INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
QIO Request Submission
Requirements for
Community Support
Services
New 6/14/2012
Topics
• Services Requiring
PA
• KEPRO SCDHHS
Website
• Service Type
Requirements
• Contact
Information
Prior Authorization
Services
Adult (22 years old and older)
•
H2017-Psychosocial Rehabilitation
Service (PRS)
• S9482-Family Support
Child (21 years old and younger)
• H2017-Psychosocial Rehabilitation
Service (PRS)
• H2014-Behavioral Modification
• S9482-Family Support
Forms
Navigate to Forms TAB
to obtain Documents
Outpatient Fax Form
Outpatient Fax Form
Adult H2017 (PRS) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
For Continuation of Services• Individualized Plan of Care (IPOC)
• Service Plan Development Note
• 90 Day Progress Summary
Adult H2017 (PRS) Criteria
For Initial Services, beneficiary must:
– Diagnosed with a serious or persistent mental illness which includes
one of the following: Schizophrenia, Bipolar Disorder, Major
Depression, Psychotic Disorder NOS, or Schizoaffective Disorder
– Moderate or severe functional impairment that interferes with 3 or more
of the following:
•
•
•
•
•
Daily living
Personal Relationships
Work Setting
School Setting
Recreational Setting
Adult H2017 (PRS) Criteria
For Initial Services, beneficiary must:
•
Meet Three or more of the following criteria as documented in the DA:
– Is not functioning at a level that would be expected of typically developing
individuals their age;
– Is at risk of psychiatric hospitalization or out-of home placement
– Experiences impaired cognitive ability to recognize personal or environmental
dangers or significantly inappropriate social behavior.
– In the last 90 days exhibited behavior that resulted in at least one intervention
by crisis response, social services, or law enforcement.
•
•
•
The services is recommended by an independently LPHA acting within the
scope of his/her professional licensure
The service, including frequency of the service, is recommended as result
of the DA
Beneficiary is expected to benefit from the intervention and needs would
not better clinically met by any other formal or informal system or support
Adult H2017 (PRS) Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC and a
revised plan addresses service modifications to address remaining
issues;
– Beneficiary continues to be at risk for out-of home-placement;
– The family/caregiver is actively engaged in the treatment process,
which is clearly documented in the clinical record
– Beneficiary continues to meet medical necessity criteria
***Please submit for continuation of services no more than 10 business
days prior to the end of your current authorization
Adult (Family Support) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
For Continuation of Services• Individualized Plan of Care (IPOC)
• Service Plan Development Note
• 90 Day Progress Summary
Adult S9482 (Family Support) Criteria
For Initial Services, beneficiary must:
– Beneficiary has been diagnosed with a serious and persistent mental
illness (SPMI) which includes one of the following: Schizophrenia,
Bipolar Disorder, Major Depression, Psychotic Disorder NOS or
Schizoaffective Disorder; or co-occurring SPMI and substance use
disorders (SUD)
– Demonstrates moderate to severe functional impairment in 3 or more
of the following areas as result of SPMI and/or SUD:
•
•
•
•
•
Daily Living
Relationships
School
Work Setting
Recreational Setting
– Family or Caregiver agrees to be an active participant, which involves
participating in interventions
Adult S9482 (Family Support) Criteria
For Initial Services, beneficiary must:
•
Meet Three or more of the following criteria as documented in the DA:
– Is not functioning at a level that would be expected of typically developing
individuals their age;
– Is at risk of psychiatric hospitalization or out-of home placement
– Experiences impaired cognitive ability to recognize personal or environmental
dangers or significantly inappropriate social behavior.
– In the last 90 days exhibited behavior that resulted in at least one intervention
by crisis response, social services, or law enforcement.
•
•
•
•
The Family or caregiver agrees to be an active participant (if family or
caregiver is unable or unwilling to be an active participant, this must be
clearly documented).
The services is recommended by an independently LPHA acting within the
scope of his/her professional licensure
The service, including frequency of the service, is recommended as result
of the DA
Beneficiary is expected to benefit from the intervention and needs would
not better clinically met by any other formal or informal system or support
Adult S9482 (Family Support) Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC and a
revised plan addresses service modifications to address remaining
issues;
– Beneficiary continues to be at risk for out-of home-placement;
– The family/caregiver is actively engaged in the treatment process,
which is clearly documented in the clinical record
– Beneficiary continues to meet medical necessity criteria
***Please submit for continuation of services no more than 10 business
days prior to the end of your current authorization
Child H2017 (PRS) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• Parenting Stress Index (PSI) – Birth to 1.5 years
• Child Behavior Check List – 1.5 to 5 years
• CALOCUS – 6 years and older
• Parent/Guardian Agreement Form (Birth to 15 years)
For Continuation of Services• Individualized Plan of Care (IPOC)
• 90 Day Progress Summary
• Service Plan Development Note
• Parent/Guardian Agreement Form (Birth to 15 years)
Child H2017 (PRS) Submission
Requirements
Providers rendering services to children
being referred by state agency:
Submit to KEPRO for Initial Services• Rehabilitative Behavioral Health Services (RBHS)
Referral Form
• Parent/Guardian Agreement Form (Birth to 15 years)
Submit to KEPRO for Continuation of Services• Individualized Plan of Care (IPOC)
• 90 Day Progress Summary
• Service Plan Development Note
• Parent/Guardian Agreement Form (Birth to 15 years)
Child H2017 (PRS) Criteria
For Initial Services, beneficiary must:
– Beneficiary (ages 0-6) has been diagnosed with a serious emotional
disorder (SED) or an applicable Z code as per the current DSM; OR
– Beneficiary (ages 7-21) has been diagnosed with a serious emotional
disorder (SED) or a co-occurring SED and substance use disorder
(SUD)
– Moderate to severe functional impairment that interferes with
performance in 3 or more of the following areas:
–
–
–
–
–
Daily living
Personal Relationships
School
Work Setting
Recreational Settings
Child H2017 (PRS) Criteria
For Initial Services, beneficiary must (cont’d):
•
Meet Three or more of the following criteria as documented in the DA:
– Is not functioning at a level that would be expected of typically developing individuals
their age;
– Is at risk of psychiatric hospitalization or out-of home placement
– Experiences impaired cognitive ability to recognize personal or environmental dangers
or significantly inappropriate social behavior.
– In the last 90 days exhibited behavior that resulted in at least one intervention by crisis
response, social services, or law enforcement.
•
•
The Family or caregiver agrees to be an active participant (if family or caregiver
is unable or unwilling to be an active participant, this must be clearly
documented).
The services is recommended by an independently LPHA acting within the
scope of his/her professional licensure
Child H2017 (PRS) Criteria
For Initial Services, beneficiary must (cont’d):
•
The service, including frequency of the service, is recommended as result of the
DA and the score on the age appropriate tool
•
Beneficiary is expected to benefit from the intervention and needs would not
better clinically met by any other formal or informal system or support
•
The score on the age appropriate assessment tool indicates need for service
–
Birth-1.5 years, has scored in the 81st percentile or above on the Parenting Stress Index
(PSI)
–
1-.5 – 5 years, has scored in the borderline to clinical range (minimum T score of 65) on at
least one syndrome scale and one DSM-Oriented Scale of The Child Behavior Check List
–
6-21 years, has been assigned a minimum CALOCUS composite score of 17
Child H2017 (PRS) Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC;
– Beneficiary continues to be at risk for out-of home-placement;
– For child and adolescent beneficiaries: The family/caregiver/guardian is
actively engaged in the treatment process, which is clearly
documented in the clinical record
– Beneficiary continues to meet medical necessity criteria.
***Please submit for continuation of services no more than 10 business
days prior to the end of your current authorization
Child H2014 (Behavioral Modification)
Submission Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• CALOCUS, Parenting Stress Index or Child Behavior
List
• Parent/Guardian Agreement Form (Birth to 15 years)
For Continuation of Services• Individualized Plan of Care (IPOC)
• 90 Day Progress Summary
• Service Plan Development Note
• Parent/Guardian Agreement Form (Birth to 15 years)
Child H2014 (Behavioral Modification)
Submission Requirements
Providers rendering services to children
referred by state agencies only
Submit to KEPRO for Initial Services• Rehabilitative Behavioral Health Services (RBHS) Form
• Parent/Guardian Agreement Form (Birth to 15 years)
Submit to KEPRO for Continuation of Services• Individualized Plan of Care (IPOC)
• 90 Day Progress Summary
• Service Plan Development Note
• Parent/Guardian Agreement Form (Birth to 15 years)
Child H2014 (Behavioral Modification)
Criteria
For Initial Services, beneficiary must:
– Beneficiary (ages 0-6) has been diagnosed with a serious emotional
disorder (SED) or an applicable Z code as per the current DSM; OR
– Beneficiary (ages 7-21) has been diagnosed with a serious emotional
disorder (SED) or a co-occurring SED and substance use disorder
(SUD)
– Engaging in behaviors in 1 or more of the following behaviors: physical
aggression, verbal aggression, object aggression, self-injurious
behavior and presents risk of harm to self or others and significantly
impact functioning in 3 or more of the following areas as documented
on the Diagnostic Assessment:
•
•
•
•
•
Daily Living
Relationships
Work Setting
School Setting
Recreational Setting
Child H2014 (Behavioral Modification)
Criteria
For Initial Services, beneficiary must (cont’d):
•
Meet Three or more of the following criteria as documented in the DA:
– Is not functioning at a level that would be expected of typically developing individuals
their age;
– Is at risk of psychiatric hospitalization or out-of home placement
– Experiences impaired cognitive ability to recognize personal or environmental dangers
or significantly inappropriate social behavior.
– In the last 90 days exhibited behavior that resulted in at least one intervention by crisis
response, social services, or law enforcement.
• The Family or caregiver agrees to be an active participant (if family or
caregiver is unable or unwilling to be an active participant, this must be
clearly documented).
• The services is recommended by an independently LPHA acting within
the scope of his/her professional licensure
Child H2014 (Behavioral Modification)
Criteria
For Initial Services, beneficiary must (cont’d):
•
The service, including frequency of the service, is recommended as result of the
DA and the score on the age appropriate tool
•
Beneficiary is expected to benefit from the intervention and needs would not
better clinically met by any other formal or informal system or support
•
The score on the age appropriate assessment tool indicates need for service
–
–
–
Birth-1.5 years, has scored in the 81st percentile or above on the Parenting Stress Index
(PSI)
1-.5 – 5 years, has scored in the borderline to clinical range (minimum T score of 65) on at
least one syndrome scale and one DSM-Oriented Scale of The Child Behavior Check List
6-21 years, has been assigned a minimum CALOCUS composite score of 17
Child H2014 (Behavioral Modification)
Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC;
– Beneficiary continues to be at risk for out-of home-placement;
– For child and adolescent beneficiaries: The family/caregiver/guardian is
actively engaged in the treatment process, which is clearly documented in
the clinical record
– Beneficiary continues to meet medical necessity criteria.
***Please submit for continuation of services no more than 10 business days
prior to the end of your current authorization
Child S9482 (Family Support) Submission
Requirements
Please submit to KEPRO:
For initial services• Diagnostic Assessment (DA)
• CALOCUS or Child Behavior Check List
• Parent/Guardian Agreement Form (Birth to 15 years)
For Continuation of Services• Individualized Plan of Care (IPOC)
• 90 Day Progress Summary
• Service Plan Development Note
• Parent/Guardian Agreement Form (Birth to 15 years)
Child S9482 (Family Support) Submission
Requirements
Providers rendering services to children
referred by state agency:
Submit to KEPRO for Initial Services• Rehabilitative Behavioral Health Services (RBHS
Referral Form)
• Parent/Guardian Agreement Form (Birth to 15 years)
Submit to KEPRO for Continuation of Services• Individualized Plan of Care (IPOC)
• 90 Day Progress Summary
• Service Plan Development Note
• Parent/Guardian Agreement Form (Birth to 15 years)
Child S9482 (Family Support) Criteria
For Initial Services, beneficiary must:
– Beneficiary (ages 0-6) has been diagnosed with a serious emotional
disorder (SED) or an applicable Z code as per the current DSM; OR
– Beneficiary (ages 7-21) has been diagnosed with a serious emotional
disorder (SED) or a co-occurring SED and substance use disorder
(SUD)
– Demonstrates moderate to severe functional impairment in 3 or more
of the following areas:
•
•
•
•
•
Daily Living
Relationships
School
Work Setting
Recreational Setting
Child S9482 (Family Support) Criteria
For Initial Services, beneficiary must
(cont’d):
•
Meet Three or more of the following criteria as documented in the DA:
– Is not functioning at a level that would be expected of typically developing
individuals their age;
– Is at risk of psychiatric hospitalization or out-of home placement
– Experiences impaired cognitive ability to recognize personal or environmental
dangers or significantly inappropriate social behavior.
– In the last 90 days exhibited behavior that resulted in at least one intervention
by crisis response, social services, or law enforcement.
• The Family or caregiver agrees to be an active participant (if family
or caregiver is unable or unwilling to be an active participant, this
must be clearly documented).
• The services is recommended by an independently LPHA acting
within the scope of his/her professional licensure
Child S9482 (Family Support) Criteria
For Initial Services, beneficiary must
(cont’d):
•
The service, including frequency of the service, is recommended as result
of the DA and the score on the age appropriate tool
•
Beneficiary is expected to benefit from the intervention and needs would
not better clinically met by any other formal or informal system or support
•
The score on the age appropriate assessment tool indicates need for
service
–
–
–
Birth-1.5 years, has scored in the 81st percentile or above on the Parenting Stress
Index (PSI)
1-.5 – 5 years, has scored in the borderline to clinical range (minimum T score of 65)
on at least one syndrome scale and one DSM-Oriented Scale of The Child Behavior
Check List
6-21 years, has been assigned a minimum CALOCUS composite score of 17
Child S9482 (Family Support) Criteria
For continuation of services:
– The desired outcome or level of functioning has not been restored,
improved, or sustained over the time frame identified in the IPOC;
– Beneficiary continues to be at risk for out-of home-placement;
– For child and adolescent beneficiaries: The family/caregiver/guardian is
actively engaged in the treatment process, which is clearly
documented in the clinical record
– Beneficiary continues to meet medical necessity criteria.
***Please submit for continuation of services no more than 10 business
days prior to the end of your current authorization
Retroactive Medicaid Eligibility
A case may be submitted as a “retro” when
retroactive Medicaid eligibility occurs or
when Medicaid becomes the primary payer
This includes:
• Member not eligible for coverage at the time services were
provided.
• Member gains eligibility that is made retroactive to the date of
service.
NOTE** A “retro” case is NOT one that is submitted late for any
reason.
KEPRO/Provider Turnaround Time
KEPRO
• Upon receipt of PA request, KEPRO must render a
decision within 5 business day of the request
submission (excluding higher level reviews)
• If the PA request is submitted for higher level review,
KEPRO has 1 additional day to render a decision.
Provider
• If additional information is required for review, the
request will be pended, and the Provider will have 2
business days to submit the additional information
required to KEPRO.
INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Registration for
Atrezzo Connect
Provider Portal
How To Register For
Atrezzo Connect
• Website Address:
https://scdhhs.kepro.com
• Select “ Registration For Atrezzo
Connect” (Slide 3)
• Enter your 10 digit National
Provider Identifier (NPI) number
and Legacy South Carolina
Medicaid provider ID
• Select a unique user name and
password & complete required
user information
Atrezzo Connect
Atrezzo Connect allows for:
– Secure access to Atrezzo
Connect (Provider Portal)
– Provider will be able to
access letters by
Case/Request,
Respond/Send messages
To/From KePRO
Required Information for
Security Verification
• The provider must enter
information to verify
authenticity for security
reasons
• Registration Code:
– SCDHHS Legacy ID
Simple -5 Step Registration Process
• Start by clicking the
Atrezzo Login
button on the
SCDHHS-KEPRO
website
Login Page
• You will be brought to this login page
Step 2 – Enter NPI and Legacy ID
• Enter your
organization’s
NPI number and
Legacy Provider
ID = Provider
Registration
Code
• Click NEXT
Step 3 – Terms of Agreement
• Review Terms of
Agreement. Upon
acceptance, you will
be taken to setup for
User information.
Step 4 – Verify Address
• Click on the correct address(s) for the
new account (this associates your user
information with these locations)
• If all apply, check all of them
• Click SELECT
Step 5 – Enter Account Information
• Enter user account
information
• User Name, Password,
First/Last Name, E-mail
and Fax Number are
required fields!
• Click NEXT-This will
take you to the
Password setup and
security question Slide)
• Passwords do not
expire. Minimum 8
characters required.
Successful Completion
• Successful
Completion of
setup, takes
you to the
Home Page
View all request and Create new request
•Click Member to search using Member id or Last
name/DOB
•Click Request/Case to search using Case id,
Member info or Request info
Create Preferences, Manage User account
and New Provider Registration
Use this tab to change your password or
update your contact information
View Atrezzo User Guide and View FAQs
Account Administrator
• All information submitted for
registration under
Provider/Facility Information will
represent as the Provider Portal
Administrator (Group Admin).
• The Group Admin is responsible
for managing and creating all
Submitting User accounts for
your NPI #
– Create other Group Admins’ &
Admin Users
– Set Preferences, i.e. Diagnosis
and Procedure codes, etc
KEPRO Contacts
Thank You!
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