Subpart D Quality Assessment and Performance Improvement. Subpart D Quality Assessment and Performance Improvement

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1 Availability of services (b) Delivery network (1) (b) Delivery network. The State must ensure, through its contracts, that each MCO, and each PIHP consistent with the scope of the PIHP s contracted services, meets the following requirements: (1) Maintains and monitors a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services covered under the contract. In establishing and maintaining the network, the MCO must consider the following: (i) The anticipated Medicaid enrollment. (ii) The expected utilization of services, taking into consideration the characteristics and healthcare needs of specific Medicaid populations represented in the particular MCO, PIHP, (iii) The numbers and types (in terms of training, experience, and specialization) of providers required to furnish the contracted Medicaid services. (iv) The number of network providers who are not accepting new Medicaid patients. (v) The geographic location of providers and Medicaid enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees, and whether the location provides physical access for Medicaid enrollees with disabilities RSN INTERLOCAL AGREEMENT: 7.1 Network Capacity Scoring for (b) (1) 1. The RSN maintains and monitors a network of appropriate providers that is supported by written agreements. 2. The RSN s network is sufficient to provide adequate access to all services covered under the contract. 3. In establishing and maintaining the network, the RSN considers the following five factors: a) anticipated Medicaid enrollment b) expected utilization of services, the characteristics and healthcare needs of specific Medicaid populations represented by the RSN c) numbers and types (training, experience, specialization) of providers required to furnish the contracted Medicaid services d) number of network providers who are not accepting new Medicaid patients e) geographic location of providers and Medicaid enrollees (including distance, travel time, means of transportation ordinarily used by Medicaid enrollees, and whether the location provides physical access for Medicaid enrollees with disabilities) Fully met The RSN meets criteria 1 3. Substantially met The RSN meets 1 2 of the criteria and 4 of the 5 factors under 3. The RSN meets 1 or 2 of the criteria and 3 of the 5 factors under 3. The RSN meets 0 of the criteria. 1

2 Documentation for (b) (1) Review the RSN s service and provider network planning documents and provider directories. Did the RSN project the number and types (in terms of training, experience, and specialization) of providers it needs to serve Medicaid enrollees? Did the RSN base its projections of the necessary numbers and types of providers on sound information about its projected Medicaid enrollment, including the considerations listed below? The expected utilization of services of its Medicaid enrollees, considering Medicaid enrollee characteristics and healthcare needs including, at a minimum, age and prevalence of health conditions The numbers and types (in terms of training, experience, and specialization) of providers required to furnish the contracted Medicaid services The number of network providers who are not accepting new Medicaid patients The geographic location of Medicaid providers and enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees, and whether the location provides physical access for enrollees with disabilities Did the assumptions and methodologies used by the RSN in planning its provider network appear reasonable, and have face validity? Did the assumptions and methodologies address: (1) types of providers who may serve as a mental health care provider; and (2) the extent to which network providers serve only the RSN s enrollees or are available to the RSN s enrollees on less than a full-time basis? Did the assumptions and methodologies also identify situations in which different types of providers will be used to provide the same service e.g., psychiatrists, psychologists, clinical social workers, mental health specialists (geriatric, disability, minority, child) and psychiatric nurses or nurse practitioners to provide mental health services? Are all contracted services (other than emergent care) generally available within the organization's network? Are network providers generally located within the RSN s approved service area? An acceptable exception would be, for example, when an organization operating solely in a nonmetropolitan area makes a service available outside the area if it is unable to contract with a sufficient number of providers within the area. Another permissible exception would be if an RSN contracts with a service provider outside of its service area if, for reasons of geography, it would be easier for some of its enrollees to reach that provider than it would be for them to reach a comparable provider located within the service area. Is the provider network geographically structured so that Medicaid enrollees residing in the service area do not have to travel an unreasonable distance, beyond what is defined in the Medicaid waiver (30 minutes rural areas, 90-minute drive in large rural areas, urban areas not to exceed 90 minutes each way), to obtain a covered service? For service areas or parts of service areas where Medicaid enrollees are expected to rely heavily upon public transportation, is the RSN s network structured so that providers are accessible using public transportation within the same time frames as enrollees who have their own means of transportation (unless the RSN ensures access through alternative means, such as home visits)? 2

3 Do enrollees with disabilities have an appropriate choice of Americans with Disabilities (ADA) accessible providers? Does the RSN s provider network appear sufficient to provide adequate access to covered services and to meet the needs of its Medicaid enrollees? Review the RSN s provider contracts, contracting and non-contracting provider selection criteria, and procedures for monitoring the provider network to determine the extent to which The RSN s provider network described in its materials, member services, and service planning documents are supported by written provider agreements Whenever provider contracts allow providers to further subcontract with other providers for the provision of services to enrollees, does the subcontract require that the provider hold its subcontractor to the same requirements that the RSN requires of the provider contracting directly with the RSN? Questions for (b) (1) (i) (v) RSN 1. How does the RSN ensure its network of providers is sufficient to provide adequate access to covered services? 2. Describe the RSN s process for assessing the need for providers to deliver each type of covered service and need for major specialties within each type. What issues were considered in the assessment process? 3. How does the RSN determine the adequacy of its network to serve its Medicaid enrollees? 4. What assumptions and methodologies are used to project the number, type (in terms of training, experience and specialization) and location of mental healthcare providers (MHCPs, LMPs) necessary to serve its anticipated Medicaid enrollees? 5. What steps does the RSN take to monitor availability and accessibility of services to Medicaid enrollees? What are the most recent findings from this process? 6. Is there any information that is routinely collected and monitored to determine that care and services are being rendered to Medicaid enrollees in a timely manner? What are the most recent findings of this monitoring? Providers 7. How does the RSN determine that providers are geographically accessible to Medicaid enrollees and physically accessible to enrollees with disabilities? 8. Describe the RSN s processes for monitoring the provider network to determine that Medicaid requirements pertaining to timeliness, availability and accessibility are being met. 9. What happens if a provider is not providing timely access or availability of services? Availability of services (b) Delivery network (3) (b) Delivery network Each MCO, and each PIHP consistent with the scope of the PIHP s contracted services, meets the following requirement: (3) Provides for a second opinion from a qualified healthcare professional within the network, or arranges for the enrollee to obtain one outside the network, at no cost to the enrollee. 3

4 RSN INTERLOCAL AGREEMENT: 14.2 Scoring criteria for (b) (3) 1. The RSN provides for a second opinion from a qualified healthcare professional within the network, or arranges for the enrollee to obtain a second opinion outside the network, at no cost to the enrollee. 2. The RSN has a policy/procedure to ensure that member materials inform enrollees of their right to a second opinion. 3. RSN staff is knowledgeable of the policy/procedure. 4. The RSN monitors and tracks this process. Fully met The RSN meets criteria 1 4. Substantially met Minimally met The RSN meets 3 of the criteria. The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (b) (3) Review the RSN s administrative policies and procedures pertaining to service authorization and coverage, utilization management and use of out-of-network providers. Determine the extent to which the RSN has procedures for providing Medicaid enrollees with: A second opinion at no cost to the enrollee from a qualified healthcare professional within the network, or outside the network if a qualified healthcare professional is not available within the network. Review the RSN s new member materials, enrollee handbooks, and other enrollee information materials. Determine the extent to which the RSN informs Medicaid enrollees of the availability at no cost to the enrollee of a second opinion from a qualified healthcare professional within the network or outside the network if a qualified healthcare professional is not available within the network. Questions for (b) (3) RSN 1. What procedures must a Medicaid enrollee follow if he/she wishes to receive a second opinion? For what types of services are second opinions available? 2. How does the RSN monitor the process for obtaining a second opinion? 3. How often do enrollees request a second opinion? 4. How does the RSN inform enrollees how to obtain a second opinion? 4

5 Availability of services (b) Delivery network (4) (b) delivery network Each MCO, and each PIHP consistent with the scope of the PIHP s contracted services, meets the following requirements: (4) If the network is unable to provide necessary services, covered under the contract, to a particular enrollee, the MCO, PIHP, must adequately and timely cover these services out of network for the enrollee, for as long as the MCO, PIHP, is unable to provide them RSN INTERLOCAL AGREEMENT: 14.3 Scoring criteria for (b) (4) 1. The RSN has an administration and services policy for covering approved out-of-network services adequately and in a timely manner. 2. The RSN s enrollee manual lists this policy. 3. The RSN tracks the out-of-network encounters, and analyzes and utilizes the information. Fully met The RSN meets criteria 1 3. Substantially met The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (b) (4) Review the RSN s administrative policies and procedures pertaining to service authorization and coverage, utilization management and use of out-of-network providers. Determine the extent to which the RSN has procedures for providing Medicaid enrollees with: Timely and adequate coverage of necessary services provided for under the contract from outof-network providers whenever the RSN is unable to provide them. Review the RSN s new member materials, enrollee handbooks, and other enrollee information materials. Determine the extent to which the RSN informs Medicaid enrollees of timely and adequate coverage of necessary medical services covered under the contract from out-of-network providers whenever the network is unable to provide necessary medical services and for as long as the RSN is unable to provide them. Questions for (b) (4) RSN 1. What is the RSN s policy and procedure for approving out-of-network services for enrollees? 2. How long does it take the RSN to approve out-of-network services for enrollees? 3. How are enrollees informed that this process must be followed? 5

6 4. What monitoring does the RSN do relative to out-of-network encounters? What is done with this information? How often do Medicaid enrollees receive services from out-of-network providers? 5. Approximately what proportion of Medicaid enrollee provider encounters are made by out-ofnetwork providers? If this is a significant percent, what are the reasons for this? 6. Are Medicaid enrollee requests for out-of-network providers tracked? How often do Medicaid enrollees request services from out-of-network providers? What are their reasons for requesting out-of-network providers? 7. Is there any routinely collected and available data on use of out-of-network providers? Is data on use of out-of-network providers separately available for Medicaid enrollees? Providers 8. What is the procedure when services are not available through the network? Availability of services (b) Delivery network (5) (b) delivery network... Each MCO, and each PIHP consistent with the scope of the PIHP s contracted services, meets the following requirements: (5) Requires out-of-network providers to coordinate with the MCO, PIHP, with respect to payment and ensures that cost to the enrollee is no greater than it would be if the services were furnished within the network RSN INTERLOCAL AGREEMENT: 14.3 Scoring for (b) (5) The RSN has a policy requiring that out-of-network providers coordinate with the RSN with respect to payment and ensures that cost to enrollee is no greater than it would be if the services were furnished within the network. Fully met The RSN meets criteria. The RSN meets 0 of the criteria. Documentation for (b) (5) Review the RSN s administrative policies and procedures pertaining to use of out-ofnetwork providers. 6

7 Determine the extent to which the RSN requires out-of-network providers to coordinate with the RSN with respect to payment. Determine the extent to which the RSN ensures that out-of-network services are furnished at no cost to the enrollee. Questions for (b) (5) RSN 1. What is your policy regarding coordination with out-of-network providers? 2. How do you pay out-of-network providers? Do you receive claim or encounter data from out-ofnetwork providers similar to the claim or encounter data that you receive from your network providers? 3. How does your RSN ensure that the Medicaid enrollee is not charged for authorized out-ofnetwork services? How does your RSN monitor this? 4. Does your IS system track services provided by and/or reimbursed to out-of-network providers? Providers 5. How often does the RSN go outside the network to secure services for enrollees? 6. How often do you coordinate with out-of-network providers that are serving RSN enrollees? 7. Is the cost of out-of-network providers greater than it would be if the services were furnished within the network? Availability of services (c) Furnishing of services (1) Timely access (c) Furnishing of services. (1) Timely access. Each MCO, PIHP, must (i) Meet and require its providers to meet State standards for timely access to care and services taking into account the urgency of need for services; (ii) Ensure that the network providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid fee-forservice, if the provider serves only Medicaid enrollees. (iii) Make services included in the contract available 24 hours a day, 7 days a week, when medically necessary. (iv) Establish mechanisms to ensure compliance by providers. (v) Monitor providers regularly to determine compliance. (vi)take corrective action if there is failure to comply RSN INTERLOCAL AGREEMENT: 7.2 7

8 Scoring criteria for (c) (1) 1. The RSN meets and requires that its providers meet State standards for timely access to care and services taking into account the urgency of enrollee s need for services. 2. The RSN ensures that network provider s hours of operation are no fewer than the hours of operation offered to non-medicaid enrollees, or if the provider serves only Medicaid enrollees, provider s hours of operation are comparable to Medicaid fee-for-service provider hours. 3. Services included in the contract are available 24 hours a day, 7 days a week, when medically necessary. 4. The RSN has established mechanisms to ensure compliance by providers. 5. The RSN monitors providers regularly to determine compliance. 6. The RSN takes corrective action if provider fails to comply. Fully met The RSN meets criteria 1 6. Substantially met Minimally met The RSN meets 5 of the criteria. The RSN meets 3 4 of the criteria. The RSN meets 1 2 of the criteria. The RSN meets 0 of the criteria. Documentation for (c) (1) Review the RSN s standards for timely access to care and services for Medicaid enrollees to determine the extent to which they meet or exceed standards established by the State Medicaid agency. Review provider contracts, manuals and orientation programs as well as credentialing policies and procedures to determine the extent to which the RSN informs affiliated (network) providers of its standards. Review the RSN s service area and strategic planning documents such as: Medicaid enrollee needs assessments, provider network planning documents, provider selection criteria, provider contracts, and provider/contractor office/facility review criteria and subsequent audit results. Look for evidence in these documents that the RSN Makes services available 24 hours per day, 7 days per week, when medically necessary. Offers provider hours of operation that do not discriminate against Medicaid enrollees relative to other enrollees; i.e., provider hours of operation for Medicaid enrollees are no less than the provider hours of operation offered to the general population. Review enrollee services policies and procedures, RSN informational materials prepared for new Medicaid enrollees, and other Medicaid member/enrollee information and educational 8

9 materials to determine the extent to which they contain provisions that document the availability of healthcare services 24 hours per day, 7 days per week, when medically necessary. Review documents identified by RSN staff during the interview process that show how the RSN ensures compliance and continuously monitors its network providers and member services for compliance with the Medicaid timeliness of access standards. Review the documentation of any instances found through the monitoring processes, tools or other processes in which the RSN failed to meet standards set by the State for timeliness of access to care or member services. Determine the extent to which the RSN initiated corrective action. Determine the extent to which the RSN assessed the effectiveness of corrective action. Questions for (c) (1) RSN 1. Describe how the RSN monitors compliance with Medicaid standards for timely access to care and services. 2. How does the RSN ensure Medicaid services are available 24 hours per day, 7 days per week when medically necessary? 3. How does the RSN determine that the individual and institutional (E&T or hospital) providers it has contracts with have sufficient capacity to make services available, when medically appropriate, 24 hours per day, 7 days per week to Medicaid enrollees? 4. How does the RSN ensure that its provider network s hours of operation do not discriminate against Medicaid enrollees; i.e., are not different for Medicaid enrollees than for other clients? 5. To what extent are services offered through the RSN available to Medicaid enrollees and others who are coordinating care 24 hours per day, 7 days per week, when medically necessary? 6. How frequently does RSN staff receive complaints about provider hours of operations not being available to enrollees, when medically necessary? 7. Does the RSN conduct surveys, focus groups or other activities to receive feedback from Medicaid enrollees? If so, what are the most recent findings about Medicaid enrollee perceptions about availability of RSN and provider services? 8. Does the RSN continuously monitor its provider network for compliance with established standards on timeliness of access to all care and enrollee services? If yes, how, and what are the most recent findings? 9. What does the RSN do when providers are not in compliance with established standards for timeliness of access to care and member services? Is a corrective action plan required? Are the corrective actions assessed for effectiveness? 10. Have any recent QAPI activities been implemented to monitor the RSN s compliance with its established standards for timeliness of access to care and member services? 11. What are the results of these QAPI activities? Providers 12. What services are available 24 hours a day, 7 days a week? 13. What is the procedure when services are not available? 14. Are the hours of operation of the provider network serving Medicaid enrollees different from the hours of operation of the provider network serving other clients? If so, why? 9

10 15. What monitoring does the RSN do regarding timeliness of access? 16. What kind of action would the RSN take if a provider was not providing timely access to services? Availability of services (c) (2) Cultural considerations (c) Furnishing of services (2) Cultural considerations. Each MCO, PIHP, participates in the State s efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds RSN INTERLOCAL AGREEMENT: 1.12; 5; ; Scoring for (c) (2) 1. The RSN participates in the State s efforts to promote delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds. 2. The RSN has documents, policies, and procedures that support the promotion of these services. 3. The RSN has enrollee materials that support the promotion of these services. Fully met The RSN meets criteria 1 3. Substantially met The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (c) (2) Review Medicaid enrollee new member materials, enrollee handbooks, enrollee educational materials and other enrollee materials and any other documentation of the RSNs efforts to promote the delivery of services in a culturally competent manner to all enrollees including those with limited English proficiency and diverse cultural and ethnic backgrounds consistent with the State s efforts. Is there evidence that the RSN has participated in the State s efforts? Questions for (c) (2) RSN 1. Have you participated in MHD s efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds? 2. How does the RSN ensure services are delivered in a culturally competent manner? What documentation exists describing the RSN s efforts and the results? 3. Describe how materials distributed to enrollees reflect cultural competency. 10

11 Coordination and continuity of care (b) Primary care and coordination of healthcare services for all MCO and PIHP enrollees Coordination and continuity of care. (b) Primary care and coordination of healthcare services for all MCO and PIHP enrollees. Each MCO, PIHP, must implement procedures to deliver primary care to and coordinate healthcare services for all MCO, PIHP, enrollees. These procedures must meet State requirements and must do the following: (1) Ensure that each enrollee has an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the healthcare services furnished to the enrollee. (2) Coordinate the services the MCO, PIHP, furnishes to the enrollee with the services the enrollee receives from any other MCO, PIHP, or PAHP. (3) Share with other MCOs, PIHPs, and PAHPs serving the enrollee the results of its identification and assessment of that enrollee s needs to prevent duplication of those activities. (4) Ensure that in the process of coordinating care, each enrollee s privacy is protected in accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to extent that they are applicable RSN INTERLOCAL AGREEMENT: Scoring criteria for (b) 1. The RSN implements policies and procedures to deliver care to and coordinate with primary healthcare services for all enrollees 2. The RSN or contracted agency consults and communicates with enrollee s physical healthcare provider. 3. The RSN or contracted agency coordinates the services it furnishes to enrollee with services enrollee receives from Healthy Options & other health plans. Fully met The RSN meets criteria 1 3. Substantially met The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. 11

12 The RSN meets 0 of the criteria. Documentation for (b) Review the RSN s Medicaid enrollee services policies and procedures, Medicaid enrollee handbooks, provider procedure manuals, and any clinical practice guidelines adopted by the RSN and determine the extent to which the RSN has in place and implements mechanisms to identify and assess Medicaid enrollees who have physical or chemical dependency (GAINS) needs and to monitor ongoing coordination of care. Review the RSN s written policies and procedures for care management/coordination with healthcare providers to: determine the extent to which these policies and procedures identify; the functions of the mental health provider in coordinating with the primary care provider; conditions under which enrollee healthcare is coordinated by the enrollee s primary care provider; the mechanisms for information sharing between the mental health provider and the primary care provider; determine the extent to which these policies and procedures contain mechanisms to ensure that each enrollee has an ongoing source of primary healthcare appropriate to his or her needs; each enrollee has a person or entity formally designated as primarily responsible for coordinating the health services furnished to the enrollee; the RSN coordinates the services it furnishes to the enrollee with services the Medicaid enrollee receives from any other plan; the results of its identification and assessment of enrollee needs are shared with other health plans from which the enrollee may be receiving services, so that these activities need not be duplicated (e.g., information sharing between physical health providers and mental health and substance abuse providers, with respect to prescribed medications). Review a sample of records of Medicaid enrollees receiving care coordination/case management services to determine the extent to which the RSN coordinates its services with services the enrollee receives from any other RSN s. Questions for (b) RSN 1. What steps does the RSN take to promote Medicaid enrollees ongoing relationship with a usual source of primary healthcare? 2. Who may serve as enrollees mental health care providers (MHCP)? 3. What process or processes are used to coordinate services with a primary healthcare provider and/or other agencies providing care for enrollees? 4. Are there different types of care coordination mechanisms for different groups of enrollees? If so, what are these mechanisms? 5. How does your RSN establish separate coordination of care with medical services and substance abuse services? 6. How does it ensure exchange of necessary information among providers? 12

13 Coordination and continuity of care (c) Additional services for enrollees with special healthcare needs (1)(2) Coordination and continuity of care. (c) Additional services for enrollees with special healthcare needs. (1) Identification. The State must implement mechanisms to identify persons with special healthcare needs to MCOs, PIHPs, as those persons are defined by the State. These identification mechanisms (ii) May use State staff, the State s enrollment broker, or the State s MCOs, PIHPs. (2) Assessment. Each MCO, PIHP, must implement mechanisms to assess each Medicaid enrollee identified by the State (through the mechanisms specified in paragraph (c)(1) of this section) and identified to the MCO, PIHP, by the State as having special healthcare needs in order to identify any ongoing special conditions of the enrollee that require a course of treatment or regular care monitoring. The assessment mechanisms must use appropriate healthcare professionals RSN INTERLOCAL AGREEMENT: 7.2.6; 10.3; WAC ; 2006 Approved Section 1915(b) Capitated Waiver all persons covered meet the definition of CMS as a person with special healthcare needs. In this carve out program those persons served have a serious mental illness or a serious emotional disturbance. For the purpose of the External Quality Review, this section refers to enrollees who need Mental Health Specialists (disabled, minority, geriatric and children) assessments. Scoring criteria for (c) (1) (2) 1. The RSN has mechanisms to identify persons with special healthcare needs. 2. The RSN implements policies and procedures to identify and assess enrollees who have specialized healthcare needs. 3. The RSN has a mechanism to ensure enrollees identified by the state with specialized needs are assessed by an appropriate mental health professional (MHP). 4. The RSN has a methodology for monitoring this process. Fully met The RSN meets criteria 1 4. Substantially met Minimally met The RSN meets 3 of the criteria. The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (c) (1) (2) Review the RSN s procedures for Identifying Medicaid enrollees who have specialized needs 13

14 Review the RSN s procedures to provide care to enrollees who have ongoing special conditions and who require a course of treatment or regular care monitoring Determine the extent to which the RSN s policies and procedures allow an enrollee (as appropriate for the enrollee s condition and identified needs) to directly access a specialist (for example, through a standing referral) Determine the extent to which the RSN s policies and procedures ensure that an enrollee with specialized needs is provided care appropriate to the enrollee s service needs: Assessment is comprehensive enough to identify specialized needs Allow access to a specialist with the expertise to address the enrollees special healthcare needs (minority, geriatric, disabled, child) Incorporate identified needs into treatment recommendations Obtain a sample of records or files of Medicaid enrollees with specialized needs and review the assessment of the enrollee needs and preliminary treatment plan. Determine the extent to which: the enrollees specific special needs are identified the assessment was conducted by a mental health professional (MHP) the enrollee was afforded access to a specialist with training related to the enrollees unique need treatment recommendations address identified specialized needs Questions for (c) (1) (2) RSN 1. How do you identify persons with specialized needs? 2. How do you assess enrollees with specialized needs? 3. What proportion of your enrollees have specialized needs? 4. Do you require providers to assess enrollees for specialized needs? If so, how does that information communicate the needs to the RSN? 5. How do you communicate this requirement to them? 6. How do you monitor providers for this requirement? Providers 7. How do you identify persons with specialized needs? 8. How do you assess enrollees for specialized needs? 9. What kind of information do you provide the RSN? 10. Who in your agency is qualified to assess enrollees specialized needs? 11. Does the RSN monitor providers for this requirement? Coordination and continuity of care (c) Additional services for enrollees with special healthcare needs (3) (c) Coordination and continuity of care. (c) Additional services for enrollees with special healthcare needs. (3) Treatment plans. If the State requires MCOs, PIHPs, to produce a treatment plan for enrollees with special healthcare needs who are determined through assessment to need a course of treatment or regular care monitoring, the treatment plan must be 14

15 (i) Developed by the enrollee s primary care provider with enrollee participation, and in consultation with any specialists caring for the enrollee; (ii) Approved by the MCO, PIHP, in a timely manner, if this approval is required by the MCO, PIHP, and (iii) In accord with any applicable State quality assurance and utilization review standards RSN INTERLOCAL AGREEMENT: ; 10.3; ; ; 14.3; WAC Scoring criteria for (c) (3) 1. The enrollees treatment plans address additional care services identified in the assessment for all enrollees with specialized needs. 2. The enrollees treatment incorporates the recommendations of other agencies and providers of specialized services. 3. The enrollees treatment plan is developed by the mental health provider with enrollees participation and/or their family. 4. The RSN has a method to monitor treatment plans for enrollees with specialized needs. 5. The RSN has a method to follow through on findings from the monitoring with a quality improvement process. Fully met The RSN meets criteria 1 5. Substantially met Minimally met The RSN meets 4 of the criteria. The RSN meets 2 3 of the criteria. The RSN meets 1 2 of the criteria. The RSN meets 0 of the criteria. Documentation for (c) (3) Obtain a sample of records or files of Medicaid enrollees with specialized needs and review the treatment plan. Determine the extent to which: The enrollee s specialized needs are incorporated into the treatment plan 15

16 The enrollees (if appropriate for the enrollee s condition and identified needs) were afforded access to a specialist The treatment plan was: - Developed by the enrollee s primary mental health provider in consultation with any specialists caring for the enrollee - Developed with participation of the enrollee and/or his guardian or family The clinical documentation demonstrates coordination of care with the specialists involved in the enrollee s care Was approved in a timely manner, if approval was required Questions for (c) (3) RSN 1. How does your RSN ensure exchange of necessary information among all care providers for enrollees identified with special healthcare needs? 2. How does the RSN ensure that those with identified specialized needs have those needs incorporated into their treatment plans? 3. How do you monitor those treatment plans to ensure that necessary services are provided? 4. How is the information gathered through your monitoring process incorporated into your quality assurance performance improvement process? 5. Has the RSN had to build capacity, add different providers, or provide flexible services for enrollees with identified special healthcare needs? Providers 6. How does the course of treatment for enrollees with specialized needs differ from routine mental health services? 7. How are other service providers involved in developing the treatment plan for enrollees with specialized needs? 8. How is coordination of care between other service providers and mental health providers accomplished? 9. Does the RSN monitor the treatment plans of enrollees with specialized needs for coordination of care? Coordination and continuity of care (c) Additional services for enrollees with special healthcare needs (4) (c) Coordination and continuity of care. (c) Additional services for enrollees with special healthcare needs. (4) Direct access to specialists. For enrollees with special healthcare needs determined through an assessment by appropriate healthcare professionals (consistent with (c) (2)) to need a course of treatment or regular care monitoring, each MCO, PIHP, must have a mechanism in place to allow enrollees to directly access a specialist (for example, through a standing referral or an approved number of visits) as appropriate for the enrollee s condition and identified needs. 16

17 RSN INTERLOCAL AGREEMENT: 14.3; ; WAC Scoring criteria for (c) (4) 1. The RSN has policies and procedures for providing direct access to specialists for enrollees with specialized needs. 2. The RSN provides direct access in a timely manner. 3. The RSN has mechanisms in place for allowing direct access. 4. The RSN monitors/measures direct access. Fully met The RSN meets criteria 1 4. Substantially met Minimally met The RSN meets 3 of the criteria. The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (c) (4) Review policies and procedures for provision of direct access to mental health specialists. Questions for (c) (4) RSN 1. Do you have a policy for referral and authorization of specialized mental health services? 2. What are the procedures for allowing access and referral to specialists? 3. How many and what types of referrals for specialty care are typically approved? 4. How many requests for access to specialists have been denied by the RSN? What were the reasons for these denials? 5. Under what circumstances may Medicaid enrollees have direct access to specialized mental health providers? 17

18 Providers 6. How do you access specialty consultations for enrollees with specialized needs? Is authorization required, or do can enrollees directly access specialists? 7. Who is responsible for coordinating care for enrollees with specialists involved in their care? 8. Have you ever had a referral to, or request for, a specialist denied by the RSN? 9. How is the coordination of care for enrollees with specialists involved in their care different from coordination of care for enrollees with routine mental health needs? Coverage and authorization of services (b) Authorization of services; (c) Notice of adverse action (b) Coverage and authorization of services. (b) Authorization of services. For the processing of requests for initial and continuing authorizations of services, each contract must require (1) That the MCO, PIHP, and its subcontractors have in place and follow, written policies and procedures. (2) That the MCO, PIHP, -- (i) Have in effect mechanisms to ensure consistent application of review criteria for authorization decisions; and (ii) Consult with the requesting provider when appropriate. (3) That any decision to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested, be made by a healthcare professional who has appropriate clinical expertise in treating the enrollee s condition or disease. (c) Notice of adverse action. Each contract must provide for the MCO, PIHP, to notify the requesting provider, and give the enrollee written notice of any decision by the MCO, PIHP, to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested. The notice must meet the requirements of , except that the notice to the provider need not be in writing RSN INTERLOCAL AGREEMENT: Scoring for (b) (c) 1. The RSN has policies and procedures in place for the consistent application of review criteria for authorization decisions. 2. The RSN has mechanisms in place to ensure consistent application of review criteria for authorization decisions. 3. The RSN consults with requesting provider. 4. The RSN s decisions to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested are made by a MHP with appropriate clinical expertise in treating the enrollee s condition or disease. 5. The RSN notifies the requesting provider of an adverse action and notifies the enrollee in writing of any decision to deny the request. 18

19 Fully met The RSN meets criteria 1 5. Substantially met Minimally met The RSN meets 4 of the criteria. The RSN meets 2 3 of the criteria. The RSN meets 1 2 of the criteria. The RSN meets 0 of the criteria. Documentation for (b) (c) Review the RSN s written service authorization policies and procedures. Determine the extent to which these policies and procedures: Specify information required for making authorization decisions and the criteria to be used in making the decisions. Promote consistent application of review criteria for authorization decisions. Assure that any decision to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested, is made by an MHP who has appropriate clinical expertise in treating the enrollee s condition or disease. Provide for consultation with the requesting provider when appropriate. Provide for notification of the requesting provider and the enrollee of any decision by the RSN to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested. Enrollee notification (but not provider notification) must be in writing. Review a sample of service authorization requests that were denied. Determine the extent to which: Decisions to deny a service were made by an MHP with appropriate clinical expertise in treating the enrollee s condition or disease. Requesting providers were notified of any decision to deny, limit, or discontinue authorization of services Enrollees were notified, in writing, of any decision to deny, limit, or discontinue authorization of services. Review the RSN s contracts or other agreements with delegated providers or with other utilization review organizations to determine that the contracts or agreements do not include any financial incentive for denial, limitation or discontinuation of authorization for medically necessary services. Questions for (b) (c) RSN 1. Does the RSN have any agreements to delegate authorization of services? If yes, are there any performance incentives? 2. What services require authorization? How are authorization decisions made? What criteria are used in making authorization decisions? 19

20 3. How does the RSN ensure consistent application of criteria used in making service authorization decisions? 4. How often and under what circumstances are requesting providers consulted when the RSN makes service authorization decisions? 5. What are the qualifications of the person(s) who make(s) authorization decisions? If an authorization request is denied or limited in amount, duration or scope that is less than requested, how does the RSN assure that the decision is made by an MHP who has appropriate clinical expertise in treating the enrollee s condition? 6. To what extent does the RSN assess the consistency of authorization decisions? How does the RSN do this? 7. How does the RSN notify providers of an adverse action? 8. How does the RSN notify the enrollee of any decision to deny a request? Providers 9. What is the process to get authorization for services? 10. What does the RSN require to make authorization decisions? 11. Are you consulted by the RSN when you have made an authorization request? If yes, under what circumstances? Give examples. 12. Are network providers notified of the information required to process an authorization request? 13. How do you know whether a request has been approved or denied? Coverage and authorization of services (d) Timeframe for decisions (1) standard decisions (2) Expedited authorization services (d) Coverage and authorization of services. (d) Timeframe for decisions. Each MCO, PIHP, contract must provide for the following decisions and notices: (1) Standard authorization decisions. For standard authorization decisions, provide notice as expeditiously as the enrollee s health condition requires and within State-established timeframes that may not exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days, if (i) The enrollee, or the provider, requests extension; or (ii) The MCO, PIHP, justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee s interest. (2) Expedited authorization decisions: (i) For cases in which a provider indicates, or the MCO, PIHP, determines, that following the standard timeframe could seriously jeopardize the enrollee s life or health or ability attain, maintain, or regain maximum function, the MCO, PIHP, must make an expedited authorization decision and provide notice as expeditiously as the enrollee s health condition requires and no later than 3 working days after receipt of the request for service. (ii) The MCO, PIHP, may extend the 3 working days time period by up to 14 calendar days if the enrollee requests an extension, or if the MCO, PIHP, justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee s interest. 20

21 RSN INTERLOCAL AGREEMENT: Scoring criteria for (d) (1) (2) 1. The RSN has policies and procedures addressing coverage and authorization of services, including expedited authorizations. 2. The RSN ensures its process is followed for standard authorization decisions and providing notice. 3. The RSN ensures its process is followed for expedited authorization decision and for providing notice. 4. The RSN has a mechanism for tracking service/expedited authorizations. Fully met The RSN meets criteria 1 4. Substantially met Minimally met The RSN meets 3 of the criteria. The RSN meets 2 of the criteria. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (d) (1)(2) Review the RSN s written service authorization policies and procedures. Determine the extent to which these policies and procedures Specify time frames for responding to standard requests for service authorization that are within the applicable limits set by the State Medicaid agency. Provide for expedited response to requests for authorization of urgently needed services that adhere to the following time frames: For cases in which a provider indicates, or the RSN determines, that following the standard timeframe could seriously jeopardize the enrollee s life, health or ability to attain, maintain, or regain maximum function, the RSN must make an expedited authorization decision and provide notice as expeditiously as the enrollee s health condition requires and no later than 3 working days after receipt of the request for service. The RSN may extend the 3 working days time period by up to 14 calendar days if the enrollee requests an extension, or if the RSN justifies (to MHD upon request) a need for additional information and how the extension is in the enrollee s interest. Review information sources identified by the RSN such as service authorization tracking logs and other authorization record-keeping documents to determine: 1) the extent to which the RSN complies with the State s time frames for standard and the above time frames for expedited authorization of service requests; and 2) the number and reasons for delayed expedited authorization of service requests 21

22 Questions for (d) (1) (2) RSN 1. What is the RSN's policy and procedures for coverage and authorization of services? 2. What is the process for authorization and what is the turn-around time? If this is a delegated process then describe how that is monitored? 3. What are the RSN's time frames for processing standard requests for service authorization? 4. What are the RSN's time frames for expedited requests for service authorization? 5. What are the RSN's standards for processing expedited requests for service authorization? 6. How does the RSN monitor compliance with these time frames? What sources of documentation exists to provide evidence of the monitoring by the RSN? Providers 7. What are the time frames for the RSN s standard authorization decisions? 8. What are the timeframes for the RSN s expedited authorization decisions? Coverage and authorization of services (e) Compensation for utilization management activities (e) Coverage and authorization of services. (e) Compensation for utilization management activities. Each contract must provide that, consistent with 438.6(h), and of this chapter, compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee RSN INTERLOCAL AGREEMENT: 9.5; WAC Scoring criteria for (e) 1. The RSN has policies and procedures regarding compensation not being structured to provide incentives to deny, limit, or discontinue medically necessary services to enrollees. 2. The RSN ensures contracted providers do not provide incentives to deny, limit, or discontinue medically necessary services to enrollees. Fully met The RSN meets criteria 1 2. The RSN meets 1 of the criteria. The RSN meets 0 of the criteria. Documentation for (e) 22