intensive community treatment - magellan of virginia...2016/10/04 · medical necessity criteria...

Intensive Community Treatment

Service Overview

October 4, 2016

Training Objectives

Provide an overview of Intensive Community Treatment (ICT), including: • Service Definition • Medical Necessity Criteria (MNC) • ICT Team Requirements • Documentation requirements

Inform providers about the information they must include in each ICT authorization request form to allow thorough yet streamlined review.

October 2016 Intensive Community Treatment

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ICT Service Definition

ICT provides these mental health services:

• Psychotherapy • Psychiatric Assessment • Medication Management • Care Coordination

ICT services are for individuals

• with significant mental illness (also known as serious mental illness) and • who need intensive support and services in their home and community to enhance their

pathway to wellness

ICT Teams

• are multi-disciplinary • must meet composition requirements established by the Department of Behavioral Health

and Developmental Services (DBHDS)

CMHRS manual, Chapter IV, p. 58 revision date 12/2/15 for exact manual language; 12VAC30-50-226

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ICT Service Criteria

To qualify for ICT, the individual must meet at least one of the following criteria (#1 or #2):

1. The individual

is at high risk for psychiatric hospitalization due to mental illness, or is at high risk for becoming or remaining homeless due to mental illness, or requires intervention by the mental health system due to inappropriate social behavior, or requires intervention by the criminal justice system due to inappropriate social behavior.

2. The individual has a history (three months or more) of

a need for intensive mental health treatment, or a need for treatment for co-occurring serious mental illness and substance abuse disorder AND demonstrates a resistance to seek out and utilize appropriate treatment options.

CMHRS manual, Chapter IV, p. 58 Revision Date 12/2/15: 12VAC30-50-226


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Who can provide ICT?

ICT providers must be licensed by DBHDS as a provider of ICT or a Program of Assertive Community Treatment (PACT). *

Intensive Community Treatment services may only be rendered by a team that meets the requirements of 12VAC35-105-1370, a DBHDS regulation.*

As of the date of this training, 12VAC35-105-1370 requires ICT teams to include at least one of the following:

• Team Leader • Nurse • Vocational Specialist • Substance Abuse Specialist • Peer Specialist • Program Assistant • Psychiatrist

Please see 12VAC35-105-1370 for further details. *CMHRS manual, Chapter IV, p. 58 Revision date 12/2/15; 12VAC30-50-226


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ICT Team Availability

ICT should be available either directly or on call for crisis:

• 24 hours per day, • 7 days per week • 365 days per year

The ICT team may arrange coverage through another crisis services provider if the team coordinates with the crisis services provider daily.

ICT Routine Service

• 8 hours per day • 5 days per week

ICT As Needed Service

• case-by-case basis • evenings • weekends

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Intensive Community Treatment

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ICT Documentation Requirements - Service Specific Provider Intake (SSPI) ICT- SSPI Requirements

• Required at the onset of services, prior to initiation of services

• Must be conducted by the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP

• Must document: • member diagnosis • how the individual meets the eligibility and medical necessity criteria for ICT • other information as specified in the CMHRS Manual, Ch. IV and 12 VAC 30-50-130

• Must be complete and current

• Reimbursement may be denied if services are based on an SSPI that is: • missing • incomplete • outdated


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ICT Documentation Requirements - Individualized Service Plan (ISP)


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ICT- ISP Requirements

• Required during the entire duration services – cannot be incomplete, missing, or outdated

• Must be developed by the LMHP, LMHP-supervisee, LMHP-resident or LMHP-RP, QMHP-A, QMHP-C , or QMHP –E

AND

• Must be approved by the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP within 30 days of the initiation of services

• Must continue to document the need for the intense level of services provided in ICT and demonstrate incremental progress toward goals

ICT - Service Limitations


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Billing Limitations

• Psychotherapy and medication management should be provided outside the clinic, hospital, or office setting.

• ICT services may be billed if the member is brought to the facility by ICT staff to see the psychiatrist. However, documentation to support this intervention must be in the member’s clinical record.

• ICT billing is prohibited for the same time period as outpatient psychotherapy and psychiatric services UNLESS designated as part of the plan of care to transition services to a lower level of care.

• Time billed for psychotherapy, medication management, and other clinic services may not exceed 25% of the total time billed for ICT during this transition period.

• The transition period is limited to a maximum of eight (8) weeks.

ICT - Service Limitations Continued


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ICT- Utilization Limits • Annual unit limit = 130 units

• One 1 unit = 1 hour

ICT- Reauthorization

• Continuation of service may be reauthorized at 26-week intervals based on written service specific provider re-assessment and certification of need by a LMHP.

• Up to 65 units can be requested per each 26 week authorization/reauthorization interval.

• Providers may call Magellan to request additional units within the total utilization limit when clinically appropriate. Providers must be prepared to provide clinical evidence related to the medical necessity criteria demonstrating the need for additional units.

• The ISP must be updated to reflect changes in the member’s clinical presentation as related to medical necessity criteria.

ICT - Service Coordination

Purpose:

• To ensure that the individual receives all needed services and supports; that these resources are well-coordinated and integrated; and that they are provided in the most effective and efficient manner possible.

• To ensure there is no duplication in services or billing

• To ensure continuity of care- stakeholder/provider collaboration is necessary

Service Coordination includes:

• Assisting members with access to and appropriate utilization of needed services and supports

• Helping members to maximize the use of these resources

• Actively collaborating with all internal and external service providers to coordinate services and supports (including family members and significant others involved in the member’s life)

• Preventing duplication of services or the provision of unneeded interventions

• Revising the service plan as clinically indicated


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Submission Tips - All ICT Requests

Submit online at https://www.magellanprovider.com

Select and complete the correct Service Request Authorization (SRA) form. Intensive Community Treatment – Initial Review for the first request Intensive Community Treatment – Continued Stay Review for ongoing care

Answer every SRA question.

Thoroughly address every service criteria.

Describe specific behaviors from the last 30 days that show how criteria are met.

Document the frequency, intensity, and duration of each behavior.

Give the name and a working phone number for a clinical contact who can answer Care Manager questions about the clinical information.

The clinical contact’s voicemail should be confidential to allow Magellan to leave detailed messages.

The clinical contact’s outgoing voice message should clearly state the contact’s name, the agency name, and that the voicemail box is confidential.


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https://www.magellanprovider.com/

Submission Tips – Initial and Concurrent ICT Requests Initial ICT Requests

Include the SSPI document with the SRA. SSPI date should be prior to requested service start date. SSPI should include the member’s diagnosis and be consistent with clinical information in the

SRA. SSPI should document how criteria are met and why the member needs ICT.

Concurrent ICT Requests

Include the ISP with the SRA for every concurrent request. ISP must document continued need for the intense level of care offered by ICT. ISP must document the member’s progress or lack of progress on all ISP goals and

objectives.


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SRA Example 1: At Risk / Intervention Criteria

Risk for psychiatric hospitalization due to mental illness Sarah is a 24 year old female who presents with risk of psychiatric hospitalizations due to active psychotic symptoms and delusions. In the last 30 days, Sarah has expressed reluctance to eat and drink fluids due to fears that someone is poisoning her food. She expresses this reluctance most days of the week and chooses not to eat for 24 consecutive hours at least once per week. She has required inpatient psychiatric hospitalization 5 times in the last year when these symptoms of paranoia prevented her from eating for extended periods such that her health has been at risk.

Risk for homelessness due to mental illness Sarah lives with a roommate and has been unable to find affordable single occupancy housing. Sarah experiences mood swings and irritability related to depression symptoms. Within the last 30 days, Sarah has exhibited extreme angry outbursts with her roommate 2 to 3 times per week, including throwing and breaking objects such as picture frames. Her roommate is looking for other housing due to this behavior, which may leave Sarah without means to fully pay the rent.

Requires intervention by the mental health or criminal justice system due to inappropriate social behavior. Sarah is currently on probation for shoplifting. She reported that she heard voices instructing her to steal items at a local store.


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SRA Example 2: History of Need for Intensive Services

Has a history (3 months or more) of a need for intensive mental health treatment or treatment for co-occurring serious mental illness and substance use disorder and demonstrates a resistance to seek out and utilize appropriate treatment options:

Josh is a 30 year old male who has experienced symptoms of Schizophrenia that have dramatically interfered with his functioning since he was 22 years old. Josh appears to respond to internal stimuli, presents with incongruent affect, and reports visual hallucinations. On a daily basis, Josh describes his belief that he has special magical powers. This appears to be part of a persistent delusional system. Due to severity of these daily symptoms, Josh has required intensive mental health treatment for several years, including psychiatric medication management, psychosocial rehabilitation services, mental health case management, and at least 5 episodes of inpatient psychiatric care. Josh’s most recent psychiatric hospital stay occurred 1 month ago. Josh is non-adherent with prescribed psychiatric medication. He isolates from others and actively avoids attending traditional outpatient treatment appointments, stating that he believes that people who work in the medical field are “out to get” him.


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intensive community treatment - magellan of virginia...2016/10/04 · medical necessity criteria...

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