BEHAVIORAL HEALTH SERVICES - Redesign Mild to Moderate Mental Health Services Overview

Redesign Mild to Moderate
BEHAVIORAL HEALTH SERVICES   Mental Health Services
                             Overview

Presenters:
                 Katy White, LMFT       PROGRAM MANAGER
                 Gina Griffiths, LCSW   PROGRAM SUPERVISOR
INTRODUCTIONS    Billie Withrow, LMFT   MENTAL HEALTH CLINICAL SPECIALIST

TRAINING OBJECTIVES

        Timeline

        Overview of services for Mild/Moderate and
        Moderate/Severe populations

        Review of new authorization process & new Form

TIMELINE

     1/6/2021      1/11/2021 –
                        2nd        1/18/2021 –
        1st                          Program
   Informational   Informational   Change Begins
      Session         Session

OVERVIEW OF CMU LINES OF BUSINESS/PROGRAMS
    Specialty Mental Health Services                 Mild to Moderate Mental Health Services
          (Moderate/Severe)                                     (Mild/Moderate)

                 • The Contra Costa Mental Health                     • Contra Costa Health Plan (CCHP) is
                                                                        responsible for service delivery. They
Responsibility     Plan (CCMHP) is responsible for   Responsibility     delegate oversight to The Contra
                   service delivery.                                    Costa Mental Health Plan (CCMHP).

  Medical                                              Medical
                 • Adheres to Medi-caid Title XI                      • Adheres to Medi-Cal guidelines which
  Necessity        criteria.                           Necessity        are less restrictive than Title XI
   Criteria                                             Criteria

                 • Registration & Admission Form
                                                                      • Registration & Admission Form
                 • Intake/Annual Assessment
    Forms        • Change of Treatment Form              Forms        • Prior Authorization Form
                                                                      • Discharge Form
                 • Discharge Form

Provider Portal will display the
             acuity – Mild/Moderate or
             Moderate/Severe

HOW WILL I
KNOW MY      Authorization Letters will display the
             acuity or program - Mild to

CLIENT’S     Moderate Mental Health Services or
             Specialty Mental Health Services

ACUITY?
             If the acuity displayed does not
             match what you feel the client’s
             acuity is, call CMU to consult

Access provides    Once an initial
                   appointment is
                                                           If services are
                                                          necessary after
                                                             the initial 8
                                                                             INITIAL
                                                                             AUTHORIZATION
individuals with   scheduled, the     After 1st session        visits, the
    a verbal           Network            submit               Network
  referral to a     Provider calls     Registration &     Provider submits
    Network
    Provider       Access for the
                   Initial Referral
                                      Admission Form            a Prior
                                                            Authorization
                                                          Request to CMU
                                                                             PROCESS

THE INITIAL AUTHORIZATION

Units for Adults & Children under the age of 21
1 99205 (this is changing from current 8 units)
6 90834
2 90846
2 90847
6 90887

PRIOR AUTH FORM:
 DEFINITION OF “URGENT” REQUEST

 It is rare that a provider would indicate a referral is Urgent because based on the definition, that would imply the
 client would most likely be moderate-severe, and thus you would not be using this Prior Auth form
 There are regulations around timely response for Urgent referrals
 A referral must be processed within 72 hours from receipt by CMU
 An appointment must be offered by provider within 48 hours
 Examples may include (this is not an exhaustive list):
     o SI: current SI with plan, recent suicide attempt, increasing risky/self-harm gestures, such as cutting
     o HI: current HI with plan/threats, recent history of physical altercation/assault
     o AVHs: gravely disabled, command hallucinations

WHAT IF A CLIENT’S ACUITY CHANGES?
Mild to Moderate Mental Health              Specialty Mental Health Services:
Services:
                                            Client’s acuity changes from
Client’s acuity changes from Severe to      Mild/Moderate to Severe (always
Mild/Moderate (always consult with a        consult with a CMU Clinician):
CMU Clinician):
                                             CMU will issue an initial authorization
 CMU will issue an initial authorization   for Specialty Mental Health Services.
for Mild to Moderate Mental Heath
Services                                    Within 30-60 days the Network
                                            Provider will submit an Intake form.
After initial 8 sessions, the Network
Provider will submit the Prior
Authorization Request form.

Justification/Presenting
                      Problem

             Medical
             Necessity

Supporting                              Measurable
                                         Tx Goals /
Documents                               Interventions

• Include level of impairment

                  • Information should be
JUSTIFICATION –     directly linked to the
  PRESENTING        diagnosis
   PROBLEM
                  • Include symptoms and how
                    symptoms are impacting the
                    client’s daily functioning

JUSTIFICATION –       Identify what will be
  MEASURABLE       addressed during treatment
                  and the measurement of when
    GOALS /          goal will be achieved.
 INTERVENTIONS     Attach a separate treatment
                         plan if needed.

Attach any other supporting
JUSTIFICATION –   clinical documentation such as
                    assessment/progress note.
  SUPPORTING
                      This can be in any form
 DOCUMENTS         maintained by the Network
                             Provider.

EXAMPLE -
    1ST PRIOR AUTHORIZATION REQUEST FORM
DIAGNOSIS
Diagnosis: Generalized Anxiety Disorder F41.1

    PRESENTING PROBLEM
    Client reports only sleeping 3 hours a day, irritability, difficulty concentrating,
    and restlessness. These symptoms are impacting the client’s ability to maintain
    a job and socialize outside of the house.

             MEASUREABLE GOALS
             Using CBT, Client will exhibit an increased understanding of anxious feelings and
             increase coping skills regarding anxiety/symptoms as evidenced by increasing
             hours of sleep to 6 hours a day, improved mood, and concentration as reported by
             client. Additionally, client will find and maintain a job for at least a 12-month
             period.

EXAMPLE -
    SUBSEQUENT PRIOR AUTHORIZATION REQUEST
    FORM(S)
DIAGNOSIS
Diagnosis: Generalized Anxiety Disorder F41.1
    PRESENTING PROBLEM
    Client reports increasing sleep to 4 hours a day and continued irritability but
    has been able to increase concentration and is not as restless. Client has not
    been able to find a job or socialize outside of the house due to symptoms of
    anxiety.
             MEASURABLE GOALS
             Continue using CBT, Client will exhibit an increased understanding of anxious
             feelings and increase coping skills regarding anxiety/symptoms as evidenced
             by improvement in sleeping patterns, mood, and concentration as reported by
             client. Additionally, client will find and maintain a job for at least a 12-month
             period.

1) After the initial 8 sessions, at least 8 units will be
                     provided per Prior Authorization request.
                  2) The number of units authorized will abide by
                     evidenced based/best practices standards and will
                     be on par with the health plan.
                  3) The Network Provider will indicate the requested
                     number of units on the Prior Authorization Form.

REAUTHORIZATION   4) If the requested number of units does not align with
                     evidenced based/best practices, the CMU Clinician
                     will issue a Notice of Action – Modification will be
                     completed.
                  5) All authorizations will be good for one year. If a new
                     Prior Authorization request is submitted for the same
                     client, the year will restart based on the date of the
                     most recent request.

REAUTHORIZATION - AUTHORIZATION
Each authorization is tailored toward the client’s needs and best practices’ guidelines.
Examples of possible options::
 Individual Therapy
  8 90834
  2 90887
 Family Therapy(Both CPT codes for services w/client and w/o client are included.
                Expectation is you keep the units to 8 total)
  8 90846
  8 90847
  2 90887
 Individual & Family Therapy
  8 90834
  8 90846
  8 90847
  2 90887

DISCHARGE
Once services end, submit the Discharge form.
A discharge form is not needed if a client’s acuity changes.

QUESTIONS?