Department of Medical Assistance Services

1
Department of Medical Assistance Services
Treatment Foster Care Case Management
October/November 2008 www.dmas.virginia.gov
2
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
• Tracy Wilcox - 804-371-2648
• Contract Monitor for Clifton Gunderson
• Tracy.wilcox_at_dmas.virginia.gov

3
Training Objectives

• Identify participation requirements
• Understand Medicaid documentation requirements
• Understand locality responsibilities
• Be aware of prior authorization (PA) requirements
  and process
• Understand changes to UAI and PA fax form
• Understand the utilization review process
• Reference handouts of October 15 and November 7,
  2008 Medicaid memo and CANS summary form

4
Objectives

• These slides contain only highlights of the
  Virginia Medicaid Psychiatric Services Manual
  (PSM) and are not meant to substitute for or take
  the place of the material in the manuals.
• Please refer to the manual, available on the DMAS
  website, for in-depth information on TFC-CM
  criteria.

5
Provider Enrollment Unit

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

6
General Medicaid Provider Participation
Requirements

• Have administrative and financial management
  capacity to meet federal and state requirements
• Have ability to maintain business and
  professional documentation
• Adhere to conditions outlined in the provider
  agreements
• Notify DMAS of any change in original information
  submitted
• and

7
Participation Requirements

• Maintain records that fully document health care
  provided
• Retain records for a period of at least 5 years
• Furnish to authorized state and federal personnel
  access to records and facilities in the form and
  manner requested
• Use Medicaid designated billing forms
• and

8
Participation Requirements

• Accept as payment in full the amount reimbursed
  by DMAS
• Provider must be participating in the Medicaid
  Program at the time the service is performed
• A provider may not bill a client for a covered
  service regardless of whether or not the provider
  received payment from Medicaid

9
Participation Requirements

• Should not attempt to collect from the client or
  family member any amount that exceeds the
  Medicaid allowance or for missed appointments
• Hold all recipient information confidential
• Be fully compliant with state and federal HIPAA
  confidentiality, use and disclosure requirements

10
Electronic Signatures

• Clarification on electronic signatures was issued
  in the 8-20-04 Medicaid Memo to all providers.
• An electronic signature that meets the following
  criteria is acceptable for clinical
  documentation
• Identifies the individual signing by name and
  title and
• Data system assures the documentation cannot be
  altered after signature affixed, by limiting
  access to code or key sequence
• and

11
Electronic Signatures

• Provides for non-repudiation that is, strong and
  substantial evidence that will make it difficult
  for the signer to claim the electronic
  representation is not valid.
• The provider must have written policies and
  procedures in effect regarding use of electronic
  signatures.

12
Common Abbreviations

• CAFAS/PECFAS-Child Adolescent Functional
  Assessment Scale/Preschool Early Childhood
  Functional Assessment Scale
• CANS-Child and Adolescent Needs and Strengths
• CPMT-Community Policy Management Team
• CSA-Comprehensive Service Act
• CSB-Community Service Board
• DMAS-Department of Medical Assistance Services

13
Common Abbreviations

• DSS-Department Social Services
• FAPT-Family Assessment Planning Team
• OCS-Office of Comprehensive Services
• PSM-Psychiatric Services Manual
• RTF-Level C Residential Treatment Facility
• SED-Seriously Emotionally Disturbed
• TFC-CM-Treatment Foster Care - Case Management

14
Definition

• Case management activities by child placing
  agencies with treatment foster care programs
• Licensed/certified by DSS
• In compliance with DMAS criteria
• Meet provider qualifications
• and

15
Definition

• Case Management activities which help SED
  children or those with behavioral disorders under
  the age of 21 who are at risk of placement into
  residential treatment
• Gain access to necessary care and appropriate
  services
• Coordinate and monitor necessary care and services

16
Required Documentation

• FAPT ASSESSMENT
• Childs immediate long range therapeutic needs
• Developmental priorities
• Personal strengths liabilities
• Potential for family reunification
• Specific planned treatment objectives
• Specific therapeutic modalities required to
  achieve objectives
• Signed and dated by a majority (at least 3) of
  FAPT members

17
Effective November 1, 2008

• The state uniform assessment instrument (UAI) has
  been the CAFAS/PECFAS since the start of the
  TFC-CM program in 2000
• On November 1, 2008 DMAS will also begin to
  accept the CANS as the state UAI
• Either the CAFAS/PECFAS or CANS can be used to
  meet criteria until June 30, 2009
• On July 1, 2009, only the CANS will be accepted
  as the state UAI for TFC-CM

18
State UAI

• At a minimum
• The CAFAS or PECFAS profile sheets for the youth
  and caregiver, OR
• The CANS summary sheet, indicating the childs
  behavioral and emotional needs, and risk
  behaviors,
• must be available in the medical record and
  current within 90 days throughout the stay

19
Initial Plan of Care

• For Medicaid purposes the initial plan of care
  must include, at a minimum, a list of services
  that will be provided during the first 45 days of
  placement
• List of services to be provided must be in the
  medical record within the first 10 days of
  placement

20
Comprehensive Treatment and Service Plan (CTSP)

• Comprehensive plan
• Completed within 45 days of placement
• Individualized
• Developed by case manager and treatment team
• Consult with parents when appropriate

21
CTSP

• Must include the following
• Assessment of childs needs
• Emotional
• Behavioral
• Educational
• Medical
• Specific treatment goals and target dates for
  completion
• The CMs program of therapies, activities, and
  services
• and

22
CTSP

• The discharge plan and target date
• For children age 16, describe transition plan
  for independent living
• Indicate team members participation in
  development of plan
• Dated signature of the case manager
• CTSP should be revised annually

23
90 Day Progress Update

• Completed 90 days from CTSP and every 90 days
  throughout the stay
• Specify time period covered
• Describe progress towards treatment goals and
  objectives
• Met
• Continued or added
• Criteria for achievement of each
• Target dates for each
• and

24
90 Day Progress Update

• Specify problems and behaviors of child
• being addressed
• Specify any changes in interventions or
  strategies
• Describe therapies, activities, or services
  provided
• Any changes needed for next 90 days
• Services to be provided in next 90 days
• Childs own assessment and

25
90 Day Progress Update

• Contacts of child family, where appropriate
• Specific medical needs, treatment and medications
  provided
• Update to discharge plans/date
• Transition plans
• Annual revision of the CTSP to include all of the
  above

26
Case Narratives

• Current within 30 days
• In chronological order
• Include
• Treatment services
• All contacts related to child
• Visits with family
• Other significant events
• Record all medications prescribed and all
  reported side effects
• Dated signature of case manager

27
MEDICAL NECESSITY CRITERIA

• Documented moderate to severe impairment
  moderate to severe risk factors as recorded on
  the UAI
• For the CANS, this would be from the Child
  Behavioral/Emotional Needs and/or Child Risk
  Behaviors areas on the summary sheet
• The moderate to severe impairment is necessary
  for admission. Continued stay reviews require
  documentation of the necessity for this level of
  care, not necessarily tied to the UAI score.

28
MEDICAL NECESSITY CRITERIA

• Childs condition must meet one of the three
  levels listed below and supported by the
  providers documentation of current behaviors

29
LEVEL IModerate impairment with one or more risk
factors

• Needs intensive supervision to prevent harmful
  consequences
• Moderate/frequent disruptive or non-compliant
  behaviors in the home setting that increase the
  risk to self or others
• and
• Needs assistance of trained professionals as
  caregivers.

30
LEVEL II

• Significant impairment with authority,
  impulsivity, and caregiver issues
• Be unable to handle the emotional demands of
  family living
• Need 24-hour immediate response to crisis
  behaviors
• or
• Have severe disruptive peer authority
  interactions that increase risk and impede growth.

31
LEVEL III

• Child must display a significant impairment
  with severe risk factors as documented on CAFAS.
• Child must also demonstrate risk behaviors
  that create significant risk of harm to self or
  to others.

32

• Responsibilities
• of the
• LOCALITY
• in
• TFC Case Management

33
Locality Responsibility

• Complete the state uniform assessment instrument
  (UAI)
• No older than maximum of 90 days
• CAFAS/PECFAS
• Youths functioning
• Caregiver Resources
• CANS
• Summary sheet
• Include Child Behavioral/Emotional Needs and
  Child Risk Behaviors sections
• Be sure to include the childs name and the
  screeners name, as well as the date completed
• and

34
Locality Responsibility

• State UAI
• Impairments identified must be related to scores
  on UAI
• CAFAS/PECFAS
• At least ONE moderate impairment noted with
  related risk factor
• Two are required if one is in School subscale
• CANS
• Two impairments indicated as a 2 or 3 on the
  summary sheet
• Impairments indicated must be supported in the
  narrative

35
Locality Responsibility

• DSM IV Diagnosis
• V Codes are not acceptable
• List of services to be provided in first 45 days
  of care
• Description of childs behavior within past 30
  days
• Be specific, give frequency and duration
• Problem behaviors should be reflected on the
  state UAI
• Alternative placement options considered
• and

36
Locality Responsibility

• Childs functional level
• Clinical stability
• Level of family support
• Discharge plan
• FAPT assessment that reflects the need for level
  of care and the state UAI
• Dated signatures of at least 3 members of the
  FAPT
• and

37
Locality Responsibility

• And either
• FAPT Certification that TFC Case Management is
  medically necessary
• OR
• Written documentation that the CPMT has approved
  admission to TFC Case Management

38
Locality Responsibility

• Be sure to submit to the provider
• Copies of the current state UAI
• FAPT Assessment documenting the need for level of
  care
• Provide specific symptoms and/or problem
  behaviors that need to be addressed
• DSM-IV
• FAPT or CPMT Certification
• 3 digit locality code that designates the
  fiscally responsible locality

39
Components of TFC-CM

• Care Plan development
• Coordinate services and service planning with
  others involved with child, such as working with
  DSS staff, juvenile justice or court staff, or
  other service providers, such as Mental Health
  Support staff
• Referral for needed services
• Follow up on progress to ensure service delivery

40
Components of TFC-CM

• Placement activities
• Planning appropriate placement
• Monitoring placement
• Discharge planning
• Evaluating effectiveness of treatment plan
  through supervision of foster parents
• Assess periodically, childs need for services
• Psychosocial
• Nutritional
• Medical
• Education

41
TFC Case Manager Initial Responsibilities

• Ensure receipt of required documents from the
  locality
• Ensure the locality has provided the correct
  locality code to reflect the locality that has
  fiscal responsibility for the child
• Submit the prior authorization request to KePRO
  within 10 days of placement
• Notify the locality of Medicaid approval or denial

42
CMs Ongoing Responsibility

• The CM shall provide to the foster family
• Supervision
• Training
• Support
• Guidance
• To facilitate the implementation of the
  treatment plan

43
Contacts with the TFC Child

• Face-to-face contact with the child should be as
  often as necessary, based on the CTSP to ensure
  effective, safe services.
• Face-to-face contacts must be no less than twice
  a month, one in the foster home, one with foster
  parent and child. The two minimum face-to-face
  visits should occur on different dates.
• GOALS
• Assess childs progress
• Provide guidance to TFC parents
• Monitor service delivery
• Allow child to communicate concerns

44
Service Limits

• If a child is temporarily out of the home,
  active CM is necessary to bill for the time out
  of home
• No other type of case management may be billed
  concurrently with TFC-CM, no matter the payment
  source
• Caseload limits
• Case manager (full-time professional staff) to
  have a maximum of 12 children
• 6 children for beginning trainees, increasing to
  9 at end of first year, and 12 by end of second
  year
• Maximum of 3 children in student intern caseload

45
Documentation

• Late Entries
• Timeliness of documentation is essential. A
  document is considered complete by review of the
  dated signature of the professional who develops
  the document. Back dating is not acceptable.

46
Prior Authorization

• KePRO is the DMAS prior authorization contractor
• Authorization can be approved for up to one year
  with medical justification
• KePRO will review requests for medical necessity,
  as well as timeliness

47
Prior Authorization

• For questions or forms, go to the PA website or
  use the web address below
• 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

48
Prior Authorization

• Submitting a request
• The preferred method is the iEXCHANGE web-based
  program
• Registration is required
• Information on iEXCHANGE is available on the
  KePRO website, or call
• 1-888-827-2884 or by e-mail at
  providerissues_at_kepro.org

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Prior Authorization

• Additional Methods of Submission
• Requests may also be submitted by
• Fax to 877-652-9329
• The Treatment Foster Care Case Management Prior
  Authorization Request Form (364) is available in
  electronically fill-able format on the KePRO and
  DMAS websites
• www.dmas.virginia.gov
• https//dmas.kepro.org

50
KePRO

• Telephone to 888-827-2884 or
• 804-622-8900 (local)
• Mail to
• KePRO
• 2810 North Parham Rd., Suite 305
• Richmond, VA 23284

51
Revised Fax Form

• A revised prior authorization fax form is
  available on the DMAS and KePRO websites
• The changeover from the CAFAS to the CANS as the
  state UAI and the dual use period is reflected on
  the revised fax form
• Added a Change Request box under item 1 of the
  fax form
• Under current behaviors, information should
  reflect UAI
• All other areas of the form remains the same

52
Revised Fax Form

• The effective date for the mandatory use of the
  new fax forms has been revised to December 1,
  2008.
• From December 1 forward, the 9-25-08 version of
  the fax form attached to the October 15th memo
  and posted on the DMAS and KePRO websites will be
  required.

53
State UAI

• Must be current. For admission the state UAI
  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 the fiscally responsible
  locality when the childs level of impairment
  changes significantly
• Completion information must be submitted to KePRO
  for PA
• Scoring notes the level of impairment that
  supports the need for the level of care

54
Initial Review

• Use when in care for up to 45 days
• Required to be submitted within 10 days of
  admission
• Completed KePRO fax form to include information
  on
• Diagnosis
• TFC-CM need
• FAPT assessment
• and

55
Initial Review

• State UAI information
• Initial services
• Symptoms and behaviors
• Information should reflect the scoring on the
  state UAI. If not, explain.
• Locality code-this should reflect the locality
  who is fiscally responsible
• For reviews not received within 10 calendar days
  of placement, approval can begin no earlier than
  the date all requested information is received.

56
Continued Stay Review

• Submitted prior to the expiration of the current
  authorization, but no earlier than 30 days
• Information required
• Confirm the locality code
• DSM-IV
• CTSP completion information
• Determination that TFC-CM required to meet
  childs needs

57
Continued Stay Review

• Information required
• Confirmation on face-to-face visits
• Symptoms and behaviors
• Specify frequency, intensity and duration of
  problem behaviors
• If no problems indicated, give reason for
  continuing services
• Current state UAI information
• Be sure the narrative supports the UAI scores, or
  explain why not

58

Preauthorization Process

• Approval based on medical necessity for TFC Case
  Management
• Review completed with receipt of all required
  materials
• Approval based on Virginia Medicaid criteria
• Approval will be for a one-year period if all
  criteria is met

59
Prior Authorization

• Appeals
• The denial of PA for services not yet rendered
  may be appealed in writing by the Medicaid
  recipient within 30 days of receipt of the
  denial.
• The provider may appeal an adverse decision for a
  service already provided by filing a written
  notice of appeal.
• Appeal rights and address for submission will be
  stated in the FHS notification. Requests for
  appeal must be submitted directly to DMAS within
  30 days of the notice of denial. and

60
Prior Authorization

• The provider may not bill the recipient for
  covered services that have been provided and
  subsequently denied by DMAS

61
Utilization Review

• Federal regulations require that DMAS review and
  evaluate the services provided through the
  Medicaid program.
• Purpose of Utilization Review
• Ensure medical necessity
• Confirm qualified provider delivered service
• Ensure program requirements met
• Address Quality of Care issues

62
Utilization Review

• DMAS has contracted with Clifton-Gunderson to
  complete audits of TFC-CM and will review records
  to assure DMAS criteria is being followed.
• They will select providers for review by
  statistical sampling, exception reporting or
  through referrals or complaints
• They will make periodic announced and unannounced
  visits and

63
Utilization Review

• They will do desk audits or on-site visits to
  review medical documentation to ensure DMAS
  criteria is met
• They will request provider qualification
  information as well as confirmation of service
  delivery
• They will assess service limits compliance
• They will determine if retraction of paid claims
  is necessary
• and

64
Utilization Review

• The criteria described in the earlier slides is
  critical to compliance, although it is not a
  complete list. 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.

65
Duplication of Services

• Intensive In-Home Services and Treatment Foster
  Care Services both have a case management (CM)
  component and so should not both be provided at
  the same time.
• No other CM service should be provided to the
  same recipient at the same time as TFC-CM, no
  matter the payment source (this includes MH and
  MR case management or other services with a CM
  component) If there is no CM component it would
  not be a duplication of services.
• Duplication is subject to retraction at audit.

66
The Reviewer Checks

• Consumers full name or Medicaid number on each
  document in the record
• Medical/clinical necessity of the service
• Appropriate admission to service
• Required documentation
• See slides 16-30 as well as the PSM for a
  complete listing

67
CAUTION!

• If a request for authorization has been
  approved, but
• the child no longer meets DMAS criteria (does
  not have impairments indicated on the UAI, and
  there is no documented reason for continued
  services
• THE PROVIDER SHOULD NOT BILL MEDICAID

68
Utilization Review

• If the UR finding is to retract prior
  reimbursement, the provider has the right to
  reconsideration and appeal.
• Reconsideration is required to be submitted
  within 30 days of the audit letter date. All
  material to support why retraction should not be
  made should be included.
• If the decision is to uphold the denial decision
  after reconsideration, the provider has the right
  to appeal. Appeal rights will be stated in the
  decision letter. Requests for appeal must be
  submitted within 30 days of the notice of
  reconsideration

69

• Questions?