1 Negotiating Managed Behavioral Health Care The Nuts and Bolts of Getting Services Financed and Approved by LMEs DRAFT: For review, feedback and revision.

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Negotiating ManagedNegotiating ManagedBehavioral Health CareBehavioral Health Care

The Nuts and Bolts of Getting Services The Nuts and Bolts of Getting Services Financed and Approved by LMEsFinanced and Approved by LMEs

DRAFT: For review, feedback and revisionDRAFT: For review, feedback and revision

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Course OutlineCourse OutlineOrientation to Managed Behavioral Orientation to Managed Behavioral Health CareHealth Care

Integrated Reporting and Payment Integrated Reporting and Payment System (IPRS)System (IPRS)

PCP BasicsPCP Basics

Service Authorization Requests (SARS)Service Authorization Requests (SARS)

Medical NecessityMedical Necessity

Key Case Responsible Person DutiesKey Case Responsible Person Duties

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Learning ObjectivesLearning Objectives

Participants will learn how reviewers Participants will learn how reviewers think and how to present a case in a think and how to present a case in a manner that greatly increases the manner that greatly increases the likelihood that a reviewer will approve likelihood that a reviewer will approve the request for care.the request for care.For non-Medicaid consumers, For non-Medicaid consumers, participants will learn how to access participants will learn how to access IPRS state dollars through the IPRS state dollars through the appropriate Target Population appropriate Target Population designation designation Participants will learn how to Participants will learn how to coordinate other insurance benefits coordinate other insurance benefits with IPRS dollarswith IPRS dollars

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Learning ObjectivesLearning ObjectivesParticipants will learn the basic Participants will learn the basic requirements for a Person-Centered requirements for a Person-Centered Plan in order to get services Plan in order to get services authorized authorized

Participants will learn how to submit Participants will learn how to submit flawless Service Authorization flawless Service Authorization Requests (SARs) Requests (SARs)

Participants will learn about “sticky” Participants will learn about “sticky” forms they may have to completeforms they may have to complete

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Learning ObjectivesLearning Objectives

Participants will learn what happens Participants will learn what happens when a service is denied or pended when a service is denied or pended

Participants will learn how to make a Participants will learn how to make a complaint or appealcomplaint or appeal

Participants will learn about the Participants will learn about the provider’s responsibility for internal provider’s responsibility for internal utilization review (UR) utilization review (UR)

Participants will learn how to offer Participants will learn how to offer “provider choice” to consumers “provider choice” to consumers

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Learning ObjectivesLearning ObjectivesParticipants will learn about Participants will learn about submitting information to the LME: submitting information to the LME: ProviderLink, faxing, other electronic ProviderLink, faxing, other electronic submissions submissions

Participants will learn how to use the Participants will learn how to use the letter of authorization (LOA) to track letter of authorization (LOA) to track authorizationsauthorizations

Participants will learn about critical Participants will learn about critical timelines in the authorization processtimelines in the authorization process

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Learning ObjectivesLearning ObjectivesParticipants will learn how to Participants will learn how to document medical necessitydocument medical necessity

Participants will learn what to do Participants will learn what to do when they have an authorization when they have an authorization problemproblem

Participants will learn about the Participants will learn about the importance of designating SA target importance of designating SA target populationspopulations

Participants will learn what to do if a Participants will learn what to do if a consumer needs deaf or language consumer needs deaf or language interpreting servicesinterpreting services

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Learning ObjectivesLearning ObjectivesParticipants will learn what to do Participants will learn what to do when a consumers change providerswhen a consumers change providers

Participants will learn how to request Participants will learn how to request services that fall within “standard services that fall within “standard care”care”

Participants will learn to check the Participants will learn to check the consumer’s funding streamconsumer’s funding stream

Participants will learn that the first Participants will learn that the first responsibility of the case responsible responsibility of the case responsible person is link the consumer with person is link the consumer with entitlementsentitlements

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Orientation to Managed CareOrientation to Managed Care

The managed care material is adapted The managed care material is adapted from from Negotiating Managed CareNegotiating Managed Care by by Michael Fauman, M.D. Michael Fauman, M.D.

Its purpose is to help you Its purpose is to help you conceptualize, present, and document conceptualize, present, and document clinical care in a manner that greatly clinical care in a manner that greatly increases the likelihood that it will be increases the likelihood that it will be approvedapproved

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Managed CareManaged Care

Serving people with mental illness, Serving people with mental illness, substance abuse problems, and substance abuse problems, and developmental disabilities is both a developmental disabilities is both a business and a humanitarian callingbusiness and a humanitarian calling

These objectives can become distorted These objectives can become distorted when business goals are couched in when business goals are couched in the language of medical necessitythe language of medical necessity

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A provider may consciously or A provider may consciously or unconsciously distort information in a unconsciously distort information in a way to make the consumer’s condition way to make the consumer’s condition seem worse than it actually isseem worse than it actually is

Sometimes family members will Sometimes family members will exaggerate symptoms as a way to exaggerate symptoms as a way to obtain treatmentobtain treatment

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Need for Clinical StandardsNeed for Clinical Standards

Many ways to diagnosis and treat Many ways to diagnosis and treat mental illnessmental illness

Clinicians vary widely in their abilities Clinicians vary widely in their abilities and competenceand competence

Medical necessity criteria, diagnostic Medical necessity criteria, diagnostic criteria, and clinical practice guidelines criteria, and clinical practice guidelines serve different purposesserve different purposes

They are subject to different, yet They are subject to different, yet equally defensible interpretations by equally defensible interpretations by different cliniciansdifferent clinicians

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Medical necessity criteria and Medical necessity criteria and diagnostic criteria are differentdiagnostic criteria are different

Diagnostic criteria focus on the signs Diagnostic criteria focus on the signs and symptoms to make a specific and symptoms to make a specific diagnosisdiagnosis

Medical necessity criteria focus on the Medical necessity criteria focus on the need for medical careneed for medical care

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Managed care strives to ensure that Managed care strives to ensure that treatment is appropriate and cost-treatment is appropriate and cost-efficientefficient

This is achieved through clinical reviewThis is achieved through clinical review

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Types of Clinical ReviewTypes of Clinical Review

Pre-certificationPre-certification review is performed review is performed when treatment begins to determine when treatment begins to determine that the consumer meets criteria for a that the consumer meets criteria for a specific type of carespecific type of careConcurrentConcurrent review is performed during review is performed during treatment, to determine that a treatment, to determine that a consumer requires continuing consumer requires continuing treatmenttreatmentRetrospectiveRetrospective review is performed after review is performed after the completion of treatmentthe completion of treatment

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Retrospective ReviewRetrospective Review

Is used to determine whether the Is used to determine whether the consumer’s illness justified the type of consumer’s illness justified the type of treatment he or she receivedtreatment he or she receivedRetrospective review has both an Retrospective review has both an educational and deterrent valueeducational and deterrent valueIt is educational when it gives feedback It is educational when it gives feedback to providers about standards of care to providers about standards of care and the quality of their clinical and the quality of their clinical documentationdocumentation

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Retrospective ReviewRetrospective ReviewIt is a deterrent when it encourages It is a deterrent when it encourages providers to correct any problems in providers to correct any problems in care and documentation so they can care and documentation so they can continue to be reimbursedcontinue to be reimbursedRetrospective review is based on a Retrospective review is based on a detailed record of the consumer’s detailed record of the consumer’s treatment during the entire episode of treatment during the entire episode of illnessillnessRetrospective review may seem like a Retrospective review may seem like a less intrusive process for providers less intrusive process for providers and consumersand consumers

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Retrospective ReviewRetrospective ReviewIt is a far more detailed scrutiny of the It is a far more detailed scrutiny of the consumer’s careconsumer’s care

There is no is overt inference of the doctor There is no is overt inference of the doctor consumer relationship, no denial of care, consumer relationship, no denial of care, and no restriction on the physician’s and no restriction on the physician’s decision making decision making

Insurance companies may require pay-back Insurance companies may require pay-back from the provider for all the services that from the provider for all the services that are judged inappropriate or unnecessaryare judged inappropriate or unnecessary

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Pre-Certification and Concurrent review Pre-Certification and Concurrent review can be characterized as a negotiation can be characterized as a negotiation between provider and reviewerbetween provider and reviewer

The provider tries to convince the The provider tries to convince the reviewer that the consumer is ill reviewer that the consumer is ill enough to require the requested level enough to require the requested level of careof care

The reviewer makes certain that The reviewer makes certain that requested service is justified based on requested service is justified based on a reasonable interpretation of the a reasonable interpretation of the clinical standardsclinical standards

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Dealing with reviewers may not always Dealing with reviewers may not always be pleasant, but it forces clinicians to be pleasant, but it forces clinicians to examine what they are doing and make examine what they are doing and make corrections where necessarycorrections where necessary

Many practitioners do not believe that Many practitioners do not believe that they should have to justify how they they should have to justify how they treat consumers to a reviewertreat consumers to a reviewer

Unfortunately, this is not a realistic Unfortunately, this is not a realistic expectation in the current age of expectation in the current age of managed caremanaged care

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Much of your success in the current Much of your success in the current behavioral health care system depends behavioral health care system depends on your ability to convince reviewers to on your ability to convince reviewers to approve the care you think will be best approve the care you think will be best for your consumersfor your consumers

That approval depends on your ability That approval depends on your ability to represent your consumer’s case to represent your consumer’s case effectivelyeffectively

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You must accept the fact that You must accept the fact that negotiating on behalf of your consumer negotiating on behalf of your consumer is not a professional loss of faceis not a professional loss of face

It is simply a new aspect of the job of It is simply a new aspect of the job of being a clinicianbeing a clinician

If you spend inordinate amounts of If you spend inordinate amounts of time trying to get services authorized, time trying to get services authorized, or find that they frequently deny your or find that they frequently deny your requests, these guidelines will be requests, these guidelines will be helpfulhelpful

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A reviewer cannot simply accept your A reviewer cannot simply accept your credentials and experience as credentials and experience as justification for your decisionsjustification for your decisionsWhen asked for evidence to support When asked for evidence to support their conclusions, some clinicians their conclusions, some clinicians become indignant that their clinical become indignant that their clinical judgment is being questionedjudgment is being questionedThis anger may stem from the This anger may stem from the realization that they do not have further realization that they do not have further detailed information about the detailed information about the consumer’s clinical conditionconsumer’s clinical condition

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Managed CareManaged CareYou must support your opinion with You must support your opinion with relevant and pertinent observations of relevant and pertinent observations of the consumer’s behaviors and the consumer’s behaviors and statementsstatementsFor example, it is not sufficient to For example, it is not sufficient to report that a consumer is agitated, report that a consumer is agitated, psychotic, or manicpsychotic, or manicYou must supply examples that You must supply examples that demonstrate how these states are demonstrate how these states are manifested by the consumer and how manifested by the consumer and how they affect the consumer’s day-to-day they affect the consumer’s day-to-day functioningfunctioning

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It is not uncommon for a practitioner to It is not uncommon for a practitioner to think he or she has provided sufficient think he or she has provided sufficient information about a consumer to information about a consumer to support a request, only to have a support a request, only to have a reviewer deny further carereviewer deny further care

This usually occurs because the This usually occurs because the practitioner has not adequately practitioner has not adequately described the consumer’s clinical described the consumer’s clinical conditioncondition

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A more detailed description of the A more detailed description of the consumer’s behavior and symptoms consumer’s behavior and symptoms may convince a reviewer to approve may convince a reviewer to approve further carefurther care

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How can differences of professional How can differences of professional opinion between clinicians and opinion between clinicians and reviewers be resolved in a manner that reviewers be resolved in a manner that providers the consumer with the safest, providers the consumer with the safest, most effective, and most efficient care most effective, and most efficient care possible?possible?

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Common Areas of DisagreementCommon Areas of DisagreementThe severity of the consumer’s The severity of the consumer’s symptomssymptoms

The impact of the illness on the The impact of the illness on the consumer’s ability to carry out the consumer’s ability to carry out the activities of daily lifeactivities of daily life

Estimates of the likelihood that the Estimates of the likelihood that the consumer will benefit from the consumer will benefit from the proposed treatmentproposed treatment

The type and intensity of clinical The type and intensity of clinical servicesservices

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Common Areas of DisagreementCommon Areas of Disagreement

Whether an unusual treatment is Whether an unusual treatment is appropriate and effectiveappropriate and effective

Whether treatment should be more Whether treatment should be more aggressiveaggressive

Whether the consumer is a danger to Whether the consumer is a danger to himself or herselfhimself or herself

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Managed CareManaged CareYour job is to provide the reviewer with Your job is to provide the reviewer with the necessary clinical information to the necessary clinical information to convince him or her that the consumer convince him or her that the consumer requires the level of care you are requires the level of care you are requestingrequestingYou need to anticipate the reviewers You need to anticipate the reviewers questionsquestionsYour presentation of relevant clinical Your presentation of relevant clinical details determines whether the details determines whether the reviewer approves or denies requested reviewer approves or denies requested carecare

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Four Key QuestionsFour Key Questions

Why does the consumer need the level Why does the consumer need the level of care you are requestingof care you are requesting

What are you trying to accomplish with What are you trying to accomplish with the care and how will you know when the care and how will you know when you have accomplished ityou have accomplished it

How will you treat the consumerHow will you treat the consumer

What are you planning to do with the What are you planning to do with the consumer after dischargeconsumer after discharge

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Providers will be far more successful if Providers will be far more successful if they learn how to identify, gather, they learn how to identify, gather, organize, interpret, and communicate organize, interpret, and communicate relevant clinical information in a relevant clinical information in a consistent, reliable, and convincing consistent, reliable, and convincing mannermanner

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It takes experience and practice to It takes experience and practice to present a concise, cogent, and effective present a concise, cogent, and effective summary of a consumer’s illnesssummary of a consumer’s illness

Presenting a clinical case is a skill that Presenting a clinical case is a skill that most practitioners learned in trainingmost practitioners learned in training

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A reviewer cannot accept a A reviewer cannot accept a practitioner’s judgment without being practitioner’s judgment without being provided sufficient clinical data to provided sufficient clinical data to determine whether the consumer meets determine whether the consumer meets the medical necessity criteria for the medical necessity criteria for servicesservices

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The better the provider’s presentation, The better the provider’s presentation, the better picture the reviewer has of the better picture the reviewer has of the consumer and the more likely that the consumer and the more likely that the reviewer will accept the provider’s the reviewer will accept the provider’s clinical judgment and approve the clinical judgment and approve the requested carerequested care

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It is to your advantage to make sure It is to your advantage to make sure that the reviewer can read and that the reviewer can read and understand your documentationunderstand your documentation

It is not sufficient to make accurate and It is not sufficient to make accurate and reasonable clinical decisions; you must reasonable clinical decisions; you must communicate them to reviewerscommunicate them to reviewers

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Reviewers are impressed with Reviewers are impressed with clinicians who can succinctly describe clinicians who can succinctly describe the consumer’s clinical problems and the consumer’s clinical problems and present logical treatment planspresent logical treatment plans

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You should try to establish credibility You should try to establish credibility with reviewerswith reviewers

The reviewer will be willing to give you The reviewer will be willing to give you some latitude when he or she believes some latitude when he or she believes you are a competent and concerned you are a competent and concerned clinicianclinician

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Reviewers are detectives, alert for Reviewers are detectives, alert for inconsistencies because they reveal inconsistencies because they reveal problems with the quality and problems with the quality and appropriateness of careappropriateness of care

Reviewers often are able to detect Reviewers often are able to detect when a provider is telling the reviewer when a provider is telling the reviewer whatever is necessary to obtain whatever is necessary to obtain approval of the serviceapproval of the service

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ResidentialResidentialClinicians often believe that a Clinicians often believe that a consumer has a far better chance of consumer has a far better chance of success if he or she is treated in a success if he or she is treated in a residential program.residential program.Medical necessity criteria, however, Medical necessity criteria, however, stipulate that a consumer first undergo stipulate that a consumer first undergo a trial of outpatient treatment, unless a trial of outpatient treatment, unless there is a high likelihood that outpatient there is a high likelihood that outpatient will failwill failYou will have to convince the reviewer You will have to convince the reviewer that the consumer is likely to fail an that the consumer is likely to fail an outpatient programoutpatient program

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ResidentialResidentialMost reviewers believe that residential Most reviewers believe that residential treatment is a temporary solution that treatment is a temporary solution that may help consumers focus on specific may help consumers focus on specific clinical problems until those problems clinical problems until those problems have improved sufficiently to be treated have improved sufficiently to be treated at a less intensive level of careat a less intensive level of careThe emphasis is on improvement, not The emphasis is on improvement, not resolutionresolutionThe expectation that every consumer’s The expectation that every consumer’s problem will be completely resolved problem will be completely resolved before discharge from residential is before discharge from residential is unrealisticunrealistic

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ResidentialResidential

What types of problems justify What types of problems justify additional days of residential care?additional days of residential care?They are often related to the They are often related to the consumer’s interaction with his or her consumer’s interaction with his or her environmentenvironmentPreparing the environment means Preparing the environment means directly intervening to change some of directly intervening to change some of the conditions in the consumer’s life the conditions in the consumer’s life outside the programoutside the program

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ResidentialResidential

Most reviewers will continue to approve Most reviewers will continue to approve care if the problems you identify seem care if the problems you identify seem relevant to the consumer’s residential relevant to the consumer’s residential treatment and you are actively working treatment and you are actively working to resolve themto resolve them

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Substance AbuseSubstance Abuse

Substance abuse treatment consists of Substance abuse treatment consists of two overlapping stagestwo overlapping stages

DetoxificationDetoxification

RehabilitationRehabilitation

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The purpose of detoxification is to The purpose of detoxification is to wean the consumer from the substance wean the consumer from the substance of dependency without causing a of dependency without causing a painful or dangerous withdrawalpainful or dangerous withdrawalThe purpose of rehabilitation is to The purpose of rehabilitation is to decrease the consumer’s craving for decrease the consumer’s craving for the abused substance and to help him the abused substance and to help him or her establish and maintain or her establish and maintain abstinenceabstinence

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Medical necessity criteria for Medical necessity criteria for detoxification stipulate that the detoxification stipulate that the consumer is at risk for significant consumer is at risk for significant physical harm or death from withdrawal physical harm or death from withdrawal without immediate medical treatmentwithout immediate medical treatment

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When is withdrawal dangerous:When is withdrawal dangerous:

There is evidence that it will be severeThere is evidence that it will be severe

The consumer has a mental illness that The consumer has a mental illness that will complicate withdrawalwill complicate withdrawal

The consumer has experienced The consumer has experienced complications during a prior complications during a prior detoxification (e.g., seizures)detoxification (e.g., seizures)

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The way to reduce the number of future The way to reduce the number of future detoxifications is to make sure that the detoxifications is to make sure that the consumer receives the necessary consumer receives the necessary follow-up care to maintain abstinencefollow-up care to maintain abstinence

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For rehabilitative services, a reviewer is For rehabilitative services, a reviewer is looking for evidence that the looking for evidence that the consumer’s drug or alcohol use is so consumer’s drug or alcohol use is so persistent and out of control that he or persistent and out of control that he or she needs treatment to abstainshe needs treatment to abstain

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Reviewers are ethical, clinically Reviewers are ethical, clinically experienced, current in their experienced, current in their knowledge, amenable to reason, willing knowledge, amenable to reason, willing to judge your case as objectively as to judge your case as objectively as possible, and willing to compromisepossible, and willing to compromise

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A reviewer should not challenge a A reviewer should not challenge a practitioner’s clinical judgmentpractitioner’s clinical judgment

The reviewer may ask for some The reviewer may ask for some verification that the mode of treatment verification that the mode of treatment chosen by the practitioner is supported chosen by the practitioner is supported by evidence in the professional by evidence in the professional literatureliterature

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If you are going to use a treatment that If you are going to use a treatment that is new, experimental, or unusual, you is new, experimental, or unusual, you can prevent misunderstandings by can prevent misunderstandings by gathering citations from the gathering citations from the professional literature that support professional literature that support your treatment decisionsyour treatment decisions

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Typically, reviewers will allow 2 or 3 Typically, reviewers will allow 2 or 3 transition sessions/days to enable you transition sessions/days to enable you to transfer the consumer without a to transfer the consumer without a hiatus in treatmenthiatus in treatment

However, reviewers will not approve However, reviewers will not approve additional days of care for consumers additional days of care for consumers who are clinically stable but waiting for who are clinically stable but waiting for discharge plans to be finalizeddischarge plans to be finalized

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In cases of treatment non-compliance, In cases of treatment non-compliance, if you want the reviewer to approve if you want the reviewer to approve further care, you must provide further care, you must provide sufficient clinical evidence to convince sufficient clinical evidence to convince the reviewer that despite the the reviewer that despite the consumer’s lack of compliance, she or consumer’s lack of compliance, she or he still requires the servicehe still requires the service

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When stepping down a level of care, When stepping down a level of care, you must have a comprehensive you must have a comprehensive therapeutic plan to provide the broad-therapeutic plan to provide the broad-based support that the consumer will based support that the consumer will needneed

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Reviewers will be looking for evidence Reviewers will be looking for evidence that treatment is effectively treating the that treatment is effectively treating the consumer’s condition, rather than consumer’s condition, rather than fostering service dependencyfostering service dependency

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Reviewers expect to see evidence that Reviewers expect to see evidence that the consumer is benefiting from the consumer is benefiting from treatmenttreatment

If the consumer is not responding to If the consumer is not responding to treatment, the reviewer will want to treatment, the reviewer will want to know why and what you are planning to know why and what you are planning to do about it.do about it.

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Most reviewers do not like to deny Most reviewers do not like to deny servicesservicesReviewers would rather arrive at a Reviewers would rather arrive at a negotiated settlement with the provider negotiated settlement with the provider in which they feel they have trimmed in which they feel they have trimmed the unnecessary services yet allowed the unnecessary services yet allowed the provider enough time and the provider enough time and resources to treat the consumer resources to treat the consumer successfullysuccessfully

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Remember, while the clinical review Remember, while the clinical review process always strives for consistency, process always strives for consistency, two equally qualified practitioners may two equally qualified practitioners may differ in their interpretation of medical differ in their interpretation of medical necessity criteria for the same necessity criteria for the same consumerconsumer

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Managed CareManaged CareNo matter how unfair you believe the No matter how unfair you believe the reviewer’s decision might be, you reviewer’s decision might be, you should always act in the consumer’s should always act in the consumer’s best interestbest interestDo not let your frustration with the Do not let your frustration with the managed care organization and its managed care organization and its reviewers inappropriately influence reviewers inappropriately influence your clinical decisionsyour clinical decisionsMake sure you document in the Make sure you document in the consumer’s record everything you do consumer’s record everything you do and why you do itand why you do it

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It is the obligation of the clinician to It is the obligation of the clinician to defend his or her positiondefend his or her position

Appeals and complaints are Appeals and complaints are appropriate avenues of resolutionappropriate avenues of resolution

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1.1. Client DemographicsClient Demographics

2.2. IPRS FormIPRS Form

3.3. Service Authorization Request (SAR) Service Authorization Request (SAR) FormForm

4.4. Person-Centered PlanPerson-Centered Plan

There are four documents you must There are four documents you must submit to obtain a service authorization:submit to obtain a service authorization:

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1. Client Demographics1. Client Demographics

All fields on the demographics form All fields on the demographics form must be completed, including Axis I-III.must be completed, including Axis I-III.

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2. IPRS2. IPRS

Integrated Payment and Reporting Integrated Payment and Reporting SystemSystem

Medicaid is a type of insurance; think Medicaid is a type of insurance; think of IPRS as a type of insuranceof IPRS as a type of insurance

If a consumer has no other insurance, If a consumer has no other insurance, or their insurance benefit has been or their insurance benefit has been exhausted, state funds (IPRS) may be exhausted, state funds (IPRS) may be usedused

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2. IPRS2. IPRS

State funds also may be used for State funds also may be used for consumers with insurance if a network consumers with insurance if a network provider is not available within 30 provider is not available within 30 minutes of the consumer’s homeminutes of the consumer’s homeComplete either the IPRS Target Complete either the IPRS Target Population form for adults or for Population form for adults or for childrenchildrenTo complete the IPRS form, you must To complete the IPRS form, you must complete a functional assessmentcomplete a functional assessment

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2. IPRS2. IPRS

Functional Assessment: GAF, CAFAS Functional Assessment: GAF, CAFAS (1995 version), SNAP, or ASAM(1995 version), SNAP, or ASAM

Whenever the consumer’s Target Whenever the consumer’s Target Population changes throughout the Population changes throughout the year, a new IPRS worksheet must be year, a new IPRS worksheet must be completecomplete

When the T.P. changes, you must When the T.P. changes, you must revise the consumer’s PCP and submit revise the consumer’s PCP and submit new SARs because the new Target new SARs because the new Target Population may affect service eligibilityPopulation may affect service eligibility

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2. IPRS2. IPRS

An annual update of the IPRS An annual update of the IPRS worksheet is required, even if the worksheet is required, even if the Target Population does not change.Target Population does not change.

If the IPRS worksheet is not updated If the IPRS worksheet is not updated annually, claims will be denied after the annually, claims will be denied after the 1 year anniversary date1 year anniversary date

Designate as many Target Populations Designate as many Target Populations as applyas apply

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2. IPRS2. IPRS

It is advantageous to have as many It is advantageous to have as many Target Populations as possible, Target Populations as possible, because if funding is exhausted for a because if funding is exhausted for a particular Target Population, another particular Target Population, another Target Population may payTarget Population may pay

It is especially important to designate It is especially important to designate an SA Target Population if it applies, an SA Target Population if it applies, because historically SA funds have not because historically SA funds have not been expended because clinicians been expended because clinicians designate a mental health T.P. onlydesignate a mental health T.P. only

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2. IPRS2. IPRSDoes Medicaid Require a Target Does Medicaid Require a Target Population to BillPopulation to Bill??Yes, although it is an entitlement and Yes, although it is an entitlement and the consumer’s needs must only meet the consumer’s needs must only meet the medical necessity criteria under the the medical necessity criteria under the particular service definition, you must particular service definition, you must still submit an IPRS Target Population still submit an IPRS Target Population form in order to bill the LME. It is form in order to bill the LME. It is important to use the correct Target important to use the correct Target Population in the event that the Population in the event that the consumer turns out to NOT have consumer turns out to NOT have Medicaid.Medicaid.

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2. IPRS2. IPRS

There are a few “concurrencies” that There are a few “concurrencies” that are not permissible:are not permissible:

A consumer cannot be CMMED and A consumer cannot be CMMED and CMSEDCMSED

A consumer cannot be AMSPM and A consumer cannot be AMSPM and AMSMIAMSMI

Only one DD T.P. can be assigned per Only one DD T.P. can be assigned per consumerconsumer

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2. IPRS2. IPRS

Not all Target Populations pay for all Not all Target Populations pay for all servicesservices

It is critical that case responsible It is critical that case responsible persons check these limitations, persons check these limitations, because services are authorized based because services are authorized based on there being a valid IPRS Target on there being a valid IPRS Target PopulationPopulation

If you don’t have a valid IPRS Target If you don’t have a valid IPRS Target Population for the service which is Population for the service which is delivered, you won’t get paid.delivered, you won’t get paid.

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2. IPRS2. IPRS

You can check for the You can check for the diagnosesdiagnoses and and servicesservices that are covered by each that are covered by each Target Population on the Division’s Target Population on the Division’s website: website: www.dhhs.state.nc.us/mhddsas/iprsmenu/htmwww.dhhs.state.nc.us/mhddsas/iprsmenu/htm

““Look behinds” indicate that clinicians Look behinds” indicate that clinicians often make errors in assigning Target often make errors in assigning Target PopulationsPopulations

Check the above website to see Check the above website to see detailed criteria for each T.P.detailed criteria for each T.P.

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3. SAR3. SARThe SAR is submitted to the Services The SAR is submitted to the Services Management Department of the LME for Management Department of the LME for existing consumersexisting consumers

For new consumers, the ACCESS For new consumers, the ACCESS Department will issue the initial Department will issue the initial services for consumer, based on the services for consumer, based on the results of the screeningresults of the screening

For new consumers, do not request For new consumers, do not request additional services until you have additional services until you have received your initial LOAreceived your initial LOA

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3. SAR3. SAR

SARs may be submitted 3 ways:SARs may be submitted 3 ways:

1.1. By faxBy fax

2.2. Through ProviderLink (must be Through ProviderLink (must be signed up with ProviderLink)signed up with ProviderLink)

3.3. Through the WHN electronic system Through the WHN electronic system (must be signed up with WHN)(must be signed up with WHN)

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3. SAR3. SARIt is critical that all fields on the SAR It is critical that all fields on the SAR form are completeform are complete

It is critical that all information on the It is critical that all information on the SAR form is accurateSAR form is accurate

Before you complete a SAR, check the Before you complete a SAR, check the last SAR which was approved so your last SAR which was approved so your start-date is the day after the previous start-date is the day after the previous SAR’s expirationSAR’s expiration

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What Happens When You Submit a SAR?What Happens When You Submit a SAR?

If your SAR is accurate and complete, If your SAR is accurate and complete, you will receive an e-mail stating that you will receive an e-mail stating that your SAR has been accepted and is in your SAR has been accepted and is in the review processthe review processIf your SAR is not accurate and If your SAR is not accurate and complete, it will pended and you will be complete, it will pended and you will be notified via e-mail about the reasonnotified via e-mail about the reasonYou have 10 days to correct the SAR or You have 10 days to correct the SAR or it will be deniedit will be denied

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If your SAR falls within standard care, If your SAR falls within standard care, an authorization technician will an authorization technician will automatically approve the request, if automatically approve the request, if your PCP is adequateyour PCP is adequate

The case manager will receive an e-mail The case manager will receive an e-mail Letter of Authorization (LOA)Letter of Authorization (LOA)

The LOA The LOA alsoalso will be sent to the will be sent to the provider who will bill for the service, provider who will bill for the service, with the authorization number on the with the authorization number on the LOALOA

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If there is a problem with the PCP, your If there is a problem with the PCP, your request will be pended and you will request will be pended and you will have 10 days to correct it before the have 10 days to correct it before the SAR is denied. If you need more time, SAR is denied. If you need more time, you may request it.you may request it.If your request does not fall within If your request does not fall within standard care, or is a high-end service standard care, or is a high-end service like residential, it will automatically go like residential, it will automatically go to a clinical specialist for reviewto a clinical specialist for review

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The clinical specialist will either The clinical specialist will either approve the SAR, deny it, or pend the approve the SAR, deny it, or pend the requestrequestYou will receive an e-mail which tells You will receive an e-mail which tells you about the statusyou about the statusIf the SAR is denied, the clinical If the SAR is denied, the clinical specialist will usually have phone specialist will usually have phone contact with youcontact with youIn the case of a pend, the clinical In the case of a pend, the clinical specialist will usually ask for additional specialist will usually ask for additional informationinformation

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Sometimes, if the SAR does not contain Sometimes, if the SAR does not contain adequate clinical justification, the adequate clinical justification, the specialist will approve it up to the specialist will approve it up to the amount of standard careamount of standard careYou may submit justification to obtain You may submit justification to obtain additional amounts of serviceadditional amounts of serviceIf your SAR is pended by a clinical If your SAR is pended by a clinical specialist, you will have 10 days to specialist, you will have 10 days to respond before the SAR is respond before the SAR is automatically deniedautomatically denied

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What Happens When You Submit a SAR?What Happens When You Submit a SAR?The case responsible person should The case responsible person should always receive LOAsalways receive LOAsKeep copies of the LOAs in order to Keep copies of the LOAs in order to track the status of your authorization track the status of your authorization (This is especially useful when (This is especially useful when designating start and end dates on designating start and end dates on your SAR)your SAR)Do not call the LME to find about the Do not call the LME to find about the status of a routine SAR; it is your status of a routine SAR; it is your responsibility to use the LOAs to track responsibility to use the LOAs to track statusstatus

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Some providers are able to access the Some providers are able to access the status of SARs within the LME status of SARs within the LME computer system; all case responsible computer system; all case responsible persons should use this feature if persons should use this feature if availableavailableAfter you have checked the status of After you have checked the status of authorizations, and you still have a authorizations, and you still have a question about the status of an LOA, question about the status of an LOA, then e-mail the LME. The name and then e-mail the LME. The name and address of the person to e-mail is on address of the person to e-mail is on the LOA.the LOA.

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What Happens When You Submit a SARWhat Happens When You Submit a SAR??

SARs should be submitted 10 days SARs should be submitted 10 days before services commence. This allows before services commence. This allows the LME 3 days to process your the LME 3 days to process your request, and an additional week to request, and an additional week to complete if your SAR is pended.complete if your SAR is pended.

There are no retroactive authorizations; There are no retroactive authorizations; the earliest date that a SAR will be the earliest date that a SAR will be approved is the date it was received at approved is the date it was received at the LMEthe LME

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One exception: If a consumer loses One exception: If a consumer loses Medicaid coverage, the LME may Medicaid coverage, the LME may approve IPRS dollars 30 days approve IPRS dollars 30 days retroactivelyretroactivelyEmergency services should be Emergency services should be approved within 3 days of deliveryapproved within 3 days of deliveryIf a consumer has an immediate need, If a consumer has an immediate need, you may contact a clinical specialist at you may contact a clinical specialist at the LME and your request can be the LME and your request can be reviewed the same dayreviewed the same day

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If you are not able to reach a clinical If you are not able to reach a clinical specialist, ask the receptionist to have specialist, ask the receptionist to have the “Officer of the Day” return your callthe “Officer of the Day” return your call

Your call will be returned within one Your call will be returned within one hourhour

If a consumer’s service is denied, the If a consumer’s service is denied, the consumer will be advised of appeal consumer will be advised of appeal rights (Medicaid) or the complaint rights (Medicaid) or the complaint process (IPRS state funds)process (IPRS state funds)

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All denials receive M.D. reviewAll denials receive M.D. review

If we anticipate a denial, we typically If we anticipate a denial, we typically conduct M.D. review, and if the denial is conduct M.D. review, and if the denial is supported, attempt to negotiate with supported, attempt to negotiate with the case managerthe case manager

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Most Common SAR ErrorsMost Common SAR ErrorsIllegibleIllegible

No Level of Care (LOC)No Level of Care (LOC)

No e-mail addressNo e-mail address

Incorrect codesIncorrect codes

MathMath

Incorrect provider # (you can find these Incorrect provider # (you can find these numbers on the WHN websitenumbers on the WHN website

Old SAR form (use current version on Old SAR form (use current version on WHN website)WHN website)

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what you are sendingwhat you are sendingfor what consumerfor what consumerand if necessary, who it needs to go toand if necessary, who it needs to go toThe easiest way to accomplish this is The easiest way to accomplish this is

to simply send us a copy of the LOA to simply send us a copy of the LOA that pended your requestthat pended your request

We receive hundreds of faxes and SARs We receive hundreds of faxes and SARs each day. So it is vital that you always each day. So it is vital that you always

tell us on the cover sheet:tell us on the cover sheet:

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4. PCP4. PCP

We recommend that you view the We recommend that you view the companion slideshow to this one: An companion slideshow to this one: An Introduction to Writing Effective Introduction to Writing Effective Person-Centered PlansPerson-Centered Plans

We also strongly recommend that you We also strongly recommend that you read the book: read the book: Treatment Planning for Treatment Planning for Persona-Centered CarePersona-Centered Care by Neal Adams by Neal Adams and Diane Griederand Diane Grieder

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PCP GuidelinesPCP Guidelines

Each goal must have a creation date Each goal must have a creation date (top of goal pages on the left)(top of goal pages on the left)Each goal must have current target Each goal must have current target dates that do not exceed 12 months.dates that do not exceed 12 months.Axis I, II, and III must be addressedAxis I, II, and III must be addressedFront page of PCP (diagnosis, Front page of PCP (diagnosis, supports/strengths, preferences, supports/strengths, preferences, problems/needs sections) must be problems/needs sections) must be completed and dated. completed and dated.

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Problems/needs must be addressed Problems/needs must be addressed within the PCP goals and interventions.within the PCP goals and interventions.Client name and number should be on Client name and number should be on all pages of the PCP.all pages of the PCP.PCP should identify goals, service type, PCP should identify goals, service type, and intervention, along with frequency.and intervention, along with frequency.Client/guardian signatures are required Client/guardian signatures are required for all created goals, changes to PCP, for all created goals, changes to PCP, additions, etc. additions, etc.

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If signatures cannot be obtained on If signatures cannot be obtained on creation or change date, then a written creation or change date, then a written specific explanation should be included specific explanation should be included for the lack of a signature and the for the lack of a signature and the signature should be obtained at the signature should be obtained at the next face-to-face visit.next face-to-face visit.

All changes to PCP must show a review All changes to PCP must show a review date, status code, and justification.date, status code, and justification.

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CBS step-down plans (required with 3 CBS step-down plans (required with 3 or more hours of daily CBS service) or more hours of daily CBS service) must be specific and reflect a system must be specific and reflect a system for reducing hours based on targeted for reducing hours based on targeted behavioral/adaptive improvements (See behavioral/adaptive improvements (See “Documentation Requirements” in CBS “Documentation Requirements” in CBS definition). definition).

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Goals in the PCP must be measurable, Goals in the PCP must be measurable, with the baseline behaviors defined in with the baseline behaviors defined in the goal as wellthe goal as wellAll requested services (on the Service All requested services (on the Service Authorization Request form) must be Authorization Request form) must be addressed in the PCPaddressed in the PCPAll services, including natural supports All services, including natural supports and other community and other community services/resources also should be services/resources also should be included on the PCPincluded on the PCP

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Most Common PCP ErrorsMost Common PCP Errors

No current PCP sent or on fileNo current PCP sent or on file

Lapsed target datesLapsed target dates

Requested service is not on the PCPRequested service is not on the PCP

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Diagnosis PrimerDiagnosis Primer

For each diagnosis, B and R, you must have For each diagnosis, B and R, you must have a goal on the PCPa goal on the PCP

Each diagnosis must have an IPRS category, Each diagnosis must have an IPRS category, if there is oneif there is one

Must complete Axis I, II, and III on the PCPMust complete Axis I, II, and III on the PCP

Axis III may be written out, versus using the Axis III may be written out, versus using the ICD-9 codeICD-9 code

B = primary/principle (only 1)B = primary/principle (only 1)

R = Other primaryR = Other primary

A = AdditionalA = Additional

P = you can ignore this oneP = you can ignore this one

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Additional Forms If ApplicableAdditional Forms If Applicable

Substance Abuse Information Form Substance Abuse Information Form (Complete if the client has an Axis I SA (Complete if the client has an Axis I SA diagnosis)diagnosis)Residential Authorization Form (Complete if Residential Authorization Form (Complete if the child is being placed in a Level II, III or the child is being placed in a Level II, III or IV facility)IV facility)Notification of Out of Home Community Notification of Out of Home Community Placement (Complete if the child is being Placement (Complete if the child is being placed in a Level II, III or IV facility)placed in a Level II, III or IV facility)Outpatient Treatment Report- OTR. Outpatient Treatment Report- OTR. Complete for Medicaid consumers after 8 Complete for Medicaid consumers after 8 (adult) or 26 (child) unmanaged sessions(adult) or 26 (child) unmanaged sessions

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How Do I Know Which Service How Do I Know Which Service Code to Use?Code to Use?

Service codes for Child, Adult, DD and Service codes for Child, Adult, DD and Substance Abuse are posted on the Substance Abuse are posted on the WHN websiteWHN website

Services codes to be used for crisis Services codes to be used for crisis intervention are posted on the websiteintervention are posted on the website

Services codes that do not require a Services codes that do not require a service authorization are posted on the service authorization are posted on the websitewebsite

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What if the Consumer Needs What if the Consumer Needs Interpretation Services?Interpretation Services?

For new consumers, ACCESS will For new consumers, ACCESS will typically authorize language or deaf typically authorize language or deaf interpreting servicesinterpreting servicesFor ongoing services, the case For ongoing services, the case manager should request Language manager should request Language Interpretation and Deaf Interpretation Interpretation and Deaf Interpretation like any other service authorizationlike any other service authorizationThe agency must contract directly for The agency must contract directly for interpreting services, and then bill the interpreting services, and then bill the LME at the allowable costsLME at the allowable costs

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What to Do When Consumers What to Do When Consumers Change ProvidersChange Providers

Someone (the consumer/guardian is Someone (the consumer/guardian is preferred, the old provider, or the new preferred, the old provider, or the new provider) must call the ACCESS provider) must call the ACCESS department at Western Highlands department at Western Highlands Network. We’ll make sure that the Network. We’ll make sure that the change is made (and both providers change is made (and both providers know about the change) and that each know about the change) and that each provider has appropriate services provider has appropriate services authorized. authorized.

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Standard CareStandard Care

When a SAR is submitted to WHN, we When a SAR is submitted to WHN, we will clinically review the utilization will clinically review the utilization either either beforebefore or or afterafter the service is the service is provided. provided.

Most services will be reviewed after Most services will be reviewed after they are provided, however, we still they are provided, however, we still must authorize the service in order for must authorize the service in order for providers to be paid. To do that, an providers to be paid. To do that, an authorization technician will check to authorization technician will check to see if the SAR fits within standard care. see if the SAR fits within standard care.

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““grids” outline pre-established clinical grids” outline pre-established clinical standards for the services and amounts standards for the services and amounts of service that consumers typically of service that consumers typically need for four degrees of impairment, or need for four degrees of impairment, or as they are called, levels of care—A, B, as they are called, levels of care—A, B, C, and D. C, and D. We strongly recommend that you use We strongly recommend that you use the standard care grids to make a the standard care grids to make a request for services. In these cases, an request for services. In these cases, an authorization technician will authorization technician will automatically approve your request if automatically approve your request if your other documentation is in order.your other documentation is in order.

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Approval for standard care services Approval for standard care services does not constitute a cart blanche does not constitute a cart blanche approval to do anything you like. You approval to do anything you like. You still can only provide the service if it is still can only provide the service if it is medially necessary. The services will medially necessary. The services will be subject to random retrospective be subject to random retrospective audit.audit.

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If your SAR falls outside of the If your SAR falls outside of the parameters of standard care or is a parameters of standard care or is a very high-end service (e.g., residential), very high-end service (e.g., residential), it will be passed for on review—from it will be passed for on review—from the authorization technician to a the authorization technician to a clinical specialist.clinical specialist.If your SAR falls outside of standard If your SAR falls outside of standard care, we recommend that you included care, we recommend that you included a detailed justification. a detailed justification.

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We revise the standard care grids from We revise the standard care grids from time-to-time, based on provider input, time-to-time, based on provider input, which is always welcome. Check the which is always welcome. Check the WHN website for the most current WHN website for the most current grids: grids: www.westernhighlands.orgwww.westernhighlands.orgIn order for an authorization technician In order for an authorization technician to act on your SAR, you must complete to act on your SAR, you must complete the level of care (LOC) on the SAR the level of care (LOC) on the SAR form.form.

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What Is The Provider’s What Is The Provider’s Responsibility for Internal UR?Responsibility for Internal UR?

Providers are required to have a Providers are required to have a utilization review plan for utilization review plan for monitoring monitoring the utilization of services for the utilization of services for appropriateness of careappropriateness of care

Per the service definition manualPer the service definition manual

The plan should guide requests for The plan should guide requests for service authorization from the LMEservice authorization from the LME

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Internal Provider URInternal Provider UR

For a new service, medical necessity For a new service, medical necessity criteria are met; service order is criteria are met; service order is completedcompleted

Amount and duration of service is Amount and duration of service is appropriate to consumer needappropriate to consumer need

PCP reflects the servicePCP reflects the service

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For ongoing service, continuation For ongoing service, continuation criteria are metcriteria are met



Or . . . Or . . .

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Service maintenance criteria are metService maintenance criteria are met



Or . . . Or . . .

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Discharge criteria are metDischarge criteria are met

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Provider Choice PolicyProvider Choice Policy

Provider choice is a major element of Provider choice is a major element of NC Mental Health ReformNC Mental Health Reform

When a consumer goes directly to a When a consumer goes directly to a provider (“No Wrong Door”), the provider (“No Wrong Door”), the consumer is assumed to have chosen consumer is assumed to have chosen for any services offered by the providerfor any services offered by the provider

A consumer may, however, ask for A consumer may, however, ask for additional choiceadditional choice

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Provider Choice PolicyProvider Choice Policy

If the provider does not offer a service If the provider does not offer a service that the consumer needs, the provider that the consumer needs, the provider must offer choicemust offer choiceIf a consumer goes through the LME If a consumer goes through the LME ACCESS Department, the consumer ACCESS Department, the consumer will be offered choicewill be offered choiceThe consumer may, at any time, change The consumer may, at any time, change providers by contacting the LME providers by contacting the LME ACCESS DepartmentACCESS Department

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Medical NecessityMedical NecessityMedical necessity is the underlying Medical necessity is the underlying concept under which payment concept under which payment decisions are madedecisions are made

Services must be individualized, Services must be individualized, specific, consistent with symptoms or specific, consistent with symptoms or with a confirmed diagnosis of the with a confirmed diagnosis of the illness or injury under treatment, and illness or injury under treatment, and not in excess of the recipient’s needs not in excess of the recipient’s needs (NC Medicaid Special Bulletin, January (NC Medicaid Special Bulletin, January 2005)2005)

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Within this medical necessity Within this medical necessity framework, entrance criteria and framework, entrance criteria and continued stay criteria have been continued stay criteria have been incorporated within the NC service incorporated within the NC service definitions. The criteria provide greater definitions. The criteria provide greater specificity regarding whether a specific specificity regarding whether a specific service is medically necessary for the service is medically necessary for the individual consumerindividual consumer

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Authorizations do not certify medical Authorizations do not certify medical necessity—you do. Authorizations necessity—you do. Authorizations confirm that if the information you have confirm that if the information you have given is correct, and should there be an given is correct, and should there be an audit, you have also correctly audit, you have also correctly documented the information documented the information supporting medical necessity—you can supporting medical necessity—you can keep the money (NC DMA Medical keep the money (NC DMA Medical Policy 8A)Policy 8A)

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Elements of Medical NecessityElements of Medical Necessity

Indicated – DiagnosisIndicated – Diagnosis

Appropriate – Match for service and Appropriate – Match for service and needneed

Efficacious – Likelihood of success of Efficacious – Likelihood of success of serviceservice

Effective – Impact and did the Effective – Impact and did the intervention workintervention work

Efficient – Use of resourcesEfficient – Use of resources

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Key Case Responsible DutiesKey Case Responsible Duties

Submit SARs within required Submit SARs within required timeframestimeframes

Track LOAs so that you know when to Track LOAs so that you know when to submit a request for more services and submit a request for more services and on what start-date (recommend that on what start-date (recommend that you keep a spreadsheet with all your you keep a spreadsheet with all your clients listed)clients listed)

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Complete an accurate IPRS form and Complete an accurate IPRS form and renew annually or when Target renew annually or when Target Population changesPopulation changes

Obtain entitlements for consumer as a Obtain entitlements for consumer as a first priority (Medicaid, Health Choice, first priority (Medicaid, Health Choice, SSI, etc)SSI, etc)

To continue to access State funds, To continue to access State funds, case managers must show that case managers must show that Medicaid or Health Choice has been Medicaid or Health Choice has been applied for/deniedapplied for/denied

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For children in residential placement, For children in residential placement, State funds for room/board will not be State funds for room/board will not be automaticautomatic

Children in residential placement Children in residential placement should be eligible for SSIshould be eligible for SSI

Case responsible persons will have to Case responsible persons will have to demonstrate why there is not another demonstrate why there is not another source of funds for room/board other source of funds for room/board other than State dollarsthan State dollars

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Case responsible persons should Case responsible persons should check the consumer’s funding stream check the consumer’s funding stream eligibility (private insurance, Medicaid, eligibility (private insurance, Medicaid, Health Choice, Medicare, IPRS state Health Choice, Medicare, IPRS state funds) funds) every monthevery month

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Key TimelinesKey Timelines

SARs should be submitted 10 days SARs should be submitted 10 days before a service commencesbefore a service commencesPended SARs must be responded to Pended SARs must be responded to within 10 days or they will be within 10 days or they will be automatically denied (You may ask for automatically denied (You may ask for additional time if it is needed)additional time if it is needed)Services will be authorized no sooner Services will be authorized no sooner than the day the SAR is received (i.e., than the day the SAR is received (i.e., no retroactive approvals)no retroactive approvals)

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Key TimelinesKey Timelines

Crisis services (e.g. residential Crisis services (e.g. residential placement) may be approved the same placement) may be approved the same day if needed, but you must contact a day if needed, but you must contact a clinical specialist via telephoneclinical specialist via telephoneIf a consumer loses Medicaid, we will If a consumer loses Medicaid, we will approve IPRS dollars, if appropriate, up approve IPRS dollars, if appropriate, up to 30 days retroactivelyto 30 days retroactivelyEmergency services must be approved Emergency services must be approved within 3 days of deliverywithin 3 days of delivery

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Helpful HintsHelpful HintsIf you are faxing a SAR, write precisely. If you are faxing a SAR, write precisely. Some quality is lost in the fax Some quality is lost in the fax reproduction. If we can’t read it, it will reproduction. If we can’t read it, it will be pendedbe pendedIf you send multiple SARs in the same If you send multiple SARs in the same fax, please group together relevant fax, please group together relevant materials for each SARmaterials for each SARWhen you submit a SAR, send all When you submit a SAR, send all relevant materials in at the same time. relevant materials in at the same time. Don’t send a SAR and then send in the Don’t send a SAR and then send in the PCP the next day.PCP the next day.

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Helpful HintsHelpful Hints

If you are completing electronic (BUI) If you are completing electronic (BUI) SARs, SARs, do notdo not fax in a paper SAR fax in a paper SAR

The Services Management Department The Services Management Department sends out an e-mail newsletter every sends out an e-mail newsletter every Friday. If you are not receiving it, talk to Friday. If you are not receiving it, talk to your CEO. All case responsible your CEO. All case responsible persons should receive itpersons should receive it

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Helpful HintsHelpful HintsAdding Additional Units to an Already Adding Additional Units to an Already Approved AuthorizationApproved AuthorizationFor example, if you have 8 events of For example, if you have 8 events of 90800 approved from 7/1/05 – 9/30/05 90800 approved from 7/1/05 – 9/30/05 and need 6 more, submit a SAR and need 6 more, submit a SAR requesting it. In the justification, note requesting it. In the justification, note that you want additional units added to that you want additional units added to an existing authorization. We will an existing authorization. We will change the existing authorization by change the existing authorization by adding units to it.adding units to it.

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Helpful HintsHelpful HintsExtending the End-Date of an Already Extending the End-Date of an Already Approved AuthorizationApproved AuthorizationFor example, if you have 8 events of For example, if you have 8 events of 90800 approved from 7/1/05 – 9/30/05 90800 approved from 7/1/05 – 9/30/05 and don’t need more units, but simply and don’t need more units, but simply want to extend the end-date, submit a want to extend the end-date, submit a completely new SAR with a start-date completely new SAR with a start-date of 10/1/05, asking for as many units as of 10/1/05, asking for as many units as you need per the new time-frame. Any you need per the new time-frame. Any authorization with a lapsed end date is authorization with a lapsed end date is no longer valid, even when some no longer valid, even when some authorized units have not been used. authorized units have not been used.

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Helpful HintsHelpful HintsNumerous providers are attempting to Numerous providers are attempting to save time by stacking SARs. For save time by stacking SARs. For example, case management may only example, case management may only be approved in 90-day increments. So be approved in 90-day increments. So providers send in 2 requests: one for providers send in 2 requests: one for January through March, and another January through March, and another for April through June. We cannot for April through June. We cannot authorize a service before the provider authorize a service before the provider has completed their required UR to has completed their required UR to determine medical necessity. In the determine medical necessity. In the example above, you may submit a SAR example above, you may submit a SAR anytime in March for the 90-day period anytime in March for the 90-day period April through JuneApril through June

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Helpful HintsHelpful Hints

Electronic (BUI) SAR users now have Electronic (BUI) SAR users now have the capability to amend a SAR. So if the capability to amend a SAR. So if you have an approved SAR for 90-days you have an approved SAR for 90-days of 90800 and you need additional of 90800 and you need additional sessions, simply go to the approved sessions, simply go to the approved SAR and use the amend button to add SAR and use the amend button to add units. This will generate an electronic units. This will generate an electronic SAR requesting the additional units. SAR requesting the additional units.

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Help!Help!The WHN website has a list of the staff The WHN website has a list of the staff in the Services Management in the Services Management Department, including their direct Department, including their direct extension to be able to always leave a extension to be able to always leave a message, as well as e-mail addressesmessage, as well as e-mail addresses

If you can’t reach someone, and it’s If you can’t reach someone, and it’s VERY important to do so, call the WHN VERY important to do so, call the WHN main number and ask for the Officer of main number and ask for the Officer of the Day. Your will get a return call the Day. Your will get a return call within an hour.within an hour.

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Helpful ResourceHelpful Resource

The WHN website has most of the The WHN website has most of the information you need. Take time to information you need. Take time to explore it and know where to get the explore it and know where to get the information you need.information you need.

www.westernhighlands.orgwww.westernhighlands.org

1 Negotiating Managed Behavioral Health Care The Nuts and Bolts of Getting Services Financed and Approved by LMEs DRAFT: For review, feedback and revision.

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