Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-170 - Utilization review of treatment foster care (TFC) case management services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Service
				description and provider qualifications. TFC case management is a
				community-based program where treatment services are designed to address the
				special needs of children. TFC case management focuses on a continuity of
				services, is goal directed and results oriented. Services shall not include
				room and board. Child-placing agencies licensed or certified by the Virginia
				Department of Social Services and that meet the provider qualifications for
				treatment foster care set forth in Part XV (12VAC30-130-900 et seq.) of this
				chapter shall provide these services.
B. Utilization control.
1. Assessment. Each child referred for TFC
				case management must be assessed by a Family Assessment and Planning Team
				(FAPT) under the Comprehensive Services Act or by an interdisciplinary team
				approved by the State Executive Council. For purposes of high quality case
				management services, the team must (i) assess the child's immediate and
				long-range therapeutic needs, developmental priorities, and personal strengths
				and liabilities; (ii) assess the potential for reunification of the child's
				family; (iii) set treatment objectives; and (iv) prescribe therapeutic
				modalities to achieve the plan's objectives.
2. Qualified assessors. A qualified assessor
				is a Family Assessment and Planning Team as authorized under §§
				2.2-5207, 2.2-5208, and 2.2-5209 of the Code of Virginia.
3. Preauthorization. Preauthorization shall
				be required for Medicaid payment of TFC case management services for each
				admission to this service and will be conducted by DMAS or its utilization
				management contractor. When service is authorized, an initial length of stay
				will be assigned. The provider must request authorization for continued stay.
				Failure to obtain authorization of Medicaid reimbursement for this service
				within 10 days of admission will result in denial of payments or recovery of
				expenditures.
4. Medical necessity
				criteria. Children whose conditions meet this medical necessity criteria will
				be eligible for Medicaid payment for TFC case management. TFC case management
				will serve children under age 21 in treatment foster care who are seriously
				emotionally disturbed (SED) or children with behavioral disorders who in the
				absence of such programs would be at risk for placement into more restrictive
				residential settings such as psychiatric hospitals, correctional facilities,
				residential treatment programs or group homes. The child must have a documented
				moderate to severe impairment and moderate to severe risk factors as recorded
				on a state-designated uniform assessment instrument. The child's condition must
				meet one of the three levels described below.
a. Level I: Moderate impairment with one or
				more of the following moderate risk factors as documented on the
				state-designated uniform assessment instrument:
(1) Needs intensive supervision to prevent
				harmful consequences;
(2)
				Moderate/frequent disruptive or noncompliant behaviors in home setting that
				increase the risk to self or others;
(3) Needs assistance of trained professionals
				as caregivers.
b. Level
				II: Child must display a significant impairment with problems with authority,
				impulsivity and caregiver issues as documented on the state-designated uniform
				assessment instrument. For example, the child must:
(1) Be unable to handle the emotional demands
				of family living;
(2) Need 24-hour
				immediate response to crisis behaviors; or
(3) Have severe disruptive peer and authority
				interactions that increase risk and impede growth.
c. Level III: Child must display a
				significant impairment with severe risk factors as documented on the
				state-designated uniform assessment instrument. Child must demonstrate risk
				behaviors that create significant risk of harm to self or others.
5. TFC case management admission
				documentation required. Before Medicaid preauthorization will be granted, the
				referring entity must submit the following documentation. The documentation
				will be evaluated by DMAS or its designee to determine whether the child's
				condition meets the department's medical necessity criteria.
a. A completed state-designated uniform
				assessment instrument;
b. Diagnosis
				(Diagnostic Statistical Manual, Fourth Revision (DSM IV), including Axis I
				(Clinical Disorders); Axis II (Personality Disorders/Mental Retardation); Axis
				III (General Medical Conditions); Axis IV (Psychosocial and Environmental
				Problems); and Axis V (Global Assessment of Functioning);
c. A description of the child's immediate
				behavior prior to admission;
d. A
				description of alternative placements tried or explored;
e. The child's functional level;
f. Clinical stability;
g. The level of family support
				available;
h. Initial plan of care;
				and
i. One of the following:
(1) Written documentation that the Community
				Planning and Management Team (CPMT) has approved the admission to treatment
				foster care; or
(2) Certification
				by the FAPT that TFC case management is medically necessary.
6. Penalty for failure
				to obtain preauthorization or to prepare and maintain the previously described
				documentation. The failure to obtain authorization for this service within 10
				days of admission or to develop and maintain the documentation enumerated above
				will result in denial of payments or recovery of expenditures.