Input Needed: INDEPENDENT ASSESSMENTS

Next week, our Founder Lainey Morrow will be meeting with DDS Director Melissa Stone, BHS Director Paula Stone, and Optum (the company doing the Independent Assessments).

They are going to answer our questions about Independent Assessments and explain the whole process. What questions would you like for Lainey to ask them?

Also, they plan to provide training on the IA process, so you can know what to expect. They’ve asked for feedback on which method each one of you would prefer. This doesn’t mean they promise to provide it in that way, but they want your input.

Use the form below to send your questions and input. If you don’t see an option that fits you, add your own.

 

Therapy Cap PA Requests: Q & A 


The PT, OT, and SH Association Presidents regularly meet with DHS and AFMC to discuss issues that providers have when requesting Prior Authorizations (PAs) for children who need therapy over the 90-minute cap. These are the results of their latest meeting.

Keep track of your questions and email them to be discussed at the next meeting.


The Recap of ArkSHA, ArPTA, and AROTA meeting with AFMC and DDS on 08-25-17:

The following are issues raised by members of ArkSHA, ArPTA and AROTA, and responses from AFMC and DDS.

Issue: Shifting of Units Between Therapist and Assistant

There are still questions regarding the length of time it is taking to shift units from PT/OT/ST to PTA/COTA/SLPA and vice versa. AFMC reports that following completion of the large number of DMS-640 form validations AFMC received many change requests to prior authorizations. AFMC encouraged their staff to continue to process initial DMS-640 validations and that all changes would need to be checked before processing. Currently, AFMC states that they are about 10 days out on corrections and Jarrod McClain, AFMC Director for Clinical Review, indicated that their staff are working diligently to get the updates made as quickly as possible. The updates to the PA’s flow to DXC each night and providers can start billing immediately upon receipt of the changes.

In addition, Jarrod stated that AFMC is working to decrease the timeframe for corrections but they have to ensure that they are getting the correct request ID modified. According to Jarrod, it takes a few days to check and update the claims data extract file. If providers continue to see a delay, please contact Jarrod McClain at AFMC. He will personally see that his staff checks on the status of their request and get it processed.

Issue: Use of evaluations from preschool programs to kindergarten

There was concern from many members as to how long their evaluations will be valid in a schools setting. The consensus is that if the evaluation utilized is an evaluation conducted by a non-educational agency, or by a provider who is not contracted by an educational agency, then the evaluation is good for one year. If an educational agency or a contractor of the educational agency conducted the evaluation, then the evaluation falls under the school-based evaluation criteria of every 3 years.

Issue: Some prior authorizations were only approved after sending in a cover sheet restating information included in the evaluation.

AFMC was aware of this issue and is working to improve their processes for approval. In the meantime, providers are encouraged to highlight justification for medical necessity in the evaluative reports, including statements about how the services recommended are under accepted standards of practice to treat the patient’s condition, how services are complex and will require the skilled services of a qualified therapist, and a statement about therapy prognosis (See Medicaid Manual Section II). Though a cover letter outlining these justifications is not required, providers are encouraged to consider using a cover letter attached to the evaluation to make these medical necessity statements more salient for reviewers.

Issue: Are reviewers actually reading the evaluations or just looking for technical language?

AFMC assured us that they are reading all evaluations. They perform both technical and administrative reviews in order to ensure that all requirements of the evaluative reports are included, as well as a medical necessity review to ensure that justification for medically based services is included.

Issue: I heard that AFMC was using nurse reviewers and not experienced pediatric therapists in each discipline. Is this true?

AFMC utilizes registered nurses to perform the initial reviews of all PA requests. If a request is denied than the request is assessed by an experienced licensed therapists specific to the discipline. If the therapist agrees with the denial it is then sent to a board certified pediatric physician for final review. If a provider does not agree with the denial or would like to request reconsideration they may do so by resubmitting the request.

Issue: What about beneficiaries who receive services from multiple providers for the same service?

AFMC and DDS continue to emphasize the need for care coordination for beneficiaries with multiple providers of the same modality (physical, occupational or speech therapy). Dr. Chad Rodgers, AFMC Medical Director, attended our meeting and reported that the pediatricians and PCPs he has been in contact with are interested in understanding what situations justify the appropriate signing off on multiple prescriptions. He asserts that although he can’t speak for all physicians he personally looks at every request for therapy services before signing them. He recognized that it is difficult to for most physicians to understand why a child needs multiple services. He and assistant director of DDS Elizabeth Pittman stated that it would be beneficial to state on the DMS-640 the specific need for a particular service and that the beneficiary will need the services of multiple therapists. AFMC and DDS are considering a change to the DMS-640 forms in the future to accommodate the different services provided within one discipline. Elizabeth Pittman reported that the new MMIS system (which has an anticipated implementation of summer of 2018) will be less burdensome on providers and will have the ability to disclose is the beneficiary is receiving services from other providers. Until then, providers need to ask during the intake process if the recipient is receiving therapy services from any other provider, and then coordinate as needed. According to Jarrod McClain, only 10 providers have bumped into challenges with the multiple provider issues thus far.

Issue: For short term scripts (i.e. ortho docs who write for 2-6 weeks) that then need an extension once the patient has had a follow-up recheck. What is the most efficient way to keep PA’s from having to be unnecessarily done?

Providers can simply go into Review Point, and click the extend button. The codes will be transferred over and the new prescription can be uploaded. Information about the progress of the patient and continued medical necessity should be included with the extension.

Issue: It has come to the attention of AFMC and DDS that some facilities are sending notices to parents that they should not allow services for their child in the school due to the need for a PA if the school and independent facility are both treating the beneficiary.

Although Medicaid is a “medical” assistance program, it recognizes the importance of school-based services. The federal Medicaid program actually encourages states to use funds from their Medicaid program to help pay for certain healthcare services that are delivered in the schools, providing that federal regulations are followed. The associations stand with AFMC and DDS that sending notices to parents regarding billing for services between schools and independent clinics is not recommended. IDEA laws require schools to provide services to beneficiaries if needed for educational purposes. Schools also must provide therapy that is medically necessary. Therapy services outside of the school setting should not replicate services provided by therapists contracted or working with the school.

Issue: A representative at DHS has stated that physical therapy re-eval codes are no longer a valid code as of July 1st. Has anything changed in the recent rule change?

Reevaluation codes are not currently and haven’t been a reimbursable code. The two billable codes for physical therapy services are 97001 and 97110.

Waiver Waiting List – Important News for “the 500”


In February 2017, DHS notified 500 people that they would be receiving the funding to come off of the waiver waiting list this year. They sent paperwork for each recipient to fill out. In July, they sent another letter.

As of today, barely 250 people have responded, and the rest are in danger of losing their chance to come off the waiting list.

Our state DHS had to request the additional 500 slots from a federal agency, and that agency, Centers for Medicare and Medicaid, finally granted it on August 22, 2017. In the meantime, DHS sent another letter this summer in order to reach the rest of the people who have not yet responded. They also began working on plans of care for those who have responded. Once a person responds, it will take 60-90 days to set up the Independent Assessment, the staff required for the plan of care, supplies, and possible residencies. 

If you have already been communicating about your plan of care, you will most likely see some progress in September to October. It is important to note that the federal approval was holding up progress. If you had chosen the company who you’d like to work with, please know that they were only notified as soon as the federal approval came through. You should be hearing from them soon.

 Those of you in the 500 who were notified in February should receive DHS’ final letter in the coming days. If you have not yet responded to DHS about your spot in the top 500, they will also attempt to reach you by phone. If they can’t reach you by phone, they will remove you from the list of 500 and move on to the next people waiting. 

If you have questions about this, you can’t simply call any office. You must call these specific people:

– For the status of applications:
Merinesa Morris
(501) 683-0571

– For all other questions:
Regina Davenport
(501) 683-0575

If you are a person on the waiting list, a caregiver, or a provider of someone on the list, please share this to ensure that this information gets to the correct people.

Here is a copy of the letter that will be going out:


Public Comment: New 0-5yo Screener

A new developmental screener will now be REQUIRED to determine if a child is eligible to go to rehabilitation centers like Easter Seals, Access, the Allen School, Peds Plus, etc.

Public comment ends tonight on this rule change – August 12, 2017! Take this chance to comment on rules that affect you! Read the manuals for things that might affect you, and then send your comments and questions to Shelby.Maldonado@dhs.arkansas.gov. Make sure to tell her which documents below you’re commenting on. If you need any help, just watch a video tutorial below.

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Here are the important Screener Rule changes that you might want to read:

DDS Standards for Certification, Investigation and Monitoring – Redline DDS-Stnds-Redline.doc DDS STANDARDS for Certification, Investigation, an Monitoring for Center-Based Community Services  1. Summary DDTCS-CHMS 2. Info
CHMS-2-17 Provider Manual Update CHMS-2-17up.doc CHMS Manual mark up with changes. 1. Summary DDTCS-CHMS 2. Info
DDTCS-2-17 Provider Manual Update DDTCS-2-17up.doc DDTCS Manual mark up with changes. 1. Summary DDTCS-CHMS 2. Info

 


 

EXAMPLE OF COMMENTS SENT:
My public comment on the new screen:
DDS-Stnds-Redline.doc – Section 502.R, 504.A
CHMS-2-17up.doc – Section 203.100 C2, 217, 218.300, 241.000 B6, 242.000 A,
DDTCS-2-17up.doc – 202.000 B

I am concerned about the lack of details, such as what type of screen this will be. How can a short screen determine whether my child’s functionality would benefit from day habilitation? Also, I ask for the credentials of the people performing the screen to be qualified clinicians.

I’m concerned that parents and physicians need training to ensure that disruption in services does not occur.

My public comment on the Opt in/Opt Out:
CHMS-2-17up.doc – Section 206,
DDTCS-2-17up.doc – 203.000, 204.000, 214.131A, 214.132, 215.100D,

I am concerned that in Opting out, a parent must relinquish the child’s IDEA rights for as long as the child attends that center and/or as long as that center chooses to be opted out. Ok top of that, I’m concerned that services could be disrupted, especially if a parent chooses not to relinquish those rights and must find another place of service. Also, this may remove the freedom of choice for the parent if there is not another place of service nearby. Last, I’m concerned that disruption of services might occur as a child is transitioned into the school system.

I’m concerned that parents, therapists, educators, and advocates need training to ensure that disruption in services does not occur.


Use this form below, and it will go to the correct DHS representative.

Public Comment: BH Rule Changes

Public comment ends tonight – August 12, 2017! Take this chance to comment on rules that affect you! Read the manuals for things that might affect you, and then send your comments and questions to Shelby.Maldonado@dhs.arkansas.gov. Make sure to tell her which documents below you’re commenting on. If you need any help, just watch a video tutorial by clicking the red button below.

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Here are the important BH Rule changes that you might want to read:

INPPSYCH-1-17 Provider Manual Update INPPSYCH-1-17up.doc Manual Update for Inpatient Psychiatric Services for Under Age 21

 

OBHS-1-17 Provider Manual Update OBHS-1-17up.doc Manual Update for Outpatient Behavioral Health Services

 

Residential Community Integration Program Certification ResCommReintCert.doc Residential Community Integration Program Certification

See all the BH manuals that show rule changes.

Independent Assessment Resource

As you may know, Independent Assessments will be required for any Medicaid recipient in Tier 2 or 3 for Behavioral Health or Developmental Disability Services of DHS, as well as other Medicaid populations in Arkansas.

Public comment for these rules ends tonight, August 12, 2017! Read the manuals for things that might affect you, and then send your comments and questions to Shelby.Maldonado@dhs.arkansas.gov. Make sure to tell her which documents below you’re commenting on. If you need any help, just watch a video tutorial by clicking the red button below.

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AR Independent Assessment Manual AR_IA_July_17.doc New manual for Independent Assessment 1. IA Public Notice
2. IA Manual Summary
3. IA fiscal Impact

See all of the manuals for Independent Assessments.


 Optum (the company that DHS has contracted to do these assessments) has released the following resource to help you understand the Independent Assessment process.

Click on the image below to learn more:

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Solution to Denied PAs for Therapy Providers

MSL has been made aware that there’s a lot of confusion on submitting PAs to request more than 90 minutes of therapy for children since the therapy cap was implemented on July 1, 2017. Lainey has talked with AFMC and DHS as well as the OT Association President who has been successful in submissions.


You need a separate statement letter that answers the following questions individual to the child’s case:

1. How does the therapy administered effectively treat the beneficiary’s condition?

2. What gives you a reasonable expectation that the beneficiary is experiencing meaningful improvement or that the therapy is preventing worsening of the beneficiary’s current condition?

3. How are the frequency, intensity, and duration of the requested therapy services realistic for the age of the child?

List the question and provide the answer. Make sure you provide the other information listed there as well. AFMC told Lainey today that they will deny any submission that does not have this requirement. If you have received denial with 3 statements that say you didn’t meet the requirement, try resubmitting with this.






Public Comment Help – PASSE Model Phase I

DHS has released a manual/rule change for public comment until August 11, 2017. After that, you will not be able to get your comments on the record. In addition, they are hosting a public hearing on August 8.


You should read the manual for yourself to make sure you cover everything that concerns you. However, even if you read it, you might still wonder what to say. The comments below are an example of what one person plans to send in.

Use the form below. By choosing “Submit,” you will send an email directly to the appropriate DHS representative. Enter your information, and type your comments into the text box. You may copy/paste the comments listed at bottom into the comment section of the form, but don’t do so unless you have read it first and agree with it all. The following comments are just examples of one person’s opinions. Public comments are most effective when you make them more personal to you!


EXAMPLE | EXAMPLE | EXAMPLE | EXAMPLE | EXAMPLE | EXAMPLE | EXAMPLE

This is my public comment regarding PASSE-New-17up.doc:

Section 211.000 – It says that the PASSEs should begin October 1, 2017. I believe that this model is not ready to begin taking on clients for several reasons. Rules like this one still have to be sent through the legislature for their approval. The Insurance Department isn’t supposed to approve the PASSEs until mid-September, which will only leave them a couple of weeks before they start managing people’s care. We don’t know what the rules will be, and we don’t know who the PASSEs will be. If the PASSEs aren’t ready and don’t do a good job, they could make mistakes. This will hurt people. I want DHS to push the date back and allow us to keep things the way they are until the PASSEs have had adequate time to review all of the finalized rules and to hire and train people who understand the rules.

Section 214.000 – It says that people can choose another PASSE during the first 90 days and once every year. How will we know what the differences between each PASSE is? I want to pick the best PASSE, but I don’t understand all of the rules or what they all offer. (At this point, I have reason to wonder if the PASSEs themselves understand the rules, as they have not been finalized.) It also says “on the beneficiary’s annual anniversary of attribution to a PASSE.” Is this a single day to respond, or is it a week? You need to define how long that amount of time would be.

Section 214.000 D – It says a client can move because of “poor quality of care,” but how do we prove that? That is a relative term. Who determines what kind of care is poor? I believe that the patient should determine whether care is poor and what that means in their situation.

Section 215.000 – What if the abeyance is due to DHS/Medicaid’s fault in paperwork (and the client can prove that)? Will the coordinator help the recipient to know that their Medicaid eligibility is in dispute and help them to figure that out?

Section 222.000 G – “The right to be provided written notice of a change in the beneficiaries care coordination” should be at least 14 days, not 7 days. If you are relying on snail mail, half of the time can be used simply in sending the notification, leaving the receiver very little time to respond or make other arrangements. Why isn’t this policy the same as 223.000 B, allowing 30 days from the time it goes into effect?

Section 231.000 – The travel times and distances listed need to be cut in half, especially for DD and BH providers who are seen on a more frequent basis. For example, it is not in the best interest of a child or adult to have to travel an hour to and then an hour to return from a location to see a therapist multiple times per week.

Section 241 G, 242 A, & 243.000 – DHS needs to give the PASSEs enough money to have a qualified individual available to help me whenever I need them, as many times as I may need them. Many providers seem to be concerned that the amount announced at the AR Waiver Conference (in July 2017) of $177 is not enough. I want them to get what they need so they can give me what I need. After December 31, 2018, they should have a different funding source and should not use any money from recipients’ care for administrative funding needs.

Section 242.000 – It says in the document that care coordinators will be employees of the PASSE (241 B). However, it does not say where the care coordinators should be located. Because Arkansas is so rural, care coordinators located in the communities they serve would be most knowledgeable for their clients.

Section 254.000 – Will DHS be required to submit the data received from PASSEs, such as data that shows savings or lack thereof, for public viewing? We want to see that data as well.

Section 261.000 – This says that grievances must be resolved within 30 days of the filing date. What will happen in the meantime? If a person needs treatment, do they have to wait all that time to receive it?

Section 264.000 – This description needs more definition. Who may serve on a Consumer Advisory Council? I believe that beneficiaries or direct consumers should serve, but caregivers who speak in place of beneficiaries who can’t speak for themselves should also be able to serve.

Friends Don’t Let Friends Go Without Health Care

Author: Lainey Morrow, MSL Founder & parent

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We’re all struggling, aren’t we? We can’t very well handle someone else’s bills probably, but there are fairly easy things we can do. One very sad thing I frequently encounter is the suffering of individuals when great resources exist to prevent such a thing. Sometimes it might be a person whose health is suffering, while for others it may be a suffering future due to delays in development.

As a matter of fact, I have experienced this myself. For 2 years, my husband and I struggled to provide for my daughter. We went into debt, staying awake many nights with worry, and she went without necessary services. We thought we were on our own. We thought we’d been denied for the only things that were out there. We worked as hard as we could, and still it wasn’t enough.

By the time she was 2, my daughter was very developmentally delayed. We didn’t find out about resources we could have accessed until we moved to another state. My friend told me about TEFRA, and my daughter was easily accepted. It makes me sick to think of all she went without simply because we didn’t know this immense resource was available to us. All I needed was someone to tell me about it, which is why that’s a huge mission of MSL – to pass along important information and to connect people with great resources that exist out there.

Someone from another state recently asked me what resources exist for them, so I started to look into it. What if you don’t qualify for Medicaid? TEFRA is an option that only certain states provide, but how do you know if it’s available in your state? If TEFRA isn’t available or you don’t qualify, then what?


Let no one go without, so here’s all my research for you to share.

Do you qualify for Medicaid?

Ways to qualify for Medicaid.

Where to start if denied.

Which states have TEFRA? (This is a specific type of Medicaid usually for kids with disabilities under 19, usually requiring families who make too much to pay a premium.)

If your state doesn’t have TEFRA or you don’t qualify, what are the other options:

 


Like I said, I didn’t find out about something my daughter desperately needed until another parent told me about it. Two long years, and we could have gone more.

We can’t help everyone, but we can help someone. Someone helped me. Keep your eyes open. You may not need a resource, but someone in your friends list might. If you see a good resource, share it! It just takes a few clicks. Charities are out there to be used. They want to help people who truly need help. Sometimes they just need a little free publicity to connect with the people who need them.

This is just a start. If you know of any great resources, especially ones that apply to all states, please send them to me to share!

 

Advocates Gather to Celebrate Medicaid’s 52nd Birthday

Medicaid Saves Lives was privileged to partner with Arkansas Advocates for Children and Families, Arkansas Citizens First Congress, and the Arkansas Chapter of the Academy of Pediatrics to host a celebration at the Capitol for Medicaid’s 52nd Birthday. Even if you missed it, you can still watch the festivities!

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