qualis health presents alaska behavioral health inpatient psychiatric review provider training...

Qualis Health Presents

Alaska Behavioral HealthInpatient Psychiatric Review

Provider Training

Anchorage, AlaskaMarch 31, 2009

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Welcome from Qualis Health Alaska Medicaid Mental Health Review

Linda Rasmussen, LCSWProgram Manager

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Qualis Health Background

• Qualis Health is a private, nonprofit healthcare quality improvement and care management organization headquartered in Seattle, with offices in, Alaska, California, Idaho, Nebraska and South Carolina.

• Qualis Health has more than 30 years of experience providing healthcare utilization, case management and quality assessment/improvement services to public and private sector customers.

• Qualis Health has collaborated with healthcare providers in Alaska since 1984.

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Goals for this Presentation• Overview of Qualis Health• Describe utilization review resources on Qualis

Health’s website• Provide updates for utilization review

processes for the Alaska Medicaid Inpatient Psychiatric Program

• Demonstrate collaboration with the State and providers in the utilization review process

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Care Management Is Our Core Business

• Vision:To be recognized for leadership, innovation and excellence in improving the health of individuals and populations

• Mission:To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes

• Values:Integrity, professionalism, collaboration and stewardship

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Qualis Health Accreditations

• Certified by Medicare as a Quality Improvement Organization (QIO)

• Accredited by URAC for compliance with nationally recognized standards in:– Case Management– Health Utilization Management– Independent/External Review

• Certified as an IRO (Ind. Review Org) in Washington State

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Care Management Services for Alaska Medicaid

• Inpatient Acute Residential Psychiatric Utilization Review Services– Admission Review– Continued Stay Review– Peer Review– Retrospective Review– Appeals

• Care Coordination Services

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Utilization and Quality of Care Services

• Utilization Management– Review medical necessity, quality of care,

appropriateness of treatment, plan of care and discharge plans

– Ensure appropriate use of resources and level of care, while upholding recognized standards of quality of care

– Assistance to identify appropriate healthcare service availability

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Payment is Contingent Upon• Eligibility as determined by the Alaska Medicaid Program

– Providers are to call the Eligibility Verification System• (800) 884-3223 (24 hour access)• In Alaska, toll free number (800) 770-5650

– 8 am to 5 pm• Compliance with the rules and regulations that govern

Medical Assistance in Alaska• Completion of the Medical Necessity Prior Authorization

Review

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Tools to Assistwith your Review Process

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Tools to Support Your Review• Go to http://www.qualishealth.org/cm/alaska-

medicaid/behavioral-health/tools.cfm to find:– Provider Manual– Provider Training– Late Submission/Retro Review Request Forms– Questionnaires for Review Processes– Contact Information for Qualis Health– Alaska Map of “Home” Regions– RPTC Bed Availability in State of Alaska – Link to State Website

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Website Orientation

• www.qualishealth.orgClick on:

Alaska

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Click on:

Tools & Forms

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List of Tools and FormsProvider Manual• Inpatient Psychiatric Review Provider Manual• Inpatient Psychiatric Retrospective Review Request

Form

Questionnaires• Admission Review Questionnaire (word)

Admission Review Questionnaire (pdf)

• Continued Stay Review Questionnaire (word)Continued Stay Review Questionnaire (pdf)

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Provider Responsibilities

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Review Submission

• Providers to submit timely reviews via iEXCHANGE®, fax, mail or phone

• Providers to submit reviews for recipients who are also covered by other Third Party Liability (TPL) resources.

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Review Submission(continued)

• Required list of demographics and other information

• Comprehensive answers to the appropriate review questionnaire

• See updated review questionnaires at http://www.qualishealth.org/cm/alaska-medicaid/behavioral-health/tools.cfm

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Exclusions from Review Process

• Substance abuse as primary disorder • Age 21 limit exception for RPTC• Adults aged 21-64 are not covered in a

free-standing institute for behavioral health• Alaska Medicaid Chronic and Acute

Medical Assistance Program (CAMA) • Medicare Part B

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Prior Authorization Submission Timelines

• Acute care admissions • In-State RPTC admissions • Out of State RPTC admissions

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Continued Stay Submission Timeline

• Next review date• Continued stay reviews submitted beyond

30 days

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Timeframes for Pended Reviews

• Qualis Health will notify the provider via iEXCHANGE and/or phone.

• Seven calendar days to submit the requested information

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Providers’ Reporting Requirements for Sentinel

Events

What is a sentinel event?

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Providers’ Reporting Requirements for Sentinel

Events• Medical

– Incidents that require outside medical attention– Burns– Lacerations requiring medical attention– Bone fractures or breaks– Substantial hematoma– Injuries to internal organ whether self inflicted or by

someone else

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• AWOL (Absent without Leave) – If gone overnight– If anything significant occurred during the

AWOL• Police intervention• Use of substances• Suspected abuse

Providers’ Reporting Requirements for Sentinel

Events

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• Sexual Acting Out/Physical Aggression– Any activity or occurrence which must be

reported to state Child Protective Service agencies

– Any time an Alaskan youth is the victim or the offender

– Suicidal attempt or serious suicidal gesture

Providers’ Reporting Requirements for Sentinel

Events

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• Sentinel event form • Providers also notify Qualis Health of

these serious events.• Further review may be taken based on

seriousness of incident

Providers’ Reporting Requirements for Sentinel

Events

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Steps for Placements to Out-of-State RPTCs

• Referring facility to contact Behavioral Health • Behavioral Health will research available in-state

services and notify Qualis Health of their determination.

• Upon approval, referring facility will proceed with transition plan.

• The receiving facility may submit the prior authorization admission review.

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Reporting Discharges• iEXCHANGE, fax or call the actual date the

recipient was discharged• Discharge information to be submitted:

– The identified services recommended for follow-up care. Include considerations regarding:

• Placement• Family • Educational services• Individual, family and group psychotherapies, as well as

other identified therapeutic interventions that may be needed at time of discharge

– The identified provider for services upon discharge– The actual discharge date

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Travel Authorization• Provider is responsible for submitting the prior

authorization review• When certification (approval) is given, use the

PA number assigned to the case• Qualis Health PA numbers for travel

– Admissions– Trial Discharge Home Passes

• Affiliated Computer Services, Inc. (ACS) is the authorized agency for travel– Toll-free in Alaska (800) 770-5650– Outside of Alaska (907) 644-6800

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Acute Care Review Criteria Updates

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Acute Care CriteriaOverview

• This overview is a condensed summary of the recent changes to the State acute care criteria.

• For a full copy of the new acute care criteria, please refer to the Providers’ Manual Appendix B.

• Provider training available on April 7th.

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Summary of Criterion A• A1. Documentation that the diagnosed mental

illness presents a likelihood of serous harm…or

• A2. Documentation that the recipient’s condition is severely impaired as a result of the mental illness…

and• A3. Documentation that a less restrictive

available level of care does not meet the treatment needs of the recipient

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Summary of Criterion B

• B1. Certificate of Need (CON)• B2. Limitation on maximum allowable

payment for the following:– 7 day maximum for Oppositional Defiant

Disorder or Conduct Disorder– 14 day maximum for Depression NOS, Mood

Disorder NOS or Unspecified Mental Health Disorder Non-Psychotic

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Criterion B continued• B3. GAF• B4. Documentation of acute disturbances

– Impaired thought processes that create imminent risk of harm

o Hallucinationso Delusionso Loose associationso Paranoia

– Severely dysfunctional patterns of behavior related to diagnoses

– Recent psychotropic medication changes that put patient at high risk for acute disturbances if not monitored in inpatient setting

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Summary of Criterion C

• C1. Diagnostic evaluation• C2. Individualized Plan of Care (IPOC)

clearly documents goals and measurable objectives related to diagnostic evaluation

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Summary of Criterion C. Continued

• C3. IPOC formulated in consultation• C4. IPOC documents appropriate

therapies, activities, and experiences designed to develop the recipient’s ability to function independently in their own environment.

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Summary Criterion C. Continued

• C5. The IPOC clearly documents a comprehensive discharge plan– based on treatment goals and objectives– approximate discharge date– post discharge services needs and providers– continually updated to reflect changes and

progress in treatment planning

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Review Questionnaire Changes

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• Updated question # 52 - Plan of Care formulated in consultation

• Updated question # 56 - Discharge planning

Changes on Admission Questionnaire

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Admission Questionnaire (continued)

• New question # 10 - Ethnicity• New question # 53 - Diagnostic Evaluation

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Changes on Continued Stay Questionnaire

• Updated question # 7 - acute disturbances

• Updated question #8 - plan of care treatment goals

• Updated question # 13 - updated discharge plan

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Changes on Master Plan of Care Questionnaire

• Updated # 27 - Discharge Plan

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Review Reminders

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Admission Review

• All five digits of the diagnostic codes • All demographics answered in the

admissions questionnaire in full

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Admission Review (continued)

• Mental Status Exam• Within 7 days prior to anticipated admission• Issues from the Mental Health Exam

– that are pertinent to the diagnostic considerations within the treatment planning

– are to be submitted in the Admission Review Questionnaire

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Plan of Care (POC) Review

• RPTC level of care• Acute level of care• Required Elements to be Addressed in the

POC

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Continued Stay Review• Updates on the diagnostic evaluation• Updates on medication changes and

effectiveness• Updates on current behavioral

impairments • Updates on Measurable Treatment Goals

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Continued Stay Reviews • Updates on assessments and treatment

progress– List update for each type of therapy

separately– Must include Individual, Family and Group

psychotherapies– Must include documentation of contact with

OCS or JJ if recipient is in state custody

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Discharge Planning• Discharge Planning

– Begins upon admission– Updated with each review– Includes specificity– Family/Guardian is actively involved – Available lower level of care services

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Trial Discharge Home Pass

• Goals and objectives • Outpatient therapy appointment• Crisis Plan• Visit with the school system needed

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Trial Discharge Home Pass

• Trial Discharge Home Pass dates will be within 1 to 3 months, and not less than 30 days, of the projected discharge date.

• Trial discharge home passes may end in discharge from the facility.

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Late Submission Continued Stay Review

Request• Definition• When to request it• Require form• Possible technical denial

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Delayed Eligibility Reasons for Late Submission Reviews

• Definition• Submit all at once

– Use the admission questionnaire– Include the plan of care– Divide the review into weekly increments

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Tips for the Review Process

• Submit current information • Clearly outline impaired behaviors• Clearly document the measurable goals

and objectives• Clearly update progress in all therapies

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We Want to Hear from You

• How the review process works for you• How well Care Coordination works for you• Any issues or concerns that may arise• Additional ways Qualis Health can assist

you• Process improvement opportunities

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Contact InformationAnchorage Office

Toll Free Phone: (877) 200-9046Toll Free Fax: (877) 200-9047

www.qualishealth.org

Qualis Health Mailing Address:PO Box 243609

Anchorage, Alaska 99524

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Contact InformationLinda Rasmussen, LCSWProgram Manager, Alaska Medicaid Mental HealthQualis Health (877) 200-9046 or (907) 562-5670lindar@qualishealth.org

Grace Ingrim, RN, BSN, CCMDirector, Medicaid ServicesQualis Health(877) 200-9046 or (907) 562-2123 gracei@qualishealth.org

Alaska State Department of Health & Social Services– Contact information is available at www.qualishealth.org

Questions??