Authorization Approval and ASAM July 2017 Overview Funding and Services IDOC and IDHW Funding and Authorization Assessment Admission, Transfer, and Continuing Care Denials Discharge BPA Health website (www.bpahealth.com) ASAM Approval exercise 2 1
Funding Sources and Levels of Care Idaho Department of Corrections has funding sources and non-asam services Idaho Department of Health and Welfare has several funding sources to be used with ASAM 3 Idaho Department of Corrections Funding: Re-Entry 19-2524 Risk to Revocate Medicaid Supplemental Service (non-asam): Parolee Aftercare Pre-Treatment Services 4 2
Idaho Department of Health and Welfare FUNDING Phone pathway: DHW Adult (adult mental health referral, or voluntary) PWWC State Hospital IVDU SOURCES Supervised Misdemeanant* Misdemeanant Problem Solving Court* Mental Health Court* CP-SUD* Adolescent (need to be referred by approved school district or police department) * Need paper referral 5 IDOC Non-ASAM Service Pre-Treatment (click for details) 4 hours a week of either group or individual treatment Pre-treatment doesn't allow for safe & sober housing or life skills ASAM is required and dimension 4 should include pre-treatment attendance guidelines (50% or better of scheduled appointments, not including GAIN appointment). 6 3
IDOC Non-ASAM Service Parolee Aftercare (click for details) 4 hours a week of bundled education, group, individual, and individual with family member present services. Allows RSS, see rate matrix. Initial authorization is for 90 days, and a second PA authorization can be requested for 30 more days. 7 Assessment Submitting the GAIN: Consent the GAIN-I Summary to either DHW Contractor or IDOC (please send to the correct place, i.e. not IDHW when it should only go to IDOC) DHW: Submit a Note to Authorizer when the GAIN is ready for review and noting any treatment and RSS being requested IDOC: Submit a Note to Authorizer if the provider is only performing the GAIN i.e.: presentence, no treatment is authorized yet by IDOC Earliest date consented has to be the date the GAIN was completed or prior Ensure "yes" is marked in the section that asks if the client has signed the paper agreement form GAIN-I (GRRS) summary has to be moved to disclosure section of the consent form Use GAIN for review for 30 days; if GAIN is older than 30 days, ASAM must be sent Request RSS and treatment; specify provider(s) if any service is being requested outside your agency Edit GAIN for funding eligibility (IVDU, PWWC) and clinical criteria (especially 3.1 or 3.5 res tx) 8 4
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IDOC ASSESSMENT PROCESS Re-entry & 19-2524 funding: BPA Health only reviews a GAIN done in the last 30 days if level 3.5 residential treatment is being requested and the client has been authorized into IDOC services already. Re-entry funding: Parolee aftercare is already authorized by IDOC. Pre-treatment services: Can be funded by either 19-2524 or Risk to Revocate funding sources. BPA Health verifies the GAIN assessment is on file (completed in the last 6 months) and that an ASAM concurrent review is completed, demonstrating the client s achievement of pre-treatment attendance guidelines (in dimension 4), and outlining admission criteria are met for the level of care being requested. 11 Admission, Transfers, Continuing Care Note to Authorizer (NTA) Request level of care & RSS if GAIN is being reviewed Request RSS only Explain why no contact with client, if this is your response to clarification Date and reason for discharge NOTE: Do not accept referral or auths until you see client face to face. (This applies to every fiscal year split, too- don t accept 7/1 until you provide services for 7/1 or after). 12 6
Note to Authorizer 13 Admission, Transfers, Continuing Care Change to Service Meet with client 1:1 in person to bill for time spent doing ASAM update ASAM must be signed your agency s WITS administrator should add your credentials Use comments box to specify the requested services. You can edit this box if BPA has not started reviewing the request yet Use the attached ASAM when the GAIN is over 30 days old, to start treatment; be detailed and include more than just a last date of use in dimension 1 Use the attached ASAM to request continued treatment or change in level of care Use the attached ASAM when requesting a move from pre-treatment to stage 1 in IDOCeven if GAIN is less than 30 days old Submit attached ASAM up to 14 days before current auth ends to request continued services Start every dimension with an "updated on" date, followed by the new/current clinical information When requesting any services or residential tx, ensure each provider is identified 14 7
Change to Service. 15 Admission, Transfers, Continuing Care Change to Service Client-specific clinical information/evidence in all 6 dimensions reflecting how the client meets ASAM criteria for the level of care being requested. 1. What progress has been made in treatment so far 2. What goals have yet to be accomplished in treatment (what you ll work on next) 3. How the client meets ASAM transfer criteria (pg. 303 in 3rd ed. manual) suitable for the level of care being requested (pg. 303 covers transfer and discharge OR when I should transfer) The WITS processor runs nightly and closes auths with no billing in 30 days; check before sending requests to avoid duplication. Call if you need reopened. 16 8
Residential Treatment 3.5 clinically managed high intensity residential (not called inpatient ) 24-hr treatment/ staff, cannot leave, all inclusive (no RSS), typical stay is 28 days Commonly denied due to either: 1. Client is not stable or too acute in dimensions 1, or 2, or 3 2. Or, dimension 5 imminent risk of harm or danger is not met 3.1 clinically managed low intensity residential 24-hr professional staff, can leave site (work, appts, etc.), use RSS, allowed longer stay than 3.5 residential treatment Available at several in-network agencies across the state Must be received concurrently with either OP or IOP; please specify which is most clinically appropriate in the request Safe & Sober Housing RSS only because no professional staff on site 17 18 9
19 Denials in order of highest frequency 1. Clarification Needed- Additional information needed for determination. Read all of BPA Health staff s notes, follow the directions, and respond within 5 business days 2. Incomplete Authorization Change Request- No GAIN on file, ASAM not signed, wrong form used (i.e., NTA does not allow ASAM to be attached) 3. Duplicate Request- Service already exists, or 2 requests for the same thing 4. Eligibility Requirements Not Met- Example: IVDU funding eligibility criteria not verified 5. Service Not Covered Under Current funding- Example: 3.1 request in IDOC 6. Clinical Denial- ASAM Concurrent Review or GAIN info doesn t meet clinical criteria for level of care requested 20 10
Discharge If client is leaving level 3.1 or 3.5 residential treatment against advice, please notify BPA Health via WITS, ASAP Send Note to Authorizer - include date and reason for discharge so all other agency authorizations can be ended Complete discharge summary within 15 days of last contact Include status at time of discharge and treatment progress Includes summary of referrals/services to be provided after discharge 21 Using ASAM to submit for authorization Start with using client statements and/or observation of behavior. Identify the criteria that the behavior and/or statement fits within ASAM Describe how behavior or statement meets criteria 22 11
Please share this presentation and Authorization Approval Guide with new hires. THANK YOU!!! 12