Xerox Care and Quality Solutions

1 Wyoming Medicaid Xerox Care and Quality Solutions Facility Training September 11th and 12th Agenda Introductions Xerox Care and Quality Solutions (CQS) overview Utilization Management review process Acute psychiatric care Psychiatric Residential Treatment Facilities (PRTF) Continued Stay reviews (CSR) Retrospective, Peer to Peer, and reconsiderations Resources Xerox CQS contact information September 12, 2012 2 Introductions Sara Walk, Provider Services Manager WY Medicaid Sandra Jensen, - Program Administrator CQS Kathy Black, RN, MHA, CCM, CCP - Clinical Manager CQS Gail Brown Utilization Review Specialist CQS CQS UM reviewers Connie McDonald, RN Karen Pouget, LPC Meggan Garwood, LCSW Philip Shupe, LCSW Margie Berry, RN Alice Keller, RN September 12, 2012 3 WY Medicaid Sara Walk Role.

2 Provider Services Manager- PRTF CQS is Medicaid s new partner for UM Contracted to provide UM services Services based on WY rules and regulations Goal: Promotion of appropriate discharge plans Available for questions: or 307-777-7257 September 12, 2012 4 Xerox Care and Quality Solutions CQS is part of Xerox Implemented UM process on 7-1-2012 to assist in appropriate utilization of services Team of specialized clinicians Certain procedures and inpatient admissions require prior authorization, continued stay reviews (CSR s)

3 Providing UM and CM September 12, 2012 5 Acute Care Facilities Acute care for psychiatric/behavioral health admissions Admission form within1 business day of admission 7 day authorizations Continued stay reviews until discharge Technical denial for late submission Involuntary Admission (Title25) the entire form needs to be completed New Acute Admission form Additional information required on forms (NPI#, primary care provider, language spoken, and GAL, and discharge) Case Management including transition care management services available F/U phone calls to clients after discharge within 7 days September 12, 2012 6 PRTF Prior Authorization Prior Authorization process takes place 3-7 days prior to admission Requests are submitted via fax Psychiatric evaluation is required Authorization is based on Medical Necessity PRTF criteria and PRTF forms can be found at NEW PRTF specific form condensed Required additional information (NPI, primary care provider and GAL information)

4 September 12, 2012 7 PRTF Criteria The client continues to display behaviors related to psychiatric condition and requires 24 hour supervision/treatment Client must meet all 5: Psychiatric diagnosis must meet Axis 1 Failed to respond to outpatient interventions Pattern of behaviors Will likely decompensate and present a risk of serious harm to self or others Psychiatric evaluation September 12, 2012 8 Court Ordered Youth WY Medicaid can reimburse services as defined by CMS The state reviews court papers to determine if the services are eligible for Medicaid funding.

5 Please submit the court order papers to Xerox with PRTF forms Sara Walk is to receive all claims for clients who are considered and paid out of general funds General fund requests do not receive authorization numbers General fund request require CSR on the next review date and are eligible for case management September 12, 2012 9 Initial PRTF Authorization 14 days to develop a treatment plan Strength-based assessment Identify goals and interventions and report progress on goals Are there any new issues/goals identified?

6 Individual therapy Family therapy is a requirement for PRTF level of care Medication management Discharge plan Safety Planning ELOS less than 120 Days for PRTF Primary Care Physician notified September 12, 2012 10 CSR for PRTF Concise clinical documentation for the current review Therapy supports primary psychiatric diagnosis(es) Individualized treatment plan not cookie cutter approach Why does the youth require continued treatment? Family involvement Identification of barriers to discharge and strategies to address Updated discharge plan September 12, 2012 11 Discharge Expectations Begins with Admission Viable/well coordinated plan 7-30 day follow up appointment with a mental health provider Discharge with prescriptions for currently prescribed medications Safety planning Outreach with local community resources September 12.

7 2012 12 Resources UPLIFT - Family Support Specialists serve in a variety of roles to best meet the needs of children, youth, and their families. Website: Main office: 888-875-4383 4 Regional offices in Buffalo, Casper, Jackson, and Riverton Children s Mental Health Waiver Ages 4-20 and CASII score of 20-27 Website - Main Office: 307-777-6494 September 12, 2012 13 Therapeutic Passes Facilities must notify Xerox CQS for all therapeutic passes A provider must indicate therapeutic reason for the pass in the client s medical chart 14 days per year Can only submit claim for pass days if the facility has 90% or higher bed occupancy rate September 12, 2012 14 Retrospective Review Retrospective Reviews are allowed for the following three reasons: Patient was made eligible for Medicaid benefits retrospectively.

8 Facility received provider number retrospectively. Primary Insurance is maxed, Medicaid is Secondary. The facility must submit the complete medical record and the verification notice when the facility was notified of the change within 30 days of notification. September 12, 2012 15 Peer to Peer Review Licensed providers are contracted or hired to review UM requests that have limited clinical information to substantiate medical necessity The provider will attempt to contact the attending provider at the facility to review clinical information to determine Medical Necessity If the Reviewing provider is unable to gather additional information from the attending provider, he/she will review the submitted clinical documentation to make a determination of approval or denial.

9 A facility or provider may request a reconsideration of a determination. The full medical record must be mailed to the Cheyenne office address The medical record will be reviewed by a matching specialist for a determination. A peer to peer phone call will be attempted. September 12, 2012 16 Reconsideration A facility or provider may request a reconsideration of a determination The full medical record must be mailed to the Cheyenne office address (see page 22) The medical record will be reviewed by a matching specialist for a determination.

10 A peer to peer phone call will be attempted. The request will be either approved or denied September 12, 2012 17 Appeal A provider or facility may request an appeal after the reconsideration A written request for an appeal to the reconsideration must be mailed to Program Integrity department attention to Christine Bates. State will review and arrange hearings as necessary September 12, 2012 18 Serious Occurrences/Incident Report 42 CFR The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State-designated Protection and Advocacy system.