#14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT)

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1 COUNTY OF SANTA BARBARA ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES Section - Policy- QUALITY ASSURANCE #14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT) Director's /{A A.. \ f' Approval <ill I.JV\_ Deputy Director's Approval ~"""~i Form Ref. - Effective: 4/1/1998 Revised: 4/1/2013 Date Date Reviewed: POLICY: It is the policy of the Santa Barbara County Mental Health Plan (SBC MHP) to ensure timely authorization for outpatient specialty mental health services to treat medically necessary conditions. Pre-authorization for all services excluding emergency services is required. All payment authorizations will be approved or denied by licensed, waivered, or registered mental health professional employees of the MHP within 14 calendar days of receipt of a request. An extension of up to 14 calendar days is given if the beneficiary or provider requests, or if the MHP identifies a need for additional information and documents the need and how the extension is in the beneficiary's interest in its authorization records. Authorization Procedures Covered in this Policy: I. Authorization of outpatient mental health services (except TBS) 11. Authorization of Therapeutic Behavioral Services Ill. Co-occurring conditions IV. Out-of-county SNF & IMO facilities V. Children in out-of-county foster care, residential placements, or adoptions VI. Day Treatment Intensive/Day Rehabilitation Services Legal Citations: CFR, Title 42, CCR, Title 9, Chapter 11, Sections , , DEFINITIONS: A. Co-Occurring Conditions: Includes individuals who have been diagnosed with both a mental health condition and a condition related to alcohol or other drugs, AND persons who have a been diagnosed with a mental health condition as well as any other condition that is not included under

2 mental health Medi-Cal medical necessity (see "Medical Necessity" definition below). Co Occurring Conditions include, but are not limited to, an included mental health condition as well as a developmental delay, autism, chronic pain, or organic brain disorder. A. Clinician means an individual employed or contracted by the MHP, or by a legal entity contracted by the MHP, who meets one or more of the criteria below: 1. Holds a valid California license as an MD, DO, Psychologist, LCSW, MFT, or LPCC. 2. Holds a valid California license as an RN and holds advanced practice certification from the Board of Registered Nursing as a Psychiatric/Mental Health (PMH) nurse. 3. Holds a valid California registration as an ASW, IMF, or PCCI. 4. Holds a valid waiver from DMH to perform the duties of a Psychologist. B. Medical Necessity: To meet medical necessity criteria for MHP reimbursement of Specialty Mental Health Services, the beneficiary and proposed services must meet criteria 1-5 below: 1. Be diagnosed by with a condition having a DSM and/or ICD-9 code in one of the following ranges: Have at least one of the following impairments as a result of the mental disorder(s) listed in subdivision (1) above: a. A significant impairment in an important area of life functioning. b. A probability of significant deterioration in an important area of life functioning. c. Except as provided in Section , a probability a child will not progress developmentally as individually appropriate. For the purpose of this section, a "child" is a person under the age of 21 years. 3. Must meet each of the intervention criteria listed below: a. The focus of the proposed intervention is to address the condition identified in (2) above. b. The expectation is that the proposed intervention will: i. Significantly diminish the impairment, or u. Prevent significant deterioration in an important area of life functioning, or i Except as provided in Section (see box below), allow the child to progress developmentally as individually appropriate. 4. The condition would not be responsive to physical health care based treatment. P&P 14 2

3 5. When the requirements of this section are met, beneficiaries shall receive specialty mental health services for a diagnosis included in subsection (b)(1) even if a diagnosis that is not included in subsection (b)(1) is also present. EPSDT CRITERIA (9CCR O) Medical Necessity Criteria for MHP Reimbursement for Specialty Mental Health Services for Eligible Beneficiaries Under 21 Years of Age., (a) For beneficiaries under 21 years of age who do meet the medical necessity requirements of Section (b)(2) and (3), medical necessity criteria for specialty mental health services covered by this subchapter shall be met when all of the following exist: (1) The beneficiary meets the diagnosis criteria in Section (b}(1 ), (2) The beneficiary has a condition that would not be responsive to physical health care based treatment, and {3} The requirements of Title 22, Section 51340(e)(3) are met; or, for targeted case management services, the service to which access is to be gained through case management is medically necessary for the beneficiary under Section or under Title 22, Section 51340(e)(3) and the requirements of Title 22, Section 51340(f) are met. (b) The MHP shall not approve a request for an EPSDT Supplemental Specialty Mental Health Service under this section if the MHP determines that the service to be provided is accessible and available in an appropriate and timely manner as another specialty mental health service covered by this subchapter. (c) The MHP shall not approve a request for specialty mental health services under this section in home and community based settings if the MHP determines that the total cost incurred by the Medi-Cal program for providing such services to the beneficiary is greater than the total cost to-the Medi-Cal program in providing medically equivalent services at the beneficiary's otherwise appropriate institutional level of care, where medically equivalent services at the appropriate level are available in a timely manner. PROCEDURE: A. INITIAL AUTHORIZATION FOR ROUTINE OUTPATIENT SERVICES 1. An individual seeking services, or a third party such as a parent or legal guardian seeking services for an individual, contacts Access staff. Access staff determine the individual's Medi-Cal status, and an LPHA determines whether or not the individual meets medical necessity criteria for outpatient services. a. Exception: For minors who are beneficiaries of full-scope Medi-Cal with zero share of cost and Santa Barbara as County of Responsibility, the minor or other party may directly contact a community-based organization which has programs contracted by the MHP to screen, assess, and admit such beneficiaries. i. If the CBO finds that the minor requires urgent services (see P&P 9 for details), the CBO will immediately refer the minor or guardian to SAFTY for evaluation and assistance. If the CBO determines that medical necessity exists, the CBO will open an admission for the minor and provide services according to the terms of the program's contract with the MHP. (A) The contracts of Fee-For-Service (FFS) programs and the Great Beginnings program require authorization from Quality Assurance (QA) before providing services other than an initial assessment to determine medical necessity. (B) An LPHA in these programs will complete an assessment sufficient to determine medical necessity and will complete the current MHP-approved Authorization Request. The results of the assessment will be documented using the official MHP Assessment or First Intake form. The assessment and Authorization will be faxed to QA, who will then follow the procedures in P&P 99, Network Provider and CBO Authorization. P&P14 3

4 b. An LPHA on the Access Team will screen the individual for whom services are sought following Policies & Procedures "Service Triage: Routine Services" and "Service Triage & Authorization: Urgent & Emergency Conditions" as appropriate. i. The "Urgent & Emergency Conditions" P&P will be followed if the contact with Access staff indicates the presence of an urgent or emergency condition. The remainder of this P&P does not apply to such individuals until such time as the urgent or emergency condition has been resolved. c. If the individual is a Medi-Cal beneficiary, and his/her condition meets the medical necessity criteria for Specialty Mental Health Services, the Access staff will work to match the beneficiary with the most appropriate provider using the procedures below. 2. Medi-Cal County of Responsibility is NOT Santa Barbara: a. If the beneficiary is not a resident of Santa Barbara County, he/she will be referred to the Access contact number for the MHP in his/her County of Responsibility. The Santa Barbara County MHP will not provide any outpatient services except Crisis Intervention without authorization from the County of Responsibility. b. If the beneficiary is in foster care, adoptive care, or KinGap placement in Santa Barbara County, the beneficiary will be referred to the MHP Quality Assurance program (QA) for assistance in proceeding with a request for assessment and other medically necessary services under the terms of SB785. c. If the beneficiary is a resident of Santa Barbara County but has not updated his/her residence information with appropriate agencies responsible for Medi-Cal since locating in this county, he/she will be referred to Santa Barbara County Department of Social Services to update that information. The beneficiary will also be referred to the MHP of the current County of Responsibility to request interim authorization of services in Santa Barbara County. 3. Dual-Eligible ("Medi-Medi") and Other Health Coverage (OHC) a. Individuals who are beneficiaries of both Medicare and Medi-Cal will be referred to contact Medicare for a list of participating providers in their area. If the individual needs assistance in connecting with Medicare, Access staff will assist in making the call to Medicare for a list of providers. i. If Access determines that it is probable that a Dual Eligible individual requires services of a type or intensity which cannot be met by local Medicare providers, Access will refer the case to the Regional Manager or Team Supervisor responsible for the county-operated program most easily accessible to the individual. The Manager or Supervisor will review the case and may assign the client to County-operated or contracted programs if there is a need for the type and level of services provided by those programs. b. Individuals who are Medi-Cal beneficiaries and have Other Health Coverage (OHC) will be referred to an appropriate provider based on whether or not the OHC includes outpatient mental health services, in keeping with established Medi-Cal regulations. 4. Santa Barbara County Medi-Cal beneficiaries and Uninsured individuals a. The Access Team will screen individuals who are Uninsured, have Emergency-Only Medi-Cal, or have Pregnancy-Only Medi-Cal and are not pregnant or perinatal for SPMl/SED status per P&P 73. If screening indicates probable SPMl/SED status, the individual will be referred to the MHP outpatient program closest to the individual's residence for full evaluation. P&P14 4

5 b. Medi-Cal beneficiaries, including pregnant and perinatal beneficiaries with Pregnancy Only Medi-Cal, will be referred to an appropriate provider based on level of need. i. An individual whose screening indicates probable SPMl/SED status per P&P 73 will be referred to the MHP outpatient program closest to the beneficiary's residence for full evaluation. i iv. An individual whose needs are determined to require short-term, solution-focused psychotherapy will be referred to a Network Provider, or to a community-based organization contracted with the MHP to provide the same type of services. A minor who does not meet the criteria for SPMl/SED but who requires services beyond short-term, solution-focused psychotherapy will be referred to a CBOoperated program contracted to provide appropriate services. Appropriateness of these referrals will be based on the beneficiary's stated preferences, level of care needed, and practitioner expertise, as well as cultural and linguistic needs. c. Network Provider services, services by CBO's offering similar services i. Access staff will give the beneficiary the names and telephone numbers of three appropriate providers, along with relevant contact and identifying information based on current referral procedures in place. i iv. If fewer than three providers who meet the beneficiary's needs are available in the relevant geographic area, the Access Team will notify ADMHS Quality Assurance. That information will be used to guide future recruitment and contracting for Network Providers and will be reported to the department's Quality Improvement Committee. The beneficiary will be instructed to call their provider of choice to set up an appointment. The beneficiary or provider will then contact MHP QA with necessary identifying information. (A) 5. No Medical Necessity If QA determines the need for, or the beneficiary requests, assistance with scheduling an appointment, QA staff will contact the appropriate providers to help beneficiary make contact and schedule an initial appointment. Quality Assurance staff will then follow the procedures in P&P 99, Network Provider and CBO Authorizations. a. If Access staff determine that a Medi-Cal beneficiary does not meet Medical Necessity criteria, the Access staff will complete an NOA-A form and mail a copy to the individual within three (3) days. A copy of the NOA-A will also be forwarded to ADMHS Quality Assurance within three days. Access will also provide the individual with information regarding free or low-cost services in the community. b. If Access staff determine that an individual who is not a Santa Barbara County Medi-Cal beneficiary is ineligible for services through a program operated or contracted by the MHP, Access will provide the individual with information regarding free or low-cost services in the community. 8. CO-OCCURRING CONDITIONS 1. If a beneficiary requests services for symptoms or impairments in which there is a clinical probability that alcohol and other drugs playa significant role, the beneficiary will be referred to ADMHS Alcohol and Drug Programs or to a Medi-Cal contracted substance abuse treatment program. P&P14 5

6 2. If a beneficiary identified as having symptoms or impairments with a clinical probability of alcohol or other drug involvement also requests specialty mental health services, the request for such services will be handled in the same way as all other requests for specialty mental health services. C. OUT-OF-COUNTY SNF & IMO FACILITIES 1. When an adult is placed in an SNF or IMO facility, and reimbursement through Medi-Cal is legally possible under current laws, regulations, and contracts, each professional providing specialty mental health services to the individual while in placement will need to be credentialed by the Santa Barbara County MHP as a Network Provider in order to obtain reimbursement. 2. When a Santa Barbara County MHP beneficiary is first placed, the Santa Barbara County IMO Liaison will notify the MHP. Monthly status reports will be submitted to the supervisor of the Liaison, who will monitor these reports to ensure that cost to the beneficiary is no greater than it would be if the services were furnished within the MHP. 3. If a Santa Barbara County MHP beneficiary is placed in an out-of-county IMD/SNF by any agency other than ADM HS, the IMD/$NF must contact the Santa Barbara County Access Team to obtain authorization for specialty mental health services. The SNF/IMD authorization form will be used, and credentialing will proceed as above. 4. At any stage during the process above, a provider may contact the IMO Liaison to consult regarding the beneficiary's needs, appropriateness of the referral, medical necessity, authorization, or any other relevant issues. Similarly, ADM HS staff may initiate contact with a provider to consult regarding the same issues. D. CHILDREN IN FOSTER CARE, ADOPTIVE CARE, AND KINGAP PLACEMENTS 1. Definitions: For purposes of this Policy and Procedure, the county in which the beneficiary is placed will be referred to as the "Host County." The county designated as the Medi-Cal county in the MEDS database or Medi-Cal verification system is referred to as the "County of Origin." 2. Applicability: This P&P applies to all Medi-Cal beneficiaries with Medi-Cal Aid Codes for Foster Care, Adoptive Parents (AAP), or KinGap. 3. Whenever the Department of Health Care Services has designed a form as mandatory, such forms will be used whenever Santa Barbara is the County of Origin or Host County. 4. Santa Barbara County Beneficiary Placements in Group Homes, Foster Homes, KinGap Homes, or Other Facilities: a. At the time a Santa Barbara County MHP beneficiary is initially placed in an out-ofcounty group home, foster home, KinGap home, or other facility, the Santa Barbara County agency (Child Welfare Services, Probation, or ADMHS Children's System of Care) which arranged the placement will include a Beneficiary Brochure among the materials provided to the program or home. b. If a child who is a Santa Barbara County MHP beneficiary is placed in an out-of-county residential situation through a Special Education Individualized Education Plan (IEP), the ADMHS Children's System of Care will provide a Beneficiary Brochure to the program or home. c. If the staff of a licensed facility, the foster parent, KinGap provider, staff of the placing agency, or a treatment provider determines that specialty, mental health services are required by a Medi-Cal beneficiary, the Host County MHP or the individual or agency requesting services will contact the County of Origin. When Santa Barbara is the P&P14 6

7 County of Origin, the request will be made to the MHP Quality Assurance program (QA). d. QA will assume the role described for Access staff in the procedures described under "Initial authorization for routine outpatient services" above. The same procedures will be followed except: e. Timeliness i. QA will authorize services for a child or youth placed outside Santa Barbara County within three (3) working days following the date of request for service and notify the host county and the requesting provider of the authorization decision. (A) If QA documents a need for additional information to evaluate the beneficiary's need for the service, the authorization may be delayed by up to three (3) working days from the date the additional information is received, or 14 calendar days from the receipt of the original Treatment Authorization Request, whichever is less. (8) If the requested additional information is not received within the timelines specified in (i) above, QA will authorize services per (a) above. Within 30 calendar days of the date of authorization of service, QA will ensure that arrangements have been completed for reimbursement for the services provided to the child or youth through the host county or requesting provider. f. Provider Selection i. QA will authorize services through the Host County unless the Host County declines authorization or the Santa Barbara County MHP has an existing contract with a provider in reasonable proximity to the beneficiary, and the provider is able to begin services within an appropriate period of time (maximum 10 days). In those situations, QA will authorize services through the contracted provider. i If the Host County declines authorization and the Santa Barbara County MHP has no existing contract with a treatment provider, QA will expedite arrangements with another provider in reasonable proximity to the beneficiary. Santa Barbara County MHP will take the steps necessary to ensure that arrangements have been completed for reimbursement for the services provided to the beneficiary through a reciprocal agreement or other suitable financial agreement with the Host County, or through a a contract with another provider. 2. Santa Barbara County Adoption Assistance Program Beneficiaries a. Requests for EPSDT specialty mental health services for a Medi-Cal beneficiary with Aid Code 03, 04, or 4A, or any other Adoption Assistance Code created in the future, with be directed to QA, regardless of whether Santa Barbara is the Host County or the County of Origin. b. When Santa Barbara is the Host County, QA will request authorization from the County of Origin and will direct the beneficiary to appropriate programs as authorized. c. When Santa Barbara is the County of Origin: i. QA will screen the beneficiary for medical necessity and determine appropriate services using the procedures described under "Initial Authorization for Routine Services" above. i QA will authorize the mental health services found to be appropriate. Per the provisions of DMH Letter 06-18, Santa Barbara County MHP will contact the Host County MHP to notify that MHP of the service authorization and obtain information regarding the point of contact for provision of services. P&P14 7

8 iv. The beneficiary will then be referred to the point of contact. v. The Host County MHP will bill Medi-Cal directly for services. vi. v If the service provider requests re-authorization of services beyond the initial authorization, or if the provider requests authorization of other services, that request will be submitted to QA for review as described under "Authorization for Continuation or Modification of Routine Outpatient Services and/or "Initial Authorization for Routine Outpatient Services" above. In addition to the notifications to the provider and beneficiary prescribed by those procedures, the outcome of the request will be communicated to the Host County MHP at the same time. 3. Beneficiaries From Other Counties Placed in Santa Barbara County a. Individual and organizational providers in Santa Barbara County may directly contact the County of Origin to request authorization of services, and may directly arrange for payment by the County of Origin. b. When the Santa Barbara County MHP is notified that a Medi-Cal beneficiary from another county with a relevant Aid Code requires Assessment and/or other services, QA will request authorization and payment arrangements from the County of Origin and will follow any necessary procedures requested by the County of Origin. 4. Disagreements Between Counties: Santa Barbara County MHP and the MHP of the Host County will resolve any disagreements through the arbitration process provided in Section of Title 9, California Code of Regulations, or through any other process established for that purpose by the Department of Health Care Services. 5. Consultation: At any stage during the process above, a provider may consult QA regarding the beneficiary's needs, appropriateness of the referral, medical necessity, or any other relevant issues. Similarly, QA may contact a provider to consult regarding the same issues. F. Day Treatment Intensive/Day Rehabilitation Services 1. Whenever Day Treatment Intensive or Day Rehabilitation services are to be provided more than five (5) days per week, the service providers must obtain authorization from the Santa Barbara County MHP in advance of service delivery. 2. Whenever counseling, psychotherapy, or other therapeutic interventions defined as "specialty mental health services" in CCR Title 9, Ch. 11, Section (excluding urgent and emergency services and TBS services) are to be provided on the same day as Day Treatment Intensive or Day Rehabilitation services, authorization must be obtained from Santa Barbara County MHP in advance. a. Requests for initial authorization must be faxed or mailed to the MHP Quality Assurance program (QA). Such requests must include all information required to establish medical necessity as specified in CCR Title 9, Section and/or b. Requests for authorization of specialty mental health services to be provided on the same day as Day Treatment Intensive must specify the reason such services cannot reasonably be provided during the same hours as Day Treatment Intensive services. c. A QA Clinician will review and authorize services based on medical necessity, and fax or mail the authorization to the provider (or mail or fax an NOA to the beneficiary with a copy to the provider if there is no medical necessity for the services). 3. The maxamum periods for which the services identified above can be authorized are: a. Day Treatment Intensive, and specialty mental health services provided on the same day as Day Treatment Intensive: three (3) months. P&P14 8

9 b. Day Rehabilitation, and specialty mental health services provided on the same day as Day Rehabilitation: six (6) months. 4. Requests for continuation of the services identified above beyond the initial authorization must be made to ADMHS Quality Assurance in writing and must include clinical details including current diagnoses, current symptoms and impairments, progress in treatment, proposed interventions, and other information necessary to determine medical necessity for the requested services. a. A QA Clinician will review and authorize requests for service re-authorizations based on medical necessity and fax or mail the authorization back to the provider. If appropriate, an NOA will be mailed to the beneficiary with a copy to the provider. 5. At any stage during the process above, a provider may consult QA regarding the beneficiary's needs, appropriateness of the referral, medical necessity, or any other relevant issues. Similarly, QA may contact a provider to consult regarding the same issues. B. Therapeutic Behavioral Services (TBS) 1. Beneficiaries Residing in Santa Barbara County a. The Care Coordinator responsible for coordinating the client's outpatient mental health services identifies a client who may benefit from TBS service. b. If the client does not currently have an open admission to a County-operated program, the Care Coordinator or a supervisor will contact the Quality Assurance program (QA), and QA will arrange an assessment to determine medical necessity for TBS services. i. When a client meets medical necessity criteria for TBS services, the client will be admitted to a County-operated program for purposes of coordination of care and any other medically necessary services. The specific program will be selected by the Regional Manager for the area in which the beneficiary resides. c. In order to qualify for TBS service the client must meet the following,criteria: i. Full-scope Medi-Cal beneficiary under 21 years old. Meets Medi-Cal necessity criteria. i Is receiving other specialty mental health services. iv. Is a certified class member. d. If the client is determined not to be eligible, the Program Manager or Team Supervisor will refer the case to QA for review. QA will determine whether a NOA is required and, if so, will send notification to the beneficiary within three (3) days. e. If the client is determined to be eligible, the Care Coordinator completes a TBS referral packet which is faxed or mailed to the TBS provider. f. The TBS provider coordinates an initial planning meeting with appropriate MHP or other agency staff as well as the beneficiary's parent or legal guardian. A detailed plan for TBS services will be developed at the initial planning meeting. TBS services are only valid if authorized by the beneficiary's parent or legal guardian. g. TBS services cannot be authorized for longer than 60 days per authorization. If TBS services are planned to last more than 12 hours per day, the maximum period for authorization is 30 days. 2. Beneficiaries Residing Outside Santa Barbara County a. Whenever ADMHS staff receive a request for TBS services for clients who are beneficiaries of the Santa Barbara County ADMHS MHP but are residing in another county, the request is referred to QA and is handled as specified under ""Children In Foster Care, Adoptive Care, And KinGap Placements" above. If the child does not quality, the parent/guardian will be instructed to notify Medi-Cal of their new address. P&P14 9

10 3. At any stage during the process above, a provider may contact QA to consult regarding the beneficiary's needs, appropriateness of the referral, medical necessity, or any other relevant issues. Similarly, QA may contact a provider to consult regarding the same issues. Assistance: Reference: Replaces: P&P14 10