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DETROIT WAYNE MENTAL HEALTH AUTHORITY UTLIZATION MANAGEMENT PROGRAM DESCRIPTION

FY 2016-2018

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Table of Contents:

I. Introduction II. Mission

III. Vision IV. Values V. Purpose

VI. Scope VII. DWMHA’s Strategic Plan and Utilization Management Program

VIII. DWMHA’s System Transformation IX. Program Structure

A. UM Staff Assigned Activities and Professional Qualifications X. Committee Structure

A. UM Committee Membership B. Committee Purpose

XI. Program Goals XII. Behavioral Health Medical Necessity and Benefit

A. Development and Description of Medical Necessity Criteria B. Criteria Review, Approval and Distribution C. DWMHA Behavioral Health Guidelines

XIII. Delegation and DWMHA Oversight XIV. UM Methods and Organization Process for Making Determinations of Medical Necessity and Benefit

Coverage for In-Patient and Out-Patient Services XV. Access, Triage and Referral Process for Behavioral Health and Substance Use Services

XVI. Emergency Care Resulting in Admissions XVII. Pre-Service and Concurrent Reviews

XVIII. Post-Service Reviews XIX. Discharge Planning XX. Utilization Management/Provider Appeals and Alternative Dispute Resolution Reviews

A. UM/Provider Appeals for Medicaid Covered Services 1. Pre-Service and Post-Service Medical Necessity or Benefit Appeals 2. Pre-Service and Post-Service Administrative Appeals

B. UM/Provider Appeals for Medicare Covered Services 1. Pre-Service and Post-Service Medical Necessity or Benefit Appeals 2. Pre-Service and Post-Service Administrative Appeals

C. UM/Provider Local and Alternative Dispute Resolution 1. Pre-Service and Post-Service Medical Necessity or Benefit Appeals 2. Pre-Service and Post-Service Administrative Appeals

D. UM/Provider Local and Alternative Dispute Resolution 1. Pre-Service and Post-Service Medical Necessity or Benefit Dispute Resolution Review 2. Pre-Service and Post-Service Administrative Dispute Resolution Review

XXI. Continuous Coverage and Service Requirements XXII. Individualized Plan of Service/Master Treatment Plan

XXIII. Utilization Management’s Role in the Quality Improvement Program XXIV. Satisfaction with the Utilization Management Process XXV. Behavioral Health UM Program Evaluation

A. Frequency of UM Program Evaluation B. Responsibility of UM Program Evaluation

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Attachments:

1. UM Functions for MI Health Link Program 2. Waiver and State Plan Amendments 3. DWMHA Prior Authorized Service UM Chart Review Tool 4. DWMHA Eligibility of Service Review Tool 5. DWMHA’s Quality Department Clinical Record Review Tool (or its Successor) 6. MCPNs’ and Crisis Service Vendor’s UM Annual Evaluation Template 7. Access Center’s UM Annual Evaluation Template 8. Access Center, Crisis Service Vendor and the MCPNs’ UM Plan Outline 9. Access Center, Crisis Service Vendor and MCPNs’ UM Plan Audit Tool

References:

1. DWMHA Affirmative Statement Policy 2. DWMHA Appropriate Professionals for Making UM Decision Policy 3. DWMHA Behavioral Health Utilization Management Review Policy 4. DWMHA Behavioral Health Medical Necessity Policy 5. DWMHA Benefit Policy and Benefit Grid 6. DWMHA Denial of Service Policy 7. DWMHA HIPPA Privacy Manual and Policy 8. DWMHA HIPAA Security Policy 9. DWMHA Individual Plan of Service Policy 10. DWMHA Inter Rater Reliability Policy 11. DWMHA Local and Alternative Dispute Resolution Policy 12. DWMHA UM/Provider Appeal Policy 13. MDHHS Person Centered Planning Policy Practice Guidelines (3/15/11) 14. Michigan Medicaid Provider Manual

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I. INTRODUCTION:

Utilization Management (UM) functions are driven by the Detroit Wayne Mental Health Authority (DWMHA) Board’s commitment to the provision of effective, consistent and quality care for behavioral health services that produces financial outcomes. The Utilization Management Program Description reflects the expectations and standards of the Michigan Department of Health and Human Services (MDHHS) and the Center for Medicare and Medicaid Services (CMS). The DWMHA Chief Medical Officer has substantial involvement in the development, implementation, supervision and evaluation of the UM program. The Board of Directors (BOD) has the ultimate responsibility for ensuring overall quality of supports and services delivered to Wayne County residents and oversight of UM functions.

II. MISSION:

DWMHA is a safety net organization that provides access to a full array of services and supports to empower persons within the Detroit Wayne County behavioral health system.

III. VISION: To be recognized as a national leader that improves the behavioral and overall health status of the people in our community.

IV. VALUES:

• We are a person centered, family and community focused organization. • We are an outcome, data drive and evidenced based organization. • We respect the dignity and diversity of individuals, providers, staff and communities. • We are culturally sensitive and competent. • We are fiscally responsible and accountable with the highest standards of integrity. • We achieve our mission and vision through partnerships and collaboration.

V. PURPOSE:

The purpose of the UM Program Description is to define and describe processes that will align the Utilization Management program with DWMHA’s Strategic Plan as identified by the Board of Directors. The UM program description will: • Guard against conflict of interest and protects the integrity of clinical decision making through the use

of written evidence based and professional consensus criteria; • Promotes DWMHA accountability for any delegated functions and responsibilities; • Confirm that individuals have a significant role in the design of the systems that support them; • Promise UM decisions are made in a fair, impartial and consistent manner that is in the best interest of

the person; • Assure UM decisions are timely, efficient and consistent with standardized guidelines to increase the

likelihood that services for vulnerable persons are equal in amount, duration and scope; • Ensure compliance with state and federal law as well as regulatory and accreditation standards.

Ensures use of Level of Care Criteria, Clinical Practice Protocols and best practices to improve process and reduce inappropriate variations in practice;

• Assure that people get individualized, appropriate behavioral health services and supports that are sufficient in scope, frequency and duration to achieve effective outcomes;

• Encourage equitable access to behavioral health services across the network; and • Promote the availability of cost effective behavioral health services within available resources for a

greater number of people; • Respond in a timely manner to member and practitioner/provider complaints/appeals regarding UM

issues after coordinating a comprehensive and timely investigation.

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VI. SCOPE: The Behavioral Health UM Program consists of activities that promote the appropriate allocation of behavioral health and substance use resources for UM individuals managed by staff in the DWMHA office, Access Center, Crisis Service Vendors and the Managers of Comprehensive Provider Networks (MCPN). Processes used within the context of UM include: pre-service, concurrent and post-service review; denials and appeals; discharge planning and other care management activities. DWMHA’s UM department maintains standardized policies and procedures that are created by the UM Director or their designee and reviewed by the Chief Medical Officer and Directors of all DWMHA departments through Policy Stat (DWMHA’s software policy and procedure management system) and are ultimately reviewed and approved by the Chief Operating Officer. The policies are reviewed on an annual basis. In addition, procedures are reviewed annually and updated on an as needed basis. The policies and procedures provide documentation of the framework of authority in which the UM program operates. The UM staff are authorized to make decisions that operate within the framework described within these policies and procedures. The Access Center, Crisis Service Vendors and MCPNs’ policies and procedures must align with DWMHA policies. Depending on the level of care, certain behavioral health and substance use services require prior authorization. For example, acute inpatient hospitalization, state hospitalization, partial hospitalization, crisis residential services and withdrawal maintenance/sub-acute detox are some of the services that need prior authorization. Along with monitoring the appropriate level and allocation of care, DWMHA assesses Ambulatory Follow-Up (AFU) rates. Ambulatory Follow-Up activities serve to ensure that enrollee/members are provided with a timely out-patient appointment after they are discharged from the hospital. Care Coordinators and Support Care Coordinators provide support to enrollee/members following discharge to ensure appointment compliance within seven (7) days following discharge and assist with rescheduling of appointments on an as needed basis for MI Health Link Enrollee/Members. MCPN Care Coordinators provide support to Medicaid enrollee/members following hospital discharge within seven (7) days of hospital discharge. DWMHA staff, contractors and subcontractors are bound by all applicable local, state and federal laws, rules, regulations, and policies, all federal requirements, state and county contractual requirements, polices and administrative directives in effect and as amended.

VII. DWMHA’S STRATEGIC PLAN AND THE UTILIZATON MANAGEMENT PROGRAM: The DWMHA Board Strategic Plan is an overarching framework that strives towards common goals, establishes agreement around intended outcomes/results, and assesses and adjusts the organization’s direction in response to a changing environment. The UM Program is one of the mechanisms to accomplish this. It is a systematic approach to providing independent, unbiased determinations of medical necessity using evidence based treatment criteria and guidelines to enhanced the quality and effectiveness of care. The DWMHA’s approach to utilization management is based on the following five (5) pillars with support from seven (7) focus areas under each pillar in the DWMHA’s Board approved Strategic Plan. Strategic Plan Pillars by Definition: • Customer: Services should be designed to meet the needs and expectations of consumers. An

important measure of quality is the extent to which customer needs and expectations are met. • Access: Provide affordability of the services provided to the customer. To ensure availability and

accessibility of the services. • Workforce: Provide staff development activities while empowering staff in the competitive and

market-driven workforce. • Finance: Ensure the Administrative Cost as a portion of the Total Cost is low and reasonable. • Quality: Deliver a robust decision support system as DWMHA will be recognized as the Behavioral

Health Subject Matter expert through the use of standardized treatment protocols and guidelines.

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VIII. DWMHA SYSTEM TRANSFORMATION/RECOVERY ORIENTED SYSTEMS OF CARE:

Many individuals and families served in the DWMHA system of care have co-occurring disorders. These persons present with co-occurring psychiatric, substance use disorders and/or intellectual developmental disabilities, which are recognized as often resulting in poorer outcomes and higher costs in multiple clinical domains. DWMHA’s efforts will focus on ensuring that consumers have access to appropriate treatment by promoting resiliency, recovery and the right to control one’s life. Together with our stakeholders, including enrollees/members, family, advocates, peer support specialists, peer mentors, recovery coaches, youth advocates, parent partners, contractors and subcontractors, DWMHA has committed to engaging in systems transformation process aimed at achieving this vision. Within the framework of efficient utilization and effective outcomes we will collect data, review utilization trends for over and under-utilization as well as ensuring the following: • Individuals and families found to have co-occurring psychiatric, substance use disorders,

developmental disabilities, physical health, cultural or linguistic challenges and/or age-specific special needs are served.

• Individuals and their families with higher utilization of supports and services associated with a higher cost of care and resources will be served and not limited to a few specialized programs.

• Individuals and their families will be engaged in a welcoming manner with a “no wrong door” policy that promotes greater treatment accessibility to treatment supports and services.

• Successful outcomes will involve the formation of empathetic, hopeful and integrated relationships among all parts of the DWMHA.

Customer Access Workforce Finance Quality

Customer

•Require providers to document stages of change for each consumer

Access

•Manage care by benefit plans

Workforce

•Train clinical staff on appropriate level of care decisions using MCG

Finance

•Monitor overutilization of General Funds exceptions to ensure accountability

Quality

•Ensure UM decisions are documented and based on medical necessity using MCG

Pillars

UM Focus Areas for 2016-2018 Extracted from the Strategic Plan

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IX. PROGRAM STRUCTURE:

DWMHA’s UM staff are highly skilled, experienced professionals who are required to have ongoing training and participate in regularly scheduled case consultations with the DWMHA Chief Medical Officer. DWMHA is committed to increasing competency and the quality of services through continuous staff development activities. UM Staff Members’ Assigned Activities and Professional Qualifications: 1. Board of Directors (BOD):

• The BOD primary responsibility is to provide leadership, governance and oversight of the region. The Board is a policy setting body, the fiduciary of the Medicaid funds.

2. Chief Medical Officer (CMO):

• Must have a valid Michigan License to practice as a physician, and Michigan controlled substance license. Additionally the must have a valid and current Drug Enforcement Authority Registration. Board certification by the American Board of Psychiatry and Neurology as an adult psychiatrist is required;

• Five (5) years of experience working in a state or community psychiatric hospital or outpatient setting, as a direct provider of mental health services;

• At least five (5) years of administrative experience as CMO in a Mental Health Program with experience in: policy writing; accreditation activities, staff development; peer review management of direct report staff (i.e. nurses, social workers, etc.);

• Responsible for setting UM behavioral healthcare policies; • Develop policies, procedures and protocols for the delivery of psychiatric and medical services; • Guides, leads and assesses the overall clinical knowledge of the UM staff; • Provides on going oversight of the UM Program; • Reviews and updates the behavioral health medical necessity criteria; • Reviews UM behavioral healthcare cases including appeal cases; • Maintain accurate records of all communications and interventions in clinical software system,

Mental Health Wellness Information Network ( (MHWIN); • Chair of the UM committee; • Active Participation in the Peer Review Committee Activities; • Active Participation in the Sentinel Events Committee Activities; • Active Participation in the Review of Death Committee; • Active Participation in the Executive Leadership Team; • Participates on various internal and external committees; • Serves as a liaison to the medical community on all issues designed to improve the quality of

behavioral health services to enrollee/members; • Develops continuing education and in-service training opportunities for Board staff, Board of

Directors, and Community Mental Health (CMH) network; • Functions as a liaison with local, state, and national psychiatric and medical organizations for the

purpose of information gathering, networking to keep the Board of Directors and staff aware of trends in psychiatric and medical practice, research, training, and issues;

• Develops advisory committees of CMOs of MCPNS, Access Center, COPE and Providers to meet on a regular basis and provide input into psychiatric and medical standards, policies, procedures, and protocols;

• Provides oversight of DWMHA contracted behavioral health psychiatrists; • Presents to the Board of Directors and Board subcommittee meetings;

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• Collaborates with Director of UM to set UM department yearly goals; • Assists with the development of quality improvement processes and ensure accreditation and

regulatory requirements are met; • Conducts analysis of internal and external reports to evaluate UM outcomes and performance; • Collaborates with Director of UM to develop annual UM program description and work plan and

revise based on UMC recommendations; and • Reviews and provides oversight to the annual UM Program evaluation.

3. DWMHA Psychiatrist:

• Must have a valid Michigan License to practice as a physician, and Michigan controlled substance license. Additionally they must have a valid and current Drug Enforcement Authority Registration. Board certification by the American Board of Psychiatry and Neurology as an adult psychiatrist is preferred but not require;

• Must have completed a Psychiatric Residency approved by Accreditation Council for Graduate Medical Education (ACGME);


• At least five (5) years of administrative experience as Medical Director in a Mental Health Program with experience in: policy writing; accreditation activities, staff development; peer review management of direct report staff (i.e. nurses, social workers, etc.);

• Reviews UM behavioral healthcare cases including appeal cases; • Maintains accurate records of all communications and interventions in clinical software system

(MHWIN); • Participates on the UM committee; • Participates on various internal and external committees; • Administration of clinical aspect of Medicaid Fair Hearings; • Administration of the Death Review Program; • Assists in Behavioral Health Policy development and review; • Provides Staff Training and Development ; • Participates in Peer Reviews; • Provides leadership within committee structures, i.e. Utilization Management, Sentinel Events,

Quality Management, Child Death Review Team etc.; and • Provides clinical consultation to Recipient Rights.

4. Access Center, Crisis Service Vendors & Manager of Comprehensive Network (MCPN) Medical

Director: • Must have a valid Michigan License to practice as a physician, and Michigan controlled substance

license. Additionally they must have a valid and current Drug Enforcement Authority Registration. Board certification by the American Board of Psychiatry and Neurology as an adult psychiatrist is preferred but not require;

• Must have completed a Psychiatric Residency approved by Accreditation Council for Graduate Medical Education (ACGME);


• At least one (1) year of administrative experience as Medical Director in a mental health program with experience in policy writing, accreditation activities, staff development, peer review management of direct report staff (i.e. nurses, social workers, etc.);

• Reviews UM behavioral healthcare cases including first level appeal cases; and • Assist in DWMHA Behavioral Health Policy development and review.

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5. Director of Utilization Management:

• Minimum Master’s Degree in Mental Health Field with a valid Michigan licensure/certification as a Psychologist (LLP, FLP), Social Worker (CSW, ACSW), Counselor (LPC), Marriage and Family Therapist (LMFT), or Nurse (RN)

• Ten (10) years’ supervised experience with adults who are seriously mentally ill, or persons with a developmental disability, or with children who have serious emotional disturbances or elderly persons with serious mental illness. Knowledge and experience with co morbid conditions. Cultural competence training required.

• Minimum eight (8) years’ management & supervisory experience in managed care clinical setting. • Eight (8) years post Master’s degree, administrative utilization management experience at least

six (6) years of which must have been in a hospital, school or community mental health agency that provides care to mentally ill and emotionally disturbed adults children and adolescents.

• Responsible for the development and continual updating of all UM processes, policies and procedures within department;

• Co-chair of UM committee; • Provides supervision and implements development plans for all UM staff; • Makes recommendations regarding staffing, hiring, training and allocation of resources; • Oversees the on-going utilization review activities to monitor usage of services across all covered

populations; • Assists with the development of quality improvement processes and ensure accreditation and

regulatory requirements are met; • Leads multidisciplinary case reviews, to recommend/develop alternative treatment plans for

complicated consumer cases; • Conducts analysis of internal and external reports to ensure compliance with contract,

accreditation and regulatory requirements; • Performs analysis of internal and external reports to evaluate UM outcomes; • Collaborates with other departments and agencies; • Sets yearly UM goals for department; • Represents DWMHA as assigned, in collaborative meetings or presentations with DCH, Board

Association, and contracted entities; • Responsible for all UM reporting requirements; • Prepares annual UM program evaluation; • Provides oversight of staff audits and evaluations; and • Provides oversight of outcomes of delegated entities.

6. UM Clinical Specialist:

• Minimum of five (5) years’ experience working in mental health services; • UM Experience strongly preferred; • At a minimum a Bachelor’s degree in social work or psychology; • For Bachelor degree social work or sociology, valid Michigan license required; • Knowledge and skills in community based behavioral health care and case management

preferred; • Assists UM Director in developing policies and procedures for daily operations of the UM staff; • Assists UM Director and CMO in writing the UM program description, work plan and annual UM

evaluation; • Works collaboratively to implement UM model with affiliated providers; • Works with behavioral health provider organizations to develop and update the UM program; • Works collaboratively with other DWMHA departments to implement and improve the utilization

management program at DWMHA; • Assists UM Director in providing oversight of the UM program processes;

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• Works collaboratively with the Integrated Care Organizations in relation to UM program for MI

Health Link enrollee/members; • Participates in meetings, committees, and collaboration internally and externally; • Offers training and education to DWMHA staff, providers, stakeholders and the community at a

large specific to medical necessity criteria and DWMHA’s UM program; • Participates in audit activities as required; • Develops written and timely reports as requested; and • Provides timely reporting of pertinent observations and system challenges which may directly

impact the achievement of expected outcomes.

7. Utilization Review Substance Use Disorder (SUD) Clinical Specialist: • Master’s degree in nursing or social work preferred. Bachelor’s degree in psychology, social work,

or sociology required. Certification as an addiction drug counselor, advanced addiction drug counselor or an approved development plan by the Michigan certification for addiction professional required;

• For Bachelor degree social work or sociology, valid Michigan license required; • Promotes and facilitates specific communication and coordination of care with enrollee/member

and their primary care practitioner(s) and behavioral health practitioner(s); • Participates in discharge planning activities that include aftercare referrals and referrals to

community resources post inpatient behavioral health admission • Provides identification, initial assessment and the development and management of the dual

eligible enrollee/member’s treatment plans including facilitating complex care arrangements; • Conducts ongoing assessment of clinical status and functioning; • Monitors enrollee/member progress and outcomes and updates plan of care as appropriate; • Provides communication with medical and behavioral health providers regarding the

enrollee/member’s treatment plan including medical and psychosocial needs; • Engages the enrollee/member and providers in identifying short and long term goals consistent

with the situation and identifies enrollee/member’s strengths and incorporates into the enrollee/member’s plan of care;

• Leads the implementation and management of the plan of care working with other enrollee/members of the care coordination team, family/caregivers, treating providers, hospitals and other facilities and community services and agencies;

• Leads care coordination team meetings; • Ensures the enrollee/member receives appropriate services thru out the continuum of care as

well as coordination of care; • Facilitates targeted case management, vocational and/or housing assistance and interacts with

outside agencies and resources as needed; • Maintains accurate records of all communications and interventions in the clinical software

system (MHWIN); and • Provides education and motivation to enrollee/members.

8. UM Reviewer:

• Master’s degree in nursing or social work preferred. Bachelor’s degree in nursing, psychology, social work required;

• For Bachelor degree nursing or social work, valid Michigan license required; • Qualified Mental Health Professional certification preferred; • Eight (8) years’ experience in mental health field and five (5) years’ experience in managed care; • Reviews pre-service behavioral health requests for benefits and/or medical necessity; • Refers cases as appropriate to physician for review; • Reviews clinical information for BH concurrent reviews, extending the length of stay for inpatient

admissions as appropriate;

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• Participates in discharge planning activities post inpatient behavioral health admission; • Provides appropriate consultant information to case management staff; • Assists in the identification of appropriate resources for each individual case to fully utilize all

available resources; • Maintains accurate records of all communications and interventions in clinical software system

(MH-WIN); and • Prepares denial letters.

9. DWMHA UM Integrated Care Review Specialist:

• Master’s degree in nursing or social work preferred. Bachelor’s degree in nursing, psychology, social work, or sociology required;

• For Bachelor degree social work or sociology, valid Michigan license required; • Qualified Mental Health Professional certification preferred; • Eight (8) years’ experience post-degree in mental health field and five (5) years’ experience in

managed care; • Reviews pre-service behavioral health requests for benefits and/or medical necessity for dual

eligible MI Health Link enrollee/members; • Refers cases as appropriate to physician for review; • Reviews clinical information for behavioral health concurrent reviews, extending the length of

stay for inpatient admissions as appropriate for dual eligible MI Health Link enrollee/members; • Participates in discharge planning activities post inpatient behavioral health admission; • Provides appropriate consult information to case management staff. • Assists in the Identification of appropriate resources for each individual case to fully utilize all

available resources; • Maintains accurate records of all communications and interventions in clinical software system

(MH-WIN) in compliance with regulatory and accreditation standards; and • Prepare denial letters for all dual eligible MI Health Link enrollee/members.

10. DWMHA UM Appeals Coordinator:

• At a minimum has a Bachelor’s degree in social work, counseling or psychology and a combined three (3) years of direct clinical, managed care and/or community service;

• For Bachelor degree social work or counseling, valid Michigan license required; • Conducts first level review of concurrent and post-service appeals; • Reviews clinical documentation to determine completeness of information submitted; • Requests additional information as needed to assist with review of appeals; • Coordinates case review with DWMHA physician consultants on clinical cases that are not

meeting the medical necessity criteria; • Prepares appeals for independent medical review and other state and federal government

reviews; • Responds to inquiries regarding status, process and outcome of UM appeals; • Communicates either verbally or in writing regarding outcome of UM appeals • Interfaces with other DWMHA departments to resolve UM appeals issues; • Completes appropriate documentation in clinical systems (MHWIN) in compliance with

regulatory and accreditation standards; • Participates on committees or special projects as needed; and • Manages the data gathering and analysis of reports regarding UM appeal activity as well as

preparation for appeal audits.

11. DWMHA Hospital Liaison: • At a minimum has a bachelor’s degree in nursing, social work or psychology; • For Bachelor degree nursing or social work, valid Michigan license required; • Communicates with the enrollee/member, family and treatment team on enrollee/members

admitted to hospital/facility for behavioral health condition(s);

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• Attends team meetings; • Works with enrollee/member, family and treatment team and MCPN and/or providers to ensure

safe and appropriate and timely transitions after an inpatient behavioral health admission; • Enters authorizations for post admission services as needed; • Completes appropriate documentation in clinical systems in compliance with regulatory and

accreditation standards; and • Participates on committees or special projects as needed.

NOTE: Staff performing UM reviews and/or UM functions such as initial, concurrent and post-service reviews, denials and appeals must be credentialed and re-credentialed. The credentialing process defined by DWMHA supports our commitment to ensure that each provider, directly or indirectly or contractually engaged, meets at least MDHHS licensing, training and scope of practice, CMS, contractual and Medicaid Provider Manual requirements. Only highly qualified clinicians (MD, DO, PhD, LPC, LMSW, LLP, MSN, NP and BSN) who have demonstrated experience in the specialty areas in which they are making decisions may initiate and carry out UM reviews and duties. Clinicians authorizing SUD services must have certification as a Certified Addiction Drug Counselor (CADC) or a Certified Advanced Addiction Drug Counselor (CAADC) or have an approved development plan by the Michigan Certification for Addiction Professionals (MCBAP), or be certified as a Qualified Mental Health Professional (QMHP). A clinician must be credentialed and re-credentialed as Qualified Mental Health Professional (QMHP), Qualified Intellectual Disability Professional (QIDP) and/or a Child Mental Health Professional (CMHP), if authorizing those populations in order to be certified to complete the pre-admission review (PAR) or Utilization Management (UM) staff functions. Due to a conflict of interest, these practitioners may not provide direct services, including crisis intervention, for the enrollee/member they are screening for pre-admission review. See DWMHA Appropriate Professionals for Utilization Management Decision Making Policy for more details.

X. COMMITTEE STRUCTURE:

A. Utilization Management Committee (UMC): DWMHA’s UM Department supports a Utilization Management Committee. The CMO is the chairperson and the UM Director is the co-chair. The UMC is a standing committee reporting up to The Quality Improvement Steering Committee (QISC), which makes reports to both the Program Compliance Committee (PPC) of the Board of Directors (BOD) and the President/CEO, who both report up to the Board of Directors (BOD). The DWMHA BOD has granted the UMC the authority to develop, monitor and annually evaluate the UM Program.

Membership includes: • Chief Medical Officer-Chair • Utilization Management Director-Co-Chair • DWMHA Psychiatrist • UM Clinical Specialist • UM Hospital Liaison • Children’s Initiatives Representative • Customer Service Representative • IT Representative • Finance Representative • Total Quality Management Representative • Network Administrators and Contract Manager Representative • Substance Use Disorder Director or designee • Peer Specialist

Others may be invited for specific projects and/or issues to serve on an as needed basis.

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The purpose of the committee is:

• Provide on-going review and oversight of the UM program; • Evaluate the utilization of services with the goal of ensuring that each enrollee/member receives

the right services, in the right amount and in the most appropriate time frames to achieve the best outcomes. To accomplish this, the committee reviews specified aggregate data in order to identify over or under utilization of services. With improved reporting capabilities in the Mental Health Wellness Information Network (MH-WIN) computer system, including Pivot Tables, Cube Analytics and newly developed dashboards, the committee coordinates and recommends quality improvement efforts that may impact structure, process and outcomes. Opportunities for improvement are prioritized based on risk factors, performance history, and effect on overall DWMHA system performance;

• Review of standing UM reports on inpatient admissions, length of stay, denials and appeals, timeliness of decisions and notifications and readmissions;

• Review monthly reports on Autism, Waivers, Hospital Liaison Activity, Access Center and Crisis Service Vendor functions, County of Financial Responsibility (COFR), Substance Abuse Disorders (SUD) and Integrated Care;

• Monitor, document and submit for review any potential quality of care concerns, for both inpatient and outpatient care;

• Monitor utilization practice patterns of contracted providers to identify variations; • Ensure that UM inter-rater reliability audits are conducted; and • Review, evaluate, revise and approve the UM Program Description, UM work plan and UM

Program evaluation annually.

The UMC meets monthly. Minutes are maintained and distributed to all committee members. The minutes are also reviewed and approved at the next meeting. The UMC has ground rules for meeting operations and membership including the decision making process, attendance, goals, participation, preparation, discussion and reporting formats. B. Quality Improvement Steering Committee (QISC):

The QISC is an advisory group with responsibility for ensuring system-wide representation in the planning, implementation, support and evaluation of the DWMHA’s continuous quality improvement program. The QISC provides ongoing operational leadership of continuous quality improvement activities for the DWMHA.

Membership includes: • Chief Medical Officer • Directors or designee from UM, Customer Service, Quality Management, Recipient Rights, Risk

Management, Compliance, SUD, Managed Care Operations, Integrated Care • Enrollee/members • Advocates • MCPN’s • Direct contracted providers of service to enrollee/members with SMI, SED, SUD, I/DD.

The purpose of committee:

• Participate in the development and review of quarterly/annual reports to the Total Quality Management Program Compliance Committee and the BOD regarding Quality Management System;

• Annually review and evaluate the effectiveness of the Quality Assessment Performance Improvement Program;

• Provide recommendations and feedback on process improvement, program implementation, program results and program continuation or termination;

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• Examine quantitative and qualitative aggregate data at predetermined and critical decision making

points and recommend courses of action; • Review reports from regulatory DWMHA reviews; • Review of DWMHA improvement plans and make recommendations based on these reviews; • Monitor progress and completion of plans of correction in response to recommended remedial

actions identified for the DWMHA or by regulatory organizations; • Oversee a process for establishing, continuing or terminating subcommittees, standing

committees, improvement teams, task and work groups • Identify training needs and opportunities for staff development in the quality management

process; • Identify future trends and make recommendations for next steps; and • Leadership in practice improvement projects.

The QISC meets at least ten (10) times a year. The committee establishes and annually reviews committee operational guidelines, meeting frequency, management of information requests, membership, the number of members required for a quorum. It annually establishes committee goals and timelines for progress and achievement. The UM Program Description and evaluation are also reported by the UM Director or designee to the QISC annually for approval prior to review and approval by the Program Compliance Committee and the Board of Directors. C. Program Compliance Committee (PCC):

The PCC consists of members from the BOD and provides leadership for the Quality Improvement process through supporting and guiding implementation of quality improvement activities DWMHA and reviewing changes, evaluating the need for board actions and approving the Quality Improvement Plan annually.

The purpose of the committee:

• Annual evaluation of the effectiveness of the Quality Assurance Performance Improvement Program (QAPIP) and recommends approval of reports and standing committee and department evaluations to the BOD;

• Monitor the system-wide trends and patterns of key indicators and attainment of goals and objectives;

• Identify opportunities for improvement; • Establish and support specific quality improvement initiatives; • Recommend studies in areas identified from data review as having the potential for affecting the

outcomes of care and related quality concerns; • Assist in the development and approval of the Quality Improvement Plan; and • Recommend board actions to the full Board of Directors.

The PCC meets monthly. The committee establishes and annually reviews committee operational guidelines, meeting frequency, management of information requests, membership, the number of members required for a quorum. It annually establishes committee goals and timelines for progress and achievement. The UM and Quality Program Descriptions and evaluations are reported to the PCC annually for approval prior to review and approval by the Board of Directors.

D. Board of Directors (BOD):

The DWMHA’s BOD’s primary responsibility is to provide leadership, governance and oversight of the region. The Board is a policy setting body, the fiduciary of the Medicaid funds. The membership is comprised of professionals in the behavioral health field and community leaders all with varied backgrounds and experience which helps sustain diversity throughout the organization. There are twelve (12) board members including the Chairman, Vice-Chairman and Secretary. The UM and Quality Program Descriptions and evaluations are reported to the BOD annually for approval.

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The BOD meets monthly. The committee establishes and annually reviews committee operational guidelines, meeting frequency, management of information requests, membership, the number of members required for a quorum. It annually establishes committee goals and timelines for progress and achievement.

E. Reporting Flow of Committees:

XI. PROGRAM GOALS:

The following UM related goals shall be incorporated in DWMHA’s 2016-2018 Fiscal year Quality Assessment and Performance Improvement Plan (QAPIP). The goals and objectives shall be completed by DWMHA and when applicable, the Access Center, Crisis Service Vendor, MCPNs and/or Service Providers and can be modified to move DWMHA toward desired outcomes. A. Advance the implementation of DWMHA’s standardized UM Program Description to assure effective

and efficient utilization of behavioral health services through on-going development and oversight of the following: The Benefit Plans/UM Authorization Guidelines; and Setting standards and monitoring adherence to the delegated entities UM Plans.

B. Promote collaboration and set the standards for service authorization system wide by identifying patterns of behavioral health service utilization by funding source and by monitoring over and under-utilization of services using dashboards.

C. Assure fair and consistent UM/review decisions based on MCG, Local Coverage Determination (LCD), National Coverage Determination (NCD) and/or American Society of Addition Medicine (ASAM )medical necessity criteria by monitoring the application of the applied criteria and service authorizations for behavioral health services (including substance use disorders) using a standard inter rater reliability process system wide.

D. Promote participation and monitor the use of specialty behavioral health waiver programs: Autism Spectrum Disorder (ASD) benefit, Habilitation and Supports Waiver (HAB), Children’s Waiver Program (CWP) and Serious Emotional Disturbances Waiver (SED) through the development and on-going review of DWMHA policies and procedures and monthly monitoring reports.

E. Engage community stakeholders in the development and implementation of processes that promote clinical review procedures, practices and corrective actions to ensure system wide compliance with DWMHA, State, Federal regulations.

F. Utilizing MCPNs, Provider and Practitioner Satisfaction Surveys related to service access and Utilization Management, make recommendations for improvement regarding service provision, treatment experiences and outcomes.

G. Provide oversight of delegated UM functions through use of policies that reflect current practices, standardized/inter-rater reliable procedures and tools, pre-service, concurrent and post-service (retrospective) reviews, data reporting (i.e. timeliness of UM decisions and notifications), outcome measurements and remedial activities.

Utilization Management Committee

Quality Improvement Steering Committee

Program Compliance Committee

Board of Directors

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XII. BEHAVIORAL HEALTH MEDICAL NECESSITY CRITERIA AND BENEFITS:

A. Development and Description of Medical Necessity Criteria: 1. DWMHA has adopted nationally developed and published Behavioral Health guidelines from MCG

which is part of the Hearst Health Network. MCG utilizes clinical editors who analyze and classify more than 100,000 peer reviewed papers and research studies each year. By applying rigorous evidence classification techniques, they select more than 25,000 unique references to formulate into medical necessity clinical guidelines. Nationally recognized quality measures from the Hospital Quality Alliance are also embedded in the guidelines. The clinical editors are supported by a team of data analysts, librarians, and medical copy editors who together have over 115 cumulative years of guideline development experience. In addition, the team coordinates peer reviews by panels that include approximately 100 additional clinicians. The MCG Behavioral Health Medical Necessity guidelines describe best practice care for the majority of mental health and substance related disorder diagnosis, covering 15 diagnostic groups with graded evidence from published resources. Some of the best known resources include the American Psychiatric Association, the American Association of Pediatrics, the American Society of Addiction Medicine, the National Institute on Alcohol Abuse and Alcoholism and the Local and National Coverage Determination criteria due to their acceptance as the best of evidence-based/best practice and emerging practice for mental health and substance use disorders. This criteria then serves as a decision support tool to help define the most appropriate treatment setting and help assure consistency of care for each individual. DWMHA believes its criteria should be transparent and available to everyone and be flexible enough to continuously adapt to the changes in mental health and substance use disorder treatment systems.

The MCG Behavioral Health guidelines are available through a secure website at the following URL, http://cgi.careguidelines.com/login-careweb.htm. Since the guidelines are proprietary, access is limited to the DWMHA provider network. A login and password can be obtained from the MCPNs or the DWMHA UM Department. DWMHA and their UM delegated entities utilize an MCG software called Indicia. DWMHA requires these entities to have at least one machine installed with the online version of the MCG Behavioral Health guidelines and to make it accessible to all their clinical practitioners during hours of operation.

2. The MCG Behavioral Health Care criteria includes:

• Behavioral health guidelines which identify the most effective level of care for specific behavioral health conditions;

• Level of care guidelines that assess a patient’s level of care needs in situations where a diagnosis-specific guideline does not apply.

• Five (5) levels of care covering inpatient, residential, partial hospitalization, intensive outpatient, and outpatient.

• Therapeutic and testing procedures that provide specific criteria for determining when a procedure, treatment, or diagnostic test may be indicated.

• Detailed discharge criteria focus on specific care elements to consider when discharging patients to a lower level of care.

• Flexible recovery courses manage longer behavioral health episodes with recovery courses listed in care days for in-patient treatments and stages for out-patient treatments.

• Alterative care planning help to select effective alternative therapies and levels of care based on the specifics of a patient’s case.

http://cgi.careguidelines.com/login-careweb.htm

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3. For MI Health Link enrollees/member, the National Coverage Determination (NCD) criteria developed by the Centers for Medicare and Medicaid Services (CMS) is utilized. If no NCD has been issued, or an NCD requires further clarification, a Local Coverage Determination (LCD) criteria will be utilized. LCDs’ are developed by the Medicare Administrative Contractor for the geographic service area and either supplement or explain when an item or service will be covered if there is no NCD. Michigan is in jurisdiction 8. In addition, the CMS Coverage Manual or other CMS-based resources such as the Medicare Program Integrity and Medicare Benefit manuals are used to determine coverage provisions for this population. In coverage situations where there is no NCD or LCD or guidance on coverage in original Medicare manuals, DWMHA may make its’ own coverage determination utilizing the MCG criteria or send out to an Independent Review entity. Communication will also be sent to the Medicare Administrative Contractor to be addressed in a future version of the LCD.

4. DWMHA has adopted nationally developed and published criteria from the American Society of

Addiction Medicine (ASAM) to determine medical necessity and level of care decisions for substance use disorders (SUD). This criteria has become the most widely used and comprehensive of guidelines for placement, continued stay, and transfer/discharge of enrollee/members with addiction and co-occurring conditions. ASAM's criteria provide separate placement criteria for adolescents and adults developed through a multidimensional assessment over five (5) broad levels of treatment that are based on the degree of direct medical management provided, the structure, safety, and security provided and the intensity of treatment services provided. It uses six (6) dimensions including Acute Intoxication and/or Withdrawal Potential, Biomedical Conditions and Complications, Emotional/ Behavioral Conditions, Treatment/Acceptance/Resistance, Relapse/Continued Use Potential and Recovery Environment to create a holistic assessment of an individual to be used for service planning and treatment across all service and levels of care. Through this strength-based multidimensional assessment, the ASAM criteria addresses the individual's needs and obstacles as well as their strengths, assets, resources and support structure. The website (https://ASAM.org.) further describes the medical necessity criteria. The ASAM Criteria, Third Edition, is copyrighted but can be purchased by contacting the American Society of Addiction Medicine located at 4601 North Park Avenue, Chevy Chase, MD, 20815, telephone (301)-656-3920, and fax (301) 656-3815. Oversight and revision of the criteria is collaborative between ASAM leadership and the Steering Committee of the Coalition for National Clinical Criteria. The Coalition represents major stakeholders in addiction treatment and has been meeting regularly since the development of the first ASAM Patient Placement Criteria in 1991. The Coalition addresses feedback and ensures that the Criteria adequately serves and supports medical professionals, employer purchasers and providers of care in both the public and private sectors.

B. Criteria Review, Approval and Distribution:

1. The MCG Behavioral Health Medical Necessity guidelines, ASAM criteria, NCD and LCD criteria and DWMHA’s procedures for application are reviewed at least annually or as new treatments, applications and technologies are adopted as generally accepted professional practice by the DWMHA CMO and is based on the most current research, relevant quality standards and evidence based/best practice, emergency practice models of care and the local delivery system (LCD/NCD).

2. The MCG, ASAM, NCD and LCD criteria are then reviewed by the committees below and approved

with applicable clinicians at the Improving Practices Leadership team meetings and the UM committee.

• Practice collaborative such as the Intellectual/Developmental Disabilities (I/DD), Adult Mental Illness and Child Seriously Emotionally Disturbed (SED);

• Quarterly Tri-County Medical Director Meetings; • Bi-monthly MCPN/Provider partnership meetings; • DWMHA Improving Practices Leadership Team Meetings; and • The UM Committee.

https://asam.org/

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3. Once approved by the DWMHA CMO and Committees above, DWMHA makes the most current

version of the online version of the MCG behavioral health medical necessity guidelines available to be installed on at least one computer accessible to all DWMHA, Access Center, Crisis Service Vendor and MCPN clinical practitioners during normal business hours of operation. DWMHA also makes the most current version of the personal computer software of the behavioral health MCG medical necessity guidelines available for download at the time of initial distribution through various means such as secured Google Drive or removable media such as a flash drive or CD thus allowing access to the criteria in the event of a mass or individual internet outrage or for contracted practitioners without internet access. Notification is emailed, mailed or faxed to all contracted providers using Indicia advising them when the criteria or updates to the criteria are available.

4. Enrollee/members and both network and out of network practitioners/providers can request a copy of the medical necessity criteria in relation to a specific requested service by contacting DWMHA’s UM Department, and this will be provided free of charge.

5. In accordance with the American with Disabilities Act, the criteria is available in other formats such

as Braille or larger font if needed.

6. DWMHA has an established process for recognizing and evaluating new technologies and new applications of existing technologies to ensure individuals have access to safe and effective care. Proven Behavioral health clinical technology (PT) includes practice standards as well as technology that have undergone extensive practical evaluation as well as research via external mechanisms and are mandated covered services through DWMHA contracts. PT’s that are not included in a benefit plan are uncovered services meaning they are not reimbursable for that benefit plan. There are a variety of mechanisms by which they may progress to covered services.

• Providers may propose a pilot utilizing a PT for a specific population to the Research Advisory Committee.

• Improving Practices Leadership Team (IPLT) may determine that there is a gap in service delivery across the network which current covered services are not addressing.

• PT’s may be covered by General Funds, Local Funds, or other appropriate resources when not covered by the member’s benefit plan.

Tecchnology/Clinical practices that have been demonstrated through controlled trials, meta-analysis of the literature to be ineffective, or whose safety profile results in a negative risk-benefit from a negative risk-benefit ratio, will not be supported nor covered by DWMHA. Technology/Clinical practices that are not sufficiently researched and/or published so as to qualify as PT’s may be presented to the Research Advisory Committee for consideration as a trial. DWMHA’s medical staff participate in regional and state level medical directors meetings which include reviews of medical procedures, pharmaceuticals, health practices and devices, regulatory changes and scientific data.

C. DWMHA Behavioral Health Guidelines:

1. The published professional literature (the National Library of Medicine database via the PubMed search engine) is systematically queried at least annually using specially developed, customized, tested, proprietary search strings. Search strategies are developed to allow efficient yet comprehensive analysis of relevant publications for a given topic and to maximize retrieval of articles with certain desired characteristics pertinent to a guideline.

2. All retrieved publications are individually reviewed by an MCG clinical editor and assessed in terms of quality, utility and relevance. Preference is given to publications that:

• Are designed with rigorous scientific methodology. • Are published in higher-quality journals (i.e. journals that are read and cited most often

within their field).

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• Address an aspect of specific importance to the guideline in question (i.e. admission criteria,

length of stay). • Represent an update or contain new data or information not reflected in the current

guideline.

3. Annually undergoes external review by clinically active experts (i.e. board-certified specialist physician without stated financial conflicts of interest) to confirm the clinical appropriateness, accuracy, validity and applicability of each guideline and then a supervising clinical editor evaluates all comments from these external reviewers and makes necessary changes to the guideline.

4. Oversight and revision of the criteria is collaborative between ASAM leadership and the Steering Committee of the Coalition for National Clinical Criteria. The coalition represents major stakeholders in addiction treatment and has been meeting regularly since the development of the first ASAM Patient Placement Criteria in 1991. The coalition addresses feedback and ensures that the criteria adequately serves and supports medical professionals, employer purchasers and providers of care in both the public and private sectors.

D. Benefit determinations are based on the following sources: To assist the Access Center and UM staff in determining services that are available based on clinical findings and available resources, DWMHA has developed a Benefit Management grid that outlines the services available by funding stream, patient population, and level of functioning. The primary funding sources currently include Medicaid, MI-Child, Healthy Michigan Plan, Medicare/Medicaid, and General Fund. Each of the Waiver programs (Serious Emotional Disturbance (SED), Habilitation and Supports Wavier (HAB), Children’s Waiver Program (CWP) and the Autism Spectrum Disorder (ASD) Benefit provide an array of services based on consumers meeting admission and eligibility criteria and subsequently receiving services that are medically necessary and clinically appropriate. In the area of Substance Use Disorders, a varied array of services is available based on the funding sources of block grant, Public Act 2 monies, Medicaid and Healthy Michigan. The Benefit Management Grid and the SUD UM Guidelines provide the foundation for UM initial and continued stay service authorizations that must be supported by documentation that supports medically necessary services. As funding changes, the benefit grid is adjusted.

Parity, as it relates to mental health and substance abuse, prohibits insurers or health care service plans from discriminating between coverage offered for mental illness, serious mental illness, substance abuse, and other physical disorders and diseases. In short, parity requires insurers to provide the same level of benefits for mental illness, serious mental illness or substance abuse as for other physical disorders and diseases. These benefits include visit limits, deductibles, copayments, lifetime and annual limits.

With the enactment of the federal Mental Health Parity Act (MHPA) in 1996 and the Mental Health Parity and Addition Equity Act (MHPAEA) in 2008, insurers are now required to make formulation of benefits, utilization management, and out-of-pocket payments equivalent between behavioral health services and other medical services.

The regulations delineate the following classifications of benefits:

1. Inpatient in-network 2. Inpatient out-of-network 3. Outpatient in-network 4. Outpatient out-of-network 5. Emergency care 6. Prescription drugs

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If a plan covers mental health or substance use services, in any of the above classifications, the plan must provide coverage for all classifications, as long as it also provides medical/surgical benefits in the classifications.

Under MHPA (1996): • Lifetime and annual dollar limits for mental health services had to be equivalent to other health

services. • Parity applied only to commercial plans offering mental health benefits.

Under MHPAEA (2008) and the interim final rule (2010): • Parity was extended to substance use services. • Financial requirements and quantitative treatment limitations for mental health & substance use

services had to be equivalent to other health services. • Utilization management techniques had to be formulated in a manner similar to that for mental

health & substance use and other services. • Application of benefits design for mental health & substance use and medical/surgical services

had to be equivalent by classification and network.

Pre-existing conditions are medical conditions or other health issues that existed before an enrollee/member’s enrollment in a health plan. Examples include chronic conditions such as asthma, heart disease and schizophrenia. Under the Affordable Care Act, health insurance companies including Medicaid cannot refuse to cover an enrollee/member and refuse to pay for essential health benefits for a condition he/she had prior to the onset of coverage. See DWMHA Benefit Policy for more details. Pharmaceuticals are covered by the Medicaid health plans or Part D plans with the exception of medications that are carved out by the state and covered by the state.

E. Inter Rater Reliability: Review of consistency of Behavioral Health UM decision making Inter-rater reliability testing is administered annually for UM reviewers and psychiatrists involved in UM reviews. DWMHA utilizes the MCG web-based Inter-Rater Reliability module which tests the proper use of MCG guidelines with clinician-developed case studies. It evaluates an individual’s ability to find and apply the appropriate guideline based on a specific scenario. DWMHA has a benchmark standard of scoring 90% or greater. Any UM reviewer or physician reviewer with an inter-rater reliability score less than 90% will be placed on a corrective action plan (CAP) with the expectation that the person pass a re-test administered within thirty (30) days. CAPS can involve such activities as face to face supervision and coaching and/or education and re-training. During the time period of the CAP, random samples of the staff member’s current cases will be audited. If upon re-testing, the staff person does not achieve 90% or greater, he/she will be subject to a transfer to a role outside the UM Department or termination. Note that annual education and training on the criteria is provided for all staff performing UM activities that involve application of the medical necessity criteria. MCG also has web-based on-demand training modules that are available 24/7. The results of the inter-rater reliability case reviews will be used to identify areas of variation among decision makers and/or types of decisions. The results will also help to identify opportunities for improvement as well as future training needs. See DWMHA Inter Rater- Reliability Policy for more details.

F. Clinical Documentation: Audits of UM Reviews are also conducted on a quarterly basis to ensure appropriate documentation and appropriate level of care decisions. DWMHA has a benchmark standard of scoring at least 85% on each documentation audit. Any UM Reviewer with a documentation audit score less than 85% will be placed on a corrective action plan (CAP) with the expectation that the person pass at the next review. CAP’s can involve such activities as face-to-face supervision and coaching and/or education and re-training. If upon the next review, the staff person does not achieve 85% or greater, he/she may be subject to a transfer to a role outside the UM Department or termination.

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XIII. DELEGATION OF UM FUNCTIONS AND DWMHA OVERSIGHT:

Delegation occurs when DWMHA gives to another organization the decision-making authority to perform UM functions on their behalf. It is a formal process, contractual and consistent with accreditation, state and federal regulations.

DWMHA has delegated several UM functions to the Access Center, Crisis Service Vendor and the MCPNs. As a result, these entities must develop and implement a UM Plan that meets regulatory and contractual requirements and mirrors DWMHA’s UM Plan. The regulatory and contractual requirements are articulated in the following documents:

• The Center for Medicare and Medicaid services, 42 CFR 438.210 • The External Quality Review Health Services Advisory Group Corrective Action Plan, Standard

5, Utilization Management • The MDHHS-PIHP Contract, Section 6.8, Service and Utilization Management • The MDHHS-PIHP Contract, Attachment P.6.7.1.1 • Substance Abuse & Mental Health Service Administration Guidelines • MDHHS Provider Manual • Application for Renewal and Recommitment (ARR) • MDHHS Special Study – 2009 • NCQA UM 1

The federal law and MDHHS contracts are clear that where any DWMHA UM functions are delegated, DWMHA UM staff must evaluate the entity’s ability to perform the delegated activities prior to delegation. DWMHA must actively oversee delegated functions using clear criteria and performance expectations, including potential contract termination. If DWMHA identifies any deficiencies or areas for improvement, the appropriate entity must take corrective action to address and provide DWMHA with documentation of completed action(s). DWMHA will provide training to the Access Center, Crisis Service Vendor and the MCPNs to assure consistent understanding and application of the MCG Medical Necessity Criteria Clinical Protocols and Evidence Based and Promising Practices. Credentialed staff must be available with expertise in each population group served by DWMHA. Cultural competency is practices and staff is also trained in specific competencies related to key ethnic groups and trans-gender groups within the community annually. Each staff person shall have credentials and licensure necessary to provide direct service to the population or group for whom he/she reviews care. The Access Center, the Crisis Service Vendor and the MCPNS must:

1. Have mechanisms to identify and correct under- utilization and over utilization; 2. Follow pre-service, concurrent and post-service (retrospective) policies and procedures

established by DWMHA; 3. Have qualified medical professionals to supervise review decisions; 4. Ensure decisions to approve, deny or reduce services are made in a fair, impartial and consistent

application of review criteria that best serve the enrollee/member; 5. Ensure decisions to approve, deny or reduce services are made by physicians who have the

clinical expertise to treat the conditions; 6. Ensure efforts are made to obtain all necessary information including pertinent clinical

information and consult with the treating provider/physician as appropriate. 7. Have the reasons for decisions clearly documented and appeal rights are available to the

enrollee/member; 8. Have well-publicized and readily available appeal mechanisms for both providers and

enrollees/members; 9. Have written notification of the denial sent to the provider and the enrollee/member; 10. Have written notification of a denial including a description of how to file an appeal.

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11. Ensure decisions and appeals are made timely as required by exigencies of the situation; 12. Ensure there are mechanisms to evaluate the program using data on recipient satisfaction,

provider satisfaction, or other appropriate measures and data is presented to DWMHA for identification of opportunities for improvement;

13. Ensure when the organization delegates responsibility for any aspect of utilization management, it has mechanisms to ensure that the delegate meets these standards;

14. Ensure the Access Center, the Crisis Service Vendor and/or the MCPN oversee and are accountable for any functions it delegates to any subcontractor;

15. Ensure that before any delegation, the Access Center, the Crisis Service Vendor and/or the MCPNs must evaluate the subcontractor’s ability to perform the delegated activity;

16. Ensure the Access Center, the Crisis Service Vendor and/or the MCPNs have a written agreement that specifies the activities and responsibilities designated to any subcontractor;

17. Ensure the written agreement provides for revoking delegation or imposing other sanctions; 18. Ensure the Access Center, the Crisis Service Vendor and MCPNs shall monitor their

subcontractor’s performance on an ongoing basis and subjects their performance to a formal review according to a periodic schedule established by the State, consistent with applicable federal laws, Medicaid Statutes, MDHHS Regulations and Industry Standards; and

19. Ensure if deficiencies or areas for improvement are identified, the Access Center, the Crisis Service Vendor and/or the MCPNs will place their subcontractors on a corrective action plan and notify DWMHA.

Below is a chart of the Utilization Management Monitoring Activities of the Delegates:

*Delegated entities not meeting compliance goals will be reported to the DWMHA’s Quality Improvement Department for follow up and to the DWMHA Quality Improvement Steering Committee (QISC).

Monitoring Activity Frequency Compliance Goal MCPNs & Crisis Service Vendor must conduct & submit a sampling of case

reviews for all staff making UM decisions utilizing the DWMHA Prior Authorized Service UM Chart Review tool to the DWMHA UM Department.

Quarterly Results will be reported to the

Utilization Management Committee (UMC)

85% or greater*

MCPNs & Crisis Service Vendor must conduct and submit 100% of denials & applicable appeals utilizing the DWMHA Prior Authorization UM Chart

Review tool to the DWMHA UM Department.

Monthly Results will be reported to the

UMC

90% or greater*

MCPNs & Crisis Service Vendor must submit denial & applicable appeal tracking logs & 100% of case files of any denied or applicable appealed case

to be audited by the DWMHA UM Appeal Coordinator utilizing Denial & Appeal Audit tools.

Monthly Results will be reported to the

UMC

90% or greater*

The Access Center must conduct & submit reviews of sampling of eligibility denials & a sampling of eligibility approvals using DWMHA’s Access Center

Service Eligibility Review tool to the DWMHA UM Department.

Quarterly Results will be reported to the

UMC

90% or greater*

MCPNs & Crisis Service Vendor must submit timely decision & timely notification reports to the DWMHA UM Appeal Coordinator.

Quarterly Results will be reported to

UMC

90% or greater for each type of decision &

notification* Access Center, Crisis Service Vendor and MCPNs must submit UM Program Plans for review by DWMHA UM Director or his/her designee utilizing the

UM Plan Audit tool.

Annually Results of audit will be

included in annual DWMHA UM evaluation & reported to

UMC

100%*

MCPNs & Crisis Service Vendor must submit results of the inter-rater(s) on all staff performing UM functions utilizing the medical necessity criteria.

Annually Results of inter-rater will be

reported to UMC

90% or greater*

Affirmative Statement will be sent annually to all staff performing UM functions.

Annually 100%*

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XIV. UM METHODS AND ORGANIZATIONAL PROCESS FOR MAKING DETERMINATIONS OF MEDICAL NECESSITY AND BENEFIT COVERAGE FOR INPATIENT AND OUTPATIENT SERVICES: DWMHA safeguards confidential recipient information and makes disclosures only within the limits of informed consent of the parties involved and in accordance with HIPAA, state and federal law, as well as industry standards and professional ethics. Therefore, all proceedings, records, writings, data, reports, information, and any other material labeled as "utilization management" are held in strictest confidence and protected from disclosure. Clinical review and information used in activities and functions of the UM program are appropriately safeguarded by DWMHA, Access Center, Crisis Service Vendor, MCPNs and Service Providers. Confidentiality safeguards apply to all UM/QI committee recipients, reports, and any employee of DWMHA whose duties require knowledge of, and access to UM information and committee activities. The UM Department collects only the information necessary to certify the admission, procedure, treatment, length of stay, frequency and/or duration of behavioral health and substance use services. See DWMHA HIPAA Privacy Manual and Policies and DWMHA HIPAA Security Policies and Procedures for more details. The purpose of the UM review is to determine enrollee/member eligibility, benefit coverage, and/or establish the presence or absence of medical necessity so that a decision can be made regarding the request for services. Services may include requests for all levels of behavioral health care and substance use and requests for services from enrollees/members and behavioral health providers. The UM process provides a clear and timely response to enrollees/members and providers regarding requests for authorization of services. DWMHA establishes UM Authorization Guidelines and Benefit Plans based on funding sources, various standard functional assessment tools and clinical presentation. It is the expectation of DWMHA that delegated entities manage adherence to the DWMHA UM Authorization and Benefit Plans. The Guidelines do not replace clinical judgement, and as such, all delegated entities must implement a clinical review process for cases that fall outside the Authorization Guidelines. The UM review staff uses all available information along with clinical judgment, department policies and procedures, needs of the enrollee/member and characteristics of the local delivery system, including the availability of the proposed services within the network service area, to make a decision. The UM review staff will request additional information if needed. The UM reviewer has the authority to approve services based on medical necessity criteria and the benefit grid. If the UM reviewer is unable to approve the request for service, the case is referred to the physician for determination. Requests for coverage of out-of-network services that are only covered when medically necessary or in clinically appropriate situations require medical necessity review. Such requests must indicate that the enrollee/member has a specific clinical need that the provider believes cannot be met in-network (i.e. a service or sooner than able to be provided or allowed by DWMHA’s access or availability standards) as long as covered by the enrollee/member’s benefit plan. If the request does not indicate the enrollee/member has a specific clinical need for which out-of-network coverage may be warranted, the UM reviewer will contact the requestor for more information.

Emergent and Urgent Service: Emergency services are defined as those health care items and services furnished or required to evaluate or stabilize a sudden and unforeseen situation or occurrence or a sudden onset of a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the failure to provide immediate medical attention could reasonably be expected by a prudent layperson, possessing average knowledge of health and medicine, to result in:

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• Placing the person’s health (or with respect to a pregnant woman, the health of the woman or her

unborn child) in serious jeopardy; or • Serious impairment of bodily functions; or • Serious dysfunction of any bodily organ or part; or • Serious harm to an enrollee/member or others due to an alcohol or substance use emergency; or • Injury to self or bodily harm to others; or • With respect to a pregnant woman who is having contractions:

1. That there is inadequate time to effect a safe transfer to another hospital before delivery or

2. That transfer may pose a threat to the health or safety of the woman or the unborn.

Urgently-needed services are covered services that: • Are medically necessary and immediately required as a result of an unforeseen illness, injury,

or condition and where application of the time frame for making routine or non-life threatening care determinations could seriously jeopardize the life, health or safety of the individual or others, due to the person’s psychological state or in the opinion of a practitioner with knowledge of the Individual’s medical or behavioral health condition, would subject the person to adverse health consequences without the care or treatment that is the subject of the request.

• Are provided when the individual is temporarily absent from the plan’s service (or, if applicable, continuation) area, or under unusual and extraordinary circumstances, when the member is in the service or continuation area, and the network is temporarily unavailable or inaccessible; and

• It was not reasonable given the circumstances to wait to obtain the services through the plan network.

Urgent service request designations should only be used if the treatment is required to prevent serious deterioration in the person’s health or could jeopardize his/her ability to regain maximum function. Requests outside of this definition will be handled as non-urgent.

XV. ACCESS, TRIAGE AND REFERRAL PROCESS FOR BEHAVIORAL HEALTH AND SUBSTANCE USE SERVICES: Serving as the central front door and screening agent for DWMHA, the Access Center is operated twenty four (24) hours a day, seven (7) days a week. The Access Center runs with a “no-wrong door” philosophy regardless of where the person contacts the public mental health system including those with co-occurring mental health and substance use disorders. The DWMHA Access Center’s purpose is to link individuals with DWMHA’s provider network via the designated MCPNs, by ensuring eligible persons are appropriately referred to a MCPN and linked with a Service Provider for a face-to-face comprehensive intake assessment. The Access Center provides most of the core functions of DWMHA’s access system and works with the local Service Providers and the MCPNs to ensure an overall integrated and effective access system for persons with severe mental illness (SMI), severe emotional disturbance (SED), intellectual developmental disabilities (I/DD), substance use disorders (SUD) and persons with co-occurring conditions (COD). The Access Center is responsible for the following:

• Coverage and Eligibility Determination • Clinical Screening • Referral and linkage to an MCPN and Service Provider for enrollees/members admitted into the

public health system • Referral, linkage and follow up to enrollees/members deemed not eligible for the public mental

health system • Substance Use Disorder Authorizations for services not requiring medical necessity review.

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The Access Center makes triage and referral decisions according to protocols that define the level of urgency and appropriate level of care. They adopt triage and referral protocols that are based on sound clinical evidence and are currently accepted practice within the industry. The protocols are reviewed and revised, as needed, annually. Triage and referral staff are supervised by a licensed behavioral healthcare practitioners with a minimum of a master’s degree and five (5) years of post-master’s clinical experience. A licensed psychiatrist oversees triage and referral decisions. Enrollee/members are instructed by the health plan to contact DWMHA through the twenty four (24) hour Access Center toll free number 1-800-241-4949 or the TYY number 1-866-870-2599 for the hearing impaired. All calls are answered by a live trained Access Center Customer Service Technician (CST) who identifies themselves by name, title and organization. The CSTs are required to have at least a bachelor of arts degree in the human services field (LBSW preferred but not required) and must have at least three (3) years of experience working in human services or one (1) year of experience working in human services with an LBSW. The CST initially ascertains if it is a “crisis call” based on safety concerns and immediacy challenges as well as protocols that define the level of urgency and appropriate level of care, and if yes, collects the required demographic information and immediately warm transfers the caller to DWMHA’s Behavioral Health Emergency Response Call Center. This organization is an integral part of the overall DWMHA’s crisis safety net, both for active enrollees/members of DWMHA services as well as for the community at large. The organization holds the highest accreditations with the American Association of Suicidology (AAS) and the Commission of the Accreditation of Rehabilitation Facilities (CARF). Using licensed Master level (or above) clinicians, the organization provides telephonic crisis intervention and stabilization services, twenty four (24) hours a day, seven (7) days a week. All of their clinicians are professionally credentialed experts in crisis work or Suicidology. The organization integrates and coordinates with other established components of the existing DWMHA’s safety net, including but not limited to the Mobile Crisis Team, 24/7 clinical services teams (ACT and Home-based) and contracted hospital providers. For more information on triage tools used by the Access Center see the UM Program Description Policy attachments regarding clinical assessment tools and flow. DWMHA also contracts with another vendor to provide mobile crisis stabilization services and in-home/community based crisis stabilization services to enrollees/members. Mobile Crisis is a behavioral health service which serves the community by providing urgent response and emergency evaluations. The program operates twenty four (24) hours a day, seven (7) days a week. Calls for mobile crisis services, including inpatient services are directed through the Access Center which will contact the Crisis Service Vendor. However, calls may also come directly to the Crisis Service Vendor at 1-800-844-296-2673 (TYY 248-424-4800 for hearing impaired) from 8am-5pm Monday-Friday and 248-995-5055 after normal business hours when the enrollee/member is reported to be in crisis. A team comprised of a master degree clinician and a peer support staff person travel together in the community and are backed up with telephonic assistance by a nurse and psychiatrist as needed. The team is expected to respond to the enrollee/member’s location, including but not limited to Hospital Emergency Rooms, Specialized AFC Homes, law enforcement settings, homeless shelters, public locations (like restaurants), private residence, or other appropriate location. The team provides mobile outreach crisis services, including screening and assessment, counseling/therapy, and therapeutic support services. The team attempts to defuse a crisis situation, enacting a person’s crisis plan when available and appropriate; resolve presenting problems; procure needed services and resources; and arrange extended support. Extended support may include daily on-site visits, or it could mean that a team member-most likely a trained paraprofessional – remains with the client for a number of hours as needed, to provide supervision, monitoring, support and assistance.

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If determined that more intensive services are needed, the team then performs an inpatient assessment in collaboration with other team members, care givers, or other contributors, and authorize the appropriate, indicated level and type of services. The team also assists with transportation, transitional housing or referral support on an as-needed basis. The team’s face-to-face assessment may occur at a Hospital Emergency Room or when an enrollee/member has walked into the Crisis Service Vendor Center.

For individuals calling the Access Center who do not require crisis response services and are requesting entry into the public health system, the CST collects the demographic information and screens the enrollee/member for initial eligibility by verifying he/she is a resident of Wayne County. The CST uses the DWMHA electronic system, MHWIN, to verify Medicaid, Medicare, MI-Child and Healthy Michigan insurance and current enrollment. Other insurance information is obtained verbally from the caller. If the caller does not require a clinical screening to determine eligibility for community mental health service and is seeking information and community resource referrals, the CST completes a warm transfer to a community resource and provides the telephone number of at least one more community resource. For enrollees/members who require a clinical screening, the CST warm transfers the caller to an Access Center Clinician in either the mental health, intellectual developmental disability screening unit or the substance use screening unit. All Access Center Clinicians are licensed/certified, credentialed and trained practitioners capable of rendering clinical triage and screening services to ensure appropriate level of services determination and eligibility coverage. All of the Clinicians are supervised by a fully licensed master level practitioner with at least 5 years post master clinical experience. There is also a fully licensed psychiatrist who oversees all triage and referral decisions.

XVI. EMERGENCY CARE RESULTING IN ADMISSIONS:

DWMHA and the MCPNs provide coverage to enrollees/members if they require emergency or urgently needed services. Prior authorization is not needed for emergency room services or any emergent services needed to stabilize the emergent or urgent condition. Emergent and/or urgent care should be rendered as needed with notification of any admission to the Crisis Service Vendor within forty-eight (48) hours of the admission. A Crisis Service Vendor UM staff will review emergent and/or urgent admissions within one (1) calendar day of request for services and make a determination

XVII. PRE-SERVICE AND CONCURRENT REVIEWS: DWMHA makes efforts to assure the enrollee/member receives individualized, appropriate and efficient services and supports that are sufficient in scope, frequency and duration to achieve effective outcomes. DWMHA uses a prior authorization review process designed to promote the appropriate utilization of medically necessary services, to prevent unanticipated denials of coverage and to ensure that all services are provided at the appropriate level of care for the enrollee/member’s needs in a timely manner. The purpose is to determine enrollee/member eligibility, benefit coverage and or establish the presence or absence of medical necessity so that a decision can be made regarding the request for services. Medical Necessity review is a process to consider whether services that are covered only when medically necessary meet criteria for medical necessity and clinical appropriateness. A medical necessity review requires consideration of the enrollee/member’s circumstances, relative to appropriate clinical criteria and DWMHA’s policies. All acute inpatient treatment, partial hospitalization, crisis residential services, substance use disorder services, state hospitalization, psychological and neuropsychological testing and electroconvulsive therapy and all out of network services require authorization prior to service being rendered from the DWMHA, the Crisis Service Vendor and/or the MCPNs.

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All authorizations shall be in compliance with the Medicaid Code of Federal Regulations 42 USC § 1396u-2(b) (8) provisions related to manage care and 42 C.F.R. § 438.210 provisions related to coverage and authorization of services. Pre-service (initial) reviews are conducted telephonically. The information for the UM activity comes from the Access Center, the requesting facility or practitioner/provider and/or enrollee/member. The request for authorization may come from the psychiatrist, physician, treatment team, enrollee/member, family or advocate or facility representative. If the caller is someone other than the enrollee/member, they should be familiar with the case as a result of a face-to-face meeting with the enrollee/member or as a result of an informed review of the clinical record. Initial reviews will include, but are not limited to, the following relevant information:

• Presenting problem including current symptoms • History of presenting problem(s) • Precipitant(s) to services • Results of clinical examination • Diagnosis • Current level of functioning and baseline level of functioning • Prior psychosocial, psychiatric, and substance abuse history and prior treatment • Mental status • Current and Past Medications (dosage and side effects) • Results of diagnostic testing • Results of the Urine Drug Screen • Blood Alcohol Level • Medical complications and significant medical history • Information on consultations with the treating practitioner • Evaluations from other health care practitioners and providers • Support Systems • Specific Severity of Illness/Intensity of Service Criteria • Treatment plan and progress notes • Discharge Plan • Information gained through peer to peer conversations with treating providers

Providers are given an opportunity to discuss any behavioral health or SUD decision with a DWMHA, Access Center, Crisis Service Vendor or MCPN physician (MD or DO) upon request during any review. Certified addiction medicine physicians are available to review substance use medical necessity cases if needed. The DWMHA Chief Medical Officer is also available twenty four (24) hours a day, seven (7) days a week as well. With medical oversight, continuing (concurrent) care reviews are completed at an interval dictated by the clinical severity of the case. Concurrent reviews are conducted prior to the end of the authorized period. Concurrent reviews will consistently include, but are not limited to, the following relevant information:

• Progress toward treatment goals and any changes in treatment goals • Current and any changes in medications (dosage and side effects) • Current level of functioning • Information on consultations with the treating practitioner • Evaluations from other health care practitioners and providers • Intensity of Service Criteria • Status of discharge plan • Information obtained through peer to peer conversations with treating providers

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DWMHA, The Crisis Service Vendor and/or the MCPNs must adhere to the following:

DWMHA only allows physicians (MD or DO) to render behavioral healthcare and SUD non-authorizations. DWMHA ensures that practitioners/physicians have the opportunity to discuss any UM decision with a physician. For non-authorization determinations, the physician reviewers must provide written documentation to justify the clinical non-authorization, and the documentation must include a description of due process rights and appeal procedures. They must also have their complete written name, signature and credentials on the written notification document. DWMHA ensures that annually an affirmative statement about incentives to all employees of DWMHA, the Access Center, the Crisis Service Vendor, the MCPNs and their Service Providers who make UM decisions is distributed. UM decisions are based only on the appropriateness of care and services, as well as the existence of coverage or service or reducing the provision of care which is deemed medically necessary. See DWMHA’s Behavioral Health Utilization Management Review Policy, DWMHA Denial of Service Policy and DWMHA’s UM Affirmative Statement Policy for more details.

XVIII. POST-SERVICE REVIEWS:

A post-service review involves a review of the medical record after the services have been provided. The review may be conducted for all or part of the treatment service/or encounter. A determination will be made within thirty (30) calendar days of receipt of the request. A post- service review that results in an authorization determination or a non-authorization is communicated in writing to the enrollee/member and provider within thirty (30) calendar days of receipt of the request as well. Post-service reviews will include, but are not limited to, the following relevant information:

• Presenting problem including current symptoms • History of presenting problem(s) • Precipitant(s) to services • Results of clinical examination • Diagnosis • Current level of functioning and baseline level of functioning

Type of Review Decision Timeframe Exception to Decision Timeframe Provider Notification Timeframe Non Urgent Pre-Service Review

Within 14 calendar days of receipt of request.

N/A Written Notification within 14 calendar days of receipt of provider’s request. Verbal

Notification within 3 hours of decision. Non Urgent

Concurrent Service Review

Within 14 calendar days of receipt of request.

N/A Written Notification within 14 calendar days of receipt of provider’s request. Verbal

Notification within 3 hours of decision. Urgent Pre-Service

Review Within 24 hours of receipt

of request if all information is received.

Timeframe extends to 72 hours if additional information is requested & the request for the information is

within 24 hours of receipt of the provider’s request.

Written Notification within 72 hours of the decision. Verbal Notification within 3 hours

of decision.

Urgent Concurrent Service Review

Within 24 hours of receipt of request if all

information is received & request is made 24 hours

prior to expiration of current authorization

period.

Timeframe extends to 72 hours if additional information is requested & the request for the information is

within 24 hours of receipt of the provider’s request or if the

provider’s request for service is not made prior to the 24 hours before

the expiration of the current authorization period.

Written Notification within 72 hours of the decision. Verbal Notification within 3 hours

of decision.

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• Prior psychosocial, psychiatric, and substance abuse history and prior treatment • Mental status • Current and Past Medications (dosage and side effects) • Results of diagnostic testing • Results of the Urine Drug Screen • Blood Alcohol Level • Medical complications and significant medical history • Information on consultations with the treating practitioner • Evaluations from other health care practitioners and providers • Support Systems • Specific Severity of Illness/Intensity of Service Criteria • Treatment plan and progress notes • Discharge Plan • Information gained through peer to peer conversations with treating providers

DWMHA only allows physicians (MD or DO) to render behavioral healthcare and SUD non-authorizations. DWMHA ensures that practitioners/physicians have the opportunity to discuss any UM decision with a physician. For non-authorization determinations, the physician reviewers must provide written documentation to justify the clinical non-authorization, and the documentation must include a description of due process rights and appeal procedures. They must also have their complete written name, signature and credentials on the written notification document. See DWMHA’s Behavioral Health Utilization Management Review Policy, DWMHA Denial of Service Policy and DWMHA’s UM Affirmative Statement Policy for more details.

XIX. DISCHARGE PLANNING:

Discharge planning supports continuity of care and efficient use of resources, and incorporates the involvement and decision-making process with the enrollee/member. DWMHA’s UM reviewers collaborate with hospital discharge planners and case managers to support the facility’s discharge planning arrangements.

XX. UTILIZATION MANGEMENT/PROVIDER APPEALS AND ALTERATIVE DISPUTE RESOLUTION: The types of UM/Provider appeal and alternative dispute resolution reviews are as follows: Administrative- an appeal or dispute review involving utilization management issues such as denials resulting from not obtaining a prior authorization and/or continued authorization for some or all types of services and/or for all dates of services. Benefit- an appeal or dispute review involving a request that is not a benefit or where the benefit limit has been exceeded. Medical Necessity- an appeal or dispute review involving a decision that a service does not meet MCG, ASAM, NCD, or LCD medical necessity criteria or is considered to be experimental or investigational. The medical necessity appeal is reviewed by a DWMHA, Crisis Service Vendor or MCPN physician with the same or similar credentials as would usually treat the condition which is being appealed. The physician reviewing the appeal has no involvement in the initial denial.

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Expedited/Urgent-a request to review a decision concerning eligibility, screening, admission, continued/concurrent stay, or other behavioral healthcare services for an enrollee/member who has received urgent services but has not been discharged from a facility, or when a delay in decision-making might seriously jeopardize an enrollee/member’s life, health, or ability to attain, maintain, or regain maximum function. Standard-a request to review a decision concerning eligibility, screening, admission, continued/concurrent stay, or other behavioral healthcare services for an enrollee/member who has received services or is currently receiving services but a delay in decision-making does not jeopardize an enrollee/member’s life, health, or ability to attain, maintain, or regain maximum function. In the event an enrollee/member, enrollee/member’s representative, or practitioner/provider disagrees with a non-authorization, an appeal process is available for redetermination of the request for services or payment for services. Enrollee/members and providers are notified of how to initiate the appeal process and the steps in the appeal process at the time of the non-certification notification. The following is a summary of the steps in the appeal process. In the event an enrollee/member, enrollee/member’s representative, or practitioner/provider disagrees with a non-authorization, an appeal process is available for redetermination of the request for services or payment for services. Enrollee/members and providers are notified of how to initiate the appeal process and the steps in the appeal process at the time of the non-certification notification. The following is a summary of the steps in the appeal process. A. UM/Provider Appeals for Medicaid Covered Services

Pre-Service or Post-Service Medicaid Medical Necessity or Benefit (Redetermination) Appeal: a. If an enrollee/member, enrollee/member’s representative or practitioner/provider chooses to

appeal an initial non-authorization of benefit coverage, screening, admission, continued/concurrent stay or other behavioral healthcare service, they must notify DWMHA of an internal appeal request within sixty (60) calendar days from receipt of the standardized Advance or Adequate Notice of Adverse Determination form or the standardized Notice of Denial of Medical Coverage form for Medicaid Covered Services. If the enrollee/member is enrolled in a Managed Care Health Plan, MI Health Link, CMHSP/PIHP or MI Choice Waiver program, he/she must also exhausted the internal appeal process before he/she can request an external Medicaid State Fair Hearing. A Medicaid State Fair Hearing is an impartial state level review of a Medicaid enrollee/members appeal of an action presided over by a MDHHS Administrative Law Judge. However, if the enrollee/member does not receive the standardized Notice of Appeal Approval form or the standardized Notice of Appeal Denial form for the Medicaid SMI, IDD or SUD population or the Notice of Appeal Decision form for the MI Health Link population within the mandated time frame, he/she may request a Medicaid State Fair Hearing as well.

b. There is only one (1) internal level appeal process for all pre-service, concurrent and/or post-service provider/practitioner medical necessity or benefit denials.

c. The request for a pre-service Medicaid (redetermination) medical necessity or benefit internal appeal can be verbal or in writing to DWMHA. However, the request for a post-service Medicaid (redetermination) medical necessity or benefit internal appeal must be in writing.

d. All requests must include at a minimum the following: • An explanation of what is being appealed and the name, address and telephone

number of the person responsible for filing the appeal; and • Any additional supporting documentation such as additional clinical information that

had not been previously submitted; • The staff member preparing case for physician review will review all information in

their electronic medical record system and gather any other information available such as previous denials and appeals and follow-up care that has occurred after the denial.

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• However, for post-service requests, the complete medical record (at a minimum the intake, psychiatric evaluation, psychiatric progress notes, social work evaluation, social work progress notes, nurse evaluation, nurse progress notes, medication administration notes and discharge summary) if not provided previously.

e. The provider and/or enrollee/member can ask for an expedited (redetermination) internal medical necessity or benefit appeal as long as the enrollee/member has not been discharged from the treatment.

f. After receiving an internal medical necessity or benefit appeal request, DWMHA must complete and send the standardized Notice of Receipt of Appeal form within twenty four (24) hours of receipt of an expedited appeal request and within five (5) calendar days of receipt of a standard appeal request.

g. Upon receipt of the medical necessity or benefit appeal request, the DWMHA is required to review the case including all documentation submitted and to fully investigate all aspects of the clinical care provided without deference to the initial determination and make a decision within the following timeframes:

• For a pre-service expedited 1st level request, within seventy two (72) hours of receipt of the request;

• For a pre-service standard request, within thirty (30) calendar days of receipt of the request; and

• For a post-service, which are all standard, within thirty (30) calendar days of receipt of the request.

h. The enrollee/member and/or DWMHA may need to ask for an extension to obtain more information that will assist in the processing of the appeal. All extensions can request the necessary information as long as the request is within fourteen (14) calendar days of the initial request.

i. The physician with the same or similar specialty will review the appeal and will not be a subordinate of the physician who rendered the initial denial.

j. The physician when reviewing a medical necessity appeal, in conjunction with independent professional medical judgment, will use nationally recognized guidelines which include but are not limited to third party guidelines, CMS guidelines, and State guidelines, recommendations from professional societies and advice from authoritative review articles and text books.

k. The physician who made the original denial determination may review the case and overturn the initial denial.

l. If the decision results in upholding part or all of the initial denial, verbal communication is given to the provider within three (3) hours of the decision. Written Notification using the standardized Notice of Appeal Denial form for the Medicaid SMI, IDD and SUD population or the standardized Notice of Appeal Decision form for the MI Health Link population and the standardized Physician Letter are sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a pre-service expedited appeal is made on the last/3rd calendar day, when the decision for a pre-service standard appeal is made on the last/30th day or when the decision for a post-service appeal is made on the last/30th day. In these cases, the Notice and Physician Letter must be mailed on the same day as the determination.

m. The Notice of Appeal Denial form for the Medicaid SMI, IDD and SUD population and the Notice of Appeal Decision form for the MI Health Link population must include a statement that this is the only internal level of appeal.

n. The Notice of Appeal Denial form and the Notice of Appeal Decision form must also include a statement that the enrollee/member has a right to an external State Fair Hearing after he/she has exhausted the internal appeal process and an explanation of the process to file a State Fair Hearing which is at no cost to the enrollee/member.

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o. If the decision results in overturning part or all of the initial denial, verbal communication is given

to the provider within three (3) hours of the decision. For a complete overturned determination, written notification using the standardized Notice of Appeal Approval form for the Medicaid SMI, IDD, SUD population or the standardized Notice of Appeal Decision form for the MI Health Link population and the standardized Physician Letter are sent to the provider and enrollee/member within twenty four (24) hours of the determination. For a partially overturned determination, written notification using the standardized Notice of Appeal Denial form for the Medicaid SMI, IDD, SUD population or the standardized Notice of Appeal Decision form for the MI Health Link population and the standardized Physician Letter are sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exceptions are when the decision for a pre-service expedited appeal is made on the last/3rd calendar day or when the decision for a pre-service standard appeal is made on the last/30th day. In these cases, the Notice and Physician Letter must be mailed on the same day as the determination.

p. A DWMHA physician is available to discuss a pre-service or post-service Medicaid (redetermination) denial.

q. When DWMHA fails to make a timely decision for a MI Health Link enrollee/member, the enrollee/member and provider will be sent the standardized Notice of Our Failure to Make a Coverage Determination form.

Post-Service Medicaid Administrative (Redetermination) Appeal: a. The provider and/or enrollee/member has up to sixty (60) calendar days from the receipt of the

standardized Adequate Notice of Adverse Benefit Determination form or the Advance Notice of Adverse Benefit Determination form for the Medicaid SMI, IDD or SUD population or the standardized Notice of Denial of Medical Coverage form for the MI Health Link population to request an internal administrative appeal for a post-service Medicaid covered service.

b. DWMHA, Crisis Service Vendor and the MCPNs have a one (1) level appeal process for post-service provider administrative denials. Examples of administrative denials are failure to authorize services according to required, contracted time frames.

c. The provider’s request for a post-service Medicaid (redetermination) administrative internal appeal must be in writing to DWMHA, Crisis Service Vendor or the MCPN.

d. Once the service or procedure has occurred or the enrollee/member has been discharged from the facility, the provider must utilize the described post-service process in order to appeal.

e. All requests must include at a minimum the following: • An explanation of what is being appealed and the name, address and telephone

number of the person responsible for filing the appeal; and • Documentation including the request, the reasons why the provider feels the services

should be paid and a copy of the claim(s). In addition, documentation of the reason for notification outside of DWMHA’s, Crisis Service Vendor or MCPN’s notification time frames must be provided.

f. DWMHA’s Customer Service Department handles all enrollee/member administrative appeals for Medicaid covered services. Enrollees/members are held financially harmless for any provider/practitioner administrative denial for Medicaid covered services.

g. After receiving an administrative appeal request from a provider, DWMHA, the Crisis Service Vendor or the MCPN must complete and send the standardized Notice of Receipt of Appeal form within five (5) calendar days of receipt of the standard appeal request to the provider and enrollee/member.

h. Upon receipt of the administrative appeal request, the DWMHA, the Crisis Service Vendor or MCPN Professional staff is required to review the case including all documentation submitted and to fully investigate all aspects of the case without deference to the initial determination and make a decision within the following timeframe:

• For a post-service request, which are all standard, within thirty (30) calendar days of receipt of the request.

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i. If the decision results in upholding part or all of the initial denial, verbal communication is given to

the provider within three (3) hours of the decision. Written Notification using the standardized Administrative Appeal Determination form is sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a post-service administrative appeal is made on the last/30th day. In this case, the Notice must be mailed on the same day as the determination.

j. The Administrative Appeal Determination Form must state that this is the final level of appeal and that the enrollee/member is to be held financially harmless for any provider/practitioner administrative denial for Medicare covered services.

k. A DWMHA, Crisis Service Vendor or MCPN professional staff are available to discuss a post-service Medicaid (redetermination) administrative denial.

B. UM/Provider Appeals for Medicare Covered Services: Pre-Service or Post-Service Medicare Medical Necessity or Benefit First Level (Redetermination) Appeal: a. If an enrollee/member, enrollee/member’s representative or provider chooses to appeal an initial

non-authorization of eligibility, benefit coverage, screening, admission, continued/concurrent stay or other behavioral healthcare service, they must notify DWMHA an appeal request within sixty (60) days from the standardized Notice of Denial of Medical Coverage form for Medicare Covered Services.

b. The request for a pre-service Medicare 1st level (redetermination) medical necessity or benefit internal appeal can be verbal or in writing to DWMHA. However, the request for a post-service Medicare 1st level (redetermination) medical necessity or benefit internal appeal must be in writing.

c. All requests must include at a minimum the following: • An explanation of what is being appealed and the name, address and telephone

number of the person responsible for filing the appeal; • Any additional supporting documentation not submitted previously; and • The staff member preparing the case for physician review will review all information

in their electronic medical record system and gather any other information available such as previous denials and appeals and follow-up care that has occurred after the denial.


d. The provider and/or enrollee/member can ask for an expedited (redetermination) internal medical necessity or benefit appeal as long as the enrollee/member has not been discharged from the treatment.

e. After receiving an internal medical necessity or benefit appeal request, DWMHA must complete and send the standardized Notice of Receipt of Appeal form within twenty four (24) hours of receipt of an expedited appeal request and within five (5) calendar days of receipt of a standard appeal request.

f. Upon receipt of the 1st level medical necessity or benefit appeal request, the DWMHA is required to review the case including all documentation submitted and to fully investigate all aspects of the clinical care provided without deference to the initial determination and make a decision within the following timeframes:

• For a pre-service expedited 1st level request, within seventy two (72) hours of receipt of the request;

• For a pre-service standard 1st level request, within thirty (30) calendar days of receipt of the request; and

• For a post-service 1st level request, which are all standard, within thirty (30) calendar days of receipt of the request.

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g. The enrollee/member and/or DWMHA may need to ask for an extension to obtain more

information that will assist in the processing of the appeal. All extensions can request the necessary information as long as the request is within fourteen (14) calendar days of the initial request.

h. The physician with the same or similar specialty will review the 1st level appeal and will not be subordinate of the physician who rendered the initial denial.

i. The physician when reviewing a medical necessity 1st level appeal, in conjunction with independent professional medical judgment, will use nationally recognized guidelines which include but are not limited to third party guidelines, CMS guidelines, and State guidelines, guidelines from professional societies and advice from authoritative review articles and text books.

j. The physician who made the original denial determination may review the case and overturn the initial denial.

k. If the decision results in upholding part or all of the initial denial, verbal communication is given to the provider within three (3) hours of the decision. Written Notification using the standardized Notice of Appeal Decision form and the standardized Physician Letter are sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a pre-service expedited appeal is made on the last/3rd calendar day, when the decision for a pre-service standard appeal is made on the last/30th day or when the decision for a post-service appeal is made on the last/30th day. In these cases, the Notice and Physician Letter must be mailed on the same day as the determination.

l. The Notice must include an explanation that the case is automatically forwarded to the Qualified Independent Contractor, MAXIMUS Federal Services for a pre-service Medicare 2nd level (reconsideration) appeal if the determination is to uphold all or part of the non-authorization of eligibility, screening admission, continued/concurrent stay or other behavioral healthcare services.

m. A DWMHA is available to discuss a pre-service or post-service Medicare (redetermination) denial. n. When DWMHA fails to make a timely decision, the enrollee/member and provider will be sent the

standardized Notice of Our Failure to Make a Coverage Decision form. Pre-Service or Post-Service Medicare Second Level Medical Necessity or Benefit (Reconsideration) Appeal: a. DWMHA automatically forwards the case to MAXIMUS for a pre-service Medicare 2nd level

(reconsideration) appeal. b. MAXIMUS attempts to review a case, make a decision and notify DWMHA, the provider and

enrollee/member of the decision within thirty (30) calendar days of receipt of the request. However

c. If MAXIMUS upholds part or all of the 1st level redetermination decision, they provide written notification of the decision to DWMHA, the provider and the enrollee/member. The Notice also includes an explanation of the next (3rd) level appeal process. However, if they overturn the 1st level redetermination decision and approve some or all of the services/days, DWMHA has thirty (30) calendar days to effectuate (pay claim) and provide MAXIMUS with the check number, check date, amount paid and explanation of benefits no later than thirty (30) calendar days from the MAXIMUS decision.

Pre-Service or Post-Service Medicare Third Level Medical Necessity or Benefit Appeal: a. The 3rd level appeal is the Administrative Law Judge (ALJ) Hearing. This hearing allows the provider

to present the appeal to a new person who will review the facts independently and listen to testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, or in some cases, in person. To secure an ALJ hearing, the minimum amount of the case must be $150. All requests for an ALJ hearing must be written and forwarded to the Office of Medicare Hearing and Appeals (OMHA). The address is documented in the MAXIMUS decision notice. In most cases, the ALJ sends a written decision within ninety (90) days of receipt of the request.

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b. If the ALJ upholds part or all of the 2nd level decision by MAXIMUS, they provide written notification

of the decision to DWMHA, the provider and the enrollee/member. The Notice also includes an explanation of the next (4th) level appeal process.

Pre-Service or Post-Service Medicare Fourth Level Medical Necessity or Benefit Appeal: a. A 4th appeal level can be sought if the provider is dissatisfied with the decision made in the

hearing. The request for a Medicare Appeals Council (MAC) review must be submitted in writing within sixty (60) calendar days of the ALJ decision and must specify the issues and findings that are being contested. (Refer to the ALJ decision for details regarding the procedures to follow when filing a request for Appeals Council review.) In general, the MAC will issue a decision within ninety (90) days of receipt of a request for review. However, that timeframe may be extended for various reasons, including but not limited to, the case being escalated from an ALJ hearing. If the Appeals Council does not issue a decision within the applicable timeframe, you may ask the Medicare Appeals Council to escalate the case to the next (5th) level, the Judicial Review.

b. If the MAC upholds part or all of the 3rd level decision by the ALJ, they provide written notification of the decision to DWMHA, the provider and the enrollee/member. The Notice also includes an explanation of the next (5th) level appeal process.

Pre-Service or Post-Service Medicare Fifth Level Medical Necessity or Benefit Appeal: a. If at least $1,460 or more is still in controversy following the MAC decision, the provider on behalf

of the enrollee/member may request judicial review before a U.S. District Court judge; this is the fifth and final level of appeal. The provider must file the request for review within sixty (60) days of receipt of the MAC’s decision, which contains information about the procedures for requesting judicial review. There is no statutory timeframe for the Federal Court decision.

b. If the US District Court Judge upholds part or all of the 4th level decision by MAC, they provide written notification of the decision to DWMHA, the provider and the enrollee/member. The Notice also includes an explanation that this is the final appeal level.

Post-service (Retrospective) Medicare Administrative First Level (Redetermination) Appeal: a. The provider and/or enrollee/member has up to sixty (60) calendar days from the receipt of the

standardized Notice of Denial of Medical Coverage form to request an internal administrative appeal for a post-service Medicare covered service.

b. DWMHA and the Crisis Service Vendor have a one (1) level appeal process for post-service provider administrative denials. Examples of administrative denials are failure to authorize services according to required, contracted time frames.

c. The provider’s request for a post-service Medicare 1st (redetermination) administrative internal appeal must be in writing to DWMHA or the Crisis Service Vendor.


e. All requests must include at a minimum the following: • An explanation of what is being appealed and the name, address and telephone

number of the person responsible for filing the appeal; and • Documentation including the request, the reasons why the provider feels the services

should be paid and a copy of the claim(s). In addition, the reason for the notification outside of DWMHA’s or the Crisis Service Vendor’s notification time frames must be documented.

g. DWMHA’s Customer Service Department handles all enrollee/member administrative appeals for Medicaid covered services. Enrollees/members are held financially harmless for any provider/practitioner administrative denial for Medicaid covered services.

h. After receiving a 1st level administrative appeal request from a provider, DWMHA or the Crisis Service Vendor must complete and send the standardized Notice of Receipt of Appeal form within five (5) calendar days of the standard appeal request to the provider and enrollee/member.

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i. Upon receipt of the 1st level administrative appeal request, DWMHA or the Crisis Service Vendor

Professional Staff is required to review the case including all documentation submitted and to fully investigate all aspects of the case without deference to the initial determination and make a decision within the following timeframe:

• For a post-service 1st level request, which are all standard, within thirty (30) calendar days of receipt of the request.

j. If the decision results in upholding part or all of the initial denial, verbal communication is given to the provider within three (3) hours of the decision. Written Notification using the standardized Administrative Appeal Determination form is sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a post-service administrative appeal is made on the last/30th day. In this case, the Notice must be mailed on the same day as the determination.

k. The Administrative Appeal Determination Form must state that this is the final level of appeal and that the enrollee/member is to be held financially harmless for any provider/practitioner administrative denial for Medicare covered services.

l. A DWMHA or the Crisis Service Vendor professional staff are available to discuss a post-service Medicare (redetermination) administrative denial.

When a non-contracted provider files an appeal for a MI Health Link enrollee/member, he/she must forward a complete and signed Waiver of Liability (WOL) form with the 1st level (redetermination) appeal request. Section 60.1.1 of Chapter 13 of the Medicare Managed Care Manual states: “A non-contract provider, on his or her own behalf, is permitted to file a standard or expedited appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal.” DWMHA cannot proceed in reviewing a non-contracted provider’s request for a 1st level appeal if there is no complete and signed. WOL form. DWMHA will make three (3) attempts via telephone or in writing to secure all needed documents including the WOL. If no WOL is forwarded to DWMHA’s UM Department within sixty (60) calendar days from the denial notice date, DWMHA must send the case to a MAXIMUS requesting a dismissal. DWMHA will also forward a written notification of the dismissal to the non-contracted provider within five (5) calendar days of the request for the dismissal.

C. UM/Provider Local and Alternative Dispute Resolution for the Uninsured or Under Insured using General Fund to cover services:

Pre-Service or Post-Service Medical Necessity or Benefit (Redetermination) Local Dispute Resolution Review: a. If an uninsured or under Insured enrollee/member, uninsured or underinsured enrollee/member’s

representative or practitioner/provider chooses to request an internal local dispute resolution review of an initial non-authorization of benefit coverage, screening, admission, continued/concurrent stay or other behavioral healthcare service, they must notify DWMHA to request a local dispute resolution review request within thirty (30) calendar days from the receipt of the standardized Advance or Adequate Adverse Determination form for the uninsured or under Insured. The uninsured or underinsured enrollee/member can request an external Alternative Dispute Resolution with the Michigan Department of Health and Human Services (MDHHS) after the local dispute resolution review process.

b. There is only one (1) internal local dispute resolution review level for all pre-service, concurrent and/or post-service provider/practitioner medical necessity or benefit denials.

c. The request for a pre-service (redetermination) medical necessity or benefit internal local dispute resolution review can be verbal or in writing to DWMHA. However, the request for a post-service (redetermination) medical necessity or benefit internal local dispute resolution review must be in writing.

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d. All requests must include at a minimum the following:

• An explanation of what is being dispute and the name, address and telephone number of the person responsible for filing the local dispute resolution request; and

• Any additional supporting documentation such as additional clinical information that had not been previously submitted;

• The staff member preparing case for physician review will review all information in their electronic medical record system and gather any other information available such as previous local dispute review denials and follow-up care that has occurred after the denial.


e. The provider and/or uninsured or under insured enrollee/member can ask for an expedited (redetermination) medical necessity or benefit local dispute resolution review request as long as the enrollee/member has not been discharged from the treatment. DWMHA will assess the request for an expedited local dispute resolution review and determine if there is clinical rationale that shows the decision or delay in making the decision may have an adverse impact on the enrollee/member’s health or well-being. If the request does not meet the expedited criteria, the local dispute resolution review is re-directed through the standard review process.

f. After receiving a medical necessity or benefit local dispute resolution review request, DWMHA must complete and send the standardized Notice of Receipt of Local Dispute Resolution Request form for the uninsured or underinsured form within twenty four (24) hours of receipt of an expedited review request and within five (5) calendar days of receipt of a standard review request.

g. The Uninsured or Under Insured enrollee/member and/or DWMHA may need to ask for an extension to obtain more information that will assist in the processing of the local dispute resolution review. All extensions can request the necessary information as long as the request is within fourteen (14) calendar days of the initial request.

h. Upon receipt of the medical necessity or benefit local dispute resolution review request, the DWMHA is required to review the case including all documentation submitted and to fully investigate all aspects of the clinical care provided without deference to the initial determination and make a decision within the following timeframes:

• For a pre-service expedited local dispute resolution review request, within seventy two (72) hours of receipt of the request;

• For a pre-service standard local dispute resolution review request, within thirty (30) calendar days of receipt of the request; and

• For a post-service local dispute resolution review request, which are all standard, within thirty (30) calendar days of receipt of the request.

i. The physician with the same or similar specialty will review the local dispute resolution review and will not be a subordinate of the physician who rendered the initial denial.

j. The physician when reviewing a medical necessity local dispute resolution review, in conjunction with the independent professional medical judgment, will use nationally recognized professional societies and advice from authoritative review articles and text books.

k. The physician who made the original denial determination may review the case and overturn the initial denial.

l. If the decision results in upholding part or all of the initial denial, verbal communication is given to the provider within three (3) hours of the decision. Written Notification using the standardized Notice of Appeal Denial form for the uninsured or under insured and the standardized Physician Letter are sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a pre-service expedited appeal is made on the last/3rd calendar day, when the decision for a pre-service standard appeal is made on the last/30th day or when the decision for a post-service appeal is made on the last/30th day. In these cases, the Notice and Physician Letter must be mailed on the same day as the determination.

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m. The Notice of Appeal Denial form for the uninsured or under insured must include a statement

that this is the only internal level of appeal. n. If the decision results in overturning part or all of the initial denial, verbal communication is given

to the provider within three (3) hours of the decision. For a complete overturned determination, written notification using the standardized Notice of Appeal Approval form for the uninsured or under insured and the standardized Physician Letter are sent within twenty four (24) hours of the decision. For a partially overturned determination, written notification using the standardized Notice of Appeal Denial form for the uninsured or under insured and the standardized Physician Letter are sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exceptions are when the decision for a pre-service expedited appeal is made on the last/3rd calendar day or when the decision for a pre-service standard appeal is made on the last/30th day. In these cases, the Notice and Physician Letter must be mailed on the same day as the determination.

o. A DWMHA physician is available to discuss a pre-service or post-service local dispute resolution review (redetermination) denial.

Post-service Administrative (Redetermination) Local Dispute Resolution Review: a. The provider and/or uninsured or under insured enrollee/member has up to thirty (30) calendar

days from the receipt of the standardized Adequate Notice of Adverse Benefit Determination form or the Advance Notice of Adverse Benefit Determination for the uninsured or under insured to request an internal (redetermination) administrative local dispute resolution review.

b. DWMHA, Crisis Service Vendor and the MCPNs have a one (1) level for a local dispute resolution review for post-service provider administrative denials. Examples of administrative denials are failure to authorize services according to required, contracted time frames.

c. The provider’s request for a post-service 1st level (redetermination) administrative internal local dispute resolution review request must be in writing to DWMHA, the Crisis Service Vendor or the MCPN.


e. All requests must include at a minimum the following: • An explanation of what is being disputed and the name, address and telephone number

of the person responsible for filing the appeal; and • Documentation including the request, the reasons why the provider feels the services

should be paid and a copy of the claim(s). It must also include the reason for notification outside of DWMHA’s, Crisis Service Vendor or MCPN’s notification time frames.

f. DWMHA’s Customer Service Department handles all enrollee/member administrative local dispute resolution reviews. Enrollee/members are held harmless financially for any provider/practitioner administrative denial.

g. After receiving am administrative local dispute resolution review request from a provider, DWMHA, the Crisis Service Vendor or the MCPN must complete and send the standardized Notice of Receipt of Local Dispute Resolution Review Request form for the uninsured or under insured within five (5) calendar days of receipt of a standard review request to the provider and enrollee/member.

h. Upon receipt of the administrative local dispute resolution review request, the DWMHA, the Crisis Service Vendor or MCPN Professional Staff is required to review the case including all documentation submitted and to fully investigate all aspects of the case without deference to the initial determination and make a decision within the following timeframes:

• For a post-service local dispute resolution review request, which are all standard, within thirty (30) calendar days of receipt of the request.

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i. If the decision results in upholding part or all of the initial denial, verbal communication is given to the provider within three (3) hours of the decision. Written Notification using the standardized Administrative Appeal Determination form is sent to both the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a post-service administrative appeal is made on the last/30th day. In this case, the Notice must be mailed on the same day as the determination.

j. The Administrative Appeal Determination Form must state that this is the final level of appeal and that the enrollee/member is to be held financially harmless for any provider/practitioner administrative denial for Medicare covered services.

k. A DWMHA, Crisis Service Vendor or MCPN professional staff are available to discuss a post-service administrative denial.

See DWMHA Denial of Service Policy, DWMHA Utilization Management/Provider Appeals Policy, DWMHA Utilization Management/Provider Local and Alternative Dispute Resolution Policy for more details.

XXI. CONTINUOUS COVERAGE AND SERVICE REQUIREMENTS:

DWMHA, the Crisis Service Vendor and/or each MCPN must have continual capacity 365 days a year (24x7x365) to perform any needed inpatient stay review and/or appeals for inpatient psychiatric hospital services or any other service requiring prior authorization. Authorization by a DWMHA, the Crisis Service Vendor or MCPN must be based on MCG criteria. The Crisis Service Vendor and the MCPNs are responsible for notifying DWMHA of their twenty four (24) hour access numbers for prior authorization and any changes in access to the services or procedures for requesting prior authorization. DWMHA UM Reviewers are accessible seven (7) days a week, twenty-four (24) hours a day via a published designated toll-free number to handle urgent requests. Non-urgent pre-service requests and/or communications received by telephone, fax or email are handled on the next business day. TYY services as well as calls through the Michigan Relay system are available for hearing impaired or speech impaired enrollee/members. Language assistance/interpretation is also available for enrollee/members to discuss UM issues.

XXII. INDIVIDUAL PLAN OF SERVICE/MASTER TREATMENT PLAN: The Individual Plan of Service (IPOS) is a written comprehensive plan of services and supports developed through a person-centered planning process, in partnership with the enrollee/member or their authorized representative and their family/caregiver (if enrollee/member agreeable) and one or more qualified professionals (e.g. mental health professional (MHP) child mental health professional (CMHP) or qualified intellectual disability professional (QIDP)) to address the identified desires and needs and to establish meaningful and measurable goals that are prioritized by the enrollee/member. The IPOS is the fundamental document in the individual’s record and must be authenticated by the dated legible signatures of the recipients/authorized representative and the person chosen by the recipient and named in the plan to be responsible for its implementation. Currently, the Master Treatment Plan (MTP) is the guiding SUD treatment document produced by a collaborative planning effort of an interdisciplinary group of professionals (therapist/counselor and supervisor) who meet with the enrollee/member utilizing the Person Centered Planning process. If required, the doctor must approve the Master Treatment Plan. However, no pre-planning meeting is required prior to the Master Treatment Plan. It must be completed within forty eight (48) hours and prior to service delivery. An IPOS/MTP must specify the following:

• Scope of Services • Amount of Services • Duration of Services • Frequency of Services • Who will provide the services

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• How will the services be rendered • Where will the services be rendered • Dates when the services will commence and when the services will end

Depending on the funding stream and responsibility for payment of services, DWMHA, MCPNs and/or Service Providers approve the supports and services outlined in the IPOS/MTP system wide. The IPOS/MTP then serves as the authorization for the supports and services. However, the IPOS/MTP is a working document that is not meant to be a once and done document. As interventions are completed, objectives are accomplished and goals are achieved, the plan should be updated to reflect current focuses and needs of the enrollee/member. See DWMHA’s Individual Plan of Service Policy for more details.

XXIII. UTILIZATION MANAGEMENT’S ROLE IN THE QUALITY IMPROVEMENT (QI)

PROGRAM: The UM program provides the Quality Improvement (QI) program with data related to monitoring and improving care and services rendered. The UM Department and the QI Department work together to monitor the care and services provided to individuals. Through this partnership, DWMHA staff is able to identify opportunities for improvement, intervene to improve care and services and conduct re-measurement activities to determine whether objectives are achieved. The DWMHA’s quality management system consists of standing committees that oversee ongoing monitoring, peer evaluation, and improvement function including receipt and review of data related to their identified areas of responsibility. This structure is designed to improve quality of care to enrollee/members, improve operations of providers and promote efficient and effective internal operations. Standing committees may be assigned quality indicators to use in monitoring aspects of care and service or may establish indicators for which data will be collected and monitored. The committees define aspects of services and supports to be monitored for opportunities to improve, based on priorities established in the MDHHS contract and on the needs of high-risk enrollee/members and high volume/problem-prone programs. Results from the DWMHA’s Performance Indicators System, which is an extension of the MDHHS data collection program, are a key source for identification of aspects to be monitored. The committee develops plans by which data for their scope of responsibility will be reviewed and opportunities for improvement identified. Quality Management staff work with the committees and assure that the principles of data based continuous quality improvements are followed. The standing committees monitor improvements that are implemented for effectiveness and improved outcomes. Standing committees identify and recommend needs for quality improvement teams, as appropriate, and may bring outside resources, if needed to facilitate the work of teams and to facilitate involvement of all team members. The Utilization Management Committee (UMC) is a standing committee of the Quality Improvement Steering Committee (QISC) who reports up to the Program Compliance Committee (PCC). Annually, the DWMHA’s UM program is reviewed and evaluated for overall program effectiveness and its impact is documented within the annual QI program evaluation. Results of the Behavioral Health UM program are used to identify quality of care concerns among providers. Key quality indicators are established in the Quality Improvement program to monitor Behavioral Health UM processes. These results provide a basis for prioritizing quality improvement initiatives. The DWMHA’s UM Annual Program Evaluation and DWMHA’s UM Program Description are approved on an annual basis by the Board of Directors, following a recommendation from the Program Compliance Committee.

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Under or over utilization of services may indicate poor quality care to enrollee/members. To ensure that enrollee/members receive the appropriate level of services, DWMHA implements a program to monitor service sites and improve the level of services received by enrollees/members. The variation in use of services is monitored by the QISC. At a minimum, the following UM measures will be reviewed to determine over and/or under-utilization and reported to QISC. Sources for UM data may include, but are not limited to:

Care Management Technology (CMT) Care Connect 360 My Care Connect DWMHA’s electronic system, MHWIN Access Center, Crisis Service Vendor and/or the MCPNs’ electronic systems

Service Event Volume including:

• Number of enrollee/members receiving services by disability designation of IDD, SED, MI, ED, SMI, age, gender, race/ethnicity, Medicaid vs. non Medicaid, residency

• Selected service encounter mix for populations designated as SED, IDD, SMI • Number of enrollees/members with co-occurring Mental Illness/Substance Use Disorders

(MI/SUD)

Hospitalization and Recidivism Reports: • Number of inpatient admissions per hospital type (community hospital, state facility, other) • Average length of stay per hospital type • Number of enrollees/members re-hospitalized within 30 days after discharge from hospital

Continuity of Care Reports:

• Percent seen within seven days post inpatient (MI/SA) hospitalization by hospital type • Average number of days from inpatient discharge to face to face with physician

Co-Occurring Management:

• Utilization of services for selected procedure codes

When potential under and/or over utilization is identified, the following steps may be taken to determine if there are, in fact, instances of actual under and over treatment:

• The number and type of enrollee/member complaints related to high volume facilities or outpatient providers associated with under/over utilization of care will be reviewed.

• If indicated based on average length of treatment, a sample review of medical records for facilities or outpatient providers will be conducted to identify any instances of under or over treatment.

• DWMHA will review the results of medical record reviews, utilization and/or readmission patterns, and any complaints received related to care delivery to determine if potential under or over utilization can be validated. If it is validated, the facilities or providers responsible will be targeted for educational outreach. This outreach will comprise the primary intervention to correct under or over treatment utilization.

The CMO is a member of multiple Quality Improvement Steering Review standing committees such as

• Critical/Sentinel Events Committee • Peer Review Committee • Death Review Committee

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DWMHA, the Access Center, Crisis Service Vendor, MCPNs and Service Providers are expected to review a statistically sound sample of consumer records, conduct sufficient billing reviews and satisfaction surveys to assure a level of confidence in the utilization management process. The DWMHA UM Appeal Coordinator is expected to audit all denials and all appeals rendered by DWMHA, the Access Center, the Crisis Service Vendor and the MCPNs monthly using the standardized audit tools, collate the results of the audits and provide a monthly report to the DWMHA UM Director. Denial and/or appeal cases not scoring 90% or greater will be reviewed with the DWMHA, Access Center, Crisis Service Vendor or MCPN UM Reviewer for the purposes of coaching and training. Any UM Reviewer that scores below 90% on the audit tool three (3) times or more will be placed on a Corrective Action Plan.

XXIV. SATISFACTION WITH THE UM PROCESS: Practitioner, provider and enrollee/member surveys are conducted annually to assess UM satisfaction. Through the satisfaction surveys as well as enrollee/member and provider complaint and appeal process, DWMHA continually evaluates the UM program to ensure that difficulties are not encountered when enrollee/members are seeking care and when providers are requesting care. The UMC reviews data at least annually to identify opportunities and develop interventions for improvement.

XXV. UTILIZATION MANAGEMENT PROGRAM EVALUATION: A. Frequency of the DWMHA UM Program Evaluation:

A formal evaluation of the UM program occurs annually. This annual evaluation includes but is not limited to the program structure and scope, UM processes, benefit coverage and medically necessity as well as the involvement of the Chief Medical Officer as well as member and provider experience. The evaluation is reported to the UMC and then reported to the QISC annually and to the PCC and then to the BOD for formal approval every two years and as needed. The UM Program evaluation is part of the QI evaluation that is reported to the PCC and to the Board annually. Results of the evaluation are used to guide the development and refinement of the Behavioral Health UM Program Description and Work Plan.

B. Responsibility for the DWMHA UM Program Evaluation: The UM Program Evaluation is compiled by DWMHA UM Clinical Specialists and the DWMHA UM Director. It is then reviewed by the CMO prior to presentation to the UMC.

The UM Program Evaluation is organized around the DWMHA Strategic Plan and includes but is not limited to:

• Monitoring trends and patterns of key utilization management indicators for under and over utilization and appropriateness of care;

• Enrollee/member and Provider satisfaction with the UM process; • Compliance with UM decision-making timeframes; • Compliance with certification, non-certification and appeal resolution timeframes; • Consistency of the selection and application of medical necessity criteria by UM decision-

makers using standardized criteria and inter-rater reliability measures; • Benefit Management; • Quality improvement activities; • Denial and Appeal category analysis; and • New Technology Recommendations.

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ATTACHMENT #1 Utilization Management Functions for the MI Health Link Program:

MI Health Link is a new health care option for Michigan adults, ages 21 and over, who are enrolled in both Medicare and Medicaid and live in Wayne County or one of the other participating regions. The goal of MI Health Link is to provide seamless access to high quality care that reduces costs for those who are eligible. MI Health Link offers a broad range of medical and behavioral health services, pharmacy, home and community-based services and nursing home care, all in a single program designed to meet the individual needs of the enrollee. The following integrated care organizations provide services to MI Health Link enrollees/members in Wayne County: Aetna, AmeriHealth, Fidelis, HAP Midwest and Molina. The benefits of being enrolled in the MI Health Link program include:

• Having one plan for all your Medicare and Medicaid benefits including medications • Not having to pay any co-payments or deductibles for in network services including medications

(nursing home patient pay amounts still apply) • Having an individual Care Coordinator to:

Work with the individual to create a person care plan based on personal goals Answer questions and make sure the person’s health care issues get the attention they deserve Connect the individual to supports and services needed to be healthy and live where he/she

wants. Access to Behavioral Health and Substance Use Services: The maximum time between a request for an appointment and the date offered is: Emergent / Life Threatening: 3 hours Emergent / Non-Life Threatening: 6 hours Urgent Care: 24 hours Routine Care: 7 business days If a provider’s schedule cannot accommodate the person requesting any appointment within these time

intervals, an appointment will be offered with an alternative provider at the same location, or if none available, at another location. The member may choose to decline alternatives and accept a delayed appointment.

Individual Integrated Care and Supports Plan (IICSP): The Person Centered Planning process assists in the design of the Individual Integrated Care and Supports Plan (IICSP). This is the driving document for all supports and services for persons in the dual eligible project. However, for behavioral health services, the Individual Plan of Service (IPOS) is also developed and implemented; it is the document that the amount, scope and duration of behavioral health services to be provided to the member. The IPOS is incorporated into the Individual Integrated Care and Supports Plan (IICSP).

Emergency Care Resulting in Admissions: DWMHA provides coverage to members if they require emergency or urgently needed services. Emergent and/or urgent care should be rendered as needed, with notification of any admission to the DWMHA UM Prior Authorization Department within forty eight (48) hours of the admission. A DWMHA UM staff will review emergent and/or urgent admissions within one business day of receipt of clinical information.

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Prior Authorized Services and Procedures: All acute inpatient treatment, partial hospitalization, crisis residential services and withdraw maintenance (sub-acute detox), state hospitalization, psychological and neuropsychological testing and electroconvulsive therapy require authorization prior to service being rendered. Prior authorization is designed to promote the appropriate utilization of medically necessary services, to prevent unanticipated denials of coverage and to ensure that all services are provided at the appropriate level of care for the enrollee/member’s needs in a timely manner. The purpose is to determine enrollee/member eligibility, benefit coverage and or establish the presence or absence of medical necessity so that a decision can be made regarding the request for services. Pre-certification is deemed necessary for all elective, non-emergent and urgent inpatient admissions and procedures rendered by a hospital/facility providing behavioral health services when consistent with current medical necessity requirements and current policies and procedures. Behavioral health care rendered by providers not participating in DWMHA network also require pre-approval for these services. Authorizations are based on MCG criteria which is updated every year by the DWMHA CMO and is based upon the most current research, relevant quality standards and evidence-based models of care. DWMHA also has behavioral health clinical protocols. Providers are encouraged to review and use them, but they should not replace clinical judgment. A copy of the level of care criteria used in clinical decision making and/or the clinical protocols is available via email at [email protected]. Both documents are available in various formats to meet ADA requirements. All authorizations shall be in compliance with the Medicaid Code of Federal Regulations 42 USC § 1396u-2(b) (8) provisions related to manage care and 42 C.F.R. § 438.210 provisions related to coverage and authorization of services. DWMHA also complies with CMS requirements and timeframes for historically Medicare primary paid services. Pre service reviews are conducted telephonically. The source of information for the UM activity comes from the requesting facility or provider and/or enrollee/member. The request for authorization may come from the psychiatrist, physician, treatment team member, enrollee/member, family or advocate. If the caller is someone other than the enrollee/member, they should be familiar with the case as a result of a face-to-face meeting with the enrollee/member or as a result of an informed review of the clinical/medical record. Providers are given an opportunity to discuss any behavioral health or pharmacy decision with a DWMHA physician during any review. The DWMHA Chief Medical Officer is also available twenty four (24) hours a day, seven (7) days a week for consultation. Both inpatient and outpatient ECT must be preauthorized. If a provider is requesting inpatient ECT treatment, the member is required to meet criteria for inpatient level of care in addition to meeting medical necessity for ECT. If the member no longer meets criteria for the inpatient level of care, then outpatient ECT can and shall be considered unless medically contraindicated. All ECT services are reviewed by a DWMHA physician.

Psychological testing and neuropsychological testing requires the submission of a standardized preauthorization request form that is faxed or emailed to DWMHA for review by the Director of UM prior to service delivery. A determination is made within three (3) calendar days of receipt of the request If medical necessity criteria is not met for inpatient admission or other high acuity service, the request for prior-authorization is denied. However, only a physician can render behavioral healthcare and pharmaceutical denial or a Doctoral-level clinical psychologist or certified addiction-medicine specialist can make a behavioral health denial or a pharmacist to render a pharmaceutical denial. A less restrictive alternative setting may be recommended, or, if no need for CMH services is identified, the applicant is referred to resources outside of the DWMHA network.

mailto:[email protected]

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Utilization Management/Provider Appeals: If a request for services is reduced, suspended or denied, the requesting provider is given verbal notification within three (3) hours of the decision. Written notification is mailed to the provider and the enrollee/member using the standardized Notice of Denial of Medical Coverage form within twenty four (24) hours of the decision. The Notice describes the reasons for the reduction, suspension or denial of services and explains the due process procedures for both Medicaid and Medicare covered services. Out of Network (Non-Contracted) Providers and Authorizations: Occasionally, an enrollee/member may be referred to an out-of-network provider because of special needs and the qualifications of the provider. DWMHA will make such decisions on a case-by-case basis. Consultation with a DWMHA physician may be necessary as well. However, if a network provider refers an enrollee/member to an out of network provider, DWMHA will authorize the services as long as they are medically necessary and if the non- contracted provider has a current, unrestricted, license to practice. When approving a service from a non-contracted provider, DWMHA assigns an authorization number which refers to and documents the approval. DWMHA sends documentation of the approval to the provider within the time frames appropriate to the type of request. By requesting authorization, the provider is affirming services are medically necessary and a covered benefit under the Medicare and/or Medicaid Program(s). As a condition of the authorization for Medicare services, the out of network provider also agrees to accept no more than 100% of an amount equivalent to the Medicare Fee-For-Service Program allowable payment rates (adjusted for place of service or geography) set forth by CMS in effect on the date(s) of service, and any portion, if any, that DWMHA or the ICO would have been responsible for paying if the member was enrolled in the Medicare Fee-For-Service Program. Servicing out of network providers also shall recognize that members are not to be balanced billed for any uncollected monies for covered services. Non Prior Authorized Services and Procedures: DWMHA has implemented the UM Guidelines document to serve as the basis for payment approval for all services that do not require prior authorization. The UM Guidelines detail the specific services, frequency per year and HCPCS codes available based on the enrollee/member’s Level of Care Utilization Systems (LOCUS) Score or Supports Intensity Scale (SIS) Level Score. As long as the provider requests supports and services that do not exceed the UM guidelines for an enrollee/member, no authorization is required for payment; the provider simply submits the claims to DWMHA. However, if the claims for supports and services exceed the UM Guidelines, the provider receives a message that the payment is pending a review by a DWMHA UM staff. The provider then submits the clinical reasoning for use of requested supports and services to the DWMHA UM staff for review and a determination is made within 3 calendar days of the submission.

DWMHA Monthly UM Reporting Requirements for the MI Health Link Program: Access to Services:

• Total number of emergent/life threatening requests for an appointment and the date offered is within 3 hours

• Total number of emergent/non-life threatening requests for an appointment and the date offered is within 6 hours

• Total number of urgent requests for an appointment and date is offered is within 24 hours • Total number of routine requests for an appointment and the date offered is within 7 business days

Hospitalization and Recidivism: • Number of admissions per service type (acute in-patient, partial hospitalization, sub-acute detox, crisis

stabilization, crisis residential) • Average length of stay per service type • Number of persons re-hospitalized within 30 days after discharge from hospital

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Continuity of Care:

• Percent seen within 7 days post-acute inpatient hospitalization by a physician • Percent seen within 7 days post-acute inpatient hospitalization by a health care professional other than

a physician • Average number of days from inpatient discharge to face to face with a physician • Average number of days from inpatient discharge to face to face with a health care professional other

than a physician

UM Decision Reviews: • Total number of authorization requests by routine, urgent and emergent by contracted providers and

by non-contracted providers • Total number of denials for prior authorized service • Total number of standard 1st level redetermination requests • Total number of decisions upheld or resulting in a split decision by DWMHA for a standard 1st level

redetermination appeal request and forwarded to MAXIMUS • Total number overturned denial decisions by DWMHA for a standard 1st level redetermination appeal

request • Total number of expedited 1st level redetermination appeal requests • Total number of decisions upheld or resulting in a split decision by DWMHA for an expedited 1st level

redetermination appeal request and forwarded to MAXIMUS • Total number overturned decisions by DWMHA for an expedited 1st level determination appeal request • Total number of 2nd level reconsideration appeal requests • Total number of decisions upheld, total number overturned and total number resulting in a split

decision for a 2nd level reconsideration appeal request by MAXIMUS • Total number of decisions overturned by MAXIMUS due to case set up by DWMHA • Total number of 3rd level ALJ hearing appeal requests • Total number of decisions upheld, total number overturned and total number resulting in a split

decision by the 3rd level ALJ hearing request • Total number of 4th level Medicare Council appeal requests • Total number of decisions upheld, total number overturned and total number resulting in a split

decision by the 4th level Medicare Council Review • Total number of 5th level Judicial appeal requests • Total number of decisions upheld, total number overturned and total number resulting in a split

decision by the 5th level Judicial court • Total number of retrospective review requests • Total number of retrospective review requests denied by DWMHA • Total number of retrospective 1st level appeal requests • Total number of decisions upheld or resulting in a split decision by DWMHA for a retrospective 1st level

appeal and forwarded to MAXIMUS • Total number overturned decisions by DWMHA for a retrospective 1st level appeal • Total number of administrative provider appeal requests • Total number of decisions upheld or resulting in a split decision by DWMHA and forwarded to MAXIMUS

for an administrative provider appeal • Total number of decisions overturned by DWMHA for an administrative provider appeal

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UM Timeliness:

• Total number of expedited decisions made by DWMHA within 72 hours of receipt of the request for an expedited 1st level redetermination request

• Average turnaround time of expedited decisions made by DWMHA for an expedited 1st level determination request

• Total number of standard decisions made by DWMHA within 60 calendar days after receipt of the request for a standard 1st level redetermination request (standard medical necessity, retrospective and/or administrative)

• Average turnaround time of a standard decision made by DWMHA for a standard 1st level redetermination request

• Total number of notification letters sent for expedited, standard and post service decisions • Total number of claims effectuated by DWMHA 30 calendar days from the date of the letter from the

MAXIMUS documenting the denial decision was overturned (the 30 calendar days includes DWMHA forwarding the check number, check date, amount paid and EOB to MAXIMUS) for a 2nd level reconsideration (medical necessity, retrospective and/or administrative) appeal

Clinical, utilization management and denial and appeal data is secured using the DWMHA electronic system MHWIN as well as using Care Connect 360 and Care Management Technologies through the Population Health Management Application. Outcomes from the data is available to the Integrated Care Organizations (ICO) with customized dashboard. However, the UM Department will generated monthly reports with the above data to the ICO. For each denial, DWMHA will include a UM denial summary with the member name, the requesting provider name, request date, type of request (i.e. routine, urgent, emergency), decision date, denial reason and date member/provider was notified of the decision. DWMHA will also monitor over and under-utilization of services quarterly and will provide documentation of such monitoring and the findings to the Integrated Care Organizations on a quarterly basis.

Quality Assurance/Improvement: Review of consistency of Behavioral Health and Substance Use UM decision making Inter-rater reliability testing is administered annually for UM reviewers and psychiatrists involved in UM reviews. DWMHA utilizes the MCG web-based Inter-Rater Reliability module, which tests the proper use of MCG guidelines with clinician-developed case studies. It evaluates an individual’s ability to find and apply the appropriate guideline based on a specific scenario. DWMHA has a benchmark standard of scoring 90% or greater. Any UM reviewer or physician reviewer with an inter-rater reliability score less than 90% will be placed on a corrective action plan (CAP) with the expectation that the person pass a re-test administered within thirty (30) days. CAPS can involve such activities as face-to-face supervision and coaching and/or education and re-training. During the time period of the CAP, random samples of the staff member’s current cases will be audited. If upon re-testing, the staff person does not achieve 90% or greater, he/she will be subject to a transfer to a role outside the UM Department or termination. Note that annual education and training on the criteria is provided for all staff performing UM activities that involve application of the medical necessity criteria. MCG also has web-based on-demand training modules that are available 24/7. The results of the inter rater reliability case reviews will be used to identify areas of variation among decision makers and/or types of decisions. The results will also help to identify opportunities for improvement as well as further training needs. MCG also provides reports outlining all of the training modules completed by each UM reviewer including physicians to ensure that all required training modules are completed.

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ATTACHMENT #2 Waiver and State Plan Amendments (SPA): State Plan Amendments and Waivers enable states expand their Medicaid programs and/or offer services that better meet the needs of Medicaid enrollees. In Michigan, DWMHA as a PIHP, manages the following:

1. State Plan Amendment for Autism Spectrum Disorder (ASD) 2. Children with Serious Emotional Disturbance Waiver (SED) 3. Children’s Waiver Program (CWP) 4. Habilitation and Supports Waiver (HAB)

Each program has specific eligibility criteria, authorization process including certification and rectification and selected service array. As part of Medicaid funding, DWMHA is responsible to monitor each program’s access and service delivery to ensure individuals receive the high quality service, in the appropriate amount, in the most appropriate time frames, taking into consideration medical necessity, prevailing standard of care and the preferences and values of the person to achieve the best outcomes. Autism Spectrum Disorder (ASD) Program and Benefit: The Medicaid Autism Benefit is a benefit under the Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) for individuals which provides access to evidence-based Applied Behavior Analysis (ABA) Services to individuals covered by Medicaid ages birth to twenty-one with an Autism Spectrum Disorder (ASD) Diagnosis. The Medicaid Autism Benefit covers Comprehensive Diagnosis Evaluations, Psychological Testing, Adaptive Testing, Behavior Assessments, Behavior Plans of Care, ABA Direct Services, Technician Direction and Observation (Supervision), and Parent/Guardian Training. Individuals receiving the Medicaid Autism Benefit also have access to any other medically necessary services covered by DWMHA. To access the Medicaid Autism Benefit, parents/guardians or individuals contact the Access Center for screening by an Access Center Clinician using the Modified Checklist for Autism in Toddler–Revised (M-CHAT-R) or Social Communication Questionnaire (SCQ). The family is offered choice and then referred to an ASD Benefit Provider for further evaluation. The Provider in receipt of the referral receives an authorization for the evaluation, cognitive, and adaptive testing from the Access Center Clinician. To determine the diagnosis of ASD and the level of Applied Behavioral Analysis (ABA) services need by the individual, the Service Provider completes the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) and the Autism Diagnosis Interview – Revised (ADIR)/Developmental Interview. For cases where it may be challenging to identify ASD Diagnosis based solely the ADOS-2 and ADIR and there is medical necessity for further evaluation, Providers are able to conduct cognitive and adaptive testing. Families also are connected to a general Developmental Disability Intake Interview, which begins the Person-Centered Planning process to begin the pre-plan and Individualized Plan of Service (IPOS). This plan includes the ASD services along with all other medically necessary services for the individual.

After receiving a referral, completing the diagnostic testing and recommending the level of ABA services, the Service Provider forwards an application to DWMHA. The UM Reviewer then conducts a clinical review of the requested service plan and records the enrollment details including the service plan into the Waiver Supports Application (WSA) which is MDHHS’s management tool for ASD services. An MDHHS Administrator then reviews the information, approves or denies the ASD benefit, uploads the decision in WSA and then forwards the decision to DWMHA. The DWMHA UM Reviewer, in turn, notifies the Service Provider. The UM Reviewer also enters re-enrollments, continued stay service plans and discharges into the WSA for MDHHS review and approval or denial.

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Per the Michigan Medicaid Manual, the medical necessity and recommendations for ASD services is determined by a physician or other licensed practitioner working within their scope of practice under the state of Michigan. The child must demonstrate substantial functional impairment in social communication, patterns of behavioral and social interaction as evidenced by meeting criteria A or B (listed below); and required ASD services to address the following areas:

A. The child currently demonstrates substantial functional impairment in social communication and social

interaction across multiple contexts, and is manifested by all of the following: 1. Child is under 21 years of age. 2. Child received a diagnosis of ASD from a qualified practitioner using valid evaluation tools. 3. The child is able to benefit from the treatment. 4. Treatment outcomes are expected to result in a generalization of adaptive behaviors across

different settings to maintain the treatment interventions and that they can be demonstrated beyond the treatment sessions. Measurable variables may include increased social communication, increased interactive play/age-appropriate leisure skills, increased reciprocal communication, etc.

5. Coordination with the social and/or early intervention program is critical. Collaboration between school and community providers is needed to coordinate treatment and prevent service duplication. Collaboration may take the form of phone calls, written communication logs, participation in team meetings.

B. The child currently demonstrates substantial restricted, repetitive and stereotyped patterns of behavioral,

interests and activities as manifested by at least two of the following: 1. Stereotyped or repetitive motor movements, use of objects or speech (e.g. simple motor

stereotypes, lining up toys or flipping objects, echolalia, and /or idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or

nonverbal behavior (e.g. extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals and/or need to take same route or eat the same food daily).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g. strong attachment to or preoccupation with unusual objects and/or excessively circumscribed or perseverative interest).

4. Hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects and/or visual fascination with lights or movement).

DWMHA UM staff also tracks monthly the following data to ensure the ASD program operates within maximum capacity:

• Number of new referrals; • Total number of children enrolled in the program; • Total number of children actively receiving services; • Number of children discharged from the program and the reason(s) for discharge; • Number of service authorizations approved; • Number of services authorizations denied; • Number of services authorizations pending; • Number of adjudicated (processed) claims • Percentage of 0-5 years open cases; • Percentage of 6-20 years open cases

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Serious Emotional Disturbance (SED) Waiver: The Children's SED waiver provides services that are enhancements or additions to Medicaid State Plan coverage for children through age 20 who have an SED. MDHHS operates the SED waiver through contracts with the Community Mental Health Service Programs (CMHSP’s). The SED Waiver is a fee-for-service program administered by the CMHSP in partnership with other community agencies. SED waiver services are intended for children with a Serious Emotional Disturbance (SED) who are at risk of hospitalization, had multiple placements or are youth/families who are in need of additional supports/services in order to maintain the young person in the home. Eligibility: The child must:

• Be under the age of 18 when initially approved for the waiver, but can remain in the waiver until age 21;

• Reside with birth/adoptive parents as a Temporary Court Ward (TCW), reside in foster care as a TCW/Permanent Court Ward (MCI), or have completed the adoption process through the Child Welfare system;

• Meet current MDHHS criteria for the state psychiatric hospital for children; • Meet Medicaid eligibility criteria and become a Medicaid beneficiary; • Be age 18 or 19 and live independently with supports.

The child must have at least one of the following:

• Severe psychiatric signs and symptoms; • Disruptions of self-care and independent function; • Harm of self or others; • Drug/medication complications or co-existing general mental condition requiring care • Special consideration: If substance abuse, psychiatric condition must be primary; • Youth who have an Intellectual Developmental Disability (IDD) are not eligible for the SED waiver; or • The child must demonstrate serious functional limitations that impair his/her ability to function in the

community (functional criteria is identified using the Child and Adolescent Functional Assessment Scale [CAFAS] or Preschool and Early Childhood Functional Assessment Scale [PECFAS]): CAFAS score of 90 or greater for children age 7 to 12; or CAFAS score of 120 or greater for children age 13 to 18; or For children age 3 to 7, elevated PECFAS subscale scores in at least one of these areas: self-

harmful behaviors, emotions, thinking, communicating or behavior toward others; and Youth can remain in the waiver even if their CAFAS or PECFAS score drops the one (1) year

commitment.

Covered SED Waiver Services: Each child must have a comprehensive IPOS that specifies the services and supports the child and his/her family will receive. The IPOS is developed through the Wraparound planning process. Each child must have a Wraparound Facilitator who is responsible to assist the child/family in identifying, planning and organizing the Child and Family Team, developing the IPOS, and coordinating service delivery, as well as the child’s health and safety, as part of their regular contact with the child and family, with oversight from the Community Team. Wraparound Services: Wraparound services is a highly individualized planning process facilitated by specialized supports coordinators. Wraparound utilizes a Child and Family Team, with team members determined by the family often representing multiple agencies and informal supports. The Child and Family Team creates a highly individualized Wraparound plan with the child/youth and family that consists of mental health specialty treatment, services and supports covered by the Medicaid mental health state plan, waiver, B3 services, and other community services and supports.

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Community Living Supports: Community Living Supports are used to increase or maintain personal self-sufficiency, thus facilitating a beneficiary’s achievement of his/her goals of community inclusion and remaining in their home. The supports may be provided in the beneficiary’s home or in community settings (including, but not limited to, libraries, city pools, camps, etc.) Respite: Respite care is services provided to beneficiaries unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care. Family Supports and Training: This service is provided by a peer-parent who has completed specialized training. It is a family-focused service provided to families (birth or adoptive parents, siblings, relatives, foster family, and other unpaid caregivers) of children with SED for the purpose of assisting the family in relating to and caring for a child with SED. The services target the family members who are caring for and/or living with a child receiving waiver services. The service is to be used in cases where the child is hindered or at risk of being hindered in their ability to achieve goals of: performing activities of daily living; improving functioning across life domain areas; perceiving, controlling or communicating with the environment in which they live; or improving their inclusion and participation in the community or productive activity, or opportunities for independent living. Therapeutic Activities: A therapeutic activity is an alternative service used in lieu of, or in combination with, traditional professional services. The focus of therapeutic activities is to interact with the child to accomplish the goals identified in the IPOS. The IPOS ensures the child's health, safety and skill development and maintains the child in the community. Services must be directly related to an identified goal in the IPOS. Providers are identified through the wraparound planning process and participate in the development of an IPOS based on strengths, needs, and preferences of the child and family. Therapeutic activities may include the following: child and family training, coaching and supervision, monitoring of progress related to goals and objectives, and recommending changes to the IPOS. Services provided under Therapeutic Activities include music therapy, recreation therapy, and art therapy. Child Therapeutic Foster Care: Child Therapeutic Foster Care (CTFC) is an evidence-based practice. It provides an intensive therapeutic living environment for a child with challenging behaviors. Important components of CTFC include:

• Intensive parental supervision • Positive adult-youth relationships • Reduced contact with children with challenging behaviors • Family behavior treatment skills

Therapeutic Overnight Camp: A group recreational and skill building service in a camp setting aimed at meeting the goal(s) detailed in the beneficiary’s IPOS. A session can be one or more days and nights of camp. Room and Board costs are excluded from the SEDW payment for this service. Transitional Services: Transitional services is a one-time only expense to assist beneficiaries returning to their family home and community while the family is in the process of securing other benefits (e.g., SSI) or resources (e.g. governmental rental assistance and/or home ownership programs) that may be available to assume these obligations and provide needed assistance.

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Home Care Training, Non-Family: This service provides coaching, training, supervision and monitoring of Community Living Supports (CLS) staff by clinicians. Professional staff work with CLS staff to implement the consumer’s POS, with focus on services designed to improve the child’s/youth’s social interactions and self-control by instilling positive behaviors instead of behaviors that are socially disruptive, injurious to the consumer or others, or that cause property damage.

SEDW Service Providers:

Southwest Counseling Solutions 5617 Michigan Avenue

Detroit MI 48210 313-831-5535

The Children’s Center 79 Alexandrine Street

Detroit, MI. 48201 313-963-2266

The Guidance Center 13099 Allen Road

Southgate, MI. 48195 734-785-7718

The Children’s Home and Community Based Services Waiver Program (CWP) and Benefit: The Children's Waiver Program (CWP) is a federal entitlement program that provides Medicaid funded home and community-based services to children (under age 18) who have developmental disabilities. The CWP waiver provides services to children with complex medical and behavioral needs who meet eligibility for the level of services similar to an Intermediate Care Facility/Individual with Intellectual Disability (ICF/IID). The CWP enables children to remain in their parent's home or return to their parent's home from out-of-home placements regardless of their parent's income.

The child must meet all of the following:

• Be below age eighteen (18); • Meets financial eligibility for Medicaid as a “family of one”; • Reside with parent(s) or guardian (relative); • Receive at least one waiver service per month; • Be at risk of out of home placement; and • Have a Developmental Disability as defined in the mental health code AND meet the criteria for an

ICF/IID which implies the need for an active treatment program of specialized and generic training, treatment, health and related services directed toward the acquisition of behaviors necessary to function with as much self-determination and independence as possible.

CWP provides services that are enhancements or additions to regular Medicaid coverage to children up to age eighteen (18) enrolled in the program. It allows Medicaid to fund necessary home and community based services for children with developmental disabilities who reside with their birth or legally adoptive parent(s) or with a relative named legal guardian under State law, regardless of their parent's income. The CWP is a fee-for-service program administered by the CMHSP (DWMHA). DWMHA is held financially responsible for any costs incurred on behalf of the CWP beneficiary that were authorized and exceed the Medicaid fee screens or amount, duration and scope parameters. The program has a capacity to serve 464 children statewide. Although the program is at capacity, a weighing list is maintained using a priority rating system to add new children to the program when openings occur. DWMHA’s UM Department is responsible to:

• Monitor the CWP providers activities of the CWP in the identification of potential waiver candidates, the completion of the pre-screening process in the WSA, the submission to the pre-screening information to MDHHS;

• Authorize the WSA roles (pre-screener, Support Coordinator and Supervisor) for each CWP provider and assuring they are current Coordination of the Child’s Waiver Program;

• Provide technical assistance (TA) and disseminate CWP information to DWMHA staff, CWP service providers, families, and stakeholders;

• Manage the waiver enrollments, (by keeping track of pre-screenings, invitations to apply for the CWP, enrollments in the CWP, organize and chair the quarterly meetings;

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• Conduct the LOC evaluation activities ((site visits, validation of Performance Measures (PM) reported quarterly through the self-monitoring tool) ;

• Assure the participants have been given freedom of choice of providers; • Assure the participants have consented to CWP services in lieu of the ICF/IDD; • Assure the family have been offered and explained the Choice Voucher option; • Assure services are provide according to the Individual Plan of Service (IPOS) and within the Category

of Care/Intensity of Care determination; • Monitor the data in the WSA; • Enter the PDN authorization for Private Duty Nursing Services into CHAMPS system.

A CWP Support Coordinator’s activities include:

• Assisting the child and his family, friends, and other professional members work cooperatively to identify the child’s needs and to secure the necessary services;

• Assuring all services and supports must be included in the child’s IPOS; • Assuring the IPOS is reviewed, approved and signed by the physician; • Assuring each CWP beneficiary receives at least one children’s waiver service per month in order to

retain eligibility; • Demonstrating the CWP participants meet the continued eligibility requirement; • Submitting request to the MDHHS Clinical Review Team (CRT) for prior authorizations when required

for Services, equipment and Environmental Accessibility Adaptations (EAAs). (The CWP Clinical Review Team at MDHHS is comprised of a physician, registered nurse, psychologist, and licensed master’s social worker with consultation by a building specialist and an occupational therapist.)

The services covered under the CWP are: Community Living Supports (CLS)

• Enhanced Transportation • Respite Care • Family Training • Fencing • Non-family Training • Specialty Services • Home Care Training, Non-Family • Specialized Medical Equipment & Supplies • Environmental Accessibility Adaptations • Fiscal Intermediary

The children enrolled in the CWP also can receive other services provided under the State Plan such as PDN, ABA, etc.

Habilitation and Supports Waiver (HSW) Program and Benefit: The HSW is a Federal Program directed to provide services and supports for beneficiaries with Developmental Disabilities (Medicaid 1915 (c) HCBS Waiver) who meet the Intermediate Care Facility for Individuals with Intellectual Disability (ICF/IID) Level of Care (LOC). The services and supports are provided under the auspices of the PIHP (DWMHA) under contract with Michigan Department of Health and Human Services (MDHHS) and must be specified in the beneficiary plan of services developed through the Person Centered Planning (PCP) process. DWMHA delegates the provision of services to the MCPNs (CLS, CLN and ICA) and their providers.

Participants enrolled may not be enrolled simultaneously in another of Michigan’s 1915(c) waivers.

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The beneficiary must also meet all of the following requirements:

• Has a developmental disability (as defined by Michigan law) no age restrictions; • Is Medicaid eligible and enrolled; • Resides in a community setting or will reside in a community setting; • Would otherwise require level of services similar to an Intermediate Care Facility/Individual

w/Intellectual Disability (ICF/IID); • Chooses to participate in the HSW instead of ICF/IID services.

The services (and their codes) offered through HSW are:

• Community living supports (H2015, H2016, H0043, T2036, T2037) • Enhanced medical equipment (T1999, T2028, T2029, S5199, E1399, T2039) • Enhanced pharmacy (T1999) • Environmental modifications (S5165) • Family training (S5111) • Goods and Services (T5999) (Only for those participating in self-determination) • Out of home non-vocational habilitation (H2014) • Personal Emergency Response System (PERS) (S5160, S5161) • Prevocational services (T2015) • Private Duty Nursing (PDN) (S9123, S9124) for those 21 y old or older • Supported employment (H2023) • Respite Care (T1005, H0045) • Support Coordination (T1016)

Service selection guidelines for the beneficiaries should be used for the determination of the amount, duration, and scope of services and supports to be used. It is important to note that in order to retain eligibility, a HSW beneficiary must receive at least, one HSW service per month; DWMHA receives monthly reports from each provider to demonstrate this continued eligibility requirement.

The role of DWMHA’s UM Department is to perform the following tasks:

• Oversight, monitoring of the activities of MCPNs and their HSW providers. • Provision of technical assistance (TA); • Organize and Chair the quarterly meetings; • Perform monthly chart reviews and periodic provider site visits; • Disseminate HSW information; • Manage the waiver enrollments within the PIHP allocation; • Review of HSW applications; • Review the LOC evaluation for the authorization of HSW re-certifications; • Assure the participants have been given freedom of choice of providers, • Assure the participants have consented to HSW services in lieu if the ICF/IID, • Monitor utilization management of waiver services by monthly tracking the total number of

beneficiaries enrolled in the HSW program, the total number of available HSW slots, the number of HSW applications submitted to DWMHA by the MCPNs, the number of applications reviewed, the number of applications pended for more information, the number of pended applications re-submitted, the number of applications withdrawn by MCPNs, the total number of application sent to MDHHS, the number of deaths, the number of annual recertification forms reviewed and signed, the number of dis-enrollments (not meeting HSW criteria).

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ATTACHMENT #3

DWMHA PRIOR AUTHORIZED SERVICE UM CHART REVIEW TOOL Initial Review (PAR Screening) Enrollee/Member Name: Name of Organization: MHWIN ID No.: Medicaid Number: Level of Care: Admit Date: Complete name and credentials of COPE UM Staff who completed the initial review (PAR Screening): Documentation

Found Found but Not Accurate/Complete Not Found

1. Date and time of initial call to request the review 2. Date and time of initiation of review (PAR) 3. Complete name, credentials of caller completing the

review (PAR)

4. Complete name of facility/location for the caller completing the review (PAR)

5. Phone number of caller completing the review (PAR) 6. Level of Care being requested 7. Living Arrangement prior to admission 8. Education and/or Work status 9. Guardianship 10. Legal Problems 11. Vital Signs 12. Presenting Symptoms/Current Stressors 13. Risk Assessment (Suicide/Homicide/Other Dangerous

or Self Aggressive Behavior)

14. Identified Support Systems 15. Past Treatment History 16. Compliance with past outpatient treatment 17. Mental Status 18. Substance Use Assessment 19. UDS Screening Information 20. ETOH Screening Information 21. Physical/Medical Health History 22. Primary Care Physician information 23. Current Medications (medication name, dose,

frequency, complete name of prescriber)

24. Compliance with Medications 25. Presence of a Crisis Plan and/or Behavioral Plan

N/A

26. Diagnosis 27. Treatment Plan/Identified Goals 28. Discharge Plan 29. Estimated Length of Stay (ELOS) 30. SI/IS criteria identified and documented (medical

necessity criteria met for level of service)

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31. Complete Clinical Summary (in clinical note section of criteria authorization screen)

32. Consult with an Organization Supervisor and/or Physician N/A

33. Number of Days/Units Authorized N/A 34. Diversion Information N/A 35. Date and Time of PAR Disposition 36. Complete name and credentials of Organization Staff

UM Reviewer and Date (can be electronic Signature)

37. Complete Name of hospital/facility to which admission/authorization was given (in PAR Disposition)

38. Complete name and credentials of the admitting physician (in PAR Disposition)

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DWMHA PRIOR AUTHORIZED SERVICE UM CHART REVIEW TOOL First Continued Stay Review Enrollee/Member Name: Name of Organization: MHWIN ID No.: Medicaid Number: Level of Care: Name of UM Staff Reviewer: Admit Date: Discharge Date:

Documentation Found Found but Not

Accurate/Complete Not

Found 1. Date and time of concurrent review was initiated 2. Name and credentials of caller completing the review 3. Telephone number of caller completing the review 4. Current status of symptoms 5. Treatment progress to date 6. Baseline functioning 7. Any changes to previous treatment plan/goals 8. Goal statement 9. Current medications, doses and frequency 10. Any side effects from medications N/A

11. Any consultations and/or assessment results

12. Presenting symptoms/current stressors

13. Status of communication/Interactions with family, guardian, legal representative, CMH service provider or other identified support systems

14. Presence of a Crisis Plan and/or Behavioral Plan N/A

15. SI/IS Criteria Identified 16. After Care/Discharge Plan (indicate level of care,

provider name and date and time of initial appointment with provider)

17. Placement Issues/Status of Placement (if no placement issues, indicate where and with whom member will live after discharge)

18. Estimated Length of Stay (ELOS)

19. Consult with Organization Supervisor and/or Physician N/A

20. Number of days/units authorized 21. Date and time of disposition 22. Complete name and credentials of Organization Staff

UM Reviewer and Date (can be electronic Signature)

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DWMHA PRIOR AUTHORIZED SERVICE UM CHART REVIEW TOOL Second Continued Stay Review Enrollee/Member Name: Name of Organization: MHWIN ID No.: Medicaid Number: Level of Care: Name of UM Staff Reviewer: Admit Date: Discharge Date:




11. Any consultations and/or assessment results

12. Presenting symptoms/current stressors

13. Status of communication/Interactions with family, guardian, legal representative, CMH service provider or other identified support systems


15. SI/IS Criteria Identified 16. After Care/Discharge Plan (indicate level of care, provider

name and date and time of initial appointment with provider)




20. Number of days/units authorized 21. Date and time of disposition 22. Complete name and credentials of Organization Staff UM

Reviewer and Date (can be electronic Signature)

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_____________________________________ _______________________ Signature, title and credential of Staff Auditor Date of the case audit (person who completed the case audit)

DWMHA PRIOR AUTHORIZED SERVICE UM CHART REVIEW TOOL Third Continued Stay Review Enrollee/Member Name: Name of Organization: MHWIN ID No.: Medicaid Number: Level of Care: Name of UM Staff Reviewer: Admit Date: Discharge Date:




11. Any consultations and/or assessment results 12. Presenting symptoms/current stressors 13. Status of communication/Interactions with family,

guardian, legal representative, CMH service provider or other identified support systems


15. SI/IS Criteria Identified 16. After Care/Discharge Plan (indicate level of care, provider

name and date and time of initial appointment with provider)




20. Number of days/units authorized 21. Date and time of disposition 22. Complete name and credentials of Organization Staff UM

Reviewer and Date (can be electronic Signature)

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For any areas where the documentation was not found or was not complete or not accurate please indicate the nature of the deficiency and any corrective action given to the Organization Staff: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INSTRUCTIONS FOR COMPLETION OF PRIOR AUTHORIZED SERVICE UM CHART REVIEW TOOL The purpose of these reviews are to ensure correct documentation, appropriate level of care decisions and to meet External Quality Review requirements relative to Utilization Management.

On a quarterly basis, the Crisis Service Vendor and the MCPNs shall review the following:

• All (100%) denial and appeal cases based on all staff making Utilization Management decisions.

• The Crisis Service Vendor and Carelink -ten (10) approved cases (PAR Screenings) for all staff making Utilization Management decisions.

• Consumer Link, Community Living Services and Integrated Care Alliance- five (5) approved request for service cases on all staff making Utilization Management decisions.

Reviews should be completed on all levels of care requiring prior authorization, including Acute Inpatient,

Partial Hospitalization, State Hospitalization, Crisis Stabilization, Intensive Crisis Residential and/or Child Caring Institutions.

The Crisis Service Vendor and the MCPNs must forward all the completed Prior Authorized Service UM

Chart Review sheets to DWMHA’s UM Department via fax or email each quarter.

An Analysis of all Prior Authorized Service UM Chart Reviews for the fiscal year shall be included in the Crisis Service Vendor’s and the MCPNs’ Annual UM Evaluation.

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ATTACHMENT #4

DWMHA ELIBILITY OF SERVICE REVIEW TOOL Enrollee/Member Name: Date of Birth: Medicaid ID No.: Date of Screening for Eligibility Name of Access Center Clinician Documentation

Found Documentation

Not Found Not

Applicable 1. Insurance Information 2. Wayne County Residency 3. Start time of screening 4. Name, address and phone number of caller 5. Documentation of call being an Emergency or Crisis 6. Reason for call/presenting problem identified 7. Type of Services Request 8. Contact Information 9. Guardianship 10. Past Treatment History 11. History of Abuse (Sexual/Physical/Emotional) 12. Current living situation 13. Financial Information including Income 14. Education Information 15. Current Health/Medical Problems 16. Referral to ER for Treatment/Clearance 17. Time ER Contacted and Consumer Referred 18. Medications (name, dose, prescribing 19. physician)

20. Primary care physician information 21. Mental Health Symptoms Identified 22. Substance Use Issues 23. Risk (Suicidal/Homicidal) assessment 24. Autism Screening Tool Completed 25. IDD Screening Tool Completed 26. Provisional Disability Designation 27. Diagnoses 28. Medical and/or Advance Directives 29. Diagnoses 30. Medical and/or Psychiatric Advance Directives 31. Eligibility Criteria Met 32. Eligibility Criteria Not Met 33. If Eligibility Criteria not met, member was given

community resource referrals.

34. If Eligibility Criteria Not Met, Access Center Physician reviewed case and provided documentation.

35. Adequate or Advance Notice Sent to the member (using DWMHA standard form)

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_____________________________________ _______________________ Signature, title and credential of Staff Auditor Date of the case audit (person who completed the case audit)

For any areas where the documentation was not found or was not complete or not accurate please indicate the nature of the deficiency and any corrective action given to the Access Center Staff: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INSTRUCTIONS FOR COMPLETION OF THE ELIGBILITY OF SERVICE REVIEW TOOL The purpose of these reviews are to ensure correct documentation, appropriate level of Care decisions and to meet External Quality Review requirements relative to Utilization Management.

On a quarterly basis, the Access Center shall review the following:

• Ten (10) denial cases based on all staff making Utilization Management decisions. • Ten (10) approved cases for all staff making Utilization Management decisions.

Reviews should be completed on all levels of care requiring prior authorization, including Acute Inpatient,

Partial Hospitalization, State Hospitalization, Crisis Stabilization, Intensive Crisis Residential and/or Child Caring Institutions.

The Access Center must forward all the completed Eligibility of Service Review sheets to DWMHA’s UM Department via fax or email each quarter.

An Analysis of all Eligibility of Service UM Reviews for the fiscal year shall be included in the Access Center’s Annual UM Evaluation.

36. Notice of Denial of Medical Coverage form sent to the member for MI Health Link (using DWMHA standard form)

37. Notice of Denial form sent to uninsured member (using DWMHA standard form)

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ATTACHMENT #5

DWMHA Quality Department’s Case Record Review Tool The Record Review tool is constructed to examine key supports, services, treatment and care. These areas should match the level of care established, should reflect natural and community supports and should clearly indicate progress or barriers to achieving the consumer’s goals. Using the tool provides a standardized mechanism for specialists to determine if the consumer is getting the right service, the right amount of service, at the right time. Quality Management has implemented the tool which reviews the following areas as applicable to each consumer:

• General Record Documentation • Assessment • Substance Abuse Access and Treatment • Person Center Planning Process • Plan of Service Documentation Requirements • Self-Determination • Behavior Treatment Plan Review • Coordination of Care

Medication/Psychiatric Crisis residential

• Peer Delivered and Operated Drop In Centers • Home Based • Assertive Community Treatment • Psychosocial Rehabilitation/Clubhouse • Crisis Residential • Targeted Case Management • Personal Care in Residential Settings • Inpatient Psychiatric Hospital Admission • Intensive Crisis Stabilization • Additional Mental Health Services • HAB Supports Waiver

An aggregate review score is calculated for reach case record review. Service Providers are expected to conduct a statistically sound sample of case records quarterly to monitor the direct provision of services using the tool. This process shall be monitored by the MCPNs who will, in turn, review a statistically sound sample of Service Providers’ case records and report the results to DWMHA every quarter and in the MCPN’s annual plan evaluations. A plan of correction shall be implemented for all staff scoring below 95%. DWMHA then analyzes the MCPNs’ findings for trends and outliers which may also result in a plan of correction.

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Provider: ______________________ MH-WIN ID# / Initials: _________________________

Date: ________________ Audit ID #_________________ Reviewer: _____________________

DWMHA Case Record Review Tool

General Documentation Note questions with asterisks (*) must have a response.

1. The Ability to Pay/Fee Agreement (including insurance information) is current, signed and dated.

Not Met/Partial/Met N/A

2. * The annual consent for treatment is current, signed and dated.


3. * The individual's signature indicates the Consumer Handbook was offered annually.


4. * If the consumer has a legal guardian, there are current court papers in the file.


5. Advanced Directive and Self-Determination were offered and explained. (Adults only)


6. There is evidence that the consumer and family were informed of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) process for recipients under 21.


7. * Recipient Rights, Person-Centered Planning and Confidentiality Notification forms are signed by the consumer, parent of minor children, or guardian/legal representative when services were initiated and annually.


Assessments

1. * Level of care is based on comprehensive assessment.


2. If the consumer is a child or adolescent, the appropriate assessment scale (DECA-I, DECA-T, DECA-C, PECFAS or CAFAS) is present as required.


3. Natural Supports are assessed.


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4. Health and safety needs, risk/at-risk behaviors are assessed.


5. Substance use, risk, and patterns are assessed.


7. There is evidence of a Diagnostic Formulation/Summary which supports the diagnosis given.


Implementation of Person-Centered Planning

1. * Services and supports identified in the individual plan of service assist the individual in pursuing outcomes consistent with their preferences and goals.


2. Family-driven and youth-guided supports and services are provided for minor children.


3. * Individuals are provided with on-going opportunities to provide feedback on how they feel about services, supports and/or treatment they are receiving, and their progress towards attaining valued outcomes.


4. The person-centered planning process is used to modify the individual plan of service in response to changes in the individual’s preferences or needs.


5. * The person-centered planning process builds upon the individual's capacity to engage in activities that promote community life.


6. * Person-centered planning addressed and incorporated natural supports.


7. * Person-centered planning addresses and incorporates health and safety.


8. Pre-planning meetings occur before a person-centered planning meeting, according to the individual’s desires and needs.


9. Individuals are provided an opportunity to develop a Crisis Plan.


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10. The individual is offered the option of Independent Facilitation.


Plan of Service and Documentation Requirements

1. * The individual plan of service identifies the roles and responsibilities of the individual, the Supports Coordinator or Case Manager, the allies, and providers in implementing the plan.


2. * Specific services, supports and treatment provided were identified in the plan of service, including the amount, scope, and duration of services.


3. * The plan of service identifies available Conflict Resolution processes.


4. Individuals are provided a copy of their individual plan of service within fifteen business days after the planning meeting.


5. Individuals are provided timely ADEQUATE Notice of Action.


6. Individuals are provided timely ADVANCE Notice of Action.


Behavior Treatment Plan

1. If the individual has a behavior treatment plan, it is developed through a person-centered planning process.


2. There is evidence of written "special consent" before the behavior treatment plan is implemented.


3. There is evidence in the clinical record to verify that all staff has been duly trained on each behavioral intervention identified in the plan.


4. There is evidence that the Behavior Treatment Plan has been followed and outcomes are documented.


Coordination of Care

1. There is evidence of the Behavioral Health provider coordinating treatment with the Primary Care Physician.

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2. There is evidence that the Behavioral Health provider received information from the Primary Care Physician. Enter "YES" or "NO" in the text box.

Text Field N/A

3. There is evidence of the Behavioral Health provider coordinating services with natural and other community supports.


4. There is evidence that the Behavioral Health provider received requested information and or communication from the consumer's natural / community supports. Enter "YES" or "NO" in the text field.

Text Field N/A

5. There is evidence of the Behavioral Health provider coordinating treatment with the Substance Use Disorder provider.


6. There is evidence that the Behavioral Health provider received information from the SUD Provider. Enter "YES" or "NO" in the text box.

Text Field N/A

7. If the individual has not visited a Primary Care Physician for more than 12 months, there is evidence of a basic health care screening, including height, weight, BMI and blood pressure.


8. There is evidence that the psychiatrist or Primary Care provider ordered a diabetic screening that includes an HbA1C or fasting blood sugar (FBS), BMI, blood pressure, and LDL cholesterol for consumers prescribed an atypical antipsychotic medication. Indicate "Met", "Not Met" or "Partial" in the text box, if applicable (see reference below).

Text Field N/A

Targeted Case Management

1. The Case Manager/Supports Coordinator completed an initial written comprehensive assessment, updates it as needed, and no less than annually. The assessment addresses the needs/wants and identifies barriers as well as supports to overcome the barriers.

Not Met/Partial/Met N/

2. The case record contains sufficient information to document the provision of case management services. The record contains the nature of the service, the date and location of the contacts between the Case Manager/Supports Coordinator and the beneficiary, and whether the contacts were face-to-face.


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3. The Case Manager/Supports Coordinator determines if the services and supports have been delivered and if they are adequate to meet the needs/wants of the beneficiary.


4. There is documentation that the Case Manager/Supports Coordinator "regularly" reviews the consumer's health status noting any issues, visits to the emergency room and hospitalizations and the Case Manager/Supports Coordinator ensures that the Critical and Sentinel Events have been reported per the Provider's Incidence Reporting Procedure and the Authority's policy.


Personal Care in Licensed Residential Settings

1. The assessment of the individual's need for personal care services uses a format that captures the required elements.


2. Personal care services are authorized by a physician or other health-care professional.


Additional Mental Health Services (b)(3)'s

1. If the consumer receives Environmental Modifications or equipment, there is evidence of prior authorization in accordance with the provider's process. This includes the physician's prescription for modifications or assistive technology purchased within the year.


2. Progress notes demonstrate appropriate implementation of the plan for Community Living Supports: Used to increase/maintain personal self-sufficiency, facilitating an individual’s achievement of his/her goals of community inclusion & participation, independence or productivity.


3. Enhanced Pharmacy: There is documentation of physician ordered, non-prescription "medicine chest" items as specified in the IPOS.


4. IPOS identifies Family Support and Training necessary to assist the individual in achieving goals. Family Support & Training is Family-focused training services provided to families of persons with SMI, SED or DD for the purpose of assisting the family in relating to & caring for and/or living with disabilities.


5. Housing Assistance: There is documentation of assistance with short-term interim, or one-time-only expenses for beneficiaries transitioning from restrictive settings into more independent, integrated living arrangements while in the process of securing other benefits (e.g., SSI).


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6. There is documentation in the clinical record that Peer-Support services/programs provides the individual with opportunities to learn and share coping skills and strategies, move into more active assistance and away from passive patient roles and identities and to build and/or enhance self-esteem and self-confidence. These may be Peer Delivered or Operated Services.


7. Peer Specialist Services: There is documentation in the clinical record indicating that the individual received support, mentoring and assistance in achieving community inclusion, participation, independence, recovery, resiliency, and/or productivity.


8. * Skill Building Assistance: There is evidence in the clinical record of activities assisting the beneficiary with increasing his/her economic self-sufficiency and/or to engage in meaningful activities such as school, work and/or volunteering.


9. * Supported Integrated Employment: There is documentation in the clinical record that job development along with initial and on-going support services was provided to assist beneficiaries to obtain & maintain paid employment that would otherwise be unachievable without such supports.


Implementation of Arrangements that Support Self-Determination

1. The individual budget and the arrangements that support self-determination are included as part of the person-centered planning process.


2. The individual participating in arrangements that support self-determination has a Self-Determination Agreement that complies with the requirements.


3. Individuals participating in self-determination shall have assistance to select, employ, and direct his/her support personnel, and to select and retain the chosen qualified provider entities.


4. There is evidence that within prudent purchaser constraints, an individual is able to access any willing and qualified provider.


5. Fiscal Intermediary Services: There is documented evidence that assistance for the adult beneficiary, or a representative identified in the beneficiary’s individual plan of service, is provided to meet the beneficiary’s goals of community participation and integration, independence or productivity.


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Medication/Psychiatric

1. All medications, (such as OTC and those prescribed by external physicians), are documented and updated as necessary.


2. Medication Consents for all program-prescribed medications are current, include dosage (if outside therapeutic range), documentation of the right to withdraw consent verbally, are signed by consumer/guardian and prescribing physician.


3. Evidence of drug-specific patient education is provided to individuals prior to administering each new drug.


4. The Physician/Medical Professional's handwriting is legible.


5. Laboratory results (ordered by Program physician) are reviewed, signed off by a physician and available in the chart.


6. Quarterly Tardive Dyskinesia testing dates and results are documented by program physician.


7. A copy of RX or Medical Orders are in the file (if prescribed by program physician).


Community Integration

1. There is evidence that the consumer’s choice for gainful employment, to volunteer, pursue education/training opportunities or unpaid internships has been discussed and encouraged during the pre-planning meeting.


2. There is evidence the consumer is being supported to pursue his/her unique path to competitively paid work options or career goals.


3. There is evidence that the employed consumer is earning at least minimum wage.


4. There is evidence the consumer who resides in General Specialized or Specialized Adult Foster Care Homes, Nursing Homes, State Hospital, Nursing Homes or other restrictive residential setting were informed of the full array of housing options, including Permanent Supported Housing (PSH).


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5. There is evidence that the consumer was offered a choice of living options based on their individual needs and desires.


6. There is evidence that the Access to Community Living Guidelines form is in the person’s case record.


Autism Program Requirements

1. There is evidence the individual, parent or guardian was informed of their right to choose among various Autism Spectrum Disorder Providers.


2. The comprehensive diagnostic evaluation and psychological assessment were uploaded within 14 calendar days of the assessment appointment.


3. There is evidence that the ABA Assessment (ABLS, VB-MAPP, AFLS) was uploaded to MHWIN within seven (7) calendar days of the assessment appointment.


4. There is evidence that as part of the IPOS, there is a comprehensive individualized ABA behavioral plan of care that includes specific targeted behaviors for improvement, along with measurable, achievable, and realistic goals.


5. There is evidence risk factors have been identified for the child/family, a description of how the risks may be minimized and the backup plan for each identified risk.


6. There is evidence the Beneficiary's ongoing determination level of service (which occurs every six months) has evidence of measurable and ongoing improvement in targeted behaviors as demonstrated with the ABLLS-R or VB- MAPP.


7. There is evidence that the IPOS Service Reviews are completed on a quarterly basis (every 90 days) while the individual was enrolled in the ASD Benefit.


8. There is evidence that the Individual Plan of Service had been updated within 365 days of the last plan of service.


9. There is evidence that the ABA Provider and Supports Coordinator communicate on a monthly basis.


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10. When more than three appointments in one month were missed, there is documentation of multiple attempts (weekly) to keep families engaged.


11. The average hours of ABA services during a quarter were within the suggested range for the intensity of services (+/- 25%).


12. The number of ABA hours of direction/observation during a quarter were equal to or greater than 10% of the total ABA Direct service provided.


MI Health Link Required Documentation

1. The DCH-3927 "Consent to Share Your Health Information" form is complete. The DCH- 3927 contains the appropriate client and/or guardian signature(s) and is uploaded to the MHWIN Consumer’s Chart “All Scanned and Uploaded Documentation” section.


2. There is evidence that a current Bio-Psycho-Social Assessment (obtained at Clinically Responsible Service Provider) was submitted into the Care Bridge within 14 days of receipt of the referral. The Assessment must address medical necessity for the treatment planned.


3. There is evidence that the appropriate assessments (LOCUS, SIS, or ASAM) were completed and submitted to the Care Bridge within 14 days of receipt of the referral.


4. If the 14-day requirement for the Level II Assessment was not met, there is documentation in the case record regarding the barrier(s) to timely completion and submission.


5. There is evidence of communication and collaboration with the Integrated Care Team (ICT), including contact with the Health Plan Care Coordinator.


Habilitation Supports Waiver Requirements

1. There is evidence of Eligibility: The Habilitation Supports Waiver Eligibility Certification is current, completed and signed by CMHSP Provider and by Clinical Review Team (CRT) Chairperson. If appropriate, the annual HSW Recertification Worksheet is current, completed and signed by CMHSP Provider and by PHIP Designee.


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2. There is evidence that the annual Waiver Services Consent under the Habilitation Supports Waiver Eligibility Certification Section 3 is current.


3. If the enrollee receives Environmental Modifications or Equipment, the CMHSP has implemented prior authorizations in accordance with their process with physician's prescription within the last year.


4. There is documentation that the selected Environmental Modifications or Equipment is the most cost-effective and fully functional option that meets the consumer’s needs which comply with the CMHSP’s process/policy.


5. There is documentation that the individual and/or guardian were informed of their right to choose among various providers and that the Consumer Handbook/Consumer Directory of Services was reviewed with the consumer and/or guardian. This evidence of choice of providers may appear in the Initial Pre Plan or IPOS.


6. The clinical record reflects that the individual and/or guardian was informed of their right to choose among various Waiver Services. Evidence may be found in the Pre Plan and/or IPOS.


7. The IPOS for individuals enrolled in the HSW is updated within 365 days of their last IPOS.


8. There is evidence that the member received at least one active habilitative treatment service as identified in the Individual Plan of Service (i.e., CLS, Out-of-Home Non-vocational habilitation and Prevocational or supported Employment).


9. For individuals receiving Private Duty Nursing (PDN), there is evidence of a minimum of one HSW service per month (i.e., CLS, Out-of-Home Non-vocational habilitation and Prevocational or supported Employment).


10. There is documentation of an annual physical examination.


Children’s Home And Community-Based Services Waiver (CWP)

1. There is evidence that the initial Children's Waiver Certification is current, completed and signed by CMHSP Provider and by Clinical Review Team (CRT) Chairperson.


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2. There is evidence that the annual Children's Waiver Re-certification is current, completed and signed by CMHSP Provider.


3. There is evidence that the Assigned Category of Care/Intensity of Care is circled and appropriate to child’s condition, as evidenced by both 1.) The Category of Care/Intensity of Care designated on the Waiver Certification and 2.) The corresponding narrative.


4. There is evidence that the child resides with his/her birth or legally adoptive parent(s) or with a relative who has been named the legal guardian of that child under the laws of the State of Michigan (provided that the relative is not paid to provide foster care for that child).


5. There is evidence that an annual medical examination was completed, as evidenced by the completion of the DHS 49-A Medical Examination Report form, and information was entered into the WSA for MDHHS review and approval.


6. There is evidence that at least one habilitative CWP service is provided to this Waiver consumer per month.


7. There is evidence that active habilitative treatment services as identified in the Individual Plan of Service were provided to consumer and their family.


8. Parent, legally adoptive parent or legal guardian (not paid to provide foster care) has signed a Freedom of Choice Statement (Section 3) on the initial and annual Waiver Certification forms, indicating knowledge and acceptance of waiver services instead of ICF/IDD, and freedom to choose any qualified provider.


9. There is evidence that the assessments support that the child is in need of active treatment to improve skills to retain the child in the home or community setting.


10. There is documentation that the service providers are employees of CMHSP, on contract with CMHSP or hired through Choice Voucher System or Medicaid-enrolled Private Duty Nursing (PDN) Providers.


11. There is evidence in the case record of an initial and annual CWP Budget.


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12. If the child receives Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), there is documentation for the review and approval of locally authorized services and equipment.


13. Physician prescriptions for OT and PT services, stating the diagnosis, date of prescription, specific service or item being provided, expected start date of the order, and the amount and length of time that the service is needed are in child’s file.


14. There is evidence that the individual budget and arrangements that support the Choice Voucher System are included as part of the person-centered-planning process.


Implementation of Arrangements that Support the Choice Voucher System for Children

1. There is evidence that information about accessing the Choice Voucher System for Children was provided and explained to parent, adoptive parent or legal guardian.


2. If the family is participating in arrangements that support the Choice Voucher System, there is a Choice Voucher Agreement that complies with the requirements.


3. There is evidence that if the family is participating in arrangements that support the Choice Voucher System, there is assistance to select, employ, and direct their support personnel, as well as, to select and retain chosen qualified provider entities.


4. If there is a Choice Voucher Agreement present, the voluntary and involuntary termination clauses meet the requirements of the Choice Voucher System Policy and Practice Guideline.


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ATTACHMENT #6

Template (Name of Crisis Service Vendor or MCPN)

Utilization Management Annual Plan Evaluation

(FY Effective Date to FY End Date)

Name, Title of Person Submitting Report:

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ANNUAL UTILIZATION MANAGEMENT (UM) PLAN EVALUATION The Crisis Service Vendor’s and the MCPNs' Utilization Management Plan shall be evaluated annually to determine its effectiveness in facilitating access, managing care, improving outcomes, and providing useful data for resource allocation, quality improvement and other management decisions. Instructions: Please provide the requested qualitative and quantitative information as indicated in each section. Additionally a description and narrative analysis of impact, trends or change from previous fiscal year is also required as appropriate. Portions of the information from the Crisis Service Vendor, the MCPNs and the Access Center’s Evaluation will be included in DWMHA’s Annual UM Program Evaluation. ORGANIZATION’S UTILIZATION MANAGEMENT COMMITTEE (CRISIS SERVICE VENDOR and MCPNs): Describe your UM Committee’s functions, consumer involvement, role of your Chief Medical Director, frequency of meetings, storage of meeting notes, goals for (insert current FY) and goal status, significant activities/achievements and outstanding issues that have not been addressed or completed.

PRIOR AUTHORIZATION REVIEW CRISIS SERVICE VENDOR or MCPN (PAR) STAFF (CRISIS SERVICE VENDOR and MCPNs): Provide a list of all staff who conducted Prior Authorization Reviews for initial or continued stay authorizations during the (insert FY), using the following headings: Provider Name Employee Last Name Employee First Name Date of Hire Degree Title License Type License Number License Expiration Date Comments (i.e., If person has a limited license, indicate name and credentials of

supervisor such as LMSW)

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LEVELS OF CARE (LOC) UTILIZATION PATTERNS: (MCPNs Only)

Place a check mark in the box next to each care level provided during the FY. Given the populations served, provide an analysis of LOC utilization patterns from the previous FY (i.e., increased/decreased/unchanged utilization rates; over-utilization, under-utilization, etc. What are the contributing factors to any remarkable findings (i.e., process issues, communication factors, integration of care factors, coordination of care factors, external factors, etc.)? Are the findings promising and encouraging or are they below expectations? What has been done or is being planned to support and sustain favorable findings or improve lower than expected findings?

(Previous FY) (Current FY) □ Inpatient Community Psychiatric Hospitalization DD Population (MCPN Only) Unduplicated count of consumers hospitalized Total number of admissions Average length of stay □ Inpatient Community Psychiatric Hospitalization SED Population (MCPN Only) Unduplicated count of consumers hospitalized Total number of admissions Average length of stay □ Inpatient Community Psychiatric Hospitalization SMI Population (MCPN Only) Unduplicated count of consumers hospitalized Total number of admissions Average length of stay (Previous FY) (Current FY) □ Inpatient State Hospitalization (MCPN Only) Unduplicated count of consumers hospitalized Total number of admissions Average length of stay □ Intensive Crisis Residential (MCPN Only) Unduplicated count of consumers served Total number of days Average length of stay □ Crisis Stabilization (CRISIS SERVICE VENDOR) Unduplicated count of consumers served Total number of units in hours □ Partial Hospitalization (MCPN Only) Unduplicated count of consumers served Average length of stay □ Specialized Residential (MCPN Only) Unduplicated count of consumers served Average length of stay

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(INSET CURRENT FY) AMBULATORY FOLLOW UP CARE AFTER DISCHARGE (MCPNs Only):

(INSERT CURRENT FY) TURNAROUND TIME FOR ROUTINE, EMERGENT AND URGENT AUTHORIZATION REQUESTS PIHP DATA (MCPNs Only):

Please provide the annualized data for your MCPN’s performance for Indicator #1a for children Table #1:

The percentages of persons during the quarter receiving a pre-admission screening for psychiatric inpatient care for whom the disposition was completed within three hours. Standard=95% Indicator #1b for adults Table #1

The percentages of persons during the quarter receiving a pre-admission screening for psychiatric inpatient care for whom the disposition was completed within three hours. Standard=95%Provide an analysis of the annualized 1st – 4th (insert current FY) quarter performance.

Although these performance indicators are included in the QAPIP Annual Report, please provide the annualized data for your MCPN performance for Indicator #4a: Table #4a for children The percentage of discharges from a psychiatric inpatient unit during the quarter that were seen for follow-up care within 7 days. Standard=95% Table #4a (2) for adults The percentage of discharges from a psychiatric inpatient unit during the quarter that were seen for follow-up care within 7 days. Standard=95% Provide an analysis of the annualized 1st – 4th (insert FY) quarter performance.

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(INSERT CURRENT FY) TURNAROUND TIME FOR EMERGENT AND URGENT AUTHORIZATION REQUESTS PIHP DATA (CRISIS SERVICE VENDOR ONLY): Please provide the annualized data for the Crisis Service Vendor’s performance for Indicator #1a for children Table #1:

The percentages of persons during the quarter receiving a pre-admission screening for psychiatric inpatient care for whom the disposition was completed within three hours. Standard=95% Indicator #1b for adults Table #1

The percentages of persons during the quarter receiving a pre-admission screening for psychiatric inpatient care for whom the disposition was completed within three hours. Standard=95%Provide an analysis of the annualized 1st – 4th (insert current FY) quarter performance.

(INSERT CURRENT FY)-PIHP READMISSION DATA - INPATIENT HOSPITALIZATION (MCPNs Only):

Please provide the annualized data for your MCPN’s performance for Indicator #10; Table #6

Indicator 10a: The percentage of readmissions of children during the quarter to an inpatient psychiatric unit within 30 days of discharge. Standard=15% or less Indicator 10b: The percentage of readmissions of adults during the quarter to an inpatient psychiatric unit within 30 days of discharge. Standard=15% or less Provide an analysis of the annualized 1st – 4th (insert current FY) quarter performance

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DIVERSIONS (CRISIS SERVICE VENDOR ONLY):

ANALYSIS OF PRIOR AUTHORIZED SERVICE REVIEWS (INSERT CURRENT FY) (CRISIS SERVICE VENDOR and MCPNs): Include data and analysis of your case reviews using the DWMHA Prior Authorized Service UM Chart Review tool. Detail any documentation issues and plans of correction (if applicable).

Document the number of diversions per quarter by population (SMI, IDD, MI Health Link and SUD). Document the diversions per quarter by the type of recommended diversion (level of care) for each population (SMI, IDD, MI Health Link and SUD). Detail any trends. Document the number of inpatient admissions due to the lack of crisis residential service beds. Document the number of individuals waiting more than 23 hours from the time of request to the time of placement by population.

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(INSERT CURRENT FY) STANDARDIZED ASSESSMENT TOOLS (MCPNs Only): Place a check mark in the box next to each of the standardized assessments provided during (insert FY). Indicate the number of the assessments completed for each tool checked. Provide any information about the provider and consumer experience with the use of these tools. Tool Total number of completed assessments

□ LOCUS

□ CAFAS

□ SIS

□ ASAM

□ Other-

CONSUMER SATISFACTION SURVEY RESULTS (CRISIS SERVICE VENDOR and MCPNs): Summarize type of any consumer experience studies done during (insert FY), targeted population(s), tool(s) used, survey methodology, survey time period(s), response rate, findings, any actions taken/to be taken as result of findings, recommendations, etc.

PROVIDER SATISFACTION SURVEY RESULTS (CRISIS SERVICE VENDOR and MCPNs): Summarize type of any provider experience studies done during (insert FY), targeted population(s), tool(s) used, survey methodology, survey time period(s), response rates, findings, any actions taken/to be taken as a result of the findings, recommendations, etc.

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ANALYSIS OF THE CRISIS SERVICE VENDOR OR THE MCPN’S PRIOR AUTHORIZED SERVICE REVIEWS FOR (INSERT FY) (Inclusive of Patient Denials & Appeals): Complete a review of the PAR logs submitted to DWMHA. Include data and analysis of reviews to ensure appropriate documentation, appropriate level of care decisions. Include number of consumer records reviewed utilizing the Prior Authorized Service Review tool. For Medicaid covered services include the number of approvals, number of denials, number of action notices sent, number of provider reconsideration/1st level appeal requests, number of upheld 1st level appeals, number of overturned 1st level appeals, number of provider 2nd level appeal requests, number of upheld 2nd level appeals, number of overturned 2nd level appeals. Discuss any trends. For General Fund covered services include the number of approvals, number of denials, number of action notices sent, number of provider reconsideration/1st level appeal requests, number of upheld 1st level appeals, number of overturned 1st level appeals, number of provider 2nd level appeal requests, number of upheld 2nd level appeals, number of overturned 2nd level appeals. Discuss any trends.

PERFORMANCE IMPROVEMENT INITIATIVES AND ACHIEVEMENTS (CRISIS SERVICE VENDOR and MCPNs): Include any highlights from your utilization management activities or work plans during (insert FY) not reported elsewhere in this evaluation.

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REPORTING (CRISIS SERVICE VENDOR and MCPNs): Which stakeholders have had an opportunity to review findings, provide comments on or provide input regarding each of these UM elements during the fiscal year? If available include numbers.

ADDITIONAL UTILIZATION MANAGEMENT INFORMATION OR DATA NOT COVERED IN THE TOPICS ABOVE (CRISIS SERVICE VEDNOR and MCPNs):

Element Consumers Board of Directors

UM Committee

Providers UM Staff (MCPN or Provider)

Crisis Service Vendor or MCPN UM Committee

Utilization of different Levels of Care(Inpatient, PHP, ICR, )

Utilization of Best, and Promising EBPs

PAR Case Reviews Inpatient Clinical Record Reviews

Use of Standardized Assessment Tools

Adverse Consumer Occurrences

Consumer Satisfaction

Provider Satisfaction Findings

Coordination/Integration of Care Initiatives

Who will receive the UM (Insert FY) report?

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ATTACHMENT #7

Template Access Center Utilization Management

Annual Plan Evaluation

(FY Effective Date to FY End Date) Name, Title of Person Submitting Report:

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ANNUAL UTILIZATION MANAGEMENT PLAN EVALUATION

The Access Center’s Utilization Management Plan shall be evaluated annually to determine its effectiveness in facilitating access to services and in determining eligibility of services. Instructions: Please provide the requested qualitative and quantitative information as indicated in each section. Additionally a description and narrative analysis of impact, trends or change from previous fiscal year is also required as appropriate. Portions of the information from the MCPNs’, the Crisis Service Vendor and the Access Center’s Evaluation will be included in DWMHA’s Annual UM Program Evaluation.

ACCESS CENTER UTILIZATION MANAGEMENT COMMITTEE: Describe your UM Committee’s functions, consumer involvement, role of your Chief Medical Director, frequency of meetings, storage of meeting notes, goals for (insert current FY) and goal status, significant activities/achievements and outstanding issues that have not been addressed or completed.

STAFF MAKING UTILIZATION MANAGEMENT DECISIONS:

Provide a list of all staff who make utilization management decisions during (insert FY), using the following headings: Provider Name Employee Last Name Employee First Name Date of Hire Degree Title License Type License Number License Expiration Date Comments (i.e., If person has a limited license, indicate name and credentials of supervisor

such as LMSW)

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TURNAROUND TIME FOR ROUTINE, EMERGENT AND URGENT AUTHORIZATION REQUESTS: Describe any aggregate performance below benchmark.

ANALYSIS OF THE ACCESS CENTER ELIGIBLITY REVIEWS FOR (INSERT CURRENT FY): Complete an analysis of case reviews for all staff making eligibility, screening determinations and/or utilization management decisions. Include data and an analysis of the reviews for eligibility that have been re-reviewed by a second reviewer. Report the number of approved cases reviewed and the number of cases denied eligibility that were reviewed. For the denied cases, how many second reviews upheld the eligibility denial decision?

Include number of cases reviewed for each staff person. Include the number of face-to-face assessments that resulted in decision to deny CMHSP services. Detail any issues, trends and plans of correction from the Unit Managers for the Customer Service and Clinical Units.

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FOLLOW UP ON REFERRALS FOR CONSUMERS DETERMINED NOT TO BE ELIGIBILE FOR SERVICES: Include the number and percentage of referral types for the following:

• Medicaid Health Plan • NSO for crisis intervention/911 • NSO for information and referrals • Commercial Insurance • Coordinating Authority • Primary Care Physician • Emergency Room • Other

Include the number and percentage of consumers who followed through with the referrals to Medicaid Health Plan, NSO, Commercial Insurance, Coordinating Authority, Primary Care Physician, Emergency Room, Other. Include the number and percentage of consumers who failed to follow through with the referrals to Medicaid Health Plan, NSO, Commercial Insurance, Coordinating Authority, Primary Care Physician, Emergency Room, Other.

LOCAL APPEALS FOR MEDICAID BENEFICIARIES/ALTERNATIVE DISPUTE RESOLUATION FOR NON MEDICAID CONSUMERS (ACCESS CENTER ELIGIBILITY DETERMINATIONS):

Include number of cases eligibility for service and cases denied eligibility. Procure appeal information from Customer Service and report number of cases appealed and appeal findings. Of the case eligibility denials, what number and percentage was there appropriate Access Center physician documentation. Include any appeal/dispute findings for non-Medicaid consumers.

ADVERSE CONSUMER OCCURRENCES: Number of critical and sentinel events received and type of sentinel events. Include follow-up actions and disposition as needed.

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UTILIZATION MANAGEMENT CALL DATA: The following per quarter and cumulative per year: • Total incoming calls • Total calls handled • Average call duration • Average time to answer • Number/Percent of call backs for clinical screening within the same day • Number/Percent of crisis calls received • Average abandonment rate

REVIEW OF CUSTOMER SATISFACTION SURVEYS: The following items should be addressed in customer satisfaction surveys annually:

• The percentage of calls that were answered by live voice; • Of the calls placed on hold, the percentage of persons reporting the hold time was too long; • The percentage of persons served that report they were treated with politeness, respect, and

dignity by staff; • For those callers determined not eligible for services, the percentage that were offered

alternative resources and referral information; • For those callers determined not eligible for services, the percentage that were satisfied with

alternative resources and referral information; • For those callers determined not eligible for services, the percentage that were informed of

right to a second opinion; and • Access Center Silent Monitoring.

REVIEW OF PROVIDER SATISFACTION SURVEY: The following items should be addressed in provider satisfaction surveys annually:

• The percentage of providers who report satisfaction with response to concerns after talking with the Access Center staff;

• The percentage of providers who report satisfaction with being assisted in a timely manner by the Access Center staff;

• The percentage of providers who report/express a complaint broken down by quality categories (quality of care, access, attitude and service, billing/financial);

• The percentage of providers who report/express a compliment broken down by quality categories (quality of care, access, attitude and service, billing/financial);

• The percentage of providers who concur with Access Center staff eligibility determinations; and

• The percentage of providers who report satisfaction with the Access Center scheduling process.

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PERFORMANCE IMPROVEMENT INITIATIVES AND ACHIEVEMENTS:

Include any highlights from your utilization management activities or work plans during (insert FY) not reported elsewhere in this evaluation. Remember to include those with consumer involvement.

ADD ANY ADDITIONAL UTILIZATION MANAGEMENT INFORMATION OR DATA NOT COVERED IN THE TOPICS ABOVE:

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ATTACHMENT #8

Template (Access Center, Crisis Service Vendor and/or MCPN)

Utilization Management Plan Annual Plan Evaluation

(FY Effective Date to FY End Date)

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Table of Contents:

I. Introduction II. (Insert Name of MCPN, Crisis Service Vendor or Access Center) Vision and Authority

III. (Insert Name of MCPN, Crisis Service Vendor or Access Center) Purpose IV. (Insert Name of MCPN, Crisis Service Vendor or Access Center) Scope V. Detroit Wayne Mental Health Authority’s Systems Transformation

VI. (Insert Name of MCPN, Crisis Service Vendor or Access Center) Program Structure A. UM staff Members’ Assigned Activities and Professional Qualifications

VII. (Insert Name of MCPN, Crisis Service Vendor or Access Center) Committee Structure A. UM Committee Structure B. Committee Purpose

VIII. (Insert Name of MCPN, Crisis Service Vendor or Access Center) Program Goals IX. Behavioral Health Medical Necessity Criteria and Benefit (MCPNs and Crisis Service Vendor only)

A. Development and Description of Medical Necessity Criteria B. Criteria Review, Approval and Distribution C. DWMHA Behavioral Health Guidelines

X. DWMHA’s Delegation and Oversight A. Inter Rater Reliability B. Case Record Reviews

XI. (Insert Name of MCPN, Crisis Service Vendor or Access Center) UM Methods and Organizational Process for Making Determinations of Medical Necessity and Benefit Coverage for In-Patient and Out-Patient Services

XII. Access, Triage and Referral Process for Behavioral Health Services XIII. Emergency Care Resulting in Admission XIV. Pre-Service and Concurrent Reviews (for MCPNs and Crisis service Vendor only) XV. Post-Service Reviews (for MCPNs and Crisis Service Vendor only)

XVI. Utilization Management/Provider Appeals and Alternative Dispute Resolution Reviews A. Provider Appeals for Medicaid Covered Services

1. Pre-service and Post-service Medical Necessity or Benefit Appeals 2. Pre-Service and Post-Service Administrative Appeals

B. Provider Appeals for Medicare Covered Services 1. Pre-Service and Post-Service Medical Necessity or Benefit Appeals 2. Pre-Service or Post-Service Administrative Appeals

C. Local and Alternative Dispute Resolution for Uninsured and Under Insured 1. Pre-Service and Post-Service Medical Necessity or Benefit Dispute Review 2. Pre-Service or Post-Service Administrative Dispute Review

XVII. Continuous Coverage and Service Requirements XVIII. Individualized Plan of Service/Master Treatment Plan (MCPNs only)

XIX. Utilization Management’s Role in the Quality Improvement (QI) Program XX. Satisfaction with UM Processes

XXI. (Insert Name of MCPN, Crisis Service Vendor or Access Center) UM Program Evaluation A. Frequency of UM Program Evaluation B. Responsibility for UM Program Evaluation

Attachments and References

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ATTACHMENT #9 Access Center, Crisis Service Vendor and MCPNs’ UM Plan Audit Template

UM Element 1: The Organization’s UM Program has clearly defined structures and processes and assigns responsibilities to appropriate individuals. Intent: The organization has a well-structured UM Program and makes utilization decisions affecting the health care of members in a fair, impartial and consistent manner. MET PARTIALLY

MET NOT MET

COMMENTS

Introduction

Access Center, Crisis Service Vendor or MCPN’s Vision

Access Center, Crisis Service Vendor or MCPN’s Authority

Access Center, Crisis Service Vendor or MCPN’s Purpose

Access Center, Crisis Service Vendor or MCPN’s Scope

Systems Transformation and/or Systems of Recovery

Access Center, Crisis Service Vendor or MCPN’s Program Structure:

a. UM Staff Members’ Assigned Activities including who has the authority to deny coverage

b. UM Staff Members’ Qualifications c. Process for evaluating, approving and

revising the UM Program: Active involvement of a senior

behavioral health practitioner

Access Center, Crisis Service Vendor or MCPN’s UM Committee Structure:

a. UM Committee Purpose b. UM Committee Membership (must

include a senior behavioral health care practitioner)

c. Frequency of Meetings d. Minutes are maintained, approved and

distributed e. UM Committee Reporting Structure to

other organization committees and administration

Access Center, Crisis Service Vendor or MCPN’s Program Goals (must be aligned with DWMHA’s program goals)

Organization’s Medical Necessity Criteria and Benefit:

94 | P a g e

a. Development, Selection and Description of Medical Necessity Criteria: Evidence based practices Objective Includes individual needs and

circumstances Assessment of local delivery

system b. Frequency and Process for Criteria

Review, Approval and Distribution: Involvement of appropriate

practitioners Staff training Methods of Availability to

stakeholders

DWMHA’s Delegation and Oversight: a. Outline Delegated Functions by

DWMHA b. DWMHA’s Monitoring:

Inter Rater Reliability Reviews Case Record Reviews

Access Center, Crisis Service Vendor and MCPN’s Delegation of UM Functions (if applicable):

a. Identify Organizations b. Outline UM Delegated Functions c. Describe Methods and Frequency of

Monitoring

Access Center, Crisis Service Vendor or MCPN’s UM Methods and Organizational Process for Making Medical Necessity and Benefit Coverage Determinations for In-Patient and Out-Patient Services:

a. Confidentiality parameters b. Define Emergent and Urgent Services

Access, Triage and Referral Process: a. Role of Access Center b. Role of Crisis Service Vendors c. Standardized Assessment Tools (if

applicable)

Emergency Care Resulting in Admissions (Crisis Service Vendor and MCPNs):

a. Authorization process

Pre-Service Review Process (Crisis Service Vendor and MCPNs):

a. Identify Services Requiring Prior Authorizations for your organization

95 | P a g e

b. Outline Clinical Information Collected to Determine Initial Medical Necessity Criteria and Level of Care

c. Outline Clinical Information Collected to Determine Concurrent (Continued) Medical Necessity Criteria and Level of Care

d. Physician to physician consultations e. Identify staff having the authority to

deny coverage or services f. Turnaround Times for Decision

Urgent pre-service Urgent concurrent Non urgent pre-service Non urgent concurrent

g. Turnaround Times for Notification Urgent pre-service Urgent concurrent Non urgent pre-service Non urgent concurrent

Post-Service Review Process (For Crisis Service Vendor and MCPNs):

a. Outline Clinical Information reviewed to Determine Medical Necessity Criteria and Level of Care

b. Identify staff having the authority to deny coverage or services

c. Turnaround Time for Decision d. Turnaround Time for Notification

Discharge Planning (Crisis Service Vendor and MCPNs)

UM/Provider Appeals and Dispute Resolution: a. Types:

Administrative Benefit Medical Necessity Standard Expedited/Urgent

b. Description of Process including decision timeframes and notification timeframes and methods to practitioner and member For Medicaid Covered Services For Medicare Covered Services For Uninsured or Under Insured

Using General Funds

96 | P a g e

Access Center, Crisis Service Vendor and MCPN’s Continuous: Coverage and Service Requirements

a. Toll Free Number b. TYY services c. Language assistance

Individual Plan of Service/Master Treatment Plan (MCPNs Only):

a. Person Centered Planning b. Amount, Scope and Duration

Access Center, Crisis Service Vendor, MCPN’s UM Role in the Quality Improvement (QI) Program:

a. Outline of Core Measures b. Process for collection of UM data and

reports c. Methods for using UM data and reports

within QI functions

Satisfaction with UM Process a. Customer/Member b. Provider/Practitioner

Access Center, Crisis Service Vendor, MCPN’s Evaluation of UM Plan:

a. Frequency b. Responsible

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