Case Management Training 2005

1
Case Management Training 2005

• Individual and Family Developmental Disabilities
  Support Waiver

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Training Goals

• To enhance the knowledge of Case Management (CM)
  in areas of
• CM changes
• EPSDT
• Waiver enrollment process
• Case monitoring
• Transfers from MR to DD Waiver
• Service authorization
• Medicaid eligibility verification
• Billing

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EPSDT Contacts
Tammy Whitlock 804-225-4714 Email
epsdt_at_dmas.virginia.gov Managed Care Helpline for
MEDALLION and Medallion II (MCO) Enrollees
1-800-643-2273 Information also may be found on
the DMAS website at www.dmas.virginia.gov
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Case Management
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New Title

• Effective February 7, 2005 the title Support
  Coordinator has been replaced with Case Manager.

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Definition-Case Management (CM)

• Activities designed to assist a child or adult
  with DD to live in the community by . . .

accessing needed medical, psychiatric, social,
educational, vocational, residential,
institutional, and other supports
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Provider Qualifications

• Must have DMAS Participation Agreement for Case
  Management.
• Provider or contract agency must employ
  individuals who possess a combination of
  developmental disability work experience and
  relevant education.

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Provider Qualifications

• Individuals and organizations providing Case
  Management cannot be direct service providers for
  any DD Waiver service except CD Services
  Facilitation.

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Provider Qualifications

• The CM and SF cannot be the same individual
  providing both services to a DD waiver enrollee.
• CM must have back-up coverage when the CM is
  absent due to illness, injury, or vacation.

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Provider Qualifications 2005 Changes

• Effective 2/7/2005, new CMs must have
  undergraduate degree in a Human Services field.
• CMs who are employed by an organization must
  receive supervision within the same organization
  every 3 months.
• Self-employed CMs must obtain one hour of
  documented supervision every 3 months.

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Provider Qualifications 2005 Changes

• The supervisor to the CM must have a Masters
  Degree in Human Services field or 5 years
  experience working with individuals with related
  conditions.
• CM provider cannot supervise another CM provider.
  
• Supervision must be documented in CMs personnel
  record.

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Provider Qualifications 2005 Changes

• CMs must have 8 hours of training annually in one
  or more area described in the Knowledge Skills
  Abilities (KSAs).
• Parents, spouses or any person living with the
  individual may not provide direct CM services for
  their child, spouse or the individual with whom
  they live.

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Provider Qualifications 2005 Changes

• CM cannot provide services to their own child,
  spouse, or individuals living in the same
  household as the CM.
• CM may provide service facilitation(SF) for the
  individuals on their caseload, if the enrollee
  chooses.

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Provider Qualifications 2005 Changes

• When a CM does not provide SF, the CM must assist
  the individual to choose a SF.
• Person Centered Planning- a process, directed by
  the family or the individual with long term care
  needs, intended to identify the strengths,
  capacities, preferences, needs and desired
  outcomes of the individual.

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Provider Qualifications 2005 Changes

• Plan of Care (POC)- Formerly CSP, document
  developed by the individual and/or
  family/caregiver of the individual
• Addresses all needs of the individual for home
  and community-based waiver services, in all life
  areas.

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2005 Service Changes

• Therapeutic Consultation- Behavioral consultation
  is no longer offered through DD waiver.
• Individuals Behavioral plans are now developed
  by the Social Worker under DD waiver.

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Case Management Activities

• Submitting the Patient Information Form
  (DMAS-122) to the local DSS
• Linking the consumer to services or institutional
  placement

• Coordinating the initial assessment, revisions
  and reassessments timely
• Coordinating services and treatment planning

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Case Management Activities

• Does not include performing medical and
  psychiatric assessment but does include referral
  for such assessments

19
Case Management Activities

• Monitoring implementation of all services
• Networking with other CMs
• Instruction and counseling
• Coordination of transfers

• Enhancing opportunities for community integration
• Making collateral contacts
• Mandatory site visits and home visits

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Case Management Activities

• Assisting the individual directly for the purpose
  of developing or obtaining needed resources,
  including crisis supports.
• Monitoring the quality of care provided for all
  services.

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Waiver Approval Process
22
Individual CHOICE of Provider

• CM must inform the individual of all available
  waiver service providers in the community in
  which he/she desires services.
• The individual shall have the option of selecting
  provider of his/her choice including CM.
• Choice must be documented and in the individuals
  record.

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Waiver Approval Process

• Accessing Waiver Services
• Once the screening team has determined an
  individual to be eligible for DD Waiver services,
  the screening team will provide the individual
  with a list of available CMs.

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Waiver Approval Process

• The individual will choose a CM within ten
  calendar days of the screening the screening
  team will forward the screening materials to the
  selected CM.
• The CM will contact the individual within ten
  calendar days of receipt of screening materials.

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Waiver Approval Process (cont.)

• The Case Manager and the individual will meet
  within 30 calendar days to discuss
• Individuals needs
• Existing supports
• Develop an initial Plan of Care (POC) which will
  identify services needed
• Estimate the annual cost of the individuals POC.

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Waiver Approval Process

• DMAS Health Care Coordinators manage the case if
  the individuals annual waiver cost is expected
  to exceed the average annual cost of ICF-MR care.

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Waiver Approval Process

• Once DMAS approves the Plan of Care, the Case
  Manager must contact DMAS to receive prior
  authorization to enroll the individual into the
  waiver service(s).

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Waiver Approval Process

• Step 1 DMAS authorizes funding for services on
  the POC and notifies CM.
• Step 2 CM notifies enrolled individual to choose
  service providers.
• Step 3 CM submits request for preauthorization
  of service(s) to DMAS

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Waiver Approval Process

• Each service provider must submit supporting
  documentation to the CM for the development of
  the POC.
• The CM assesses the POC and supporting
  documentation to ensure that all providers are
  working toward the identified goals of the
  individual.

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Waiver Approval Process

• The individual will be notified by DMAS when
  there is no available funding and the individual
  will be placed on the waiting list until funding
  is available.

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Remember to ask Questions?
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Plan of Care (POC)
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Plan of Care (POC)

• Organizes and describes the type, intensity and
  frequency of services and the necessary supports
  for meeting an individuals goals for living
  successfully in the community.
• An individualized approach should be utilized to
  ensure that functional supports are identified,
  as well as the individual's desired outcomes.

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POC (DMAS-456)

• Is developed by the CM, but is a responsibility
  shared with the individual (or legal
  guardian/family caregiver if applicable), family
  members, and service providers.
• Factors to be considered when developing this
  plan must include the individuals age, primary
  disability, and level of functioning.

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Case Management Goals

• Supporting Documentation (a component of the POC)
  which identifies the case management objectives
  and activities necessary to carry out the plan.
  It also identifies time frames for meeting goals.
  
• Example CM will assist Mary Doe with her Social
  Security and Medicaid benefits as needed by
  9/30/05.

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Examples of Goals

• The CM will monitor Marys progress in her Day
  Program, assure the appropriateness of services
  and Marys satisfaction with services. This will
  be assessed quarterly, or more frequently as
  needs change.

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Example of Goals

• CM will link Mary to a local physician who
  accepts Medicaid and assist to schedule an
  appointment by 1/15/06.

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Social Assessment

• Comprehensive assessment process must be
  completed to determine the individuals need for
  services and supports and the outcomes desired
  from the services.
• Must be updated annually with any changes that
  have occurred during the POC year.

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Social Assessment

• Assessment includes the individuals strengths,
  personal preferences and desires, and previous
  services or supports, significant life changes
  that may or may not have been successful.

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Social Assessment

• The assessment addresses the current status and
  changes from the previous annual assessment of
  the individual in the following areas
• Physical or Mental Health, Personal Safety, and
  Behavioral Issues.

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Social Assessment

• Financial, Insurance, Transportation, and other
  Resources
• Home and Daily Living Issues
• Education and Vocation
• Leisure and Recreation
• Relationships and Social Supports
• Legal Issues and Guardianship and
• Individual Empowerment, Advocacy, and
  Volunteerism.

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Social Assessment Updates

• The updated Social Assessment must include all of
  the areas addressed in the initial assessment.
• The Social Assessment must be an ongoing account
  of what is happening in the individuals life.

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Social Assessments Updates

• Examples include
• Progress, or lack of progress
• Changes in the individuals life, whether
  positive or negative
• Medical changes, including list of medications,
  and all medication changes
• Changes within the family, social dynamics
• Psychological evaluations and
• Status in school, IEP updates, etc.

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Social Assessment Tips

• Are the physicians and mental health providers on
  the same page?
• Are meetings or correspondence taking place
  between providers?
• Is there a need to refer for a medical
  evaluation?

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Social Assessments Updates

• Discussion Questions
• Why does this document need to be updated
  annually with the following areas addressed?
• Should anyone be able to pick up the social
  assessment and know whats going on with the
  individual? Why?

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Supporting Documentation
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Supporting Documentation Form (DMAS-457)

• Includes comprehensive assessment of the
  individual including functioning levels, goal
  attainments and the reasons for beginning,
  continuing, or ending services.
• Describes long and short term goals and any
  modalities for achieving those goals.
• Frequency and duration of services is outlined
  and signed by each provider.

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The DMAS-457

• The specific justification for each service must
  be well documented on the 457 to receive initial
  and ongoing service approval from DMAS.

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Supporting Documentation

• Supporting documentation must justify any
  increase or decrease in service(s).
• If there is a change in service(s), this must be
  documented.

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The 457 with AT/EM Requests

• CMs must include specific information about
  equipment and a quoted price from a potential
  vendor on the 457 or include an addendum/specs
  form for each request.
• Locate the vendor, call for a price quote and
  submit the quote to DMAS for the items requested.
  
• Without specific amounts for those items the AT
  or EM on the POC will not be approved!
• Request DME (including some AT items) through SPO
  before requesting through DD Waiver.

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Provider Documentation to Case Management

• Each service provider will submit supporting
  documentation (457) and schedule of each service
  to the CM for the development of the POC.
• The CM will monitor the POC and supporting
  documentation to assure that all providers are
  working toward the identified goals of the
  individual.

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Incomplete Enrollment Requests

• If additional information is needed, DMAS staff
  will submit a written request for missing
  information to the CM.
• CM needs to obtain additional information - not
  responsibility of individual/family or DMAS to
  obtain.

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Incomplete Enrollment Requests

• The individual will not be enrolled or placed on
  the waiting list until all information required
  by DMAS is received.

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Enrollment is Completed

• The CM will receive a copy of the eligibility
  letter and will forward this to the local DSS
  with the eligibility notification form and the
  DMAS 122 as notification that the individual
  meets Medicaid eligibility using institutional
  criteria.
• Once DMAS-122 is completed and received by CM,
  send a copy to DMAS Health Care Coordinator so
  enrollment in the DD Waiver can be completed.

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DMAS-122 and Case Management Responsibilities

• DSS will send the DMAS 122 to the CM once
  eligibility is verified.
• DMAS 122 will note any patient pay obligations.
• Once received, CM will inform DMAS, the
  individual or the family so services listed in
  the POC can be initiated.

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DMAS-122 and Support Coordinator Responsibilities

• Services for the DD Waiver CANNOT BEGIN until the
  CM receives a completed DMAS-122 from DSS.
• The service provider with the greatest number of
  hours or units of DD Waiver services will be
  designated as collector of patient pay.

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DMAS-122 and Case Management Responsibilities

• CM will distribute copies of DMAS-122 to all
  service providers and maintain a copy.
• If a consumer-directed service will collect the
  patient pay, forward a copy of the DMAS-122 to
  DMAS Fiscal Agent when requesting authorization
  of services.

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DMAS-122 and Case Management Responsibilities

• CM must update DMAS 122s when
• An individual has a change in address
• A different agency will be providing CM services
• There is an increase or decrease in monthly
  income or
• Death
• DSS is responsible for notifying the CM when the
  individual no longer meets Medicaid eligibility
  requirements.

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Extension Letters

• If services are not initiated within 60 days, the
  CM must submit information to DMAS demonstrating
  why more time is needed to initiate services.
• DMAS has the authority to approve or deny the
  request in 30 day increments.
• DMAS must receive the extension letter within the
  30 day extension period.

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Monitoring
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Monitoring of Service Needs

• 1.Quarterly/Semi-Annual Reviews must be written
  to include the following
• CM reviews ALL DD waiver services listed on the
  POC in addition to CM.
• Information for revisions to POC address general
  status of individual (Ex. Goals met and date
  met).
• Significant events
• Individual and family satisfaction with
  all services.

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Monitoring

• If sporadic or temporary services were provided,
  the CM is required to obtain details of the
  services from the provider and include
  information in the quarterly report.

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Monitoring of Service NeedCase Management
Responsibilities

• Continuously monitor the appropriateness of the
  POC and make revisions as requested or needed by
  the individual, and in conjunction with the
  provider(s).
• CM must have documented monthly activity
  regarding the individual and a minimum of a
  face-to-face contact every ninety (90) days for
  active cases.

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Monitoring

• Renewals
• The renewal POC must be completed prior to
  reauthorization of all services. DMAS must have
  this information 30 days prior to the POC
  expiration date. Information included on 457 and
  social assessment must reflect goals attained and
  new goals for renewal POC year.
• Approval date of the new POC does not begin
  until the previous one expires.

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Monitoring

• All service providers must complete a written
  semiannual review in conjunction with the
  individual, and forward it to the CM within the
  agreed upon time frame.

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Please ask Questions?
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Modifications to POC Year

• Revisions
• If the individuals needs change or there is a
  request for change in services, individual
  providers can make revisions to the goals,
  objectives, and strategies of the supporting
  documentation at any time during the POC year.

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Modifications to POC Year

• A new "Provider Choice" form is needed along with
  an updated social assessment and an updated
  document of agreement (signature page).
• CMs can add a new service (supporting
  documentation) to an existing POC at any time
  during the POC year. The end date and semi-annual
  review dates must coincide with POC year.

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Modifications to POC Year

• With a reduction or termination of services, the
  CM is required to send the individual a Right to
  Appeal letter.
• If there are no changes during the POC year in
  the total hours or units, no new supporting
  documentation is needed.
• Every 365 days, or 366 in a leap year, a new POC
  is required (30 days prior to the current POC
  expiration date).

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Modifications to POC Year

• Supporting documentation and the POC must be
  forwarded to DMAS within 10 calendar days of the
  revision date. If not received within 10 calendar
  days, then the date the plan is received at DMAS
  is the effective date of the plan.

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Modification to POC Year

• If the individual and team, in collaboration with
  the CM, agrees to the changes, then the POC is
  revised and an effective date for the change is
  stated on the POC.
• If the total hours or units change at any time
  during the POC year (additional services,
  increases or decreases in services),
  authorization is required prior to
  implementation.

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Revisions and Renewals

• Plans without the individual and CM updated
  signatures are invalid.
• Urgent- Priority Please
• Remember 14 calendar days for plans and 10 days
  for Preauthorization Requests.

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Renewal of the Services

• Since most service approvals are now open ended,
  it is imperative to receive ongoing approval for
  services on the POC prior to the end of the
  existing POC year.
• Existing authorizations will be ended for all
  non-approved services, or if the POC lapses.

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Renewal of the Services

• All provider documentation must be completed
  according to DMAS program standards.
• Selected services will require annual pre
  authorization, but most will be open ended as
  long as they remain active on the current POC.

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Renewal of the Services

• Review all supporting documentation to make sure
  each service meets DMAS definition of that
  service.
• The CM acts as a filter to manage the service
  requests and answer any questions. The CM also
  ensures the providers are submitting the
  appropriate documentation.
• Ensure the completion of all provider plans
  include updated signatures from the individual
  and provider(s).

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Renewal of the Services

• Please include the necessary details describing
  any new or unusual service requests

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Renewal Includes All Necessary Information

• Use the need information form
• (DMAS 454 handout)
• as a guide for sending complete supporting
  documentation with the POC.
• Review each service for documentation needed from
  the providers for the POC renewal.

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Renewal of Services

• High service hours must be documented to justify
  why the hours are needed.
• Investigate and document other attempted
  resources and why these cannot be utilized.
• Document choice of service omissions which
  would ordinarily meet the need of the individual
  (why isnt Day Support being used?)

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Renewal of the Services

• AT and EM requests should have the vendor quote
  and the evaluation for each item included in the
  renewal plan.
• Dont forget the vendor is the individuals
  choice not CM assignment or recommendation.
• If it is not complete, send a revision with a
  complete request later.

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Renewal of the Services

• Selected services will require annual pre
  authorization, but most will be continued as an
  open ended PA as long as the service remains on
  the current POC.
• This will increase efficiency for CMs, providers
  and enrolled individuals, however the information
  needs to be complete for the continuation of
  services for the individual.

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Modifications to POC Year

• Termination of services requires a termination
  POC and a DMAS 122 with end dates and reason for
  termination.

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Modification to POC Year

• Interruption of services when the individual
  enters an institutional setting, including
  nursing home, inpatient rehabilitation facility,
  long stay hospital (greater than 30 days), or
  ICFMR.
• CM needs to notify local DSS and DMAS via DMAS
  122 and note the reason.
• An interruption POC is required with
  communication and notification to DMAS.

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Modification to POC Year

• If resuming services within 90 days of facility
  discharge, the CM is required to forward a
  revised DMAS 122 to DMAS and DSS.
• Any individuals who no longer meet Level of Care
  criteria must be referred to DMAS.

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Plan Of Care

• Tips for Smooth Sailing

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Smooth Sailing Tips

• Submit all required documentation in accordance
  to the specific service.
• Team (individual, providers, CM) assures
  documentation clearly identifies the individuals
  needs.
• CMs responsibility to review and assure accuracy
  of all documents to secure services for the
  individual.

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Smooth Sailing Tips
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Monitoring

• If there is evidence that the individual, family,
  or primary caregiver are dissatisfied with
  services, services are not delivered as described
  in the POC, or the individuals health and
  safety are at risk, the CM must take necessary
  actions and document the results in the
  individuals record.

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Monitoring (cont.)

• Necessary actions include requesting a written
  response from the provider.
• Informing the individual of other providers of
  the service, and informing the individual that
  eligibility may be in jeopardy should he or she
  choose to continue receiving services from a
  provider who cannot ensure health and safety.

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Monitoring (cont.)

• Reporting the information to the appropriate
  licensing, certifying or approving agency,
  DMHMRSAS, and DMAS.
• Any time abuse or neglect is suspected, the CM is
  required to inform the local Department of Social
  Services Child Protective Services or Adult
  Protective Services unit.

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Purpose of the Face to Face

• CM must observe the individuals status.
• Verification that services are being provided.
• Assessment of the individuals satisfaction with
  services.
• Determining any unmet needs or changes to the
  POC.

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Documentation of the Face to Face Visit

• Documentation must clearly state the CM was in
  the presence of the individual receiving
  services.

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Face to Face Contact Example

• Spoke with Mary today. Asked her if she was
  satisfied with her services. She said,yes.
  Told me she had taken a bath today. Staff
  reported that she had refused to eat breakfast
  for the past 2 mornings. No additional needs
  noted. Anita Baker , CM 10/1/03
• Is this appropriate Face to Face(FF) note? If
  not, why?

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Example of Face to Face Note

• FF Observed Mary in her home making lunch with
  help from in home staff . Was neatly dressed
  smiled while working with staff. Stated that she
  really liked living at her new home, especially
  when they went to the movies. Asked if CM could
  help her find a day support center to attend.
  Agreed to set up times for her to meet and talk
  with providers. Anita Baker, CM 10/1/03
• Is this an appropriate FF note?

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Monitoring of Service Need

• A minimum of one scheduled or unscheduled contact
  or communication per month is required for active
  cases.
• This contact must reflect progress in the
  individuals status and, as appropriate, toward
  the goals on the supporting documentation (457).
  Examples monitoring service delivery,
  investigating a complaint, etc. and consist of
  more than a telephone call to check on the status
  of the individual.

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Monitoring of Service Need

• The local DSS also reviews the individuals
  Medicaid eligibility every twelve months.

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Case Management Chart
97
Case Management Individual Charts

• Medical physicals, medications
• Psychological necessary if existing assessment
  fails to reflect current psychological status,
  cognitive abilities and adaptive functioning
• Functional Plan of Care
• Social Assessment updated annually
• Level of Functioning LOF

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Case ManagementIndividual Charts

• 6. All service providers documentation must be
  reviewed and maintained in CM record for a period
  of not less then five years from start of DD
  Waiver services.
• 7. Must be documentation of Choice of
  Service Providers.
• 8. Copy of your agencys consent form.
• 9. Current DMAS-122.

99
Case Management Documentation

• 10. Ongoing Documentation
• 11. Quarterly/Semiannual Reviews
• 12. Annual Update of POCs
• 13. Right to Appeal letters
• 14. Choice between Institutional Care or Home and
  Community Based Services

100
Case Notes

• Ongoing documentation, in the form of case notes,
  must indicate the dates, services, and nature of
  CM rendered.
• All relevant communication with the providers,
  individual, DMAS and other state agencies, or
  other related parties must be documented in the
  case notes.

101
Example of Case Notes

• 3/15/03- Received a copy of Marys new physical
  from Day Support staff. The latest tests show
  her cholesterol levels are within normal range.
  She has lost 10 lbs. in the last 6 months. Will
  continue to monitor Day Support, cholesterol and
  weight loss. Anita Baker 03/16/03

102
Example of Case Notes

• 3/30/03- Scheduled Marys annual POC meeting for
  6/15/04. Received third quarter review from Free
  House reviewed for upcoming staffing. She
  remains on target for all objectives. Note to CM
  looking for quarterly to reflect change. Anita
  Baker 10/1/03
• This note was not done within a timely manner
  (this would be an overpayment if reviewed by UR)

103
Transfer of Case Management

• If individual indicates interest in switching
  CMs, the current CM is responsible for
• Sending the individual a recent listing of
  available CMs.
• Informing the individual that they need written
  permission to exchange information (A copy of
  your agencys Consent Form).

104
Transfer of Case Manager

• When individual has selected another CM and
  provided consent to exchange information,
  existing CM copies complete record and forwards
  to new CM.
• CM needs to follow-up with phone call and
  document that they updated the new CM on the
  case.
• Inform DMAS and individual in writing of the
  change (fax is fine).

105
Transfers From Other Waivers

• From EDCD Waiver
• Contact current provider agency.
• Current provider must send DMAS 122 to WVMI with
  last date services provided.
• Get a copy of 122 and WVMI fax.
• Notify Department of Social Services via 122 that
  individual now has DD waiver.
• Send DMAS new 122 from DSS in order to enroll.

106
Transfers from Nursing Home

• CM contact Nursing Home.
• Nursing Home fills out 122 with end date and
  sends to DSS.
• DSS fills out 122.
• CM sends 122 to DMAS with PA request saying
  urgent to enroll.
• POC date will start the next day after discharge.

107
The Preauthorization Process
108
Why is Preauthorization Needed?

• The purpose of preauthorization (PA) is to
  ensure that services are delivered in a cost
  effective manner and that service programming
  matches the intent of the Plan of Care.

109
Definitions

• PA Pre-authorization of services (after the POC
  is approved). Individual must be enrolled.
• PA - eleven-digit number generated by VaMMIS
  system.
• DMAS 455-A - IFDDS Waiver Request for Services
  Form.

110
Definitions, continued

• Procedure code represents a specific service
  being requested. Contains 5 characters, alpha and
  numeric or only numeric. Some codes also have 2
  character modifiers.
• DME Durable Medical Equipment (includes durable
  equipment and disposable supplies).
• PA Action Reason Code 4 digit number entered by
  the analyst into the VaMMIS system that generates
  a statement identifying analysts decision.

111
Where Does My Request Go?

• Clerical
• Documents the date the request is received on the
  DMAS 455-A. Determines status of request
  (duplicate, complete, etc.)
• Does the request contain the necessary forms?
• Analyst Review
• Does the service requested meet criteria?
• Decision is made by analyst and entered into
  VaMMIS and authorization database.

112
Which Services Require PA?

• Adult Companion Care/ Agency CD
• Assistive Technology
• Personal Care (Agency CD)
• Respite (Agency CD)
• Crisis Stabilization
• Day Support/ Prevocational
• Environmental Modifications
• Family Caregiver Training

113
Services Requiring PA

• In-home Residential Support
• PERS
• Skilled Nursing
• Supported Employment
• Therapeutic Consultation

114
When to Request PA

• After DMAS enrollment and before service begins
• Preauthorization is not granted retrospectively.
• Exception Consumer Directed Services. Personal
  Care, Respite and Crisis Stabilization, as
  defined in manual. CS request must be received by
  DMAS within 72 business hours of the start date
  in order to receive authorization beginning on
  the requested date.

115
Where Do I Request PA?

• Request must be submitted to DMAS by the
  individuals CM. Requests submitted by
  individual providers will be rejected.
• Fax [phone]
• Mail DD Waiver Unit
• 600 East Broad Street
• Richmond, VA 23219

116
Completion of DD Waiver Request for Services Form

• Complete individuals information.
• Complete CM Provider Name and Contact Person at
  CM company.
• Complete Service Provider Information
• Complete Procedure Code
• Complete units requested See Procedure code
  list to determine how to complete form
• Complete dates of service requested

117
Types of PA Requests

• New - Dates of services that have not been
  previously requested, or the request was
  previously rejected (4000-4999 action reason
  codes).
• Change to approval- Only for an existing PA! Need
  to increase units, decrease units or end service
  under that provider and PA for previously
  approved dates of service. The PA number must be
  indicated on the 455-A.
• Pend Response information that was missing in
  the original request for services. If no response
  to pend, it will be rejected.
• Both use the DMAS 455-A

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Types of Decisions

• Approve Pend Deny Reject
• Reconsiderations and Appeals

119
Approvals

• Information submitted is complete and
  documentation submitted demonstrates request
  meets DMAS regulatory criteria for the service.
• Indicated by A on the DMAS 455-A
• Official copy of authorization is
  Preauthorization Activity Report generated by
  VaMMIS. (White page, usually horizontal)
• Authorization generated by VaMMIS is sent to CM,
  service provider, and individual.

120
Pends

• Cover sheet information complete and
  documentation submitted not complete.
• Indicated by P on DD Waiver Requests for
  services form.
• Do not need to wait for pend letter to act upon
  pended request.
• Letter generated by VaMMIS is sent to CM, and
  service provider.

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More Pend Info

• A pend is NOT a denial
• Action to be taken CM must submit information
  requested within 10 days of date on pend letter.
  If response not received within 10 business days,
  it will be rejected.
• If information submitted as pend response is not
  information requested then request will be
  rejected. Do not pend twice for the same issue.
• Pend letters generated by VaMMIS are sent to CM,
  and service provider.

122
Reject

• Cover sheet information or justification
  incomplete.
• Indicated by R on DD Waiver Requests for
  services form.
• Letter generated by VaMMIS is sent to CM, and
  service provider.
• NOT a denial.
• May resubmit without penalty.

123
More Reject Info

• Action to be taken
• If request is rejected because DD Waiver Request
  for Services Form or justification is incomplete,
  complete/correct information and resubmit entire
  package.
• Some reject codes indicate that the service is
  covered through another Outpatient Service such
  as Outpatient Rehabilitation or DME. The service
  provider must submit a request directly to that
  department.

124
Rejections Related to DD Waiver Request for
Services Form

• If any of the following items on the fax cover
  sheet are not completed your request will be
  rejected and you must resubmit the entire package
  for review. The analyst will not review your
  request.
• Recipient Medicaid Number and SSN
• CM Provider number
• Service Provider Name and Provider number

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Reasons for Rejects, Continued

• Procedure code submitted must be in National Code
  format.
• Always request in 1-unit if requesting
  Environmental Modifications or Assistive
  Technology.
• Effective From and Thru Dates
• CD and Agency Respite Thru Date always 12/31/YR
• All other services thru date must end on or
  before the last date prior to Anniversary Date
  (Date of enrollment into the Waiver).

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Denials

• May request reconsideration or appeal.
• Documentation submitted is incomplete or the
  request does not meet DMAS criteria.
• Indicated by D on DD Waiver Requests for
  services form.
• Letter generated by VaMMIS is sent to CM, service
  provider, and individual. Appeal rights are
  included in this letter.

127
Reconsideration

• Denials - the provider may request
  reconsideration within 30 days of the date of
  denial by writing to
• Supervisor, DD Waiver Unit
• Department of Medical Assistance Services
• 600 East Broad Street, Suite 1300
• Richmond, VA 23219
• Or by faxing request to Supervisor, Behavioral
  Health and Developmental Disabilities Unit
• _at_804-371-4986

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Appeals

• If a reconsideration is upheld a written request
  for appeal may be submitted to
• Director, Appeals Division
• Department of Medical Assistance Services
• 600 East Broad Street, Suite 1300
• Richmond, Virginia 23219

129
Submitting Documentation

• Tips for Smooth Sailing

130
Smooth Sailing

• DMAS has 10 business days to process service
  authorization requests.
• Plan ahead!

131
Tips for Smooth Sailing

• Check individual eligibility monthly, especially
  prior to submitting a request.
• Assure all requested services are approved on the
  most current POC.
• Ensure that the need for the service is indicated
  on the LOF and Social Assessment.

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Smooth Sailing

• Always send the request at least two weeks prior
  to the proposed start of services.

133
more smooth sailing

• Meet with the provider prior to service
  initiation.
• Coordinate start dates with the individual,
  provider and other agencies involved prior to
  requesting preauthorization for services.

134
more smooth sailing

• Assure that the provider number is the correct
  number for the service being requesting.
• Request hours/units in weekly increments.
• Include a description and cost for Assistive
  Technology and Environmental Modification
  requests.

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136
Procedure Codes and the Paper Trail

• Refer to your IFDDS Waiver procedure code list.

137
Got Questions?
138
Part II Case Management Training

• To enhance the knowledge of CM in areas of
• Utilization Review
• Pre Authorization
• Level of Functioning
• Intermediate Care Facilities for Mentally
  Retarded
• Utilization of Home Health

139
ICF/MR Referral Process

• Linking, coordinating, assessing, locating,
  enhancing community integration, developing or
  obtaining needed services.

140
ICF/MR Referral Process

• Referrals for ICF/MR are coordinated by the CM.
• This is linking the individual to a service need.

141
ICF/MR Referral Process

• Call potential ICF/MR and ask if they are
  licensed in their state as an Intermediate Care
  Facility for persons with Mental Retardation or
  (ICF/MR).
• This is a different license than group homes or
  residential treatment, it is specific to Federal
  ICF criteria.

142
ICF/MR Referral Process

• If they are licensed as an ICF, then identify the
  contact person for the state licensing agency.

143
ICF Process

• Determine if there are beds available or if one
  will become available.
• Have family sign authorization to exchange
  information with ICFMR and DMAS.
• Identify the ICF agency contact in order for DMAS
  to begin the contract negotiations with that
  ICF/MR.
• Placements may in or out of state.

144
ICF Contract Process

• DMAS will contact ICF/MR licensing agency to send
  us the licensure and certification requirements
  for ICF/MR. Once it is determined that licensing
  is comparable with Virginias ICF license
  requirements, then the process is easier for
  future placements in that state.

145
ICF Process

• The family may apply for services at the ICF
  after the contract is successfully negotiated
  through DMAS.
• Always consider other waiver options such as
  crisis intervention or a sponsored residential
  placement for the individual.

146
QUESTIONS?

• Please ask any questions you may have at this
  time pertaining to any part of this training.

147
What to Expect During a Utilization Review

• Department of Medical Assistance Services

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What Generates a Review

• Statewide Sample
• A computer generated list is created and reviews
  are scheduled randomly.
• Complaints
• DMAS receives a concern regarding services from a
  constituent.

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Utilization Review

• Unannounced
• May be on-site or desk review
• May include
• observation of service delivery,
• face to face or telephone interviews with the
  consumer and caregivers.
• Usually 1 3 days in length
• depends on size of review sample

150
Utilization Review (contd)

• Upon Arrival, Analyst Will
• Request charts be gathered together in a central
  location.
• Secure a workplace to conduct the review.

151
Utilization Review (contd)

• During the review
• Analyst may ask questions regarding your
  documentation.
• Analyst will let you know how long the review
  will last and time of the Exit Conference.

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152
Utilization Review (contd)

• Exit Conference will occur on the last day of the
  review.
• You may have any of your staff attend.

153
Items to be Reviewed

• Assessments
• Plan Of Care (CSP)
• Supporting Documentation (457)
• Quarterly/Semiannual Reports
• Patient Pay (DMAS-122)

154
Items to be Reviewed

• Individual records
• Appropriate data, contact notes, or progress
  notes
• Personnel files

155
Patient-Pay Requirements

• If there is a patient-pay, and the provider is
  designated to collect any portion of it, it must
  be indicated on the HCFA-1500.
• A copy of the current DMAS-122 (completed by DSS)
  should be in the consumers record.

156
Terminations

• Terminations of single Waiver services should be
  reflected on notification letters to consumers.
• Terminations of all Waiver services should be
  reflected on a completed DMAS-122.

157
Report Contents

• Technical Assistance
• Issues not in compliance with Medicaid policy
  that should be addressed by the provider
• Overpayment
• Situations in which the provider has failed to
  comply with federal and state regulations or
  policy guidelines.
• If licensure issues are found, the appropriate
  licensing agency will receive a copy.

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Possible Overpayment Reasons

• No documentation in the CM record that the
  consumer meets
• eligibility criteria
• functional criteria

159
Possible Overpayment Reasons (contd)

• Absence of adequate documentation to support
  services billed or the need for service
• Unqualified staff delivering the service
• Patient-pay errors

160
Other Options

• Reconsideration
• Request will be reviewed and response letter sent
  to provider.
• If denial is upheld, provider has the right to
  appeal.

161
Other Options (contd)

• Appeals
• Informal Fact Finding Conference (IFFC)
• Provider may request within 30 days of receipt of
  reconsideration decision.
• Formal Evidentiary Hearing
• Request must be made within 30 days of receipt of
  IFFC decision.

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Recent Findings Trends (contd)

• Essential components to a POC include
• Social Assessment
• primary goals and measurable outcomes desired by
  the consumer
• supporting documentation for each DD Waiver
  Service (including case management),
• a signature page or documentation of agreement by
  those participating in the development and
  implementation of the CSP.

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Recent Findings Trends

• POC is reviewed by the CM and updated annually
  and when changes or service modifications occur.
•  
• Social assessment completed no earlier than one
  year prior to start date of services and updated
  annually.
•  
• Documentation that demonstrates consumers
  receiving DD Waiver services are receiving any
  necessary medical care.

164
Recent Findings Trends

• Quarterly Reviews
• Should accurately reflect the individuals
  response for that quarter
• Documentation of reviewing this information with
  individual

165
Recent Findings Trends

• Monthly CM contact notes
• Staff signatures, dates, month and year
  documented entry. Individual full name or
  Medicaid number must be on all documents.
• Health and safety must be documented in POC.

166
Any Questions?