Client Name: SAR#: Administrative Review Process notes: When documenting call outs to provider, please document the call in a patient note in Alpha the day the call is made. tes should be coded as Care Management. Review for HUM 26: are there immediate health/safety concerns? If YES, consult with medical staff and document recommendations in a physician consult note. Review for Unable to Process Criteria The requested effective start date does not precede the submission date of request. t If unjustified retro request, then unable to process. t The dates of the request do not overlap with an existing authorization for the same service. If more than 5 days overlap, then unable to process. If overlap is 5 days or less, then make documented contact with provider to verify intended request dates. Please make a note for Care Manager for dates of service adjustment as requested by provider here: t For initial, the recipient s age is under 65. If met, please note age here: If not met, then unable to process. The SAR is submitted no more than 30 days before requested start date. If not met, t then unable to process. Did the provider state a desire to withdraw or rescind the request, but was unable to use the rescind option in Alpha? If yes, then unable to process. Review for Administrative Denial: If anything is not met, please submit for QOC tracking For initial, signed service order and dated by Approved Signatory. If not met, contact t the provider to request and give deadline to submit. If not received, administratively deny the request. t t t t For concurrent, the updated PCP is present, which includes ACT and provider and a valid service order. If none present, then contact the provider to request and give deadline to submit. If not received, administratively deny the request. For concurrent, the Comprehensive Crisis Plan is present. If none present, then contact provider and give a deadline to submit. If not received, administratively deny the request. For initial, the Comprehensive Clinical Assessment and/or Addendum is present. If not present, then document call to provider. If not provided by deadline, administratively deny. LOCUS/ASAM level noted is in SAR or other documentation. If not, then contact the provider to request and give deadline to submit. If not received, administratively deny the request. Is LOCUS/ASAM worksheet submitted? If not present, contact provider to request and document call to provider (can NOT administratively deny for lack of worksheet). Are there any current authorizations for other services? If so, consider if there are ACTT 1
service exclusions and if so, contact provider for clarification. If no response, administratively deny the request. te the services here: Other Items of Review: If documents are not present, please submit for QOC tracking Is the Consumer s Name, DOB, and MID number accurate on submitted documents? If not, contact provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. For concurrent, is there evidence of active discharge planning? Consider reviewing for the following elements: anticipated discharge date barriers to discharge anticipated discharge level of care efforts made to coordinate discharge appointment If not, then make documented call to provider to request. Is the ATR worksheet submitted? If not, contact provider and ask for worksheet to be submitted. If not present, can NOT administratively deny. Document contact. For concurrent requests, is the contact spreadsheet submitted? If not, contact provider and ask for worksheet to be submitted. If not present, can NOT administratively deny. Document contact. Are there any past denials or partial approvals within this current episode of care? Please note here: Do the # of units requested match calendar days requested? (4 for each full or partial month. Requested lapse dates should end at month s end or their billing will be compromised). If not, make documented contact with provider to verify intended request dates/units. Please note here: Length of stay in current service (if applicable). te here: Review current medications. Is a referral to medical review needed? If review is needed (yes), complete Medication Review Consultation Form: http://mysp.smokymountaincenter.com/dept.clop/cm/shared%20documents/forms/ AllItems.aspx?RootFolder=%2Fdept%2Eclop%2Fcm%2FShared%20Documents%2FMH SA%20UM%20FORMS%20AND%20REVIEW%20TOOLS&FolderCTID=0x012000B4D86B 6A1F01BA459A100B130004E563&View={AD74E0AD-01EF-4476-9101- 2266E0F75027}, email to Dr. Cree, and document all of the above in a patient note. This note should be labeled as Pharmacist Consult. Is consumer identified as dually diagnosed (either I/DD or SU along with MH)? If so, please note here: The above administrative review was completed by Care Reviewer: Unable to Process (if checked, upload checklist in to SAR Service Tile) Administrative Denial (if checked, upload checklist in to SAR Service Tile and notify Clinical Support Team of an Administrative Denial): 1. Please complete the Request Template and note Administrative Denial. 2. Send to Clinical Support Team. 3. te that, if within 24 hours of submitting the Request Template to Clinical Support, a new ACTT 2
SAR is received from the provider that contains the needed documentation, notify Clinical Support Team so that they may halt the process for generating and mailing the Administrative Denial Letter. 4. When a new SAR is received as described above, please document in a patient note a description of why an administrative denial letter was not generated for the initial SAR. Sending to Care Manager for Clinical Review (if checked, re-assign the SAR and e-mail the checklist to the Care Manager that previously reviewed any SARs for the consumer. If not previously reviewed for services prior to this request, please circular assign the SAR) Clinical Review Is the recipient under 21? If yes, review for EPSDT. For concurrent, is the recipient over 64, or will he/she turn 65 during the next 6 months? If yes, consider transition plans and implications of approving. Have the consumer s concurrent medical needs been appropriately assessed or reassessed? If not, make documented contact with provider to make recommendations regarding this and refer to QOC. Review for QOC Concerns specific to CCA. First, complete this section. If any boxes are selected no in this section, send for QOC tracking with inadequate CCA as the concern. Assess for Diagnostic Clarity: - If concurrent review, check the box and proceed to continued stay review. Is there a description of the presenting problems including: source of distress precipitating events, and associated problems or symptoms, and recent progressions? (all above should be selected to choose ) Was the course of illness clearly documented regarding: onset, triggers, intensity, frequency, duration of symptoms, and course of illness? (all above should be selected to choose ) Is the diagnosis clear? (i.e. there aren t multiple, incompatible or frequently changing diagnoses.) Was there adequate assessment of co-occurring behavioral health/substance abuse/idd conditions? Are current physical/medical medications listed? Are current psychiatric medications listed? ACTT 3
Service Review Criteria Are known allergies and adverse reactions clearly documented? (Or if there are no known allergies, is this documented?) Is the mental status sufficiently documented and does it support the diagnosis? A review of the following dimensions is included: biological (include strengths, weaknesses, risks, and protective factors) psychological (include strengths, weaknesses, risks, and protective factors) familial (include strengths, weaknesses, risks, and protective factors) social (include strengths, weaknesses, risks, and protective factors) developmental (include strengths, weaknesses, risks, and protective factors) environmental (include strengths, weaknesses, risks, and protective factors) (all above should be selected to choose ) Environment and psychosocial factors potentially contributing to functional status are identified and considered: housing, legal, financial, educational or vocational, and nutrition or sleep. (all above should be selected to choose ) Is the treatment history adequate; information went beyond prior dates of service to include: levels of care, types of interventions, and responsiveness to/engagement with prior treatment? (all above should be selected to choose ) Is there evidence of beneficiary and family and/or legally responsible person s involvement in the assessment (if applicable)? Is there evidence of provider discussion of results with beneficiary and family and/or legally responsible person? Is there analysis and interpretation of the assessment information with an appropriate case formulation? (i.e. does this assessment support the diagnosis?) Are there recommendations for additional assessments, services, support, or treatment including specific evidence-based practices based on the results of the CCA? Is there a strengths/protective factors/problem summary which addresses: risk of harm, functional status, co-morbidity, (behavioral and medical) recovery environment, and treatment and recovery history? (all above should be selected to choose ) Is the CCA dated and signed by the assessor? Monitoring Adherence to Clinical Guidelines Major Depressive Disorder ACTT 4
Is the consumer diagnosed with Major Depressive Disorder? (This is documented in the SAR and/or accompanying clinical documentation). If yes, complete the following questions and send e-mail for Clinical Guideline tracking with SAR ID and MDD in the subject line. If no, move on to Medical Necessity Criteria review and select for the next 3 lines. Is there documented evidence that the consumer received, or will receive a standardized assessment for depression (examples include but are not limited to the following: PHQ-9, Beck Depression Inventory, Child Depression Inventory, etc.)? If yes, ask provider to upload copy of assessment or the score. If no, recommend that standardized assessment be completed and document recommendation. Is there documented evidence that the provider gave psychoeducational information about the following?: The nature of depression, its typical course and treatment alternatives available. If no, recommend provider share psychoeducational information with consumer and document. Is the Major Depressive Disorder severity noted as moderate or severe? If so, is there documented evidence that a referral/recommendation for a medical evaluation was made? If not, contact the provider and ask about whether a referral was made for medical evaluation either with primary care physician or psychiatrist. If no, recommend referral and document. Eligibility Criteria Medicaid shall cover ACT services for a beneficiary 18 years and older with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), and bipolar disorder because these illnesses more often cause long-term psychiatric disability. Beneficiaries with other psychiatric illnesses are eligible dependent on the level of the long-term disability. Beneficiaries with a primary diagnosis of a substance use disorder, or intellectual developmental disabilities, borderline personality disorder, traumatic brain injury, or an autism spectrum disorder are not the intended beneficiary group and should not be referred to ACT if they do not have a co-occurring psychiatric disorder. ACT teams shall document written admission criteria that reflect the following medical necessity criteria required for admission: A. Has a current Diagnostic and Statistical Manual (DSM) 5 (or its successor) diagnosis consistent with a serious and persistent mental illness (SPMI) reflecting the need for treatment and the covered treatment must be t medically necessary for meeting the specific preventive, diagnostic, therapeutic, and rehabilitative needs of the beneficiary. AND t B. Has significant functional impairment as demonstrated by at least one of the following conditions: 1) Significant difficulty consistently performing the range of routine tasks required for basic adult functioning in the community (for example, caring for personal business affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions; meeting nutritional needs; attending to personal hygiene) or persistent or recurrent difficulty performing daily living tasks except with ACTT 5
t t t Service Review Criteria significant support or assistance from others such as friends, family, or relatives; 2) Significant difficulty maintaining consistent employment at a selfsustaining level or significant difficulty consistently carrying out the headof-household responsibilities (such as meal preparation, household tasks, budgeting, or child-care tasks and responsibilities); or 3) Significant difficulty maintaining a safe living situation (for example, repeated evictions or loss of housing or utilities); AND C. Has one or more of the following problems, which are indicators of continuous high-service needs: 1) High use of acute psychiatric hospital (2 or more admissions during the past 12 months) or psychiatric emergency services; 2) Intractable (persistent or recurrent) severe psychiatric symptoms (affective, psychotic, suicidal, etc.); 3) Coexisting mental health and substance use disorders of significant duration (more than 6 months); 4) High risk or recent history of criminal justice involvement (such as arrest, incarceration, probation); 5) Significant difficulty meeting basic survival needs, residing in substandard housing, homelessness, or imminent risk of homelessness; 6) Residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided; or requiring a residential or institutional placement if more intensive services are not available; or 7) Difficulty effectively using traditional office-based outpatient services; AND D. There are no indications that available alternative interventions would be equally or more effective based on rth Carolina community practice standards and within the Local Management Entity-Managed Care Organization (LME-MCO) service array. Continued Stay Criteria Medicaid shall cover a continued stay if the desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the beneficiary s PCP or the beneficiary continues to be at risk for relapse based on current clinical assessment, history, or the tenuous nature of the functional gains; AND ONE of the following applies: ACTT 6
t t Service Review Criteria a. The beneficiary has achieved current PCP goals and additional goals are indicated as evidenced by documented symptoms; b. The beneficiary is making satisfactory progress toward meeting goals and there is documentation that supports that continuation of this service will be effective in addressing the goals outlined in the PCP; c. The beneficiary is making some progress, but the specific interventions in the PCP need to be modified so that greater gains, which are consistent with the beneficiary s pre-morbid or potential level of functioning, are possible; d. The beneficiary fails to make progress or demonstrates regression in meeting goals through the interventions outlined in the PCP. (In this case, the beneficiary s diagnosis must be reassessed to identify any unrecognized cooccurring disorders, and treatment recommendations should be revised based on the findings); or e. If the beneficiary is functioning effectively with this service and discharge would otherwise be indicated, the ACT team services must be maintained when it can be reasonably anticipated that regression is likely to occur if the service is withdrawn. The decision must be based on either of the following; 1) The beneficiary has a documented history of regression in the absence of ACT team services, or attempts to titrate ACT team services downward have resulted in regression; or 2) There is an epidemiologically sound expectation that symptoms will persist and that ongoing outreach treatment interventions are needed to sustain functional gains. Transition or Discharge Criteria Beneficiary shall meet at least ONE of the following: a. The beneficiary and team determine that ACT services are no longer needed based on the attainment of goals as identified in the person-centered plan and a less restrictive level of care would adequately address current goals; b. The beneficiary moves out of the catchment area and the ACT has facilitated the referral to either a new ACT provider or other appropriate mental health service in the new place of primary private residence and has assisted the beneficiary in the transition process; c. The beneficiary and, if appropriate, the legally responsible person, choose to withdraw from services and documented attempts by the program to reengage the beneficiary with the service have not been successful; or d. The beneficiary has not demonstrated significant improvement following reassessment and several adjustments to the treatment plan over at least three months and: 1) Alternative treatment of providers have been identified that are deemed necessary and are expected to result in greater improvement; or ACTT 7
2) The beneficiary s behavior has worsened, such that continued treatment is not anticipated to result in sustainable change; or 3) More intensive levels of care are indicated. Clinical Review: Approved Send to Peer Review (see below for notes on this process) Reviewer Name, Credentials: Date: Clinical Justification: Process tes: If Approval is granted under EPSDT, please include the following in Clinical Justification: An individualized statement about why this service is needed that provides explanation of how EPSDT criteria are met. A checklist that notes generalized EPSDT criteria is not sufficient to document the need for an EPSDT service. Document consideration/exploration of less restrictive/less costly community-based alternatives and include rationale for appropriate rejection of such alternatives If continued stay review, document progress/lack of progress or changing needs since last review and sufficiently document needs that support the continued stay determination To best understand the whole picture of what is going on for the individual receiving services, please review Care Coordination notes (if applicable) in the EHR. Sending to Peer Review: Complete the initial peer review referral form Ensure that the contact information provided to the Peer Reviewer is correct by calling the number yourself and verifying that a clinician can be contacted. If the number provided is not correct, please note on the QOC spreadsheet. Complete the email template for the Clinical Support Team and attach the necessary documents Ensure that the SAR is designated as being in peer review status in Alpha ACTT 8