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Department of Medical Assistance Services


Department of Medical Assistance Services Residential Treatment For Children & Adolescents Level C (RTC) September & October 2010 – PowerPoint PPT presentation

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Transcript and Presenter's Notes

Title: Department of Medical Assistance Services

Department of Medical Assistance Services
Residential TreatmentFor Children
AdolescentsLevel C (RTC)
September October 2010
Residential TreatmentLevel C
  • DMAS Contacts
  • William OBier - 804-225-4223
  • Pat Smith - 804-225-2412 for KePRO related
  • Tracy Wilcox-804-371-2648
  • Contract Monitor for Clifton Gunderson Audits

Training Objectives
  • Identify participation requirements
  • Understand Medicaid documentation requirements
  • Be aware of Service Authorization (SA)
    requirements and process

Objectives cont
  • These slides contain only highlights of the
    Virginia Medicaid Psychiatric Services Manual
    (PSM) and are not meant to substitute for the
    comprehensive information available in the
  • Please refer to the manual, available on the DMAS
    website, for in-depth information on psychiatric
    residential treatment criteria.

Provider Enrollment Unit
  • For enrollment, agreements, change of address,
    and enrollment questions contact
  • Provider Enrollment Unit
  • P.O. Box 26803
  • Richmond, VA 23261
  • Toll free -- 888-829-5373
  • Fax -- 804-270-7027

Provider Agreements
  • A Restraint Seclusion (RS) attestation letter
    must be submitted to DMAS by July 1 each year or
    sooner if change in CEO
  • Sample RS attestation letter in manual

General Medicaid Provider Participation
  • Have administrative and financial management
    capacity to meet federal and state requirements
  • Have ability to maintain business and
    professional documentation
  • Adhere to conditions outlined in the provider
  • Notify DMAS of any change in original information
    submitted and

Participation Requirements
  • Maintain records that fully document health care
  • Retain records for a period of at least 5 years
  • Furnish access to records and facilities in the
    form and manner requested
  • Use Medicaid designated billing forms
  • Accept as payment in full the amount reimbursed
    by DMAS. Provider must be participating in the
    Medicaid Program at the time the service is
    performed and

Participation Requirements
  • A provider may not bill a client for a covered
    service regardless of whether or not the provider
    received payment from the state
  • Should not attempt to collect from the client or
    family member any amount that exceeds the
    Medicaid allowance or for missed appointments
  • Hold all recipient information confidential
  • Be fully compliant with state and federal HIPAA
    confidentiality, use and disclosure requirements

Definition-Level C RTF
  • Program for children under age 21 to treat severe
    mental, emotional and
    behavioral disorders
  • When outpatient and day treatment fails
  • Provides inpatient psychiatric treatment
  • 24-hours per day program
  • Child-specific care and treatment
    planning and

Definition-Level C RTF
  • Highly organized and intensive services
  • Planned therapeutic interventions
  • All services required to be provided on-site,
    including academic program
  • Physician-directed mental health treatment

Restraint Seclusion
  • Remain in compliance with signed agreement
    regarding seclusion and restraint
  • In case of injury requiring medical attention
    off-site or a suicide attempt, DMAS must be
    notified by fax within one business day of
  • childs name, Medicaid number
  • facility name address of incident
  • location date of incident
  • and

Restraint Seclusion Contd
  • Notification continued
  • names of staff involved
  • description of incident
  • outcome, including persons notified
  • current location of child
  • Fax to William OBier at 804-612-0059
  • Restraint Seclusion reporting is a condition of
    participation and non-reporting subject to
    retraction for paid claims and of provider

Out-of-State Facility Enrollment
  • Border-state facility (within 50 miles)
  • Provides a service not available in Virginia or
  • No in-state facility willing to admit a specific
  • Procedure
  • Contact DMAS at 804/225-4223 to discuss
  • child-specific, out-of-state placement need
  • DMAS can enroll facility for single placement,
  • if appropriate
  • and

Out-of-State Placement Criteria
  • Requires prior authorization for Medicaid
  • Recipient specific information required to be
    sent to DMAS
  • Demographics
  • Referral source information
  • Current placement and services and why these are
    not adequate
  • Current documentation on diagnosis, behaviors,
    discharge plan
  • Current psychological evaluation -within past
    year and

Out-of-State Placement Criteria
  • Social and Service History pertinent to placement
  • Out-of-state facility information-website,
  • List of Virginia facilities explored, and reasons
    for admission denial
  • This will be reviewed by DMAS staff to assess the
    appropriate level of care and facility placement,
    and who will coordinate with provider enrollment
    if out-of state placement is approved

Electronic Submission of Claims
  • Claims should be submitted electronically
  • For CSA cases, when submitting SA information to
    KePRO, the 3-digit locality code and the
    Reimbursement Rate Certification rate are
    required. This will facilitate electronic
    submission of claims
  • For NON-CSA cases, reimbursement will be at the
    rate established at enrollment.
  • All providers are expected to have a rate
    established at enrollment

Electronic Signatures
  • Clarification on electronic signatures issued in
    the 8-20-04 Medicaid Memo http//www.dmas.virginia
  • An electronic signature that meets the following
    criteria is acceptable for clinical
  • Identifies the individual signing by name and
    title and

Electronic Signatures
  • Data system assures the documentation cannot be
    altered after signature affixed, by limiting
    access to code or key sequence
  • Provides for non-repudiation that is, strong and
    substantial evidence that will make it difficult
    for the signer to claim the electronic
    representation is not valid and
  • The provider must have written policies and
    procedures in effect regarding use of electronic

Required Documentation
  • The following slides describe the required
    documents for admission
  • All documents must be complete, timely and
    include all required dated signatures
  • Sample forms are available in the manual

Reimbursement Rate Certification
  • For CSA Cases Only
  • Negotiated rate between locality and facility
  • Total rate can be no more than the Medicaid
  • Payment from any other source such as Title IV-E,
    must be deducted prior to establishing the rate
  • and

Reimbursement Rate Certification continued
  • Identify responsible locality
  • Locality code must be sent in for PA
  • If rate is revised by the locality, must be sent
    in to KePRO within 1 week to update the PA
  • Payment based on the rate on the certification
    which is entered by KePRO into the MMIS
  • All versions of the rate certification must be
    available at the facility for review

  • If the case is an Adoption Subsidy case, it is
  • The education payment source is not considered
  • If the education is paid for by the Dept. of
    Education/CSA funded, it is a CSA case
  • If a child has been receiving CSA funding for
    other services, it is a CSA case
  • If the child is in foster care, it is a CSA case

Certification of Need
  • CSA Cases
  • CON must be completed by both the physician and
    the FAPT
  • Must include dated signatures of physician and at
    least 3 members of the FAPT
  • Authorization can begin no earlier than the date
    of the latest signature
  • Must be child-specific and relate to the need for
    RTF level of care
  • Must be available in the medical record

Certification of Need(Independent Team
  • NON-CSA Cases
  • The CSB is responsible for completing the
    Independent Team Certification
  • The CSB completes the DMH224 and must include a
    physicians dated signature, as well as the
    screeners dated signature
  • The CSB may use the sample CON in the manual in
    place of the DMH224
  • and

Certification of Need
  • NON-CSA Cases
  • CON may be completed by the FAPT and must include
    a physicians dated signature, as well as a
    member of the FAPT
  • Authorization can begin no earlier than the date
    of the latest signature
  • Must be child-specific and relate to the need for
    RTF level of care
  • Must be available in the medical record

Certification of Need
  • CSA and NON-CSA
  • Should reflect the childs current condition and
    must be completed within 30 days of admission
  • Is required to be completed prior to admission
    with all necessary dated signatures
  • If discharged and readmitted, a new CON is
  • If the child transfers to an acute psychiatric
    facility, the acute care team can do the new CON

State Uniform Assessment Instrument
  • The CANS is the only uniform assessment
    instrument that is accepted

State UAI
  • CSA Cases Only
  • Must be current. For admission the state UAI
    should reflect the requested level of care
  • To be completed at least every 90 days
  • and must be in the medical record
  • Should be updated by the fiscally responsible
    locality when the childs level of impairment
    changes significantly
  • Completion information must be submitted to KePRO
    for SA and

State UAI
  • Scoring notes the level of impairment that
    supports the need for the level of care
  • At a minimum
  • The CANS summary sheet, indicating the childs
    behavioral and emotional needs, and risk
  • The CANS must be available in the medical record
    and current within 90 days throughout the stay

Initial Plan of Care
  • Must be completed within 24 hours of admission
  • Requires a dated physicians signature signifying
    the physician has had a face-to-face visit with
    the child (Authorization can begin no earlier
    than the date of the signature)
  • All required elements must be in the plan
  • See sample form in PSM-DMAS 371
  • Be sure to specify the number and type of
    child-specific therapies
  • Must be in the medical record

Comprehensive Individual Plan of Care (CIPOC)
  • Must be completed within 14 days of admission
  • Must include dated signatures of the team
    responsible for the care (physician at least
    one other team member specified in regulations)
  • Must include all required elements
  • See sample form in PSM-DMAS 372
  • Be sure to include specific orders for therapies
  • Must be in the medical record

CIPOC 30-Day Progress Updates
  • Must be updated every 30 days
  • Must have dated signatures of team members
  • Must include all required elements
  • See sample form in PSM-DMAS 373
  • List Individual and Family Therapy dates
  • If the therapy is not provided by a qualified
    professional, or the session was not at least 20
    minutes, or there is no note, it should not be
    considered a delivered service
  • Address progress, or lack of progress. If no
    progress, how is this being addressed?

Therapeutic Interventions
  • Individual, Family and Group Psychotherapy must
    be physician-ordered, provided by a licensed
    Medicaid enrolled provider and addressed in the
    treatment plan
  • Individual Psychotherapy
  • Must occur 3 times every 7 days. Facility
    determines the 7-day count.
  • Sessions must be, at a minimum, 20 minutes
  • If the session includes more than the therapist
    and the patient it is not considered individual
  • Telephone calls to family members are not
    considered individual psychotherapy and

Therapeutic Interventions Contd
  • Family Psychotherapy
  • Must occur at a minimum of 2 times a month if
    there is family involvement
  • If there is family dysfunction that impacts the
    child, therapy should be at least once a week.
  • Must be provided as is ordered in the treatment
  • Group Psychotherapy
  • Group Psychotherapy billed to Medicaid must not
    consist of more than 10 patients
  • and

Therapeutic Interventions
  • Individual, Family and Group Psychotherapy notes
    must be completed by a qualified therapist
  • If therapy is provided by an individual who has
    completed his or her graduate degree and is
    working towards licensure, they may do so under
    direct supervision
  • Appropriately licensed under state law and is a
    Medicaid-enrolled provider
  • Supervision meets requirements of individual
  • and

Supervision of Unlicensed Therapists
  • Does not need to be the same person who is
    supervising for licensing purposes
  • Reviews patients medical history
  • Approves and signs Plan of Care indicating the
    need for the specific service
  • Countersigns Plan of Care updates
  • Reviews each therapy note
  • Must be in the facility during the session, but
    not required to be in the session and

Supervision of Unlicensed Therapists
  • Dated signature on each therapy note on date of
    service indicating note was reviewed
  • Meet regularly with supervisee (every sixth
    session or every 90 days, whichever comes first,
    to include all types of therapies )
  • Discuss Plan of Care
  • Review record
  • Assess patients progress
  • Document supervisory meetings
  • A Physicians Assistant, under supervision, is
    not eligible to provide psychotherapy

Therapeutic Interventions (including 21 weekly
  • Notes must contain, at a minimum
  • Childs name
  • Type of session (Individual, group, medication
  • If this is a group session, the type of group
    must be stated, such as Anger Management or
    Coping Skills
  • Treatment Modality
  • Start and stop time for session
  • and

Therapeutic Interventions Contd
  • Pre-printed forms with date and time of session
    already printed is not acceptable
  • Written on the date service is provided
  • Activity of session-what therapeutic
    intervention/ interaction occurred, and how does
    it relate to goals
  • Purpose of note is to document service,

Therapeutic Interventions Contd
  • as well as to assist staff in providing focused
    ongoing therapeutic services to the child
  • Level of participation (a check box is not
  • Plan for next session
  • Dated signature of provider
  • All notes should be child-specific

21 Treatment Interventions Documentation
  • 21 Treatment Interventions every 7 days
  • May count group psychotherapy
  • Must not include individual and family therapy
  • Must be documented on a daily basis
  • Each intervention must be documented
  • Forms with check boxes as the majority of the
    note are not acceptable
  • and

  • Must document child-specific therapeutic
  • Interventions that are not billable separately
    may include more than 10 residents (this does not
    include the group psychotherapy that may be
    billed separately)
  • Must include the dated signature of the provider
    for each intervention
  • This does not need to be licensed staff

Documentation Contd
  • Late Entries---
  • Timeliness of documentation is essential. A
    document is considered complete by review of the
    dated signature of the professional who develops
    the document. Back dating is not acceptable.

Restraint Seclusion
  • Reports must be sent to DMAS reporting any injury
    requiring medical attention. These should be sent
    in within one business day of the occurrence.
    (See slide 9)
  • Restraint Seclusion reporting is a condition of
    participation and non-reporting subject to
    retraction for paid claims and provider

Staffing and Signatures
  • All signatures must be dated, and should include
    the professional title of the author
  • All medical documentation must include dated
    signatures on the date of service delivery
  • Auditors will request a staffing list with proof
    of licensure if license is required to provide a
    Medicaid reimbursed service

Service Authorization Contractor
  • KePRO is the DMAS contractor for SA
  • For questions go to the SA website
  • and click on Virginia
  • Phone 1-888-VAPAUTH or
  • 1-888-827-2884
  • Fax 1-877-OKBYFAX or 1-877-652-9329
  • Web Provider Issues _at_

Service Authorization Contractor
  • Submitting a request
  • The preferred method is the iEXCHANGE web-based
  • Registration is required
  • Information on iEXCHANGE is available on the
    KePRO website, or call
  • 1-888-827-2884 or by e-mail at

  • Telephone to 888-827-2884 or
  • 804-622-8900 (local)
  • Mail to
  • KePRO
  • 2810 North Parham Rd., Suite 305
  • Richmond, VA 23284

Service Authorization
  • Requests for SA are required to be submitted to
    KePRO prior to services being rendered, but no
    sooner than 10 days prior
  • Authorization can be for up to 90 days with
    medical justification
  • KePRO will review requests for medical necessity,
    as well as timeliness
  • KePRO will apply McKesson InterQual Behavioral
    Health Criteria and DMAS supplemental criteria

Service Authorization
  • NON-CSA Cases
  • Must have a NON-CSA rate established by DMAS in
    order to request PA from KePRO
  • Contact Provider Reimbursement at
  • 804-686-7931 to establish a rate. This should be
    done at the time of enrollment as a provider.
  • If no rate has been established, the request for
    PA will be rejected by KePRO.
  • If a rate is later established, the request will
    not be retroactive

Service Authorization
  • For CSA cases only
  • CANS is acceptable as the state UAI and continue
    to be required at least every 90 days
  • the Reimbursement Rate Certification is no longer
    required to be attached
  • The locality code and the rate on the RRC must be
    provided to KePRO

Service Authorization
  • For both CSA and non-CSA requests
  • No attachments are required, but information on
    the CON, IPC and CIPOC and updates are required
  • Severity of Illness questions are critical to

Service Authorization
  • Narrative must address the need for level of
  • Initial Review
  • -symptoms and behaviors within past 7 days,
    frequency, intensity and duration
  • current functioning
  • support system

Service Authorization
  • Continued Stay
  • Symptoms and behaviors in past 30 days
  • Level of function in past 30 days
  • Describe recipient investment in treatment
  • Describe progress or lack of progress
  • If no progress, how is this addressed?

Service Authorization
  • Initial Review--
  • CSA cases only
  • 3-digit locality code
  • Reimbursement Rate Certification information
  • State UAI information
  • CSA and NON-CSA cases
  • Confirmation of completion
  • Certificate of Need
  • Initial Plan of Care

Service Authorization
  • Continued Stay Review--
  • CSA Cases
  • Current UAI information
  • Confirm locality code
  • Reimbursement Rate Certification update if
  • CSA and NON-CSA Cases
  • Confirmation of completion
  • 30-Day Update-most recent

Service Authorization
  • Appeals
  • The denial of SA for services not yet rendered
    may be appealed in writing by the Medicaid
    recipient within 30 days of receipt of the
  • The provider may appeal an adverse decision for a
    service already provided by filing a written
    notice of appeal within 30 days of receipt of the
  • and

Service Authorization
  • Appeal rights will be stated in the SA
    notification letter. Requests for appeal must be
    submitted to
  • Appeals Division
  • Department of Medical Assistance Services
  • 600 East Broad Street, 11th Floor
  • Richmond, Virginia 23219
  • The provider may not bill the recipient for
    covered services that have been provided and
    subsequently denied by DMAS

Utilization Review
  • Federal regulations require that DMAS review and
    evaluate the services provided through the
    Medicaid program.
  • Purpose of Utilization Review
  • Ensure medical necessity
  • Confirm qualified provider delivered service
  • Ensure program requirements met
  • Address Quality of Care issues

Utilization Review
  • DMAS has contracted with Clifton-Gunderson to
    complete audits of RTFs and will review records
    to assure DMAS criteria is being followed