Notice of Adverse Benefit Determination Training

Transcription

1 Notice of Adverse Benefit Determination Training Santa Cruz County Behavioral Health Quality Improvement Mental Health Plan / Drug Medi-Cal Plan From here-out to be referred to as Plans 05/1/18

2 Goal Training Goals & Objectives NOABDs are only sent to Medi-Cal Beneficiaries (when it is their primary or secondary insurance) To improve your understanding of NOABD requirements and utilization of associated letters Objectives You will learn Federal and state reasons for uniform letters for MHP & DMC-ODS services You will be able to identify timeframes for providing each notice letter You will have an understanding of each letter, and appropriate letter specific language 2

3 Effective 2/14/18, per DHCS Info Notice & E (Department of Health Care Services) The purpose of the notice is to provide the Plans with clarification and guidance regarding the application of revised federal regulations for processing appeals; NOABD letters provide information to beneficiaries about their appeal rights and other beneficiary rights under the Medi-Cal program. Uniform notice templates were provided with this notice and are now required to be used. A NOABD supports beneficiary protection by advising beneficiaries of their rights in writing. 3

4 ABDs Adverse Benefit Determinations The term Action has been replaced with Adverse Benefit Determination (ABD). A NOABD letter is sent to a beneficiary when any of the following actions are taken by the Plan: 1. Beneficiary does not meet medical necessity criteria for MHP or DMC-ODS Plan services 2. Denial or limited authorization of a requested service 3. Reduction, suspension or termination of a previously authorized service (when beneficiary disagrees) 4. Modification or limit of a provider s request for a service and approval of alternative services 5. Denial, in whole or in part, of payment for a service 6. Failure to provide services in a timely manner 7. Failure to process authorization decision in a timely manner 8. Failure to act within the required timeframes for grievance and appeals resolutions 9. Denial of a beneficiaries' request to dispute financial liability

5 NOABD - Timing of the Notice The Plan must mail the notice to the beneficiary within the following timeframes: Type of NOABD Termination Delivery System Modification Timely Access Timely Response to Grievance / Appeal Denial Authorization Delay Payment Denial Financial Liability When are you required to send the letter? At least 10 days before the date of Action Within 2 business days of the decision Within 2 business days of the decision Within 2 business days of the decision Within 2 business days of the decision Within 2 business days of the decision At the time of the action At the time of the action At the time of the action

6 BH Policy and Procedure 3223 NOABD Shared MHP and DMC-ODS policy located on county intranet, under Quality in Beneficiary Protection 3200 section

7 Required Formatting Please do not change Each available letter and required attachment has been customized for Santa Cruz County users and translated into Spanish. The type of letter name is located: 1) Word File name, 2) on upper right corner and 3) letter footer. Each available letter is FINAL VERSION and shall not be modified; Citations shall remain in the letter. Letter author shall only insert clear, simple and concise wording into identified areas. Author shall print out letter and the three (3) attachments using both sides of paper when possible to minimize volume. Please do not change any font sizing or special characterization. Author shall send a secure electronic copy of all completed letters to Quality Improvement via askqi for filing and storage. 7

8 There are Required Citations in each of the NOABD letters, please do not remove the citations There are 3 Required Attachments for all NOABD letters: 1. NOABD Your Rights Attachment 2. Nondiscrimination Notice 3. Language Taglines

9 Delivery system Not meeting eligibility criteria for services (Both MH and DMC-ODS Gates) Who would use the Delivery System NOABD: ACCESS, Children Gates, DMC-ODS Gates MHP Does not meet the eligibility criteria for specialty mental health services Referral to Beacon Health Options or Primary Care Setting or County DMC-ODS Plan DMC-ODS Does not meet the eligibility criteria for any DMC-ODS services Referral to other health care provider (primary care MD), mental health services (Beacon or County Behavioral Health)

10 Delivery system MH suggested content 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff use Santa Cruz County Behavioral Health Contractor staff use Contractor s name 3. Service requested = Type of service requested (therapy, medication management, case management coordination) 4. Check which Plan that applies Mental Health Plan

11 Delivery system MH suggested narrative (continued) 4. Narrative box: Our assessment is based on Medi-Cal managed care guidelines and state regulations which staff utilized to determine if medical necessity criteria are met. Your request for services is denied because (author inserts best choice of below): your mental health diagnosis as identified by the assessment is not covered by the mental health plan, your mental health condition does not cause problems for you in your daily life that are serious enough to make you eligible for specialty mental health services from the mental health plan, the specialty mental health services available from the mental health plan are not likely to help you maintain or improve your mental health condition, Your condition has been determined to be of mild to moderate severity, and therefore you have been referred to Beacon Health Options at (855) Beacon Health Options is the provider for individuals with mild to moderate conditions such as yours, your mental health condition would be responsive to treatment by a physical health care provider.

12 Delivery system DMC-ODS suggested language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff = Santa Cruz County Behavioral Health & Your Program of Service Contractor staff = Contractor s name & Your Program of Service 3. Service requested = Type of service requested (Assessment, methadone/ntp, withdrawal management/detox, residential, OP) 4. Check which Plan that applies Drug Medi-Cal Plan 5. Narrative box: Our decision is based on Medi-Cal managed care and American Society of Addition Medicine (ASAM) guidelines to determine medical necessity of requested services. Your request for services is denied because (author inserts best choice of below): The Brief ASAM assessment determined that you have no active SUD disorder nor do you have a history of substance use behaviors that qualify for SUD treatment services (tobacco disorders are excluded). You are not a current resident of Santa Cruz County and your Medi-Cal is connected to another county. You are recommended to contact (Name) County to either request services or initiate a transfer of Medi-Cal coverage to Santa Cruz County. 12

13 Timely Access Failure to provide service within 10 working days of date of service request Who would use the Timely Access NOABD: ACCESS, Children s Gates, DMC-ODS Gates MHP Gate/Access not offering a Psychosocial Assessment or Medication Support Appointment within 10 working days DMC-ODS Provider not able to provide an initial treatment service within 10 working days of initial request date. Beneficiary Request Brief ASAM Referral Initial treatment service (within 10 working days) Collaboration between the Gate (Brief ASAM) and treatment provider (referral) to ensure timely services. Letter from treatment provider if unable to admit within timeframe.

14 Timely Access MHP & DMC-ODS language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff = Santa Cruz County Behavioral Health & your Program of Service Contractor staff = Contractor s name & your Program if Service 3. Service requested = Type of service requested MHP = therapy, medication support, etc DMC-ODS = methadone/ntp, withdrawal management/detox, residential 4. Check which Plan that applies Drug Medi-Cal Plan or Mental Health Plan 5. Plan or Name of requesting provider = Treating Provider s name 6. The number of days to insert = 10 working days 7. date requested = Enter the date of the initial request for services

15 Denial - of authorization for requested services Denials include determinations based on: type or level of service, requirements for medical necessity, appropriateness, setting or effectiveness of a covered benefit Who would use Denial NOABD: ACCESS, FQHC Therapist, DMC-ODS providers MHP Denial of County Coordination request based on adequate level of functioning Denial of FQHC Therapy request because client cannot benefit from service (service is not appropriate) DMC-ODS Denial of requested LOC treatment services when beneficiary does NOT meet ASAM LOC criteria (service request is not appropriate) Denial Letter provided when beneficiary is not interested in utilizing the appropriate LOC service. (ASAM scores as 2.1 but individual only wants residential services)

16 Denial letter suggested MH language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff use Santa Cruz County Behavioral Health Contractor staff use Contractor s name 3. Service requested = Type of service requested (therapy, case management, medication management) 4. Name of requester = Beneficiary or County program name or Contracted provider name 5. Check which Plan that applies Mental Health Plan 6. Narrative: The reason for the denial is the Plan has reviewed your Provider s request for services and determined we are unable to provide such services based on state Medi-Cal managed care guidelines due to (choose most appropriate): Type or level of services Lack of medical necessity for services Services not appropriate for the condition Service will not be beneficial to you

17 Denial letter DMC-ODS suggested language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff use Santa Cruz County Behavioral Health Contractor staff use Contractor s name 3. Service requested = Type of service requested (residential treatment, intensive outpatient, methadone/ntp, withdrawal management) 4. Name of requester = Beneficiary or County program name or Contracted provider name 5. Check which Plan that applies Drug Medi-Cal Plan 6. Narrative: The reason for the denial is the Plan has reviewed your request for services and determined we are unable to provide such services based on Medi-Cal managed care guidelines and ASAM assessment criteria due to (choose most appropriate): Type or level of services (including denied residential service requests if not ALOC) Lack of medical necessity for services (not ASAM LOC appropriate) Services not appropriate for the condition (non-perinatal client wanting continued perinatal services) Setting not appropriate (readmission request after completing the 2 residential maximum)

18 Modification When the Plan modifies or limits a PROVIDER s request for a service (and the client disagrees) The Plan may: Reduce or limit a service frequency and/or duration, Approve alternative treatments and services Who would use the Modification NOABD: Supervisors, Managers, (Chief of Psychiatry or designé), County SUD LPHA Staff, DMC-ODS provider/gate MHP Eating Disorder (approval of alternative treatment) Decrease in therapy frequency from panel provider DMC-ODS Co LPHAs: Extension of residential treatment request declined and IOT approved based on medical necessity SUD provider: Reduction of OP service based on medical necessity (duration and/or frequency) Gate: Brief ASAM: When pt. meets ASAM Residential LOC but no network bed available, and network can offer IOS)

19 Modification MH suggested language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff use Santa Cruz County Behavioral Health Contractor staff use Contractor s name 3. Service requested = Type of service requested (therapy, medication support, case management) 4. Name of Requestor = Provider Name

20 Modification MH suggested language (continued) 5. Check which Plan that applies Mental Health Plan 6. Narrative: We cannot approve this treatment as requested. This is because the Plan has reviewed your Provider s request for services and has changed the services based on (choose most appropriate): Your condition has improved and you require the service less often Services are no longer appropriate for the condition (alternative treatments / services) However we will instead approve the following treatment: Example: individual therapy twice per month.

21 Modification DMC-ODS suggested language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff use Santa Cruz County Behavioral Health Contractor staff use Contractor s name 3. Service requested = Type of service requested (extended residential services) 4. Name of Requestor = Provider s Name 5. Check which Plan that applies Drug Medi-Cal Plan 6. Narrative: We cannot approve this treatment as requested. This is because. Next Slide

22 Modification DMC-ODS suggested language Narrative: We cannot approve this treatment as requested. This is because the Plan has reviewed your providers request for services and has changed the services based on a review of ASAM Criteria and Medi-Cal managed care guidelines, which require us to ensure your services are appropriate in amount, duration and scope. Then choose : Your condition has improved and you require service less often (indicated ASAM LOC change) Services are no longer appropriate for the condition (not MN justified for extended residential services) Based on the results of our brief ASAM assessment interview, you currently meet the medical necessity criteria for residential substance use treatment services; and we anticipate that a residential bed will become available upon a pending discharge. In the interim, we are authorizing you for an immediate alternative treatment service. The IOT program will provide a reassessment of you medical necessity and staff will assist with your transfer to a residential level of care if appropriate. However we will instead approve the following treatment: Adult: Intensive outpatient services between 9-19 hours/week. 22

23 Termination of a previously authorized service [notification at least 10 days before action, except as permitted under 42 CFR & ] The agency may send a notice later than the 10 days prior to the date of action if Exceptions: 1. Confirmed death of individual 2. Individual provided a written statement declining further services 3. Ineligibility for further services (such as, loss of Medi-Cal, could include violation of program safety rules or not meeting medical necessity for services) 4. A change in the level of medical care is prescribed by the beneficiary s physician (facility Medical Director) #4 related to a change to care based on ASAM level of need and medical necessity determination 5. The beneficiary s whereabouts are unknown with no known address and failed outreach efforts Exceptions: Advance notice may be shortened to 5 days before the date of action if- 1. Agency has facts indicating that action should be taken because of probable fraud by the individual. a. Such facts have been verified, if possible, through secondary sources The facility may not transfer or discharge an individual while an appeal is pending, when an individual exercises his or her right for continued services during appeal of a termination notice, unless the failure to discharge would endanger the health or safety of the other individuals in the facility. The facility must document the danger that failure to discharge 23 would pose.

24 Termination of a previously authorized service [notification at least 10 days before action, except as permitted under 42 CFR and ] Who would use the Terminate NOABD: Supervisors, Managers, (Chief of Psychiatry/Delegate), DMC-ODS Network Providers, County SUD Staff MHP Client no longer meets medical necessity for County Mental Health services No longer meet criteria for a service type (case management, county coordination, therapy) DMC-ODS ASAM criteria indicated a client meets criteria for a higher or lower level of service and client disagrees with transition of services Ending a beneficiary s residential treatment service, due to violation of program safety rules (unsafe behaviors to self and/or others, bringing drugs to program, violence and causing risk to other beneficiaries).

25 Termination suggested MH language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff use Santa Cruz County Behavioral Health Contractor staff use Contractor s name 3. RE: Service requested = Service currently authorized that is being terminated (therapy, medication support, case management) 4. Service to be terminated : Same as #3, service requested 5. Termination date = at least 10 days after letter is sent 6. Narrative: The Plan has determined, based on a review of state Medi-Cal managed care guidelines, that.. Your condition has improved and you no longer require the service Services are no longer appropriate for the condition (ongoing authorization for alternative treatment) 7. Check which Plan that applies Mental Health Plan

26 Termination DMC-ODS suggested language 1. Beneficiary s Name: for adult, adult s name; for child, To the parent or guardian of 2. Treating Provider s Name County staff = Santa Cruz County Behavioral Health & Your Program Name Contractor staff = Contractor s name & Your Program Name 3. RE: Service requested = Service currently authorized that is being terminated (such as,-asam 3.1 residential treatment services or NTP Methadone services) 4. Service to be terminated: Same as #3, service requested 5. Termination date = at least 10 days after letter is sent unless meet , or criteria 6. Narrative: The Plan has determined, based on a review of ASAM Criteria and Medi-Cal managed care guidelines, that.. Your condition has improved and you no longer require residential treatment services as you continue to wait for your SLE housing. The Plan is aware that you have declined the recommended discharge plan to intensive outpatient services due to not having SLE housing. Services are no longer appropriate for your current condition (not meeting ASAM LOC criteria) Due to your behavior which resulted in an unsafe environment for yourself and/or others, your services are being terminated immediately to prevent endangerment to others 7. Check which Plan that applies Drug Medi-Cal Plan 26

27 Delay in processing authorization of services (County staff only) [delay in processing a PROVIDER s request for MHP or DMC-ODS services, including extensions due to a need for additional information from the beneficiary or provider ] Who would use the Delay of Authorization NOABD: MH Managed Care Senior Manager, Children s MH Management or Designée or DMC-ODS LPHA Staff MHP Decision Timeframes: Standard decision requests: 14 calendar days Expedited decision requests: 72 hours after receipt of the request Decision Examples of County pre-authorizations:??? SARS-Service Authorization for Services Neuropsych testing Eating Disorder Obsessive Compulsive Disorder DMC-ODS Decision Timeframe: 24 hour for preauthorization of residential treatment services Decision Makers: County SUDS LPHA role

28 Dispute of Financial Liability County Staff Only When the Plan denies a beneficiary s request to dispute financial liability, including cost-sharing and other beneficiary financial liabilities 28

29 Questions? Thank You