stay review
Continued Stay Review
  • Submitted prior to the expiration of the current authorization, but no earlier than 30 days
  • Information required:
    • Confirm the locality code
    • DSM-IV
    • CTSP completion information
    • Determination that TFC-CM required to meet child’s needs
continued stay review1
Continued Stay Review
  • Information required:
    • Confirmation on face-to-face visits
    • Symptoms and behaviors
      • Specify frequency, intensity and duration of problem behaviors
      • If no problems indicated, give reason for continuing services
    • Current state UAI information
      • Be sure the narrative supports the UAI scores, or explain why not
slide58

Preauthorization Process

  • Approval based on medical necessity for TFC Case Management
  • Review completed with receipt of all required materials
  • Approval based on Virginia Medicaid criteria
  • Approval will be for a one-year period if all criteria is met
prior authorization4
Prior Authorization

Appeals

  • The denial of PA 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.
  • Appeal rights and address for submission will be stated in the FHS notification. Requests for appeal must be submitted directly to DMAS within 30 days of the notice of denial. and
prior authorization5
Prior Authorization
  • 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 TFC-CM and will review records to assure DMAS criteria is being followed.
  • They will select providers for review by statistical sampling, exception reporting or through referrals or complaints
  • They will make periodic announced and unannounced visits and
utilization review2
Utilization Review
  • They will do desk audits or on-site visits to review medical documentation to ensure DMAS criteria is met
  • They will request provider qualification information as well as confirmation of service delivery
  • They will assess service limits compliance
  • They will determine if retraction of paid claims is necessary

and

utilization review3
Utilization Review
  • The criteria described in the earlier slides is critical to compliance, although it is not a complete list. See the Psychiatric Services Manual for a complete listing. Review all referenced federal and state regulations, as well as Medicaid Memos that are sent to providers and available on the DMAS website.
  • Review the sample forms provided in the PSM.
duplication of services
Duplication of Services
  • Intensive In-Home Services and Treatment Foster Care Services both have a case management (CM) component and so should not both be provided at the same time.
  • No other CM service should be provided to the same recipient at the same time as TFC-CM, no matter the payment source (this includes MH and MR case management or other services with a CM component) If there is no CM component it would not be a duplication of services.
    • Duplication is subject to retraction at audit.
the reviewer checks
The Reviewer Checks:
  • Consumer’s full name or Medicaid number on each document in the record
  • Medical/clinical necessity of the service
    • Appropriate admission to service
  • Required documentation
    • See slides 16-30 as well as the PSM for a complete listing
caution
CAUTION!

If a request for authorization has been approved, but:

  • the child no longer meets DMAS criteria (does not have impairments indicated on the UAI, and there is no documented reason for continued services:

THE PROVIDER SHOULD NOT BILL MEDICAID

utilization review4
Utilization Review
  • If the UR finding is to retract prior reimbursement, the provider has the right to reconsideration and appeal.
  • Reconsideration is required to be submitted within 30 days of the audit letter date. All material to support why retraction should not be made should be included.
  • If the decision is to uphold the denial decision after reconsideration, the provider has the right to appeal. Appeal rights will be stated in the decision letter. Requests for appeal must be submitted within 30 days of the notice of reconsideration