Authorization & Functions Procedures (pdf)

More information, contact: Lee Ann Reinert, Community Services - (217) 782 -0059

Presenters

  • Lee Ann Reinert, LCSW
    Clinical Policy Specialist, DHS/DMH
  • Patricia Palmer, LCSW, CADC
    Clinical Director, Collaborative

Author

Patricia E. Hill, CSS

Summary

This document will review the procedures regarding the authorization and functions of the Region 1 South Crisis are System.

Glossary of Terms

  • CMHC-Community Mental Health Center
  • LOC-Level of Care
  • SMI-Serious Mental Illness
  • LOCUS-Level of Care Utilization System
  • USARF-Uniform Screening and Referral Form
  • ASAM-American Society of Addiction Medicine
  • MNC-Medical Needs Criteria
  • CCM-Clinical Care Manager

What is it?

A Utilization Management Service implemented by the State of IL in conjunction with DHS/DMH where the Collaborative will handle:

  • Authorization for Region 1 South Crisis Care, including inpatient, residential and acute community care

Who is eligible?

  • Consumers that are Unfunded
  • Consumers that would previously have been admitted to Tinley Park Hospital
  • Consumers with SMI that need immediate evaluation and care during a crisis situation

Type of Service

  • The Assessor will assess in two categories:
    • Mental Health
    • Co-morbid Substance Abuse and Mental Health

The Process

  • Once the Consumer has met the criteria, the Evaluator will contact the Collaborative at (866)359-7953 and select option "#4"to obtain authorization
  • The Collaborative will review the clinical information to verify that the Consumer meets the Medical Necessity Criteria (MNC) for the LOC being requested
  • Once the Consumer has been approved, the Collaborative will assist with locating a bed if the assessing hospital does not have an appropriate available bed
  • The Collaborative will issue an Initial Review Authorization according to the LOC determined by the Evaluator

The Collaborative Call

Demographics

  • Consumer Information
    • First and Last Name
    • RIN
    • Date of Birth
    • Social Security Number
    • Address (last known address or current location if homeless)
    • Gender
    • Ethnicity
    • Provider Information
  • Financial Information
    • Funding Source (verify non-funded status)
  • Level of Service Requested
    • Inpatient
    • Mental Health Crisis Residential
    • Substance Abuse Residential
    • Acute Community Care
  • Type of Service
    • Mental Health or Substance Abuse and Mental Health

Assessment

  • Diagnosis
    • Axis 1
    • Axis 2
    • Axis 3
    • Axis 4
    • Axis 5
      • Current
      • Past
  • Current Risks
    • Mental Status
    • Risk to Self
    • Risk to Others
  • Current Impairment
    • Mood Disturbance(s)
    • Anxiety
    • Psychosis
    • Eating Disorder
    • Chemical Dependence
    • Under 19 or Over 65
  • LOCUS Score
    • Dimension 1: Risk of Harm
    • Dimension 2: Functional Status
    • Dimension 3: Medical, Addictive & Psychiatric Co-Morbidity
    • Dimension 4a: Recovery Environment-Level of Stress
    • Dimension 4b: Recovery Environment-Level of Support
    • Dimension 5: Treatment & Recovery History
    • Dimension 6: Engagement
    • Composite Score
    • LOCUS Recommended Level of Care
    • Evaluator Recommended Level of Care
    • Reason for Deviation (if any)

Consumer History

  • Treatment History
    • Psychiatric Treatment in the past 12 months
      • Outpatient
      • Intensive Outpatient
      • Hospitalization
    • Substance Abuse in the past 12 months
      • Outpatient
      • Intensive Outpatient
      • Hospitalization
    • Medical Treatment in the past 12 months
      • Routine Medical Treatment
      • Significant Medical Treatment

Medication History

Psychotropic Medications

  • Medicine
    • Dosage
    • Frequency
    • Side Effects
    • Compliance
    • Effectiveness
    • Prescriber
  • Additional Medications
    • Medicine
    • Dosage
    • Frequency
    • Side Effects
    • Compliance
    • Effectiveness
    • Prescriber

Substance Abuse History

  • Substance Used
    • Total years of use
    • Length of current use
    • Amount of current use
    • Frequency of current use
    • Date last used
  • Withdrawal Symptoms
  • Vitals
  • ASAM
    • Dimension 1: Intoxication/Withdrawal potential
    • Dimension 2: Biomedical conditions
    • Dimension 3: Emotional/Behavioral/Cognitive conditions
    • Dimension 4: Readiness to change
    • Dimension 5: Relapse Potential
    • Dimension 6: Recovery Environment

Decisions

If the CCM proposes an alternative level of service due to either clinical factors or lack of capacity

  • The Evaluator will discuss the alternative with the ED physician, the individual and appropriate parties
  • If agreement on the proposed alternative level of service is reached, then authorization will be provided
  • If the ED physician or Evaluator cannot accept the proposed alternative level of service, then the CCM will call Madden Mental Health Center (Madden Intake) to initiate an appeal (via a 3-way call if possible)
  • Madden's decision will be final

What's Next?

FOR INPATIENT CARE

Once the Collaborative has determined the Consumer meets MNC, the Collaborative will:

  • Verify if the Assessing Hospital has beds available
  • If there is an available bed, an authorization will be given and the initial authorization process will be complete
  • If there are no beds available, the Collaborative will assist with locating a bed via the approved facility listing
  • Once a bed is located for the Consumer, the initial authorization process will be complete

FOR MENTAL HEALTH CRISIS RESIDENTIAL OR SUBSTANCE ABUSE RESIDENTIAL LOC

Once the Collaborative has determined the Consumer meets MNC, the Collaborative will:

  • Assist with locating a bed via the approved facility listing
  • Provide the Evaluator with the contact information for the approved facility and an authorization number

FOR ACUTE COMMUNITY CARE

Once the Collaborative has determined the Consumer meets MNC, the Collaborative will:

  • Assist with determining the appropriate provider via the geographic provider listing
  • Provide the Evaluator with the contact information for the provider and an authorization number

Contact

www.illlinoismentalhealthcollaborative.com

(888) 359-7953