ValueOptions - Arkansas Frequently Asked Questions

Transcription

1 The series of questions and answers below are intended to assist the Arkansas providers and stakeholders. This FAQ document will continue to be reviewed and updated frequently in order to provide the most current and pertinent information. General Questions Q1. What changes are taking place? A. The Arkansas Department of Human Services Division of Medical Services (DMS) has contracted with ValueOptions to perform Utilization Review (UR) Inpatient Mental Health services for children under 21 and Outpatient Mental Health services for children and adults. Q2. What is the effective date that this transition will occur? A. July 1, However, providers should begin to submit requests to ValueOptions on June 26, Q3. What services are being added and/or removed? A. There is no change in covered services. Q4. Does ValueOptions exist in Arkansas today? A. Today, ValueOptions provides Mental Health & Substance Abuse and EAP services to employees of many companies operating in Arkansas and is no stranger to the Arkansas provider community. We look forward to the expanded opportunity and working with the Arkansas Medicaid provider community. Q5. If I have more questions after reading the FAQs, who can I call? A. On June 28, you may begin to use the Arkansas toll free number to ValueOptions (877) , 8am to 5pm CST. You may also contact Provider Relations today and in the future at voarkansasproviderrelations@valueoptions.com Q6. Will providers be offered assistance and/or contact information by provider relations? A. Arkansas providers will have access to Provider Relations staff in Arkansas for assistance. Providers can reach a representative by calling the ValueOptions toll free (877) number or via at voarkansasproviderrelations@valueoptions.com Page 1 of 26 Revised: 11/9/2010

2 Q7. Has ValueOptions developed a backup plan for communication backlog, especially during the first few weeks of the transition? A. We are working with DMS to ensure that providers are given all information to ensure a smooth transition. ValueOptions will have national resources available during the transition. Q8. Will beneficiaries be issued new identification cards? A. No Q9. How often will beneficiary s information be updated in the ValueOptions system? A. ValueOptions will be receiving a file from DMS. However, it is the responsibility of the providers to verify eligibility with Medicaid prior to requesting authorization from ValueOptions. Q10. Will beneficiaries continue to receive their initial packets after July 1 st? A. Yes Q11. Currently, APS & First Health have different inspection dates. How will ValueOptions coordinate those dates when they start their audits? A. As the single vendor for the Arkansas contract, ValueOptions will coordinate the Inpatient and Outpatient audits while still meeting the requirements of the audit process and the audits themselves. There will be no need to coordinate schedules with another vendor thus making it more convenient for the provider. Q12. Will your webinars be recorded in case you miss a session? A. At this time, the webinars will not be recorded. However, the presentations will be posted to the ValueOptions - Arkansas specific website and can be viewed by accessing the following link: Q13. Why do we use ValueOptions if you are not the payment source? A. ValueOptions is the prospective winner of two contracts awarded by the Arkansas Department of Human Services Division of Medical Services. We will handle Utilization Review for Inpatient services for children under the age of 21, and will administer Outpatient Mental Health services for children and adults. ValueOptions will provide Utilization and Quality Management. Your Page 2 of 26 Revised: 11/9/2010

3 payment source will not change and will continue through HP. Clinical/Authorization/Quality Q14. What are the hours of operation for the ValueOptions Clinical Department? A. Clinical staff is available from 8:00AM to 5:00PM CST. Q15. What is the transition plan for current Medicaid beneficiaries I am seeing? A. ValueOptions is honoring all First Health and APS authorizations. Providers should continue to submit authorization requests to the current vendors through end of day June 25 and at the time of concurrent review, submit to ValueOptions. Providers will need to contact ValueOptions for services that APS or First Health previously authorized prior to the end of the date of services. Q16. When will current authorizations expire? A. Current authorizations will be valid through their existing expiration dates issued by APS or First Health. Q17. What is the procedure for after-hours authorizations? A. On line authorization requests can be submitted 24/7 online via ProviderConnect sm. In addition, ValueOptions has telephonic coverage Monday through Friday from 8:00 AM to 5:00 PM CST. Q18. How will authorization decisions be acknowledged? A. Authorization decisions will be available online via ProviderConnect sm. Providers have the option to print or download the authorization. Q19. What is the process for obtaining additional authorized units of service, if all the initially authorized units are used prior to the authorization expiration date? A. Processes and procedures are not changing. All program types require pre-authorization except emergency treatment. Authorization requests for additional units can be submitted on line or telephonically. When completing the Outpatient treatment request, please check the revision box so that it is clear to the care management staff that the request is for additional units. Providers need to Page 3 of 26 Revised: 11/9/2010

4 clearly document the change in condition and why the request is needed. The additional units can only span the current authorization requests. Q20. How will returned treatment plans be handled? Will they be returned electronically or will a Care Manager call the provider? A. A Care Manager will call the provider to review the treatment plan. However, if a request is submitted via fax and the information is not clear, units are not noted, or the provider or beneficiary is not eligible, the request will be returned. Q21. On concurrent authorization reviews, will the ProviderConnect sm application have beneficiary information from the prior submission, such as Axis I-V Diagnoses, Medications, Goals, Progress, etc? A. Upon transition, basic information will be transmitted to ValueOptions. The first time you obtain authorization from ValueOptions, you will need to enter information into the ValueOptions system such as: medication and progress notes. If you need information from the current vendor system, it is recommended that you print or download before the transition. When additional authorizations are completed by ValueOptions, the system will pre-populate certain data. Q22. Once information is entered into ProviderConnect sm, will it be available to update upon subsequent reviews? (Ex: IRP goals, progress) A. ValueOptions system has the ability to allow providers to review previous authorizations as well as enter requests for continued authorizations. During the continued auth request process updates can be made to numerous clinical areas including diagnoses, risks and impairments, medications, and treatment plans. Q23. Will we be able to maintain multiple users per registration in ProviderConnect sm? A. Providers will be able to obtain single or multiple logins based on the provider s administrative preference. The initial login can be obtained by self registering on using your Medicaid ID. Additional logins can be obtained by downloading and faxing a completed Account Request Form (from: faxing to the EDI Helpdesk at Page 4 of 26 Revised: 11/9/2010

5 Access to multiple provider records/medicaid ID s can be obtained by completing the Multiple Provider Account Request form (download here: Multiple_Providers.pdf). This form will also need to be faxed to the EDI Helpdesk at Faxed Account Request Forms will be processed and completed within 3-4 business days. You will receive an from e-supportservices@valueoptions.com with your USERID & password once the account setup is complete. For additional assistance, please contact the ValueOptions EDI helpdesk at e-supportservices@valueoptions.com or Monday - Friday, 8:00am to 6:00pm EST. Q24. Can providers submit Inpatient authorizations electronically or telephonically? A. All authorization requests can be submitted electronically, by fax, or telephonically. However, providers are encouraged to use the electronic option. Q25. Will retroactive authorizations be granted? A. Retroactive authorizations are not allowed. Providers should submit requests at least five business days prior to the end date of Outpatient requests, two days prior for Inpatient, and seven days prior for Residential requests. Q26. Currently for Residential care, you have to have a letter for approval from Outpatient. Is there any way to change this? A. No, Outpatient providers need to support Residential care. Q27. Currently we submit 15 days early on concurrent. Will this stay the same? A. Concurrent reviews should be submitted no sooner than 15 days and no less than 5 days from the current end date. Q28. How many services will you authorize for a new beneficiary? Page 5 of 26 Revised: 11/9/2010

6 A. The authorization parameters have not changed. The providers should request services based on the treatment plan developed. Q29. In the current APS system, batches are posted twice a day that give a summary of authorizations and can be viewed or downloaded. Will this remain the same? A. You will have a similar capability via ProviderConnect sm to download your authorizations anytime at your convenience. Q30. Is there a template for questions that will be asked in telephonic reviews? A. The Inpatient Treatment Report (ITR) is the template for both electronic and telephonic reviews. Q31. What is the retroactive eligibility review process for each program type? A. Retroactive eligibility processes will remain the same. Q32. Will hospitals with large volumes be assigned a dedicated reviewer/case manager? A. Yes, ValueOptions believes strongly in the dedicated Case Management model. Q33. What is the turnaround time for responses to authorization requests? A. The turnaround time requirements have not changed. Q34. How will we receive notification of an authorization denial? A. Both Authorization and Denial notification letters can be viewed on ProviderConnect sm. Additionally, Denial letters will be generated from the system and mailed to the provider. Q35. Where can I get a copy of the discharge form? A. A copy of the discharge form is available in ProviderConnect sm. Discharge planning is also included on our inpatient review form. We are currently working on add this information to our outpatient form. Page 6 of 26 Revised: 11/9/2010

7 Q36. Do you have to submit paperwork on spend downs? A. Yes, the complete Medical record is required. Q37. Is there a box to identify a request as a retroactive review? A. This option is being added, until that time please continue to use initial date of service which will inform our CCM that the request is a retroactive review. Q38. When you do a retroactive review, do you have to wait for that to be authorized to do concurrent stay? A. No, please submit retroactive one day and the next day you may submit the concurrent. Q39. When will current authorizations expire? A. Current authorizations will be valid through their existing expiration dates issued by APS or First Health. Q40. What is the procedure for after-hours authorizations? A. Online authorization requests can be submitted 24/7 online via ProviderConnect sm. In addition, ValueOptions has telephonic coverage Monday through Friday from 8:00 AM to 5:00 PM CST. Q41. How will returned treatment plans be handled? Will they be returned electronically or will a Care Manager call the provider? A. A Care Manager will call the provider to review the treatment plan. However, if a request is submitted via fax and the information is not clear, units are not noted, or the provider or beneficiary is not eligible, the request will be returned. Q42. Care Coordinators have been contacting our facility; however I am an Outpatient provider. I thought Care Coordinators would be for inpatient providers? A. Outpatient providers will be part of the care coordination process and will be contacted by ValueOptions Care Coordinators. Q43. When we submit an unscheduled revision, where on the form do we enter the end date of the authorizations we have with APS / First Health? Page 7 of 26 Revised: 11/9/2010

8 A. At this time please attach an additional document that will include the end date requested. Q44. What is the purpose for attaching documents for request? A. Our system is designed to give information for routine request. If you have a beneficiary that receives multiple requests, attaching additional information will help the reviewers to process your request. Q45. How can you submit an admit date for RTC request when you do not know if they have been approved yet? A. It would be the project admission date. Q46. Will the authorizations for kids and adults be linked together or will they come separately on a different report? A. It will depend on the way you set up your parameters for your report. Q47. If a PA expires, do I have a window or grace period to submit a CSR (Outpatient)? A. Requests are due prior to the last approved date. Q48. We need clarification on UM review process? A. Requests are submitted by fax or through ProviderConnect sm using our Outpatient review form or the Inpatient review form with additional information attached as required. A reviewer looks at the info, reviews the request and makes a determination for medical necessity. The auth is entered into the system and the provider is able to look at the auth or the auth letter. If the care manager has questions about medical necessity, they will outreach to one of our doctors who would complete a review. A letter will be downloaded into the system and mailed to the provider. If needed you may request reconsideration. Q49. Do we still receive 30 days for RTC review requests? B. Yes Q50. Can you fax the Outpatient letter with your RTC request? Page 8 of 26 Revised: 11/9/2010

9 A. Yes, it can be faxed. Please remember when faxing to use the appropriate cover sheet. However, ValueOptions prefers that you use our online system if possible. Q51. How many days prior to last paid day are there to submit a review? A. If it s an Outpatient request, you have at least 5 days before the last authorized date, or it can be up to15 days before. You can get the request between 15 and 5 days treatment. 7 days for Residential and 2 days for Inpatient. Q52. Does an MD need to see a patient daily on acute care? A. The rules already in place are not changing. It will be based on the medical condition of the beneficiary. Q53. Will providers be able to use their auth through APS if they need to request additional units through ValueOptions? A. APS or First Health authorization data will not be accessible by providers or viewable on the VO system. Providers will need to contact VO for services with a start date of treatment of June 26 or after. Be sure to clearly state the date you want the authorization to start. Q54. What is the process for initial retroactive reviews? Can retroactive reviews be uploaded instead of faxing? A. Yes, retroactive reviews can be done by sending an attachment as part of the request for services functionality in ProviderConnect sm. Q55. If you have an auth from APS that extends past July 1 st, will you continue to bill from that auth or do you have to contact VO for a separate auth? A. Continue to bill until that end date. Submit your request to ValueOptions within five days of the end date for Outpatient, 2 days for Inpatient, and 7 days for Residential. Q56. APS faxed our first initial CON to us for Residential. After that our nurses provide it every 30 days. Will this stay the same? A. Yes Q57. Currently for Residential care, you have to have a letter for approval from Outpatient. Is Page 9 of 26 Revised: 11/9/2010

10 there any way to change this? ValueOptions - Arkansas A. No. Outpatient providers need to support residential care. Q58. Currently we submit 15 days early on concurrent. Will this stay the same? A. Concurrent reviews should be submitted no sooner than 15 days and no less than 5 days from the current end date. Q59. For Residential care, are you required to attach a treatment plan to your authorization request? A. For Residential care, treatment plans are required. Q60. How long will your authorizations be viewable online? A. Searching authorizations by specific date ranges will result in a more limited search result. However, authorizations created by ValueOptions for a provider can be viewed by using the view all function. Q61. Our authorizations are valid for 6 months to a year. Will this process stay the same with VO? A. Yes Q62. Do you request an authorization twice if you provide the same service at two different locations, such as a school and a facility? A. No Q63. Will YOQ be mandatory? A. Yes Q64. If units are exhausted during transition period between First Health and VO, will you need to request another authorization? Page 10 of 26 Revised: 11/9/2010

11 A. Yes. Submit the request prior to the end date. Q65. On the ORF form, what is ACT 911 referring to? A. This is a special client designation for informational purposes. Q66. Will Psychological testing require a prior authorization? A. Authorization rules are not changing. Q67. Will code automatically be paid? A. Authorization rules are not changing Q68. Will it be possible to reprint a prior authorization from your system? A. Prior Authorization results can be viewed online via ProviderConnect sm through the authorization search functionality. In addition, authorization letters can be viewed and printed. Printing the entire request for services as originally entered is only possible at the time of first submission. Q69. What is the difference between units and visits? Are there any increments? A. All requests for outpatient services should be requested in 15 minute increments. One 15 minute increment equals one unit. Q70. Who makes the final decision on requests for need of stay or authorization? Will this person be local? A. All final decisions are made by a ValueOptions licensed physician or the local Medical Director. Q71. Whose guidelines do you use for clinical criteria? A. Guidelines are not changing Q72. What guidelines are your facility inspections on? Are they Medicaid regulations? Page 11 of 26 Revised: 11/9/2010

12 A. Yes. They are on Medicaid regulations. ValueOptions - Arkansas Q73. Is it possible for inspections to be done all together for facilities with multiple locations? A. If the state approves, this would be our preference. Q74. Is there a difference in the rate of Outpatient and RSPMI? A. Reimbursement rates are not changing. Q75. What can I do when a beneficiary has truly accessed all possible lower levels of care in a region and I still get denials stating they could be treated at a lower level? A. We will need to look at case examples and potentially provide training on the authorization request procedures around this issue. Q76. I provide services for sex offenders and I am receiving denials stating they could have been treated in outpatient. However, there are no outpatient providers who can serve them. What can I do? A. We will need to look at case examples and potentially provide training on the authorization request procedures around this issue. Q77. On the ORF, on service requested boxes please define revision on LMHP, SBMH, and RSPMI on ACT911. Please define what it means? A. LMHP is Licensed Mental Health Professional. Please refer to the Arkansas Medicaid provider manuals located at Q78. How will specific services be requested since Arkansas does not use level of care? A. Services should be requested as RSPMI, Acute Inpatient, RTC/RTU Inpatient, LMHP, SBMH, or RSYC. Q79. Will the provider be able to request specific services/units or is it based on the clinical provided? Page 12 of 26 Revised: 11/9/2010

13 A. Providers should request the specific units/services needed. Q80. Will a Change of Provider form be needed for client's who have received services elsewhere? Will these be available on your website? A. Yes a change of provider form is necessary and it is available on our website at Q81. What is the process to ask for additional units for rehab day or individual therapy, etc? During the 6 month period before the auth has expired? A. It would be considered a revision. Please inform us of the revision and we will review against the prior request. Q82. Can you tell us specifically what you want sent as a document with a continued stay review? A. For outpatient review, please submit your last updated treatment plan. For inpatient review, please complete the ValueOptions ITR form. If you have special circumstances, please note them in the participant treatment planning boxes. For residential, an updated treatment plan with the progress to date. Q83. Is a court order considered the certificate of need? A. No, Certificate of Need has its own field on the inpatient HLOC review form. Q84. Do you have a less complex form for 911 clients who are mandated treatment? A. It will be the same form. Please remember to check the AR911 box. Q85. Is the court order for 911 clients considered the certificate of need? A. Certificate of Need is not required for 911. Please check the AR911 box on the treatment form and ValueOptions will process the request. Q86. What is the process for an appeal if an RTC admit is denied? Page 13 of 26 Revised: 11/9/2010

14 A. This process has not changed. It will be the reconsideration process in which you would contact ValueOptions with the additional information and our doctors would review. Q87. How long will it take to know if approved for admit vs. continued stay reviews? A. For inpatient reviews, we have 1 day to process the request. For residential, other than an inpatient unit we have 7 days to process. For outpatient we have 9 calendar days. Provider Network Q88. I am not a provider in the ValueOptions network. What do I do to join the network? A. ValueOptions will be receiving your provider file information and it will be loaded into the ValueOptions system. There is nothing additional you need to do at this time. Q89. Do I have to be credentialed by ValueOptions? A. No. Online Services Q90. What online services does ValueOptions offer? A. ValueOptions has enhanced our on-line system, called ProviderConnect sm to provide added convenience for our providers. The following online services are available for Arkansas providers: Our online provider services (ProviderConnect sm ): Use ProviderConnect sm to conduct the following electronic transactions: Request authorization View authorization status Download authorization file Submit inquiries to customer service Page 14 of 26 Revised: 11/9/2010

15 Access and print forms * Through upcoming provider educational webinars and Face to Face sessions, you will have the opportunity to learn more about these provider tools and more. See the schedule of upcoming provider training opportunities located at our Arkansas Network specific site. Click on the following link and then scroll to the bottom of the list to find ValueOptions - Arkansas. Arkansas Network specific Web site: Here you will find information developed specifically for Arkansas Medicaid providers including upcoming trainings, handbooks, and other important information and updates. Q91. Will I be able to use all online services offered? A. Yes, you will be able to access all online services; however some of our online features may not be available to you initially or may not be applicable to the Arkansas provider network. We will keep you informed of what functions are available to you. Q92. Will there be training for providers on the ValueOptions online processes? A. An introduction to ValueOptions online self-service tools was provided during the May 2010 face to face provider forums. In addition, webinar trainings were scheduled in June and July The schedule for additional webinars can be found by accessing the ValueOptions Arkansas network specific link at Q93. Will clinicians have access to the ValueOptions online system? A. Clinicians and administrative staff will have access. Any Arkansas provider registered in ProviderConnect sm will be able to view information about beneficiaries in their care. Q94. How soon can we register for ProviderConnect sm? Do we have to wait until 7/1? A. As of June 10, 2010 Arkansas providers can begin to register for ProviderConnect sm. Instructions on the registration process will be sent to providers by DMS and posted to the ValueOptions Arkansas provider website. Access the following for more information. Q95. Do you have to be a participating provider with ValueOptions to register in ProviderConnect sm, or will a provider file be downloaded from Medicaid? Page 15 of 26 Revised: 11/9/2010

16 A. You do not need to be a participating ValueOptions provider to register in Provider Connect. However, providers do need to be in the ValueOptions system in order to register. Provider file information has been received from MMIS II (Medicaid s database) and ValueOptions is in the process of loading the information into our system. Q96. If we have one user ID in ProviderConnect sm, can multiple users be signed on at the same time? A. Yes Q97. Will your care coordinators contact information be posted online? A. Yes Q98. What is the process if the beneficiary is not found in ProviderConnect sm system, and we need to enter an authorization request? A. Providers should verify eligibility with Medicaid prior to contacting ValueOptions. Once eligibility has been verified, you may contact our customer service department. Customer service will do an eligibility inquiry / research and get the beneficiary loaded into the system. Q99. Will it be possible to reprint a prior authorization from your system? A. Prior Authorization results can be viewed online via ProviderConnect sm through the authorization search functionality. In addition, authorization letters can be viewed and printed. Printing the entire request for services as originally entered is only possible at the time of first submission. Q100. Can residential stay reviews be processed online? A. Yes. Supporting documentation can be added as attachments. Q101. Will modifiers populate when a specific code is selected? A. No. Providers will need to populate modifiers. Q102. Is it possible to track requests for reconsideration in ProviderConnect sm? Page 16 of 26 Revised: 11/9/2010

17 A. This function is currently not available. We are looking into adding this capability to ProviderConnect sm. Q103. Attachments are difficult in ProviderConnect sm. Once you go beyond the 1 st page, you can t submit attachments and you loose attachments if you save as a draft. A. It is correct that attachments cannot be attached to drafts and that they must be attached to the initial page. Training can be arranged for staff having difficulty with attachments. Q104. How do I correct a request that I made in error for the wrong number of units? A. This can be submitted as an inquiry in ProviderConnect sm. Q105. Are plans being made to develop a way for providers to import PA submissions into their electronic medical record? A. We are currently discussing this enhancement. However, you do have the ability to download a spreadsheet of all your authorizations requests, via the authorization download function in ProviderConnect sm. Q106. Will each service code have a drop down description? A. The description is not currently available. A cheat sheet has been developed. Q107. Will it be possible to fax PCP referrals? A. The preferred method is an attachment through ProviderConnect sm to ensure and track that the form has been received. Q108. Are your online services compatible with all browsers? I.e. Safari? A. ProviderConnect sm is currently compatible with Internet Explorer versions 6.0, 7.0, and 8.0 (in compatibility mode) as well as Safari and Firefox. Q109. Is there a built in feature to prevent you from proceeding prematurely on ProviderConnect sm when requesting an authorization? Page 17 of 26 Revised: 11/9/2010

18 A. Yes. All required information on each section of the authorization request must be completed prior to moving on to the next step in the authorization. Q110. Will there be a section on ProviderConnect sm that lists the service codes? A. Yes, the Provider Handbook lists the service codes. A cheat sheet is also available. Q111. Will it be possible to go back and view the number of units in ProviderConnect sm? A. When reviewing an authorization in ProviderConnect sm, the requested number of units and approved number of units will be displayed by clicking on the Auth Details tab. Q112. Will your system inform us if the beneficiary Medicaid number is inactive? A. Yes. However, Medicaid eligibility should still be verified through the current process. Q113. How long does it take to get a response from an online inquiry via the send inquiry function? A. You should experience a response within 2-3 business days. Audits Q114. Can day treatment facilities provide snacks and lunches? A. Yes Q115. Where do we find the regulations for frequency of YOQ? A. The Arkansas Medicaid Web Site under the Providers section RSPMI Update # 129. Q116. How far will the auditors go back in documentation? Due to so much paper work we have to thin charts periodically. What should we focus on leaving in the charts? A. Most likely, on-site chart audits will be for the most current certification span. However, if indicated Page 18 of 26 Revised: 11/9/2010

19 by the review or at the reviewer s discretion, on-site chart audits may extend further back. All documentation supporting all services rendered should be present in the chart. Q117. Do you need documentation to be at the site for all QI, policies, etc? A. Yes, if the site is the main/home office of the provider. If the site is a satellite clinic, evidence that the required QI policies exist and are being implemented at the site will suffice. Q118. How do we reconcile the CASSP / Wraparound / SSBG expenditures for family crisis to keep kids out of placements versus this statement that we can't provide anything of monetary value? Virtually all CASSP-eligible kids have RSPMI. A. Goods and services received by beneficiaries and their families through CASSP / Wraparound / SSBG expenditures are not in violation of RSPMI Section I G. Q119. Will ValueOptions do interviews in groups or must they be individual or per family? A. Interviews will not be conducted in groups. Q120. For transportation, can we specify that billing occurred only upon arrival? A. Section reimbursement for other RSPMI services is not allowed for the period of time the Medicaid beneficiary is in transport. Q121. Will audits be conducted to an organization or to the individual programs within the company once a year? A. Audits will be scheduled at least once annually for all service sites. Q122. Will your audits be documentation reviews or Quality of Care? A. Both Q123. Will Therapeutic Foster Care programs be audited differently? I.e. visits in the foster homes. A. Auditors will not be visiting Therapeutic Foster homes unless specifically directed by DMS. Page 19 of 26 Revised: 11/9/2010

20 Q124. What is IOC? A. An IOC is an Inspection of Care. The word audit is used interchangeable to mean IOC. Q125. If a family was provided needed food, could that be considered payment for Medicaid services? A. RSPMI Section I G.: Except for Medicaid-covered services and other professional services furnished in exchange for the provider s usual and customary charges, a Medicaid provider may not knowingly give, offer, furnish, provide or transfer money, services or anything of value for less than fair market value to any Medicaid beneficiary, to anyone related to any Medicaid beneficiary within the third degree of any person residing in the household of a beneficiary. This rule does not apply to: 1. Pharmaceutical samples provided to a physician at no cost or to other comparable circumstances where the provider obtains the sample at no cost and distributes the samples without regard to Medicaid eligibility. 2. Provider actions taken under the express authority of federal Medicaid laws or rules or the provider s agreement to participate in the Medicaid Program. Q126. Please elaborate on the expectation/requirements of incorporating YOQ into treatment. A. Please see the Arkansas Medicaid web site to see the YOQ policy that was recently promulgated. Q127. Will ValueOptions contact the facility directly or the main corporate office for the company when a sit audit is scheduled? A. Yes, ValueOptions will contact the service site scheduled for the audit, or contact the primary contact person specified by the provider. Q128. We some times provide Wal-Mart gas card for some of our clients to participate in treatment and Kroger cards to buy groceries when they've exhausted all options for local pantries. Would that be construed as monetary encouragement for services? A. RSPMI Section I G.: Except for Medicaid-covered services and other professional services furnished in exchange for the provider s usual and customary charges, a Medicaid provider may not knowingly give, offer, furnish, provide or transfer money, services or anything of value for less than fair market value to any Medicaid beneficiary, to anyone related to any Medicaid Page 20 of 26 Revised: 11/9/2010

21 beneficiary within the third degree of any person residing in the household of a beneficiary. This rule does not apply to: 1. Pharmaceutical samples provided to a physician at no cost or to other comparable Circumstances where the provider obtains the sample at no cost and distributes the samples without regard to Medicaid eligibility. 2. Provider actions taken under the express authority of federal Medicaid laws or rules or the provider s agreement to participate in the Medicaid Program. Q129. Approximately how long will interviews take per client? A. Interviews are designed to take from 10 to 15 minutes. Q130. Can Interviews be conducted by phone or are clients expected to be available on site for interviews or are interviewers available to go into the community? A. Auditors/interviewers will not be available to conduct interviews off site. All interviews must be conducted on site. We prefer that all interviews be done face-to-face. Interviews via telemedicine venues are considered face-to-face. In rural satellite clinics where most services are performed in the home or community, telephone interviews may be arranged, if necessary. Q131. We already have an audit scheduled. It states that records can be scanned by ValueOptions and taken off site. What is the intent of taking copies of records off site? A. The purpose of scanning is an accountability measure to substantiate the justification of deficiency citations. Q132. Can copies of personnel licenses, HS education verification and training be faxed to the site if HR records are not available on site? A. Yes. Q133. Will the auditors be able to call the clients randomly selected--to have them come in for the interview? A. It is the provider s responsibility to contact and make arrangements for the selected beneficiaries/families to be interviewed. Q134. Will this audit take the place of a Medicaid audit, if not what will be the difference in the Page 21 of 26 Revised: 11/9/2010

22 two audits? A. No, Medicaid Program Integrity audits are conducted at the discretion of DMS. However, every effort is made to inform PI of the ValueOptions IOC scheduling. Q135. Could you discuss how community integration offsite activities can be justified? Please describe any limitations. A. Community integration offsite activities must meet the criteria of one of the appropriate RSPMI manual service code definitions. All services must be medically necessary therapeutic interventions prescribed on the treatment plan to treat the specific symptoms of the beneficiary s mental illness. Case management, case management type services and recreational/social outings which have not been prescribed for the purpose of treating a specific, active symptom of the beneficiary s mental illness are not covered under the RSPMI service definition codes. Services provided must be congruent with the objectives and interventions articulated on the most recent treatment plan. Services must be consistent with established behavioral healthcare standards. Q136. What are some examples of active care? A. Individual sessions, Group sessions, Meeting with MD, Passes if documented why passes are needed on MTP, (practice coping skills), family sessions in person and telephonically, organized/structured psychosocial activities which address specific symptoms of the resident. Q137. Will all Inpatient locations be audited at the same time? A. No, they will not be audited at same time or necessarily same time of year. Fiscal year runs July thru June and audits will be done once during that time frame at a minimum. Audits may be scheduled more than once annually as needed. Q138. Can parents be given gas cards to get to family sessions? A. Section I G.: Except for Medicaid-covered services and other professional services furnished in exchange for the provider s usual and customary charges, a Medicaid provider may not knowingly give, offer, furnish, provide or transfer money, services or anything of value for less than fair market value to any Medicaid beneficiary, to anyone related to any Medicaid beneficiary within the third degree of any person residing in the household of a beneficiary. This rule does not apply to: 1. Pharmaceutical samples provided to a physician at no cost or to other comparable circumstances where the provider obtains the sample at no cost and distributes the samples without regard to Page 22 of 26 Revised: 11/9/2010

23 Medicaid eligibility. 2. Provider actions taken under the express authority of Federal Medicaid laws or rules or the provider s agreement to participate in the Medicaid Program. Q139. You stated that individual plans of care should be developed before prior authorizations, can you clarify? A. Section II Development of the Individual Plan of Care Individual plan of care means a written plan developed for each recipient to improve the condition of the recipient to the extent that inpatient care is no longer necessary. The individual plan of care must be: B. Developed no later than fourteen (14) days after admission and before prior authorization of services; Q140. Will ValueOptions institute recoupment as part of the deficiency process? A. As the policy states below recoupment is instituted through DMS. ValueOptions is a QIO for DMS and is responsible for informing DMS of all audit findings Program Integrity (PI) Federal Regulations require the implementation of a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate utilization of care and services and excess reimbursements by the Medicaid program. The purpose of the Medicaid Program Integrity Unit (PI) is to ensure Arkansas Medicaid Program Integrity compliance. [Title XIX of the Social Security Act, Arkansas Code Annotated, 42 C.F.R. 455 and the Arkansas State Plan]. The goal of the unit is to verify the nature and extent of services reimbursed by the Medicaid program, while ensuring reimbursements made are consistent with the quality of care being provided and protecting the integrity of both state and federal funds. B. When the Quality Improvement Organization (QIO) denies all or part of a hospital admission C. When medical consultants to the Medicaid Program determine lack of medical necessity D. When Medicaid, Medicare or the Attorney General s Medicaid Fraud Unit discovers evidence of overpayment Page 23 of 26 Revised: 11/9/2010

24 E. When a provider has been assessed a monetary penalty for failure to follow a corrective action plan which was developed to correct a pattern of non-compliance as provided in sections and 190. Q141. In the Outpatient webinar it was stated gift cards are not allowed to be given? Are they allowed for inpatient? A. Section I G.: Except for Medicaid-covered services and other professional services furnished in exchange for the provider s usual and customary charges, a Medicaid provider may not knowingly give, offer, furnish, provide or transfer money, services or anything of value for less than fair market value to any Medicaid beneficiary, to anyone related to any Medicaid beneficiary within the third degree of any person residing in the household of a beneficiary. This rule does not apply to: 1. Pharmaceutical samples provided to a physician at no cost or to other comparable circumstances where the provider obtains the sample at no cost and distributes the samples without regard to Medicaid eligibility. 2. Provider actions taken under the express authority of federal Medicaid laws or rules or the provider s agreement to participate in the Medicaid Program. Q142. What is the location of the settings on the progress notes? A. The location refers to the place where the service was rendered on site or off site. If the service occurs off site, the address of the location must be given. Q143. In regards to Outpatient treatment plans, A treatment plan is just a plan, it is not a prescription (never been looked at that way)? A Scope Rehabilitative Services for Persons with Mental Illness may be covered only when: A. Provided by qualified providers, B. Approved by a physician within 14 calendar days of entering care, C. Provided according to a written treatment plan/plan of care, and D. Provided to outpatients only except as described in section Page 24 of 26 Revised: 11/9/2010

25 E. In order to be valid, the treatment plan/plan of care must: 1. Be prepared according to guidelines developed and stipulated by the organization s accrediting body and 2. Be signed and dated by the physician who certifies medical necessity. If the beneficiary receives care under the treatment plan, the initial treatment plan/plan of care must be approved by the physician within 14 calendar days of the initial receipt of care. The physician s signature is not valid without the date signed. And Physician s Role Physician s Role for Adults Age 21 and Over RSPMI providers are required to have a board certified or board eligible psychiatrist who provides appropriate supervision and oversight for all medical and treatment services provided by the agency. A physician will supervise and coordinate all psychiatric and medical functions as indicated in treatment plans. Medical responsibility shall be vested in a physician licensed in Arkansas, preferably one specializing in psychiatry. And: Physician s Role for Children Under Age RSPMI providers are required to have a board certified or board eligible psychiatrist who provides supervision and oversight for all medical and treatment services provided by the agency. A physician will supervise and coordinate all psychiatric and medical functions as indicated in treatment plans. Medical responsibility shall be vested in a physician licensed in Arkansas, preferably one specializing in psychiatry. Q144. Is the 14 day audit notification timeframe calendar days or business days? A. The timeframe are in Calendar days. Q145. What is the process for determination of sufficient or insufficient CAP? A. The ValueOptions Quality Manager will review the submitted CAP to determine whether the CAP has fully addressed the requested information, such as how will the deficiency be remediated, who Page 25 of 26 Revised: 11/9/2010

26 will implement/supervise the action and estimated date the corrective measure(s) will take place. Q146. How does a provider object to an insufficient CAP? A. A letter from ValueOptions will be sent to each provider in response to a submitted CAP to indicate whether it was accepted or rejected. If the CAP is rejected, the letter will clarify the reason and request any further information required to accept the CAP. If the provider chooses not to provide further information as requested, the CAP will be forwarded to DMS per procedure along with all correspondence related to the CAP. Q147. Will there be a recoupment on inspections of care? A. The inspection of care audits will focus on medical necessity and quality of care issues. Although, if a potential recoupment issue is identified, it will be investigated and handled according to the Medicaid requirements. Page 26 of 26 Revised: 11/9/2010