State of Florida Agency for Persons with Disabilities PRIOR SERVICE AUTHORIZATION PROCESS http:www.m

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State of FloridaAgency for Persons with
DisabilitiesPRIOR SERVICE AUTHORIZATION
PROCESShttp//www.maximus.com/flpsap
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Training Overview

• What Is PSA?
• PSA Staff
• Current Selection Criteria
• Revised Operational Guidelines
• Roles and Responsibilities
• PSA Process
• Reconsideration Reviews
• Expedited Reviews
• PSA Forms
• Documentation Requirements

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Training Overview, contd

• Review Considerations
• Medicaid Medical Necessity
• Florida Medical Necessity Conditions
• Service Justifications
• Activity Report as of 2/28/05
• Trends and Concerns
• Wrap-up
• Things to Remember
• Questions and Answers

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What Is PSA?

• Prior service authorization
• Is the service covered by the Waiver
• Is the service request within Waiver Coverage
  Limitations?
• Is it Medically Necessary?
• Is there another funding source?
• Requirement for all DD/HCBS Waiver Services
• MAXIMUS performs reviews that meet selection
  criteria

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PSA Program Staff

• Registered Nurse Reviewers
• Behavioral Reviewers
• Qualified Mental Retardation Professional (QMRP)
  Reviewers
• Physicians and Dentists
• Professional Qualifications and Background
• Developmental Disabilities Experience
• Professional Certifications (CBA, RN, PhD, Ed.D,
  LSCW)
• Psychologist
• Former service providers DD program staff

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Selection Criteria (4/16/04)

• APD guidelines establishing which cost plans and
  support plans are subject to review by the PSA
  Unit
• High Cost Plans over 77,975 annually
• Adult Dental more than 3,000
• Durable Medical Equipment over 5,000
• Environmental Accessibility Adaptations over
  12,000

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Selection Criteria, contd

• Behavior Analysis of more than 7,700
• Behavior Assistant of more than 18,750
• Private Duty Nursing of more than 77,975
• Skilled Nursing of more than 20,100
• Residential Nursing of more than 37,000
• Personal Care Assistance of more than 16,600
• Residential Habilitation of 6 hours or more per
  consumer per day

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Selection Criteria, contd

• Residential Habilitation live-in rate
• Residential Habilitation-Intensive Behavior

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Selection Criteria, contd

• Support/cost plans require review if they meet
  the specified selection criteria AND
• Individual is newly enrolled in waiver
• Individuals support plan/cost plan anniversary
  date
• Individuals needs change resulting in an
  amendment
• High-cost plans require review if there is any
  change to the cost plan

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Operational Guidelines

• Revised version effective April 15, 2005
• Outlines
• Roles and Responsibilities
• Operating Procedures
• Standardized Forms
• Documentation Requirements

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Roles Responsibilities

• Waiver Support Coordinators
• Attend PSA training
• Identify services or cost plans that meet current
  selection criteria
• Complete pertinent forms and assemble PSA
  requests
• Notify and collaborate with recipients and/or
  legal guardians on all matters regarding PSA
  reviews

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Roles Responsibilities contd

• Submit PSA review packets and Form 2 responses
  to PSA Program
• Submit copy of Form 1, annual support plan or
  support plan update to Area Office designee
• Work with service providers to obtain necessary
  documentation and justifications

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Roles Responsibilities contd

• Assist recipient and/or legal guardians with
  completion of Requests for Reconsideration and/or
  Medicaid Fair Hearing requests
• Keep recipients and/or legal guardians informed
  of all PSA matters specific to their request
• Assist recipients and/or legal guardians in
  understanding DD/HCBS waiver services,
  limitations and exclusions, and other funding
  mechanisms

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Roles Responsibilities Contd

• Area APD Office Staff
• Provide PSA training to new Area Office staff and
  Waiver Support Coordinators
• Notify WSCs regarding the outcome of the PSA
  reviews
• Act as liaison between the PSA Unit and all other
  parties

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Roles Responsibilities contd

• PSA Contractor
• Conduct two training sessions by Video
  Teleconference for APD staff and WSCs
• Conduct reviews of PSA requests
• Make determinations of approval, denial,
  reduction or termination of services based on
  DD/HCBS waiver coverage limitations/exclusions
  and medical necessity conditions

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Roles Responsibilities Contd

• Provide written notice to recipients or legal
  guardians regarding Notifications of Missing
  Information, denials, terminations and
  reductions, and the right to request a
  reconsideration and/or Medicaid Fair Hearing
• Complete reconsideration reviews
• Participate in Medicaid Fair Hearings

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Roles Responsibilities Contd

• Submit monthly report to Central APD Office
• Create, modify and maintain standardized forms
• Provide on-going technical assistance to APD
  staff regarding matters related to PSA reviews

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PSA Process

• WSC completes the PSA Request Form 1
• WSC gathers all required information and submits
  to PSA Program
• PSA Unit completes preliminary screening of PSA
  request for clarity and completeness
• If information is incomplete, PSA Unit issues a
  Notification of Missing Information (Form 2)

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PSA Process contd

• If information is complete, PSA Unit completes
  review within 10 business days
• If Form 2A is issued, WSC submits requested
  information within 10 business days
• High cost plans, denials, terminations and
  reductions
• Peer Review, MD or DDS Review

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PSA Process contd

• If response to a Notification of Missing
  Information is not received in 60 days, the PSA
  Unit will terminate/ deny the service being
  requested, in accordance with APD policy
• PSA Unit issues notification to Area APD when all
  services are approved

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PSA Process contd

• If a service is denied, reduced or terminated,
  PSA unit issues due process notification
• Individual and/or legal guardian may submit one
  Request for Reconsideration to PSA Unit and/or a
  request for a Medicaid Fair Hearing to the Area
  APD Office.

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Reconsideration Reviews

• Must be received within 14 days after due process
• Request for Reconsideration is assigned to a
  different review team
• No more than one Request for Reconsideration may
  be submitted per review
• Reconsideration requests and Medicaid Fair
  Hearings are two separate and distinct processes
• Reconsideration does not ensure same rights
  regarding continuing service as a Fair Hearing
  Request

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Expedited Reviews

• Reviews that need to be expedited due to
  emergency situations should be clearly marked
  across the top of the Form 1
• Expedited Reviews will be assigned to a review
  team right away
• Only true emergencies should be marked as
  Expedited Review and information submitted should
  indicate the reason

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PSA Forms

• Prior Service Authorization Request Form 1
• Lists documentation requirements for each service
• To be prepared by Waiver Support Coordinator
• Demographic information should be fully completed
• Each service requested for review should be
  clearly checked
• Box for new service or continuation should be
  checked
• Staff ratio of service should be checked if
  applicable

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PSA Forms contd

• Notification of Missing Information (Form 2A)
• Issued by the PSA Unit when incomplete or
  insufficient information is in the review packet
• Waiver Support Coordinator gathers requested
  information from service provider and submits a
  response to the APD Area Office, who forwards to
  the PSA Unit
• Under very rare circumstances, the PSA Unit will
  issue a Form 2B
• Service Denied/Terminated in accordance with APD
  procedures if no response received within 60 days

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PSA Forms contd

• Determination of Prior Authorization Review (Form
  3A)
• Issued by PSA Unit when a review is complete
• This form lists the services reviewed and
  provides a determination of approval, denial,
  approval with changes reduction, or termination
  for each service

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PSA Forms contd

• Determination of Prior Authorization Review (Form
  3B) Rationale and Recommendations for
  Reductions, Denials or Terminations
• Issued by PSA Unit along with a Form 3A for each
  service that resulted in an adverse decision
• Provides a narrative explaining the reason for
  reducing, denying or terminating a service

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PSA Forms contd

• Determination of Prior Authorization Review (Form
  3C) Lead Reviewer Notes
• Issued by PSA Unit when needing to communicate
  anything pertinent to the review that is not
  already included in one of the other forms

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PSA Forms contd

• Request for Reconsideration (Form 4)
• Prepared by the individual or legal guardian and
  the Waiver Support Coordinator
• Must contain additional information and
  justification not already included in the initial
  review packet
• Only one Request for Reconsideration may be
  submitted per review

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PSA Forms contd

• Determination of Reconsideration Review (Form
  5A)
• Issued by the PSA Unit
• Names the service(s) reconsidered, indicates
  initial determination and determination resulting
  from the reconsideration review

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PSA Forms contd

• Determination of Reconsideration Review (Form
  5B)
• Issued by the PSA Unit along with the Form 5A
• Contains a narrative describing the results of
  the reconsideration review and any
  recommendations that the lead reconsideration
  reviewer thinks are appropriate

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PSA Forms contd

• Notification of Closed Review (Form 6)
• Issued by the PSA Unit if a request submitted for
  review does not meet the selection criteria, if a
  cost plan expires while awaiting a response to a
  Notification of Missing Information, or if the
  APD Office asks for the review to be closed.

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Documentation Requirements

• All Requests
• Current Support Plan and annual summary, if
  applicable
• Indicating persons strengths and needs, progress
  made and continued need for the service(s)
• Indicating how each requested service supports
  the individuals desired outcomes
• Providing sufficient justification to establish
  the need for each requested service
• Listing coordination with other funding
  mechanisms (such as school system)
• Indicating availability of unpaid supports and
  other sources of coverage

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Documentation contd

• Providing a description or schedule of a
  representative week for services that require
  coordination (PCA, ADT, Residential Habilitation
  and NRSS), to demonstrate that services (both
  waiver and non-waiver) do not overlap and are not
  duplicative

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Documentation contd

• Cost Plan
• Ensure the cost plan is current on ABC
• Enter all requested services prior to submitting
  the PSA request
• Ensure that start and end dates are accurate
• Ensure that unit, frequency and rate are correct

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PSA Review Considerations

• Is the requested service covered by the Waiver?
  (refer to Handbook)
• Is the requested amount/intensity of service
  within the Waiver limitations? (refer to
  Handbook)
• Does the service requested meet medical necessity
  conditions as required by Medicaid?
• Are there any sources of coverage (other than the
  Waiver) for the service?

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Medicaid Medical Necessity

• Federal government requires every state to
  establish medical necessity conditions for all
  Medicaid funded services
• Established by AHCA in section 59G-1.01(166)(a),
  Florida Administrative Code
• Included in DS Waiver Services Medicaid Coverage
  and Limitations Handbook (2002), page 2-5 and
  section 59G-8.200, F.A.C.

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Florida Medical Necessity Conditions

• Necessary to protect life, to prevent significant
  illness or disability, or alleviate severe pain
• Individualized, specific, and consistent with
  symptoms or confirmed diagnosis, and not in
  excess of individuals needs
• Consistent with generally accepted professional
  medical standards and not experimental or
  investigational

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Florida Medical Necessity Contd

• Reflective of the level of service that can be
  safely furnished, and for which no equally
  effective, more conservative, or less costly
  treatment is available statewide
• Furnished in a manner not primarily intended for
  the convenience of the recipient, caretaker or
  provider

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• BREAK

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Service Justifications

• Examples (refer to handout)
• Adequate justification
• Inadequate justification

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Activity Report as of 2/28/05

• Contract to Date
• (1/1/03 2/28/05)
• Approvals 8,990
• Denials, Terminations or Reductions 3,183
• Total Received 13,803

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General Trends and Concerns of 2004

• Missing, incomplete or old information
• Lack of justification for amount or intensity,
  for services such as PCA, ADT and Residential
  Habilitation
• Missing documents required for reviews such as
  behavior plans, and required number of bids

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Trends and Concerns, continued

• Old information such as implementation plans,
  behavior plans, graphs, and summary reports,
  generated more than one year before the beginning
  of the support plan year in review
• Multiple reviews
• Multiple requests/amendments submitted for same
  individual within a period of a few days

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Trends and Concerns, continued

• Unnecessary information and paperwork
• WSC Complaint Procedures
• Bill of Rights
• Grievance Procedures
• Abuse or Neglect Reporting Information
• Emergency Evacuation Procedures
• Privacy Information
• Consumer Satisfaction Checklist
• Nursing Notes

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Trends and Concerns, continued

• Support Plan Issues
• Support plans that did not accurately reflect the
  individuals current situation
• Annual updates that appeared to be previous
  years support plan with dates crossed through
  and new dates written in
• Personal goals and outcomes that were very vague
• Inadequate information indicating time and
  duration of requested services

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Trends and Concerns, continued

• Cost Plan Issues
• Requests for services not entered on ABC
• Numerous cost plan amendments with unclear
  service start and end dates resulting in unclear
  total cost for the entire cost plan year

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Trends and Concerns, continued

• Cost Plan Issues, continued
• Written indication that a service is ending and
  another beginning, but no appropriate entries on
  ABC
• Cost plan amendments not entered on ABC
• Incorrect units, services names, rates and
  calculations

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Trends and Concerns, continued

• Requests for ADT for individuals under age 22
  with no high school diploma
• Requests for large amounts of Behavior Analysis
  for school aged children with no behavior
  supports from the school system
• Requests for large amounts of PCA for children
  with behavior problems and no behavioral services

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Trends and Concerns, continued

• Requests for EAA that should have been DME
• Requests for large amounts of IHSS at the hourly
  rate on top of live-in daily rate
• Requests for PCA to be used as after school
  childcare
• Requests for Residential Habilitation with a high
  intensity of direct care staff hours and
  insufficient justification

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Trends and Concerns, continued

• Bundling of services under Residential
  Habilitation
• Requests for rates that do not appear in the
  Uniform Rate Structure
• Multiple requests for reconsideration for the
  same PSA review

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Trends and Concerns, continued

• Lack of knowledge regarding the Waiver Handbook
  and Waiver coverage and limitations

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Wrap-Up

• Things to Remember
• Support plan with individuals goals, service
  justifications
• Cost plan with services that support goals
• Documentation thats required, but no unnecessary
  paperwork
• Questions and Answers
• Five minutes per Area Office
• All other questions will be answered in writing