Illinois Department of Human Services,
Division of Mental Health
The Illinois Mental Health Collaborative
for Access and Choice
Authorization Requirements
for
Therapy Counseling, Psychosocial Rehabilitation
and Community Support Group Services
Effective January, 2011
November 2010
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Introductions
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Lee Ann Reinert, LCSW - IL DHS/DMH Clinical Policy Specialist
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Emily Sherrill, LCSW - Collaborative Clinical Director
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Todd Kasdan, MD - Collaborative Medical Director
Presentation Online
Today’s presentation will be available online
http://www.illinoismentalhealthcollaborative.com/provider/prv_informati
on.htm
Be sure to share this information with your staff!
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Agenda
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Overview of Utilization Management Program
Medical necessity
Overview of authorization processes
Mental Health Assessment (MHA) requirements
Individual Treatment Plan (ITP) requirements
Requests for reconsideration and appeal of denial
decisions
Questions and answers
Utilization Management Program Overview
Introduction:
 The Utilization Management (UM) Program is the vehicle
through which DHS/DMH ensures that individuals being served
receive:
– the services best suited to support their recovery needs and
preferences,
– cost effective services in the most appropriate treatment
setting,
– services consistent with medical necessity criteria and
evidence-based practices.
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Utilization Management Program Overview
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By implementing the UM Program, DHS/DMH strives to achieve
a balance between:
– the needs, preferences, and well-being of persons in need
of mental health services
– demonstrated medical necessity
– the availability of resources
Utilization Management Program Overview
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The UM Program:
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does not limit medically necessary Medicaid services
is fully compliant with the Illinois Medicaid State Plan and
associated federal rules
In developing the UM Program, DHS/DMH
acknowledges the following guiding principles:
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UM is dynamic and evolutionary. As additional data, new research, and
other new information occurs with experience, the UM Program will evolve and
change.
UM must be based on data. The UM Program must use data to identify
patterns of utilization, work with clinicians to determine if the patterns and
variations are desirable or not, and work with providers to make needed
improvements.
Individuals accessing services should have a consistent threshold of
medical necessity statewide. The UM Program must provide clear guidance
for medical necessity decisions so that all individuals accessing services have
consistent and equitable access to specific services.
Authorization must be clinically focused and conducted by qualified staff.
Where authorization is determined to be necessary, it must be based on clinical
information and reviewed by staff at the independent license level (LPHA).
UM Program Overview, continued
The DHS/DMH Utilization Program has the following
components:
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Medical Necessity Guidance and Criteria
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Limited External Authorization
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Ongoing Data Reporting and Analysis
UM Program Overview, continued
Medical Necessity Guidance and Criteria.
 DHS/DMH is initially providing medical necessity criteria for
the following services:
Assertive Community Treatment (ACT)
Community Support Team (CST)
Psychosocial Rehabilitation (PSR)
Community Support Group (CSG)
Therapy/Counseling (T/C)
Community Support Individual (CSI)
 For those services available to both adults and children,
separate criteria are provided for each.
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UM Program Overview, continued
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These criteria may be found in the DHS/DMH Medical
Necessity Criteria and Guidance Manual (within the Provider
Manual)
These criteria should be used by providers to guide them in
making consistent admission, continuing service, and
termination of service decisions for each consumer.
Providers must use these criteria consistently, regardless of
whether or not DHS/DMH or its designee externally authorizes
the service.
Provider adherence to these criteria may be subject to post
payment review.
UM Program Overview, continued
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Limited External Authorization.
 Authorization for payment by DHS/DMH or its designee will be
required for specific services, based on a review of service
utilization patterns for a previous fiscal year.
– Thresholds are the same for adults and
children/adolescents and are calculated by provider and
consumer per fiscal year. For FY11, thresholds will be
calculated for the remainder of the fiscal year, beginning
with dates of service of January 3, 2011.
– Authorization for payment of services beyond the specified
thresholds will be based on medical necessity criteria.
– Services will continue to be authorized as long as medical
necessity is in evidence.
UM Program Overview, continued
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For purposes of determining clinical review thresholds, PSR and CSG utilization
will be managed as a combined benefit. Clinical review and continuing service
authorization will be required whenever an individual’s utilization of PSR and
CSG combined exceeds 800 units per fiscal year, with recognition that an
individual may use one or both of these services during the year.
UM Program Overview, continued
Ongoing Data Reporting and Analysis
 DHS/DMH will continue to report and analyze
– utilization patterns
– post payment review results
– authorization impacts
– other quantitative and qualitative aspects of service
delivery.
 These data will be used to inform
– provider technical assistance efforts
– training
– future UM Program modifications
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Medical Necessity Criteria
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Diagnosis
Service Initiation Criteria
Continuing Service Criteria
Exclusion Criteria
Service Termination Criteria
Medical Necessity Criteria
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DIAGNOSIS:
– Current eligible mental health diagnosis for which the
proposed course of treatment has been determined to be
effective
– Symptoms consistent with those described in the current
edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the International Statistical Classification of
Diseases and Related Health Problems (ICD)
– Symptoms addressed do not have their primary origin in a
diagnosis of an Autism Spectrum Disorder, substance-related
disorder, or a principal Axis II diagnosis of Mental Retardation
Medical Necessity Criteria
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Service Initiation Criteria
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Continuing Service Criteria
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To be considered for all individuals receiving services for which
guidance is published
May be subject to Post Payment Review
Establishes basis for need for service
To be utilized for determination of need for ongoing services,
once individual meets threshold
Will be basis for the Collaborative’s authorization decision
Medical Necessity Criteria
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Exclusion Criteria
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Termination Criteria
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Reasons for service to be considered inappropriate for an
individual
Could be cited at either Post Payment or Authorization Review
Reasons for discontinuing service
Could be cited during Clinical Practice Guidance or
Authorization Review
Medical Necessity Criteria
Therapy/ Counseling
SERVICE INITIATION CRITERIA - Severity/complexity of
symptoms and level of functional impairment
require this service, as evidenced by:
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Individual has an emotional disturbance and/or diagnosis that
is destabilizing or distressing
Individual’s assessment identifies specific mental health
problems that may be effectively addressed by
Therapy/Counseling
Level of Care Utilization System (LOCUS) score equating to
Level of Care 2 or higher for adults or clinician-rated Ohio
scale of 16 or higher for youth age 5 and up
Medical Necessity Criteria
Therapy/ Counseling
Continuing Service Criteria
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Evidence of active participation by individual
Demonstrated evidence of significant benefit from this
service:
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as evidenced by the attainment of most treatment goals,
but the desired outcome has not been restored
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and the individual’s level of emotional stress continues to
be destabilizing, significantly interfering with daily
functioning
Individual cannot be safely and effectively treated solely
through the use of Community Support services, case
management, and the engagement of natural support
systems.
Medical Necessity Criteria
Therapy/ Counseling
Additional Criteria for Specific Modalities
 Individual – necessity of one to one interventions
 Group – specifically identified problems with social
interactions, interpersonal difficulties, etc, for which
involvement in group process is expected to be beneficial
 Family – identified problems are exacerbated by family
dynamics and/or can be most effectively addressed
through family involvement
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Medical Necessity Criteria
Therapy/ Counseling
Exclusion Criteria
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Cognitive impairment, mental status or
developmental level that makes it unlikely individual
would benefit
Primary problem to be addressed could be more
effectively/efficiently addressed by another modality
Medical Necessity Criteria
Therapy/ Counseling
Service Termination
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Treatment goals achieved
Majority of goals achieved and remainder can be
safely achieved by accessing other services and/or
natural supports
No significant improvement and needs to be
reassessed for more effective treatment
Medical Necessity Criteria
Psychosocial Rehabilitation
Service Initiation Criteria
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Significantly impaired role function in at least 2 of the following:
– Management of financial affairs
– Ability to procure needed services
– Socialization, communication, adaptation, problem solving and coping
– Activities of daily living
– Self-management of symptoms
– Concentration, endurance, attention, direction following and planning
and organization skills necessary for recovery
LOCUS Score equating to level of care of 3 or higher
Discharge/transition plan expressly focused on increasing community
integration through the application of skills in community settings.
Medical Necessity Criteria
Psychosocial Rehabilitation
Continuing Service Criteria
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Treatment plan reflects modifications in PSR services for skills
that the individual has not yet been able to successfully
demonstrate
Individual cannot be safely/effectively treated through provision
of alternative community-based services or engagement of
natural supports
Medical Necessity Criteria
Psychosocial Rehabilitation
Exclusion Criteria
 Individual under age 18
 Individual chooses not to participate
 Primary etiology of dysfunction related to Axis II
diagnosis, or an organic process or syndrome
including normal aging
 Individual’s ADLs/skills are sufficient to enable
progress in recovery
 Individual requires more intensive contact
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Medical Necessity Criteria
Psychosocial Rehabilitation
Service Termination Criteria
 Individual has learned the skills and requests
termination or no longer needs active treatment
 Has learned most of the skills, can apply and
improve skills in natural settings
 Is not making progress and needs reassessment to
determine more appropriate services
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Medical Necessity Criteria
Community Support Group
Service Initiation Criteria
 Significant impairment in functioning, inability to apply skills in
natural settings, and/or to build/utilize natural supports
 Require small group support to facilitate more effective role
performance
 Identification of specific functional impairments that can only be
remediated through small group practice to reinforce target
skills
 LOCUS level of care recommendation of 2 or higher
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Medical Necessity Criteria
Community Support Group
Continuing Service Criteria
 Has demonstrated significant improvement with this service,
attaining most skill-building and community integration, but
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Desired outcome/level of functioning has not been
restored/sufficiently improved
or
Without these services, the individual would not be able to
consolidate treatment gains or progress in recovery
Cannot be safely/effectively treated through provision of
alternative services or engagement of natural supports
Medical Necessity Criteria
Community Support Group
Exclusion Criteria
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Individuals daily living skills are sufficient to enable progress in
recovery without CSG services
Cognitive impairment, current mental status or developmental
level makes it unlikely to benefit from CSG services
Primary etiology related to Axis II or organic processes,
including normal aging
Requires more intensive services/cannot be safely treated with
CSG
Medical Necessity Criteria
Community Support Group
Service Termination Criteria
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Individual has achieved goals and requests termination or no
longer needs this service
Has successfully demonstrated most of the skills, can be safely
and effectively treated without CSG
Is not making progress and needs reassessment to determine
more appropriate services
Authorization in a nutshell
for Therapy/Counseling, Psychosocial Rehabilitation and
Community Support Group
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Who – any consumer, for whom the provider is seeking
reimbursement, receiving over the threshold hours/units of T/C, PSR,
CSG services
When – Authorization for payment of services is required after January
3, 2011 for any consumer receiving services above and beyond the
threshold hours/units of service
What – Authorization request form with a Mental Health Assessment
(MHA) and Individual Treatment Plan (ITP), along with any other
supporting documentation to establish Medical Necessity Criteria
How - Submit authorization request electronically through
ProviderConnect and supporting clinical documentation either as
secure clinical attachments with request or via facsimile
What do I send when requesting
an authorization?
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Information required:
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Authorization request via ProviderConnect
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Current MHA and ITP
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All required and applicable fields completed
– Including age appropriate functional scales (LOCUS, Ohio Scale, DECA)
– Current Axis I – V elements
Securely attached with ProviderConnect request or faxed to the Collaborative
(866-928-7177) within 1 business day
Additional documentation may be necessary if the MHA and
ITP do not fully support medical necessity for the request
Authorization Process
Therapy/Counseling:
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Eligible Consumers are able to initially receive up to 10 hours (40
units) of this service, if provider LPHA deems medically necessary,
without submission of an authorization request
If provider deems additional hours (units) of T/C are medically
necessary above and beyond the 10 hour (40 unit) threshold, a
request for authorization must be submitted and authorization must be
obtained in order to be reimbursed for services
Determination of additional hours (units) to be reimbursed are based
upon medical necessity. This will take into consideration the number
of units requested and will be based on what is medically necessary.
Authorization Process, continued
PSR & Community Support Group:
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Eligible Consumers are able to initially receive up to 200 hours (800
units) of PSR, CSG, or a combination of PSR & CSG, if provider
deems medically necessary, without submission of an authorization
request
If provider LPHA deems additional hours (units) are medically
necessary above and beyond the 200 hour (800 unit) threshold, a
request for authorization must be submitted and authorization must be
obtained in order to be reimbursed for services
Determination of additional hours (units) to be reimbursed are based
upon medical necessity. This will take into consideration the number
of units requested and will be based on what is medically necessary.
Authorization Process, continued
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Collaborative clinical care managers review submitted documents for
adherence to Medical Necessity Criteria (MNC), and Rule 132.
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If the MNC are met for the service(s), the Collaborative will enter an
authorization.
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In order for the provider to be reimbursed for services provided beyond
initial thresholds, requests for authorization must be submitted and
approved prior to service provision. Providers must submit requests
for authorization prior to the authorization expiration date and/or the
maximum number of hours/units allowed
Authorization Request
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All requests for authorization MUST be submitted via
ProviderConnect. The Collaborative will not review requests for
authorization submitted via facsimile.
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If choosing to fax, rather than attach to the on-line request, the
supporting clinical documentation for the request (e.g. MHA,
ITP, etc.), please ensure that each consumer’s information is
faxed separately.
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If choosing to fax, rather than attach to the on-line request, the
supporting clinical documentation for the request (e.g. MHA,
ITP, etc.), please ensure that the service being requested is
noted on the fax cover sheet.
Authorization request, continued
Authorization requests for
T/C, PSR, and CSG will
require completion of the
following information for
adults:
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Identifying information
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Diagnosis
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LOCUS (Functional Impairment)
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Services Requested- PSR & CSG
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Services Requested- T/C
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Transition or Service Termination
Plan
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Ohio/Devereaux Scale Results
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Required for CSG and T/C requests for all consumers under the age of
18
Ohio Scale Results are required for youth ages 5 through 17
– Service initiation (all)
– Current (if in services more than 90 days)
Devereaux Scale Results (DECA Subscale for children under the age
of 5)
– Protective Factor Scores
 Service Initiation (all)
 Current (if in services more than 90 days)
– Behavioral Concern Scores (only for children over the age of 3,
under the age of 5)
 Service Initiation (all)
 Current (if in services more than 90 days)
Ohio/Devereaux Scale Results
continued
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MHA Requirements
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MHA Requirements
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A consumer’s MHA is required to be submitted as
part of the authorization process
The Collaborative Clinical Care Managers will be
determining if the MHA identifies needs consistent
with the service being requested.
ITP Requirements
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The consumer’s ITP is required to be submitted as a
part of the authorization process to assure clinical
congruence between the goals/interventions listed in
the ITP, service definition criteria, and the LOCUS
score/Ohio scale/DECA.
The Collaborative Clinical Care Managers will be
determining if the treatment plan describes
interventions and goals consistent with the service
being requested.
Additionally required
documentation
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When MHA and ITP do not appear to fully justify or support MNC for the
requested service and/or appear to have inconsistencies, additional
documentation must be submitted with the request
Examples:
 Progress notes
 Psychiatric notes/evaluations
 MHA and/or ITP addendums
 A letter of statement from clinician acknowledging
inconsistencies with explanation of rationale for this request
– Must be securely attached to the request or faxed to the Collaborative
(866-928-7177) within 1 business day
– If information is necessary to support medical necessity but not
included with request/received within 1 business day, the
Collaborative staff will contact the provider to explain the additional
information that is required and the request will be closed without
review. The provider must resubmit the entire request for
authorization with all supporting documentation.
Collaborative review process
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Provider submits a request for authorization
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Collaborative staff verifies:
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Collaborative clinical care manager (CCM) reviews submitted documents
for the following 3 elements:
1.
2.
3.
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Information for completeness (documents required based upon request type)
Provider’s participation status (e.g., contracted provider of IL DHS/DMH)
Provider’s certification status to provide requested service
Consumer information is in/available to the Collaborative system
The information in the request is consistent with information found in the
supporting documentation. If inconsistencies are found, the provider will be
contacted regarding the inconsistencies. The request will be closed and the
provider will be required to resubmit the request with all supporting
documentation.
Completeness
Adherence to Rule 132
Adherence to Medical Necessity Criteria (MNC)
If the above 3 elements are met for the service(s), the CCM will enter in an
authorization.
Collaborative review process,
continued
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If medical necessity IS established, request is authorized by CCM
and communicated to provider in writing
OR
If medical necessity is NOT established, the CCM contacts provider
to seek clarification and offer education/consultation regarding
authorization criteria
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The Collaborative and the Provider will reach mutual agreement
with respect to next steps (e.g., additional information will be
submitted for review, alternative service will be considered, etc.)
OR
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If mutual agreement has NOT occurred and provider believes
medical necessity is present, the CCM will forward information to a
Collaborative physician advisor (PA) reviewer
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PA reviews and either authorizes OR denies authorization
Collaborative review process,
continued
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Turn around time (TAT) for authorization
requests
– The Collaborative will respond to requests
for authorizations within 7 business days
of receipt of a completed authorization
request.
Provider requests for Reconsideration and Appeal
related to denial of authorization
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2 levels:
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1st  Request for Reconsideration
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2nd DMH Director’s review
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The Collaborative staff is not involved in this level
This shall be a review to ensure that all applicable
procedures have been correctly applied and followed
Provider requests for Reconsideration and
Appeal related to denial of authorization
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In the case of a denial of authorization-- If the provider, consumer, or
designated representative disagrees with the clinical decision, a
Reconsideration may be initiated in writing or by phone.
The Reconsideration must be requested within 30 days after the
denial.
– The review will be conducted by a Collaborative PA.
• Not the same PA who issued the original denial
• Not a subordinate of the PA who issued the original denial
– The review and notification by phone will be completed by the
Collaborative within 15 days of the receipt of the reconsideration
request.
– Outcome  Either:
 Reversal of the denial decision
 Upholding of the denial decision
Provider requests for Appeal related to denial of
authorization
DMH Director’s review:
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If the provider, consumer, or designated representative
disagrees with the outcome of the Reconsideration request, an
Appeal may be filed within 5 days of receipt of the outcome of
the reconsideration request.
This review shall not be a clinical review, but rather a review to
ensure that all applicable appeal procedures have been
correctly applied and followed.
The final administrative decision shall be subject to judicial
review exclusively as provided in the Administrative Review
Law [735 ILCS 5/Art. III].
Summary
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Utilization Management Program is being implemented to ensure
responsible management of resources
Plans of care for individuals for whom reimbursement from DMH will be
sought should be based on the Medical Necessity Guidance/Criteria
Manual published within the DMH Provider Manual
In order to be reimbursed for services, providers must follow the
utilization management program as it applies to individual situations
Authorization request reflecting the most current clinical presentation as
documented in the consumer record must be sent to the Collaborative
The Collaborative Clinical Care Managers will review authorization
requests and issue a decision within 7 days.
If an authorization request is denied, the provider or consumer may
request a reconsideration of that decision
If a request for reconsideration also results in denial of authorization,
there is an appeals process through the Director of DMH and finally
through the administrative law process at Healthcare and Family Services
Questions?
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Thank you!
Illinois Mental Health Collaborative for
Access and Choice
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