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Post-Payment Review Tools for Licensed Independent Practitioners. Presented by Alison Rieber Provider Network Evaluation Supervisor Alliance Behavioral Healthcare Representing the NC Council of Community Programs. Revised 3-4-14. Developed by the NC DHHS-LME/MCO-Provider

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post payment review tools for licensed independent practitioners
Post-Payment Review Toolsfor Licensed Independent Practitioners

Presented by Alison Rieber

Provider Network Evaluation Supervisor

Alliance Behavioral Healthcare

Representing the NC Council of Community Programs

Revised 3-4-14

Developed by the

NC DHHS-LME/MCO-Provider

Collaboration Workgroup

February 2014

organization of ppr tools
Organization of PPR Tools

The PPR Tool questions address these areas:

  • Authorizations/Consents/Eligibility/ Service Orders/Plans
  • Service Documentation
  • Qualifications/Training of Service Providers/Record Checks/Supervision
consents referrals authorizations eligibility service orders service plans
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 1: Is there a referral from an approved source prior to the date of service, if applicable?CCP 8C 5.4.1, 5.4.2 and 7.3.6

  • Children under 21 need an individual verbal or written referral from a CCNC/CA (Carolina Access) primary care provider, the LME-MCO or a Medicaid-enrolled psychiatrist.
  • Referrals may be accepted from schools or DSS, but must still be supported by one of the referral sources above.
consents referrals authorizations eligibility service orders service plans1
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 1 continued:

  • Documentation of the verbal or written referral includes the name and NPI # of the individual or agency making the referral
  • Services provided by a physician do not need a referral
  • Individuals 21 or over may be self-referred or referred by another source. If not self-referred, referral must be documented.
consents referrals authorizations eligibility service orders service plans2
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 2: Is there a valid utilization management authorization for the service billed, if applicable?

  • Prior approval needed after:
    • 16 unmanaged visits/calendar year for children under 21
    • 8 unmanaged visits/calendar year for adults 21 or over
    • If unmanaged visits were exceeded review for LME-MCO authorization that covers date of service
  • E&M codes for medication management do not require prior authorization.
consents referrals authorizations eligibility service orders service plans3
Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans

Q 3: Is there a valid consent for treatment in the service record?10A NCAC 27G.0205; CCP 8C

  • Review for a consent for treatment signed by the individual or LRP on or prior to the date of service being reviewed.
  • A separate consent for treatment form is not necessary if the individual/LRP has signed the PCP/service plan.
consents referrals authorizations eligibility service orders service plans4
Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans

Q 3 continued:

  • The individual/LRP signature on the treatment plan or PCP is sufficient to demonstrate consent. 
  • If written consent is not obtained, the provider must produce a written statement as to why consent could not be obtained.
consents referrals authorizations eligibility service orders service plans5
Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans

Q 4: Is there a valid/appropriate service plan current for the date of service?CCP 8C

  • The format required by service definition is used.
  • Plan is rewritten annually and/or updated/ revised:
    • If the needs of the person have changed
    • On or before assigned target dates
    • When a new service is added
    • When a provider changes
consents referrals authorizations eligibility service orders service plans6
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 4 continued:

  • If the plan is a PCP, the service must be identified in the Action Plan to be ordered via appropriate signature on the PCP.
  • If the service does not require a PCP, a separate service order form is acceptable.
consents referrals authorizations eligibility service orders service plans7
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 5: Is there a valid service order for the service billed, if applicable?CCP 8C

  • The need for a service order matches the need for an authorization.
  • If needed, service must be ordered on or before date of service.
  • If a PCP is not required, a separate service order form can be used. See Service Plan question for services ordered via PCPs.
consents referrals authorizations eligibility service orders service plans8
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 5 continued:

Dated Signatures

  • Medicaid-funded services must be ordered by a licensed MD or DO, licensed psychologist, licensed nurse practitioner or licensed physician’s assistant unless otherwise noted in the Service Definition.
  • Each service order must be signed and dated by the authorizing professional.
  • Dates may not be entered by another person or typed in.
  • No stamped signatures unless there is a verified Americans with Disabilities Act [ADA] exception.
consents referrals authorizations eligibility service orders service plans9
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 6: Is there an appropriate service plan that identifies the type of service billed?

  • The service plan must indicate the specific service in order to bill Medicaid.
  • Review the goals in a treatment plan or the Action Plan of a PCP for this information.
service documentation
Service Documentation

Q7: Is the documentation signed by the person who delivered the service?CCP 8C – 7.3

  • Signature includes credentials, license, or degree for professionals; position name for paraprofessionals.
  • Credentials/job titles may be typed, stamped or handwritten.
  • Do not rate “Not Met” if credentials are missing. If it is a systemic issue, require a Plan of Correction.
service documentation1
Service Documentation

Q7 continued:

  • The note is written and signed by the person who provided the service [full signature, no initials]. “Written” means “composed.” If a signature is questionable, request the provider’s signature log to validate the signature.
  • Documentation is completed within 24 hours of the day the service is provided.
service documentation2
Service Documentation

Q7 continued:

  • In order for a service to be billable, the note must be written or dictated within 7 working days (for the staff who provided the service). After the 24-hour time frame, the note shall be entered as a “late entry” and include a dated signature. If an electronic note is used and late entries are tracked/stamped in the system, this will meet documentation requirements.
service documentation3
Service Documentation

Q7 continued:

  • If there is no note for the date being audited, then audit questions related the qualifications, training, supervision, record checks of the staff who provided the service are rated “N/A.”
  • If there is an unsigned note, review and rate other questions related to the note accordingly. Questions related to the staff person remain rated as “N/A." Do not assume based on handwriting that you can identify the service provider.
service documentation4
Service Documentation

Q 8: Does the service note relate to goals listed in the service plan?CCP 8C

  • Note reflects purpose of the intervention
  • Note states, summarizes and/or relates to a goal or references a goal # in the service plan.
  • Goal is not expired or overdue for review
  • If goal does not match the goal # indicated, review all goals to see if it relates to another goal
service documentation5
Service Documentation

Q 9: Does the service documentation include an assessment of progress toward goals?CCP 8C

  • Service note needs to indicate progress made toward the goal/effectiveness (how it turned out for the person; how did he/she respond to the intervention)
  • If the information is not in the traditional section of the note, read the entire narrative note to determine if it was addressed.
service documentation6
Service Documentation

Q 10: Does the documentation reflect the specific service billed?CCP 8C

  • Service documented must match procedure code billed.
  • Intervention must match procedure code billed.
  • No provider may bill H codes.
service documentation7
Service Documentation

Q 11: Is the service note individualized specific to the date of service?CCP 8C

  • Review notes around the date of service.
  • Notes should vary from day to day and person to person
  • No xeroxed notes with dates or signatures changed
  • No handwritten notes copied throughout with different service dates
service documentation8
Service Documentation

Q 11 continued:

  • Look very closely if you see any of the following:
    • Exact wording across 2 or more notes for one person or across records
    • Conflicting pronouns (he/she, him/her)
    • The name or identifying information of another individual is found within the service note.
service documentation9
Service Documentation

Q 12: Does the documentation reflect treatment for the duration of the service billed?CCP 8C

  • Intervention relates to the stated purpose of goal
  • Intervention/Tx documented justifies amount of time billed – reasonably took place in the amount of time documented
  • There is actual treatment reflected in the intervention related to goals, symptoms, diagnoses
service documentation10
Service Documentation

Q 12 continued:

  • The following are not billable:
    • Verifying eligibility and obtaining prior approval
    • Completing NCTOPPS
    • Internal agency supervision
qualifications training of service providers record checks supervision
Qualifications/Training of Service Providers/Record Checks/Supervision

Q 13: Is there documentation that the staff is qualified to provide the service billed?

  • Review personnel record for each person who provided a service
  • Verify staff has required licensure, experience and certification (as appropriate)
qualifications training of service providers record checks supervision1
Qualifications/Training of Service Providers/Record Checks/Supervision

Q 13 continued:

  • If service provider is unknown (note not signed or illegible or unverifiable my signature log), rate all staff related questions as “N/A.”
  • Do not assume based on handwriting in a note that you can identify the provider of an unsigned note.
  • If staff name is typed but not signed, review for qualifications but rate “Not Met” for the question about the note being signed.
consents referrals authorizations eligibility service orders service plans10
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 14: Do the results of the Comprehensive Clinical Assessment (CCA) support the level of care for the treatment service recommended?CCP 8C

  • Review the Entrance Criteria listed in the service definition against the CCA. The CCA must support the required criteria.
consents referrals authorizations eligibility service orders service plans11
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 14 continued:

  • The CCA must support the level of care (LOCUS, CALOCUS, CASII, ASAM) for the treatment service recommended.
    • LOCUS – Level of Care Utilization System
    • CALOCUS – Child and Adolescent Utilization System (the precursor to the CASII
    • CASII – Child and Adolescent Service Intensity Instrument
    • ASAM – American Society of Addiction Medicine Patient Placement Criteria
consents referrals authorizations eligibility service orders service plans12
Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans

Q 15: Is there documentation that coordination of care is occurring with both medical and non-medical providers involved with the individual receiving services?CCP 8C

  • May be found in service notes, summary reports, documentation of telephone calls, Tx planning notes
  • Coordination of Care expected as applicable for example with primary care, LME-MCO, other mh/dd/sa service providers
questions
Questions

If you have any questions about how the use the automated workbook and review tools, please send your questions to the Provider Monitoring mailbox:

provider.monitoring@dhhs.nc.gov

Please include in the Subject line the nature of your question.