INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
South Carolina KePRO
QIO Request Submission
Requirements for RPS
New 6/14/2012
Topics
• Service Type(s)
• KePRO SCDHHS Website
• Service Type
Requirements
• Contact Information
Prior Authorization Service Type
• Mental Health Counseling
– Specific to Psychosocial Rehabilitation (RPS)
• Procedure Code – H2017
South Carolina Web Site
Forms
Navigate to Form
Tab to obtain Fax
Document
H2017- PA Submission Request
– Fax Form
H2017- PA Submission Request
• Required Documentation
– Rehabilitative Psychosocial Services Fax Form (See Slide 7)
– IPOC
– Clinical Presentation
– Sample Required Clinical – Documentation should
support the members Clinical presentaton
Documentation (see Slides 9- 10)
– For PA, individuals must meet the Diagnostic Statistical
Manual of Mental Disorders, Current Edition, Text
Revision (DSM-IV-TR) diagnostic criteria for an Axis I or
Axis II Mental Health Disorder.
H2017- PA Submission Request
Eligibility of Services for RBHS/Diagnosis Criteria:
• Confirmed Psychiatric Diagnosis from the current edition of the DSM IV or Current ICD.
– V – Codes - Use of V-codes is allowed under certain
circumstances, but in general is considered temporary (See RBHS
Manual section 2-9 for further clarification)
– V- Codes may not be used for ages 7 and up for longer than a six
month duration (See RBHS Manual section 2-9 for further
clarification)
– Exclusions:
Unless they co-occur with a serious mental disorder that meets
current edition DSM-IV criteria.
• Irreversible Dementias
• Mental Retardation
• Developmental disorders
H2017- PA Submission Request
• Sample Required Clinical Documentation
• Describe Symptoms/Severity of illness:
– Individual must exhibit significant functional impairments in major
life activities due to a mental, behavioral, or emotional illness.
– Must meet two of the following:
• Have difficulty establishing or maintaining normal interpersonal
relationships to the degree they are at risk of hospitalization,
homelessness, or isolation from social supports; or
• Have behaviors that require repeated interventions by the
mental health, social services or judicial system; or
• Be unable to recognize personal danger or significantly
inappropriate social behavior; or
• Require help in basic living skills to such a degree that health or
safety is jeopardized.
H2017- PA Submission Request
Sample Required Clinical Documentation
Individual must meet one of the following:
• Have experienced long-term or repeated
psychiatric hospitalizations; or
• Lack daily living skills and interpersonal skills; or
• Have limited or non-existent support system; or
• Be unable to function in the community without
intensive intervention; or
• Require long-term services to be maintained in
the community.
KePRO Contacts
Thank You!
12