EmblemHealth Provider Manual Subject: Chapter - Clinical Practice Guidelines Created Date: 20190913022317Z ...
Medically Fragile Children. Office of Health Insurance Programs Principles. Back to Table of Contents. EmblemHealth Provider Manual. PDF created on: 06/28/ ...
CLINICAL PRACTICE GUIDELINES TABLE OF CONTENTS .O. V. .E. R. .V. I.E. W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. .6.9. . . .E.M. .B. .L.E.M. . H. .E. A. .L.T. H. . -.A. .D. O. . P. .T.E. D. . .C. L. I. N. .I.C. A. .L. .P.R. A. .C. .T.I.C. E. .G. .U. .ID. .E. .L.IN. . E. .S. . . . . . . . . . . . . . . . . . . . . . . . . . . 4. .6.9. . . .M. .e.d. i.c.a.l. M. . a. .n.a.g. e. .m. e. .n.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 6. .9. . . . . .B.e. h. .a.v.i.o.r.a.l.H. .e.a. l.t.h. S. .e.r.v.i.c.e.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .0. . . . . .M. .e.d. i.c.a.l.ly. .F. r. a. .g.il.e. .C. .h.il.d. r. e. .n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .1. . . . . .O. f. f.i.c.e. o. .f.H. .e.a. l.t.h. .In. .s.u.r.a. n. .c.e. P. .r.o.g. r. a. .m. s. .P. r. i.n. c. i.p. l.e. s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .1. . . . . Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 468 CLINICAL PRACTICE GUIDELINES This chapter contains evidence-based recommendations to assist practitioners in providing medical care. OVERVIEW EmblemHealth encourages the use of Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic and behavioral health issues. We've adopted these guidelines from professionally recognized sources and through consultation between board-certified specialists and our Health Status Improvement Subcommittee. All CPGs are reviewed at a minimum of every two years and are updated as appropriate. (The HIV/AIDS CPGs are reviewed and updated annually.) CPGs are not intended as a substitute for the professional assessment of the health care practitioner but to assist the practitioner in the management of certain types of preventive and clinical care. Individual patient treatment may vary from these guidelines based on the health care practitioner's clinical judgment. The CPGs approved by EmblemHealth are listed below. Updates will be posted regularly to our Web site, so please check for updates on a monthly basis. If you are unable to access a specific CPG on the Web, please contact our Quality Management department at 1-888-447-5451 to request a mailed copy. EMBLEMHEALTH-ADOPTED CLINICAL PRACTICE GUIDELINES Medical Management (Please access these clinical practice guidelines at www.emblemhealth.com.) Adults Exposed to the World Trade Center Disaster Adult Preventive Services Appropriate Use of Antibiotics for Adults and Children Arthritis Asthma Cholesterol Management for Adults at Risk for Cardio/Vascular Disease Chronic Kidney Disease Chronic Obstructive Pulmonary Disease (COPD) Community-Acquired Pneumonia in Adults Congestive Heart Failure Coronary Artery Disease Diabetes Mellitus Helicobacter Pylori HIV/AIDS Hypertension Low Back Pain Diagnosis and Treatment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 469 CLINICAL PRACTICE GUIDELINES Lyme Disease Obesity and Weight Management in Adults Obesity and Weight Management in Children and Adolescents Osteoporosis Pediatric and Adolescent Preventive Services Preconception Care Prenatal/Postpartum Care Sexually Transmitted Diseases (STDs) Smoking Cessation Stroke Prevention Tuberculosis Urinary Incontinence Behavioral Health Services Beacon Health Options manages behavioral health services for members served by Emblem Behavioral Health Services Program (for plans underwritten by HIP and HIPIC and administered by VHMS) and Behavioral Management Program (for plans underwritten by GHI). Please access the Beacon Health Options Treatment Guidelines listed below at https://www.beaconhealthoptions.com/pcp-toolkit/. Diagnosed Based Acute Stress Disorder and Post-Traumatic Stress Disorder (PDF) Adopted from APA 8/10/06 Reviewed 5/21/12 Assessing and Treating Suicidal Behaviors (PDF) Adopted from APA 8/10/06 Reviewed 5/21/12 ADHD Guidelines (Adults) (PDF) Adopted from Weiss and Weiss 5/11/09 Reviewed 3/13/13 ADHD Guidelines (Child/Adolescent) (PDF) Adopted from AACAP Reviewed 3/13/13 Autism Spectrum Disorders (PDF) Reviewed 8/20/12 Bi-Polar Disorder (PDF) Adopted from APA 6/2004 Reviewed 5/21/12 Co-Occurring Mental Substance Related Problems (PDF) Reviewed 7/16/12 Eating Disorders (PDF) Adopted from APA 5/12/05 Reviewed 3/18/13 Generalized Anxiety Disorder (PDF) Adopted from Canadian Psychiatric Association Anxiety Guidelines 10/12/06 Reviewed 8/20/12 Major Depression (PDF) Adopted from APA 5/12/05 Reviewed 3/18/13 Tip 43 Medication Assisted Treatment for Opioid Addicition in Opioid Treatment Programs (PDF) Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 470 CLINICAL PRACTICE GUIDELINES Reviewed 4/18/11 Suboxone (PDF) Reviewed 8/20/12 Treating Schizophrenia (PDF) Adopted from APA Reviewed 3/18/13 Schizophrenia Guideline Watch (PDF) Adopted 3/21/11 Reviewed 5/21/12 Treating Panic Disorder (PDF) Adopted from APA 8/10/06 Reviewed 5/21/12 Treating Substance Use Disorders (PDF) Adopted from APA 8/10/06 Reviewed 5/21/12 Program Based EAP Guidelines (PDF) Reviewed 3/18/13 Treatment Based Electroconvulsive Therapy (ECT) (PDF) Adopted from APA 8/11/05 Reviewed 9/19/11 Medically Fragile Children For the Medicaid children carve-in effective July 1, 2018, and the foster care children carve-in in 2019, EmblemHealth will incorporate the following into its guidance: OMH Clinic Standards of Care: https://www.omh.ny.gov/omhweb/clinic_standards /care_anchors.html OASAS Clinical Guidance: https://www.oasas.ny.gov/AdMed/recommend /recommendations.cfm OHIP, Policy and Proposed Changes to Transition Children in Direct Placement Foster Care into Medicaid Managed Care, April 2013 https://www.health.ny.gov/health_care/medicaid /redesign/docs/policy_and_proposed_changes_fc.pdf OCFS Working Together: Health Services for Children in Foster Care Manual httsp://ocfs.ny.gov/main/sppd/health_services/manual.asp Office of Health Insurance Programs Principles for Medically Fragile Children Office of Health Insurance Programs Principles A "medically fragile child" (MFC) is defined as an individual who is under 21 years of age and has a chronic debilitating condition or conditions, who may or may not be hospitalized or institutionalized, and meets one or more of the following criteria: (1) is technologically dependent for life or health-sustaining functions, (2) requires a complex medication regimen or medical interventions to maintain or to improve their health status, (3) is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health, or development at risk. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 471 CLINICAL PRACTICE GUIDELINES Chronic debilitating conditions include, but are not limited to: bronchopulmonary dysplasia cerebral palsy congenital heart disease microcephaly pulmonary hypertension muscular dystrophy With respect to medically fragile children, and children in foster care EmblemHealth: A. Will, in accordance with the requirements of C/THP and EPSDT as described in Section 10.4 of the DOH Model Contract, cover all services that assist a medically fragile child in reaching their maximum functional capacity, taking into account the appropriate functional capacities of children of the same age. EmblemHealth will continue to cover services until that child achieves age-appropriate functional capacity. B. Shall not base determinations solely based upon review standards applicable to (or designed for) adults to medically fragile children. Adult standards include, but are not limited to, Medicare rehabilitation standards and the "Medicare 3-hour rule." Determinations have to take into consideration the specific needs of the child and the circumstances pertaining to their growth and development. C. Will accommodate unusual stabilization and prolonged discharge plans for medically fragile children, as appropriate. Areas that plans must consider when developing and approving discharge plans include, but are not limited to: sudden reversals of condition or progress, which may make discharge decisions uncertain or more prolonged than for other children or adults necessary training of parents or other adults to care for a medically fragile child at home unusual discharge delays encountered if parents or other responsible adults decline or are slow to assume full responsibility for caring for a medically fragile child the need to await an appropriate home or home-like environment rather than discharge to a housing shelter or other inappropriate setting for a medically fragile child the need to await construction adaptations to the home (such as the installation of generators or other equipment) and lack of available suitable specialized care (such as unavailability of pediatric nursing home beds or pediatric ventilator units). EmblemHealth will develop a person-centered discharge plan for the child, taking the above situations into consideration. D. Will identify an available provider of needed covered services, as determined through a person-centered care plan, to effect safe discharge from a hospital or other facility. Payment will not be denied to a discharging hospital or other facility due to lack of an available post-discharge provider as long as they have worked with EmblemHealth to identify an appropriate provider. EmblemHealth will approve the use of out-of-network (OON) providers Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 472 CLINICAL PRACTICE GUIDELINES if we do not have a participating provider to address the child's needs. E. EmblemHealth will ensure that a medically fragile child receives services from appropriate providers that have the expertise to effectively treat the child. EmblemHealth contracts with providers with demonstrated expertise in caring for medically fragile children. Network providers shall refer to appropriate network community and facility providers to meet the needs of the child or seek EmblemHealth's authorization for out-of-network providers when participating providers cannot meet the child's needs. EmblemHealth will authorize services as fast as the enrollee's condition requires and in accordance with established time frames in the Medicaid Managed Care Model Contract. EmblemHealth expects those who treat medically frail and foster children to comply with this guidance. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 473EmblemHealth Services Co., LLC via ABCpdf