Department of Medical Assistance Services

1
Department of Medical Assistance Services

• Medicaid
• and
• Childrens Mental Health Services

April - May, 2002
NEW
www.dmas.state.va.us
2
This training is designed to assist in your
understanding of

• Your responsibilities to children with Medicaid
  covered mental health services,
• as a member of a local Family Assessment
  Planning Team (FAPT) or Community Service Board
  (CSB)
• as a Medicaid Provider of mental health services

3
Objectives of Training (contd)

• Documentation requirements for localities and
  Providers
• Covered mental health services and limitations of
  each service
• WVMI and the preauthorization process
• Reimbursement and billing on the HCFA 1500

• Psychiatric Service Manual
• Community Mental Health Rehabilitative
  Services Manual

4
HIPAA
NEW

• Healthcare Insurance Portability and
  Accountability Act, enacted 8/21/99
• Will improve efficiency of health care system by
  standardizing electronic transactions and codes
• Provides for standards and enforcement of
  security and privacy of patient information
• All providers transmitting health information
  electronically will have to ensure protection of
  all data from unauthorized persons

5
HIPAA (contd)

• All providers will have to ensure patient
  information of any kind is kept in strictest
  confidence and released ONLY with proper
  authorization of the patient
• HIPAA has established regulations to ensure these
  standards
• For more information/questions about HIPAA,
  contact
• hipaaprivacy_at_dmas.state.va.us

6
Recipient Eligibility

• Medicaid eligible children/ adolescents up to age
  21
• Meet Medicaid medical necessity criteria
• In a Medicaid enrolled facility
• appropriately licensed by DMHMRSAS
• appropriately accredited

7
Mental Health Services

• Inpatient Psychiatric Services
• Acute care
• Residential Treatment
• Treatment Foster Care Case Management
• Psychiatric Services Manual
• Outpatient Psychiatric Services
• Psychiatric Services Manual
• Community Mental Health Rehabilitative Services
• Community Mental Health Rehabilitative Services
  Manual

8
Residential Treatment
9
RESIDENTIAL TREATMENT Admission Criteria
Severity of Illness

• and

History
Intensity of Treatment
10
- Severity of Illness
First.

• Care and treatment must be provided in the
  least restrictive treatment environment
  possible.

What does this mean?
11

• One or more must be present
• Child is currently receiving less restrictive
  care in the community with evidence of failure
  
• /or
• Childs condition is escalating
• /or
• A previously acute condition is recurring

12

• - Severity of Illness (contd)

Second.

• The child must be diagnosed with a psychiatric
  disorder

What does this mean?
13

• Documented evidence of recent onset of one or
  more
• Unable to function in a less restrictive
  environment

What evidence is there?

• /or
• History of acute psychiatric episodes is not
  currently either making progress or cooperating
  with a treatment plan (in less restrictive level
  of care)
• /or

14

• There are recent increased threats of harm/
  aggression towards self or others /or
• The child is unable to function in the
  community without jeopardizing the safety of self
  or others /or
• Recent stabilization while hospitalized
  24-hour therapeutic environment needed
• prevent regression,
• solidify gains, and/or
• further resolve complex psychiatric
  symptoms /or

15

• Recent outpatient treatment has failed

What does this mean?

• Ambulatory care cannot meet treatment needs
  because
• child also has medical disorder(s) which family
  is not effectively addressing

16

• - Intensity of TreatmentTo meet criteria for
  admission, the

• INTENSITY of treatment must relate to the
  SEVERITY of the illness with the goal of
• preventing an acute stage or regression
• improving clients condition so services are no
  longer needed

17
Locality
Provider
18
Responsibilities of the Locality
19

• Certificate of Need or Pre-Admission Screening
  Report (Independent Team Certification)
• Copy of CAFAS/PECFAS (CSA only)
• Obtain all relevant background information AND
  treatment history
• Negotiate reimbursement rate with provider
• Obtain CPMT signature on Reimburse- ment Rate
  Certification
• Provide Reimbursement Rate
  Certification to provider

20

• Independent Team Certification

• CSA Children
• Family Assessment Planning Team
  (FAPT)
• Collaborative, multidisciplinary team approved
  by the State Executive Council (CSA)
• Non - CSA Children
• Community Service Board Team (CSB)

21
Team members (FAPT or CSB)

• Competence in the diagnosis treatment of
  mental illness (preferably in child psychiatry)
• and
• have knowledge of the individuals situation

22
Certificate of Need (CSA) orPre-Admission
Screening Report (CSB)

• No more than 30 days before admission, and signed
  by
• majority of Team members (FAPT/CSB)
• AND
• independent physician
• childs pediatrician
• psychiatrist/MD
• team member experience

23
Certificate of Need (contd)

• MUST contain these elements
• Outpatient care wont meet treatment needs of the
  recipient
• Proper treatment of psychiatric condition
  requires inpatient care under direction of a
  physician
• Inpatient care expected to improve recipient's
  condition/prevent further regression so that the
  services will no longer be needed.

24
CAFAS/PECFAS(CSA children only)

• The 2000 version is the current one
• PECFAS 4 - 6 years
• CAFAS 7 - 17 years

• Must be within 90 days
• Profile Youths functioning
• Profile Caregiver Resources
• Do NOT rate the provider
• If the caregiver is unwilling/unable to
  participate in treatment, this should be noted on
  the CAFAS/PECFAS

25

• Forwarding background information and treatment
  history to provider and assisting in the
  development of a Plan of Care
• Negotiating a reimbursement rate with provider
• Obtaining CPMT (Community Planning Management
  Team) signature on the Reimbursement Rate
  Certification

26

• Providing Reimbursement Rate Certification to
  provider
• The Certification should indicate ONLY the
  amount expected to be billed to Medicaid
• All other payer sources should be DEDUCTED prior
  to establishing the Medicaid per diem rate (on
  the Certification form)

27
Responsibilities of the
Provider
28

• Negotiating a rate with locality
• Developing the Initial Plan of Care within 24
  hours of admission
• Completing and submitting Pre-authorization
  forms (within 1 business day of admission)
• Notify locality of Medicaid approval or
  denial
• Developing a Comprehensive Individual Plan of
  Care within 14 days of admission

29
Initial Plan of Care

• Developed coordinated with the locality
• Within 24 hours of admission
• Diagnosis, symptoms, and complaints indicating
  the need for admission
• Description of the functional level of the
  recipient

30
Initial Plan of Care
(contd)

• Treatment objectives with short and long-term
  goals
• Orders for medications, treatments, etc.
• Plans for continuing care, including review of
  the Plan of Care
• Discharge Plans
• Signed and dated by physician.

31
Requirements forComprehensive Individual Plan of
Care (CIPOC)

• Completed within 14 days after admission
• Based on diagnostic evaluation
• Be developed by a team of professionals in
  consultation with the child, and the childs
  guardians
• State treatment objectives

32

• Prescribe an integrated program of therapies,
  activities, and experiences designed to meet the
  objectives
• Each intervention needs
• type of intervention
• goals
• duration and frequency
• Include comprehensive discharge plans and after
  care services
• Plan reviewed every 30 days.
• Reviewed and updated annually, to incorporate all
  current plans.

33
Active Treatment Plan

• The plan must be related to the admission
  diagnosis reflect ALL of the following
• Individual therapy 3 out of 7 days by a licensed
  professional
• and
• Minimum of 21 distinct therapeutic sessions
  EACH WEEK of appropriate treatment interventions.

34
21 Appropriate Treatment Interventions

• NO YES
• individual treatment group therapy
• school attendance socialization
  intervention
• family therapy behavioral
  intervention
• Play/art/music/occupational/physical therapy
  may be included, but cannot be the major
  treatment modality
  
  
• and

35
Treatment Plan
(contd)

• Family therapy minimum of twice monthly,
  EXCEPT
• if family dysfunction is a reason for
  admission, then family therapy must be at least
  once per week
• and
• Comprehensive discharge planning for aftercare
  placement treatment.

36
Treatment Plan
(contd)

• Active treatment must begin at admission and be
  related to the discharge plan

• Family/guardian/caretaker/case manager is
  actively involved in the treatment planning
• Comprehensive discharge planning must begin at
  admission

37
RESIDENTIAL TREATMENT Continuing Stay Criteria

• - Severity of Illness
• and
• - Intensity of Treatment

History
38

• - Severity of Illness

• All of the following must be present
• Continued complex symptoms and/or emergence of
  new symptoms that are amenable to treatment in a
  residential facility
• Child involved and cooperative in treatment
• Continued impairment in level of functioning

39

• Restrictive setting still required
• Ambulatory care resources will not meet
  treatment needs of child
• Condition can reasonably be expected to improve
  and/or regression can be prevented.

40

• - Intensity of Treatment

• All of the following must be provided
• Plan of Care updated every 30 days
• include long and short term goals
• measurable objectives
• interventions with time frames for achievement
• Revised when
• goals achieved
• unresolved problems
• new problems

41
RECERTIFICATION OF NEED

• Services must continue to require the supervision
  of a physician
• Integrated program of therapies related to
  treatment goals
• individual
• group
• family
• other activities/experiences

Required at least every 60 days
42
Progress Notes

• Daily
• stabilization/improvement of symptoms
• positive/negative reactions to treatment
• Reflect a continued need for
• skilled observation,
• structured interventions,
  and support that can
  only be provided in a
  residential setting

43
Progress Notes (contd)

• Concurrent therapies provided
• Reasons for any deviations from the Treatment
  Plan
• Signed and dated

44
Concurrent Therapy Notes

• Each session
• modality/type of session
• how activities of session relate to this clients
  treatment goals
• length of session
• level of clients participation
• progress or lack of progress towards goals
• plan for next treatment
• signature of provider
• dated

45
Overnight Therapeutic Passes

• Must be part of discharge plan
• ONLY after successful day passes
• Documentation
• Addressed in Treatment Plan
• Specific goals before visit
• Effects of visit upon return
• 18 days maximum for 12 month period (ALL
  providers)

46
Seclusion Restraint
NEW

• Signed Condition of Participation Letter
• Remain in compliance with conditions regarding
  seclusion and restraint
• In case of injury, 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 804-786-5799

47
When to Discharge
HOME FOR NOW RTF
48

Discharge Criteria

• Review Severity of Illness and Intensity of
  Treatment criteria
• Residential care is not appropriate AND will not
  be covered when
• Symptoms are stabilized
• ability to perform activities of daily living
  appropriate for age
• Child is able to function in facility and in
  community
• or

49

Discharge Criteria

• Required treatment can be provided in a less
  restrictive environment or
• Child has functioned successfully during day and
  an overnight pass or
• Client has not responded (20-days) to current
  treatment and written Plan has not been
  changed or
• Child refuses to cooperate with treatment plan

50
When Residential treatment is NOT justified..

• Child has this disorder (without other
  Severity of Illness or medical necessity
  criteria)
• Hyperactivity
• Attention Deficit Disorder
• Dyslexia
• Behavior/personality disorders
• Eating disorders
• Alcohol/drug abuse
• Mental retardation

51

• Education
• Evaluation for placement
• Testing
• Remedial
• Psychological testing
• For institutional admission/placement
• Therapy/Treatment for alcohol/drug abuse
• Partial hospitalization programs

52
Residential Treatment Care
PREAUTHORIZATION REVIEW
53
Residential Review Process

• Based on medical necessity and need for
  Residential Treatment Care (RTC)
• Facsimile process initiated with receipt of
  requested review materials
• Review process based on Virginia Medicaid
  criteria

54
Review Forms

• Initial Review Form
• for Medicaid recipients in care for less than
  30 days
• Care in Progress Form
• for Medicaid recipients in care for 30 days
  or more
• Continued Stay Form
• for Medicaid recipients requiring continued
  pre-authorization
• Current Forms Required
• only forms with revision date of 4/10/01 will
  be accepted as of 7/15/01

55
Review Process

• WVMI will reply within 3 business days
• Fax line - [phone] or locally - (804)
  343-9782
• Phone line - [phone] or locally - (804)
  648-3159
• Review processed by qualified, Masters level
  medical/mental health professionals

56
Review Process

• Initial review required within one business day
  of admission into residential placement
• Care in Progress review required when the
  recipient has been in care for more than 30 days
• A length of stay that will not exceed 31 days may
  be approved
• Entire package of material required each time
  information is sent to WVMI

57
Review Process

• Providers must submit Continued Stay Reviews
  (CSR) no later than the last day of the previous
  authorization
• Providers may submit CSR by the 25th day of the
  prior authorization, no earlier
• Need to meet both severity of illness and
  intensity of treatment criteria
• A decision notice will be faxed by WVMI, and an
  authorization notice will be mailed by First
  Health Services (FHS)

58
Pend Process-Top 10 Reasons for Pends-

• DSM-IV All five axes required.
• Behaviors prior to admission Must have recent
  onset (within 7 days) and be congruent with
  checked reasons for admission.
• Discharge plan Comprehensive discharge planning
  for aftercare placement and treatment must begin
  at admission and should be child specific.
  Include estimated LOS or projected d/c date and
  aftercare services.

59
Pend Process-Top 10 Reasons for Pends-

• Overnight passes Must have documented day
  passes prior to scheduling overnight passes. No
  more than 18 days of therapeutic leave annually
  is reimbursable. Days of leave are counted from
  the first overnight at any Medicaid funded
  residential placement.
• Review form questions Answer all questions
  completely and check Yes or No boxes.
• Goals Need child specific long and short-term
  goals with measurable objectives. Goals should
  be revised to address progress or lack of
  progress in treatment.

60
Pend Process-Top 10 Reasons for Pends-

• Family therapy Document attempts to schedule
  sessions (list dates). Must participate at a
  minimum of twice monthly. If family dysfunction
  is reason for admission, should occur at least
  once per week. Includes Problems with Primary
  Support on Axis V of admit diagnosis and/or
  identified as problematic on CAFAS/PECFAS. If
  therapy is not occurring as required, document
  why it is not feasible or not in childs best
  interest, as well as alternatives to involvement
  in therapy.

61
Pend Process-Top 10 Reasons for Pends-

• Reasons for Continued Stay Provide a specific
  description of continuing symptoms and impairment
  in functioning that require current level of care
  including specific behaviors.
• Certificate of Need (CON) Must be dated and
  have all required signatures. Transfer to and
  from acute psychiatric hospitalization during a
  pre-authorized RTC stay would require a new
  Initial Request with a new CON.

62
Pend Process-Top 10 Reasons for Pends-

• CAFAS/PECFAS Must be updated every 90 days.
  Individual item scores must be complete and
  legible. Item scores need to be congruent with
  documented behaviors. Caregiver scales should
  rate the family, whether actively involved or
  not. Note the childs name, assessor, and date
  completed on the profile sheets. For caregiver
  scores, also note the relationship to the child.
  Do not rate the provider.

63
Denial Process

• A denial may be issued for the following reasons
• Untimely submission
• Incomplete submission
• Medical necessity not met

64
Reconsideration Process

• Request for reconsideration must be made in
  writing to the Behavioral Health Supervisor or
  Assistant Supervisor within 10 business days of
  receipt of denial notice from FHS
• FAX [phone] or [phone]
• Exceptions are made for holidays and weekends

65
Reconsideration Process

• With request, include supporting documentation
  along with rationale for why review merits
  reconsideration
• Approval will begin date complete information is
  received at WVMI
• Concurrent review is responsibility of provider
  during this process and not contingent on
  reconsideration process

66
Reconsideration Process

• Once a reconsideration is received at WVMI, a
  supervisor has 3 business days to render a
  decision (denial upheld or overturned)
• If the provider does not agree with the
  reconsideration decision they have the right to
  request an appeal

67
Appeals

• The provider must submit their letter of intent
  to appeal along with a copy of the medical record
  within 30 days of receipt of denial to
• Director of Appeals, DMAS
• Suite 1300
• 600 East Broad St.
• Richmond, VA 23219

68
Discharge Procedure

• If recipient is discharged, advise WVMI via
  facsimile notice. Include recipient name,
  Medicaid number, tracking number, and date of
  discharge

69
Treatment Foster Care

• Case Management
• Psychiatric Services Manual

70
RECIPIENT ELIGIBILITY

• Under age 21
• Seriously emotionally disturbed (SED)
• or
• At risk for more restrictive placement
• Referred to TFC and a qualified Case Manager by
  FAPT
• Meet medical necessity criteria

71
Medical Necessity Criteria

• The child must meet ONE of three levels,
  documented on CAFAS/PECFAS
• LEVEL I
• moderate impairment with
• moderate risk factors
• LEVEL II
• significant impairment (problems with authority,
  impulsivity, and caregiver issues)
• LEVEL III
• significant impairment with
• severe risk factors

72
CAFAS/PECFAS

• Documentation needed
• At least ONE moderate impairment noted
  with related risk factor
• Risk factors checked must be related to items
  marked

73
TREATMENT FOSTER CARE CASE MANAGEMENT

• Activities which help client
• gain access to necessary care and services
• coordinate necessary care and services
• Casework
• Direct treatment with child(ren)
• Intervention on childs behalf

74
Components of Treatment Foster Care Case
Management

• Focus is a CONTINUITY OF SERVICES
• Goal-directed
• Results-oriented
• Emphasizes permanency planning
• Planning Providing Treatment
• Monitoring Treatment Plan
• Linking child to community resources

75
Covered Services

• Placement activities
• Care planning
• Placement monitoring
• Discharge planning
• Case Management/casework services
• Evaluating effectiveness of treatment plan
  through supervision of foster parents

76
Case Management Limitation

• 7-day limitation if child is out of home
  temporarily (for Medicaid reimbursement of Case
  Management)
• Inpatient services to assist in transition back
  to home
• Runaway
• Detention (verify Medicaid eligibility)

77
Responsibilities of the Locality
78

• Give to Provider
• A. Copies of the latest CAFAS/ PECFAS
• Must be within 90 days
• Youths functioning
• Caregiver Resources
• B. Documentation
• DSM IV Diagnosis
• List of services to be provided in first 45 days
  of care (Initial Plan of Care)

79
Give to Provider (contd)

• Description of childs behavior within past 7
  days
• Alternative placement options considered
• Childs functional level
• Clinical stability
• Level of family support
• Discharge plan

80
Give to Provider (contd)

• C. Either
• FAPT Certification that TFC Case Management is
  medically necessary
• OR
• Written documentation that the CPMT has approved
  admission to TFC Case Management

81
Give to Provider (contd)

• D. FAPT Assessment
• Childs
• Immediate/long-range therapeutic needs
• Developmental priorities
• Personal strengths and liabilities
• Potential for reunification
• Set treatment objectives
• Therapeutic modalities to achieve objectives

82
More Locality Responsibilities at Admission

(contd)

• Negotiating a reimbursement rate with provider
• Obtaining CPMT signature on the Reimbursement
  Rate Certification.
• Providing Reimbursement Rate Certification to
  provider

83
Provider Responsibilities
84

• Complete and submit Preauthorization Request to
  WVMI within 10 business days of placement
• Negotiating reimbursement rate with locality
• Notify locality of Medicaid approval or denial
• Provide leadership training to Treatment Team
• Involve the child/family in plans progress
• Ensure Treatment Team consults at least quarterly

85
Initial Continued StayAuthorization

• If criteria are met, initial length of stay is
  assigned
• Provider contacts WVMI BEFORE expiration of
  initial length of stay
• Concurrent review process
• Analysis of information provided
• Concurrent review continues until discharge

86
Case Manager Duties

• Periodic assessment of childs
• need for services
• psychosocial
• nutritional
• medical
• education
• Develop treatment service plans
• consulting parents when possible
• services resources
• Assist child in accessing services
• Record all medications prescribed and report side
  effects

87
Case Manager Duties (contd)

• Coordinate services service planning
• Refer child to services supports
• Follow up and monitor progress
• Support childs relationship w/foster family
• Visit treatment parents
• address issues
• resolve problems
• build relationships
• Provide casework activities

88
Comprehensive Treatment Service Plan

• Completed within 45 days of placement
• Individualized
• Assessment of childs needs
• Specific treatment goals/target dates
• Program of therapies, activities, etc.
• Permanency/independent living planning
• Target dates for discharge from TFC
• Indicates team members participation

89
Progress Reports Ongoing Service Plans

• Completed every 90 days by Case Manager
• Childs progress/input
• Foster parents/parents/agency input
• Progress toward permanency planning
• Annual update to include above AND to evaluate
  update Comprehensive Plan

90
Casework Objectives

• Meeting childs needs
• Helping child confront problems
• Strengthening childs capacity to function
  productively
• Lessening childs stress
• Enhancing opportunities
• Enhancing childs capacity for fulfillment

91
Case Manager Requirements

• Qualifications DSS regulations
• Minimum of 2x/month visits
• One in foster home
• One with child and one foster parent (to assess
  the relationship between child and foster
  parents)

92
Case Manager Requirements (contd)

• Children interviewed privately at least 1x/month
• Maximum of 12 in caseload for full-time staff
• Exceptions Responsibilities, difficulty of
  population, trainee, student intern, combined
  caseload

93
Treatment Foster Care Case Management
PREAUTHORIZATION REVIEW
94
Treatment Foster Care Case Management Review
Process

• Based on medical necessity and need for Treatment
  Foster Care Case Management (TFC-CM)
• Facsimile process completed on receipt of
  requested review materials
• Review process based on Virginia Medicaid criteria

95

Review Forms

• Initial Review Form
• for Medicaid recipients in placement for less
  than 45 days
• Care in Progress Form
• for Medicaid recipients in placement for 45
  days or more
• Continued Stay Form
• for Medicaid recipients requiring continued
  pre-authorization
• Current Forms Required
• only forms with revision date of 4/10/01 will
  be accepted as of 7/15/01

96
Review Process

• Fax line - [phone] or locally -
  [phone]
• Phone line - [phone] or locally -
  [phone]
• WVMI will reply within 10 business days
• Review verified by Masters level medical/mental
  health professionals

97
Review Process

• Initial review required within 10 business days
  of entry into placement
• Care in Progress review required when the
  recipient has been in care for more than 45 days
• For reviews not received within 10 business days
  of placement, approval may begin no earlier than
  the date all requested information is received

98
Review Process

• Authorization for an initial length of stay of up
  to 6 months if all medical necessity criteria is
  met
• Entire package of material required each time
  information is sent to WVMI

99
Continued Stay Review

• Providers must submit Continued Stay Reviews
  (CSR) no later than the last day of the previous
  authorization
• Materials can be submitted 10 days prior to end
  of the approval period
• A decision notice for all reviews will be faxed
  by WVMI, and an authorization notice will be
  mailed by First Health Services (FHS)

100
Pend Process-Top 8 Reasons for Pends-

• DSM IV All five axes required.
• FAPT Assessment Must include all four elements
  and be child specific.
• Quarterly progress reports Need to address
  behaviors that require TFC-CM level of care, and
  be congruent with CAFAS scores

101
Pend Process-Top 8 Reasons for Pends-

• Discharge Plan Comprehensive discharge
  planning for aftercare placement and treatment
  must begin at admission and should be child
  specific. Include estimated LOS or projected d/c
  date and aftercare services. Single word
  descriptors of d/c plans such as adoption or
  permanent foster care are not sufficient.

102
Pend Process-Top 8 Reasons for Pends-

• Reasons for Continued Stay Provide a specific
  description of continuing symptoms and impairment
  in functioning that require current level of care
  including specific behaviors.
• Review form questions Answer all questions
  completely and check Yes or No boxes.
• Goals Need child specific long and short-term
  treatment-oriented goals with measurable
  objectives. Goals should be revised to address
  progress or lack of progress in treatment.

103
Pend Process-Top 8 Reasons for Pends-

• CAFAS/PECFAS At least one moderate or severe
  impairment noted with a related risk factor
  congruent with admission/continued stay. Must be
  updated every 90 days. Individual item scores
  must be complete and legible. Item scores need
  to be congruent with documented behaviors.
  Caregiver scales should rate the family, whether
  actively involved or not. Note the childs
  name, assessor, and date completed on the profile
  sheets. For caregiver scores, also note the
  relationship to the child. Do not rate the
  provider.

104
Denial Process

• A denial may be issued for the following reasons
• Untimely submission
• Incomplete submission
• Medical necessity not met

105
Reconsideration Process

• A request for reconsideration must be submitted
  in writing to the behavioral health supervisor,
  within 30 days of official notification of
  adverse decision at
• WVMI
• Attn Behavioral Health Supervisor
• Suite 402
• 1111 East Main St.
• Richmond, VA 23219

106
Reconsideration Process

• With request, include supporting documentation
  along with rationale for why review merits
  reconsideration
• Approval will begin date complete information is
  received at WVMI
• Concurrent review is responsibility of provider
  during this process and not contingent on
  reconsideration process

107
Reconsideration Process

• Once a reconsideration is received at WVMI,
  supervisors have 10 business days to render a
  decision
• If the denial is upheld the provider may request
  an appeal

108
Appeals

• The provider must submit their letter of intent
  to appeal along with a copy of the medical record
  within 30 days of receipt of denial to
• DMAS
• Director of Appeals
• Suite 1300
• 600 East Broad St.
• Richmond, VA 23219

109
Discharge Procedure

• If recipient is discharged, advise WVMI via
  facsimile notice. Include recipient name,
  Medicaid number, tracking number, and date of
  discharge

110
Outpatient Psychiatric
Services Psychiatric Services Manual
111
General Information

• OUTPATIENT PSYCHIATRIC SERVICES
• are available to Medicaid recipients in
• practitioners office
• school
• Recipients may be living in
• own home
• group home
• foster care
• treatment foster care

112
Medical Necessity Criteria

• All of the following must be met
• A. The child requires treatment in order to
  sustain behavioral or emotional gains
• or
• to restore cognitive functional levels which
  have been impaired
• and

113
Criteria (contd)

• B. Exhibits one or more of
• deficits in peer relations
• deficits in dealing with authority
• hyperactivity
• poor impulse control
• clinical depression
• other symptoms adversely impacting on attention/
  concentration/education, etc.
  and

114
Criteria (contd)

• C. Is at risk for developing or
• requires treatment
• for maladaptive coping strategies
• and
• D. Presents a reduction of adaptive/ coping
  strategies
• or
• demonstrates extreme increase in
  personal distress

115
Psychiatric Limitations

• 26 sessions within the first 12 months without
  prior authorization
• Additional sessions in the first 12 months when
  pre-authorized
• Sessions are available in subsequent years when
  pre-authorized

116
Specific Limitations

• NO MORE THAN 3(total) OF THE FOLLOWING IN A SEVEN
  DAY PERIOD
• Individual Therapy (limited to once per day)
• Group Psychotherapy (limited to once per day
  10 per group)
• Family Psychotherapy (limited to once per day)

117
Appropriate Providers

• Psychiatrist
• Licensed Clinical Psychologist
• Licensed Professional Counselor
• Psychiatric Clinical Nurse Specialist
• Licensed Clinical Social Workers
• Mental Health Clinic

118
Provider Responsibility

• Preauthorization request
• DMAS 412
• to WVMI prior to billing for services
• Preauthorization does not guarantee payment, but
  is required for services after the first 26
  sessions and/or after the first year (ALL
  providers)

119
Documentation

• Medical Evaluation
• Diagnosis
• Functional Limitations
• History
• Plan of Care
• (As noted on the DMAS 412)
• Continuation Plan
• Progress Notes

120
COMMUNITY MENTAL HEALTH REHABILITATION SERVICES
Community Mental Health Rehabilitative Services
Manual
121

• INTENSIVE IN-HOME SERVICES
• THERAPEUTIC DAY TREATMENT
• DAY TREATMENT/PARTIAL HOSPITALIZATION
• PSYCHOSOCIAL REHABILITATION
• CRISIS INTERVENTION
• INTENSIVE COMMUNITY TREATMENT
• CRISIS STABILIZATION
• MENTAL HEALTH SUPPORT
• SUBSTANCE ABUSE TREATMENT (Residential/Day) for
  PREGNANT WOMEN

122

• EACH SERVICE must be
• Appropriately licensed by the Department of
  Mental Health Mental Retardation Substance
  Abuse (DMHMRSAS)
• Enrolled with Medicaid

123

• INTENSIVE IN-HOME SERVICE
• Interventions normally in the residence of a
  child/adolescent who is
• at risk of being moved into an out-of-home
  placement or in transition
• Significant functional impairments in major life
  activities
• 2 of these and 1 of these
• conflicts w/authority more
  intensive than
• inappropriate behavior OP treatment
• cant recognize danger home more
  successful AND
• 1 parent involved

124

• THERAPEUTIC DAY TREATMENT
• Psychotherapeutic educational mental health
  issues 2 hours a day with groups
• 2 of these and 1 of these
• conflicts w/authority need
  year-round treatment
• inappropriate behavior need more than
  ED
• cant recognize danger would be
  homebound
• deficit in skills

125

• DAY TREATMENT/
• PARTIAL HOSPITALIZATION
• Programs provided to groups for 2 hours a day

2 of these require help in
basic living skills
inappropriate behavior cant recognize danger
126

• PSYCHOSOCIAL REHABILITATION
• Programs provided to groups for 2 consecutive
  hours a day

2 of these conflicts
w/authority require help in basic living
skills inappropriate behavior cant
recognize danger
1 of these
long-term/repeated hospitalizations lack daily
living skills limited support system no
functioning in community need long-term
services
127

• CRISIS INTERVENTION
• Mental health care available 24/7/365
• Acute dysfunction
• Requires immediate attention
• marked reduction in functioning
• extreme personal distress

128

• INTENSIVE COMMUNITY TREATMENT
• Serious emotional illness
• Need intensive support in natural environment
• Available 24 hours/day
• No service in clinic setting

1 of these high risk for hospital history
of long treatment
129

• CRISIS STABILIZATION
• Direct Mental health care available 24/7/365
• Acute crisis
• Non-hospitalized
• 2 of these
• conflicts with authority
• require help in basic living skills
• inappropriate behavior
• cant recognize danger

130

• MENTAL HEALTH SUPPORT
• Training support to achieve community
  stability and independence
• 2 of these
• conflicts w/authority
• require help in basic living skills
• inappropriate behavior
• cant recognize danger
• history of psychiatric hospitalizations
  

131

• SUBSTANCE ABUSE TREATMENT SERVICES FOR PREGNANT
  WOMEN
• Comprehensive treatment in residential or
  day programs
• Woman actively involved in treatment
• 2 of these
• pregnant/postpartum
• continue pregnancy

132

• For specific requirements, please
  refer to the Manuals
• Psychiatric Services
• Community Mental Health Rehabilitation Services

133
Childrens Mental HealthServices

• Medicaid Eligibility/Billing 2002
• www.dmas.state.va.us

134
Recipient EligibilityMEDICAID CARDS
135
Eligibility Medicaid
Recipients enrolled in the traditional Medicaid
Program will be identified by a Virginia
Medicaid Eligibility Card. Eligibility can be
verified by Automated Voice Response System
(AVRS), Provider Helpline or other system
options.
136
Recipient Eligibility Card
CASE I.D. NUMBER
PLUS
123-456789
I.D. NUMBER
01-5
02-3
03-8
04-6
05-4
3
137
Recipient Eligibility Card
BIRTH DATE
SEX
10 31 195309 22 195504 05 198501 14
198911 02 1990
FMMMF
4
138
Recipient Eligibility Card
THE FOLLOWING INDIVIDUALSARE ELIGIBLE THROUGH
THELAST DAY OF
April 2002
SI
NAME
CBAAA
DOE, JANEDOE, SAMDOE, TEDDOE, ALLENDOE, ANN
5
139
Recipient Eligibility Card
THE FOLLOWINGINDIVIDUALSARE ELIGIBLE FROM
BEGIN DATE
04 01 0204 01 0204 01 0204 01 02 04
01 02
6
140
Recipient Eligibility Card
THE FOLLOWING INDIVIDUALSARE ELIGIBLE THROUGH
THELAST DAY OF
April 2002
SI
NAME
CBAAA
DOE, JANEDOE, SAMDOE, TEDDOE, ALLENDOE, ANN
7
141
Recipient Eligibility CardInsurance Information
CASE I.D. NUMBER
PLUS
123-456789
I.D. NUMBER
CARRIER BEGIN DATE
182182
02-3
04 01 0204 01 02
02-3
Chap. 3
8
142
Recipient Eligibility CardInsurance Information
TYP
POLICY / MEDICARE
Chap. 3
9
143
Eligibility Medallion II HMO
You will be able to identify recipients enrolled
in a Medallion II HMO by their member ID Card.
The recipients enrolled in a Medallion II HMO
will carry a card bearing the name of the one if
the following plans Carenet, Sentara Family
Care, Healthkeepers Plus, or VAPremier.
144
Important Contacts

• Automated Voice Response System (AVRS)
• Provider Helpline
• Recipient Helpline
• Provider Enrollment
• Billing Inquiries
• Forms and Manuals

145
Automated Voice Response System
AVRS

• Recipient Eligibility - REVS
• Check Status
• Claim Status

800-884-9730 804-965-9732 804-965-9733
146
Provider Helpline
Claims, covered services, billing
inquiries Department of Medical Assistance
Services 600 East Broad Street, Suite
1300 Richmond, VA 23219 800-552-8627 804-786-6273

147
Recipient Helpline
Claims, covered services and billing
inquiries [phone]
148
Provider Enrollment
New provider numbers or change of address First
Health Provider Enrollment Unit First Health
VMAP-PEU P. O. Box 26803 Richmond, VA
23261-6803 888-829-5373 804-270-5105
804-270-7027- Fax
149
Billing Inquiries
Customer Service Department of Medical
Assistance Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
150
Forms and Manuals
DMAS Order Desk Commonwealth Mailing Systems 1700
Venable Street Richmond, VA 23222 Order
Desk 804-780-0076 Fax Number 804-780-0198
151
Client Medical Management

• DMAS may designate certain recipients to be
  restricted to specific physicians and
  pharmacies.
• When this occurs, it is noted on the recipients
  Medicaid card

152
Client Medical Management(CMM)
Recipient Monitoring Unit [phone] (804)
786-6548
153
Basic Billing on the HCFA-1500
154
Claims Address
HCFA-1500
Department of Medical Assistance
Services Practitioner P. O. Box 27444 Richmond,
VA 23261-7444
155
Timely Filing

• ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR
  FROM THE DATE OF SERVICE
• EXCEPTIONS Retroactive Eligibility/Delayed
  Eligibility Previously rejected or denied
  claims
• Submit claims with documentation attached
  explaining the reason for delayed submission.

156
HCFA-1500 FORM
Use ONLY the original
RED
WHITE
and
(12-90)
Invoice
Photocopies are not
acceptable!
157
Block 1 Check Medicaid
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
CHECK ONLY ONE BLOCK
158
BLOCK 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789 01 4
(Be sure to include all 12 digits)
159
Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
160
Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c
161
Block 10d Conditional Use
10d. RESERVED FOR LOCAL USE
ATTACHMENT
You MUST use the word "ATTACHMENT"
if you attach anything to the HCFA form.
162
Required Attachments

• Residential Treatment Facility
• Reimbursement Rate Certification
• CSA billing only
• Treatment Foster Care
• Reimbursement Rate Certification

163
Blocks 17 and 17a- Conditional
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17- Name of the Recipients PCP
(primary care physician) 17a- PCPs 7-digit
Medicaid provider ID
17a. ID NUMBER OF REFERRING PHYSICIAN
(Medicaid 7-digit provider ID)
30
164
Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
31202
1.
3.
2.
4.
May enter up to 4 codes
Omit decimals
165
Block 23 PRIOR AUTHORIZATION NUMBER
23. PRIOR AUTHORIZATION NUMBER
Enter the nine digit PA number assigned by WVMI.
32
166
Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
01
01
08
01
08
01
1
08
01
01
30
01
08
2
Both FROM and TO dates
must be completed
DATES MUST BE WITHIN THE SAME CALENDAR MONTH
167
Block 24B Place of Service Block 24C Type of
Service
B
C
Place
Type
of
of
Service
Service
56
1
56- Psychiatric Residential Treatment Center
1- Medical Care
Psychiatric Services Manual Chapter V Pages
35-37
168
Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
Z9990
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
22
22
Z8897
Psychiatric Services Manual, Chapter V Page 4
169
HIPAA and Local Codes

• To establish uniform data standards, Local Codes
  will be eliminated and replaced with National
  Standard HCPCS and CPT codes.
• There are several national organizations
  responsible for defining and maintaining codes.

170
HIPAA and Local Codes

• DMAS homegrown codes now utilized will be
  replaced and National codes representing these
  services will be used for submitting Medicaid
  claims.
• Bottom Line-
• No More Local Codes!

DMAS
171
Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
31202
30928
1.
3.
30983
2.
4.
E
DIAGNOSIS
CODE
1
1,2,3
172
Block 24 F Charges
F
CHARGES
Enter the usual
and customary charges
173
Block 24G Days or Units
G
DAYS
OR
Enter the number of times the procedure, service,
or item was provided during the service period.
UNITS
1
31
174
Block 24H EPSDT/ Family Planning
H
EPSDT
Family Plan
1-EPSDT
2-Family Planning
If neither,
leave blank
175
Block 24I EMG
I
EMG
1-Emergency
If not emergency-
related, leave
blank
176
24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier
177
Block 31 Signature Date
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature.
178
Block 33 Provider ID and Address
33. PHYSICIAN'S, SUPPLIER'S BILLING NAME,
ADDRESS, ZIP CODE
PHONE
765432 1
PIN
GRP
Be sure to put the MEDICAID
7-digit ID number!
179
Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
532
345674213
Adjustment or
From original
Void
remittance
Resubmission
Code
Psychiatric Services Manual, Chapter V Pages
33-34
180
Specific Billing Instructions
181
Residential Treatment Facility

• Medicaid provides an all inclusive rate to
  inpatient psychiatric facilities.
• Medicaids per diem rate includes
• Room and board
• Minor ancillaries
• May include pharmacy
• Preauthorization by WVMI is required.

182
Residential Treatment Facility

• For residential treatment facility recipients,
  professional services may be billed separately.
• These services may include
• Lab
• OT/PT/SLP
• Pharmacy

183
Treatment Foster Care

• Z8897-Treatment Foster Care Case Management
• Rates negotiated between providers and the CPMT
  in the localities based upon intensity of need
• Reimbursement rate certification must be attached
  to the claim

184
Outpatient Psychiatric Codes

• 90801-90802-Diagnostic Testing
• 90804-90815-Individual Psychotherapy
• 90845-Psychoanalysis
• 90846-90847-Family Psychotherapy
• 9085390857-Group Psychotherapy
• 90885-Psychiatric evaluation of hospital records
• 96100-Psychological Testing

185
Psychiatric Reimbursement

• Psychiatrists 100
• Psychologists 90
• CNS-psychiatric
• LCSWs 75 of the 90
• LPCs

186
Problems being encountered withHCFA-1500 Claims
Submission
BLOCK
PROBLEM AREA
Block 1
Incorrect block checked
Block 1a
Incorrect Recipient's ID
Block 10d
Incorrect information entered
All of Block 24
Comments entered in blocks
Block 24E
Diagnosis code written out
Blocks 24 J K
(J) left blank (K) incorrect info.
Block 33
Not entering Provider ID by "PIN"
187
Remittance Voucher Sections of the Voucher

• APPROVED - for payment.
• PENDING - for review of claims.
• DENIED - no payment allowed.
• DEBIT- Adjusted claims creating a
  positive balance.
• CREDIT - Adjusted/Voided claims
  creating a negative balance.

188
REMITTANCE VOUCHERColumns of the Voucher

• Recipient's Identification Number
• Reference Number
• Visits/Units/Studies

189
PRESENTING...
The MedicaidTOP TEN
190
TOP 10 DENIAL REASONS
191
Thank You
www.dmas.state.va.us