Service Authorization (SBHC Subcontracted Providers) Date Issued: January 2006; Revised April 2, 2016 Responsible Dept:

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Policy Title: Service Authorization (SBHC Subcontracted Providers) Date Issued: January 2006; Revised April 2, 2016 Responsible Dept: Executive; Program Management POLICY Southwest Behavioral Health

Abuse and Mental Health (DSAMH). Covered services that are determined to be medically necessary will be authorized for as long as needed. PROCEDURES 1.

1 Policy Title: Service Authorization (SBHC Subcontracted Providers) Date Issued: January 2006; Revised April 2, 2016 Responsible Dept: Executive; Program Management POLICY Southwest Behavioral Health Center (SBHC) subcontracted providers will adhere to the requirements and service mandates stated in the Center's contracts with the Utah Department of Health (UDOH) and the Division of Substance Abuse and Mental Health (DSAMH). Covered services that are determined to be medically necessary will be authorized for as long as needed. PROCEDURES 1. A client who has a medically necessary need for services may be assigned to a subcontractor to provide those services based on one or more of the following criteria: The client needs only outpatient therapy on a short-term basis and medication management can be provided by a Primary Care Physician. This determination is based on a screening/evaluation conducted by an assigned SBHC clinician. The client needs a specialized service that can t be provided by SBHC clinicians. The client has been unable to establish a therapeutic alliance with SBHC clinicians or has developed a therapeutic alliance with a subcontracted provider prior to becoming eligible for Medicaid. 2. All subcontracted providers will be required to record and document services using either the Center s Electronic Health Record (EHR) or documentation templates that meet SBHC s documentation requirements. A. Initial Service Authorization for Standard Requests 1) When a PMHP Enrollee requests authorization to receive services from a Subcontracted Provider (SP), or an SP requests authorization to provide services to an Enrollee, the Program Manager (PM) who is responsible for the client s county of residence and age-group must be involved as soon as possible so that s/he can respond within the timeframes described below. Also, the PM will have support staff verify that the Enrollee is currently eligible for Medicaid benefits by accessing Medicaid s Eligibility Lookup Tool. 2) After this initial contact/request, the PM has 14 calendar days to decide and notify the Enrollee and SP of his/her decision to authorize the request. 3) If the enrollee has not been evaluated by the SP, the following will occur within 14 calendar days of the request: a. The PM will assign an SBHC Clinician to determine whether mental health services are medically necessary and, if so, complete an evaluation, determine diagnoses, SPMI/SED status, and assign a service level. Southwest Behavioral Health Center Clinical Policies Page 1 of 6

2 4) Based on the clinical evaluation, the PM will determine whether to authorize services or not, based on the criteria in 1 above. a. If authorized, the PM notifies the Managed Care Coordinator (MCC) and the Specialty Populations Evaluator and Coordinator (SPEC). b. The SPEC completes the following: Sets up client in Liaison program Makes himself the Recovery Coordinator Makes subcontractor a primary provider Un-assigns client from other programs Completes an authorization in the EHR authorization module c. The SPEC will inform the SP of authorization, including the type and number of services authorized, and the duration of the authorization. d. The SPEC will consult with the SP to ensure that the completed evaluation and Recovery Plan meets SBHC documentation standards (refer to the Documentation Standards and Timeframes policy). e. If denied, PM, MCC and SPEC follow the procedures described in Section (J) below. f. If the PM cannot make the authorization decision within 14 calendar days, s/he will follow the procedures outlined in Section G or H of this document. g. SBHC employs the Specialty Populations Evaluator and Coordinator (SPEC) to manage the utilization of all subcontracted services. The SPEC will authorize the most appropriate services to best meet the immediate needs of the client/enrollee. The SBHC SPEC is a salaried employee with no other incentives or bonuses associated with his/her utilization management and review. This arrangement ensures that SBHC staff are not incentivized to deny, limit, or discontinue medically necessary services to any enrollee, physicians or physician groups will not be paid in any manner to induce them to reduce or limit medically necessary services provided to enrollees. B. Service Authorization for Pre-Existing Relationships with an SP When a new Enrollee requests authorization to receive services from a SP with whom s/he has a clinical relationship that predates his/her eligibility, the PM who is responsible for the client is involved as soon as possible so that s/he can respond within the timeframes described below. If the enrollee has not been evaluated by the SP, the same process in Section A is followed. 1) If the enrollee has been evaluated by the SP, the following will occur within 14 calendar days of the request: a) The PM will review the Enrollee s mental health evaluation. b) If the evaluation is adequate, the PM will determine whether mental health services are medically necessary. If the PM determines that the SP s evaluation is inadequate, s/he will assign a SBHC Clinician to complete the screening portion of the mental health evaluation before evaluating medical necessity. Southwest Behavioral Health Center Clinical Policies Page 2 of 6

3 c) Following this, the PM will consult with the SP to ensure that the request meets the criteria stated in 1 above. d) If criteria are met, the PM will refer to the SPEC to complete the authorization (see steps 4 a - d above). e) If the PM cannot make the authorization decision within 14 calendar days, s/he will follow the procedures outlined in Section G or H of this document. C. Service and Documentation Review 1) The SPEC reviews all unapproved, multi-stage services and either approves, according to guidelines below, or asks SP for corrections, if needed. a) The SPEC is to complete reviews within 7 days of being submitted by the SP. b) The SPEC will use the multi-stage approval system in the EHR and searches for all unapproved contractor services back to 7/1/2012 (Credible start-date) to assure that any late submissions are reviewed. c) The SPEC determines if all services were provided according to the current authorization, including authorized time-frame, type and volume of services. d) The SPEC will assure that documentation meets standards in the Documentation Standards and Timeframes policy. D. Continuing Authorization for Standard Requests 1) The SP makes request for continued authorization to the SPEC. 2) The SPEC completes the following: a) Reviews the request to determine if the services requested meet medical necessity criteria. The SPEC may require an updated evaluation when necessary to justify medical necessity. The review is to be completed within 7 days of being submitted by SP. b) If approved, the SPEC enters a new Authorization in Credible. c) The SPEC informs the SP and MCC of continued authorization. d) If not approved, the SPEC follows procedures described in Section G or H below. 3) If the SPEC cannot make the authorization decision within 7 calendar days, the procedures outlined in Section E of this document are followed. E. Expedited Service Authorization Decisions 1) When an SP,PM, or SPEC determines that following the standard time frame could put the Client/Enrollee at risk, the PM expedites the service authorization decision within three (3) working days after receipt of the request for service authorization. 2) The PM may extend the time period of three (3) working days by up to 14 calendar days if: Southwest Behavioral Health Center Clinical Policies Page 3 of 6

4 a) The extension is requested by the Client/Enrollee or the Subcontractor or b) The SP/PM justifies that the extension is in the PMHP Enrollee s interest and that additional information must be gathered. c) Upon request, the MCC SPEC relay justification to UDOH that the extension is in the PMHP Enrollee s interest and that additional information must be gathered. F. Processing Notices of Adverse Action for Standard and Expedited Service Authorization Decisions to Deny or Authorize Less than Requested 1) If SBHC denies or gives a limited authorization of a requested service, including the type of level of service, the PM will notify the MCC within the same workday and the MCC SPEC will mail the Client/Caregiver a written Notice of Action by or on the expiration date of the applicable time frame for making the decision. The Notice of Action shall meet all contract requirements. 2) It is not an Action if the MCC agrees to give the requested service, but does not approve a requested SP. 3) SBHC will also notify the requesting SP of the Action, although the notice need not be in writing. G. 14-Calendar Day Extension 1) A 14-calendar day extension can be taken if the enrollee or SP requests SBHC to take more time to make the authorization decision or if the PM is unable to make an initial or continuing authorization decision within the initial 14 calendar day timeframe. 2) When the PM needs to take the 14 calendar day extension, the PM will inform the MCC who will do the following: a) Give the Client/Enrollee a written notice of the reason for the decision to extend the timeframe b) Inform the Client/Enrollee of his or her right to file a Grievance c) Explain the SBHC Grievance System if the Client/Enrollee disagrees with the extension d) Implement the extension respective to the demands of the Client/Enrollee s behavioral health needs but, and not later than, the date the extension expires e) Upon request, the MCC will relay justification to UDOH that the extension is in the PMHP Enrollee s interest and that additional information must be gathered. H. Service Authorization Decisions Not Reached Within Required Time Frames 1) If SBHC does not reach service authorization decisions within the time frames specified in the contract for standard and expedited service authorization requests, this constitutes a denial and is thus an adverse Action. Southwest Behavioral Health Center Clinical Policies Page 4 of 6

5 2) The MCC will mail a Notice of Action to the Client/Enrollee and notify the requesting provider by or on the date the applicable time frame for making the decision expires. I. PM or SPEC Recommend Decision to Terminate, Suspend or Reduce Previously Authorized Services and Time Frames for Notification 1) If the PM or SPEC decides to terminate, suspend, or reduce previously authorized services, and the Client/Enrollee disagrees with the change in his or her recovery plan, this constitutes an Action. 2) The PM or SPEC will notify the MCC of the adverse decision; the MCC will notify the requesting SP and mail a Notice of Action to the Client/Enrollee respective to his/her behavioral health needs and within the following timeframes: a) At least ten days before the date of the Action; or b) Five days before the date of the Action, if SBHC has facts indicating that the Action should be taken because of probable fraud by the Client/Caregiver, and the facts have been verified, if possible, through secondary sources c) By the date of the Action if the SP, PM, or MCC: has factual information confirming the death of the Client; or receives a clear written statement signed by the Client/Enrollee if s/he no longer wishes services; or receives information from the Client/Enrollee that requests termination or reduction of services and indicates that s/he understands that this must be the result of providing that information; or discovers the Client/Enrollee has been admitted to an institution where s/he is ineligible for further services; or discovers the Client/Enrollee s whereabouts are unknown and the post office returns mail directed to the Client/Enrollee indicates no forwarding address (in this case any discontinued services must be reinstated if the Client/Enrollee s whereabouts become known during the time s/he is eligible for services); or discovers the Client has been accepted by the PMHP services by another local jurisdiction; or discovers the Client/Enrollee s physician or SP changes the level of behavioral health care J. PM or SPEC Recommendation to Deny in Whole or Part of Payment for a Service for Clinical Reasons 1) SBHC will notify the requesting SP or Organization of decisions to deny payment in whole or in part. 2) SBHC will mail the Enrollee a written Notice of Action at the time of the Action affecting a claim. 3) A Notice of Action to the Enrollee is not necessary if: Southwest Behavioral Health Center Clinical Policies Page 5 of 6

6 a) the subcontracted provider billed SBHC in error for a non-authorized service; or b) the claim included a technical error (incorrect data including procedure code, diagnosis code, Enrollee name or Medicaid identification number, date of service, etc.) K. Services by Contracted Providers. Contracted providers (out-of-network) must coordinate with SBHC with respect to authorization and payment. SBHC may negotiate a single case agreement if services are medically necessary, meet SBHC practice guidelines, and the client s needs cannot be met within the network. L. SBHC will stipulate in contract and in singe-case agreements that the member cannot be billed for services (this ensures that the cost to the member is no greater than it would be if the services were furnished within the network.) M. For information regarding Emergency Services, please see the Emergency Services policy. Revised Dates Southwest Behavioral Health Center Clinical Policies Page 6 of 6

ADHERENCE TO MEDICAID CONTRACT REQUIREMENTS C 3.01

WASATCH MENTAL HEALTH SERVICES SPECIAL SERVICE DISTRICT ADHERENCE TO MEDICAID CONTRACT REQUIREMENTS C 3.01 Purpose: To ensure that Wasatch Mental Health Services Special Service District (WMH) adheres