DHS/DMH Authorization Requirements
Utilization Management Program Overview

Introduction:

  • The Utilization Management (UM) Program is the vehicle through which DHS/DMH ensures that individuals being served receive:
    • the services best suited to support their recovery needs and preferences,
    • cost effective services in the most appropriate treatment setting,
    • services consistent with medical necessity criteria and evidence-based practices.
  • By implementing the UM Program, DHS/DMH strives to achieve a balance between:
    • the needs, preferences, and well-being of persons in need of mental health services
    • demonstrated medical necessity;
    • the availability of resources.
  • The UM Program:
    • does not limit medically necessary Medicaid services
    • is fully compliant with the Illinois Medicaid State Plan and associated federal rules.

UM Program Overview, continued

The DHS/DMH Utilization Program has the following components:

  • Medical Necessity Guidance and Criteria
  • Limited External Authorization
  • Ongoing Data Reporting and Analysis

UM Program Overview, continued

Medical Necessity Guidance and Criteria.

  • Medical Necessity Guidance and Criteria.
    • DHS/DMH has published medical necessity criteria for the following services:
      • Assertive Community Treatment (ACT)
      • Community Support Team (CST)
      • Psychosocial Rehabilitation (PSR)
      • Community Support (CSI, CSG, CSR)
      • Therapy Counseling (TC)
    • For those services available to both adults and children, separate criteria are provided for each.

UM Program Overview, continued

  • These criteria may be found in the DHS/DMH Medical Necessity Criteria and Guidance Manual (within the Provider Manual)
  • These critieria should be used by providers to guide them in making consistent admission, continuing service, and termination of service decisions for each consumer.
  • Providers must use these criteria consistently, regardless of whether or not DHS/DMH or its designee externally authorizes the service.
  • Provider adherence to these criteria may be subject to post payment review.

UM Program Overview, continued

Limited External Authorization.

  • Authorization for payment by DHS/DMH or its designee is required for specific services, based on a review of service utilization patterns for a previous fiscal year.
    • Thresholds are the same for adults and children/adolescents and are calculated by provider and consumer per fiscal year.
    • Authorization for payment for services beyond the specified thresholds is based on medical necessity criteria.
    • Services will continue to be authorized as long as medical necessity is in evidence.

UM Program Overview, continued

Service Admission Authorization Required Continuing Service Authorization Required?
ACT Yes
CST Yes
PSR

Not for first 800 units (combined PSR and

CSG) each fiscal year

Yes, for services beyind 800 units (combined PSR and CSG) each fiscal year
CSG

Not for first 800 units (combined PSR and

CSG) each fiscal year

Yes, for services beyind 800 units (combined PSR and CSG) each fiscal year

Therapy

Counseling

Not for first 40 units each fiscal year Yes, for services beyound 40 units each fiscal year
  • For purposes of determining clinical review thresholds, PSR and CSG utilization will be managed as a combined benefit. Clinical review and continuing service authorization will be required whenever an individual's utilization of PSR and CSG combined exceeds 800 units per fiscal year, with recognition that an individual may use one or both of these services during the year.

UM Program Overview, continued

Ongoing Data Reporting and Analysis

  • DHS/DMH reviews
    • utilization patterns
    • post payment review results
    • authorization impacts
    • other quantitative and qualitative aspects of service delivery.
  • These data are used to inform
    •  provider technical assistance efforts
    • Training
    • future UM Program modifications

Medical Necessity Criteria

  • Diagnosis
  • Service Initiation Criteria
  • Continuing Service Criteria
  • Exclusion Criteria
  • Service Termination Criteria

Medical Necessity Criteria

  • DIAGNOSIS:
    • Current eligible mental health diagnosis for which the proposed course of treatment has been determined to be effective
    • Symptoms consistent with those described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical Classification of Diseases and Related Health Problems (ICD)
    • Symptoms addressed do not have their primary origin in a diagnosis of an Autism Spectrum Disorder, substance-related disorder, or a principal diagnosis of Mental Retardation/Intellectual Disability

Medical Necessity Criteria

  • Service Initiation Criteria
    • To be considered for all individuals receiving services for which guidance is published
    • May be subject to Post Payment Review
    • Establishes basis for need for service
  • Continuing Service Criteria
    • To be utilized for determination of need for ongoing services, once individual meets threshold
    • Is the basis for the Collaborative's authorization decision

Medical Necessity Criteria

  • Exclusion Criteria
    • Reasons for service to be considered inappropriate for an individual
    • Could be cited at either Post Payment or Authorization Review
  • Termination Criteria
    • Reasons for discontinuing service
    • Could be cited during Clinical Practice Guidance or Authorization Review

Medical Necessity by Service

  • Some content in the following slides is taken verbatim from the DHS/DMH Medical Necessity Criteria and Guidance Manual (MNCGM). Others is paraphrased to fit within the time allotted for the presentation. Participants are strongly encouraged to review the MNCGM in its entirety for full understanding of DHS/DMH requirements.

Medical Necessity Criteria

Therapy/ Counseling

SERVICE INITIATION CRITERIA - Severity/complexity of symptoms and level of functional impairment require this service, as evidenced by:

  • Individual has an emotional disturbance and/or diagnosis that is destabilizing or distressing
  • Individual's assessment identifies specific mental health problems that may be effectively addressed by Therapy/Counseling.
  • Level of Care Utilization System (LOCUS) score equating to Level of Care 2 or higher for adults or clinician-rated Ohio scale of 16 or higher for youth age 5 and up

Medical Necessity Criteria

Therapy/ Counseling

Continuing Service Criteria

  • Evidence of active participation by individual
  • Demonstrated evidence of significant benefit from this service:
    • as evidenced by the attainment of most treatment goals, but the desired outcome has not been restored
    • and the individual's level of emotional stress continues to be destabilizing, significantly interfering with daily functioning
  • Individual cannot be safely and effectively treated solely through the use of Community Support services, case management, and the engagement of natural support systems.

Medical Necessity Criteria

Therapy/ Counseling

Additional Criteria for Specific Modalities

  • Individual - necessity of one to one interventions
  • Group - specifically identified problems with social interactions, interpersonal difficulties, etc, for which involvement in group process is expected to be beneficial
  • Family - identified problems are exacerbated by family dynamics and/or can be most effectively addressed through family involvement

Medical Necessity Criteria

Therapy/ Counseling

Exclusion Criteria

  • Cognitive impairment, mental status or developmental level that makes it unlikely individual would benefit
  • Primary problem to be addressed could be more effectively/efficiently addressed by another modality

Medical Necessity Criteria

Therapy/ Counseling

Service Termination

  • Treatment goals achieved
  • Majority of goals achieved and remainder can be safely achieved by accessing other services and/or natural supports
  • No significant improvement and needs to be reassessed for more effective treatment

Medical Necessity Criteria

Psychosocial Rehabilitation

Service Initiation Criteria

  • Significantly impaired role function in at least 2 of the following:
    • management of financial affairs
    • ability to procure needed services
    • socialization, communication, adaptation, problem solving and coping
    • Activities of daily living,
    • Self-management of symptoms
    • Concentration, endurance, attention, direction following and planning and organization skills necessary for recovery
  • LOCUS Score equating to level of care of 3 or higher
  • Discharge/transition plan expressly focused on increasing community integration through the application of skills in community settings.

Medical Necessity Criteria

Psychosocial Rehabilitation

Continuing Service Criteria

  • Treatment plan reflects modifications in PSR services for skills that the individual has not yet been able to successfully demonstrate
  • Individual cannot be safely/effectively treated through provision of alternative community-based services or engagement of natural supports

Medical Necessity Criteria

Psychosocial Rehabilitation

Exclusion Criteria

  • Individual under age 18
  • Individual chooses not to participate
  • Primary etiology of dysfunction related to Intellectual Disability, or an organic process or syndrome including normal aging
  • Individual's ADLs/skills are sufficient to enable progress in recovery
  • Individual requires more intensive contact

Medical Necessity Criteria

Psychosocial Rehabilitation

Service Termination Criteria

  • Individual has learned the skills and requests termination or no longer needs active treatment
  • Has learned most of the skills, can apply and improve skills in natural settings
  • Is not making progress and needs reassessment to determine more appropriate services

Medical Necessity Criteria

Community Support Group

Service Initiation Criteria

  • Significant impairment in functioning, inability to apply skills in natural settings, and/or to build/utilize natural supports
  • Require small group support to facilitate more effective role performance
  • Identification of specific functional impairments that can only be remediated through small group practice to reinforce target skills
  • LOCUS level of care recommendation of 2 or higher

Medical Necessity Criteria

Community Support Team

The individual meets eligibility criteria for CST services (59 ILAC 132.150.h.4), including:

  • Rule 132 eligible diagnosis with symptoms consistent with the diagnosis
  • Requires team based outreach and support, and as a result of receiving these team-based clinical and rehabilitative support services, is expected to be able to access and benefit from a traditional array of psychiatric services, AND
  • has tried and failed to benefit from a less intensive service modality or has been considered and found inappropriate for less intensive services at this time, AND

CST (cont)

  • Exhibits three (3) or more of the following:
    • Multiple and frequent psychiatric inpatient readmissions, including long term hospitalization;
    • Excessive use of crisis/emergency services with failed linkages;
    • Chronic homelessness;
    • Repeat arrest and incarceration;
    • History of inadequate follow-through with elements of an ITP related to risk factors, including lack of follow through taking medications, following a crisis plan, or achieving stable housing;
    • High use of detoxification services (e.g., two or more episodes per year);
    • Medication resistant due to intolerable side effects or their illness interferes with consistent self-management of medications;
    • Child and/or family behavioral health issues that have not shown improvement in traditional outpatient settings and require coordinated clinical and supportive interventions;
    • Because of behavioral health issues, the child or adolescent has shown risk of out-of-home placement or is currently in out-of-home placement and reunification is imminent;
    • Clinical evidence of suicidal ideation or gesture in last three (3) months;
    • Ongoing inappropriate public behavior within the last three months including such examples as public intoxication, indecency, disturbing the peace, delinquent behavior;
    • Self harm or threats of harm to others within the last three (3) months;
    • Evidence of significant complications such as cognitive impairment, behavioral problems, or medical problems.

CST (cont)

  • The individual's severity or complexity of symptoms and level of functional impairment require coordinated services provided by a team of mental health professionals and support specialists, as evidenced by one or more of the following:
    • Two or more psychiatric inpatient readmissions over a 12 month period or one long term hospitalization of 180 days or more (Source: NAMI PACT Criteria);
    • Excessive use (2 or more visits in a 30 day period) of crisis/ emergency services with failed linkages;
    • Chronic homelessness (HUD Definition of Homelessness);
    • Repeat (2 or more in a 90 day period) arrests and incarceration for offenses related to mental illness such as trespassing, vagrancy or other minor offenses;
    • Multiple service needs requiring intensive assertive efforts to ensure coordination among systems, services and providers;
    • Continuous functional deficits in achieving treatment continuity, self-management of prescription medication, or independent community living skills;
    • Persistent/severe psychiatric symptoms, serious behavioral difficulties, a co-occurring disorder, and/or a high relapse rate;
    • Significant impairments as a result of a mental illness, as evidenced by:
    • For adults, a Level of Care Utilization System (LOCUS) Level of Care 4 or justification of need for service if less than a 4.
    • For youth five years or older, a minimum score of 16 for problem severity on the worker's form of the Ohio Youth Problems, Functioning, and Satisfaction Scales (Ohio Scales).

CST (cont)

EXCLUSION CRITERIA:

  • Individual's daily living skills are sufficient to enable them to progress in their recovery with the support of other mental health services that provide less intensive contact/support than CST.
  • Individual's level of cognitive impairment, current mental status, or developmental level make it unlikely for him/her to benefit from CST services.
  • Individual requires a more intensive team service (such as ACT) or a more restrictive treatment setting that provides continuous supervision and structured daily programming and cannot be safely or effectively treated with CST services.

CST (cont)

SERVICE TERMINATION CRITERIA

  • Individual has achieved a significant number of the treatment goals identified on his/her treatment plan and either a) requests termination of services and/or b) is assessed to no longer require active mental health treatment.
  • Individual has successfully achieved some of the goals on his/her treatment plan; can be safely and effectively treated in a less intensive treatment modality; and has a written plan to facilitate transition to the needed services.
  • Individual has not demonstrated significant improvement in functioning as a result of this treatment modality and requires reassessment to identify a more effective treatment setting or modality.

Medical Necessity Criteria 

Assertive Community Treatment

Diagnosis

  • The individual has a current eligible mental health diagnosis (as specified in 59 ILAC 132.25) for which the proposed course of treatment has been determined to be effective. To be eligible for ACT services, an individual must have one of the following diagnoses:
    • Schizophrenia (295.xx)
    • Schizophreniform Disorder (295.4x)
    • Schizoaffective Disorder (295.70)
    • Delusional Disorder (297.1)
    • Shared Psychotic Disorder (297.3)
    • Brief Psychotic Disorder (298.8)
    • Psychotic Disorder NOS (298.9)
    • Bipolar Disorder (296.xx; 296.4x; 296.5x; 296.7; 296.80; 296.89; 296.90)
  • The symptoms of the individual's diagnosis are consistent with those described in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical Classification of Diseases and Related Health Problems (ICD).
  • The symptoms to be addressed by ACT services do not have their primary origin in a diagnosis of an Autism Spectrum Disorder, substance-related disorder, or a principal Axis II diagnosis of Mental Retardation.

ACT (cont)

Service Initiation

  • The individual has indicated their agreement with the need for and choice of this service modality and has been actively involved in the development and implementation of the treatment plan.
  • Individual is age 18 or older and is affected by a serious mental illness requiring assertive outreach and support in order to remain connected with necessary mental health and support services and to achieve stable community living.
  • Traditional services and modes of delivery have not been effective.

ACT (cont)

  • The individual's severity or complexity of symptoms and level of functional impairment require this service, as evidenced by one or more of the following:
    • The individual exhibits one or more of the following problems that are indicators of a need for continuous high level of services (i.e., greater than eight hours per month) by multiple members of a multi-disciplinary team.
      • Two or more psychiatric inpatient readmissions over a 12 month period or one long- term hospitalization of 180 days or more (Source: NAMI PACT Criteria)
      • Excessive use (2 or more visits in a 30 day period) of crisis/emergency services with failed linkages.
      • Chronic homelessness (HUD definition of homelessness)
      • Repeat (2 or more in a 90 day period) arrests and incarceration for offenses related to mental illness such as trespassing, vagrancy or other minor offenses.
      • Consumers with multiple service needs requiring intensive assertive efforts beyond routine case management to ensure coordination among systems, services and providers.
      • Consumers who exhibit continuous and severe functional deficits in achieving treatment engagement, continuity, self-management of prescription medication, or independent community living skills.
      • Consumers with persistent and severe psychiatric symptoms, serious behavioral difficulties resulting in incarceration, a co-occurring disorder that severely and negatively affects participation in mental health services, and/or evidence of multiple relapses.

ACT (cont)

  • The individual has significant functional impairments as demonstrated by at least one of the following conditions:
    • Severe difficulty consistently performing the range of practical daily living tasks required for basic adult functioning in the community (e.g., caring for personal business affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions; meeting nutritional needs; achieving good personal hygiene) or persistent or recurrent difficulty performing daily living tasks even with significant support or assistance from others such as friends, family, or relatives.
    • Severe difficulty achieving employment at a self-sustaining level or severe difficulty carrying out the homemaker role (e.g., household meal preparation, washing clothes, budgeting, or child care tasks and responsibilities) or of achieving consistent educational placement (depending on developmental level).
    • Severe difficulty achieving a safe living situation (e.g., repeated evictions or loss of housing).
    • LOCUS level of care recommendation of 4

 
ACT (cont)

  • The individual has a current treatment plan with specific goals, objectives, and a discharge or transition plan. The proposed course of treatment includes specific ACT interventions (including the type and frequency of services to be provided by ACT team members) to facilitate the individual's recovery in a community-based environment.
  • The individual can only be expected to progress if they are receiving services from a highly coordinated team inclusive of a psychiatrist, nurse, recovery support specialist, clinicians, and vocational specialists. The individual's severity of illness requires multiple consultations, staffings, and/or coordination meetings by the team on a daily or weekly basis.
  • There is no equally effective, less intensive service available to treat the individual's current clinical condition or assist the individual in achieving his/her recovery goals, including Community Support: Team(CST), Community Support: Group (CSG) or Community Support: Individual (CSI) services.

ACT (cont)

Examples of Continuing Service Criteria

  • The person's severity of illness and resulting impairment continues to require ACT services in order to maximize functioning and sustain treatment gains. The individual cannot be safely and effectively treated using a less intensive treatment modality. .
  • The individual has demonstrated significant benefit from this service, as evidenced by the attainment of some treatment plan goals, and continued progress toward goals is anticipated. However:
    • the desired outcome or level of functioning has not been restored or improved or
    • without this level of intensity of services, the individual would not be able to sustain treatment gains, and there would be an increase in symptoms and decrease in functioning
  • Services are consistent with the person's recovery goals and are focused on reintegration of the individual into the community and improving his/her functioning in order to reduce unnecessary utilization of more intensive treatment alternatives.
  • The mode, intensity, and frequency of treatment is appropriate and reflects the individual's receipt of frequent, closely coordinated services from multiple members of a multidisciplinary team, including medical support services.
  • Active treatment is occurring and continued progress toward goals is anticipated.

ACT (cont)

Exclusion Criteria:

  • Individual's daily living skills are sufficient to enable them to progress in their recovery with the support of Community Support, Case Management, and other mental health services that provide less intensive contact/support than ACT.
  • Individual's level of cognitive impairment, current mental status, or developmental level make it unlikely for him/her to benefit from ACT services.
  • Individual requires the intensity of contact and range of supportive interventions only available through more intensive services (e.g., treatment in settings that provide direct supervision and structured daily programming) and cannot be safely or effectively treated in a community-based setting.

ACT (cont)

Discharge Criteria (Must meet one of the following):

  • Individual has achieved a significant number of the treatment goals identified on his/her treatment plan and either a) requests termination of services and/or b) is assessed to no longer require active mental health treatment.
  • Individual has successfully achieved some of the goals on his/her treatment plan; can be safely and effectively treated in a less intensive treatment modality; and has a written plan to facilitate transition to the needed services.
  • Individual has not demonstrated significant improvement in functioning as a result of this treatment modality and requires reassessment to identify a more effective treatment setting or modality.
  • Person has moved out of the ACT team's geographic area or cannot be located, in spite of repeated ACT efforts.

Authorization Process

ACT and CST

  • All team services require authorization from the initiation of team services.
  • If medical necessity is demonstrated:
    • and the assessment and treatment plan are completed prior to the authorization request, then ACT can be authorized for up to one year, and CST can be authorized for up to six months.
    • and the authorization is sought PRIOR to completion of all documents, then the authorization will be provided for only 3 months
  • For team services ONLY, the authorization can be back-dated to the initiation of services.

Authorization Process

Therapy/Counseling:

  • Eligible Consumers are able to initially receive up to 10 hours (40 units) of this service, if provider LPHA deems medically necessary, without submission of an authorization request
  • If provider deems additional hours (units) of T/C are medically necessary above and beyond the 10 hour (40 unit) threshold, a request for authorization must be submitted and authorization must be obtained in order to be reimbursed for services.
  • Determination of additional hours (units) to be reimbursed are based upon medical necessity

Authorization Process, continued

PSR & CSG:

  • Eligible Consumers are able to initially receive up to 200 hours (800 units) of PSR, CSG, or a combination of PSR & CSG, if provider deems medically necessary, without submission of an authorization request
  • If provider LPHA deems additional hours (units) are medically necessary above and beyond the 200 hour (800 unit) threshold, a request for authorization must be submitted and authorization must be obtained in order to be reimbursed for services.
  • Determination of additional hours (units) to be reimbursed are based upon medical necessity

Authorization Process, continued

  • Collaborative clinical care managers review submitted documents for adherence to Medical Necessity Criteria (MNC), and Rule 132.
  • If the MNC are met for the service(s), the Collaborative will enter an authorization.
  • In order for the provider to be reimbursed for services provided past initial thresholds, requests for authorization must be submitted and approved prior to service provision.
    • This means that providers need to submit authorization requests before the authorization expiration date or maximum number of hours/units stated

Audit Process

  • To ensure the integrity of the authorization process, the Collaborative will randomly audit approved authorization requests.
  • If selected for the random audit, the provider must submit additional documentation that supports the information submitted to the Collaborative at the time of the authorization request.
  • This includes information from the mental health assessment, treatment plan, and any progress notes the provider LPHA deems particularly relevant.

Appeals Process

Should the Collaborative deny an authorization, the provider has the opportunity to appeal.

The appeals process will be explained in detail during the authorization training from the Collaborative.