Provider Advisory Sub-Committee (PAG) Meeting
June 13, 2006 3:30 – 5:15

Location: LO(B Room 3800
Topic: Review of PAG Recommendations & Responses to Date

Attendees: Susan Walkama, Bill Kania, Mary Gratton, Karen Andersson, Mark Schaefer, Jill Benson, Kristen Isham, Teresa Pazio winters, Lisa Honigfeld, Marie Mormile, Judith Meyers. Marcy Neff, Sherry Perlstein, Jody Rowell, , David Lawrence-Hawley, Linda Russo

Agenda

1. Status of Recommendations Review: Updated Status Report on Items Italicized

Status of Recommendations

• Nearly all of the recommendations on care guidelines were incorporated
• An item-by-item review was done for the remaining recommendations

- 1. Additional guidelines need to be developed for SA, Dual Disorders and Adults
Status: Completed and approved by Oversight Council
- 2. The ASO should review and manage all inpatient facilities, including Riverview Hospital, under the same acute inpatient clinical care guidelines

Status: Riverview admission criteria have been revised. These criteria now state how Riverview admissions may differ from other hospitals – Completed.

- 3. Care determinations regarding the number of service days authorized for intensive service levels should be based on the individual needs of clients and not on arbitrary per-determined numbers dictated within the care guidelines

Status: Concerns were raised by providers regarding denials for intensive services and some standardized authorization practices that do not appear to be individualized. PAG will request authorization denial data to be reported routinely to the Oversight Council. Data to include: Number of denials at each LOC, reasons for denial at each LOC, alternative services provided, and number of appeals at each LOC, appeal Determinations at each LOC.

VO has agreed to provide a monthly update regarding denials as part of their routine report to the Oversight Council. As of 6/12, no denials have been issued.

A Provider handbook has not been issued. Appeal procedures have not been publicized to date.

Provider handbook has been approved by the Departments and will be posted on the CT BHP website by July 1, 2006. A Provider notice will also be released alerting Providers that the Handbook is available on line.

- 4. DCF should clarify the program model and practice standards for Extended Day Treatment
Status: DCF is in process of doing this – Marilyn Cloud from DCF provided an update

- 5. Extended time billing codes should be included for some outpatient level care service types such as group therapy (e.g., providers should be able to bill higher rates for groups that run longer than one hour)
Status: No procedure code or rate is available in the OP fee schedule.

- 6. In cases of denial of services, it should be the responsibility of the ASO to offer a clinical rationale for the denial and an alternative recommendation for treatment

Status: Refer to Quality Committee.

- 7. The ASO should allow for multiple levels of care to be authorized concurrently to allow for treatment continuity and flexibility in service planning. There should be a minimal administrative burden on the provider to obtain and maintain these authorizations

Status: Protocols not yet established – follow-up needed.

The Departments recognize the need for protocols that articulate the rules around concurrent authorizations and will work with VO to prepare and disseminate by September 1, 2006. In the interim, providers may request an ICM review or speak with the ASO Clinical Director to arrange services.

- 8. Extended Day Treatment: Can therapeutic recreation be billed under Medicaid? If not, it is recommended references to therapeutic recreation be removed from the definition/description of this service type.
Status: This language was removed from the care guidelines.
- 9. Care managers will insure a viable discharge plan is in place for all intensive service level of care discharges
Status: Quality Committee
- 10. Family members assist the ASO in providing training to providers to assist providers in understanding the family's perspective in discharge planning
Status: Currently under consideration
- 11. PRTF (Private Residential Treatment Facility) level of care needs to be reviewed to determine if 24 hour nursing should be made available in these programs
Status: Nursing will be required. Specifics of requirements to be determined.

A CMS in-service around this issue is planned within the next three months. PRTF providers will be notified.

- 12. DCF should follow the IICAPS credentialing process in the certification process for IICAPS providers
Status: It appears this may occur although the process has not been clearly stated.

While DCF has yet to draft and promulgate its Certification Regulation, the

Department is currently looking to the program developers for all of the curriculum based home based services currently being implemented under the
CT BHP to credential providers. DCF will recognize this developer based
Credential as the basis upon which to confer certification. We do not expect credentialing criteria to be addressed in under three months. Family Support Teams and other home based models need to be included.

- 13. Providers should be allowed to bill more than one 90801 (Intake evaluation code) per year
- Status: BHP has indicated that the State Medicaid Plan will be amended to allow one 90801 per performing provider rather than one per clinic. When will this go into effect?

DSS is proposing a draft state plan amendment that will

allow multiple 90801s to be billed under the following conditions; “no more than one evaluation per performing provider per episode of care for the same
recipient.

- 14. A rate for crisis intakes should be established for outpatient clinics.
Status: This recommendation is under review. This requires resolution. Providing crisis intakes is a requirement of ECC. Crisis intakes may be substantially different (involving crisis intervention, de-escalation) and be longer in duration than a routine intake.

The Enhanced Care Clinic rates will offer approximately 25% increased funding to clinics that provide this and other clinic services. The Departments are examining the
Introduction of special codes and rates for emergent and urgent access to a psychiatric
evaluation performed by a medical psychiatric provider ( M.D., APRN) in clinic settings irrespective of whether the clinic is an ECC.

- 15. Definitions of what constitutes billable case management are needed.
Status: Clarifications on IICAPS billing definitions is still pending. Definition of
billable case management for OP level of care has not been provided.

The latest revised draft of billing guidelines for curriculum based in home
services was distributed to the DCF Advisory Subcommittee, to the trade
organizations and IICAPS provider network on June 7, 2006. The
Departments will continue to work with providers to further clarify and refine
as needed.

Case management criteria for the outpatient level of care need to be developed.

- 16. DCF ensures that Comprehensive Global Assessments are completed on all new referrals to Group Homes prior to or no later than 60 days into admission. (There was concern that there may not be adequate resources available to do all these assessments prior to admission).
Status: Hiring for CGAs has been frozen. Status unclear.

DCF is currently exploring alternatives to the Comprehensive Global
Assessment process to address the numerous vacancies within the network
(due to provider recruitment difficulties). DCF will propose alternatives by
September, 2006.

- 17. DCF immediately convene Level 1 Group Home providers to address client related transition issues that will arise in these programs as new Level 1 guidelines are implemented by the ASO.
Status: DCF Central Office is meeting routinely with Level I group home
providers to address these issues.

- 18. Outpatient billing should be allowed off licensed site: Clients may need to be seen in crisis off site by the primary clinician or the symptom picture may warrant a home-based visit by the clinician.

Status: Current Medicaid rules do not allow off site billing.

- 19. Psychological Testing: Extended time in authorizations should be granted to allow for linguistic or cultural issues that increase administrative time in testing.
Status: Handled on individual basis – No further action required.

- 20. Non-intensive home-based services should have a billing rate.
Status: Non-intensive home based services can be billed at the base rate for H2019 and T1017 as posted on the CT BHP website. Clarification requested regarding LOC guideline that applies and authorization process.

This billing arrangement is temporary to prevent service disruption to clients. It appears these services may be reimbursable on an ongoing basis should a care guideline be developed that meets rehabilitation requirements. PAG recommends this LOC be developed and be added to the Care Guidelines.

Next Meeting: June 21 2006 LOB Room 3800