Procedure Name: Responsible Department: Lane County Health and Human Services- Trillium Behavioral Health Plans: Medicaid Medicare Marketplace PEBB Current Effective Date: 1-26-16 Scheduled Review Date: 1-26-17 A. Purpose To describe Trillium Behavioral Health s (TBH) (ISA) authorization process. B. Definitions Word / Term Child and Adolescent Service Intensity Instrument (CASII) Child Clinical Criteria Collateral Diagnostic and Statistical Manual of Mental Disorders (DSM) Early Childhood Service Intensity Instrument (ECSII) ICD Level of Care (LOC) Definition Instrument to assist provider and others caring for children and adolescents in determining intensity of services need for children and adolescents ages 6-18 years a person under the age of 18. An individual with Medicaid eligibility, who is in need of services specific to children, adolescents, or young adults in transition, must be considered a child until age 21 for purposes of these rules. Written decision rules, medical protocols, or guidelines used as an element in evaluation of medical necessity and appropriateness of requested medical and behavioral health care services. A contact between an individual s primary treating behavioral health provider and other behavioral health providers, relative to the treatment of an individual authorizing other treating behavioral health practitioners or providers to bill for non-duplicated services. Standard classification of mental disorders used by mental health professionals in the United States, consisting of three major components: 1) Diagnostic classification; 2) Diagnostic criteria sets; 3) Descriptive text. Instrument to assist provider and others caring for young children in determining intensity of services need for infants, toddlers, and children from ages 0-5 years. The International Classification of Diseases. Range of available services provided from the most integrated setting Page 1
Word / Term Level of Care Determination Medically Appropriate Mental Health Assessment Oregon Health Plan (OHP) Qualified Mental Health Professional (QMHP) Service Plan Utilization Management (UM) Definition to the most restrictive and most intensive in an inpatient setting. The standardized process implemented to establish the type, frequency, and duration of medically appropriate services required to treat a diagnosed behavioral health condition. Services and medical supplies required for prevention, diagnosis or treatment of a physical or mental health condition, or injuries, and which are: (a) Consistent with the symptoms of a health condition or treatment of a health condition; (b) Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community and professional standards of care as effective; (c) Not solely for the convenience of an individual or a provider of the service or medical supplies; and (d) The most cost effective of the alternative levels of medical services or medical supplies that can be safely provided to an individual. The process of obtaining sufficient information, through a face-to-face interview to determine a diagnosis and to plan individualized services and supports. In Oregon, the Medicaid Program is called OHP. Person demonstrating the ability to conduct an assessment, including identifying precipitating events, gathering histories of mental and physical health, substance use, past mental health services and criminal justice contacts, assessing family, cultural, social and work relationships, and conducting a mental status examination, complete a DSM diagnosis, write and supervise the implementation of a Service Plan and provide individual, family or group therapy within the scope of their training. (a) QMHPs must meet the following minimum qualifications: (A) Bachelor s degree in nursing and licensed by the State or Oregon; (B) Bachelor s degree in occupational therapy and licensed by the State of Oregon; (C) Graduate degree in psychology; (D) Graduate degree in social work; (E) Graduate degree in recreational, art, or music therapy; or (F) Graduate degree in a behavioral science field A comprehensive plan for services and supports provided to or coordinated for an individual and his or her family, as applicable, that is reflective of the assessment and the intended outcomes of service. Evaluating and determining coverage for and appropriateness of medical care services, as well as providing needed clinical assistance to patient, in cooperation with other parties, to ensure appropriate use of resources. C. Procedure 1. Referrals 1.1. The referred member must: 1.1.1. Be enrolled in Trillium, and 1.1.2. Be under the age of eighteen (18) years 2. Authorizations: 2.1. Provider must submit from any combination of practitioners: 2.1.1. A psychiatric or psychological assessment conducted and documented within previous 60 days when available, and Page 2
2.1.2. A behavioral health assessment conducted and documented within the previous 60 days by a Qualified Mental Health Professional (QMHP) including sufficient biopsychosocial information to support the presence of a Diagnostic and Statistical Manual of Mental Disorder (DSM) and International Classification of Diseases (ICD) diagnosis for medically appropriate services, and 2.2. Document Service Plan reflecting: 2.2.1.1. Assessment, 2.2.1.2. LOC to be provided, and 2.2.1.3. Recommended service and supports through signature of licensed qualified mental health professional (QMHP). 2.3. In addition to considering the level of service intensity need indicated by the assessments and service, TBH must take into consideration factors including, but not limited to: 2.3.1. Child and Adolescent Needs and Stregths (CANS) 2.3.2. Child and Adolescent Service Intensity Instrument (CASII); 2.3.3. Early Childhood ServiceIntensity Instrument (ECSII); 2.3.4. Elevating or significant risk of harm to self or others; 2.3.5. History of emergency and or psychiatric hospitalizations; 2.3.6. Significant risk of out-of-home placement; 2.3.7. School disruption due to mental health symptomology; 2.3.8. Usual and customary services are insufficient; 2.3.9. Multiple system involvement; 2.3.10. Significant caregiver stress; 2.3.11. Frequent or imminent need for acute psychiatric hospitalizations or other intensive treatment services; 2.3.12. Multiple placement disruptions; 2.3.13. Increased risk of suicide; 2.3.14. History of abuse or neglect; 2.3.15. Significant relationship disturbance between child and parent. 2.4. Trillium Behavioral Health (TBH) Licensed Utilization Management (UM) staff:: 2.4.1. Review submitted clinical documentation from provider; 2.4.2. Make a determination whether the child or youth is authorized for recommended level of (ISA) service; 2.4.2.1. During this period, existing mental health Service Plan is continued. 2.4.3. Notifiy the referral source of the determination decision and answers further questions as needed; and 2.4.4. Facilitate referrals to a higher LOC as needed. 2.5. If the authorization is denied based on assessed clinical need or if a child is placed in a correctional facility solely for the purpose of stabilizing a mental Page 3
health condition, medically appropriate alternative treatment will be recommended. 2.6. Children or Youth authorized for an ISA service are eligible for one of the following: 2.6.1. Psychiatric Day Treatment Service (PDTS); 2.6.2. Psychiatric Residential Treatment Services (PRTS); and/or 2.6.3. Intensive Community-Based Treatment and Support Service (ICTS). 3. Certification of Need (CON) 3.1. A CON review must be completed by the CON Team before a child or youth is placed in psychiatric residential services. 3.1.1. The CON Team must include: 3.1.1.1. A psychiatrist (in attendance or by consultation) who is: 3.1.1.1.1. Not involved in the care or treatment of the individual being referred for PRTS; 3.1.1.1.2. Knowledgeable in diagnosis and treatment of mental illness; and 3.1.1.1.3. Knowledgeable about the individual s situation through comprehensive review of clinical records and other information available. 3.1.1.2. A BHCC; and 3.1.1.3. The Licensed Behavioral Health Practitioner (LBHP). 3.1.2. Provider must complete a written psychological or psychiatric evaluation within the previous 60 days. 3.1.3. CON determination is to be made within three (3) businessdays of receipt of the request. 3.2. Approval of CON: 3.2.1. When an individual is approved by the CON Team: 3.2.1.1. A BHCC: 3.2.1.1.1. Notifies the referral source, ordering and requesting provider/individual/family/guardian as soon as an authorization determination is made; and 3.2.1.1.2. Coordinates care with the Child and Family Team to support development of a service plan that can help stabilize and adequately meet the needs of the individual. 3.2.1.2. The Child and Family Team: 3.2.1.2.1. Assures appropriate services and safety plans are in place pending availability of placement; 3.2.1.2.2. Reviews and revises individual s Service Plan as needed; and 3.2.1.2.3. Provides supportive services to further assist the individual and family with stabilization while awaiting placement. Page 4
3.3. Denial of CON: 3.3.1. When an individual is denied by the CON Team: 3.3.1.1. A BHCC: 3.3.1.1.1. Provides information to the referral source and ordering provider/individual/family/guardian of denial, and 3.3.1.1.2. Coordinates care with the Child and Family Team to provide alternative mental health services and to support a service plan that can help stabilize and adequately meet the needs of the individual. 3.3.1.2. Services continue to be delivered at medically appropriate LOC. 3.3.1.3. Members not determined as needing PRTS services are referred to other ISA services or to outpatient behavioral health services. D. Regulatory or Administrative Citations Name NCQA NCQA Location UM 2: Clinical Criteria for UM Decisions UM 5: Timeliness of UM Decisions E. Related Material Name American Academy of Child and Adolescent Psychiatry Policy Child Outpatient Behavioral Health Services Policy Location TBH Database TBH Database Page 5