Northern Mental Health Care Management

Policy and Procedure

Authorization / Reauthorization

Policy

All Northern Mental Health Care Management services will be authorized by Northern Mental health Care Management Utilization Management Department. Initial authorizations and reauthorization will occur consistent with approved Affiliation Procedure.

RATIONALE

  1. PRE-AUTHORIZATION OF SERVICES- All affiliation services must be initially authorized by the Central Access Center. Except for certain psychiatric emergencies and emergency inpatient hospitalizations, all services must be pre-authorized. Requests for clinical services, support services, emergency psychiatric assessments, psychological testing, and inpatient hospitalization are examples of types of requests needing pre-authorization .
  1. Clinically evaluate the Consumers initial need for services and care; and through application of the NMHCM Medical/Clinical Necessity, Beneficial Care and Support Services Criteria determine the most clinically appropriate, least restrictive level/setting of care/service and most clinically appropriate network provider to deliver the care/services.
  2. To verify eligibility for care and services

(In the case of needed emergent/urgent care and /or services, a determination of consumer eligibility is made after the person is in a safe, secure environment where s/he can be closely monitored and is not a danger to self/others).

  1. To facilitate the Consumers entry into care by referring and coordinating the Consumers care and related services based on the above clinical evaluation.
  2. To initiate the care management process for any care or related services provided.
  3. To provide a process for peer review and appeal decisions when initial care is unauthorized.
  4. Work closely with the individual Boards to ensure consistency with regional needs and contract compliance.

PROCEDURE

  1. INITIAL REVIEWS can either be accomplished by phone or through documentation review. Initial review is conducted at the specified time frames for emergency and non-emergency entry into care.

1. TIME FRAMES FOR INITIAL REVIEW OF EMERGENCY ENTRY INTO CARE ARE:

  1. Within the next business day of emergency admission for acute level of care (including Detoxification Admissions)
  2. Within the next business day of the emergency admission for partial hospitalization.
  3. Within the next business day of the emergency admission for inpatient chemical dependency rehabilitation.
  4. Within the next business day of emergency admission for crisis stabilization services
  5. Within the next business day of the emergency admission for crisis respite/crisis group home.
  6. All other services will be pre-authorized.
  1. CONCURRENT AUTHORIZATIONS- All NMHCM services, which have expired by way of frequency or duration, must be re-authorized by a Care Manager (Access Center) if they are to continue. This means that eligibility, benefit from services, appropriate level-of-care, medical necessity, net alternatives, least restrictive care, and consumer satisfaction must be determined before services are re-authorized. Requests for clinical services, support services, and continued hospital stays are examples of types of requests needing re-authorization.
  1. A consumer or Provider initiates ongoing concurrent review of all subsequent care. The Care Managers certify clinical, support services at all levels and enter authorizations into appropriate information system to guide claims payment, and monitor services provided for subsequent reviews.
  2. The Care Manager may require supporting documentation and may request to speak directly to the provider to confirm Medical/Clinical Necessity and Level of Care Criteria.
  3. The Provider must submit a written request for reauthorization of services 10 days prior to services lapsing.
  4. If care is denied, reason for denial and appeal procedure is delineated and sent to the Consumer and the Provider. A denial determination is a decision to not pre-certify and does not obviate provider the responsibility to provide care in best interest of the consumer.
  1. AUTHORIZATION / REAUTHORIZATION PERIODS
  1. The Intake Assessment date marks the case opening and the start of the initial authorization period. Access unit staff must interview the consumer and authorize services, if approved, for one of the designated time periods. The case is assigned to an affiliation approved clinical provider.
  2. The assigned provider must conduct a person-centered-planning interview with the consumer and complete a Plan within 5 working days. A PLAN OF SERVICE ADDENDUM must be completed to record additional treatment goals as the person-centered planning process continues. Both of these documents are submitted for entry into the system by the Data Coordinator and then returned directly to the clinical provider.
  3. All services are authorized for specific time periods in accordance with accreditation, DCH and agency Managed Care standards. NMHCM Managed Care Officer is responsible for assigning specific time periods within these standards, within Level Of Care Guidelines.
  4. Concurrent reviews are based on several sources of data to include but not limited to:
  1. The NMHCM Medical/Clinical Necessity, Beneficial care based on

Several Services Criteria to include Level Of Care Guidelines

  1. Discussion between the NMHCM care manager and the treating provider during telephone review and/or the treating provider documentation on the NMHCM required forms describing the written plans for mental health, developmental disabilities and substance abuse services.
  2. The treating provider documentation in the Consumers medical record to include:

a. The Consumers current DSM_IV diagnoses and current clinical condition.

  1. The Consumers involvement in treatment
  2. The Consumers progress towards the goals established during earlier review
  3. Family involvement in treatment
  4. Appropriateness and documented effectiveness of individualized treatment plan
  5. Inappropriate delays of needed treatment interventions and/or missing aspects of the treatment plan.
  6. Changes in the treatment plan
  7. Indication of continuous and comprehensive discharge planning
  8. Clinical documentation by Physician, therapists, nursing staff and ancillary staff, as appropriate to level of care
  9. Medical/specialty consults, if applicable
  1. If information is consistent with care guidelines, care is authorized. If information is not consistent with level of care guidelines, provider may request authorization to transfer a consumer to a different level of care after appropriate authorization by the Care Manager. Appeals process is available if decision is not agreed upon.