Welcome to

Health Care Excel

Who We Are

Ann Carter, RN, BSN – Project Director Kim Smith, LPCC-S – Project Leader June Green, LSW – Clinical Advisor

Who We Are

We are clinicians. We respect your clinical judgment.

We want your client to receive the necessary and appropriate services.

What We Do

We contract with the ODMH to review prior We contract with the ODMH to review prior authorizations for Partial Hospitalization authorizations for Partial Hospitalization (PH) and Community Psychiatric Supportive (PH) and Community Psychiatric Supportive Treatment (CPST) Services.Treatment (CPST) Services.

We answer clinical and technical questions We answer clinical and technical questions related to the prior authorization process.related to the prior authorization process.

We offer telephonic and on-site provider We offer telephonic and on-site provider education.education.

What We Don’t Do

We do not receive financial incentive to deny or limit services.

Our Goal

To ensure the

right service for the

right client in the

right setting at the

right level of care.

HCE and ODMH

HCEHCE Manages the prior Manages the prior

authorization programauthorization program Conducts provider Conducts provider

educationeducation Identifies utilization Identifies utilization

trendstrends

ODMHODMH Oversees the Medicaid Oversees the Medicaid

program for mental program for mental health serviceshealth services

Answers MACSIS and Answers MACSIS and billing questionsbilling questions

Interprets Ohio Interprets Ohio Administrative Codes and Administrative Codes and State laws and State laws and regulationsregulations

Determinations

Our determinations are based on the current State-approved definition for medical necessity.

Medical Necessity

Ohio Administrative Code 5101:3-1-01 Medicaid: Medical Necessity

“Medical necessity” is a fundamental concept underlying the Medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, “medically necessary services” are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.

Medical Necessity

A Medically Necessary Service Must:(1) Meet generally accepted standards of medical practice;(2) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;(3) Be appropriate to the intensity of service and level of setting;(4) Provide unique, essential, and appropriate information when used for diagnostic purposes;(5) Be the lowest cost alternative that effectively addresses and treats the medical problem; and(6) Meet general principles regarding reimbursement for Medicaid covered services found in rule 5101:3-1-02 of the Administrative Code.

Medical Necessity (continued)

(B) Preventive health care, though not customarily thought of as a “medically necessary” service, is available through the department’s early periodic screening, diagnosis and treatment (EPSDT, also known as Healthchek) program or through managed care plans (MCPs) that have contracted with the department.

Community Psychiatric Supportive Treatment

Ohio Administrative Code 5122-29-17 CPST services are community based and mobile.

CPST is a service comprised of individualized mental health activities which are delivered in a variety of locations based on the natural environment(s) of the individual, i.e. home and community locations. These services are provided to children, teens, adults, and families and will vary with respect to hours, type, and intensity of services depending on the changing needs of each individual.

CPST (continued)

The purpose of CPST services is to provide specific, measurable, and individualized services to each client served. These services are focused on the client’s ability to succeed in the community and demonstrate improvement in major life areas such as school, work and family.

The goal is to minimize the negative effects of the symptoms of mental illness which interfere with the client’s baseline functioning and activities of daily living by assisting the client in identifying effective treatment options.

Partial Hospitalization Program

Ohio Administrative Code 5122-29-06 (A)

A Partial Hospitalization Program (PHP) is an intensive, structured, goal-oriented, distinct, and identifiable treatment service that utilizes multiple mental health interventions that address the individualized mental health needs of the client. Partial hospitalization services are clinically indicated by assessment with clear criteria. The environment at this level of treatment is highly structured and there should be an appropriate staff-to-client ratio in order to guarantee sufficient therapeutic services and professional monitoring, control, and protection.

PH (continued)

The purpose and intent of Partial Hospitalization services is to stabilize, increase, or sustain the highest level of functioning and promote movement to the least restrictive level of care.

The outcome is for the individual to develop the capacity to continue to work toward an improved quality of life with the support of an appropriate level of care.

Resource

http://mentalhealth.ohio.gov/assets/licensure-certification/rules/5122-29-17.pdf

Prior Authorization (PA) Process

Provider

The PA request is completed by the provider on-line.

If the provider is unable to complete the form on-line, a hard copy of the form is available and may be faxed.

Please note: all documentation must provided on the PA form. We cannot accept additional documents.

Health Care Excel

Using the approved Medical Necessity Criteria, Ohio-licensed clinical specialists review the application and render a determination.

Process for Providers

The provider is notified of the determination within the following timeframes. 24 hours for PH requests 72 hours for CPST requests

The provider is notified via e-mail of the determination with authorization number and approved number of units.

Approved Case

A PA number is assigned to the case.    Determinations will contain the following.

• UCI number• Authorization number• Number of units approved

Denial

If clinical documentation on the PA form does not support the need for continued services, the clinical reviewer defers the case to the HCE Medical Director.

HCE Medical Director

The HCE Medical Director has a contractual obligation to follow all State and Federal Medicaid laws including the Medical Necessity rule.

The HCE Medical Director and all physician consultants are Ohio-licensed, board certified psychiatrists in active practice.

Physician Review

The Medical Director reviews the case and renders a determination.

If approved, the case is assigned an authorization number.

Denial

If denied, the Medical Director’s rationale for denial will be cited in the determination.

The provider and client are provided written information regarding the right to a State Hearing.

Appeal Process

The client may request a State Hearing in the following ways.

1. Mail the request to:Ohio Department of Job and Family ServicesBureau of State HearingsP.O. Box 182825Columbus, Ohio 43218-2825

2. Fax the request to ODJFS Bureau of State Hearings at 614-728-9574.

Appeal Process

3. Client may send an e-mail to the ODJFS Bureau of State Hearings at bsh@jfs.ohio.gov.

4. Client may telephone the ODJFS Consumer Access Line at 1-866-635-3748 and follow the instructions for State Hearings.

5. Client may contact Legal Aid at

1-800-LAW-OHIO.

Implementation

Start Date

For

On-line Registration

and

Prior Authorization

Submissions

Monday, December 5, 2011

How to Submit

www.hce.org

Click on Ohio Medicaid/Ohio CMH

Download instructions for PA submission Download registration form Obtain hard copy of the PA form.

Completing the PA Form

The PA form was designed to capture pertinent and relevant clinical

information.

Demographic Information

Client name Client Medicaid number Client UCI number Social Security number Date of birth Race and gender Responsible party Provider UPI number

Clinical Information

Diagnosis (Axis I, II, III, IV, and V required) Baseline Current functioning Treatment goals Progress Lack of progress Need for continued service

Clinical Information

Risk factors Legal Mental status examination Abuse Substance use Medications Prior inpatient and outpatient treatment

Client’s Baseline

Describe the client’s usual or optimal level of functioning.

What is the client’s typical level of independence?• Can the client take his/her own medication?• Can the client meet his/her own basic needs?• Does the client require routine care or

supervision?

Current Functioning

Describe current functioning as compared to baseline.

Address factors that could affect functioning.• Treatment compliance• Medication compliance• Increase in symptoms• Decrease in independence• Use of or dependence on support system• Risk factors

Treatment Goals

Questions to consider.

What are the goals for continued treatment? Are the goals specific and measurable? What are the target dates for completion of

goals?

Progress

Indicators of progress may include the following.

Participation/motivation Attendance Compliance Response to interventions

Lack of Progress

Indicators of lack progress may include the following.

Participation/motivation Attendance Compliance Response to interventions

Need for Continued Service

Summarize the need for continued services.

Questions About PA

Who can complete the PA form?

Completion of the prior authorization request is at the discretion of the provider.

A clinical contact person must be provided.

Units of Service Request

How many units will be authorized? What is the maximum amount of units

authorized? What is the minimum amount of units

authorized? How many times can the provider submit a

PA for the same client?

Answer

PA’s may be submitted at anytime.

Determinations are on an individualized,

case-by-case basis.

Authorizations are based on current medical necessity criteria.

When Do Prior Authorizations Expire?

Prior authorizations expire the end of the current State fiscal year (June 30, 2012).

Ohio CMH Provider Handbook

A handbook will be mailed to each provider by the week of November 18th, 2011.

*Outlines the PA process.

*Contains hard copies, examples, and

instructions on everything we have

reviewed.

Provider Education

Health Care Excel staff are available

Monday through Friday from 8:00a.m. to

5:00p.m. to answer questions. Health Care

Excel staff are available for the following.

• Community trainings• On-site education

How to Contact Health Care Excel

Mailing AddressHealth Care Excel

Ohio CMH Program30 East Broad Street, 7th Floor

Columbus, OH  43215(614) 752-9854

Toll-free number1-888-239-7758

How to Contact Health Care Excel

Toll-free Fax1-888-763-4575

Hours of OperationMonday through Friday

8:00 a.m. to 5:00 p.m.

Web Sitewww.hce.org

How to Contact Health Care Excel

Our E-mail

OhioCMH@hce.org

All correspondence will be addressed within one business day.

Health Care Excel

Questions?

Health Care Excel

Thank you