Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11036A (10/08)

STATE OF WISCONSIN HFS 107.22(1), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / IN-HOME TREATMENT ATTACHMENT (PA/ITA) COMPLETION INSTRUCTIONS
ForwardHealth require certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the services. The use of this form is mandatory to receive PA for certain procedures/services/items. If necessary, attach additional pages if more space is needed. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a determination about the request. Attach the completed Prior Authorization/In-Home Treatment Attachment (PA/ITA), F-11036, to the Prior Authorization Request Form (PA/RF), F-11018, a physician prescription, and HealthCheck screen documentation dated within 365 days prior to the grant date being requested and send it to ForwardHealth. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit PA requests by fax to ForwardHealth at (608) 221-8616 or by mail to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 GENERAL INSTRUCTIONS The information contained on this PA/ITA will be used to make a decision about the amount of intensive in-home treatment that will be approved for ForwardHealth reimbursement. Complete each section as thoroughly as possible. Where noted in these instructions, the provider may attach material from his or her records. Initial Prior Authorization Request Complete the PA/RF and the entire PA/ITA. The initial authorization will be for a period of no longer than 13 weeks. Attach a copy of the HealthCheck verification and physician order dated not more than one year prior to the requested first date of service (DOS). First Reauthorization Complete the PA/RF and Sections I-III of the PA/ITA. Attach a copy of the HealthCheck verification and physician order dated not more than one year prior to the requested first DOS. (As long as the HealthCheck verification and physician order submitted in the initial request are timely, they may be used for subsequent requests.) Attach a brief summary of the treatment to date, including progress on treatment goals, and affirm that the family is appropriately involved in the treatment process. The treatment summary information should correspond specifically to the short-term and long-term goals of the previous treatment plan and reference the same measures of improvement. If changes were made to the treatment plan, send a copy of the amended or updated plan. Authorization may be granted for up to 13 weeks. Subsequent Reauthorizations Complete the PA/RF and Sections I-III of the PA/ITA. Attach a copy of the HealthCheck verification and physician order dated not more than one year prior to the requested first DOS. (As long as the HealthCheck verification and the physician order submitted in the initial request are timely, they may be used for subsequent requests.) Attach a brief summary of the treatment to date, including progress on treatment goals, and affirm that the family is appropriately involved in the treatment process. The treatment summary information should correspond specifically to the short-term and long-term goals of the previous treatment plan and reference the same measures of improvement. If changes were made to the treatment plan, send a copy of the amended or updated plan. Summarize the treatment since the previous authorization. The need for continued in-home treatment must be clearly documented. Where no change is noted in the treatment summary, justify the continued use of the in-home treatment or note how changes in the treatment plan address the lack of progress. Specifically address aftercare planning. Discuss plans for terminating in-home treatment and the services that the member/family will require. Authorization will be for a period of no longer than 13 weeks. Check the appropriate box at the top of the PA/ITA to indicate whether this request is an initial, first reauthorization, or subsequent reauthorization. Make sure that the appropriate materials are included for the type of request indicated.

PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA) COMPLETION INSTRUCTIONS F-11036A (10/08)

Page 2 of 6

SECTION I -- MEMBER INFORMATION Element 1 -- Name -- Member Enter the member's last name, first name, and middle initial. Use Wisconsin's Enrollment Verification System (EVS) to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. Element 2 -- Age -- Member Enter the age of the member in numerical form (e.g., 16, 21). Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Use the ForwardHealth card or the EVS to obtain the correct member ID. SECTION II -- PROVIDER INFORMATION Element 4 -- Name -- Medicaid-Certified Clinic Enter the name of the Medicaid-certified psychotherapy/substance abuse clinic that will be billing for the services. Element 5 -- Clinic's National Provider Identifier (NPI) Enter the NPI of the Medicaid-certified psychotherapy/substance abuse clinic that will be billing for the services. Element 6 -- Name -- Rendering Psychotherapist/Substance Abuse Counselor Enter the name of the Medicaid-certified psychotherapist/substance abuse counselor who will be the lead member of the team providing services. Master's-level psychotherapists must obtain a rendering provider NPI in order to bill for these services even if this is not ordinarily required for the type of facility by which they are employed. Element 7 -- Rendering Psychotherapist's or Substance Abuse Counselor's NPI Enter the NPI of the certified psychotherapist/substance abuse counselor identified in Element 6. Element 8 -- Telephone Number -- Psychotherapist/Substance Abuse Counselor Enter the telephone number, including the area code, of the certified psychotherapist/substance abuse counselor identified in Element 6. Element 9 -- Discipline -- Psychotherapist/Substance Abuse Counselor Enter the discipline of the certified psychotherapist/substance abuse counselor identified in Element 6 (e.g., Ph.D.). SECTION III Element 10 Enter the requested start and end dates for this authorization period. The initial authorization may be backdated up to 10 working days prior to the receipt of the request at ForwardHealth if the provider requests backdating in writing and documents the clinical need for beginning services immediately. Note the guidelines for the length of authorizations under the "General Instructions" section of these instructions. Element 11 Enter the total expected number of hours the family will receive direct treatment services over this PA grant period (e.g., the current 13-week period). When two therapists are present at the same time, this is still counted as one hour of treatment received by the family. Also indicate the anticipated pattern of treatment for each team member (e.g., a two-hour session once a week for 13 weeks by the certified psychotherapist, a two-hour session once a week for 13 weeks by the second team member with a certified therapist, plus a one-hour session twice a week for 13 weeks with the second team member independently). More than 104 hours of direct treatment to the family during a 13-week period will not be authorized. Element 12 Indicate the number of hours that the certified psychotherapist/substance abuse counselor will provide direct treatment services to the family and the number of hours that the second team member will provide direct treatment to the family. If more than two providers will be involved in providing services, document that all individuals meet the criteria in these guidelines. Total hours of treatment must not exceed the limitation noted in Element 11. Reimbursement is not allowed for more than two providers for the same treatment session. Since two providers may be providing services at the same time on occasion, the total hours in this section may exceed the number of hours of treatment the family will receive as noted in Element 11. If the primary psychotherapist is involved in treatment more than 50 percent of the time (e.g., if the primary therapist's direct treatment hours exceed those of the second team member's), special justification should be noted on the request.

PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA) COMPLETION INSTRUCTIONS F-11036A (10/08)

Page 3 of 6

Indicate the name and qualifications of the second team member. Attach a résumé, if available. The minimal qualifications must be one of the following: · An individual who possesses at least a Bachelor's degree in a behavioral science, a registered nurse, an occupational therapist, a Medicaid-certified substance abuse counselor, or a professional with equivalent training. The second team member must have at least 1,000 hours of supervised clinical experience working in a program whose primary clientele are emotionally disturbed youth. · Other individuals who have had at least 2,000 hours of supervised clinical experience working in a program whose primary clientele are emotionally disturbed youth. The second team member will be reimbursed at a lower rate, even if that person is a Medicaid-certified psychotherapist. The second team member works under the supervision of the certified psychotherapy provider. If the second team member is a Medicaid-certified psychotherapy/substance abuse provider, indicate his or her qualifications by entering his or her rendering provider NPI. Element 13 Indicate the travel time required to provide the service. Travel time should consist of the time to travel from the provider's office to the member's home or from the previous appointment to the member's home. Travel time exceeding one hour one-way will generally not be authorized. SECTION IV Element 14 Present a summary of the mental health assessment and differential diagnosis. Diagnoses on all five axes of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, or for children to age four, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: 0-3, are required. The assessment should address the level of reality testing, thought processes, drive control, relational capacity, and defense functioning. The assessment summary should provide documentation supporting the diagnosis. A psychiatrist or psychologist must review and sign the summary and diagnosis indicating his or her agreement with the results. In those cases, where the only, or primary, diagnosis is a substance abuse disorder, requests will be approved only if there is sufficient justification for the services to be provided in the home, rather than in another setting. Providers may attach copies of an existing assessment if it is no longer than two pages. Element 15 Present a summary of the member's illness, treatment, and medication history. In those cases where the member has spent significant amounts of time out of the home, or is out of the home at the time of the request, the treatment plan must specifically address the transition, reintegration, and attachment issues. For individuals with significant substance abuse problems, the multiagency treatment plan must explain how these will be addressed. For individuals 16 years and over who have spent significant amounts of time out of the home, the request must discuss why intensive in-home treatment is preferred over preparing the member for independent living. Providers may attach copies of illness/treatment/medication histories that are contained in their records if they do not exceed two pages. Element 16 Complete the checklist for determination that an individual meets the criteria for severe emotional disturbance (SED). a. List the primary diagnosis and diagnosis code in the space provided. Not all ForwardHealth-covered in-home mental health and substance abuse treatment services are appropriate or allowable. Professional consultants base approval of services on a valid diagnosis, acceptable child/adolescent practice, and clear documentation of the probable effectiveness of the proposed service. Federal regulations do not allow federal funding of rehabilitation services, such as child/adolescent day treatment or in-home or outpatient mental health and substance abuse services, for persons with a sole or primary diagnosis of a developmental disability or mental retardation. Complete the checklist to determine whether an individual would substantially meet the criteria for SED. Check those boxes that apply. The individual must have one symptom or two functional impairments described as follows. Symptoms 1. Psychotic symptoms -- Serious mental illness (e.g., schizophrenia) characterized by defective or lost contact with reality, often with hallucinations or delusions. 2. Suicidality -- The individual must have made one attempt within the last three months or have significant ideation about or have made a plan for suicide within the past month. 3. Violence -- The individual must be at risk for causing injury to persons or significant damage to property as a result of emotional disturbance.

b. c.

PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA) COMPLETION INSTRUCTIONS F-11036A (10/08)

Page 4 of 6

Functional Impairments (Compared to Expected Developmental Level) 1. Functioning in self care -- Impairment in self care is manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes, and meeting of nutritional needs. 2. Functioning in community -- Impairment in community function is manifested by a consistent lack of age-appropriate behavioral controls, decision making, judgment, and a value system that results in potential involvement or involvement in the juvenile justice system. 3. Functioning in social relationships -- Impairment of social relationships is manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults. 4. Functioning in the family -- Impairment in family function is manifested by a pattern of significantly disruptive behavior exemplified by repeated and/or unprovoked violence to siblings and/or parents, disregard for safety and welfare of self or others (e.g., fire setting, serious and chronic destructiveness), inability to conform to reasonable limitations, and expectations that may result in removal from the family or its equivalent. 5. Functioning at school/work -- Impairment in any one of the following: a) Impairment in functioning at school is manifested by the inability to pursue educational goals in a normal time frame, such as consistently failing grades, repeated truancy, expulsion, property damage, or violence towards others. b) Meeting the definition of "child with a disability" under ch. PI 11, Wis. Admin. Code, and s. 115.76, Wis. Stats. c) Impairment at work is the inability to be consistently employed at a self-sustaining level, such as the inability to conform to work schedule, poor relationships with supervisor and other workers, or hostile behavior on the job. d) The individual is receiving services from two or more of the following service systems: · Mental health. · Juvenile justice. · Social services. · Special education. · Child protective services. Eligibility criteria are waived under the following circumstances: · · The member substantially meets the criteria for SED, except the severity of the emotional and behavioral problems have not yet substantially interfered with the individual's functioning, but would likely do so without in-home mental health and substance abuse treatment services. Attach an explanation. The member substantially meets the criteria for SED, except the individual has not yet received services from more than one system and in the judgment of the medical consultant, would be likely to do so if the intensity of treatment requested was not provided.

Element 17 Present an assessment of the family's strengths and weaknesses. Present evidence that the family is willing to be involved in treatment and is capable of benefiting from treatment. Where the presence of significant psychological dysfunctioning or substance abuse problems is indicated among family members, indicate on the multi-agency treatment plan how these problems will be addressed. Element 18 The provider is required to specifically identify the rationale for providing services in the home for this child/family. A significant history of failed outpatient treatment along with documentation that identifies a significant risk of out-of-home placement will support such a request. Strong justification is needed if outpatient clinic services have not been previously attempted. The provider should identify specific barriers to the family receiving treatment in a clinic setting or specific advantages for this family receiving services in the home (not simply general advantages of in-home treatment). The provider should present this justification in his or her own words and not assume that the consultant can infer this from other information submitted with this request. Element 19 Indicate the expected date of termination or expected duration of in-home treatment. Describe services expected to be needed following completion of in-home treatment and transition plans. While providers are expected to indicate their expectations on the initial requests, it is critical that plans for terminating in-home treatment be discussed in any authorizations for services at and beyond six months of treatment.

PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA) COMPLETION INSTRUCTIONS F-11036A (10/08)

Page 5 of 6

SECTION V Element 20 The following materials must be attached and labeled: a. The PA/RF may be obtained from ForwardHealth. Providers should use processing type "126" in Element 2. The "HealthCheck Other Services" should be marked in Element 1. Providers should use the appropriate procedure codes, modifiers, and descriptions in Elements 18, 19, and 21 of the PA/RF. The quantity requested in Element 22 of the PA/RF should represent the total hours for the grant period requested and Element 23 of the PA/RF should represent charges for all hours indicated in Element 22. b. c. Attach a physician's prescription order for in-home treatment services dated not more than one year prior to the requested first DOS. The request must include documentation that the member had a comprehensive HealthCheck screening within 365 days prior to the grant date being requested. This documentation must be one of the following: · Verification that a HealthCheck screen has been performed by a valid HealthCheck screener dated not more than one year prior to the requested first DOS. · A copy of the HealthCheck provider's billing form showing a claim for a comprehensive HealthCheck screening. · A copy of the HealthCheck provider's Remittance Advice showing a claim for a comprehensive HealthCheck screening. · A HealthCheck referral from the HealthCheck provider. · A letter on the HealthCheck provider's letterhead indicating the date on which they performed a comprehensive HealthCheck screening of the member. The multi-agency treatment plan must be developed by representatives from all systems identified on the SED eligibility checklist. The plan must address the role of each system in the overall treatment and the major goals for each agency involved. The plan should be signed by all participants, but to facilitate submission, the provider may document who was involved. Where some agency was not involved in the planning, the provider is required to document the reason and what attempts were made to include them. The plan should indicate why services in the home are necessary and desirable. The individual who is coordinating the multi-agency planning should be clearly identified. A psychiatrist or psychologist is required to sign either the multi-agency plan or in-home treatment plan. If the child is prescribed psychoactive medication, the prescriber is required to be identified in the multi-agency treatment plan. Providers may use the Model Multi-Agency Treatment Plan, F-11106. If a multi-agency plan other than the model plan is used, all information on the model plan must be included. e. The in-home treatment team is required to complete a treatment plan covering their services. A psychiatrist or psychologist is required to sign either the in-home treatment plan or the multi-agency treatment plan. The Model Plan: In-Home Mental Health/Substance Abuse Treatment Services, F-11105, may be used for this purpose. The plan must contain measurable goals, specific methods, and an expected time frame for achievement of the goals. The methods must allow for a clear determination that the services provided meet criteria for ForwardHealth-covered services. Services that are primarily social or recreational in nature are not reimbursable. The plan should clearly identify which team members are providing the ForwardHealth-covered services being requested. Services provided to the member's parents, foster parents, siblings, or other individuals significantly involved with the member are deemed appropriate as part of the in-home treatment plan when these services are required to directly affect the member's functioning at home or in the community. Such services include family therapy necessary to deal with issues of family dysfunctioning, behavior training with responsible adults to identify problem behaviors and develop appropriate responses, supervision of the child and family members in the home setting to evaluate the effect of behavioral intervention approaches and provide feedback to the family on implementing these interventions, and minimal supportive interventions with the family members to ensure their continued participation in the in-home treatment process. Interventions with family members or significant others that are primarily for the benefit of these individuals are not reimbursable under these guidelines, except where these individuals meet the criteria for intensive in-home treatment (e.g., they are 20 years of age or under) and authorization has been received for such services under these guidelines. For instance, intervention directed solely at a parent's alcohol abuse is considered substance abuse treatment, is covered as a substance abuse treatment service, and is not reimbursable in the home. However, when the intervention is with the whole family and is focusing on the way in which the parent's alcohol abuse is affecting the child and/or contributing to the problem behaviors, an in-home intervention may be authorized under these guidelines.

d.

PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA) COMPLETION INSTRUCTIONS F-11036A (10/08)

Page 6 of 6

Initial treatment goals may include assessment of the member and family in the home and these goals may be procedural (e.g., complete assessment, have all members of family attend 75 percent of meetings, complete substance abuse assessment). Where an assessment is part of the initial intervention, be specific and detailed as to the components of the assessment (e.g., psychiatrist will complete psychiatric evaluation, substance abuse counselor will complete substance abuse assessment). Where appropriate, identify any standardized assessment tools that will be utilized. If an in-home mental health/substance abuse treatment plan other than the model plan is used, all information on the model must be included. f. Providers are required to complete and attach the results of either the Achenbach Child Behavior Checklist or the Child and Adolescent Functional Assessment Scale. Information about these screening instruments is available on the Internet under "Achenbach Behavior Checklist" and "Child and Adolescent Functional Assessment Scale." A substance abuse assessment must be included if substance abuse-related programming is part of the member's treatment program. The assessment may be summarized in Element 14 as part of the psychiatric assessment or illness history.

g.

The PA/ITA must be signed and dated by the certified psychotherapy/substance abuse treatment provider who is leading the inhome treatment team. It must also be signed and dated by the supervising therapist if the certified psychotherapy/substance abuse provider is not a Ph.D. psychologist or psychiatrist. In signing, these individuals accept responsibility for supervising the other individuals who are part of the in-home treatment team. In signing, they provide assurance that an individual who meets the criteria for a Medicaid-certified psychotherapy/substance abuse treatment provider will be available to the other team members when they are in the home alone with the child/family. Element 21 -- Signature -- Certified Therapist Enter the signature of the certified therapist. Element 22 -- Date Signed Enter the month, day, and year the PA/ITA was signed (in MM/DD/CCYY format). Element 23 -- Signature -- Supervising Therapist Enter the signature of the supervising therapist. Element 24 -- Date Signed Enter the month, day, and year the PA/ITA was signed (in MM/DD/CCYY format).