LifeWays Operating Procedure

Transcription

1 AUTHORIZATION OF LIFEWAYS NETWORK SERVICES I. PURPOSE The purpose of this operating procedure is to detail the process for authorization of services by Utilization Management team members. II. III. DELEGATED AUTHORIZATIONS A. All Utilization Management authorization decisions are made solely based on appropriateness of care and service as defined by Utilization Management Criteria. B. Initial service authorizations may be delegated to Access staff. In such a case, authorization guidelines shall be developed by Utilization Management defining the targeted population(s), specifying the services that may be authorized and defining related parameters such as numbers of and/or length of service that may or must be authorized. These guidelines shall be published in the LifeWays Provider Manual and updated as necessary. Any guidelines for delegated authorizations must be reviewed at least annually by the Utilization Management Supervisor or designee with appropriate clinical expertise (Utilization Management Operating Procedure, Clinical Competencies ). Utilization Management team members are responsible for providing technical and other assistance as necessary to staff to which service authorizations are delegated. C. Initial and on-going service authorizations may be delegated through the service grid/benefit plan in LEO (LifeWays Electronic Medical Record system). These delegations are for specific services which can be approved automatically based upon an individual s age, diagnosis and eligibility. REQUESTS FOR SERVICE AUTHORIZATION/EXTENSION OF SERVICES THAT REQUIRE UTILIZATION MANAGER REVIEW A. All service requests or requests for service extensions must be submitted electronically: Any written requests or additional information that is not automatically dated (as with fax and those submitted electronically) must be dated as they are received at Utilization Management. Service Authorization requests will be processed (approved, pended/additional information requested/returned to requestor or denied) within two business days starting the next business day from the date of receipt. B. All requests will be reviewed for medical necessity of service/service array being requested: C. Medical Necessity: The following excerpt was obtained from the Michigan Department of Health and Human Services, Medicaid Provider Manual, October 1, 2016 that outlines the criteria for medical necessity. Page 1 of 9

2 2.5 Medical Necessity The following medical necessity criteria apply to Medicaid mental health, developmental disabilities and substance abuse supports and services. 2.5.A. Medical Necessity Criteria Mental health, developmental disabilities, and substance abuse services are supports, services and treatment: 1. Necessary for screening and assessing the presence of a mental illness, developmental disability or substance abuse disorder; and/or 2. Required to identify and evaluate a mental illness, developmental disability or substance abuse disorder; and/or 3. Intended to treat, ameliorate, diminish or stabilize the symptoms of mental illness, developmental disability, or substance abuse disorder; and/or 4. Expected to arrest or delay the progression of a mental illness, developmental disability, or substance abuse disorder; and/or 5. Designed to assist the beneficiary to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence, recovery or productivity B Determination Criteria The determination of medically necessary support, service or treatment must be: 1. Based on information provided by the beneficiary, beneficiary s family and/or other individuals (e.g., friends, personal associates/aides) who know the beneficiary; and 2. Based on clinical information from the beneficiary s primary care physician or health care professionals with relevant qualifications who have evaluated the beneficiary; and 3. For beneficiaries with mental illness or developmental disabilities, based on person centered planning, and for beneficiaries with substance abuse disorders, individualized treatment planning; and 4. Made by appropriately trained mental health, developmental disabilities, or substance abuse professionals with sufficient clinical experience; and 5. Made within federal and state standards for timeliness; and 6. Sufficient in amount, scope and duration of the service(s) to reasonably achieve its/their purpose. 2.5.C Supports, Services and Treatment Authorized by the PIHP Supports and services authorized by the PIHP must be: 1. Delivered in accordance with federal and state standards for timeliness in a location that is accessible to the beneficiary; and Page 2 of 9

3 2. Responsive to particular needs of multi-cultural populations and furnished in a culturally relevant manner; and 3. Responsive to the particular needs of the beneficiaries with sensory and mobility impairments and provided with the necessary accommodations; and 4. Provided in the least restrictive, most integrated setting. Inpatient, licensed residential or other segregated settings shall be used only when less restrictive levels of treatment, service or support have been, for that beneficiary, unsuccessful or cannot be safely provided; and 5. Delivered consistent with, where they exist, available research findings, health care practice guidelines, best practice and standards of practice issued by professionally recognized organizations or government agencies. D. Evidence of medical necessity may include the following: 1. Intake/Updated Assessment: a) Presenting complaint and history of presenting complaint b) Symptoms c) Mental status observation d) Past psychiatric history e) Pertinent medical history f) Current medications g) Impression h) Diagnosis (if diagnostic criteria for your diagnosis are not met, documentation as to why you feel this is appropriate should be included) i) Treatment strategy 2. Crisis/Progress Note: a) Mental status observation b) Current level of symptomatology as it relates to diagnosis c) The specific therapeutic intervention d) Current impression e) Diagnosis (if diagnosis changes, document new data to justify f) Current treatment strategy E. Service Authorization Requests. 1. Service authorization requests shall be reviewed and processed by a utilization manager with applicable clinical expertise. 2. Each service type and/or provider shall have a primary and a back up utilization manager and requests for each service type shall be completed by the primary utilization manager. Page 3 of 9

4 3. Utilization management shall maintain a list of utilization manager assignments and publish it annually or any time there is a permanent change to the assignments. 4. Each utilization manager is responsible for referring to a back-up utilization manager with appropriate clinical expertise in cases of time off for two full days or more, or if the primary utilization manager requires assistance. F. Written requests for services are scanned into LEO: These written requests and associated information shall be retained in a manner that is compliant with HIPAA regulations and ensures that access is limited to appropriate staff members only. IV. SERVICE EXTENSIONS FOR INPATIENT/ INPATIENT ALTERNATIVE SERVICES A. Utilization managers responsible for management of State Inpatient services shall have oncall availability to allow for an initial consult to occur AFTER the access points have made a recommendation for inpatient. This screening may occur on the phone or face to face. Utilization Management s responsibility is to determine appropriate level of care and any additional linkage, diversion or crisis planning that may be of importance for individual well-being. If admission is denied, the rationale must be specified in applicable documentation AND a individual notice must be completed in LEO indicating that adequate notice is completed. LifeWays' Community Member Services Team completes the individual notification process. B. For Community Inpatient Services, UM conducts a continued stay review at the end of the initial authorization (3 days) and may extend the stay or deny any requested extension based on whether the individual continues to meet criteria. If the continued stay is denied, the rationale must be specified in applicable documentation AND an individual notice must be completed in LEO indicating that adequate notice is completed. LifeWays' Community Member Services Team completes the individual notification process. C. For Inpatient Alternative Services, the utilization manager conducts a continued stay review at the end of the initial authorization and may extend the stay or deny any requested extension based on whether the individual continues to meet criteria. All information pertinent to the continued stay must be documented in LEO. If the continued stay is denied, the rationale must be specified in applicable documentation AND a individual notice must be completed in LEO indicating that adequate notice is completed. LifeWays' Community Member Services Team completes the individual notification process. D. Evaluation and Management services (Medication Reviews) and correlated Nursing Assessments will not require prior-authorization. Utilization Management will develop concurrent review procedures for monitoring use of these services. No authorization will Page 4 of 9

5 need to be entered by the Primary Case Holder for these services, however a related objective will need to be included in the Individual Plan of Service. V. SERVICE EXTENSIONS FOR INDIVIDUALS RECEIVING PERSONAL CARE OR COMMUNITY LIVING SUPPORTS PER DIEMS A. For authorizations to support the treatment plan: the primary provider is responsible to enter the treatment plan and all supporting service authorizations into LEO. For individuals receiving residential supports, the PC/CLS request form must be incorporated in the planning meeting. When this is completed outside of the planning process, that lack of integration in the IPOS is evident. For individuals residing in an unlicensed setting receiving CLS, the Department of Health and Human Services (DHHS) home help authorization must be in LEO and part of the assessment of level of care and accounted for prior to any request for CLS. If denied DHHS Home Help, the denial letter must be present in LEO. This DHHS review process must be reviewed at least annually by Utilization Management. For individuals in licensed settings, the PC/CLS request must account for the responsibilities of the licensed facility to its residents. The request for specialty mental health services must be for needs above and beyond those services and supports already the responsibility of the licensed facility. The assigned utilization manager reviews the request and may request additional information as necessary to process the request. All requests for Personal Care and/or CLS per diem services for new individuals must occur as part of a person-centered planning meeting with a LifeWays representative present to discuss the service expectations as identified in the Medicaid Provider Manual. All initial approved requests for CLS in an Unlicensed Setting may be approved for 90 days pending outcome of DHS Home Help application. As this service occurs daily and impacts health and safety issues this service may be backdated. VI. GENERAL CONSIDERATIONS FOR SERVICE AUTHORIZATION DECISIONS A. Urgent/emergent outpatient services may be post authorized by the assigned utilization manager if the request is made by voice mail on the day it is provided. If a utilization manager must make a decision related to an urgent/emergent service, the decision must be made within 3 hours of receiving the request. B. Services shall be authorized if requests meet applicable Utilization Management criteria including medical necessity (Utilization Management Criteria), requests are complete and accompanied by any additional information required by LifeWays to process the request. Requests will be pended and returned to the provider if additional information from the provider is needed to process the request. When requests are pended and returned for more information, the Utilization Manager communicates with the requesting provider through LEO regarding what is needed to allow processing of the request. Requests pended Page 5 of 9

6 for longer than 5 business days due to incomplete documentation will be denied due to provider error, and no adequate/advance notice will be required. The provider may then resubmit the request with the necessary and requested information. When requests are submitted to the designated UM team member or Director for specialist review, the specialist review shall be completed within 3 business days and forwarded back to the UM manager who is responsible for processing the request. The request must then be processed according to the specialist review instructions within 2 business days. In cases where this would cause interruption of on-going services, small amounts of the service for short term duration may be authorized by the utilization manager until a final decision is made. Utilization managers may set authorization end dates at intervals that will allow closer monitoring of service outcomes as necessary. C. Denials: Services will be denied in LEO when the service is inappropriate for the individual's condition, if the service intensity is not supported by clinical data/rationale (i.e. medical necessity), the individual is not eligible for the service or exclusion criteria are present. For all of these reasons, the utilization manager shall complete an individual notice in LEO. When an appeal or hearing is filed the individual/guardian may ask the primary clinician or their supervisor for services to remain in place if they file the appeal within 12 calendar days of the notice and if the authorization has not expired. If the services remain in place the individual/guardian may have to repay the cost of these services if the hearing or appeal upholds the decision, if the individual/guardian withdraws their appeal or hearing request or if the individual/guardian or their representative does not attend the hearing. Utilization Management will also offer to hold an informal meeting with the individual/guardian and supports to clarify rational for denial and if necessary consider additional information that may not have been submitted with the initial request. Authorization requests shall also be denied if the request is an error by the provider, or a duplicate request; in these cases, the individual notice IS NOT completed. D. Medical Necessity: The following excerpt was obtained from the Michigan Department of Health and Human Services Medicaid Provider Manual, October 1, 2016 bulletin that outlines the criteria for medical necessity. 2.5.D PIHP Decisions Using criteria for medical necessity, a PIHP may Deny Services that are: 1. Deemed ineffective for a given condition based upon professionally and scientifically recognized and accepted standards of care; 2. Experimental or investigational in nature; or Page 6 of 9

7 3. For which there exists another appropriate, efficacious, less restrictive and cost-effective service, setting or support that otherwise satisfies the standards for medically necessary services; and/or 4. Employ various methods to determine amount, scope, and duration of services, including prior authorization for certain cervices, concurrent utilization reviews, centralized assessment and referral, gate keeping arrangements, protocols, and guidelines LifeWays may not deny services based solely on preset limits of cost, amount, scope and duration of services. Instead, determination of the need for services shall be conducted on an individualized basis. LifeWays will not deny/refuse services due to an individual s inability to pay. LifeWays will also provide crisis and referral/supportive services to any individual regardless of residence and if individual is residing in another county will provide warm transfer and engagement supports to get them to services in their county of residence. E. Specialist Reviews: If service requests are outside of established length of stay ranges, involve authorizing of services outside of established criteria or a specialist review is required for that service, a specialist review must be conducted before the authorization may be completed. For on-going existing services, sufficient services must be authorized to allow time to complete the specialist review. The Utilization Manager may be required to coordinate additional information as necessary for the review. Specialist reviews may be conducted through individual, peer and supervisory review. Specialist review decisions are based on individual, unique, individual service needs and shall not be construed as precedent setting. Specialist reviews shall be processed within 3 business days from the day after the authorization request. The Utilization Manager shall process the request as indicated by the specialist review decision within two business days starting the day the specialist review is directed back to the designated Utilization Manager. All other processes above related to approval and denial shall apply as above. F. Special Monitoring of NGRI individuals and Individuals currently admitted to State facilities: Notification by the State of admission of a individual for whom LifeWays is responsible to the Forensic Center shall be directed to the designated Utilization Manager. The designated Utilization Manager authorizes LifeWays payment portion for this admission, unless it is determined that the individual is not LifeWays responsibility. The Utilization Manager consults with the Medical Director and documents decision regarding admission in LEO. If the admission is denied individual notice shall be completed per established process. The designated Utilization Manager monitors court hearings and court orders for individuals relative to NGRI. If a individual is to be transferred to a State facility from the Forensic Center, the designated utilization manager is notified. The designated utilization Page 7 of 9

8 manager is then responsible for identifying a primary service for the individual and initiating a community-based care plan (good faith plan) for that individual, if appropriate. Any such plans will be requested to be submitted to LifeWays within 5 business days. If the designated Utilization Manager determines that an adequate community plan is in place for an NGRI individual and decides to deny further extension of State hospital stay, the State hospital will be notified with a letter. The designated utilization manager monitors the status of individuals through minimally a quarterly face to face visit and at least monthly consultation with treatment team, this will be documented in the chart notes section of LEO and authorizes extensions of stay if appropriate and reports monthly on this status to identified LifeWays staff, indicating whether on-going services in that facility are authorized by LifeWays or not. VII. VIII. IX. OTHER SERVICE AUTHORIZATIONS A. Unique services or an array of services may be authorized on an individual basis to meet unusual needs. Any such authorizations may require the additional approval of LifeWays Medical Director, with written instructions forwarded to the designated utilization manager. MONITORING OF AUTHORIZATION DECISIONS BY UTILIZATION MANAGERS A. The Utilization Management Supervisor shall review reports of authorized services by diagnosis and LOS. Any outlier authorization decisions will be individually reviewed, comparing individual service use history with length of stay (LOS) protocols and eligibility criteria. Any problems that are discovered will be discussed with the assigned utilization manager as part of the performance evaluation process. In addition, the responsible provider and responsible contract manager will be notified of any treatment recommendations related to service array, intensity and duration. Any suspected fraud or abuse of authorization authority shall be immediately reported to LifeWays corporate compliance officer and recipient rights for investigation and authorization privileges suspended until completion of the investigation. UTILIZATION REVIEW OF POPULATIONS AND TRENDS A. Ongoing utilization review shall be conducted by the Utilization Review Committee, for population groups, utilization review is conducted by reviewing trends of service use over time and across similar individuals. Significant increases or decreases in utilization must be reviewed. Utilization managers coordinate with LifeWays' Quality Management staff through LifeWays Utilization Review Committee (URC) to build and/or refine reports for this process. UM shall review the reports and identify any outliers, discuss possible reasons for the differences from projected amounts, and propose recommendations for resolution Page 8 of 9

9 as appropriate. Utilization review activities may also be prompted by findings from LifeWays' Management report. Although service authorizations for individuals will not be determined based on financial matters, significant changes (on a provider level) in expected expenditures are a valid measure to prompt investigation of utilization patterns and potential causes. Utilization issues for individuals are managed through the Utilization Management team in coordination with the individual's primary clinician and contract manager but may be forwarded to Leadership if there are issues that that may affect a larger segment of the population. ATTACHMENTS Request for Automatic Authorization of Primary and Psychiatric Services LW# A #1284 Utilization Management request for Extension/Addition of Services LW# B #1286 REFERENCES Audience: LifeWays Staff LifeWays Provider Network LifeWays Provider Manual s Protection of Recipient Rights Clinical Case Reviews Person-Centered Planning Utilization Management Criteria Behavior Treatment Committee Special Treatment Procedures Medication Guidelines Renewal Requests Grievance and Appeal HISTORY Effective 07/01/2000 Reviewed/Revised: 10/02, 4/05, 8/05, 9/06, 7/07, 10/07, 2/08, 10/08, 4/09, 5/09, 8/09, 3/10, 8/11, 4/12, 4/13, 11/14, 4/16, 6/16, 4/17, 5/17, 9/18 Page 9 of 9