Tips for Successful Completion of a Continued Stay Request. Clinical Webinars for Therapy February 2012

Transcription

1 Tips for Successful Completion of a Continued Stay Request Clinical Webinars for Therapy February 2012

2 Goals 1. Describe the continued stay process. 2. Describe key elements that are needed to successfully submit a request for a prior authorization (PA). 3. Avoid pends for continued stay requests. 4. Respond to questions regarding the continued stay process for occupational therapy, physical therapy, and speech and language pathology. 2

3 AHCA Guidelines for a Continued Stay 2008 Florida Medicaid Therapy Services Coverage and Limitations Handbook: 1) a progress report that evaluates the recipient s accomplishments toward a stated goal; 2) a description of the recipient s attitudes and behaviors toward the therapy; 3) an assessment of the effectiveness of the services provided; and 4) an assessment of the recipient s rehabilitation potential. 3

4 What is a Continued Stay? A continued stay is the term used for a request to continue therapy that has been occurring. Other terms consistent with continued stay are: Continuance of treatment Next round of therapy 4

5 Continued Stay Request It is appropriate to request a continued stay when: A Transition PA is expiring; An initial PA is expiring; A previous continued stay PA is expiring; or The recipient is returning to therapy after a rest period away from therapy. 5

6 Continued Stay Request Requirements 1. A continued stay request is defined by a need for continuation of services for a recipient with an existing PA. 2. Each therapy provider involved in the care of a recipient is required to submit a continued stay request. 3. In the event that a recipient requires more than one therapy discipline, each treating therapist is required to submit a continued stay request for their respective discipline. 6

7 May the same Plan of Care (POC) be submitted with only a change in the date range? Based on the AHCA guidelines, the therapy reviewers use previous progress, as well as current functional limitations, in determining continued stay requests. If the same POC is submitted, a pend will be issued. The pend will request updated information on the recipient s progress toward previous goals and objectives. Submitting the same POC, without a progress summary and an update of goals, is insufficient to support medical necessity for a continued stay request. 7

8 Continued Stay Examples Example A provider obtained a PA from Transition from 11/11/2011 through 12/31/2011. A new request was submitted on 12/6/2011 for 1/2/2012-5/18/2012. Yes This is a continued stay. They submitted a reevaluation, a review of the plan of care signed by the physician and therapist. 8

9 When may requests for a Continued Stay be Submitted? Continued stay requests may be submitted 14 days prior to the end of a current authorization period. Submissions before this time frame cannot be processed and the request will be pended. 9

10 Continued Stay Information Requirements Provide current objective data and progress towards goals. If a provider is continuing services and the first provider is no longer servicing the recipient, please provide a letter from the parent indicating that services are no longer being rendered by the first provider. Include information that would normally be found in a discharge note. 10

11 Avoidable Frequent Errors in Continued Stay Requests 1. Submission of a continued stay request with no documentation of progress toward previous goals and objectives. 2. Submission of continued stay request without baseline evaluation information from a transition case or reevaluation information. 11

12 Overlapping Dates Overlapping dates of service in a continuing stay request with an existing PA date range prevents assignment of another PA; the request will be pended. Example of Pend: Please grant permission via a web annotation to change the start date to 2/1/

13 No Evidence of Progress on Continued Stays No summary of progress noted toward stated goals No baselines established on the POC for a Continued Stay 13

14 How to Document Progress Achieved for a Continued Stay Request Make reference to the previous certification period s goals and progress and/or lack of progress. Describe what was accomplished using metrics. Do not use percentages achieved, as this is not clear. In most cases, some new goals are indicated. 14

15 Address Progress Toward Previous Goals and Objectives Include the following: 1. Note progress or lack of progress. 2. If progress was observed, please indicate in metrics. 3. If the recipient did not meet previous goals or objectives, or made little progress, please include a rationale (frequent absences, hospitalization). 4. If the recipient has mastered all of his or her goals, and needs a new POC, please indicate that either in the re-evaluation results or the POC. Consult the 2008 Florida Medicaid Therapy Services Coverage and Limitations Handbook 15

16 Other Avoidable Submission Errors 16

17 Common Clerical Errors that Cause Pends An input error is often made. There is a transposition of numbers. For example: 9 units per visit, 3x/week for 3 weeks is entered. However, the provider really meant 3 units per visit, 3x/week for 9 weeks. 17

18 Documentation Requirements: Multiple Providers Documentation of coordination of care is necessary when two different providers are treating the same recipient. Provide documentation of coordination. Coordinate units to be shared, not to exceed 14 units. Coordination can occur through , telephone calls or meetings. 18

19 Examples of Pends Recipient is currently receiving ST services from another provider. Please clarify how requested services differ from current services. Please describe how coordination of service is taking place between providers. Please submit further justification for services to validate need for intensity of services. 19

20 Frequently Missing Required Documents Example of Pend: We are waiting to authorize this request, but the provider has not submitted the necessary information. Frequently missing documentation: Signed Orders Signed Plan of Care Signed Evaluation Long-Term Goals and/or Short-Term Goals 20

21 Adjusting a Request Based on Medicaid Eligibility Reviewer comment: Requested service dates of 12/23/2011-2/17/2012; date of 1/31/2012 exceeds beneficiary's eligibility expiration. Please adjust service dates to not exceed 1/31/2012. Please submit a web annotation in eqsuite "Additional Info" tab clarifying the new dates of service. 1/3/

22 Do the items tab and the POC need to match? Please ensure the POC matches the request put in the Items Tab: Date; Length of session; and Frequency of sessions. Example of Pend: Please submit additional information to substantiate duration of 26 weeks for this diagnosis. Plan of care submitted is for 8 weeks. If this duration was entered in error, please authorize reviewer, via entry into case, to modify duration of PA request to match plan of care. 22

23 Submission of Tests Scores Providing test scores without an explanation will result in a pend for clarification. Interpretation of tests results is necessary. Ask yourself this question, What are the deficits/limitations and how do they impact function? 23

24 Tips for Requesting a Modification Modification is only for an increase in service due to a change in the recipient's status. Modification can only occur within the time frame of an approved PA. When entering your modification request items, ONLY input the number of new units requested, not the entire total of units. 24

25 QUESTION AND ANSWER SESSION 25