PROVIDER MANUAL - Integrated Care AllianceThis Provider Manual reflects only the policies that are...

October 2016 Integrated Care Alliance, LLC Manual and attachments i

10-1-2016

“Your Vision is Our Mission”

INTEGRATED CARE ALLIANCE, LLC

PROVIDER MANUAL

EFFECTIVE OCTOBER 2016

A CARF Accredited Network as

Services Management Network with Access Center Governance Standards Applied

2016 Integrated Care Alliance Provider Manual and Attachments (10/2016)

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IMPORTANT NOTICE

This Provider Manual explains many important aspects of Integrated Care Alliance, LLC (ICA’s) contracted provider policies and procedures. Integrated Care Alliance’s I/DD Contracted Provider Agreement and this Provider Manual outline the requirements and procedures which contracted providers must follow to be included in the Integrated Care Alliance (ICA) provider network. ICA reserves the right to interpret and construe any terms or provisions in this Provider Manual and to amend it at any time. To the extent there is an inconsistency between the Provider Manual and the Contracted Provider Agreement, ICA or its agent reserves the right to interpret such inconsistency. ICA or its agent’s interpretation shall be final and binding.

Disclaimer

THIS PROVIDER MANUAL MAY NOT BE REPRODUCED WITHOUT THE EXPRESS WRITTEN PERMISSON OF INTEGRATED CARE ALLIANCE, LLC

Copyright © 2016 Integrated Care Alliance, LLC


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TABLE OF CONTENTS

1.0 WELCOME

1.1 Vision, Mission and Values.................................................................................................... 1 1.2 Contacting Integrated Care Alliance, LLC ............................................................................ 2 1.3 Referrals ............................................................................................................................... 3 1.4 Customer Service Department ............................................................................................. 4 1.5 Recipient Rights Department ............................................................................................... 5 1.6 Consumerism ........................................................................................................................ 8 1.7 Cultural Competency and Accommodations ......................................................................... 9

2.0 ELIGIBILITY

2.1 Eligibility Overview................................................................................................................. 9 3.0 QUALITY MANAGEMENT

3.1 Contracted Provider Participation in Quality Measurement and Improvement Initiatives ................................................................................................................................ 12 3.2 Quality Management for Facility, Clinical and Group Practice-Based Providers ................... 12 3.3 Provider Performance Profiling, Performance Standards and Measures ............................. 13 3.4 Exchange of Information With Primary Care Providers ........................................................ 13 3.5 Release of Information Form ................................................................................................ 13 3.6 Management of Clinical Records .......................................................................................... 13 3.7 Peer Review, Organization Review, Quality Assurance and Consultation With Health Professionals .......... 15 3.8 Grievances ............................................................................................................................ 16 3.9 Critical and Sentinel Events Reporting ................................................................................. 17 3.10 Completing the Critical and Sentinel Events Form ............................................................... 17 3.11 Death Reports ....................................................................................................................... 18 3.12 Quality Initiatives ................................................................................................................... 18 3.13 Contracted Provider Responsibility for Local Appeals, Local Dispute Resolution &

Grievance / Compliant System ............................................................................................. 18 3.14 Health Insurance Portability and Accountability Act (HIPAA) ................................................. 22 3.15 Quality Oversight of MH-WIN (Mental Health Wellness Information Network) ....................... 22

4.0 CLINICAL POLICIES AND PROCEDURES AND LEVEL OF CARE

4.1 Clinical Philosophy ............................................................................................................... 22 4.2 Organizational Structure and Staff Accountability ................................................................. 23 4.3 Determining Medical Necessity ............................................................................................ 23 4.4 Confidentiality ...................................................................................................................... 24 4.5 Person-Centered Planning, Supports Coordination and Service Authorization ................... 25 4.6 Emergency Services ............................................................................................................ 27 4.7 Level of Care ........................................................................................................................ 27 4.8 Peer Review for Inpatient Psychiatric Hospitalization ........................................................... 29 4.9 Process of Determining “No Medical Necessity” ................................................................... 30 4.10 Protocol for the Peer Review Process .................................................................................. 30 4.11 Peer Review Procedures ...................................................................................................... 30 4.12 Concurrent Review Process/Inpatient .................................................................................. 31 4.13 Concurrent Review Process/All Other Levels of Care .......................................................... 33 4.14 Transfers to Higher and Lower Levels of Care: Guidelines to All Levels of Acute

Care ...................................................................................................................................... 34 4.15 Required Documentation of Treatment, Services and Supports ........................................... 34


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5.0 PROVIDER RELATIONS/NETWORK MANAGEMENT

5.1 Compliance with Data Reporting Requirements ................................................................... 35 5.2 Change of Status or Address ................................................................................................ 36 5.3 Mergers, Acquisitions and New/Closing Sites or Programs .................................................. 36 5.4 Claims Management ............................................................................................................. 37 5.5 Network Development ........................................................................................................... 37 5.6 Provider Sanctions ................................................................................................................ 37 5.7 Provider Terminations ........................................................................................................... 38 5.8 Authorization for Services Not Covered by ICA .................................................................... 39 5.9 Staffing Standards ................................................................................................................. 40

6.0 BILLING POLICIES AND PROCEDURES

6.1 Claims Submission and Guidelines ..................................................................................... 40 6.2 Claims Filing Requirements .................................................................................................. 42 6.3 Special Billing Instructions .................................................................................................... 46 6.4 Billing Charts ......................................................................................................................... 46 6.5 Provider Mergers and Acquisition ......................................................................................... 54

7.0 GLOSSARY OF TERMS ........................................................................................................................... 55 ATTACHMENT A/ FORMS ................................................................................................................... 63 ATTACHMENT B/ LEVEL OF CARE CRITERIA ................................................................................. 65


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1.0 WELCOME Welcome to the Integrated Care Alliance, LLC (ICA) network of contracted providers. Effective January 1, 2015, ICA became responsible for supports and services to individuals with intellectual/developmental disabilities who chose ICA as their Manager of Comprehensive Provider Network (MCPN). ICA, as a MCPN, is a business contracting entity responsible for, and established to, develop and manage a comprehensive network of providers who can meet the treatment, service and support needs of eligible individuals with intellectual and developmental disabilities throughout Wayne County. Integrated Care Alliance became an Administrative Services Organization (ASO) in January 1, 2015. Integrated Care Alliance is responsible for:

Utilization management of specified services

Quality management and improvement

Claims management

Customer services and community benefit

Provider credentialing and re-credentialing, as applicable

Provider network development and management

Coordination of Integrated Care Alliance recipient rights activities in concert with the Detroit Wayne Mental Health Authority’s Office of Recipient Rights

This Provider Manual has been prepared as a guide to ICA policies and procedures for providers contracted with Integrated Care Alliance, LLC and their respective subcontracted providers. It provides important information regarding the managed care features as incorporated by reference in the Integrated Care Alliance provider agreements. This Provider Manual reflects only the policies that are applicable to the Integrated Care Alliance, LLC MCPN system.

This manual has been designed to be a helpful tool for everyday use by contracted providers.

A convenient feature of the Provider Manual is the Glossary of Commonly Used Terms, provided in the final section. It will be helpful to understand the meaning of these important terms.

ICA understands that our relationship with you is essential to fulfilling our commitment to assist individuals in receiving necessary supports and services in an efficient, cost-effective and confidential manner. We look forward to a mutually cooperative and beneficial relationship.

October 2016 Integrated Care Alliance, LLC Manual and attachments 1

10-1-2016

1.1 Vision, Mission, and Values

Vision A recognized leader in achieving full community inclusion for people with intellectual and developmental disabilities and mental illness and their families. Mission

ICA is the network of choice ensuring the provision of comprehensive, accessible behavioral health services. Values Excellent Customer Service Outstanding Stewardship Person and Family Focused Outcomes Cultural Competency


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1.2 Contacting Integrated Care Alliance, LLC The office of ICA is located at: Integrated Care Alliance, LLC 3031 West Grand Boulevard, Suite 555 Detroit, MI 48202-3082 Customer Service (866) 724-7544 TTY (866) 227-1261 Fax (313) 748-7405 Website: icarealliance.org E-mail: [email protected]


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1.3 Referrals The Integrated Care Alliance, LLC MCPN exclusively serves individuals who have been determined to have an intellectual or developmental disability and have chosen, or are assigned to, ICA as their provider network. As of this writing, there are approximately 1,700 Individuals enrolled with Integrated Care Alliance, LLC. As a contracted provider, you may receive referrals from:

Supports Coordinators approved by ICA

Individuals calling or coming to your office for services

The Detroit Wayne Mental Health Authority Centralized Access Center

Prior to supports and services initiation, and before any admission to a facility, service or program, the contracted provider’s office must query the MH-WIN system or call ICA’s Customer Service Department at (866) 724-7544 to determine the person’s eligibility. Should the person be enrolled in a MCPN that is not ICA, or not be enrolled in a MCPN at all, ICA’s Customer Service Representatives will assist with connecting the individual with the Detroit Wayne Mental Health Authority (DWMHA) Centralized Access Center. The individual may wish to have the telephone number to contact the Access Center, or may choose to have the provider or ICA do a “warm transfer” of the call. Contracted providers should be prepared to provide ICA and/or the Detroit Wayne Mental Health Authority Centralized Access Center with the following information:

Person’s name, date of birth and social security number

Additional insurance coverage, if applicable As of July 1, 2013, children ages newborn to six-years-old, who are not enrolled in a MCPN and who desire mental health services, will have eligibility determined at a provider site by a qualified child mental health professional. The provider will then contact the Detroit Wayne Mental Health Authority Centralized Access Center for completion of the enrollment. Children ages 18 months to 18 years-old who desire autism/applied behavioral analysis services will have eligibility determined by the Detroit Wayne Mental Health Authority Centralized Access Center. If the person is in the ICA network, ICA’s Customer Service Representatives will verify the person’s eligibility, and assist with an authorization for the initiation of services, if appropriate. Contracted providers who identify a need to refer a person enrolled with Integrated Care Alliance, LLC to another provider for services should call the ICA Customer Service Department at (866) 724-7544, or contact the person’s identified Supports Coordinator. ICA shall not discriminate against individuals on the basis of race, gender, creed, ancestry, lawful occupations, age, religion, marital status, sexual orientation, mental or physical disability, color, and national origin, place of residence, health status or source of payment for services. Note: (1). Eligibility verification is not a certification or authorization for services or a guarantee of benefits or reimbursement.


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4 CUSTOMER SERVICE DEPARTMENT 1.4.1 Customer Service

The Customer Service Department at ICA has comprehensive knowledge of the organization’s policies and procedures as they relate to the ongoing education of, and assistance to, individuals served, the provider network and the community-at-large. The role of the Customer Service Department is to assist providers, individuals served, caregivers, guardians or other inquirers with questions regarding supports and services, claims submission, eligibility, contracting and reimbursement rates.

ICA’s Customer Service Program is designed to ensure full participation of individuals served through timely and accurate responses to all stakeholder inquiries, concerns or comments in a manner that conveys an atmosphere that is welcoming, helpful and informative. ICA delegates to its Supports Coordination contracted Providers only, the following customer service responsibilities:

1. The Provider shall maintain an identifiable Customer Service staff person who has as part of his/her job duties the enrollment/orientation of new enrollees.

2. All Customer Service staff shall be trained on Customer Service standards, policies and

procedures within 30 days of hire and annually thereafter. Training shall be provided by Detroit Wayne Mental Health Authority approved trainers utilizing DWMHA approved modules.

3. Customer Service staff will be expected to attend continuing staff training as indicated by the

DWMHA and should be proficient in conflict resolution, consumer advocacy, enrollee rights, grievance and appeals processes and cultural competency.

4. The Customer Service staff shall:

a. Provide systems navigation services b. Provide problem resolution and inquiry assistance c. Provide grievance and appeals and recipient rights assistance d. Ensure consumers are provided with an approved orientation that includes approved

brochures and other informational documents e. Provide to ICA monthly reporting as required by the DWMHA f. Ensure all calls received during regular business hours (as advertised on brochures, etc.) are

answered by a live voice g. Have the capability of providing callers who wish one a “soft transfer” to the DWMHA

Centralized Access Center and, if requested, provide the individual with a telephone and private place to make a call to the Centralized Access Center.

YOU CAN REACH CUSTOMER

SERVICE AT:

(866) 724-7544

MONDAY THROUGH FRIDAY

8:00 AM – 4:30 PM

FOR 24-HOUR ASSISTANCE

CALL:


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1.5 RECIPIENT RIGHTS DEPARTMENT The Detroit Wayne Mental Health Authority (Authority) holds primary responsibility for many of the functions of the Recipient Rights program. Delineation of such roles and responsibilities as training and investigation are determined by the contract between ICA and the Authority. ICA and its contracted providers must ensure the Rights of recipients of service are not abridged and must have Recipient Rights policies, which comport with the Authority’s Recipient Rights policy.

1.5.1 Recipient Rights It is the policy of ICA to ensure that all contracted providers have, as part of their service program(s), a Recipient Rights program that meets all state, county and federal laws, requirements, policies, procedures and guidelines related to Recipient Rights. To assist with this endeavor, the ICA Recipient Rights Liaison will coordinate rights activities with the Rights Liaisons for all contracted providers. Each contracted provider is responsible for having a designated Rights Liaison who understands all requirements as stipulated in the policies of the Detroit Wayne Mental Health Authority’s Office of Recipient Rights and those of ICA. Each contracted provider’s Rights Liaison is responsible for coordinating the rights program for his/her specific organization. This responsibility includes: 1. Reviewing and keeping comprehensive logs of all Incident Reports 2. Reviewing all complaints received, including those that are referred to other contracted providers 3. Assisting The Detroit Wayne Mental Health Authority in the processing of Complaint Investigations for

complaints that fall within his/her jurisdiction 4. Arranging and tracking Recipient Rights training for staff of their organization All contracted providers will ensure that: 1. All new staff must receive the two-part D-WMHA New Hire Recipient Rights Training. As of August 1,

2015, all employees, volunteers or agents of the D-WMHA Network who have not previously completed a New Hire Recipient Rights Training using an approved curriculum and provided by approved trainers, OR existing staff who have been previously trained but cannot provide proof of that training must complete the two-part New Hire Recipient Rights training.

o Part 1 – Complete online New Hire Recipient Rights Training through the Virtual Center of Excellent (VCE) website-vce.org within 30 days of hire for existing staff; within 30 days of notice or lack of proof.

o Part 2 – Attend a face to face New Hire Recipient Rights class within 120 days of their hire date. 2. Individuals enrolled with ICA receive verbal and written Recipient Rights information within 72 hours of

service initiation (within 24 hours for inpatient settings), and that contracted providers retain a document with the person’s/guardian’s signature validating receipt of the information and that the information was explained to them in a way the person could understand.

3. Each service site has an operational Recipient Rights Program that includes:

a. Display of, and easy access to: I. The contact number(s) for reaching the Authority’s Recipient Rights Department II. The reporting responsibilities for abuse and neglect III. Rights complaint forms (accessible without having to ask staff) IV. Incident report forms and Recipients Rights booklets V. Approved Recipient Rights policies


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b. Recipients Rights training for each staff person within 30 days of hire (except for group home staff, who must be trained before providing direct services) and annually thereafter utilizing the Virtual Center of Excellence (VCE) web-based training; training must be documented in employee files.

c. Staff of each contracted provider act in a manner conducive to compliance with all Recipient Rights specified by law, and where this has not taken place, remedial action takes place that is within the parameters of the contracted provider’s personnel policies for disciplinary procedures.

d. Individuals are afforded all of the Recipient Rights stipulated by law, including the use of a person-centered process for assessment of their needs and desires and the development of a person-centered plan of service.

e. Contracted providers make available to all individuals information on their rights to access the grievance and appeals process for denial of services, the suspension of services, the reduction of services or the termination of services previously provided.

f. Each Rights Liaison has access to tools necessary for the completion of their job duties. It is ICA’s policy to ensure that individuals are treated in a manner that respects their rights and confidentiality. All contracted providers are required to distribute Detroit Wayne Mental Health Authority approved Your Rights booklets to ICA enrollees and to adhere to policies, procedures and guidelines related to Recipient Rights as defined in the Michigan Mental Health Code.

It is the policy of ICA to ensure that:

Individuals have a right to be provided general information about ICA, its services, contracted providers and their rights and responsibilities

Individuals have a right to participate in decision-making regarding their family’s behavioral health care and their person-centered plan of service and unrestricted clinical dialogue with their contracted provider

Individuals have a right to be treated with respect and dignity; the right to expect privacy and that clinical information, including diagnosis, will be kept in strict confidence not be shared inappropriately

Individuals have the following rights regarding access to services: o Life-threatening emergency: immediate o Urgent: within 24 hours o Non-urgent initial, routine, ongoing visit: 14 calendar days o Acute inpatient: within 3 hours for assessment, determination and disposition

Individuals have a right to a clear explanation of how they can access services

Individuals have a right to a clear explanation of the proposed plan of treatment if medications are prescribed, and a clear explanation of the drug name, symptoms to be affected by the medication and which physical signs would require them to contact a physician

Individuals have a right to refuse treatment, if they so desire

Individuals have a right to be provided information about how to file a grievance/complaint or appeal, and to be allowed to appear in-person for the review

Individuals have a right to voice grievance/complaints about ICA and about the services provided to them or their family

Individuals have a right to formally address a complaint and/or allegation through the Quality Management Department and or the Detroit Wayne Mental Health Authority’s grievance process.

Individuals have the right to exercise choice of contracted providers from within the ICA network


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1.5.2 Recipient Responsibilities It is the policy of ICA that individuals receiving supports and services are responsible for:

Providing current, detailed information about their present condition needed by the contracted provider to provide treatment, supports and services

Telling their contracted provider about their hopes and expectations of treatment, supports and services

Cooperating with the agreed upon person-centered plan of service, instructions and guidelines, and discussing progress or lack thereof with their contracted provider Supports Coordinator

Discussing any concern they have about their services with their contracted provider, including :

o The refusal of treatment, supports and/or services

o Asking questions about benefits, co-payments, allowed number of days/visits

o Notifying their contracted provider in advance if they cannot make a scheduled visit, or if they plan to stop treatment or the receipt of supports or services


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1.6 Consumerism ICA encourages individuals served and their families and/or guardians to take an active role in making choices and decisions about the supports and services they receive, and to actively participate in the designing of individual person-centered plans of service, and programs and services of ICA. To this end, it is the policy of ICA to engage community stakeholders in the design, delivery and evaluation of its network by recruiting individuals to participate on the ICA Management Board and ICA Full Inclusion Committee, and to actively seek participation in Satisfaction Surveys, Person-Centered Planning Questionnaires and participation at Community Forums.

To assist in facilitating a meaningful and dynamic dialogue between ICA contracted providers and individuals served, ICA will assist to:

Support the Consumer Advisory Board, primary and secondary consumer members of the ICA Management Board, and members of provider boards and committees by providing meaningful orientation regarding the mental health system, ICA, and the specific committee (mission, goals, governance, etc.) to individuals and families appointed to committees and boards

Establish communication mechanisms with contracted providers, individuals served, family members, advocates and other key community stakeholders via newsletters, a Web site, social media, a library of materials, Community Forums, a Facebook page, etc.

Utilize satisfaction surveys to monitor the perception of our supports and services and assist in determining necessary expansion or modifications of such

Individuals who are recipients of ICA contracted providers’ services will be actively recruited to occupy positions on the ICA Management Board. The Management Board will have representation of not less than one-third primary or secondary consumers, at least one-half of which will be individuals who personally access services or supports. Contracted providers are expected to include individuals served and their families on similar managing and advisory boards. ICA and its contracted providers are expected to make all reasonable efforts to assure accommodations for individuals with disabilities so that they can effectively communicate their choices and preferences. Such accommodations may include:

Providing transportation to and from meetings

Providing interpreters for individuals with visual, hearing or speech impairments

Ensuring cultural diversity among staff to ensure that individuals can be assisted by those who consider and understand various cultural issues and values

Scheduling of meetings to accommodate the greatest number of participants

ICA will support individuals wishing to become Peer Mentors by facilitating participation in Peer Mentor training; advising and encouraging providers regarding the use of Peer Mentors; and encouraging Peer Mentors to be actively involved on ICA and ICA Provider committees.


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1.7 Cultural Competency and Accommodations ICA requires services to be delivered in a manner that will assure sensitivity and demonstrate accommodations and cultural competencies to individuals of diverse cultural and ethnic backgrounds. To this end, ICA will ensure that:

Accommodations are made for individuals that will facilitate full access to supports and services. These accommodations include, but are not limited to:

o Interpreter and translation services o Brochures and other written material at a reading level accessible by the population (generally around

a fourth grade reading level) and prepared in alternative formats (i.e., visually limited, threshold languages)

o TTYs located in offices where primary services are provided

Sensitivity is used and accommodations are made for people with diverse cultural and ethnic backgrounds

Services and supports are designed and provided in a manner that demonstrates cultural competency. When appropriate, ICA will contract with and make referrals to providers from different ethnic groups so those requiring such service may receive them from a provider who shares his or her cultural background

Staff receives ongoing training in cultural competency It is the expectation of ICA that contracted providers will develop comprehensive cultural competence and accommodations plans and integrate these plans into their organizational structure. To effectively demonstrate cultural competence and accommodations the following must be in place:

Method of community assessment

Method of organizational cultural competence assessment

Plan to address cultural competence improvement

Policy and procedure for ensuring cultural needs are met

Policy and procedure for ensuring accommodations are available to facilitate access and on-going services

Plan for ongoing staff training Cultural and linguistic assessment consideration is a prerequisite for ethical and accurate assessment. A culturally and linguistically competent assessment incorporates, at all levels, the adaptation of services to meet the person’s culturally and linguistically unique needs. As such, contracted providers will give each person the opportunity to receive an assessment and the appropriate services in his or her primary language. When the person’s specific cultural customs and communication norms guide the information sharing process, the content and accuracy of the assessment and plan are enhanced.

2.0 ELIGIBILITY 2.1 Eligibility Overview Contracted providers may verify person’s eligibility using MH-WIN or by calling ICA’s Customer Service Department at (866) 724-7544. This verification may be performed prior to rendering service and/or submitting a claim; however, claims payment is based on the person’s eligibility at the time the service is rendered. Neither prior verification of eligibility nor actual service authorization by ICA or its agent is a guarantee of payment.


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3.0 QUALITY MANAGEMENT Clinical excellence and the highest business ethics are at the forefront of ICA’s operations. ICA has a responsibility to demonstrate unwavering strength of character, a solid commitment to superior clinical quality and service that is consumer-focused, clinically appropriate, cost-effective and culturally competent. This is achieved through an organization-wide, network-wide, systematic and coordinated continuous quality improvement process involving all stakeholders. ICA is CARF accredited and requires each of its contract providers to be accredited by a recognized accrediting body, to be working toward such accreditation, or to meet the unaccredited provider standards of CARF. A quality management philosophy through which the organization continuously monitors and evaluates appropriateness of care, identifies opportunities for improving quality and access, establishes initiatives to accomplish agreed-upon improvements and monitors resolution of problem areas is utilized. This philosophy is an ongoing process that spans every aspect of program operations and unites individuals served, their families, advocates, contracted providers and other stakeholders in a continuously repeating cycle of quality planning, action and evaluation (Continuous Quality Improvement, or CQI). The quality management process is structured to:

Delineate thresholds and benchmarks for key processes

Identify parties responsible for improvement initiatives

Implement action plans and procedures for monitoring improvement initiatives

Act upon the results of improvement plans All ICA and contracted provider employees are responsible for improving clinical and service quality. To that end, ICA and our providers have embarked on a journey of Systems Transformation to become a more Comprehensive, Continuous and Integrated System of Care. ICA’s goal is to become a network of care that is welcoming, hopeful, integrated, trauma-informed, culturally competent, person/family oriented and prepared to meet the needs of all individuals served, with enhanced emphasis on those with complex co-occurring conditions of all types. ICA, as part of the system wide CQI partnership, has organized a quality improvement culture, partnership, and improvement process within its own organization, in partnership with its own provider network. This Systems Transformation Committee meets regularly to discuss Systems Transformation activities at the macro level (i.e. State, County, DWMHA, MCPN, and between systems such as SA, DHS, etc.). In addition, ICA and many of its providers have identified System Transformation leads, referred to as Change Agents. Each participating organization, including ICA, has developed its own Systems Transformation committee to work toward the shared goals discussed in the previous paragraph. In addition, each organization agrees to:

Encourage and provide technical assistance to other organizations wishing to begin a Systems

Transformation process,

Fully support their Systems Transformation team and ensure it includes broad representation from

internal staff, provider leadership, and consumer/family advocacy,

Empower the Systems Transformation team with the responsibility for organizing the change

process, and coordinating multiple initiatives toward a common vision, and

Develop an improvement plan which addresses the following indicators of progress in relation to

transformation. It is expected that the plan will address those improvements that are relevant to each

provider, not that providers will be mandated to expand their programs to provide supports and

services not in their business plan. The improvement plans are expected to focus first on those areas

thought to be of primary concern, with additional areas added in subsequent years.


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Some of the indicators are the responsibility of ICA, as the MCPN.

1. Improvement in organizing a CQI culture and Systems Transformation team within the MCPN,

with organized empowered participation from MCPN leadership and staff, provider leadership and

change agents, and consumer/family advocacy.

2. Improvement of participation of all providers and all programs in organized improvement

activities: Program self-assessments with the COMPASS tool, Program specific improvement

plan for co-occurring capability, change agent participation, workforce development for co-

occurring competency.

3. Improvement in welcoming individuals and families with co-occurring issues at every program in

the system, including welcoming individuals in mental health crisis with active substance use

and/or intellectual disabilities at all crisis and emergency settings.

4. Improvement in the removal of access barriers to engagement and assessment based on co-

occurring conditions (length of sobriety, required alcohol level below 0.8, etc.) at all routine

access and crisis access points.

5. Improvement in screening and identification of individuals with co-occurring mental health,

substance use, trauma, and I/DD conditions, including improving the accuracy of recognition in

the ICARE system.

6. Improvement in the development of welcoming, recovery oriented, co-occurring competency for

all service/support staff, regardless of level of degree and licensure. (This is NOT an expectation

of increasing the number of staff who are dually licensed or certified).

7. Improvement in the engagement of individuals and families with co-occurring conditions and other

complex needs in relationships that are empathic, hopeful, and integrated, with individual staff

and/or teams.

8. Improvement in the development of integrated, hopeful, strength based, stage matched

assessment and service planning for individuals and families with complex needs.

9. Improvement in the engagement of co-occurring competent Peer Mentors in the provision of

services and in participation in treatment or service/support teams.

10. Progress in establishing guidelines and mechanisms for care coordination, information sharing,

and partnership between the MH MCPNs, I/DD MCPNs, and the Coordinating Agencies, and for

helping providers make progress in creating similar guidelines and partnerships with appropriate

complementary providers, in accordance with DWMHA policy.

11. Progress in aligning internal ICA and provider policies, procedures, QI tools, etc., with the clinical

practices and principles of transformation, including welcoming, engagement, access, recovery,

hope, screening and assessment, and continuous quality improvement

12. Progress in completion the Supports Intensity Scale (SIS®) for all adults in our provider

network. The SIS is a strength-based, comprehensive assessment tool that measures an

individual’s support needs in personal, work-related, and social activities in order to identify and

describe the types and intensity of the supports an individual requires. The SIS® includes

background information on health, medical conditions, activities of daily living, and cognitive,

social, and emotional skills. The SIS® was designed to be part of person-centered planning

processes that help all individuals identify their unique preferences, skills, and life goals.


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3.1 Contracted Provider Participation in Quality Measurement and Improvement Initiatives On an ongoing basis, a range of quality measurement and improvement initiatives will be conducted. Contracted providers are expected to participate in these initiatives when requested and to incorporate the results into their quality management plans. Common examples of quality measurement and improvement initiatives in which contracted provider participation will be requested include:

Random Review of Treatment Records For providers delegated to provide Supports Coordination services, a representative sampling of clinical records will be reviewed at least quarterly. Clinical records of all other contracted providers will also be reviewed at least annually. Contracted providers are expected to ensure quality management staff has access within two (2) business days’ notice to the records of all ICA enrollees. The purpose of these clinical record reviews includes:

Determining whether the clinical or medical necessity criteria for the level of care provided was

established

Assessing the quality of care provided

Verifying the inclusion of required medical record elements (see Section 3.6, “Management of Clinical Records”)

Assessing implementation of the person centered planning process

Other performance indicators, as required

The results of these reviews will be shared with contracted providers for use in future quality improvement initiatives and to refine the contracted providers' utilization management practices. Outcome Studies and Person Satisfaction Surveys Contracted providers may be asked to participate in the administration of outcome studies and satisfaction surveys. Aggregate results from all studies and surveys will be shared with participating contracted providers and other interested parties when available, and as delineated in ICA’s Quality Management Program Description.

3.2 Quality Management for Facility, Clinical and Group Practice-Based Providers ICA is committed to building and making available a broad array of quality services and supports to meet the needs of individuals with developmental disabilities. To this end, ICA is committed to working with contracted providers to continuously improve quality of care for the purpose of ensuring positive treatment and life outcomes for individuals. ICA believes this commitment to continuous quality improvement is best realized when the principles of quality management are the foundation for ongoing program operations. We invite and expect contracted providers to join us in this endeavor by utilizing quality management principles in their daily operations and through explicit quality improvement activities that are linked to the contracted providers' annual quality management work plans. Contracted provider quality management programs and annual quality management work plans should include quality measurement and improvement activities for the following:


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Quality indicators aimed at measuring, monitoring, managing and improving key internal processes of program operations (access, person-centered planning, discharge planning, outcomes, and satisfaction of individuals served)

Treatment outcome studies, such as the percentage of treatment goals achieved or Functional Status Assessment, which is administered at intervals during the course of supports and service delivery

Person served satisfaction surveys

Contracted providers are required to submit the results of quality measurement and improvement activities in these areas to the quality management department upon request.

3.3 Performance Profiling, Performance Standards and Measures The quality management department performs measurement activities on specific elements of care that serve as proxies for the quality of those services. Process and Outcome Performance measures are crucial elements in ICA’s Provider Performance Profile. Contracted providers will be expected, when requested, to collect and to submit these and other data for the purpose of Provider Performance Profiling. It is therefore expected that contracted providers have access within their organizations to the (ICARE System and the Detroit Wayne Mental Health Authority’s - Mental Health Wellness Information Network (MHWIN) to support this function. Contracted providers are encouraged to generate data regularly on related measures as a means of measuring and managing their own performance. ICA providers that have contracts with residential providers must comply with State and Detroit Wayne Mental Health Authority requirements. There are several components related to compliance, some of which include ensuring State licensure, if required; onsite residential monitoring, using the appropriate tools (e.g.; fire and safety, evacuation scoring); staff training; contractor file maintenance, etc. On a routine basis, but no less than annually, ICA will perform a random file audit of the residential provider contracts to assess compliance.

3.4 Exchange of Information with Primary Care Providers ICA is committed to supporting the role that Primary Care Providers (PCPs) play in coordinating all aspects of a person’s care. ICA expects behavioral health contracted providers to obtain a release from individuals served authorizing the exchange of treatment information between PCPs, behavioral health contracted providers, state agencies, insurers, family members, and others as appropriate, and that relevant treatment information is exchanged among these parties, as clinically appropriate.

3.5 Release of Information Form ICA encourages the use of a standardized Release of Information (see Attachment A) to facilitate this exchange of information. The Release of Information form authorizes, with the person’s consent, the communication of health care information. It facilitates communication between Primary Care Providers, contracted providers, state agencies, insurers, family members and other parties. Many managed care plans collaborated in developing this Release of Information form to reduce the administrative confusion caused by each organization using a different release form. The contracted provider is not mandated to use this specific Release of Information form, but it is recommended. At the initial intake, it is recommended the Release of Information form be presented to the person.

3.6 Management of Clinical Records Contracted providers must maintain adequate clinical records relating to the provision of covered services to individuals in such form, and containing such information as required by applicable federal and state laws and


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regulations. Subject to applicable legal restrictions, contracted providers must forward any requested clinical information pertaining to individuals served to ICA, Contracted providers must maintain their clinical records for the greater of seven (7) years or the period required under applicable state and federal law to maintain such records. Clinical records must comply with the following requirements:

Each page in the record must contain the person’s name or ID number.

Each record must include the person’s address, employer or school, home and work telephone numbers including emergency contacts, marital or legal status, appropriate consent forms and guardianship information if relevant.

All entries in the treatment record must include the responsible clinician's name, professional degree and relevant identification, if applicable.

All entries must be dated.

The record must be legible to someone other than the writer.

The record includes all required elements of the person centered planning process.

Relevant medical conditions must be listed, prominently identified and revised as necessary.

Presenting problems along with relevant psychological and social conditions affecting the person’s medical and psychiatric status must be documented.

Special status situations, such as imminent risk of harm, suicidal ideation or elopement potential must be prominently noted, as well as documented and revised in compliance with written protocols.

Each record must indicate what medications have been prescribed, the dosages of each and dates of initial prescription or refills.

Allergies and adverse reactions must be clearly documented.

A lack of known allergies and sensitivities to pharmaceuticals and other substances must be prominently noted.

A medical and psychiatric history must be documented, including previous treatment dates, contracted provider identification, therapeutic interventions and responses, sources of clinical data, relevant family information, results of laboratory tests and consultation reports.

For children and adolescents, prenatal and peri-natal events, along with a complete developmental history (physical, psychological, social, intellectual and academic) must be documented.

For i12 and older, documentation must include past and present use of cigarettes and alcohol, as well as illicit, prescribed and over-the-counter drugs.

A mental status evaluation documenting the person’s affect, speech, mood, thought content, thought processes, judgment, insight, attention or concentration, memory, impulse control, suicidal ideation and homicidal ideation must be indicated.

A DSM-IV diagnosis consistent with the presenting problems, history, mental status examination, and/or other assessment data must be documented.

Treatment plans must be consistent with diagnoses and have objective, measurable goals and estimated time frames for goal attainment or problem resolution. Treatment plans with include type, scope and duration of levels of care, as well as start and stop dates for each.

The focus of treatment interventions must be consistent with the treatment plan goals and objectives.

Informed consent for medication and the person’s understanding of the treatment plan must be documented, to be updated at least annually.

Progress notes describe person’s strengths and limitations in achieving treatment plan goals and objectives and satisfaction with supports and services.

The record must clearly reflect that the person(s) who becomes homicidal, suicidal or unable to conduct activities of daily living are promptly referred to the appropriate level of care.

The treatment record documents preventive services, as appropriate (e.g., relapse prevention, stress management, wellness programs, lifestyle changes, and referrals to community resources).


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A crisis plan is in place or there is clear documentation in the record that assistance in developing a crisis plan has been offered and declined.

The treatment record reflects continuity and coordination of care between the primary clinician, consultants, ancillary providers and healthcare institutions, and includes a signed Release of Information form.

The treatment record documents dates of follow-up appointments or, as appropriate, a discharge plan.

3.7 Peer Review, Organization Review, Quality Assurance and Consultation with Health

Professionals Contracted providers will cooperate with the applicable Centers for Medicare & Medicaid Services approved independent peer review organization in the performance of quality of care and utilization reviews carried out by the organization. The contracted provider agrees to cooperate with quality assurance and quality improvement programs carried out by the Quality Management Department and comply with medical management decisions made by or on behalf of Integrated Care Alliance, LLC.


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3.8 Grievances A grievance is a verbal or written expression of dissatisfaction by a contracted provider, person served or representative for a person served that is not immediately resolved to the individual’s satisfaction after reasonable efforts at resolution are made. Sources for dissatisfaction can include any aspect of ICA’s administrative or claims practices, as well as concerns about quality of care and service. With respect to supports and service delivery: All ICA consumers and their authorized beneficiaries have access to mechanisms to present and have resolved grievances and complaints. For all purposes, both Medicaid and non-Medicaid recipients will be afforded the same due process when requesting grievance resolution. All ICA consumers and authorized beneficiaries will be given information regarding the grievance and complaint process, including the expedited appeal process. Grievances that involve denial of an expedited resolution of an appeal, requires a review by a health care professional with the clinical expertise in treating the individual’s condition or disease. All ICA consumers are provided information regarding their grievance rights at the time of initial enrollment and at least annually thereafter. The completion and the consumer’s understanding of the process are evidenced through provider staff and consumer signatures on the Individualized Person Centered Plan of Service. All ICA consumers will be offered reasonable assistance in completing all forms and if applicable provided with interpreter services and toll-free numbers that have adequate TTY/TDD and interpreter capability. Grievances will be initiated and reported through ICA’s Quality Management Department at the time a consumer expresses dissatisfaction with residential level of care services. The process ensures the following: 1. Appropriate staff, which is not the subject of the grievance, resolves the consumer’s concerns. 2. Professionals with the appropriate clinical expertise are consulted for all grievances, which involve clinical issues. 3. Residential level of care grievances are forwarded to the ICA Quality Management Department. ICA will assume responsibility for entering all information into MH-WIN. 4. Acknowledgment letters are completed by ICA and forwarded to consumer within (5) business days of receipt of their grievance. 5. Status letters are completed by ICA and forwarded to consumer within 30 calendar days if not resolved. 6. A Letter of Resolution is completed by ICA and forwarded to consumer within 60 calendar days. 7. Residential level of care grievances are logged and submitted to the DWMHA’s Customer Service Grievance coordinator by the 15th of each month. D-WMHA will review and coordinate grievances relative to outpatient level of care services. It is the standard of ICA to ensure that all grievances or complaints will not result in retaliation or a barrier to services. It is the standard of ICA that all staff employed by ICA and Contracted Providers are trained in the grievance process within 30 days of hire and bi-annually thereafter utilizing the VCE. ICA and its contracted providers will ensure that poster and brochures concerning grievance rights as approved by DWMHA-Authority are be prominently displayed in public areas at each Contracted Provider service site. Grievances are typically received over the telephone or in writing. Complaints can be submitted in writing to:

ICA Quality Management Coordinator (Grievance & Appeals Coordinator)

3031 W. Grand Blvd. Suite 555 Detroit, MI 48202-3082

(866) 724-7544 Or

Detroit Wayne Mental Health Authority Division of Customer Service

640 Temple-2nd Floors Detroit, MI 48201

(888) 490-969


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Grievances are categorized into the following categories: Quality of care Access to staff Access to services Financial matters Customer service Interpersonal relationships with therapist, psychiatrist, case manager, and staff etc. Clinical issues Environment Delivery of services Program issues Transportation Other

3.9 Critical and Sentinel Events reporting Acute level of care contracted providers (e.g., inpatient psychiatric units and acute residential treatment centers) and non-acute level of care contracted providers (e.g., outpatient facilities and all other levels of care) must make notification of an occurrence, utilizing an approved DWMHA “Incident” form, within one business day of the event. The completed form must be faxed to the supports coordination provider, the DWMHA office of Recipient Rights and to ICA (at ICA’s secure fax number: 313-748-7405). ICA will review all such reports and determine whether a critical/sentinel event has occurred. Sentinel events are defined as unexpected occurrences which represent actual or potential serious harm to the well-being of the person or to others by the person while the person is in treatment. These include, but are not limited to, the following:

Self-inflicted harm requiring urgent or emergent medical treatment (e.g., self-mutilatory behavior or

attempted suicide)

Unanticipated death (occurring in any setting) not related to the natural course of the person’s medical illness or underlying condition (e.g., suicide, homicide, death by medical cause)

Violent/assaultive behavior with physical harm to self or others (e.g., attempted murder, actual assault)

Serious adverse reaction (e.g., neuroleptic malignant syndrome, tardive dyskinesia, other serious drug reaction)

Sexual behavior with other consumers of behavioral health services or staff, whether consensual or not, while in a program

Elopements from hospital or residential placements where person is considered a danger to self or others

Injuries either in a facility or provider office that require urgent or emergent medical treatment

Fire setting/property damage while in the treatment setting

Medication errors resulting in the need for urgent or emergent medical intervention

Arrest and/or conviction

Any serious challenging behaviors or behavioral episodes that are not already addressed in a treatment plan

3.10 Completing the Critical and Sentinel Events Form ICA’s contracted service provider in conjunction with the consumers’ supports coordination provider and/or, clinical and quality staff are responsible for all critical/sentinel event documentation, investigation, analysis and

plan of corrections. Supports coordinator providers are responsible for entering all consumers identifying information including the date of occurrence into MH-Win within 2 business days of the occurrence. If applicable, the results of the final investigation must be completed within 10 business days of the occurrence and, when appropriate, include a root cause analysis. The results are to be attached to the original CE/SE entry into MH-Win with notification to ICA’s QM Department at (313) 748-7405 within 2 business days of the results.


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3.11 Death Reports All deaths must be reported to the ICA Quality Management Department within 24 hours of the occurrence. The Detroit Wayne Mental Health Authority approved Incident/Accident/Death/Arrest Report must be completed. For specific details, refer to the Recipient Rights Manual for the policy on death reporting. If the death is a sentinel event, then the sentinel event process, as described previously, must be completed.

Quality Management Coordinator 3031 W. Grand Blvd., Suite 555

Detroit, MI 48202-3082 (866) 724-7544

3.12 Quality Initiatives The Quality Management Department, in concert with the Quality Management Committee, develops and implements quality initiatives designed to improve the support and service delivered to individuals enrolled with Integrated Care Alliance, LLC. Quality improvement activities are identified through performance indicator tracking and trending. Additionally, quality initiatives, as described in the Detroit Wayne County MCPN Manual, are implemented.

3.13 Contracted Provider Responsibility for Local Appeals, Local Dispute Resolution and Grievance/Compliant System It is the policy of ICA, as a contractor of the Detroit Wayne Mental Health Authority (Authority), that an applicant for, or a person receiving services within the ICA network of contracted services be provided with accessible mechanisms to present and have resolved any concerns, complaints, appeals, disputes and recipient rights complaints in a timely and organized fashion. Contracted providers are to ensure that applicants for and receiving supports and services are informed of and have access to all available methods through informal and formal mechanisms to resolve concerns, appeals, grievances and recipient rights complaints. Each contracted provider shall provide access to the following mechanisms for applicants, individuals applying or served, and/or their representatives to express dissatisfaction with services and shall establish a position in the entity to coordinate grievance and appeals (i.e. “Grievance and Appeals Coordinator”). A person receiving services through an ICA contracted provider shall be able to orally or in writing contact the contracted provider and be assisted in obtaining action from the appropriate party through that first contact. Each process designed to address dissatisfaction with services will have a timely and organized procedure that clearly defines the criteria for accessing the processes: Local Appeal: Request for review of an “action” (Adequate or Advance) that can be initiated as either an oral or written request. Action: A decision that adversely impacts a Medicaid beneficiary’s claim for services due to: 1. Denial or limited authorization of a requested service, including the type or level of service. 2. Reduction, suspension, or termination of a previously authorized service. 3. Denial, in whole or in part, of payment for a service.

4. Failure to make a standard authorization decision and provide notice about the decision within 14 calendar days from the date of the receipt of a standard request for service.

5. Failure to make an expedited authorization decision within three (3) working days from the date of receipt of a request for expedited service authorization. 6. Failure to provide services within 14 calendar days of the start date agreed upon during person-


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centered planning and as authorized by the service provider. 7. Failure to act within 45 calendar days from the receipt of a request for a standard appeal. 8. Failure to act within three (3) working days from the date of the request for an expedited appeal. 9. Failure to provide disposition and notice of the local grievance within 60 calendar days of the request. Adequate Notice of Action: A written notice provided to an individual or guardian at the time of the action. This includes the denial of service, denial of access into the service provider programs and at the time of the Individual Plan of Service (IPOS) development. The IPOS developed through a person-centered planning process and finalized with the beneficiary, must include, or have attached, the adequate notice provisions. Advance Notice of Action: A written notice advising the beneficiary or guardian of a decision to reduce, suspend, or terminate services currently provided. Advance Notice is to be provided/mailed at least 12 calendar days prior to the proposed date the action is to take effect. Local Dispute Resolution: Process for individuals not receiving Medicaid who are dissatisfied with decisions rendered by, or on behalf of, ICA and/or contracted provider regarding denial, reduction, suspension, or termination of services and supports, and/or for beneficiary’s dissatisfaction with services. This process is managed through the Grievance and Appeals Coordinator. Second Opinion: Process as requested by individuals or their representatives for reconsideration when the person is determined to be inappropriate for any community mental health service or admission to a psychiatric hospital. Mediation: Process as requested by individuals served or their representatives; managed through the Grievance and Appeals Coordinator. Medicaid Fair Hearing: A hearing before the MDHHS Administrative Tribunal for any Medicaid beneficiary or their authorized hearing representative when there is disagreement with the type, scope, duration or intensity of the services and supports included in the individual person-centered plan of service, or when the beneficiary or their representative wishes to appeal an adverse action. The Grievance and Appeals Coordinator manages notification of this appeal of the adverse action. Alternative Dispute Resolution: Process at MDHHS for individuals not receiving Medicaid who wish to appeal an adverse action. The person may choose a traditional review or a mediated solution. This process requires use of the local complaint process prior to filing a complaint at the State level. The Grievance and Appeals Coordinator manages notification of this appeal of the adverse action. Financial Determination Appeal: Process for beneficiaries or their representatives who wish to appeal the determination of ability to pay. The finance division manages this process. Complaints may be filed with the finance division or the Grievance and Appeals Coordinator and may be appealed to the probate court. Recipient Rights Complaint: Process for any beneficiary or their representatives who wish to file a recipient rights complaint. The Detroit Wayne Mental Health Authority shall have an adequately staffed Office of Recipient Rights, which meets the requirements of the Mental Health Code, Administrative Rules and Authority policies. Unless otherwise specified, the desire to utilize one process does not limit the availability of other processes. Established procedures will not prohibit or discourage a person from access to other options that may be available, including the Office of Recipient Rights. ICA and its contracted providers shall establish and maintain written mechanisms to process and monitor grievances, which include at a minimum:

An adequately staffed Customer Service Department, including a toll-free telephone service to: o Receive telephone calls o Respond to questions


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o Meet personally with individuals served or individuals seeking services o Resolve complaints informally through direct discussion with the parties involved o Refer complaints to the appropriate party for action

Grievance and Appeals reviewers at the first and second level review shall:

Not include any individual whose decision(s) or determination(s) is the subject of the grievance procedure

Have necessary and relevant knowledge and expertise and no financial interest in the resolution, and must have the authority to order corrective action

Consider all relevant and reliable medical evidence, including review of the person’s record, the opinion of the treating clinician, and any evidence presented by or on behalf of the person

Render and issue written decision within defined time frame (business days) specific to type of compliant (appeal, local dispute, and/or grievance) or as mandated in applicable Authority policies

A notification of the Grievance, Appeals, and Recipient Rights process shall be posted at no less than one conspicuous location in each reception area of ICA and each contracted provider service site. In addition, individuals served shall be informed orally and in writing of the complaint procedure upon:

Enrollment

Each time service is denied, reduced, suspended, delayed, terminated and/or replaced with another service than that requested

Contacting ICA or a contracted provider regarding a problem or complaint The notice shall state:

The person’s grievance and appeal rights; the procedural options that exist to resolve service delivery disputes

How to file complaints and grievances, as well as Medicaid Fair Hearing and Alternate Dispute Resolution requests

Timeframes for filing, including requests for expedited consideration

Availability of assistance with the complaint procedure and Medicaid Fair Hearing

The toll-free phone number that a person can use to file a grievance or appeal by phone ICA and/or contracted providers shall include in notifications a statement that filing of a grievance or request for Medicaid Fair Hearing will not affect eligibility, benefits or the way the person is treated by ICA and/or the contracted provider. All written and oral materials regarding the procedure, including posted notices, forms, and decisions, must be made available orally and in writing in the person’s primary language and alternative formats, such as TTY and communication devices for the hearing impaired, Braille, large-print and cassette. For each Adverse Action, the person shall receive in writing:

The reason for a service denial, reduction, suspension, termination or delay (e.g., not a covered service under the contract)

The local appeal or local dispute resolution procedures and how to exercise those rights

The circumstances that will cause an expedited review and how to request an expedited review 1. A description of alternative services recommended

If a Medicaid Fair Hearing is requested within ten days of a notice to terminate or reduce benefits, Medicaid benefits must be continued at pre-notice levels pending final resolution. The person may be notified that, if a final decision is adverse to them, they may be required to repay the costs of services provided to them pending final resolution.


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If a request for a Medicaid Fair Hearing is made, copies of all relevant records relating to the request shall be forwarded to the Authority’s Medicaid Fair Hearing Coordinator within 5 days of receipt of a notice that the fair hearing has been filed, so that the Hearing Coordinator may file a timely hearing summary with the MDHHS Administrative Tribunal. In the event of a request for expedited review of covered services in an emergency or urgent situation, the time required to complete the appeal review must be no more than 24 hours. The person shall be provided the opportunity to present additional information to substantiate the medical necessity of the services. All notices and communications regarding complaints shall be maintained in the person’s case record. The contracted provider shall maintain documentation of appeals, local dispute resolutions, and grievances that shall include, at a minimum:

The name of the person or the person’s identification number, if any

Medicaid or non-Medicaid beneficiary

Who the concern is lodged against

A short summary of each issue or problem

Date of contact

Resolution and date of resolution

All complaints must be logged into a management information system, and reported to the Authority’s management information system by the 10th day of each month. Each contracted provider shall establish a mechanism for a person to file a second level complaint if the person is not satisfied with the resolution .This complaint would go through ICA if it is regarding a residential provider, otherwise, all other complaints would go through DWMHA’s Customer Service Department,. The second appeal shall be acted upon within 10 business days of its receipt or as mandated in applicable Authority policies. Individuals who file complaints or appeals shall not be subjected to discrimination or retaliation. Staff that participates in the review or resolution of appeals or grievances shall not be subjected to discrimination or retaliation. Staff must receive training in procedures described in the Authority’s Dispute Local Appeals for Medicaid Beneficiaries and additional Grievance, and Local Dispute Resolution Systems policies within 30 days of hire and bi-annually thereafter utilizing the VCE. Local Appeals and Local Dispute Resolution policies or procedures must be reviewed and updated annually. ICA and all contracted providers must utilize the current and approved Authority’s Local Appeals forms and processes, some of which are included in the MH-WIN, including: 1. Advance Notice 2. Adequate Notice 3. Local Appeal Request Form 4. Request for Hearing Form 5. Local Appeal Acknowledgement Letter 6. Local Appeal Notice of Disposition 7. Local Appeal Disposition Form 8. Local Appeal Log Failure to comply with the requirements of federal and state law regarding appeals and grievances will result in contract sanctions.


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3.14 Health Insurance Portability and Accountability Act (HIPAA)

The federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients/individuals served with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for individuals served across the country. State laws providing additional protections to individuals served are not affected by this new rule. ICA requires all participating contracted providers to comply with HIPAA standards related to privacy, transactions and security. The following activities are necessary to assist in HIPAA compliance, but are not all inclusive:

Notify individuals served about their privacy rights and how their information can be used

Adopt and implement privacy procedures for your Authority

Ensure and document that all new employees understand privacy requirements and procedures and have completed the HIPAA training available through VCE. HIPAA training shall be completed bi-annually thereafter.

Designate an individual to be responsible for ensuring privacy procedures are adopted and followed

Secure individuals served records containing individually identified health information so they are not available to those who do not need them

3.15 Quality Oversight of MH-WIN (Mental Health Wellness Information Network) The Quality Department of ICA will provide technical assistance and oversight related to Providers’ use of MH-WIN. As each function of the MH-WIN system is implemented, the QM staff of ICA will review the new practices with Provider staff and provide training and on-going support as needed. The QM staff will also put into practice on-going review and reporting of Providers’ adherence to MH-WIN requirements as put forth by the Detroit Wayne Mental Health Authority. Providers must be in full compliance with all requirements of the Detroit Wayne Mental Health Authority with respect to the use of the MH-WIN system.

4.0 CLINICAL POLICIES AND PROCEDURES AND LEVEL OF CARE The purpose of the Clinical Policies and Procedures section is to provide a description of processes, procedures, and criteria used by ICA to conduct authorization and utilization management activities.

4.1 Clinical Philosophy The clinical philosophy of ICA is to provide a care management system which offers easy and immediate access to the most appropriate, quality services for individuals with an I/DD (Intellectual Developmental Disorder or I/DD) and a utilization management system to support contracted providers in delivering medically necessary and effective supports and services with minimal administrative barriers. The Utilization Management Plan encompasses management of care from the point of entry through discharge. To the extent possible, macro-management of care, through the use of objective, standardized, widely distributed clinical protocols and outlier management programs, will be implemented. Intensive utilization management is reserved for high-cost, highly restrictive levels of care and cases that represent clinical complexity and risk. ICA’s Utilization Management Coordinators base their reviews on clear and concise criteria developed specifically to guide level of care, treatment, and length of stay determinations. Utilization Management Coordinators are trained to match the needs of individuals to appropriate services, levels of care and community supports. This requires a careful consideration of the intensity and severity of clinical data


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presented with the goal of quality treatment, supports and services in the least restrictive environment. The clinical integrity of the Utilization Management Program ensures that individuals who present for supports and services have those supports and services appropriately monitored. Those cases that appear to be outside of best practice guidelines are referred for specialized reviews. These may include evaluation for intensive care management or more frequent utilization management review.

The Utilization Management Department has designed a system that is based on principles of quality care, and one that is flexible in meeting the diverse needs of ICA enrollees. Our system:

Provides easy and immediate access to appropriate treatment, supports and services

Ensures supports and services are approved/contained within the Individualized Person Center Plan of Service (IPCPOS)

Works collaboratively with contracted providers in delivering quality treatment, supports and services according to accepted best-practice standards

Addresses the needs of special populations, paying particular attention to providing integrated, comprehensive and culturally competent supports and services

Targets high-risk cases for intensive care management

4.2. Organizational Structure and Staff Accountability ICA places a high value on the selection, training, coaching and performance evaluation of clinical staff performing utilization management services on its behalf. All staff involved in utilization management activities possess advanced degrees and licensure in their field. The Medical Director is an experienced clinician who is Board-Certified, eligible in his/her specialty areas and is required to maintain a current knowledge of research findings and nationally recognized practice guidelines in the area of intellectual developmental, mental health, and substance use disorders. Licensed Clinical Psychologists provide peer reviews for psychological testing and outpatient treatment. The Utilization Management staff is able to manage treatment, supports and services in all areas of I/DD, and behavioral health. All Utilization Management Coordinators are required to be fully licensed professionals with a minimum of three (3) years prior clinical experience. These reviewers complete all types of reviews, including pre-certification, concurrent review, discharge planning and care management. Contracted providers are required to comply with the review process.

4.3 Determining Medical Necessity Clinicians must ascertain medical necessity for a service (Medical Necessity Criteria is defined below). Requests for copies of ICA’s medical necessity criteria can be directed to the Customer Service Department at (866) 724-7544 or by submitting a request to:

Integrated Care Alliance, LLC 3031 West Grand Blvd., Suite 555

Detroit, MI 48202-3082 ATTN: Utilization Management Director

4.3.1 Medical Necessity “Medically necessary” mental health, intellectual disability, and substance abuse services are supports, services, and treatment:

Necessary for screening and assessing the presence of a mental illness, I/DD or substance use disorder; and/or

Required to identify and evaluate a mental illness, I/DD or substance use disorder; and/or


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Intended to treat, ameliorate, diminish or stabilize the symptoms of mental illness, I/DD or substance use disorder; and/or

Expected to arrest or delay the progression of a mental illness, I/DD, or substance use disorder; and /or

Designed to assist the individual to attain or maintain a sufficient level of functioning in order to achieve his/her goals of community inclusion and participation, independence, recovery, or productivity.

The determination of medically necessary support, service or treatment must be:

Based on information provided by the individual, individual’s family, and/or other individuals (e.g., friends, personal assistants/aide) who know the individual; and

Based on clinical information from the individual’s primary care provider or health care professionals with relevant qualifications who have evaluated the individual; and

Based on person centered planning and for beneficiaries with co-occurring I/DD, mental health and/or substance use disorders, determination must be made by appropriately trained professionals with sufficient clinical experience in the areas of mental health, I/DD and substance use/abuse; and

Made within federal and state standards for timeliness; and

Sufficient in amount, scope and duration of the services(s) to reasonably achieve its/their purpose. Supports, services and treatment authorized by ICA must be:

Delivered in accordance with federal and state standards for timeliness in a location that is accessible to the beneficiary; and

Responsive to particular needs of multi-cultural populations and furnished in a culturally relevant manner; and

Responsive to the particular needs of beneficiaries with sensory or mobility impairments and that they are provided with the necessary accommodations; and

Provided in the least restrictive, most integrated setting. Inpatient, licensed residential or other segregated settings shall be used only when less restrictive levels of treatment, service or support have been, for that beneficiary, unsuccessful or cannot be safely provided; and

Delivered consistent with, where they exist, available research findings, health care practice guidelines, best practices and standards of practice issued by professionally recognized organizations or government agencies.

Using criteria for medical necessity, ICA may:

Deny services a) that are deemed ineffective for a given condition based upon professionally and scientifically recognized and accepted standards of care; that are experimental or investigational in nature; or for which there exists another appropriate, efficacious, less-restrictive and cost-effective service, setting or support, that otherwise satisfies the standards for medically-necessary services; and/or

Employ various methods to determine amount, scope and duration or services, including prior authorization for certain services, concurrent utilization reviews, centralized assessment and referral, gate-keeping arrangements, protocols, and guidelines.

ICA may not deny services solely based on preset limits of the cost, amount, scope, and duration of services; but instead determination of the need for services shall be conducted on an individualized basis.” (Michigan Mental Health Code definition)

4.4 Confidentiality ICA employees routinely maintain confidentiality of all information collected relating to:

Past and present individuals served, including identity, as well as personal information

Organizational planning and development

Financial status of the organization


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Confidential information is made available during the course of the relationship between the person served and Utilization Management Coordinator as well as between the Utilization Management Coordinator and contracted provider. All ICA employees are required to sign a statement of confidentiality at the time of employment and annually thereafter and to adhere to all rules and regulations as defined in the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, commonly known as HIPAA. All requests for release of information will be directed to management staff and are reviewed and responded to in accordance with ICA policies and procedures. Any inquiries from individuals served must be strictly governed by state and federal guidelines (including HIPAA) for confidentiality as well as from a clinical perspective, which will be determined by the Chief Executive Officer [or designee]. ICA’s management staff may also consult with its Legal Counsel as needed. Confidential information may include, but not be limited to:

Verification of eligibility of benefits

Certification of treatment /services related to individuals with developmental disabilities

Processing claims

Utilization review

Peer review

Response to congressional inquiries (made at the request of the Person)

Appeals

Quality assurance

Contracted providers will maintain confidentiality policies and procedures in accordance with accrediting bodies and all federal, state and county guidelines.

4.5 Person-Centered Planning, Independent Facilitation, Supports Coordination and Service Authorization The person-centered planning process is comprised of those actions, changes, and functions focused on and controlled by the individual, which facilitate the identification of his/her desires and dreams, determine the supports he or she wants and/or needs to achieve a desired future, and encourage formal and informal feedback from the person about those supports, the progress made, and any changes desired or required. The Quality Management Department will use the following as a list of indicators in reviewing contracted providers’ adherence to the implementation of person–centered planning processes.

Person-Centered Planning

Builds on the Person’s capacity to engage in activities that promote community life and that honors the person’s preferences, choices and abilities

Involves family/significant other, friends, independent facilitators and professionals as chosen for inclusion by the person

Is to be incorporated into existing delivery system as a routine part of intake, assessment/evaluation, development, implementation, monitoring and reviews scheduled and unscheduled as requested by the person, or required, and revisions of the person-centered plan as indicated

Takes into account health, safety and legal considerations (e.g., serious medical conditions; aggressive behavior towards self and/or others; involuntary commitment for treatment; not guilty by reason of insanity (NGRI) status; involvement with the correctional, criminal, juvenile justice systems)

Is not a document or meeting intended to subvert the community mental health (CMH) role as a “safety net” for individuals with dysfunction due to active symptoms of mental illness, emotional disturbance and/or intellectual/developmental disabilities


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Includes planning sessions, meetings, appointments, visits and calls between the person and supports coordinator/clinical support staff at times and places preferred by and convenient to first the person, then to the people he/she wants present

Includes exploration by the Supports Coordinator/clinical support staff and the person his/her relationship network to determine who is important to the person and who is an existing or potential friend or ally

Explores during the planning session(s) the person’s desires: where he/she wants to live, how he/she wants to spend each day, with whom he/she wants to spend time, and hopes and dreams for the future.

Explores all necessary accommodations for full implementation of the plan

Offers options/education related to choice, self-determination and crisis planning

Includes, as applicable, evaluations by clinicians that are based on the person’s identified desires, dreams for his/her future, his/her skills, strengths, abilities, and finally, his/her needs

Ensures that supports and services which are identified in the plan, as well as how, when and where they are provided, are based on the person’s preferences and achieving stated desires and dreams.

Encourages the person’s informal and formal supports to serve as advocates

Is inclusive of a service satisfaction process that has been put in place and reviews that process to determine that the individuals is utilizing it as desired

Includes a process for reviewing the plan is achieved at the planned meeting

ICA’s contracted providers of children’s services will maintain policies related to Early and Periodic Screening and Diagnostic Treatment (EPSDT). As part of the person-centered planning process, ICA expects its contracted providers of children’s services to inform all families of children who are receiving community mental health services and are Medicaid recipients that EPSDT services are available and to encourage the families to participate in the EPSDT program. ICA requires that the contracted providers document in the clinical record of children participating in the EPSDT program, the services provided to the child or adolescent and his or her family, as well as supporting documentation including all medical reports prepared by physicians and nurses, as made available by the family. Independent Facilitation As an integral part of the person-centered planning process, ICA contracted providers will explain Independent Facilitation options to all individuals. The intent of Independent Facilitation is to ensure that all of the dreams, desires, strengths and challenges of the individual are addressed and included in the document. At the time of the Pre-Planning meeting, or at any time prior to the planning meeting date, a request for Independent Facilitation may be made. An individual who receives services from a ICA contracted provider may request a person of his/her choice, who is trained and certified in Independent Facilitation, to facilitate the PCP process meeting. ICA will maintain an agreement with at least one organization to provide trained Independent Facilitators for those individuals who request assistance in identifying an Independent Facilitator. In the event Independent Facilitation is utilized, the Facilitator will work with the individual’s Supports Coordinator to complete the finished person-centered plan of service (PCPOS) document utilizing the format developed by ICA. ICA will have Supports Coordinators facilitate the development of an individual person-centered plan of service (IPCPOS), when the option of using an Independent Facilitator has not been chosen, for all individuals who have support/service needs. The Supports Coordinators will be the employees of contracted providers with whom ICA has contracted for Supports Coordination services.


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Authorizations Requests for registration or authorization for supports and services, other than inpatient acute care and partial hospitalization, will be conveyed to ICA utilizing the Integrated Care Alliance Reporting & Exchange System (ICARE). Requests will be conveyed by the person’s Supports Coordinator and will be a result of:

A review of the individual’s eligibility status for a specified level of care (Medicaid, Healthy Michigan Medicaid, MI Health Link, Adult Benefits Waiver, MI-Child or General Fund)

Goals established during an Individual Person-Centered Plan of Service (IPCPOS) planning meeting

A requested Amendment to the IPCPOS

An emergency

Each registration or authorization request will include the Level of Care being requested, the number of units being requested, the stop and start dates for which the authorization is being requested, and the name of the contracted provider who will be providing the service. Authorization for Inpatient Hospitalization is requested by the hospital via telephone consultation with the Utilization Management Coordinator. Contracted providers who do not have the Supports Coordination responsibility for a person, but for whom they wish to receive a service registration or authorization, should have such an authorization or registration request conveyed to ICA via the person’s assigned Supports Coordinator. A contracted provider who is not familiar with the name of the Supports Coordinator, or believes one needs to be determined or chosen by the person, should contact the ICA Customer Service Department at (866) 724-7544 for assistance.

4.6 Emergency Services The Detroit Wayne Mental Health Authority - Community Outreach for Psychiatric Emergencies program

(COPE) is responsible for the provision of emergency evaluation and follow-up interventions for adults with urgent or emergent psychiatric needs. These services include:

On-site crisis evaluation and intervention

Mobile crisis evaluation, intervention and follow-up

Crisis stabilization services

Inpatient psychiatric hospital, partial hospitalization, and crisis residential authorization In addition, ICA has established contractual agreements with area community hospital and IMD’s to provide inpatient psychiatric care. Contracted providers should contact COPE at 844-269 COPE (2673) for assistance in facilitating services.

4.6.1 Emergency Admissions With-out Pre-certification Not applicable for ICA outpatient providers.

4.7 Levels of Care (see Attachment B, Level of Care Manual) Three concepts underlie determinations of the appropriate level of care:

Severity

Intensity of service

Psychosocial, and cultural and linguistic factors

Taken as a whole, consideration of these three concepts enable the Utilization Management Coordinator


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to make recommendations based on an understanding of the person’s clinical, psychosocial and related needs. Diagnosis alone does not determine the necessity of treatment, supports or services at a given level. Individuals with the same diagnosis or one person over time may exhibit a wide range of severity of signs and symptoms of illness or psychosocial needs. The applicability of these criteria to each person will depend on the information obtained by the Utilization Management Coordinator from the person, behavioral health and medical providers, family members and other caregivers.

Severity of Condition This concept addresses the question: “What specific clinical condition exists as a result of a present DSM-IV TR diagnosis or ‘contract specific’ situation (e.g., the need for out-of-home placement)”? These represent, for a given level of care, the signs, symptoms, and functional impairments of such a nature and severity as to require treatment at a specified level at a given point in time. In addition, the presence of certain “high risk” clinical factors warrants consideration in evaluating a person to determine his/her severity of condition. These factors include (but are not limited to):

Repeated attempts at self-harm, with documented suicidal intent

Significant co-morbidities (e.g., psychiatric/medical; psychiatric/substance abuse; psychiatric/ I/DD; substance abuse/medical; co-morbid personality factors)

Coexisting pregnancy and substance abuse disorder

Medication non-adherence

Unstable Axis I or Axis II disorder

History of violent or assaultive behavior

Multiple family members requiring treatment

Decline in ability to maintain previous levels of psychosocial functioning

Intensity of Service This concept considers the question: “Does this person’s condition and situation (e.g., behavior, symptoms, psychosocial and related issues) warrant this level of care (i.e., is it medically necessary)?”

The level of care should match the person’s condition, taking into consideration his/her developmental strengths and limitations (e.g., physical, psychological, social, cognitive/intellectual, academic) and psychosocial and related needs. Intensity of services issues are represented in Admission, Exclusion and Continued Stay Criteria and reflect levels of service that, by virtue of their complexity and/or attendant risks, require a specified level of treatment, services and or supports for their safe, appropriate and effective application. For example, acute mental health inpatient services may be necessary for individuals with a condition that results in the expression of suicidal/homicidal ideas, threats, plans or attempts. While some individuals’ condition may be less serious, the presence of psychosocial, cultural or linguistic factors (e.g., isolation, last-chance agreement, non-English speaking) may warrant a more intensive level of care. Psychosocial, Occupational and Cultural and Linguistic Factors These considerations represent factors that are either aggravating a person’s clinical condition or need to be addressed in order to allow for effective treatment. An inappropriate or more intensive level of care may be

the result if the issues are not addressed. These considerations address the question:


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“What specific psychosocial, occupational, and cultural or linguistic factors are present that may change the risk assessment or may present a barrier to effective treatment and should be considered when making level of care decisions?

Psychosocial Factor Psychosocial factors to consider when making this determination include:

Homelessness

Housing issues (e.g., risk of losing housing; inadequate housing; dissatisfaction with housing arrangements; hazardous living situation; placed at risk for abuse by current housing situation)

Lack of effective social support (e.g., minimal social network; strained interpersonal relationships; abuse/neglect in living environment; family member with substance abuse disorder; single parent or non-parent family)

Physical disability

Financial difficulties

Lack of access to medical/dental care

Recent critical life event (e.g., sudden death of parent/caretaker)

Chronic illness

Isolation (e.g., rural resident, homebound)

Lack of transportation

Lack of daycare

Active legal issues

Performance pressure and/or non-supportive school environment

Recent release from a period of incarceration

Cultural and Linguistic Assessment Considerations Unbiased knowledge of the person’s culture and language is a prerequisite for ethical and accurate assessment. Thus, cultural and linguistic competency are an integral part of all efforts to deliver services, and are a means of ensuring access, quality, cost effectiveness, and relevant outcomes. An understanding of the relationship between culture, health beliefs, health behaviors, help seeking, recovery, illness, rehabilitation, health policy and social policy is necessary for timely, accurate and appropriate treatment planning and interventions. The importance of culture and language, the cultural strengths associated with people and communities, the assessment of cross-cultural relations, vigilance towards the dynamics inherent in cultural and linguistic differences, and the expansion of cultural and linguistic knowledge are critical. ICA strives to provide services to individuals of heterogeneous populations composed of many subcultures. The person’s qualities, characteristics and choices must not be ignored in efforts to develop and implements standards and guidelines. Only consistent, quality-driven efforts toward cultural competency can lead to the establishment of best practices. A culturally and linguistically competent assessment incorporates, at all levels, the adaptation of services to meet the person’s culturally and linguistically unique needs. As such, the person should have the opportunity to receive an assessment and the appropriate services in his/her primary language. When the person’s culturally specific customs and communication norms guide the information sharing process, the content and accuracy of the assessment and person-centered plan are enhanced.

4.8 Peer Review for Inpatient Psychiatric Hospitalization Physician peer advisors provide clinical case review of those cases that cannot be determined to meet Medical Necessity or that present quality of care issues. For after-hours coverage, the Utilization Management


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Director is on-call to handle any emergencies.

4.9 Process of Determining “No Medical Necessity” If a Utilization Management Coordinator questions the Medical Necessity and/or appropriateness of the recommended treatment, supports and services as outlined in ICA clinical criteria, or if there are quality of care concerns, the case is referred to the Utilization Management Director. The Utilization Management Director reviews the available information and speaks directly with the attending or primary contracted provider to discuss the case. Through this communication, the Utilization Management Director may obtain clinical data that was not available to the Utilization Management Coordinator at the time of the review. This collegial clinical discussion allows the Utilization Management Director the opportunity to explore alternative treatment plans with the contracted provider and to gain insight into the contracted provider’s anticipated goals, interventions and time frames. The Utilization Management Director may request more information from the contracted provider to support specific treatment protocols and ask about treatment alternatives. Determinations of “No Medical Necessity” for inpatient services are rendered only by the Medical Director and only if the Medical Director and the attending contracted providers are unable to reach an agreement.

Disagreement may be a result of any one or a combination of the following:

The frequency of a specific treatment modality

The duration of care

The treatment modality being utilized When a determination of No Medical Necessity is made in a case, the treating contracted provider (and hospital, if applicable) is notified telephonically of the decision. Written notification of a determination of ‘No Medical Necessity’ is comprised of notification being sent to the person, treating contracted providers, and the facility/program within two (2) business days of the determination. For substance abuse treatment, ICA will follow federal and state guidelines regarding release of information. Notification letters specify the level of care for which a determination of “No Medical Necessity” has been made, the reason(s) why the determination has occurred and instructions on how to initiate an appeal. The ICA Utilization Management Coordinator always works with contracted providers in finding alternatives when a given level or type of care is determined to be not medically necessary, and this is documented in the case review notes.

4.10 Protocol for the Peer Review Process If, based on criteria for Medical Necessity, the Utilization Management Coordinator concludes that the proposed treatment of a person does not appear to meet the Medical Necessity criteria; the Utilization Management Coordinator will review these concerns with the facility Utilization Review staff or treating contracted provider on the same business day. If the Utilization Management Coordinator and the treating contracted provider are not able to resolve these concerns, the Utilization Management Coordinator will begin the process for referral of the case which may include a discussion with the Utilization Management Director. If the Utilization Management Director concurs with the Utilization Management Coordinator decision that the case lacks Medical Necessity for treatment at the current level of care, the case will be sent for peer review.

4.11 Peer Review Procedures An appointment is scheduled for the Peer Advisor (PA) and the treating contracted provider by an


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administrative staff member. If the treating contracted provider cannot be reached, a message will be left, indicating that the call pertains to a question of Medical Necessity determination. Unless a call is received within 24-hours, an administrative denial decision will be issued. After reviewing the information with the treating contracted provider, the Peer Advisor (PA) will determine whether the treatment services the contracted provider intends to render (or has already rendered) are medically necessary. If so, the case is referred back to the Utilization Management Coordinator for continued review. If not, the contracted provider will be informed of the determination of “no Medical Necessity” and of the appeal process. Peer review decisions are usually rendered immediately, but in all cases within 24-hours of the review. Note: It will always be possible that additional written or verbal information will be needed from the treating contracted provider. This additional information may alter the Medical Necessity determination. However, once ICA has sent a “No Medical Necessity” determination letter according to contractual standards, the case is governed by the protocols established for an appeal. The determination remains valid until and/or unless it is overturned by an appeal.

4.12 Concurrent Review Process/Inpatient Ongoing concurrent review of inpatient treatment is essential to determine the continuing Medical Necessity of care. The concurrent review process is accomplished through clinically-focused discussions between the treating contracted provider and a member of ICA’ clinical staff. The following is an example of the type of questions discussed:

Continued Stay Questions for Acute Care

1. DIAGNOSIS

Have there been any changes to the patient’s diagnosis? 2. SUICIDAL/HOMICIDAL (IDEATIONS, PLAN, SAFETY, MEANS HISTORY)

Ideations: o Does the patient have any current suicidal ideation(s)? Describe. o Does the patient have any current homicidal ideation(s)? Describe. o If so, who is at risk?

Intent: o Does the patient have any intent to harm him/herself? o Does the patient have any intent to harm another?

Plan: o Does the patient have a plan? o If so, please specify detail: i.e., how, when, where?

Means: o Does the patient have the ability/access to resources to complete their plan? o Are precautions being taken to prevent the patient from utilizing the means for their plan? o If so, how?

Contract for safety: o Is the patient willing/able to contract for safety at the time of the review?

3. RESTRAINED/SECLUDED (NO. OF TIMES MEMBER NEEDED TO BE RESTRAINED/SECLUDED)

How many times has the patient been in restraints/seclusion?

What was the precipitant?


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When was the last time the patient needed to be restrained/secluded? How long did the seclusion last?

Has the patient required any prescription medications? If yes, what? When? 4. MEDICATION INFORMATION (COMPLIANCE, SIDE EFFECTS, BARRIERS)

Have there been any recent changes in any of the patient’s medications?

Is the patient compliant with taking his/her medications?

If patient is not compliant, what are the barriers to taking the medications? What steps are being taken to overcome the barrier(s)?

Is the patient experiencing any side effects from his/her medications?

If there are side effects from medication(s), is this interfering with their mental health/substance abuse treatment?

What, if any, alternatives are being explored?

5. NEED FOR CONSULTATION AND/OR ADDITIONAL ASSESSMENTS 6. RESPONSE TO CURRENT TREATMENT

How is patient responding to current treatment (descriptors/specifics)?

Has the patient been able to comply and remain complaint with their person-centered plan?

What part of the patient’s person-centered plan presents barriers to compliance and/or positive response?

If the barrier(s) are within the patient’s person-centered plan, what can be implemented to help overcome them?

Has patient participated in their person-centered plan?

7. TREATMENT PLAN (PROBLEMS, GOALS, OBJECTIVES)

Any recent changes to the person-centered plan?

What is the patient’s progress toward the goals (need to be measurable) of the patient’s person-centered plan?

Are there any unforeseen barriers to progress toward any specific goals on the person-centered plan?

What changes have been made to the person-centered plan to address lack of progress?

8. STRESSORS & SUPPORT

Any recent changes in support system or current stressors?

9. DISCHARGE PLAN (DATE, GOALS, ETC.)

Any change in the estimated length of stay (any changes to discharge date?

Changes to the discharge plan for this patient?

Progress toward the development of the discharge plan?

Will he/she be returning back to previous living situation?

If not, what options are the contracted providers exploring?

Is the patient’s appointment scheduled? If yes, with whom? When?

Are there any barriers to the patient attending their follow-up services/treatment?

Are there any barriers to the development of the discharge plan?

If yes, which one? For what?

Have any community supports been referred to?

Has contact been made with the primary physician related to any medical issues?


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10. BASELINE

At what level does the person function when not acute?

4.13 Concurrent Review/All Other Levels of Care Contracted providers are required to utilize the Integrated Care Alliance Reporting & Exchange System (ICARE) to either register or request authorization for specific levels of care related to the Individual Person Centered Plan of Service. Please refer to ICA’s coding manual for more information on services that require prior authorization. In most cases, a Utilization Management Coordinator will conduct the concurrent review for applicable levels of care. All requests for authorization of concurrent reviews should be made before the expiration of the last authorized day. Please keep these important points in mind when requesting authorizations:

Information to be reviewed should be concise; I/DD oriented, and present a clear rationale for the level of

care being requested

Care, supports and services should be focused on goal achievement, with specific symptoms/issues being addressed that are reasonably expected to result in the person’s transitioning to the least restrictive level of care in the most efficacious time period possible

Care, supports and treatment requires, with consent, timely contact with and involvement of family, significant others, and contracted providers who are important to the person’s level of functioning and community involvement. Failure to make these collateral contacts may be perceived by ICA as lack of active treatment and/or supports.

Discharge planning for acute inpatient levels of care should begin from the date of admission and identify early barriers to discharge. Active pursuit of collateral agencies/resources that will have an impact on discharge, and contact with the primary care provider to discuss any medical issues is an expectation of ICA.

Where clinically appropriate, and with the person’s consent, information about the person’s treatment must be coordinated with the person’s primary care provider. This is especially important in situations in which there is reason to believe there are co-occurring physical disorders.

Contracted providers must be prepared to provide ICA with complete clinical information at the time of the review. Please use the interview and documentation guidelines found in Section 4.12 of this Provider Manual as a guide for concurrent reviews.


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4.14 Transfers to Higher and Lower Levels of Care: Guidelines to all Levels of Acute Care All prospective transfers to higher or lower levels of care should be reviewed with the Utilization Management Coordinator. The ICA Utilization Management Director must approve transfers to the same acute level of care (e.g., inpatient care to inpatient care at another facility). The Supports Coordination contracted provider for a person admitted for inpatient care, or to an alternative residential setting, is to be involved in, and/or provided with relevant, necessary and appropriate information (with appropriate consent) regarding the person’s progress in treatment. The person is to be scheduled with the outpatient clinician for follow-up upon discharge, as appropriate. When a transfer is necessary, it is the responsibility of the current treating facility to locate the facility to which the person is to be transferred, secure ICA’s authorization and to facilitate the transfer in a safe and coordinated manner. Within the bounds of consent, the contracted provider must ensure communication verbally and/or in writing of relevant clinical information regarding the person whose care is being referred/transferred. This should include, at a minimum, the following:

Brief history of the present illness

Current treatment plan

Response to treatment

Medical status

Current medications including type, dosage, prescribing clinician

Coordination with family and/or significant others as applicable, and relevant coordination with primary care, if any

For transfer within outpatient levels of care, a copy of the current Individual Person Centered Plan of Service should be sent to the new outpatient contracted provider within three (3) business days of termination. 4.15 Required Documentation of Treatment, Services and Supports All treatment, services and supports rendered require documentation. Minimally, the documentation must include:

The beneficiary’s full legal name,

The beneficiary’s MH-WIN number,

The date of the treatment, service or support,

The stop/start times of the treatment, service or support,

The name of the contracted organization providing the treatment, service or support,

The location where the treatment, service or support was rendered,

A description of the treatment, service or support, and

A description of the individual’s response to the treatment, service or support. Documentation must be signed, include appropriate credentials, be dated and made a permanent part of the clinical record.


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5.0 PROVIDER RELATIONS/NETWORK MANAGEMENT

Network Management develops and refines the ICA provider network. Key activities include: quality improvement initiatives, contract management, and overseeing the credentialing process. The network management strategy emphasizes taking the long-term view of working with contracted providers to ensure individuals receive appropriate, high quality care resulting in positive outcomes. Working in close concert with contracted providers and facilities leads to increasing and solidifying the existing linkages between various agencies and programs. ICA seeks to work with contracted providers to strengthen continuity of care principles within community-based, locally integrated delivery systems. ICA seeks to collaborate with contracted providers to ensure not only the highest quality treatment services for individuals, but to ensure high quality administrative, contractual, and documentation standards are met by contracted providers. ICA will ensure the following credentialing requirements:

Credentialing of all staff at the provider organization has taken place including primary source verification prior to contracting.

Continue ongoing monitoring of staff credentials as per D-WMHA

Request copy of impaneling letter and service grid to determine what services each provider is impaneled for prior to contracting.

5.1 Compliance with Data Reporting Requirements

Data Requirements

ICA may require the contracted provider to provide information that will include, but not be limited to, the contracted provider’s service authorization or utilization management activities, claims submission activities, incidents, complaints, appeals / grievance information, and sentinel events. All contracted providers will collect and report performance indicator data as required by the Centers for Medicare and Medicaid, the State of Michigan, Detroit Wayne Mental Health Authority and ICA. Contracted providers are responsible for data collection, entry, and submission at the required date/time and interval to the assigned body. Contract Provider shall participate with and cooperate in ICA’s contracting program, including meeting all applicable laws, licensure requirements, insurance coverage requirements, applicable accreditation and standards of professional conduct, and represents and warrants that all information submitted to ICA in connection with such contracting program is true, complete and accurate. Contract Provider shall maintain licensure, insurance coverage and according to contract, as well as maintain and provide ICA with updated certificates upon expiration. Contracted providers must notify ICA in writing within 24 hours upon the occurrence of any of the following:

Revocation, suspension, restriction, termination, or voluntary relinquishment of any of license, authorization, or accreditation required by the contracted provider agreement

Any pending legal action for professional negligence which may reasonably be considered to be a material loss contingency, and the final disposition of the action

Any indictment, arrest, or conviction for a felony or for any criminal charge related to an individual’s or a facility’s professional practice

Any lapse or material change in contractually required insurance coverage


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Restriction, suspension, revocation, or voluntary relinquishment of medical staff membership or clinical privileges at any healthcare facility

Any termination from another network, which must be submitted in writing

Filing of bankruptcy, voluntary or otherwise

Restrictions and/or sanctions imposed by any state and/or federal regulatory body to include, but not limited to Medicaid and/or Medicare

Contracted Providers must also notify ICA

Immediately of their inability to provide emergency care by contacting the Customer Service Department at (866) 724-7544.

Inability to provide adequate service at any time due to a loss of electricity or water; during extreme heat (90 degree heat with no means of cooling); or during cool weather (no furnace with temperatures below 65 degrees). Providers must have policy which describes actions to be taken to both provide for the emergency and alert ICA to the emergency and action being taken. The policy will be reviewed during annual quality audits.

Within 24 hours of inability to deliver urgent care by contacting the Customer Service Department at (866) 724-7544.

Within seven (7) business days of inability to provide routine care by contacting the Customer Service Department at (866) 724-7544.

Immediately or within 24-hours of any critical or serious incidents as defined in the Quality Management section

Please see Glossary of Terms for definitions of emergency and urgent care.

5.2 Change of Status or Address Contracted providers are responsible for keeping their files current and notifying ICA and Detroit Wayne Mental Health Authority of changes in the status of their services provided or address. Information can be submitted to ICA in writing by mailing your changes to or fax (313) 748-7405

Integrated Care Alliance, LLC

Attn: Provider Relations 3031 West Grand Blvd., Suite #555

Detroit, MI 48202-3082 Failure to notify ICA of changes may result in delay in payment of claims or a change in the contracted provider’s network status that may include suspension or termination from the network.

5.3 Mergers, Acquisitions or New/Closing Sites or Programs Contracted providers are required to notify ICA in writing of the following events at least 35 days before such events occur: (1) mergers, (2) acquisitions, (3) changes in control or changes in ownership, (4) requests to add and/or remove a practice site or program. Such changes may require reapplication depending on the nature and scope of the change. If the changes will occur in less than 35 days, notification is expected within 24 hours of the finalization of the merger, acquisition, change in ownership and/or change in program or site. Contracted providers should not assume satellite offices, facilities or new services acquired under


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these transactions are covered under the original contracted provider application or provider agreement. The addition of a satellite office, facility or program is likely to require a separate application and may not receive approval as a contract site.

5.4 Claims Management Integrated Care Alliance will reimburse claims submitted by contracted providers according to the Policies and Procedures described in this Manual in Section 6.0, “Billing Policies and Procedures.”

5.5 Network Development Contract Provider represents to ICA that, unless it is exempt from being empaneled, it is empaneled by the Detroit Wayne Mental Health Authority (Authority) and agrees to maintain compliance with all requirements for Contract Providers as required by the Authority. Contract Provider shall notify ICA immediately in writing if it ceases to be empaneled. Integrated Care Alliance has adopted the credentialing criteria detailed on the provider application. ICA can contract only with those providers meeting these criteria. Please review the credentialing criteria for your licensure level, Authority or program type to ensure that you comply with these criteria.

5.6 Contracted Provider Sanctions Though Integrated Care Alliance is able to resolve most contracted provider quality issues through consultation and education, occasionally further action is necessary to ensure quality service delivery and protection of those we serve. ICA may impose any of the following sanctions for issues related to quality of care or contract compliance. ICA will comply with all local, state and federal reporting requirements regarding professional competence and conduct to ensure the highest quality of care, supports and services from our contract providers.

Individual Practitioner – Sanctions

Type Definition

Consultation A call is placed to the practitioner notifying him/her of the alleged improper action to include an explanation of possible sanctions if corrective actions are not taken. The call will be documented to include the date and subject for consultation; a copy of the consultation will be placed in the practitioner’s file. Educational materials will be sent via certified mail.

Written Warning A written notice will be sent to the practitioner warning him/her of an alleged improper action that has been reported or discovered. An explanation will be given of possible sanctions if corrective actions are not taken. A copy of the letter is put into the practitioner’s file, and educational materials will be sent via certified mail. Corrective action will be monitored as necessary.

Monitoring The practitioner will be placed on monitoring status when data indicate a practitioner is out of conformance with Integrated Care Alliance standards, and when Integrated Care Alliance determines it is in individuals served interest to allow the practitioner to continue or initiate active participation in the network. The practitioner may be provided a copy of an action plan. The action plan consists of steps that, when taken by the practitioner, will remedy the identified deficiencies or concerns. The practitioner is expected to make a best effort to comply with the monitoring action plan. If an action plan has been sent to the practitioner she/he is expected to notify Integrated Care Alliance in writing of the status of the issue for which monitoring was initiated at the end of the action plan timeline, or sooner if applicable. Monitoring may last for up to 180 days at which time it may be continued depending on the status of the issue. The contracted provider is expected to keep Integrated Care Alliance updated in writing of all changes in the issue/concern that triggered monitoring.

Suspension The practitioner will be given written notice via certified mail of the alleged improper action for which he/she is being placed on Suspension. A copy of the letter is placed in the


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practitioner’s file. The Suspension may last for a period of 14 days during which time an investigation may take place and is only used for serious infractions, which are probable cause for termination.

Termination The practitioner will be given written notice via certified mail that he/she is being terminated from the network, and the reason for termination identified. A copy of the letter is put in their file. Individuals in care will be notified and given assistance for referral to a new practitioner for continuing care as necessary.

Facility Providers – Sanctions Type Definition

Consultation A call is placed to the head (e.g. CEO) of the organization notifying him/her of an alleged improper action, which includes an explanation of possible sanctions, if corrective actions are not taken. The call will be documented in writing to include the date and subject for consultation and a copy of the consultation will be placed in the Facility/Program file. Appropriate educational materials will be sent via certified mail.

Written Warning A written notice will be sent to the head (e.g. CEO) of the organization notifying him/her of the alleged improper action that occurred. An explanation will be given of possible sanctions if corrective actions are not taken. A copy of the letter is put into the Facility/Program file, and appropriate educational materials will be sent via certified mail.

Monitoring Organizational contracted providers may be placed on monitoring when data indicates the contracted provider is out of conformance with Integrated Care Alliance standards and when Integrated Care Alliance determines it is in individuals’ served interest to allow the contracted provider to continue or initiate active participation in the network. The contracted provider is expected to make a best effort to comply with the monitoring action plan. If an action plan has been sent, the contracted provider is expected to notify Integrated Care Alliance in writing of the status of the issue for which monitoring was initiated at the end of the action plan timeline, or sooner if applicable. Monitoring may last for up to 180 days at which time it may be continued depending on the status of the issue. The contracted provider is expected to keep Integrated Care Alliance updated in writing of all changes in the issue/concern that triggered monitoring.

Suspension A suspension can be imposed when deemed appropriate based on quality of care concern(s). The head (e.g., CEO) of the organization will be given written notice via certified mail of the specific concern(s) deemed to warrant suspension. A copy of the letter is placed in the facility/program file. The suspension may last for a period of 14 days during which time an investigation may take place to verify the improper action. This investigative period may be extended by Integrated Care Alliance and is only used for serious infractions, which are probable cause for termination.

Termination The organization will be given written notice sent certified mail that the facility/program is being terminated from the network for an alleged improper action. A copy of the letter is put in the contracted provider’s file. Individuals in care will be notified and given assistance for referral to a new contracted provider for ongoing care as necessary.

NOTE: Contracted providers who are convicted of crimes involving sexual misconduct, or the violation of a member’s civil rights, or who are the subject of malpractice judgements or settlements, or licensure actions involving sexual misconduct or violation of a member’s civil rights, will undergo immediate review by ICA.


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5.7 Provider Terminations

Either Integrated Care Alliance or a contracted provider may choose to terminate the provider agreement.

If a contracted provider chooses to resign from the network, Integrated Care Alliance must be notified in writing as specified in the termination section of the Provider Agreement. Integrated Care Alliance will acknowledge receipt of the contracted provider’s request and confirm the disenrollment date.

If Integrated Care Alliance chooses to terminate a contracted provider, written notification or the disenrollment including the effective date will be given as specified in the Provider Agreement.

The following are the types of terminations that can be initiated by ICA: Termination for cause-administrative

Automatic termination

Non-renewal of provider agreement

Termination for cause-quality

5.7.2 Automatic Termination

Providers and individual practitioners will be immediately terminated upon the happening of any of the following events:

Insolvency or Dissolution: If the provider becomes insolvent, or the subject of a bankruptcy, receivership, reorganization, dissolution, liquidation or other similar proceeding.

Loss of License: The individual practitioner’s license issued by the state is revoked, suspended, surrendered or not renewed.

Conviction of fraud

Limited ability to practice: Final disciplinary action by a governmental authority or licensing board that impairs the professional’s ability to practice.

Death: The death of the practitioner.

5.7.3 Non-Renewal of Provider Agreement

ICA’s provider agreements are effective from the date specified in the contracted Provider Agreement, and

can be allowed to expire on the anniversary date with ninety (90) days’ notice to the contracted provider (unless prohibited by state regulations).

5.7.4 Right to Continuing Course of Treatment When Practitioner Leaves the Network

When a contracted provider resigns or is terminated from the ICA network, current ICA enrollees may have the right to continue an ongoing course of care with their current provider for a transitional period of up to ninety (90) days, subject to the employer's policy, practitioner’s consent to continue to accept the same

reimbursement rate and adhere to ICA policies and procedures, and the person’s benefit provisions.


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Individuals served through ICA enrollment should also be encouraged to contact ICA’s Customer Service Department to learn what options are available to them for continuing their treatment after the transition period.

5.8 Authorization for Services Not Covered

For services not covered by Integrated Care Alliance, LLC, please contact the Customer Service Department at (866) 724-7544 for a listing of possible referrals, current providers, and for information about the authorization process.

5.9 Staffing Standards

Contracted providers and their subcontractors must establish job descriptions, and follow staffing policies and procedures, and hiring practices that ensure only those individuals who meet the requirements of each position are hired. The contracted providers’ policies must reflect the most current Detroit Wayne Mental Health Authority’s policies related to Credentialing and Criminal Background Checks. All providers are required to follow all direction related to mandatory employee and volunteer training as put forth by the Detroit Wayne Mental Health Authority

6.0 BILLING POLICIES AND PROCEDURES 6.1 Claims Submission and Guidelines These policies and procedures are intended to be an initial source of information for contracted providers that submit electronic/paper claims to Integrated Care Alliance, LLC. Most questions are answered here or give direction as to where additional information exists. Prior to calling Integrated Care Alliance with claims questions please have this manual in front of you and ready to reference with claims support personnel.

6.1.1 Claims Submission Policy

Claims for services must be submitted electronically into the Integrated Care Alliance Reporting and Exchange System (ICARE System). Paper claims are accepted only for acute inpatient services and must be sent directly to:

Integrated Care Alliance, LLC Attn: Claims Department

3031 West Grand Blvd., Suite 555 Detroit, MI 48202-3082

(313) 748-7405 (FAX) Contracted providers are responsible for verifying each person’s eligibility. Claims payment is based on eligibility at the time the service is rendered. Neither prior verification of eligibility nor actual service authorizations by Integrated Care Alliance are guarantees of payment. Please refer to Section 2.0 for a detailed eligibility overview. Please refer to your Provider Agreement for covered services you have contracted for and the definition of services included in unit rates. (Exhibit A)


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Integrated Care Alliance accepts only those claims submitted electronically according to guidelines contained in the Integrated Care Alliance Reporting and Exchange System (ICARE System). Directions for submitting electronic claims can be found at www.icarealliance.org Contracted providers needing to return checks to Integrated Care Alliance should use the following address:


Attn: Finance Department 3031 West Grand Blvd., Suite 555

Detroit, MI 48202-3082

http://www.icarealliance.org/


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6.1.2 Electronic Claim Submission Requirements Integrated Care Alliance accepts electronic claim submissions from contracted providers for services rendered according to the specifications contained in the Integrated Care Alliance /ICARE EDI Specification materials. Integrated Care Alliance accepts electronic 837 Professional and Institutional files. A 835 electronic remittance advice/ Explanation of Benefits (E.O.B.) can also be printed by contracted providers through the claims submission process. If you are a contracted provider interested in learning how to submit claims electronically, please call ICA’s Customer Service Department at (866) 724-7544 to schedule training. There are additional instructions on the ICA’s website (www.icarealliance.org) relating to claims.

6.2 Claim Filing Requirements Integrated Care Alliance will adjudicate a clean (complete and error-free claim) as billing batches are received into the ICARE System. Batches are adjudicated daily by the Claim Adjudicators. Providers are to ensure that all documentation pertaining to the services rendered are complete, accurate, and available prior to submitting a claim for reimbursement. (Claims Policy C-004 Medicaid Claims Verification Audit Review)

If the documentation is not available upon request at an “onsite” audit, a 24 hour time frame will be enforced to submit requested documentation. If the documentation is not available upon request for a “sampling” of provider services audit, a 48 hour time frame will be enforced to submit the requested documentation. Upon the expiration time frame, documents not submitted to Integrated Care Alliance will be subject to a Debit/Credit Transaction, recouping the dollars due to non-compliance.The Integrated Care Alliance Acknowledgement Letter must accompany the documents submitted.

All original submissions of claims must be made within 60 days of the date of service Claims submission prior to the day of service being performed will be returned to the provider with the following explanation.

Claims are not accepted for a service until at least the day after the date of service.

6.2.1 Time Limit for Filing Claims Claims for “covered” outpatient services and emergency services must be submitted within sixty (60) days of the date of service to be considered for reimbursement. Claims for “ inpatient and diversionary” services must be authorized and submitted within sixty (60) days of the discharge date to be considered for reimbursement. Claims involving “coordination of benefits” (COB) must be submitted within thirty (30) days of the date of the other carrier’s notification of payment or denial. Provider is responsilbe to submit the EOB to ICA to ensure accurate billing is adjudicated and reimbursed. Payments will not typically be made for initial services billed later than sixty (60) days from the date of service and contracted providers are prohibited from billing beneficiaries for such services (see Reconsideration Review Process, Section 6.2.5).

http://www.icarealliance.org/


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6.2.2 Incomplete Claims/Batch(es) Integrated Care Alliance will deny claims/batches in the event of incorrect, or incomplete, required data elements.These claims/batches will be returned with an explanation to the provider for correction and resubmission through the adjudication process.

6.2.3 Resubmission of Denied Batch(es) Claims that are denied due to incorrect or incomplete data elements must be resubmitted for payment consideration within thirty (30) days from the date of the submission.

Contracted providers may resubmit batch(es) that were denied for incomplete or incorrect required data elements electronically utilizing the ICARE System. Providers may appeal a denial of payment due to the failure of filing a claim timely. The appeal must be made in writing to the Chief Financial Officer of Integrated Care Alliance and be made within (5) days of the date of the denial.

6.2.4 Adjustment of Claims Paid Incorrectly In the ICARE System, under Claims Submission, the Provider has an identifier labeled View All Batches & Claims. This section in the ICARE System allows the provider the capability to view all provider balances and allows the provider to review the Reconsideration Transaction in detail. The provider can print the Explanation of Benefits (EOB) for reference.

6.2.5 Reconsideration Review Process In accordance with Integrated Care Alliance contract, all claims must be submitted within sixty (60 )days of the date of service. This time limit for claims submission is measured from the last date of service or discharge date on which a claim is received. This does not mean the claim must be postmarked by day 60; this means that the claim must be physically, or electronically, delivered to Integrated Care Alliance by the close of business on day 60. Claims that are submitted within 60 days of the date of service or discharge that are denied due to incorrect or incomplete required data elements must be resubmitted for payment consideration within (30) days from the date of denial from Integrated Care Alliance through the batch process in the ICARE System.

Claims that are submitted beyond the (60) day time limit will be denied through the batch process. These claims may only be submitted for reconsideration through the Reconsideration Review Process as outlined below. It is necessary to complete a Reconsideration Review Form for each original submission. The form can be located in the forms section of the manual and on the website.

Complete form in full, as it would normally be completed

Include supporting letter explaining the reason(s) justifying the reconsideration of the 60-day time limit

Submit this information to Integrated Care Alliance at the following address or fax to (313) 748-7405


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Attn: Finance Department-CFO 3031 West Grand Blvd., Suite 555

Detroit, MI 48202-3082

The information will be reviewed for approval or denial. If denied the Provider will be notified within five (5) working days. Retroactive Contracted Provider Eligibility

If the Network Operations/Provider Relations Unit issues a contract for network participation on a retroactive basis, the Claims Department will approve waiver requests submitted within (60) days of the application approval date. A copy of the letter received from Integrated Care Alliance must accompany the reconsideration request. Retroactive Utilization Management Authorization for Service

If Integrated Care Alliance, LLC’s Utilization Management Department authorizes service on a retroactive basis, the provider must submit a Recosideration Review form within (60) days of the approval date. A copy of the authorization and letter must accompany the Reconsideration Review request.

Completing the Reconsideration Request Form

All items on the Recosideration Review Form are required. Incomplete forms will be returned.

a. PROVIDER NAME: Enter the name of the contracted provider that rendered the service and is seeking reimbursement.

b. PROVIDER ADDRESS: Enter the address of the contracted provider seeking reimbursement.

c. CONSUMER NAME: Enter the person’s name as it appears on the Integrated Care Alliance ID card or claim form. One waiver form must be submitted for each consumer served.

d. DATE OF SERVICE: Enter the date or dates of service. One review form can be submitted for multiple dates of service if the review request has the same reason for all claims.

e. BATCH NUMBER/ AMOUNT: Enter the claim’s Batch number as found on the system.

f. REASON: Place an "X" on the line that best describes service rendered. Requests marked “Other” that do not have an explanation will be returned to contracted providers for further information. A formal letter explaining the reason in detail must accompany the Reconsideration Review form.

g. SIGNATURE: The reconsideration request cannot be processed without a typed, signed, stamped, or computer-generated signature. "SIGNATURE ON FILE" is not accepted.

h. DATE: Indicate the date that the form is completed. The Reconsideration Request Form is a one (1) part form. As with a claim form, the contracted provider should make a copy for his/her records and send the original copy with the appropriate letter.

i. APPROVAL: The Chief Financial Officer (CFO) must approve the Reconsideration Review Form before the processing can occur. If approved the Debit/Credit Transaction will be submitted for processing. If denied the claim will be processed as a zero pay claim.

Reconsideration Review Request Processing

Prior to claims processing, all Reconisderation Requests will be reviewed to determine the appropriateness of the request. The reconisderation request will either be approved or denied. The approval of a reconsideration request does not exempt claims from the standard claim processing edits. After approval of a reconsideration request, a claim could still deny for reasons unrelated to the actual reconsideration request.


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6.2.6 Administrative Review Process Definition An Administrative Review is a request to review a denied authorization and/or claim based on a disagreement about the Integrated Care Alliance administrative policies and procedures. The following topics do not constitute acceptable basis for review through the Administrative Review process: Retroactive Provider Eligibility, Retroactive Person Eligibility, and Retroactive Clinical Authorization for Service. Instead, if your review request involves one of the reasons listed above, you must submit your request through the Reconsideration Review Process outlined in Section 6.0 of this manual.

Administrative Review Filing Procedures

Contact the Integrated Care Alliance Claims Department at (866) 724-7544 to rectify the problem that might have caused the denial of the authorization or claim. If the issue cannot be resolved to the contracted provider’s satisfaction, A Reconsideration Review form may be submitted.

Administrative Reviews must be submitted to Integrated Care Alliance within (60) days of the date of service, with a Reconsideration Review Form attached (Form is located in Form Section of this Provider Manual and on the ICA website). Reconsideration Review forms received later than (60) days from the date of service of the claim may be returned to the provider or submitted as a zero pay claim, in which case no further action will be taken by Integrated Care Alliance.

If the Administrative Review you are requesting concerns a claim or claims that have not met the original timely filing requirements, you must also complete the Reconsideration Review form & submit a letter detailing the reason the claim was not submitted within the required timely filing requirement.

The following supporting documentation must accompany the Reconsideration Review Form when applicable:

Explanation of Benefits (EOB) from primary insurance carrier

Time-stamped faxes or copies of authorizations

Other supporting documentation

Administrative Reviews must be submitted to the following address or fax to (313) 748-7405

Integrated Care Alliance, LLC Attn: Finance Department-CFO


Integrated Care Alliance may request additional information before rendering a decision. The contracted provider will be notified in writing of the final decision within (30) days from receipt of all required

documentation. 6.2.7 Coordination of Benefits Integrated Care Alliance processes all contracted provider claims involving Coordination of Benefits (COB) according to the Birthday Rule in compliance with state mandate. This rule states that if both parents have family coverage fewer than two different health plans, the primary carrier for dependents is the insurance of the parent whose birthday comes first in the calendar year. There are exceptions to this rule in certain circumstances involving divorce, custody and court orders.

The ICARE System will prompt Supports Coordinators to enter current health/insurance information when conducting annual assessments on the Person-Centered Plan of Support.

When a decision regarding reimbursement has been made by another insurance carrier, a copy of the disposition of payment or explanation of benefits (EOB) must accompany the HCFA 1500 claim submission.

Attachment of the disposition of payment or EOB is required with the UB92. However, Fields 50, 54, 58b and 58c must denote the disposition of the claim from the other insurance carrier.


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Service Authorization procedures outlined in Section 4.0 of this manual must be followed when providing services to an individual when COB is involved.

All timely filing rules are enforced based on the date of disposition from the other insurance carrier, but no later than 180 days from the date of service.

6.2.8 Ability to Pay

DWMHA service providers are required to annually assess fees for services for all consumers based on their Ability to Pay (ATP) in accordance with the Michigan Mental Health Code, and the Michigan Department of Community Health (MDCH) Administrative Rules.

State law requires that individuals with the financial means must pay a portion of the cost of services provided. This portion is referred to as the “Ability to Pay” (ATP) amount.

In order to remain in compliance with Sections 818 & 819 of the State of Michigan Mental Health Code, individuals are required to pay a portion of the cost of services provided based upon their annual Michigan Income Tax return.

If an individual is eligible and approved for the state’s Medicaid program they are automatically deemed to have a $0 ATP amount. However, if the individual is a Medicaid spend-down beneficiary, required income tax information must be submitted.

6.3 Special Billing Instructions 6.3.1 Covered Outpatient Professional Services Billed by Providers Contracted as Individuals All claims must comply with Integrated Care Alliance, LLC’s billing requirements specified in Section 6.0

6.3.2 Covered Outpatient Professional Services Billed by Providers Contracted as Facilities All claims must comply with Integrated Care Alliance billing requirements specified in Section 6.0

To avoid rejection of claims and assist with timely reimbursement, contracted providers must submit a separate claim for each treating practitioner.

Claim line items cannot span multiple outpatient dates of service.

Claims must include the appropriate assigned Integrated Care Alliance contracted provider.

6.3.3 Contracted Providers Are Prohibited From Billing for Missed Appointments Integrated Care Alliance does not authorize payment to contracted providers for missed appointments, nor are providers allowed to bill the person receiving services.

6.4 Billing Charts The following charts have been developed to assist contracted providers in complying with the billing requirements of Integrated Care Alliance, LLC.

6.4.1 Charts 1, 2 and 3

Charts 1 and 2 give detailed instructions on completing the following acceptable “paper” claims forms. Chart


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1 is HCFA 1500 Paper Claim Form Instructions and Chart 2 is UB92 Paper Claim Form Instructions. Chart 3 gives the HCFA Place of Service Codes.

6.4.2 Chart 1

Chart #1 HCFA 1500 Paper Claim Form Instructions

Block Number

HCFA1500

Field Type

Description Additional Information

1 Required Check applicable program

1a Required Insured’s ID number ICA ID Number

2 Required Patient’s Name Last name, first name, middle initial

3 Required Patient’s birth date (MM, DD, YY) and

sex (check box)

4 Not Required Insured’s Name Last name, first name, middle initial

5 Required Patient’s address Number, street, city, state, zip code, telephone

number with area code

6 Required Patient’s relationship to insured Check box: self, spouse, child or other

7 Not Required Insured’s Address Number, apartment number, street, city, zip

code, telephone number with area code

8 Required Patient’s Status Check boxes: single, married, other,

employed, full-time student, part-time student

9 Conditional Other insured’s name (if applicable) Last name, first name, middle initial

9a Conditional Other insured's policy or group number

(if applicable)

9b Conditional Other Insured’s Date of Birth (MM,

DD, YY) and Sex (if applicable)

9c Conditional Employer's Name or School Name

(If Applicable)

9d Conditional Insurance plan name or program name

(If Applicable)

10a-c Required Patient's condition related to

employment

Auto accident (place, state, other accident)

(check the boxes)

11 Not Required Insured's Policy, Group or FICA

Number (if applicable)

11a Not Required Insured's Date of Birth (MM, DD, YY)

and Sex (check box)


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Block Number

HCFA1500

Field Type


11b Not Required Employer's name or school name

(if applicable)

11c Not Required Insurance plan name or program name

(if applicable)

11d Required Is there another health benefit plan? Check "yes" or "no"

12 Required Patient's or Authorized Person's

Signature and Date On File

13 Required Patient's or authorized Person's

signature

Authorizing payment of medical benefits to

undersigned physician or supplier for services

described below.

14 Not required Date of current illness

15 Not required Date of same or similar illness

16 Not required Date client unable to work in current

occupation

17 Not required Name of referring physician or other

source (if applicable)

18 Not required Hospitalization dates related to current

services (if applicable)

Required only if hospital stay involved

19 Not required Former control number (if applicable) Original control number assigned by


21 Required Diagnosis or Nature of Illness or Injury Relate items 1 and 2 to item 24E by line item.

Use DSM-IV.

23 Not required Prior Authorization Number

(if applicable)

24a Required Date of Service If billing Outpatient Professional services, no

date range billing is allowed.

24b Required Place of service code

(standard HCFA POS codes)

Refer to 1500 service grid for acceptable

standard HCFA POS codes.

24d Required Procedure code (CPT-4) Refer to 1500 service grid and provider

agreement for contracted service codes.

24e Required Diagnosis Code: 1, 2, 3 or 4

24f Required Charges

24g Required Days or Units

25 Required Federal Tax ID Number


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Block Number

HCFA1500

Field Type


26 Optional Patient Account Number

27 Required Accept Assignment (check box)

28 Required Total Charges

29 Not required Amount paid by the patient and/or

another payer for services billed

30 Not required Balance due

31 Required Signature of physician or supplier Include degrees or credentials and date of

signature.

Note: the person rendering care must sign;

computer generated facsimile accepted.

32 Required Name and address of facility where

services were rendered

If other than home or office

33 Required Physician's/supplier's address Billing name, address, zip code and telephone

number

33

PIN #

Required Servicing Provider ICA Number. If contracted as an individual, then ICA

assigned provider number.

If contracted as a facility, and billing

outpatient professional services: servicing

provider must contain one of the following

licensure level codes denoting the appropriate

licensure level of the servicing provider:

0300010 =Masters/MSW/LICSW

0300040 = MD/DO

0300050 = PhD/PsyD/EdD

0300080 = RNCS

33

Group #

Required ICA Assigned Pay To Provider Number ICA Assigned Pay To Provider Number


50

6.4.3 Chart 2 Chart 2: UB92 Paper Claim Form Instructions

Block: UB92

Field Type


1 Required Provider name, address, telephone

number

3 Optional Patient account number

4 Required Type of bill 11x = Place of Service 21 (Inpatient)

13x = Place of Service 22 (Outpatient)

33x = Place of Service 12 (Home)

5 Required Federal Tax ID Number

6 Required Statement Covers Period The date of admission to the date of discharge.

7 Required Covered Days Total number of days represented by the period

indicated in Block 6 less the day of discharge,

transfer or death for inpatient claims.

12 Required Patient Name

13 Required Patient's Address

14 Required Patient's Birth date (MM,DD,YY)

15 Required Patient's Sex

16 Required Marital Status

17 Required Admission Date (MM,DD,YY)

19 Required Admission Type 1 = Emergency; 2 = Urgent; 3 = Elective; 9=

Unknown

20 Required Admission Source 1 = Physician Referral 6 = Transfer f/ Facility

2 = Clinic Referral 7 = Transfer from ER

3 = HMO Referral 8 = Transfer from Court

4 = Transfer f/ Hospital 9 = Unknown

5 = Transfer from SNF


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CHART 2 UB92 PAPER CLAIM FORM INSTRUCTIONS (Continued)

Block UB92

Field Type Description Additional Information

22 Required Discharge status 01 = Routine discharge 07 = Left AMA

02 = Dischgd/Transfd 09 = Adm. Inpat.

03 = Dischgd/Transd to SNF 20 = Expired

04 = Dischgd/Transfd to ICF 21 - 29 to be defined

06 = Dischg/Transfd to home 30 = Still Patient

37a Conditional Former control

number (if

applicable)

Original control number assigned by ICA

42 Required Revenue code

(if applicable)

Refer to UB92 service grid and provider agreement

for contracted service codes

43 Required Revenue description Refer to UB92 service grid and provider agreement

for contracted service codes

44 Required HCPCS code: for

outpatient

professional services

only

(if applicable)

Refer to UB92 service grid and provider agreement for contracted

outpatient professional service codes

45 Required Service date Actual date service rendered

46 Required Units of service Quantitative measure of service rendered by revenue category to

or for the member to include items, such as number of

accommodation days.

47 Required Total charges Total charges by Service Code Category and pertaining to the

related revenue codes for the current billing period as entered in

the statement covers period

50 Required Payer Identification Name identifying each payer organization from which the

provider might expect some payment for the bill. The first line is

the Primary Payer Identification. Second line is Secondary Payer

Identification. Third line is Tertiary Payer Identification.

Providers should list multiple payers in priority sequence

according to the priority the provider expects to receive payment

from these payers.

51 Required Provider Number ICA Assigned Pay To Provider Number


52

CHART 2: UB92 PAPER CLAIM FORM INSTRUCTIONS (Continued)

Block

UB92

Field Type


52 Required Release of Information

Authorization Indicator

53 Required Assignment of Benefits

Authorization Indicator

A code indicating whether the provider has on file a signed

statement permitting the provider to release data to other

organizations in order to adjudicate the claim. Code Structure:

A, B and C indicators refer to the payers in Block 50 on the

UB92.Y = Yes – The hospital has signed written authority to

release medical/billing information for the purposes of claiming

insurance benefits. N = No Release: The hospital does not have

permission to release any medical/billing information. R =

Restricted or Modified Release: The hospital has limited or

restricted authority to release some medical/billing information

for the purpose of claiming insurance benefits.

54 Conditional

Prior payments

(if applicable)

Whether the provider has a signed form authorizing the third

party payer to pay the provider. A, B & C indicators refer to

Block 50 on the UB92. Y = Yes, N = No.

58 Required Insured's name

59 Required Patient’s relationship to

insured

Enter the standard UB92 code that best defines the relationship of the patient to the insured.

60 Required Insured’s Identification

number

Certificate/Social Security Number/Health Insurance Claim ID

Number

61 Required Group name Name of the group or plan through which the insurance is

provided to the insured (if applicable)

67 Required Principal diagnosis code Principal Diagnosis Code (DSM-IV) describing the principal

diagnosis that exists at time of admission or develops

subsequently that has an effect on the length of stay

68 Required Other diagnosis code Secondary diagnosis code (if applicable)


53

CHART 2: UB92 PAPER CLAIM FORM INSTRUCTIONS (Continued)

Block# UB92

Field Type


82 Required Attending Physician

ID. Provider Number

Enter the name and/or the assigned number of the attending

physician.

If Billing for Outpatient Services which have a varying rate of

reimbursement by Licensure Level Code one of the following codes

must be used to denote the licensure of the servicing provider

0300010 = Masters/MSW/LICSW

0300040 = MD/DO

0300050 = PhD/PsyD/Ed.D

0300080 = RNCS

Note: Licensure level codes are required for Outpatient Professional

Services billed by providers contracted as facilities. Individually

contracted providers who are billing under their own Provider

Number must use the same ICA Assigned Provider Number in both

the "Pay To" and "Servicing Provider Number" fields.

85 Required Provider

Representative

Signature

An authorized signature indicating that the information entered on

the face of the bill conforms to the authorization on the back of the

bill.


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6.4.4 Chart 3 Chart 3: HCFA Place of Service Codes

Place Of Service Code

Place Of Service Code Description

11 Office

12 Home

14 Specialized Residential - AFC

19 School

21 Inpatient, General Hospital

22 Outpatient, General Hospital

23 Emergency Room, General Hospital

32 Nursing Facility

33 Custodial Care Facility

50 Federally Qualified Health Center

51 Inpatient Psychiatric Facility

52 Partial Hospital Psychiatric Facility

53 Community Mental Health Center

54 Intermediate Care Facility

55 Residential Substance Abuse Treatment Center

56 Residential Treatment Center

99 Other

6.5 Contracted Provider Mergers and Acquisitions

If a contracted provider merges with another provider, contracted or otherwise, you must notify the President & CEO of Integrated Care Alliance in writing.

If you do not notify us within thirty (30) days your claims will be denied through the claims adjudication process.

Please send changes to the following address or fax (313)748-7405

Integrated Care Alliance, LLC Attn: Finance Department


All changes must have an effective date of the change.


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7.0 GLOSSARY OF TERMS Access Line: The Integrated Care Alliance toll-free number (866) 724-7544, which provides access to services for individuals and contracted providers. Administrative Denial: A situation in which care is not authorized due to procedural or contractual issues (e.g., contracted provider fails to participate in an authorization review; benefits do not cover requested care). Administrative Appeal: A situation in which a person, person’s representative, or contracted provider requests that care originally not authorized due to procedural or contractual issues (e.g., contracted provider fails to participate in an authorization review, benefit do not cover requested care) be approved.

Adverse Action: A decision that results in a denial, reduction, suspension or termination of Medicaid-covered or MDCH-defined services or other benefits.

Alternate Dispute Resolution: A Michigan Department of Community Health (MDCH) review available to individuals not eligible for Medicaid coverage. This process is an impartial review of an adverse action decision by Authority, MCPN or contractor. This process can only be utilized after all Local Dispute Resolution processes have been exhausted.

Applicant: An individual or his or her legal representative who makes a request for mental health services, treatment/services/supports available in the array of services provided by the Authority’s network of contractors.

Beneficiary: A person who is eligible for and receiving Medicaid benefits.

Care Management: The identification of a person’s treatment needs, referral of a person to appropriate contracted providers for assessment and treatment, and consultation with contracted providers in treatment planning to achieve optimal Person outcome.

Clean Claims: Claims that are correct, complete, and have all required data elements prior to submission.

Clinical Denial: A determination made by a physician, Integrated Care Alliance or its agent, not to certify requested services. This determination is based on medical necessity. Clinical Appeals

Expedited Appeal a request to review a decision concerning the admission, continued stay, or other behavioral health care services of a person who has received emergency services but has not been discharged from a Facility, or when a delay in decision making might seriously jeopardize the life or health of the Person.

Level I a telephonic or written request by a contracted provider, person or person’s representative to reverse a non-authorization (denial) decision. With Level I appeals, determinations are made by a Physician Advisor not previously involved in the case and are based on medical necessity determination.

Level II a telephonic or written request by a contracted provider, person or person’s representative to reverse a non-authorization (Level I denial) decision. Second-level appeals are reviewed by a panel comprised of two or more individuals who were not involved in the prior decision. The person has the right to appear before the panel. This type of appeal can only be made if the Level I appeal process has occurred and is based on medical necessity.


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Concurrent Review: A review to determine the Medical Necessity and appropriateness of continued treatment at the present level of care.

Consumer Advisory Board: A panel of individuals and/or their family members and advocates who meet as often as needed, or quarterly, to discuss quality of services issues and consumer satisfaction, and make suggestions regarding improvements to ICA.

Contracted Provider: Any hospital, institution, group of practitioners, individual practitioner or other healthcare professional providing Services.

Covered Individual: A person who is eligible and enrolled for coverage under Integrated Care Alliance, LLC

Covered Services: Services, which are Medically Necessary and covered as benefits by Integrated Care Alliance, LLC.

I/DD: means either of the following:

If applied to an individual older than 5 years, a severe, chronic condition that meets all of the following requirements:

is attributable to a mental or physical impairment or a combination of mental and physical impairments is manifested before the individual is 22 years old is likely to continue indefinitely results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity, and economic self-sufficiency reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration, and are individually planned and coordinated. If applied to a minor from birth to age 5, a substantial developmental delay or a specific congenital or

acquired condition with a high probability of resulting in I/DD as defined above if services are not provided.

Discharge Planning: The evaluation of a person’s mental health or substance abuse service needs, or both, in order to arrange for appropriate care after discharge from one level of care to another level of care.

Dispute: a complaint made by a person or their representative, alleging denial, reduction, suspension or termination of any services and supports managed and/or delivered by a Community Mental Health Service Program (CMHSP) (i.e., this Authority and contractor network); that may be resolvable by internal, local procedures (i.e., clinical second opinion, reconsideration review and appeal to the Authority); may lead to filing of a recipient rights complaint against the contractor; or may involve the filing of a Fair Hearing request to the State of Michigan Administrative Tribunal by a Medicaid beneficiary instead of or at the same time as 1 and 2 above.

Emergency: The sudden and unexpected onset of a condition manifesting itself by acute symptoms so severe (including severe pain) that a prudent layperson possessing average knowledge of health and medicine could reasonably expect that without immediate medical attention; (i) his/her health (physical or mental) would be in serious jeopardy; (ii) his/her body organs or parts or some bodily function would be seriously impaired; or (iii) he/she would experience serious dysfunction of any bodily organ or part.

External Review: A situation in which a person who remains aggrieved by a clinical adverse determination and has exhausted all available internal appeal processes may seek further review by a review panel or


57

independent review organization. This avenue of appeal is not available to contracted providers. Grievance: A structured process to request reconsideration of a decision rendered by the Authority, its contractors or their subcontractors, regarding denial, reduction, suspension or termination of mental health or substance abuse services or supports. Grievance and Appeals Coordinator: Employee(s) responsible for assuring effective coordination of all complaints and appeals; tracking and trending the data; assisting in the generation of regularly scheduled reports on complaints for review by the Executive Director and Quality Management Director; and ensuring avoidance of conflict of interest or purpose related to complaints. Guardian: An individual appointed by the court to exercise specific powers over an individual who is a minor, legally incapacitated or developmentally disabled.

Grievance: A telephonic or written request by a person or contracted provider to reverse a resolution rendered about a complaint. In a grievance, a senior Integrated Care Alliance manager provides a second level review and resolution of the concerns raised. An informal grievance is a grievance that is filed directly to the service provider or ICA. A formal grievance is a grievance that is filed directly with Detroit Wayne Mental Health Authority’s Customer Service Office. Grievances are categorized into the following categories:

Quality of care Access to staff Access to services Financial matters Customer service Interpersonal relationships with therapist, psychiatrist, case manager, and staff etc. Clinical issues Environment Delivery of services Program issues Transportation Other

Level of Care: The duration, frequency, location, intensity and/or magnitude of a treatment setting, treatment plan, or treatment modality, including, but not limited to: (i) acute care facilities; (ii) less intensive inpatient or outpatient alternatives to acute care facilities such as residential treatment facilities or intensive outpatient programs; (iii) outpatient visits; or (iv) medication management.

Local Dispute Resolution: The process for resolving complaints, disputes and grievances at the level closest to the service delivery (Authority, MCPN and independent contractor). It provides for a reconsideration review involving adverse actions, and Person dissatisfaction with services.

MCPN: Manager of Comprehensive Provider Network

Mediation: A private, informal dispute resolution process in which an impartial, neutral individual, in a confidential setting, assists parties in reaching their own settlement of issues in a dispute and has no binding decision-making power.

Medicaid Fair Hearing: An impartial review process maintained by the MDCH Administrative Tribunal, that ensures Medicaid-covered beneficiaries or their legal representatives involved in a Community Mental Health Services Program Managed Care Plan have the opportunity to appeal adverse action decisions of the Authority, MCPN or contractor to deny, suspend, reduce or terminate Medicaid-covered services. A Medicaid Beneficiary may request a hearing at any point during the rendering of mental health services or supports.


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Medically Necessary or Medical Necessity: “Medically necessary” mental health, developmental disabilities, and substance abuse services are supports, services, and treatment:

Necessary for screening and assessing the presence of a mental illness, I/DD or substance use disorder; and/or

Required to identify and evaluate a mental illness, I/DD or substance use disorder; and/or Intended to treat, ameliorate, diminish or stabilize the symptoms of mental illness, I/DD or substance use

disorder; and/or Expected to arrest or delay the progression of a mental illness, I/DD, or substance use disorder; and /or Designed to assist the individual to attain or maintain a sufficient level of functioning in order to achieve

his/her goals of community inclusion and participation, independence, recovery, or productivity The determination of medically necessary support, service or treatment must be: Based on information provided by the individual, individual’s family, and/or other individuals (e.g.,

friends, personal assistants/aide) who know the individual; and Based on clinical information from the individual’s primary care provider or health care professionals with

relevant qualifications who have evaluated the individual; and For beneficiaries with mental illness or developmental disabilities, based on person-centered planning,

and for beneficiaries with substance us disorders, individualized treatment planning; and Made by appropriately trained mental health, developmental disabilities, or substance abuse

professionals with sufficient clinical experience; and Made within federal and state standards for timeliness; and Sufficient in amount, scope and duration of the services(s) to reasonably achieve its/their purpose

Supports, services and treatment authorized by the PIHP must be:

Delivered in accordance with federal and state standards for timeliness in a location that is accessible to the beneficiary; and

Responsive to particular needs of multi-cultural populations and furnished in a culturally relevant manner; and

Responsive to the particular needs of beneficiaries with sensory or mobility impairments and that they are provided with the necessary accommodations; and

Provided in the lease restrictive, most integrated setting. Inpatient, licensed residential or other segregated settings shall be used only when less restrictive levels of treatment, service or support have been, for that beneficiary, unsuccessful or cannot be safely provided; and

Delivered consistent with, where they exist, available research findings, health care practice guidelines, best practices and standards of practice issued by professionally recognized organizations or government agencies

Using criteria for medical necessity, a PIHP may:

Deny services a) that are deemed ineffective for a given condition based upon professionally and scientifically recognized and accepted standards of care; that are experimental or investigational in nature; or for which there exists another appropriate, efficacious, less-restrictive and cost-effective service, setting or support, that otherwise satisfies the standards for medically-necessary services; and/or

Employ various methods to determine amount, scope and duration or services, including prior authorization for certain services, concurrent utilization reviews, centralized assessment and referral, gate-keeping arrangements, protocols, and guidelines


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Medicare Member: A person who is enrolled in a Medicare Plan.

Contracted Provider: (a) a provider who has: (i) met Integrated Care Alliance credentialing and re-credentialing standards; (ii) entered into a provider agreement with Integrated Care Alliance or its agent, or contracted as an independent contractor with ICA ; (iii) agreed to accept the rate or fee agreed to with Integrated Care Alliance as payment in full for covered services provided to individuals; (iv) agreed to hold individuals harmless from the payment of any amount owed ICA ; and, (v) agreed to cooperate with Integrated Care Alliance regarding Quality Management and Utilization Review procedures incident to Integrated Care Alliance arrangement of services

Peer Advisor/Physician Advisor: Experienced senior-level clinicians, many of whom remain active in private practice. They are board certified in their specialty areas and maintain a current knowledge of behavioral health research findings and nationally recognized practice guidelines. Licensed clinical psychologists provide peer reviews for psychological testing and outpatient treatment. Only Physician Peer Advisors and the Medical Director can render a non-authorization decision. Peer Advisors report to the Medical Director and perform their reviews as designees of the Medical Director.

Performance Standards: Integrated Care Alliance established quality improvement initiatives that reflect “Best Practice” treatment standards and are the quality indicators that ICA, in conjunction with contracted providers, is expected to improve upon in any given year.

Person(s): Individuals who are currently receiving treatment/services/supports within ICA’s network of contractors and subcontractors.

Person: An individual who receives mental health services from MDCH, a community mental health services

program, or a facility; or from a provider that is under contract with the department or a community mental health services program.

Person-Centered Planning: A process for planning and supporting the individual receiving services that builds upon the individual’s capacity to engage in activities that promote community life and that honor the individual’s preferences, choices, and abilities. The person-centered planning process involves families, friends, and professionals as the individual desires or requires.

Person Centered Planning Satisfaction Questionnaire: A feedback form to be completed at the end of the person-centered individual support plan meeting, which provides feedback related to the person’s satisfaction with scheduling, content and outcomes of the planning process.

Person Satisfaction Survey: A questionnaire made available in an understandable fashion and completed by individuals/individuals’ representatives, which measures the level of satisfaction with the services provided by ICA.

Pre-certification: A clinical decision that establishes the Medical Necessity and appropriateness of treatment with the Integrated Care Alliance clinical criteria prior to commencement of mental health substance abuse care. This review should occur immediately following a contracted provider’s evaluation and is authorized based on Medical Necessity of the proposed requested level of care. Based on clinical data, the Clinical Care Coordinator will do one of the following:

Authorize the treatment based on medical necessity

Suggest an alternate level of care

Refer to peer advisor


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Provider Agreement: A binding contract between Integrated Care Alliance and a contracted provider.

Recipient Rights: In addition to the rights, benefits, and privileges guaranteed by other provisions of law, the Michigan State constitution of 1963, and the constitution of the United States, a recipient of mental health services shall have the rights guaranteed by Chapter 7 of the Michigan Mental Health Code (Act 258 of the Public Acts of 1974 as amended)

Recipient Rights Complaint: Any complaint by a person or an individual acting on behalf of a person alleging violation of recipient rights as defined in the Mental Health Code and its Administrative Code.

Reconsideration/Peer Review: Reconsideration is the final step of the initial non-authorization process, and as such, it is not considered an “appeal.” A reconsideration through a Peer Reviewer must always be offered before any non-authorization opinion rendered by a ICA peer reviewer becomes a non-authorization decision.

Responsible Mental Health Authority: The MCPN or contractor that has primary responsibility for the Person’s care or for the delivery of services or supports to that person.

Root Cause Analysis: A part of the clinical peer review process to identify basic and/or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes not individual performance. Second Opinion: A request for reconsideration when an applicant is determined to be ineligible for any mental health services or when an applicant or person is determined to be ineligible for admission to a psychiatric hospital.

Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Criteria to determine a sentinel event are:

Death of recipient-Death which does not occur as a natural outcome to a chronic condition (e.g., terminal illness) or old age

Physical illness requiring admissions to hospitals. This does not include planned surgeries, whether inpatient or outpatient. It also does not include admissions directly related to the natural course of the Person’s chronic illness, or underlying condition. For example, hospitalization of an individual who has a known terminal illness in order to treat the conditions associated with the terminal illness is not a sentinel event

Serious challenging behaviors are those not already addressed in a treatment plan and include significant (in excess of $100) property damage attempts at self-inflicted harm or harm to others, or unauthorized leaves of absence

Accidents requiring visits to emergency rooms, medical-centers and urgent care clinics/centers and/or admissions to hospitals. This will include incidents of abuse, neglect, or serious injuries that require medical attentions

Any arrest or conviction. Police transport to a screening center on a petition is not an arrest. Arrest and convictions are to be reported as separate incidents

Medication Errors: Means: a) wrong medication; b) wrong dosage c) missed dosage, which resulted in death or serious injury or the risk thereof It does not include instances in which Individuals have refused medication

Serious Harm: “physical damage suffered by a recipient that a physician or registered nurse determines caused, or could have caused, the death of a recipient, caused the impairment of his or her bodily functions, or caused the permanent disfigurement of a recipient.

Supports Coordination: Planned face-to-face and related contacts including activities that assure:


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The needs and desires of the person are elicited

The supports and services needed and desired by the consumer are identified and implemented

Employment and housing concerns are addressed

Person centered planning is provided

Social networks are developed

Natural and community supports are used

Appointments and meetings are scheduled

Income benefits are maximized

The quality of supports and services, as well as the health and safety of the consumer, are monitored

Individual plans of service are reviewed at intervals stipulated during the planning

Activities are clearly and professionally documented

Supports coordination does not include activities defined as supported employment, prevocational services, community living supports, habilitation education services or out of home non-vocational habilitation

Supports coordination is viewed as part of the overall service plan implementation and/or as a vehicle to assure the initiation of other services

Utilization Management Coordinator: A professionally qualified licensed social worker, psychiatric nurse or other clinically licensed professional who is employed by Integrated Care Alliance or its agent to perform Case Management and Utilization Review functions.

Utilization Review: A process in which established criteria are used to recommend or evaluate services provided in terms of cost-effectiveness, necessity, and effective use of resources.


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Attachment A

Forms

Integrated Care Alliance Release of Information Form

Reconsideration Review Form


63

Provider Primary Care Provider State Authority

Family Member

Other:________

_________

Name: Name: Name:

Address:

Address:

Address:

Phone: Fax: Phone: Fax: Phone: Fax:

I, (or I on behalf of) _____________________________________________________________________ (Print Person’s Name and Address)

give permission to the individuals or organizations listed above to exchange information about my medical history.

This includes my diagnosis and/or treatment related to alcohol abuse, substance abuse, mental health or psychiatric

care. This does NOT include results of any blood test for HIV antibodies or any other HIV or AIDS related

information. The purpose of this release of information is to allow the individuals or organizations to assure continuity

of care among my health care providers, including carrying out discharge planning arrangements; to carry out

utilization review and quality assurance activities; and to determine clinical eligibility for covered benefits; and to

make payment decisions.

If there are any limitations about the release of information, they are written here: _____________

______________________________________________________________________________

I may cancel this agreement at any time except if the information has already been released. If not canceled, this

agreement will end one year from the date written below.

________________________________ __________________________________ (Signature of Witness) (Signature of Member/Guardian/Authorized Representative)

________________________________ (Date)

Refusal to Release Information

I do not give permission for the release of information as described above. However, I understand that, if I do not

allow my providers to exchange information about me, which may limit their ability to fully coordinate my care. I

understand that, in an emergency situation, my providers may exchange information about me to the extent

allowed by law.

Prohibition on Re-disclosure

To person receiving released information:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making

any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise

permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict

any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.


Release of Information Form

Person’s Name: ____________________________________________ Date of Birth: ____________________

Insurance: Insurance ID #: ____________________


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Type of Service: Inpatient

Other

Date of month (s) range:

Please note that a formal letter and copy of claim (s) explaining the reasons for this review must be attached to this form along with

documentation that supports the review request. This may include, but is not limited to, reference to conversations

with ICA employees, ICA authorization letters, remittance advices, or other materials deemed important to

substantiate your review request. ( ATTACH LETTER)

Provider Signature: _____________________________________ Date: _________________

____/____/_____

Marcia Quainton, CFO Date: ____________ Approved Denied

Comment:

C-002a

$ Amount:______________


Reconsideration Review Form - 60 day - Zero Pay Claims

Provider Name:

Provider Address:

Contact Person:

Telephone #:

Extension #:

INTEGRATED CARE ALLIANCE ONLY

Received Date:

Date(s) of Service :

Supports Coordination

Community Living Support

Service (s) to be reviewed

Residential

1:1 StaffingSkill Building

Consumer Name:____________________________ Batch #_________


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INTEGRATED CARE ALLIANCE

Level of Care Manual 2016

Attachment B


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1.00 Inpatient Mental Health

Acute inpatient mental health treatment represents the most intensive level of psychiatric care. Multidisciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed and psychiatrically supervised treatment environment. Twenty-four hour skilled psychiatric nursing care, daily medical care, and a structured treatment milieu are required. The goal of acute inpatient care is to stabilize individuals with a I/DD who display acute psychiatric/behavioral conditions associated with a relatively sudden onset and a short, severe course, or a marked exacerbation of symptoms associated with a more persistent, recurring disorder. Typically, the individual poses a significant danger to self or others, or displays severe psychosocial dysfunction. Special treatment may include physical and mechanical restraint, seclusion, and a locked unit.

Criteria

Admission Criteria

All of the following are necessary for admission to this level of care:

1. Individual has been evaluated by a licensed clinician and demonstrates symptomatology consistent with a current DSM-IV (AXES I-V) diagnosis that requires and can reasonably be expected to respond to therapeutic intervention.

2. Individual has a severe, chronic condition that is attributable to a mental

or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:

Self-care

Receptive and expressive language

Learning

Mobility

Self-direction

Capacity for independent living

Economic self-sufficiency

3. Individual must demonstrate a need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and need to be individually planned and coordinated

4. Individual exhibits significant inability to attend to age appropriate

responsibilities, and there has been a serious deterioration/impairment of interpersonal, familial, and/or educational functioning due to an acute psychiatric disorder or severe developmental disturbance.


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Admission Criteria (Cont.)

There is evidence of actual or potential danger to self or others or severe psychosocial dysfunction as evidenced by at least one of the following:

5. A suicide attempt that is serious by degree of lethality and intentionality or suicidal ideation with a plan and means. Impulsive behavior and the persistent pattern of this behavior increase the need for consideration of this level of care. Assessment should include an evaluation of:

a. the circumstances of the suicide attempt or ideation; b. the method used or contemplated; c. statements made by the individual; and d. the presence of continued feelings of helplessness and/or

hopelessness, severely depressed mood, and/or recent significant losses.

e. availability of responsible support systems

6. A persistent pattern of assaultive threats or behavior, resulting from an Axis I disorder, with a clear risk of escalation or future repetition (including destruction to property, setting fires, etc.)

7. Recent history of significant self-mutilation (chronic), significant risk-

taking, or loss of impulse control resulting in danger to self or others. 8. Recent history and persistent pattern of violence resulting from an Axis I

or Axis II (Borderline Personality) disorder. 9. Command hallucinations (chronic) directing harm to self or others. 10. Disordered/bizarre behavior or psychomotor agitation or retardation that

interferes with the activities of daily living to such a degree that the individual cannot function at a less intensive level of care.

11. Disorientation or memory impairment that is due to an Axis I disorder

and endangers the welfare of the individual or others.

12. The individual manifests gravely disabling/incapacitating functional impairments or severely and pervasively impaired personal development that constitute a risk to the individual of victimization in an alternative care environment.

13. Inability to maintain adequate nutrition or self-care due to a developmental disability and family/community support and services cannot provide the essential care needed. 14. The individual has experienced severe or life-threatening side effects of atypical complexity from using therapeutic psychotropic drugs.


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Exclusion Criteria Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual can be safely maintained and effectively treated in an acute inpatient setting or at a less intensive level of care.

2. Symptoms result from a medical condition that warrants a

medical/surgical setting for treatment.

3. The individual exhibits serious and persistent mental illness and is not in an acute exacerbation of the illness.

4. The primary problem is social, economic (e.g., housing, family conflict,

etc.), or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration.

Continued Stay Criteria ALL of the following criteria are necessary for continuing treatment at this level of care:

1. The individual's condition continues to meet admission criteria for acute

inpatient care and no other less intensive level of care would be adequate.

2. Close and continuous skilled medical observation and supervision are

necessary to monitor and/or make changes in psychotropic medications.

3. Close and continuous skilled medical observation is necessary due to otherwise unmanageable side effects of psychotropic medications.

4. Individual exhibits frequent and/or recent behavior or statements

suggesting an impulse or wish to harm self or others and continues to demonstrate generally poor impulse control and/or has continued to require periods of physical restraints, seclusion, one-to-one, and/or other close monitoring activities.

5. A comprehensive multi-modal therapy plan is needed, requiring close

medical supervision and coordination, due to its complexity and/or the severity of the individual’s signs and symptoms,

6. IPCPOS (Individual Person Centered Plan of Service)/Treatment Plan is regularly reviewed and revised and addresses current, prioritized problems/needs, and is being followed by the staff responsible for implementing the treatment services.

7. IPCPOS/Treatment Plan reflects consistent progress towards completing

treatment goals, there is aggressive and continuous evaluation of the patient’s response to the plan, timely modifications are made, as indicated, and the treatment focus/goal is stabilization or reduction of those prioritized psychological mental/behavioral impairments so that the individual can be managed successfully at a lower level of care.

8. IPCPOS/Treatment Planning is individualized and appropriate to the

individual's changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated.


69

9. All services and treatment are carefully structured to achieve optimum results in the most time-efficient manner possible consistent with sound clinical practice.

10. Progress in relation to specific symptoms or impairments is clearly

evident and can be described in objective terms, but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress and/or psychiatric/medical complications are evident.

11. Care is rendered in a clinically appropriate manner, and focused on the

individual's behavioral and functional outcomes as described in the discharge plan.

12. When medically necessary, appropriate psychopharmacological

intervention has been prescribed and/or evaluated.

13. There is documented active discharge planning.

14. There are documented active attempts at coordination of care with the Behavioral Health Provider and the PCP (primary care physician), when Appropriate

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. IPCPOS/Treatment plan goals and objectives have been substantially met.

2. The individual no longer meets admission criteria or meets criteria for a

less intensive level of care. 3. Consent for treatment is withdrawn and, either it has been determined

that involuntary inpatient treatment is inappropriate, or the court has denied continued involuntary inpatient treatment.

4. Support systems that allow the patient to be maintained in a less

restrictive treatment environment have been thoroughly explored and/or secured.

5. The individual's physical condition necessitates transfer to a medical

facility.

6. The individual, family, legal guardian and/or custodian are competent but non-participatory in treatment or in following program rules and regulations. The non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues. In addition, either it has been determined that involuntary inpatient treatment is inappropriate, or a court has denied a request to issue an order for involuntary inpatient treatment.

7. The individual is not making progress toward treatment goals and there

is no reasonable expectation of progress at this level of care.


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2.00 State Inpatient (Long Term) Mental Health

State hospital inpatient mental health services for adults, adolescents and children are provided for those individuals who require a longer length of treatment to stabilize their condition than is offered in acute inpatient settings. Individuals requiring this most intensive level of care display signs and symptoms of a serious psychiatric disorder or I/DD, demonstrating functional impairments, and manifesting a degree of clinical instability/risk that, either individually or collectively, are of such severity that treatment in an alternative setting would be unsafe or ineffective. Active treatment is directed toward stabilizing or diminishing those psychological/mental/behavioral impairments that cannot be managed at a lower level of care. Multidisciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed and psychiatrically supervised treatment environment. There is twenty-four hour skilled psychiatric nursing care, daily medical care, and a structured treatment milieu. Treatment may include physical and mechanical restraint or seclusion

Criteria

Admission Criteria


a. Individual has been evaluated by a licensed clinician and demonstrates symptomatology consistent with an ongoing diagnosis of severe psychological/mental, or emotional disorder classified under current DSM-IV (AXES I-V) diagnosis and requires a longer length of treatment in order to stabilize the condition, and

b. The person must have a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:

Self-care


Learning’

Mobility

Self-direction


Economic self-sufficiency, and

c. The individual must demonstrate a need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and need to be individually planned and coordinated, and

d. Individual’s self-care and independent functioning, consistent with the

stage of development relative to the individual’s age, are gravely disrupted due to lack of ability or willingness and the individual consistently requires assistance with eating/personal hygiene/dressing, and other essentials of daily living, beyond reasonable, age/stage-appropriate verbal prompting.


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Admission Criteria (Cont.)

There is evidence of actual or potential danger to self or others or severe psychosocial dysfunction as evidenced by at least one of the following:

e. A suicide attempt that is serious by degree of lethality and intentionality or suicidal ideation with a plan and means. Impulsive behavior and the persistent pattern of this behavior increase the need for consideration of this level of care. Assessment should include an evaluation of:

1. the circumstances of the suicide attempt or ideation; 2. the method used or contemplated; 3. statements made by the individual; and 4. the presence of continued feelings of helplessness and/or

hopelessness, severely depressed mood, and/or recent significant losses.

5. availability of responsible support systems

f. A persistent pattern of assaultive threats or behavior, resulting from an Axis I disorder, with a clear risk of escalation or future repetition (including destruction to property, setting fires, etc.)

g. Recent history of significant self-mutilation (chronic), significant risk-

taking, or loss of impulse control resulting in danger to self or others. h. Recent history and persistent pattern of violence resulting from an Axis I

or Axis II (Borderline Personality) disorder. i. Command hallucinations (chronic) directing harm to self or others.

j. Disordered/bizarre behavior or psychomotor agitation or retardation that

interferes with the activities of daily living to such a degree that the individual cannot function at a less intensive level of care.

k. Disorientation or memory impairment that is due to an Axis I disorder

and endangers the welfare of the individual or others.

l. The individual manifests gravely disabling/incapacitating functional impairments or severely and pervasively impaired personal development that constitute a risk to the individual of victimization in an alternative care environment.

m. Inability to maintain adequate nutrition or self-care due to a chronic psychiatric disorder and family/community support and services cannot provide the essential care needed.

n. Individual requires close and continuous observation and monitoring which cannot be accomplished at a less restrictive level of care and/or there is a history of :

history of repeated failures of placements in lesser intensive levels of care such as: The presence of a general medical condition, or the

necessary treatment of a serious general medical condition that complicates essential complicate psychiatric treatment; or the presence of, or history of, or high potential for

development of, serious side-effects from the administration of specific, indicated psychotropic medication


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1. The individual can be safely maintained and effectively treated in an acute inpatient setting or at a less intensive level of care.

2. Symptoms result from a medical condition that warrants a medical/surgical setting

for treatment.

3. The individual exhibits signs and symptoms/behaviors of a mental illness that is an acute exacerbation and can reasonably be expected to respond to treatment in an acute setting.

4. The primary problem is social, economic (e.g., housing, family conflict, etc.), or

one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration.

Continued Stay Criteria ALL of the following criteria are necessary for continuing treatment at this level of care:

1. The individual's condition continues to meet admission criteria for state inpatient care and no other less intensive level of care would be adequate.

2. Close and continuous skilled medical observation and supervision are necessary to

monitor and/or make changes in psychotropic medications.

3. Close and continuous skilled medical observation is necessary due to otherwise unmanageable side effects of psychotropic medications.

4. Individual exhibits frequent and/or recent behavior or statements suggesting an

impulse or wish to harm self or others and continues to demonstrate generally poor impulse control and/or has continued to require periods of physical restraints, seclusion, one-to-one, and/or other close monitoring activities.

5. A comprehensive multi-modal therapy plan is needed, requiring close medical

supervision and coordination, due to its complexity and/or the severity of the individual’s signs and symptoms,

6. Individual Person Centered Plan of Service (IPCPOS)/Treatment Plan is regularly reviewed and revised and addresses current, prioritized problems/needs, and is being followed by the staff responsible for implementing the treatment services.

7. IPCPOS/Treatment Plan reflects consistent progress towards completing treatment

goals, there is aggressive and continuous evaluation of the patient’s response to the plan, timely modifications are made, as indicated, and the treatment focus/goal is stabilization or reduction of those prioritized psychological mental/behavioral impairments, so that the individual can be managed successfully at a lower level of care.

8. IPCPOS/Treatment planning is individualized and appropriate to the individual's

changing condition with realistic and specific goals and objectives stated. IPOS/Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated.

9. All services and treatment are carefully structured to achieve optimum results in the

most time-efficient manner possible consistent with sound clinical practice.

10. Progress in relation to specific symptoms or impairments is clearly evident and can

be described in objective terms but goals of treatment have not yet been achieved,


73

or adjustments in the treatment plan to address lack of progress and/or psychiatric/medical complications are evident.

11. Care is rendered in a clinically appropriate manner and focused on the individual's

behavioral and functional outcomes as described in the discharge plan.

12. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated.


14. There are documented active attempts at coordination of care with the Behavioral

Health Provider and the PCP (primary care physician), when appropriate.

Discharge Criteria Any of the following criteria are sufficient for discharge from this level of care:

1. IPCPOS/Treatment plan goals and objectives have been substantially met.

2. The individual no longer meets admission criteria or meets criteria for a less intensive level of care.

3. Consent for treatment is withdrawn and, either it has been determined that

involuntary inpatient treatment is inappropriate, or the court has denied continued involuntary inpatient treatment.

4. Support systems that allow the patient to be maintained in a less restrictive

treatment environment have been thoroughly explored and/or secured.

5. The individual's physical condition necessitates transfer to a medical facility.


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4.00 23-Hour Crisis Observation, Evaluation, Holding and Stabilization

4.00 23-Hour Crisis Observation, Evaluation, Holding and Stabilization This level of care provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment that includes continuous nursing services and an on-site or on-call physician. The primary objective of this level of care is for rapid diagnosis, treatment and stabilization of individuals with a I/DD who are presenting with acute psychiatric symptoms or distress and are transiently at risk of harm, temporarily unable to meet basic needs, provisionally impaired in functioning and require medical observation and a protected environment. Duration of services at this level of care may not exceed 23 hours, by which time stabilization and/or determination of the appropriate level of care will be made, with facilitation of appropriate treatment and support linkages by the treatment team. Before or at admission, a comprehensive assessment is conducted and a treatment plan developed. The treatment plan should place emphasis on crisis intervention services necessary to stabilize and restore the individual to a level of functioning that does not require hospitalization and will sufficiently ameliorate the situation to allow the individual to be discharged and transferred to an ambulatory care service. This level of care may also be used for a comprehensive assessment in order to clarify previously incomplete patient information that may lead to a determination of a need for a more intensive level of care. This service is not appropriate for individuals who, by history or initial clinical presentation, require services of an acute care setting exceeding 23 hours.

Criteria

Admission Criteria All of the following are necessary for admission to this level of care:

1. Symptoms consistent with a DSM-IV (Axis I-V) diagnosis likely to respond to therapeutic intervention, and

2. Individual has a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:

a. Self-care b. Receptive and expressive language, c. Learning, d. Mobility, e. Self-direction, f. Capacity for independent living, g. Economic self-sufficiency, and

3. Individual demonstrates a need for a combination and sequence of special,

interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and need to be individually planed and coordinated, and

4. Indications that the symptoms may stabilize and an alternative treatment may be initiated within a 23-hour period, and 5. Presenting crisis cannot be safely evaluated or managed in a less restrictive

Setting, and 6. The individual is willing to sign in voluntarily or has been brought to the facility

involuntarily in accordance with relevant State Statutes, as applicable.

In addition to the above, at least one of the following must be present:

1. An indication of actual or potential danger to self as evidenced by serious suicidal intent or a recent attempt with continued intent as evidenced by the circumstances


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of the attempt, the individual's statements, or intense feelings of hopelessness and helplessness.

2. Command auditory/visual hallucinations or delusions leading to suicidal or

homicidal intent. 3. An indication of actual or potential danger to others as evidenced by a current

threat. 4. Loss of impulse control leading to life-threatening behavior and/or other symptoms

related to the I/DD or psychiatric condition that require immediate stabilization in a structured, psychiatrically monitored setting.

5. Substance intoxication with suicidal/homicidal ideation. 6. The individual is experiencing a crisis demonstrated by an abrupt or substantial

change in normal life functioning brought on by a specific cause, sudden event, and/or severe stressor.

7. The individual demonstrates a significant incapacitating or debilitating disturbance

in mood/thought/ or behavior interfering with ADLs to the extent that immediate stabilization is required.


1. The individual can be safely maintained and effectively treated at a less restrictive level of care.

2. Threat or assault toward others is not accompanied by a DSM-IV diagnosis.

3. Presence of any condition of sufficient severity to require acute psychiatric

inpatient, medical, or surgical care.

4. The primary problem is social, economic (i.e. housing, family conflict, etc.), or

one of physical health without a concurrent major psychiatric episode meeting the criteria for this level of care.

5. Admission is being used as an alternative to incarceration.

Continued Stay Criteria There is no continued stay associated with 23-hour observation. Individuals must be transferred to a more/less intensive level of care within the 23 hour period.


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1. Treatment plan goals and objectives have been substantially met.

2. Individual no longer meets admission criteria or meets criteria for less/more

restrictive level of care.

3. Length of stay at this level of care has surpassed the program's maximum 23-hour length of stay and a plan for continuation of services at another level of care has been established.

4. The individual, family, guardian and/or custodian is competent but non-

participatory in treatment or in following the program rules and regulations. The non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues. In addition, either it has been determined that involuntary inpatient treatment is inappropriate, or a court has denied a request to issue an order for involuntary inpatient treatment.

5. Consent for treatment is withdrawn and either it has been determined that

involuntary inpatient treatment is inappropriate or the court has denied involuntary inpatient treatment.

6. Support systems allowing the individual to be maintained safely in a less

restrictive treatment environment have been thoroughly explored and/or secured.


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5.00 Community Support Services; Skill Building, Volunteer and Employment Services; Peer Services

5.00 Community Support Services

Services within the community that represent an array of services, supports, and opportunities needed by individuals (and/or families of individuals) with developmental disabilities in order to live, work, and participate in their communities. This spectrum of services allows for creative and flexible planning, as guided by the consumer’s strengths, unique needs, and desires. In developing the individual person-centered plan of service and coordinating discharge and transition processes, the following locally-based services and supports are available for individuals living in his/her own home, family home, foster care, residential setting or other community setting:

5.01 Community Living Supports (in community) –These activities include providing supports that focus on personal self-sufficiency, facilitating an individual’s independence and promoting his/her integration into the community. The supports may be provided in the participant’s residence or in community settings. The supports are: Assisting, reminding, observing, guiding and/or training in the following activities:

Meal preparation

Laundry

Routine, seasonal and heavy household care and maintenance

Activities of daily living such as bathing, eating, dressing and personal hygiene

Shopping for food and other necessities of daily living Assistance, support and/or training with such activities as:

Money management

Non-medical care

Socialization and relationship building

Transportation (excluding to and from medical or dental appointments) from the beneficiary’s residence to community activities, among community activities, and from the community activities back to the beneficiary’s residence

Leisure choice and participation in regular community activities

Attendance at medical appointments

Acquiring or procuring goods other than those listed under shopping, and non-medical services And companionship, monitoring or protection to insure the health and safety of the individual in order that he/she may reside or be supported in the most integrated community setting.

Community Living Support (CLS) services cannot supplant other services, such as Home Help or Enhanced Home Help. However, it can be used when an individual cannot obtain Home Help or Enhanced Home Help because the Department of Human Services (DHS) has denied coverage. Community Living Supports can be used to compliment Home Help or Enhanced Home Help services when the individual’s needs exceed the DHS’s allowable parameters. CLS may be used while the beneficiary awaits determination by DHS of the amount, scope and duration of Home Help or Enhanced Home Help. Supports Coordinators should also assist the beneficiary in his/her request for Fair Hearing when DHS denies access to the Home Help program, or the amount of Home Help that appears to be needed. CLS may be provided while the beneficiary awaits the decision from a Fair Hearing of the appeal of an DHS decision. CLS may be provided in a licensed specialized residential setting as a complement to, and in conjunction with, state plan Personal Care Services.

Transportation to medical appointments is covered by Medicaid through DHS or the Medicaid Health Plan. Payment for CLS services may not be made, directly or indirectly, to responsible relatives (i.e. spouses, or parents of minor children).

5.02 Community Living Support (in a Specialized Residential Setting) - This is enhanced support staff to provide additional supervision to the specialized residential group home for one-to-one supervision for the purposes of managing psychiatric symptoms, personal health and safety, promoting self-sufficiency or insuring a structured therapeutic milieu/environment. This type of supportive staff is provided in specialized residential settings only by trained direct care staff and is in addition to the direct care staff working in the specialized residential setting. Activities include all those listed above in Community Living Supports.


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5.03 Community Living Support (in a Specialized Residential Setting)-These are activities as described in 14.01 Community Living Supports, that, when combined with Personal Care (in a Specialized Residential Setting (see below) make up the “unbundled” billable services for Specialized Residential settings. This Level of Care is provided in specialized residential settings only by trained direct care staff. 5.04 Personal Care (in a Specialized Residential Setting) - These activities include assisting a consumer when they are unable to care for themselves, often but not always, due to a physical limitation. Personal Care may include some prompting and monitoring, but this service is more “hands on”. For example, the resident with much prompting, may be able to perform a limited subset of the activity some of the time, but direct care staff will need to complete the task the majority of the time. Personal Care activities must be outside the scope required by the facility licensure. For example, a provider cannot consider the everyday preparation of meals for the consumer as personal care. However, if staff must grind or puree the food or assist in feeding the consumer, this time spent may be considered as personal care. Some types of personal Care include:

Assisting with food preparation

Clothing and laundry

Housekeeping beyond the level required by facility licensure

Eating/feeding

Bathing

Grooming

Dressing

Transferring (between bed, chair, wheelchair, and/or stretcher)

Ambulation

Assistance with self-administration of medication This type of supportive staff is provided in specialized residential settings only by trained direct care staff.

5.05 Support Coordination – These are activities that disseminate the full range of options available to DWMHA eligible individuals and their families including planning using Person Centered principals; linking to, coordinating with, follow-up of, advocacy with, and/or monitoring of specialty services; brokering of services and supports, assistance with access to entitlements and/or legal representation, and coordination with the QMRP or other health care provider. Supports coordinators will work closely with the individual face-to-face to assure his/her ongoing satisfaction with the process and outcomes of the supports, services, and available resources. Supports coordinators work to ensure:

Desires and needs of the individual are determined

Supports and services desired and needed by the individual are identified and implemented

Housing and employment issues are addressed

Social networks are developed

Appointments and meetings are scheduled

Person-Centered Planning is provided

Natural and community supports are used

Quality of the supports and services, as well as the health and safety of the individual, are monitored

Income/benefits are maximized

Activities are documented, and

Plans of supports/services are reviewed at such intervals as are indicated during planning.

5.06 Targeted Case Management- Targeted Case Management services assist specific sub-populations of individuals with developmental disabilities (i.e. those in State Hospitals, those living outside of Wayne County, etc.) to design and implement strategies for obtaining services and supports that are goal-oriented and individualized. Services include assessment, planning, linkage, advocacy, coordination and monitoring to assist beneficiaries in gaining access to needed health and dental services, financial assistance, housing, employment, education, social services, and other services and natural supports developed through the person-centered planning process. Target case management is provided in a responsive, coordinated, effective and efficient manner focusing on process and outcomes. Providers must document initial and ongoing training for case managers related to the core requirements and applicable to the target population served.

5.07 Housing Assistance - Housing assistance encompasses the limited term financial assistance associated with independent living, and/or the ongoing costs in excess of resources available to the individual for room and board and/or assistance with needs associated with home ownership or leasing/renting a swelling such as rent, utilities, home maintenance, insurance, and moving expenses; and/or with a need for food/consumables, and that exceed the capacity of the individual’s other sources of funding for room and board. Individuals have the right to pursue housing


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options of their choice. Education is provided to the individual about housing options and supports available and locating housing is to be directed by the individual’s interests, involvement and informed choice, sensitive to cultural and ethnic preferences. When providing housing assistance, it must be ensured that supported housing:

Blends into the community (supported housing units should be scattered throughout a building, complex, or the community in order to achieve community integration when possible. (Use of self-contained campuses or otherwise segregated buildings as service sites in not the preferred mode)

Promotes and supports home ownership, individual choice, and autonomy

Shall not exceed community norms for the number of people living together

Shall be accessible to the individual and in compliance with applicable state and local standards for occupancy, health, and safety

Encourages and supports self-sufficiency

Includes an on-going assessment of housing needs

Includes assistance to coordinate available resources to meet basic housing needs

5.08 Family Training – Education and counseling services provided for families in the community (parents, spouse, siblings, children, relatives) who are caring for, or who regularly interact with a family member who has a serious mental illness, I/DD, or serious emotional disturbance. Education includes information about mental illness, I/DD, emotional disturbances, treatment options and regimens, use of medication, management of crisis situations and symptomatic behaviors, and use of assistive technology, etc. Family training goals and the content, frequency and duration of the training and/or counseling, should be identified in the beneficiary’s IPOS. The training is to be completed by the appropriate credentialed professional who is responsible for the goal.

Vocational, Volunteer and Employment Related Services

5.09 Integrated Employment-Supported Employment Program - These are initial and ongoing support services designed to assist individuals in obtaining and maintaining paid employment including consumer run businesses, mobile crews and enclaves. Examples of these services are the vocational components of job development, job placement, job coaching, and long-term follow-along services required to maintain employment.

5.10 Skill Building Assistance– This is a community based out-of-home service that is aimed at assisting the person to achieve economic self-sufficiency or engage in sufficient endeavors or meaningful activities. This Level of Care may include activities to prepare for, obtain and maintain employment such as pre-vocational or vocational services or supported employment, etc.; or the activities may include therapeutic activities to improve concentration, task performance, etc. and/or socialization interaction or adjustment skill training.

5.11 Out of Home Non Vocational Habilitation (HAB waiver individuals only) - These are non-vocational services that assist with acquisition, retention, or improvement in self-help, socialization, and adaptive skills, and the supports services, including transportation to and from, incidental to the provision of the assistance that this level of care takes place in a non-residential setting, separate from the home or facility in which the consumer resides. Examples of incidental support include:

Direct care aides helping the beneficiary with his mobility, transferring, and personal hygiene functions at the various sites where habilitation is provided in the community

When necessary, helping the person to engage in the habilitation activities (e.g., interpreting). Services must be furnished on a regularly scheduled basis (typically at least 4 hours per day, one or more days a week) unless provided as an adjunct to other day activities included in the beneficiary’s plan of service and as determined in the individual plan of service. These supports focus on enabling the person to attain or maintain his maximum functioning level, and should be coordinated with any physical, occupational, or speech therapies listed in the plan of services. Services may serve to reinforce skills or lessons taught in school, therapy, or other settings. 5.12 Out of Home Pre-Vocational Habilitation (HAB waiver individuals only) - These are services aimed at preparing a consumer for paid or unpaid employment, but that are not job task-oriented. They include teaching such concepts as compliance, attendance, task completion, problem solving and safety. Prevocational services are provided to people not expected to be able to join the general workforce, or to participate in a transitional sheltered workshop within one year (excluding supported employment programs).


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Activities included in these services are primarily directed at reaching habilitative goals, such as improving attention span and motor skills, not at teaching specific job skills. These services must be reflected in the person’s individual plan of service and directed to habilitative objectives rather than employment objectives.

Peer Services

5.13 Peer Delivered and/or Operated Services – These are activities intended to provide individuals 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. Services are provided by individuals with mental illness or I/DD for the purpose of promoting wellness and/or recovery. Such services may include consumer run drop-in centers, group home monitoring, self-help groups, peer counseling and support services. Peer Support Mentors who have completed the certification and internship activities may provide support services as part of an individual’s Individual Person Centered Plan of Services, should the individual served choose to include this level of care in his/her plan. When built into the plan and authorized by ICA, Peer Support services are a fee for service level of care.


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6.00 Respite Care - In-Home and Out-of-Home

6.00 Respite Care - In-Home and Out-of-Home Respite In-Home: Respite is only provided on a short-term basis, because of the absence or need for relief of those

individuals normally providing the care of a consumer during times when they are not being paid to provide care. “Short-term” means the respite service is provided during a limited period of time, for example, a few hours, a few days, weekends, or for vacations. Respite is not intended to be provided on a continuous, long-term basis where it is a part of daily services that would enable an unpaid caregiver to work full-time. In those cases, community living supports, or other services of paid support or training staff, should be used. Decisions about the methods and amounts of respite are decided during the person-centered planning process. Families and caregivers are informed of all available means of receiving respite supports and, based on personal choice, receive assistance in obtaining such via a contracted home health provider (direct care worker, LPN or RN) or enrollment into the Family Friend Respite Program. Respite care may not be provided by a parent of a minor beneficiary receiving the service, the spouse of the beneficiary, the beneficiary’s legal guardian, or the primary unpaid caregiver. Trained childcare workers, relatives, neighbors, or licensed nurses usually provide these services. Respite Out-of-Home: Respite services provided outside of the individual’s (adult or child) home, typically in a licensed foster care home, a CCI, a group home, licensed respite care facility, or the home of a friend or relative. This type of respite care is also temporary for the relief of the unpaid caregivers normally providing the care of the individual. Trained child care workers provide services for children.


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Criteria

Admission Criteria


1. The person must have a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:

Self-care


Learning’

Mobility

Self-direction


Economic self-sufficiency, and

2. The individual must demonstrate a need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and need to be individually planned and coordinated, and

3. Individual’s self-care and independent functioning, consistent with the stage of

development relative to the individual’s age, are gravely disrupted due to lack of ability or willingness and the individual consistently requires assistance with eating/personal hygiene/dressing, and other essentials of daily living, beyond reasonable, age/stage-appropriate verbal prompting.

4. Day-to-day caregiver of the individual is in need of temporary relief of care-giving duties, or is experiencing an emergency situation and needs to temporarily cease care-giving duties

5. The individual may or may not be receiving active clinical services

6. The proposed respite site is not a day program, ICF/MR, nursing home or hospital

7. The respite services do not supplant or substitute for community living support or other services of paid support/training staff.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. The request for Respite care is to relieve paid caregivers

2. The request for Respite care is to provide relief to someone who is not the primary unpaid caregiver,

3. The request for Respite is to provide continuous, long-term service as part of daily services that would enable an unpaid caregiver to work full-time, etc.

Continued Stay Criteria

Any of the following criteria are necessary for continuing treatment at this level of care:

Does not apply, Respite services are temporary, short-term.


Does not apply, Respite services are temporary, short-term and based upon the choice of the unpaid primary caregiver.


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7.00 Home-Based Services

7.00 Home-Based Services


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Home Based Services is an MDCH approved program designed with a family focus and provides intensive services in the home and community to individuals and families with multiple service needs and who require access to a wide array of mental health services. The family unit is the focus of treatment. The primary goals are to promote normal development, promote healthy family functioning, support and preserve families, reunite families who have been separated, and reduce the usage of, or shorten the length of stay in, psychiatric hospitals and other substitute care settings. The services provided support a strength-based approach, emphasizing assertive intervention, parent and professional teamwork, and community involvement with other service providers. Mental health home-based services include case management, individual, family and group therapy, crisis intervention, service coordination, and family collateral contacts and are identified in the family plan of service. Additional services range from assisting individuals in meeting basic needs such as food, housing, and medical care. Parenting education/training is a component of home-based services and may be recommended for individuals, such as the following:

1) Teenage mothers; 2) Parent(s) who have demonstrated a lack of parenting skills in controlling the behavior of their

child/adolescent; and 3) Parents who are inclined to conflict around their role as parents. Individual training sessions should

occur outside the therapy hours. Parents are instructed by trained staff in methods of minimizing and preventing dysfunctional behaviors. The training may take place in a self-help group of other parents. Parents learn how to avoid collusion with negative attention-seeking, breaking of rules, and how to set reasonable limits, expectations, and consequences.

Mediation services to children/adolescents and/or family members in order to enhance the likelihood of successful reunification. Services are provided by professional staff who have demonstrated knowledge of dynamics of domestic relations; child development, clinical issues related to children, effects of loss on children, psychology of families, specific knowledge of the individual child and family's cultural values, norms, and language needs, and skills in the process and techniques of mediation, and community resources to which parties may be referred for assistance with medication-related issues.

Criteria


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Admission Criteria

All of the following criteria are necessary for participation in this level of care:

1. The child has a mental, behavioral, or emotional disorder sufficient to meet

diagnostic criteria specified within the current version of the DSM or ICD not solely the result of mental retardation or other I/DD, drug abuse/alcoholism or those with a V-code diagnosis, and the beneficiary meets the criteria listed below for degree of disability/functional impairment and duration/service history.

2. There is substantial interference with, or limitation of, the child’s proficiency in performing age-appropriate skills as demonstrated by at least one indicator drawn from two of the following areas:

General and/or specific patterns of reoccurring behaviors or expressiveness

indicating affect/modulation problems, e.g., uncontrollable crying or screaming, sleeping and eating disturbances and recklessness; the absence of developmentally expectable affect, such as pleasure, displeasure, joy, anger, fear, curiosity; apathy toward environment and caregiver.

Distinct behavioral patterns coupled with sensory, sensory motor, or

organizational processing difficulty (homeostasis concerns) that inhibits the child’s daily adaptation and interaction/relationships. For example, a restricted range of exploration and assertiveness, dislike for changes in routine, and/or a tendency to be frightened and clinging in new situations, coupled with over-reactivity to loud noises or bright lights, inadequate visual-spatial processing ability, etc.

Incapacity to obtain critical nurturing (often in the context of attachment-

separation concerns), as determined through the assessment of child, caregiver and environmental characteristics. For example, the infant shows a lack of motor skills and/or language expressiveness, appears diffuse, unfocused and undifferentiated, expresses anger/obstinacy and whines, in the presence of a caregiver who often interferes with the infant’s goals and desires, dominates the infant through over-control, does not reciprocate to the child’s gestures, and/or whose anger, depression or anxiety results in inconsistent parenting.

3. The family (or individual acting in the role of family), and the child/adolescent has

multiple mental health and other service needs 4. Traditional outpatient services are not sufficient to meet the family's needs for

support an education

5. Family is not receiving similar services from any other Authority; and

6. Child/adolescent and family members give consent and are motivated to participate in the program.


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Psychosocial, Occupational, and

Cultural and Linguistic Factors

These factors, as detailed in the Introduction, may change the risk assessment and should be considered when making level of care decisions.

1. Assignment of support and clinical staff who meet the cultural and language specifications as requested by the family.

Exclusion Criteria


1. Child/adolescent's home environment presents safety risks to the staff making home visits

2. Child/adolescent is at risk to harm self or others, or sufficient impairment exists

that requires a more intensive level of care beyond community-based intervention

3. Child/adolescent has medical conditions or impairments that would prevent

beneficial utilization of services, or is not stabilized on medications.



1. IPOS/Treatment plan is individualized and appropriate to the individual

and family’s changing condition with realistic and specific goals and objectives stated. Treatment planning should be person and family focused and include other support systems, social, occupational, educational, and other, with involvement when indicated.

2. Clinical condition continues to warrant family stabilization services in order

to maintain the child/adolescent in the community and continue progress toward treatment plan goals.

3. Child/adolescents and family’s treatment does not require a more

intensive level of care, and no less intensive level of care would be appropriate.

4. All services and treatment are carefully structured to achieve optimum

results in the most time efficient manner possible, consistent with sound clinical practice.

5. Progress in relation to specific symptoms or impairments is clearly evident

and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident.

6. Child/adolescent and family are participating to the extent all parties are

able.

7. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated.


9. There are documented active attempts at coordination of care with the

Behavioral Health Provider and the PCP (primary care physician), when appropriate.


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1. Child/adolescent's and family’s treatment plan goals and objectives have been

substantially met 2. Child/adolescent and family no longer meets admission criteria, or meets criteria

for a less/more intensive level of care; and 3. Child/adolescent, family, guardian, and/or custodian are non-participatory with

treatment or in following program rules and regulations, despite attempts to address non-participation issues.


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8.00 Adult Foster Care

8.00 Adult Foster Care - General, Basic Supervision

NOTE: The Adult Foster Care facilities that are general, non-certified and non-specialized are available for ICA members; however this service is not a level of care nor is it reimbursed by the member’s ICA benefit plan.

Adult (General, Basic Supervision, non-certified, non-specialized):

Services provided by an Adult Foster Care facility licensed by the Michigan Department of Human Services for individuals 18 years and older who require room and board with basic verbal reminders and support (i.e. personal care services). This level includes basic 24-hour supervision, plus supports necessary to maintain individuals with a I/DD who are exhibiting only minimal psychiatric and behavioral manifestations. All clinical and case management/support coordination services, if needed, will be recorded and reported separately, including other appropriate levels of care.

Criteria

Admission Criteria All of the following criteria are necessary for admission:

1. Individual has a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:

a. Self-care b. Receptive and expressive language, c. Learning, d. Mobility, e. Self-direction, f. Capacity for independent living, g. Economic self-sufficiency



3. Individual is currently demonstrating only mild deficits in independent living skills,

4. The individual presents with psychiatric and behavioral manifestations that can be reasonably expected to respond to general, basic supervision, support, and verbal reminders in a non-specialized adult foster care home,

5. The individual does not exhibit acting out behavior; has no recent history of

moderate or serious behavioral problems, and has no recent history of destruction to property


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6. The individual does not require the level of supervision and support offered in a specialized residential program,

7. The individual is not sufficiently stable or lacks the adaptive living skills to live

outside of a 24 hour environment with general, basic supervision,

8. The individual is able to function with a fair degree of independence and participate in community-based activities,

9. This level of care is needed to help the individual achieve and maintain the

10. highest level of functioning of which he or she is capable, and the Individual Person

Centered Plan of Service (IPCPOS)/Treatment Plan describes reasonable goals to achieve that level of functioning

11. This level of care is needed, because if the service is not provided, the individual may have to move to a more restrictive setting.

Exclusion Criteria Any of the following is sufficient for exclusion from this level of care:

None. Individuals choosing this level of care utilize private of entitlement funds not managed by the Manager of Comprehensive Provider Network.

Continued Stay Criteria All of the following criteria are necessary for continued stay at this level of care:

1. The individual’s condition continues to meet admission criteria for this level of care,

2. Individual’s treatment does not require a more intensive level of residential care,

and no less intensive residential level of care (SIL) would be appropriate,

3. IPCPOS (Individual Person Centered Plan of Service) is regularly reviewed and revised with the individual as well as family, guardian, friends, and professionals as the individual desires or requires, to reflect the individual’s need/desire for continued stay,

4. IPCPOS /Treatment planning is individualized and appropriate to the individual’s

changing condition with realistic and specific goals and objectives stated. IPCPOS /Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated,

5. Services and treatment are carefully structured to achieve optimum results in the

most time efficient manner possible consistent with sound clinical practice,

6. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated,

7. There are documented active attempts at coordination of care with the behavioral health provider and the primary care physician, when appropriate


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Discharge Criteria


1. The individual’s documented IPCPOS /Treatment Plan goals and objectives have been substantially met, support systems that allow the individual to be maintained in a less restrictive living environment have been thoroughly explored and secured, and the person moves to an independent or semi-independent residential setting

2. Individual is not making any progress toward treatment goals and there is no

reasonable expectation of progress at this level of care, and a more restrictive living environment (i.e. licensed/certified) is necessary to maintain the health and safety of the person,

9.00 Intensive Crisis Residential – Adult and Child

9.00 Intensive Crisis Residential – Adult and Child Intensive therapeutic services that provide a short-term alternative to in-patient psychiatric services for adults and children with a I/DD experiencing an acute psychiatric crisis. Services are intended solely to avert a psychiatric admission, or to shorten the length of an in-patient stay and are designed for a sub-set of individuals who meet psychiatric inpatient admission criteria or are at risk of admission, are not imminent risk to self/others, and who can be appropriately serviced in a setting less intensive than a hospital setting. Services are provided 24 hours per day, 7 days per week. Active treatment is provided and includes psychiatric supervision, therapeutic support services, medication management, behavioral services, milieu therapy and nursing services. Services are provided by a sufficient number of qualified clinical staff and non-degree staff who are supervised by qualified clinical staff. Medication reviews must be performed by a physician, physician assistant or a nurse practitioner and additional covered services must be supervised by a master prepared mental health professional at least eight hours per day Monday through Friday (and on call at other times). Paraprofessional staff and Peer Supports may be part of the team. Individuals admitted must be offered the opportunity to explore and learn about crisis, substance abuse, identity, values, choices and choice making, recovery and recovery planning. Services must be coordinated with the Primary Care Physician and other human service organizations as appropriate. ICR specialized services are only provided in a 16-bed of less home licensed/certified by the State of Michigan Department of Community Health to provide this level of care. Services may not be provided in a hospital or other institutional setting. For children and adolescents, Intensive Crisis Residential (ICR) services are only provided in a home or institutional setting licensed as a child caring institution (CCI) by the Michigan Department of Human Services and certified to provide this level of care by the Michigan Department of Community Health.

Criteria


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Admission Criteria


1. Individual is an meets the criteria for Severe Mental Illness; and, 2. Individual has a severe, chronic condition that is attributable to a mental or

physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:


3. Individual demonstrates active symptomatology consistent with a DSM-IV (AXES

I-V) diagnosis which requires and can reasonably be expected to respond to intensive structured intervention, and,



5. Individual demonstrates a significant incapacitating or debilitating disturbance in

mood/thought/behavior interfering with ADLs to the extent that immediate stabilization is required; and


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6. Individual demonstrates active symptomatology consistent with a DSM-IV (AXES I-V) diagnosis, which requires and can reasonably be expected to respond to intensive, structured intervention; and,

7. Individual’s condition indicates recent significant decompensation with a strong

potential for danger to self or others, and the individual cannot be safely maintained in a less restrictive level of care; and,

8. Individual can be effectively treated with short-term intensive crisis intervention

services and returned to a less intensive level of care within a brief time frame; and,

9. Individual requires 24-hour observation and supervision to maintain safety

needs, but not the constant observation of an inpatient psychiatric setting, except where being used as a downward substitution for Inpatient; and,

10. A less intensive or restrictive level of care has been considered or attempted; or,

11. Clinical evaluation indicates the onset of a life-endangering psychiatric condition,

but there is insufficient information to determine the appropriate level of care.

Exclusion Criteria


1. Individual’s I/DD and psychiatric condition is of such severity that it can only be safely treated in an inpatient setting

2. Individual’s medical condition is such that is can only be safely treated in a

medical hospital

3. Individual’s alcohol and/or drug use is such that the individual can only be safely treated for detoxification in a medical hospital

4. Individual or guardian does not voluntary consent to admission or treatment

5. Individual can be safely maintained and effectively treated in a less restrictive

level of care

6. Primary problem is social, economic (i.e. housing, family, conflict, etc.) or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care

7. Admission is being used as an alternative to incarceration


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ALL of the following criteria are necessary for continuing treatment at this level of care:

1. Individual’s condition continues to meet admission criteria at this level of care and must be authorized on an on-going basis as necessary

2. Individual’s treatment does not require a more intensive level of care, and no

less intensive level of care would be appropriate

3. Care is rendered in a clinically appropriate manner, and is focused on the individual’s behavioral and functional outcomes, as described in the discharge plan

4. IPCPOS (Individual Person Centered Plan of Service)/Treatment Plan is

regularly reviewed and revised with the individual as well as family, friends, and professionals as the individual desires or requires, to reflect the individual’s need for continued stay and the goals of the discharge plan

5. IPCPOS /Treatment planning is individualized and appropriate to the individual’s

changing condition with realistic and specific goals and objectives stated. IPCPOS /Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated

6. Services and treatment are carefully structured to achieve optimum results in the

most time efficient manner possible consistent with sound clinical practice

7. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident

8. When medically necessary, appropriate psychopharmacological intervention has

been prescribed and/or evaluated

9. There is documented active discharge planning

10. There are documented active attempts at coordination of care with the behavioral health provider and the primary care physician, when appropriate

11. Services may be provided for a maximum of 30 days.

Discharge Criteria


1. The individual’s documented IPCPOS /treatment plan goals and objectives have been substantially met

2. The individual no longer meets admission criteria or meets criteria for a less or

more intensive level of care


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3. The individual, family, guardian and/or custodian is competent but non-participatory in treatment or in following the program rules and regulation. Non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues. In addition, either it has been determined that involuntary inpatient treatment is inappropriate, or a court has denied a request to issue an order for involuntary inpatient treatment.

4. Consent for treatment is withdrawn, and it is determined that the individual has

the capacity to make an informed decision and does not meet criteria for an inpatient level of care


reasonable expectation of progress at this level of care

6. Support systems that allow the individual to be maintained in a less restrictive treatment environment have been thoroughly explored and/or secured


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Admission Criteria (cont.)

2. Individual demonstrates a need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration, and need to be individually planed and coordinated, and

3. Individual is expected to respond favorably to basic supervision, support, and verbal reminders for behaviors that are typically not acceptable in a general, non-specialized residential or foster care setting,

10.00 Specialized Residential Services: Minimal Supervision

10.00 Specialized Residential Services: Minimal Supervision Adult and Child/Adolescent

Adult (Basic Supervision): Services are provided by a Michigan Department of Human Services licensed Adult Foster Care

facility that is certified by the Michigan Department of Community Health as a Specialized Residential Program. This level of care is intended for individuals 18 years and older who require verbal reminders and support. This level includes basic 24-hour supervision, plus supports necessary to maintain individuals with minimal psychiatric and behavioral manifestations of their I/DD and mental disorder, in accordance with the IPCPOS (Individual Person Centered Plan of Service). All clinical and case management/support coordination services will be recorded and reported, including other appropriate levels of care. CCI: Child/Adolescent (Open, Basic Supervision): Services are provided in a community based setting licensed as a child

caring institution (CCI) by the Michigan Department of Human Services. This 24/hr. semi-structured level of care is intended for children/adolescents (under 18 years old) who exhibit severe emotional disturbance in addition to a I/DD, and who are clinically/psychiatrically stable. This setting does not have an on-grounds special education program. This level includes therapeutic assessment, treatment planning, services and supports in areas of psychiatry, education, social work, nursing, psychology and general medical or these same services are provided through community-based service providers. Supports Coordination/Case management services are provided and reported separately by the responsible Child Placement Provider. This level of care can be presumed to be a step-down level of care from a restrictive to a less restrictive environment prior to discharge from specialized residential services. CCI: Child/Adolescent (Open with On-Grounds School): Services are provided are as described above (Open, Basic

Supervision), however this setting is more self-contained and structured to treat children/adolescents who are unable to attend school in the community due to their need for more consistent supervision and a more individualized and structured education experience. This campus-based setting has an on-grounds full time and certified special-education program.

Criteria

Admission Criteria


1. Individual has a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity: a. Self-care b. Receptive and expressive language, c. Learning, d. Mobility, e. Self-direction, f. Capacity for independent living, g. Economic self-sufficiency


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Adult:

1. Capacity to respond favorable to rehabilitative counseling and training in areas, such as problem solving, life skills development, and medication compliance training

2. Judgment is fair/good, impulse control good, and behavior is in control allowing for the individual to live in the community with minimal supervision

3. Willing to attend to basic self-care and respond to verbal instruction and prompts

4. Able to complete daily routine activities with minimal reminders, such as oral and personal hygiene, ambulating, feeding self, bathing, shaving, and dressing appropriate to weather conditions

5. Able to effectively communicate basic needs and preferences, and complete independent living activities

6. Not at risk to self/others

7. Understands the need for daily medication and compliant with medication regime

OR

Child/Adolescent - Open (No On-Grounds School):

1. As age appropriate and in keeping with the level of I/DD, needs only occasional verbal prompts/supervision to consistently perform his/her personal hygiene and grooming activities, or to care for his/her personal living space

2. As age appropriate and in keeping with the level of I/DD, takes responsibility for his/her treatment and educational or vocational programming with guidance and supervision for the appropriate adults

3. Demonstrates an ability and willingness to engage in age-appropriate activities as described in the Individual Person Centered Plan of Service (IPCPOS)/treatment plan

4. Appropriately communicates needs/problems/areas of concern to staff/parents/other adults in authority/peers

5. Behaviors reflect a decreasing need for adult intervention and/or supervision

6. Demonstrates active involvement in his/her IPCPOS /treatment plan

7. Increasing evidence to manage living at home and in the community.

OR

Child/Adolescent –Open with On Ground School

1. There is a need for consistent adult intervention and supervision and monitoring of behavior

2. Educational performance lacks consistency, and child/adolescent shows an inability to take responsibility for his/her education and behaviors, which continues to be the focus of educational intervention activities

3. The individual’s condition can be reasonably expected to respond to a 24-hour

supervision in an open setting (or semi-structured or semi-secure for children/adolescents) offering enhanced supervision, and psychiatric, medical and educational services,

4. The individual requires a minimal level of supervision, monitoring, and support,

but not the moderate level of supervision and support provided in a moderate supervision residential setting,

5. The individual is not sufficiently stable to be treated outside of a minimally

supervised 24 hour environment,


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6. The individual functions with some independence and participates in community-

based activities for limited periods of time (if clinically appropriate and supervised) that are appropriately structured to develop independent living skills,

7. This level of care is needed to help the individual achieve and maintain the

highest level of functioning of which he or she is capable,

8. This level of care is needed, because if the service is not provided, the consumer will have to move to a more restrictive setting, and

9. There is a I/DD with symptoms that significantly impairs familial, interpersonal,

social and/or educational functioning, and requires temporary separation from the natural support system or living arrangement to prevent further deterioration of those relationships and supports.


1. The individual’s I/DD and serious emotional disturbance is of a level of severity that cannot be controlled in this residential setting and requires a level of supervision and structure beyond the scope of this level of care,

2. The individual (or parent or guardian of a child/adolescent) does not voluntarily consent to admission or treatment,

3. The individual has medical conditions or impairments that would prevent beneficial utilization of services, or is not stabilized on medications,

4. The individual can be safely maintained and effectively treated in a non-specialized residential setting,

5. The primary problem is social, economic (i.e. housing, family, conflict, etc.) or one of physical health without a concurrent major psychiatric illness meeting criteria for this level of care,





2. Individual’s treatment does not require a more intensive level of residential care, and no less intensive residential level of care would be appropriate,

3. IPCPOS (Individual Person Centered Plan of Service) is regularly reviewed and revised with the individual, as well as family, guardian, friends and professionals as the individual desires or requires, to reflect the individual’s need for continued stay,

4. IPCPOS reflects consistent progress towards completing IPCPOS/ treatment goals, or if no progress is evident, the IPCPOS/ treatment plan reflects efforts to develop treatment goals/objectives to address the lack of progress,

5. IPCPOS /Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated,

6. Services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practice,


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8. There is documented active discharge planning with evidence of coordination and linkages with both the residential or CCI and community resources, for effective and clinically appropriate aftercare services for the individual and his/her family,

9. There are documented active attempts at coordination of care with the behavioral health provider and the primary care physician, when appropriate,


1. The individual’s documented IPCPOS /treatment plan goals and objectives have been substantially met,

2. The individual no longer meets admission criteria or meets criteria for a less or more intensive level of care,

3. The individual, family, guardian, and/or custodian are competent, but non-participatory in treatment or in following the program rules and regulation. Non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues,

4. Consent for treatment is withdrawn, and it is determined that the individual has the capacity to make an informed decision and does not meet criteria for an inpatient level of care,


reasonable expectation of progress at this level of care.


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11.00 Specialized Residential Moderate Supervision

11.00 Specialized Residential Services: Moderate Supervision

Adult, Child/Adolescent

Adult (Moderate Supervision): Services provided by a licensed Adult Foster Care facility that is certified by

Michigan Department of Human Services as a Specialized Residential Program. Disturbances related to the I/DD in thought, mood, cognition, self-care skills, and potential self-harm behaviors are expected to significantly decrease in severity and intensity with appropriate treatment/supports and implementation of time limited additional enhanced staff supervision (staff : resident ratio higher than minimum supervision) to augment other therapeutic/supportive services. This level of care is designed to include activities necessary to implement the IPCPOS (Individual Person Centered Plan of Service) and prepare the individual to live more independently. All clinical and support coordination case management /services will be recorded and reported separately, including other appropriate levels of care.

Child/Adolescent (CCI: Semi Secure): Services are provided in a secure locked unit or locked building licensed as

a child caring institution (CCI) by the Michigan Department of Human Services. This 24/hr. self-contained structured environment is intended for children/adolescents (under 18 years old) who are clinically unstable and present with serious management problems in all areas of the milieu, requiring close supervision and monitoring. This level includes: therapeutic assessment, Individual Person Centered Plan of Service/treatment planning, services and supports in areas of psychiatry, education, social work, nursing, psychology and general medical, plus a full time certified special education program on-site within the locked facility or children are escorted to the site of the on-ground school. The expectation is that treatment will reasonably result in improvement in the child/adolescent’s condition, so that discharge to a step-down program or to his/her family is the identified outcome. Supports Coordination/Case management services are provided and reported separately by the responsible Child Placement Provider.

Criteria

Admission Criteria


1. The individual has the diagnosis of I/DD (Axis II) as defined by the Federal Developmental Disabilities Association and Bill of Rights Act.

2. Adult: The adult individual infrequently exhibits signs and symptoms of

his/her serious mental illness and concomitant I/DD that interfere with their daily functioning. The illness is manifested by disturbances in self-care


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3. Child/Adolescent: The child/adolescent presents with severe emotional

disturbances, such as risk to self, others or the community due to his/her aggressive conduct, oppositional behaviors, impulsivity, depression and suicidal behaviors, and potential truancy and other at-risk behavior.

Adult:

At least one of the following criterion is present::

1. Judgment may be impaired, impulse control decreased, and behavior may be hostile, agitated, or disorderly. The level of disorderly or hostile behavior is severe and usually necessitates the implementation of a behavior plan, but not so severe, extreme or unstable as to require restraints or to pose a danger to others who are residing at the residential facility

2. Unable or unwilling to fully attend to basic self-care and significant impairment in ability/motivation to respond to verbal instruction

3. Unable to complete daily routine activities and requires assistance related to oral and personal hygiene, ambulating, feeding self, bathing, shaving, and dressing appropriate to weather conditions

4. Assistance is required to communicate basic needs and preferences and to complete independent living activities (beyond what would be expected related to the I/DD),

5. Significant deterioration in behavior is unacceptable by environmental standards (without any serious injury to others)

6. Intrusive, impulsive behaviors putting self/others at risk of injury necessitating close monitoring and supervision

7. Close supervision, special monitoring, and additional reporting is needed as related to the individual’s response to medication, which may potentially cause adverse reactions

Child/Adolescent:

At least one of the following criterion is present:

1. As age appropriate and with consideration of the I/DD, needs frequent prompts/supervision to consistently perform his/her personal hygiene and grooming activities, or to care for his/her personal living space

2. As age appropriate and with consideration of the I/DD, often refuses to take medication and/or denies need for prescribed medication, and on occasion must be closely monitored to avoid “checking’ the medication

3. As age appropriate and with consideration of the I/DD, needs adult intervention, supervision and assistance in understanding and appropriately participate in his/her treatment and educational programming

4. Uses personal care issues adversely (e.g. refuses to bathe, use deodorant, comb hair) to provoke staff, family and peers

5. Engages in self-mutilation activities and must be closely supervised to prevent serious harm or medical intervention

6. Interpersonal interactions are seriously impaired

7. Constant observation and supervision is necessary, because the behaviors reflect impaired reality testing, temporary deficient internal controls and impaired self-preservation

8. Refuses to attend school and/or when attends is often disruptive. School performance is not improving and he/she takes little interest in his/her educational progress


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9. Inability to communicate needs/problems/areas of concern to the adults in the milieu; and an inability to use any of the treatment modalities to change and/or modify his/her behaviors

10. Inability to take active and appropriate interests in his/her Individual Person Centered Plan of Service/treatment and discharge planning

11. Unable to have consistent home passes due to behaviors in the program or at home.

12. The individual requires a moderate level of supervision and support, but not the intensive level of supervision and support provided in an intensive residential setting,

13. The individual’s condition can be reasonably expected to respond to a 24-hour secure setting, offering enhanced supervision and psychiatric, medical and educational services,

14. The individual is not sufficiently stable to be treated outside of a moderately supervised 24 hour environment,

15. The individual may function with some independence and participate in community-based activities for limited periods of time (if clinically appropriate and supervised ) that are appropriately structured to develop independent living skills,

16. This level of care is needed to help the individual achieve and maintain the highest level of functioning of which he or she is capable,

17. This level of care is needed, because if the service is not provided, the consumer will have to move to a more restrictive setting.

Exclusion Criteria


1. The individual’s psychiatric condition is of a level of severity that cannot be controlled in this residential setting (i.e. poses danger to self, others, requires restraints) and requires a level of supervision and structure beyond the scope of this level of care,

2. The individual (or parent or guardian of a child/adolescent) does not

voluntarily consent to admission or treatment,

3. The individual has medical conditions or impairments that would prevent beneficial utilization of services, or is not stabilized on medications and exhibits more than infrequent signs and symptoms of their mental illness,

4. The individual can be safely maintained and effectively treated in a

minimum supervision specialized residential setting,

5. The primary problem is social, economic (i.e. housing, family, conflict, etc.) or one of physical health without a concurrent major psychiatric illness and I/DD meeting criteria for this level of care






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3. Treatment planning is individualized and appropriate to the individual's IPCPOS (Individual Person Centered Plan of Service) is regularly reviewed and revised with the individual, as well as family, guardian, friends and professionals as the individual desires or requires, to reflect the individual’s need for continued stay at a level of moderate supervision as an essential intervention,

4. IPCPOS (Individual Person Centered Plan of Service) /Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. The treatment plan demonstrates progress towards treatment goals, according to the IPCPOS, or if no progress has been made, the treatment plan is revised accordingly with a reasonable expectation of stabilization or reduction of prioritized psychological, mental/behavioral impairments. IPCPOS /treatment planning should include: active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated,



7. There is documented active discharge planning within a person-centered planning process, which involves /supports coordination/case management activities and appropriate coordination and linkages with community resources for aftercare and continued recovery for the adult, adolescent or child,

8. There are documented active attempts at coordination of care with the behavioral health provider and the primary care physician, when appropriate,

Discharge Criteria


1. The individual’s documented IPCPOS / treatment plan goals and objectives have been substantially met,


3. The individual, family, guardian, and/or custodian is competent, but non-participatory in treatment or in following the program rules and regulation. Non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues,


5. Individual is not making any progress toward IPCPOS / treatment goals and there is no reasonable expectation of progress at this level of care,

6. Support systems that allow the individual to be maintained in a less restrictive treatment environment have been thoroughly explored and/or secured.


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12.00 Specialized Residential Intensive Supervision

12.00 Specialized Residential Services: Intensive Supervision Adult and Child/Adolescent

Adult (Moderate Supervision): Services are provided by a licensed Adult Foster Care facility that is certified by the

Michigan Department of Human Services and certified as a Specialized Residential Program. This level includes enhanced supervision (staff : resident ratio higher than moderate supervision) and intensive support necessary to manage and habilitate individuals with serious mental illness and I/DD, and who exhibit symptoms of psychiatric and behavioral disturbance and/or individuals with a I/DD who are in need of total assistance in ambulation and activities of daily living. The intensity of support and services provided distinguishes this level of care that represents the most restrictive residential environment. These individuals require long-term intensive supervision in the areas of psychiatric, behavioral and/or general medical/therapeutic. Assistance is provided in areas of psychiatric, behavioral and general medical/therapeutic, as well as any support services necessary to implement the IPCPOS (Individual Person Centered Plan of Service). All additional clinical and support coordination/case management services will be recorded and reported separately, including other appropriate levels of care. Child/Adolescent (CCI: Semi Secure/Secure): Services are provided in a secure locked unit or building licensed as a

child caring institution (CCI) by the Michigan Department of Human Services. This 24/hr. highly structured, self-contained, restricted and supervised environment is intended for children/adolescents (under 18 years old) who exhibit severe emotional disturbance, a I/DD and severe management problems. There is a minimum of 3 children/adolescents to 1 staff. This self-contained locked environment represents the most restrictive residential environment. This level includes: therapeutic assessment, treatment planning, services and supports in areas of psychiatry, education, social work, nursing, psychology and general medical, plus a full time certified special education program on-site. All therapeutic services occur within the locked unit/building. Supports coordination/ Case management services are provided and reported separately by the responsible Child Placement Provider.

Criteria

Admission Criteria


1. The individual has a diagnosis of I/DD (Axis II) as defined by the Federal Developmental Disabilities Assistance and Bill of Rights Act, with significant symptomatology, which requires 24 hour consistent observation and supervision,

2. Adult: The adult individual frequently exhibits signs and symptoms of their

serious mental illness or co-occurring disorders that interfere with his/her daily functioning. The illness is manifested by disturbances in self-care, interpersonal relationships, judgment, thought processes, perception, memory, mood and behavior severe enough to require 24-hour enhanced supervision and intensive support, or the person needs total assistance in the areas of ambulation and self-care, or


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1. Child/Adolescent: The child/adolescent presents with severe emotional

disturbances, such as risk to self, others and the community due to his/her aggressive/assaultive conduct against others and property, substantial thought disturbances and impaired reality testing, possible depression and/or suicidal behavior, seriously maladaptive behaviors, and

2. The individual requires an intensive level of supervision and support, but not the extensive level of supervision and support provided in a multiple needs residential setting,

3. The individual is not sufficiently stable to be treated outside of an intensively supervised 24 hour environment,

4. Requires close medical observation and supervision to effect regulation of medications and/or to minimize untoward side effects

5. Requires daily verbal/physical assistance in order to maintain functioning and to promote optimum individualized skills and abilities, according to the IPCPOS,

6. The individual may function with some independence and participate in community-based activities (when clinically appropriate and with supervision), for limited periods of time that are appropriately structured to assist with habilitation of the individual,

7. This level of care is needed to help the individual achieve and maintain the highest level of functioning of which he or she is capable,

8. This level of care is needed, because if the service is not provided, the consumer will have to move to a more restrictive setting, and

Adult:

At least two of the following areas must apply:

1. Serious, disruption of mood/affect, cognition, memory, perception, and/or behavior due to serious emotional distress or mental illness with conjoint functional impairments

2. Affective disturbances (hallucinations, delusions, depression) which have reached a baseline/stabilized level of severity so as to pose a minimal risk of danger towards others, but continue to impair ability to independently perform routine activities of daily living

3. Social function is seriously impaired and may pose a risk of self-harm

4. Impaired ability to perform ambulation and/or activities of daily living independently, appropriately and/or effectively (oral and personal hygiene, ambulating, feeding self, bathing, shaving, laundry, maintaining personal area, and dressing appropriate to weather conditions) and with consideration of the I/DD

5. Deterioration of person’s ability to participate appropriately in daily work/day activity or school program due to psychiatric symptoms/behaviors

6. Exhibits behaviors/symptoms (i.e. eating non-food substances, impulsive and excessive water intake, confusion and memory impairments, wandering, etc.) requiring close supervision and monitoring

7. Significant history of suicide attempts/inclinations, which are now under control,

8. Intrusive, impulsive behaviors putting self/others at risk of injury necessitating close monitoring and supervision

9. Close supervision, special monitoring and additional reporting is needed as related to the individual’s response to medication, which may potentially cause adverse reactions

10. Significant history of problems with medication compliance


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Child/Adolescent:

At least two of the following areas must apply:

1. As age appropriate, needs constant prompts/supervision to consistently perform his/her personal hygiene and grooming activities, or to care for his/her personal living space

2. As age appropriate, often refuses to take medication and/or denies need for prescribed medication/and on occasion must be closely monitored to avoid “checking’ the medication

3. As age appropriate, needs adult intervention, supervision and assistance in understanding and appropriately participate in his/her treatment and educational programming

4. Uses personal care issues adversely (e.g. refuses to bathe, use deodorant, comb hair) to provoke staff, family and peers

5. Engages in self-mutilation activities and must be closely supervised to prevent serious harm or medical intervention

6. Interpersonal interactions are seriously impaired

7. Constant observation and supervision is necessary, because the behaviors reflect impaired reality testing, temporary deficient internal controls, and impaired self-preservation

8. Refuses to attend school and/or when attends is often disruptive. School performance is not improving and he/she takes little interest in his/her educational progress

9. Inability to communicate needs/problems/areas of concern to the adults in the milieu; and an inability to use any of the treatment modalities to change and/or modify his/her behaviors

10. Inability to take active and appropriate interests in his/her treatment and discharge planning

11. Unable to have consistent home passes due to behaviors in the program or at home, and cannot attend activities in the community when on pass due to impulse control problems, poor reality testing, etc.

Exclusion Criteria


1. The individual’s I/DD and/or Serious Emotional Disturbance/Mental Illness is of a level of severity that cannot be controlled in this residential setting and requires a level of supervision and structure beyond the scope of this level of care,

2. The individual (or parent or guardian of a child/adolescent) does not voluntarily consent to admission or treatment,

3. The individual has medical conditions or impairments that would prevent beneficial utilization of services, or is not stabilized on medications and exhibits more than frequent signs and symptoms of their mental illness,

4. The individual can be safely maintained and effectively treated in a moderate supervision specialized residential setting,

5. The primary problem is social, economic (i.e. housing, family, conflict, etc.) or one of physical health without a concurrent major psychiatric illness meeting criteria for this level of care,



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3. IPCPOS (Individual Plan of Service) is regularly reviewed and revised with the individual as well as family, guardian, friends, and professionals as the individual desires or requires, to reflect the individual’s need for continued stay,

4. IPCPOS /Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. IPCPOS /Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated,



7. There is documented active discharge planning,

8. There are documented active attempts at coordination of care with the behavioral health provider and the primary care physician, when appropriate.

Discharge Criteria


1. The individual’s documented IPCPOS /treatment plan goals and objectives have been substantially met,


3. The individual, family, guardian, and/or custodian is competent, but non-participatory in treatment or in following the program rules and regulation. Non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues,


5. Individual is not making any progress toward treatment goals and there is no reasonable expectation of progress at this level of care,

6. Support systems that allow the individual to be maintained in a less restrictive treatment environment have been thoroughly explored and secured.


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13.00 Enhanced Health and Health Services

13.00 Enhanced Health and Health Services

15.01 Health Services, INDIVIDUAL - Health Services are those services performed in a mental health clinic and provided

one-to-one for purposes of improving the individual’s overall health and ability to care for health-related needs. This includes:

a) nursing services b) dietary/nutrition services c) maintenance of health and hygiene d) teaching, self-administration or side effects of medication e) care of minor injuries or first aid f) teaching the individual to seek assistance in case of emergencies

15.02 Health Services, GROUP - Groups designed for purposes of improving the individual’s overall health and ability to

care for health-related needs. Group topics include:

a) dietary/nutrition b) maintenance of health and hygiene c) teaching, self-administration or side effects of medication d) care of minor injuries or first aid, and teaching the individual to seek assistance in case of emergencies

These groups are designed and led by health care professionals, such as physicians, nurses, pharmacists and physician assistants. Other QMHP’s may co-lead groups under the direct supervision of the health care professional. 15.03 Private Duty Nursing (HSW)-Private Duty Nursing (PDN) services consist of nursing procedures to meet an

individual’s health needs that are directly related to his/her I/DD. The criteria is explained in detail in the Medicaid Provider Manual, and includes:

a) Medical Criteria I (in part)-The beneficiary is dependent daily on technology-based medical equipment to sustain life.

b) Medical Criteria II (in part)-The beneficiary has frequent episodes of medical instability within the past three to six months, requiring skilled nursing assessments, judgments, or interventions due to a substantiated progressively debilitating physical disorder.

15.04 Enhanced Health Care DENTAL- Accepted Dental procedures that are not available to adults over 21 under regular

Medicaid dental coverage; provided to beneficiaries with dental problems sufficient to lead to more generalized disease due to infection or improper nutrition. Services include: treatment of multiple recurrent chronic periodontal disease, chronic pain, chronic abscess formation, congenital deformities of the midface, palate, maxilla and mandible, multiple recurrent cavities due to inability to maintain optimal oral hygiene, and other unique conditions that could lead to infection and/or nutritional deficiency if not otherwise corrected. 15.05 Enhanced Health Care PHARMACY - These are physician ordered, nonprescription “medicine chest” items as

specified in the person’s support plan. Allowable items include the following: cough, cold, pain, headache, allergy, and/or gastrointestinal distress remedies, vitamins, first aid supplies (e.g. “band aids”, iodine, rubbing alcohol, cotton swabs, gauze, antiseptic cleansing pads), special oral care products to treat specific oral conditions beyond routine mouth care (e.g. special toothpaste, tooth brushes, anti-plaque rinses, antiseptic mouthwashes), special tweezers and nail clippers the accommodate the person’s disability (e.g. reaches, or longer and wider handles), products or prostheses necessary to ameliorate negative visual impact of serious facial disfigurements (e.g. absence of ear, nose, or other feature or massive scarring), and/or skin conditions (including exposed area eczema, psoriasis, and/or acne) are included. Routine cosmetic products (e.g. make-up base, aftershave, mascara, and similar products) are not included. 15.06 Enhanced Health Services - These are health services beyond the responsibility of the individual’s health plan that

are provided for rehabilitative purposes to improve the individual’s overall health and his/her ability to care for health related needs. These services must be carefully coordinated with the individual’s health care plan. Services include:

a) nursing services, b) dietary/nutrition services, c) maintenance of health and hygiene, d) teaching, self-administration or side effects of medication, e) care of minor injuries or first aid, and f) teaching the individual to seek assistance in case of emergencies


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15.07 Enhanced Medical Equipment and Supplies- Enhanced medical equipment and supplies include: devices,

supplies, controls, or appliances that are not available under regular Medicaid coverage or through other insurances. All enhanced medical equipment and supplies must me specified in the plan of service, and must enable the beneficiary to increase his/her abilities to perform activities of daily living; or to perceive, control, or communicate with the environment. Items that are not of direct medical or remedial benefit or that are considered to be experimental to the beneficiary are excluded from coverage. Coverage includes:

o Adaptations to vehicles; o Items necessary for life support; o Augmentative Communication Devices o Ancillary supplies and equipment necessary for proper functioning of such items; and o Durable and non-durable medical equipment not available under the Medicaid state plan. o Generators may be covered for an individual who is ventilator dependent or requires daily use of an

oxygen concentrator. The size of the generator will be limited to the wattage required to provide power to essential life-sustaining equipment.

15.08 Environmental Modifications-Physical adaptations to the home and/or workplace required by the beneficiary’s

support plan that are necessary to ensure the health, safety, and welfare of the beneficiary, or enable him/her to function with greater independence within the environment(s) and without which the beneficiary would require institutionalization. Adaptations may include:

o The installation of ramps and grab bars; o Widening of doorways; o Modification of bathroom facilities; o Installation of specialized electric and plumbing systems that is necessary to accommodate the medical

equipment and supplies necessary for the welfare of the beneficiary. 15.09 Personal Emergency Response Systems (PERS)-Electronic devices that enable beneficiaries to secure help in the

event of an emergency. The beneficiary may also wear a portable “help” button to allow for mobility. The system is connected to the person’s phone and programmed to signal a response center once the button is activated.

Services are provided according to the professional’s scope of practice and under appropriate supervision.

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. Child/adolescent has a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:


2. Child/adolescent demonstrates a need for a combination and sequence of special,

interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and need to be individually planned and coordinated, and

3. For services described above that are for a specialized population, the individual must

meet specific clinical criteria for each and be enrolled in the appropriate program or waiver described to receive the supports and/or services.

Exclusion Criteria Any of the following is sufficient for exclusion from this level of care:

1. Individual’s condition is of a level of severity that cannot receive benefit from services described.


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a. The individual, parent, or guardian does not voluntarily consent to

services 2. The individual does not meet clinical criteria for the specific program or

waiver.


All of the following criteria are necessary for continued stay at this level of care:

1. The individual’s condition continues to meet criteria for this level of care and for the program or waiver within which the LOC is contained.

2. IPCPOS (Individual Person Centered Plan of Service) is regularly reviewed and revised

with the individual, as well as family, guardian, friends, and professionals as the individual desires or requires, to reflect the individual’s need for continued case management services

3. All services are carefully structured to achieve optimum results in the most time efficient

manner possible consistent with sound clinical practice

4. IPCPOS/Treatment planning is individualized and appropriate to the individual’s goals and changing condition. The IPCPOS/treatment plan demonstrates progress towards treatment goals, according to the IPCPOS, or if no progress has been made, the treatment plan is revised accordingly.

5. Individual demonstrates ability to comply with program requirements

Discharge Criteria


1. The individual’s documented IPCPOS/treatment plan goals and objectives have been substantially met.

2. The individual no longer meets specified criteria, or meets criteria for a less or more

intensive level of care, and/or no longer meets criteria for the program or waiver within which the LOC is contained.

3. The individual, family, guardian and/or custodian is competent, but non-participatory in

IPCPOS/treatment or in following the program rules and regulation,

4. Consent for treatment is withdrawn.


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14.00 Outpatient Services

14.00 Outpatient Services (Adult, Child / Adolescent)

Outpatient individual, family, or group therapy services are rendered in an office, clinic environment, an individual's home, or other locations appropriate to the provision of service for psychotherapy or counseling. Services focus on the restoration, enhancement and/or maintenance of an individual's level of functioning and the alleviation of symptoms that significantly interfere with functioning in at least one area of the individual's life (e.g., familial, social, occupational). Services are provided in accordance with the individual’s Individual Person Centered Plan Of Services (IPCPOS). The goals, frequency and length of treatment will vary according to the needs of the individual and their response to treatment.

16.01 Individual Therapy: Individual therapy is a 1:1 intervention designed to reduce maladaptive behaviors, maximize

behavioral self-control, or restore normalized psychological functioning, reality orientation and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships. 16.02 Family Therapy: Family therapy is therapeutic interventions with the individual and his/her family members, or other

individuals significant to the consumer, for purposes of improving individual and family functioning. 16.03 Group Therapy: Group therapeutic treatment activities designed to reduce maladaptive behaviors, maximize

behavioral self-control, or restore normalized psychological functioning, reality orientation and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships. Outpatient services may be conceptualized according to the following 3 levels: • Problem Focused Treatment – Brief treatment (typically 1-10 visits), which focuses on resolution of a life crisis or an adjustment reaction to an external stressor or developmental challenge. • Symptom Focused Treatment – Intermediate treatment (typically 1-20 visits) that may include

pharmacotherapy, which focuses on reduction of symptoms and dysfunction related to an Axis I or II diagnosis. • Complex Case Treatment – Longer term psychotherapy, usually with pharmacotherapy, which is

considered for individuals after trials of Problem Focused or Symptom Focused Treatment have failed to adequately ameliorate ongoing significant symptoms and dysfunction. This level of care may require scheduled or intermittent contact (e.g., every other week) with a clinical professional to maintain the individual’s level of functioning and to prevent the use of more intensive levels of care.


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Criteria

Admission Criteria


1. The person must have a severe, chronic condition that is attributable to a mental or physical impairment or a combination of mental and physical impairments that were manifested before the individual was 22 years old, is likely to continue indefinitely, and results in substantial functional limitations in 3 or more of the following areas of major life activity:

a. Self-care b. Receptive and expressive language c. Learning’ d. Mobility e. Self-direction f. Capacity for independent living g. Economic self-sufficiency, and

2. The individual must demonstrate a need for a combination and sequence of

special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and need to be individually planned and coordinated, and

3. The individual’s psychiatric and behavioral symptomatology can reasonably be

expected to respond to outpatient therapeutic intervention. 4. There is an expectation that the individual has the capacity to make significant

progress toward treatment goals or treatment is necessary to maintain the current level of functioning.

5. Unless specifically contraindicated, the parents/guardians of a child/adolescent are

involved and cooperative with family evaluation and appropriate family treatment

Exclusion Criteria


1. The individual requires a level of structure and supervision beyond the scope of non-programmatic outpatient services.

2. The individual has medical conditions or impairments that would prevent beneficial utilization of services.

3. Medication management level of outpatient care is sufficient to stabilize the individual.

4. Rehabilitative or community services are provided and are adequate to stabilize or

assist the individual in resuming prior level of roles and responsibility.


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1. The individual's condition continues to meet admission criteria at this level of care.

2. The individual's treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.

3. IPCPOS (Individual Person Centered Plan of Service)/Treatment Plan is regularly reviewed and revised with the individual as well as family, guardian, friends, and professionals as the individual (or family/guardian) desires or requires, to reflect the individual’s need for continued outpatient services.

4. IPCPOS/Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include: active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated.

5. All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practice.

6. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress are evident, or stabilization of functioning is documented.

7. Care is rendered in a clinically appropriate manner and focused on the individual's behavioral and functional outcomes, as described in the discharge plan.

8. There is documented active discharge planning with evidence of

coordination and linkages with community resources for effective and clinically appropriate aftercare services.

9. There is a documented active attempt at coordination of care with the behavioral health provider and the primary care physician, when

appropriate.


1. The individual's/family's documented treatment plan goals and objectives have

been substantially met. 2. The individual/family no longer meets admission criteria, or meets criteria for a

less or more intensive level of care. 3. The individual, family, guardian, and/or custodian are competent, but

noncompliant in treatment. The noncompliance is of such degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-compliance issues.

4. Consent for treatment is withdrawn and it is determined that the individual (or

parent/guardian) has the capacity to make an informed decision and does not meet criteria for an inpatient level of care.

5. The individual/family is not making progress toward treatment goals, and there is

no reasonable expectation of progress at this level of care.

6. It is reasonably predicted that continuing stabilization can occur with discharge

from care and/or medication management only and community support.


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15.00 Assessments, Evaluations and Screenings

15.00 Assessments, Evaluations and Screenings (Non-Medication) Level of Functioning Assessments

Level of functioning assessments are standardized instruments designed to measure an individual’s level of functioning in different spheres. All level of functioning assessments must be administered by appropriately qualified professionals who are trained in their specific use. The following are level of functioning assessment instruments that may be used, when indicated: Clinic Assessments

Screening Intake – This is the initial intake for an individual requesting services via telephone or face to face where a

professional staff person completes an initial referral form and includes the documentation necessary to register the person in the behavioral health system. The screening intake represents the time of the clinical staff used to determine the referrals that are appropriate to give the individual, based on the individual’s request and/or presenting problem and the prioritization of those requests. Clinical Assessment- Generally accepted professional assessments or tests, other than psychological tests or specialized

assessments that are conducted for the purpose of determining levels of functioning and the treatment needs of the individual. The assessment is a discipline-specific, thorough evaluation of a person’s psychological/mental and social condition which identifies strengths, problems, needs, disabilities and appropriate recommended measures to relieve conditions that are manageable and treatable, and concludes with a summary of significant findings and recommendations. The clinical assessment will assist in directing the service planning process. All individuals receiving behavioral health services receive a clinical assessment by a qualified mental health professional at the time of admission to the service/treatment and a re-evaluation on an annual basis. Other Assessments/Evaluations

PASARR OBRA Assessment – The OBRA Pre-Admission Screening and Annual Resident Review is an initial

screening/assessment to determine if a person with a primary diagnosis of a mental illness or a I/DD meet the criteria for nursing home placement; or an annual assessment to determine if the individual’s medical needs are such to continue to meet the criteria for a nursing home placement as determined by MDCH. This assessment is provided in the individual’s environment e.g. hospital, nursing home, community, residence, or a mental health clinic. This service includes: completion of notification, explanation of the appeal process, and staff transportation. The assessments are conducted by qualified mental health professionals. This service is provided by an Authority contracted directly with the Detroit Wayne Mental Health Authority and ICA coordinates with this Authority when this service is necessary.

Court Ordered Evaluation - Evaluations or screenings that are court ordered prior to the completion of the probate, civil,

or criminal proceedings, including the development of the written report and preparation for court testimony. Required psychological testing is included.


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16.00 Medication Services

16.00 Medication Services

The following medication services at the level of outpatient treatment may be provided to ensure individuals requiring psychotropic medications receive medications with optimal efficacy for his/her condition, and with the least side effects. The following are medication services that are available: Medication Management/Review – New & Existing Consumer: This is the face to face process conducted by an

MD/DO, PA, RN/RPH to evaluate and monitor medications and their side effects, complaints of the individual regarding the medication, and the need for continuing or changing the psychotropic medication regime for individuals when needed. Individuals with medication management must have their medication reviewed at least quarterly. Medication Administration- This service is the process of administering physician prescribed oral medication, injection, or

topical medication to an individual throughout the day. AIMS Screening – This is specific testing to determine the existence of side effects to neuroleptic medication. This testing

is usually performed during the medication review or medication session. Clozapine Monitoring- This is the monitoring of individuals who have been prescribed the anti-psychotic medication

Clozapine. This includes: blood draws, pharmacy and lab coordination to monitor side effects. This does not include the clinical services provided as part of the medication management service (described above).

Criteria

Admission Criteria


1. All of the admission criteria for Outpatient Services

2. There is a need for prescribing and monitoring psychotropic drugs.

Exclusion Criteria


1. There is a need for the prescribing physician to also provide interactive psychotherapy. (In this instance, one of the other levels of outpatient treatment would be applicable)



1. All of the continuing stay criteria for Outpatient Services.


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1. The individual no longer requires psychotropic medication 2. The individual, family, guardian and/or custodian are competent, but non-

participatory in treatment. The non-participation is of such degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues.

3. Consent for treatment is withdrawn, and it is determined that the individual has

the capacity to make an informed decision and does not meet criteria for an inpatient level of care.

17.00 Occupational, Physical and Speech Therapies

17.00 Occupational, Physical and Speech Therapies

Each service below is available only with a physician’s prescription.

Occupational

Occupational Therapy (Individual) – One to one occupational or goal-oriented activities designed to achieve optimum

functioning to prevent dysfunction and to promote health. The term occupation, as used in occupational therapy, refers to any activity engaged in for evaluating and identifying treatment problems interfering with functional performances. Activities provided by a qualified occupational therapist/assistant based on the individual’s need for services and to recommend a course of treatment in an individual modality. Occupational Therapy (Group) – Group occupational or goal-oriented activities designed to achieve optimum functioning

to prevent dysfunction and to promote health. The term occupation, as used in occupational therapy, refers to any activity engaged in for evaluating and identifying treatment problems interfering with functional performances. Activities provided by a qualified occupational therapist/assistant based on the individual’s need for services and to recommend a course of treatment in a group modality. Occupational Therapy Evaluation - Activities performed by a qualified occupational therapist/assistant to determine the

individual’s need for services and to recommend a course of treatment.

Physical

Physical Therapy – Activities including the treatment of an individual that employ effective properties of physical measures

and the use of therapeutic exercises and rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating a physical or mental disability. Activities are performed by a physical therapist or

physical therapy assistant on an individual basis as prescribed by a physician.

Physical Therapy Evaluation - Activities performed by a qualified physical therapist/assistant to determine the

individual’s need for services and to recommend a course of treatment.

Speech-Language-Hearing

Speech-Language-Hearing (Individual) - Diagnostic, screening, preventive or corrective services provided on an

individual basis, when referred by a physician (M.D., D.O.)

Speech-Language-Hearing (Group) - Diagnostic, screening, preventive or corrective services provided on an individual

basis, when referred by a physician (M.D., D.O.)

19.08 Speech-Language-Hearing Evaluation - Activities provided by a speech pathologist or audiologist to determine

the individual’s need for services and to recommend a course of treatment.


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117

Criteria

Admission Criteria


1. The person must have a severe, chronic condition that is attributable to a mental or



2. The individual must demonstrate a need for a combination and sequence of special,



development relative to the individual’s age, are gravely disrupted due to lack of ability or willingness and the individual consistently requires assistance with eating/personal hygiene/dressing, and other essentials of daily living, beyond reasonable, age/stage-appropriate verbal prompting.

Exclusion Criteria Any of the following criteria are sufficient for exclusion from this level of care: None

Continued Stay Criteria All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual’s condition continues to meet admission criteria at this level of care.

2. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.

3. Care is rendered in a clinically appropriate manner and is focused on the

individual’s behavioral and functional outcomes, as described in the Individual Person Centered Plan of Service (IPCPOS).

4. IPCPOS/Treatment plan is individualized and appropriate to the individual’s

changing condition with realistic and specific goals and objectives stated. Treatment planning should include: active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated.

5. All services, supports and treatment are carefully structured to achieve optimum

results in the most time efficient manner possible consistent with sound clinical practice.

6. IPCPOS reflects progress in relation to specific symptoms, impairments or support

needs is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the IPCPOS/treatment plan to address lack of progress are evident.

Discharge Criteria The following criterion is sufficient for discharge from this level of care:

1. The individual’s documented IPCPOS goals and objectives have been substantially met.

2. The individual no longer meets admission criteria or meets criteria for a less

or more intensive level of care

3. Consent for services, supports and/or treatment is withdrawn


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18.00 Clinical Services

18.00 Clinical Services

The following are various clinical services that are provided to individuals with developmental disabilities. Psychiatric Evaluation (New Consumer) – This is a comprehensive examination, performed face-to-face by a psychiatrist that investigates an individual’s clinical status including the presenting problem, the history of the present illness, previous psychiatric history, physical and medication history, relevant personal and family history, personal strengths and assets, and mental status examination. This examination concludes with a written summary of positive findings, a biopsychosocial formulation and diagnostic statement, an estimate of risk factors, initial treatment recommendations, estimate of length of stay when indicated, and criteria for discharge. Psychiatric Evaluation (Existing Consumer) – This is an update of the comprehensive examination, performed face-to-face by a psychiatrist that investigates an individual’s clinical status including the presenting problem, the history of the present illness, previous psychiatric history, physical and medication history, relevant personal and family history, personal strengths and assets, and mental status examination. This examination concludes with a written summary of positive findings, a biopsychosocial formulation and diagnostic statement, an estimate of risk factors, initial treatment recommendations, estimate of length of stay when indicated, and criteria for discharge.

Person Centered Planning (PCP) - These are activities associated with assisting the individual and those of his/her choosing in the development and periodic (as determined by the plan, but at lease annually) review of the person-centered plan. This includes assisting the consumer in pre-planning (identifying who will participate, where, and when, etc.); in sharing needs, concern, desires, and dreams; in designing strategies for addressing them, and in the periodic review of the plan to determine if progress is being made and/or that additional needs must be addressed. PCP activities performed as part of the supports coordinator or case

management function should not be counted here. Behavioral Management Review – These are services that include the development, review, approval and revision of a behavioral management plan according to Authority policy and requirements of the MDCH. Services are delivered according to a behavioral plan that is based on a functional assessment of the individual’s behavioral needs. Services should be actively designed to reduce maladaptive behaviors, maximize behavioral self-control, or restore normalized psychological functioning, reality orientation, and emotional adjustment enabling the individual to function more appropriately in interpersonal and social relationships. These services may be provided on an individual or group basis. OBRA-Nursing Home Monitoring Services – This is the review of individuals and their cases, including direct client contract and consultation with nursing home staff to determine whether recommendations from mental health assessments are adequate and to follow-up for treatment furnished in response to emergency problems or needs of a nursing home resident. This face-to-face service is not intended to provide ongoing case management. This service is provided by an Authority under direct contract with the Detroit Wayne Mental Health Authority; ICA coordinates with the provider Authority when this service is necessary. OBRA-Specialized Services - Traditional mental health clinic services for nursing home residents who have been assessed and whose individual plan of services identifies a need for specialized mental health services to be delivered in the nursing home. Services are to supplement nursing home services and are to be coordinated with NH staff and include: crisis intervention, individual therapy, behavior modification, group therapy, case consultation, family therapy, program consultation, day treatment, teaching nursing home staff how to implement skill building techniques or behavioral plans, medication management, psychiatric evaluations, and other assessments and testing. This service is provided by an Authority under direct contract with the Detroit Wayne Mental Health Authority; ICA coordinates with the provider Authority when this service is necessary.


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19.00 Psychological Testing

19.00 Psychological Testing

Psychological testing involves the culturally and linguistically competent administration and interpretation of standardized. Adaptive, projective and IQ tests to assess an individual's emotional and behavioral characteristics and cognitive and adaptive functioning levels. Standardized instruments administered measure or assess an individual’s mental skills, characteristics, and functioning abilities in areas, such as cognitive functioning, adaptive functioning, memory, psychopathology, organization, intelligence, comprehension, and recall. Services include: the pre-testing interview and the interpretation of the testing results. The testing record must indicate the name of the person administering the test and the actual test. Although all testing approval is subject to the general admission and exclusion criteria delineated below, the following are guidelines regarding the most common testing issues:

Testing is approved only for licensed psychologists or limited licensed psychologists for whom testing falls within the scope of their clinical license and who have specialized training in psychological and/or neuropsychological testing (note: when testing is performed by a limited licensed psychologist, the result must be reviewed and authenticated by a fully licensed psychologist.

When neuropsychological testing is requested secondary to a clear, documented neurological injury (e.g., stroke, traumatic brain injury), ICA may consider this service to be the responsibility of the medical carrier, though this determination may be subject to account-specific guidelines. ICA may request that a neurology consult be done prior to making a medical necessity determination. In the case where neuropsychological testing is requested to differentiate the presence of organic brain dysfunction versus a psychological disorder, a screening of no more than 4 hours of testing may be pre-certified for this purpose. A neurological consult may be requested prior to a certification decision for a complete testing battery. When administration of neuropsychological testing is delegated to a psychometrician/psychological assistant, the report must be signed by the neuropsychologist responsible for the interpretation of test results.

Testing requested by the legal or school system is not generally a covered benefit, except when requested for the sole purpose of a guardianship hearing.

The administration of a standard battery of tests is not routinely considered medically necessary; thus, the "process method" of selecting specific tests, which are directly responsive to the referral questions, and presenting problems, is generally endorsed by ICA. Frequently, a portion of a testing request may be approved as a screening to determine the need for further testing, just as an

x-ray might be approved before an MRI in an orthopedic work-up.

Testing requested on an inpatient basis should be completed within 48 hours of being ordered.


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Criteria

Admission Criteria Any of the following are necessary for psychological testing:

a. The person must have a severe, chronic condition that is attributable to a mental or



2. The individual must demonstrate a need for a combination and sequence of special,



development relative to the individual’s age, are gravely disrupted due to lack of ability or willingness, and the individual consistently requires assistance with eating/personal hygiene/dressing and other essentials of daily living, beyond reasonable, age/stage-appropriate verbal prompting.

4. Testing is needed for a differential diagnosis, which is not clear from a traditional

assessment (i.e., clinical interview, and brief rating scales), and diagnostic clarity is needed for effective treatment planning.

5. The individual has not responded to standard treatment with no clear explanation of

treatment failure, and testing will have a timely effect on the Individual Person Centered Plan of Service (IPCPOS)/treatment plan.

6. The individual is a new ICA consumer, and testing is needed to determine eligibility of the

new consumer when there is not sufficient historical records (school records/reports, physician reports, other) that support a diagnosis of I/DD.

7. The Probate Court has mandated a guardianship hearing for the individual (occurring no

more than once every five (5) years).

Exclusion Criteria Any of the following criteria are sufficient for exclusion from this service:

1. Testing was administered within the last year, and there is no strong evidence that the consumer's situation or functioning is significantly different.

2. Testing is primarily for educational purposes.

3. Testing is requested within 30 days of active substance abuse.

4. Testing is primarily to guide the titration of medication.

5. Testing request appears more routine than medically necessary.


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6. Interpretation and supervision of neuropsychological testing (excluding the administration of tests) is performed by someone other than a licensed psychologist with a specialty in neuropsychology.

7. Measures proposed have no standardized norms or documented validity.

8. The time requested for a test/test battery falls outside established time parameters.

9. Symptoms of acute psychosis interfering with proposed testing validity are present.

Continued Stay Criteria Any of the following criteria are necessary for continuing treatment at this level of care:

Does Not Apply


Does Not Apply

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