POLICY TITLE: CONTINUED STAY REVIEWS EFFECTIVE DATE REVISED DATE. (Signature)
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1 Policy 5.13 Page 1 of 2 POLICY TITLE: CONTINUED STAY REVIEWS EFFECTIVE DATE REVISED DATE CHAPTER: SYSTEMS OF CARE Approved by: LRE BOARD OF DIRECTORS Approval Date: Maintained by: LRE Clinical Director, LRE UM Coordinator Applies to: Member CMHSPs REVIEW DATES Supersedes: Authorized by: N/A LRE Chief Executive Officer (Signature) I. POLICY In accordance with Michigan Department of Health and Human Services (MDHHS) contract requirements, the (LRE) shall ensure utilization management functions sufficient to control costs and minimize risk while assuring quality care. It is the policy of that continued stay reviews will be conducted for all individuals who have been admitted for inpatient/partial inpatient or crisis residential in which the primary funding source is Medicaid. Medicaid payment cannot be authorized for continued stays that are due solely to placement problems or the unavailability of aftercare services. II. PURPOSE Medicaid requires that hospitals providing inpatient psychiatric services or partial hospitalization services obtain authorization and certification of the need for admission and continuing stay from PIHPs. The LRE has delegated the continued stay review function to member CMHSPs. The purpose of this policy is to establish the standards that define, guide and detail how LRE Member CMHSPs comply with the federal laws and Michigan Department of Health and Human Services (MDHHS) contract requirements pertaining to the practice of continued stay reviews III. APPLICABILITY AND RESPONSIBILITY This Policy applies to all member CMHSPs IV. MONITORING AND REVIEW This policy will be reviewed annually by the LRE Clinical Director or designee with input from the appropriate ROATs.
2 Page 2 of 2 V. DEFINITIONS N/A VI. RELATED POLICIES AND PROCEDURES LRE Organizational Procedures 5.13.a- Continued Stay Reviews Inpatient 5.13.b - Continued Stay Reviews Crisis Residential 5.13.c - Continued Stay Reviews Partial Inpatient VII. REFERENCES/SUPPORTING DOCUMENTS MDHHS/PIHP Contract Section 4.0 Access Assurance, Attachment Michigan Medicaid Provider Manual, Behavioral Health and Intellectual/Developmental Disability Supports and Services chapter (8.5 Eligibility Criteria) Michigan Mental Health Code, Section Continued Stay Reviews
3 ORGANIZATIONAL PROCEDURE Page 1 of 3 PROCEDURE # 5.13.a EFFECTIVE DATE REVISED DATE TITLE: CONTINUED STAY REVIEWS Inpatient Hospitalization POLICY #: 5.13 ATTACHMENT TO POLICY TITLE: CONTINUED STAY REVIEWS REVIEW DATES CHAPTER: SYSTEMS OF CARE I. PROCEDURES Partial hospitalization services may be used to treat a person with mental illness who requires intensive, highly coordinated, multi-modal ambulatory care with active psychiatric supervision. Treatment, services and supports are provided for six or more hours per day, five days a week. The use of partial hospitalization as a setting of care presumes that the beneficiary does not currently need treatment in a 24-hour protective environment. Conversely, the use of partial hospitalization implies that routine outpatient treatment is of insufficient intensity to meet the beneficiary s present treatment needs. The SI/IS criteria for admission assume that the beneficiary is displaying signs and symptoms of a serious psychiatric disorder, demonstrating significant functional impairments in self-care, daily living skills, interpersonal/social and/or educational/vocational domains, and is exhibiting some evidence of clinical instability. However, the level of symptom acuity, extent of functional impairments and/or the estimation of risk (clinical instability) do not justify or necessitate treatment at a more restrictive level of care. A. Continued stay reviews will be conducted by licensed, appropriately credentialed individuals, who have been determined by the CMHSP to possess the appropriate experience, credentials, and clinical competence. B. After a beneficiary has been certified for admission to an inpatient psychiatric setting, services must be reviewed at regular intervals to assess the status of the treatment process and determine the necessity for continued care in an inpatient setting. Frequency of reviews should be based on information provided by the facility and should not exceed four days. The individual must meet all three criteria outlined as follows: 1. Diagnosis: The beneficiary has a validated current version of DSM or ICD mental disorder (excluding ICD-9 V-codes and ICD-10 Z-codes) that remains the principal diagnosis for purposes of care during the period under review. 2. Severity of Illness:
4 Page 2 of 3 a. Persistence/intensification of signs/symptoms, impairments, harm inclinations or biologic/medication complications which necessitated admission to this level of care, and which cannot currently be addressed at a lower level of care. b. Continued severe disturbance of cognition, perception, affect, memory, behavior or judgment. c. Continued gravely disabling or incapacitating functional impairments or severely and pervasively impaired personal adjustment. d. Continued significant self/other harm risk. e. Use of psychotropic medication at dosage levels necessitating medical supervision, dosage titration of medications requiring skilled observation, or adverse biologic reactions requiring close and continuous observation and monitoring. f. Emergence of new signs/symptoms, impairments, harm inclinations or medication complications meeting admission criteria. 3. Intensity of Service: a. The beneficiary requires close observation and medical supervision due to the severity of signs and symptoms, to control risk behaviors or inclinations, to assure basic needs are met or to manage biologic/medication complications. b. The beneficiary is receiving active, timely, treatment delivered according to an individualized plan of care. c. Active treatment is directed toward stabilizing or diminishing those symptoms, impairments, harm inclinations or biologic/medication complications that necessitated admission to inpatient care. d. The beneficiary is making progress toward treatment goals as evidenced by a measurable reduction in signs/symptoms, impairments, harm inclinations or biologic/medication complications or, if no progress has been made, there has been a modification of the treatment plan and therapeutic program, and there is a reasonable expectation of a positive response to treatment. C. CMHSP staff will conduct continued stay review for all inpatient admissions by: 1. Verifying that medical necessity criteria are met 2. Authorize payment for days of care based on medical necessity criteria as defined in the Medicaid Provider Manual 3. Begin discharge planning from day of initial authorization 4. Coordinate all after-care activities with hospital liaison and community provider 5. Document all continued stay review activity in the clinical record. Documentation to include: a. Admission date b. Name of inpatient facility c. Total length of stay PROCEDURE: 5.13.a Continued Stay Reviews - Inpatient
5 Page 3 of 3 d. Total number of days authorized i. Total days authorized where medical necessity was met ii. Total days authorized where medical necessity was not met (alternative [non-medicaid] funding source used). iii. Total number of days denied payment of any funding source e. Evidence that coordination of care between the inpatient facility and the CMHSP/Provider occurs throughout the course of hospitalization. f. Discharge planning must begin at the onset of treatment in the inpatient unit. Discharge criteria must be documented in the beneficiary s record. g. Discharge date h. Aftercare plan i. Aftercare appointment scheduled within seven (7) days of discharge or explanation for delayed scheduling. (i) Dates and times of all aftercare appointments (ii) Name of agency(ies) providing aftercare (iii) Clinician s name(s) 6. In circumstances where the CMHSP determines that medical necessity criteria are no longer met, the CMHSP will Inform the inpatient facility of the determination a. If the inpatient facility agrees, discharge process will be initiated. b. If the inpatient facility does not agree, CMHSP will initiate local dispute resolution process II. REFERENCES/SUPPORTING DOCUMENTS LRE Policy 5.13 Continued Stay Reviews PROCEDURE: 5.13.a Continued Stay Reviews - Inpatient
6 ORGANIZATIONAL PROCEDURE Page 1 of 3 PROCEDURE # 5.13.b EFFECTIVE DATE REVISED DATE TITLE: CONTINUED STAY REVIEWS Partial Hospitalization POLICY #: 5.13 ATTACHMENT TO POLICY TITLE: CONTINUED STAY REVIEWS REVIEW DATES CHAPTER: SYSTEMS OF CARE I. PROCEDURES A. Continued stay reviews will be conducted by licensed, appropriately credentialed individuals, who have been determined by the CMHSP to possess the appropriate experience, credentials, and clinical competence. B. After a beneficiary has been certified for partial hospitalization admission, services must be reviewed at regular intervals to assess the status of the treatment process and determine the necessity for continued care in a partial hospitalization setting. Frequency of reviews should be based on information provided by the facility and should not exceed four days. The individual must meet all three criteria outlined as follows: a. Diagnosis: i. The beneficiary has a validated current version of DSM or ICD mental disorder (excluding ICD-9 V-codes and ICD-10 Z-codes), which remains the principal diagnosis for purposes of care during the period under review. b. Severity of Illness: i. Persistence of symptoms, impairments, harm inclinations or medication complications which necessitated admission to this level of care, and which cannot currently be addressed at a lower level of care. ii. Emergence of new symptoms, impairments, harm inclinations or medication complications meeting admission criteria. iii. Progress has been made in ameliorating admission symptoms or impairments, but the treatment goals have not yet been fully achieved and cannot currently be addressed at a lower level of care. c. Intensity of Service:
7 Page 2 of 3 i. The beneficiary is receiving active, timely, intensive, structured multimodal treatment delivered according to an individualized plan of care. ii. Active treatment is directed toward stabilizing or diminishing those symptoms, impairments, harm inclinations or medication complications that necessitated admission to the program. iii. The beneficiary is making progress toward treatment goals or, if no progress has been made, the treatment plan and therapeutic program have been revised accordingly and there is a reasonable expectation of a positive response to treatment. 2. CMHSP staff will conduct continued stay review for all partial hospitalization admissions by: a. Verifying that medical necessity criteria are met b. Authorize payment for days of care based on medical necessity criteria as defined in the Medicaid Provider Manual c. Begin discharge planning from day of initial authorization d. Coordinate all after-care activities with hospital liaison and community provider e. Document all continued stay review activity in the clinical record. Documentation to include: i. Admission date ii. Name of partial hospitalization facility iii. Total length of stay iv. Total number of days authorized (i) Total days authorized where medical necessity was met (ii) Total days authorized where medical necessity was not met (alternative [non-medicaid] funding source used). (iii) Total number of days denied payment of any funding source v. Evidence that coordination of care between the partial hospitalization facility and the CMHSP/Provider occurs throughout the course of hospitalization. vi. Discharge planning must begin at the onset of treatment. Discharge criteria must be documented in the beneficiary s record. vii. Discharge date viii. Aftercare plan (i) Aftercare appointment scheduled within seven (7) days of discharge or explanation for delayed scheduling. (ii) Dates and times of all aftercare appointments (iii) Name of agency(ies) providing aftercare (iv) Clinician s name PROCEDURE: 5.13.b Continued Stay Reviews Partial Inpatient
8 Page 3 of 3 f. In circumstances where the CMHSP determines that medical necessity criteria are no longer met, the CMHSP will inform the partial hospitalization facility of the determination i. If the partial hospitalization facility agrees, discharge process will be initiated. ii. If the partial hospitalization facility does not agree, CMHSP will initiate local dispute resolution process II. REFERENCES/SUPPORTING DOCUMENTS LRE Policy 5.13 Continued Stay Reviews PROCEDURE: 5.13.b Continued Stay Reviews Partial Inpatient
9 ORGANIZATIONAL PROCEDURE Page 1 of 3 PROCEDURE # 5.13.c EFFECTIVE DATE REVISED DATE TITLE: CONTINUED STAY REVIEWS Crisis Residential POLICY #: 5.13 ATTACHMENT TO POLICY TITLE: CONTINUED STAY REVIEWS REVIEW DATES CHAPTER: SYSTEMS OF CARE I. PROCEDURES Crisis residential services may be provided to adults or children who are assessed by, and admitted through, the local CMHSP. Beneficiaries must meet psychiatric inpatient admission criteria but have symptoms and risk levels that permit them to be treated in a crisis residential facility. Services are designed for beneficiaries with mental illness or beneficiaries with mental illness and another concomitant disorder, such as substance abuse or developmental disabilities. For beneficiaries with a concomitant disorder, the primary reason for service must be mental illness. Services may be provided for a period up to 14 calendar days per crisis residential episode. Services may be extended and regularly monitored, if medically necessary as determined by the interdisciplinary team. Stays authorized for more than 14 days require that the treatment plan is reviewed and updated. A. Continued stay reviews will be conducted by licensed, appropriately credentialed individuals, who have been determined by the CMHSP to possess the appropriate experience, credentials, and clinical competence. 1. After a beneficiary has been certified for admission to a crisis residential facility, services must be reviewed at regular intervals to assess the status of the treatment process and determine the necessity for continued care in a crisis residential facility.. Frequency of reviews should be based on information provided by the facility and should not exceed four days. The individual must meet all three criteria outlined as follows: a. Diagnosis: The beneficiary has a validated current version of DSM or ICD mental disorder (excluding ICD-9 V-codes and ICD-10 Z-codes) that remains the principal diagnosis for purposes of care during the period under review. b. Severity of Illness: i. Persistence/intensification of signs/symptoms, impairments, harm inclinations or biologic/medication complications which necessitated
10 Page 2 of 3 admission to this level of care, and which cannot currently be addressed at a lower level of care. c. Continued severe disturbance of cognition, perception, affect, memory, behavior or judgment. d. Continued gravely disabling or incapacitating functional impairments or severely and pervasively impaired personal adjustment. e. Continued significant self/other harm risk. f. Use of psychotropic medication at dosage levels necessitating medical supervision, dosage titration of medications requiring skilled observation, or adverse biologic reactions requiring close and continuous observation and monitoring. g. Emergence of new signs/symptoms, impairments, harm inclinations or medication complications meeting admission criteria. 2. Intensity of Service: a. The beneficiary requires close observation and medical supervision due to the severity of signs and symptoms, to control risk behaviors or inclinations, to assure basic needs are met or to manage biologic/medication complications. b. The beneficiary is receiving active, timely, treatment delivered according to an individualized plan of care. c. Active treatment is directed toward stabilizing or diminishing those symptoms, impairments, harm inclinations or biologic/medication complications that necessitated admission to crisis residential care. d. The beneficiary is making progress toward treatment goals as evidenced by a measurable reduction in signs/symptoms, impairments, harm inclinations or biologic/medication complications or, if no progress has been made, there has been a modification of the treatment plan and therapeutic program, and there is a reasonable expectation of a positive response to treatment. B. CMHSP staff will conduct continued stay review for all crisis residential facility admissions by: 1. Verifying that medical necessity criteria are met 2. Authorize payment for days of care based on medical necessity criteria as defined in the Medicaid Provider Manual 3. Begin discharge planning from day of initial authorization 4. Coordinate all after-care activities with hospital liaison and community provider 5. Document all continued stay review activity in the clinical record. Documentation to include: a. Admission date b. Name of crisis residential facility c. Total length of stay d. Total number of days authorized PROCEDURE: 5.13.b Continued Stay Reviews Crisis Residential
11 Page 3 of 3 i. Total days authorized where medical necessity was met ii. Total days authorized where medical necessity was not met (alternative [non-medicaid] funding source used). iii. Total number of days denied payment of any funding source e. Evidence that coordination of care between the crisis residential facility and the CMHSP/Provider occurs throughout the course of hospitalization. f. Treatment plan is reviewed and updated every 14 days. g. Discharge planning must begin at the onset of treatment in the crisis residential facility. Discharge criteria must be documented in the beneficiary s record. h. Discharge date i. Aftercare plan i. Aftercare appointment scheduled within seven (7) days of discharge or explanation for delayed scheduling. (i) Dates and times of all aftercare appointments (ii) Name of agency(ies) providing aftercare (iii) Clinician s name(s) 6. In circumstances where the CMHSP determines that medical necessity criteria are no longer met, the CMHSP will Inform the crisis residential facility of the determination a. If the crisis residential facility agrees, discharge process will be initiated. b. If the crisis residential facility does not agree, CMHSP will initiate local dispute resolution process II. REFERENCES/SUPPORTING DOCUMENTS LRE Policy 5.13 Continued Stay Reviews PROCEDURE: 5.13.b Continued Stay Reviews Crisis Residential
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