Psychiatric Rehabilitation Treatment Facility Diversion and Assessment Program Clinical Coverage Policy 8D-1 State Funded MH/SA/DD Service Definitions Service Code 0911 (modifier pending); up to 30 day assessment Pre-Review Met Not Met N/A Review for HUM 26: immediate health/safety concerns. If MET, refer to medical staff and outreach phone call to Provider. Please note concerns here and in the Clinical Justification: Met Not Met N/A Review for expedited criteria. If not met, notify provider and take off of expedited status. Review for Unable to Process Criteria Met Not Met The requested effective start date does not precede the submission date of request. If unjustified retro request, then “unable to process”. Met Not Met The dates of the request do not overlap with an existing authorization for the same service. If not met, make documented contact with provider to verify intended request dates. Can adjust authorized dates as requested by provider. Please note here: Met Not Met The number of units requested match the date range requested: (One unit per day) If not met, make documented contact with provider to verify intended request units/dates. Can adjust authorized dates as requested by provider. Please note here: Met Not Met The SAR is submitted no more than 30 days before requested start date. If not met, then unable to process. Review for Administrative Denial: Met Not Met PCP is present, which includes the PRTF Diversion and Assessment Program, frequency and provider. If none present, then contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Met Not Met Initial PCP and/or Annual PCP Rewrite have signed service order and written date by Approved Signatory. In addition, the following are also present: Beneficiary and/or Legally Responsible Person signature Person Responsible for PCP signature DJJ and/or CFT attestation, if applicable Attestation boxes checked by Approved Signatory—if not checked, Administratively Deny For all others, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Met Not Met Review for Comprehensive Crisis Plan. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request.
Met Not Met CON is present and accurate. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request. (NOTE: The CON can only be signed by an Independent physician and LCSW or Licensed Psychologist.) Met Not Met CALOCUS/ASAM level noted in SAR or other documentation. If not, then contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Recommended CALOCUS Level 6* Recommended ASAM Level 1-3.7 *CALOCUS expected to decline as treatment progresses toward transition/discharge If necessary, Review and/or request CALOCUS/ASAM worksheet; If not present, can NOT administratively deny. Other Items of Review: Met Not Met N/A Review for “stacked” services. If there are current authorizations for other services, consider if there are service exclusions and if so, review under EPSDT. Requires clinical denial if EPSDT criteria not met. Note the services here: Met Not Met The Beneficiary’s Name, DOB, MRN and MID number are present and accurate in necessary places (ie. PCP, CCA, Service Notes, etc)? If not contact Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. Met Not Met Is there evidence of active discharge planning with any concurrent requests? Consider reviewing for the following elements: anticipated discharge date barriers to discharge anticipated discharge level of care efforts made to coordinate discharge appointment If not, then make documented call to provider to request. Met Not Met N/A Review for past denials or partial approvals within this current episode of care. Consider implications of previous decisions/recommendations and need for clinical staffing. Please note here: Met Not Met Are the requested days/units within the MCO guidelines? If not, make documented contact with provider to verify intended request dates/units. Can adjust authorized dates/units as requested by provider or educational notice to match Clinical Coverage Policy. Please note here: Met Not Met N/A Length of stay in current service. Note here: Met Not Met N/A For concurrent request, ask for the following information: # of therapeutic leave days utilized # individual and/or family therapy sessions during previous auth. period Previously requested documentation from prior authorizations Please note here: Met Not Met N/A Evidence of use/intended use of Evidence Based Practices. List EBP here: