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Appendix 4

Reauthorization Process for Organizational Providers

The following is an overview and procedure for the organizational provider reauthorization of services
  1. Reauthorization Overview and Transition

    1. Purpose of Reauth

      1. To establish a system to authorize continuing care
      2. To promote continuity of care through a single plan
      3. To assure that quality and financial risk management principles are implemented in the MHP

    2. Principles and assumptions

      1. Simple
      2. Those who require more care receive more intensive utilization review
      3. Integrated quality assessment and improvement
      4. CMHS bears the greatest financial risk and delegates some of that risk to the PURQCs

    3. Essential components.

      1. Care Managers initiate and complete reauth requests for all providers
      2. Initial assignment of a service intensity
      3. A 25% decrease in service utilization will qualify for expedited review by the PURQC for most Adult and Geriatric Programs.
        1. Children's programs will require an annual review of all clients.
      4. Little if any review once the client attains a maintenance service intensity, (0 to 16 hours)
      5. Reauth required when level of care changes, addition of new providers and at the annual anniversary
      6. Approval by the PURQC, Access or Twenty Four Hour Authorization (e.g., Bed Committee, IAPC)
      7. Oversight of PURQC activity by QM and SOC

    4. A work in progress

      1. This is a new system which will need ongoing evaluation
      2. Service intensity parameters will need continuing evaluation
      3. The work of the PURQCs will need evaluation
    Questions about reauthorization should be directed to:
    Children's services: Albert Eng at 255-3506
    Adult services: Kevin McGirr at 255-3481
    David Cassell at 255-34445
    Geriatric services: Tom Mesa at 255-3749

  2. Reauthorization Agents

    There will be four general authorizing agents who will approve reauthorization requests, they are:

    1. Program Utilization Review Quality Committees (see next page).

    2. The Access Authorization Team will reauthorize some non-PURQC outpatient programs and services provided by the private practitioner network.

    3. Twenty Four Hour Authorization (Bed Committees):

      CMHS will continue to authorize referrals to 24 hour services through centralized committees and processes (adult, geriatric and child). In addition, Children's Services manages access to day treatment and intensive case management through central processes. Services that are authorized through these mechanisms do not require authorization through the PURQC. You should contact the following individuals if you have general questions about the interface with their areas:

      Michael Reiter: Adult and Geriatric Inpatient
      Jack Rabin: Child inpatient and residential
      Gloria Gonzales: Adult 24 Hour
      Tom Mesa: Geriatric 24 Hour
      Steve Banuelos: Child Day Treatment/ Intensive Case Management

      All services provided by the residential treatment provider while a client is in residential treatment will be reauthorized by the twenty four hour process. This does not include private practitioner provider services which will be reauthorized by the Access Team. Outpatient services provided by residential treatment providers, e.g., day treatment, to clients not enrolled in the residential program will be reauthorized by the appropriate PURQC.

    4. Single Points of Responsibility programs such as Family Mosaic, Westside, Mission ACT and UC Community Focus have already developed protocols for their authorization processes. These will remain unchanged until further notice.

    5. Other programs, such as Cal Works, early intervention, outreach or prevention programs will also have distinct reauthorization procedures.

  3. Structure and function of the Program Utilization Review Quality Committees (PURQCs) and oversight

    Certain organizatonal providers will be invited to form a program utilization review quality committee (PURQC). The PURQC should be designed to review service utilization and quality of care. The primary objective for the PURQC is to assure that care is appropriate and effective.

    PURQC designated programs shall be required to submit a proposal pursuant to the formation of their PURQC. The PURQC proposal shall include the following components:

    1. PURQC Membership

      All PURQCs must include the program and medical director. There should be at least two licensed clinicians on the PURQC. The program Director will normally act as the chair of this committee. Other licensed mental health professionals may be added to the PURQC e.g., MD, RN, LCSW, Phd, MFCC. If other programs are included in the PURQC, please indicate in the proposal.

    2. Record of the PURQC Meetings

      All PURQCs shall meet at least monthly and shall be required to maintain a record of actions taken at that meeting.

    3. Approval of routine Care Manager (CM) requests

      One of the PURQC's functions is to review and approve all service intensity assignment and reauth requests. It will be necessary for one of the PURQC members to sign all reauth requests. No PURQC member may approve his/her own reauth request. The PURQC approval signature needs to be a licensed clinician.

    4. Intensive Utilization and Quality of Care Review

      On an annual basis, the PURQC shall intensively review a 10% sample of cases. The sample will include care management clients who require intensive services. Cases might be selected for their Clinical or cultural complexity, high service use, acute service use or non compliance. The review may include a peer reviewed chart examination, case conference or any other appropriate method of evaluating quality of care. The PURQC proposal should indicate how the PURQC proposes to complete the intensive review. Children's services review requirements will be somewhat different in percentage and method of review.

    5. PURQC Monitoring and Oversight

      A committee of Quality Management and SOC monitors will serve to review the functioning of the individual PURQC for each of the age specific sectors.

  4. Care Manager Role and Responsibility

    The care manager in the organizational provider system of care shall serve as the foundation for integrated quality of service to the client.

    The following responsibilities apply to all care managers regardless of the authorizing agent:

    1. Updates the assessment

    2. Completes and updates the plan of care which includes input from all providers on an annual basis AND distributes the plan of care to all included providers

    3. Completes and submits the reauth request which includes all non-twenty four hour providers whenever the required service level changes OR for the addition of new providers OR at the anniversary date. Practitioner providers will not be included in this reauth request.

    4. Actually provides and links the client with necessary services

    5. Acts as the informational source for all inquiries about the client

    6. Acts to modify reauthorization request as needed

    7. Provides input to the Bed Committee when his/her client is in need of twenty four care.

    8. Maximizes continuity of care for the client in the system.

  5. Care Manager Assignment

    Who can be a care manager?

    1. In general, ongoing community service providers will provide care management. This excludes time limited residential treatment programs.

    2. All other programs, e.g., day treatment, residential care case managers, may serve as care managers. Interns may NOT serve as care managers.

    3. SPR or other intensive case management programs will always act as the care manager when a client is enrolled in those programs.

    4. For out of county long term locked facility clients who do not have a link with a community based care manager, the conservator will act as the care manager. For Mental Health Rehab Facility (MHRF) clients, the linkage team (255-3446) will act as care manager.

    5. New clients will normally be assigned to your program based on availability through the Access Team. It will be the program's responsibility to assign the actual care manager.

    6. Clients who are in transition from inpatient or long term locked facilities will be assigned to short term or interim case management programs, e.g., CRT, linkage team. Clients should be assigned a care manager within 90 days. Care management assignment will be required for reauthorization.

    7. In the initial transfer to the care manager role, the provider (in concert with his/her program director) who provides the primary service OR the provider who is most familiar with the client should assume the care manager role.

      1. During the transition period, the current coordinator of record should collaboratively decide as to whom is most logical to assume the care manager role keeping in mind that it should be an actual provider of service. The current coordinator should consult with that service provider to obtain their consent. Once the care manager has been agreed upon, the current coordinator should convey the decision to all other ongoing community service providers.

      2. In the event that you are the only provider, you are automatically elected.

      3. Staff psychiatrists who are providing meds only service may act as the care manager.

      4. If it is not clear as to who should logically become the care manager, you should consult with the PURQC.

      5. If the PURQC is not able to decide as to who should act as the care manager, the age director should be consulted.

        Any program that provides care management services may chose to limit who is eligible to perform the care manager role. The one system wide exception to the guideline are interns. Interns may not formally act in the care manager role. Interns may however, partake in documentation and care delivery activities but all plans of care and authorization documents will need an onsite supervisor co-signature.

  6. Completing the Organizational Provider's Client Service Authorizations (CSA) Service Authorization - All Care Managers will complete the following:
    1. Each program will receive a set of reports including an MHS 140 Client History, and a Client Service Reauthorization (CSA) report for each client assigned to a Coordinator working at that program. The CCT500 includes a master list of clients with detail forms and a one page transitional reauth form per client. An administrative support person should be assigned the responsibility to receive the reports and deliver them to the Coordinators.

      Section 1 - Care Manager Assignment

    2. If the client has had no services from ANY part of the system over the last six months, that client should be closed. If the client has received only Acute services over the last six months and no linkage has been made, that client can be closed as long as s/he is not currently receiving Acute treatment.
    3. To close the client, check "Yes" for the question "Close Client's Coordinating episode?" on the CCT500. To update the closing diagnosis, enter the information in section #3 below.
    4. The Coordinator reviews the open clients and decides according to the criteria whether or not s/he will become the Care Manager for each client.
    5. If the Coordinator is the Care Manager, check "Yes" for the question "Assign Coordinator as Care Manager".
    6. If the Coordinator is not the Care Manager, check "No". The Coordinator is responsible for facilitating the discussion among the client's service providers to agree upon whom to assign as Care Manager. The Coordinator prints the Care Manager's name and RU number in the line "If not, agreed upon Care Manager" and sends the client's form to the Care Manager.
    7. The Care Manager completes the CCT500.

      Section 2 - Demographic Data

    8. Printed on the form is the client's current information recorded in Insyst for the following fields:
      DOB (Date of Birth)Race/Ethnicity
      Primary LanguageLegal Status
      GenderCurrent Living Situation
      Review this information and correct it as needed. A list of codes for those items (marked with an asterisk*) requiring corrections is on the back of the form.
    9. This section also requests new information in addition to the existing INSYST data. The requested information is Sexual Orientation, Medical Condition (if any), Primary Care Physician name and phone number. If the client doesn't have a significant medical condition, write in "None". If you don't know if the client has a significant medical condition, write in "Unknown". Otherwise, write in the short name of the condition, for example: High Blood Pressure. If the client doesn't have a Primary Care Physician, write in "None". If you're unsure, write in "Unknown". Otherwise write in the Physician's name and phone number (if available).

      Section 3 - DSM IV Diagnosis

    10. Enter the following information for the client's diagnosis. If Substance Abuse is a secondary diagnosis, be sure to include it on the form.
      • Date of diagnosis
      • Name of diagnosing clinician
      • Axis 1, up to 3 DSM IV codes
      • Axis 2, up to 2 DSM IV codes
      • GAF

      You should indicate with a "P" one primary diagnosis. All other diagnoses will be considered secondary. Substance abuse diagnoses must be secondary. Section 4 - Authorized Services

    11. All Providers who will need authorization should be indicated on this form except Inpatient and 24-Hour Services, which are authorized by committees. Authorizations are NOT needed for socialization, vocational rehab, crisis, and emergency services. However, these services should be included in the client's Plan of Care as appropriate.
    12. The information required for an authorization is (1) Service Type, (2) RU of the Provider's Program, (3) number of units or hours of service, (4) expected frequency of the service (if relevant), (5) starting date, and (6) ending date.
    13. The first Service Type listed is for Day Treatment (DayTx). If the client will receive Day Treatment services, check the code DayTx. Print the RU number of the program providing the service. Print the number of units the client will need. In this case, units are days. In frequency, print the number of days per week and indicate if Day Treatment is a half or full day. Print the starting date of the authorization and the ending date of the authorization.
    14. Continue entering services for the client. The additional choices are Medication Support, Mental Health Services, Meds/Mental Health Services, Case Management/Brokerage, Medication Support/Brokerage, Mental Health Services/Brokerage, and Meds/Mental Health Services/Brokerage. Use only one line per service type. A provider may have more than one line.
    15. Many clients receive all their services from one clinic. For example, a client may receive mental health services, medication support, and case management from a single clinic. Using this form, the client would have one authorization. You must enter the number of hours you expect the client to use for each Service Type during the time period authorized. Normally, the time period will be a year.

      Section 5 - Service Intensity Justification

    16. Following the Service Authorization, is space for providing justification of the Service Intensity requested. Use this area to write in the justification for services if the Service Intensity or the total number of hours authorized exceeds the suggested guidelines.

      Section 6 - Authorizing Signatures

    17. The Care Manager must sign and date each form when it's completed. Submit the completed form to the authorizing agent for approval. This process will vary by program.
    18. Be sure to check the box "Plan of Care completed?" before submitting the form.
    19. The Authorizing Agent must sign and date the form before it can be sent to data entry.
    20. The Organizational Provider/QM PURQC Oversight Committees will decide disagreements between the PURQC and the Care Manager that cannot be resolved at the clinic.
    21. Each program will assure that reauthorization documentation is reviewed for completeness and legibility and make corrections as needed before sending the forms to data entry. Incomplete or illegible documents may delay authorization, data entry and billing.
    22. The program point person (administrative support person) makes two copies of each completed form, checks off the names of the clients on the master list with completed forms, and returns the original to the Care Manager.

  7. Where and When to send the form

    1. All Adult PURQC program approved authorizations should be sent to: SFMHP Access/ Authorization Team
      c/o
      1380 Howard Street, 2nd Floor
      SF, CA 94103

      Geriatric PURQC programs will send approved reauthorizations to the address above until further notice.

      Children's PURQC programs will send approved authorizations according to the Children's section directions.

    2. Programs that require Access approval should be sent to:

      SFMPH Access/ Authorization Team
      1380 Howard Street, 2nd Floor
      SF, CA 94103

      For all programs, the following should be observed in completing the reauthorization requests:

      • When all client forms are completed or when the point person has enough forms to send in as a batch, s/he will transmit them to the central data entry point either via fax, interoffice mail, or regular mail.

      • Each batch submitted should have a cover page with the name of the program, contact person's name and phone, date sent, number of pages sent.

      • When the batch is received at the central data entry point, the person receiving the batch will transmit a receipt to the clinic with the date, time, name of person receiving, and number of pages received. Generally the receipt will be sent via fax, but may also be sent by regular mail or given to a delivery person. If the program finds a discrepancy with the number of pages, the program point person is responsible for contacting data entry to resolve the difference.
      The data entry supervisor assigns the batch to a data entry person
    .

  8. Notification of Authorization

    1. A notification of authorization will be sent to each authorized provider (see attached).

    2. The Access Team will contact you in the event that there is a need for clarification in your request. In most instances the communication will be through fax.

    3. During the transition period, your reauth request will be entered into cCura3 and an approved coordination plan will be entered at 1380 Howard Street.

    4. You will enter an approved service plan at your site once you have received notification of authorization.

  9. Information Systems Reports

    We will continue to solicit input from providers as to the type and frequency of reports that will be most helpful in managing client quality and utilization. In the appendix you will find a number of drafts of possible reports, for example:

    1. Client Costs Reported Against Authorizations

    2. Open Authorization List

    3. Notice of Authorization Expiration

    4. Care Manager Assignment, Client List

  10. Plan of Care Form

    • The Plan of Care is a clinical document, not an authorization document.

    • Every SOC client requires one completed Plan of Care to be done annually

    • In cases where there are more than one provider, the providers shall provide input to the care manager in the development of the plan

    • Copies of the Plan of Care shall be distributed to all providers of care for an individual client.

    Diagnosis Section

    1. All diagnoses that contribute to functional impairment should be listed and should be a focus of intervention.

    2. If there is a secondary diagnosis of substance abuse, it should be listed in the diagnosis section.

    3. Check the medical necessity box.

    Goals and Interventions

    • Goals should be observable or quantifiable.

    • Target symptoms, behaviors & impairments being addressed in treatment should be consistent with diagnosis.

    • Intervention should include modality, should list multiple providers if appropriate with modality for each.

    • Modality should relate to clinical picture and be appropriate to ameliorate impairment.

    • A sample Plan of Care and a list of goals are in the appendix.

    Signatures

    • Plan should be signed by the developer of the plan.

    • Client signature signifies that s/he understands and /or has participated in the development of the plan as well as being informed of freedom of choice and grievance procedure. If signature is unobtainable, signify where in the progress notes these can be found.
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