ADHERENCE TO MEDICAID CONTRACT REQUIREMENTS C 3.01

Transcription

1 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 to all provisions contained within its current contract with the Utah State Department of Health regarding the Medicaid Prepaid Mental Health Plan (PMHP). Definitions: Policy: Medicaid Prepaid Mental Health Plan: A managed care mental health insurance plan funded by the Utah Department of Healthcare Financing and administered by WMH for Medicaid enrollees in Utah County who have been certified eligible for Medicaid benefits by the Ut. St. Dept. of Health. A. Wasatch Mental Health shall develop and follow written policies and procedures that incorporate the provisions contained in all required subsections (Articles) contained in the current version of the PMHP Medicaid contract. B. WMH shall update all policies and procedures as necessary to remain current with the PMHP Medicaid contract. C. WMH Executive Committee shall approve all initial and revised written policies and procedures. WMH shall document the date policies and procedures, including any revisions, are approved and adopted. D. New staff members shall receive training on policies and procedures pertaining to their assigned positions including but not limited to access to services, service authorizations, grievance/appeal process. Upon implementation of training, staff members shall acknowledge receipt and understanding of the policies and procedures. Staff members shall receive refresher training therein annually. E. All policies and procedures shall be posted in an assigned section of the WMH shared drive for all staff members to review. (S:\Shared.Center\Policies and Procedures for WMH). WMH policies and procedures identified in each subsection (Article) of the current PMHP Medicaid contract are as follows: Article I: Definitions Adherence to Medicaid Contract Policy #: C-3.01 Approved: Review Date: Page 1 of 6

2 Article II. Enrollment Enrollment Process Policy A-1.05 PMHP 834 Eligibility Policy Article III: Scope of Service includes minimum services, service limits, medical necessity, hospital, emergency and outpatient services. The Medicaid Member Handbook also addresses hospital, emergency and outpatient services. Policy C 3.06 Client Access to Treatment Performance Standards - Provide access to mental health care following the prescribed performance standards. Policy A Selection and Retention of Employees, Contracted (Outside) Providers, Vendors, Volunteers. Policy C 4.30 Intake, Recovery Planning, and Discharge Services for Medicaid Clients-In-house Providers. Policy C 4.31 Intake, Recovery Planning, and Discharge Services for Medicaid Clients-Outside Providers. Policy C 3.09 Prepaid Medicaid Client Transportation Services. Policy C Hour Crisis/Emergency Response Service - Provide enrollees with access to 24 hour, seven days a week crisis/emergency response service. Policy C 4.29 Post-Stabilization (Inpatient) Admissions - Provide enrollees with poststabilization (inpatient) and outpatient services outlined in the contract. Payment to non contracting hospitals. Article IV: Contractor Assurances Access: Policy C 3.06 Client Access to Treatment Performance Standards Oral Interpretation Services: Policy C 3.03 Interpreter Services - Provide Interpreters or services in the enrollees preferred language Advance Directives: Policy C 5.06 Advance Health Care Directives Charges to Enrollees/Enrollee Liability: Policy C 2.06 Clinician Authorization to Bill Third Parties. Choice of Mental Health Professional: Policy C 4.30 Intake, Recovery Planning, and Discharge Services for Medicaid Clients-In-house Providers. Policy C 4.31 Intake, Recovery Planning, and Discharge Services for Medicaid Clients-Outside Providers. Policy C-3.05 Client Rights, Medicaid Member Handbook. Nondiscrimination: Policy A 1.10 Selection and Retention of Employees, Contracted Providers, Vendors, Volunteers. WMH shall provide a Wasatch Mental Health Nondiscrimination Coordinator in behalf of clients who will (1) ensure its employees comply with Federal laws and regulations regarding nondiscrimination, including title VI of the Civil Rights Act of 1964, title IX of the Education Amendments of 1972 Adherence to Medicaid Contract Policy #: C-3.01 Approved: Review Date: Page 2 of 6

3 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973 and the Americans with Disabilities Act; and (2) take complaints and grievances clients alleging nondiscrimination violations based on race, color, national origin, physical or mental disability, or age; and (3) will maintain a Methods of Administration Plan. Coordination: Policy C 4.34 Primary Service Coordinators Transferring Clients to New PSC s. Clinical Records Policy C 1.01 Clinical Records: Tracking, Storage, Security, Content, Placement, Retention and Destruction Third Party Collections Policy C 2.06 Clinical Authorization to Bill Third Party Fraud and Abuse: Policy C Fraud and Abuse. Maintain a mandatory compliance plan designed to guard against fraud and abuse. Policy A 1.10 Selection and Retention Corporate Compliance Plan. Note: Included in Medicaid Performance Report. Fraud and Abuse forms are submitted and tracked. Notice of Subcontractor Termination: Policy C 3.14 Termination of Contracted Outside Provider. Policy C 4.34 Primary Service Coordinators Transferring Clients to New PSC s. Article V: Information Requirements Medicaid Member Handbook. Policy C 3.02 Medicaid Member Handbook. Policy C 3.10 Readability of Documents - Ensure vital enrollee informational and instruction materials meet specific readability levels. Production and Distribution of Medicaid Member Handbooks to Medicaid Enrollees. During admissions, staff explain the information in the handbook. Staff draw particular attention to the sections of the handbook regarding access to emergency services, transportation, obtaining services from providers and other providers, filing appeals and grievances. Staff document through the client s signature that the Medicaid Member Handbook has been explained and given to the enrollee or the enrollee s parent, legal guardian, or representative. The enrollee s signed document is placed in the client s clinical record. The handbook is available on audio tape or compact disc (CD) in either English or Spanish (upon request) The handbook is also available electronically so that individuals are able to use the "zoom in" feature to get a close-up view of the handbook. WMH purchases and provides copies of the handbook to the Utah State Mail Services who mails a copy to all Medicaid Enrollees when they apply for Medicaid benefits. Notice of Change of Information WMH has developed a Medicaid Member Handbook Revision Notice form (#A 8.0) Adherence to Medicaid Contract Policy #: C-3.01 Approved: Review Date: Page 3 of 6

4 Article VI: Enrollee Rights and Protections Listed in the Medicaid Member Handbook. Policy C 3.05 Client Rights. Policy C 2.08 Professional Ethics Standards. Policy C 9.01 Electroconvulsive Therapy Provider Enrollee Communications VII, D, 1-4 Included in the outside provider contract attached to policy C-4.31 Intake, Recovery Planning, Discharge Services by Outside Provider. Article VII: Delivery Network Policy A 1.10 Selection and Retention of Employees, Contracted Providers, Vendors, Volunteers. Includes Provider Selection and Network Management, Credentialing and Recedentialing of Providers, Nondiscrimination, Excluded Entities and Providers. NOTE: Policy includes notice template to send to contract (outside providers) when WMH has decided to discontinue contracting. Subcontracts for Covered Services Policy C 4.31 Intake, Recovery Planning, and Discharge Services for Medicaid Clients-Outside Providers. Article VIII: Program Integrity Requirements Policy C 3.13 Fraud and Abuse Prevention and Reporting Article IX: Quality Assessment and Performance Improvement Policy C 3.07 QAPI. Related Policies: Policy A Fatality Reporting Review. Policy A Provider Selection and Retention. Policy C Client Access to Treatment Performance Standards. Policy C Peer and Electronic Record Review. Policy C Intake, Recovery Planning, Discharge Services Inhouse Provider. Policy C Medicaid Enrollee Actions and Grievance System. Policy C Preferred Practice Guidelines. Recognize the preferred practice guidelines developed by the Division of substance Abuse and Mental Health Policy HR Cultural Competency Plan. Policy C 3.08 Medicaid Enrollee Grievances Policy C 3.08b Medicaid Actions and Appeals Reviews for Underutilization and Overutilization Policy C-3.12 Peer and Electronic Record Review. NOTE: Meeting Minutes for Subcommittees are tracked. Adherence to Medicaid Contract Policy #: C-3.01 Approved: Review Date: Page 4 of 6

5 Article X: Authorization of Services Internal Intake System Policy C 3.06 Client Access to Treatment Performance Standards. Standard Service Authorization Decisions Expedited Service Authorization Decisions Compensation for Utilization Management (Authorization) Activities Policy C Intake, Recovery Planning, Discharge Services Inhouse Provider. Note: Policies state WMH shall ensure that utilization management activities are not structured in such a way as to provide incentives to any individual or entity to deny, limit, or discontinue medically necessary mental health services to any Enrollee. Article XI: Actions and Notice of Action Medicaid Member Handbook Policy C 3.08 Medicaid Enrollee Grievances Policy C 3.08b Medicaid Actions and Appeals Policy C 3.06 Client Access to Treatment Performance Standards. Policy F 1.07 Action to Deny Claim Payment. Article XII: Grievance Systems Medicaid Member Handbook Policy C 3.08 Medicaid Enrollee Grievances Article XIII: Compliance Monitoring Audits Article XIV: Reports and Data Policy A 1.05 PMHP 834 Eligibility. Policy A 1.06 Accuracy of Data. Reports Encounter Data Francis Quan Appeals and Grievances Leslie Olson Cultural Competency Summary Jim Fincher Performance Standards Francis Quan Adequate Capacity and Services - Jim Fincher Fraud and Abuse Included in Annual Performance Report Leslie Olson Article XV: Payment Rate Cells Premium Payments Error in Payments Adherence to Medicaid Contract Policy #: C-3.01 Approved: Review Date: Page 5 of 6

6 Premium Adjustments Status of Risk for Covered Services Article XVI: Recoupment of Disallowances or Overpayments No Policies and Procedures Article XVII: Termination of the Contract No Policies and Procedures Article XVIII: Confidentiality Applies to all HIPAA Privacy and Security Policies and Procedures Article XIX: Miscellaneous No Policies and Procedures Procedure: 1. The Director of Care Management Services shall maintain oversight responsibility for WMH s adherence to the enrollee, enrollee related services, and enrollee related reporting portions, of the contract. 2. The Director of Business and Financial Operations shall maintain oversight responsibility for WMH s adherence to the administrative, financial, and non-clinical reporting related portions of the contract, and ensure that the appropriate staff members receive sufficient training and supervision to maintain the contracted requirements. 3. The Director of Care Management and his/her designee shall develop web-based and live training curriculum, regarding provisions contained in the current version of the PMHP contract. Specific training for each department is the responsibility of the department program manager. 4. Upon completion of training, the staff member shall be required to sign a training log certifying that he or she received the training. The Privacy Officer or his/her designee will track and maintain all training logs for six years from the date of the training. Right to Change and/or Terminate Policy: Reasonable efforts will be made to keep employees informed of any changes in the policy; however, WMH reserves the right, in its sole discretion, to amend, replace, and/or terminate this policy at any time. Adherence to Medicaid Contract Policy #: C-3.01 Approved: Review Date: Page 6 of 6