Department of Medical Assistance Services

1
Department of Medical Assistance Services
Residential TreatmentFor Children
AdolescentsLevel C (RTF)
November 2007 www.dmas.virginia.gov
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Residential Treatment-Level C

• DMAS Contacts
• Shelley Jones - 804-786-1591
• shelley.jones_at_dmas.virginia.gov
• Bill OBier - 804-225-4050
• william.obier_at_dmas.virginia.gov
• Pat Smith - 804-225-2412 for KePRO related
  questions
• patty.smith_at_dmas.virginia.gov

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Prior Authorization Contractor

• KePRO is the DMAS contractor for PA
• For questions or forms, go to the PA website
• DMAS.KePRO.org
• and click on Virginia Medicaid
• Phone 1-888-VAPAUTH or 1-888-827-2884
• Fax 1-877-OKBYFAX or 1-877-652-9329
• Web Provider Issues _at_ KePRO.org

4
Objectives of Training

• Understand recent changes in residential
  treatment facility (RTF) criteria
• Understand recent changes in the prior
  authorization process
• Understand the Utilization Review criteria and
  documentation requirements for RTF
• Identify new Medicaid mental health services for
  children

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Objectives

• These slides contain only highlights of the
  Virginia Medicaid Psychiatric Services Manual and
  are not meant to substitute for the comprehensive
  information available in the manual.
• Please refer to the manual, available on the
  DMAS website, for in-depth information on
  psychiatric residential treatment criteria.

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Provider Enrollment Contacts

• For provider agreements, change of address, and
  enrollment questions
• First Health VMAP Provider Enrollment Unit
• P.O. Box 26803
• Richmond, Va. 23261
• Helpline-804-270-5105-Richmond
• Toll free-888-829-5373
• Fax-804-270-7027

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Out-of-State Facility Enrollment

• Border state facility (within 50 miles)
• Provides a service not available in Virginia
• No in-state facility willing to admit a specific
  child
• Procedure
• Contact DMAS at 804/786-1591 to discuss
• child-specific, out-of-state placement need
• DMAS can enroll facility for single placement,
• if appropriate

8
Participation Requirements

• Adhere to conditions outlined in the provider
  agreements-a sample is available in the PSM
• Notify Provider Enrollment Unit of any change in
  original information submitted
• Provider must be participating in the Medicaid
  Program at the time the service is performed

9
Restraint Seclusion

• Remain in compliance with signed agreement
  regarding seclusion and restraint
• In case of injury requiring medical attention or
  a suicide attempt, DMAS must be notified by fax
• childs name, Medicaid number
• facility name address of incident
• location date of incident
• names of staff involved
• description of incident
• outcome, including persons notified
• current location of child
• Fax to Shelley Jones at 804-612-0059

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Definition-Level C RTF

• Program for children under age 21 to treat severe
  mental, emotional and behavioral disorders
• Inpatient
• 24-hours per day
• Child-specific care and treatment
• Highly organized and Intensive services
• Planned therapeutic interventions
• All services required to be provided on-site,
  including academic program

11
Psychiatric Services Manual Update

• July 31, 2007 manual updated to add information
  on a new service and to clarify criteria for RTF
  and identify minor changes to the prior
  authorization process

12
Manual Update Contd

• Added Substance Abuse Services (SAS) on an
  outpatient basis-not applicable while in Level C
• Outpatient SAS therapy follows the same PA and
  documentation requirements as Outpatient
  Psychiatric Services
• See PSM and Medicaid memo dated October 10, 2007
  for particulars
• Clarified new provider type for SAS only
• Other new SA services are covered in the
  Community Mental Health Rehabilitation Services
  Manual

13
Manual Update Contd

• Provider qualification changes for Outpatient
  Psychiatric Services (codes are also applicable
  to RTF services)
• -Clarified LPC licensed by the Board of
  Counseling
• -Added Psychiatric Nurse Practitioner, licensed
  by the Board of Nursing

14
Manual Update Contd

• Provided additional clarification on the
  Restraint and Seclusion requirements
• -RS attestation letter must be submitted to
  DMAS by July 1 each year or sooner if change in
  CEO
• -Sample RS attestation letter in manual
• Clarified attestation letter and reporting
  requirements must be met to continue
  participation as a provider

15
Manual Update Contd

• Clarified Out-of-State placement criteria
• Requires true prior approval for Medicaid
  coverage
• Recipient specific information required to be
  sent to DMAS
• Demographics
• Referral source information
• Current placement and services and why these are
  not adequate
• Current documentation on diagnosis, behaviors,
  discharge plan
• Current psychological evaluation (within past
  year)

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Manual Update Contd

• Out-of-State Placement criteria contd
• Social and Service History pertinent to placement
  needs
• Facility information-website, documentation
• List of Virginia facilities explored, and reasons
  for admission denial
• This will be reviewed by DMAS staff to assess the
  appropriate level of care and facility placement,
  and who will coordinate with provider enrollment
  if out-of state placement approved

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Manual Update Contd

• Reviewed need to have the CAFAS/PECFAS in the
  medical record and updated at least every 90 days
• Reviewed the need to have all medical
  documentation to include dated signatures on the
  date of service delivery
• Clarified notification process for transfer or
  closure of a provider or facility

18
Manual Update Contd

• Reviewed the prior authorization process
• Initial Review
• CSA cases only
• 3-digit locality code
• Reimbursement Rate Certification
• CAFAS/PECFAS scores
• CSA and NON-CSA cases
• Certificate of Need
• Initial Plan of Care

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Manual Update Contd

• Continued Stay Review
• CSA Cases
• Current CAFAS/PECFAS
• Confirm locality code
• Reimbursement Rate Certification
• CSA and NON-CSA Cases
• CIPOC
• 30-Day Update-most recent

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Manual Update Contd

• NON-CSA Cases
• Must have a NON-CSA rate established by DMAS in
  order to request PA from KePRO.
• Contact Provider Reimbursement, 804-686-7931 to
  establish a rate. This should be done at the time
  of enrollment as a provider.
• If no rate has been established, the request for
  PA will be returned by KePRO without action.

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Electronic Submission of Claims

• On October 9, 2007 a Medicaid Memo was
  distributed covering the changes necessary to
  submit RTF claims electronically
• On October 10, the PSM was updated to reflect
  this change.
• For CSA cases, when submitting PA information to
  KePRO, the 3-digit locality code and the
  Reimbursement Rate Certification are required.
  This will facilitate electronic submission of
  claims.
• For NON-CSA cases, reimbursement will be at the
  rate established at enrollment.

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Utilization Review

• DMAS has contracted with Clifton-Gunderson to
  complete audits of RTFs and will review records
  to assure DMAS criteria is being followed.
• The following criteria is critical to compliance,
  although it is not a complete listing. See the
  Psychiatric Services Manual for a complete
  listing. Review all referenced federal and state
  regulations, as well as Medicaid Memos that are
  sent to providers and available on the DMAS
  website.
• Review the sample forms provided in the PSM.

23
Reimbursement Rate Certification

• For CSA Cases Only
• Negotiated rate between locality and facility
• Total rate can be no more than the Medicaid max
• Payment from any other source such as Title IV-E,
  must be deducted prior to establishing the rate
• Identify responsible locality
• Must be sent in for PA
• If revised by the locality, must be sent in to
  KePRO to update the PA within 1 week
• Payment based on the rate on the certification
  entered by KePRO on the FHS system
• All versions of the rate certification must be
  available at the facility at the time of audit

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CSA or NON-CSA?

• If the case is an Adoption Subsidy case, it is
  NON-CSA
• The education payment source is not considered
• If the education is paid for by the Dept. of
  Education/CSA funded, it is a CSA case
• If a child has been receiving CSA funding for
  other services, it is a CSA case

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Certification of Need

• CSA Cases
• CON must be completed by both the physician and
  the FAPT
• Must include dated signatures of physician and at
  least 3 members of the FAPT
• Authorization should begin no earlier than the
  date of the latest signature
• Must be child-specific and relate to the need for
  RTF level of care
• Must be available in the medical record

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Certification of Need Contd

• NON-CSA Cases
• CON may be completed by the FAPT and must include
  a physicians dated signature
• The DMH224 may be used as the CON and must also
  include a physicians dated signature, as well as
  the screeners dated signature
• The CSB completes the DMH224
• Authorization should begin no earlier than the
  date of the latest signature
• Must be child-specific and relate to the need for
  RTF level of care
• Must be available in the medical record

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Certification of Need Contd

• CSA and NON-CSA
• The CON should reflect the childs current
  condition and so should be completed within 30
  days of admission.
• The CON is required to be completed prior to
  admission with necessary dated signatures.
• If discharged and readmitted, a new CON is
  required.
• If the child transfers to an acute psychiatric
  facility, the acute care team can do the new CON
• The CON must be in the medical record.
• A copy of the CON must be submitted to KePRO.

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CAFAS/PECFAS

• CSA Cases Only
• Must be current. For admission the CAFAS should
  reflect the requested level of care
• To be completed at a minimum of every 90 days and
  must be available in the medical record
• Should be updated by locality when the childs
  level of impairment changes significantly
• Scores must be submitted to KePRO

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Initial Plan of Care

• Must be completed within 24 hours of admission
• Requires a dated physicians signature signifying
  the physician has had a face-to-face visit with
  the child (Authorization should begin no earlier
  than the date of the signature)
• All required elements must be in the plan
• See sample form in PSM-DMAS 371
• Be sure to specify the number of child-specific
  therapies
• Must be submitted to KePRO
• Must be in the medical record

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Comprehensive Individual Plan of Care

• Must be completed within 14 days of admission
• Must be signed by the team responsible for the
  care (physician and at least one other team
  member specified in regulations)
• Must include all required elements
• See sample form in PSM-DMAS 372
• Be sure to include specific orders for therapies
• Must be submitted to KePRO
• Must be in the medical record

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CIPOC 30-Day Progress Updates

• Must be updated every 30 days
• Must have dated signatures of team members
• Must include all required elements
• See sample form in PSM-DMAS 373
• List Individual and Family Therapy dates
• If the therapy is not provided by a qualified
  professional, or the session was not at least 20
  minutes, or there is no note, it should not be
  considered a delivered service

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Documentation

• Individual Psychotherapy
• Must occur 3 times every 7 days. Facility
  determines the 7-day count.
• Individual, Family and Group Psychotherapy
• The full week of RTF reimbursement will be
  retracted if
• Fewer than 3 sessions occur (Individual Therapy
  only)
• Notes are not completed by a qualified therapist
• An unqualified therapist provides the therapy and
  there is no documentation of supervision every
  6th session (includes individual, family and
  group psychotherapy) the full week of RTF payment
  will be retracted

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Documentation Contd

• Individual, Family and Group Psychotherapy,
  contd
• Notes do not contain, at a minimum
• Childs name
• Type of therapy
• Start and stop time for session
• Pre-printed forms with date and time of session
  already printed is not acceptable
• Group Psychotherapy billed to Medicaid must not
  consist of more than 10 patients

34
Documentation Contd

• Activity of session (what therapeutic interaction
  occurred), and how it relates to goals
• Purpose of note is document service, as well as
  to assist staff in providing ongoing therapeutic
  services to child
• The level of participation (a check box is not
  sufficient)
• Plan for next session
• Family therapy required at least 2x a month and
  required weekly if relationship impacts treatment
  or discharge plan to return to family

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Documentation Contd

• 21 Treatment Interventions every 7 days
• May include group psychotherapy
• Must not include individual and family therapy
• Must be documented on a daily basis
• Forms with check boxes as the majority of the
  note are not acceptable
• Must provide child-specific therapeutic
  intervention
• Interventions that are not billable separately,
  may include more than 10 residents (this does not
  include the group psychotherapy that may be
  billed separately)

36
Documentation Contd

• The full week of RTF reimbursement will be
  retracted if
• Notes do not contain, at a minimum
• Childs name
• Type of therapy
• Start and stop time for session/length of session
• Pre-printed forms with time of session already
  printed is not acceptable

37
Documentation Contd

• The full week of RTF reimbursement will be
  retracted if
• Notes do not contain, at a minimum
• Activity of session (what therapeutic interaction
  occurred), and how it relates to child-specific
  goals
• Purpose of note is to document service delivery
  as well as assist staff in providing ongoing
  therapeutic services to child
• The level of participation (a check box is not
  sufficient)
• Narrative is expected
• Dated signature of the provider

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Restraint Seclusion

• Reports must be sent to DMAS reporting any injury
  requiring medical attention. These should be sent
  in within one business day of the occurrence.
  (See slide 9)
• Restraint Seclusion reporting is a condition of
  participation and non-reporting subject to
  retraction for paid claims and provider
  enrollment.

39
Staffing and signatures

• All signatures must be dated, and should include
  the professional title of the author.
• Auditors will request a staffing list with proof
  of licensure if license required to provide a
  Medicaid reimbursed service.

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Wrap Up

• If all required information is contained within
  the record, no retractions will result.
• DMAS staff is available to do on-site training on
  facility-identified areas of concern regarding
  DMAS criteria.
• Contact Shelley Jones or Bill OBier to arrange
  on-site training.