Microsoft 2012 CM Presentation [Compatibility Mode] HV 18

SoonerCareSoonerCare

Case Management PolicyCase Management Policy

Who is the contact?Who is the contact?

Prior Authorization*

OHCA Provider

Helpline for

Cl i d Billi

Cl

a

i

ms an

d

Billi

ng

(800)522-0114

Option 2,3

Call or email if you have a question:Call or email if you have a question:

J Dll

J

avey

D

a

ll

as

(405) 522-7543

JDll@kh

J

avey.

D

a

ll

as

@

o

kh

ca.org

What are the rules of the road?What are the rules of the road?

How to find the rules:How to find the rules:

khkh

www.o

kh

ca.orgwww.o

kh

ca.org



Go to the Providers

’

section



Go to the Providers section

Policies & Rules, and then, OHCA

Medicaid Rules

Chapter 30 – Medical Providers

SubChapter 5

–

Individual Providers

Part 67 – CM

Part 21 – OPBH Agencies

SoonerCare Requirement:SoonerCare Requirement:

For behavioral health case mana

g

ement

g

services to be compensable by

SoonerCare, the case mana

g

er

g

performing the service must have and

maintain a current behavioral health

case manager certification from the

ODMHSAS.

◦A provisional certification is not allowable.

◦Sus

p

ended certification is not allowable.

p

Change 7/1/2010Change 7/1/2010

For Certified Case Mana

g

er II, after

J

ul

y

1,

gJy

2010: Any bachelors or masters degree

earned from a re

g

ionall

y

accredited

gy

college or university recognized by the

USDE is allowable.

Case Management Professional Levels

Case

Management

Professional

Levels

Level of CM Code Modifier Rate

CM III

,

LBHP T1017 HO 13.53

,

CM II, MA/BA level T1017 HN 10.48

CM I, less than BA T1017 HM 7.43

SOC, CM III, LBHP (ODMHSAS only) T1016 TF 21.61

SOC, CM II, BA (ODMHSAS only)

T1017

TF

16.21

SOC,

CM

II,

BA

(ODMHSAS

only)

T1017

TF

16.21

Intensive - CMHC, CM III, LBHP (ODMHSAS only) T1016 TG 19.55

18 and

up

Intensive - CMHC, CM II, BA (ODMHSAS only) T1017 TG 14.74

Age

Daily

Limits

Monthly

Limit

Contract

Type

A

ge

Limits

Limit

Type

Targeted Case Management, CM III, SOC,

LBHP level T1016 HE/HF/HV TF 0-20

16 56 ODMHSAS

Targeted Case Management, CM II, SOC,

MA/BA level T1017 HE/HF/HV TF 0-20

16 56 ODMHSAS

Targeted Case Management, CM III,

Intensive, CMHC, MA level T1016 HE/HF/HV TG 18 - 999

16 25 ODMHSAS

Targeted Case Management, CM II,

Intensive, CMHC, BA level T1017 HE/HF/HV TG 18 - 999

16 25 ODMHSAS

Targeted Case Management, CM III,

LBHP/MA l l

T1017

HE/HF/HV

HO

0

999

16 25 110 - OPBH

LBHP/MA

l

eve

l

T1017

HE/HF/HV

HO

0

-

999

Targeted Case Management, CM II,

MA/BA level T1017 HE/HF/HV HN 0 - 999

16 25 110 - OPBH

16

25

110

-

OPBH

Targeted Case Management, CM I,

less than BA T1017 HE/HF/HV HM 0 - 999

16

25

110

OPBH

Targeted Case Management,

PACT

T1017

HE/HF/HV

18

999

16 56 ODMHSAS

PACT

T1017

HE/HF/HV

18

-

999

Always use the rates and code sheetAlways use the rates and code sheet

Modifiers

1

st

Position Modifiers

1

Position

Modifiers

HE Mental Health

HF Substance Abuse

HH Integrated MH & SA

HV

Gambling

HV

Gambling

2nd Position Modifiers

TF Low Complexity

TG This modifier is multipurpose:

Complex/high level of care for CALOCUS

Targeted CM

HN This modifier is multipurpose:

Bachelor Level designation for CM

Psychotherapy codes only: CADC (HN to signify CADC is sometimes required in 2nd and in other situations

3rd.)

HS

Filth

ith t

ti t t

HS

F

am

il

y

th

erapy w

ith

ou

t

pa

ti

en

t

presen

t

HR Family therapy with patient present

HQ Group

HL Intern Program

HP Doctoral Level

HO LBHP

3rd Position Modifier

HN CADC

TF ODMHSAS

HK Specialized Program (PACT)

Modifiers are required to be listed in the correct position in order for claims to be paid in a correct manner. Incorrect

positioning of a modifier may lead to an incorrect payment and result in a recoupment.

This next part is This next part is

This next part is

.

This next part is

.

Who is Case Management for?Who is Case Management for?

“

p

ersons under a

g

e 21 who are in

pg

imminent risk of out-of-home placement

for

p

s

y

chiatric or substance abuse

py

reasons or are in out-of-home placement

due to

p

s

y

chiatric or substance abuse

py

reasons and chronically and/or severely

mentall

y

ill adults who are

y

institutionalized or are at risk of

institutionalization”

Strengths based model of Strengths based model of

case

managementcase

management

Policy says: “In order to be compensable, the

service must be performed utilizing the

ODMHSAS Strengths Based model of case

management

.

”

management

.

United States Department of Health and Human United States Department of Health and Human

Services

,

Substance Abuse and Mental Health Services

Services

,

Substance Abuse and Mental Health Services

,,

AdministrationAdministration

A Life in the Community for Everyone:

Behavioral Health is Essential to Health,

Prevention Works, Treatment is Effective, People

Recover.

SAMHSA Defines RecoverySAMHSA Defines Recovery

Recovery From Mental and Substance

Use Disorders:

A process of change through which

individuals im

p

rove their health and

p

wellness, live a self-directed life, and strive

to reach their full potential.

Guidin

g

Princi

p

les of Recover

y

:Guidin

g

Princi

p

les of Recover

y

:

gp ygp y

*Recovery is person-driven.

*

Recovery occurs via many pathways

.

* Recovery is holistic.

* Recovery is supported by peers and allies.

* Recovery is supported through relationships

and social networks.

*

Recovery is culturally based and influenced

*

Recovery is culturally based and influenced

.

* Recovery is supported by addressing trauma.

*Recover

y

involves individual

,

famil

y,

and

y,y,

community strengths and responsibility.

* Recovery is based on respect.

*

R f h

*

R

ecovery

emerges

f

rom

h

ope.

More in policy: “Behavioral case

management:

◦Promotes recovery;

◦

Maintains community tenure; and

◦

Maintains community tenure; and

◦Assists individuals in accessing services for

th l ”

th

emse

l

ves.

”

Love this statement in the policyLove this statement in the policy

Per

p

olic

y

: “This model assists individuals

py

in identifying and securing the range of

resources, environmenta

l

and

p

ersona

l

,

p

needed to live in a normally

interde

p

endent wa

y

in the communit

y

.”

py y

CM service plan development CM service plan development

bll bl bll bl

is

b

i

ll

a

bl

e.is

b

i

ll

a

bl

e.

Th li

“Th i di id l l f



Th

e

po

li

cy

states

:

“Th

e

i

n

di

v

id

ua

l

p

l

an

o

f

care

must be developed with participation by, as well

id d id b h

b

h

as,

rev

i

ewe

d

an

d

s

i

gne

d b

y

t

h

e

mem

b

er,

t

h

e

parent or guardian (if the member is under 18),

h bh i l h lh

CM

d

LBHP

t

h

e

b

e

h

av

i

ora

l h

ea

l

t

h

CM

,

an

d

a

LBHP

as

defined at OAC 317:30-5-240” for it to be

bl

compensa

bl

e

Licensed Behavioral Health Practitioner’s Licensed Behavioral Health Practitioner’s

Role in CMRole in CM

In order to obtain an authorization for

case management, the LBHP needs to

complete a BH assessment.



This is a requirement for anyone to

receive Medicaid compensable services.

Asacasemanageryoumaynotbeabletochangethe

world,butyoucanchangetheworldforoneperson.

Service PlansService Plans



“

The service plan must include

general

goals and



The service plan must include

general

goals and

objectives pertinent to the overall recovery

needs of the member

”

needs of the member

.

It is OK for the service plan to be written in

the member

’

s words

the member s words

.

It needs to be a therapeutically meaningful

f h b I i h

b’ l

process

f

or

t

h

e

mem

b

er.

I

t

i

s

t

h

e

mem

b

er

’

s

p

l

an

and it is being developed for them.

“If you give a man a fish he eats for a “If you give a man a fish he eats for a

day, teach them how to fish and they day, teach them how to fish and they

eat forever”eat forever”

SoonerCare reimbursable behavioral health SoonerCare reimbursable behavioral health

case management services include the following:case management services include the following:

(

I

)

Gatherin

g

necessar

y

p

s

y

cholo

g

ical, educational, medical, and

()

gypyg

social information for the purpose of service plan development.

(II) Face-to-face meetings with the member and/or the

p

arent/

g

uardian/famil

y

member for the im

p

lementation of

pg y

p

activities delineated in the service plan.

(III) Face-to-face meetings with treatment or service providers,

necessar

y

for the im

p

lementation of activities delineated in the

yp

service plan.

(IV) Supportive activities such as non face-to-face communication

with the child and/or

p

arent/

g

uardian/famil

y

member.

pg y

(V) Non face-to-face communication with treatment or service

providers necessary for the implementation of activities

delineated in the service

p

lan.

p

Specific Case Management ActivitiesSpecific Case Management Activities

◦Needs Assessment

◦Service Plan Development

◦Referral

◦Linkage

◦Advocacy

◦Follow-up

◦Monitoring

◦Outreach

◦Crisis Diversion

New as of 3/3/2010New as of 3/3/2010

Crisis diversion

(unanticipated unscheduled

Crisis diversion

(unanticipated

,

unscheduled

situation requiring supportive assistance, face-

to

-

face or telephone to resolve immediate

to

-

face or telephone

,

to resolve immediate

problems before they become overwhelming

and severely impair the individual

'

s ability to

and severely impair the individual s ability to

function or maintain in the community) to assist

member(s) from progression to a higher level of

care.

Case management crisis diversion is different Case management crisis diversion is different

than crisis intervention. than crisis intervention.

317:241.4317:241.4--241.4 Crisis 241.4 Crisis

Ii Ii

[I d 04[I d 04

0101

09] 09]

I

ntervent

i

on

I

ntervent

i

on

[I

ssue

d 04[I

ssue

d 04

--

0101

--

09] 09]

(1) Definition. Crisis Intervention Services are for the purpose of responding to

ac te beha i ral r em ti nal d sf ncti n as e idenced b s ch tic s icidal

ac

u

te beha

v

i

o

ral

o

r em

o

ti

o

nal d

y

sf

u

ncti

o

n as e

v

idenced b

y

p

s

y

ch

o

tic

,

s

u

icidal

,

homicidal severe psychiatric distress, and/or danger of AOD relapse.The crisis

situation including the symptoms exhibited and the resulting intervention or

recommendations must be clearly documented.

(2) Limitations. Crisis Intervention Services are not compensable for SoonerCare

members who reside in ICF/MR facilities, or who receive RBMS in a group home

or Therapeutic Foster Home. CIS is also not compensable for members who

experience acute behavioral or emotional dysfunction while in attendance for

other behavioral health services, unless there is a documented attempt of

placement in a higher level of care.The maximum is eight units per month;

established mobile crisis response teams can bill a maximum of sixteen units per

month, and 40 units each 12 months per member.

New as of 3/3/2010New as of 3/3/2010

(VIII) Transitioning from institutions to the community. Individuals

( d d l 22 64 h d f

(

except

in

d

ivi

d

ua

l

s

ages

22

to

64

w

h

o

resi

d

e

in

an

institution

f

or

mental diseases (IMD) or individuals who are inmates of public

institutions) may be considered to be transitioning to the

community during the last 60 consecutive days of a covered

,

long-term, institutional stay that is 180 consecutive days or

longer in duration. For a covered, short term, institutional stay of

l

ess t

h

a

n

1

80 co

n

secut

i

ve

d

ays,

indi

v

id

ua

l

s

m

ay be co

n

s

id

e

r

e

d

to

ess t a 80 co secut ve ays, v ua s ay be co s e e to

be transitioning to the community during the last 14 days before

discharge. These time requirements are to distinguish case

management services that are not within the scope of the

iii' dih l i iii f

i

nst

i

tut

i

on

'

s

di

sc

h

arge

p

l

ann

i

ng

act

i

v

i

t

i

es

f

rom

case

management

required for transitioning individuals with complex, chronic,

medical needs to the community.

Transition Case ManagementTransition Case Management

Excludes individuals ages 22 to 64 who are on a

psychiatric inpatient unit (IMD) or inmates of

public institutions.

Individuals may be considered transitioning the

last 14 days before discharge of a stay that is

less than 180

consecutive days

less than 180

consecutive days

.

Individuals may be considered transitioning the

last

60

days of a covered long

-

term institutional

last

60

days of a covered

,

long

-

term institutional

stay that is 180 days or longer in duration.

ExclusionsExclusions

SoonerCare members who reside in

nursing facilities, residential behavior

mana

g

ement services,

g

rou

p

or foster

ggp

homes, or ICF/MR's may not receive

SoonerCare com

p

ensable case

p

management services.

This includes DHS and OJA children who

are in their custody

.

Case Management Indirect Case Management Indirect

SiSi

S

erv

i

ces:

S

erv

i

ces:

With regard to the TCM rates, CMS has shown a trend across

states of not reimbursin

g

for “indirect case mana

g

ement” in the

gg

situations where the case manager spends time preparing the

actual assessment document and the service plan paperwork.

Our state plan does refer to “indirect case management” but those

services are intended for the time that the case manager is not face

to face with the actual client, but is spending time speaking with

family members, other health care providers, etc. that can provide

information about the client. These research activities are

considered reimbursable

.

The model assumptions upon which the rate is based include 10%

for administrative and/or management costs. This accounts for

overhead and the other administrative duties such as the time it

takes to prepare the assessment and/or service plan documents

.

Case Management Travel Time:Case Management Travel Time:

With regard to the question on travel time, when

the rate was re

calculated travel time was built

the rate was re

-

calculated

,

travel time was built

into the average length of face to face time spent

with a member (i.e. the rate assumes that the

ill d t f ti

case

manager

w

ill

spen

d

some

amoun

t

o

f ti

me

traveling to the member for the face to face

service). The case manager should only bill for

h l f f i h h d ih

t

h

e

actua

l f

ace

to

f

ace

t

i

me

t

h

at

t

h

ey

spen

d

w

i

t

h

the client providing actual CM services & not bill

for “windshield time”. This would be considered

duplicative billing since the rate assumes the

travel component already.

Reimbursable case management Reimbursable case management does notdoes not

ildild

i

nc

l

u

d

e:

i

nc

l

u

d

e:

(

I

)

p

h

y

sicall

y

escortin

g

or trans

p

ortin

g

a member to scheduled

()

py y g p g

appointments or staying with the member during an

appointment; or

(

II

)

monitorin

g

financial

g

oals; o

r

()

gg

(III) providing specific services such as shopping or paying bills;

or

(

IV

)

deliverin

g

bus tickets, food stam

p

s, mone

y

, etc .; o

r

()

gpy

(V) services to nursing home residents; or

(VI) counseling or rehabilitative services, psychiatric assessment,

or dischar

g

e

;

o

r

g;

(VII) filling out forms, applications, etc., on behalf of the member

when the member is not present; or

(

VIII

)

fillin

g

out SoonerCare forms

,

a

pp

lications

,

etc.

,

or

;

()

g , pp , , ;

(IX) services to members residing in ICF/MR facilities.

From

p

olic

y

: The relationshi

p

between the member

py

p

and the behavioral health case manager is

characterized b

y

mutualit

y

, collaboration, and

yy

partnership.

Remember: It is your job to empower them not

to enable them!

Documentation of recordsDocumentation of records

All behavioral health case management services rendered must be reflected

by documentation in the records. In addition to a complete behavioral health

case management service plan documentation of each session must include,

but is not limited to:

(1) date;

(2) person to whom services are rendered;

(3)

d i f h i

(3)

start

an

d

stop

t

i

mes

f

or

eac

h

serv

i

ce;

(4) original signature of the service provider

(5) credentials of the service provider;

(

6

)

s

p

ecific service

p

lan needs

,

g

oals and/or ob

j

ectives addressed

;

()

pp,g j ;

(7) specific activities performed by the behavioral health case manager on

behalf of the member related to advocacy, linkage, referral, or monitoring

used to address needs, goals and/or objectives;

(

8

)

p

ro

g

ress or barriers made towards

g

oals and/or ob

j

ectives;

()

pg g j

(9) member (family when applicable) response to the service;

(10) any new service plan needs, goals, and/or objectives identified during the

service; and

(

11

)

member satisfaction with staff intervention.

()

Primary Care PhysiciansPrimary Care Physicians

Network with

p

h

y

sician’s offices. Let

py

them know that you are available to assist

them with an

y

one who needs BH

y

services. We are encouraging physicians

to routinel

y

screen for

p

s

y

chiatric

ypy

problems: substance misuse, abuse,

de

p

endenc

y

, emotional and other

py

behavioral health problems.

What Irks Primary Care Physician What Irks Primary Care Physician

No responses back when they refer a patient.

Long responses that use mental health jargon.

Lack of ex

p

licit recommendations the

y

can act

py

on.

No res

p

onse to a medical record/release of

p

information request.



Long delays in getting the patient seen for an



Long delays in getting the patient seen for an

initial consult.

Medicare's 8 Minute Rule

Units Actual

Time 8 Minute Rule

Minimum and Maximum Times

1it

15

8it t22it

1

un

it

=

15

8

m

i

nu

t

es

t

o

22

m

i

nu

t

es

2 units = 30 23 minutes to 37 minutes

3 units = 45 38 minutes to 52 minutes

4 units = 60 53 minutes to 67 minutes

5 units = 75 68 minutes to 82 minutes

6 units

=

90

83 minutes to 97 minutes

6

units

90

83

minutes

to

97

minutes

7 units = 105 98 minutes to 112 minutes

8 units = 120 113 minutes to 127 minutes

9it

135

128 i t t 142 i t

9

un

it

s =

135

128

m

i

nu

t

es

t

o

142

m

i

nu

t

es

10 units = 150 143 minutes to 157 minutes

11 units = 165 158 minutes to 172 minutes

12 units = 180 173 minutes to 187 minutes

Qi ?Qi ?

Q

uest

i

ons,comments

?Q

uest

i

ons,comments

?

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