Mississippi Medicaid Services for EPSDT Eligible Beneficiaries Provider Manual Effective Date: July 1, 2017
Services for Introduction: eqhealth Solutions Services (ASD) Utilization Management Program includes prior authorization of ASD services listed in the manual and provided by a board-certified behavior analyst. Authorization for ASD Services by the Utilization Management/Quality Improvement Organization (UM/QIO) applies to Mississippi Medicaid Early and Periodic Screening Diagnostic and Treatment (EPSDT) eligible beneficiaries who are not enrolled in the Mississippi Coordinated Access Network (MSCAN) or Children Health Insurance Program (CHIP). This manual should be used as a companion to Medicaid regulations and fee schedule. Page: 1
Services for Section I What you need to know before examining a Medicaid beneficiary: Did you check beneficiary eligibility? The plastic Medicaid card is not a guarantee of Medicaid eligibility. You must access the beneficiary s eligibility and service limit information through the eligibility verification options before submitting a prior authorization request to eqhealth Solutions. You are responsible for verifying a Medicaid beneficiary s eligibility each time the beneficiary appears for service. You are also responsible for confirming the person presenting the card is the person to whom the card is issued. You can verify eligibility by the Medicaid ID number or Social Security number of the beneficiary to access either of the following services: Website verification: o https://www.ms-medicaid.com/msenvision/ Automated Voice Response System (AVRS) at 1-866-597-2675 Provider/Beneficiary Services Call Center at 1-800-884-3222 Medicaid Eligibility Verification Services (MEVS) transaction using personal computer (PC) software or point of service (POS) swipe card verification device. Medicaid Coverage ASD Services eqhealth Solutions Utilization Management of ASD Services is applicable for Mississippi Medicaid beneficiaries in the following eligibility categories: Fee-for-service EPSDT eligible beneficiaries Other health insurance (covered by private insurance and Medicaid) Page: 2
Services for The following beneficiaries are not eligible for ASD Services or do not require authorization by eqhealth Solutions : Beneficiaries who are not eligible for EPSDT Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN) or Children Health Insurance Program (CHIP) Beneficiaries in COE 29, Family Planning Waiver Beneficiaries with no Medicaid coverage for the date of service Beneficiaries covered by both Medicare and Medicaid Please check eligibility at each visit. Services codes requiring authorization The following tables provide information about available services, procedure codes, and maximum units. *Service Description *Procedure Code Maximum Units Observational 0360T (30 minutes) Behavioral Follow-up 0361T (each additional 30 2 per 6 months Assessment minutes) Exposure Behavioral 0362T (30 minutes) Follow-up Assessment 2 per 6 months Adaptive Behavior Treatment by Protocol Group Adaptive Behavior Treatment by Protocol Adaptive Behavior Treatment with Protocol Modification Family Adaptive Behavior Treatment Guidance 0363T (each additional 30 minutes) 0364T (30 minutes) 0365T (each additional 30 minutes) 0366T (30 minutes) 0367T (each additional 30 minutes) 0368T (30 minutes) 0369T (each additional 30 minutes) 0370T 50 per week 6 per week 2 per week 1 per week Page: 3
Services for Multiple Family Group Adaptive Behavior Treatment Guidance Adaptive Behavior Treatment Social Skills Group Exposure Adaptive Behavior Treatment with Protocol Modification 0371T 0372T 0373T (60 minutes) 0374T (each additional 30 minutes) 1 per week 3 per week 1 per month 1 per month ADMISSION CRITERIA All of the following criteria are necessary for admission. 1) Beneficiary has a definitive diagnosis of an (DSM 5). 2) The diagnosis in (1) above is made by a licensed developmental pediatrician, psychiatrist, psychologist, or neurologist experienced in the diagnosis and treatment of autism with developmental or child /adolescent expertise. 3) The child or adolescent has received a comprehensive diagnostic and/or functional assessment (e.g. ABLLS-R, Vineland-II, ADI-R, ADOS-G, CARS2, VB-MAPP, or Autism Behavior Checklist), which include the following: a) Complete medical history includes pre-and perinatal, medical, developmental, family, and social elements; b) Physical examination, which may include items such as growth parameters, head circumference, and a neurologic examination; c) Detailed behavioral and functional evaluation outlining the behaviors consistent with the diagnosis of ASD and its associated comorbidities. A diagnostic evaluation must include the scores from the use of formal diagnostic tests and scales as well as observation and history of behaviors. Screening scales such as the MCHAT-R are Page: 4
Services for not sufficient to make a diagnosis and will not be accepted as the only formal scale; and d) Medical screening and testing has been completed to identify the etiology of the disorder, rule out treatable causes, and identify associated comorbidities as indicated. 4) Beneficiary exhibits atypical or disruptive behavior that significantly interferes with daily functioning and activities or that poses a risk to the beneficiary or others related to aggression, self-injury, property destruction, etc. 5) Behavior Identification Assessment (CPT Code 0359T) performed by a Board-Certified Behavior Analyst (BCBA or BCBA-D) supports the request for the ASD services. 6) The diagnostic report clearly states the diagnosis and the evidence used to make that diagnosis. 7) Services are not duplicative of services that are part of an Individual Educational Plan (IEP) or Individual Service Plan (ISP) when applicable. 8) There is a time limited, individualized treatment and monitoring plan developed as indicated by ALL of the following: a) Treatment intensity (i.e., number of hours per week) is individualized and designed to meet needs of beneficiary, and will be adjusted according to beneficiary's response to therapy and ability to participate effectively. b) Treatment is to be administered across real-world settings, including school (primarily by school personnel), home, and the community for generalization of skills to occur. c) Plan defines specific target behaviors and skills to be addressed and includes explicit and measurable goals (e.g., behavior change, skill development) that will define beneficiary improvement. Page: 5
Services for d) Plan includes regular interval assessments of beneficiary progress (or lack of progress) as measured by identified goals. e) Treatment duration will depend on beneficiary's attainment of specified goals. f) Plan has documentation of planning for transition through the continuum of interventions, services, settings, as well as discharge criteria. g) Plan addresses parent/guardian/caregiver involvement in behavioral techniques training. CONTINUED STAY CRITERIA All the following criteria are necessary for continuing treatment at this level of care. 1) The beneficiary s condition continues to meet admission criteria for ASD, either due to continuation of presenting problems, or appearance of new problems or symptoms. 2) There is reasonable expectation that the beneficiary will benefit from the continuation of ASD services. Treatment planning is individualized and appropriate to the beneficiary s changing condition with realistic and specific goals and objectives stated. The treatment plan is updated based on treatment progress including the addition of new target behaviors. 3) Behavior Identification Assessment (CPT Code 0359T) performed by a Board-Certified Behavior Analyst (BCBA or BCBA-D) supports the request for the ASD services. 4) Beneficiary s progress is monitored regularly evidenced by behavioral graphs, progress notes, and daily session notes. The treatment plan is to be modified, if there is no measurable progress toward decreasing the frequency, intensity and/or duration of the targeted behaviors and/or increase in skills for skill acquisition to achieve targeted goals and objectives. Page: 6
Services for 5) There is documented skills transfer to the beneficiary and treatment transition planning from the beginning of treatment. 6) There is a documented active attempt at coordination of care with relevant providers/caretakers, etc., when appropriate. If coordination is not successful, the reasons are documented. 7) Parent(s) and/or guardian(s) involvement in the training of behavioral techniques must be documented in the beneficiary s medical record and is critical to the generalization of treatment goals to the beneficiary s environment. 8) Services are not duplicative of services that are part of an Individual Educational Plan (IEP) or Individual Service Plan (ISP) when applicable. DISCHARGE CRITERIA Any of the following criteria are sufficient for discharge from this level of care. 1) Beneficiary s treatment plan and goals have been met. ASD is not custodial in nature, meaning the beneficiary has reached the maximum level of physical or mental function and is not likely to make further significant improvement. 2) The beneficiary has achieved adequate stabilization of the challenging behavior and less-intensive modes of treatment are appropriate and indicated. 3) The beneficiary no longer meets admission criteria, or meets criteria for a less or more intensive services. 4) Treatment is making the symptoms persistently worse. 5) The beneficiary is not making progress toward treatment goals, as demonstrated by the absence of any documented meaningful (i.e., durable and generalized) measurable improvement or stabilization of challenging behavior and there is no reasonable expectation of progress. Page: 7
Services for 6) No documentation of parent/guardian/caregiver involvement in behavioral techniques training. EXCLUSION CRITERIA Any of the following criteria are sufficient for denial of this level of care. 1) The beneficiary has medical conditions or impairments that would prevent beneficial utilization of services. 2) The beneficiary requires the 24-hour medical/nursing monitoring or procedures provided in a hospital setting. 3) The beneficiary is receiving on going MYPAC services or services similar to ASD 4) The following services are not included within the ASD treatment process and will not be certified: a) vocational rehabilitation b) supportive respite care c) recreational therapy d) respite care 5) The services are primarily for school or educational purposes. 6) The treatment is investigational or unproven. 7) Beneficiary is not EPSDT eligible, or is enrolled in Mississippi Coordinated Access Network (MSCAN). 8) Information submitted does not support medical necessity. CODES The beneficiary must have one of the following ICD-10 diagnoses to be considered for coverage. Page: 8
Services for ICD-10 ICD-10 Code Description Codes F84.0 Autistic disorder F84.2 Rett s Syndrome F84.3 Other childhood disintegrative disorder F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified Page: 9
Services for Section II Submitting your authorization request: Providers can access the Services Certification Request Form at ms.eqhs.org. Completed forms should be faxed to 888.204.0377 or mailed to: eqhealth Solutions 460 Briarwood Dr., Suite 300 Jackson MS 39206 New Services/Admission: Authorization requests to start treatment should include: Services Certification Request Form, assessment findings, treatment plan, and any other relevant clinical information. Requests should be faxed at least (3) three business days prior to the planned service date. If mailed, please allow additional time for delivery. eqhealth will complete processing within three (3) business days of receipt of all required documentation. Continued Services: Authorization requests to continue treatment should include: Services Certification Request Form, any follow-up assessment findings, revised treatment plan including progress towards goals, and any other relevant clinical information. Requests should be faxed at least seven (7) business days prior to the end of the current authorization. If mailed, please allow additional time for delivery. eqhealth will complete processing within seven (7) business days of receipt of all documents. Retroactive eligibility: For beneficiaries who are determined to be retroactively eligible, and have been discharged from care, submit the request as soon as eligibility is confirmed and within one (1) year of the retroactive eligibility determination date. Authorization requests should include, the Services Certification Request Form, and all clinical records. Page: 10
Services for Requests can be faxed or mailed. eqhealth will complete processing within (20) twenty business days of receipt of all documents. If services are in progress when the retroactive eligibility is determined, submit an admission review request. For extenuating circumstances call eqhealth Solutions HELPLINE 1-866- 740-2221. Retrospective services: For beneficiaries who received services between the effective date of this manual and January 1, 2017, and have been discharged from care, please submit the request no later than one (1) year from the start of care. Authorization requests should include, the Services Certification Request Form, and all clinical records. If services that began between the effective date of this manual and January 1, 2017, and are currently in progress, submit an admission review request. Requests can be faxed or mailed. eqhealth will complete processing within (20) twenty business days of receipt of all documents. For extenuating circumstances call eqhealth Solutions HELPLINE 1-866- 740-2221. Page: 11
Services for Section III What eqhealth looks for when reviewing request The eqhealth Review Team, who we are: eqhealth is a multidisciplinary team. Services review is conducted by Mississippi licensed registered nurses, certified social workers, psychologists, psychiatrists, and physicians. Administrative Screening When the review request is received by eqhealth, we apply a series of administrate electronic algorithms to ensure authorization by eqhealth is required and that all Medicaid eligibility requirements are satisfied. If there is an eligibility issue or the services are not subject to review, the request is cancelled and the requestor is notified. Clinical Reviewer (1st Level) Screening of the Request When there are no review exclusions identified the request is routed to a first level reviewer who screens and reviews the request. The first level reviewer evaluates the entire request for compliance with any Medicaid requirements that cannot be applied by the automated process and for compliance with supporting documentation requirements. If the first level reviewer identifies an issue with the request related to Medicaid requirements, a technical determination (TD) is rendered and your review will not proceed. You will be notified via letter, and phone call. Since a technical determination is rendered for an administrative reason (not a clinical or medical necessity reason) it is not subject to reconsideration or appeal/fair hearing. If all required information is not received with the request, the first level reviewer pends the request. You will be notified via letter and by phone call. The information must be received within ten (10) business days. If it is not received within the specified time frame the review request is suspended and you will be notified via letter and phone call. If the information is received on a later date, eqhealth will re-open the review and the review will be performed for services from the date the information is received. eqhealth cannot backdate the request. Page: 12
Services for Clinical Information: Screening, Pended and Suspended Requests Clinical Information Screening Before performing the medical necessity review, the first level reviewer screens the submitted clinical information for completeness. When additional clinical information is required or when the available information requires clarification, the first level reviewer pends the review request and specifies the information or clarification needed. Pended and Suspended Review Requests When the clinical reviewer pends a review request: You will receive a phone call and a written notification concerning what additional information is needed. The requested information must be submitted within ten (10) business days. If eqhealth does not receive the information within ten (10) business days, from date of notification, the review request is suspended and no further review processing occurs until the additional information requested has been received. You are notified electronically and by phone, the request is suspended. If the information is submitted at a later date, eqhealth re-opens the request and reviews the services beginning from the date the complete information was received. eqhealth cannot backdate the request. First Level Medical Necessity Review Process When all information has been submitted and the clinical information screening is completed, the first level reviewer performs the medical necessity review. When performing the review, the first level reviewer evaluates all clinical information submitted by the provider. Guidelines for Services: eqhealth Solutions uses DOM approved InterQual criteria as a decisionmaking tool when making clinical determinations concerning the medical necessity of care. A copy of DOM approved ASD Provider Guidelines are available at http://ms.eqhs.org. Approvals First level reviewers apply Medicaid approved criteria and guidelines to determine whether the services are medically necessary or otherwise allowable under Medicaid Regulations. If the criteria are satisfied, the Page: 13
Services for clinical reviewer renders an approval determination for each line item, for the number of units requested and for the requested time frame or regulations maximum. Approval Notifications Approval notifications are generated for all services determined to be medically necessary. Within one business day of the determination eqhealth mails or faxes a provider notification letter. The notification specifies the authorized service(s), the number of units, the authorization period, and the Treatment Authorization Number (TAN). eqhealth transmits the Treatment Authorization Number (TAN) to the Medicaid fiscal agent. Referral to a Second Level Reviewer (SLR) First level reviewers may not render an adverse determination; any requests which they cannot approve are referred to a SLR. Second Level (Physician) Review Process The SLR uses clinical experience, knowledge of generally accepted professional standards of care and judgment. Approval Determinations and Pended Reviews For each service, the first level reviewer was unable to approve the SLR determines the medical necessity of the service and the number of units and service duration requested. Approval based on available information: When the available information substantiates the medical necessity of the service(s), units and service duration, the SLR approves them as requested and the review is completed. Notifications are issued as described under First Level Medical Necessity Review Process: Approval Notifications. You may receive a pend if additional information is required: If a SLR is not able to approve the service(s) based on the available information, the SLR may attempt to speak with the treating practitioner to obtain additional or clarifying information. If the treating practitioner is not available when the SLR calls, the SLR may issue a pend determination at that time. Any information obtained telephonically or via pend is documented in the review record. If the Page: 14
Services for SLR can authorize the service(s) based on the additional or clarifying information obtained, an approval determination is rendered. The review is complete and notifications are issued as described under First Level Medical Necessity Review Process: Approval Notifications. SLR pended review requests: If the treating practitioner is not available when the SLR calls, the SLR may issue a pend determination at that time. Any additional information received telephonically or via electronic pend is documented in the review record. You will receive an electronic notification of the pended review. o The information must be provided within ten (10) business days. o If the requested information is not received within ten (10) business days, the SLR renders a determination based on the information that is available. Adverse Determinations Only a SLR may render an adverse determination (denial). As noted in the preceding section, prior to rendering an adverse determination the SLR may attempt to discuss the request with the treating practitioner. There are two types of adverse determinations: denial and partial denial. Denial The SLR may render a (full) medical necessity denial of one or more-line items. Within one (1) business day of the determination, you will be notified by phone. Written denial notifications also are mailed to you and to the beneficiary, the beneficiary s parent or legal guardian/caretaker. The written notification includes information about your and the beneficiary s right to a reconsideration of the adverse determination. The beneficiary s notification also includes information about his/her right to request an appeal. Page: 15
Services for Partial Denial The SLR also may render a partial denial for the services. When a partial denial is rendered, some of the services are approved and some are denied. Partial Denials Notification: Notifications are issued to the parties as described in the preceding section, Denial. For the services that are approved, the approval information is provided to the fiscal agent. Reconsideration Reviews You, the beneficiary, or parent/guardian/caretaker may request a reconsideration of an adverse determination. Denial notices contain instructions for requesting reconsideration; the request must be within 30 calendar days of the date of the denial notification. Additional information may be found in our Reconsideration Manual. Page: 16
Services for Section IV IF YOU NEED INFORMATION OR ASSISTANCE We offer a variety of ways for you to obtain information or assistance you need when submitting authorization requests. In the following sections we identify, by topic or type of assistance needed, useful resources. Questions about the Services Utilization Management Program For questions or information about the Services Utilization Management Program, the following resources are available: Resources available on our Web site: http://ms.eqhs.org: o eqhealth Solutions Services Provider Manual. o Training presentations: Copies of training and education presentations are available under the Education tab. eqhealth Solutions toll free HELPLINE - 1-866-740-2221. eqhealth Solutions HELPLINE For general inquiries, questions, complaint, or compliments contact our HELPLINE at 1-866-740-2221. The helpline is available from 8:00AM 5:00PM Central Time, Monday through Friday. If you call during non-business hours, you will be provided the option to leaving a message. If you have a complaint or compliment and would prefer to write to us, you may fax the information to our toll free Quality Concerns fax number: 1-888-204-0221 or mail the information to: eqhealth Solutions- Mississippi Division Attention: Quality Concerns 460 Briarwood Drive, Suite #300 Jackson, MS 39206 Page: 17
Services for SECTION V - DEFINITIONS Term Administrative Appeal New Service/Admission Review Denial First Level Reviewers Pend Authorization Definition If the reconsideration outcome was to uphold the denial and there is a disagreement with this decision, the beneficiary/legal representative may request an administrative appeal from the Division of Medicaid The review performed by eqhealth when a new or existing patient s information is entered for the first time or is new to the precertification process. Admission Review is interchangeable with Precertification Review. Occurs when requested services are not approved. Only a SLR can clinically deny a request. eqhealth first level reviewers: Apply DOM policy. Apply DOM approved medical necessity clinical guidelines. Request additional information. Refer requests that cannot be approved for review and determination by second level reviewer. Authorize care. Refers to the process of placing a review request on hold until additional information has been received. eqhealth will notify the provider of the information needed along with a time frame for submission Process for receiving approval for services. Page: 18
Services for Quality Improvement Organization (QIO) Reconsideration Second Level Reviewers A federally designated organization as set forth in Section 1152 of the Social Security Act and 42 CFR Part 476. (QIOs were formerly called Peer Review Organizations [PROs].) They are firms that operate under the federal mandate to provide quality and cost-management services for the national Medicare Program and for states Medicaid programs. The Center for Medicare and Medicaid Services (CMS) oversees the national Medicare QIO Program, and it requires that states contract with QIOs to assist them in managing the cost and quality of health care services provided to Medicaid recipients. By law, the mission of the federal QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to recipients. CMS reports that Throughout its history, the Program has been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality. Following a clinical denial either the beneficiary/legal representative, service provider and/or attending physician can request reconsideration or another look by an eqhealth SLR, (different from the initial SLR) to review the request and any additional information submitted. eqhealth second level reviewers (SLR): Make certification, denial or reconsideration determinations. That decision is: o Based on documentation that supports prognosis and medical appropriateness of setting. o Patient-centered and takes into consideration the unique factors Page: 19
Services for associated with each patient care episode. o Sensitive to the local healthcare delivery system infrastructure. o Based on his or her clinical experience, judgment and accepted standards of healthcare. Request additional information. Clinically deny certification Only a SLR can clinically deny request. Supporting documentation Suspended review The second level reviewer may contact the ordering physician or vision service provider to obtain additional information when the documentation submitted does not clearly support medical necessity. Supporting documentation is particular documentation required at the time of an authorization request for particular services. The nature of the required documentation varies according to the type of service and may vary according to the type of authorization request. The status of a review request when a provider is notified that additional clinical information is needed to complete a review, but the provider does not submit the requested information within the required timeframe. A suspended review is a cancellation of the provider s review request. If the requested information is submitted at a later date, the review request is unsuspended and review is performed. (Also see Pend (or pended) review and Unsuspended review.) Page: 20
Services for Treatment Authorization Number (TAN) Unsuspended review The acronym for Treatment Authorization Number is the number issued by eqhealth following the review approval process. The status of a review request when a provider submits all additional clinical information that was needed to complete a review. When all required information is submitted, eqhealth unsuspends the review request and completes the review. (Also see Suspended review and Pend (or pended) review.) Page: 21