SALISH BEHAVIORAL HEALTH ORGANIZATION UTILIZATION MANAGEMENT POLICIES AND PROCEDURES

Transcription

1 SALISH BEHAVIORAL HEALTH ORGANIZATION UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: AUTHORIZATION FOR OUTPATIENT SERVICES BASED ON MEDICAL NECESSITY Policy Number: 7.01 Reference: 42 CFR , -.210; WAC ; WAC ; DSHS Contract; WISe Manual Version 1.7 Effective Date: 11/2005; 8/2016 Revision Date(s): 7/2017 Reviewed Date: 6/2016; 7/2017 Approved by: SBHO Executive Board CROSS REFERENCES Letter: Notice of Adverse Benefit Determination Form Letter Template Letter: SBHO Authorization Notification Letter Template Letter: SBHO Letter of Ineligibility Template Policy: Corrective Action Plan Policy: Notice of Adverse Benefit Determination Requirements PURPOSE To ensure the Salish Behavioral Health Organization (SBHO), network providers, and the subcontracted Administrative Service Organization (ASO), share a standardized process for authorizing care based on the medical necessity established by the SBHO. The SBHO has adopted a medical necessity definition that includes the state Washington Administrative Code (WAC) and contract definition for medical necessity and the statewide Access to Care standards. This policy applies to outpatient, including residential services, authorization determinations for Medicaid and non-medicaid individuals. Non-Medicaid outpatient and residential services are authorized within available resources. DEFINITIONS Access to Care Standards (ACS) are defined as standards established by the Department that SBHO must implement for the purposes of determining minimum eligibility for Medicaid Authorization for Outpatient Services 7.01 Page 1 of 7

2 Salish BHO Policies and Procedures enrollee and non-medicaid individuals seeking admission and continuing authorization into behavioral health services. Authorization is defines as the power and authority exercised by SBHO, or their designee ASO, to approve and non-approve authorization of intake assessments, outpatient, inpatient, and residential services for individual seeking mental health services. Individual means a person who has applied for, is eligible for or who has received publicly funded mental health services. For a child under the age of thirteen, the definition of individual includes the parents or legal guardians. For a child thirteen years or older who provides consent for their parents or legal guardians to be involved in the treatment planning, the definition of individual includes the parents or legal guardians. Also, referred to enrollee WAC defines Medical necessity or medically necessary as a term to describe a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions in the recipient that endanger life, or cause suffering or pain, or result in illness or infirmity, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause or physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the person requesting service. For the purpose of this definition course of treatment may include mere observation or, where appropriate, no treatment at all. Request for Services is defined as the point in time when a request for behavioral health services are sought or applied for through a telephone call, in person, or receipt of a written request by an individual or person authorized to consent to treatment for that person through any of the following access points. Contacting SBHO Contacting CommCare Contacting the Network Provider Crisis Services WISe is defined as wrap around with intensive services, a range of Medicaid-funded service components that are individualized, intensive, coordinated, comprehensive, culturally relevant, and home and community based. WISe is for youth who are experiencing mental health symptoms that disrupt or interfere with their functioning with the family, school, or with peers. PROCEDURE 1. The SBHO has adopted a medical necessity definition that includes the WAC and contract definitions for all levels of care. In addition, the SBHO admission criteria for medical necessity include the statewide Access to Care standards. Authorization for Outpatient Services 7.01 Page 2 of 7

3 Salish BHO Policies and Procedures Non-Medicaid outpatient and residential services are authorized within available resources. 2. The SBHO contracts with an administrative service organization (ASO) to provide regional authorization determinations for SBHO services requiring authorization for Medicaid and non-medicaid individuals, excluding all requests for WISe (Wrap Around with Intensive Services) youth and family services. Requests for WISe services will be authorized through the Washington State BHAS (Behavioral Health Assessment System) database algorithm. a. All authorization clinical reviews are conducted through the completion of a SBHO treatment authorization request process developed by the SBHO and ASO. The ASO shall conduct inter-rater reliability training and reviews at least annually for all staff for both initial and continuing authorization decisions. Electronic transmission between the network provider and ASO complies with the HIPAA on-line technology standards. b. The ASO is contracted to use the formally adopted SBHO utilization policies, Utilization Management Plan, Levels of Care which includes the Access to Care standards, and related guidelines when making authorization determinations. c. The SBHO network providers are required to request authorization for services by completing the appropriate authorization process and communicating any unique circumstances to the ASO for an authorization determination. 3. All SBHO authorization tools require review of the SBHO specific level of care standards that include the medical necessity criteria. The ASO is responsible to adhere to the SBHO Level of Care standards, when reviewing authorization requests. SBHO monitors for inter-rater reliability and utilization trends. 4. Following an Intake Assessment. The ASO utilization care managers review requests for authorization of services following a mental health or substance use disorder assessment. a. Authorization requests are reviewed by a mental health professional (for mental health services) or chemical dependency professional, or, Master s Addiction Counselor (for substance use disorder services) who has the appropriate clinical expertise to determine if the individual s current condition/diagnosis meets SBHO adopted medical necessity criteria as defined above. In consultation with a specialist, if required Excluding WISe services b. Standard authorization decisions are made as expeditiously as the individual s mental health condition requires and within state established timeline. The Authorization for Outpatient Services 7.01 Page 3 of 7

4 Salish BHO Policies and Procedures authorization determination must occur within 14 (fourteen) days of the date of the request for service. The network provider is required to request an authorization extension if medical necessity cannot be established and /or additional time is required beyond the 14 (fourteen) day limit. An extension request can only be approved for up to14 (fourteen) additional calendar days. c. An expedited authorization is made in cases when following the standard time frame could seriously jeopardize the individual s life, health or ability to attain, maintain, or regain maximum function. An expedited decision must be made as expeditiously as the individual s condition requires but not to exceed 3 (three) working days from the request for service. d. Approved admission authorizations must meet the Washington State Access to Care Standards. e. For non-medicaid individuals, all the above apply, in addition to within available resources and other admission criteria identified in the SBHO Levels of Care. f. Individuals are notified, in writing, of all outpatient determinations. The ASO mails an authorization letter, along with the SBHO handbook within 14 (fourteen) days of the determination to all individuals authorized for services. The ASO mails a Notice of Adverse Benefit Determination (NOABD) to Medicaid individuals and Letters of Determination to non-medicaid individuals within one working day of the determination, excluding WISe service requests. All ineligible WISe screens entered into BHAS will receive an NOABD letter from the SBHO, within the above listed timeframes. The SBHO receives a list of all letters mailed. 5. Continuing Stay and/or Concurrent Review. The ASO utilization care managers review an authorization for services request for outpatient continuing stay and/ or concurrent service authorization. The authorization request must document that medical necessity is established and additional criteria is met for the requested level of care. a. Continuing Stay and Concurrent services requests are reviewed by a mental health professional (for mental health services) or chemical dependency professional, or, Master s Addiction Counselor (for substance use disorder services) who has the appropriate clinical expertise to determine if the individual s current condition/diagnosis meets SBHO adopted medical necessity criteria, SBHO Level of Care standards, and contract elements for the reauthorization of requested service. b. In reviewing the request for authorization, the ASO is responsible for ensuring the requested services are clinically and fiscally sound. Authorization for Outpatient Services 7.01 Page 4 of 7

5 Salish BHO Policies and Procedures c. For non-medicaid individuals, all the above apply, in addition to within available resources and other continuing care criteria identified in the SBHO Levels of Care. 6. Service Denial Authorization Decisions. The ASO is contracted to make the service denial authorization decisions for Medicaid and non-medicaid individuals, excluding the determination for WISe level services. Prior to a service denial decision based on clinical criteria, the ASO will: Request additional information, if needed. Conduct a peer to peer review, to include staff with clinical expertise with the individuals specific need, and review all of the SBHO required documentation and additionally requested information. 7. Notice of Adverse Benefit Determination (NOABD) Requirements. a. In the event requested services are denied, the ASO mails a Notice of Adverse Benefit Determination (NOABD) letter within one day of making the denial determination to the individual at the last known address. All WISe service level ineligibility determinations as defined by the CANS screen will initiate a NOABD letter within one day of computation by the BHAS system. These NOABD letters will be mailed to the requestor for services by the SBHO. For Medicaid: The notification is provided on a SBHO Notice of Adverse Benefit Determination (NOABD) letter. The ASO uses the NOABD template provided by the Department and inserts the information specific to the SBHO, such as the letterhead and local Ombuds contact information. When a Medicaid individual is determined by the provider to not meet the Access to Care standards, the SBHO NOABD letter is mailed. The ASO is responsible for sending these letters to an individual. For non-medicaid individuals: The Notice of Determination letter states the individual has been found ineligible for services and the reasoning, the information includes how to request a second opinion if the decision was based on clinical criteria versus resource limitations, the right to request a fair hearing, and local crisis service contacts. The letter may include referral information, such as other community resources that could more appropriately serve the individual. The ASO is responsible for sending this letter to the individual. b. The NOABD letter includes an explanation of the individual s right to appeal the decision and is: In writing. In the individual s primary language and be easily understood. Explains the action the SBHO, or its contracted provider, has taken or intends to take. Authorization for Outpatient Services 7.01 Page 5 of 7

6 Salish BHO Policies and Procedures Explains the reasons for the adverse benefit determination. Explains the individual s or community behavioral health agency s right to file an appeal. Explains the procedures for exercising the individual s rights. Explains the circumstances under which expedited resolution is available and how to request it. Explains the individual s rights to have services continue pending a resolution of an appeal, how to request that services be continued, and the circumstances under which the individual may be required to pay the costs of these services and be mailed as expeditiously as the individual s mental health condition requires. For denial of payment, at the time of any adverse benefit determination affecting the claim. In the event WISe services are denied based on the CANS algorithm, the NOABD letter will include information to request a re-screen for WISe level of services. 8. Authorization Reporting Requirements and System Monitoring a. All authorization determinations, approved and denied, made by the ASO for SBHO services is recorded by the ASO and the network provider making the request. b. Monthly utilization data reports are provided from the ASO and reviewed monthly by the Utilization Management Committee c. All service denials, including NOABD letters, are copied and mailed to the SBHO office for 100% review within one day of the denial decision. The submitted utilization data reports included service denial decisions. Denials will be tracked and reported to the Department in accordance with DBHR Medicaid Grievance and Appeal Reporting Form. MONITORING This policy is mandated by statute and contract. 1. The SBHO monitors this policy through the use of the SBHO: Annual SBHO Provider and Subcontractor Administrative/ Sub-delegated Review Annual Provider Chart Reviews SBHO Grievance Tracking Reports Biennial Provider Quality Review Team review Quarterly Provider Performance Reports Utilization Committee activities, such as the ASO case review Authorization for Outpatient Services 7.01 Page 6 of 7

7 Salish BHO Policies and Procedures Quality Management Plan activities, such as review targeted issues for trends and recommendations 2. If a provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. Authorization for Outpatient Services 7.01 Page 7 of 7

8 (Date) To: (Name) (Street Address) (City, State, Zip) Authorization #: FOR YOUR INFORMATION ONLY (Agency) requested authorization for behavioral health services from the Salish Behavioral Health Organization (SBHO) on your behalf. The SBHO provides the funding for (Agency) and is required by the state to provide you the specific approval information below. You have been authorized to receive outpatient services from (Agency) for the period beginning with the admission date of and ending as the last day of outpatient services for this authorization period. Payment for additional days may be authorized based upon clinical evaluation and determination of ongoing clinical needs. What this means is you have been authorized to receive services as determined by your treatment plan from (Agency) during the period stated above. It very important you participate in your treatment planning process. Depending on your benefits and coverage, you may be responsible for a portion or co-payment for your services according to the financial agreement signed with the agency. If you are receiving Medicaid benefits you will not be billed for Medicaid covered services. As you work through your treatment goals, you and your care provider will discuss whether an extension beyond the approved period is needed. If it is decided that services need to continue, we require your provider to submit a new request near the end of this period. If you are under the age of 21 years and have Medicaid coverage, you may also be eligible for additional coordination of care services under Early and Periodic Screening Diagnosis and Treatment (EPSDT). Your assigned provider can answer any questions and provide you more information about these services.

9 In addition to your authorized services, the SBHO also provides local crisis services that you can access, at any time, (please refer to page 2 in the Member Handbook for specific agency information). You can also access Ombuds services, free of charge, to advocate for your behavioral health services at (360) or toll free (888) Again, this is only an informational letter describing your authorized behavioral health services. No further action is needed on your part. If you have questions or concerns about this letter, please feel free to contact the SBHO at (360) or (800) Thank you.

10 Anders Edgerton Administrator Serving Clallam, Jefferson and Kitsap Counties (Fecha) Para: (Nombre) (Dirección postal) (Ciudad, estado, código postal) Nro. de autorización: PARA SU INFORMACIÓN (Agencia) solicitó en su nombre la autorización para los servicios de salud del comportamiento por parte de la Organización de Salud del Comportamiento de Salish (Salish Behavioral Health Organization, SBHO). La SBHO ofrece financiamiento para (Agencia) y el estado exige que se le brinde la información específica de aprobación, la cual se muestra a continuación. Usted tiene autorización para recibir los servicios ambulatorios de (Agencia) durante el periodo que comienza en la fecha de admisión y finaliza el, como el último día de cobertura de servicios ambulatorios. Esto quiere decir que usted está autorizado para recibir los servicios, según se estipula en su plan de tratamiento de (Agencia) durante el periodo anteriormente mencionado. Es muy importante que participe en el proceso de planificación de su tratamiento. Dependiendo de sus beneficios y cobertura, podría ser responsable de una parte del copago de sus servicios, según el acuerdo financiero firmado con la agencia. Si usted está recibiendo actualmente beneficios de Medicaid, no se le facturarán los servicios cubiertos por Medicaid. A medida que trabaja en las metas de su tratamiento, usted y su proveedor de cuidados discutirán si se requiere una extensión adicional al periodo aprobado. Si se decide que los servicios deben continuarse, necesitamos que su proveedor presente una nueva solicitud cuando se aproxime el final de dicho periodo. Si es menor de 21 años de edad y cuenta con la cobertura de Medicaid, también podría calificar para recibir coordinación adicional de los servicios de cuidado bajo el programa de Exámenes, Diagnóstico y Tratamiento Periódico y Temprano (Early and Periodic Screening Diagnosis and Treatment, EPSDT). Su proveedor asignado puede responder cualquier pregunta y ofrecerle más información sobre dichos servicios. 614 Division Street, MS-23 Port Orchard, WA (360) FAX (360)

11 Además de sus servicios autorizados, la SBHO también ofrece servicios locales para casos de crisis a los que puede acceder en cualquier momento, (consulte la página 2 en el Manual para Miembros para información específica de la agencia). Asimismo, usted también puede acceder a los servicios de Ombudsman, sin costo alguno, para que defiendan sus servicios de salud del comportamiento a través del (360) o de la línea directa gratuita (888) Nuevamente, esto es solo una carta informativa que describe sus servicios de salud del comportamiento autorizados. No se requieren de más acciones de su parte. Si tiene alguna pregunta o inquietud sobre esta carta, siéntase libre de contactar a la SBHO al 360) o (800) Gracias.

12 SALISH BHO UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: AUTHORIZATION OF SERVICES INDEPENDENCE FROM FINANCIAL INCENTIVES Policy Number: 7.02 Reference: 42 CFR ; WAC ; DSHS Contract Effective Date: 7/2005 Revision Date(s): 9/2005; 5/2016 Reviewed Date: 5/2016; 6/2017 Approved by: SBHO Executive Board CROSS REFERENCES Policy: Corrective Action Plan PURPOSE The SBHO delegates and contracts with an experienced managed care entity, outside the provider network, to make independent authorization of care decisions related to outpatient, inpatient, and residential service requests from the provider network. The SBHO network provider payment structure is separate from the authorization for service decisions, and provides no financial incentives to the requesting network provider(s), the sub-delegated Administrative Service Organization (ASO) or the Salish Behavioral Health Organization. PROCEDURE 1. The SBHO contracts with an administrative service organization (ASO), with URAC or NCQA accreditation, to provide authorization and utilization management services to the SBHO service delivery system. The contractual fee is a fee negotiated prior to executing the contract and is not based on network provider financial incentives. 2. Network providers shall have effective policies and procedures that separate the staff responsible for requesting services from staff responsible for agency financial matters. Authorization of Services Independence from Financial Incentives 7.02 Page 1 of 2

13 Salish BHO Policies and Procedures 3. Network providers shall have established policies and procedures that ensure the staff responsible for requesting inpatient ITA authorization/certification are separate from staff responsible for agency financial matters. 4. The sub-delegated ASO shall be responsible to make all final authorization determinations based on the formally adopted SBHO utilization policies, Utilization Management Plan, Levels of Care which includes the Access to Care standards, and related guidelines when making authorization determinations. MONITORING This Policy is a mandate by contract and statute. 1. This Policy is monitored through use of SBHO: Annual SBHO Provider and Subcontractor Administrative Review SBHO Grievance Tracking Reports Biennial Provider Quality Review Team on-site review Quarterly Provider Performance Reports Semi-annual Provider Revenue and Expense Report 2. If a provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. Authorization of Services Independence from Financial Incentives 7.02 Page 2 of 2

14 Salish BHO 7.03 SALISH BHO UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Salish Behavioral Health Organization Level of Care Condensed Version Revised July 2017 Effective October 1, 2015 SBHO LOC Guidelines, Rev

15 Table of Contents Age Definitions 3 Child and Youth Services 4 Outpatient Level 1 Services: Admission & Continuing Stay 5 Outpatient Level 2 Services: Admission & Continuing Stay 6 Outpatient Level 1 & 2 Services: Expedited Reviews 8 Outpatient Level 1 & 2 Services: Inactivation & Reactivation 9 Inpatient Services: Community Hospital Voluntary & Involuntary 10 Inpatient Services: YIU Voluntary & Involuntary 11 Residential Services: Children s Long Term Inpatient (CLIP) 12 Adult Services 13 Outpatient Level 1 Services: Admission & Continuing Stay 14 Outpatient Level 2 Services: Admission & Continuing Stay 15 Outpatient Level 1 & 2 Services: Expedited Reviews 16 Outpatient Level 1 & 2 Services: Inactivation & Reactivation 17 Inpatient Services: Community Hospital Voluntary & Involuntary 18 Inpatient Services: AIU Voluntary & Involuntary 19 Residential Services: Brief & Long Term Intensive 20 Adult and Child/Youth Services 21 Crisis & Stabilization Services 22 Respite Services 23 2

16 Age Definitions Child: A child is defined as a person birth to 12 (twelve) years of age. Youth: A youth is defined as a person years of age, requires youth consent. For persons eligible for the Medicaid program, the term youth extends to individuals that have not reached their 21 (twenty-first) birthday. NOTE: The new ACS defines youth as below age 21, and either the Adult or Child & Youth ACS criteria may be applied to individuals age Adult: An adult is generally defined as a person over the age of 18 (eighteen) years. For the purposes of residential services, an adult is always defined as a person 18 (eighteen) years or older. 3

17 Child & Youth Services 4

18 Child and Youth Services Level 1 Outpatient Services Service Description Brief Intervention is a solution focused, outcomes oriented cognitive and behavioral intervention intended to resolve situational disturbances that do not require long term treatment. Authorization benefit: 12 service hours within 6 months, one time only authorization. Low Intensity Treatment is provided to allow a child/ youth and family to continue in treatment to maintain their recovery progress. Functional problems identified in the ISP, include steps that demonstrate on-going treatment progress. This level may be used as a step down from a higher, more intense level of care and authorized for multiple episodes. Authorization benefit: 24 service hours for 12 months. Routine Admission Criteria Individuals must meet the Washington State Access to Care Standards (ACS), and the requested service is determined medically necessary by MHP. EPSDT. Any Medicaid recipient under the age of 21 who meets ANY of the following criteria in addition to the ACS may be authorized for Level 2 services: 1. Involved in one or more of the following systems in addition to mental health: Children s Administration Developmental Disabilities Administration Juvenile Rehabilitation or Department of Corrections 2. Diagnosed with Substance Abuse or Addiction 3. Receiving Special Education Services 4. Has a chronic and disabling medical condition 5. As a Medicaid recipient, has previously been authorized for Level 1 services twice. In addition to the ACS, Non-Medicaid individuals will only be authorized for services if there are sufficient resources and meet ONE of the following criteria: 1. Present with psychotic symptoms 2. Present with a risk of Danger to Self or Danger to Others, or have been hospitalized for psychiatric care within the last 6 months 3. Recently released from JRA or Juvenile Detention facility 4. A MHP determines that current symptoms and history demonstrate treatment is necessary to avoid hospitalization. 5. Under age of 6 years, inadequate caregiver 6. Applied for Medicaid and enrollment decision is pending Continuing Stay Criteria Medicaid individuals can only be re-authorized for Brief Level 1 services ONCE. Review and documented treatment progress, update ISP, and review / update the crisis prevention plan, as appropriate. Requested continued service is determined medically necessary by MHP, and must meet all of the following: 1. Current ACS covered diagnosis. 2. Current symptoms (from the covered diagnosis) and history demonstrate a significant likelihood of deterioration if treatment is discontinued; and continued treatment is necessary to maintain gains to maintain community safety or to avoid hospitalization. 3. Intervention is deemed necessary to improve or stabilize functioning (from the covered diagnosis). 4. The individual is expected to benefit from the intervention(s). 5. Any other formal or informal system or support would not more appropriately meet the individual s unmet need(s). Type of Services/Modalities Intake assessment, group treatment, brief intervention treatment services, individual and family services, medication management, medication monitoring, psychoeducation, and family/ peer supports. Intensity of Service Brief intervention and/ or low intensity mental health services Duration of Episode Brief: Maximum of 12 individual service hours within 6 months, intended for one time only authorization Low Intensity: Maximum of 24 individual service hours for 12 months Authorization Protocol CMHA determines funding eligibility, conducts intake assessment by an MHP, establishes medical necessity. Consults with appropriate specialists (child, ethnic minority, disability). CMHA submits a PRAT (identifying the service level, determination of ACS requirements and medical necessity) to SBHO delegated ASO within 14 days from when the intake was initiated. ASO reviews PRAT and supporting documentation and then provides an authorization determination within 14 calendar days from the date of the intake assessment beginning. ASO reviews and authorizes extension requests, when indicated. Written notification of authorized services is provided via mail. 5

19 Child and Youth Services Level 2 Outpatient Services Service Descriptions Long Term Rehabilitation and Children s Intensive Services (CIS) are necessary to improve or maintain stability in the community. Intense level of acute outpatient treatment may include active outreach and home-based services necessary to prevent hospitalization, out of home placement, reinforce personal and community safety and/or decrease the use of other costly services. CIS is the most intensive outpatient authorization for children s services. Authorization benefit: More than 24 service hours up to 12 month authorization episode. Wraparound with Intensive Services (WISe) is a range of Medicaid-funded service components that are individualized, intensive, coordinated, comprehensive, culturally relevant, and home and community based. WISe is for youth who are experiencing mental health symptoms that disrupt or interfere with their functioning in family, school or with peers. WISe services may be requested prior to intake by either the youth, family, or family representative. Youth eligible for WISe based services, if not enrolled in SBHO agency, will be referred for intake and to determine further medical necessity and access to care standards. Routine Admission Criteria Individuals must meet the Washington State Access to Care Standards (ACS), and the requested service is determined medically necessary by MHP. EPSDT. Any Medicaid recipient under the age of 21 who meets ANY of the following criteria in addition to the ACS may be authorized for EPSDT services: 1. Involved in one or more of the following systems, in addition to mental health: Children s Administration Developmental Disabilities Administration Juvenile Rehabilitation or Department of Corrections 2. Diagnosed with Substance Abuse or Addiction 3. Receiving Special Education Services 4. Has a chronic and disabling medical condition 5. As a Medicaid recipient, has previously been authorized for Level 1 services twice. CIS. Any Medicaid recipient from 5-17 years of age who meets any one of the following criteria may be authorized for CIS services: 1. Involved in two or more of the following systems, in addition to mental health Children s Administration Developmental Disabilities Administration Juvenile Rehabilitation or Department of Corrections Receiving Special Education services Involved with substance abuse or chemical dependency services 2. Has been hospitalized for psychiatric care within the previous 12 months 3. Three or more crisis contacts in the previous 6 months (to be counted by day) 4. Has received inpatient treatment for substance abuse within the previous 12 months ** In addition to the ACS, Non-Medicaid individuals will only be authorized for services if there are sufficient resources and meet ONE of the following criteria: 1. Present with psychotic symptoms 2. Present with a risk of Danger to Self or Danger to Others, or have been hospitalized for psychiatric care within the last 6 months 3. Recently released from JRA or Juvenile Detention facility. 4. A MHP determines that current symptoms and history demonstrate treatment is necessary to avoid hospitalization. 5. Under age of 6 years, inadequate caregiver 6. Applied for Medicaid and enrollment decision is pending Safety/ Risk Assessment. In addition to the above criteria, one of the following qualifying risk factors must apply for an individual: 1. Current severity of symptoms makes the individual at risk for hospitalization, if services are not provided at this level 2. Child/ youth s placement is at significant risk 3. More than 3 contacts with the provider crisis team in the previous month 4. Psychiatric hospitalization in the previous three months 5. Current suicidal or homicidal ideation, or history of an attempt 6. Is EPSDT program eligible ***Additionally, WISe services are determined by a CANS screen documenting eligibly for WISe services, performed by someone certified in performing the CANS screens and assessments, either prior to authorization for services or in conjunction with the intake assessment. Consideration for referral begins with youth who are Medicaid eligible, under age 21 and who have complex behavioral health needs. Other indicators to consider for a WISe referral may include, but are not limited to: 1. Youth with involvement in multiple child-serving systems (e.g., child welfare, mental health, juvenile justice, developmental disabilities, special education, substance use disorder treatment). 2. Youth for whom more restrictive services have been requested, such as psychiatric hospitalizations, residential 6

20 placement or foster care placement, due to mental/behavioral health challenges. 3. Youth at risk of school failure and/or who have experienced significant and repeated disciplinary issues at school due to mental/behavioral health challenges. 4. Youth who have been significantly impacted by childhood or adolescent trauma. 5. Youth prescribed multiple or high dosages of psychotropic medications for mental/behavioral health challenges. 6. Youth with a history of detentions, arrests, or other referrals to law enforcement due to behaviors that result from mental/behavioral health challenges. 7. Youth exhibiting risk factors such as suicidal ideation, danger to self or others, behaviors due to mental/behavioral health challenges. 8. Youth whose family requests support in meeting the youth s mental/behavioral health challenges. Continuing Stay Criteria Review and document treatment progress, update ISP, and review/update the crisis prevention plan, as appropriate. For WISe services, documented Cross System Care Plans (CSCP) with updated WISe screens every 90 days is annotated in the electronic health record via Child and Family Team (CFT) notes validating continued services with WISe. Medicaid individuals: EPSDT and CIS program requirements are met (listed above in admission) as determined medically necessary by MHP In addition to the above criteria, all of the following must apply to an individual, as determined by MHP: 1. Current ACS covered diagnosis. 2. Current symptoms (from the covered diagnosis) and history demonstrate a significant likelihood of deterioration if treatment is discontinued; and continued treatment is necessary to maintain gains to maintain community safety or to avoid hospitalization. 3. Intervention is deemed necessary to improve or stabilize functioning (from the covered diagnosis). 4. The individual is expected to benefit from the intervention(s). 5. Any other formal or informal system or support would not more appropriately meet the individual s unmet need(s). Non-Medicaid individuals: Sufficient resources and continue to meet ONE of the ** additional criteria as determined medically necessary. Type of Services/ Modalities/ Intensity of Service Includes all allowable outpatient services under the state plan; full scope of outpatient treatment modalities. EPSDT and CIS can require establishing a formalized Individual Service Team and further development of a Cross-System Treatment Plan. Authorization Protocol CMHA determines funding eligibility, conducts intake assessment by an MHP, establishes medical necessity. Consults with appropriate specialists. CMHA submits a PRAT to SBHO delegated ASO within 14 days from when the intake was initiated. Excluding WISe services, the ASO reviews PRAT and supporting documentation, then provides an authorization determination within 14 calendar days from the date of the request for service. ASO reviews and authorizes extension requests. Written notification of authorized services is provided via mail. 7

21 MEDICAID ONLY (42 CFR ) Child and Youth Services Level 1 & 2 Services Expedited Reviews: Admission & Continuing Stay for Medicaid This Level of Care applies to expedited authorization reviews for admission and continuing stay for Level 1 and 2 outpatient services. Service Description For cases in which a network provider (CMHA) indicates that the following the standard timeframe could jeopardize the individual s life or health or ability to attain, maintain, or regain maximum function, the CMHA MHP must make an expedited authorization request for services, indicating urgent or emergent review status, and provide an authorization request as expeditiously as the individual s health condition requires. Crisis services can be provided while the expedited authorization request is pending. Expedited Admission Criteria Individuals with Medicaid coverage, only. The standard timeframe could jeopardize the individual s life or health or ability to attain, maintain, or regain maximum function For admission authorization determination: Must meet Access to Care Standards (ACS) for Admission into Level 1 or 2 services criteria (medical necessity criteria, functional impairment, and diagnosis) For continuing stay authorization determination: Must meet continuing stay criteria, as defined by the requested level. Requested service is determined medically necessary by MHP Type of Services/Modalities Level 1: Intake assessment, group treatment, brief intervention treatment services, individual and family services, medication management, medication monitoring, psychoeducation, family/ peer supports. Level 2: Includes all allowable outpatient services under the state plan, including a screening for WISe eligibility. The full scope of outpatient treatment modalities and level of intensity for each modality may be provided based on clinical assessment, medical necessity and individual needs. EPSDT referred Level 2 services for Medicaid youth can require establishing a formalized Individual Service Team for each child/ youth to further develop a cross system Individual Treatment plan (refer to Child/ Youth LOC for criteria and requirements) Intensity of Service Level 1: Brief intervention and low intensity mental health services Level 2: Service intensity is individualized, based on continued assessment of need and adjustments are reflected in the ISP. Duration of Episode Level 1 Brief: Maximum of 12 individual service hours within 6 months, intended for one time only authorization Level 1 Low Intensity: Maximum of 24 individual service hours within 12 months Level 2 Long Term Rehabilitation: Minimum of 24 individuals service hours in 12 months Authorization Protocol CMHA determines funding eligibility, conducts an intake evaluation by an MHP that establishes medical necessity. Consults with appropriate specialists (child, ethnic minority, disability). CMHA telephonically provides or forwards a completed PRAT request with the urgency category flagged to the SBHO ASO. All telephonic information is followed-up with the required documentation. ASO immediately reviews the PRAT information, diagnosis information and any additional clinical documentation to support the request, prior to making a service determination, within 3 days from the request. ASO provides an authorization determination within 3 working days from the date of request for mental health services. The CMHA may extend the 3 day time period up to 14 calendar days if the individual applying for services requests an extension, or if the provider justifies a need for additional information and how the extension is in the individual s interest. Written notification of approved or denied services is provided via mail. 8

22 Child and Youth Services Level 1 & 2 Services Inactivation & Reactivation of Services Service Description Clinical inactivation refers to an individual who has left services within an authorized benefit period. Clinical Inactivations can occur at any point throughout an authorized episode of treatment. When there has been no direct services provided for authorized episodes over 90 days, the SBHO strongly recommends supervisory review and consideration for administrative closure. Administrative inactivation refers to the expiration of an authorized benefit period (6 or 12 months). In rare occurrences, an administrative inactivation is requested when an individual moves out of the catchment area (including enters the prison system) or dies within an authorized benefit period. Reactivation refers to re-opening a previously clinically inactivated case, within the initial authorized benefit period. Inactivation Scenarios Applies to Medicaid and Non-Medicaid individuals. Clinical inactivations may occur when any of the following apply: 1. The client met their expected treatment goals/outcomes 2. The client is over the age of 13 years and requests inactivation of treatment 3. The client is not participating in treatment, has not responded to engagement efforts, and imminent risk issues are not present 4. The client s whereabouts are unknown, and three attempts to contact them (by two different means) have been unsuccessful 5. The client s treatment needs can be met through other services available within their support system; care is being/ has been transitioned to another entity Administrative inactivations may occur when any of the following apply: 1. The client does not meet continuing stay criteria and the benefit period expires 2. The client has moved out of the SBHO 3. The client is deceased Reactivation Criteria Applies to Medicaid and Non-Medicaid individuals. The request for reactivation is made by a MHP or the primary clinician, under the supervision of a MHP. Non-Medicaid individuals may only be re-activated if there are sufficient resources to support the re-activation service plan. Reactivation summary is required to document current information. For WISe services, a new CANS screening must be completed and entered into BHAS for eligibility determination. No additional authorization is required (as a case is being re-opened during a previously authorized and within a current benefit period). Authorization Protocols Inactivations CMHA records the clinical inactivation and documentation summary in the Profiler clinical record. The ASO generates a monthly report to identify individuals with pending administrative inactivations. After 10 days, if the Medicaid individual does not contact the ASO or CMHA requesting on-going services the inactivation is processed/ authorized. Reactivations Reactivation documentation is present in the clinical record and re-activation status is entered into Profiler. No additional authorization through the ASO is required (as a case is being re-opened during a previously authorized and within a current benefit period). 9

23 Child and Youth Services Community Hospital Inpatient Services - Voluntary & Involuntary Service Description Inpatient psychiatric services at community hospitals include evaluation, stabilization and treatment and can be authorized prior to an intake. All ITA and revocations to inpatient services are provided a certification number and automatically authorized for 20 days. The SBHO network crisis team designated to an individual s geographical area (DMHP) may provide a face to face assessment for inpatient service requests. All voluntary hospitalization requests must be made by a MHP in consultation with, or by a child mental health specialists. Voluntary Admission Criteria Voluntary inpatient admissions must meet all of the following baseline criteria (includes Parent-Initiated Voluntary hospitalizations): 1. The existence of a DSM-5 disorder. 2. Evidence that admission is medically necessary. 3. The child/youth poses an actual or imminent danger to self, others or property due to a mental disorder, or The child/youth requires brief stabilization and assessment to rule out danger to self and/or others, or The child/youth is experiencing significant deterioration in age appropriate behavior including family, school, and social functioning and an alternative care setting would be unable to provide sufficiently intensive services to diagnose and treat the mental disorder. 4. There is a verified failure of treatment at a lesser level of care, or A crisis team/ DMHP determines that due to the severity of symptoms, intensity of treatment or lack of supports services cannot be provided at a lesser level of care. 5. Medical evaluation determines that the current medical needs do not exceed the level of care available in the inpatient setting. Voluntary Continuing Stay Criteria & Extension Requests When a child/youth may exceed the initial authorization expiration date, a request for continuing stay is required prior to the expiration date. The inpatient facility is responsible for requesting an extension at least 24 hours prior to the expiration date. The inpatient facility must contact the designated network CMHA to request the extension. Only the network CMHA can make a request for a continuing stay voluntary hospitalization to CommCare. The continuing stay/ extension request is case specific and there is no range for authorization. At least one of the following criteria must be present inpatient extension authorization (includes Parent-Initiated voluntary hospitalizations): 1. The full assessment has not been completed and cannot be completed at a lesser level of care 2. The child/youth continues to pose actual or imminent danger to self, others, or property that cannot be contained at a lesser level of care 3. The child/youth demonstrates an inability to function or is gravely disabled and continues to require on-going inpatient care. 4. The child s/youth s level of functioning has regressed since admit 5. The child/youth continues to need stabilization to reach baseline functioning and further improvement in condition is expected. Discharge Considerations Discharge happens as soon as a less-restrictive plan for treatment can be safely implemented. Reasonable efforts must be made to meet all of the following: 1. Inpatient treatment plan objectives have been substantially met or unmet objectives can be resolved at a lesser level of care. 2. Unresolved treatment plan objectives are addressed in a discharge plan and an appropriate outpatient program is identified. 3. Discharge to a less intensive level of care does not pose a threat and the treating physician authorizes the discharge. 4. For AMA discharges, contact information for local crisis line and community mental health agency is provided. Inpatient Facility Transfers and Legal Status Changes With changes within an authorized episode, a child/youth can be transferred from one inpatient facility to another without meeting new admission criteria. With transfers occurring with expiring authorization, a child/ youth must meet continued stay criteria to be authorized. A new certification number must be requested and is automatically issued to differentiate between inpatient facilities and legal status changes. Retro-authorizations A community hospital may request retro-authorization reviews. For out of state retro-authorization requests, the request must be must be made within three months of discharge. 1. The retro-authorization determination can take up to an additional 30 days. 2. Individual currently admitted to an inpatient facility, CommCare may provide a verbal review and retro-authorization. 3. Individual discharged from inpatient facility, CommCare requires hospital documentation for comprehensive review and determination. Type of Services/Modalities May include individual and family therapy, milieu therapy, psycho-educational groups and pharmacology. Intensity of Service 24/7 acute psychiatric inpatient care Duration of Episode For ITA or if LRA is revoked, the authorization is automatically approved (admission and continuing stay) for 20 days. For voluntary hospitalizations, the standard benefit period for admission and extension requests is determined and requested by the CMHA crisis team (standard range is 1 to 3 days ). Authorization Protocol The ASO collects the necessary information for Provider 1 Prior Authorization from Profiler or verbally, identifying the requested inpatient authorization, funding source, and supporting clinical documentation. CommCare will notify DBHR of all Parent-Initiated Voluntary stays. ASO verifies voluntary criteria sufficiently met through supporting documentation, and provides the authorization determination within 12 hours of request. If criteria and medical necessity for voluntary admission is not sufficiently met, CommCare may authorize administrative days. With an inpatient service denial, the ASO provides a Peer Review and service denial notification within 1 business day. 10

24 Child and Youth Services Youth Inpatient Unit (Network E&T) - Voluntary & Involuntary Service Description Inpatient hospitalization services for children and youth at Kitsap Mental Health Services (KMHS) Youth Inpatient Unit (YIU) include evaluation, stabilization and treatment and can be authorized prior to an intake. All ITA and revocations to inpatient services are provided a certification number and automatically authorized for 20 days. The SBHO network crisis team designated to an individual s geographical area (DMHP) may provide a face to face assessment for inpatient service requests. All voluntary hospitalization requests must be made by a MHP in consultation with, or by a child mental health specialists. Voluntary Admission Criteria- up to a standard 20 day initial authorization. Voluntary inpatient admissions must meet all of the following baseline criteria (includes Parent-Initiated Voluntary hospitalizations): 1. The existence of a DSM-5 disorder. 2. Evidence that admission is medically necessary. 3. The child/youth poses an actual or imminent danger to self, others or property due to a mental disorder, or The child/youth requires brief stabilization and assessment to rule out danger to self and/or others, or The child/youth is experiencing significant deterioration in age appropriate behavior including family, school, and social functioning and an alternative care setting would be unable to provide sufficiently intensive services to diagnose and treat the mental disorder. 4. There is a verified failure of treatment at a lesser level of care, or a crisis team/ DMHP determines that due to the severity of symptoms, intensity of treatment or lack of supports services cannot be provided at a lesser level of care. 5. Medical evaluation determines that the current medical needs do not exceed the level of care available in the inpatient setting. Voluntary Continuing Stay Criteria & Extension Requests- up to 10 additional days, per request When a child/youth may exceed the initial authorization expiration date, a request for continuing stay is required prior to the expiration date. The E&T must contact the network CMHA that initiated the admission to request the extension. Only the network CMHA can make a request for a continuing stay voluntary hospitalization. Each extension request must be reviewed by the SBHO. Upon SBHO review, the request is forwarded from the SBHO to CommCare for authorization. At least one of the following criteria must be present for continuing stay authorization (includes Parent-Initiated Voluntary hospitalizations): 1. The full assessment has not been completed and cannot be completed at a lesser level of care 2. The child/youth continues to pose actual or imminent danger to self, others, or property that cannot be contained at a lesser level of care 3. The child/youth demonstrates an inability to function or is gravely disabled and continues to require on-going inpatient care. 4. The child s/youth s level of functioning has regressed since admit 5. The child/youth continues to need stabilization to reach baseline functioning and further improvement in condition is expected. Once an individual is admitted to the E&T, the CMHA must contact the E&T to begin coordinating care within one business day. Discharge Considerations Discharge happens as soon as a less-restrictive plan for treatment can be safely implemented. Reasonable efforts must be made to meet all of the following: 1. Inpatient treatment plan objectives have been substantially met or unmet objectives can be resolved at a lesser level of care. 2. Unresolved treatment plan objectives are addressed in a discharge plan and an appropriate outpatient program is identified. 3. Discharge to a less intensive level of care does not pose a threat and the treating physician authorizes the discharge. 4. For AMA discharges, contact information for local crisis line and community mental health agency is provided. Inpatient Facility Transfers and Legal Status Changes With changes within an authorized episode, a child/youth can be transferred from one inpatient facility to another without meeting new admission criteria. With transfers occurring with expiring authorization, a child/ youth must meet continued stay criteria to be authorized A new certification number must be requested and is automatically issued to differentiate between inpatient facilities and legal status changes. Type of Services/Modalities May include individual and family therapy, milieu therapy, psycho-educational groups and pharmacology. Intensity of Service 24/7 acute psychiatric inpatient care. Duration of Episode For ITA or if LRA is revoked, the authorization is automatically approved (admission and continuing stay) for 20 days. For voluntary hospitalizations, the benefit period for admission is up to 20 days. Extension requests (up to 10 days) are requested by the CMHA, reviewed by the SBHO, and authorized by CommCare. Continuing stay and extension requests range of days authorized are on a case by case basis. Authorization Protocol Only network CMHA can request authorization for E&T inpatient services, all other parties must facilitate their request through the CMHA. The ASO collects the necessary information for an inpatient certification from Profiler or verbally- identifying the requested inpatient authorization. All extension requests must be submitted to the SBHO for review 3 calendar days prior to the expiration. Upon SBHO review, the request is forwarded to CommCare for authorization. CommCare will notify DBHR of all Parent-Initiated Voluntary stays. The ASO verifies voluntary criteria sufficiently met through supporting documentation, and provides the authorization determination within 12 hours of request. If criteria and medical necessity for voluntary admission is not sufficiently met, CommCare may authorize administrative days. With an inpatient service denial, the ASO provides a Peer Review and service denial notification within 1 business day. SBHO conducts 100% review of all NOAs and tracks appeals. 11

25 Child and Youth Services Children s Long Term Inpatient (CLIP) Services Service Description CLIP services are a blended residential program that includes therapeutic, medical, and educational modalities for severely emotional disturbed children and youth. CLIP is considered the most restrictive setting. The average length of stay is 6 months. This criteria is for voluntary CLIP services. Routine Admission Criteria Applicants must have a severe psychiatric impairment which warrants the intensity and restrictions of the treatment provided in a CLIP Program with verified failure (unable to stabilize) of treatment at a lesser level of care determined medically necessary. Per CLIP Administration policy, an individual will be considered to have an impairment if a severe emotional disturbance, corroborated by a clear psychiatric diagnosis, is demonstrated, with one or more of the following behaviors exhibited: 1. Symptoms explicitly associated with marked, severe and/or chronic thought disorders, as defined in the DSM-5, such as bizarreness, delusions, hallucinations, disturbed thought processes (e.g., loosened associations, illogical thinking, poverty of content of speech), blunt, flat or inappropriate affect, or grossly disorganized behavior 2. Symptoms explicitly associated with a marked, severe or chronic affective disorders, as defined in the DSM-5, including mania, depression, vegetative signs, suicide attempts or self -destructive behaviors. 3. Chronic or grossly maladaptive behaviors due to a diagnosed severe psychiatric impairment. The presence of such symptoms should be clearly identified as resulting from a mental disorder and not be solely attributable to other factors. Medical evaluation determines that the child s/ youth s current medical needs do not exceed the level of care available in the CLIP setting. Clear treatment goals and discharge planning recommendations including placement are provided to the CLIP program, prior to admission. Youth (13 years or older) are willing to agree to voluntary admission and to comply with treatment. Youth (13 years and older) whose mental state incapacity or developmental stage does not rule out a good faith voluntary admission by virtue of significant cognitive impairment that precludes making a reasoned decision. Determination of Good Faith Voluntary may include a review of previous voluntary hospitalizations and the recent pattern of outpatient treatment compliance. The local CLIP gatekeeping committee reviews all the material in accordance with these admission criteria, discusses alternative options to CLIP, and provides a determination for CLIP admission. 1. If the application is approved, it is forwarded to the CLIP Admission for review and approval. 2. If the application is denied by the community gatekeeping committee, a letter is provided with alternative treatment recommendations outlined. Continuing Stay Criteria Per the CLIP policy, once a child/ youth has been approved for voluntary admission by the CLIP Certification Team and placed on the CLIP Waiting List, the designated child psychiatrist shall review the youth s continued need for admission every 30 days up until the time when they are admitted. Discharge Considerations When the individual meets their treatment goals, no longer meets CLIP criteria for continued stay treatment, and a discharge date is identified: 1. The CLIP treatment team members, including the community treatment team, shall plan for a smooth transition back to community services. 2. The CLIP case manager is responsible for coordinating outpatient mental health services and will invite ancillary community-based formal systems to participate in the discharge planning, per established designated working agreements (e.g. DCFS and DDA). 3. All youth discharging from CLIP treatment will be screened for WISe services prior to discharge, by a certified CANS screening and assessment staff member. 4. If the child/ youth is planning to move to another BHO, the SBHO CLIP case manager coordinates with the local community mental health agency to liaison and transition care. Type of Services/Modalities Blended residential program that includes therapeutic, medical, and educational modalities for SED children and youth. Intensity of Service 24/7 long-term statewide residential program Duration of Episode Upon admission to a CLIP facility, as determined by CLIP attending psychiatrist. Average LOS is 6 months. Authorization Protocol Voluntary admission authorization occurs through a local gatekeeping panel review, and statewide CLIP Review. No additional authorization is required, upon admission. 12

26 Adult Services 13

27 Adult Services Level 1 Outpatient Services Service Description Brief Intervention is a solution focused, outcomes oriented cognitive and behavioral intervention intended to resolve situational disturbances that do not require long term treatment. Authorization benefit: 12 service hours within 6 months, one time only authorization. Low Intensity Treatment is provided to provide a person to begin or maintain their recovery progress. Functional problems identified at Intake are included in the ISP, which includes specific steps that demonstrate on-going treatment progress. May include beginning or ongoing care, maintenance or monitoring of current level of functioning, assistance with self-care, or life skill training. This level may be used as a step down from a higher, more intense level of care and authorized for multiple episodes. Authorization benefit: 24 service hours for 12 months. Routine Admission Criteria Individuals must meet Access to Care Standards (ACS), and the requested service is determined medically necessary by MHP. EPSDT. Any Medicaid recipient under the age of 21 who meets ANY of the following criteria and ACS may be authorized for Level 2 services (reference Child/ Youth LOC for criteria and requirements): In addition to the ACS, Non-Medicaid individuals will only be authorized for services if there are sufficient resources and meet ONE of the following criteria: 1. Have a diagnosis of Schizophrenia, Schizoaffective Disorder, or have psychotic symptoms 2. Present with a risk of Danger to Self or Danger to Others, or have been hospitalized for psychiatric care within the last 6 months 3. Recently released from jail or prison. 4. A MHP determines that current symptoms and history demonstrate treatment is necessary to avoid hospitalization. 5. Applied for Medicaid and enrollment decision is pending Continuing Stay Criteria Continuing Stay criteria only apply for continuation of previously authorized services. Medicaid individuals can only be re-authorized for Brief Level 1 services ONCE. Review and documented treatment progress, update ISP, and review/update the crisis prevention plan, as appropriate. Requested continued service is determined medically necessary by MHP, and must meet all of the following: 1. Current ACS covered diagnosis. 2. Current symptoms (resulting from the covered diagnosis) and history demonstrate a significant likelihood of deterioration if treatment is discontinued. 3. Current symptoms and history demonstrate continued treatment is necessary to maintain gains in functional ability, maintain community safety, or to avoid hospitalization. 4. Intervention is deemed necessary to improve or stabilize functioning resulting from a covered mental health diagnosis. 5. The individual is expected to benefit from the intervention. 6. Any other formal or informal system or support would not more appropriately meet the individual s unmet need(s). 7. SBHO adopted Practice Guidelines recommend continued treatment. In addition to the above, Non-Medicaid individuals will only be authorized continuing care if there are sufficient resources and meet ONE of the following additional criteria: 1. Have a diagnosis of Schizophrenia, Schizoaffective Disorder, or have psychotic symptoms 2. Present with a risk of Danger to Self or Danger to Others, or have been hospitalized for psychiatric care within the last 6 months 3. Recently released from jail or prison. 4. A MHP determines that current symptoms and history demonstrate treatment is necessary to avoid hospitalization 5. Applied for Medicaid and enrollment decision is pending Type of Services/Modalities Intake assessment, group treatment, brief intervention treatment services, medication management, medication monitoring, and psychoeducation. Intensity of Service Brief intervention and/ or low intensity mental health services Duration of Episode Brief: Maximum of 12 individual service hours within 6 months, intended for one time only authorization Low intensity: Maximum of 24 individual service hours for 12 months Authorization Protocol CMHA determines funding eligibility, conducts intake assessment by an MHP, establishes medical necessity. Consults with appropriate specialists (ethnic minority, disability). CMHA submits a PRAT (identifying requested service level, determination of ACS requirements and medical necessity) to SBHO delegated ASO within 14 days from when the intake was initiated. ASO reviews PRAT and supporting documentation and then provides an authorization determination within 14 calendar days from the date of the intake assessment beginning. ASO reviews and authorizes extension requests, when indicated. Written notification of authorized services is provided via mail. 14

28 Adult Services Level 2 Outpatient Services Service Description Long Term Rehabilitation is necessary to achieve or maintain stability in the community. Intense level of acute outpatient treatment may include active outreach and intensive services to prevent hospitalization, out of home placement, reinforce personal and community safety, and promote the stability and independence of an individual in the community while decreasing the use of other costly services. Authorization benefit: More than 24 service hours in 12 months. Routine Admission Criteria Individuals must meet the Access to Care Standard (ACS), and the requested service is determined medically necessary by MHP. EPSDT. Any Medicaid recipient under the age of 21 who meets ANY of the following criteria may be authorized for Level 2 services (reference Child/ Youth LOC for criteria and requirements): In addition to the ACS, Non-Medicaid individuals will only be authorized if there are sufficient resources and they meet at least ONE of the following criteria: 1. Have a diagnosis of Schizophrenia, Schizoaffective Disorder, or have psychotic symptoms 2. Present with a risk of Danger to Self or Danger to Others, or have been hospitalized for psychiatric care within the last 6 months 3. Recently released from jail or prison. 4. A Mental Health Professional determines that current symptoms and history demonstrate treatment is necessary to avoid hospitalization. 5. Applied for Medicaid and enrollment decision is pending Safety/ Risk Assessment. In addition to the above criteria, one of the following qualifying risk factors must apply for an individual: 1. Current severity of symptoms makes the individual at risk for hospitalization, if services are not provided at this level 2. More than 3 contacts with the provider crisis team in the previous month 3. Psychiatric hospitalization in the previous 3 months 4. Current suicidal or homicidal ideation, or history of an attempt Continuing Stay Criteria Continuing Stay criteria only apply for continuation of previously authorized level or less intensive level of care. Review and document treatment progress, update ISP, and review/update the crisis prevention plan, as appropriate. Requested continued service is determined medically necessary by MHP, and must meet all of the following: 1. Current ACS covered diagnosis. 2. Current symptoms (resulting from the covered diagnosis) and history demonstrate a significant likelihood of deterioration if treatment is discontinued. 3. Current symptoms and history demonstrate continued treatment at this level is necessary to maintain gains to maintain community safety or to avoid hospitalization. 4. Intervention is deemed necessary to improve or stabilize functioning resulting from a covered mental health diagnosis. 5. The individual is expected to benefit from the intervention. 6. Any other formal or informal system or support would not more appropriately meet the individual s unmet need(s). In addition to the ACS, Non-Medicaid individuals will only be authorized if there are sufficient resources and they meet at least ONE of the following additional criteria: 1. Have a diagnosis of Schizophrenia, Schizoaffective Disorder, or have psychotic symptoms 2. Present with a risk of Danger to Self or Danger to Others, or have been hospitalized for psychiatric care within the last 6 months 3. Recently released from jail or prison 4. A MHP determines that current symptoms and history demonstrate treatment is necessary to avoid hospitalization. 5. Applied for Medicaid and enrollment decision is pending Type of Services/Modalities Includes all allowable outpatient services under the state plan; full scope of outpatient treatment modalities and level of intensity is provided based on clinical assessment, medical necessity and individual needs. Intensity of Service Continuum of high intensity and comprehensive mental health services Duration of Episode Minimum of 24 individuals service hours in 12 months Authorization Protocol CMHA determines funding eligibility, conducts intake assessment by an MHP, establishes medical necessity. Consults with appropriate specialists (child, ethnic minority, disability). CMHA submits a PRAT (identifying requested service level, determination of ACS requirements and medical necessity) to SBHO delegated ASO within 14 days from when the intake was initiated. ASO reviews PRAT and supporting documentation, then provides an authorization determination within 14 calendar days from the date of the intake assessment beginning. ASO reviews and authorizes extension requests, when indicated. Written notification of authorized services is provided via mail. 15

29 MEDICAID ONLY (42 CFR ) Adult Services Level 1 & 2 Services Expedited Reviews: Admission & Continuing Stay for Medicaid This Level of Care applies to expedited authorization reviews for admission and continuing stay for Level 1 and 2 outpatient services. Service Description For cases in which a network provider (CMHA) indicates that the following the standard timeframe could jeopardize the individual s life or health or ability to attain, maintain, or regain maximum function, the CMHA MHP must make an expedited authorization request for services, indicating urgent or emergent review status, and provide an authorization request as expeditiously as the individual s health condition requires. Crisis services can be provided while the expedited authorization request is pending. Expedited Admission Criteria Individuals with Medicaid coverage, only. The standard timeframe could jeopardize the individual s life or health or ability to attain, maintain, or regain maximum function For admission authorization determination: Must meet Access to Care Standards (ACS) for Admission into Level 1 or 2 services criteria (medical necessity criteria, functional impairment, and diagnosis) For continuing stay authorization determination: Must meet continuing stay criteria, as defined by the requested level. Requested service is determined medically necessary by MHP Type of Services/Modalities Level 1: Intake assessment, group treatment, brief intervention treatment services, individual and family services, medication management, medication monitoring, psychoeducation, family/ peer supports. Level 2: Includes all allowable outpatient services under the state plan. The full scope of outpatient treatment modalities and level of intensity for each modality may be provided based on clinical assessment, medical necessity and individual needs. EPSDT referred Level 2 services for Medicaid youth can require establishing a formalized Individual Service Team for each child/ youth to further develop a cross system Individual Treatment plan (refer to Child/ Youth LOC for criteria and requirements) Intensity of Service Level 1: Brief intervention and low intensity mental health services Level 2: Service intensity is individualized, based on continued assessment of need and adjustments are reflected in the ISP. Duration of Episode Level 1 Brief: Maximum of 12 individual service hours within 6 months, intended for one time only authorization Level 1 Low Intensity: Maximum of 24 individual service hours within 12 months Level 2 Long Term Rehabilitation: Minimum of 24 individuals service hours in 12 months Authorization Protocol CMHA determines funding eligibility, conducts an intake evaluation by an MHP that establishes medical necessity. Consults with appropriate specialists (child, ethnic minority, disability). CMHA telephonically provides or forwards a completed PRAT request with the urgency category flagged to the SBHO ASO. All telephonic information is followed-up with the required documentation. ASO immediately reviews the PRAT information, diagnosis information and any additional clinical documentation to support the request, prior to making a service determination, within 3 days from the request. ASO provides an authorization determination within 3 working days from the date of request for mental health services. The CMHA may extend the 3 day time period up to 14 calendar days if the individual applying for services requests an extension, or if the provider justifies a need for additional information and how the extension is in the individual s interest. Written notification of approved or denied services is provided via mail. 16

30 Adult Services Level 1 & 2 Services Inactivation & Reactivation of Services Service Description Clinical inactivation refers to an individual who has left services within an authorized benefit period. Clinical inactivations can occur at any point throughout an authorized episode of treatment. When there has been no direct services provided for authorized episodes over 90 days, the SBHO strongly recommends supervisory review and consideration for administrative closure. Administrative inactivation refers to the expiration of an authorized benefit period (6 or 12 months). In rare occurrences, an administrative inactivation is requested when an individual moves out of the catchment area (including entering the prison system) or dies within an authorized benefit period. Reactivation refers to re-opening a previously clinically inactivated case, within the initial authorized benefit period. Inactivation Scenarios Applies to Medicaid and Non-Medicaid individuals. Clinical inactivations may occur when any of the following apply: 1. The client met their expected treatment goals/outcomes 2. The client is over the age of 13 years and requests inactivation of treatment 3. The client is not participating in treatment, has not responded to engagement efforts, and imminent risk issues are not present 4. The client s whereabouts are unknown, and three attempts to contact them (by two different means) have been unsuccessful 5. The client s treatment needs can be met through other services available within their support system; care is being/ has been transitioned to another entity Administrative inactivations may occur when any of the following apply: 1. The client does not meet continuing stay criteria and the benefit period expires 2. The client has moved out of the SBHO 3. The client is deceased Reactivation Criteria Applies to Medicaid and Non-Medicaid individuals. The request for reactivation is made by a MHP or the primary clinician, under the supervision of a MHP. Non-Medicaid individuals may only be re-activated if there are sufficient resources to support the re-activation service plan. Reactivation summary is required to document current information. No additional authorization is required (as a case is being re-opened during a previously authorized and within a current benefit period). Authorization Protocols Inactivations CMHA records the clinical inactivation and discharge summary in the clinical record and Profiler system. The ASO generates a monthly report to identify individuals with pending administrative inactivations. After 10 days, if the Medicaid individual does not contact the ASO or CMHA requesting on-going services the inactivation is processed/ authorized. Reactivations Reactivation documentation is present in the clinical record and re-activation status is entered into Profiler. No additional authorization is required (as a case is being re-opened during a previously authorized and within a current benefit period). 17

31 Adult Services Community Hospital Inpatient Services - Voluntary & Involuntary Service Description Community hospitalization services for adults include evaluation, stabilization and treatment services and can be authorized prior to an intake. All ITA and revocations to inpatient services are provided a certification number and automatically authorized for 20 days. A SBHO network crisis team designated to an individual s geographical area (DMHP) may provide a face to face assessment for inpatient service requests. All voluntary hospitalizations must be made by a MHP Voluntary Admission Criteria Voluntary inpatient admissions must meet all of the following baseline criteria: 1. The existence of a DSM-5 disorder. 2. Evidence that the admission is medically necessary. 3. The individual poses an actual or imminent danger to self, others or property due to a mental disorder, or The individual has experienced a marked decline in ability to care for self due to the onset or exacerbation of a psychiatric disorder. 4. There is a verified failure of treatment at a lesser level of care, or A DMHP determines severity of symptoms, intensity of treatment or lack of supports cannot be provided at a lesser level of care. 5. Medical evaluation determines that the individual s current medical needs do not exceed the level of care available in the inpatient setting. Voluntary Continuing Stay Criteria & Extension Requests When an individual may exceed the initial authorization expiration date, a request for continuing stay is required prior to the expiration date. The inpatient facility is responsible for requesting an extension at least 24 hours prior to the expiration date. The inpatient facility must contact the designated network CMHA to request the extension. Only the network CMHA can make a request for a continuing stay voluntary hospitalization to CommCare. The continuing care/ extension request is case specific and there is no range for authorization. At least one of the following criteria must be present for continuing stay authorization: 1. The full assessment has not been completed and cannot be completed at a lesser level of care 2. The individual continues to pose actual or imminent danger to self, others, or property that cannot be contained at a lesser level of care 3. The individual demonstrates an inability to function or is gravely disabled and continues to require on-going inpatient care. 4. The individual s level of functioning has regressed since admit 5. The individual continues to need re-stabilization to reach baseline functioning and further improvement in condition is expected. Discharge Considerations Discharge happens as soon as a less-restrictive plan for treatment can be safely implemented. Reasonable efforts must be made to meet all of the following: 1. Inpatient treatment plan objectives have been substantially met or unmet objectives can be resolved at a lesser level of care. 2. Unresolved treatment plan objectives are addressed in a discharge plan and an appropriate outpatient program is identified. 3. Discharge to a less intensive level of care does not pose a threat to the individual, others or property and the treating physician authorizes the discharge. 4. For AMA discharges, contact information for local crisis line and community mental health agency is provided. Inpatient Facility Transfers and Legal Status Changes With changes within an authorized episode, an individual can be transferred from one inpatient facility to another without meeting new admission criteria. With transfers occurring with expiring authorization, an individual must meet continued stay criteria to be authorized A new certification number must be requested and is automatically issued to differentiate between inpatient facilities and legal status changes. Retro-authorizations A community hospital may request retro-authorization reviews. For out of state retro-authorization requests, the request must be made within three months of discharge. 1. The retro-authorization determination can take up to an additional 30 days. 2. Individual currently admitted to inpatient facility, CommCare may provide a verbal review and retro-authorization. 3. Individual discharged from inpatient facility, CommCare requires hospital documentation for comprehensive review and determination Type of Services/Modalities May include individual and family therapy, milieu therapy, psycho-educational groups and pharmacology. Intensity of Service 24/7 acute psychiatric inpatient care. Duration of Episode For ITA or if LRA is revoked, the authorization is automatically approved (admission and continuing stay) for 20 days. For voluntary hospitalizations, the standard benefit period for admission and extension requests is determined and requested by the CMHA crisis team (standard range is 1 to 3 days ). Authorization Protocol The ASO collects the necessary information for Provider 1 Prior Authorization from Profiler or verbally, identifying the requested inpatient authorization, funding source, and supporting clinical documentation. ASO verifies voluntary criteria sufficiently met through supporting documentation, and provides the authorization determination within 12 hours of request. If criteria and medical necessity for voluntary admission is not sufficiently met, CommCare may authorize administrative days. With an inpatient service denial, the ASO provides a Peer Review and service denial notification within 1 business day. 18

32 Adult Services Adult Inpatient Unit (Network E&T) - Voluntary & Involuntary Service Description Inpatient hospitalization for adults at Kitsap Mental Health Services (KMHS) Adult Inpatient Unit (AIU) that include evaluation, stabilization and treatment and can be authorized prior to an intake. All ITA and revocations to inpatient services are provided a certification number and automatically authorized for 20 days. The SBHO network crisis team designated to an individual s geographical area (DMHP) may provide a face to face assessment for inpatient requests. All voluntary hospitalizations must be made by a MHP Voluntary Admission Criteria- up to a standard 20 day initial authorization. Voluntary inpatient admissions must meet all of the following baseline criteria: 1. The existence of a DSM-5 disorder. 2. Evidence that the admission is medically necessary. 3. The individual poses an actual or imminent danger to self, others or property due to a mental disorder, or The individual has experienced a marked decline in ability to care for self due to the onset or exacerbation of a psychiatric disorder. 4. There is a verified failure of treatment at a lesser level of care, or A DMHP determines severity of symptoms, intensity of treatment or lack of supports cannot be provided at a lesser level of care. 5. Medical evaluation determines that the individual s current medical needs do not exceed the level of care available in the inpatient setting. Voluntary Continuing Stay Criteria & Extension Requests When an individual may exceed the initial authorization expiration date, a request for continuing stay is required prior to the expiration date. The E&T must contact the network CMHA that initiated the admission to request the extension. Only the network CMHA can make a request for a continuing stay voluntary hospitalization to CommCare. The continuing care/ extension request is case specific and there is no range of days for authorization. At least one of the following criteria must be present for continuing stay authorization: 1. The full assessment has not been completed and cannot be completed at a lesser level of care 2. The individual continues to pose actual or imminent danger to self, others, or property that cannot be contained at a lesser level of care 3. The individual demonstrates an inability to function or is gravely disabled and continues to require on-going inpatient care. 4. The individual s level of functioning has regressed since admit 5. The individual continues to need re-stabilization to reach baseline functioning and further improvement in condition is expected. Once an individual is admitted to the E&T, the CMHA must contact the E&T to begin coordinating care within one business day.. Discharge Considerations Discharge happens as soon as a less-restrictive plan for treatment can be safely implemented. Reasonable efforts must be made to meet all of the following: 1. Inpatient treatment plan objectives have been substantially met or unmet objectives can be resolved at a lesser level of care. 2. Unresolved treatment plan objectives are addressed in a discharge plan and an appropriate outpatient program is identified. 3. Discharge to a less intensive level of care does not pose a threat to the individual, others or property and the treating physician authorizes the discharge. 4. For AMA discharges, contact information for local crisis line and community mental health agency is provided. Inpatient Facility Transfers and Legal Status Changes With changes within an authorized episode, an individual can be transferred from one inpatient facility to another without meeting new admission criteria. With transfers occurring with expiring authorization, an individual must meet continued stay criteria to be authorized for 20 days A new certification number must be requested and is automatically issued to differentiate between inpatient facilities and legal status changes. Type of Services/Modalities May include individual and family therapy, milieu therapy, psycho-educational groups and pharmacology. Intensity of Service 24/7 acute psychiatric inpatient care. Duration of Episode For ITA or if LRA is revoked, the authorization is automatically approved (admission and continuing stay) and LOS is determined by court order. For voluntary hospitalizations, the benefit period is up to 20 days for admission and extension requests are requested by the CMHA/ determinations are made by the ASO. Authorization Protocol Only the network CMHA can request authorization for inpatient E&T services, all other parties must facilitate their request through CMHA. The ASO collects the necessary information for an inpatient certification from Profiler or verbally, identifying the requested inpatient authorization, funding source, and supporting clinical documentation. All extension requests must be submitted to the SBHO for review 3 calendar days prior to the expiration. Upon SBHO review, the request is forwarded to CommCare for authorization. The ASO verifies voluntary criteria sufficiently met through supporting documentation, and provides the authorization determination within 12 hours of request. If criteria and medical necessity for voluntary admission is not sufficiently met, CommCare may authorize 19

33 administrative days. With an inpatient service denial, the ASO provides a Peer Review and service denial notification within 1 business day. SBHO conducts 100% review of all NOAs and tracks appeals. 20

34 Adult Services Residential Services: Brief & Long Term Intensive Service Description Residential services are services provided to assist individuals living in community-based settings, like Keller House and Arlene Engel House. Residential services differ from other services in terms of location and duration. Residential services can be brief or long-term: Brief Residential Service is defined as residing 28 days or less at a facility. Long Term Intensive Service is defined as residing 180 days or less (within 6 months) at a residential facility. Routine Admission Criteria Individuals with Medicaid and Non-Medicaid coverage. Non-Medicaid individuals will only be authorized within available resources. Must meet Access to Care Standards (ACS) or admission to outpatient services (medical necessity criteria, functional impairment, and diagnosis) Must be requested service by MHP and deemed medically necessary. An individual must demonstrate one of the following to be admitted: 1. The presenting signs of a psychiatric illness clearly demonstrate a need for residential level structure, supervision and treatment that cannot be stabilized at a lesser level of care. 2. The individual has a history or recent episode of failing to live independently in the community due to his/her psychiatric illness. In addition to the above criteria, all the following must apply: 1. The individual is an adult age 18 years or older. 2. The individual is ambulatory and does not require physical or chemical restraints. 3. The individual has adequate cognitive functioning to enable him/her to respond to fire alarms and evacuate the premises without emergency assistance. 4. The individual is currently enrolled in outpatient services and has a current Crisis Plan, or is in the process of being authorized and assigned to outpatient services. Exclusion Criteria If an individual demonstrates any of the following, they are excluded from residential services: However, the exclusion can be waived based on the individual s level of functioning. 1. The individual has a psychiatric condition that qualifies for a higher level of care. 2. The individual is actively suicidal and/or homicidal, per MHP staff assessment. 3. The individual has a recent history of a pattern of assault/violent behaviors toward self or others. 4. The individual has a physical condition requiring medical or nursing care available only in a hospital or other more intensive nursing environment. Cases requiring limited medical or nursing care will be evaluated on an individual basis by SBHO Registered Nursing (RN) staff. 5. The individual is in need of detoxification. 6. The individual has a history of being a sexual predator or of committing arson. Continuing Stay Criteria At least one of the following criteria must be met: 1. Admission criteria for residential services continues to be met. 2. The individual must have a treatment plan that identifies need and measurable goals for residential services. The individual must be making progress toward treatment goals. 3. For supported living homes, the individual may choose to stay for an extended period while enrolled in an outpatient episode of care. Discharge Considerations One of the following must be met for discharge from residential services: 1. The individual s residential treatment goals have been sufficiently met. 2. The individual no longer meets admission or continuing stay criteria for residential services, or meets criteria for a less/more intense LOC. 3. There is an appropriate discharge plan to a less restrictive level of care that identifies components for maintaining treatment gains. 4. Consent for treatment is withdrawn, and it is determined that the individual does not meet the criteria for residential treatment. If the individual is non-compliant in treatment or in following the residential program rules and regulations, despite treatment attempts to address non-compliance issues, they may be discharged to a more/less intensive level of care. Type of Services/Modalities Residential program that includes therapeutic, medical, and assisted living for individuals. Authorization Protocol The SBHO residential authorization requirements will not conflict with or overrule Boarding Home licensing requirements. Evictions will be in compliance with Boarding Home WAC A-2660 (Residents Rights) and applicable Landlord/Tenant laws. CMHA determines funding eligibility, establishes medical necessity, and identifies placement. 21

35 CMHA submits a PARS form (identifying requested residential service level, documenting criteria requirements and medical necessity) to SBHO delegated ASO. ASO reviews PARS and supporting documentation prior to authorization determination. ASO provides an authorization determination within 14 calendar days from the date of request for services. With a service denial, the ASO mails written notification to the individual. 22

36 Adult & Child/Youth Services Crisis & Stabilization Respite 23

37 Adult & Child/Youth Services Crisis & Stabilization Service Description A crisis is defined as a turning point in the course of anything decisive or critical, a time, a stage, or an event or a time of great danger or trouble, whose outcome decides whether possible bad consequences will follow. Services are intended to stabilize the person in crisis, prevent further deterioration and provide immediate intervention. Stabilization services are to be provided in the person's own home, or another home-like setting, or a setting that provides safety for the individual and the mental health professional. Stabilization services may include ancillary crisis services to cover costs for room and board. SBHO network CMHAs mental health crisis response teams are authorized to coordinate stabilization services. The CMHAs may coordinate crisis stabilization services outside their designated areas, and within the network, in order to ensure access and availability. Routine Admission Criteria Individuals with Medicaid and Non-Medicaid coverage. For stabilization services to be provided, all of the following baseline criteria must be met: 1. The individual is in crisis, as defined above. 2. The stabilization services will prevent further deterioration. 3. The stabilization services are located in the best-suited and least restrictive environment. 4. The stabilization services are medically necessary, as determined by a MHP. 5. The individual does not meet criteria for a more intensive level of care. 6. The individual agrees to participate in the voluntary stabilization service(s). 7. A description of the stabilization services that are to be provided with an estimate length of the service(s) duration, up to 14 days per episode, is documented in the crisis/ clinical chart. Admission Exclusion Criteria Stabilization services are not provided if any of the following apply: 1. The individual is in need of medical stabilization for physical/organic dysfunctions beyond the scope and resources of the stabilization service(s). 2. The individual is assessed to be in need of an inpatient facility. 3. The individual is in need of drug/alcohol detoxification. 4. When an individual exceeds the initial authorization amount and a request for continuing stay is made, at least one of the following criteria must be met. Continuing Stay Criteria All of the following must apply: 1. Admission criteria for this level continues to be met. 2. A description of explaining the continued need for the stabilization service(s) with an estimated length of the service(s) duration documented in the crisis/clinical chart. When an individual exceeds the initial planned amount (up to 14 days), continuing stay is required to continue to provide the stabilization services. Discharge Considerations Any of the following may lead to a discharge of stabilization service(s): 1. The individual no longer meets admission criteria. 2. The individual requires a less/more restrictive level of care. 3. There is a reasonable plan for follow-up services, in or outside the network, identified.. The individual requests discharge/ termination of stabilization service(s). If a child, the caregiver requests discharge/ termination of stabilization service(s). Type of Services/Modalities Stabilization services include short-term (up to 14 days, per episode) face-to-face assistance with life skills training and/ or understanding of medication effects. Authorization Protocol Stabilization services are considered a crisis service modality available to all residents of the SBHO. Crisis stabilization services do not require authorization from the SBHO and can be provided prior to an intake assessment. The CMHA MHP determines when stabilization services are medically necessary for initial and continuing stay. Initial authorization cannot exceed14 days and continuing stay cannot exceed 14 days, per episode. Only one episode can be authorized at a time. 24

38 Adult & Child/Youth Services Respite Service Description Respite Care services are used to sustain the primary caregivers of children and youth with emotional disorders or adults with mental illness. Respite care is provided in a manner that provides necessary relief to caregivers. Respite services include providing observation, direct support and monitoring to meet the physical, emotional, social and mental health needs of a individuals by someone other than the primary caregivers. Respite services are provided by, or under the supervision of, a mental health professional. Respite services may be provided in a variety of settings, such as the caregiver's home, in an organization's facilities, or in the respite worker's home. The care should be flexible to ensure that the individual's daily routine is maintained. Respite services may be provided on a planned or an emergent basis and are voluntary. Only SBHO network CMHAs are authorized to provide respite services. All other interested parties must facilitate their requests through the CMHAs. Routine Admission Criteria Individuals with Medicaid and Non-Medicaid coverage. For respite care service(s) to be provided, all of the following standard criteria must be met: 1. The individual must be currently authorized for SBHO funded outpatient care, the expedited admission review process can be used 2. The respite care services are medically necessary. 3. The individual does not meet criteria for a more intensive level of care. 4. The individual agrees to participate in the voluntary respite care service(s). 5. A description of the respite care service(s) that are provided with an estimate length of the service(s) duration is documented in the clinical chart. In addition to the required criteria listed above, at least one of the following must apply: 1. The individual s caregiver has no other respite options available at the time of the needed service. 2. The individual faces a potential crisis such as a housing emergency, significant loss, etc. and without respite support would be at significant risk for decompensation and potential hospitalization. 3. The individual is in need of continuous support and supervision during a medication titration. Admission Exclusion Criteria Respite care services are not provided if any of the following apply: 1. The individual is in need of medical stabilization for physical/organic dysfunctions beyond the scope and resources of the respite service. 2. The individual is assessed to be in need of an inpatient facility 3. The individual is in need of drug/alcohol detoxification. Continuing Stay Criteria All of the following must apply: 1. Admission criteria for this level of care must continue to be met. 2. The individual must have a treatment plan that identifies need and measurable goals for respite care services. The individual s progress toward treatment goals is based on the effectiveness of the respite services to the overall treatment plan. Discharge Considerations Any of the following may lead to a discharge of respite service(s): 1. The individual no longer meets respite admission criteria, or outpatient authorization expired and does not meet criteria for continued outpatient services. 2. The individual requires a less/more restrictive level of care. 3. The plan for the respite service was successfully completed. 4. There is a reasonable plan for follow-up services in place. 5. The individual requests discharge/ termination of respite service(s). If a child, the caregiver requests discharge/ termination of respite service(s). Type of Services/Modalities Respite services include providing observation, direct support and monitoring to meet the physical, emotional, social and mental health needs of a individual by someone other than the primary caregivers. Authorization Protocol Respite services are authorized with outpatient services, no additional authorization is required. A Respite benefit period is the same as the authorized outpatient services benefit period. Reference LOC for Outpatient Services. 25

39 SALISH BHO UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: INTAKE ASSESSMENT AND EVALUATION SERVICES STANDARDS Policy Number: 7.04 Reference: WAC ; WAC A-0130 DSHS Contract Effective Date: 9/2005 Revision Date(s): 1/2013; 7/2016 Reviewed Date: 12/2014; 7/2016; 6/2017 Approved by: SBHO Executive Board CROSS REFERENCES Attachment: Access and Authorization Standards Grid Form: Peninsula Regional Assessment Tool (PRAT) Letter: Notice of Action Form Letter Template Letter: SBHO Authorization Notification Letter Template Letter: SBHO Letter of Ineligibility Template Policy: Access to Services, Timely Policy: Corrective Action Plans Policy: Notice of Action Requirements Policy: Option to Choose a Mental Health Care Provider/Clinician PURPOSE The Salish Behavioral Health Organization (SBHO) shall ensure Medicaid enrollees requesting outpatient services will receive an intake assessment and evaluation services that are provided in accordance to Access to Care standards, and other applicable state and federal regulations, culturally and age appropriate, and conducted in a standardized and uniform way. For Non-Medicaid individuals requesting outpatient services, authorization will depend on the individual meeting the SBHO additional Non-Medicaid criteria and within available resources. Intake Assessment and Evaulation Services Standards 7.04 Page 1 of 6

40 Salish BHO Policies and Procedures DEFINITIONS A request for mental health services is defined as a point in time when mental health services are sought or applied for through a telephone call, Early Periodic Screening and Diagnostic Testing (EPSDT) referral, walk-in to a network provider, or written request for mental health services by the individual or by a person authorized to consent for treatment for that individual. A Medicaid eligible, recipient, or enrolled individual with entitlements that include mental health benefits shall be considered as Medicaid funded. A Non-Medicaid individual shall be considered a person with no Medicaid mental health benefit coverage. Some examples of non-medicaid include individuals with private insurance, private insurance and no mental health benefits, no insurance, and individuals on a Medicaid spend-down and the spend-down has not been met during a specific time period to ensure Medicaid mental health coverage. PROCEDURE 1. An intake assessment is initiated prior to the provision of any non-crisis mental health services. 2. The SBHO ensures individual choice by contracting with comprehensive mental health agencies that: a. Provide individuals a choice of accessible mental health care providers and programs. Reference SBHO Policy: Option to Choose a Mental Health Care Provider/Clinician b. Are responsible for geographical catchment areas. The agencies are contracted to meet the required travel standards for their designated areas. c. Bring services to the individual or locate services (such as off-site offices) to sites where transportation is available to individuals. d. Ensure that when individuals must travel to service sites, the sites are accessible per the following contract standards: In rural areas, service sites are within a 30-minute commute time. In large rural geographic areas, service sites are accessible within a 90-minute commute time. In urban areas, service sites are accessible by public transportation with the total trip, including transfers, scheduled not to exceed 90- minutes each way. Intake Assessment and Evaluation Services Standards 7.04 Page 2 of 6

41 Salish BHO Policies and Procedures Travel standards do not apply: a) when the individual chooses to use service sites that require travel beyond the travel standards; b) to psychiatric inpatient services; c) under exceptional circumstances (e.g. inclement weather, hazardous road conditions due to accidents or road construction, public transportation shortages or delayed ferry service). 3. Medicaid and Non-Medicaid Intake Assessment and Evaluation Services availability: a. Medicaid enrollees shall be provided an intake assessment and/or evaluation services, based upon Medicaid verification and request for services. All covered mental health services deemed medically necessary shall be authorized, per the SBHO Level of Care standards, and provided. b. Non-Medicaid individuals shall be provided an intake assessment and/or evaluation services and all other medically necessary mental health services, if there are available resources and criteria is met. 4. Access to services: a. The SBHO network providers must provide an intake assessment and/or evaluation services that are consistent with WAC that is culturally and age relevant. b. Routine outpatient services may begin before the completion of the intake assessment once Access to Care criteria and medical necessity are established, and services are authorized. c. Ensure that services provided in the office, an individual should not have to wait for over an hour beyond their scheduled appointment time. d. Provide emergent mental health services within two (2) hours of the request for mental health services from any source. Reference SBHO Policy: Access to Services, Timely e. Provide urgent care within twenty-four (24) hours of the request for mental health services from any source. f. Intake assessments and evaluation services are provided by a mental health professional. For children and youth, the mental health professional must be a child mental health specialists, or under the supervision of. 5. All Intake Assessment documentation must: a. Be conducted by a mental health professional b. Be initiated prior to the provision of any non-crisis mental health services c. Be initiated within ten (10) working days of the request for services and completed within thirty (30) days of the initiation Intake Assessment and Evaluation Services Standards 7.04 Page 3 of 6

42 Salish BHO Policies and Procedures d. Be developed in collaboration with the individual seeking services e. Be inclusive of input of people who provide active support to the individual f. Include a copy of consent for treatment or copy of the detention/ ITA treatment order g. Include a determination if medical necessity criteria is met for requested treatment services h. If seeking any of the information required presents a barrier to the provision of services for the individual, any portion of the intake may be left incomplete providing the reason for the omission is clearly documented in the clinical record. 6. Full intake assessment must be completed for individuals authorized for outpatient services. In addition to the above, a full intake assessment documentation must include: a. A description of the presenting problem and presented needs b. A description of the individual s and family s strengths c. Needs of the individual and desired outcomes in their own words d. History of the individual s culture/ cultural history e. A history of the other disorders, substance/alcohol abuse, developmental disability, any other relevant disability and treatment, if any f. History of medical issues, hospitalizations, treatment, past and current medications g. History of mental health services, past and current medications h. Assessment of current risk, including suicide/ homicide and self-harm i. Sufficient information to support a provisional diagnosis j. Documentation of if they ve been asked if they are under the supervision of DOC or juvenile court. k. In addition for children and youth the following must be included: a developmental history parent s goals and desired outcomes (with minor consent, as required), family or placement issues, including family dynamics, placement disruption and current placement needs conducted by (or under the supervision of ) a child mental health specialist, and With an EPSDT referral, the additional assessment and evaluation information required in the SBHO EPSDT Plan and Requirements 7. At the time of the Intake Assessment, the individual seeking services must be provided: Intake Assessment and Evaluation Services Standards 7.04 Page 4 of 6

43 Salish BHO Policies and Procedures a. Consent for treatment information b. Individual rights, reviewed. The DSHS Benefit booklet, made available when an individual enrolls in a Medicaid plan, includes the individual rights information. c. SBHO Grievance and Ombuds Information d. An opportunity to choose a primary mental health care provider. Reference SBHO Policy: Option To Choose A Mental Health Care Provider policy 8. Intake Assessment and Authorization Timeliness. 1. For Medicaid enrollees. an intake assessment must be initiated within ten (10) working days from the time of the request for services. The intake assessment must be completed within thirty (30) calendar days of the initiation of the intake assessment or provided documentation how gathering the information would present as a barrier to the individual seeking the service. Reference: Access and Authorization Standards Grid A request for services is defined above. 2. An authorization request for outpatient services (PRAT) and supporting documents must be submitted to the ASO immediately following the initiation of the intake assessment. The Intake Assessment document does not need to be complete at the time of request. An authorization determination will take no longer than fourteen (14) calendar days from the time of the initiation of the intake assessment, otherwise an extension authorization must be requested and approved by the ASO. A provider may request an additional fourteen (14) days, once the initial fourteen (14) days has expired following the initiation of an intake assessment, to determine medical necessity and request outpatient authorization. An extension must be requested on the admission PRAT if the date exceeds fourteen (14) calendar days past the date the intake assessment begun. The PRAT, along with extension request statement, must be submitted and approved by CommCare. 3. Upon authorization approval, the first routine outpatient appointment must be offered within fourteen (14) calendar days. 9. Medicaid denial of authorization for an Intake Assessment. Medicaid enrollees will be offered an intake appointment, upon request, and are not denied an intake assessment. a. Any denial to provide an Intake Assessment to a Medicaid enrollee by a SBHO contracted network provider shall result in a SBHO Notice of Action (NOA) letter sent to the individual requesting outpatient services. b. The SBHO network provider will contact the SBHO office immediately to report that an intake assessment for a Medicaid recipient/enrollee had been denied. Intake Assessment and Evaluation Services Standards 7.04 Page 5 of 6

44 Salish BHO Policies and Procedures c. Once an intake assessment is complete and it is determined that the Medicaid individual does not meet Access To Care entrance criteria, Notice of Action (NOA) letter must be mailed to the individual. Information about requesting a second opinion, local Ombuds, and how to request appeal are all included. d. A copy of all NOA letters sent must be forwarded to the SBHO office for 100% review. Reference SBHO Policy: Notice Of Action Notification 10. SBHO ensures that providers maintain the ability to provide intakes to Enrollees in their residence, including adult family homes, assisted living facilities and skilled nursing facilities when required due to medical needs. MONITORING This policy includes contract and statute mandates. 1. This policy is monitored through the use of the SBHO: Annual SBHO Provider and Subcontractor Administrative Review Annual Provider Chart Review SBHO Grievance Tracking Reports Quality Management Plan activities, such as review targeted issues for trends and recommendations UM Monthly Authorization Tracking Report 2. If a provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. Intake Assessment and Evaluation Services Standards 7.04 Page 6 of 6

45 7.04a Appointment and Authorization Standards for Medicaid 42 CFR Calendar Days 42 CFR CFR Appointment Standards (5.8.5, 6.3) Intake Evaluation (Initiation) (per CFR) Available and offered within 10 working / 14 calendar days 1 Intake Evaluation (Completion) (per CFR) Completed within 28 working days of request for service 2 1st Routine Appointment 3 Must be offered no later than 28 calendar days from date of request for services 3 Authorization Standards (6.6.4, 7.3) Authorization Decision Within 14 days of request for service Up to 14 additional days upon request of enrollee or BHA 4, 5 Notice of Determination Notice of Adverse Benefit Determination Continuation of Routine Services (7.3) Authorization of Additional Routine Services Within 14 days of request for service (services authorized, no additional services requested by MHA due to lack of medical necessity, right to 2nd opinion, availability of other EPSDT services) Within 14 days of request for service, when the decision is to deny or authorize services in an amount, duration, or scope that is less than requested 6 Within 14 days of the date request for service Within 14 days of authorization decision (services authorized, no additional services requested by BHA due Notice of Determination to lack of medical necessity, right to 2nd opinion, availability of other EPSDT services) Termination, Reduction, or Suspension of Previously Authorized Services ( ) Notice of Adverse Benefit Determination At least 10 days prior to the date of the Adverse Benefit Determination 7 1 Unelss both of the following conditions are met: 1) an intake has been provided in the previous 12 months that establishes medical necessity and 2) the PIHP agrees to use the previous intake evaluation as the basis for authorization decisions. 2 Contractor must request authorization extension and document reason for delays. This includes documentation when the Individual declines an intake appointment within the first ten (10) business days. 3 Contractor must document reasons for any delays, including when the individual declines an appointment offered within 28 days and must monitor the frequency of appointments that occur after 28 days and apply corrective action where needed. 3 May occur before the completion of the intake evaluation once medical necessity has been established. 4 Should all include, "the Contractor demonstrates the need for additional information to make an authorization decision and that the extension is in the Enrollee's best interest." 5 Must have P&P to ensure consistent application of extensions within the service area must monitor use and pattern of extensions apply corrective action where necessary. 6 Includes instances where Individual is requesting a specific Level of Care (LOC) the SBHO provides, and that LOC is denied. 7 See 42 CFR for exceptions to 10 day advance notice

46 SALISH BHO UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: PENINSULA REGIONAL ASSESSMENT TOOL (PRAT) Policy Number: 7.05 Reference: 42 CFR Effective Date: 1999 Revision Date(s): 1/2013 Reviewed Date: 12/2014; 6/2017 Approved by: SBHO Executive Board CROSS REFERENCES Attachment: Outpatient Access and Authorization Standards Grid Form: Peninsula Regional Assessment Tool (PRAT) Form Policy: Authorization for Outpatient Services Based on Medical Necessity PURPOSE This policy applies to all Salish Behavioral Health (SBHO) enrollees and contracted Salish Behavioral Health (Mental Health) provider agencies. The Peninsula Regional Assessment Tool (PRAT) is the standardized authorization request tool, used to request and authorize outpatient mental health services. The PRAT is updated and revised as needed. PROCEDURE 1. All SBHO Contracted Provider Mental Health Agencies use the PRAT All SBHO contracted mental health provider agencies use the PRAT as the standard mechanism for requesting outpatient mental health service authorization, including: Admission Admission criteria- not met Continuation of an expired benefit period Change of level requests Inactivation The PRAT is NOT used to request crisis, inpatient, or residential services. Peninsula Regional Assessment Tool (PRAT) 7.05 Page 1 of 4

47 Salish BHO Policies and Procedures 2. Roles a. Network Provider Agency: The primary assigned clinician, under the supervision of a mental health professional, or a mental health professional completes the PRAT with current information and submits it to the SBHO contracted Administrative Service Organization (ASO) requesting authorization of services. For children and youth, an agency-based child mental health specialist must review the authorization request prior to submitting to CommCare for a determination. b. The SBHO ASO Utilization Management contractor: Provides staff members with the clinical expertise in treating the client s condition to review the PRAT service level request. Reviews the PRAT for completeness, including Medicaid eligibility verification. Requests any additional information required to make an authorization determination. May consult with the agency staff completing the PRAT, when appropriate. Using the SBHO Level of Care criteria, makes an authorization determination for the requested outpatient mental health services. Returns PRAT to provider agency with the authorization determination specified. Must make the authorization request within the contract specified timeframes. Reference SBHO grid: Outpatient Access and Authorization Standards Grid For denial of services determination, notifies the individual requesting the services. Reference SBHO Policy: Authorization for Outpatient Services Based on Medical Necessity c. Network Provider Agency, upon receiving authorization determination: If the PRAT is pended, immediately follows-up with the ASO to provide the requested additional information If authorized as requested, the authorized PRAT becomes part of the agency permanent electronic medical record Implements the actions outlined in the SBHO Utilization Management Protocols 3. PRAT is completed at Specific Treatment Intervals The network provider completes the PRAT and submits it, as well as any requested supporting documentation to the SBHO ASO within the specified timeframes: For admission requests and denials, immediately following the intake assessment. Peninsula Regional Assessment Tool (PRAT) 7.05 Page 2 of 4

48 Salish BHO Policies and Procedures If the request is fourteen (14) days following a request for service, the request must include a PRAT Extension request statement. For continuing stay requests when an administrative authorization period expires, a month prior to services expiring (due to service hours or date) or within 14 (fourteen) days after an authorized episode has expired. For change of service level requests, as client needs change (increase or decrease) within a current authorized episode or within 14 (fourteen) days prior to services expiring (due to service hours or date) or after an authorization has expired For Medicaid individuals, reductions in previously authorized services, including duration and scope, a Notice of Adverse Benefit Determination (NOABD) must be issued by SBHO ASO. For inactivation requests, between two weeks prior or following the inactivation request date. For Medicaid individuals, the inactivation effective date must be ten (10) days following the date of the mailed Notice of Adverse Benefit Determination (NOABD). *Exception: When the client temporarily resides in a Children s Long Term Inpatient Facility (CLIP) or Western State Hospital (WSH). The admission PRAT will be completed upon the client s return to outpatient services. 4. PRAT Evaluates Treatment Progress and Outcomes Through use of the PRAT, the SBHO tracks: Client treatment progress Outcomes through GAF/CGAS/DC-03 scores Number of requests for changes in service level, Number of admission, continuing stay, and inactivation s- monthly trends Resource management- delivery system adequacy, trends, projected gaps MONITORING This policy includes contract and statue mandates. 1. This policy is monitored through the use of the SBHO: Annual SBHO Provider and Subcontractor Administrative Review Annual Provider Clinical Chart Review SBHO Grievance Tracking Reports Quality Management Plan activities, such as review targeted issues for trends and recommendations UMC Monthly Authorization Tracking Report Periodic Under and Over Utilization Projects Peninsula Regional Assessment Tool (PRAT) 7.05 Page 3 of 4

49 Salish BHO Policies and Procedures 2. If a provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. Peninsula Regional Assessment Tool (PRAT) 7.05 Page 4 of 4

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52 SALISH BEHAVIORAL HEALTH ORGANIZATION Utilization Management Plan FY Salish BHO Policies and Procedures The Salish Behavioral Health Organization (SBHO) Utilization Management (UM) Plan summarizes the processes, procedures, standards and monitoring mechanisms that govern the utilization management program. The SBHO UM functions attempt to strike a balance between promoting a recovery based service delivery system and effectively managing resources. The SBHO UM Plan is designed to comply with the contractual requirements outlined in the Agreement with the Washington State Department of Social and Health Services. SBHO Mission The Salish Behavioral Health Organization (SBHO) is dedicated to ensuring and continually improving the delivery of quality behavioral health care so that the individuals we serve may better manage their illness, achieve their personal goals, and live, work and participate in their community. The SBHO is committed to creating and supporting a behavioral health treatment system that focuses on supporting individuals and encouraging recovery and resiliency. We understand and promote the understanding that behavioral health is an essential element of overall health. Physical illness, mental illness, and substance use disorders are conditions from which people can and do recover. The SBHO UM program strives to assist every individual in receiving quality care through utilization of adequate resources in the most cost effective manner. The SBHO believes a managed care structure allows for the delivery of the highest possible quality care, in a coordinated and cost effective manner. Introduction The SBHO provides a full range of behavioral health services to individuals within the service delivery geographical area, providing the required covered services for the Medicaid and state only revenue contracts. The SBHO provides comprehensive and medically necessary services in a variety of settings including, but not limited to outpatient, inpatient, residential, and intensive outpatient programs. The SBHO delivers timely, appropriate, and quality behavioral health services through an effective and carefully monitored network of behavioral health providers. All services requested, authorized, and provided for individuals using SBHO funding are subject to utilization review. State funded services are provided according to the state defined priority services and additional outpatient services are provided based upon available resources. Service Delivery Structure: The SBHO has an extensive and fully licensed network of behavioral health providers that delivers comprehensive, quality care. The SBHO sub-capitates the Medicaid service funding with the core network providers, thereby ensuring full participation in implementing cost effective utilization management strategies. Rev. FY Utilization Management Plan 7.06 Page 1 of 17

53 Salish BHO Policies and Procedures Standard Authorization Structure: The SBHO has contracted with Community Network for Behavioral Healthcare, Inc. (CommCare) to authorize SBHO services requests from the provider network. CommCare is accredited by the Utilization Review Accreditation Commission (URAC) and is required to maintain the accreditation per contract. CommCare is responsible for providing service authorization determinations for services the SBHO has identified as requiring prior authorization, on behalf of the SBHO, for Medicaid and non-medicaid individuals seeking behavioral health services. SBHO Oversight Committee: The SBHO operates a UM committee to provide network oversight of the UM Plan activities, identify UM program and plan improvements, and review the Plan at least annually. The SBHO UM committee is responsible for prioritizing the UM Plan activities, targeting areas needing improvement, identifying benchmarks, and maintaining threshold capacity. The UM Committee members are listed in attachment 1. Utilization Program Goals The goal of the SBHO UM program is to provide a process that systematically monitors and evaluates service delivery to ensure individuals have access and are receiving timely and appropriate behavioral health services to meet their needs. In addition, the UM activities provide a continuous framework for network evaluation of the appropriate use and amount of current resources within the network. The process focuses on monitoring contract requirements and developing cost-effective strategies within the service delivery structure. Utilization Management Program Objectives The SBHO UM program strives to ensure easy and timely access to appropriate treatment; work collaboratively with each network provider in delivering quality care; address the needs of special populations; and make appropriate clinical decisions at the level closest to the individual. The UM program attempts to integrate with the network providers UM activities and internal quality management strategies where possible. The SBHO UM program emphasizes the principles of recovery, reintegration, rehabilitation, and resiliency which include involvement of individuals, and their families, in the direction their treatment. Utilization Management Program Structure The UM program operates in a clearly defined organizational structure (see attachment 1). The SBHO UM program is supported by adequate clinical staff from multiple levels within the service structure, including staff from CommCare, the SBHO staff, and the network provider s senior management and clinical staff. The SBHO Quality Improvement Committee (QUIC) is responsible for the overarching oversight of the UM program, prioritizing monitoring activities and reviewing UM committee functions. CommCare, the SBHO utilization management contractor, is required to adhere to Utilization Review Accreditation Commission (URAC) standards. CommCare is contracted to review authorization requests for outpatient, inpatient, and residential care. CommCare s utilization management system improves the functioning and quality of life of individual served by the SBHO by applying a clinically sound, individual-oriented, and costeffective authorization process to the regional system of care. Rev. FY Utilization Management Plan 7.06 Page 2 of 17

54 Salish BHO Policies and Procedures CommCare s Care Managers are behavioral health clinicians who are trained to address not only the psychological needs of the individual and their families, but also their medical, substance use disorder, and social needs. Each member of the clinical staff averages over four (4) years of experience in the case management of Medicaid populations. The CommCare Medical Director is a board- certified psychiatrist who oversees all of CommCare s clinical activities. (see attachment 2) The SBHO Deputy Administrator, Resource Manager, Adult Services Manager, Quality Assurance Manager, Children s Services Manager, Chemical Dependency Manager, and Residential and Long Term Care Manager participate in the SBHO UM program. The SBHO Resource Development Manager is responsible for this plan and activities monitoring for network sufficiency, facilitates the monthly UM meetings, and maintains the SBHO Level of Care criteria. The Adult Services Manager facilities the SBHO network Clinical Directors meetings. The Service Managers conduct clinical chart review, monitors internal network adherence to authorized care, and participate in the network Clinical Directors meetings. The SBHO Quality Assurance Manager is responsible for providing the linkages between the UM Plan to the SBHO Quality Management (QA) Plan, including plan activities and committees. The SBHO Children s Services Manager is responsible for oversight of the continuum of care for Children s services. The Chemical Dependency Manager conducts agency clinical reviews and monitors contract and policy adherence. The Residential and Long Term Care Manager participates in clinical reviews and provides support to residential and inpatient settings in mental health. The Utilization Management Committee (UMC) reports to the QUIC that is compiled of SBHO staff, network provider senior clinical management staff, advisory board members and clients/ client advocates. The network agency representatives have been oriented and trained on SBHO clinical criteria, case management philosophy and procedures, and treatment resources available. Each network agency provides at least one representative that routinely attends the UMC quarterly face to face meetings. The UMC is responsible for: Monitoring of the service authorization process; ensuring access to care standards are being met. Establish and review application of the SBHO criteria for each level of care. Monitoring of authorizations across all levels of care. Monitoring the process of re-authorizing or extended service outpatient authorization. Tracking inpatient service denials (including the process of appeal). Monitoring inpatient utilization trends. Established regional benchmarks and thresholds of authorization procedures. Evaluating current network sufficiency and recommending changes to the governing boards and other SBHO committees, as necessary. Recommends Corrective Action Plans for concerning trends, such as late PRAT requests. Assists in the development of UM Policies and Procedures (including Levels of Care criteria), and annually reviews UM Plan. Rev. FY Utilization Management Plan 7.06 Page 3 of 17

55 Salish BHO Policies and Procedures Reviews and makes recommendations for updates to the authorization forms (PRAT for outpatient services, PARS for residential services, certification/authorization for inpatient services, and other relevant authorization documents). Operationalizes state-directed inpatient authorization requirements/ modifications, such as the Community Psychiatric Instructions and parent Initiated Treatment. The SBHO ensures that utilization management activities are not structured in such a way as to provide incentives to any individual or entity to deny, limit, or discontinue medically necessary behavioral health services to any enrollee as evidenced in the SBHO policy: Authorization of Services: Independence from Financial Incentives. Service Authorization for Routine Care, Medicaid and non-medicaid The SBHO utilization management contractor, CommCare, uses the medical necessity criteria, Levels of Care standards, and resources available when making authorization determinations. The SBHO requires prior authorization for all routine outpatient service levels. These standards are reviewed at least annually (through chart reviews and data reports) to incorporate the evidence based and best practice industry standards in the behavioral health field. The SBHO adopts Levels of Care Standards that: a. Include the Department s Access to Care Standards. b. Promote individual progress towards the highest possible level of health and selfsufficiency. c. Can be reasonably expected to benefit the individual s behavioral health. d. Are medically necessary and appropriate to the individual s condition. e. Are designed to assist individuals in managing their illness to the greatest extent possible in order to live, learn, and work in their own communities. f. For non-medicaid services, are provided based upon available resources. Service Authorization Principles 1. The service authorization process is intended to meet all applicable requirements of the Centers for Medicare and Medicaid Services (CMS) and the Washington State Department of Social and Human Services (DSHS), Division of Behavioral Health and Rehabilitation (DBHR). 2. The service authorization process is designed to allow for rapid approval, with a minimum of steps to promote timely access to services. All service authorizations provide an expedited review process for urgent and emergent situations, as well as a standard review process. Corrective Action plans will be required for late PRATs, exceeding 15% of the monthly total. 3. Medicaid recipients/enrollees will be authorized and receive all medically necessary behavioral health services defined in the Medicaid state plan. Rev. FY Utilization Management Plan 7.06 Page 4 of 17

56 Salish BHO Policies and Procedures 4. Individuals not enrolled in Medicaid will be authorized and receive medically necessary outpatient behavioral health services subject to availability of resources. 5. All individuals residing within the SBHO have access to state funded crisis services. 6. Family member involvement is valued by the SBHO. Families will be encouraged to be involved in the assessment, service planning and treatment process whenever possible. Family non-involvement will not result in denial of service. 7. Authorized services will be provided in the most clinically effective, cost effective and least restrictive setting. Outpatient Service Authorization Process 1. Following the Intake Assessment, service admission authorization requests typically are made by the SBHO network provider behavioral health professional that conducted the intake assessment. Requests are made using one of the following methods: (1) the Peninsula Regional Assessment Tool (PRAT) and submitted electronically to CommCare via ProFiler. ProFiler is the regional Electronic Medical Record (EMR). (2) the Substance Use Disorder Outpatient Authorization Tool and is submitted via secured or fax to Commcare. 2. The admission PRAT for outpatient services requires the following information: Medicaid recipient/enrollee or Non-Medicaid assigned funding. Multi-axial diagnosis, including if there is a covered A or B diagnosis and the required additional criteria for B diagnosis. Access to Care standards, including medical necessity criteria questions. Requested Level of Care (Mental Health refer to Mental Health Level of Care Policy, 7.03 and Substance Use Disorders refer to Substance Use Disorder Level of Care Guidelines Policy, 7.08). o Mental Health: For Level 2 services, additional risk assessment criteria. For admission authorization beyond 14 days from the intake or assessment, a request for an extension is required. For Substance Use Disorder Outpatient Authorizations: Releases for both CommCare and SBHO are completed and sent with completed authorization. For Substance Use Disorder Outpatient Authorizations: Priority is given to the following: pregnant women who use IV drugs, pregnant women, others who use IV drugs, post-partum women (up to one year). Other prioritized groups that are considered: Parents/legal guardians involved with Child Protective Services, parenting adults, and youth. (optional) If entrance criteria is not met, referral provided. (optional) There is a text box that allows for additional information to be provided by the requestor. Rev. FY Utilization Management Plan 7.06 Page 5 of 17

57 Salish BHO Policies and Procedures 4. CommCare may review additional documentation, such as the Intake or Assessment and other relevant information available in the electronic medical record in making an authorization determination according to the SBHO standards. 5. CommCare will make an authorization determination within 14 days. CommCare will document the determination either on the PRAT and transmit an on-line authorization determination back to the network provider or complete their portion of the Substance Use Disorder Outpatient Authorization Request Tool (indicating the appropriate level of care and authorization dates) and return it to the agency via secure or fax. Authorization determinations will be placed in client s chart. The SBHO directly notifies individuals in writing when outpatient services are authorized. The SBHO Handbook accompanies the notification letter. When requested services are denied authorization, CommCare mails a letter of determination to the individual. 6. If the requested service is denied, individuals are found to not qualify for outpatient services, or there are not sufficient resources to provide services, CommCare will issue a Notice of Adverse Benefit Determination letter, on behalf of the SBHO, to the Medicaid and non-medicaid individual. The notification letter is mailed directly to the individual and a copy is mailed to the SBHO office. CommCare will conduct the Adverse Benefit Determination Appeals for authorization decisions and service denials they issue for Medicaid individuals. (Reference SBHO policy: 6.05 Adverse Benefit Determination Requirements). 7. Authorization termination applies to Outpatient SUD services for an individual who has left services within an authorized benefit period. These can occur at any point during an authorized period benefit, but the providing agency must notify CommCare within 24 hours of the individual change of circumstances. Authorization termination instructions are available in SBHO policy The SBHO staff conduct retrospective reviews of a sample of authorized charts, as a part of the quality management plan and annual chart reviews of network contractors and subcontractors. The individual service plan (ISP)/treatment planning process is reviewed as a part of the retrospective reviews to ensure it: Meets the needs of the individual. Is consistent with the requested LOC and, if applicable, adopted SBHO Clinical Practice guidelines. Includes individual participation in the treatment planning process. Involved family members, when appropriate, in the evaluation and service planning processes. Rev. FY Utilization Management Plan 7.06 Page 6 of 17

58 Salish BHO Policies and Procedures Includes input from other formal service systems and is consistent with privacy requirements. 9. The SBHO staff conduct targeted chart reviews in cases in which a concern or grievance regarding the authorization determination is raised, when a network provider staff requests a review, when there has been a concerning adverse incident or potential for negative media occurs, or when determined necessary due to repeated and uncorrected errors identified in retrospective reviews. 10. If a network provider performs below expected standards during any of the reviews, listed above, a Corrective Action will be required for SBHO approval. Authorization for Inpatient Services, Medicaid and Non-Medicaid The SBHO utilization management contractor, CommCare, uses the Department of Social and Health Services Statewide Community Psychiatric Inpatient Instructions Per Diem (implemented August 1, 2007), medical necessity criteria and SBHO Levels of Care standards for Mental Health when making inpatient authorization determinations. The SBHO requires prior authorization for all inpatient services. The SBHO provides an expedited review process for urgent and emergent inpatient authorizations. All service denials of requested inpatient care are made by CommCare s board certified psychiatrist or consulting physician. A. Service Authorization Process for Inpatient The SBHO inpatient authorization process follows the Community Hospital Billing Instructions. 1. The request for inpatient services is verbally requested and followed-up with an electronically submitted request to CommCare to authorize. CommCare is required to use the medical necessity and SBHO Levels of Care for authorization determination. 2. CommCare is required to provide an authorization determination (certification) to the requesting entity. This may be an initial verbal determination via phone; followed by confirmation entered into ProFiler, Provider 1 database, and/or secure . CommCare provides written certification to the facility or individual. For voluntary retro reviews, CommCare will provide written certification to the facility and individual. 3. A SBHO Designated Mental Health Professional (DMHP) conducts a crisis face to face evaluation within 2 hours of a request and determine the level of acuity. For out of region requests, the request is verbally assessed by CommCare within 2 hours of the request. 4. The SBHO DMHP submits the request for inpatient services, providing the necessary documentation, to make an inpatient authorization determination. Mental Health/DMHP: The determination to authorize inpatient care shall be completed within 12 (twelve) hours from the initial request for authorization. The determination is entered into Provider 1 by the next business day for community Rev. FY Utilization Management Plan 7.06 Page 7 of 17

59 Salish BHO Policies and Procedures inpatient facilities and ProFiler. Determinations for requests at the local Evaluation and Treatment Centers are entered into ProFiler by the next business day. 5. If the requested service is denied, CommCare will notify provider via ProFiler and/or secure . For individuals without Medicaid coverage, a notice of adverse benefit determination (NOABD) letter will be sent and include how to request a second opinion. 6. The SBHO staff conducts retrospective reviews of a sample of inpatient authorized charts, as a part of the quality management plan, annual E&T administrative reviews, and chart reviews of network contractors and subcontractors. 7. The SBHO staff conducts targeted chart reviews in cases in which a concern or grievance regarding the authorization determination is raised, when a network provider staff requests a review, when there has been an adverse incident or potential for negative media occurs, or when determined necessary due to repeated and uncorrected errors identified in retrospective reviews. 8. If a network provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. 9. The inpatient facility is responsible for requesting extension/continuing stay requests and retro-certifications, 24 (twenty-four) hours (Mental Health, Inpatient) prior to the expiration of an episode. Extension/continuing stay authorization requests are reviewed by a mental health professional (for mental health services). CommCare makes authorization determinations for extension, continuing stay requests and retro-certifications B. Discharge Planning for voluntary hospitalizations The SBHO expects the network provider to coordinate the discharge planning for individuals voluntarily hospitalized The discharge planning process must begin within 3 days of admission and include: Purposeful use of the individual s/family s strengths Identification of what caused the individual to need hospital or out of home placement What the individual and his/her family need to be successful in the community Identified solutions to getting those needs met Offered Outpatient appointment (within 7 days of inpatient discharge) A follow-up outpatient appointment must be offered within 7 (seven) days of discharge. These discharge coordination dates are tracked using monthly UM reports. An individual, and their family, must be an integral part of the treatment and discharge planning, with a voice in the discharge placement decisions. Discharge planning is integral to the authorization, retrospective certifications, and re-authorization process. Rev. FY Utilization Management Plan 7.06 Page 8 of 17

60 Salish BHO Policies and Procedures Authorization for Substance Use Disorder and Mental Health Residential Services, Medicaid and Non-Medicaid The SBHO utilization management contractor, CommCare, uses the medical necessity criteria and SUD or Mental Health Levels of Care standards developed and adopted by the SBHO when making residential service authorization determinations. The SBHO requires prior authorization for SUD residential service and is based upon ASAM criteria. Authorization of residential services for non-medicaid individuals will be based upon available resources. For Substance Use Disorders, DSHS Division of Behavioral Health and Recovery (DBHR) prioritizes the following for state-funded treatment, including inpatient treatment: pregnant women who use IV drugs, pregnant women, others who use IV drugs, post-partum women (up to one year). Other prioritized groups that are considered: Parents/legal guardians involved with Child Protective Services, parenting adults, and youth. A. Service Authorization Process for SUD Residential (Inpatient) Services 1. The SBHO network Outpatient provider completes an assessment and obtains signed ROI s for both CommCare and SBHO. If the individual meets medical necessity for residential services, the SBHO network provider locates a suitable residential provider and obtains a bed date Whereas for Substance Use Disorder or CD Involuntary Treatment Activity (CD-ITA) a CD-ITA specialist conducts an assessment utilizing the LOC Guidelines and ASAM criteria to determine if the individual meets medical necessity for CD-ITA services. 2. The SBHO network provider submits a Substance Use Disorder Residential Authorization Request Tool with completed CommCare and SBHO ROI s via ProFiler, secure and/or fax. CommCare may review additional documentation, such as the Assessment, ASAM criteria, and other relevant information in making an authorization determination according to the SBHO standards. 3. CommCare will document an authorization determination within the Substance Use Disorder Residential Authorization Request Tool and return via ProFiler and/or secure within 3 days of initial request. The network provider is responsible for providing and verbally notifying individuals of their authorized residential services. 4. If the requested service is denied, CommCare will notify provider via ProFiler and/or secure . For individuals without Medicaid coverage, a notice of adverse benefit determination (NOABD) letter will be sent and include how to request a second opinion. 5. The inpatient facility is responsible for requesting extension/continuing stay requests and retro-certifications, 24 (twenty-four) hours (Mental Health, Inpatient) or at least 5 days (Substance Use Disorder, residential), prior to the expiration of an episode. 6. The SBHO staff conduct retrospective reviews of a sample of charts authorized for residential services, as a part of the quality management plan and annual Residential Reviews of network contractors and subcontractors. Rev. FY Utilization Management Plan 7.06 Page 9 of 17

61 Salish BHO Policies and Procedures 7. The SBHO staff conduct targeted chart reviews in cases in which a concern or grievance regarding the authorization determination is raised, when a network provider staff requests a review, when there has been an adverse incident or potential for negative media occurs, or when determined necessary due to repeated and uncorrected errors identified in retrospective reviews. 8. If a network provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. B. Service Authorization Process for Mental Health Intensive Residential Services 1. The SBHO network provider submits an electronic Peninsula Assessment for Residential Services (PARS) request (for intensive residential services authorization) service authorization to CommCare via Profiler. CommCare may review additional documentation, such as the Intake Assessment, Crisis Prevention Plan, Individual Service Plan (ISP)/treatment plan and other relevant information in making an authorization determination according to the SBHO standards. 1. CommCare will make an authorization determination; document the determination on the PARS form and transmits an on-line authorization determination back to the network provider. The network provider is responsible for providing and verbally notifying individuals of their authorized residential services. 2. If the requested service is denied, CommCare will issue a service denial notification, on behalf of the SBHO, to the Medicaid and Non-Medicaid individual. 4. The SBHO staff conduct retrospective reviews of a sample of charts authorized for residential services, as a part of the quality management plan and annual Residential Reviews of network contractors and subcontractors. 5. The SBHO staff conduct targeted chart reviews in cases in which a concern or grievance regarding the authorization determination is raised, when a network provider staff requests a review, when there has been an adverse incident or potential for negative media occurs, or when determined necessary due to repeated and uncorrected errors identified in retrospective reviews. 5. If a network provider performs below expected standards during any of the reviews listed above a Corrective Action will be required for SBHO approval. Notice of Adverse Benefit Determination (NOABD) If access to care standards are not met for any level of service, including outpatient, intensive outpatient, residential, and/or inpatient, a Notice of Adverse Benefit Determination (NOA Determination) is sent to individual and provider (via Profiler and/or secure ). Individuals without Medicaid coverage will be sent a notice of determination letter and how to request a second opinion. Continuing Stay and Service Re-Authorization Rev. FY Utilization Management Plan 7.06 Page 10 of 17

62 Salish BHO Policies and Procedures The SBHO network providers use the Levels of Care (LOC), Mental Health and/or Substance Use Disorder, developed and adopted by the SBHO when making re-authorization determinations. The SBHO requires prior re-authorization for all continuing stay inpatient services. The SBHO requires re-authorization for outpatient service episodes within 30 days of a previously authorized benefit period expiring. The SBHO requires reauthorization for SUD residential treatment service episodes at least 5 days in advance. The SBHO does not require a re-authorization within a current authorized benefit period. The SBHO network providers may close and re-open a clinical episode within an authorized administrative benefit period. The SBHO LOC for outpatient and inpatient care outline the re-authorization criteria must be met, documentation provided to support criteria, and information reviewed when re-authorizing a service episode. Service re-authorizations for Non-Medicaid individuals must meet the LOC additional requirements to serve the individuals. There must be available resources to provide the services. The SBHO may request a review of the individual service plan (ISP) as part of the continuing stay service authorization process to ensure it: Meets the needs of the individual. Is consistent with the requested LOC and, if applicable, adopted SBHO Clinical Practice guidelines. Includes individual participation in the treatment planning process. Involved family members, when appropriate, in the evaluation and service planning processes. Includes input from other formal service systems and is consistent with privacy requirements. Consistency of Authorization Determination and Service Requests The SBHO has formally adopted the Authorization of Outpatient Services Based on Medical Necessity policy and Levels of Care protocols to ensure the SBHO, network providers, and CommCare share a common definition and standardized process to determine the medical necessity of requested and authorized behavioral health services provided by the SBHO. The SBHO expects the utilization management contractor, CommCare, to consistently apply and authorize the most appropriate Level of Care and service modalities, based upon the request and clinical documentation provided for determining medical necessity. The SBHO expects the network providers to provide clear and consistent assessments, request clinically appropriate services, and adhere and deliver services within the scope of authorized behavioral health services. Limitations on the Provision of Covered Services, Medicaid and Non-Medicaid Rev. FY Utilization Management Plan 7.06 Page 11 of 17

63 Salish BHO Policies and Procedures The SBHO contracts with CommCare to make all the service authorization decisions on behalf of the SBHO. A. There are several ways that CommCare can limit the provision of Medicaid covered services. These include: Determining that an enrollee does not meet Access to Care standards. Denying authorization for a requested covered service: Denials of a requested service will be addressed through the SBHO service denial and notification policy and procedures. Determining to reduce, suspend or terminate a previously authorized service. Pend an authorization request, awaiting additional information B. There are several ways that CommCare can limit the provision of services to Non-Medicaid individuals. These include all the above, a reduction of resources, as well as the additional criteria for Non-Medicaid individuals. C. When one of the above actions occurs, CommCare through the notification process informs an individual in writing. Medicaid recipients receive an Adverse Benefit Determination for all actions and Non-Medicaid individuals receive a SBHO Letter of Ineligibility. When services are reduced as a result of reduced state funding, a notification letter is mailed to the individual with a copy sent to the SBHO. CommCare will conduct the NOA appeal, if requested. SBHO will conduct a Grievance investigation, if requested. DSHS will conduct a Fair Hearing, if requested. Ensuring Client Rights Are Provided The SBHO places a high priority on informing individuals seeking services of their rights. The SBHO ensures individuals are provided this information through the DSHS booklet, the SBHO Handbook and brochures, and reviews the provision of information through monthly on-site chart reviews, and annual Administrative Reviews. A clinical chart must evidence that individuals were given the client rights information prior to the completion of the intake assessment. The SBHO developed and distributes the informational SBHO Handbook and brochures, and a standardized outpatient client rights form to network providers to be given to each individual seeking services. The SBHO also distributes the informational material to subcontractors, such as the local Ombuds office, BRIDGES to Parent Voice program, and NAMI advocacy groups. Individuals with sensory impairments, or who speak a language other than English, are provided equal access to this information through: Provision of material in Braille. Use of a DSHS TDD language or TTY line. Access to certified sign and language interpreters. SBHO contracted hearing impaired consultant. Client rights are posted in common areas of the network agencies in the twelve DSHS identified languages. Rev. FY Utilization Management Plan 7.06 Page 12 of 17

64 Salish BHO Policies and Procedures Clients are informed that behavioral health professional and primary behavioral health care providers, acting within the lawful scope of behavioral health practice, are not prohibited or restricted from advising or advocating on behalf of them with respect to their behavioral health status. Reference the SBHO policies: General Information and Requirements, Enrollee Rights, and Behavioral Health Care Professional Advocacy policies. Clients are informed of their second opinion rights, how and when to request a second opinion, and payment of costs associated with providing a second opinion in the published and distributed documents, as well as on the Adverse Benefit Determination and SBHO Letter of Ineligibility. SBHO Oversight and Sampling Methodology The SBHO utilizes random sampling to select charts for clinical and targeted reviews. The SBHO conducts a minimum of 500 chart reviews annually, sufficient to meet CMS and the Department requirements for reviews. Additional reviews may occur to address performance issues, concerning trends, or to accomplish utilization management or quality management activities. The SBHO conducts annual Administrative Reviews of each network provider, the ASO, and the local Ombuds office. Over and Under Utilization Project The SBHO monitors and detects for consistent application of requested, authorized, and provided services through an over and under utilization project that meets federal requirements. Both of these projects are monitored through regional quality assurance activities. Both projects are explained in the SBHO Quality Management Plan. High Utilizers: The SBHO monitors for high inpatient utilization through chart reviews, with a targeted data pull and with specific items on the crisis chart review tool. Under Utilizers: The SBHO monitors for outpatient under utilization through a data report and/or chart reviews. Examination of Network Sufficiency The SBHO UM program uses a variety of measures as indicators of network sufficiency and resources sufficiency. These indicators include: Historical use of resources. Current use of resources. Projections for future use and need of resources. Funding shifts- expenses and revenue reports. Quarterly Provider Performance Reports Census information for Medicaid and general population growth, by age, ethnicity, and gender. Monitoring of outpatient and inpatient utilization through the Authorization and Utilization Management Reports reviewed monthly by the UMC. Rev. FY Utilization Management Plan 7.06 Page 13 of 17

65 Salish BHO Policies and Procedures The SBHO has policies and procedures for collecting the service data, demographic, and census data, as evidenced in the Using the Information System for Utilization and Resource Management policy. Integration of Utilization Management Data Utilization management data is an integral part of the SBHO overall quality improvement strategy. The SBHO UM Plan defines areas of focus, establishes thresholds and benchmarks against which performance is measured, and defines special utilization management studies to be conducted. The SBHO utilizes a regional and statewide database system to collect the required service data for individuals receiving SBHO funded services: Client Demographic Information. Social Security Number. Health Insurance Information (plan, group number, subscriber name). Attending Physician/Practitioner Information/Primary Behavioral Health Care Provider assigned. Client Diagnosis/Treatment Information. Inpatient/Residential Facility Information. Unique situations may require for additional information prior to making an authorization determination. Clinical and demographic information may be shared within the SBHO service network to avoid multiple requests for information from patients and providers. Information from utilization management activities is aggregated, trended and analyzed to establish validity for completeness, accuracy, and timeliness. The SBHO staff and UMC evaluate the data using comparative statistical methods to identify variance from expected performance and reviews progress over time for trends or patterns. They report their findings to the SBHO QUIC. The SBHO staff, UMC, and QUIC monitor performance against the benchmarks established in the Quality Management Plan. Should require activities not result in attainment of established benchmarks, the QUIC can impose corrective actions or implement concurrent reviews, as required to achieve benchmarks. When analysis of available data suggests a deficiency in the sufficiency of the network, the UMC and/or the QUIC presents the issue for discussion and decision making to the SBHO governing boards. Annual Evaluation of the SBHO UM Program The SBHO Utilization Management Program is reviewed, evaluated and revised annually. The plan evaluation includes an assessment of the UM plan activities, and the extent to which compliance was achieved with the specified performance standards and outcomes. Rev. FY Utilization Management Plan 7.06 Page 14 of 17

66 The plan evaluation includes: Salish BHO Policies and Procedures 1. Identification of activities to be included in the subsequent year s Utilization Management Program. 2. Identification of any barriers to implementing the Utilization Management Program. 3. Recommended changes in the SBHO infrastructure, as needed, to accomplish the goals of the UM Plan. 4. Identification of opportunities for improvement through the provision of on-site technical assistance or training. 5. Updating information within the UM Plan that accurately reflects the monitoring and oversight activities. 6. Recommended changes or additions to the criteria for monitoring over or underutilization project. The written summary of the evaluation is prepared by the SBHO staff, in conjunction with UM Committee, and presented to the QUIC. The annual UM Program evaluation is the basis for the development and focus of the upcoming fiscal year s established priorities. Rev. FY Utilization Management Plan 7.06 Page 15 of 17

67 Salish BHO Policies and Procedures SBHO Utilization Management & Clinical Directors Committee Organizational Chart Attachment 1 SALISH BEHAVIORAL HEALTH ORGANIZATION Quality Improvement Committee (QUIC) Utilization Management Committee CommCare Staff SBHO Staff Network Providers UM Director Deputy Administrator KMHS Senior Clinical Mngr & IS Director UM Care Mngr Resource Manager DBH Senior Clinical Mngr Medical Director, upon request Quality Assurance Mngr PBH Senior Clinical Mngr Adult Services Mngr WEOS Senior Clinical Mngr Children s Services Mngr Chemical Dependency Mngr Residential and Long Term Care Mngr Rev. FY Utilization Management Plan 7.06 Page 16 of 17

68 Salish BHO Policies and Procedures SALISH BEHAVIORAL HEALTH ORGANIZATION Contracted Authorization and Utilization Management CommCare Organizational Chart Attachment 2 Organizational Chart BOARD OF DIRECTORS CommCare Terry Trafton, MS, LPC, NCC President/CEO Deanna Pugel, RN,CCM,PMP,LCP Director of Clinical Operations Mark Cannon, M.D. Medical Director Pam Janeway Office Manager/Credentialing Lindsey Stone Admin. Assisant Michelle Watson, LMSW Clinical Call Services Coordinator Beth Monahan, LCPC Clinical Care Manager Jessica Woodruff, LCSW, LSCSW Clinical Care Manager Etienne Clatanoff, LPC Clinical Care Manager Wylie Taul, LMSW Clinical Care Manager Michell Peppers, LCSW Clinical Care Manager Shari Lanzendorf, LCSW Senior Clinical Care Manager Beth Belcher, LMSW, LCSW Clinical Care Manager Megan McVay, LMSW Clinical Care Manager Stephanie Olmstead, LMSW Clinical Care Manager Deb Schafer, LMSW, LCSW Clinical Care Manager Shanna O'Brien, LMSW Clinical Care Manager Kristie Pfaff, LCSW Clinical Care Manager Rev. FY Utilization Management Plan 7.06 Page 17 of 17

69 SALISH BHO UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: OVER AND UNDER UTILIZATION PROJECTS Policy Number: 7.07 Reference: 42 CFR, DSHS Contract Effective Date: 7/2007 Revision Date(s): 12/2013; 7/2017 Reviewed Date: 12/2014; 7/2017 Approved by: SBHO Executive Board CROSS REFERENCES Plan: Quality Management Plan Policy: Advance Directives Policy: Corrective Action Plan Policy: Mental Health Crisis Prevention Plan Standards Policy: Practice Guidelines Policy: Standard Chart Reviews Tool: Crisis Chart Review Tool Tool: Re-Auth Standard Chart Review Tool PURPOSE The Salish Behavioral Health Organization (SBHO) will ensure the network providers will effectively coordinate medically necessary mental health services for individuals who meet the definition of over and underutilization in a given time period. The SBHO will ensure that medically necessary services are provided in the least restrictive setting, while monitoring the costs and efficiently managing intensive resources that can be associated with these projects. The SBHO ensures and monitors for consistent application of requested, authorized, and provided services to detect over and underutilization. The SBHO network providers participate in the process. Over and Under Utilization Projects 7.07 Page 1 of 4

70 Salish BHO Policies and Procedures DEFINITIONS Over Utilization is defined as: An individual who has had more than one hospitalization within a thirty (30) day time period. This is an inpatient utilization project. On occasion, there are individuals that have brief inpatient respite episodes built into their discharge plan; these individuals are not included in this definition. Underutilization is defined as: An individual who is authorized for Level II outpatient services and has received less than five (5) face to face services within a six (6) month period or is receiving treatment in frequency or type of service than less than what is clinically indicated. This is an outpatient utilization project. PROCEDURE SBHO has a variety of mechanisms in place to detect both overutilization and underutilization of services. These projects were developed in consultation with stakeholders through the Advisory Board, Quality Improvement Committee (QUIC), Utilization Management and Clinical Directors Committee (UMC) and may be informed by quality assurance monitoring results including noted utilization management trends. Project Monitoring 1. The SBHO will identify all individuals that meet the definition of over and underutilization, for a specific period of time, through regional database reports. 2. The SBHO may conduct targeted chart reviews for individuals that meet over or underutilization definitions. The over utilization chart review items are located on the crisis chart review tool, high utilizer section. Underutilization is measured in the standard outpatient chart review tool. 3. The underutilization review may include an analysis of patterns such as use of crisis services, hospitalizations, and diagnosis. Services of identified clients are reviewed to examine barriers to treatment, risk factors, as well as appropriateness of service level authorization. 4. The SBHO may request the network providers to participate in the chart review process. The network provider shall use the review method identified by the SBHO. An agency will be expected to report back to the SBHO within thirty (30) days from the request. 5. As a result of the chart reviews, regional and agency-specific utilization patterns may be analyzed, such as: use of crisis services use of advance directive hospitalizations diagnosis Over and Under Utilization Projects 7.07 Page 2 of 4

71 Salish BHO Policies and Procedures barriers to outpatient treatment, and appropriateness of outpatient service level authorization. 6. Chart review and project results will be tabulated and reported to the QUIC. QUIC will delegate notable trends to the appropriate regional committee for problem solving. 7. The SBHO may request the agency for a corrective action, if necessary. 8. SBHO staff may request a meeting with the agency to discuss specific trends of concern. The purpose of the meeting would be to further analyze the identified trend and discuss possible solutions with the agency. Case specific concerns may be addressed with provider clinical staff. Target Population- expectations of clinical care 1. Individuals meeting the project definitions for over utilization, who are not currently enrolled at a network agency for outpatient services will be offered an Intake Assessment, as appropriate. 2. Individuals currently authorized for outpatient services and meet the definition under or over utilization may be referred for consideration for a change of outpatient level authorization on the Peninsula Regional Assessment Tool (PRAT) to access/provide more appropriate level of service. a. A Crisis Prevention Plan will be required for all enrolled individuals who meet the definition of high utilizer. The plan shall clearly specify ways to prevent decomposition, as well as: Early warning signs of increased psychiatric symptoms that are particular to the individual client. Proactive and progressive measures to divert or prevent a crisis or psychiatric hospitalization. Client s family and other supports roles, directives, and responsibilities, (with the consent of the client.) and contact information. A clearly defined progressive process that includes: 1) Specific steps the client will take when his or her symptoms begin to increase. 2) Specific steps or actions a client s family or significant others will take to assist the client (with client s consent.) 3) Intervention strategies the primary clinician and other care providers can employ to assist the client in averting a crisis. b. A copy of the Crisis Prevention Plan shall be given to the individual. The local Crisis Response Team shall have unencumbered access to, or be provided a copy of, the Crisis Prevention Plan. Over and Under Utilization Projects 7.07 Page 3 of 4

72 Salish BHO Policies and Procedures 3. The SBHO may choose to provide intensive oversight of care provided by the network (including crisis, outpatient, residential, evaluation and treatment, and inpatient services) for SBHO individuals who are identified as over utilizers of inpatient services. Such intensive oversight will be conducted by SBHO clinical staff, and may include the contracted Administrative Service Organization (ASO). All SBHO clinical staff members are Mental Health Professionals with the availability of licensed mental health professionals and child specialists. ASO is URAC accredited, with multi-dimensional experienced behavioral health clinical staff. The SBHO does not discriminate and protects against provider discrimination for serving high risk populations, costly treatment, or specializes in conditions that require costly treatment. Other Related Monitoring Activities 1. The SBHO tracks over and underutilization throughout our system in a number of related monitoring activities. These other monitoring activities include: Child and Youth Inpatient Extension Authorization- process includes SBHO staff case specific review Annual chart reviews of zero PRATs for each agency. Review of services given to consumers and whether they are adequate for the consumer s level of care authorized and clinical presentation. This is addressed during annual chart reviews. Quality Indicator Tracking readmission rates Network Agency Administrative Reviews- review of zero PRATs Monthly Provider Chart Reviews Exhibit N SBHO Grievance Tracking UMC Monthly Authorization Tracking Data and Graphs MONITORING 1. This policy is a contract requirement. This policy will be monitored through use of SBHO: Annual Provider Chart Reviews SBHO QUIC, Clinical Directors and UM Committees may provide oversight/ monitoring and review for targeted issues for trends and recommendations SBHO regional database report compiled quarterly to identify the target population 2. If a provider performs below expected standards on a specific chart review tool, a corrective action plan will be required for SBHO approval. Over and Under Utilization Projects 7.07 Page 4 of 4

73 Salish BHO Policies and Procedures SALISH BHO UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: Substance Use Disorder Level of Care Guidelines Policy Number: 7.08 Reference: WAC B, Contract requirements DSM-5, ASAM, SBHO P&P 7.09 Effective Date: 4/2016 Revision Date(s): 10/2016, 6/2017 Reviewed Date: 6/2016; 9/2016, 10/2016, 6/2017 Approved by: SBHO Executive Board Definitions American Society of Addiction Medicine (ASAM): Enhances the use of multidimensional assessments to develop patient-centered service plans and to guide clinicians, counselors, and care managers in making objective decisions about patient admission, continuing care, and transfer/discharge for various levels of care for addictive, substance-related, and co-occurring conditions. Levels of Care (LOC): Referral to a specific level of care must be based on a careful assessment of an individual with a substance use disorder. A primary goal underlying ASAM criteria is for an individual to be placed in the most appropriate level of care. Substance Use Disorder (SUD): A condition in which the use of one or more substances leads to a clinically significant impairment or distress. SBHO maintains standard level of care (LOC) guidelines for all authorized services. These LOC guidelines incorporate contract requirements, American Society of Addiction Medicine (ASAM) criteria, and Washington Administrative Codes. SBHO contracts with an Administrative Service Organization (ASO), CommCare, to facilitate service authorization requests. CommCare utilizes these Level of Care guidelines for making decisions about scope, duration, intensity and continuation of services. Decisions regarding initial authorizations for Substance Use Disorder treatment services or authorizations for extensions of services must abide by these guidelines. Substance Use Disorder Level of Care Guidelines 7.08 Page 1 of 7

74 Salish BHO Policies and Procedures 1. Determining Medical Necessity for the Authorization Process A. Evaluating ASAM Level of Care Criteria: Prior to authorizing a request for SUD treatment services, the following must be accomplished to determine medical necessity : 1) The individual has received a comprehensive Substance Use Disorder Bio-Psycho-Social assessment from a Washington State certified Chemical Dependency Professional (CDP) or a CDP-Trainee under the supervision of a Chemical Dependency Professional. The assessment process includes the administration of the GAIN-SS. 2) A substance use disorder diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and included in the statewide ACS as a covered diagnosis has been assigned based on information gathered from the assessment. The DSM-5 diagnosis is identified by an ICD-10 code. 3) ASAM level of care requirements (medical necessity), sufficient to meet the individual s needs, have been determined by a CDP, or a CDPT under supervision of a CDP supervisor, through evaluation of ASAM criteria. 4) The individual is expected to benefit from the recommended intervention. 5) The individual s unmet needs cannot be more appropriately met by another intervention. 6) There are no restrictions as to the number or frequency of assessments an individual can receive. 2. Outpatient Substance Use Disorder Services A. CommCare administers authorization determinations for the following levels of outpatient treatment based on medical necessity: 1) ASAM Level 1.0 Outpatient 2) ASAM Level 2.1 Intensive Outpatient B. Service Expectations 1) Individuals will be able to receive medically necessary outpatient services at their current ASAM level. Services provided must include at least the following: a. ASAM Level 1: Outpatient Treatment Services i. Provides up to nine contact hours per week for adults and up to six hours per week for adolescents. ii. Available Services: a) Case Management b) Opiate Substitution Treatment c) Group and individual counseling b. ASAM Level 2.1: Intensive Outpatient Treatment Services i. Provides 9-19 hours of structured programming per week for adults, and, 6-19 hours per week for adolescents. ii. Available Services: Substance Use Disorder Level of Care Guidelines 7.08 Page 2 of 7

75 Salish BHO Policies and Procedures a) Case Management b) Group and individual counseling c) Chemical dependency outpatient treatment services that provide a concentrated program of individual and group counseling, education, and activities, including at least one individual session each month. C. Who May Request an Authorization Requests for outpatient authorization are accepted from SUD agencies that are licensed by Washington State and have a contract with SBHO for outpatient services. D. Authorization Period CommCare may approve an initial authorization request for Level 1.0 and Level 2.1 Outpatient treatment services for a period of up to nine months. When an ongoing assessment indicates that the individual no longer needs the authorized level of care, it is expected that the outpatient provider will transition the individual to a lower level of care. E. Continuing Care Criteria If the outpatient provider determines the individual needs outpatient services longer than 9 months, an authorization request for continuing care must be submitted to CommCare. Submissions to CommCare must include an evaluation of the effectiveness of services provided during the initial nine month authorization and a justification for continuation of services. Any extensions beyond 9 months will be for a 3 month period. In those cases where an individual was authorized for outpatient care but then required residential treatment, the amount of time the individual was in residential treatment will be added to the initial outpatient authorization period. Requests for extended Outpatient services must be received by CommCare a minimum of seven days prior to the expiration of the benefit period. F. Discharge Criteria Individuals are ready for discharge when they no longer meet medical necessity requirements determined by a review of ASAM criteria. Discharge criteria will be determined by a CDP or a CDPT under the supervision of a CDP supervisor. G. Authorization Request Denials If CommCare denies a request for authorization of outpatient treatment services, CommCare will send a Notice of Adverse Benefit Determination (NOABD) for Medicaid individuals and services (SBHO P&P 6.05) or a Notice of Determination for non-medicaid individuals and services (SBHO P&P 7.01) as well as provide a peer clinical review. The goal of the peer clinical review is to allow the treating provider a chance to discuss UM determinations before the initiation of the appeal process. If a peer to peer conversation Substance Use Disorder Level of Care Guidelines 7.08 Page 3 of 7

76 Salish BHO Policies and Procedures or review of additional information does not result in resolution, CommCare informs the provider and the individual of the right to initiate an appeal and the procedure to do so. H. Authorization Request Protocol Refer to the Substance Use Disorder, Outpatient Treatment Authorization Request (SBHO P&P 7.09a) and instructions (SBHO P&P 7.09). I. Covered Individuals The following individuals may be authorized for SUD Outpatient treatment services if the requirements of this section are met: a) Medicaid enrollees b) Individuals without Medicaid who meet the state definition of low income (including those with Medicare only coverage) who have no other SUD insurance benefit and were referred to treatment from: i. The criminal justice system ii. A withdrawal management facility iii. A residential treatment facility These services may be funded by CJTA, SABG, or the agency s state funded contract. If an agency does not have any of these funding sources available at the time the individual applies for services, individual should be referred to an alternative agency. 3. Residential Substance Use Disorder Services A. CommCare administers authorization determinations for the following levels of residential treatment based on medical necessity: 1) Level 3.1 Clinically Managed, Low Intensity Residential Services (Recovery House) 2) Level 3.3 Clinically Managed, Population Specific, High Intensity, Residential services 3) Level 3.5 Clinically Managed, High Intensity Residential Services B. Enrollees cannot be required to relinquish custody of minor children in order to access residential SUD treatment services. C. Who May Request an Authorization Requests for authorization of residential services should be made by an SBHO contracted outpatient, residential, or local Tribal SUD provider. The authorization request follows an assessment by a CDP, or a CDPT under supervision of a CDP supervisor, and is based on ASAM criteria. The referring provider arranges a bed date at a residential facility, requests authorization from CommCare, and then informs the residential facility of the authorization. Refer to the residential treatment services authorization process in SBHO P&P D. Authorization Period Initial authorizations for residential treatment are for up to 30 days (90 days for PPW), based on an assessment of the individual s needs and appropriateness of placement. Substance Use Disorder Level of Care Guidelines 7.08 Page 4 of 7

77 Salish BHO Policies and Procedures CommCare may contact the residential facility for more information as needed. It is expected that the individual will be transferred to a lower level of care when clinically indicated. E. Continuing Care Criteria If the residential provider determines that the individual needs services in excess of the initial authorization, an additional authorization request for continued residential care must be submitted to CommCare. Requests for extended residential treatment must be based on medical necessity determined by a CDP s review of ASAM criteria. Determination of medical necessity must include an evaluation of the effectiveness of services provided during the initial benefit period and justification for continuation of services. Extension requests for residential services may be made for up to 30 days per request (90 days for PPW). Requests for extended Residential services must be received by CommCare a minimum of five days in advance of the expiration of the benefit period. CommCare has up to three days to respond. F. Discharge Criteria Individuals are ready for discharge from residential treatment services when they no longer meet medical necessity requirements determined by a review of ASAM by a CDP or a CDPT under supervision of a CDP supervisor. G. Denials If CommCare denies a request for authorization of Residential treatment services, CommCare will send a Notice of Adverse Benefit Determination (NOABD) for Medicaid individuals and services (SBHO P&P 6.05) or a Notice of Determination for non-medicaid individuals and services (SBHO P&P 7.01) as well as provide a peer clinical review. The goal of the peer clinical review is to allow the treating provider a chance to discuss UM determinations before the initiation of the appeal process. If a peer to peer conversation or review of additional information does not result in resolution, CommCare informs the provider and the individual of the right to initiate an appeal and the procedure to do so. H. Authorization Protocol Refer to Substance Use Disorder Residential Treatment Authorization Request (SBHO P&P 7.09b) and instructions (SBHO P&P 7.09). I. Covered Individuals The following individuals may be authorized for SUD Residential treatment services if the requirements of this section are met: 1) Medicaid enrollees 2) Individuals without Medicaid who meet the state definition of low income (including those with Medicare only coverage) who have no other SUD insurance benefit and were referred to treatment from: i. The criminal justice system ii. A withdrawal management facility 3) Those entering residential treatment through the CD-ITA process Substance Use Disorder Level of Care Guidelines 7.08 Page 5 of 7

78 Salish BHO Policies and Procedures 4. Withdrawal Management Services A. CommCare administers authorization determinations for Withdrawal Management services based on medical necessity B. Who May Request an Authorization Authorization requests for Withdrawal Management Services are accepted from appropriately credentialed facilities licensed to provide Withdrawal Management services in compliance with ASAM. C. Authorization Period 1) Initial authorizations, determined by the admitting provider, are limited to the following: i. Alcohol detoxification: 3 days ii. Drug detoxification: 5 days D. Extension Requests Withdrawal Management providers may request an extension to services if needed. Provider will forward request for additional services to CommCare. CommCare has up to 24 hours to make a continuing care determination decision. E. Discharge Criteria Individuals are ready for discharge from withdrawal management services when they no longer meet medical necessity requirements as determined by appropriately credentialed staff. F. Denials If CommCare denies a request for withdrawal management services, CommCare will send a Notice of Adverse Benefit Determination (NOABD) for Medicaid individuals and services (SBHO P&P 6.05) or a Notice of Determination for non-medicaid individuals and services (SBHO P&P 7.01) as well as provide a peer clinical review. The goal of the peer clinical review is to allow the treating provider a chance to discuss UM determinations before the initiation of the appeal process. If a peer to peer conversation or review of additional information does not result in resolution, CommCare informs the provider and the individual of the right to initiate an appeal and the procedure to do so. G. Authorization Request Protocol Refer to the Substance Use Disorder Withdrawal Management Treatment Authorization Request (SBHO P&P 7.09d) and instructions (SBHO P&P 7.09). H. Covered Individuals 1) The following individuals may be authorized for this service if the requirements of this section are met: i. Medicaid enrollees Substance Use Disorder Level of Care Guidelines 7.08 Page 6 of 7

79 Salish BHO Policies and Procedures ii. Individuals without Medicaid who meet the state definition of low income (including those with Medicare only coverage) who have no other SUD insurance benefit. Substance Use Disorder Level of Care Guidelines 7.08 Page 7 of 7

80 SALISH BEHAVIORAL HEALTH ORGANIZATION UTILIZATION MANAGEMENT POLICIES AND PROCEDURES Policy Name: SUD AUTHORIZATION REQUEST INSTRUCTIONS Policy Number: 7.09 Reference: WAC B, Contract requirements DSM-5, ASAM, 42 CFR 438 Effective Date: 4/2016 Revision Date(s): 6/2017 Reviewed Date: 6/2016; 9/2016, 6/2017 Approved by: SBHO Executive Board CROSS REFERENCES Letter: Notice of Adverse Benefit Determination Form Letter Template Letter: SBHO Authorization Notification Letter Template Letter: SBHO Letter of Ineligibility Template Policy: Corrective Action Plan Policy: Notice of Action Requirements DEFINITIONS Access to Care Standards (ACS) are defined as standards established by the Department that the SBHO must implement for the purposes of determining minimum eligibility for Medicaid and non-medicaid enrollees seeking admission and continuing authorization into SUD services. Authorization is defined as the power and authority exercised by the SBHO, or their designated Administrative Service Organization (ASO), CommCare, to approve and disapprove authorization requests for outpatient, inpatient, residential, and withdrawal management services for individuals seeking substance use disorder services. Individual means a person who has applied for, is eligible for, or who has received publicly funded substance use disorder services. Also referred to as Enrollee. Request for Services is defined as the point in time when services are sought or applied for through a telephone call, walk-in, or a written request for services from an Individual/Enrollee or an authorized representative. Authorization Request Instructions for SUD Services 7.09 Page 1 of 6

81 Salish BHO Policies and Procedures PROCEDURE Outpatient Authorization Requests 1. The SBHO contracted Outpatient provider s CDP, or CDPT under the supervision of a CDP, completes an assessment per WAC and contract requirements. 2. The Outpatient service provider must obtain ROIs for both CommCare and SBHO signed by the individual. 3. Based on the ACS, LOC Guidelines, and ASAM criteria, the outpatient provider determines if the individual meets medical necessity for Outpatient treatment. 4. If the individual does not meet medical necessity, the agency completes the Substance Use Disorder Outpatient Treatment Authorization Request form and forwards to CommCare, indicating the person s level of care is Zero. This will prompt a notice to be sent to the individual (SBHO P&P 6.05). 5. If the individual does meet medical necessity, the agency completes the Substance Use Disorder Outpatient Treatment Authorization Request and submits to CommCare, indicating the appropriate level of care based on ASAM criteria and the requested start date for Outpatient treatment. 6. All sections of the form must be completed, except those CommCare is responsible for. 7. The requesting agency must forward the ROI signed by the individual to CommCare along with the Authorization request. 8. The Authorization request form and signed ROI will be submitted to CommCare via secure requests@commcare1.org or Fax # CommCare will complete their portion of the Substance Use Disorder Outpatient Treatment Authorization Request (indicating the appropriate level of care and authorization dates) and return it to the agency via secure . For standard authorization decisions, when sufficient information is provided, the notice will be provided as expeditiously as the individual s condition requires and within Stateestablished timeframes that may not exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days, if the individual or provider requests extension or justification is provided for a need for additional information and how the extension is in the individual s best interest. 10. The completed authorization request form will be placed in the individual s medical record. 11. Outpatient treatment services extension requests will be submitted via secure or fax by the provider within 30 days prior to the expiration of the benefit period. CommCare has up to 14 days to authorize extension requests for Outpatient services and will respond to the provider via secure . Completed extension requests will be placed in the individual s medical record. 12. The agency must enter the authorization data in their EMR. This data will be sent to SBHO at regular intervals. Authorization Request Instructions for SUD Services 7.09 Page 2 of 6

82 Salish BHO Policies and Procedures Authorization termination of Outpatient SUD treatment services Service Description The term authorization termination applies to the termination of authorized Outpatient SUD services for an individual who has left services within an authorized benefit period. Authorization termination can occur at any point during an authorized benefit period. Authorization Termination Scenarios: a) Authorization terminations may result when any of the following circumstances occur: 1. The individual has met their treatment goals prior to the expiration of the authorized benefit period. 2. The individual chooses to transfer to another Outpatient provider to receive Outpatient SUD services. 3. The individual commits an agency rule violation and the agency discharges the individual in accordance with their policy and procedure. 4. The individual becomes hospitalized or incarcerated and is unable to return to Outpatient SUD services prior to the expiration of the authorized benefit period. 5. The individual is/was authorized under Medicaid, and becomes ineligible for Medicaid. 6. The individual leaves treatment against program advice. 7. The individual s whereabouts are unknown, and three attempts to contact and re-engage them in Outpatient SUD services (by two different means) have been unsuccessful. Authorization Termination Procedures: b) For circumstances that apply to #1, #2, #3, #4 or #5 above: 1. The agency notifies CommCare within 24 hours of the individual s change of circumstances and the need for authorization termination. 2. The agency notifies CommCare of the need for authorization termination by either secure or fax. 3. CommCare sends the Notice of Adverse Benefit Determination letter to the individual. 4. After 10 days, if the Medicaid individual does not contact the ASO or agency requesting ongoing services the inactivation is processed/ authorized. 5. CommCare terminates the authorization and informs the agency via secure . c) For circumstances that apply to #6 or #7 above: 1. After there has been no treatment service received by the individual for an entire calendar (billing) month within an authorized benefit period, the authorization shall be terminated. 2. An entire calendar month in most situations will be in addition to the number of days in the preceding month since the individual s last documented, billable service. 3. Once the required timeframe as outlined above has elapsed, the agency notifies CommCare by either secure or fax within 24 hours of the individual s change of circumstances and the need for authorization termination. 4. CommCare sends the Notice of Adverse Benefit Determination letter to the individual. 5. After 10 days, if the Medicaid individual does not contact the ASO or agency requesting ongoing services the inactivation is processed/ authorized. 6. CommCare terminates the authorization and informs the agency via secure . Authorization Request Instructions for SUD Services 7.09 Page 3 of 6

83 Salish BHO Policies and Procedures Residential Authorization Requests 1. The SBHO contracted Outpatient provider s CDP, or CDPT under the supervision of a CDP, completes an assessment per WAC and contract requirements. 2. The provider must obtain ROIs for both CommCare and SBHO. 3. Based on the ACS, LOC Guidelines, and ASAM criteria, the provider determines if the individual meets medical necessity for residential services. 4. If the individual meets medical necessity for residential services, the agency locates a suitable residential provider and obtains a bed date. 5. Once a bed date is identified, the agency completes the Substance Use Disorder Residential Treatment Authorization Request and submits to CommCare. 6. The requesting agency must forward the ROI signed by the individual to CommCare along with the Authorization request. 7. All sections of the form must be completed, except those CommCare is responsible for. 8. The authorization request will be submitted to CommCare via secure requests@commcare1.org or Fax # CommCare will complete the authorization portion of the Substance Use Disorder Residential Treatment Authorization Request (indicating the appropriate level of care and authorization dates) and return it to the agency via secure . CommCare has up to three days to authorize initial requests for Residential services. 10. The completed authorization form will be placed in the individual s medical record and will be sent, with appropriate ROI, to the residential provider as evidence of authorization. 11. The agency must enter the residential authorization data in their EMR. This data will be sent to SBHO at regular intervals. 12. Residential treatment services extension requests will be submitted to CommCare via secure or fax by the residential provider at least five days prior to expiration of the current authorization. CommCare has up to three days to authorize extension requests for Residential services and will respond to the provider via secure . Completed extension requests will be placed in the individual s medical record. Residential Authorization Requests by Out-of-Network Providers 1. The Out-of-Network Outpatient provider s CDP, or CDPT under the supervision of a CDP, completes an assessment per WAC requirements. 2. The provider must obtain ROIs for both CommCare and SBHO. 3. Based on the ACS, LOC Guidelines, and ASAM criteria, the Out-of-Network Outpatient provider determines if the individual meets medical necessity for residential services. 4. If the individual meets medical necessity for residential services, the Out-of-Network provider locates a suitable residential provider and obtains a bed date. Authorization Request Instructions for SUD Services 7.09 Page 4 of 6

84 Salish BHO Policies and Procedures 5. Once a bed date is identified, the provider completes the Out-of-Network Provider SUD Residential Treatment Authorization Request and submits to CommCare. 6. All sections of the form must be completed, except those CommCare is responsible for. 7. The authorization request will be submitted to CommCare via fax. CommCare s Fax # CommCare will complete the authorization portion of the Out-of-Network Provider SUD Residential Treatment Authorization Request form (indicating the appropriate level of care and authorization dates) and returns it to the agency via secure . CommCare has up to three days to authorize initial requests for Residential services. 9. The completed authorization form will be placed in the individual s medical record and will be sent, with appropriate ROI, to the residential provider as evidence of authorization. 10. The agency must enter the residential authorization data in individual s clinical file. This data will be forwarded to SBHO. 11. Residential treatment services extension requests must be submitted (faxed) by the residential provider at least five days in advance. CommCare has up to three days to authorize extension requests for Residential services and will respond to the provider via secure . Completed extension requests will be placed in the individual s medical record. Withdrawal Management Authorization Requests 1. The Withdrawal Management provider s qualified staff completes a screening per WAC requirements. 2. The Withdrawal Management provider must obtain ROIs for both CommCare and SBHO. 3. Based on the ACS, LOC Guidelines, and ASAM criteria, the Withdrawal Management provider determines if the individual meets medical necessity for Withdrawal Management services. 4. If the individual meets medical necessity for Withdrawal Management, the Withdrawal Management provider forwards the information to CommCare via telephone. The requesting agency must fax the ROI to CommCare signed by the individual. CommCare s Fax # CommCare will complete the authorization portion of the Substance Use Disorder Withdrawal Management Authorization Request form and return it to the agency via secure . CommCare has up to 12 hours to authorize initial requests for Withdrawal Management services and requests for extension of Withdrawal Management services. 6. The completed authorization form will be placed in the individual s medical record. Authorization Request Instructions for SUD Services 7.09 Page 5 of 6

85 Salish BHO Policies and Procedures MONITORING This policy is mandated by statute and contract. 1. The SBHO monitors this policy through the use of the SBHO: Annual SBHO Provider and Subcontractor Administrative Review Annual Provider Chart Reviews SBHO Grievance Tracking Reports Biennial Provider Quality Review Team Review Utilization Committee activities, such as the ASO case review Quality Management Plan activities, such as reviews of targeted issues for trends and recommendations 2. If a provider performs below expected standards during any of the reviews listed above a Corrective Action Plan will be required for SBHO approval. Authorization Request Instructions for SUD Services 7.09 Page 6 of 6

86 Salish Behavioral Health Organization Substance Use Disorder Outpatient Treatment Authorization Request *Fax requests to CommCare at or submit via encrypted to Agency Name Agency NPI # Salish BHO Provider # Date and time of Authorization request Date: Time: Date and time of Request For Services Date: Time: Date and time of Assessment Date: Time: Is Client requesting a specific level of care? Yes No If yes, what level of care is being requested? Date of Termination (if requesting discharge) Termination reason (if requesting discharge) Name and title of person making request Requesting agency s address Client Name Client ID # Client s preferred language English Spanish Other Language: Is Client PPW? Yes No Client DOB Client s mailing address Client s Funding Source Medicaid Provider One ID: Non-Medicaid If client is Non-Medicaid please complete below Non-Medicaid Only Referred by Criminal Justice System SUD Residential SUD Withdrawal Management SABG Funded Referent Name DSM-5 diagnosis assigned? Yes: Complete Form No: Please complete Comments section below and forward to CommCare for tracking purposes. DSM-5 diagnosis (ICD-10 code) Recommended ASAM LOC Recommended length of care Requested Outpatient treatment start date Supporting evidence for ASAM LOC and treatment duration DIM LOC Dim-1 Dim-2 Dim-3 Dim-4 Dim-5 Dim-6 Comments: (If Authorization request is for Assessment only, include any recommendations for the individual.) SBHO 7.09a 8/7/17

87 COMMCARE TO COMPLETE BELOW THIS LINE Date and time of Authorization decision Date: Time: CommCare originated Authorization # Authorized ASAM LOC and duration Authorized treatment start date Last covered day of services Date and time individual is notified Date: Time: Signature of CommCare Rep SBHO 7.09a 8/7/17

88 Salish Behavioral Health Organization Substance Use Disorder Residential Treatment Authorization Request *Fax requests to CommCare at or submit via encrypted to Agency Name Agency NPI # Salish BHO Provider # Date and time of Authorization request Date: Time: Date and time of Assessment Date: Time: Date of Request for Residential Services (bed day) Name and title of person making request Requesting agency s address Client Name DOB ID # Client s preferred language English Spanish Other Language: Is Client PPW? Yes No Client s mailing address Client s Funding Source Medicaid Provider One ID: DSM-5 diagnosis (ICD-10 code) Non-Medicaid Criminal SUD Only Justice System Residential Referred by Recommended ASAM LOC DIM Dim-1 Dim-2 Dim-3 Dim-4 Dim-5 Dim-6 Comments: LOC SUD Withdrawal Management Non-Medicaid SABG Funded Recommended length of care Supporting evidence for ASAM LOC and treatment duration Referent Name Requested Residential Treatment Provider NPI # Requested Provider contact information COMMCARE to complete below Date and time of Authorization decision Date: Time: CommCare originated Authorization # Authorized ASAM LOC and duration Authorized treatment start date Last covered day of services SBHO 7.09b 8/7/17

89 Date and time individual is notified Date: Time: Signature of CommCare Rep: SBHO 7.09b 8/7/17

90 Salish Behavioral Health Organization Substance Use Disorder Treatment Extension Authorization Request *Fax requests to CommCare at or submit via encrypted to Agency Name Agency NPI # Salish BHO Provider # Date and time of Authorization request Date: Time: Date of Termination (if requesting discharge) Termination reason (if requesting discharge) Name and title of person making request Requesting agency s address Client Name DOB ID # Client s preferred language English Spanish Other Language: Client s mailing address Client s Funding Source Medicaid Provider One ID: Current Authorization Start Date Non-Medicaid Criminal SUD Only Justice System Residential Referred by Current CommCare Authorization Number Current DSM-5 Diagnosis DIM Dim-1 Dim-2 Dim-3 Dim-4 Dim-5 Dim-6 Non-Medicaid Last Covered day of services SUD Withdrawal SABG Funded Management Referent Name Current ASAM LOC Provide Evaluation of the effectiveness of services provided during current Authorization period DIM Dim-1 Provide justification for continuation of services Dim-2 Dim-3 Dim-4 SBHO 7.09c 8/7/17

91 Dim-5 Dim-6 Level of Care Client will continue to receive Recommend Client s transition to monthly monitoring Requested length of extension Comments: ASAM LOC COMMCARE to complete below Date and time of Authorization decision Date: Time: CommCare originated Authorization # Approved length of extension ASAM LOC Extension start date Last covered day of services Date and time individual is notified Signature of CommCare Rep: SBHO 7.09c 8/7/17

92 Salish Behavioral Health Organization Substance Use Disorder Withdrawal Management Authorization Request *Telephone all Withdrawal Management requests to CommCare at Agency Name Agency NPI # Salish BHO Provider # Date and time of Authorization request Date: Time: Is Client requesting a specific level of care? Yes No If Yes, what level of care is being requested? Name and title of person making request Requesting agency s address Client Name DOB ID # Client s preferred language English Spanish Other Language: Race (enter code) Client s mailing address Hispanic Origin (Enter Code) Gender (enter code) Sexual Orientation (enter code) Client s Funding Source Non-Medicaid Only Referred by Criminal Justice System Medicaid Provider One ID: ICD-10 diagnosis Recommended Level of Withdrawal Management SUD Residential SUD Withdrawal Management Screening criteria met to support need for Withdrawal Management services: Non-Medicaid SABG Funded Recommended length of Withdrawal Management Referent Name Requested Service Provider NPI # Requested Provider contact information Comments: COMMCARE to complete below Date and Time of Authorization decision Date: Time: CommCare originated Authorization # Authorized Level of Withdrawal Management Authorized treatment start date Last covered day of services Length of authorized Withdrawal Management services Date and time individual is notified Date: Time: Signature of CommCare Rep: SBHO 7.09d 8/7/17

93 SBHO 7.09d 8/7/17

94 Salish Behavioral Health Organization Out of Network Provider Substance Use Disorder Residential Treatment Authorization Request *Fax requests to CommCare at or submit via encrypted to Agency Name Agency NPI # Salish BHO Provider # Date and time of Authorization request Date: Time: Date and time of Assessment Date: Time: Date of Request for Residential Services Date: (bed day) Name and title of person making request Requesting agency s address Client Name DOB ID # Client s preferred language English Spanish Other Language: Race (enter code) Client s mailing address Hispanic Origin (Enter Code) Gender (enter code) Sexual Orientation (enter code) Client s Funding Source Medicaid Provider One ID: DSM-5 diagnosis (ICD-10 code) Non-Medicaid Criminal SUD Only Justice System Residential Referred by Recommended ASAM LOC DIM Dim-1 LOC SUD Withdrawal Management Non-Medicaid SABG Funded Recommended length of care Supporting evidence for ASAM LOC and treatment duration Referent Name Dim-2 Dim-3 Dim-4 Dim-5 Dim-6 Requested Residential Treatment Provider NPI # Requested Provider contact information COMMCARE to complete below Date and time of Authorization decision CommCare originated Authorization # Authorized ASAM LOC and duration Authorized treatment start date Last covered day of services Date and time individual is notified Date: Time: SBHO 7.09e 8/7/17

95 Signature of CommCare Rep: SBHO 7.09e 8/7/17

96 Salish Behavioral Health Organization Authorized Absence from Residential Treatment # Required Information 1 Name of Agency Agency NPI # Salish BHO Provider # 2 Client name DOB 3 Current DSM-5 diagnosis Current ASAM LOC 4 Authorized length of treatment stay 5 Date of admission to treatment Last covered day 6 Dates of authorized absence from facility Depart: Return: Reason for client s absence: 7 Contact requirements for client while away from facility: 8 Activities to support client s stability while away from facility: 9 10 Scheduled date and time of client s return Date: Time: 11 Name and title of agency supervisor approving client s absence 12 Clinic contact # s Primary Counselor #: Clinical Supervisor #: After hours supervisor #: Administrative staff #: 13 Date and time of client s departure Date: Time: 14 Date and time of client s return Date: Time: 15 Comments: SBHO 7.09f 10/14/16

97 SBHO 7.09f 10/14/16

98 Salish Behavioral Health Organization Data Codes Required for Withdrawal Management, Tribal Residential, and Out of Network Provider Authorization Requests MILITARY SERVICE Y or N HISPANIC ORIGIN Definition - Indicates the Hispanic origin of the client. Hispanic denotes a place of origin or cultural affiliation rather than a race. Code Definition 000 Hispanic - Specific Origin Unknown 709 Cuban 722 Mexican 727 Puerto Rican 799 Other Specific Hispanic (e.g., Chilean, Salvadoran, Uruguayan) 998 Not of Hispanic Origin 999 Unknown - Required for all MH & SUD clients at intake and assessment and whenever status changes. - Only one option allowed. RACE Definition - Indicates the race(s) the client identifies as. Race categories are based on the US Department of Heath and Human Services implementation collection standards for race and ethnicity. Code Definition 010 White 021 American Indian/ Alaskan Native 031 Asian Indian 032 Native Hawaiian 033 Other Pacific Islander 034 Other Asian 040 Black or African American 050 Other Race 604 Cambodian 605 Chinese 608 Filipino 611 Japanese 612 Korean 613 Laotian SBHO 7.09g 10/14/16

99 660 Guamanian or Chamorro 801 Middle Eastern 999 Not Provided - Required for all MH and SUD clients at intake/assessment and whenever status changes - Select one or more categories. If a person selects more than 1 code, enter each one in sequence up to 3. - If client does not identify with any of the coded races then code 050 for Other Race - If information is not available or unknown then code 999. GENDER Definition - Indicates a person s self-identified gender Code Definition 1 Female 2 Male 4 Transgender 5 Intersex: Person born with characteristics of both 6 Unknown - Required for all MH and SUD clients - Only one option allowed - Collected at intake/assessment and whenever status changes SEXUAL ORIENTATION Definition - Indicates a person s voluntarily stated sexual orientation Code Definition 1 Heterosexual 3 Gay/Lesbian/Queer/Homosexual 4 Bisexual 5 Questioning 9 Choosing not to disclose - Only one option allowed - Required for all MH and SUD clients at intake/assessment and whenever status changes. - Do not collect for individuals under age 13. SBHO 7.09g 10/14/16

100